Distended

Respiratory System


Frame 1


You smile at the irony of the song playing on the radio, as you drive to your job as an ER physician.

"Stayin' alive! Stayin' alive! Ha! Ha! Ha! Ha! Stayin' aliiiive. . . . " you belt out the words, keeping perfect rhythm.


After successfully finding a parking space, you enter the hospital and greet your coworkers in the emergency room.


A nurse hands you a chart, and you start acquainting yourself with your first patient of the day, Mr. Silva.


Frame 2


As you briefly look over the chart you learn that Mr. Silva is 53 years old and that he was brought to the ER by his son David this morning, with the chief complaint of sudden onset dyspnea.


"Hello Mr. Silva, I'll be taking care of you today," you start off. "How are you feeling?"


You note that Mr. Silva is having difficulty answering your questions and that he appears increasingly more dyspneic, diaphoretic, and cyanotic.


You quickly note that the cardiac monitor reveals a heart rate of 134 bpm, with a blood pressure of 100/60 mm Hg, respirations of 24 cpm, and an oxygen saturation of 87%, while on 35% oxygen via a nasal cannula.


On the physical exam, you note that he has distended neck veins and that his trachea is deviated to the right.

The left thorax does not expand upon inspiration, is hyper-resonant on percussion, and breath sounds are absent on auscultation.


You make eye contact with your nurse who states, "This patient is deteriorating rapidly, doctor."


Frame 3

What do you do now?

Choice Outcome Score Continues
Increase the oxygen flow, and ask for an 18-gauge needle Correct 1 → Frame 6
Increase the oxygen flow, and ask for a chest tube Incorrect 0 → Frame 4
Call for a crash cart Incorrect 0 → Frame 5

Frame 4


As you ask the nurse for the tube thoracostomy kit, she looks at you questioningly,

"Are you sure there is time for a tube to be placed, doctor?"


You take a look at your patient who is obviously tired from his efforts to breathe and note that his skin is turning a purplish shade. Yes, she is quite right!

You quickly ask the nurse for an 18-gauge needle and perform a needle thoracostomy instead, barely saving Mr. Silva's life.


Frame 5


You ask for the crash cart thinking Mr. Silva has a tachyarrhythmia with hemodynamic instability that can be cardioverted.


You decide to take another look at Mr. Silva, and it suddenly strikes you - as his trachea is deviated, this is most likely a pneumothorax!

Instead of performing cardioversion, you ask the nurse for an 18-gauge needle and increase the oxygen flow.


Frame 6


You suspect a tension pneumothorax. There is no time to waste.


Frame 7

You place an 18-gauge angiocatheter in the midclavicular line of the second left intercostal space, successfully performing a needle thoracostomy.

You immediately feel air rushing out of the cannula, confirming your diagnosis.


Mr. Silva's condition immediately improves. His heart rate goes down to 102 bpm, and his SpO2 increases to 97%.


Frame 8


You proceed by placing a chest tube to help drain the remainder of the pneumothorax.

Once the drain is in place and the patient is stable, you order a chest x-ray to confirm that the tube placement is correct.


While waiting for the chest x-ray, you call Mr. Silva's son to obtain more history about the patient.

"Hello, David. I am taking care of your father in the emergency room. Can you tell me a little more about what happened to him earlier this morning?"


"Yes, doctor. My dad would have been at work but hasn't felt well for the past few days. He's been breathless and coughing up a lot of sputum for the last six weeks. He also told me that he feels weak and that he was sweating a lot at night", David explains, and concludes,

"The difficulty in breathing suddenly became worse this morning, while he was watching TV".


You confirm this with Mr. Silva who further explains that his symptoms began about a month or two after arriving from Portugal.


Frame 9


You obtain some more history from Mr. Silva and learn he is a Portuguese immigrant who came to the US four months ago.

He has no significant past medical history and does not take any medications. Prior to the onset of these symptoms, he was otherwise healthy.


You observe that Mr. Silva appears quite thin. He confirms that he has lost about 4 kgs in the past three months.

You perform a more thorough exam and find diminished breath sounds in the apex of the left lung, and crepitations in the left lower lobe. No other untoward findings are noted.


Before sending Mr. Silva to the x-ray department, you decide to order several lab tests.


