Thursday, January 20, 2011

The Purpose of Wives

I was working as a PA in an internal medicine office seeing out-patients.  One afternoon I was in the clinic hallway when I saw an elderly looking wife in her 60s pushing her husband who had dug his heels into the clinic tile floor and was trying to resist her from getting him into the next open exam room.  She finally won due to her husband’s obvious shortness of breath and noticeable wheezing I heard as they passed by me. 
I proceeded to go into see my next patient, keeping an ear cocked to any sounds coming from the clinic hallway which might portend some trouble coming from the next exam room with the husband’s shortness of breath/wheezing episode.  I quickly took care of my patient who had strep throat, gave them their antibiotics and walked into the adjacent exam room with the wheezing husband. 
The medical assistant gave me his vital signs, his pulse oximetry showed his oxygen saturation was 90, his pulse was 94, blood pressure was normal, respirations were 22.  A quick look at him told me he wasn’t using any of his accessory chest muscles to breath with.  I asked the medical assistant to go and get the nebulizer set up with an albuterol treatment and bring it into the exam room. 
As she left to go retrieve the equipment, I asked the husband, whose name was Bill what brought him into the clinic.  Bill, who was quietly sitting on the exam table told me, “ask her” pointing at his wife who was now sitting in one the exam room chairs. 
I turned to her to see an exasperated, angry stern look on his wife’s face.   She quickly told me, “He’s been wheezing since this morning and he refused to make an appointment to come into be seen.  He was coughing last night.  He has asthma, but he doesn’t always take his medicine for it.  I told him to take his advair this morning, but he said he didn’t need it.  Then he started wheezing about an hour later.  But he still wouldn’t take his inhaler.  At times, he’s too stubborn for his own good.   That’s why I called up this morning and got this appointment for him.  He needs help!”
“I see.”  Turning to Bill I asked him, “how long have you had asthma?”
Bill slowly wheezed out an answer, “About 40 years, I came down with it during college.”  

Asthma is a disease that is caused by chronic inflammation of the airways which causes airway constriction and subsequent problems with breathing.  Patients typically have shortness of breath, coughing, wheezing, and/or chest tightness.  It is a common chronic condition found in 5% of all patients. 
It is caused by a hyperresponsiveness to an allergen, exposure to occupational smoke, viral infections, or can be exercise induced.  It is generally believed to have a genetic basis to it, with multiple genes involved.  Most patients are diagnosed with it when they are a child, although some patients are diagnosed when they are an adult.
 
Just then the medical assistant came back into the exam room with all of the necessary equipment for an albuterol nebulizer treatment.  The two of us quickly set it up and I handed Bill the breathing apparatus end of the tubing, what I commonly called the ‘peace pipe.’
He sat there for a few minutes breathing in the nebulized albuterol as I listened to his lungs through his chest wall with my stethoscope.  His wheezing was slowly becoming becoming less and he was able to breathe a little bit better.  His pulse oximetry showed his pulse to be 96 and his pulse oximetry oxygen level was 92.  I gave him a peak flow meter to breath into a few times so that I could get a result as to how much airway obstruction he had.  The peak flow meter showed he was at 400 when he should have been at 580, due to his tall stature.   
“Okay, when was the last time you used your inhalers?”
“I used my ventolin inhaler last night.  I haven’t needed to use the advair inhaler, so I quit using it about two weeks ago.”
With that, his wife almost came unglued.  Her eyes became fiery and she accusingly said to Bill, “you quit taking your advair inhaler?  No wonder you’re so bad.  When are you going to learn that you don’t stop your maintenance medications just because you’re feeling alright?”
Bill with a look of meekness on his face replied, “I only take the advair when I think I need it, I don’t need to take it every day.”
His wife was not going to let up on him.  “You take the advair every day whether you think you need it or not.  It’s what keeps your airways open and allows you to breathe normally.  It’s what keeps you out of the doctor’s office like today.  When are you finally going to admit that you need that medication?”
Bill didn’t have a reply and he just sat quietly on the exam table. 

Asthma is typically treated with inhalers.  Ventolin is the first medication tried.  It is a short acting albuterol, which dilates the airways.  If patients need additional help then they are started on a long acting bronchodilator and an inhaled steroid.  If they still need additional help above this then they are generally referred to a pulmonary specialist who can assess them for the possibility of being put on the latest medication for asthma, a monoclonal antibody against IgE, which patients who have an allergy component of their disease respond to quite well. 

