When the Patient Becomes a Specimen

He lay in the hospital bed, belly-up, staring at the ceiling. We knocked as we entered and asked the patient a barrage of questions. How was he feeling?
What doctors had he seen in the past? What other medical conditions did he have? When did he first start to notice uncontrolled nosebleeds? What other
symptoms did he notice? An endless series of questions for a patient already overwhelmed with newly diagnosed leukemia, a cancer of white blood cells. As these cells proliferate uncontrollably due to bone marrow dysfunction, they crowd out other cells in the blood.

Platelets
, for example, which create clots to stop bleeding, decrease in number leading to spontaneous bleeding. White cells malfunction, allowing bacteria, fungi,
and viruses to slip past the body’s floundering immune system. Patients with certain types of leukemia also develop an enlarged spleen, called splenomegaly. This occurs because the body looks for places other than the bone marrow to produce blood
products. The spleen and liver are two organs capable of producing red blood cells (or once were during embryonic development). They enlarge in their
attempts to compensate for bone-marrow failure.

Red blood cells.
Image via Shutterstock

“Come over here and feel this,” the attending physician said to the three of us, all medical students, after interviewing the patient and performing a physical
exam. “Is it alright if they feel for your spleen?” he asked. After the patient assented, the three of us, one by one, began to poke on the left side of
his abdomen, palpating up and down and subsequently tapping and listening for when our taps became dull or tympanic. We searched for where the spleen began
and ended. And there it was, a large, blown-up balloon inside the patient’s belly, squirming around as we attempted to assess its size through palpation.
We stood in line, each excitedly repeating what the previous student had done. It was, after all, the first time any of us had ever felt splenomegaly. In
this particular interaction we converted this human being into a test tube by observing, exploring, feeling, and assessing, detached from the reality of the
patient’s experience.

We do this regularly during our third year of medical school — we violate patients’ privacy for the sake of our education. Part excited, part
nervous, part sheepish, we come when called by our teachers to listen to lung sounds and heart sounds; to inspect wounds and infections; to feel for
various organs, tendons, and muscles in living human bodies. Though this experience feels new and uncomfortable for us, it is worth noting that medical
students have learned in this way — with a lot less regard for the patient — for quite some time.

In a 1946 issue of Now, a political and literary journal, George Orwell published an essay entitled “How the Poor Die.” In this essay we accompany Orwell, who in 1929 experienced a
bout of severe pneumonia, through a frightening, dark, and even humorous tour of a French hospital he simply calls the Hôpital X.

Image via Shutterstock

Orwell describes the admissions process: “I was kept answering questions for some twenty minutes before they would let me in…. At my back a resigned little
knot of patients, carrying bundles done up in coloured handkerchiefs, waited their turn to be questioned.” From here, with a 103 degree fever, Orwell
disrobed, put on a short hospital dressing gown and walked, without shoes, 200 yards outside on a February evening to his hospital ward. Unfortunately, his
quarters were no better than the journey to them. There was a “foul smell, faecal and yet sweetish,” [my comments on hospital smells are here] and the room contained three rows of beds
“surprisingly close together.” It seems, from Orwell’s description, to have been more of a mess hall than a hospital floor.

In the bed across from him, Orwell witnessed a patient undergoing a medical procedure: “a doctor and a student performed some strange operation on him. First the doctor produced from his black bag a dozen small glasses like wine glasses, then the student
burned a match inside each glass to exhaust the air, then the glass was popped on to the man’s back or chest and the vacuum drew up a huge yellow
blister…. It was something called cupping, a
treatment which you can read about in old medical text-books but which till then I had vaguely thought of as one of those things they do to horses.” (A recent review of the efficacy of this treatment has shown the evidence for it to be largely inconclusive.)

Subsequently, Orwell, who ostensibly also required cupping for his illness, joined in the medical education as “the doctor and the student came across to
my bed, hoisted me upright and without a word began applying the same set of glasses, which had not been sterilized in any way. A few feeble protests that
I uttered got no more response than if I had been an animal.” And in his classically dark humor, Orwell notes, “I was very much impressed by the impersonal
way in which the two men started on me…. It was my first experience of doctors who handle you without speaking to you or, in a human sense, taking any
notice of you.”

