Though his novels were penned in the latter portion of the 19th century, Sir Arthur Conan Doyle’s character Sherlock Holmes continues to captivate modern readers. What about Sherlock Holmes remains so fascinating to us? As a physician, Conan Doyle understood the power of careful observation so much so that his character seems to have near super powers by nature of his ability to observe the world around him, see things and make connections that others do not.
Monitoring is every day practice in all aspects of veterinary medicine and especially in veterinary emergency and critical care. Technological advancements have made monitoring once elusive vital signs, such as blood pressure, the standard of care. Multi-parameter monitors give us the simultaneous and real time values of blood pressure, ECG, pulse oximetry, end tidal CO2, and body temperature in our anesthetized patients. Point of care blood work has given us the ability to trend biochemical values with only a delay of seconds to minutes. CT, MRI, and ultrasound have given us the ability to look into body cavities including the calvarium and spinal canal and look through solid organs that were once closed off to us without post-mortem exam.
These technologies have improved the way we practice medicine, and have increased our early diagnosis and detection of disease. However I would argue that they have also allowed us to lean on a crutch and become disconnected from an important monitoring tool… ourselves.
Few monitoring parameters are as important in the ICU as trends in physical monitoring. Physical monitoring parameters are vitals that are assessed with your eyes, finger tips, and ears, via observation, palpation, and auscultation. When assessing a patient with changes in their respiratory rate, your observation of the character of breathing and your auscultation findings can help you localize the problem (upper respiratory, large away disease, small airway disease, pleural space or parenchymal lung disease, or cardiac disease) to create a more accurate differential list and diagnostic plan or give you a rational place to start empiric therapy. Pulse quality and heart rate can tell us more about perfusion status than an isolated blood pressure reading.
No technologic monitoring parameter can give you an impression of how the patient feels, but your observations can detect trends that more confidently suggest improvement or worsening. Is the cat purring today? Is he interactive in the front of his cage compared to hiding in the back? Did he greet his owners when they visited? Did he sniff at food with greater interest? In training new veterinarians, I find myself often reminding them of the importance of physical examination in monitoring trends.
I don’t suggest that we put technology aside, but let’s remind ourselves to harness the secret to Sherlock Holmes’ success and re-connect with our skills of observation.