It’s 1 a.m., and I’m afraid this guy is going to die. He’s gasping for air, hunched over a table as I poke his chubby back and try to find a rib. Oxygen is flowing through nasal prongs at six liters per minute, and it’s barely making a difference as his oxygen saturation hovers around eighty-five percent (it should be in the high-nineties.) He’s sick, but what’s more worrisome is how fast he’s deteriorated. Just yesterday, I’d sent him home.
The media jumps on cases like this, often using the word “misdiagnosis.” If we’re lucky, these patients return when their condition worsens. Sometimes they don’t. And sometimes, they can’t.
Yuri Shepelev’s heart tracing looks like saw-teeth on the cardiac monitor. It was one-forty before I’d asked him to sit up, and it’s now around one-sixty. It’s too fast to be pumping efficiently. He could pass out and hit the floor at any moment. I pierce his skin with a needle and hit the rib, instilling local anesthetic into his tissues. “Are you okay?” I ask.
“Yeah,” he says, barely getting the syllable out.
“Let me know if you need me to stop.”
Twenty minutes earlier, I’d called the radiologist, and apologized for waking him. He agreed — it was probably a pleural effusion, a collection of fluid just outside the lung. Probably. Fluid can fill an injured knee or elbow, causing it to swell. Inflammation can cause a similar process between the lung and its lining. The consequences, however, can be much worse. Drainage is usually straight-forward, except if you go too far, you puncture the lung, and sometimes, it collapses completely.
I puncture the skin again, this time with a catheter — a sharp-edged tube large enough to drain the fluid. With each quarter inch, I pull back the syringe plunger, hoping for a rush of yellow fluid. Once the flow starts, it often fills several bottles, liters upon liters emptying from the space. He winces as I push further.
“Ya,” he says. “Just drain it.”
“Nothing’s coming,” I say. I try several different angles and depths. Nothing. Nothing at all. I wonder whether or not to put in a large chest tube. Maybe it isn’t fluid around the lung, but something thick and red — something that could clot easily, making it impossible to suck out of a syringe. It was, after all, an injury for which he’d presented to the the hospital the day before. But maybe, the fluid seen on the X-ray is inside the lung, filling space that’s needed for air. Even the radiologist couldn’t tell for sure.
One of my colleagues had handed him over to me a little more than twenty-four hours earlier. “Can you check on this guy for me? He’s a diabetic, and he hasn’t been taking his medications. His sugar was close to thirty, so I gave him some insulin. Give him an hour and re-check it. You should be able to send him home.”
Yuri is an electrician. He’s fifty-two, is married, and has two grown children. I’d forgotten that I was supposed to look in on him until a nurse called, and told me that his sugar had come down. He was ready for discharge.
When I saw him, however, he didn’t care about his sugar. “What about my ribs?” he said. “That’s why I’m here. I fell asleep watching TV, and then I fell off the sofa. My chest is killing me.” His hand was cupped below his right armpit as he leaned to the side, visibly distressed.
I placed my stethoscope on his black AC/DC T-shirt. His lungs were clear and his heart sounds normal. I reviewed the X-ray that had been taken hours earlier – normal, as were dedicated rib views. Blood drawn showed the high sugar, as well and an elevated white count, which could have indicated infection, inflammation or even the stress of the injury.
Yuri’s normal X-ray on the day of initial presentation.
“Have you had a fever?”
I examined him for a source of infection, but found none. I discharged him home with analgesics.
Twenty-four hours later, however, the change is dramatic. He can’t breathe. The pain in his right side is still there, but he can handle it. It’s the air — or lack of it — that has both of us worried.
Yuri’s X-ray 24 hours later. The right lung is a white-out.
I discuss Yuri’s case with the specialist, and order IV antibiotics. We decide against inserting a larger tube as the fluid may be within the lung, not outside it. With supplemental oxygen, intravenous steroids and inhalation treatments to open his airways, he settles overnight. The next day, a CT scan shows multiple pus pockets in and around the lung. Days later, when he’s stable, he’s taken to the operating room to clean out his lung and pleural space. He would spend almost a month in the hospital and continue on antibiotics for three weeks after that. Months later, the illness is just a bad memory, and he has no signs of recurrence.
Every three months our emergency physician group reviews these cases – patients discharged and then readmitted within seventy-two hours. Last year, as a group, we reviewed over a thousand. It sounds terrible. One thousand patients discharged home, and then re-admitted less than three days later. It’s a small fraction — less than one percent of our total volume. We comb through our own cases, and each others’, looking for those patients we could have served better. We discuss these cases and hope that we’ll do better the next time around. Many patients, however, are like Yuri — those whose illnesses haven’t yet reared their ugly heads. And we’re happy to see them again so that we can have a second chance.
Raj Waghmare is an emergency physician who blogs at the ERTales.com.
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