Pulmonary Medicine Sample Case 1.pdf

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AIDS Patient with Pneumonia Receives Steroids and No Ventilator Which Causes Premature Death.

When a patient is HIV positive and has AIDS (Acquired Immuno-Deficiency Syndrome), his immune system is very impaired. This patient is very susceptible to infections, including pneumonia. 

If a patient has asthma (a spasm of the brachial tubes), then in addition to bronchial dilator medications and antibiotics (if he has an infection), the use of steroid medications may be necessary to help overcome the allergic nature of the cause of the bronchial tube spasm. The lungs will have high-pitched wheezes, not rhonchi (wet, congested) breath sounds. 

This patient, at age 62, was HIV positive and developed shortness of breath and pneumonia. He had “rhonchi” and no wheezing. There are no x-ray reports in the medical records, and they should be obtained. 

In the Emergency Room, he was evaluated and they noted he had been to other Hospital Emergency Rooms recently and received antibiotics. Their records should be obtained. 

He received antibiotic therapy for his pneumonia. The usual standard of care is to obtain a sputum (deep cough) specimen for laboratory testing (culture and sensitivity) to determine which germs are present, and the best antibiotics to kill them. I do not find that in the records, and if it was not done, is a departure from the proper standards of care. 

Upon arrival and for the entire stay (6/24-7/1), he received potent steroid medication by intravenous injection (30-60 milligrams of Solu-Medrol every 6-12 hours). He had no wheezing or evidence of bronchial spasm. In my opinion, this worsened his already damaged system’s ability to combat any infection. 

On admission, his arterial blood oxygen level was very poor and required an oxygen mask. I will discuss this issue in some detail. The red blood cell pigment is called hemoglobin. It holds oxygen like a sponge holds water. However, its grip is not linear. It follows an “S” shaped curve. Room air is 21% oxygen. With normal lungs, the pressure of oxygen in the blood is 95-99 (PO2 ,also called TORR). The saturation of the hemoglobin is normally close to 100%. With lung disease (including pneumonia), less oxygen enters the blood, but the hemoglobin still is highly saturated. With an oxygen pressure of 50-60, the hemoglobin is usually 85% saturated. But that is at the beginning of the sharp downslope of the “S” shape curve. With a little further drop off of the arterial blood oxygen pressure (PO2), the saturation falls dramatically, the patient turns blue and will die. 

In his case, on 6/23 at 3:28 p.m., his PO2 was 74.2 and his oxygen (O2) saturation was 86.5%. On 6/30, with an oxygen mask giving him 50% oxygen to breathe (versus 21% on room air), his PO2 (oxygen pressure in his aterial blood) was only 50.8 and his oxygen saturation was 90%. His condition worsened late that night. He was not intubated (tube put into his windpipe (trachea) and a ventilator was not used to force oxygen into his lungs to increase the oxygen in his blood). The oxygen mask would not work with his lungs failing from pneumonia. 

His blood count also worsened, consistent with severe infection. The white blood count (WBC) ws normal on 6/23 at 5100 and had risen to 12,000 on 6/30. But the differential smear changed (shift to the left), consistent with severe infection. 

He became very anemic (less red blood cells and hemoglobin to carry any oxygen to his body’s cells), the platelet count (clotting particles made in his bone marrow) dropped severely (thrombocytopenia) and he would bleed. All this hospital stay he received high doses of the steroid drug Solu-Medrol, as I noted. 

He required this ventilation mask, but then on 6/30, he required the intubation and ventilator. However, on 6/30, at 8 p.m., when he was still alert and conscious, he signed a Consent Form for “no intubation.” The Hospital Personnel considered this the same as a Do Not Resuscitate (DNR) order, but it is not quite the same. As few hours later, they watched him die. 

In my opinion, the abuse of steroids allowed the lung infection (pneumonia) to progress, which ended his damaged life. Without the steroids and with the correct antibiotics and pulmonary care, he had a better chance to live. 

I suggest that you obtain the missing records (x-ray reports and any culture and sensitivity bacterial reports). I also suggest that you obtain good copies of the chest x-rays and the previous emergency room records, plus all documentation as to his HIV and AIDS status. Then authorize us to have all these records evaluated by Board Certified Experts in Pulmonary Medicine, Emergency Medicine and Infectious Disease for their opinions as to the care at this Hospital and those Physicians, as well as try to determine his AIDS status and potential longevity. 

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