Pulmonary Consult

My last rotation, pulmonary consult, was a good one to end with. I could really tell how much I've learned since third year as the fellow gave me more and more responsibility. I think I finally started feeling like a resident, becoming more efficient, developing more self-confidence in my clinical judgment, starting to make a plan, learning independently. Indeed, a lot of residency is self-directed learning, and on this rotation, I began to make that a daily habit. The rotation itself was pretty good; I reviewed basic pulmonary physiology, pharmacology, and disease states and dabbled a little in some of the more obscure diagnoses (lymphangiomyomatosis!). I saw a good variety of patients, glad to return to the routine of clinical medicine after being out of it for teaching, interviews, and radiology.

There was a dry spell in consults for a bit and then we had a deluge the last week. One day we had six consults, almost all after noon on a day that my fellow had clinic. Thus, the attending and I fielded all the consults, scrambling about the hospital to see all the patients. It was really crazy, a preview to intern year where I might have half a dozen notes to write after sign-out. One of the more interesting yet unfortunate cases came to a close at the end of my rotation. An older man with a complicated medical history including GI bleed presented with fever of unknown origin. Despite broad spectrum antibiotics, he was spiking daily fevers. As a result of the fluid resuscitation from the GI bleed, he appeared to be volume overloaded. He also had gotten a contrast load on top of chronic kidney disease and appeared to be going into renal failure. His mental status was altered compared to baseline. After the primary team began diuresing him, a spiculated lung nodule was seen on CT, presumably the cause of his fever of unknown origin. Yet he was deteriorating too quickly; even on broad spectrum bacterial and mycobacterial coverage, he became more altered, his creatinine rose, he required more oxygen, and he continued to have fevers. We knew we needed to bronch him or do an CT-guided biopsy of the lesion, but he became more and more unstable. Eventually, he displayed florid septic physiology, becoming hypotensive requiring two pressors, tachycardic, anuric, and finally unresponsive. Unfortunately, in the end, with discussion with family, care was withdrawn. The final diagnosis was sepsis of unknown etiology. Could it have been a fungus that escaped our antibiotics? Could it have been a strange or resistant bug we didn't anticipate? Could we have figured things out sooner? A case like this always leaves me with many "what ifs."