Sunday, April 11, 2010

A Couple Days

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 spelling 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 this patient.

"Hello, maam," 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. "Maam," 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, maam," 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, maam?" Her answer was short and sweet. "Yes." Now I figured it out, cracking her. "And when did you quit smoking, maam?"

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, though, 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.

Sorry this posted late. As always, though, big thanks for reading. Next post will be on Wednesday, April 14. I hope your day goes well...


Katie said...

"I can't imagine the effort it would take to pull that yellowing thread from one's life quilt."
That's a beautiful sentence.

My grandparents smoked. Grandpa quit cold turkey after medical warning; Grandma took more time. That meant the rest of us had to endure the second-hand smoke (outside only) and the stench for a majority of my childhood. They're both cigarette free now and relatively healthy for being in their 70s. As for my younger generation, a lot of college campuses are becoming tobacco-free. This means there are more students having to walk all the way across the street to take a 'moke. At least they're getting excerise, right?

<>< Katie

Heather said...

You know what bugs me? When medical people know, when the entire nursing staff "steps out" for a minute.

It's difficult to quit..and the mind has to be ready (sometimes far later than the body is ready)

Capt. Schmoe said...

"A couple of days". It reminds me of "two beers", the standard answer to "How much have you had to drink tonight?"

You are right, she likely will be smoking again, probably soon.

She has heard the PSRs on the radio and the television, the speeches by her PMD and her loved ones. She knows what the deal is, she is probably resigned to the fact that her fate is already sealed and was done so when she tried and failed to quit the first time, so many years ago.

You have to keep trying though. Lets be honest, if everybody always behaved responsibly, many of us would be in other professions.

Thanks for the post.

AtYourCervix said...

I live with a smoker. He's 35 years old, and started smoking when he was 25 yrs old. Why? Because he hung out with smokers on their smoke breaks at work, and started joining in. Thus, an addiction. I hate his smoking. He won't quit. He says he doesn't want to quit. Doesn't matter that he's had two DVTs already. Doesn't matter that he's also obese, and has a chronic cough, and difficulty with exercise, and his heart pounds when he does exercise (and he can't figure out why!). Doesn't matter that I love him, and I'm a nurse, and I tell him how unhealthy it is to smoke. Doesn't matter that our young daughter doesn't want him to smoke.

I make him smoke outside, lest he pollute our lungs too.

Loki said...

Addiction is a terrible thing, nicotine addiction doubly so. I'm a nursing student with all the firsthand knowledge of what smoking will do to me if I continue to do it. But the pull of addiction is strong, and I find myself justifying, excusing, forgetting or whatever else is necessary to smoke at least one a day (I've gotten down to this level but I've been here forever).

What I think I need is more support, or maybe more willpower. Regardless, most of us smokers want to give it up; so don't give up on trying to help us, I know I appreciate it.

Pissed Off Patient said...

It just goes to show the power of addiction--it'll kill you if you let it.

For myself, I hate being sick and work my butt off to avoid it. I can't imagine a mind set where respiratory distress is okay.


Pissed Off Patient said...

@ Loki--I did some freelance writing on smoking cessation.

The success rates are stunningly low, but the more you try, the more likely you are to be successful. I think successful quitters tried something like 8 times.

Supposedly medications like Chantix are really effective, but I don't know much about their side effects.

As an asthmatic who is incredibly sensitive to smoke--doesn't matter how 'clean' a smoker you are, I can smell it and it can cause an acute attack--I worry about health care workers who smoke quite a bit.


Diana said...

Unfortunately, I am one of the many that nicotine got his grip on. Why? I don't really know, especially since I was born with pulmonary stenosis.

I started at the age of 12. We would walk home from school, find butts in the gutter, and light up. This was also back in the day where one could go to a vending machine. They also had not begun enforcing the laws as well as they do today. At the age of 13/14, I could walk into 7-11 or Woolworths, as for a pack, and 9/10 be handed one. If they asked for ID, I simply would state that I left it in the car.

I turned 30 last month, so this was not very long ago. Sickening because my son is 12. I cannot imagine him ruining his life.

Anonymous said...

