What the heck is a pleural effusion?

During my trip to Europe, my lovely host--and loyal blog reader--Sarah (she's An American in Paris and cooks a mean English-muffin sandwich) suggested that I write about my goings-on as a doctor-to-be amongst the fine pages of this blog. Hence, I shall do so, and I will try and use regular person words so, at the very least, you won’t think I’m as big a dork as I actually am. And you might even learn something.

So today I am shadowing at the Hematology/Oncology ward at my university. And I can see I already lost half of you, so:

Hematology = blood studies
Oncology = cancer studies

So Heme/Onc focuses mostly on blood-related cancers, such as leukemias, which are found primarily in bone marrow, but may migrate elsewhere in the blood to other organs, and lymphomas, which primarily involve lymph nodes, where your body has little store-houses of immune cells that fight off infections (they swell up during infections b/c cells there are rapidly multiplying to fight the invaders, so if you’re sick the doc will often feel under your neck to see if lymph nodes there are enlarged—quick and dirty check to see if you’re infected). Heme/Onc also deals with other blood-related conditions, too, such as sickle cell anemia, which one patient we saw today has.

In any case, today I got to help out with a thoracocentesis—don’t worry, I’ll define it in a sec. Tumors can cause many different secondary effects. We had a patient who developed a pleural effusion, which I’ll define in a sec also, but you first you need to know about your lungs. Your lungs are normally surrounded by membranes—thin layers of tissue, called the pleura. You can see them in this picture from Wikipedia—don’t worry, it’s public domain. The pleural membranes kind of make a balloon—the membranes are in blue, and the space within is in black. Your lungs (red) kind of fit into and are surrounded by the pleura on most sides.

Imagine punching a balloon with your fist, and having it spread all over your clenched hand. This is what the pleura do around the lungs—they cover most of the lung surface, except where the lungs connect to your windpipe and the blood vessels connect to the heart (your wrist punching the balloon). The space in between the layers of the pleura is squashed pretty small. Normally, it’s filled with fluid—about 15 ml, or half an ounce per lung. This allows the inside and outside layers of the pleura to slide across one another when you breathe, so your chest can expand and your lungs fill smoothly.

Sometimes too much fluid can go into the pleural space. This is a pleural effusion, and happened to our patient today as a result of his lymphoma. Here is an x-ray picture from Wikipedia by Clinical Cases that is much like the case I saw today. In both cases, the patients’ right lung (left side of x-ray) is normal—air looks black in x-rays. The left lung is almost completely cloudy due to fluid—not inside the lung, but inside the space around the lung.

Our patient had trouble breathing, so we performed a thoracocentesis. We had him lean over on a table near his bed, and the internist (sort of novice resident) carefully inserted a needle in between the ribs and into the pleural space—but not into the lung. The needle was hooked up to a syringe, which was used to withdraw fluid and pump it through a one-way valve into a bag. This took probably 15-20 minutes from start to finish. When the patient was leaned over with the internist behind him, this transpired:

Patient: “But what if I have to fart?”
Resident (internist’s advisor): “It’s ok, you can fart.”
Patient: “I know, but it would be awfully mean.”

I should note here the patient had two Percosets in the morning. It’s too bad these things don’t get written up in case reports. Then again… (and to think, I’ve been looking all over for “gas impermeable Mylar pantaloons.”)

We removed over 1000 ml of fluid. That's a quart, you metric-hatin' Yankees. And I got to hold the table the patient leaned on so it wouldn’t roll away. I am basically paying $30,000 a year to be a door-stopper. With a white coat. Living the dream.

Also, I know I've been bad about updating, but I'll try to do better. Promise! I know my Week of Being a Real Man turned into a Month of Being a Bum, and everyone's been pestering for the Official Finches and Sparrows Europe Experience, which I just might deliver to you, if I can decipher whatever I scribbled on that napkin at the train station in Munich. Witness the potential--posts on Wall-E; Blade Runner; biological perfectionism; the Louvre and the dying art world; German beers and Italian wines; why your photos are terrible; why my photos are only mediocre; more medical adventures; the long-awaited Weekend Blog round-up; peculiar cocktails you can't afford but wouldn't like anyway; novel art with novels; the best meal of my life; building a culture of heart and hands; the Holocaust; the Gospel according to Mark; T.S. Eliot, and the craziest Italian wedding that didn't involve the mafia (as far as I know).

Plus I might even redesign the blog layout itself, which, if I pull off, will be beautiful, but will require more Photoshop skills than I have, John James Audubon, a better understanding of CSS and XHTML, typographic vector art, a new blog host, and Scotch whisky. Maybe even a fountain pen. I told you it was crazy, and I'll probably just end up spilling liquor and ink all over my computer.

That being said, pray for me.

PS. John, that last inside joke was for you. If you didn't get it, I'm marching down the hall and smacking you.