1. 74 yo female presenting with right pleural effusion presenting with a spiking fever and disturbed consciousness. Severe leukocytosis. CXR shows ground glass opacities at the right costophrenic angle. Began treatment with Unasyn (ampicillin + sulbactam) for one week. Switched to oral form Augmentin. Fever came back. CXR at this time shows white consolidation and pleural effusion at the right posterior chest wall. Thoracocentesis results show that fluid is sticky and viscous. Consult chest surgeon in this case. Fluid covers surface of pleura so that the lung cannot expand completely. Surgeon must remove the fibrous peel. Surgeon hesitates for procedure due to complications of DM and that the patient and family has not decided on yet. [Surgery and anesthesia provoke a neuroendocrine stress response that releases counterregulatory hormones (epinephrine, glucagon, cortisol) that causes hyperglycemia and increased catabolism. Type 1 DM pts will be susceptible to diabetic ketoacidosis. Type 2 DM pts will be susceptible to hyperglycemic hyperosmolar nonketotic syndrome and DKA if they have poor metabolic control. Hyperglycemia leads to imparied wound healing, decreased tensile strength of surgical wounds, increased infections (glucose levels above 250 mg/dl impair leukocyte chemotaxis and phagocytosis), increased plasminogen activator factor inhibitor, abnormal platelet function resulting in abnormal coagulation, and exacerbate ischemic brain damage in the elderly.] After treating with antibiotics for a couple days, patient became conscious and does not want the operation but family encourages her to do it. Unable to decide after 5 days and Dr. You even referred patient to another hospital for a second opinion. Empyema is usually a 4-6 weeks treatment course. Pt has been shifted to an oral Ab a week ago and CXR has improved and indicates no need for a surgical intervention. There has been no significant culture result because there is no sputum production due to sticky fluid. Currently pt on Augmentin (amoxicillin-clavulinic acid). Dr. You guesses pathogen as Strep. pneumoniae since it is most common; 2nd most common is H.influenzae. These two pathogens are susceptible to Augmentin.
2. 90 yo male patient presenting with pneumonia, dementia, and on NG. Dementia patients often lack the coordination to swallow correctly and are prone to aspiration pneumonia. Pt was discharged early June but admitted again because NG tube was removed resulting in aspiration pneumonia when resumed oral feeding. NG tube reinsertion. Impending RF, applied BiPAP (noninvasive positive pressure support) but will be taken off soon when discharged. Indications for BiPAP: acute pulmonary edema, COPD w/ acute exacerbation, and asthma - all dz that can be easily resolved in a short amount of time. Contraindications of BiPAP: facial bone trauma and deep coma. Dr. You believes that BiPAP is overused bc it is very convenient, you never have to explain the risks, and can provide respiratory assistance in elderly patients when the family predictably refuses intubation. There are not enough NPPVPs in the hospital because they are incorrectly being used for relative contraindications instead of absolute indications. Dr. You believes that the life quality declines if on BiPAP too long. Adverse effects: causes gas distention in the abdomen that needs to be expelled and can affect breathing patterns. Pt. presents with constipation and Dr. You treats with stool softeners "Lactulose". He does not want to use a suppository because too much suppository tablets use can damage the anus through inflammation and decrease function. In severe constipated cases, Castor oil can be used. CXR may not show aspiration PNA right away and may show in a later CXR. This does not necessarily mean the aspiration PNA progressed, but that the appearance may be delayed. Sputum culture shows ESBL E.Coli. Even though it is extended spectrum, Dr. You did not upgrade the Ab because there is a possibility it might just be colonization. Even if the culture result is drug resistant bacteria, the strategy is to wait and see if fever begins. The ESBL E.Coli might not be the actual pathogen causing the PNA.
One interesting part of this case is how important the NG tube is in pts who cannot swallow. Relying on oral feeding causes pts to easily choke on their food and cause food to go in the airway. For the family it may be more comfortable to feed the patient after the NG tube fell out, but they are unaware of the great risks it bring. Still I can see how the innocuous it is to believe that since the NG tube fell out, it would be natural to just resume oral feeding.
From these two cases Dr. You shows that there is an intersection of efficient health care and patient care. He does not want BiPAP to be abused because other patients who actually may benefit from it might not be able to use it. He chooses not to give strong antibiotics and decides to wait and see how the patient does even if the culture shows sputum culture as ESBL E. Coli. Dr. You also has a TB patient he does not discharge because he knows that other facilities will be unable to accept him. Dr. You also made sure that each patient knew what was expected of them after they were discharged. I think that this intersection, the intersection of delivering cost effective health care and good patient care, is the art of what being a doctor. How do you do what's good for the hospital and for the patient? How do you keep your integrity as a physician and portray information to squabbling families who all have their own individual agendas? It is truly an art.
In the afternoon we watched Dr. You perform three thoracocentesis procedures.
Sonography is used to locate the pleural effusion. The first patient he had was a 61 yo female who presented with hemoptysis. She had over approximately 1.5 L of pleural effusion drawn out of her.
In a chest sonography, the lung motion can be identified with the liver (if you're on the right side) and the spleen (if you're on the left side). Air is a poor conductor under sonography - you should be able to see the parenchyma of the lung. Pleural effusion will show up as black.
Thoracocentesis pearls:
- check if there is adequate thickness between chest wall and spleen
- insert needle directly above the rib (superior aspect) to avoid puncturing the vein artery and nerve that run in the intercostal groove inferior to the rib.
- Dr. You marks the spot he will puncture by digging in his nail at the spot to make a mark. I find that resourceful.
- pt not given anesthetic because it can cause local swelling, making the area to puncture harder to localize.
- equipment used: 24 gauge, IV catheter, negative pressure bottles to pull fluid out so it is not dependent on gravity.
- lung expansion and chest tightness signifies that draining is almost done. Re-expansion can also cause dyspnea and lead to another form of edema (!) Pain during thoracocentesis can also signifiy that the rate of drainage is too fast.
- typical pleural effusion studies are cell block cytology, pleural fluid cell count, total protein, glucose [(if glucose below 60 mg/dl, can signify 1) severe infxn (empyema) 2)malignant cells (inc use of glucose) and rheumatoid arthritis), LDH levels, and CEA levels.
- even though effusion does not show blood, cannot rule out malignancy because it is possible that the cancer cells caused effusion and will not be present in the actual fluid.
Once again, I am amazed at the efficiency and almost casualness of Taiwanese healthcare. Things are done quickly and often without much of an explanation (or perhaps this procedure was explained earlier during rounding?). Thoracocentesis was performed in 10-15 minutes; I'm not sure how it's done in the U.S. but I assume there's a lot more hand holding that occurs. The doctors and family members here just say "忍耐一下“ (bear with the pain) when the patients express pain or discomfort. I see this a lot in the ED and with mildly painful procedures. The relationship between doctor and patient is curious to me. At some points the patients are bullying the doctor and challenging them constantly with their demands. Often they outright refused tracheostomy and intubation without hearing the doctor's explanation. As soon as they heard those words, they would cringe and say "absolutely not". At other times they are extremely grateful for the doctor and put their hands together in a gesture that means "please do all you can to help" at the end of the visit. So I'm a bit confused by the doctor patient interaction; do they see doctors as mere health care dispensers, or do they over respect doctors? The juxtaposition between the angry family member and the overly grateful one is an interesting point. I wonder how much the healthcare system influences the culture of medicine in Taiwan.
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