I honestly think that most of the youth that starts smoking now has NOT seen the ill health effects-not the true reality that is found in hospitals. Spending a few hours in an ER where almost every patient is there because of smoking complications would certainly be eye-opening for anyone.

Mark p.s.2 said...

Cigarette packages have to have pictures on them of diseases you get from smoking.
example pic

Cathy said...

I have to tell you I doubled over with laughter when I read "Three hours ago"..This was just priceless.

Seriously though, I quit in 1996 after a year of struggling with it when I received a cancer diagnosis in 1995. I have talked about it and posted about it being about the hardest thing I ever did. I also think the older generation get a bad rap from people about smoking. The younger people have no idea that when we were small creatures, everyone in our life smoked, including our doctors, teachers, parents and grandparents. When I went to college we had ashtrays right on the armrests of our chairs. Everyone sat in lecture and smoked their heads off.

It was inevitable that most of us would be smokers. I bet you don't remember the time when hospitals allowed smoking for patients and their visitors? On everyone's nightstand was a clean ashtray when you were admitted.

Eileen said...

And to back Cathy up - it wasn't just that EVERYONE smoked, there were doctors telling them how GOOD it was for you! Seriously. And in the films it was always the beautiful and handsome leads who smoked looking oh, so sexy.

I smoked for a while - until I met the man who is now my husband. He's never even tried a cigarette - so nearly 40 years ago, I gave up as it didn't seem fair on him. His brother died of lung cancer. Horribly. He'd never smoked as far as we know. But we don't know how much secondhand smoke he'd had forced down into his lungs.

And the thing worse than the nurses who smoke? The ones who buy cigarettes for their patients.

Jim UK said...

My brother has been smoking for 45 years ; he is 65 , looks 80 .
Go into a room at night , switch the light on . Switch the light off : your lungs after 40 years .

Anonymous said...

My mother has blown smoke in my face for many decades. She now suffers numerous health problems from her addiction. I can't stand being around the filthy things. I try to keep my visits to her house as short and infrequent as possible. I am at a loss as to why anyone would take up the habit.

MLee said...

Smoking is evil habit that is hard to break.Withdrawals feel like your skin is rejecting your body.(If that makes any sense). I have quit many times over the years, yet I go back to them. The last time I quit I had not smoked for 63 days. However, my habit is a coping mechanism, isn't that a hell of an excuse. Two weeks ago I picked them up again, and one day ago I threw them away again... Lord only knows how many times she tried to quit before, but maybe to her three hours is a heck of a start. It is a shame at what we as smokers do to our bodies, but sometimes it is harder to be treated like a leper for being a smoker. Have to give you compliments for your sentence, "I can't imagine the effort it would take to pull that yellowing thread from one's life quilt." Because it is a daily fight for many and for most a fight to the day they die from a resp syndrome.

Tonjia said...

I am also amazed at the high number of young people who are taking up smoking nowadays. It is staggering. I live in western Colorado and we are supposed to be such a freaking healthy state, one sunday afternoon I kept track and 3 of every 5 people under the age of 35 who came into my triage room smoked! Amazing.

She will be back, hopefully next time she wont wait too long and have to be tubed......

Have a great week Doc!

Felix said...

Quitting probably was easier when one's word still was considered important, and when shame counted for a lot more. Both worked to my advantage -- I told all my friends I would stop smoking on Monday, Feb. 27th, 2006. Sunday evening, I threw out all ashtrays, lighters, matches and such, and all cigarettes except for one pack. Monday morning we had a small ceremony: A hammer, and my last pack met, briefly, to mark the occasion.

I was tempted for a few months, but the shame of admitting to my friends that I went back on my word always kept me from "just that one smoke" and all those that would have followed.

Those who are not willing to commit in public, in advance, to everyone -- those don't intend to quit yet. If you are one of them, give yourself a shove. Your friends will be proud of you, and you will, too.


Cal said...

