By Meaghan Smith and Anja Frost EBS Guest Medical Columnists
We are fourth-year medical students from George Washington Medical School in Washington, D.C., and spent the month of January working at the Medical Clinic of Big Sky with Dr. Jeff Daniels. Aside from all the interesting people we met at the clinic, we’d like to tell you about our “extra-curricular” adventure.
Friends of ours came to town, and like all good hosts we wanted to participate in an activity unique to the area. We heard about a sleigh ride dinner in the mountains and embarked on an adventure for the night. The sleigh ride up the hill is just over an hour long, and several stops are made along the way for the horses to rest and passengers to enjoy the views.
Our sleigh was packed with friends, the views were breathtaking, and we were truly isolated, without cell phone service or the noise of busy roads. But halfway through our journey, one of the wranglers approached our carriage and asked if there were any medical personnel present, as a member of the group was having trouble breathing.
As medical students only four months away from graduation, and soon to be introducing ourselves as Dr. Smith and Dr. Frost, we were hesitant to speak up, yet we felt a sense of moral obligation and medical duty. We aren’t doctors yet; surely there had to be someone else to step up to the plate. We soon realized that we were the closest to medical professionals on this trip.
We hopped out of our carriage, ran up the hill, and found a little girl huddled in her carriage in respiratory distress, with a look of fear on her face. Her parents informed us that she had a history of asthma induced by cold and exercise, and on further questioning we discovered her allergy to horses.
Her parents were not carrying a rescue inhaler, and without a stethoscope to listen to her lungs or pulse oximetry to measure the oxygen saturation in her blood, our ability to adequately assess her condition was limited. We were lucky enough to have a friend as a part of our group who also had a history of childhood asthma, and graciously offered up his rescue inhaler for our use.
Unfortunately, the advances of modern day medicine have pushed medical students and residents away from using the most basic and informative physical exam maneuvers, especially for assessing a child in respiratory distress. The most revealing clinical sign of child struggling to breathe is to lift their shirt and look for retractions around the rib cage, breastbone and clavicle. Retractions are a sign someone is working hard to breath.
Normally, when we take a breath the diaphragm and the muscles around your ribs create a vacuum that pulls air into your lungs. When someone is having trouble breathing, extra muscles kick in to help and these can be visualized by looking at the rib cage.
The little girl was showing significant evidence of subcostal (below the rib cage) and substernal (bottom of the breastbone) retractions. Additional revealing signs that our new patient was in respiratory distress included her quick and labored breathing, and fast heart rate revealed by feeling her radial pulse.
We spent approximately 30 minutes educating the young girl about why she may be struggling to breathe and how the medicine we had could help her. She was able to take four puffs of the rescue Albuterol inhaler with excellent effect. Her respiratory rate began to decrease, her heart rate slowly declined, and she informed us that she was having a much easier time breathing.
Although she had clinically improved at that time, her parents made the educated decision to return back to the base of the mountain, as they didn’t have an epinephrine pen with them and were unsure if she would remain stable for the rest of the journey. We checked in with the head of the touring company two days later and were informed that she was doing very well and had only continued to improve after we left her.
The moral of this story is that when you’re out in the middle of nowhere, you have to be prepared. If you have asthma, carry your inhaler at all times.
Meaghan Smith and Anja Frost are senior medical students from George Washington University in Washington, D.C. They both spent January participating in the elective opportunity at the Medical Clinic of Big Sky. Smith will be specializing in pediatrics, and Frost will be doing gynecological oncology.
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