The most complex thing we do is think, but that’s not reimbursed. Too often doing things to, as opposed to for, the patient is what generates income.
She was short of breath. In Room 6. It’s where we put people who are short of breath. No good reason, just habit. Rooms 2 to 6.
The usual questions: Pain? No. Short of breath? Yes (didn’t I read?). Trouble worse lying down? Yes (why do you think I’m sitting up, leaning on this rolling stand?).
And on went the questions, many rather routine. I could see she was slightly tachycardic, O2 saturation too low for the supplemental dry plastic-smelling oxygen shooting up her nose. Color was a bit off, sclera not quite jaundiced but a faint yellow tone to her thin skin.
Her physical exam bore out her story. Slight aortic stenosis. Dull right-sided breath sounds halfway up the medical scapular border. Egophony. I couldn’t find the ripe melon sound of normal lung until three-quarters up her right chest. Pleural effusion, likely renal failure.
Basic labs held no surprise: Creatinine = 3.5, BUN = 40. Chest x-ray: white out three-quarters right chest. Right lateral recumbent confirmed free right pleural effusion.
And the morning was picking up steam. Ambulances were arriving every seven to 10 minutes. Definitely manageable if you have second-level coverage and are free to keep up. Today, neither held true.
I had a student and a resident. Neither had seen a thoracentesis, much less done one. This lady needed one and she was in the right place.
She and I discussed the procedure; informed consent is a conversation, not a form. She was set up for the right pleural tap, prepped, draped. As a group, we reviewed the indications for her tap, her findings on lab and physical exam, including auscultation and percussion. The top of the seventh rib was identified at the lateral angle. Skin and rib surface were anesthetized. The parietal pleura received its own bleb and fluid was found with a 22- gram scout needle. Fortunately, she was of normal body mass index.
The thoracic pigtail catheter was inserted along the same track by myself, explaining all along to the enthralled audience of two. The patient listened, too. Nearly two liters of fluid were drained; I prefer manual suction. I have trouble with the application of one-liter vacuum pressure to the chest in a frail elderly patient; it’s likely just my misgivings.
Meanwhile, the ER got busier. And that got me thinking.
The thinking went on hold as we finished up, removed the catheter, placed a bandage and showed the patient the results. She was breathing better, which pleased her and her family almost as much as seeing the products of our labor. Post-procedure x-ray showed no problems and she was admitted for further evaluation.
I went back to work to dig out from my half-hour time down and started thinking again.
The target was the size of a cantaloupe. The needle was the size of a lethal weapon, maybe six inches long, with built-in protection from piercing a lung. The target and needle were separated from each other by less than the thickness of my index finger. So what’s the big deal? If I can’t get those items together from across the room, I need to take archery all over!
Yet our system takes the most scarce, contested and expensive resource out of the ER because this is a “procedure.”
This procedure, which can be taught in 10 minutes to a monkey, however, pays more than my next two hours’ work. And maybe that’s whence some of our system’s nuttiness.
The value here lies not in doing the procedure, which is certainly easier than starting an IV, but in knowing when not to do it and in knowing what to do with the information obtained. That learning takes orders of magnitude more time to learn and is more fraught by far than the actual procedure.
The money confuses things. What would happen if a thoracentesis paid the same as starting an IV? We’d do them when needed and we’d push them down to the lowest level trainable to do it. Witness suture and ortho techs.
It can be done. We just need to think differently.