This month Night Shift changes gears, publishing a post from one of our favorite medical blogs,
I walked into Room 17 to see a sixty-ish woman who, by the nurse’s triage note, had come to our ER for shortness of breath. A smoker, with a history of chronic obstructive pulmonary disease (COPD). The nurse’s note reflected her suspicions that this patient may have pneumonia.
I walked into the room to find a woman who appeared much older than her stated age. Her thin, gray hair hung lifelessly along her face to her shoulders, a needed washing evident. Her face was pale. Thick, crevassed wrinkles hovered at the corners of both her eyes and lips. Clear plastic tubing ran along the front of her emaciated, gowned torso, only to wrap around her ears, swing back, and sit comfortably within the patient’s nose. Necessary oxygen, since her levels had been below normal upon her arrival.
The most telling observation, however, was the smell of the room. Overpowering. A stale, cigarette-scented heaviness combined with a musty, ill-human smell. The smell of a neglected, mistreated body.
Except for her nurse standing at the room’s corner counter, this patient was alone. And as we awaited the arrival of a respiratory therapist and a radiology tech to take a portable chest X-ray, I had my chance to interview her.
“Hello, ma’am,” I approached, my gloved-hand extended. “I’m Dr. Jim and I’ll be working with Nurse Denise to take care of you today.”
She nodded her acknowledgement, took a deep breath through her nose, and mumbled a return greeting.
“What can we do to help you today?” Although she was in some degree of respiratory distress, I didn’t know how far she was from her baseline. Something told me, though, that this woman lived every day with some respiratory struggle.
“Well,” she started, her voice dry, “I’ve had a wicked cough for a couple days and now I’m having trouble breathing.” She spoke fragmented sentences, squeezing out four or five words at a time before pausing to drag in a hit of oxygenated air through her flaring nares.
I asked my usual questions. Fever? “Yes, a couple days.” Sputum? “Yes, a couple days.” Achy? “Yes, a couple days.” Are you eating okay? “No.” For how long? You guessed it – “A couple days.” Have you been using your nebulizer? “Yes, a couple days.”
It became a game between us. This patient, despite her distress, was having some fun with me. She was able to successfully twist almost each of my questions around until her answer, “a couple days,” seemed an appropriate response. Every question, no matter how I phrased it, was artfully turned on itself. Nurse Denise, now starting the patient’s IV, kept glancing at me, loving the mind-play that she no longer had to endure.
I liked this patient.
Finally, I knew I had her. “Ma’am,” I asked with sincerity, “do you smoke?” From the smell of the room and her body, from her wrinkles and parched, scratchy voice, I knew the obvious answer. Like any other patient, though, I needed her to share the specifics of her smoking habit with me.
She took another deep inhalation before answering. “No.” Her answer surprised me.
“Excuse me, ma’am,” I said, arching my brows, “you don’t smoke?”
Again, emphatically even, with a defiant glint to her eyes, she answered me. “No, I don’t smoke.”
Hmmm, I questioned myself, how could I have been off-base on this one? I decided to take the round-about way. “Have you ever smoked, ma’am?” Her answer was short and sweet. “Yes.” Now I figured it out, cracking her. “And when did you quit smoking, ma’am?”
Although her answer was somewhat expected, even I was surprised by it. “Three hours ago.”
Seriously? Are you kidding me here? As much as her answer annoyed me, I had to appreciate this woman’s gumption. “So you quit three hours ago?” I confirmed with her. She nodded her head.
“Yes. I decided to just throw those nasty things out.”
“Congratulations to you,” I said, smiling, “but do you think that qualifies you as a non-smoker now?”
“Well, why wouldn’t it?” she asked, sincerely. “I don’t plan on smoking ever again.”
That’s a story I’ve heard time and time again, unfortunately, and this patient had a long medical history of coming to our ER for similar complaints. She would be a non-smoker only until she got back home and pulled those “nasty things” back out from her garbage can. Unless she stopped at a convenience store first, after her discharge.
This patient did well for us, turning around much better than I had expected. She received IV steroids, several breathing treatments, antibiotic coverage, and some cough syrup. Soon, she was speaking full sentences again.
After fine-tuning her, I discussed with her my wish to admit her and make sure she continued to improve. She flatly refused. “I’ve got cats to feed at home,” she said, “they’re my babies.” And although I believed her, I think the stronger reason was that her cigarettes were getting quite lonely without her attention. And she for them, too.
She signed out against medical advice. I called her family doctor, who assured me that he would follow up with this patient the next day. He seemed frustrated by this woman’s self-negligence, as we all were, failing to persuade her to give up her addiction. Nurse Denise even gave her a smoking cessation talk, but it fell on deaf ears.
With this patient’s lack of desire to help herself and her cause, I knew that our ER team would be seeing her again. Years of smoking one to two packs of cigarettes a day had taken an irreversible toll on her body. She was approaching the phase where soon, she would be requiring supplemental oxygen at home. And more and more medical attention.
A part of me feels bad for the older folks who began smoking years ago, when the ill-effects were not as clearly defined. This habit breeds itself into so many aspects of a person’s life, and I can’t imagine the effort it would take to pull that yellowing thread from one’s life quilt. I have a harder time, though, understanding the younger population who imbibe in smoking. Haven’t they seen the aging effects? The portable oxygen tanks that their predecessors rely on? The escalating cost of their habit? From a medical standpoint, treating asthmatics and COPDers who smoke remains a staggering portion of our patient load within our department.
After a social service consult, this patient was discharged to home and encouraged to follow up with her doctor in the morning, as we had scheduled, or return if her symptoms worsened or changed in any concerning way.
As much as we tried to help this patient, I knew she would be back. Eventually.
I just hope not in a couple days.
The blog StorytellERdoc, written by an anonymous emergency physician living in the Northeast, won best literary medical weblog in MedGadget’s 2009 Medical Blog Awards