Frame 10


After Mr. Silva is taken for the x-ray, his son approaches you looking extremely worried. "Doctor, is my dad suffering from something dangerous?"


"Please stay calm David. We are going to do all that we can for your father. Before I can make a definitive diagnosis, however, I need some further lab work and tests," you explain.


"Thank you so much doctor," David replies.


Frame 11


In approximately thirty minutes, the lab work and chest x-ray are delivered to you with the following findings:

WBC: 16,200/L (3,500 - 11,000)

Hct: 48% (38 - 50)

Hb: 16.8 g/dL (14 - 17.5)

Platelets: 400,000/mm3 (150,000 - 450,000)

CRP: 32 mg/dL (0-10)

ESR: 120 mm/h (< 20)


The chest x-ray shows a small left pneumothorax with a visible rim of about 1 cm between the lung margin and the chest wall. The chest tube appears well positioned.

There is a well-defined opacity in the mid-left lung, which is compatible with a cavitation.


Frame 12

What do you do now?

Choice Outcome Score Continues
Admit Mr. Silva for observation until the pneumothorax resolves Incorrect 0 → Frame 13
Admit Mr. Silva and treat the underlying pneumonia Incorrect 0 → Frame 14
Admit Mr. Silva and place him under isolation Correct 1 → Frame 15

Frame 13


Just as you start to write the admission orders for Mr. Silva, a sudden thought makes you reconsider your diagnosis ...


Frame 14


You decide to admit Mr. Silva, and then start treatment for a suspected community-acquired pneumonia.


A short while later, a colleague approaches you with a look of confusion on his face.

"Do you really think that this patient is suffering from community-acquired pneumonia? The history and chest x-ray suggest something worse. . . " he explains.


Frame 15


You realize Mr. Silva's symptoms, history, and physical exam are suggestive of a spontaneous pneumothorax, potentially secondary to tuberculosis.

You decide to admit him and place him in an isolation room for now.


While writing out the orders, you notice a nursing student looking at the x-ray, and glancing at you occasionally, as if unsure whether to approach you.

"If you have any questions, please feel free to ask," you tell her.


"Actually, Doctor, I do have a question. Shouldn't we use suction on him?" she asks


Frame 16

What do you reply?

Choice Outcome Score Continues
"Yes, we will start doing so shortly" Incorrect 0 → Frame 17
"No, that is not an option right now" Correct 1 → Frame 19

Frame 17


"Yes, you are probably correct. We should apply high volume, low-pressure thoracic suction," you reply.


After starting suction, you are paged to see another critical patient and rush away.


Frame 18


Thirty minutes later, Mr. Silva develops dyspnea, chest pain, hypotension, and a productive cough.


Just as you are about to give orders to the nurse, the head of the department takes the lead. "Nurse, remove the suction and give 40 mg furosemide," he commands.

He turns to you with disapproval, stating, "You need to be aware of re-expansion pulmonary edema. You shouldn't use suction so hastily."


Mr. Silva's blood pressure continues to go down rapidly, and he develops cardiac arrest. You immediately begin resuscitation, but it is too late. You cannot get him back.


You have made a horrendous mistake, and the guilt is overwhelming. You collapse on the floor and black out. . .

The end


Frame 19


"It's not an option right now. Using suction too early after chest drain insertion may precipitate re-expansion pulmonary edema," you tell the nursing student.

"Oh, I see. Thanks for explaining", she replies.


Frame 20


After clearing her doubts, you meet with Mr. Silva's son, David, again.

"Hello, David. I'll give you a little update about your father's situation," you tell him.


You explain about your suspicions that Mr. Silva might have tuberculosis, but make certain to reassure him about the good prognosis of the disease when correctly treated.

"I'm sure he's in good hands. Please do your best, doctor," David replies.


Frame 21

You need to confirm your clinical suspicion of secondary spontaneous pneumothorax, so you ask that three sputum samples be sent for microscopy and culture for suspected respiratory tuberculosis.

You also start considering the therapeutic approach.


Frame 22

What do you do?

Choice Outcome Score Continues
Start isoniazid, rifampicin, pyrazinamide, and ethambutol Correct 1 → Frame 25
Start dapsone, clofazimine, and rifampicin Incorrect 0 → Frame 24
Wait for confirmation before starting treatment Incorrect 0 → Frame 23

Frame 23


A few minutes after submitting the admission orders, you receive a call from Dr. Anderson, the chief of the infectious diseases department.

