Wednesday, April 2, 2014

Dyspnea


I’m supposed to write something inspirational. Something uplifting. Encouraging to the soul.

I don’t feel like writing anything cheery.

She’s dead.

I knew she was going to die. I could see it in her eyes. The heaviness. The weariness.

Pleading.

A resigned exhaustion.

Haunted by her existence.

Yearning for her release.

The look of death.

Yeah… this isn’t turning into a bright and happy piece of writing, is it?

Madam H was 50 years old. She came early in the morning. Too early in the morning. Concerned relatives had packed her into the car and shuffled her from hospital X to our health centre after she failed to respond to the treatment regime she was receiving.

“Coming,” my husband unlocked the front door. We were both trying to rejoin the land of wakefulness at the early hour. Jordan, our dog, had alerted us to the nurse on our front porch with her usual energetic barking. (No need for a doorbell. Most visitors don’t even realise we have one)

“It’s the nurse,” my husband called back to me.

“What does she want?” I inquired. I sighed. Already? Couldn’t the consults wait for another hour until the clinic actually officially opened?

“I don’t know. She wants to see you.” My husband relayed the message.

“Tell her I’m coming. I’ll be over in the hospital in a few minutes.” I hurried to finish dressing. Mornings come too early.

With a growing sense of trepidation, I threaded my way to the hospital through the milieu of animated visitors who invariably come along with a sick patient. It’s actually a little intimidating to walk past the crowds of them… all waiting and watching with expectant gazes for the white doctor. Their heads turned in unison as I passed them. I ducked away from their intense stares into the general adult ward in the hospital.

Madam H was positioned in a semi-upright position with the head of the bed cranked upright. She gasped like a trout out of water for air – hungry, mouth-open, inhalations -- without finding relief from her oxygen deprivation.

“What’s the story on Madam?” I turned to the night duty nurse.

“Difficulty breathing, doctor,” the night duty nurse gave me the very abbreviated version of the patient’s medical history.

“Anything else?” I pushed for more details.

“Doctor, the family says she can’t breath. She’s been taking medicines to no avail. They brought her here because of severe neck pain.”

“Oh?” I bent over and placed my stethoscope on Madam H’s chest, listening to the air enter, listening as some unseen force halts her efforts at breathing – preventing her from taking a long, deep, satisfying, lung full of air. No crackles. No wheezes. Just rapid, gasping breathes… not shallow but not deep and gratifying either.

“How long has she been like this?”

“Ten days.”

I stared incredulously at Madam’s troubled breathing. “She’s been breathing like this for 10 days?!” I raised my eyebrows, not quite believing.

The night duty nurse looked at Madam’s medical book in her hand. “Yes, doctor.”

“And what has the family been told is the problem?” I counted Madam’s respirations. Forty breaths per minute. Not as bad as I’d initially thought. Her heart was beating regular with a pulse of about eighty. She had a little swelling in her legs but not much.

“They said she has pneumonia, doctor.”

“Can I see which medicines she’s been taking? Do they have the other lab results from the hospital?” I turned my attention to the plastic sack of medications at the bedside cupboard. Augmentin. Tot’heme. Terpone cough syrup. Ventolin inhaler spray.

I addressed Madam and held out the Ventolin spray to her. “Take,” I instructed, “then tell me if it helps you breath better.”

Without wasting air to reply, she deftly took the Ventolin asthma spray and inhaled a few puffs.

“Did it help?”

“She looked at me with vague eyes and gave a noncommittal nod of yes.” I wasn’t impressed. Certainly not a dramatic improvement. She still put enormous effort into every breath.

“Doctor, she complained of neck pain and chest pain,” the nurse reminded me.

I nodded at her words. “Any fevers?”

The sister shook her head, “No, doctor.”

“Cough?”

“No.”

“Headache?”

“No.”

“Any pain anywhere besides her neck and chest?”

“No.”

“Does she have asthma?”

“No.”

“Has she ever had diabetes or hypertension?” I noticed that her blood pressure was up. The last reading on the blood pressure machine was 160/105 mmHg.

“No, she has never had high BP,” her sister looked around at the other members of the family who offered nothing to the alternative.

