Tag Archives: Medicine

The Long Thoracic Nerve

The smell of formaldehyde sticks in your nose, it hides, I believe, right on the olfactory bulb waiting for those brief 10 minutes when you decide to have some dinner and then makes a sudden reappearance. Standing in the cold lab room, double gloved, aproned, and with goggles on I stand before my cadaver. Holding the scalpel as steadily as possible the first incision is made, on the back (i’m told it’s easier this way, to start on the back rather than the front… gives time to dissociate). A long sagital cut made from the superior occipital protuberance to the space between the iliac crests and several horizontal cuts across to reflect the skin and reveal the muscle.

This is Physician Assistant School, summer semester, Advanced Human Anatomy Cadaver Lab. Most programs begin this way. Dissection of a cadaver is, for me a sort of contract. Somone donated their body to help me learn and it is my responsibility to make sure their gift is utilized well. We decided to name our cadaver, as many do, because it helps lighten the tension. I’m realizing, however, that PA school seems to be about tension. They (past PA studnets) use the phrase “Drinking from a firehose”. I find this especially true in lectures. One powerpoint presentation may take an hour to present but hours upon hours and cup after cup of coffee to master.

Some of the material we memorize has a popular mnemonic or rhyme to go along with it; as one of the former PA students said “It might suprise you to find out others have studied medicine before you. Use their resources.” Some are inappropriate, some are violent, some are insensitive but those are the ones that stick so those are the ones we use. Some don’t make any sense. My first day of class I settled into my seat in the lecture hall of Sydney Kimmel Medical School and the professor approached the podium to introduce the sylabus, at one point stating casually “Roses are red, violets are blue, and the long thoracic nerve innervates the serratus anterior.” Everyone laughed and I sat unsure of what just happened. Now just barely three weeks into classes I can tell you all about the long thoracic nerve, where it comes from, where it goes, what happens if it is impinged, what the tissue looks like under the microscope, where the serratus anterior muscle comes from and goes to, what action it helps you perform, and much more. It went this way with each muscle we learned in the back, the shoulder, the forearm and hand. We’ve been invited to drink deep from the firehose and store away as much as possible. As they tell us when we begin, “Don’t study for the test, study for the time when that information is the only thing standing between your patient and the grave.”

So I’ll eat my dinner with the formaldehyde still in my nose because I know it will be worth it in the end and it may mean the difference between a lifesaving decision or a deadly mistake. 

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The Physical Exam

Recently I visited the urologist. I was getting a consult to follow up with a previous diagnosis given to me after a night in the Emergency Room. I have kidney stones. For the exam, if you could call it that, I remained fully clothed. My temperature wasn’t taken, my blood pressure not checked, I wasn’t touched by the doctor a single time, not even to shake hands.

This isn’t uncommon.

I didn’t need a physical exam, but I was in pain, I desperately wanted the Physician to check my back and the pain near my kidney. I wanted the doctor to ask about the strange symptoms I was experiencing for the first time; but she didn’t.

What is the importance of the physical exam?

Doctors of old are pictured standing over their patients, listening to the heart, lungs, and stomach, sometimes with their ear. It was a ritual of care, love, and empathy.

The Doctor exhibited 1891 by Sir Luke Fildes 1843-1927

The Doctor exhibited 1891 by Sir Luke Fildes 1843-1927

The painting above is titled The Doctor, and was painted by Sir Luke Fildes in 1891. In it a doctor is seen anxiously poised over a gravely sick child. His face conveys a powerful mixture of confusion, fear, and empathy. In the background we see the child’s father watching the doctor and the mother with her head on the table, her obvious despair well out of the child’s view. From the parents position within the painting we see a situation of great trust. It is the doctor, not the parents, who has the responsibility of taking care of the child.  What a profound position, a position that deserves respect.

When I volunteer at medical clinics, regardless of what the patient is there for (whether it be a cough, a rash, chest-pain, or depression) I will look into their eyes and ears, listen to their heart, and ask them to say “ahh”. Why? Because it makes them feel better, and I’ve heard enough testimonies to convince me.

Today, the patient has been replaced by a computer screen, printed test results, and x-ray images.

There is no question that our diagnostic abilities have improved. But what have we lost with the abridged physical exam? Dr. Verghese argues we are missing diagnoses, and this very well may be true. What we can say with certainty, however, is that we have lost the position of care pictured above. There is no substitute for a physician’s touch and the impact it has on the emotional and physical well-being of the patient.

Next time I go for a checkup, I’ll make sure to ask my doctor to listen to my heart and i’ll explain the weird pain i’ve had in my side, or that unpleasant symptom that has stuck around a week too long. I won’t be shocked when they seem antsy to leave and be with their next patient, but perhaps my persistence will trigger something in my doctor. Hearing about my pain might make me a little less of a test result or x-ray image and instead I will become a flesh and blood patient and the doctor will assume the position of empathetic patient advocate once again.

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