September 8, 2008

Radiology Today Book Excerpt: Looking Within: Imaging the Body, Exploring the Human Spirit
Radiology Today
Vol. 9 No. 18 P. 20

Editor’s Note: This article is excerpted from Looking Within: Imaging the Body, Exploring the Human Spirit, the forthcoming book by radiologist Cullen Ruff, MD, an abdominal imager in private practice and an assistant professor at Virginia Commonwealth University in Fairfax.

“Whenever I share the results of a study, patients invariably tell me how amazing it is to see inside the body, and how fascinating our work must be,” Ruff said in a prior interview with writer Matthew Robb about the book. “Showing a woman an abnormal mammogram and explaining she can’t feel her cancer, yet we can detect it and have it removed before it spreads, that’s an amazing thing.”

Ruff discussed limitations and complications, including a life-threatening embolism during a lung biopsy described in this excerpt. “That’s my example of trying to live by the Hippocratic oath, yet also understanding that everything in medicine carries some risk,” he added.

The book is written for a general audience, and Ruff hopes to convey the message that “radiologists are more fulfilled as physicians not just by maximizing the number of studies we read, but by understanding and strengthening the human impact of medical imaging.”

Do No Harm
“My brother has a little trouble with his short term memory,” the woman explained. “But he understands why he’s here. He lives with me and my husband.”

Her brother looked older than his sister, but was actually younger, about sixty. She was well nourished; he was thinner, more haggard, with the lined face of a long-term cigarette smoker who liked more than an occasional cocktail.

“She’s good to me,” he said. “She takes good care of me.”

“He’s pretty easy,” she said.

“You’ve had quite a year,” I said, shifting the conversation to his medical history, and the biopsy I was preparing to perform on him. “Your doctor told me that you had surgery for throat cancer about a year ago.”

“You bet,” he said, tracing his finger along a scar that coursed under his jaw and down his neck. “And radiation, too.”

“My husband and I never could get him to stop smoking. But he was doing OK until his recent test results.”

“I reviewed those this morning before you got to the hospital,” I said, turning to face the man directly. “What did your doctor tell you?”

“He set me up to come in here and see you. He said you were going to put a needle in my lung.”

“That’s right,” I agreed. “The CT scan showed that you have a new nodule in your lung that wasn’t there a year ago. The PET scan you had last week tells us that the nodule is active.”

“That’s what the doctor said,” his sister confirmed, “and that it could be a new cancer.”

“It could. It could be a new lung cancer, or it might be a metastasis from the throat cancer. The purpose of the biopsy is to tell the difference, because that would determine how this new tumor gets treated.”

We went through the steps of a lung biopsy for the purpose of informed consent. He would lie face down on the CT table, and we would scan his chest. The pictures would guide me in placing a needle into the nodule toward the back of his lung, after giving him a pain killer and sedative. A pathologist would analyze the tissue.

We discussed the procedure risks. There was a chance he could bleed, and a very low chance of infection. He had about a fifty-fifty chance of getting an air leak inside the chest cavity from the lung puncture site, called a pneumothorax.

“Is that dangerous?” his sister asked.

“It can be, but usually not. Usually it’s small, and you don’t have to do anything about it. We watch you and get another x-ray in a couple of hours. If the air leak stays small on the x-rays, and you’re doing all right, we let you go home after a couple of hours. Maybe one person out of twenty has an air leak big enough to need a tube placed in the chest, to re-inflate the lung and let it heal. If that happens, you’ll be spending the night in the hospital.”

“I can handle those odds,” he nodded. His sister smiled.

“Good. We try to control any pain with the medicine you’ll get from the nurse.”

“I’m all for that,” he smiled.

“Most people are,” I agreed. “Very rarely could anything else occur, and if so, we’d treat it as best as we could. Any questions?”

“No, I think you’ve explained it,” he said, reaching for the pen to sign the consent paper.
“Thank you,” she said, looking more relieved.

“You’re welcome,” I said. “We’ll do our best to look after him.”

Little did any of us know what lay in store for him later that morning. His case would be anything but routine, and I would not have explained all there was to know. He might not handle the odds after all, and those nice people would end up looking anything but relieved. Very rare complications are sometimes so uncommon that even the doctor performing the procedure is barely aware of their existence, until they occur.

The biopsy began routinely. The man held his breath when I asked him to, and breathed quietly when I told him it was safe to do so. He tolerated the pain, and the pain medicine, just fine. I placed the needle the first time and was only a few millimeters to the side of the small lung mass being targeted.

“Close,” the CT tech said.

“Yeah, but not quite close enough,” I countered, going back to reposition the needle slightly.

The man held still. I pulled the needle back slightly, changed the angle, and readvanced. His vital signs on the monitor were normal. The nurse and I stepped out of the room again and watched through the window, while the CT tech fired up the radiation in her scanner and took another set of pictures.