I have never smoked, but grew up with smoking around me, not at home, as my parents did not smoke, but everywhere else. In high school kids had smoke breaks, no one blinked twice at it. Everywhere people smoked, bank tellers while depositing your checks, in every cafe, restaurant, everywhere, stores, nowhere you were safe. I remember as a teenager being pressured to light up, but never did. Cigarettes were dirt cheap too and anyone could buy them. I remember vomiting in a long car trip, during which the driver, a friend's dad, kept lighting up one after the other, with all windows closed... I just hope my lungs escaped that second hand exposure without too much damage!

KateA said...

My dad told me he would disinherit me if I smoked cigarettes. He said I could smoke all of the pot I wanted because that was not addictive. I grew up as one of the only non-smokers in my group of friends. I don't understand it when people that have intimate medical knowledge smoke. Oddly enough, many of the pathologists I knew in school smoked. You would think, of all doctors, these would SEE and FEEL what happened to the lungs. Alas. I hate walking into an exam room with someone that is a life long smoker: the nicotine seeps through the pores and imbeds into the walls. Takes forever to get the smell out.

Outrider said...

One of my dearest friends is now a non-smoker. She's an intelligent, educated person and over the years she had tried to quit multiple times, unsuccessfully. What finally worked was watching her smoker husband go from diagnosis to hospice to death from throat cancer in less than a year.

Leslie said...

Sorry Jim, I have to...How long had she not smoked?

...a couple hours...


Jabulani said...

I started smoking 19 years ago. I'd moved into a flat with a girlfriend and she and her boyfriend were chain smokers. I found the easiest way to combat the effects of the smoke on me was to smoke myself. (Yeah, silly, but hey ...) On and off for the next 9 years I smoked. A little over 10 years ago I stopped because I'd discovered I was pregnant with my son. I haven't had a cigarette since, and whilst the "yellow thread" has been pulled from my "life's quilt", it sits on the side looking at me every single day, waving and calling Yoohoo. I know, for sure, even if I only had a drag off someone else's cigarette, that yellow thread would instantly weave its way back into my quilt. So I endeavour to ignore it; and hey, there's chocolate and coffee instead, right??!!

Why do young people smoke? Well, because it's a truth universally known (with apologies to Jane Austen)- to teenagers at least - that when you're young, you're invincible and smoking doesn't affect you. Warnings are for, like, those old people. Teens I've quizzed about this ACTUALLY tell me that it won't affect them til they're "like 30 or summin'". Seriously. I hope their lungs/ throats/mouths know this and have the sense to avoid the cancer they're dancing with!

Peter said...

Hi! There has been some debate here and overseas whether or not smokers should be denied some types of surgery, especially if they won't give up the habit.

Are the advocates for this trying to be cruel to be kind or is it a cost saving measure?

Even our Prime Minister, Kevin Rudd, with his new $18 billion health reform package, has called for a $6.50 increase to the cost of a pack of 30 cigarettes in the May budget.

Yes, a pack will soon cost 20 Australian dollars. Still, a smoker will find the money no matter what the price hike.

Yes, our government will make a lot more out of smokers soon but to be cruel to be kind, I suggest, getting rid of cigarettes completely.

Yes, prohibit them and see where that takes us - and all of this coming from a smoker.

Take Care,

Jabulani said...

Peter, interesting comment. I was staggered to find recently that fags here in the UK now cost nearly £6 for 20!! How can people afford to smoke 20-40 a day?? Ah well, as you say, smokers will always find a way.

I like your idea of banning cigarettes altogether, but then who on earth would sponsor all the cricket?? Oh...and those other insignificant sports and stuff too ... Shame we can't synthetically produce Will Power and inject everyone with increasing doses of it!

SeaSpray said...

I worked with a nurse who's mother was in the hospital dying with a respiratory condition and she still wanted to smoke. But I guess if it's that far a long and brings pleasure...

It is difficult to break entrenched bad habits. Not impossible ..but difficult. maybe she figures it's all she has ..her cigarettes and her cats.

My mother was a heavy smoker all her life ..but she quit cold turkey in her 70s and lived to be almost 86. I never would've believed she could do it.

She told me she had a talk with the Lord... and then went back to it. Then had another talk and never smoked again. I should've asked her what she said.

At the hospital I worked at ...all but one respiratory therapist smoked. Ironic.