Vital Signs – 1st December 2007

Vital Signs

BMA News, 1st December 2007

Aidan M. O’Donnell.

Agnes was 65. She was listed for a carpal tunnel decompression on a list of minor orthopaedic cases for which I was the anaesthetist. I was in early and went to see her first thing.

The ward nurse told me Agnes had suffered an asthma attack during the night.

I flicked through the notes. Agnes was from an impoverished part of town. She had lived at three different addresses in the previous five years. She had attended out-patients in a variety of specialties with minor complaints (including asthma), but otherwise there was little. At two o’clock that morning she had become very breathless and wheezy. The house doctor had sensibly started oxygen and nebulisers, and given antibiotics and steroids. An arterial blood gas had been taken and the results were normal.

Agnes was sitting up in bed, with the oxygen mask perched on her forehead. She was a little unkempt, but pink and undistressed. She could readily speak in sentences. I introduced myself, and asked her how her breathing was.

“A lot better now doctor, thanks,” she replied. “I don’t mind if you have to cancel the operation for a day or two.”

“Well, maybe we could do it under local,” I said. “Let’s go through the rest of the history.”

She was overweight, and a smoker, but her asthma seemed normally well controlled. She had never had a hospital admission for an asthma attack, although she told me it flared up in the winter.

I took out my stethoscope and listened to her chest. It sounded dreadful, with loud, rasping groans and shudders heard throughout both lung fields, on inspiration and expiration. On an impulse, I pulled one of the earpieces out of my ear as I listened. Agnes was deliberately closing her glottis, making her breath sounds very abnormal. I put my hand on her shoulder.

“Just breathe quietly through your mouth, Agnes,” I said. “No, just quietly, in and out, like this.”

The breath sounds were clear, without a hint of a wheeze, right down to the bases. Agnes looked disappointed when I said her breathing was normal and we could go ahead with the operation.

I told the orthopaedic registrar that there was no sign of asthma, and that I thought that Agnes was deliberately exaggerating her symptoms, perhaps to prolong her stay in the hospital. The registrar went to look at the wrist, and came back. “She doesn’t have carpal tunnel syndrome. I’ve cancelled her from the list. She can go home today.”

Agnes needed to feel safe and cared for, perhaps only for a couple of days, and feigning symptoms must have seemed like the best method. Sending her home when she needed help made me sad, but performing a needless operation was not the way to help her. What we did was right from our point of view, even if wrong from hers. I still don’t know if there was a way for us both to be right.

Aidan O’Donnell is a consultant anaesthetist from Livingston.

Copyright © Aidan O’Donnell 2007.
This article first appeared in BMA News on 1st December 2007.
Unauthorised reproduction prohibited.