God Slaps

(N.B. This post should in no way be construed to endorse a belief in imaginary beings)

There was a guy who came in last Friday with right-sided chest pain. He had HIV. He had normal breath sounds on the left side, but none at all on the right side where the pain was. When I percussed his chest I could feel/hear exactly where it shifted from tympanic (air-filled) to dull (pus-filled). This was a pleural effusion.

If I was confident in my history and physical, I could have put a needle in and drained the fluid out. But that idea made my palms sweat. Stick a needle in someone’s lung? I’d only done one thoracentesis in my whole life, and it was under close supervision of a pulmonologist.

Instead, I got a chest X-ray. It showed a massive opacity at the right base, just where I suspected the effusion was. Still, I convinced myself as I looked at the X-ray that it could be a pneumonia. Hard to tell. I wouldn’t want to stick a needle in if there was no fluid there.

God was already slapping me in the face here, though. The guy had a written note from another hospital, documenting clearly that he had been treated for pneumonia less than a week ago. I asked him if he had taken the medicines, secretly hoping that he hadn’t.

Yes, he said, I took every pill. When was the last dose? Two days ago, he replied.

So we have an infection that is not responding to oral medicines. Why not? Because there’s a huge collection of pus in the lung, and the antibiotics can’t penetrate it. He has a pleural effusion, and the fluid needs to come out.

Still, I hedged. I told myself that I should be a good doctor and play it safe. There’s a small chance that this is just a pneumonia, so why don’t you go to ultrasound tomorrow and have them take a look? He came back the next day with the hand-written ultrasound report in his hand: “Massive fluid collection in the right supradiaphragmatic space.”

At this point God has moved on from slaps to punches. What are you gonna do, He’s saying? It’s right there, you got it in writing now. Are you gonna drain it?

So I ask the guy more questions. How bad is the pain in his chest? Can he live with it? Because, you know, maybe the best thing would be to just continue those antibiotics for a while longer. I mean, maybe they’re just taking a while to work, and we should give them a chance. And hey, if that means the resident who comes after me does the thoracentesis --- well, I can handle the disappointment. What’s most important is the best interests of the patient.

The guy answers me: he’s having fever and he’s having trouble breathing. I measure his respirations and sure enough they’re up.

God is now holding me by my lapels and punching me in the nose while calling me a sissy little girl. How many reasons, He is saying as He does this, do I have to give you, before you drain this guy’s effusion? How obvious do I have to make it?

Look, He says, I know you’ve only done one of these procedures, and you’re not very confident with it. That’s why this is a test. It wouldn’t mean anything if you were completely comfortable with it.

The reason I had this patient present in such an unambiguous way (still God talking --- I’m incoherently blubbering) is because I knew that you would try to wuss out of it. But guess what: you’re out of excuses! So get it in gear, chickenshit! We don’t always have the luxury of a hundred hours in the batting cage before getting called up to the Majors. Step up to the plate! Step up, you whiny bitch!

(I guess you can tell I’m an Old Testament kind of guy.)

So I explain to the guy that I’m going to take some fluid from his lung. Like I’m taking some milk from the refrigerated case in the deli. Just gonna pick up a liter or two of clear yellow fluid. Transudate, exudate, whatever’s in there.

I look at my watch casually. It’s getting late, I say. Why don’t we do it tomorrow? He nods and leaves.

And I go home to the textbooks and spend the next three hours reminding myself how to do a thoracentesis.