On a daily basis, nurses woke the patients at five in the morning and measured their temperatures but never washed them. Orwell remarks, “if you were well
enough you washed yourself, otherwise you depended on the kindness of some walking patient.” The doctor typically dropped by later with interns and medical
students and “there were many beds past which he walked day after day, sometimes followed by imploring cries.” Only if there was a patient with some
interesting medical illness or presentation would the doctors attend to them. The attention they paid Orwell was almost too much for him, with “a dozen students queuing up
to listen” to his chest.

It was a very queer feeling — queer, I mean, because of their intense interest in learning their job, together
with a seeming lack of any perception that the patients were human beings. It is strange to relate, but sometimes as some young student stepped forward to take his turn at manipulating you he would be
actually tremulous with excitement, like a boy who has at last got his hands on some expensive piece of machinery…. You were primarily a specimen, a
thing I did not resent but could never quite get used to.

Orwell proceeds to describe in great detail the other patients in the hospital, a potpourri of
characters. We read about an older man who cannot urinate, and about a veteran of the Franco-Prussian War of 1870, dying as female relatives look on, “obviously scheming for some pitiful legacy.”

Then Orwell discovered a patient with cirrhosis of the liver due to alcoholism (a surprisingly common type of patient in hospitals these days, too).
“About a dozen beds away from me was Numéro 57 — I think that was his number — a cirrhosis-of-the-liver case.” This patient’s liver was so enlarged that he was
“a regular exhibit at lectures.” The physician lectured to the medical students on 57, describing the particular physical findings of someone with chronic
alcoholism and an enlarged liver. The doctor felt for the patient’s liver and showed his students what it was like. “Utterly uninterested in what was said
about him, [the patient] would lie with his colourless eyes gazing at nothing, while the doctor showed him off like a piece of antique china.”

Numéro 57 died in the middle of the night, although no one knew it until the morning. “This
poor old wretch who had just flickered out like a candle-end was not even important enough to have anyone watching by his deathbed. He was merely a number,
then a ‘subject’ for the students’ scalpels.” Orwell, as soon as he had gained enough strength, fled the hospital: “it was a hospital in which not the methods,
perhaps, but something of the atmosphere of the nineteenth century had managed to survive, and therein lay its peculiar interest.”

Finally, Orwell offers an incisive comment on hospital medical care: “Whatever the legal position may be, it is unquestionable that you have far
less control over your own treatment, far less certainty that frivolous experiments will not be tried on you, when it is a case of ‘accept the discipline
or get out.’” Orwell directs his social critique at hospitals which treated and took advantage of the poor — forcing them into crowded quarters, ignoring
their cries for help and even operating on them without anesthetic.

Despite the comparative pleasantness of my own experience in my medical studies, whenever I read this essay I wince at Orwell’s descriptions because of how familiar they are to
me. The instances of the patient as a kind of specimen resemble in some remarkable ways the example I gave at the beginning. To be sure, we always thank a
patient, ask if we can perform the appropriate physical exam maneuver, and acknowledge the patient’s right to refuse an exam. Nevertheless, we treat the
patient as a test subject, which, however unfortunate, is necessary for our future profession. As patients we must ask ourselves whether we want to be
treated by physicians who have never heard wheezes on a physical exam or never felt for an enlarged liver. Patients at teaching hospitals indeed make
sacrifices for our education and for the welfare of our future patients.

Orwell also points out the patients’ abdication of privacy in the hospital. Unquestionably, this is accurate even today. When patients arrive, they put on
a hospital gown, or uniform, depending on how you look at it. The gown is, humiliatingly, almost completely open in the back except for a meager string
that, even after being tied, barely holds the back together. With the uniform on, they become hospital patients under the supervision and care of the
nursing staff and doctors. Each patient has the same gown with the same color scheme. Each patient is similarly under our watch.

