OUT OF BREATH | Rebecca Tuttle
He arrived by cab. He slowly made his way to the check-in window. The curve of his upper back mirrored the crook of his cane— his arthritic knuckles like its knobby wood. The nurse at the triage desk recognized the breathlessness of his words and the wobble in his step. He gave into the offered wheelchair, sinking into the invitation, a slight relaxation in his wrinkled brow.
As he wheeled into the acute bay, the team sprang into action. They stripped off his worn navy flannel. His suspenders fell from his shoulders, his threadbare undershirt pulled over his bobbing head, his belt unbuckled, and pants relocated to the bag for patient belongings. He lay back on the stretcher, naked and generic.
His heaving chest became decorated with a collage of stickers. Five leads spread like the arms of a starfish from his body to the bedside monitor. Ensnared in twelve wires stretching like strings of a spiderweb, the electrocardiogram machine captured his heart rhythm. A rubbery gray pulse-oximeter covered his finger with a red glow, its blue cord carrying the truth of his hypoxia and quantifying his respiratory distress. Clear tubing of the nasal canula snaked around his face, hissing oxygen into his flaring nose.
I took in his cachectic pallor, the wasting at his temples, the cavern of his eyes. With each labored breath, his mottled mound of an abdomen gave a gelatinous shudder. I introduced myself as his doctor. He told me how he had not been able to eat or take his pills for the last few days. The effort was too great. Today, he could not catch his breath. He looked to me, pleading for help. With one hand, I set my stethoscope on his chest. I listened to the faint, rapid beat as his heart struggled to keep up with his body’s demand. With my other hand, I held his wrist, feeling his thready pulse. I listened to the rattling inside the barrel of his chest. My hand slid atop his and gave a comforting squeeze.
I looked in his eyes. With a serious level stare, I asked him how far he wanted me to go. Would he want a breathing tube? Chest compressions? He returned my gaze with eyes glistening in desperation. “Do whatever you need to do to help me breathe, doc.”
Two hours later, the ICU team was at the bedside. The patient’s respiratory effort had improved significantly at this point in the resuscitation. His breathing calmed. His heart rate normalized. Unfortunately, the workup revealed that he was in multisystem organ failure, likely originating with the inadequate squeezing of his heart. Like toppled dominos, the backflow of blood building up in his congested liver had led to hepatic failure. The malperfusion of his kidney had led to renal failure. Despite temporizing the storm, the straits were dire.
The ICU fellow crouched down next to the head of the bed. He asked the patient about his goals at the end of life. Would he prefer longevity if it came at the cost of comfort? The patient pondered this question for a moment. With a slight shake of his head, he said. “I’m ninety. I’ve got to go sometime. Please just keep me comfortable.”
The room was still. We stood in reverence at his choice. He came here for help. A hunched man in a flannel shirt. He bared himself to us with fear. He was hungry for air, clinging to a frantic need to breathe. He was a collection of vital signs and lab results. We found answers, but he determined the conclusion. With the suffocating squeeze of his respiratory distress temporized, he had clarity of mind and deep humility. As he journeyed nearer to death, he brought out the humanity in all of us standing around his bed. He showed us the wisdom in recognizing our own mortality and the nobility in its acceptance.
Rebecca Tuttle is an emergency physician and educator in Portland, Oregon. When not taking care of veterans, she spends time having adventures with her two young children. She enjoys dining out with her husband, listening to audiobooks, and competing on nationally televised game shows. She is immensely grateful for the moments of human connection that occur at the bedside, whether with hearing patient stories in the emergency department or tucking in her daughters at night.