Short of Breath Read online

  SHORT OF BREATH

  Dr. CAROL L. KOENIG, MD, FAAFP

  CHAPTER 1

  The Sweet Smell of Spring

  Some people call it Spring - I call it Allergy Season. That time of year when rural roads acquire a golden glow and turning lanes develop ruts in the thick dusty layer of pollen. When bleary-eyed people who swear they don’t have allergies wonder why they go around sneezing and sniffling and snorting.

  I was confined to my desk using what my office nurse Landry jokingly called the bong. It was connected to a nebulizer, and the prescription mist I breathed in was good for my temperamental asthmatic lungs. Distracted, I watched for the baby barn swallows in their mud daub nest outside my window. As soon as food arrived, four open mouths magically appeared, resembling the Pop-Up Singers my kids used to play with. I noticed a car pull up and recognized the white-haired woman driver, a regular allergy-shot patient, as she walked slowly to the front door. Megan, my medical student, had her nose buried in the Merck Manual on her lap and munched absently on the sandwich in her left hand. I gradually returned my attention to the birds.

  Things change quickly for them, I mused, inhaling the medicine deep into my lungs. They’ll be out of the nest in another week or so, starting new adventures and fending for themselves, while I’ll still be here seeing patients and fending off Corporate stupidity.

  Or so I thought.

  When the treatment ended, I switched off the machine, straightened my skirt as I settled into the chair, and began eating my lunch and entertaining myself with an incomplete chart.

  “Whew, I’m glad you turned that noise off,” Megan said, turning the page. “I see why some people treat this book like a complete Bible. The pages are thin and the type is small.” She looked up and smiled at me.

  “Cute. Sorry about the racket. That last patient’s perfume kicked up my asthma. I have signs up asking people not to use scents, I tell people, and yet some of them bathe in it.”

  “It only seems that way in the small exam room,” Megan said, going back to her book. Rather, my book.

  I mused as my eyes swept the patient parking lot on their way back to my paperwork. Several cars were still there. I wondered where the patients were hiding until I realized I’d finished early because I cut the perfumed patient’s visit short when I couldn’t breathe. Maybe next time she’ll remember not to use scents. Gee, the front office must be busy, and Timothy should be back from the nursing home by now. I frowned, thinking that as my Physician’s Assistant, he was frequently not of much assistance, although his nursing home visits saved me time and …

  “Dr. Wirth, I need you now!” Landry’s commanding voice cut through me. The hairs stood up on the nape of my neck, my pulse quickened, and I felt a brick drop into my stomach. I tossed the chart I was working on onto the desk, yanked my stethoscope from around my neck, and ran. I heard my Merck Manual hit the floor as Megan followed.

  Petite sixty-seven year old Mary Alice Connors sat bolt upright on the trauma room exam table, breathing rapidly, struggling for each breath.

  In her usual calm, matter-of-fact style, Landry filled me in while she finished setting up the nebulizer. “I gave Mrs. Connors her allergy shot like always and she went out to wait her twenty minutes. That woman with the heavy perfume finally finished with Christina and walked by Mrs. Connors on her way out. I could tell the perfume bothered her ‘cause she fanned the air with her hand.” Mary Alice nodded and demonstrated fanning.

  “Then she went to the desk and asked Christina for some water,” Landry continued, “but Christina thought Mrs. Connors was breathing a little fast and called me to help. I figured she was having an asthma attack like you from the perfume, but while I was setting up the other neb for her, I could see her breathing was getting worse, so I called you.” She handed the nebulizer mouthpiece to the patient. “Is that about it, Mrs. Connors?”

  The patient held the mouthpiece close to her lips. “Yes,” she said.

  Mrs. Connors never had a problem with her shots. Is this reaction from the perfume? She went bad too fast. Maybe perfume plus allergy shot plus spring pollen was too much for her. I prayed she wasn’t going into anaphylaxis, a life-threatening allergic reaction, but I knew that if she was, I needed to act quickly. I listened to her lungs. Squeaky wheezes, meaning almost no air flow. She was far along in her attack.

