Breathe

“I’m a difficult patient,” declaims Mrs. Olafsen proudly around a mouthful of Whopper with cheese. “Nobody knows what’s wrong with me.”

“Really? It certainly looks like that from your chart.” Mrs. Olafsen is gigantic. It took four nurses to get her from the stretcher to her bed. Her legs, like two scaly tree-trunks, encircle a greasy fast food sack which was supplied by one of her skinny daughters.

“I’m Dr. Bear, one of the Emergency Medicine residents working with the pulmonary service. Your doctor asked us to come take a look at you.”

There is a lot of Mrs. Olafsen to look at.

“They tell me you had some trouble breathing.”

“Oh yeah.” She carefully shifts her enormous body and gestures for her daughter to hand her the vat of soda resting on the night stand. “I couldn’t hardly breath when I came in. Isn’t that right?”

Her daughters nods furiously.

The chart does not do Mrs. Olafsen justice. Asthma, COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), NIDDM (Non-Inuslin Dependent Diabetes mellitus), PVD (Peripheral Vascular Disease)…all the usual abbreviations. Everything about her is larger than life. She actually looks and sounds pretty good, all things considered.

“I’ve had the flu or something for the last two weeks. I just couldn’t breath at all this morning and my daughter called the ambulance.” She roots in the bag for the greasy debris and finishes her drink with an exuberant slurp.

No kidding. She presented a few hours earlier in Status Asthmaticus, a sometimes fatal exacerbation of asthma which is refractory to the usual treatments. Imagine every small airway in your lungs clamping down tight. I read with interest on her chart that the use of heliox (a low-density mixture of oxygen and helium that results in less airway resistance) was contemplated but not used because she got better.

The oxygen going to her small tracheostomy hisses and bubbles in the humidifier. I see that she is at her baseline oxygen requirement and is “satting” in the upper nineties. Vitals suprisingly good. Her blood pressure is better than mine and she is the most alert and engaged patient I have seen all day.

Mrs. Olafson. Viking fertility godess surrounded by her pretty, reverential daughters. Nothing much to do, really, except write the usual admission orders and the standard prose on the admission HPI. (“46-year-old woman with a history of asthma presented to the Emergency Department in staus asthmaticus…etc. etc.”) However, If there’s one thing I’ve learned this month it’s that everybody can have a pulmonary embolus and Mrs. Olafson is a set-up for one. The D-dimer was equivocal so I order a doppler ultrasound of her massive lower extremities.

The ultrasound lab pages me an hour later.

“You’ve got to be kidding.”, says the tech, “It’ll take three of us just to lift her pannus out of the way.”

“Just do the best you can. I don’t think she’ll fit in the CT scanner.” I know it’s asthma but we’ve had a bad experience recently with a pulmonary embolus (PE) so the service is a little spooked. I examine my logic for ordering the ultrasound. A negative scan, by itself, does not rule out a pulmonary embolus which can only be confirmed or excluded by a CT 0f the pulmonary artery and it’s branches. A low D-dimer would have done it but it is high…but not that high. Why not just skip the ultrasound? We’re going to start DVT prophylaxis anyways.

“When will I get a bed,” asks Mrs. Olafson clearly tired of repeating her story to another guy in a white coat.”

“I don’t know. But we’ll get you upstairs eventually.” The moon will not set before I see Mrs. Olafson safely transferred and slumbering in semi-upright splendor. She seems melted in the flickering light of the television.

The Fresh Prince of Bel Air. I swear, it’s the only thing on at 3 AM.

Mr. Bomagard has died. An hour ago, the ICU informs me.

“Who?” I’ve never heard of him. I’m cross-covering.

“You know, the guy we coded for half an hour yesterday.”

Oh. That guy. I was at the code but it was very well-attended so I didn’t do much. An elderly and demented gentleman who checked out several months ago but whose body had been preserved as a museum to our arrogance and folly.

Mr. Bomagard actually died yesterday. He was in asystole for close to ten minutes before his heart was coaxed back into sputtering life. That was the best CPR I have ever seen. His arterial line measured optimistically normal blood pressure during compressions but trickled away to nothing when they were stopped. And he had the oxygen saturation of a teenager. He came back in stages. From asystole to ventricular-fibrillation at which point he was shocked, the response becoming more dramatic as the current was dialed up. He was finally stabilized in a tenuous sinus rythm on a continuous infusion of amiodarone. And three different pressors to keep his blood pressure up.

What were we doing to you, Mr. Bomagard? You have been in a nursing home for the last three years and haven’t spoken or moved in nine months. This was your fourth ICU visit in the last year. Maybe when you’re being fed through a tube, breathe through a tube, defecate and urinate through a tube…maybe it’s time to let you go. It’s not even a question of your dignity because we’ve taken that away from you. Your shrivelled naked body bounced to the rythms of chest compressions under the bright flourescent lights for ten minutes while your children looked on from just outside the door. Another minute and we would have called it off.

We should have let him go a year ago but families lie. The patient always perks up for them. He knows they’re in the room. It’s not much of a quality of life but we’ll take it. Please don’t let him die. We still see the man we knew in the contracted husk with the tubes and wires sticking out of him. You didn’t see him when he held his first grandchild or on our honeymoon before he shipped out for the Pacific. He’s still in there, somewhere.

He has to be.

“It’s not like they held a gun to my head and made me smoke,” says Mrs. Needlebacker between coughs. “I knew it was bad but I still did it.”

“Don’t beat yourself up, Mary,” I say, “We all have bad habits.”

“Do you, young man?”

“Well, I used to drink but my wife made me quit.”

Mrs. Needlbacker laughs then coughs. I didn’t really drink that much but what can I say? She is 65-years-old and lung cancer has got her in its death grip. When, in her 150 pack-year history of smoking did she realize it was kiling her? When she became short of breath working at her job as a cashier? When her need for supplemental oxygen finally overlapped into her entire day?

She has been coughing up blood. I write “hemoptysis” on my daily note.

“Can I do anything for you, Mary?”

“Yeah, let me out to smoke.” She laughs but she’s serious.

“You’re on oxygen. Your hair might explode.” If it was in my power I’d wheel her downstairs myself and let her smoke as much as she could stand. “Besides, those things will kill you.”

More laughter, more coughing. “No, you’re killing me.” We make the same jokes every day.

I will be off the service on Monday. We are transferring her to hospice in the morning.