Waiting to Exhale: Lung Doc on Call

 

I first met him around a year and a half ago through Telemedicine. He was a 79-year-old farmer living in the province who used to be a heavy smoker; the uncle of one of my long-time patients. She referred him to me because despite having a laundry list of drugs for COPD, he still had a productive cough with copious sputum, shortness of breath, and wheezing. He was emaciated, anorexic, and depressed. Once an active individual who loved to tramp up and down his farm, he could now barely do his activities of daily living. He sat there apathetically as I practically shouted at him through the choppy Messenger video call, an oxygen cannula on his nose and his mouth gasping like a landed trout.

Anyway, it turned out that he probably had an ongoing respiratory infection, and he was taking two inhalers that shouldn’t be used together. I put him on a course of antibiotics and revised his medications so that he was actually on fewer of them.   I saw him after a week, and again after that.  The difference was remarkable and heartwarming. Within two weeks, he had improved drastically from an invalid who could barely talk or move, to an elderly but energetic pensioner who had gone off oxygen and was even attempting to water his plants.  Within a month, I learned from his niece that he was tramping up and down his farm like the old days again.  Even his children were astounded by the transformation; they didn’t realize that “he still had it in him.”

For about a year, I saw him every three to four months, not because he had any ongoing problems, but just to check that he was continuing his regimen (and that he wasn’t attempting to smoke again now that he was feeling better).  For a while, everything was sunshine and roses.

And then disaster struck.

The problem started when Uncle refused to get vaccinated.  No matter how much I coaxed, cajoled, wheedled, and practically threatened, he just wouldn’t be convinced that it was important.  He kept citing anecdotal reports of this and that neighbor or relative who had died days or weeks after being vaccinated.  In vain did I try to explain that the two incidents were not necessarily related, and that even if they were, he still had much more to fear from the disease itself than the vaccine.   After each unsuccessful attempt, I usually ended up telling him to just stay home because there was nothing else that I could do.  It didn’t help that the rest of his household didn’t want to get vaccinated, either. 

That worked well enough with the first few variants of the virus.  And then the latest iteration came along—the legendarily infectious Omicron—and shot the whole system to hell. 

Uncle lived with his wife, his kids, their spouses, and a few grandchildren in a bungalow with a large common living area where everyone stayed most of the time.  A few weeks ago, at the height of the surge, one of them contracted colds and cough.  A few days later, another one got it.  No one thought to swab or even to isolate. So the infection hopped along, until it finally reached my patient. 

As expected, it hit him like a freight train.  The family reached out to me for a consult about 3 days after he first developed symptoms.  Everyone else was getting better, except for him.  He had developed fever, cough with phlegm, difficulty of breathing, wheezing, generalized weakness, and loss of appetite. His oxygen saturation had dropped to just seventy-three percent.  He lay there on a cot, cheeks sunken, frantically sucking in air like a goldfish.   It was like our first consultation again, but this time it was much worse. 

I scribbled several pages’ worth of prescriptions and laboratory requests.  I doubted that they would be of any use (I’ve actually seen more severe cases, but I had a bad feeling about Uncle’s condition), so before signing off, I pleaded with his relatives to bring him immediately to the emergency room.  Later on, I learned to my dismay that they had only half-heartedly called the nearest hospitals, as they thought that Uncle probably only had “hika” like the first time, and would recover soon.  Unfortunately, my first spectacular save had rather unexpectedly returned to stab me in the back. I couldn’t convince them that this was different, that this was serious, and that if we didn’t move quickly, that this could very well mean THE END.    

My exhortations turned out to be prophetic. When I saw him again the following afternoon, I couldn’t believe my eyes. From being lethargic but blearily communicative, he was now totally unresponsive. From a respiratory rate of thirty with excessive use of his chest and neck muscles, his weak breathing efforts could now only be called “agonal”. He had not eaten or drunk anything since that morning. His oxygen saturation was just eighty-eight percent on six liters oxygen per nasal cannula, and I suspected that the level of carbon dioxide in his body was extremely high, essentially sedating him into a hypercapneic coma.

