What a radiologist learned about a thoracentesis from a pulmonologist

It was 1989. While alternating between NCAA basketball tournament games on broadcast television, reruns of an older version of the game show Wipeout on cable, and the 8-bit Nintendo game Top Gun, a child sat in a hospital bed in the middle of rural America wondering why he was there. All he knew was that he had a sharp pain in the left side of his chest and that couldn’t breathe very well. If you looked at him, however, you would be able to tell that his face was masked in pallor, and he had lost about 17 pounds over the course of a week. He was too weak to walk very far.

Having no pediatric lung specialist in town, an adult pulmonologist agreed to evaluate the boy a few days after the hospital admission. After glancing at a series of chest X-rays, he recommended a thoracentesis, a procedure in which a small catheter is used to remove fluid accumulated between the ribs and the lungs through a small incision.

The sudden appearance of a new doctor startled the family, as they had been kept relatively uninformed. He told the boy’s mother that he didn’t know what was going on, but the child might have to be transferred to a larger city hospital if they couldn’t figure it out soon, as his life was in danger. The boy heard this discussion which resulted in a rush of fear.

The pulmonologist, still basically a stranger to the boy and family, came in and told the child to sit backwards on a chair, exposing his back through the gown. A student nurse named Daphne held his hand. Before starting, the physician put his stethoscope over several areas of the back, as decreased breathing sounds would indicate where the fluid was likely to be.

Likewise, he tapped on several areas with his finger, as fluid produces a different reverberation than lung. He found what he thought was the right spot. The area was cleaned, and the skin was numbed with a local anesthetic before a catheter was introduced over a needle to access the fluid. The doctor gave no explanation of what the procedure involved, but the student nurse provided some comfort.

“Don’t be scared,” assured Daphne. As fluid filled the collecting bag, his mother’s eyes got bigger as if to say, “Where did all of that fluid come from?” A few dry, large coughs signified that the lung was re-expanding and that the fluid was nearly all out. The doctor removed the catheter, and the fluid was sent to the laboratory. The boy went back to his bed and pretended to be interested in the game show. The doctor left without explaining what would come next. The boy wondered if his short life was coming to an end. A few days later, he would go to the operating room, as re-accumulated fluid would later develop into an empyema (essentially a chest wall abscess). Only time would tell if the boy would ever recover from the illness.

We have come a long way since 1989. Advancements in technology have produced bedside ultrasound machines which are omnipresent in hospitals, and the ultrasound is used to show precisely where the fluid is before the catheter is inserted.

What the story of the boy reminds us is that even though the doctor may have performed the procedure a thousand times, it’s often the first time for the patient, and as such, the physician must always take the time necessary to establish appropriate rapport and trust before starting the procedure. All too often nowadays, doctors write orders for radiologists to perform spinal taps, thoracenteses, or feeding tube placements even though the radiologist has no relationship with the patient whatsoever. Establishing that trust is a challenge for the radiologist when he or she is asked to act on behalf of an ordering provider.

Fast forward to 2014. A radiologist and a sonographer approach a patient before explaining the risks and benefits of the thoracentesis they have been asked to perform. The radiologist talks for a few minutes about other procedures the patient may have had and inquires as to how the patient wound up in the hospital. He explains how and when the ordering provider will follow up. The radiologist listens with a stethoscope in several areas before the sonographer locates the fluid using the ultrasound. The radiologist cleans the area and performs the procedure without a hitch. The patient compliments the radiologist on his technique and thanks him for his time.

Before leaving the room, the sonographer comments that he is the only radiologist she has ever seen who uses a stethoscope and asks if that was something he learned in residency.

“I actually learned it from a pulmonologist 25 years ago.” Hopefully, my bedside manner has improved in comparison to my first thoracentesis experience.

Cory Michael is a radiologist.

Image credit: Shutterstock.com

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