Tag Archives: CO poisoning

Ignis Fatuus

ig·nis fat·u·us

1 : a phosphorescent light that hovers or flits over swampy ground at night, possibly caused by spontaneous combustion of gasses

2 : something that misleads or deludes; an illusion

“Some say his sweat can be used to clean precious metals and he appears on high-value stamps in Sweden. All we know is – he’s called The Stig.” A man in a white racing outfit and tinted visor accelerates an impossibly expensive sports car away from the starting line as he speeds around an air strip turned race track somewhere in England.

The crackle of the radio interrupts our moment of down time. “Medic-40, copy Code-3 for an unknown.”

Lifting the iPad off of the MDT I see the call information appear as Scottie acknowledges the dispatcher that we’re en route. Pressing pause on the video of our latest down time obsession, Top Gear (BBC version), I switch to the mapping application and plug in the new address. Scottie isn’t wearing a white racing outfit but he’s doing a good approximation of The Stig as we race our ambulance through the hood. I pull up the street view on the iPad to see the street level photographs of our destination.

“Hey, we’re going to the post office.” All I know is that we’re heading to the post office for an unknown emergency. The call information in the MDT is useless – it doesn’t say what’s going on or why we’re going there.

The fire engine beat us to the call, as they usually do in this area, so we walk right into the post office to see what’s going on. The firefighters are standing in the lobby with a short man in his forties. He’s dirty with black smudges on a shirt that used to be white and he tracks me with his eyes as I walk up.

The fire medic looks up as we approach. “Hey guys, we just got here a minute ago and we’re still trying to figure out what’s going on. Basically this guy has been wandering around the lobby for the last ten minutes and wouldn’t leave when the manager told him to. He’s not talking to us and he seems altered.”

“Great, let’s go to the hospital!” Unlike our friends across the pond in England I don’t have any alternative transport decisions. I’m quite envious of their ability to transport to an urgent care facility, or even schedule a home visit by nurse for later in the day. They can even refuse to transport someone based on no medical merit. I only have three possibilities on each call; transport to the ED, transport to emergency psychiatric services, or have the person sign an AMA (against medical advice) form. Since an altered person can’t sign out it’s obvious that I’m going to the ED and I can do all of my assessment en route.

My new patient, Jose, walks with me to the ambulance. Although he’s not talking to me I  can assess quite a bit just from a little walk. He’s moving all extremities without difficulty, he’s obeying commands as he walks, he’s looking at me when I talk to him, and his skin signs are normal. I’m not getting any smell of alcohol and that’s high on my list of rule-outs given his appearance and the neighborhood.

Scottie passes the computer back to me and starts driving to the ED. All of my assessments are coming back perfectly normal, even his blood sugar and 12-lead EKG. I attempt to check for nystagmus in the pupils but Jose doesn’t get the concept of following my pen and not turning his head. I hold his head straight and move my face to his peripheral extreme and tell him to look over at me. He’s finally able to do it and I see the characteristic pupils bouncing off the side of the eye that is usually indicative of a high blood alcohol level. I feel that I’ve got the best-rule out I’m going to get so I start an IV, put some oxygen on Jose, and start typing in my computer as Scottie gets closer to the ED.

About a mile from the ED Jose looks over at me, “Wh-where are we going?”

“Hey, Jose, we were a little worried about you so we’re taking you to the hospital. What’s your last name?”

He answers yet it’s slow. There’s no slur to the speech but he has a delay almost like he needs to think about the right answer before he tells me. I run him through some stroke tests and he passes without any noticeable deficits.

“H-how did I get here?”

“You were at the post office and they called us. Do you remember seeing me at the post office.”

“Y-yes.” He’s still delayed and has a round-eyed thousand yard stare.

“Why didn’t you talk to me earlier?”

He thinks for a second. “I-I don’t know.”

“How did you get to the post office?”

“I th-think I walked.”

“What were you doing before I saw you?”

“I’m n-not sure.” It must be strange for someone to be missing parts of their memory.

Just as Scottie puts the rig in park at the ED Jose has a revelation. “I th-think I know where I was. I was in the garage working on my son’s go-cart.”

Now I’m the one having a revelation. “Was the garage door closed?”

“Y-yes.”

Jose did in fact have elevated carbon monoxide levels in his blood. The CO bonded to the hemoglobin, pushing out the oxygen, and tricking my machine to read a 100% oxygen saturation. He was actually having a hypoxic event and the oxygen that I gave him helped him enough to start talking again. Although nystagmus is usually a sign of an elevated blood alcohol level, CO poisoning can create the same effect. Jose didn’t present with the typical flushed/rosy skin tone. Yet even if he did I would have seen that as a further sign of alcohol use. The black smudges on his shirt were not indicative of a homeless man yet they are a byproduct of being a mechanic. Sometimes a drunk is just a drunk but sometimes it’s a real emergency. It’s nice every once in a while to be reminded of that.  

We were able to confirm that no one else was in the garage when we called his family. I certainly didn’t want my next call to be for his son. He was discharged a few hours later with strict instructions not to enter the garage.