Hydropneumothorax: the Case for Mrs. Dolly
- The Intern
- The patient (Mrs. Dolly)
- The radiologist
- The storyteller
A 52-year-old woman had a diagnosis of a localized non-small cell lung cancer in her right lung. She had a right pneumonectomy four months before the actual visit. After a recovery period she started with adjuvant chemotherapy. Five days after chemotherapy she went to the emergency clinic with high fever, a mild shortness of breath and a non-productive cough . Her blood test showed neutropenia and the doctor started intravenous antibiotics. A thoracic x-ray (Fig. 1) showed air and liquid in her right lung.
“As I see liquid and air in the right lung without parenchyma , I believe that the patient has a pleural effusion and a pneumothorax” I,m going to ask for a written report”.
Report: A thoracic x-ray showing liquid and air, compatible with mild hydropneumothorax. Right pneumectomy with surgical staples.
“I will ask for an appointment with the thorax clinic to insert a drainage tube to extract liquid and to resolve the pneumothorax”.
“The doctor told me that tomorrow I will have a procedure in my chest to insert a tube to extract my liquid and the air. I,m very nervous, I don´t know if it will be very painful. I can´t sleep”.
“Good morning Mrs. Dolly. This morning you are going to have the procedure in your right lung to extract the liquid and the air inside and then the rest of your right lung will be fine again”.
“Excuse me doctor, did you say my right lung? I suppose not to have my right lung after the surgery”. The surgeon told me that all my right lung was removed to resect the lung cancer”.
Final Diagnosis: right pneumectomy with liquid filling the residual cavity , a normal evolution after the surgical procedure.
The patient was surprised about the intention to expand her right lung, because she knew that it was removed totally. The insertion of the thoracic tube was aborted. The patient recovered successfully from the neutropenia.
Type of Diagnostic Error: Wrong Diagnosis
- Representativeness heuristic: the intern associates liquid and air with pleural effusion (tumor or infection related) and the air with pneumothorax, a way of thinking reinforced after the radiological report. The intern was not used to this clinical situation because there was not Thoracic Surgery at her hospital and also because she was not used to the normal development after a pneumectomy.
- Blind obedience : the intern never doubted about the information transmitted by the attending in Radiology.
- Work overload: the first attention to the patient was in the Emergency Department, during rush hours, a situation prone to evaluate a patient without visualizing all the details of the medical records.
- Communication: there was a lack of communication between the radiologist and the intern about the details of the surgery.
The patient had to suffer the whole night thinking about a procedure , with all the uncertainty about the pain and possible side effects.
- A good communication between a doctor attending a patient and the radiologist is a key element to decide about the images of the patient.
- Retrieve properly the previous medical interventions of the patient and be sure about the type of intervention.
- Confront a superior medical authority if you are not confident about a decision.
Author: Lorenzo Alonso, MD