it’s a first

this past week i was on service rounds for family medicine, which is basically just seeing patients from the practice in the hospital.  i loved this time because i generally like working in the hospital, not outpt clinics.  i worked with an intern who was fresh on the floors, so i actually was able to really help people because i was functioning almost at an intern level.  it was a great feeling.  i would make recommendation treatments for my patients that we followed through on, and on his patients, if i thought there was something better to be done, he listened and took my advice. 

on my last day, however, i felt let down.  not by the resident, but by the system.  we saw a patient who had a history of copd who was recently in for a pneumonia.  she was discharged, but shortly returned for epigastic pain and n/v.  when presenting her at morning report, one of the resident’s brought up her xray.  they evaluate it, and despite the hugely deviated trachea, they try to read it as normal…until i point to the screen and go: what’s that?  then some idiot is like, oh that’s the main stem bronchus… which i’d just love to know in what world he thought that was the right answer.  upon every seeing it’s a trachea, we realize we should take a closer look at this woman. 

 i show the xray to my surgical bud and he explains what is going on the picture…her abdominal contents are in her chest because of a weakened diaphragm.  from the xray you can’t tell if it’s herniated or not, but her presentation more recently is that of a bowel obstruction and thus likely herniation…but nooo it’s way more like she has acute pancreatitis.  i kept pushing for a surgical consult, and in the end i lost.  not because i was wrong mind you, but because the doc said ‘i don’t really know if there’s anything you can do’.  and that’s just it, they didn’t know.  but surgeons would.  so we should consult them.

i ended coming home and looking it up.  there are things you can do.  now, not every patient needs to have something done, but there are indications for surgical repair of this woman’s diaphragm.  and she might have them.  instead, we discharge her because she’s whining.  one person said to me, did she seem to care? no, she didn’t seem concerned…but she’s also not a doctor.

the reason i cared so much about fixing something that she didn’t seem to care about?  her symptoms.  she has a history of copd and here she is with her abdominal contents pushing and compressing her left lung.  she already has compromised lung function.  then we add the fact that her blood pressure continued to go up despite adding an ace inhibitor.  plus she had bilateral pitting edema.  all signs of badness.    she came into the hospital not needing oxygen and left with home oxygen of 3L, no small sum (6L is max before you do serious damage).  

i fought and fought for that consult, but we would rather go with a radiologist’s interpretation that she probably doesn’t need a consult.  well, no doubt she’ll be back again, and no doubt for something worse like incarcerated or dead bowel.


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