What do you hear?

By Arne Vainio, M.D.
News From Indian Country

This had been a complicated operation and the incision was long. The sutures needed to come out and this was going to take some time. After any surgical procedure, the sutures need to stay in long enough to allow the incision to heal and stick, but not so long that they become a wick for bacteria and a risk for infection.

I was working with a first year medical student. Being in the clinic allows them to actually see their education put into practice. The first two years of medical school are mostly classroom and sometimes it seems like hands on care is a long time in the future. Most of the time they observe and even though they have worked hard to get into medical school, everything is new and medicine is a complicated field. All medical students sit in the classroom with valedictorians and salutatorians from all over and the competition to get into medical school is fierce.

I was looking at his incision and I asked him. “Today is your chance to teach a medical student how to be a doctor. Is it OK if she takes out your sutures?”

“That’s fine by me. I’ve never had a chance to be a teacher before.” He answered.

I showed her how the knots in the sutures were tied and she put her gloves on. She held the suture scissors in one hand and the forceps in the other. I could see she was a little shaky and uncertain and I could also tell she was excited to be carrying out a procedure. She cut the sutures carefully and the nurse painted tincture of benzoin along the edges of the incision to make the steristrips stick. After every other suture came out, the steristrips would go on and stick to the benzoin. These could take over a week to come off and they were strong and reinforced strips of tape made to hold the incision together as it continued to heal.

The end result was beautiful and she was rightfully proud of her work.

We walked into the next room and as soon as we walked in I asked her, “What do you hear?”

The room was quiet and we listened carefully and there was an easily audible and rhythmic sound of a buzz and a click,“dzzzzt-click, dzzzt-click, dzzzt-click….”

“What is that?” I asked.

“I don’t know.” She answered. “His watch?”

“It’s an artificial heart valve.” I answered. “Let’s listen to it for a bit.” Not all valves are this audible and I asked him how that valve changed his life.

“I was tired all the time before and it was getting worse. Dr. Vainio sent me for an echocardiogram and my aortic valve wasn’t working. He sent me to a Cardiologist. I had my valve replaced and I’ve never felt better. I hear it all the time, but it reminds me what I have to be thankful for.”

We saw a patient with alcoholic liver failure. Her liver couldn’t make the protein that helps keep fluid in her blood vessels and watery fluid was leaking into all of her tissues. Her ankles were huge and swollen and a week or so earlier she had nine liters of fluid drained from her abdomen. That’s the equivalent of four and a half of those big two liter bottles of soda. Normally there is the equivalent of less than half a can of soda in the abdomen so the internal organs can slide against each other. She was short of breath for the last couple of days and I ordered a chest x-ray and we looked at it with the patient. It showed a huge amount of fluid around her right lung and I called the Radiologist at the hospital and sent her there. She had a liter and a half drained from around her lung and her breathing was better and she was sent home.

We saw a prenatal patient at 14 weeks of pregnancy. She wasn’t sure she was feeling her baby move yet and she was worried. That first movement is called quickening and with a first pregnancy is normally felt at 16 to 18 weeks. I let the student find the fetal heart tones with the Doppler. She put the gel on the probe of the Doppler and carefully moved it around the mother’s abdomen. At first she was listening too far up and I had her move the probe farther down. We heard a heartbeat with a rate in the 70s per minute and the medical student kept the probe there and listened.

“Is that the baby?” I asked.

“I don’t know. How could I tell?” She asked. I had her feel the mother’s pulse and her pulse beat was in exact rhythm with the Doppler. I had her move the Doppler even farther down and there were heart tones with a rate of 140. Babies normally run rates of 120-160. Both the medical student and the mother knew this rate was much faster and they looked at me.

“That’s your baby and the heart rate is perfect.” I explained. This was the first time the mother could hear her baby and she started to cry. “I was so worried. I’m not really showing that much yet and I wasn’t feeling the baby move. I was starting to wonder if I was even pregnant!”

I ordered an ultrasound at the hospital and when we left the room the medical student had tears in her eyes. “That was so cool! I’ve never had a chance to listen to a baby! Thank you for letting me do that!”

We saw a woman for a follow up of a hospitalization for pneumonia. That was six weeks earlier and she was feeling much better. She was here for a follow up chest x-ray to make sure her pneumonia was resolved and to make sure there wasn’t something else in her lungs that was hidden by her pneumonia when she was in the hospital. Her chest was clear with just a few crackles in her right lower lung. I had the medical student listen.

“What do you hear?” I asked.

She listened for a long time. “Nothing. I can hear her breathing, but I don’t hear anything else.”

I had her roll a little bit of her hair between her fingers and told her that crackling sound was what she should listen for. She listened again. “Nothing. I just hear her breathi…No, wait! I hear it!”

I ordered a chest x-ray and we looked at it with the patient. “Your pneumonia is gone and I don’t see anything else it might have been hiding. Your diaphragms are flatter than they should be and this is usually caused by smoking. How long have you been smoking?”

“Over forty years.” She answered. “I stopped six weeks ago when I was in the hospital and I’m going to do my best to quit for good this time.”

I offered and she accepted help with smoking cessation and I set her up for low dose CT scan of her chest to screen for lung cancer. She thanked both of us as she left.

At the end of the day, the medical student waited until I was done charting and watched me go through a long list of refills and watched me send out lab letters and go through hospital reports.

“Dr. Vainio, thank you for such a great day! I have never been so excited about anything and I want to go into family practice!”

“I’m glad to hear it.” I answered. “We need more Native American doctors and we need more medical students. Your people need you and they already look up to you. You’re breaking barriers and you’re defying stereotypes. I see all the makings of a great physician in you and I will do everything I can to help you. Traditional healers have always spent long times away from their families during their training and their families didn’t fully know what sort of commitment that training meant. It’s no different now. This is a sacred path you are on and sometimes it will feel like you’re alone. I want you to know I will always believe in you and I’m looking forward to the day you become a physician. We need you.”

These future doctors are our children and our grandchildren, our nieces and nephews and members of our communities. Becoming a physician is a commitment to a life of service and I can see them getting ready for it.

I still don’t know how things aligned to open my path to medical school, but I do know others went out of their way to make it happen. Go to www.aaip.org online.

We are the Association of American Indian Physicians. We’re ready to teach our students.

We’re ready to pay it forward.


Arne Vainio, M.D is an enrolled member of the Mille Lacs Band of Ojibwe and is a family practice physician on the Fond du Lac reservation in Cloquet, Minnesota. He can be contacted at This email address is being protected from spambots. You need JavaScript enabled to view it..

 


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