How two different attending physicians approach similar conditions

I recently finished my second month of internal medicine. I had a different attending physician for each month. It is interesting to see how two different attending physicians will approach similar conditions. There is a lot of flexibility in the standard of care. Neither of them is wrong by any stretch of the imagination. Just different.

It is also amazing how much of a difference a good, well informed resident can make. I was blessed with amazing residents for my first month. I am not going to say much about the one I had for the first two weeks of my second month, because, well, if I can’t say something nice, I am going to keep quiet. And I can’t say anything nice. Anything.

We had a lot of patients with chest tubes this month. My attending blames it on me. He says that he probably won’t get this many patients with chest tubes in an entire year. I got to scrub in on a video-assisted thoracostomy surgery (VATS), with pleurodesis. It was an incredible procedure. I got to see a pulsating aortic arch. Wow. I got to see the beating heart. Double wow.

This was a really interesting case. She had a collapsed lung and a pleural effusion. This procedure allowed us to take a biopsy, drain the pleural effusion, cut adhesions that had formed between the lung and the pleura that were keeping the lung from fully expanding, and do the pleurodesis. The pleurodesis was twofold: the surgeon performed mechanical abrasions on the pleura, and then used talc as a chemical pleurodesis. The concept behind a pleurodesis is intriguing — you irritate the pleura, the sac surrounding the lung, to try to form adhesions to keep the lung from collapsing again. Yes, she already had adhesions, but the lung wasn’t fully inflated when they formed, so they were holding the lung in a partially collapsed position. The point of the chemical and mechanical pleurodesis was to attach the lung to the pleura when it is fully inflated. The space between the pleura and the lung is supposed to be a “virtual space”. Having air or fluid in that space is pathological.

The same cardiothoracic surgeon did sclerotherapy on another patient we had with a collapsed lung and pleural effusion, but with a different etiology. This is a similar process, but a chemical irritant, in this case doxycycline, is introduced via the chest tube. It was interesting to see two different treatments for a similar condition in two different patients. It was a good example of how one can’t just follow a cookie cutter approach to medicine, and care needs to be tailored to the individual situation and history.

“MomTFH” is a medical student who blogs at Mom’s Tinfoil Hat.

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