The System is real: a small detail can change the clinical decision


The objective of this case is to show the influence of the “System” in the diagnosis of a situation with a particular patient. The System , something that sounds out of the clinical environment,  is conditioning our outcome in multiple clinical areas, and it is also responsible of wasting time and money, and the origin of the many wrong decisions.

Clinical Case

Your patient is a 49-year-old woman with a diagnosis of breast cancer and a right pleural effusion. She went to the Emergency Department (ED) after several days with shortness of breath, without a fever or a thoracic pain, and now she is not able to walk to the bathroom. After an initial differential diagnosis, you decide to ask for the Pulmonary Service for a thoracocentesis.

Clinical Evolution

Everything was working fine and the patient started to feel more comfortable and less symptomatic when the pleural liquid started to pour out of the bag connected. Five days after the procedure, the patient was better , but she was still referring some shortness of breath. The practitioner in charge was happy, because the pleural liquid was no longer drained any more and he planned a pleurodesis.


The catheter is twisted on itself, interrupting the flow of liquid

We set the intervention for the next day, and the patient was very happy to know that probably in two more days she would free of the catheter. Unfortunately, a last review of the situation, supervised by the pulmonologist, showed that the catheter was twisted, and once we correct the problem, the pleural liquid started to flow again.


A simple situation was responsible for causing distress to a patient, and waste time and clinical resources. The first impression is that every procedure needs a clear supervision by the specialist. The second impression is that, before deciding an action with the patient, every step must be checked to implement a safe and practical decision.

Author: Dr. Lorenzo Alonso