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Hi guys, it's been quite a while since I showed up here telling you a story.
I guess work has gotten the most of my time. I don't play StarCraft as often as I'd like, and even though I finally have the Hearthstone beta I can't play it as much either.
Still, so much work isn't so bad. It has gotten me quite a few stories to tell you. And I'd like to share one of them to you.
This happened just yesterday (yeah, I've just left a 24 hrs shift and I'm utterly destroyed, but what the hell). As I've told you a couple times before, I work at a small, small complexity countryside hospital in southern Chile. We have no laboratory or X rays on non-office hours and days. We make very rudimentary medicine with next to no resources. It's harsh. But we try to give our best and make a difference.
There's this patient most of the hospital already knows. It's a 50 years old male who has COPD (chronic Obstructive Pulmonary Disease) because he smoked like a motherfucking chimney for over 25 years. COPD is a bitch. It's like asthma, but much different. Asthma presents mostly in young patients, COPD in old, smoking patients. Asthma patients can recover full lung function with inhalers, COPD patients can't. COPD has been recognized to be progressive, Asthma isn't.
![[image loading]](http://img.medscape.com/article/725/444/725444-fig3.jpg) TLDR: Asthma vs COPD. Not the same thing.
This patient has what we call a COPD stage GOLD IV. GOLD stages mark how advanced the disease is. Stage IV means a patient depends on additional oxygen at home. The patient had additional oxygen prescribed as part of his therapy, 1 litre per minute for 16 hours a day.
He arrived at the ER yesterday morning, just after my medical round through the hospitalization ward, as I was arriving at the ER myself to start my shift. I've known this patient for years. He didn't look good at all. He was kinda bloated, blueish, and was breathing heavily, and had tremor in his hands and feet.
He's rushed into the ressusitation area.
Monitors are connected to him.
His blood oxygen saturation levels are at 60%.
High blood pressure. Very high heart rate. Heavy sweating.
An electrocadriogram is performed. Enlarged right heart (nothing strange for a patient like this), fast heart rhythm. Nothing more.
He was unconscious. He barely opened his eyes when I exerted pain manuevers. He's under a deep stupor.
I put my sthetoscope to his chest and listen. His heartbeat was very faint. Lung murmurr was barely hearable. No signs of obstruction, no wheezing, no secretions, no nothing. Just very very faint noises.
As I begun giving instructions to the paramedics and nurse about getting peripheral vein acceses to put him on certain meds, his wife then catches a glimpse at me and takes my arm and says "doctor, my husband has been using oxygen all day, 24-7, for the past week..."
That was the final piece of the diagnostic puzzle.
![[image loading]](http://upload.wikimedia.org/wikipedia/commons/thumb/3/35/Main_symptoms_of_carbon_dioxide_toxicity.svg/694px-Main_symptoms_of_carbon_dioxide_toxicity.svg.png) He was having a MASSIVE carbon dioxide retention.
You see, we breathe because of a rather clever mechanism in our brainstems. Our lungs let oxygen into our bloodstream, and elliminate excess carbon dioxide; this gas lowers the pH of the blood, thus, making it more acid. There are certain receptors for acidity in the brainstem that are vital to us. If blood is too acid, respiration is inhibited in order to keep the blood acidity balance through a complicated mechanism.
![[image loading]](http://emptynosesyndrome.org/wp-content/uploads/2013/02/Respiratory-7-21.jpg) TLDR no.2: The respiratory rhythm generator: A diagram of how it works.
Since this patient had been using fucking insane amounts of oxygen, he had artificially inhibited his ability to breathe. He was slowly shutting down the part of his brain which made him move his chest up and down to get air. If you don't breathe in the proper frecuency and amplitude, CO2 begins to accumulate in the bloodstream, thus lowering the blood's acidity, and inhibiting the breathing cycle. Excessive blood oxygen can also produce the same thing.
A fatal combination...
And suddenly, it happened.
He stopped breathing. He had a respiratory arrest.
It was just a matter of time before it happened.
I intubated the patient. It was a very difficult intubation. He had a short neck and prominent jaw. I managed to do it anyways, with the invaluable help of my head nurse who provided assistance with handling the airway and moving it around so I had a better view of the larynx when I was intubating.
