Pneumothorax

One day, I came on duty. That was an afternoon shift. There were rules that for shift exchange. For stable patients, the off going shift may only give oral and writing report, but for unstable patient who were in the pediatric intensive care room, there were always the needs to go to the bedside to give report to up coming shift.

The morning shift doctor was Dr. Li. She went to the pediatric intensive care room with me and introduced a little boy to me: “This 1 year old boy admitted with Pneumonia yesterday. He was in room 7 before transferred to the intensive care room. His heart had stopped beating for few times and every time he was brought back with CPR. I do not know why and what is happening to him. Therefore, I transferred him to this room so we can keep a closer eye on him.”

I started to exam the boy while listening her report: he was well nourished and on 1L oxygen delivered by nasal cannula, with moderated respiration distress. I listened to his lungs, there were dismissed breath sound in his left side of the lung, and then I performed palpation and percussion of the chest, there were decreased voice vibration and tympani noise on percussion at the left side.

“ Did we do any x-ray exam on his chest today?” I asked. “Yes. The X-ray film showed pneumonia. It was Dr. Wang in radiology gave the report.” “Is there any sign of Pneumothorax?” “Not I can tell.” Dr. Li replied. “OK. I want to borrow the film to take a look.” I said. “Why not we go together and take a look there?” Dr. Li suggested. “Sure.”

Dr. Li and I followed by four medical students, we went to the radiology department and found Dr. Wang, the chief radiologist in the hospital. Dr. Wang got the film out, put on the negatoscope, and explained to us: “Look, here, the white spots are the increases of density of the lungs showing us there is pneumonia on this film.” I look at the film; I saw the left side of chest showing a fine line around the lung, and between the line and the chest wall, there was a clear black area. I pointed the black area: “Dr. Wang, is this possible there is pneumothorax exist here?” Dr. Wang exam the film again and said: “Yes. You are right. It is a pneumothorax.” “Ok. Thank you. That is all I want to know.”

I went back to the unit, wrote an order for a thorax surgeon consolation, and later on we transferred the boy to their unit to get chest tube put in. The boy was recovered and discharged a week later.

In China, it is not required to be able to read X-ray film for every clinical practitioner even they do have classes in medical school for X-ray. There are radiologists who read the X-ray and give report. As a clinical doctor, we only read the report but the film itself. In addition, the radiologist sometimes lack of clinical experiences, and sometimes the clinician did not provide enough information of the patient’s history on the order of X-ray, it could be difficult for the radiologist to give the exactitude report. That really is the gap of clinical practice and accessory examination.

I can see the pneumothorax does not mean I was better then the radiologist. In fact, I was just learning. The only benefit I had was I did exam the patient, I did the basic physical examination as a doctor should do and I knew the patient‘s history better than the radiologist. Based on these, I already knew there were air in his chest. That was what I was looking for. That is why I got it right away.

It is the doctor’s preference to learn how to read X-ray film at that time. Doctors are very busy in China. They do not even have a personal life. Their house doors are opened to all patients. They even have prescription pad and lab order forms at home to serve the patients who may come and knock their doors. In addition, the pay was very little. My first years pay as a resident was 45 Chinese Yuan per month and after served the hospital for 15 years, my salary was 500 Yuan per months. They are very busy workers. There is very little time left after work. That is why many doctors decide not to learn more than they have to. Reading X-ray film is one of the knowledge that they do not have to learn.

I learned this when I was doing my graduate study in Tianjing Children’s hospital. There I spent a month to listen to the radiologist and read all different kind of children’s chest films. It really helped me a lot. I always appreciate the class they offered there. I appreciate the knowledge of reading X-ray films I got from there.

It is true that if I did not learn the skill, the baby boy would still get the correct treatment probably one or two days later. However, it certainly helpful having that skill so that I can help my patients to get less time suffering and cost less for curing.





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