When we enter a patient’s room, the knock at the door is more of an announcement than a question. Overnight, patients are poked and prodded for their blood
samples. How strange that even their blood seems to be property of the physicians, nurses, and lab technicians. Many patients are attached to an IV pole
which holds bags of fluids and medications being pumped into their veins. And thus, they cannot get up without dragging hospital property along with them.
Of course, the staff does not usually treat patients like hospital property; of course, patients can choose to leave at any time; and of course, patients
are there so they can get better. Regardless, the situation is one in which a patient submits himself or herself to the hospital so completely that,
inevitably, some aspect of the patient’s sense of privacy, independence, and humanness is lost.

Even taking all these similarities into account, Orwell’s hospital experience is more of a nightmare from our perspective. But the parallels should give us pause. Has
something of the atmosphere of the nineteenth century managed to survive even in the latest and best conditions? Must it?

How the ED (Emergency Department) Works

Ambulance image via Shutterstock

The Emergency Department is one of the most active and exciting parts of the hospital because it is the hospital’s sieve. The ED physician determines
whether an injury or complaint is life-threatening or not and then treats or admits the patient to the hospital if necessary. Someone usually comes in by
ambulance or private vehicle with a general complaint — referred to as the chief complaint — such as “stomach pain,” “chest pain,” “leg pain,” or “shortness
of breath.”

But occasionally, the first assessment of this chief complaint begins outside of the emergency room. Paramedics or emergency medical technicians who bring
the patient in by ambulance identify someone clearly in need of medical attention. Outside of the hospital they take the patient’s blood pressure, heart
rate, breathing rate, and temperature (collectively known as vital signs). These measurements indicate the seriousness of the situation. For example, if a
patient looks pale and sweaty, and his blood pressure is 80/40 (extremely low), this indicates the need for emergency treatment. However, if a patient calls
for an ambulance but has normal vital signs and looks healthy, then he can wait a bit longer for medical care, and the ambulance does not rush to the
hospital.

When the patient arrives in the emergency room, he will see a similar setup at many different institutions (I can testify to this because of my days spent
as an emergency medical technician in New York City, where I saw the emergency rooms of many hospitals). The doctors and nurses sit at an open station with
computers in the center of the circular or semi-circular room. The patient beds stand on the outer edges of the circle in small slots separated from each
other by curtains and, in some cases, by an actual wall. Usually, a patient is hooked up to a machine that continually takes vital signs and projects them
onto a screen facing the doctors and nurses.

Once the nurses bring a new patient back to a bed, the resident physician assigned to that bed asks one of the medical students to go see the patient. We
have ten minutes to interview the patient about the chief complaint and do a focused physical exam, which means we only ask about and examine bodily
systems that relate to the chief complaint. If a patient has chest pain, we do not ask about or examine the foot.

Difficulties abound with this assignment. First, some patients come to the ED and want to have all their problems taken care of, which is impossible to do
in a short period of time. Additionally, the ED is only meant to handle emergencies. Someone who has a broken leg, for example, may also want to talk about
a muscle sprain in his shoulder — but a sprain is far less concerning and does not need immediate attention. Second, some patients want to have a long
conversation with a medical student or physician. They may feel lonely at home, or have a difficult social situation, or just want to chat. And while we
must listen to the patient, these conversations may be irrelevant to the chief complaint. Moreover, other patients with life-threatening problems arrive
regularly and need an ED doctor more urgently. Finally, some patients come seeking pain medications because of an addiction, or some may malinger (faking an illness for some type of secondary gain, like getting out of school
or criminal prosecution).

Dealing with these kinds of patients is integral to the art of medicine in the ED. The methods we were taught in first and second year
about how to manage disease and what questions to ask tend to dissolve when dealing with human beings who have different motivations for coming in to the
ED. We need to understand those motivations and, occasionally, quickly work around them in order to address a patient’s life-threatening
illness.

After we see and examine the patient, we tell the resident what we think the diagnosis is and what lab tests or imaging we want to get. The resident then
sees the patient briefly and tells the attending physician his or her plan for the patient. The attending finalizes the plan for the patient and the
resident executes it. All this might be clearer with an example from my own experience.

