The most important principle in medicine is pretty simple: “Primum non nocere.” : First of all: Do no harm. People, who go to the hospital and are worse afterwards many times were treated by doctors who don’t follow this piece of advice. Afterwards the patients generally seek legal advice.
So remembering this principle is really helpful. But how do we apply it?
Does that mean that I should refrain from all procedures that imply a risk?
The treating physician on the other side has to decide whether the patient profits from this procedure in this special setting with the patient’s precondition. This decision has to be made by an intensivist or an internist with plain common sense. No lab test or MRI can answer this question.
- What kind of risks are involved with this procedure and are they higher than generally?
- If the patient experiences this complication: will he recover from that?
So let’s look at an example: 92-year-old patient with shortness of breath due to cardiac decompensation and pleural effusion:
Should we do a pleural puncture: yes or no?
The answer to question 1 is: Yes! I fear hematothorax as a main complication.
Is the chance of hematothorax to occur higher in a 92-year-old than in a 25-year-old ? Yes. He will be difficult to position, have anatomical difficulties and coagulopathies, and his aspirine treatment and his inability to follow commands will make hematothorax more likely.
But more important is question number 2: If he suffers hematothorax, will he easily recover from that?
And this is the main point in this example: PROBABLY NOT!
Hematothorax will require a chest tube and drainage, which means 2-4 days on the ICU. He will need analgesics, then he’ll get kidney failure and delirium followed by hospital acquired pneumonia. I’m not being cynical or bitter, this is just a realistic approach to this patient trying to prevent this all from happening.
So my treatment of choice is diuretics, oxygen and referral to the floor as soon as possible to prevent further complications. If that fails, I’ll give dobutamine a try, but then he needs a central venous catheter and that will lengthen the ICU stay for two days.
Only if he is headed towards intubation I’d go for ultrasound-assisted pleural puncture.
If our colleagues, the nurses or our boss think we are lazy or cowards because we didn’t drain this pleural effusion: so be it. Our main concern is the patient: Primum non nocere.
Often that will require more courage than inserting a needle in a chest.
Any thoughts on complications? Leave a comment!