Smoke Gets in Your Eyes

I send my intern to get the chart so he can present the emphysema patient. While he does this, I look in on our drunken friend and see she has quieted down. Her eyes are closed and she is no longer talking. Her eyes are moving under their lids rapidly and she is mugging a bit. I imagine she is having quite a conversation inside her head, or maybe she is dreaming of chasing rabbits. Seeing how quickly she quieted down, I feel a bit badly for laying so hard into my intern.

I go back into the consult room and listen as my intern presents his patient. She is, he tells me, a 65 year-old white woman with a profound smoking history, uses oxygen at home, and comes to the ED with a worsening of her shortness of breath.

There are two things about smokers that are very boring that my intern confuses with very interesting.

The first boring thing about smokers is that they tell you they have quit. Medical students fall for this all the time, I am a little disappointed that my intern fell for it. The important follow up question is, ‘how many hours ago?’

The other boring thing about them is that they still smoke. When family and friends complain that a patient hasn’t quit smoking despite slowly suffocating, I feel sleepy.

He finishes telling me about the patient, making a few minor errors. I correct his terminology and we progress. His assessment is that the patient has multilobar pneumonia and an exacerbation of her emphysema. He feels she is stable, but needs to be admitted to our service for IV fluids & antibiotics, steroids, nebulizer treatments, oxygen and monitoring.

This next bit hinges on a technical detail. I will try to keep it as streamlined as possible.

The reason my intern and the emergency resident felt the patient was stable was despite her looking sick, her arterial blood gas looked good.

A blood gas tells us a patient’s pH, oxygen, carbon dioxide, and bicarb levels. The body regulates these very stringently and fluctuations in any of them have a profound effect on the others.

Her numbers were pretty normal, aside from a slightly low oxygenation. This was what they were taking comfort in.

But what they didn’t consider is that patients with severe emphysema often have very abnormal results. They typically show a high carbon dioxide and bicarb. A normal lab in an abnormal patient can signal a problem. That both values had normalized suggested to me that she had been having a lot of trouble oxygenating her blood for at least several days. For her to resolve her compensatory metabolic alkalosis as well as her respiratory acidosis suggested to me that she would be reaching the point of exhaustion and would likely require intubation soon.


I was concerned and suggested we examine the patient together...