What You Don’t See May Be the Problem
Over the years, I have had the opportunity to hear numerous patient stories presented to me by colleagues, residents, and students. Although I find each and every one unique and interesting in its own right, occasionally there is a story that stands out as worth sharing. The following case is one such example; not because there is any major new finding or disease entity to present, but because something so simple was missed—and many other medical centers may find themselves with a similar situation.
Mr. J is a 93-year-old gentleman who was active and in his usual state of health until two days prior to his presentation at the hospital’s emergency room. He complained to his daughter that he was increasingly short of breath, but denied any chest pain or sputum production. This continued to progress, and his daughter wanted him to have an evaluation. The ER obtained a chest x-ray and noted infiltrates that were believed to be either congestive heart failure or pneumonia, and admitted him to the medical service. His lung exam noted some crackles bilaterally but no wheezes or stridor. The chest x-ray was viewed by the resident team assigned to the patient both in the ER and on the floor using a conventional x-ray view box. After considering a cardiac etiology, pneumonia was decided to be the best possibility and he was placed on antibiotics.
He continued to become increasingly short of breath, and his blood gases confirmed that he was in need of ventilatory assistance. He was transferred to the intensive care unit, and plans were made for the critical care attending physician to intubate this patient. On initiation of the intubation process, the critical care attending physician noted to his great surprise that there was a foreign body lodged in the upper airway below the level observed on simple oral-pharynx examination. It was a denture bite plate with no teeth attached.
On further questioning, the family reported that despite the fact that the dentures were old and had “lost the teeth,” the patient still had the habit of putting in the bite plate. They had no recollection of the last time they actually saw the bite plate, however.
How could this have been missed? The family reported that the patient had worn dentures in the past. The physicians examining the patient did report observing the oral cavity and noted the absence of teeth or dentures, and saw nothing in the oral cavity. No stridor or sign of a foreign body was evident by the examining physicians, and thus there was no further questioning as to the etiology on seeing the pulmonary findings. Why did this finding not show up on the chest x-ray? Was it out of the range of the chest examination that was performed or, in fact, missed by the physician team assigned to the patient?
Indeed, on further and more detailed review of the original film, the bite plate was faintly visible at the top margin of the x-ray. Due to its high position on the film, however, it was unfortunately obscured by the metal lip on the view box that was intended to hold the film in place. We since have identified that this same type of a metal lip is present on all other view boxes throughout the hospital other than the radiology reading room, where a carousel system has been used to display x-rays. It was no surprise, therefore, to read the original dictated radiology report and to find that this foreign body was mentioned. Unfortunately, the radiologist did not call the treating team with this finding; the x-ray report came to the floor after the patient was already admitted to the ICU and the bite plate discovered.
After a few days being ventilated by artificial means and on antibiotic therapy, this gentleman was on the road to recovery. No one knows for sure how long the bite plate was lodged in his upper airway, or if, in fact, it did cause his pneumonia. Most agreed that it would have predisposed him to aspiration pneumonia in any case. Perhaps if the bite plate were removed sooner it would have prevented his requiring ventilation, but this also remains uncertain.
We have since discussed the limitations of the x-ray view boxes, and have also reinforced with radiology the need for critical findings to be called in promptly to the primary physician. Fortunately, we are currently introducing a computerized viewing or PAX system that will also eliminate the use of the ubiquitous, yet apparently out-of-date, x-ray view boxes that we have relied on for years.
I hope that by sharing this strange turn of events with you, the reader, that you will be more cognizant not only of what is at first apparent on the x-ray but also what is not so clearly visible on first viewing.
Send comments to Dr. Gambert at firstname.lastname@example.org.