Still Smoking...

Several times each shift I encounter an older male or female with emphysema from prolonged smoking who is brought in to the ER after calling 911 because they are short of breath. (really- you’re having trouble breathing after smoking for 30 years? Go figure). By the time they get to me they are often starting to feel a little better after getting nebulized albuterol and supplemental oxygen from the paramedics. I throw in some steroids and more breathing treatments in addition to some antibiotics if they are hawking up a lot of phlegm, and if they still can’t walk around without dropping their blood oxygen saturation I admit them to the hospital (again) for more rounds of treatment. My personal favorite was a fairly obese woman, probably 350 pounds, who was brought in by medics regularly for altered mental status due to hypercarbia – meaning she had destroyed her lungs so much that she could barely breathe enough to exhale and off-gas all the carbon dioxide her prodigious body was producing. Too much carbon dioxide leads to hypercarbic narcosis which is an altered mental state that further impairs the ability to breathe and the patient spirals down from there. This patient would arrive to the ER and get intubated (time after time) so that we could mechanically breathe for her and reduce her sky-high carbon dioxide levels. The really sad thing was that the patient’s sister (who also is a smoker) would see the patient getting sicker and sicker and would try to get the patient to call 911, but the patient would persistently refuse because she knew she wouldn’t be allowed to smoke in the hospital. So the patient’s sister would watch carefully while they patient chain-smoked herself into a stupor – often still with a lit cigarette between her lips or fingers- before calling 911 for a trip to the hospital and another lengthy and costly ICU stay. I have walked into exam rooms to see a patient and have almost choked because my patients were giving off fumes so bad I could swear they had just smoked a pack in the room. I’ve had to apologize and open the door so I could breathe enough to complete my history and physical exam and decide how to treat the patient. Then I would leave the room gratefully breathing in (relatively) fresh air only to discover that I could taste the sickening flavor of tar on my lips and smell the smoke on my scrubs just from being close to these people. They smoked so much it stained their fingertips, impregnated their hair, and gave them breath that would cause me to gag when I had to examine their oral cavity (when your patient’s breath smells worse than their ass you know you’re in trouble). I can’t judge to harshly because I smoked while growing up, but after seeing the long term effects that have destroyed so many people- some of them very endearing and pleasant patients- I am glad I dropped that habit before I developed emphysema and had to make weekly visits to the ER for shortness of breath.