Looking at the Ant!

In one of my rounds with the medical department, I was asked to present the findings on my case and read the plain chest x-ray the consultant handed me out. We were taught that when reading an x-ray I should read it in a systematic way. Like reading the name first then the date it was taken then comment on the image if it was well exposed etc etc etc until I reach the abnormal findings and comment in details on it. And never comment on the abnormal findings directly as not to miss some of the small findings that might be important.

So I began commenting in a systematic way, although this patient has an obvious cardiomegaly "enlarged heart". The consultant was impatient with me and began shouting and waving the x-ray at my face saying "Just tell me what you are seeing!!!! You are looking at the elephant and telling me that you are seeing the ant!!!!". All I could say was "OK! this patient has a cardiomegaly, but I was taught to read the x-ray in a systematic way and not jump into the obvious findings so as not to miss anything".!

I mentioned this story because the obvious sometimes is missed by doctors. As it happened to one of my teacher whose a respiratory pediatrician. He said that he had an young patient;around 11 months old, came with recurrent respiratory problems. His father was so worried and visited many doctors that told him your son has an asthma problem. The father wasn't convinced, he said that my child's condition is not improving with any kind of medication the doctors gave us.

The doctor-our teacher- then examined the child thoroughly and looked at the x-ray. He gave us -medical students- that x-ray "he kept it with him as a teaching tool" and told us to read it. The first thing that struck me was the round opaque shadow that was located in the throat area, it was circular in shape and about 2 cm in diameter. I asked the doctor" is this an artifact in the x-ray?". He told me that he thought the same thing and asked to do another chest x-ray of the child. He showed it to us and the round shadow was still there. He told us" OK , what do you think?". I said"is this a foreign object stuck in the patient throat? how could he breath? how could the previous doctors missed it? it was so obvious?". He said" yes, that's right. It was a foreign object. A coin that was aspirated and was stuck in the trachea -windpipe-in a vertical way, that what made the wheezing sound. And for the cough symptoms it was because of the recurrent infection that was caused by the foreign object. And yes the doctors before me missed the obvious in the x-ray! that's why it's so important to read the x-ray thoroughly."

And for the child a simple procedure was done to remove the coin and he was free of any symptoms when he got back home.

For me it taught me a lesson to look for both the elephant and the ant in any case in the future :)