Case presentation

A 69-year-old man was admitted to our emergency department shortly after falling from a ladder from a height of about 2 m while attempting to prune a dead branch in his garden. He showed bruising on the back and had severe back pain. He had been in his usual state of health prior to the accident and had been receiving outpatient treatment for chronic obstructive pulmonary disease at our hospital. He had smoked two packs of cigarettes per day for 42 years, but had stopped 6 years earlier. He drank occasionally, but did not use illicit drugs. He had a history of colon cancer. Medications included ipratropium bromide, salmeterol and theophylline. He had no known allergies.

In the emergency room, he appeared uncomfortable. His blood pressure was 145/110 mm Hg, pulse was 112 beats per minute and temperature was 36.7°C; his respiratory rate was 34 breaths per minute and oxygen saturation was 85% while breathing …