Coughing Fits

I was working the night shift at a local ER when a large gentleman drove up to the ER ambulance doors. He honked the horn a couple of times and waited for someone to come out and help him. He was sitting in a faded bluish-green Buick and was holding his right hand on his left chest. Occasionally a tremendous cough would rack his corpulent body.

You couldn’t see it in the dim outside lights but he was hospital sheet white and sweating rivers. As we approached we could tell the situation was just about out of control. Because of the extreme size of the patient we opted to transfer him directly to a gurney rather than a wheelchair. He coughed and wheezed soaking us with sweat as we helped him from his car. We immediately rushed him to the first trauma bed and began to undress and asses him. Stat O2, EKG, CXR, and blood work were ordered. After the chest x-ray (CXR) was returned to the department we could see exactly what the problem was. The entire left lung glowed white on the x-ray. Air, what is supposed to be in the lungs, shows up as black on x-rays. Generally the more dense a material the lighter it shows up on x-ray. Air is black, tissue is opaque, bone comes in shades of gray to white, and metal usually shows up glowing white. Liquids (blood) show up white.

Although in great pain the patient was able to tell us what had happened. He was a salesman and used his car as his office. He had stopped at Walmart to get some supplies and after he was done shopping he sat in the front seat of his car. There he experienced a coughing fit. A severe coughing fit that just would not stop. After about five minutes of severe coughing and shortness of breath he had a searing sharp stabbing left chest pain and the shortness of breath worsened.

He was quite calm and thought that there was probably something wrong so he called 911 and waited for help. This was about 0200. The usual two engines, one truck, and one ambulance were dispatched. Fourteen people in all to handle one questionable emergency. Ah the efficiency of the Phoenix Fire Department.

When the first paramedic on the scene arrived he began the process of evaluating the patient. I have no idea if he listened to the patients heart or lungs or even actually looked at the patient. The patient told me that the medics came out, asked what happened, told him his chest pain was probably a pulled muscle from coughing, then drove away. He was left to his own to drive to the hospital. Later when the engine company transported another patient to our ER I told them of their fuck-up. No one was apologetic.

Anyway, at some point I listened to the patients lungs. I wasn’t sure what I was hearing because the patient was so large assessment was very difficult. The doctor listened as did another nurse and we were all a little concerned. Once the x-ray was returned and we could see that the entire left lung was full of fluid we were even more concerned.

I set up a chest tube set. I used the standard chest tube set not the autotransfusion one, a small mistake. When the doctor cut into the skin and advanced the trochar through the chest wall, eliciting that unique crunching sound, blood began to run from the wound. As the doctor guided the chest tube into the pleural space blood shot out the end of the chest tube and shot all over the ER. The doctor quickly put his finger over the end of the chest tube and we connected the entire set up. Blood began to drain into the chest tube. When 1500 cc’s filled the first collection device I hooked up the second one. Blood continued to flow.

We informed the doctor and he ordered a type and cross, hold 4 units. The second 1500 cc collection device filled and I replaced it with another new collection container. By now we were pretty concerned. The patient had lost over 3000 cc’s it short order. He said the pain had subsided and he was breathing easier, but he started to turn a sallow yellow color that corpses turn as the blood stops circulating in the body. We rushed him upstairs to the ICU and heard later that in surgery he received 17 units of blood. One week after discharge he returned and required another 12 units of blood for the same problem. I cared for him in the ER for both visits.

He was just one of those people who coughed so hard he ruptured a blood vessel in his lungs and ended up with a severe hemothorax.

Lesson: When you see a patient in the field it might not always be a bullshit call.

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