Category Archives: The Disease

the ounce of prevention

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A code that came in this weekend brought me back in time about a decade.

He came in dead, and he left that way too, as these things are sometimes wont to go. Later, after the post-mortem, the infection control officer did her customary chasing down of the staff members who were at the code. Seems the patient had meningococcal meningitis, a severe infection of the brain linings caused by a bacterium which spreads in the droplets of respiratory secretions. The infection control officer was there with a stack of prescriptions for antibiotics, a dose of which we all had to take to ensure that we who were exposed would not succumb to this infection.

The scariest part about meningococcus isn’t antibiotic resistance (MRSA) or disease mutations in animal hosts making the pathogen more dangerous to humans (H1N1), but rather how fast the disease progresses from an asymptomatic incubation stage to causing severe brain damage or death. Vaccination is available against the infection but vaccination campaigns in Canada haven’t been part of the routine immunization series, so herd immunity is nonexistent. The last time a number of teenagers died of this vaccine-preventable disease was when I received my immunizations against it.

About ten years ago, several high-school aged kids where I lived contracted meningococcal infection. Some of them got treated early enough on for meningitis, but the unlucky ones ended up like this kid. The infection overwhelmed their bodies, resulting in a the typical meningitis-type rash growing and growing into purpura, a sign the infection had caused DIC. At that point, the sepsis had progressed so far that the likelihood of a good outcome was extremely poor, and as a result, two very healthy kids died very suddenly.

Meningococcal disease is downright frightening, and is one of the few examples of infections you shouldn’t wait to get antibiotics for. It’s one of relatively few infections that, even in industrialized nations, still kills people fast enough that a matter of hours can make the difference between alive and dead. It’s one infection where the best treatment is that ounce of prevention: vaccination for those who are at risk. It’s one infection that emphasizes how important vaccination can be in avoiding preventable deaths. It’s one infection that really lays bare how little the medical community can do if we don’t catch you in time. And it makes it very starkly clear how dangerous it can be to not pay attention to your body.

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learning to take it seriously

I’ve had asthma ever since I was a baby, I think. I won’t lie and say that it didn’t factor into my decision to get into respiratory, either — I wanted to have control.

I’d always hated games with running. I remember hating tag in elementary school — I could never outrun anybody. Eventually my chest would get tight and hurt, and I’d cough and feel like I couldn’t breathe. I’d have to stop and then I’d get tagged, and I couldn’t tag anybody else. So I just didn’t play.

Mom put me in soccer. I hated it instantly, with its constant running after the ball. Other sports seemed like more of the same. This continued until I was about 13, when I walked into the doctor’s office (by myself) and demanded some kind of testing. I got a Ventolin inhaler and a referral for some testing. The testing showed airway obstruction with reversibility — a hallmark of asthma.

I had a problem, though. My parents had never taken me seriously about this (“You’re just out of shape” is something I heard a lot) and I had some real misconceptions about severity and proper treatment. I ended up at one point taking a steroid inhaler but I ended up with a lot of hoarseness of the voice (I later learned this is a common side effect) and eventually stopped taking it. I had no idea how severe I was.

It wasn’t until I was older, several years older, and looking to get into respiratory, that I had a second spirometry and learned to interpret what it means. I was a bit taken aback by the degree of impairment it showed — I had always thought I was relatively mild, that my asthma was “well controlled” with just my Ventolin inhaler to take when I needed it. (The truth was, my asthma had always been poorly controlled, and would remain poorly controlled for years afterwards.) It was the first opportunity I’d had to print out a copy of the testing and show it to my parents — “See, I’m not making this shit up” — and interpret it for them. I showed my family physician a copy — he was a bit tickled and compared it to the one I’d had done before — and he immediately adjusted my medication to better control things, seeing that my lung function had declined significantly since the one I’d had previously. It would be a few more years before I would learn that this was a bad sign, a negative effect of poor control, that poor control would sabotage my lung function slowly until I ended up like somebody who’d smoked for years.

Even after I’d gotten into respiratory, denial is somewhat of a strong impulse. I see these people who are wheezing and struggling, I do PFTs on the asthmatics who have even poorer control than I do (and perhaps, still smoke,) and I get the groove carved into my brain that this is what ‘severe’ looks like. My daily symptoms, my inability to participate in any kind of real ‘cardio’ without symptoms, my exacerbations which would have me wheezing for weeks on end, those didn’t register as ‘severe’. I had had poor breathing for so long that attacks didn’t frighten me. I could breathe through them and limit my activity. I could suck on cough drops and take my Ventolin only when the coughing was paroxysmal, with me gagging, doubling over, seeing stars.

