American College of Physicians: Internal Medicine — Doctors for Adults ®

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Trusting your instincts

From the October ACP Hospitalist, copyright © 2010 by the American College of Physicians

By Kimberly Manning, FACP

ACP Hospitalist's blog runs weekly excerpts by Kimberly Manning, FACP. A hospitalist at Atlanta's Grady Memorial Hospital, Dr. Manning writes about the personal side of her job for Reflections of a Grady Doctor. All names and details have been changed to protect individuals' privacy.

It was the winter of my intern year, and I was looking at the schedule for inpatient ward assignments. I found my name and dragged my index finger across the paper to see who my fearless leaders would be. My resident was a feisty third-year woman, with an excellent reputation for being smart, though tough. I could handle that. I followed the column upward until it landed on a name that I wasn't so sure I could handle: Dr. Olds. Gasp. My attending was...eek...the Chairman of Medicine? Great.

Photo courtesy of Kimberly Manning.

Photo courtesy of Kimberly Manning.



Here's the thing: I was in a combined training program where every three months I switched from assignments in Pediatrics to Internal Medicine, then back again. Finding my footing during those early days wasn't always easy. This upcoming ward month would be my “back to Medicine” month after three rigorous months of Pediatrics. Those first few days after the switch always felt a little shaky; I'd mastered the art of looking confident when deep down I was a quivering blob of Jello. But this was even more terrifying than usual. Now I might have a meltdown in front of the Chairman himself. Super.

Picture it. Every day, you get to present your patients and what you discerned from your history and physical, then field a barrage of Socratic questioning. From your Chairman. This meant that a screw-up or a bad day could have monumental consequences. A category 1 nausea hurricane quickly organized in the pit of my stomach, threatening to turn into a category 5.

The good news was that, despite how intimidated I was by my Chairman-turned-ward attending, he was pretty nice. In fact, he was more than that—he was really, really nice and surprisingly approachable. The other good news was that my resident was excellent that month, and she cracked a mean whip on the interns. She'd make us present our patients to her first, then pick our write-ups apart and reassemble them before rounds every day. In other words, there was never a performance without a dress rehearsal and a sound check.

Put to the test

One night on call, I was being covered by a different resident. Gary, a second-year resident, was smart but much less confident than the mini-general I'd become accustomed to. He would ask me what I thought we should do, and not just in the obligatory way folks often do when talking to medical students or interns. This guy really needed me to co-sign his decisions. His anemic leadership was terrifying. Especially since my attending was—had he gotten the memo? The freakin’ Chairman of Medicine.

It came to a head when we admitted a woman with community-acquired pneumonia. Gary and I had just gone down to the Radiology suite to review her X-rays which, consistent with her lung exam, revealed a moderate-sized fluid collection around her left lung. My wobbly leader discussed the next steps with me as we rode the elevator back up to the patient's room.

“She has a pleural effusion, so the next step is to sample the fluid with a thoracentesis, OK?” Gary asked/said. He looked up. “I think that sounds like the right thing to do, don't you?”

I didn't like this co-sign thing. I wanted him to be so comfortable with this situation that he could quiz me on the Light's criteria for pleural effusions while picking dirt out of his nails with the edge of an index card. I furrowed my brow and answered, “Uh, it's my understanding that an effusion that size needs to be tapped. And I guess depending on what it shows, you determine whether or not a chest tube is necessary.”

What did I say that for? Gary's face went pale, and he swallowed hard. “Oh my gosh. I really, really hope she doesn't need a chest tube.” He shook his head. Now I felt like a jinx.

But this patient looked good. In fact, the only thing that had prompted her admission was her abnormal X-ray. She'd had a fever for two days associated with a cough, and when it didn't go away, she decided to come to the emergency department. She was in her forties and had been in perfect health. She didn't smoke, didn't use drugs or alcohol, and was breathing well enough to not require oxygen. She just had an ugly X-ray.

A third-year senior from the ICU supervised me as I did the procedure, since Gary wasn't comfortable being the overseer. The patient tolerated the thoracentesis quite well—in fact, what I remember the most about her was just how great she looked. Clinically cool, yes. Radiographically cool? No.

After carefully removing a sample of fluid from the space around her lungs, I confirmed that we hadn't introduced air or caused any complications by checking on both her follow-up X-rays and how she was doing. Just like when I'd seen her in the emergency department earlier that night, she looked great. My nervous upper level stood beside me as I led the conversation.

“How are you feeling, Mrs. Elmore?”

“I'm actually feeling a lot better. The cough seems to be loosening up some more, and now I'm bringing up more phlegm. I still have a little pain on my left side, but it seems a touch better since you guys took some of the fluid off my lung.” She did look better.

“Are you breathing alright?”

