Abstract
The message contained in the above letter by Ethan G. Brown and Dr Jay Lemery regarding the enhanced importance of the physical examination of patients in a wilderness setting has been driven home to me. I am now 1 week home after responding as part of an emergency medicine team with the International Medical Corps (along with Dr Paul Auerbach, Dr Anil Menon and other emergency medicine professionals from Stanford University and Columbia University) to earthquake victims in Haiti. We responded to the completely incapacitated Hôpital de l'Université d'État d'Haiti (HUEH) in Port-au-Prince on day 5 after the quake and found ourselves confronted with approximately 800 severely traumatized victims. It was our job to rapidly assess and resuscitate these victims, clean and bandage horrendous wounds, splint shattered extremities, and transport victims by priority of medical necessity to a limited operating room (2 functioning operating tables where dedicated orthopedists performed “battlefield surgery”). We relied solely upon our physical examination skills to make diagnoses—to differentiate crushed and contused extremities from humeral fractures, femur fractures, and pelvic fractures—in the absence of radiographic capabilities for the first week of our stay. We limited administration of tetanus immune globulin to persons with signs and symptoms of early tetanus in order to conserve critically short supplies, and prudently reserved use of precious intravenous fluids and sodium bicarbonate for victims whose exams supported the diagnosis of actual or impending rhabdomyolysis. After several days, when the Mercy class hospital ship, USNS Comfort, anchored offshore, we worked with the Army and the Navy to airlift patients with needs beyond our capabilities to the ship (and to other local medical relief sites). The types of cases these providers sought were precisely defined, which further put our physical diagnosis skills to the test. Anemia was diagnosed by the color of a victim's tongue, conjunctivae, and the soles of his feet; pneumothorax by decreased breath sounds and subcutaneous crepitus; and necrotizing infection by the putrid odor.
For our first week, we used nothing more than physical diagnosis skills to inform critical triage and treatment decisions. Medical students who read Brown and Lemery's letter should take it to heart and pay close attention to the professors teaching “physical diagnosis.” You never know when you will be put to the test.