- Case 1: A 78-year old Asian male was admitted with an acute exacerbation of COPD and a PMH of Type II DM. He was treated with cefulin (ceftazidime - a 3rd generation cephalosporin) and his symptoms improved. However, his family signed a DNR due to his advanced stage of COPD, which was terminal. Due to his chronic respiratory failure, he was put on BIPAP. What we learned in school was that these therapies are mainly used for sleep apnea where CPAP is used to treat primary alveolar hypoventilation. This is accomplished by a continuous positive airway pressure using a face mask. BiPAP or bilevel positive airway pressure refers to the machine being able to alternate between two pressures (exhalation component allows you to breathe out against a lower pressure). Although it is mainly used for central sleep apnea, this form of non-invasive ventilation therapy is preferred in cases where a DNR is signed without having to place an invasive artificial airway such as an endotracheal tube. This is one avenue for palliative care when the family wishes prioritizes the beneficial efficacy of a tracheal tube.
- Case 2: A 85-year old Asian male was admitted with classical presentation of pulmonary TB (coughing up bloody sputum, night sweats, and recent weight loss). Unfortunately, his TB had metastasized and invading other organs as well (miliary form). A DNR was issued by the family and he was placed into a contact isolation room and given a standard TB regimen (INH, rifampin, pyrazinamide, and ethambutol).
Personal Note: It was interesting to see how many DNRs were signed as soon as the prognosis was poor. The family weighed the benefit vs. risk (money to provide care outside the hospital) and even in unclear cases, it was still executed. This is a stark contrast to the thought process of families in the US where extraordinary measures are taken until nothing can be done and a DNR is ordered. Also, the average time between patient interactions was about 2 minutes. This involved just checking up on the patient and making sure that the treatment was working. Even with such limited interaction, the families and caretakers that were there were extremely grateful for the physician's help and bowed as a sign of respect. Not sure if this would be similar in the United States where physician-patient-family interaction is a right, not a privilege (based on today's experience).
In the afternoon, I met up with Dr. Huang in the ICU, where patients need more intense support for failing organ systems and constant monitoring to hopefully bring them into a more stable condition. Although we did not round with his patients, we had a crash course on reading and interpreting chest x-rays on a patient that was currently in the ICU. He was a 61-year old Asian male with fever and shortness of breath with a PMH of CVA and subdural hemorrhage. Although there were many methods for interpretation of an x-ray, he taught us the systematic method, ABCDEFG:
- Airway
- Bone
- Cardiac/Cartilage
- Diaphragm
- Esophagus/Extrapulmonary
- Foreign Body
- GI
Each of these steps relies on systematically checking each region as a whole instead of just honing into a specific lung field because alot of things could be easily missed in doing so especially when the symptoms do not match what you are seeing. By taking a step back, something else can show up, which can improve your differential diagnosis and help to make a more meaningful link between the history/physical and the x-ray. The chest x-ray should not be the only way to determine what is wrong with the patient, but used as a tool along with history/physical. There are other regions to check because they are easily missed as well: retrocardiac, subdiaphagmatic, lung apex and base.
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