VOL 48: FEBRUARY • FÉVRIER 2002 Canadian Family Physician • Le Médecin de famille canadien 263
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Reflections
“Help me breathe”
Finding the right way to respond
Ian Cameron, MD, CCFP, FCFP
Dr Cameron is a Professor in the Department of Family Medicine at Dalhousie University in Halifax, NS.
H
er baby was cradled snugly in her arm as she untied the bonnet strings. Their eyes met, and the tiny lips parted in a cooing smile that spread to the mother, and her smile filled the room. I would not have predicted this scene 3 years earlier.Theresa moved to Halifax, NS, from a small Acadian community at the other end of the province. She had made an appointment with our office to get her asthma prescription refilled. She had pale blue eyes;
bouncy, curly reddish-blond hair; and traces of acne. I introduced myself and asked her how she was getting along in the city.
“ I like the city.”
“ Tell me about your asthma.”
“ It’s OK now.”
“ How long have you had asthma?”
“ Since I was a baby.”
“ Have you ever had to go to the hospital or emergency room because of your asthma?”
“ Twice.”
“ Recently?”
“ No, it was a long time ago. When I was 3 or 4.”
“ How often are you [using] your asthma puffer?”
“ Three or four times a week.”
“ How often were you using your puffer back home?”
“ I hardly had to use it at all.”
Theresa was not sure why she was using her puffer more often.
“Maybe it’s the cold air [or]
maybe I’m allergic to something.
I don’t know.”
She was exposed to cigarette smoke at work, but she could not identify much else in her
new environment that would aggravate her asthma.
Results of her physical examination were normal. I filled the prescription for her puffer, and she agreed to come back to the office to be reassessed if she had to use it more than three times a week.
Her condition was critical
Theresa returned a few months later for a well-woman examination and was seen by Dr Susan Hebb, the resident who was working with me. In the interval, she had had only occasional wheezing, no trips to the emergency room, and had not missed any work. Dr Hebb filled her asthma prescription.
Six months later we received a note from the emer- gency room. Theresa had been seen for an acute asthmatic attack. She had had a viral infection, had run out of medication, and had presented acutely short of breath. Her clinical condition was critical, and a decision was made to intubate her and admit her to hospital. She improved quickly, was extubated, and discharged several days later on a tapering dose of oral steroids and her regular puffer.
Dr Hebb and I saw Theresa in the office 10 days after her discharge. She was sitting on the edge of her chair, and she did not look up when we entered the room.
Her acne had worsened. Susan asked her how she was feeling.
“My breathing is better today.”
“What happened before you were admitted to hospital?”
“I don’t know, I guess I wasn’t paying attention. I had a cold, my puffer was empty, suddenly I just couldn’t breathe. A friend took me to emergency.”
Canadian Family Physician invites you to con- tribute to Reflections. We are looking for per- sonal stories or experiences that illustrate unique or intriguing aspects of life as seen by family physicians. The stories should be personal, have human interest, and be writ- ten from the heart. They are not meant to be analytical. Writing style should be direct and in the first person, and articles should be no more than 1000 words long. Consider sharing your story with your colleagues.
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264 Canadian Family Physician • Le Médecin de famille canadien VOL 48: FEBRUARY • FÉVRIER 2002
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Aside from the events leading up to her hospital- ization, nothing had changed in Theresa’s history:
her family back home was fine, none of her relation- ships had gone sour, and she had received a promo- tion at work. Results of her physical examination were normal and so were results of her peak expiratory flow test. We reassured Theresa and added a steroid puffer to her medication.
“Thank you,” she said and looked at us without say- ing anything.
Dr Hebb asked, “Do you have any questions?”
“No.”
Emergency visits continued
For the next 4 months we were in contact with Theresa two and three times a week. There were night calls and visits to the emergency room. The complaint was always the same: “It’s my asthma. I can’t breathe.” And the findings were always the same: no evidence of acute asthma. Often Theresa had a rapid pulse, a side effect of using one of her puffers too often, and she was asking for refills of her prescriptions too frequently. We talked to her on the proper use of her medication and warned her about overuse. We restricted her refills and gave her a long-acting medication. We referred her to a respirologist who tested her lung function, which was normal, and who made some recommen- dations. We discussed the consultant’s report with Theresa and made the recommended changes.
The night calls and office and emergency room visits continued.
At times we would see Theresa sighing and over- breathing. We talked to her about hyperventilation and the symptoms it could cause. We taught her about rebreathing and how to slow her respirations. We asked her if there was anything else we could do.
“Help me breathe,” she would say.
We witnessed Theresa’s decline, her tired exas- peration, her hopeless looks at the ceiling when we told her we could find nothing wrong. We saw her limp hair, her unattended appearance, her averted eyes. We knew she was missing time at work. We asked about her sleeping pattern. Was she eating reg- ularly? Did she have any disturbing thoughts? Did she weep? How was she coping? And she replied, “Just help me breathe.”
The notes from the emergency room became pre- dictable: “no evidence of acute asthma.” The dis- charge diagnoses began to change from asthma to anxiety or panic attacks. We talked to Theresa about
anxiety and suggested a trial of a medication that would make her less anxious.
She asked, “Will that help me breathe?”
“It will reduce your anxiety about breathing,” we said hopefully.
It did not, so we talked to Theresa about the pos- sibility of seeing a psychiatrist.
“Will the psychiatrist help me breathe?”
“The psychiatrist can help us understand what the underlying problem might be.”
Theresa said she would think about it.
A turn of events
The next day Theresa was in the office. “I can’t breathe.” Dr Hebb saw her, listened to her short interval history, and examined her. Then a change occurred. After months of failing to discover Theresa’s problem, Dr Hebb did something completely differ- ent. She asked Theresa to write a letter explaining why she could not breathe and to bring it back to the office the next day. Theresa agreed.
The following day Theresa arrived with a five-page, handwritten letter for Dr Hebb. The letter outlined in precise detail what had happened the night she had gone to the emergency room and was intubated. She was afraid because she knew that her asthma was worse than it had ever been before, and she knew she was not getting any better with the aerosols. The emergency doctor said something about her oxygen level dropping. The nurses set up an intravenous line, and the doctor gave her an injection. Suddenly she was paralyzed; she could not move, speak, or breathe.
She was wide awake, could hear the conversation around her, but could do nothing to help herself. She was suffocating in a room full of people.
Then the doctor opened Theresa’s mouth, stuck a metal object down her throat and then a tube, and then everything went black. When she awoke in the hospital, she knew she was better, but since then the thought of being paralyzed and not being able to breathe haunted her continuously. Every day she feared her asthma would suddenly get out of control, and she would have to relive her nightmare. Dr Hebb asked her why she had not told anyone about this. “I couldn’t until now,” Theresa replied.
Epilogue
Theresa made a full recovery. She taught me to look for the message behind persistence, and Dr Hebb taught me how to open another door when we could not find the right answer.
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