Autopilot

After a night of turbulent air travel home from the American Academy of Family Physicians Conference this weekend, I relaxed by watching a NOVA documentary on— what else —air travel. This particular program investigated Air France flight 447, a flight from Brazil to Paris which crashed into the Atlantic Ocean on June 1, 2009, killing 218.

A team of independent investigators compiled evidence from the plane wreckage, weather conditions, transcripts from radio communication, and reports from past malfunctions of similar aircraft. It was determined that the plane had encountered a severe thunderstorm, which coated exterior speed sensors with ice. This caused the automatic flight systems to shut off, leading rapid deceleration and an eventual stall of the plane. A flight simulator was set up with similar conditions to that faced by the pilots of Flight 447. During the simulation, experienced training pilots relied on their manual skills to fly the plane, and immediately took control to right the plane. It was postulated that the pilots of Flight 447 may not have had the training to manually maneuver a plane out of complex situations, due to the over-reliance on automated technology. Once the automatic system failed, they may have hesitated to take manual control, advancing into an irreversibly, and ultimately fatal situation.

How does this apply to medicine? In this day and age, the growth of technology has been exponential in the healthcare setting. Digital imaging, electronic medical records, nuclear scans, Doppler ultrasounds, tablets and laptop computers have all become commonplace in America's hospitals and clinics over the past decade. Vital information regarding patient treatment and history is stored digitally. Simultaneously, blogs and editorials have been published describing the "death" of the physical exam, criticizing the ineptitude of recent medical graduates performing basic exams and missing obvious signs. 

Like the crew members of Air France Flight 447,  we are highly trained professionals, tested and trained for the worst-case scenarios. We are very comfortable with technology, and do our jobs using electronic tools as aids. This is sufficient greater than 90% of the time, but what happens when we encounter situations which void our tools? Can we effectively rely on "manual" medicine (inspection, auscultation, palpation, percussion) to diagnose and treat? Can we function without "autopilot" applications and calculators? Are we less adequate physicians because of our reliance on technology? And, in the worst case scenario, will our inadequacy cost lives?

Morte

  ** Names and details have been changed to protect patient confidentiality, privacy, and dignity **

 

Simone, a 15 year old patient with sickle-cell anemia walked into the specialty clinic today. She was not yet due for a follow-up, but her condition had changed. She was now 2 months pregnant.

As I performed the history and physical, critical thoughts ran through my mind. "What was she thinking? Teenage mothers are already at increased risk for premature birth, hypertension, and low birth weight. The additional burden of sickle-cell anemia may prove fatal for mother or baby. How did this happen?" I worked hard to remain non-judgmental, and tried to focus my interview to pertinent health issues.

After discussing the situation with a colleague, I came away with a different point of view. I expressed my worries of the teen mother and child. He coyly asked me to remind him of the life expectancy of patients with SCA. Based on current statistics, most never reach the age of 50. I immediately realized my error.

Considering this young woman's life, she has most likely had several bitter tastes of mortality. Living with sickle-cell anemia has probably brought her to many emergency departments due to "pain crises"-- severe pain in her extremities, abdomen, and chest caused by the stiff, sharp edges of her red blood cells occluding her delicate capillaries. She may have developed gallstones in her short lifetime, and may already experience declining kidney function. The threats of blindness, heart attacks, and strokes remain with her. Young Simone will probably endure numerous surgeries to save her organs, with lengthened post-op recovery time.

As I began to delve more deeply into Simone's situation, the picture broadened. As a young black female in an urban southern city, chances are that she has known victims of violent crime. She may have buried classmates, neighbors, and relatives by this point. She is also most likely bombarded with images of mortality on a daily basis; bleak news reports of war casualties, drowning victims, suicide bombers, celebrity overdoses, murder-suicides, bizarre accidents can all take their toll. In fact, it is quite challenging to open a news web page without viewing an article involving death. Simone may feel the underlying need to experience as much life as possible before she passes on. 

Perhaps this issue is not limited to young sickle-cell anemia patients. Perhaps the idea of impending mortality is pervasive among all young adults. Graphic media coverage of the Columbine shootings, the 9/11/01 attacks, Hurricane Katrina, the Haiti earthquake, Osama bin Laden's death emphasize the fragility of human life, and drive the urgency to live life to the fullest. Like Simone, young people may subconsciously strive to become adults prematurely and experience as much as possible, pressured by impending doom. 

How can I best inspire these patients? Is there any way to infuse hope? 

Death twitches my ear. 
''Live,'' he says, ''for I am coming."

- Virgil