Friday, August 17, 2012
The ability of technology to look inside the body always amazes me. It also has changed the way we practice medicine, being less invasive, and in many cases allowing the body to heal itself. This is especially true when it comes to caring for patients with abdominal pain. In the past, the art of medicine was a skill to be learned, allowing physical examination and experience to decide if a patient needed to go to the operating rom. Now the art of medicine is deciding when to use technology to enhance the bedside experience.
Jason Witten now sits in a hospital bed being observed for a fracture spleen. The Dallas Cowboy tight end was hit during a game, developed abdominal pain and ended up in the hospital. The spleen sits high up in the left abdomen protected by the lower rib cage. It acts like a large filter removing old and damaged cells from the blood stream and also plays an important role as part of the immune system of the body. A generation ago, if the emergency physician and surgeon were concerned that a spleen injury existed, the next step was to go to the operating room for exploratory surgery to look inside. If the spleen was injured, it was removed. Today, if there is worry that the spleen is damaged; CT scan is the next step to look at the organs inside the abdomen without cutting.
Technology doesn’t just stop at looking. The spleen can be fractured (a fancy way of saying broken or cracked) and yet any bleeding may be contained within its walls. Sometimes, the spleen ruptures and blood spills out into the abdominal cavity. Unless the patient is in shock and appears to be bleeding to death, there is time to decide how to make things better. If the issue is localized bleeding, the surgeon may ask an interventional radiologist to thread a catheter into the damaged artery, clot it off and take care of the problem. It takes the skill of a surgeon to decide what patient will benefit from an operation and when that operation should take place. It also takes the surgeon’s to decide when to use technology instead.
The problem with using non-invasive techniques like ultrasound, CT and interventional radiology is that they are expensive and take time. An injured spleen that is managed without an operation will spend a couple of days being observed in ICU, with repeated physical examinations and blood tests. The further out from the injury, the less likely that unexpected bleeding will occur, but it will be at least a month until the patient can return to regular activity. Aside from the cost, there is the downside of radiation exposure and intravenous dye injection that accompanies a CT scan. That said most people would prefer an x-ray to an operation.
In today’s medical world, technology can help make a diagnosis that is potentially lethal and would be otherwise hidden. The art of the history taking and physical examination at the bedside is what drives what technology to use. Withholding a test because of cost or inconvenience is unacceptable but so is ordering too many tests when they are not indicated. The bedside skills of the physician have evolved to decide what patient might benefit from technology and perhaps prevent a patient from going under the surgeon’s knife.