In our ED we have some recliners that are where we put asthma patients to suck on their nebulizers. Unfortunately, when we are crowded, we put all sorts of patients there.
This weekend, I got a young gentleman who was complaining of shortness of breath and chest pain. He had a negative EKG, and on further investigation, he mentioned that he had smoked a little pot that morning and was feeling a little paranoid. He was a little anxious appearing, but was basically all right.
It was very crowded, and he was sitting around for about an hour, waiting to see the doctor. I was running around like a chicken with its head cut off, taking care of the actual asthma attacks, and some renal failures and cellulituses (celluliti?) that got put in the chairs, when I looked over and saw that he looked a little pale and dusky around the lips. I checked his O2 sat, and it was 89 on room air. He admitted that he was feeling a little "weird" and "freaked out." I told the charge nurse I would probably need a bed for this guy, started him on 100% O2 via a nonrebreather mask (one of the ones that has the little bag hanging off it to act as a reservoir for the oxygen), and decided to draw some bloods and pop a line in there just in case.
He warned me that he "didn't like needles," so I put his feet up in the recliner. Sure enough, as I flushed the line, he vagaled out on me: his eyes rolled back in his head and he did the little vagal dance with his hands and feet (you know the one--they clench and release a couple of times and then stop). I reclined him all the way back so he was a little upside down, and called his name a couple of times. No response. I reached out and shook him a little bit. Nope. So I did a sternal rub to see if I could get him to open his eyes.
And that's when I felt it. Poppity pop crackle under the skin of his chest. I felt around a little more and then yelled for a doctor.
Subcutaneous emphysema. The kid had a pneumomediastinum! Ding ding ding! You win a bed in the ICU! He woke up from his faint and was fine(ish), but got a monitored spot until we got the okay to send him upstairs.
The docs thought maybe he got the pneumomediastinum either from toking too hard on his joint, or from coughing too hard after smoking.