During one of my shifts, a patient presented to the ED with severe back pain. He could not sit still, and cried out every few seconds. He squirmed on the
stretcher, moving his legs up and down, tearing sheets off the bed and clenching his hands to his chest while grimacing. Watching someone in pain is
extremely difficult and can even cause the observer to feel pain. And
there is no question that I felt incredibly sympathetic for this man — so much so that I didn’t want to disturb him by asking him questions and examining
him.

This is another difficulty in the field of medicine. We need to perform certain exam maneuvers or tests even though they cause the patient pain and
frustration. But it can be so difficult to bring oneself, especially in the student role, to swallow that difficulty and foist the necessary exam onto
the patient. How could I bear to push on and examine this man’s back when I knew this would cause immense discomfort? With difficulty, I continued the
interview and briefly palpated the spot on his back that hurt.

Once I finished the interview, I thought about a differential diagnosis. A differential diagnosis is a list of possible diagnoses for the patient given the
signs and symptoms the patient is presenting with, usually listed from the most likely to least likely. This gentleman with left lower back pain, for
instance, had a differential diagnosis list as follows:

1. Kidney stones

2. Herniated disc

3. Pulled muscle

4. Kidney infection (pyelonephritis)

5. Spinal abscess

6. Appendicitis

This list may not be complete, but it gives a sense of the kind of approach a physician takes to a medical issue. And as the physician questions the patient, the list changes. A doctor might ask if this particular patient had his appendix removed. If the answer is yes, then appendicitis comes off the list. A
practitioner uses interview questions and physical exam maneuvers to narrow the list down to one or two very likely diagnoses.

As for labs or imaging tests, these are only done to rule out or in diagnoses after narrowing down the list of possibilities with an interview and physical
exam. This man most likely had a kidney stone, as his presentation of severe back pain with an inability to sit still is a classic demonstration of this
pathology. Therefore, a urinalysis (examination of the urine) or CT scan (an imaging study to look for the stone) was integral to the diagnosis.

After deciding on this, I presented the patient to the resident. Across the field of medicine, medical students, residents, and attending physicians
present patients to each other in a standard format with an ordered listing of information. This information includes the age of the patient, history of
the chief complaint, relevant past medical history, physical exam findings, and a plan for the patient’s care. This gives all medical professionals a
concise, relevant, and standardized summary of the situation. In this case, for example, I might present the patient to the resident by saying this:

“Mr. B is a 44 year old caucasian male with a relevant past medical history of previous kidney stones, here today with a chief complaint of severe back
pain. The pain began five hours ago while showering with no apparent preceding incident. The pain is only better when the patient brings his knees up to
his stomach but otherwise remains severe. The pain is sharp and unilateral on the left side and does not radiate anywhere. The patient took ibuprofen
earlier, but that has not helped. He reports no blood in the urine, no difficulty urinating and no change in bowel movements. On physical exam, the patient
is extremely tender to palpation on his left flank but the exam is otherwise normal. My differential diagnosis includes kidney stones, pyelonephritis,
herniated disc, pulled muscle, spinal abscess, and appendicitis. I’d like to get a urinalysis and CT scan of the kidneys, ureters, and bladder, and give the
patient morphine for pain.”

That’s not a perfect presentation (and at the time mine was far less comprehensive), but it is the kind of formatted presentation that doctors look for
when they see a patient who has severe back pain.

If the ED attending physician is unsure of what is going on or how to treat the problem, the resident usually calls a consult. If the patient is bipolar,
for example, the ED resident calls a psychiatrist to see the patient in the ED and possibly admit the patient to the psychiatric ward in the hospital. If
the patient presents with a stroke, the resident calls a neurologist, who treats and admits the patient to the stroke service. While emergency medicine
physicians are excellent at figuring out what might be going on and whether it is serious, and while they are meant to know a little bit about everything, they
don’t know as much about specific problems as a specialist in that field. Therefore, it is not the ED physician’s job to treat everything neurological,
psychiatric, or cardiac in nature. It is the ED physician’s job to determine who needs to see which specialist physician, and to treat those urgent problems
that they can treat.