“So who, among you, let’s see, one, two, three…six, would so kindly explain to our dear patient, Mrs. Hudson, and perhaps to me as well. Mrs, Hudson, my favorite patient of all time, a seasoned asthma survivor, presented with pulsus paradoxus when she was admitted into the ER last night. Listen up, what is the pathophysiology behind all this. Or let me rephrase it this way in case you don’t understand: Mechanism, please.” asked Dr. Montag, an attending hospitalist in his mid 50s, admittedly, enjoyed the fast-pace of the hospital setting, but what’s more, the everyday helpless, exhausted faces of these young future doctors’. He was well-known among the residents and the medical students, or infamously, to be precise, had a vigorous teaching discipline.
No one was making a sound, not a bit. The only audible presence at that moment was Mrs. Hudson’s labored breathing. But the atmosphere of this room was so intense that even she, poor lady, was trying so hard to hide the noise she made while effortfully breathing through the mask.
“Oh, dear lord, give your mercy on these kids”, she said to herself, with an apologetic look at those doctor-soon-to-bes, if only she was able to give a hint, be it minute, a simple hint. Yet she knew nothing, nothing medicine at all, she’s an editor of a local newspaper, had no medical exposure whatsoever, other than a constant visitor to her doctor’s office of course. “Pulsus paradoxus, sounds like Latin, I should pick up my Latin again, when was it, the last time I had a Latin word pass my lips? What was it? Vivamus…vivamus….
Vivamus, mea Lesbia, atque amemus,
rumoresque senum severiorum
omnes unius aestimemus assis!
soles occidere et redire possunt:
nobis cum semel occidit brevis lux,
nox est perpetua una dormienda.
da mi basia mille, deinde centum,
dein mille altera, dein secunda centum,
deinde usque altera mille, deinde centum.
dein, cum milia multa fecerimus,
She soon immersed herself into the youthful memory sparkled by a medical term, eyes gently closed.
Meanwhile the group of nervous-to-death medical students were staring at her, everyone, six pairs of eyeballs, doubled with glasses, all on her, trying to dig the answer out of her face, her hair, her nose, her chin, her earrings.
“She has makeup on, “ one desperate kid noticed. “what a lady, she looks so classic.”
That was the moment when you can tell someone started to crash, he started noticing things that were far from relevant at that very point of time , you can hear him crying deep down, with the ultimate self-questioning -“WHY ON EARTH AM I HERE?!”
“Dynamic hyperinflation”, murmured someone back in the crowd.
“Louder please, it’s not a secret, no one is going to steal it, say it loud.” with a bit surprise, demanded Dr. Montag.
This brought back Mrs. Hudson, before she could finish enjoying her college times.
“It’s mainly due to DYNAMIC HYPERINFLATION”, like an announcement, an Asian guy came forward. It was actually not he himself stood out, it was rather other students made some space for this “oh god he saved us” announcement.
“Very well, go on.” a faint smile flashed across Dr.Montag’s face, though soon faded away.
“Normally, there’s a small variation in intrathoracic pressure with respiration, which drops 2-5mmHg below atmospheric pressure during inspiration,”
One kid next to this guy was texting his friend: “Room 303, come to see god and his divine miracle.”
“In patient with severe asthma and COPD,” the Asian guy continued, with an Asian accent, apparently, he had some difficulty pronouncing the “th” in “asthma”. “the drop in intrathoracic pressure is greatly exaggerated, up to 40mmHg. This negative pressure causes pooling of blood in the pulmonary vasculature, decreasing left ventricular preload. Marked expansion of the lung in asthma and COPD can also impinge upon the outward expansion of the heart. Together, these factors lead to an excessive drop in blood pressure that is detected as pulsus paradoxus”
“Oh dear lord, what a lovely bright kid.” again, Mrs. Hudson praying.
“Bravo! What’s your name my son?” Dr. Montag asked, nodding his head, for the first time this month.
“Zhen, sir. Zhen, Tian.” replied the guy, humbly, yet in confidence, whose name, later in the next 5 years, would become the one that people will always refer to as “THE dermatologist I would ever recommend”