Clump Clump

At 3 AM I was feeling like a cop on his beat, only my tools were a penlight and a stethoscope, not a badge and a gun. I had made one mistake however, and worn my leather soled shoes, not the quiet rubber ones. I tried to step quietly, but each footfall made an echoing sound in the long empty hallway. During the day and evening shifts, the corridors were so noisy that my footsteps went unnoticed, but in the middle of the night they sounded almost… ominous.

About halfway down the corridor, I heard a small cough to my left, and saw a frowning, gray haired  woman standing in the doorway to her room. Her arms were folded, her thin lips pursed in disapproval, coconut knees and broomstick legs poking from beneath her hospital johnny..

“Clump. Clump. Clump – Young man, you sound like the damned Angel of Death walking down this hallway!”

“Sorry ma’am, just answering a page by one of the nurses. Please try to sleep.”

A few noisy steps later I was at the nurses station and Donna, the night charge nurse, gave me a wry grin.

“I hear Mrs. Johnson gave you your comeuppance huh Rob?”

“I forgot my quiet shoes, I don’t blame her actually. Why the urgent page?”

Donna then gave a quick report as she steered me toward the patient’s room, directly across from the nurse’s station.

“Mr Lightman is a 58 year old diabetic black male, four days post M.I. (heart attack, or myocardial infarction), Transferred from Coronary Care last evening. He now complains of shortness of breath. Respiratory rate 32, pulse 124, blood pressure 78/56, skin is cool. His O2 saturation is 83% (anything below 88% we get worried about) on nasal cannula at 4 liters.”

“Any chest pain?”

Donna shook her head, “No he hasn’t mentioned any.”

"Any history of respiratory illness?”

“None charted.”

We entered the room and I observed a heavy set, anxious appearing black male sitting up in bed. I noticed a bag containing a small amount of dark urine attached to the bed rail and a tube leading under the sheet.

Donna introduced me, and Lightman nodded. “Jack,” he gasped between breaths.

“Donna let’s change the nasal cannula to an O2 mask at 12 liters. OK Jack, I’m gonna do a quick check here, and help you to feel a bit better.”

I listened to his chest starting at the top, then moving side to side as I moved down to the bases of his lung fields. It always helps to compare one side to the other. I like to close my eyes when I listen to a patient’s chest, because it seems to me I can hear better. His heart sounds were faint but normal. About half way down I heard what I had feared, high pitched crackling sounds with every inspiration. Rales – a sure sign of fluid in the lungs. We leaned him forward and as Donna supported his chest, I listened to his back, and once again heard the telltale rales. For some reason, his lungs were filling with fluid.

Fluid in the lungs can have many causes, but the most common, especially post M.I., is usually due to heart failure. The injured heart can’t pump out all the blood that flows into it, so the blood backs up into the lungs. If it backs up enough, the plasma leaks into the little airspaces, and as it mixes with the inspired air, turns to foam. In severe cases, pink foam can actually flow from the patient’s nose and mouth. Non medical people always describe this as ‘downing in his own fluids,’ but it’s essentially correct. Once in ER I had seen a three pack per day smoker in severe failure, and the foam coming out was not pink, but brown.

Another way fluid may back up into the lungs is simply that there may be too much fluid in the body. This usually occurs when the kidneys fail to excrete enough urine. There are many causes of kidney failure, but the two I was thinking of with Jack were: First, an effect of his kidneys not getting enough blood flow during his heart attack. This puts the kidneys into shock, and they may fail a few days later. Second, a complication of his diabetes.
I looked at the urine bag and again noted the small amount and dark, concentrated color. “Donna, whats his output?”

“Less than 20 ml since the shift started. I was about to call you about that when I noticed he was having respiratory distress too.” Usually you want a patient to average about 30 ml per hour.

“Jack it seems to me that you have some fluid in your lungs. I’m not sure yet what’s causing it, but I’m ordering some medications that should make you feel better pretty soon.” I put my hand on his shoulder and gave it a squeeze. He was too short of breath to do more than nod.

I gave orders for some I.V. meds. First, a diuretic to help excrete more of the retained fluid; second a medication to increase the force of his heartbeat to help drain the lungs, and third, a little morphine. Morphine is ideal in this situation because it does two important things: first, it lessens the feeling of shortness of breath, and second, it causes a dilation of the distal veins, causing some of the extra fluids to pool in Jack’s extremities, and not clog up his heart. I adjusted the hospital bed so Jack was sitting straight up. Gravity could help a little in draining his lungs.

I drew some blood to test for kidney and heart function as Donna got a urine sample from the collection bag. We sent them to the lab for STAT testing.

By the time we finished starting the IV medications and drawing the blood, Jack was breathing a bit easier. Respirations down to 28, pulse 116 and his oxygen saturation had increased to 87%, not great, but a definite improvement.

I sat down in the bedside chair to review Jack’s chart. As I read I noticed Jack looking at me. He seemed a little less anxious so I gave him a wink.

“I’m feelin’ better Doc.”

I wondered if it was the meds kicking in, or just his knowing that someone was with him, and decided it was possibly a little of both.

As I read his chart I noticed that his kidney indicators since admission were all borderline high, and his blood glucose levels seemed hard to stabilize. Perhaps it was kidney failure secondary to diabetes or the shock from his MI after all. I would know for sure when the STAT labs came back.

I gave Jack a pat on the shoulder and told him I would be right outside his room at the nurse’s station, and to buzz if he had any problems. Donna was hanging up the phone and gave me the lab values she had jus

t written down. All the kidney indicators were up. Jack was in kidney failure. I wrote an order for a consult from nephrology (kidney) services. It was close to 5 AM now, and I checked on Jack one last time. He was sleeping, and the numbers on his monitor were all close to the normal range. I always found it amazing how fast patients can respond to the proper meds under the right conditions.

I tried to walk quietly on my way back to the call room, but my leather soles were echoing in the deserted hallway again. Clump. Clump. I couldn’t help it. As I passed Mrs Johnson’s room I saw her glaring at me from her bed, and remembered her comment about sounding like the Angel of Death approaching.

“Not tonight Mrs Johnson,” I thought, “not tonight.”