“Did her breathing problem come on slowly or did she get difficulty breathing quickly?”

“It just came like that,” her sister tried to explain. “It has never happened before.”

“So, she just woke up suddenly with difficulty breathing?”

“Yes, doctor,” the sister answered with hesitation.

“Has the treatment improved her breathing at all?” I looked around at Madam H and the rest of her family. Madam was busy breathing so I relied on her entourage to fill me in on the details.

They all shook their heads empathically. “No, she has only been having this difficulty to breathe, doctor.” The sister spoke on behalf of the crowd.

“Can I see her medical books and laboratory tests?” I sat down at the nurse’s station with an assortment of papers, receipts, several paper booklets, and a chest x-ray.

HIV negative.

Random blood sugar, 117.

Malaria negative.

Chest X-ray report read, ‘bilateral pneumopathy’.

‘for right breast biopsy’… huh?

“Did they do a biopsy of her breast?” I was confused. Why was there a work up for a breast lump going on in the middle of a hospitalization for shortness of breath?

“I don’t know, doctor,” the sister answered with a shrug.

Strange. I would peruse her books a bit more but for the moment Madam H, her family, and the night-duty nurse were anxiously awaiting a plan of action.

“Check the Hb (haemoglobin level). She looks a bit pale.” I instructed. “Then tell the family to repeat the chest x-ray.”

Surprisingly, the Hb came back normal – 12.2 g/dl. The chest x-ray, when compared with the picture from 10 days ago, looked very similar. This time the report read, ‘bilateral pneumopathy with small pleural effusion’.

I wrote orders for IV antibiotics and furosemide (diuretic). The underlying question remained though – why was Madam having pneumonia that wasn’t responding to appropriate oral antibiotics? Where was the pleural effusion coming from? Why wasn’t she having any fevers? Was the neck and chest pain related to the lungs or the heart or something else?

Time is a funny thing in medicine. It can pass in what seems like one blink of the eye or it can drag on forever, counted second by endless second with each laboured breath.

“How is she?” I came to check on madam in the afternoon after most of the consultations on the outpatients were finished. “She’s ok, doc,” the nurse shrugged without enthusiasm. “Her blood pressure is high.”

“How is her breathing? Any better?”

“Not really, doc. She’s complaining that the Lasilex makes her chest pain more when I give it.”

“Ok,” I acknowledge this odd factoid.

On examination at the bedside, I found madam sitting up. “Does she breath better when she’s sitting?”

“Yes,” the sister confirmed.

Her oxygen saturation was 99%. Her pulse and blood pressure were relatively unchanged. Respirations were still laboured. Her lungs on auscultation with my stethoscope sounded the same. No change. And, she still didn’t have even the faintest hint of a fever. I examined her conjunctiva. White.

“Check her Hb again,” I requested.

I searched through her records again. I found evidence for a ten-year history of breast pain and a small surgery with excision of a breast lump several years ago. Otherwise, I could not find anything new. I didn’t know what to think.  Her symptoms did not add up to equal simple pneumonia. They didn’t fit a simple pleural effusion either. In spite of producing plenty of urine, her breathing had not improved at all. My mind stared grasping for other explanations. Pulmonary embolus? Heart attack? Cancer? Pericardiac effusion? Pericarditis? Parapneumonic effusion? Questions; no answers.

I felt like an idiot. The family stared at me like I was an idiot too. How come the white doctor couldn’t tell them exactly what was wrong with Madam H and fix her? Their silent stares and background animated chatter felt eerie and accusing every time I passed the hospital entrance.

“I feel like I’m missing something.” I lamented to a friend online. “What is it?”

She graciously messaged with me and helped alleviate my insecurities. I felt somewhat more confident that at least my line of reasoning was logical, medically speaking, afterward.

I plunged forward with my questions and investigations while Madam H continued to struggle to breath. She was able to sleep and relax a bit when we gave her oxygen. I left the oxygen concentrator next to her bedside. Anything to alleviate her air hunger and discomfort even though it wasn’t the solution.

I took photographs of her chest X-rays and emailed them to another friend for reassurance that the local radiologist and myself weren’t missing anything significant on the films.

