Harold Moskowitz - I.C.U. Chest Radiology: Principles and Case Studies

CONTENTS

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Library of Congress Cataloging-in-Publication Data

Moskowitz, Harold.

I.C.U. chest radiology: principles and case studies/Harold Moskowitz.

p.; cm.

ISBN 978-0-470-45034-5 (cloth)

1. Chest-Radiography-Case studies. 2. Chest-Diseases-Diagnosis-Case

studies. 3. Critical care medicine-Case studies. I. Title.

[DNLM: 1. Intensive Care Units-Case Reports. 2. Radiography, Thoracic-methods-

Case Reports. 3. Thoracic Diseases-diagnosis-Case Reports. WX 218 M911i 2010]

RC941.M67 2010

617.5407572-dc22

2010001874

FOREWORD

Disclosure: The following story is true. And the author of this book is my father.

My first rotation during internship was hematology-oncology at Brigham and Womens Hospital in Boston. I felt confident enough; after all, I had been studying and preparing for this moment for 4 years. I inherited quite a service, including four women under the age of 40 with advanced non-Hodgkin lymphoma. The outgoing intern smiled with relief as he signed out to me, adding that the sickest of these young women was the favorite patient of the chief of the division. As he left, he simply added, I wouldnt let her die on your watch if I were you.

Needless to say, this young woman began to deteriorate with worsening respiratory failure my first night on call. I reviewed the differential diagnosis in my head: pneumonia because she was immunosupressed, pneumothorax or hemothorax from the internal jugular line that had been placed for access, transfusion-related acute lung injury from the platelets she had received earlier, congestive heart failure from fluid overload or chemotherapy-induced cardiomyopathy, or even pulmonary embolus given her sedentary status. A brief perusal of my Washington Manual bolstered these thoughts, and I ordered a stat chest x-ray.

That is when the panic really began to set in. I would have to interpret and act on that chest x-ray was I really prepared for this? I had always been comfortable in the x-ray department, as I had spent significant time in my childhood following my father around while he read films, but I had had little formal training. Radiology wasnt an individual requirement of my medical school curriculum; it was assumed you would be exposed to it during your clinical rotations. I had even taken the elective in radiology, but this actually consisted of simply sitting in an empty reading room reviewing chest films from case studies in the film library, on my own. Yet now I was on the front line caring for a sick woman and would have to implement the appropriate therapy based on my interpretation of the film.

So what were my resources? My resident was tied up with an admission in the emergency room. The radiology resident would give me a quick read when he had time, but he was busy with another procedure. The radiology attending wouldnt over-read the film until the morning. The clinical scenario demanded an immediate decision on therapy, so I would have to try my best to interpret the film.

My experience that night led to the first of many conversations with my father regarding the status of radiology education in our medical training. Given the explosion of diagnostic imaging we use and rely on every day in the care of our patients, change would be imperative. Since that time, great strides have certainly been made. In many medical schools, imaging studies are now fully integrated into many courses such as anatomy; my father pioneered just such an initiative at UConn. Other schools have now added radiology requirements to their core curricula. Nevertheless, we still have a way to go. Standardization of basic curriculum requirements remains lacking. Many medical schools have shifted their training focus to outpatient settings, where direct interaction with diagnostic imaging is less likelyyou will certainly review the report but not necessarily the imaging itself. And there is a growing component of care provided by physician extendersPAs, NPs, and RNswhose background training in reading even the most basic of radiology imaging is even less rigorous.

Why wasnt there a radiology equivalent to the Washington Manual that could help care providers get through a night like the one I had? It made perfect sense, but I could find no resource like this available. I jokingly referred to my idea as Lines, Tubes, and Drains: Radiology for Dummies. But once I discussed it with my father, it was no joke: A new project was born. It has grown and evolved over time, but he has worked tirelessly and diligently to bring a radiology reference manual aimed at providers on the front line of care to fruition. As we rely ever increasingly on imaging, I think this resource will prove invaluable to generations to come. I am extremely proud to introduce this new effort of my father, and I hope it fulfills its role for you.

January 21, 2009

ROBERT MOSKOWITZ, MD

PREFACE

During the past several years, there have been very few publications concerned with the field of ICU radiology. The portable chest x-ray has always been, and still is, one of the most important parts of the work up and treatment of a patient in the ICU. The film provides a reflection of the hemodynamics and an assessment of the etiology of the pathology of each patient. While the rest of radiology has enjoyed incredible change due to technological innovation and improvement, the ICU portable is still performed with equipment that has not changed over the past 3040 years and is probably the least technologically advanced piece of equipment in the radiologic armamentarium. While the portable film can be augmented by other sophisticated studies, such as CT and MRI, moving the patient to obtain these studies is often extremely difficult and, at times, impossible. In effect, the portable film serves as a screening device as well as a diagnostic tool for the treatment of these very sick patients.