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I am still learning

Posted Dec 18 2012 1:25am
It's good in this biz to get a patient with something you've never seen before. It keeps you on your toes, reminds you to be humble, and gets you to dust off those old textbooks. I had a guy who very late in the day had a few too many beers to drink. He stumbled backwards off of his porch (I'd guess a couple of feet, though I never saw the porch) and got a pain in his back. But, he managed to brush himself off, sit back down on the porch and crack open another cold one. Less than an hour later, though, he started to feel short of breath.
This is the part where I come in, finding him wandering through the back of his property nowhere near a house. (hence how I never even saw what he fell off of). He looked peculiar to say the least. Stumbling in the dark, he was caught by our headlights by chance. For a moment I thought I was in a zombie movie as we watched him grope for a hand hold that wasn't there while moaning between unintelligible words. We walked him to the ambulance and tried to get his story straight.
In a well lit setting he looked like he had been stung by bees. His face was swollen beyond recognition, red and angry. His eyes were all but swollen shut. He managed to tell us about his beers and his fall of the porch, but that didn't add up for me. He hadn't eaten anything else for hours and it seemed unlikely that he would have stirred up bees at that wee hour.
With mild wheezing (but moving air) and all other normal vital signs, he got a neb and a transport. Though I can assure you my worried brow was furrowed the entire transport. He didn't appear to be getting worse, but certainly wasn't getting better. Now, the astute medical practitioners may already know the moral of this story, but I, for the life of me, was vexed and worried.
In the ER, we did attract attention. People that look like they're face might explode tend to do that. He was put in a gown when it appeared the swelling had made it down to his chest. How odd, thought I, as I instinctively reached out to touch him. His skin was like weak popping paper and my diagnosing lighbulb finally got a little power.
 'He has sub-q air.' said the nurse, and then they were off. The patient was not well by a long shot, but still not horrible in the sense that his vitals were normal and he wasn't struggling terribly to breathe. But now he had earned the trauma treatment, and I will try to explain why.
When he fell of his porch, his back hurt because he broke a rib. Said rib poked through into his lung. He kept breathing, of course, and air that should have stayed in the lung, moved into the space between the lung and this outside. (under the skin) This air traveled through this space and because of gravity ended up in his face and head. As he continued to breathe, the air continued to fill in the wrong spaces, traveling south as the space filled up. This is called subcutaneous emphysema. Eventually, this leaking air screwed up the pressure system that makes breathing possible and collapsed a small part of his lung. Therefore, he was full of air and won himself a chest tube. I really, really hope that I've explained this correctly and in an understandable way. Please correct me if I'm wrong.

So, there's that. Something I hadn't seen in real life. This is not a common occurrence and my colleagues could only think of one other time they'd seen it. (the medic then had treated the patient for an allergic reaction). Don't drink alone and fall of your porch in the middle of the night. Do assess your whole patient and try to piece it together as best you can. Do fulfill the function of taking patients to the hospital. Do be happy you didn't freak out and treat him for anaphylaxis which would have been so, so wrong. Do be totally grossed out about how sub-q air feels like popping paper. Gross.
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