Carol Koenig [Koenig - Short of Breath

SHORT OF BREATH

Dr. CAROL L. KOENIG, MD, FAAFP

C HAPTER

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 dont 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. Theyll be out of the nest in another week or so, starting new adventures and fending for themselves, while Ill 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, Im 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 patients 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 Id finished early because I cut the perfumed patients visit short when I couldnt breathe. Maybe next time shell 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 Physicians Assistant, he was frequently not of much assistance, although his nursing home visits saved me time and

Dr. Wirth, I need you now ! Landrys 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 wasnt 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.

Im sure youre feeling pretty bad right now, I said, but hang in there and well 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. Shes 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 Timothys here, tell him we need him in the trauma room.

Hes 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.?

Im not good at it yet, Megan confessed.

I turned back. Then youre 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 patients oxygen level, on Mary Alices 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 heard him snort. A quick glance at Megan showed her bent over the clipboard, writing furiously, back plastered to the wall.