Smokey

Some patients you remember by an unusual aspect of their disease, a unique physical exam finding, a quirk in their personality, or even a common nonmedical interest. Occasionally, though, something else stands out, as happened to me during residency in the late 1980s at the old VA hospital in Houston. The patient's name wasn't Smokey, but everyone called him that, including Smokey himself.

We were on a general medical service when Smokey was assigned to us. He was admitted with probable pneumonia but also with a need to exclude tuberculosis. He was unhoused and had a history of high-volume consumption of a variety of legal and illegal intoxicants. He was not highly forthcoming in relaying his medical history, perhaps exacerbated by a significant level of alcohol withdrawal and vitamin B12 deficiency. What he could tell us, with a bit of chagrin, was why his name was Smokey: His daughter had found him a place to live, but he had inadvertently burned it down.

His case posed a diagnostic dilemma. His chest X-ray was most impressive; it seemed inconsistent with a survivable respiratory status. It showed a constellation of plaques, infiltrates, blebs, and scars. It was as if there was no normal lung tissue at all, although the patient reported that he smoked “whenever he could get them.” In those days it was not easy to hold on to an X-ray, especially an interesting one. ID was consulted, so was pulmonary, and each service sent a sneaky student to snag the film to show to their attending. We spent many hours hunting down their meeting rooms in search of our stolen goods. But eventually we had taken enough images that there were plenty to slake everyone's radiologic thirst. For days on end, we puzzled over them. Eventually, an ancient film of Smokey's chest was unearthed from some cavernous archive in the bowels of the hospital, revealing the exact same radiologic pattern. This was nothing new. And before we knew it, he had surreptitiously discharged himself.

Life goes on as a resident. Months later, I found myself rotating at the old Ben Taub Hospital (note that both facilities have been replaced and thus are officially old, as is your dear author). I was walking through the ICU, on my way to see a patient with severe lupus flare. The team there was huddled over some obscure films on the view box. Wanting to help (or just being nosy), I took a look and had a clinical flashback. That constellation of plaques, infiltrates, blebs, and scars was imprinted on my cortex.

I asked the team about the patient. He was unidentified, intubated, and unresponsive after an out-of-hospital resuscitation. They were puzzling over what the diagnosis could be and had consulted a variety of services, all of which were flummoxed. They were discussing a bronchoscopy or open-lung biopsy. I told them I had the answer.

They didn't believe me. I almost didn't believe myself, so I suggested we go to his bedside. The patient was clean-shaven, but there was no mistaking that X-ray. I leaned toward him and said in a very loud voice, “Smokey, is that you?”

He opened his eyes. It was.