![[image loading]](http://www.paramedicine.com/pmc/Secondary_A_files/droppedImage_1.jpg) An intubation procedure. That is, getting a tube inside the windpipe of a person in order to secure an airway and artificially give breaths to somebody. In short, "the tube of life".
I give a call to my referal center, a high complexity hospital 50 miles away from my location. My colleagues are informed of the severity of the situation; an advanced medicalized ambulance with an onboard mechanical ventilator is dispached to move the patient to the nearest ICU.
30 minutes later they arrive at my hospital. They take the patient to their centre and rush him into the ICU.
After the patient left, I continued attending the ER normally. When I had the chance, I gave the referal centre's ICU a call.
Patient had died 2 hours after admission from a cardiac arrest because of the massive disregulation his excessive oxygen use had produced. There was next to nothing to be done.
It's hard to believe how something so vital can be so deadly. But it is.
Oxygen can actually kill some of us.
Thanks for reading.
 
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Having worked in the 911 system with a wife going to nursing school I love reading this kind of medical info (especially when presented with the story and background) - Thanks for sharing!
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Actually, Oxygen is a poison with a high dose, the whole body regulates the amount of entering Oxygen and leaving Carbon Dioxyde, actually the pH sensors made him unable to evacuate the CO2 that started becoming carbonic acid (H2CO3 -> H+ + HCO3-), that inhibited the breathing cycle.
That was the CO2 and O2 that killed him, not only the O2.
There are two reason the patient died.
1. He smoked. Smoking (any herb, not tobacco only) is the first avoidable death cause. People seem to don't care, it is not only just cancer, but your whole body is damaged.
2. He did not follow O2 breathing instructions. Doctors must explain to people that following medical prescription is crucial, and that overtaking the treatment can be deadly.
Too bad he died, docs must inform more people regarding their treatment.
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On November 03 2013 04:22 vAtAZz wrote:
Actually, Oxygen is a poison with a high dose, the whole body regulates the amount of entering Oxygen and leaving Carbon Dioxyde, actually the pH sensors made him unable to evacuate the CO2 that started becoming carbonic acid (H2CO3 -> H+ + HCO3-), that inhibited the breathing cycle.
That was the CO2 and O2 that killed him, not only the O2.
There are two reason the patient died.
1. He smoked. Smoking (any herb, not tobacco only) is the first avoidable death cause. People seem to don't care, it is not only just cancer, but your whole body is damaged.
2. He did not follow O2 breathing instructions. Doctors must explain to people that following medical prescription is crucial, and that overtaking the treatment can be deadly.
Too bad he died, docs must inform more people regarding their treatment.
Indeed.
COPD and CO2 retention cannot be disregarded. It was the combination of both O2 overtaking and CO2 retention what caused his death.
He was informed time and time again, even by the respirologist. He had undergone 2 long ICU hospitalizations this year. It was pretty damn sad to see his wife lamenting over the fact he was a stubborn man who had everything his way. We can't get over the fact people sometimes just disregard the information we give them and do their own thing.
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Fighting urge to write it in more succinct way. Must.....resist.....
Was the guy in ICU for straight up respiratory failure secondary to oxygen or was it pneumonia? Just out of interest?
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On November 03 2013 04:45 MoonfireSpam wrote:
Fighting urge to write it in more succinct way. Must.....resist.....
Was the guy in ICU for straight up respiratory failure secondary to oxygen or was it pneumonia? Just out of interest?
Respiratory faliure secondary to oxygen overuse.
Or could have just gone with "accute over chronic respiratory acidosis".
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On November 03 2013 04:53 UmbraaeternuS wrote:Show nested quote +On November 03 2013 04:45 MoonfireSpam wrote:
Fighting urge to write it in more succinct way. Must.....resist.....
Was the guy in ICU for straight up respiratory failure secondary to oxygen or was it pneumonia? Just out of interest? Respiratory faliure secondary to oxygen overuse. Or could have just gone with "accute over chronic respiratory acidosis".
