Pulmonary fibrosis is usually an insidious process. Over the next few days I searched for a reason for her abrupt decompensation. No cause was found. Despite quitting her five-cigarette-a-day smoking habit, she wasn’t able to maintain her sats above 90 percent without supplemental oxygen. Arrangements were made for her to have home oxygen as well as an urgent consultation with the nearest available lung specialist. When everything was in place, I discharged her from hospital.
Over the next several months Molly made a number of trips to the respirologist. A lung biopsy revealed progressive pulmonary fibrosis of unknown origin, so she was started on high-dose corticosteroids.
Although she was a pleasant person, Molly had always been a loner who pretty much kept to herself. She was single and had no living relatives. As her shortness of breath worsened, so too did her anxiety. With nowhere else to turn, my office gradually became her main source of support.
The steroids failed to halt the progression of her disease, so immunosuppressants were initiated. When it became obvious that they, too, weren’t helping, she was referred further south to a transplant unit in Toronto. The team there reviewed her case carefully and concluded she was a good candidate for their program. There was only one catch – she would have to move to Toronto. This was not an unreasonable request. Due to the logistics involved in harvesting and transplanting lungs, patients on the waiting list must be able to get to the surgical centre on short notice. Our town was 800 kilometres away from Toronto.
The idea of moving petrified Molly. She agonized over the decision for a long time, but in the end she opted to go. She had no choice, really – to remain at home in our isolated town would have meant certain death.
Packing up and moving to Toronto when you can hardly breathe is no easy feat. It’s even more difficult when you have limited savings and no family. True to the spirit of the North, our town came through for Molly. After a lot of searching, a suitable place for her to stay in Toronto was found. A community member whom she barely even knew volunteered to go live with her and provide general assistance. In addition to that, a local service club held a fundraiser to help offset her mounting expenses. Eventually everything was organized and a departure date was set.
A couple of weeks before she was scheduled to leave, Molly came in for an office appointment. Her shortness of breath had worsened and she was feeling overwhelmed. She asked if I could admit her to our hospital until she left for Toronto. I called the medical ward and let them know she’d be coming in.
A fresh battery of tests failed to turn up any new problems. Even so, I didn’t think she was well enough to handle a commercial flight. I spoke to the transplant team and they agreed to a direct hospital-to-hospital transfer by jet in one week.
For the next six days I made a point of dropping in and chatting with her for as long as time permitted. If there was no longer anything medical I could do for her, at least I could listen.
At 5:30 on the evening before the transfer a nurse on the medical floor called me at my office to say Molly wanted to speak to me. Apparently she needed to tell me something important. It had been a long day and I was tired. I had already spent 15 minutes with her during my lunch break and I just didn’t feel like doing it again. I asked the nurse to tell her I’d see her first thing in the morning before the jet arrived.
Molly died in her sleep at 6:00 a.m. on the morning of her scheduled transfer.
Sometimes at night I lie in bed and wonder what it was she wanted to tell me.
Thank You
It’s hard to figure out where the expression “thank you” fits into the practice of modern medicine. Are people obliged to thank me when I help them? Of course not. Would it be nice? Why, yes, it would. Most people do say thanks when I help lighten their load, but a surprising number do not. When I stay up all night struggling to keep a family’s loved one alive, I obviously don’t expect any sort of material reward, but I don’t think it’s unreasonable to expect a thank-you.
Now, I know what you’re thinking: “But Slim, it’s not like you’re treating these people purely out of the goodness of your heart! You’re well-paid by the Ministry of Health to provide these services!”
Yes, I know that. However, I say thanks when the operator puts my call through. I say thank-you whenever the guy at the service station fills my car’s tank with gas. I say thanks every morning when the woman at Tim Hortons hands me my bagel and coffee. Should it not therefore be reasonable for me to expect a simple thank-you for treating someone’s hemorrhoid, headache or heart attack?
One Sunday afternoon I was paged to the ER stat. I raced into the major treatment room to find a screaming 20-month-old boy with multiple second-degree burns all over his body. An older sibling had accidently knocked a kettle off the stove and doused him with boiling water. Large blisters were welling up everywhere and he was in acute distress. He needed immediate fluid resuscitation and pain relief. Unfortunately, he was an unusually chubby little fellow and there were no accessible veins in sight.
A few weeks earlier I had attended a pediatric trauma course and learned about a relatively new way to access the circulatory system of a child. It was called an intraosseous infusion. The technique involves drilling a large bore needle through the shinbone and into the marrow beneath it. Fluids and medications can then be administered directly into the bone marrow. From there they enter the bloodstream. As soon as I got back from the course I ordered some intraosseous kits for our ER. I figured they might come in handy someday.
Several attempts at starting a regular IV were unsuccessful, so I asked one of the ER nurses to open an intraosseous kit. The device consisted of a sharp, hollow, inch-long needle attached to a round, plastic handle. I explained the procedure to the boy’s mother. She gave her consent and went outside to wait until we were finished. The nurse immobilized the child for me. While I injected local anaesthetic into his upper shin, I reviewed the procedure in my mind. In the course I had taken we had practised inserting intraosseous needles into inert chicken bones, but this was the real deal – a shrieking, writhing toddler. I pushed the needle firmly into his tibia. When it was solidly embedded I began to twist it in deeper by rotating my wrist from side to side. I could feel the metal grinding its way through the bone. It was a strikingly unpleasant sensation.
Eventually the needle punched through to the marrow. After confirming proper placement we attached it to an IV bag and began infusing morphine and fluids.
As his condition stabilized we inserted catheters and applied dressings to his wounds. I contacted a burn specialist at a pediatric hospital in southern Ontario and had him flown down for definitive care.
Over the next several days we followed his progress via a number of sources, both direct and indirect. By all accounts he was doing well and was expected to have a satisfactory recovery. We were especially proud to hear the pediatric burn unit had been impressed with the quality of care he had received at our facility. We patted ourselves on the back for a job well done.
The only thing that bothered me slightly about the case was that the mother hadn’t thanked me for looking after her child in the ER.
“ But Slim, she had other things on her mind! Her son had just been badly burned!”
Yeah, I know. I was there, remember? Although I realize it sounds petty of me to even mention it, I still think a brief thank-you would have been nice. Oh, well. Life goes on.
Exactly one week later I was out in my front yard raking. My daughters were having fun running around and jumping into the piles of leaves. Suddenly an unfamiliar truck pulled up to the curb in front of our house. A man jumped out and strode purposefully across our lawn directly towards me. My kids stopped playing and eyed the stranger cautiously.