“Hospital?” I inquired desperately.  There were no vacancies, the relatives told me with a shrug.  But at least they had been able to find a stay-in nurse who could insert an intravenous line.  The nurse and I stared at each other dubiously for a few seconds, knowing what the lay people in the conference call did not seem to understand—that an IV could do precious little at this point.  At the very least, Uncle needed to be intubated and hooked to a ventilator.  He needed broad-spectrum antibiotics, stat.  He needed the kind of high-level care that could only be given in the ICU with a host of bleeping, high-tech machinery and very, very expensive drugs.   But none of those were available.  All I had was her, and all she had to instruct her was me, hundreds of miles away on the other side of an iPad. 

“I have to prime them,” I thought, not realizing that I had said it out loud.  To “prime”, in medical vernacular (at least in the Philippines), means to gently inform the relatives that the patient is probably going to die.  The nurse glanced at the cot behind her and nodded grimly.  “Yes, I think you should, doctor.”

Of course, I still gave her tons of written instructions.  Very optimistic they were, listing various drugs for several days, requests for a myriad labs, NGTs, catheters, the works. 

The patient died that very night.  They hadn’t managed to buy anything before he abruptly quit breathing.    

That would have been enough of a tragedy in itself, but more was yet to come.  For whatever reason, the family wasn’t convinced that COVID was the probable cause of their patriarch’s death (how would they know, as they refused to get anyone tested?). So in order to hold a wake and a burial, they lied and told everyone that the old man had actually died of heart disease.  And the representative of the municipal government who came to check believed them.

“What?!” I practically screeched when the niece told me about this insane development.  “The whole family was sick with classic symptoms of COVID! They were all unvaccinated in the middle of the worst surge the world has ever seen! And the municipal physician believed that the patient died of a myocardial infarction?!”

“Yes, Doc, he was even laughing about it,” said Uncle’s niece, shaking her head.  “We tried to tell them that we consulted you, but he just said, ‘Who is this doctor who can’t differentiate between a heart attack and COVID?’”

“He didn’t even see the patient until after he was dead!” I roared.  His niece could only shake her head in resignation.  “He wouldn’t listen to me, Doc.  Maybe if you wrote them…?”

Full of righteous indignation, I whipped out my laptop and proceeded to construct a long, intricate medical certificate detailing the patient’s symptoms and my clinical impression that he had suffered from Probable Critical COVID.  At the end, I recommended that the municipal government test and quarantine the entire family, cremate the deceased, and cancel the wake.  The niece was grateful for my efforts, and promised to update me if anything came out of it. 

I waited for a day. And then two.

After three days, I could no longer stand it, so I texted the niece. 

Hi, Ma’am. What happened?

The reply, when it came, was both infuriating and disheartening. 

Nothing, Doc.  I sent the certificate to the email they provided and they just ignored me.  No text, no call, no reply.  Nothing.

What happened to the wake?

It’s still going on.  And…Doc.  There’s been another death in the family.

What?!

An elderly relative who attended the first day of the wake came down with confirmed COVID 2 days later.  She succumbed after 24 hours.  So now, there’s another wake.  And they didn’t tell anyone that she died because of COVID, either. 

So now there are potentially TWO superspreader events going on in that town?!

Yes, Doc.

            I could only throw up my hands at this exasperating and deadly turn of events.

            Now we know why this surge is so bad!

            We did all that could, Doc.

            After texting my goodbyes to the niece, I sat there for a while and pondered.  Had we really done all that we could? Should I have phoned the offending official myself to press my point? Should I have called the immediate relatives of the patient to berate them for their shortsightedness and thoughtlessness? Was I still culpable for the deaths that I could have prevented by making an unholy fuss in a faraway town over a patient whom I had never even seen face to face? Where does the duty of a doctor end and the line of personal responsibility begin?  

            We did all that we could, Doc.

            I comforted myself with this last remark from Uncle’s niece.  It didn’t quite ring true, but sometimes, that yawning difference between what you should have done and what you actually did is just something that you have to accept in order to go on with your life. 

            Even doctors can’t fix everything. All we can do is try.