Thursday, January 26, 2012

Hands on the Skin

Exit the Diagnostician

It is the best of times when the psyche is geared towards the health and welfare of each individual. Yes we discuss, we promulgate policies with a philosophical bent, we climb up on soapboxes and advocate altruistic motives, we decry other’s utterances, we subsume the world of thought into an arbitrary morass of chaotic thinking and hold ourselves high as the pillars of societal paragons. It is all good intent. But the results seem tempered with ambiguity at every level. Something is amiss. We have the computing power, oh yes! We have terabytes of storage memory and petaflops of throughput. We have the answers to most of the questions or so we think. We are delighted as we see the light refracted in the color of our viewing. We are educated and well rounded in our grasp of things, after all we carry the domain of science and philosophy and all that is to know in the palm of our hands, don’t we? We are blessed! Yes indeed it is the best of times! Or is it?

Why did I start this offering with such a distasteful paragraph? Why, you ask? Therein lies a short story:

It was the better of days, the sun was in full bloom and the clouds had parted to reveal the blue beyond. Everything seemed in sync with the time of his mental tide. He had just finished his review of cases. He happened to be the Attending and his ward was a second year Resident. This second year resident was “spiffed up” in his faded jeans, an open collar shirt and a short white lab coat with an array of pens in the front pocket. The attending was in a long lab coat with “Medicine” embroidered on his lapel. Beneath his lab coat was a freshly laundered shirt with stiff collars and a handsome blue and red colored tie.

“So what is your impression?” the attending asked.

The resident went into a discourse of the medical background, which mostly was composed of lab and X-Ray data. There was mention of a negative family history and also something about previous admissions. All in all, the resident was able to convey a historical and current status of the patient from his point of view fairly well.
“So it seems that Mr. G is in reasonable good health. He came in with mild congestive heart failure and that based on your assessment is resolved, Correct?” The attending inquired.
“Yes sir.” The resident replied. This attending, it was known in the training circles, wanted to be addressed as “sir”. He was the “old school” who had been nicknamed “Dr. Dinosaur.”

They walked down the corridor towards Mr. G’s room. The resident flicking digital pages on his iPad, expanding and contracting images to make sure he had covered all bases.
“What about that elevated LDH that remains high, what do you make of that?”
“The Lactate Dehydrogenase, sir half-life delays its resolution compared to the CHF symptoms.” The resident answered quietly, he had to know all the answers or reasonable understanding of the potential questions, for he knew that Dr. Dinosaur’s recommendation was a necessary requisite and carried weight when it came to obtaining a fellowship.
“And what about that slightly elevated Uric Acid?” The attending frowned just a smidgen, as if in thought.
“Well sir his renal function is also minimally impaired but getting better from the pre-renal event, preceding the CHF, that would account for it” The resident replied.
“I see.” The Attending stroked his chin gently and eyes narrowed under the frown. If you were able to see his pupils they were in full dilation of thought.

They walked into the room,

The resident stood in the corner as Dr. Dinosaur started examining the patient. He kept talking with the patient as he examined him. Asking questions, nodding to the answers elicited and moving on to more questions. The dialogue was barely audible over the din of the air-conditioning unit that was at medium blast. 
Star Trek's Tricorder

The resident was thumbing through the digital universe looking for any loopholes in his presentation that might be under review. He noticed that Dr. Dinosaur displayed a calmness and thoroughness about the way he proceeded through the half-an-hour or so of examination. After he was done, they walked out of the room.

The resident kept scanning his iPad for information that the attending might need.
“So what is your final diagnosis?”
“CHF sir.”
Okay, did you examine Mr. G?”
“Yes sir.”
“I asked about any issues that he had. I did listen to his lungs for crepitus to confirm the resolving CHF.”
“There were some basilar crackles, but all in all his lungs were clear.”
“Uh huh.” Dr. Dinosaur rubbed his right temple with his fingers. The grey hair stuck out in stark relief against his reddened skin.
“Please go back and reexamine Mr. G and come back and report your findings to me in my office…in about a half an hour. Okay?”
“Yes Sir!”

Half an hour later the resident reported. “His examination was negative sir.”
“Now go back and check his right neck area and ask him about his smoking history, there is a golf-ball sized lump that you wont miss. It is just below the clavicle in the supra-clavicular region. That lymph node is about 2 by 2 centimeter. Also bring in the real films from the X-Ray department and lets look at his Chest X-Rays together. He might need a CT scan of the chest. Ask a consult with the surgical specialty for a needle biopsy of the node and then we will take it from there.”

The resident turned pale and then the color of blush warmed over his face, as if he had seen a ghost and recognized it. He stood there for a moment longer then necessary wishing his body to move, to obey the command that it resisted. Finally he turned and walked out.

Enter the Diagnostician.

With a pair of hands, a gentle touch, a few whisperings of questions and acknowledgements the mind can comprehend more than all the digitized words in the Library of Congress. On paper the patient is doing fine, in health he may not. What is it we hope to seek? What is it we hope to convey? What is it we wish to fix? What is our ultimate aim? Are we to hope for a better future filtering the patient through the refractive lenses of a digital world or with physical contact? If we cannot bridge the gap towards the “real-digital” future this indeed will be the worst of times.
Nanobots in the blood stream

There will come a day, when a hologram will diagnose the problem through a virtual scanner and a nano-labeled fluorescent diagnostic tool floating around in the blood stream of humans will diagnose all the maladies that afflict us and in so doing that nanobots will inject us with the required antidotes of all current and future problems? Unfortunately the time is not ripe for that just yet. Our today’s digitally astute students are living under the premise of that hologram society, today, unfortunately without the necessary available tools in this present and minus the clinical acumen of the Dr. Dinosaur. The promise of that “beautiful life” is just that, a promise.
Star Trek's Holodoc

Until then, we still need the “hands on the skin.”

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