“Is There a Doctor…?”

I’m on the Amtrak Northeast regional train headed from NYC to DC on a recent Friday afternoon. The amplified metallic voice of the conductor is booming, but instead of the usual “Next station stop: New Carrollton, Maryland,” I hear in a plaintive tone: “Is there a doctor on the train?” followed by a request for any physician aboard to proceed immediately to the rear car.

A moment of indecision; I am the dean of a prominent NYC medical school, and yes, I have an M.D. degree, but do I have the skills needed to attend to who knows what kind of emergency at the back of the train? And more selfishly, do I want to get embroiled in a situation that may delay my departure from the train at Union Station, two stops hence?

Shrugging off both concerns, I move rapidly through each car on the long train. When I reach the rear car, I find two Amtrak conductors and a young fellow passenger hovering over an overweight, middle-aged woman seemingly asleep in her seat.

One of the con­ductors had found her completely unresponsive rather than just asleep when he asked for her destination, and sounded the request for a doctor. The young passenger who is tending to the woman is an emergency medical technician (EMT). I confer with my EMT colleague and learn that no one knows how long the woman has been unresponsive. Her breathing is somewhat shallow but regular and unlabored. Her pulse is steady with a slow rate. What is the diagnosis and what treatment can we administer?

I lift her eyelids and the EMT and I note miosis, “pinpoint” pupils. The list of possible diagnoses is long, but overdose of an opiate (morphine-like) drug is high on the list. Sure enough, we find a bottle of prescription tablets containing narcotics in her purse. We don’t have access to opiate antagonists that could reverse the effects of her presumed overdose.

Fortunately, she hasn’t taken a sufficient amount to suppress her breathing completely, but to be safe, we ask the conductors to alert emergency medical per­sonnel to meet us at the next station, where appropriate observation and treatment will be avail­able.

I never did learn why she had been prescribed a narcotic drug, nor the circumstances that led to her overdose.

This is not the first time in my tenure at Einstein that I have been confronted with a medical emergency outside the fully equipped setting of a major hospital emergency room, an environment I last worked in during my residency at Mass General Hospital 40 years ago. In July 2006, within a month of my assuming the Einstein deanship, a slender woman in her thirties fell unconscious, not more than twenty feet in front of where I had settled on Central Park’s Great Lawn, anticipating a New York Philharmonic “Summer in the Park” concert. I stepped over outstretched bodies to reach her.

To her good fortune and mine, a nurse had also arrived on the scene. I let the nurse know that I was a physician and together we assessed our patient, having already called 911 for emergency assistance. The woman was breathing, with a regular pulse, for which I was grateful. It had been several years since I had last practiced cardiopulmonary resuscitation (CPR) as part of a CPR recertification course. But she was completely unresponsive, and no one around her could clarify how she became unconscious. She was not wearing a “Med-alert” bracelet, but the nurse found the critical clue by rummaging through the women’s purse next to her: an insulin injection kit.

Given her appearance, I concluded that she had type 1 diabetes, had come to enjoy the concert, but had mistimed her insulin dose in relation to her food intake, and was now likely unconscious due to insulin-induced hypoglycemia—low blood sugar depriving the brain of fuel critical to normal function. Unfortunately, her purse lacked the antidote to her hypoglycemia, a glucagon injection kit, and we were reluctant to force juice or cola down her throat for fear of her aspirating fluid into her lungs. The only recourse was to hand her off to the emergency techs who had speedily arrived.

Both episodes led me to reflect on my own medical training and career choices, and on two central questions in medical education: what does every physician need to know, and how much specialization is desirable in our medical workforce?

With biomedical knowledge increasing at an ever more rapid rate, medical educators recognize that having students accumulate endless facts is a futile task. Rather than merely acquiring knowledge, what is needed is development of “critical thinking skills” and becoming a “lifelong learner.” These are competencies that every physician, irrespective of career path, will need.

At Einstein, our senior leadership recently asked a faculty task force  to define the competencies that anyone receiving an Einstein M.D. should have developed.

The task force’s draft list of competencies is still being reviewed by a broader set of faculty members, but it’s likely that critical thinking skills, lifelong learning, qualities such as professionalism and human­ism, and communication skills with both patients and colleagues (including other health profession­als such as the emergency medical tech and the nurse I joined in the episodes described earlier) will make the final list.