  “I’m sure you’re feeling pretty bad right now,” I said, “but hang in there and we’ll get you feeling better soon.”

  She nodded and breathed in the medication as deeply as she could, and promptly started coughing.

  “Landry, give her point three of epi sub q now. Run oxygen through the neb, and set up for an I.V.”

  Landry quickly pulled a syringe out of the drawer with one hand while reaching for the brown bottle of epinephrine kept on the counter with the other. Megan brought the oxygen tank to the patient.

  “Mary Alice, have you been exposed to a lot of dust lately?” She was severely allergic to dust, although the shots were helping. Dust exposure could explain the rapid decompensation.

  She shook her head. Her lips were still pink, but barely. I listened again. No wheezes now – there was too little air moving to cause them. The asthma attack had caused the tiny bronchioles that bring air deep into the lungs to swell, blocking air flow.

  She was slowly suffocating before my eyes.

  “Be right back,” I said as Landry injected the medication into her arm.

  I darted out toward the front desk, Megan on my heels. “This is called an ‘Aw, shit’ situation. She’s going into anaphylaxis. I hope we can break it in time.”

  Epinephrine, or adrenaline, was a first line drug, easily given just under the skin. Everything else was intravenous. I hoped the dose would buy us time to get an IV line in.

  I stood between the reception desk and business office. “Christina, we need you in the trauma room – impending code.” Christina, an EMT, scrambled out while the office manager, Kelly, moved to the front desk. “Call 911 – severe respiratory distress. If Timothy’s here, tell him we need him in the trauma room.”

  “He’s in his office,” Christina said over her shoulder as Kelly nodded.

  I wheeled, almost knocking Megan over, and headed back. She stayed one-half step behind me.

  Turning my head toward her I asked, “Did you get your ACLS yet?” Passing the Advanced Cardiac Life Support certification was required before graduation. Megan shook her head. “BCLS? CPR? Can you start an I.V.?”

  “I’m not good at it yet,” Megan confessed.

  I turned back. “Then you’re the recorder. Be sure to get the time, medication, and dose. Do your best, we can copy it legibly later if need be,” I said as we reentered the trauma room.

  The team worked well. Landry finished prepping the I.V. supplies while I got the catheter into the vein. Megan took the clipboard from the hook on the side of the crash cart and stepped out of the way, careful not to block the cheat sheets for various protocols taped around the walls. Christina put the pulse oximeter, which measures the patient’s oxygen level, on Mary Alice’s finger, then set up the cardiac monitor. Each of us performed our task to the rhythm of the others with no wasted motion. Landry kept talking to Mary Alice in a calm voice as she readied the medications in their pre-filled syringes from the crash cart and handed them off to Timothy, who had just joined us. But what we all heard was the increasingly labored breathing. Mary Alice was tiring and her oxygen levels were drifting downward. The bluing lips told me that.

  “Oh-two sat at 80%,” Christina said, confirming my observation. The oxygen level was low. How much lower would it go? “And pulse now one fifty and irregular.”

  I looked at Timothy, but he was glowering at Megan, and I thought I hea
rd him snort. A quick glance at Megan showed her bent over the clipboard, writing furiously, back plastered to the wall.

  “Timothy, push the Benadryl then the Solumedrol,” I said.

  He wiped the IV port with alcohol, inserted the syringe, and injected the Benadryl through the line without a problem. As he started the Solumedrol, Mary Alice’s eyes rolled back and she lost consciousness. The oxygen level plummeted.

  I had no choice but to insert a tube down her throat and force air into her lungs. I felt panic rise in my chest. Intubation is my worst ACLS skill, but still markedly better than Timothy’s efforts. Take a deep breath and just do it!

  I inhaled. “Laryngoscope with straight blade and adult E.T. tube with stylet.”