“Bullseye,” she said. The needle tip was right in the middle of the nodule. The lung had not collapsed at all. Vaguely and briefly, something distracted my attention subconsciously, but only for a fleeting moment, with no conscious recognition. The needle was right where it needed to be, and that pleased me, but the satisfaction quickly faded as we walked back in the room.

“Ow, oh,” he groaned, “it hurts in my chest!”

“Toward your back, where the needle is?” I asked.

“No, in the front,” he moaned.

“His rhythm is different,” the nurse cautioned. I looked up at the monitor.

“His pulse is now 132. It looks like he might be going into V-tach,” she said in a raised voice, meaning ventricular tachycardia, a rapid heart rate with a dangerous rhythm.

“Hang on!” I said, quickly taking one biopsy sample, then pulling the needle out of the man’s back. “The needle’s out, sir, we’re done. Let’s get you on your back.” He was moving poorly. We rolled him over.

“Hand me a stethoscope. He didn’t have a pneumo a second ago!” I listened to him breathe. Air entered both lungs equally. His heart beat too fast, his rhythm too wildly.

“He’s in V-tach,” the nurse reiterated.

“Call a code,” I said. The tech grabbed the red telephone on the wall.

“His pressure and O2 sat are still normal,” the nurse said.

“Give him more oxygen anyway,” I said.

“I just did, he’s on five liters and is at 99%,” she explained.

“Sir, how are you feeling now?” I yelled. He barely responded.

“Sir, talk to us—does your chest still hurt? Talk to us! Damn it, what the heck is going on? Is he having an MI?!” I said, meaning a myocardial infarction, otherwise known as a heart attack.

Residents in white coats and surgical scrubs poured into the room. “I’m running the code team,” one doctor announced. “What’s going on?”

“I was doing a lung biopsy. He complained of sudden onset of anterior chest pain, not at the biopsy site. He got tachycardic, with probable V-tach. There was no pneumothorax a minute ago on the CT, plus he’s moving air on both sides, and his pulse ox and blood pressure have stayed normal. He’s got no cardiac history, but he’s a heavy smoker and could be having an MI.”

“What was the biopsy for?” he asked.

“A new lung nodule. He had laryngeal cancer treated a year ago.”

The doctors crowded around the man were assessing him in the resuscitation, preparing to give drugs and standing by with defibrillation paddles, ready to shock him if needed. The man’s skin had turned from lightly tanned to ashen. He flinched only slightly when a resident dug her knuckles into his breastbone to check his level of consciousness.

“Let me check his scan once more while you guys are here,” I said, quickly returning to the computer monitor outside the room. A colleague who had heard the resuscitation code announcement had just arrived, and was scrolling through the images on the screen while watching us from across the glass.

“I heard the code called,” he said. “This is your lung biopsy? What happened?”
“Hell if I know,” I said, briefly rehashing the events while we looked together at the images. “He doesn’t have a pneumo at all. His coronaries are full of calcium. He could be having an MI, but why now?”

“Wait a second,” he pointed, “what’s this?”

There it was on the screen. It took a moment to register in our minds, and suddenly I realized that I had seen something subtly but dangerously different on his last images moments ago, when I was focused on the position of the needle tip. We were now staring at a life threatening complication that could kill him any minute, a complication that I had unknowingly and inadvertently caused, trying to help the man. It was so rare that, until that moment, neither of us had ever seen it, and barely remembered that it could even happen from doing a lung biopsy. I had not specifically warned the man or his sister that there was even a tiny chance that he could die from the procedure.

“Oh my God!” I exclaimed. “He’s got air in his aorta—and his left heart chambers?!”

“Yeah, look,” he pointed, detached from the emotion and commotion of the procedure room. “He’s got air in his pulmonary veins here.”

“Unbelievable. Absolutely unbelievable. He’s got an air embolism.”

“I think he had to,” he said. “Somehow air got from the lung into a vein branch where you did your biopsy; then the air passed to his heart, and out his aorta.” He scrolled back to the images after the needle was first placed, when the tip was close to the small mass but not quite in it. “Look, there was no air here before, but there is after you repositioned the needle tip.”

There it was. Like a scuba diver who stays underwater too long and surfaces too rapidly, air had entered the man’s bloodstream. The air bubbles could lodge in his arteries and block the flow of blood to critical organs, including his brain and his heart. The air could kill him right before our eyes by causing a stroke or a heart attack.

“I’ve never seen this. I was focused on the needle tip. I barely even had to reposition it. He was fine after the first pass. I only crossed the pleura one time. My God, have you ever seen this before?”

“No,” he said. “But what else could it be?”    

