A frail, thin 66 year old lady was admitted to the ward this week. I observed her as she sat crosslegged on the raised dias where patients sleep. She was struggling to take her breaths, having to use the muscles in her neck to suck in more air. I noticed her hands were shaking. As I counted her respiratory rate, she looked at me and shook her hand, as if to indicate she found it uncomfortable to be scrutinised.
Karen people find it strange to be observed like this. They often think that doctors have magical diagnostic ability, like the shaman in their village, and find it odd to be interrogated about their symptoms, as well as being poked, prodded and auscultated during a clinical examination. But being unable to understand the Karen dialect, I need all the additional clues I can gather to help me make a diagnosis. Her fingers might be shaking, but they were not stained with nicotine, and her lips were pink because her blood was well oxygenated, not blue because she was cyanosed, not deep red because she had been chewing bevel nut.
The nurse told me that this patient had chronic asthma, and was regularly admitted when she was suffering from an acute exacerbation. She lives far from the clinic and finds it difficult to travel for follow up and to get a repeat prescription for inhalers. We started treatment and the following day she was so much improved that she wanted to go home.
“What should we do?” I asked.
“Discharge the patient with preventer and reliever inhalers,” said the nurse.
First, I thought we should check on her inhaler technique and her knowledge of how to manage the asthma herself. We started with salbutamol and the patient said that our inhalers were more powerful than the ones she could buy in her nearby pharmacy. “I used this one up in two days and it still didn’t relieve my wheezing,” she said. One inhaler contains about a month’s medication, and she had exhausted it in two days. No wonder her hands were trembling. This is a sign of excessive use of beta adrenergic agonists, like salbutamol.
I asked the nurses what they thought caused her to have an exacerbation of her asthma. Viral upper respiratory infection? Stopping her steroid inhaler? Maybe both these factors, they thought.
“What about cooking over a wood fire in a confined space, inhaling all the smoke and particulate matter? Do you know it is equivalent to smoking a pack of cigarettes a day?” I asked.
The patient knew about this. She had arranged for her 13 year old grandson to do all the cooking early in the morning before going out to work in the fields. So that’s alright, then.
Lesson of the day. Don’t presume that patients who have suffered from an illness for many years know how to manage their medication and their symptoms.