You Be the Doc: Shortness of Breath

Dear Doctor-reader of SW101,

In your case today, you are seeing a 58 year old woman with respiratory distress.  When you enter the exam room, she is lying on the table, sweatshirt over her head, coughing into a full sized towel.

Upon your entry, she emerges looking disheveled.  You can see that she’s sweating a bit and she is breathing a bit faster than normal (about 18 breaths per minute).  You could hear almost continual God-awful hacking well before you entered the room.

The woman is pleasant and communicative – although she constantly interrupts herself to cough so hard you think she will gag each time.  It takes her nearly 10 seconds to recover after each paroxysm of coughing.

Your patient says she has had the cough “forever”, but is has been really bad over the past 2 months.  She has taken all kinds of over the counter stuff, none working well or for long.  She uses an albuterol inhaler.  Someone somewhere said she had “asthma” once, but she doesn’t really know what that means or if it’s real.

She has a normal blood pressure.  Her pulse is around 100 (normal is 80) and respirations are already mentioned.  The O2 saturation is 97% on room air (normal is 98% or so).

What should you do, doc?

Ode to McDonalds and Cigarettes

You can say you saw it here. This family medicine doctor – supposed bastion of all that is healthy and wholesome – recently found himself encouraging a patient to keep up the McDonald’s and smoking. Instantly after proclaiming my support of these two great sins of the developed world, I heard my program director’s voice in the back of my head saying not unkindly, “Nice job, doctor, good work…we’ll most likely kill you in the morning.” Although never tempted by cigarettes, I frequently fight the urge to hit a McD’s and constantly rail against both as all that is disjointed and wrong with our society (celery is another problem, IMO, but that’s another discussion entirely).

I saw a patient this weekend who unabashedly describes smoking about a half-pack of cigarettes a day, and has been doing it for “goin’ on 50 years now, and I ain’t quittin’ no matter what you tell me.” The patient is 78 years old with advancing COPD. When she inhales, the wispy flimsy breath she drags down into her rapidly deteriorating lungs rattles around aimlessly like a blind baboon in Grand Central Station. She then forces the air back out; little of the oxygen actually used. She is on 14 medications to treat everything from her diabetes to the high amounts of fat in her blood.

“Smoking makes me feel…” She closes her eyes, her face taking on a distant, faraway look as if she just lost herself in recollections of her torrid love affair in Paris on a college philosophy tour, “like I’m surrounded by friends when I’m actually all alone.” How can I beat that?

This patient lived a full life, been smoking for a good majority of it. Now she is stuck in that impartial vice-like vortex of half-life and half-death that American medicine has so expensively provided us. Historically, people just died when they got as sick as her. Today, people linger, in a sort of daily, living suffering. The institutions they inhabit have innocuous-sounding descriptions like “assisted-living communities”, but everyone knows what they really are. Places where the clock of mortality hangs largest on every wall, where the clanging metal hammer pounding on anvil cannot go ignored, but can’t be rushed. It pounds in measured, inexorable rhythms, indifferent to anguish it causes. Hundreds of thousands of Americans waste away in these communal halls, most abandoned by their families, waiting for that final insult and staring droolingly at the wall in the meantime. But when this insult finally does arrive – a heart attack, hemorrhagic stroke, maybe a pulmonary embolism – it shows up with a slouch, hands in pockets, irresolute, nuanced and often as slow as a sadist. These days, the Reaper arrives in a robe of gray, eschewing the dramatic and abrupt pitch black somewhere around the time we invented beta-blockers.

So, go ahead, lady. Smoke to your heart’s content (or infarct). The damage is done, really. If you did stop today, the additional few weeks or maybe even year would be so miserable for someone who loves smoking this much it wouldn’t do much for you. Mortal time isn’t everything. There’s such a thing as life quality, too.

“The other thing I love,” She continued, “is Saturdays.”

Her face, looking like gravity used physical hands to pull her face to the ground for the past 200 years, suddenly filled with a smile. Her losing battle with age suddenly clamoring to a standstill. “My wonderful daughter comes every Saturday and brings me a McDonald’s egg McMuffin sandwich and coffee. I just love that. I look forward to it all week. Say, what day is it? Maybe she’s coming today. Do you know?”

“Well, it’s Saturday night at 11. Maybe she came earlier before your care facility staff thought you needed to come to the hospital.”