“Hold on,” I said, hurrying back into the room where the team of doctors was still assessing the man. “He’s got an air embolism! He’s got air in his left atrium and ventricle, and his aorta—put him in Trendelenburg position! Lower his head! Damn it, he’d better not be having a stroke and an MI both!” Residents quickly tilted the patient’s stretcher to move his head lower than his feet, so that if the air left his heart it would be more likely to travel away from his brain.

“His heart rhythm already reverted to normal,” the doctor in charge of the code said. “We didn’t have to defibrillate. He may be stabilizing.” We then rolled the man onto his left side, to move his major coronary arteries lower than the dangerous bubbles in his heart chambers, still keeping his head down and his feet up. It may not have been much more sophisticated than a hope and a prayer, but those were all we could offer at that moment.

“Let’s get him to the ED,” the chief commanded. The horde of young doctors wheeled the stretcher to the emergency department. I prayed that he would not be later wheeled to the morgue.

“His sister is still out in the hallway and is understandably confused and upset,” the CT tech said. “Are you going to talk to her?”

I hesitated just slightly out of dread, but exited the door leading to the hallway. She sat alone in a small, exposed waiting area, wiping her eye with a tissue. She saw me coming to her.

“Doctor, what happened? What’s wrong?” she implored as I sat next to her.

“We did the procedure, but there’s been a complication, something I’ve never seen before. Some air got into his bloodstream from the biopsy, and it affected his heart.”

“Is he going to be OK? I’m so scared!” She grabbed my hand.

“We don’t know yet.” I squeezed her hand back in return. “His heart rhythm changed temporarily, and he quit talking. I had to call a resuscitation code. They didn’t have to do CPR or shock him, but he may have had a heart attack, maybe even a stroke.”

“Oh, please God, no,” she teared, her hands trembling.

“I’m so sorry,” I continued. “His heart was doing better just a minute ago, and they took him to the emergency room. I’d like to go there now myself, to see how he’s doing and make sure they have all the information we can tell them.”

“Please, do whatever you can,” she said, dabbing her eyes again.

The nurse reappeared. “You go on. I’ll walk her over in a bit.”

The man’s heart rhythm remained normal, and his pulse had also slowed down to normal. Within a few minutes of arriving in the emergency room, he woke up. His mental status reverted to his usual baseline. He resumed talking normally. His memory was no worse than what it had been before we started, only he had no recollection of what happened after his chest had started hurting. He showed no sign of stroke, and his chest pain was gone.

When I entered his room the man was lying on his stretcher, still with his head lowered. He was casually talking with a nurse and a medical student.

“I can’t tell you how happy I am to see you awake and talking,” I said, grabbing his hand. “Don’t sit up. Keep your head down. How are you feeling now?”

“OK, really. I feel fine,” he said.

“Squeeze my fingers,” I said, placing my fingers in each of his palms. He gripped them strongly and equally. He was able to move both arms and legs fine. He showed no sign of a stroke. The color and pulses were good in both hands and feet.

“We were really worried. You blacked out on us for a little bit there and gave us all quite a scare.”

“I know,” he said, “but I really don’t remember much about it. Then I woke up here and all of these doctors were crowded around me. It kind of scared me.”

“You’re not the only one,” I said, then tried to explain why it was important that he lie still. “You’re definitely not going home today. We’ve got to watch you closely; you still may have had a heart attack.”

“You think so?” he asked.

“Maybe. We have to wait and see. You look better now, for sure, but we need to keep a close eye on you.

Some of the residents and medical students who had been at his resuscitation code were talking at the nurses’ station right outside the door. They had been looking up air embolism and its treatment. The young doctors had already contacted a local university with a hyperbaric chamber, a sealed room where the air pressure can be increased above normal, causing gas bubbles in the circulation to dissolve back into the blood. However, we ended up not needing to send the man over there. His heart rate and rhythm stayed normal, and he showed no sign of permanent damage. We did a CT scan of most of his body after a couple of hours, and the air in his bloodstream had been reabsorbed and had gone away. He showed no sign of stroke or other organ damage. He did get admitted to the hospital for a couple of days, but continued to do well and showed no evidence of an actual heart attack.

He got discharged and went home. A few days later I called to check on him and spoke to his sister on the telephone. By that point the biopsy result had come back, diagnosing a new lung cancer, caught early. He could be treated; the biopsy had been justified.

“It’s not your fault,” she said, ironically trying to comfort me. “I told my husband, I played bridge last night, and I got dealt a bad hand. That’s just how it goes sometimes.”

“I sure do appreciate your being so understanding,” I thanked her. “I’m still just so glad that he came through.”

“We all are,” she said. “Thank you.”

A surgeon removed the small lung cancer a few weeks later, and he recovered uneventfully.

Air must have entered one of his coronary arteries, causing his arrhythmia and chest pain, but did not block the blood flow completely and permanently damage his heart muscle. He had been extremely lucky that day, but not as lucky as I had. His coronary event was fortunately temporary, but the lessons it had for the rest of us remain quite permanent.