An ultrasound doppler study of her leg veins failed to show any blood clots. The sonographer didn’t feel there were any signs of a dilated right heart ventricle or atrium. “It just looks like congestive heart failure.” She gave her opinion of the ultrasound study as I discussed it with her.

So… no definitive answers.

“What was the repeat Hb?” I stood at the nurses station trying to decide what else to do. Nothing seemed to be helping.

“Her Hb was 13.3 g/dl,” the nurse informed me.

“How can that be?” I asked, still not believing. “She’s white. You’ve seen her, right?”

“Yes, doc.”

Madam H’s conjunctivas were white, her tongue was pale, her fingers appeared bloodless. I searched my memory banks for anything that would make her Hb falsely elevated. And yet, her pulse was not tachycardic. Her blood pressure was high; not low. The haemoglobin metre had churned out appropriate low values of 8.7 g/dl and 9.9 earlier.

“How are you?” I walked over to Madam H’s bedside and addressed her. During her entire stay, she’d barely uttered more than a yes or no. All oxygen was savoured in favour of expending her efforts to breath.

She stared at me with tired eyes. I didn’t need her to tell me. She wasn’t better. She was worse.

I checked her oxygen saturation. Sitting straight up with her legs dangling over the side, the oxygen saturation levels rose to a meagre 89%. When she leaned back into the bed, in spite of the inclined head of the bed, her saturations dropped to the 70s. Not good.

“Can you think of anything else?” I turned to my nurses at their station.

They shook their heads. “Doctor, I think we need to transfer her.”

Wearily I agreed. She was clearly not improving.

“We’ve tried everything we can here at our small health centre…” I began as Madam’s relatives sat opposite me in the make-shift family conference room. “I don’t know what all is causing her difficulty breathing. It’s more than a simple pneumonia though. She needs to go to the big hospital in D_____ where there are more specialists and capabilities to treat her.”

“You’re right, doctor,” one of the male relatives spoke and nodded.

“Don’t waste your time going to the other small hospitals. Just go to D_____ now. You’ve already been to one other hospital and I know the hospitals here in Buea are not big enough to do anything more than we’ve done for her here. Go to D_____.”

“Ok, doctor.”

We wrote up the appropriate paperwork and helped the family load Madam H into the waiting taxi.

I was relieved that she was going somewhere that could do more for her. I was frustrated that I couldn’t help her. I felt drained and apathetic. Discouraged. Empty.

I couldn’t even figure out what the real problem was. She was dying and I didn’t have a clear picture of what was really happening. There could still be a pulmonary embolus. Perhaps it was heart failure from a recent heart attack… maybe it was complications from breast cancer…. a resistant pneumonia… anaemia (even though our metre pointed to an alternative diagnosis she still looked very very pale). Too many questions. My mind wouldn’t stop processing Madam’s case. In spite of my musings, the meagre facts of the case swirled around without coalescing into any solid diagnosis. Like a computer trying to open a bad file, my brain whirled endlessly and fruitlessly. No program loaded. No answers popped up.


These types of medical cases are difficult. They drain my psyche insidiously and poison my confidence. So much effort with no return on the investment. I knew I’d probably never hear from the family again. I’d sent them off into the mysterious depths of the system of specialists in D_____. Historical experience informed me that there was a 95% chance I’d never know what happened.

Postscript:

The family took Madam H to another nearby hospital in Buea. They did not go to D____. At the hospital, they were again referred to D___ but instead chose to remain. Madam died at in the hospital the next day. The impression by the doctors at the other hospital was that she died of congestive heart failure brought on complications from breast cancer.

One may be tempted to lay blame on the family for not transporting her to a big, expensive specialty hospital where she’d have the best chances of survival. However, perhaps the family, like myself, saw the ‘handwriting on the wall’. Knowing that she was near death, they chose to let her die in her hometown and save the resources it would have cost just to get her through the front gate of the D____ hospital. Contrary to certain cultural attitudes in other parts of the world, there are financial limits and medical care is not an unlimited resource.


 “Who comforts us in all our troubles, so that we can comfort those in any trouble with the comfort we ourselves receive from God. For just as we share abundantly in the sufferings of Christ, so also our comfort abounds through Christ.”
2 Corinthians 1:4,5