Thursday, November 13, 2008

Spontaneous Shortness of Breath...And Planting a Seed...

Good Evening Everyone,

Well we had a busy day today. Sick call was swamped and we felt like just when we could get ahead then another flood of troops would come in. But today had it's rewards. We were honored to have the Medical Director of the local medical centers visit our clinic today. The medical director is in charge of five medical facilities and 13 remote clinics in the surrounding Balad area. What makes this Medical Director so special is that the Director is a woman. I was so pleased to see a female in the position of authority in this country. I have always found it a great tragedy that a country would fail to realize the potential of half of their population. I truly believe that true success in the Middle East will only occur when the women can have equal rights and have the ability to receive the same educational opportunities as men. So, I was very pleased to see this very capable physician leading her team through our clinic especially considering two of her nurses were men. As a past nurse, I was happy to see Middle Eastern men take on this role. The Iraqi medical team wanted to see how we operated and was hoping to obtain some ideas on how to better serve their patients. We shared information, asked and answered questions, and parted with an agreement that we would see eachother soon.

Then later this afternoon, I held the Thursday afternoon Provider meeting where I meet with just the Physicians and PA's and our nurse LT. Nott. We have been working on updating policies and changing protocols to make our clinic run smoother. The last medical team were great people but they ran a rather lax clinic, so I have had to tighten things up. We have implemented several changes. We had three years of X-rays that had been burned to CD's and were sitting on a back shelf of a cabinet in the radiology suite. They had not been sent to radiology for an official reads by a radiologist. Which means that these films are not placed in the pt. record. So, I called the Chief of Radiology at the Air Force hospital and he was most accomodating. He has agreed to read our films on a daily bases. So I have instructed our radiologic tech to take the films over daily for a read. We of course read our own films after we examine the patient and then we examine the films for obvious anomolies. But it is a rule in medicine to have an official read from a radiologist so that the results can be placed in the record. So, we have accomplished that.

Another item that we addressed at our Provider Meeting was the appointment of Lt. Nott as our new Clinical Director. I have placed him in charge of the entire clinic. He will serve as my clinical medical officer and will be an extension of my position. I am the first to admit that I am at times overwhelmed with my duties to see my fair share of patients, manage the needs and concerns of the provider staff, ensure that the enlisted medics are being trained appropriately and have their needs met, and trying to manage other unmentioned missions that are getting ready to come. So, adding the very capable Lt. Nott to my staff has been a great snag for me. He is competent and strong in his clinical skills. He has great rapport with our medics and he is a natural teacher. He usually scrubs in with me when I do a small surgical procedure and he has been a good friend to me. He also gets along well with our providers so he will serve as a go between them and the rest of the staff. So, I am happy to have him on board and look forward to saving the world together. It is tough using our superhuman powers for good and not evil.

But now onto the show. We had a young man come into the clinic tonight who was complaining of shortness of breath. He is a 26 year old thin young man who is very athletic. He said that he felt a pop in the side of his right chest and then he started having a difficult time breathing. Well what would your clinical diagnoses be based on these symptoms?

Well my friends...He has a spontaneous pneumothroax or what is commonly called a collapsed lung.

So how does a lung suddenly collapse? Well your lungs and chest wall are elastic and as you breath in and out your lungs tend to recoil inward while your chest wall expands outward. These two oppossing forces creates a negative pressure in the pleural space between your ribs and the lung. When the air enters into that space between the rib and lung the pressure that it exerts on the lung and the air coming from the inside of the lung can exerts pressure on all or part of that lung and it can collapse. Now a lung may collapse completely or me only pull away from the chest wall and end up with a partial collapse.
The patients who are at risk for spontaneous pneumothroax are generally young men between the ages of 20-40. They are generally tall, and thin and tend to be smokers. And recent studies show that perhaps there is a family history of pneumothorax. What happens in these folks is that a small bleb of air can forms on the lung and can rupture thus causing the lung to collapse.