Acute on chronic respiratory failure is too vague :p
Interestin tho. Ta for the story, only met a few with lungs that fucked up from COPD, but they died from other things.
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Thanks for the story, as always,
I knew too much oxygen was poisonous, interesting to read the details (and about a real case).
Also, very saddening that stubbornness was the original cause. :/ But almost impossible to treat.
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On November 03 2013 05:37 Badjas wrote:
Thanks for the story, as always,
I knew too much oxygen was poisonous, interesting to read the details (and about a real case).
Also, very saddening that stubbornness was the original cause. :/ But almost impossible to treat.
Not so much stubbornness as lack of education. Guy like that gets a script for oxygen, comes home and starts using it and suddenly feels better. The doctor giving him the O2 never explained to him what hypoxic drive is, and that it's the reason he's on such a restricted flow and usage rate, so he figures "if a little is good, a lot is great."
Wish I could say it's uncommon, but being a paramedic myself, I can say I pretty much saw this one coming when you said "COPD patient on home oxygen."
It's totally possible to treat though, with an intubation and mechanical ventilator like the OP put him on... just came in to the hospital too late  .
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oh man thats really sad. i was hoping for a happy ending, but i guess thats reality. thank you for sharing the story with us,
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LOVE reading these, thanks once again for writing it up
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Thanks for sharing the story. It must be terrible to see someone die out of stubbornness. Good luck in your work mate.
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I LOVE the way you word things sometimes, I find it so hilarious!!
"It's a 50 years old male who has COPD (chronic Obstructive Pulmonary Disease) because he smoked like a motherfucking chimney for over 25 years." XD
Anyway...umm...I suppose its a tragedy and everything. Unfortunately I don't know him and you're in Chile so I can't empathize very easily. All I can say is your blogs are very informative and highly entertaining. It sounds like being a doctor is an incredibly tiring, laborious job
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I guess Paracelsus was right
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I've missed your blogs, they are always interesting. Thanks!
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The hypoxic drive theory has actually never been proven with studies. Some studies have shown approximately 25 % of COPDs (chronic retainers) will decrease ventilation minimally given excessive oxygen.
The general theory for it is fine and what it does to our practice generally is fine as well as it encourages us to use less oxygen for COPD patients (generally sat goals of 88-92 %). This is perfect as there is no benefit in trying to keep a COPD patients PaO2 at 80 - 100 mmHg but there is a lot of harm from the toxic qualities of oxygen.
Many physicians treat this theory like the holy grail and for the most part that's fine because it indirectly causes the correct choices to be made. Just keep in mind that you should never withhold oxygen from any patient who needs it. If a COPD patient is desating give them oxygen; the damage done to their hearts and other organs is significantly more severe than the very minimal decrease in ventilation of a small percentage of COPDers.
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too much of anything can kill you
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On November 04 2013 15:04 HURM wrote:
Just keep in mind that you should never withhold oxygen from any patient who needs it. If a COPD patient is desating give them oxygen; the damage done to their hearts and other organs is significantly more severe than the very minimal decrease in ventilation of a small percentage of COPDers.
True.
Sometimes we forget how important this very thing is. Hypoxic damage to the heart and other organs is severe and sometimes the temptation not to act on improving sats in exacerbated COPDers gets the best of us.
Great advice.
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Drinking water can kill you too, 100% of the people who drank water during their life will/have die(ed)
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On November 05 2013 07:24 algue wrote:
Drinking water can kill you too, 100% of the people who drank water during their life will/have die(ed)
No joke. My first blog of the year (Jan 1st) explained how a patient almost died because he drank too much water...
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On November 05 2013 07:24 algue wrote:
Drinking water can kill you too, 100% of the people who drank water during their life will/have die(ed)
Water intoxication can be lethal. I know you were just joking around but it is true and heck I almost did a lot of damage to myself playing century club with my friends as a protest.
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We're all going to die someday. Hopefully he lived a fun filled life. Sounds like he lived to be pretty old if he lived to develop COPD. Hopefully he enjoyed smoking cigarettes.
Regardless of him having an enlarged heart and other problems we will all end up as dust, as we all started as dust.
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EPT
