26 Jun 2008
6 minute read
agk’s Library of Low Resource Medicine
One problem with a lot of alternative practitioners is that their patients usually arrive with a diagnosis from a doctor, and often a suggested treatment. As a result, they don’t get the same day-to-day hands-on diagnostic experience western practitioners get, who have to figure out a situation with no prior information whatsoever.
In fact, I think, when you look at how medicine is performed in hospitals and clinics, you find a similar relationship between labs and practitioners – the clinical assessment, once the cornerstone of medical training (think Dr. Joseph Bell – and look him up yrself!) – is now mostly used to confirm the findings of a blood screen, imaging study, or EKG. There’s a reason for this – clinical presentations are confusing and unreliable, lab tests are much more accurate. I don’t mean to criticize the idea that a doctor, in a hospital, uses ultrasound rather than tapping on McBurney’s point and asking a patient to lift their knee against pressure to diagnose the extent of a case of appendicitis. However, the historical tests and practices are highly effective and useful if you don’t have an ultrasound machine to begin with.
If you are medically trained, there’s a good chance your assessment class was like mine (I’m a paramedic.) You start with vital signs, the primacy of which is never explained or questioned. You move on, system by system, to a series of tests which boil down to looking at, listening to, and poking different body parts. You have to memorize the names of a half dozen things that can go wrong with fingernails (most of which indicate a recent blow with a hammer) and list of technical terms for skin lesions (quick! what’s the minimum diameter of a “bulla”?) You spend a great deal of time listening to your classmates’ normal heart tones, and you maybe palpate each others’ ovaries, which isn’t nearly as fun as it sounds (and even if you don’t have your ovaries, your assessment partner will claim to have felt them.) You pass the test and then never do any of those things again.
I called in a pre-hospital report that described a bulla on someone’s… face? I forget, anyway nobody at the ER knew what I was talking about, and I never tried that kind of unnecessary smartassery again.
What you have just experienced, or more likely endured, is a relic, a ruination of what was once a great monument to human endeavour. For a few thousand years two developments kept pace with each other. One was the development of technology that allowed precise measurement of human physiology, such as accurate chronometers for measuring a pulse rate, and the other was libraries, communications networks, and teaching institutions that allowed someone in Andalusia, say, to read the commentaries of someone from Persia, on an anatomist from Greece. What came from this was the idea, not obvious in its own right, that diseases leave marks on the body, and that these marks can be noticed in advance and used to identify the disease and predict its course.
Over the years, these marks, these signs and symptoms, were systematized, until a set of practices were developed that would bring these to the fore, where they could be recognized and reacted to. Since most of this multi-millenial development occurred before IVs, EKGs, MRIs or other such tools, most of The Assessment centered around easily produced technology like stethoscopes, reflex hammers, clocks, and above all eyes, ears and fingertips. Interviews with patients were simplified until a few dozen questions (have you noticed any recent changes in your urine?) could elicit enough information to significantly narrow down your “differential” of possible concerns to where you could focus efficiently on what you needed to know. And it is this ritual, deprived of interpretive rigor, that is reënacted in the course of a one-semester patient assessment class.
Our job, as low-resource practitioners, is to go back and get it.
I suggest a few places to start. First, hello, those patient assessment classes. The information being taught isn’t bullshit at all, its absolute dynamite. I wish I’d paid better attention though – what’s missing is the idea that these skills might someday be all you have to go on. For that reason I think the patient assessment taught to paramedics and ER docs is probably better than what’s taught to, say, oncologists, simply because they have to make quick decisions without benefit of technology far more often. Even outside those classes (and I stress – don’t try to just “read up” on your own!) there are textbooks for all levels of skill and all types of training which include voluminous information for anyone who cares to absorb it.
Furthermore, there are always nerds among medical professionals, and chances are at least one person you work with makes a habit of knowing these sorts of skills a little better than they really need to for their job. Since they’ve most likely been practicing, and can actually answer your questions better than a textbook, I suggest finding them and pissing them off with your inquisitiveness. Finally, there are medical historians and medical histories as well as anomalous compendia like Wikipedia’s exhaustive list of eponymous medical signs for you to look into. Obviously this one isn’t organized by resource level or interpretive value but by whether or not its named for someone in particular, but ah well. Better than nothing. By the way – look that over, and realize that eighty years ago, a doctor would be expected to be able to conduct all those little tests if necessary. I don’t, by the way, mean to imply that the historical legacy is a value in itself – going back a bit, you don’t need to know that the spot just inside the upper hip-bone towards the belly-button is called McBurney’s point, let alone who McBurney was, but you might want to remember that pain there is associated with appendicitis.
I want to mention something about the technology used for assessment. The more, I think, that you can swing without a CLIA license, the better. But, of course, there are people who will read this who will be particular about what devices they choose to rely on, especially in emergencies. Speaking personally, I would never want to be without the following:
A stethoscope – look, they work for about a hundred different things, and you can’t hear, say, heart tones without them.
A blood pressure cuff – why is blood pressure so important and widely taught compared to oxygen saturation? Because its easier to measure with lower levels of technology. I’d love a capnograph, but I’d feel kind of helpless being unable to tilt-test someone. Its how I’ve learned, its how patients have been assessed for a hundred years, and its called a “sphygmomanometer” which is a very cool word.
A thermometer – did your mom use one on you when you got sick? Fine then! I’m talking about the analog glass-tube-with-alcohol kind you hold under your tongue. I hear some people objecting now – sure, with some leather and a maple burl you could home-make a stethoscope, sure with some milkweed-rubberized-silk cloth you could make an air bladder for a sphygmomanometer, but a thermometer is completely unsustainable. What if it breaks? To those people I say, buy two. Buy more than two. Hell, I don’t care how extreme a fast-crash survivalist you are: if you take delivery on a gross of medical thermometers and store them safely in your bunker, you’ll be queen of the swap meet some day.
A penlight or something equivalent – not just for pupils. How are you going to see into somebody’s mouth? Coated tongues, dry tongues, swollen tonsils… can’t see those at night without a penlight. If it takes captive fireflies so be it.
I’ve never tried to get good with a tuning fork or a reflex hammer, but folks over at the WFR school say those are pretty damn useful too.
----------------------------------------------------- from HUCK FINN ON ESTRADIOL © . My friend Anne's old blog, available via http at tagonist.livejournal.com -----------------------------------------------------
agk’s Library of Low Resource Medicine is hosted on sdf