musings . . .
I'm coming to the rather interesting and somewhat disappointing conclusion, that I will need to live with a lot of diagnostic uncertainty in pulmonary medicine. There isn't a symptom much more real and yet vague at the same time as dyspnea, and there isn't a single radiologic finding like the pulmonary "opacity" (of various kinds) for the long and drawn out differential possibilities.
Same goes for the ICU. People are simply too chronic ill with too many chronic diagnoses that when they get critically ill, it's simply an impossibility to pigeon hole these people into this critical illness syndrome, or that critical illness syndrome - my favorite is watching cardiology and MICU attendings argue about shock states . . . Hey guys, it's going to be multiple kinds of shock in these patients. And when you factor sick livers into the mix all bets are off. There is simply nothing that a liver patient can't do - spend a million dollars chasing and trying to diagnose exactly what is causing their particular white count, or renal failure, or hypotension, or lactate levels, and you don't often find any good information - the common denominator? The sick liver. Sick livers will just **** with you until they get a new one or die.
Actually, that shall be thusly declared as: jdh71's axion #1 - sick livers will just **** with you until they are replaced or the patient dies.
And I think I spend too much time thinking for other people who should know better - maybe this is the bias of all sub-specialists. It's not like I think you all are idiots - far from it - I KNOW you guys are not idiots so why are you bugging us with stuff you should be able to handle. I can hold your hand through basic COPD and Asthma admits if you really like. I'll follow them in my clinc upon d/c if that makes you happy. But if you've got an 88 y/o demented gentleman, who is a chronic aspirator, weak cough, and thickened secretions he can't get out leading to a mild hypoxia . . . I can't fix that - I'll NEVER be able to fix that. You can trach the old guy for easier pulmonary toilet, but to what end? In my opinion this is YOU having a talk with the family saying, "gramps is never going to get better than this, and we think you should let the old guy go home and live out his days as best he can," rather than jacking him around in the hospital for weeks and weeks - sending him to a nursing facility where he's going to bounce back. Did some surgery to an old, chronically ill guy and he's still a little hypoxic post op day #2? Yeah. That's what happens. Try some patience. Pulmonary toilet and mobilization - get him into a freaking chair at least! Lungs won't expand if they can't, ya dig? Pulmonary nodules of ANY size are an out-patient work-up. No we are not going to bronch your infectious pneumonia patient if you haven't tried getting sputums first. If you're going to bug me about a pleural effusion, at least make sure you've ordered the correct labs on the fluid, and tried to piece it together yourself - a transudate, which is easy to identify, does not need an pulmonary doctor. Do not have IR put a chest tube into a patient with a bad heart or bad liver until you've run the idea past your lung colleagues - or we will all be stuck with that tube for a long, long, long time. Hepato-pulmonary syndrome, easily diagnosed by any internist with access to uptodate (or similar) does not need a pulmonary consult.
That's it for now.
