Monday: On my first day with the pulmonology consult team, some cosmic karma balance was achieved as I had the privilege of apologizing for the terrible communication and bedside manner from a surgery team. They apparently cancelled a surgery after the patient was already under general anesthesia for a complication that could have been easily foreseen days before. Then they didn't tell the patient or family what happened or what the next steps were. It just takes a little communication, folks!
MondayIL: Ground glass opacities on CT scan can be misleading. This term means that the there are areas of light and dark patches making up the lung tissue. The question is: which is the healthy tissue and which is diseased? By tinkering with the image settings you can make the light or dark look normal, so radiologists have to use special tools to compare the lung tissue with known brightnesses in the image, letting us know which it is. We can also make educated guesses based on the condition(s) we're suspecting.
TuIL: What a bronchoscopy procedure looks like. I had heard about this sort of colonoscopy of the lungs, but hadn't seen one performed yet. Having seen many colonoscopies and endoscopies while volunteering before med school, the process is very similar. The only catch, of course, is that instead of exploring a solitary tube, you are exploring an incredibly complicated tree. Also, with the GI tract, you can inflate it with air to help you see, but the lung pipes are not nearly as expandable, so you run out of room and visibility very quickly. Want to rinse something with water? No problem in the bowel but, in the lungs, you are literally drowning the patient so you have to suction the fluid back out immediately.
WIL: There is a super rare condition called Erdheim-Chester disease that has only been reported in less than 500 individuals. Odds are the patient we are consulting on is the only one with this disease I will ever see in my career. It has many diverse manifestations, but for my pulm team, we are most concerned with the devastating cystic lung dysfunction that is seen in these patients. Unlike in emphysema, where the tiny bubbles of the lung stretch outward like bubble gum blown too big, cysts have thick capsules that keep them from popping. When your whole lung slowly turns to these thick balloons of useless tissue, it makes breathing rather difficult.
Thursday: This was a weird morning because we waded into an ethical quagmire due to some dubiously informed consent. We wanted to try 'scoping a man who the anesthesiologist considered a very high risk patient. The problem was that the patient didn't seem to grasp that there was a small, but non-zero risk of needing to be intubated (put on a breathing tube) if his vital signs deteriorated. He wanted the procedure, but not the risk and you can't have it both ways.
We tried calling his family, but they were similarly indecisive. Meanwhile, Anesthesia recruited two more of their own to consult as to the risk to this patient. Our team was four people on its own. Nursing had at least two people in the conversation. For patient privacy reasons, we moved the mob to the still empty procedure room. After going back and forth about the risks and options for different levels of anesthesia and trying to justify why we were doing this case at all, it was decided to call the patient's primary doctor for this admission, the head of cardiac transplant surgery, who decided to join us for the discussion.
The man swaggered into the suite and basically dismissed everyone's concerns about both patient safety and consent. "The guy's heart is failing; of course it's risky. So is anything on this guy." He then wandered over to the patient's bedside and asked, "You want the procedure, right? Good. Let's just get this done." So we did. The patient got very limited sedation (because anesthesia wasn't comfortable giving him anything that might jeopardize his cardiac function) and was coughing and gagging the entire time we had a tube down his throat. We got our samples. The patient didn't remember a moment of the half-hour I was restraining his hand from pulling out the tube in his lungs. He woke back up with no ill effects.
I still don't think we should have done the procedure. The patient consented wholeheartedly by the time we went (even though he still didn't want a breathing tube), but he explicitly said that it was because he wanted to eat after a whole night of being NPO (nothing by mouth). There was a lot of gray area in every aspect of this event and, if the patient's life is not on the line, it probably makes sense to take a step back and reschedule the procedure for the next day, once we can be more clear about the risks and the patient's understanding thereof.
ThIL: Jugular venous distension is a very specific physical exam finding but not very sensitive, because the anatomical distances we use are severely underestimated.
FIL: Tree-in-bud opacities are a radiographic finding on CT imaging that looks... like a budding tree. It can represent many different pathologies, but generally means there is something filling up the deepest airways of the lungs.
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| From: http://pubs.rsna.org/doi/full/10.1148/rg.253045115 |
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