"Hello, doctor! I hear you have a patient with suspected tuberculosis. Is that correct?" he asks.

Wow, you think to yourself, news sure travels fast!


"Yes, Dr. Anderson, that is indeed correct," you answer.

You proceed to give him a brief review of the patient's case making sure to highlight the fact that you are awaiting confirmation of the disease before starting treatment.


"Hmmm. . . ." Dr. Anderson states.

"I realize you don't see many such cases in your daily practice, but treatment should not be delayed. If a patient presents with typical signs and symptoms, you should go ahead and begin treatment."


"Thank you for the recommendation, Dr. Anderson," you reply.


Frame 24


While completing the orders, Dr. Anderson, the chief of the infectious diseases department, comes to your station apparently to inquire on a different patient.


After greeting him and directing him to his other patient, you speak to him about Mr. Silva's case.


"Although we haven't confirmed the diagnosis yet, we're getting ready to start him on an anti-tuberculosis regimen with dapsone, clofazimine, and rifampicin," you explain.


Dr. Anderson looks at you in surprise.

"I realize you don't see many such cases in your daily practice, but you really need to get your facts straight. The drugs you are considering using are actually for leprosy, NOT TB."


You are quite embarrassed but proceed to thank him for the clarification. You immediately change the orders for isoniazid, rifampicin, pyrazinamide, and ethambutol.


Frame 25


You decide to start an anti-tuberculosis regimen with isoniazid, rifampicin, pyrazinamide, and ethambutol.

You also order screening for HIV infection, because it is well known that tuberculosis is frequently associated with HIV-positivity.


Frame 26


The following day as you are walking to your station, you are greeted by a nurse who has more of Mr. Silva's laboratory results.


You thank her and begin reviewing them.

Mr. Silva's HIV test is negative. His sputum smear is positive for Mycobacterium tuberculosis.


"Do you think Mr. Silva is at risk of having drug-resistant TB?" the nurse asks.


Frame 27

What do you answer?

Choice Outcome Score Continues
"Yes, he's at high risk" Incorrect 0 → Frame 28
"No, he's not at risk" Correct 1 → Frame 29

Frame 28


"Yes, he's at high risk," you reply.


One of the senior doctors who happens to be nearby overhears your conversation and comes walking towards you.

"I apologize for my intrusiveness, but I assure you Mr. Silva is not at such risk," she explains.


"Because Mr. Silva has not had tuberculosis before and has no history of previous contact with a drug-resistant patient, and because of his country of origin, his chances of having a drug-resistant infection are very low."


You are quite ashamed of your lack of knowledge and realize you need to read a bit more about tuberculosis.

"Thank you for the explanation", you reply.


As the other doctor leaves, the nurse turns to you again. "I nearly forgot Doctor, but Mr. Silva is asking to see you."

"Thanks, nurse. I'll pay him a visit in just a few minutes," you state.


Frame 29


"No, he's not at risk," you reply.

You explain to the nurse that since Mr. Silva has not had tuberculosis before, does not have a history of previous contact with a drug-resistant patient, and because of his country of origin, his chances of having a drug-resistant infection are very low.


"I see. Thanks for the explanation!" she says.

"You're welcome," you reply.


"Oh, I almost forgot! Mr. Silva is asking for you, doctor" the nurse says.

"I'll pay him a visit in a couple of minutes. Thank you!" you reply.


Frame 30


You arrive at Mr. Silva's room and place your face mask on before knocking on the door. You are immediately greeted by David.


"Please come in, Doctor", David states.

"Good morning Mr. Silva," you greet your patient. "How are you feeling today?"


"I'm feeling much better, thank you for coming," he replies.

"I was told you wanted to see me. What can I do for you?", you ask.


"Father and I have been worrying about something since getting this diagnosis. Tell him Father," David states.

"Doctor, do you think that I may have passed this disease onto someone in my home, or on the plane? I didn't have any symptoms when I came here four months ago", Mr. Silva asks, while looking very worried.


Frame 31

How do you answer?

