Blog | Thursday, June 15, 2017

Repetition and the basics -- #meded

Discussing a new patient recently, two important teaching points crystallized once again. The patient was relatively young without any past medical problems. He had dyspnea, first on exertion, and then at rest. On exam he was tachypneic with crackles, wheezes and rales throughout his lungs. After receiving nasal oxygen he “looked comfortable”.

His electrolyte panel:

135, 90, 8, 103

4.8, 30, 0.6

So I asked why his bicarbonate was 30.

A fairly long discussion ensued. The major point of the discussion was that an elevated bicarbonate here might be a danger sign. I believed (as did a critical care attending in the audience) that this suggested hypoventilation. The learners did not consider hypoventilation because the patient was tachypneic.

As Dr. Orhan Muren (one of my educator heroes taught me), pCO2 is a pure measure of ventilation. Some tachypneic patients are actually hypoventilating, while some patients with “normal respirations” are actually hypoventilating.

The elevated bicarbonate made us worry about compensation for a respiratory acidosis, a danger sign in respiratory failure (unless the patient has chronic hypoventilation).

These learners had been taught this concept in the past, but they did not recall it in context. This is a basic concept.

As medical educators we must reinforce and repeat basic medical concepts. No matter how brilliantly we teach them, if the learners do not absorb the knowledge we have failed. Our job is to repeat until the knowledge is virtually intuitive.

Teach the basics.


db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.