“Yes. This could be. You see dear, I can’t really tell the difference between days and weeks and months and years anymore. They’re all sorta the same to me anymore. I just know my Jerry comes on Saturday and we have breakfast together. And you know…that McDonald’s does a lot of good for other people, too. They hire young kids, old folks…give people a start in life, or help them do something worthwhile. The buy all kinds of ingredients from local grocers and farmers. Why, when they moved in here 30 years ago, my son was one of the first they hired. He has his own business today. Employs 30 people.”

“Wow. I’ve never thought of them that way.”

“And them McMuffins…ain’t so bad for you, either. They fill you up, keep you fed through almost a whole day. It’s good food.”

By any primary health care measure, someone who smokes daily and eats fast food at least once a week, is not healthy. But exceptions to every rule emerge in unlikely places. This woman did not come to the hospital to make me re-evaluate my unbending belief in the immutable evils of fast-food and smoking. But her defense of their place in her own life was unassailable. This woman won’t live to be 90 years old. The end may come in the next few days, in fact. But this is true for all of us. This very moment, our lives could be required of us. Should this happen, could you depart with the same gentle serenity?

If deprived of her simple vices, could she?

I found myself answering no to both questions. So this family doctor ended up departing the room, encouraging an overweight patient with COPD and hyperlipidemia to “keep up the smoking and enjoy your McDonald’s.”

I’ll start typing my resume. I hear there’s good jobs in the restaurant business.

Saturday Night Quotes I Like – March 1

A compendium of quotes I’ve noticed over the past week that were provocative, thoughtful, interesting, funny or patently absurd.  Sent out (’Lord tarry and the creek don’t rise’) every Saturday:

  • Health nuts are going to feel stupid someday, lying in hospitals dying of nothing. – Redd Foxx
  • Astounded, I pointed out the obvious. “Your wife died, you stopped eating, cried or slept all the time…and prayed to God that you would die? Sounds like you are very depressed.””No, I’m not depressed,” [my patient] said. “I just don’t want to live anymore.” – Fat Doctor
  • After saying she found her “voice” in New Hampshire…we’ve had Experienced Hillary, Soft Hillary, Hard Hillary, Misty Hillary, Sarcastic Hillary, Joined-at-the-Hip-to-Bill Hillary, Her-Own-Person-Who-Just-Happens-to-Be-Married-to-a-Former-President Hillary, It’s-My-Turn Hillary, Cuddly Hillary, Let’s-Get-Down-in-the-Dirt-and-Fight-Like-Dogs Hillary. – Maureen Dowd
  • buck.jpgBuckley was arguably the most important public intellectual in the United States in the past half century. For an entire generation he was the preeminent voice of American conservatism and its first great ecumenical figure. – George H. Nash, American conservative movement historian.
  • “Even if one takes every reefer madness allegation of the prohibitionists at face value, marijuana prohibition has done far more harm to far more people than marijuana ever could.” – William F. Buckley, Jr.
  • “I won’t insult your intelligence by suggesting that you really believe what you just said.” – William F. Buckley, Jr.
  • Buckley’s greatest talent was friendship. The historian George Nash once postulated that he wrote more personal letters than any other American…He showered affection on his friends, and he had an endless stream of them, old and young. – David Brooks
  • Faith, which is the belief in the supernatural despite lack of evidence, is, in the terms of some theologies, a gift from God. It is the belief in things not seen…Anyone can believe in a God who walks the Earth. – PalMD
  • A physician who treats himself has a fool for a patient,” – Sir William Osler.
  • …New physicians view medicine more like a job than a calling [while]…politicians and the public have decreasing respect for the profession. In addition, the constant siege by the lawyers is taking its toll…in such hostile times, why should doctors sacrifice more to the profession than they already have? – Kevin, M.D.
  • Today, thanks to the Internet, we are all physicians. And potential fools. – Andre Picard
  • Intubated COPD patients are generally stable patients..[with a] protected airway…[in a] controlled environment… Except when they aren’t.Happy Hospitalist
  • When I was a child, it was an easy time to dream. When you turn on your television set and men are landing on the moon, anything is possible, and we should never lose that spirit. – Randy Pausch, professor at Carnegie Mellon currently dying of pancreatic cancer. See his final lecture on following your dreams here.