Bottle up and explode

This is the X-ray you’re never meant to take. So we’re told

This is the x-ray i took on Friday morning.

93 year old lady (background of chronic lung disease, but in pretty good nick considering, gets out and about once a week, no other co-morbidities) , short of breath for a week, worse on the day of admission.

She was breathless but alert, orientated and able to speak. Minimal air entry on either side of the chest, normal BP and heart rate, no distended neck veins.

Mild to moderate type II respiratory failure on her gas. Seemed like a good candidate for non-invasive ventilation.

Got a quick CXR and popped her on the ventilator while waiting for the film to print out. After 10 minutes on the vent she’s improving, less work of breathing, resp rate dropping.

X-ray comes back and yes of course there’s the tension pneumothorax.

Mea Culpa.

So what about the x-ray you’re never meant to take? Most medical dogma is just that. Based on cliche and things grey haired consultants say on post-take ward rounds. They have little relevance to real world medicine.

In the real world of frail, crumbly elderly patients (and this is a large part of our population, not the young professionals of ER and House) “classic” presentations are rare and examination findings in acutely sick people are frequently unreliable.

If you work in emergency medicine long enough you learn quickly not to make dogmatic statements or speak with too much certainty. If you have no room for doubt and uncertainty then find another job.

One of my last referrals last night was a 52 year old lady whose Dad died at the age of 50 with an MI and with chest pain that just might have been ischemic in nature (we see 20 of these patients a  day and maybe one of them rules in for ischemic heart disease).

I wanted her admitted for serial ECGs and enzymes. The response of the medical reg was the she was too young to have anything significant. I suggested that we should have told the patients father that when he died at the age of 50 with the same symptoms.

Medicine is a complex and often unpredictable beast and as much as we’d like it to be it’s not nearly as scientific as we’d like it to be.

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March 2010

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