Two Views are Better than One

A middle-aged man was found on the highway. A concerned passerby called 911, and then EMS made him a patient of mine. Approaching the stretcher, the aroma of alcohol permeated the air. Such is my life as an inner-city nocturnist.This patient was a little different, though. He said he had been short of breath before passing out. Peeking out from the bottom of the sheet was an ankle boot. The patient provided little assistance with his history. His exam was otherwise completely normal.Just that week at the mortality and morbidity conference, a case bearing similarities struck terror in our hearts. A middle-aged man with a leg injury came back coding. His autopsy revealed a massive pulmonary embolism. I believe the fear generated from his death made me send a D-dimer on this patient.​With the roll of the dice, we lost. The D-dimer was elevated.After an unrevealing portable chest x-ray, he went to CTA. I was going home. Signing out, my last words were send him home after his CTA is negative and he can walk.​Arriving back for my next night shift, I saw this patient was admitted. I couldn't believe this patient with normal vitals and a normal pulse ox really had a PE. He didn't. He had a mediastinal mass. What had I missed on his x-ray?Clicking through the slices, I saw that the teaching from medical school was right. Really, one view is no view with x-rays. The very narrow, long mass hid right behind the sternum. My best chance of finding that on plain radiographs would have b...
Source: Lions and Tigers and Bears - Category: Emergency Medicine Tags: Blog Posts Source Type: blogs