The Doctor Will See You Now [Non-Fiction]

Chapter 67: Acute Medicine

Quentin, Part 1.

My pager goes off and I answer it. The ward nurse informs me there is a new admission.

"A seventy-year-old man admitted for shortness of breath," she reads from the A+E notes over the phone. "Coming up to the ward currently on 10L of oxygen, blood pressure is stable, heart rate 120bpm, saturation 88%."

"88?!" I get up and hurry to the lift. "OK, I'm coming right now."

Oxygen saturation in the normal person without lung disease is usually at least 95% on air. On supplemental oxygen, this should be at least in the high 90s. 10L is a pretty significant amount of oxygen and to only saturate at 88% on that much O2 is bad news. This patient is very sick.

This patient is Quentin, a 70-year-old man with mild dementia, heart disease, diabetes, previous gallbladder infection (cholecystitis) which was complicated by a leg blood clot (deep vein thrombosis, DVT) which then threw a clot into his lung (pulmonary embolism, PE), for which he is on a blood thinner. He comes in very short of breath and drowsy. My immediate concern is if that PE has gotten bigger. His chest sounds clear and his chest x-ray isn't fuzzy anywhere, which makes me think it's less likely to be an infection. I turn up his oxygen to 15L -- full blast -- but his oxygen saturation remains at 90%, which is also bad news.

Plus, he shouldn't be getting a bigger clot if he has been taking his blood thinner. His wife confirms he has been good with his meds and takes them every day.

I am frank with the wife. Quentin is very sick. His lungs aren't getting enough oxygen. He's frail. He's either got a massive blood clot or he has a severe infection and his lungs are failing. He's got a high chance of suddenly getting very bad and dying. I ask her to decide quickly if she wants us to intubate (put a tube down his throat to help him breath) and to resuscitate (CPR) him if he continues to deteriorate. She is tearful and isn't sure. Her children are on their way. I encourage them to decide quickly before he does get to that point, otherwise we will jump on him to CPR if his heart stops.

Meanwhile, I grab ICU and Radiology on the phone. ICU to assess this critically ill patient as a potential candidate to ICU -- unlikely, given he was pretty much chairbound prior to admission so his baseline function is pretty poor, so it's likely he won't survive ICU even if they take him (and this is a critical part in ICU decision-making as to whether they take over a patient: whether they think the patient will actually survive the ICU stay. If the stay won't change the outcome, ICU won't take them.) -- and Radiology to urgently do a CT scan of this guy's chest (CT pulmonary angiogram, CTPA) to see if he really does have a humongous clot stuffing up his lungs. I change his oral blood thinners to a blood thinning injection (heparin), which acts quicker for the theoretical clot in his lung, and give him strong antibiotics.

His arterial blood gas, an artery blood test that shows a patient's oxygen, carbon dioxide, and blood acidity level, returns. pH is 7.15 (very acidotic, meaning he is very sick). pO2 (oxygen load) is 10, which is a normal reading if he were on air (i.e. on no extra oxygen). Quentin is on maximal oxygen therapy. This is very bad. pCO2 (carbon dioxide load) is 7, which is high. Quentin is in decompensated, Type 2 respiratory failure with mixed metabolic and respiratory acidosis.

ICU comes to see the patient and advises he is not an ICU candidate. They can intubate him but also suggests to try non-invasive ventilation (NIV) first, which is a machine to help him breathe by forcing him to breathe in and out via a tight face mask, and if that fails, they will intubate him if the family wishes.

Later, the family agrees not to intubate not to resuscitate (DNACPR). I start him on NIV and finish work for the day, half-expecting him to not be on the ward by the time I arrive the next morning.