A reminder of the power of highly developed physical exam skills

It’s rare these days that I hear such a wonderfully complete presentation with a physical exam that Degowin and Bates (authors of two of our most beloved physical exam guides) would even be proud of. In the US everything can be imaged quickly, from obtaining a chest X-ray to look at the lungs to an echocardiogram to look at the heart. Here, each exam finding is reported, the presence or absence of something may be crucial to the diagnostic management. A resident was scrutinized for reporting a murmur incorrectly, the implications of which change the patients clinical presentation quite dramatically.  

The day started on the 8th floor, where the pulmonary office is located. I made the mistake of taking the elevator which almost didn’t close and worse yet had well over the maximum amount of people..this is a lesson I should have learned in Bangladesh. It turns out most of the medical staff take the stairs no matter how far—a habit I am happy to take on.  We rounded through the ICU, located on the 4th floor, along with the surgical ICU and pediatric ICU. The number of beds allocated for the medical icu are 4-6 at most. To give you a reference, the main Medical ICU at UPenn can accommodate 24 patients and there’s a second medical ICU that accommodates 8. Both of those ICUs are always full. However here, given the limitation of resources the criteria for admission is strict—only patients who are salvageable. This seems brutal but to be honest it is the unfortunate reality. For instance—we saw a young patient who received a recent diagnosis of leukemia, she received a round of chemotherapy and this was complicated by a severe infection which is now why she is in the ICU. The unfortunate thing is that her disease while treatable has a poor prognosis and now with this infection and to complicate the matter she is on a ventilator, she almost certainly will not recover to the extent that she could be treated for her underlying cancer. Her admission to the ICU was controversial. Meanwhile another woman has been admitted for 4 months with overall poor prognosis and no sign of any recovery. She was admitted after a cardiac arrest and likely was not resuscitated in time. The attending physician said to me, “in your country this is a patient who would benefit from hospice but we don’t really have a mechanism for that here”. If you followed my posts from Bangladesh you’ll remember that this was also missing in the repertoire of the critical care physicians. But this is not a criticism, this is an acknowledgement that often times the culture is what it is and to introduce something like hospice and palliative care it would potentially mean an upheaval of cultural norms. 

My first day was quite incredible. I am humbled by the expertise around me and how much can be done with such limited resources. I am again reminded that a limitation of resources never means a limitation on quality care—the patients here at Black Lion Hospital are receiving wonderful care and I look forward to getting to know the medical staff over the next two weeks. 

(View from the stair well as I took a quick breather at flight 6 of 8)