We are all of us — different

September 27, 2008  |  General

I recently had an experience of the sort any experienced physician has now and then. One of the doctors in the emergency department asked me to come down and help evaluate a small boy with breathing difficulties. The child indeed was breathing hard, although he was holding his own for the moment with the help of some extra oxygen. What was striking about the boy’s examination was that when I put my stethoscope to the child’s chest I couldn’t hear any air at all going into his left lung — none at all.

This is a common scenario for having something blocking the bronchus, the breathing tube, that leads to one of the lungs. In toddlers, it usually means there is what we call a foreign body, such as a peanut, a bit of popcorn, or a plastic toy down there, because toddlers are famous for putting anything in their mouth. If they suddenly breathe in, the object can end up where it shouldn’t be. After listening to the child’s chest, I assumed this was what had happened. So had the emergency department physician.

The treatment for an inhaled foreign body is not trivial. It requires the child to be anesthetized and have an instrument called a bronchoscope pushed down into his lungs looking for the object. Once found, we have attachments to fish it out. Before he arranged that, the emergency physician wanted to be surer of the diagnosis, and there were a couple of things that didn’t fit.

For one thing, no one had seen the child put anything in his mouth and he hadn’t been around any of the likely culprits. For another, his breathing problems came on over a couple of hours or so, not suddenly as usually happens with an inhaled object. Finally, although these objects can end up in either lung, they usually go to the right one, not the left. For these reasons the emergency doctor had ordered a couple of tests: first a chest x-ray, and then a CT scan. Neither one of them suggested a foreign body. In fact, they showed some abnormalities in both lungs.

Meanwhile, the child was about the same. He still had moderate difficulty breathing and needed oxygen. When he got back from the CT scanner, however, his examination findings had changed — now you could hear some air getting into his left side. More importantly, now it was easy to hear wheezing throughout his lungs. He was having an asthma attack.

This was a simple case, and the child did fine after some breathing treatments. One reason this case was interesting is that it illustrates an old medical saying, one which warns us that if we see something odd, it’s much more likely to be an uncommon manifestation of a common thing than an uncommon thing. Asthma blocks airflow out of the lungs. Although it usually does this more or less equally throughout the lungs, in this case it didn’t, at least at first.

But another reason it was an interesting case is that it reminds us that each of us is unique, and diseases can affect each of us differently. Usually these differences are small, but sometimes they are large. It’s also why you often find that the more experienced the physician, the more unwilling he is to predict with absolute certainty what will happen.


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