Dave Caesar: Another day in the life of a doctor

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Dave Caesar, clinical director of emergency medicine, Edinburgh Royal Infirmary and St John’s Hospital, Livingston, has a patient who has turned blue

Blue Man Show

BARRY is one of life’s ­unlucky ones – 20-years old, in with a bad crowd, easily led astray, and often the butt of his pals’ jokes.

He has a job, though, at a decorating company, and has a bit of cash to spend.

Last weekend was no different to many for Barry, but, it being Festival time, the venues were all a bit different. The excitement of extra crowds of tourists, offbeat fringe performers promoting their talents, pop-up stalls and entertainment, balmy weather, and drinking outside, had all led to a slightly deeper “thirst” than usual.

By 11pm that night, Barry and his pals had consumed enough alcohol to sink one of the cruise ships down in the docks.By 2am, one of the gang had got hold of some cocaine, and, as was often the case, it was Barry that they were egging on to take some and he cracked.

The rest of the night was not very clear for Barry. He remembers feeling slightly underwhelmed after snorting the white powder, and then not really recalling how he got home. He did have the usual good sense to eat something before bed, but that could not prevent him waking on Sunday with a hangover like no others.

It didn’t feel like his normal post-alcohol headache and mild nausea. He certainly had both symptoms this morning, but what struck him most was his complete inability to get his breath. He had no pain in his chest or cough, but any slight movement, even getting out of bed, left him gasping for breath. He finally made it to the bathroom, and was startled by what he saw in the mirror.

Barry never looked his best after 14 pints and some recreational Class A narcotics, but this morning he hardly recognised himself. He first wondered whether his eyes had been affected by something or other, as he had this unmistakable tinge of blue to him. In fact, when he looked closer, it was more than a tinge, his lips and his tongue were deep blue. The combination of a lack of sleep and breath, the mother of all hangovers, and starting to look like you might be turning into a smurf would scare most people. In Barry, it was outright panic – 999 was dialled, and, after a frantic exchange with the call-­handler, an ambulance arrived and took Barry to the Emergency Department.

En route, the ambulance paramedic had done some of their routine measurements of pulse, blood pressure and oxygen levels. The pulse was high, more than 120 beats per minute, and the oxygen levels were low, sitting at 85 per cent (normally a 20-year-old would have oxygen levels comfortably more than 95 per cent). The paramedic started to administer some oxygen through a mask to Barry, but this seemed to make no difference to his levels. He still felt and looked extremely breathless. With all these features (and the undoubted blueness of Barry), the ambulance crew requested a stand-by medical and nursing team for him in the resuscitation room in the Emergency Department.

On arriving at the ED, Barry is whisked into the resus’ room, and we receive a handover from the ­ambulance crew summarising the story so far, and what treatment has been given, and how effective it has been. Barry’s details are then entered into our electronic patient management system, so we can order tests and entering information.

At the same time, we are starting to attach monitoring equipment to Barry to keep track of his pulse, oxygen levels, blood pressure, breathing rate and the heart’s electrical activity. We are also taking a brief focused story of what happened to Barry, and how he is feeling now.

(No previous illnesses, no allergies, no regular meds. Check) We take two different blood types – one set venous, and one smaller from the artery in the wrist. This arterial sample is important as it gives us information that will confirm and quantify the diagnosis. The venous samples will check his bodily functions, but the look of the blood is almost diagnostic on its own: it is chocolate brown.

We briefly examine him – particularly his chest to ensure no cause for breathlessness reveals itself – but the most salient finding is his blueness. Barry has a condition called methaemoglobinaemia. It is caused by various compounds, some legal and prescribed, some illegal, that convert our normal blood molecule, haemoglobin, into an alternative form, methaemoglobin. This form is unable to carry oxygen as well, making you go blue (no matter how much oxygen you give patients), and feel breathless. It can cause all sorts of possible problems, including heart attacks and strokes, as the body is essentially starved of oxygen.

Slightly un-nervingly for patients, the treatment is to convert the methaemoglobin back to normal haemoglobin with a compound we inject slowly through the drip.

This compound is methylene blue, which, as the name suggests, is bright blue.

So we end up giving a blue man a whole syringe worth of bright blue solution, and, after 45 minutes or so, Barry is breathing much easier, looking human and back to being pink again.