Nothing can help me now.By Arne Vainio, M.D. She was working hard to breathe. She always worked hard, but this time was different. She didn’t even pay attention to me, she just looked straight ahead at nothing. There was fear in her wide open eyes as she struggled to catch her next breath. She had been given a dose of steroids in the emergency room and the first dose of the antibiotic was going in to her IV. She chronically used most of her energy just working to breathe and because of that constant effort she weighed less than a hundred pounds. She was almost skeletal and her ribs were starkly visible and every single vertebrae stuck up through the wrinkly skin of her back. The area above her collarbones sunk in with every breath as the oxygen starved lung tissue underneath pulled for air. Her heart was working hard trying to get what little oxygen she had to her tissues and I could see where it was hitting against the inside of her chest wall on the left and the sunken tissue between her ribs would form a small bump every time the tip of her heart pounded against it. The respiratory therapist put the BiPAP mask over her face and it started pushing air mixed with oxygen into her lungs and it held some pressure to keep her airway open so she could exhale. She tried to fight it at first and her panic worsened, but then the machine gave her a few breaths and she slowly started to calm down. She had been having trouble breathing for the last three days and her son said she wouldn’t let him call the ambulance. Every time she was in the hospital, her stays were longer and longer and when she was here she couldn’t smoke. Even though she was on oxygen at home, she still smoked and no one had been able to convince her to stop. She refused to go into assisted living or a nursing home for the same reason. We finally got her settled in and her oxygen saturation came into a low normal range. There wasn’t anything more to do right now and the ICU nurse would be with her all night. The next day I went to the ICU and she was still on the BiPAP machine. She was much less fearful, but difficult to understand with the mask covering her mouth and nose and the pressure it generated with each breath made it hard for her to talk. She still needed time and the antibiotic and steroids needed time to get into her system. This was her third COPD exacerbation this year and a lifetime of smoking had damaged most of her lung tissue and she only had a little bit of reserve left. A simple cold or any kind of lung infection used that reserve up quickly and when she got into trouble, it came on fast.
By the next day she was able to come off the Bipap machine and she was breathing on her own. Even getting up to the bedside commode was an ordeal for her and she struggled to breathe with even that much exertion. When I came in to see her, she was lying back in bed and her breakfast tray was untouched, “It’s just too much work to eat right now.” The next morning she was much more comfortable and was on the amount of oxygen she used at home. I pulled a chair up next to her bed. “You were afraid when you came in this time.” I said. “Why did you wait so long?” “I like to be at home so I can watch my shows.” “They have the same shows here.” I said. “It’s not the same. I like sitting on my couch at home. Everything is right where I need it.” “What are you able to do at home?” I asked. “I can make it back and forth to the bathroom and to my bed. That’s all I really need. My son does the cooking and cleaning and he’s always been good to me.” “Are you still smoking?” I asked. “I was wondering when you were going to ask that. I smoke about two packs of cigarettes every day.” “You must know smoking is why your lungs are so bad.” I said. “I do know that and I wish I would have stopped years ago when my breathing was still good. By the time I started getting sick, I never really got better in between and I figured stopping then wouldn’t make any difference.” “Did you ever try to quit?” I asked. She looked at me for a long time before she answered and I could tell she had been thinking about this for a while. “I did try to quit once. Right after my husband Warren died from lung cancer. We were saving for a trip to Mexico after we got married. We got married right out of high school and we used to sneak away from the school and smoke on the lunch recess and lots of the other kids did the same thing. We both smoked before the kids were born and we smoked in the car when we picked them up from school. No one thought twice about it and no one ever said it was bad for you. Cars didn’t have seat belts, but they had ash trays and cigarette lighters. I think the doctor who delivered my son went out for a cigarette just before the delivery.” “What happened with Warren?” I asked. “He started to cough and we just thought it was a cold that wouldn’t go away. By the time he went in to see the doctor, they said he had lung cancer and there wasn’t anything they could do for him. They gave him six months to live and he died in three and I was alone with two kids to raise. I had to take a job as a waitress and we smoked right in the restaurant. It was a stressful job and I looked forward to my smoke breaks.” “When did your lungs start to get bad?” I asked. “I don’t know. I suppose when I was in my thirties. I noticed I couldn’t walk as far without getting tired and if I caught a cold, it was even worse. Once in a while I thought the cigarettes might have something to do with it, but there were ads on TV and in magazines and everyone in all those ads seemed fine.” “But that was when you were younger.” I said. “Smoking has been known to cause lung disease for a long time.” “To tell the truth, I knew that before all that news came out. I loved Warren and we smoked together all the time. Every time I have a cigarette I think about him and sometimes I think of the trip we were going to take to Mexico. I can’t quit now and there isn’t any reason for me to quit. Nothing can help me now and I’m just waiting.” She was getting tired just talking, but she still had more to say. She took a few long, slow breaths before she went on. “I hate these cigarettes more than anything and I wouldn’t wish this on my worst enemy. Fighting to breathe all the time is miserable and if I panic just a little bit, it spirals out of control. I’ve had nights where I swear death is walking down the hallway to my apartment and I’ve sat awake all night watching the door. I know there will come a day when you or any other doctor won’t be able to save me and I’m afraid of that day. The damage has already been done and if I quit smoking right now it wouldn’t change a thing.” “What can I do for you?” I asked. “Nothing.” She said. “You and I both know I’m going to have a cigarette as soon as I get home. My son needs to have a life of his own and not just be worrying about some old sick woman. Maybe you could have this conversation with a younger person while they can still quit. Let them know this day comes sooner than they think.” Arne Vainio, M.D. is an enrolled member of the Mille Lacs Band of Ojibwe and is a family practice physician on the Fond du Lac reservation in Cloquet, Minnesota. He can be contacted at email@example.com.