Choice Outcome Score Continues
"Your contacts in Portugal should be screened, as well as the passengers during the flight, and any other contacts in this country" Incorrect 0 → Frame 32
"Only your close contacts in this country need to be screened" Correct 1 → Frame 33
"There is no need for screening at all" Incorrect 0 → Frame 32

Frame 32


Just as you are getting ready to answer Mr. Silva, you realize that this might not be the most accurate response.


"Just give me one minute please," you say, and quickly call up a colleague about contact screening.

"He's been here for more than 3 months, so screening his contacts in this country will be adequate," comes the response.


Frame 33


"Well Mr. Silva, fortunately, your contacts in Portugal and those during the flight are safe, but those over here will need screening," you answer him.


"Oh god..." Mr. Silva replies a bit glumly.

"Don't worry father, I'm sure everyone will be just fine. Have faith," David cheerfully says.


Frame 34


After several days Mr. Silva appears to be responding quite well to the treatment.

You are also told that none of his close contacts are infected, including his son David.


He no further constitutional symptoms and his pneumothorax has resolved.

Mr. Silva is discharged after a week on an anti-tuberculosis treatment regimen.


Frame 35

How will you follow him up?

Choice Outcome Score Continues
In one month, with a sputum culture Correct 1 → Frame 36
In two months, with a chest x-ray and sputum cultures Incorrect 0 → Frame 36
After the end of the drug course, with a chest x-ray and sputum cultures Incorrect 0 → Frame 36

Frame 36


You take the time to read through the relevant guidelines before writing out Mr. Silva's follow-up plan.

You decide that it is best to see him monthly, to check the evolution of sputum cultures, identify possible adverse effects of the antituberculosis medications, and assess adherence.


Frame 37


On the second follow-up visit, after two months of treatment, Mr. Silva is vastly changed from when you first saw him.

"Hello there Mr. Silva! How have you been feeling?", you ask.


"Great, Doctor! I've even put on some weight!" he adds happily.

Thus far, there have been no adverse effects from the treatment, and he has gained a total of 2 kg of weight since the first visit.


However, you check his follow up tests, you see that his cultures are still positive, although the chest x-rays appear completely normal.


Frame 38

What do you do now?

Choice Outcome Score Continues
Add an additional 2 months of therapy with rifampicin, isoniazid, pyrazinamide, and ethambutol (8 months total) Incorrect 0 → Frame 39
Add an additional 2 months of therapy with rifampicin and isoniazid (8 months total) Incorrect 0 → Frame 39
Add an extra 3 months of therapy with rifampicin and isoniazid (9 months total) Correct 1 → Frame 40

Frame 39


You are unsure about your options, so you quickly look up the guidelines.


After searching for a couple of minutes, you discover the correct approach is to add an extra 3 months of therapy (9 months total), and subsequently reassess with chest x-rays and sputum cultures.


Frame 40


"Mr. Silva, it looks like you will need to be on antibiotics for a little longer," you state.

You proceed to explain your decision in terms he will understand.


"If you believe that this will lead me to a complete recovery, I agree!" he replies.


Frame 41


After an additional two months, on his fourth follow up visit, you re-evaluate Mr. Silva. He looks and feels better, has gained some more weight, and has not reported any adverse drug reactions.

His x-ray is clear, and sputum cultures have been consistently negative, since the third month.


"Well, Mr. Silva, everything appears to be going great! We'll continue the current plan until you finish the seven months of treatment," you state.


Mr. Silva appears happy with this and shares some news.

"Doctor, my daughter is going to get married in Portugal in two weeks… please tell me I can go?!", he looks anxiously at you.


Frame 42

What do you tell him?

Choice Outcome Score Continues
"Sorry, you won't be able to travel until the course of treatment is complete" Incorrect 0 → Frame 43
"Of course you can, since you're not infectious now" Correct 1 → Frame 44
"I recommend against air travel, because this might cause the pneumothorax to recur" Incorrect 0 → Frame 43

Frame 43


You decide to quickly read through the guidelines before telling him your decision. This reveals that as long as Mr. Silva is no longer infectious, he can travel.

Also, his previous pneumothorax is no longer a contraindication to travel, because it was more than 3 weeks ago.


Frame 44


"Of course you can travel, Mr. Silva!" you state.

He looks relieved, and a broad smile crosses his face.


You wish Mr. Silva all the best and say goodbye, feeling a glow of satisfaction.

Well done!

The end