Beginning work as an RT probably was the best thing for my asthma. I had peer pressure from coworkers when my tight cough manifested itself at work. I figured out something that worked for my symptoms — and ended up taking a fairly large dose of it to remain in some semblance of ‘control’ — but wasn’t exactly compliant with it. (I’m not alone, rates of nonadherence to medication are really high and is the main reason for severe exacerbations in asthmatics.) It wasn’t until I sought investigation for allergy testing that I got appropriately slapped for this.

Little did I know, the allergy specialist I was booked to see is also an asthma specialist. I didn’t expect my (terrible) spirometry to be put on display in his office, but there it was. I also didn’t expect to have to detail, in mortifying detail, my lack of adherence to my prescribed medication regimen.

I endured, hanging my head, my scathing lecture about how I should know better, about how my spirometry was all chronic changes, about how he should not have to belabour this point, about taking it seriously. I don’t know if it was internalized ignorance, I don’t know if it was mostly denial, but I do know I took this guy seriously.

I went home with a renewed conviction to take this seriously. I was adherent to the medication regimen properly for the first time since ever, and around about six weeks of this I had an epiphany. I could breathe. I could breathe and I was simultaneously amazed at how used to not being able to breathe a person could get. I had always thought that constant symptoms were normal, and I had a high tolerance for feeling awful all the time.

During this time, I took up running. I had always resigned myself to never being able to run. I amazed myself and conquered running, and found that after a small uphill battle training period I began to enjoy it. I began to become very sensitive to changes in how I felt and I learned to respond quickly to symptoms instead of suffering through them. When I had a significant exacerbation, I went to the doctor and went on Prednisone, instead of digging my heels in, instead of deciding that a month of feeling terrible was worth not having to take five days of oral steroids. I was shocked at how fast I felt better from the bronchitis that had me exceeding the recommended dose of bronchodilators.  I found the side effects were not as terrible as I had been led to believe.

I know now that I was playing with fire. I don’t entirely know why I did it, if it was denial or if it had more to do with not wanting to be seen as malingering. I do know that if I hadn’t done something about it, it very well could have killed me or left me critically ill. Now, I make it my mission to knock some sense into those like me, those lulled into the fog of thinking they’re not as severe as they really are, those that think they’re in control when they’re really not. Somebody saved my life once, by making me take this seriously. I feel the need to pay it forward.

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even when it’s different, it’s always the same

It’s funny how reading news stories bring back memories.

It’s always awful when a new mum dies. It’s usually such an awful death, too.

I remember the first time I ever was at a birth like that. An emergency section, an abrupted placenta. Baby’s heart rate frighteningly low, respiratory came for baby, and ended up with front row seats at the show. Enough bleeding for a horror movie. More bags of PRBCs and FFP than I had ever seen before. Fluids, fluids, fluids. I’d been at many c-sections before and they were all elective, scheduled, methodical things. The most tension in the room was an obstetrician demanding a student justify their presence or an anaesthetist calling someone out for making a mess of the OR with gloves covered in baby cheese. None of this wide-eyed adrenaline, the obstetrician and his assistant scrambling to get the baby out as fast as possible, the air thick with the sense of urgency. The jokes about us making him feel like a “real obstetrician” lighten the mood only the tiniest of margins. There’s a little person in there, and it’s not exactly scheduled to come out.

This story, however, is about the mum. When mum gets sick, or something horrifyingly bad happens. These scenes stick in my mind forever, not only because of the family, the husband, the tiny baby. The father and tiny baby aren’t there to see those last five, ten, thirty-five minutes. Just me, and the code team, there to witness what will later be described in one sentence.

Pick your pathology, really; there’s no shortage of pathologies that can cause this type of thing. The one that crosses my mind when thinking about these events is the amniotic fluid embolus. A seemingly normal birth, a happy fresh baby, an elated family. The endings of birth didn’t stop the bleeding. It continued and continued, and what began as a mild worry quickly escalated into a high-strung fear. The bleeding wasn’t stopping.

The infusions of blood products are really only a stopgap measure. By the time her heart stops, it’s already too late. We can only infuse so much. I have, arguably, the easiest job: stand at the head of the bed and watch, while I make her limp body breathe. Everyone else is scrambling and using their brain. I, I am standing there with one hand on the bagger and one hand on the yankauer, suctioning blood that flows freely from her lips, nose, eyes. It seems wrong, these young people coding in our ICU. As if the codes should all involve 90 year olds who were ready to let go. All I can think of, while watching this person die of DIC, is their husband, their family members, their brand new baby.

It’s been a long time since women routinely died in childbirth. These events are admittedly quite rare. But they happen. And when they happen, everything inside me twigs about how abnormal it is for a new mother to die in this place of western medicine and modern cures, of nothing other than having a baby.

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