As this conversation was going on around me I quietly sat at the exam room table and started to type in my clinic note into the electronic medical record.  I asked the medical assistant to go and get one of the pharmaceutical samples of advair out of the closet.  I wanted to give him a treatment of a long acting albuterol and a long acting inhaled steroid.  She came back into the exam room with it and I handed it to Bill to use, which he did. 
“Okay, now that you’re breathing better, I need to ask you a few more questions, Bill.”
“Sure, fire away.”
“Have you had any fevers, or any upper respiratory symptoms during the past week or so that could be making your asthma act up?”
“No.”
“Any change in your exercise tolerance during the past two weeks since stopping your advair?”
With that he looked at his wife and meekly answered, “yes.”
At this point I could well imagine claws beginning to grow out of Bill’s wife’s fingers as she sat there with an angry look on her face. 
“How has your exercise tolerance been affected?”
“I haven’t been able to do my usual 18 rounds of golf and walk besides the caddy, I’ve had to ride in the golf cart instead, from one hole to the next.”
“Okay, well I don’t think I need to go into why you need to stay on your advair medication twice a day, do I?”
“No.”
“Alright, well then let me finish doing my physical exam, I’ll listen to your chest again and your heart.”
With that I completed my physical exam, his lung sounds were clearing up, his wheezing was less. 
“You have a peak flow meter at home, correct?”
“Yes.”
“Am I to assume that you know how to use it and write down your readings every day?”
“I know how to use it.”
“Good. Then what I want you to do is use your peak flow meter at home every day, write down your readings and come back in and be seen in two weeks.  I want you to use your advair every day whether you think you need it or not.  Agreed?”
“Okay.”
I looked over at his wife who was slowly calming down.  I knew once she got Bill home he was going to end up hearing yet another tirade from her about his not taking his medications the way they were prescribed.
“Do you need a refill of your ventolin inhaler?”
“No, I’m fine with that.”
“Then I’ll see you in two weeks.”

There are many ways to assess the severity of asthma.  You can use a pulse oximetry, which is easy to put on the patient’s finger, and it gives you their pulse as well as their oxygen saturation.  You can use a peak flow meter which gives you a reading anywhere from 200 to 650.  Based on the patient’s height you can then correlate this to what the patient should be expiring with each breath.  80% or higher of what is expected is considered the ‘green zone’, 50-79% of the patient’s expected expiratory volume is considered the ‘yellow zone’, and below 50% is considered the ‘red zone’ with the patient typically needing to be hospitalized. 
Physician’s offices also have spirometry machines which the patients can use.  This gives the physician a reading of the patient’ forced expiratory volumes.  Patients can also be tested for potential allergens which is setting off their asthma is the physician thinks that this is playing a role.

Two weeks later Bill kept his appointment.  I walked into the exam room to see a calm appearing wife sitting in the exam room chair and Bill sitting on the exam room table breathing easily with no audible wheezing or shortness of breath.
“Well, I’m glad to see the two of you again.  How’s your asthma been at home, Bill?”
“Much better.  Here’s my peak flow meter readings for you.”
I took at look at his readings and I was impressed.   On day one after seeing us his peak flow meter showed that he was at 400, over the next several days his peak flow meter slowly went from 400 up to 450.  During the last few days his peak flow meter showed that he was at 500 and staying there. 
“I’m impressed by your readings.  You’re staying in the green zone by keeping your peak flow readings above 465.  You must be feeling better and breathing a whole lot easier I would assume.”
“Yes.”
 Okay, well I see here that the medical assistant got your pulse oximetry reading and your oxygen saturation is at 95% and your pulse is at 80.  That’s wonderful, I’m glad to see that.  Let me listen to your chest and make sure there’s no wheezing going on and then I’ll sit down with you and we’ll come up with a workable plan for you to deal with your asthma at home, okay?”
“Alright.”
I listened to his lungs and they were totally clear.  I sat down and explained to him about what the peak flow meter readings told us about the condition of his asthma.  He agreed with me to take his peak flow meter reading once a day and to take or not take his advair medication based on his reading.  If his reading was below 475 or lower he was to take his advair as prescribed for the day.  If his peak flow meter reading was 476 or higher then he could decide whether he wanted to take or not take the advair.  This way he had control over his asthma treatment and could manage it more effectively without asking himself, am I wheezing or not today?  He was to continue to use his albuterol inhaler as a rescue inhaler and only when he needed it for short term relief. 
Bill seemed pleased to be able to self manage his asthma at home with the meter.  It gave him a number to strive for and it would also allow his wife to know what the condition of his asthma was for the day without having to ‘nag’ him into taking his meds. 
Hopefully this would work for him. 
“Alright, if you have any problems at home, you call us, agreed?”
“Agreed.”
“Good, then I’ll see you in two months.  Bring your peak flow readings with you.”

I had seen this scenario played out many times in my years of working in clinical medicine.  It was typically the man who refused to be seen by a physician or admit that he was ill and needed help.  It would be the wife or significant other who would drag their spouse into the clinic office to be seen and taken care of.  I had seen it happen with men who had asthma, rectal bleeding, acid reflux, hypertension, etc (they would stop their blood pressure meds because they didn’t think they needed them, hence the name ‘silent killer.’).  
On the whole, male patients believed that they were ‘okay’ and nothing would happen to them.  They would refuse to admit that they needed help.  And refusing to get help can be a killer, men dying of heart disease because they refuse to admit that they have been having chest discomfort, men dying of colon cancer because they refused to be seen for rectal bleeding, etc. 
If it wasn’t for the wives in the picture, men’s health suffers.  It’s the wives who bring their male companions into to be seen and taken care of.  It’s the wives who make the doctor’s appointments and then make sure their spouses keep them.  It’s generally the wives who keep the men in their lives on track about their health and watch out for what they are eating, whether they are exercising, etc.  Thank goodness for wives!

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