A ship’s captain gets into an argument with a pretty damsel in front of the main sail of his immense boat. Unbeknownst to him someone hasn’t tied off the jib in a secure fashion. During the height of the argument the wind comes up and the tie comes loose, causing the arm of the jib to crash into his chest. With facial expressions worthy of an Emmy or a constipation commercial, the captain falls to the deck. Cut to the expressions on the faces of the witnesses to the event, including the well-known physicians assistant. Dramatic, foreboding music comes up and we go to black and a commercial for erectile dysfunction medication.
Good times! I created this scene at JFK airport trying to get onto an overbooked JetBlue flight at 11p.m.; its destination home to Boston and a loving, warm wife. As I am pleading my case to a very professionally sympathetic counter agent, my phone rings. The screen reads a LA area code and with dread and unwillingness I click to talk to the writer’s room.
“Irv we need a scene…”
The basic premise of Royal Pains (that was fucked up by the middle of the second season by those same writers) was a doctor that could think on his feet and save lives in unconventional environments using unconventional tools.
We will come back to this.
In Emergency Medicine News, a decent throw away news/educational publication, an article presented a new use for the $30,000+ ultrasound machine your E.R. “JUST HAS TO HAVE OR ELSE IT IS A THIRD WORLD CLINIC THAT HAS RATS IN IT GNAWING AT THE TOES OF YOUR PATIENTS AND DOCTORS THAT CAN BARELY SPEAK ENGLISH, AND SCAPALS THAT HAVE RUST ON THEM…” you get the idea.
“USE THE ULTRASOUND TO DIAGNOSE YOUR PATIENT WITH AN ANTERIOR SHOULDER DISLOCATION…” For readers that have not had the agony of this affliction, simply put the ball of the shoulder pops out of its socket and ends up in front of the socket. It’s painful and when diagnosed a trained doctor must carefully manipulate that ball back into the socket. The manipulation needs to be done ASAP because the longer the shoulder is dislocated the harder it is to get back in.
The interesting part of the article is that I must have an ultrasound to diagnosis this problem. Not so says the moderately trained physician. First, the history is usually some variation of a fall on an outstretched arm. Second, you can usually feel the ball of the shoulder joint right under the skin of the chest. Really in most cases it doesn’t take a neurosurgeon or Harvard law professor to figure this one out. So I ask once again, why do I need an ultrasound? (Come on you can guess why? Money!) Here is the bigger problem (money and healthcare costs are big, but as I am close to retirement from medicine it won’t be my problem soon enough)… EDUCATION. We are training whole new generations of doctors to “get a test” as a substitution for examining a patient. We no longer touch, palpate, listen, smell, or look at a patient. We order a test spending precious capital when that gold is needed to vaccinate, research, and cure more important conditions.
Back to the beginning.
Our brilliant physician assistant immediately examined our poor and hurting captain. She already had his history by seeing the mechanism of injury play out before her eyes. She palpated the captain’s chest hearing the crepitus of the chest wall. She looked and saw the ecchymosis (bruising) of the chest wall. She also saw that a section of his chest wall was moving abnormally during his inhalation. Instead of the ribs sinking into the chest during inhalation she saw that the section actually rose relative to the rest of the chest (paradoxical movement). No chest x-ray, ultrasound, CT scan. No blood test, urinalysis, or cardiogram needed. She had been taught well by Hank Lawson, MD (me). This was a flail chest and needed not thousands of dollars of tests, but treatment toward the stabilization of the chest wall.
Of course this being TV and because her teacher (me again) is an old fart that was trained in the archaic and prehistoric, she didn’t need the intubation with the endotracheal tube, respirator, and other modern equipment. She figured out how to recreate a 1950′s method of chest wall stabilization using objects found on a boat; fish hooks, pulleys, ropes, and liquor bottles. In reality you’d have to be pretty desperate to try this on a patient, but WHAT IF?
There may come a time a doctor is in a place with no equipment, no imaging machines, no stethoscope, and a patient is in extremis. Do you let the captain die because you were never taught how to really examine and think through the process? Has medicine become the purview of a technician running in data gleaned from one machine that digests the numbers and tells another machine what to do? Is there no room anymore for human beings that know how to take care of a patient accurately, cheaply, and efficiently? Remember for each machine used inappropriately, less treasure is available for other souls.
One machine can do the work of 50 ordinary men. No machine can do the work of one extraordinary man.