Monday, July 10, 2006

Asthma versus The Beaver

Oscar was 28 years old, thin and muscular, with the look of the outdoors in his eyes. He was not from one of my villages, and I had never seen him as a patient before. His appointment was for “cough and runny nose x 2 days.” His chart was as thin as he was, which told me he had not been seen in the hospital very often. When I asked him why he had come to clinic that day, he said “it’s just a cold. I’m coughing a lot at night, and I wondered if I could get some cough syrup.”

We discussed his symptoms and their duration, and I noticed that his breathing was unlabored and his speech regular. His vital signs were normal, except that the oxygen saturation seemed a little low (96%) for a person of his age and apparent level of fitness. He denied any chronic meds, but when I asked him if he were taking any meds for his cold, he said “I have a puffer if I really need it.” I saw in his chart that he had been given an albuterol inhaler about a year earlier.

“When did you last use it?” I asked.

“About two weeks ago,” he said.

I asked whether he had ever been given a second inhaler or other medicines to help his breathing, but he said no. He denied a history of asthma, had never been told he had reactive airway disease. He did admit that he often didn’t sleep well, and woke up tired in the morning.

His physical exam was unremarkable except for the runny nose and the persistent expiratory wheezes in all lung fields. His best effort on a peak flow meter was 85% of predicted for his age and height. His chest x-ray was normal.

He admitted when I asked him that he could hear himself wheezing. “So why haven’t you been using your inhaler?” I wondered.

“Well, I’m still breathing good, even I’m wheezing, and I don’t want to get hooked on it,” was his reply. “I’ll use it if my breathing is really bum.”

“Oscar,” I said, “what you have is asthma. You need to have two inhalers, an inhaled steroid that you use all the time, and albuterol that you use whenever you are coughing and wheezing.”

“It works like this. Asthma causes the lining of your airways to be inflamed, you know, like red and warm and extra-sensitive. That makes the little muscles encircling the airways want to squeeze up, so instead of breathing through a nice big garden hose, you have to breathe through a tiny little straw. It is hard work and it makes you cough and wheeze. If you use the albuterol inhaler, it will help the squeezing to relax and let you breathe better. But it won’t take away the inflammation, so as soon as the albuterol wears off, your lungs will squeeze back up again. You need a second type of puffer, an inhaled steroid, to take away the inflammation so you don’t squeeze back up. The albuterol is your rescue medicine; when your breathing is bum, it will help you right now. The inhaled steroid is your maintenance medicine; it will work to keep your lungs cooled down so they don’t want to squeeze up, and your breathing will stay good.”

He was mostly getting it, but not quite. I could feel an analogy coming on.

Think of it this way. Your house is next to a stream, and you get your water from that stream. Up stream there lives a beaver. He is working night and day, chewing through saplings and dragging them across the stream to build a dam. When he does that, you don’t get enough water at your house. You can spend all your time with a saw, cutting through the saplings he has piled up, and you can keep the water flowing well enough to get what you need. Or you can get rid of the beaver.

“Ah,” he said. “I get it.” He smiled sideways at me. “I’ve got a beaver in my lungs.”



Blogger Dr. A said...

I always have a difficult time finding the right analogy. Great job! Is that something that just came to you in the moment, or, did you have that in your bag of tricks from a previous encounter with a patient? Just wondering.

Monday, July 10, 2006 7:08:00 PM  
Blogger The Tundra PA said...

Thanks, Dr. A! That one was truly an inspiration of the moment.

Monday, July 10, 2006 11:18:00 PM  
Blogger Jordan said...

Hah! Congrats on making it into grand rounds!

Tuesday, July 11, 2006 5:23:00 AM  
Anonymous Anonymous said...

That is the best explanation of asthma i have ever heard!! I have had it for years... and heard plenty of explanations.. I like that one the best Great Job!!!

Tuesday, July 11, 2006 7:30:00 PM  
Blogger The Tundra PA said...

Jordan--thank you! Grand Rounds has become the highlight of my Tuesdays. And I love what it does to my Sitemeter on the weeks that I am included. But since I spent what little free time I had today reading GR, I missed the Blogaholics Anonymous meeting over at Carrie's beach house. *drat*

Wolfbaby--how sweet of you to say so. I'm honored.

Tuesday, July 11, 2006 10:38:00 PM  
Blogger Intelinurse said...

I love it, an anology completely appropriate to the man and his familiar environment-thats a gift you know~
I am but a lowley nursing student w/ high aspirations. I start labor and delivery rotation in August and I found your Grand Rounds post fascinating. It will season what I see and experience this fall, Im sure.
I have added you to my blogroll. I look forward to more great stories and please post more sunsets!

Wednesday, July 12, 2006 5:27:00 PM  
Blogger Wil said...

Great analogy. As another asthma sufferer, it indeed feels like a beaver has a hold of your lungs some days.

I'm looking forward to the day when a new patient arrives at one of the village clinics, complaining about the "little beaver in my chest."

Wednesday, July 12, 2006 6:01:00 PM  
Anonymous Anonymous said...

That is an awesome analogy. I was happy to see you again on grand rounds. Your stories are always great and we all had a good laugh about the beaver. My classmates and I were lectured not long ago about Albuterol and inhaled steroids.

Once again a great post...

Evan PA-S

Friday, July 14, 2006 8:16:00 AM  
Blogger Couz said...


I'm quickly becoming a fan!

Friday, July 21, 2006 5:10:00 PM  
Blogger The Tundra PA said...

Intellinurse, Wil, Evan, and Couz--quyana cuk nuk! (when you say it, it sounds like "kwee-anna chuck nuck"; means something like thank you with strength) I'm glad you enjoyed the story, and hope you will all visit frequently. And thanks for leaving comments, I don't seem to get many. Must have a little blogenvy for Dr. A's many comments!

Saturday, July 22, 2006 12:49:00 PM  
Blogger Jessica said...

Excellent post, thanks for pointing it out to me.

That is almost exactly what my doctor told me when she wanted me to start Flovent. Only I didn't get the cool analogy.

One other thing to watch for is that people are using their inhalers correctly. It wasn't pointed out to me that I was using it wrong till I was in the hospital.

I was breathing in too quickly and I never realized it. I now use a spacer (which makes the funky noise when you breathe too fast). I'm really feeling the benefits of my inhaler now. I wish someone would have pointed that out sooner.

Wednesday, July 26, 2006 2:29:00 PM  
Blogger The Tundra PA said...

drytears--you make a very good point. Inhalers are difficult to use correctly, even for experienced users. Spacers make a huge difference, and I always encourage people to use them. I usually have patients demonstrate their technique to me, and have sometimes been amazed at what they show me. One man took a deep breath, put the inhaler in his mouth and exhaled forcefully as he pumped the inhaler. As you can imagine, he got nothing from it. The spacers that make a noise when not used correctly are very instructive. I'm glad your inhaler is working for you now!

Wednesday, July 26, 2006 5:02:00 PM  
Anonymous Anonymous said...

Readers who don't comment are called "lurkers", I usually lurk, but want to encourage you to share more stories, well written and useful. It's great when function and form come together.
-Rachel, RN in MN

Monday, July 31, 2006 4:36:00 PM  

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