In All My Career…Stories from the ED


 

 

 

 

Please send your stories to Tracy Napper (tnapper@acep.org) today!

The night after Christmas day was a busy day in the department.  We had already slogged our way through a stream of what seemed like endless patients when Triage alerted the team of a potentially sick patient. “They are coming straight over to the Acute Care side now, and they are turning blue!” With this information, my interest was instantly piqued. 

The patient rolled quickly across the ED into a bed via wheelchair.  I half-jogged to the room to find a young patient, in no apparent distress. A quick glance up at her monitor revealed normal vital signs, normal oxygen saturations on room air.  Hmmm. “What brings you in today?” I started. “My mom told me to come in tonight. She said, I don’t look right and that my face and hands look blue. I feel fine.” It was only then that I was able to see the subtle, but easily recognizable blue hue around her mouth, lips, and her fingertips. 

 My first thought was, this girl is cyanotic. She sure is. And with the involvement of her face and lips, she has central cyanosis. From what? But, she has normal oxygen saturations, heart rate, and blood pressure. A quick listen to her chest revealed no murmur and no extraneous lung sounds. Hmmm. Very interesting.

 I turned my attention to her hands. Closer inspection revealed the subtle blue hue to primarily be located on her fingertips. I squeeze her fingertip to assess her capillary refill, and it was normal. However, when blanched, her fingertip remained slightly blue. 

 “I don’t know why this is happening to me, I feel fine. I’m a little freaked out right now because everybody looked very worried in triage,” she said anxiously. At this point, she looked very nervous, drumming her fingers on her leg, tapping her foot. I looked at her hands again. She was wringing them, tapping her fingers on her leg, rubbing them together, then back again, drumming her jeans. Her dark blue, denim jeans. 

 “Did you get some new jeans for Christmas?” I asked. “Yeah….,” she replied, looking very confused. I took an alcohol swab out of the drawer, ripped open the package, and wiped one of her fingertips. I showed her the results. Her face now turned a beet red. “I’m so embarrassed,” she said putting her hands up to her mouth. “It’s a rare disorder, but a very curable case,” I teased. 

 It’s not every shift you catch a “zebra” like Blue Jean Pseudo-Cyanosis. But when you do, it reminds you why you love this job, even during the holidays.

 Jeremy Webb, PGY3

Wake Forest Baptist Health. Winston Salem, NC

 

 

  1. #1 by Steve - October 19th, 2012 at 06:39

    I’ll never forget the first time I saw that. The young man was diffusely blue. After reviewing his normal vitals, examining him and listening closely to his history, I couldn’t think of anything except the fact that he really is blue. I’m a PA so I consulted my attending. He looked at me a little funny but decided to see the patient and had never seen this before either. It was midweek so my medical director was in his office pushing papers. I sat down and explained the case to him. He didn’t say much but asked me to follow him. All three of us walked into the room. He quickly peeked at the young man then went directly for the alcohol swab. After a quick swipe on the man’s arm and realizing the smurf blue present on the swab, we all looked at each other and couldn’t help but laugh. That was a great teaching moment for us all. The only challenge after that was trying to find that diagnosis in the EMR.

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