  Christina checked the light on the scope and held it out as I positioned myself at the unconscious woman’s head, tilting it back to open the airway. She inserted the flexible metal stylet into the plastic endotracheal tube and held that out to me. I placed the scope’s spoon-like “blade” in the patient’s mouth, moved the tongue out of the way, and lifted the back of her throat straight up to expose the vocal cords. The hard part done, I smoothly threaded the tube between the cords and down into the trachea, then pulled out the stylet with a fast flourish. I held fast to the tube while Christina attached the Ambou bag and squeezed air into stiff lungs. Timothy listened to Mary Alice’s chest, then smiled as air moved in the lungs and not the stomach. The tube was in the right place.

  I exhaled.

  Another dose of epinephrine, this time down the tube and directly into the lungs. Christina continued rhythmically squeezing the bag, watching the oxygen level slowly climb. “Bagging is getting easier,” she reported as Landry finished taping the tube in place. The medications were starting to work. The monitor now showed a rapid but stable heartbeat. I saw Megan’s wide eyes and open mouth as she surveyed the scene.

  I listened carefully to Mary Alice’s chest. The heartbeat was strong, regular. The wheezes were becoming audible again, a sign the airways were opening back up and the air moving at least a little. As she started to come around, Landry talked to her, again in those soothing, reassuring tones, telling her what happened.

  Less than fifteen minutes had passed when the ambulance crew pushed the gear-laden gurney through the doorway. As they transferred Mary Alice onto the stretcher and hooked up their monitor, they gave us a thumbs up for the intubation and I.V. line already completed. While I gave the lead EMT a verbal report, the staff each gave Mary Alice words of encouragement. Stabilized, she was transferred into the ambulance for a trip to the hospital complete with lights and sirens.

  As the sirens dimmed, we all heaved a collective sigh.

  “Great job!” I said. We were coming down off the adrenaline rush yet maintained grave concern for our patient. “Uh, does anyone else need a change of underwear?”

  As if on cue, everyone started talking at once, reliving the drama. Everyone, that is, except Timothy. After a freeze-frame moment, he straightened his imaginary cuffs and gave me a look as if I’d just disgorged an alien. He glided to the door, his stentorian voice proclaiming, “I say, ‘Are you in the place of God?’ Exodus 50:19.”

  I let the implied insult that I was playing God float by without taking the bait, and noticed him leaving the room. The rest of us clapped each other on the back and hugged akin to football players after a playoff win. Mary Alice Connors was quite ill and would be in the intensive care unit for a while, but we all felt good that she had left the office alive and was likely to stay that way.

  ***

  I heard increasing chatter from the waiting room, where, in rural America, friends and acquaintances meet and catch up while waiting for their appointments. Megan was in my side chair, scribbling furiously on the code record. Suddenly she looked up and gazed into space, then said, “I’ll be right back.”

  I watched her scurry down the hallway, clipboard in hand, and into the trauma room. The office was divided roughly into thirds: my consult room, hallway, exam rooms, and the trauma room on the east side; Timothy’s exam rooms, the patient lavatory, business office, and office lounge along the west side; and the waiting room, reception area, and nursing area / lab down the center.

  When she returned she plunked the clipboard onto her lap as she sat, then rested the pen on my desk. “Do you have emergencies like this often?”

  I could see she’d filled in the drug names, probably off the labels still in the room. “Thankfully not. We use the trauma room mostly for minor surgeries and treatments. We have a lot of elderly patients who take a long time to dress and undress, so it’s nice to have one big room for special needs,” I said. As Megan leaned her elbows on the clipboard, I added, “I hope you appreciate how important observation and gut instinct are. Christina and Landry saved that woman’s life: Christina by listening when her EMT gut cried ‘foul’ and Landry with her quick action. Don’t let Christina's quiet efficiency or Landry’s blond hair and baby face fool you. They’re both good.”

  Megan cocked her head. “Did you know she’d pass out – the patient, I mean? Is that why you called nine-one-one?”

  “No, I was covering the worst case scenario, which I thought was a real possibility. I learned a long time ago that it’s better for me to look stupid by calling for help too early than for my patient to look dead by my calling for help too late. Help can be a long time coming out here in the sticks.”

  “Oh.” She picked up the pen and fixed some spellings. “OK if I rewrite this?”