“Yeah, I'm okay. My nurse says I am still breathing a little faster than normal, but I was surprised when they wanted to keep me. I guess I'm glad you guys did—what did you call that again?”

“A pleural effusion,” I said, with careful enunciation.

“Right, the pleural effusion. I think I'll try to rest now.”

“You rest,” I agreed. “I'll check on the results of your fluid, and will let you know what it says. Right now, I'm anticipating we won't see anything alarming.” I did my best to speak with the authority I knew my supervisor had not quite grown into. We both bid Mrs. Elmore adieu as she rolled over in her bed.

One hour later

I was taking a catnap at the nurses station when my pager woke me. It was the “Stat Lab.” I whipped out my pen and paper in preparation for Mrs. Elmore's unexciting pleural fluid values.

“I have a critical lab value for you on patient Elmore,” said the lab technician. He didn't waste any time. “I've got a pH on a pleural fluid specimen of 6.9.”

I thought I'd heard him wrong. “Excuse me?”

“The pH on your pleural fluid sample. It's 6.9,” he repeated.

“6.9? On patient Elmore?” Again, he affirmed that this was indeed the patient. I felt the hurricane swirling in the pit of my stomach. A pH of less than 7.2 meant the fluid was likely pus. And one of the first things you learn in medical school is that ‘pus must pass.’ Uggh. Mrs. Elmore needed a chest tube.

“Shoot!” I said. I imagined us rustling her awake only to have some baby-faced surgical intern get her consent to insert a tube the size of her pinkie finger into her chest. Before I could even fully process it, Gary was flitting about me like a nervous hummingbird. “You saw that the pH is 6.9!” he exclaimed. “I already called surgery for a chest tube. They're coming. You think she needs a chest tube? I mean, less than 7.2 and she does, right? This is awful. This is so, so awful.” He looked like he was going to be sick, which made me feel the same. I longed for my drill sergeant day resident, who likely would have smacked Gary and told him to get a grip. He was making me anxious. I gathered my cards up and prepared myself to speak to Mrs. Elmore.

Gary shuffled beside me as I reached the foot of her bed. I could hear her breathing peacefully without oxygen or respiratory distress. I whispered to Gary, “Don't you think she looks too good for that pH and way too good to need a chest tube?”

He gave me a puzzled look. “But the pH is 6.9,” he said, more firmly than he had all night. He paused so we didn't wake her. “Despite how she looks, she needs a chest tube!”

“Could it maybe be a lab error? I'm just worried because a chest tube is a really big deal,” I said. We both stared at her quietly for a few moments. I turned and faced Gary before saying the unthinkable. “I think you should call the attending.”

It was like my mouth moved in slow motion. I had just suggested to my nervous upper level that he call the Chairman of Medicine—and at 2:40 in the morning, to boot.

“But it is clearly less than 7.2. It's even under 7.0, Kim. This is clear-cut. She needs the chest tube.”

Great. He finally finds his courage on the first decision of our call that I actually wanted him to get my input on. I decided to challenge him. “This doesn't make sense, Gary. Dr. Olds always tells us to pay attention when things don't make sense. I think we should call him. If you won't, I'm willing to.”

“Call Olds?” he gasped. “You will not call our Chairman at 3 a.m. to ask him an obvious question. Absolutely not.” He scowled and walked out of the room to punctuate his position.

I wouldn't give up. I finally convinced Gary to let me call Dr. Olds, but he made it clear that I should tell him I did so without his blessing. That was fine with me. I just didn't want to subject this healthy woman to a chest tube she may not need.

And so I called the Chairman at three-something in the morning, waking up first his wife, who (as I sat there mortified) let me hear her call him “honey” until he was wakeful enough to grab the receiver.

Fortunately, just like he had been all month long, the Chairman was wonderfully patient when I got him on the phone. I methodically ran down all that had happened—including her low-grade temperature, bright smile/not-sick appearance, normal oxygenation, and peaceful slumber. “Could she look this good with a rip-roaring 6.9 pH empyema in her chest?” I asked.

“Call the lab and ask them to repeat it,” said Dr. Olds decisively. “It sounds like a lab error. Definitely don't put a thoracostomy tube in her without having them run it again.”

“OK,” I eked out while looking at Gary. He held his hands out as if to say “What?” I wrote in all caps on an index card: “REPEAT IT. NO CHEST TUBE YET.”

And that's exactly what we did.

Another hour later, we got a page from the Stat Lab:

“Repeat pleural fluid pH: 7.38.”

Normal.

Later that morning before rounds, I stood at the foot of Mrs. Elmore's bed as she continued to sleep. I looked at my pinky finger, then back at her, and breathed a sigh of relief. She was discharged early the following day—without an extended hospitalization, complications...or a chest tube.

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