The Xray that should never be.

I will keep medical posts to a minimum, but this one was worthy of relating.

One of our responsibilities in the hospital is to read X-rays ordered by the MAs.  This one caused us to run out of the office to try and locate the patient.

Some of the findings are easier to see: at the bottom of the patients left lung, the diaphragm appears flattened out, the left lung field appears larger than the right and I'll tell you the heart is shifted to right as well.  It's being pushed to the right by what's going on in the left half of the chest - a tension pneumothorax.  What this quality of image can't show is the fine line in the left lung field that shows the left lung has 'popped'.  What makes this different from a plain pneumothorax is that the hole in the lung is acting as a one-way valve, slowly pressurizing the left half of the chest.  Initially this pressure just pushes things to one side, but eventually the pressure can build to where blood return to chest (and heart!) is diminished... then it becomes very quickly life threatening as the blood pressure drops.  This should be picked up clinically - you should never makes this diagnosis on an X-ray.  This Xray should never be.

We couldn't find the patient.  He was out getting lunch!  So he couldn't be that sick.  After lunch he turned up to find out the results of his X-ray and was shuttled into the emergency hallway.  Though quite short of breath, his blood pressure was not yet low, so it hadn't progressed far enough to be immediately life threatening.  We placed a chest tube (the very tip of which can be seen on the edge of the X-ray below) which permitted the left side to decompress.  Over three days he improved and we removed the tube.  You can see the diaphragm is less flattened and the heart has shifted back its accustomed position.  He went home very happy.