Dx: Missed Non-Traumatic Pneumothorax
Although the findings on the radiograph are subtle, the lack of apical aeration, compared to the left side, in the context of explained pleuritic chest pain, should prompt the wise EP to consider the diagnosis of pneumothorax.
Common errors in the ED often fall into several broad categories. First, there are errors of omission, where we fail to consider a diagnosis (like ischemic heart disease) or fail to order a relevant test (such as cardiac enzymes). Next, there are decision-making errors. In this type, we get the data, but fail to act in a clinically prudent fashion (e.g. elderly patient with hypoxic pneumonia, sent home). There are also errors of commission, where we order a medication on the wrong patient OR use an improper dose of medication (especially in pediatrics).
This case illustrates another type of error, namely the misreading of a diagnostic test. For EPs, some of the most challenging reads we face are interpreting EKGs and plain X-rays. Even though cardiology and radiology over-read these studies in nearly all hospitals, many facilities lack real-time readings. And the specialists are human just like us. They will miss things too.
The treating clinician, though not a specialist in radiology, has a distinct advantage over the radiologist, namely that he or she has examined the patient, formulated a provisional diagnosis, and approaches the X-ray with this diagnosis in mind. It is the outstanding radiologist who phones the ordering clinician and asks a question, and the exceptional one who will go and examine a patient themselves. I have met a few who have done this. So, in the case of a young patient with chest pain, the clinician specifically looking for a pneumothroax has an advantage over his/her colleague who does not have a pre-conceived diagnosis in-hand.
Disposition and treatment are easy in this case. How about some pain meds, a small chest tube, thoracic catheter or needle aspiration. Whether admitted or discharged, providing the right diagnosis is so much better than saying, “go home, there is nothing serious wrong with you,” only to have them return the next day with a larger, potentially more serious pneumothorax. In this case, the doctor’s brain scores the shot-on-goal, with a well-deserved assist from the doctor’s eyes.
Dr. Dallara practices Emergency Medicine in Virginia and North Carolina, and directs the Emergency Medicine PREP Course. www.emprepcourse.com
The management of these first-time spontaneous pneumothorax cases isn’t always straight-forward. What about simple needle aspiration of the pneumothorax, or even better yet, watchful waiting with repeat CXR after 6-hours? Go to http://tinyurl.com/6allbbs (October 2009 Journal Club) to find an extensive discussion on how using these less invasive strategies might safely avoid admission (and the painful chest tube!) for 74% of these cases.
-Christopher Carpenter, MD, MSc