The lung can completely collapse which can become a surgical emergency or the lung could only partially collapse which may be managed by a night in the hospital on positive pressure air. If surgey is need then a chest tube is inserted in between the rib space between the two ribs that overlay the site of the collapse.

These spontaneous pneumothorax can happen at any time and any place. They can happen after an traumatic injury. change in air pressures like sky diving or under water diving, or doing mountain climbing. But the truth is that most of these pneumothorax' occur when a young man is simply walking.

Pt. may present to your office with nothing more then a feeling of shortness of breath and no other symptoms. Pulse oximetry may be misleading and the pt. may have a 98 or 99% on room air. But the pt. will say that he just doesn't feel right and cannot catch his breath. Now, you have to have your differentials in play here as this young man could have a pulmonary embolisms so be careful. A PE will present with similar symptoms except pain is more common with a PE. Spitting up blood is a sign of a PE as well as true dyspnea and a feeling an overwhelming sense of doom and gloom. Pneumothroax patients, whereas, maybe uncomfortable, are not in a panic mode.
A simple PA and lateral chest x-ray should give you the anwer. See the chart below:

You see the lung can pull away and only deflate about 25% or the lung could collapse completely. The degree of the collapse can often times determine the severity of the symptoms.

This situation should be handled as a surgical emergency or at least the pt. should have an immediate visit to the ER

Tonight we had just such a case and the young man came in with these symptoms. Dr. Baez evaluated the patient and had a suspicion that he may be dealing with a pneumothorax so he went and obtained an x-ray and sure enough the patient has about a 25% reduced pneumothorax. Dr. Baez asked me to look a the film and to provide him with a second opinion. Sure enough this young man had a pneumothorax. So, we sent him over to the hospital and he is being tubed as we speak. This is just one of those uncommon cases that we get in from time to time. I do not, of course publish or discuss any wound or injury that happens to our American soldiers who have been injured in combat. Whereas those type of wounds are much more significant and much more complex, we will never put those type of injuries on line. And fortunately for us and our troops, we have not had a problem with combat injuries in our clinic.

Well, when I finished in the clinic, I finally made it back to my room. When I opened my army email, I had a note from a young Captain that wants to go to PA school so she is trying to get some experience in a clinical setting. I am off tomorrow, well actually on call, and so I had to go and ask Travis a favor. It isn't fun to ask Travis a favor because he ususally wants something in return. But he never tells you what it is right away. He will come back in two weeks and expect me to shine his boots or to do his laundry. But I humbled myself and asked him if he could supervise her tomorrow morning. He agreed but I am sure that I will be paying something in return. Maybe I can help him out by teaching him that orthopedics is not the only area of medicine that is important. I just don't know if I will be successful in that endevour.

O.K. my friends thank you for listening to me drone on about my day. I have shared with you that we had a hectic day, that woman are receiving an eduction in this country, that Lt. Nott will be my our new Clinical Director, and that young skinny guys who smoke can sometimes have a lung pop and collapse. We also learned that Travis will do you a favor but it will come at a price.

So, this is how my day went. Tomorrow I am off. I will sleep until someone knocks on my door and ask me to arbitrate some argument. Then I will go to the gym and lift until my body aches which is about ten minutes into my routine and then Bryan and I will stop by and get pizza at pizza hut and then we will sit in my room and watch a classic movie like that 'Ballad of Ricky Bobby. I love the oldy but goodies.

I will then spend sometime with the Lord and then Pray for you, my friends, family, and past friends who I pray will return to my life. I have a friend from high school that I reconnected with before I deployed and I would like to catch up with him. He is the guy who led me to the Lord.

I hope you will all remember that God has planted seeds in all of you to go and do great things. And in at least one of you He has planted a seed that I pray will change your life for the better. It is a beautiful place where the Lord will take you. Full of love and kindness and understanding. Full of hope and joy and glory. The Lord will lead you into the direction of his purpose to fulfill promises and duties of the past. Let us honor our duties to the Lord and submit to his plans for us, no matter where these plans may take us. God bless you everyone and thank you for checking in.

1 comment:

Roxy said...

wow! May God continue to bless and protect you!