  “As long as you keep the original with it.”

  I watched her write, my mind drifting back to Mary Alice. Megan looked up and caught my eye. “You know what I like about medicine?” I said.

  Megan moved her eyes side to side as though looking for the right answer. “No. Should I?”

  I chuckled. “See, I read mysteries. And I discovered, much to my chagrin, that patients don’t come in with the diagnosis written on their foreheads. So figuring out their problems is like solving mysteries. And I love it. Most of the time,” I said. “But something’s off here. So I need you to think.”

  She took less than a New York minute to say, “I always think!” After a moment, she softened and added, “I’m not sure I understand what you mean.”

  “Medicine is both an art and a science. In the classroom, you learned the science. You have these two years to develop the art, the gestalt, the gut feelings.”

  “Like Christina and Landry.”

  I nodded. “And my gut is hollering at me. Consider these facts: One: the major side effect of allergy shots is the risk of anaphylaxis,” I said, shooting the corresponding number of fingers as though playing Odds-Evens. “Two: this patient has been getting regular allergy shots for years. Three: she always waits the twenty minutes afterward to be sure there’s no reaction and has never had one. Four: her dosage hasn’t changed in years. And five: she’s been exposed to perfume in the waiting room before with no reaction.”

  I had Megan’s attention.

  “Now, I need you to think outside the box. Why did she have this reaction out of the blue?”

  “Maybe it’s not out of the blue.” Landry’s voice startled me. I hadn’t seen her leave the nearest exam room to lean against my door jamb, holding the next patient’s chart to her chest.

  “What do you mean?” I asked.

  She stepped into the room, closed the door, and handed me the chart. “When I went to get Mary Alice’s shot ready, I felt there was something wrong but didn’t know what.” She glanced quickly from Megan to me, then cleared her throat. “When I put it back, I realized what was bothering me. See, each patient’s vials are kept together in the small box they’re shipped in, and the boxes are kept in a bin in the nursing refrigerator. They wind up sorted by how often the patient comes in, with the frequent fliers on top because we’re always taking them out and we just put the box back on top when we’re done. So Mary Alice’s stuff is usually the eighth or ninth one down.” She paused, then lowe
red her voice. “But not today. Today it was so near the top I went right past it and had to go back.”

  I heard the “Ta-da!” in her voice as I squinted at her, trying to reach whatever conclusion she’d reached.

  “Doc,” she said, “I think someone messed with her vials. I don’t know why or how, but that’s the only thing that makes sense.”

  “Why would anyone do that?” I said. “Surely anyone with access to those meds would know how dangerous it is.” I shook my head and held out my hands palm up. “There must have been contamination, that’s all.”

  “If you say so, Doc,” Landry said, all business. “Patient in One is ready.” She turned on her heel, opened the door, walked with a heavy footfall.

  “Oooh, she’s pissed,” Megan said.

  I pursed my lips, wiggling them from side to side while I considered her comment. I had to appreciate her outspokenness. At times I wished she’d be more diplomatic, but that wouldn’t be the Megan I met only a few days ago.

  I’d walked into my office to find an apparent teenager sitting beside my desk.

  “Hello. And you are …?” I greeted her.

  “Megan Hendricks, M3 from UVA? An African American woman, like, let me in? Christina, I think she said?” Her voice rose at the end of her sentences, so I wasn’t sure if she was asking me or telling me. “I’m supposed to spend this month with you?” she said, rising from her chair to shake my hand.

  “Of course! Your Community Medicine rotation.” Having spent the first two years of medical school in the classroom, she was spending big parts of the next two in the real world, sampling the various branches of medicine. “By the way, Christina is the receptionist. She showed you around?”

  Megan nodded. “Nice set up. She like told me to wait here for you. I was like reading the certificates on your walls. You have a nice, you know, collection.”

  “But only these few are important,” I said, pointing to my diplomas and license. I stowed my purse in the bottom desk drawer and offered Megan space there as I settled in my chair for a brief get-acquainted chat. “So tell me, what’ve you done already?”