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Microsoft word - a man my own age.docA Man My Own Age
I thought my mild asthma was under control. I rode my bicycle, played my flute, lifted weights and did yoga. I was doing everything I should be doing. I was in terrific condition for a man my age. Everybody said so. I only took an occasional puff from one of my inhalers. Sometimes I took more. I told myself it didn’t matter. I was the old jock, the street kid, the tough guy. Fitter than most men thirty years younger. A week ago, on a Tuesday night, I went to a session and played my flute from nine till twelve-thirty. I had one pint and one small sandwich after the session, on the house. I felt strangely bloated and didn’t have great breath but I thought it was just a touch of asthma. A tickle. Nothing a puff or two on the inhaler wouldn’t fix. I spent a restless night but fell asleep towards morning. Wednesday morning I still felt full. I ate very little. I stuck to my schedule and went to the gym. I could only drink half of my protein drink. I puffed three or four times throughout the day. Maybe five. Nothing to worry about, I told myself. I had a bit more asthma than usual but it was probably just some left-over jet lag from the week before. Roz and I had a light supper of beans and veggies. By night-time I had a full-blown asthma attack, the worst in years. Breathing was an effort. If I stood up it took a few seconds to catch my breath. I spent a sleepless night tossing from side to side, trying to sleep sitting up in bed, leaning back against the headboard. I used the inhaler three or four times more in the course of the night. Maybe five. I lost count. More puffs than I’d ever taken in the past. Thursday morning I got out of bed after three or four hours of sleep and knew something was wrong. This was not a mild asthma attack. It was unlike anything I’d experienced before. Then I remembered what it was! I had another lung infection, as my old doctor, nine months ago in the States, had predicted would occur. He’d given me some antibiotics in the event the deep-seated opportunistic bug reappeared and the infection returned. I started taking Biaxin (Clarithromycin), confident that in a day or two I would be well. I struggled through Thursday. I couldn’t do very much so there was no question of my overdoing it. I played the flute for about five minutes, very slowly, my labored breathing making it impossible to phrase properly. I went to bed early, totally exhausted. Thursday night was even worse than Wednesday night. I listened through the night to BBC 5. I consoled myself with the thought that the antibiotics would soon be working. I woke Friday and took the antibiotics, after spending the night high as a kite from the Ephedra I had taken in an effort to breathe freely. The Ephedra, a powerful bronchodilator and stimulant, had very little effect. This was the second day on the Biaxin. I can ride this out, I thought. Tomorrow it will be better. There was no need to go to a doctor, even though the weekend was coming and Roz was urging me to see somebody. I could breathe when I had to, so long as I took it easy. But I had to sit upright all day. I couldn’t lie down at all. If I reached up to take off my sweatshirt I got breathless. If I made a trip to the bathroom I had to sit on the seat for a minute to recover. Friday night was even worse than the night before. My throat was raw and when I took a puff on the inhaler my lungs hurt. Surely the Biaxin should be kicking in this late in the game. It was the end of the second day of the antibiotics course, the third day with difficult breathing. The antibiotics had helped in the past. Generally a full day is all that’s needed for the antibiotics to get going. Must be a very severe infection. I squirted my inhaler. Again. One for immediate relief and one for prevention. Again. I took more Ephedra. Nothing was working. Be patient, let the antibiotics work, I told myself. Friday was the third night in a row without sleep. I put my earphones on and listened to the radio until daylight, drifting in and out of sleep, but always sitting up. I turned continually from side to side, reaching out every two hours or so to gasp on the inhaler. Then a puff an hour. Sleep wasn’t the issue Friday night. Breathing was. Saturday dawned rainy. Perfect, I thought. I can sit and read all day. No guilt. I can’t do any work, or even play the flute. I will drink tea, take my Biaxin, and get better. But I didn’t. Hour after hour, nothing changed. It even got a little worse, although it couldn’t get much worse. If I got up to walk across the room it took total effort and forethought. I had to gear up for it. It was out of the question for me to leave the house. An afternoon nap was impossible. I couldn’t lie down and breathe at the same time. In any case I was too wired from the meds to sleep. If I lifted my hands above my head to stretch I had to sit absolutely still to recover my breath. I became breathless if I turned in the chair or reached for the TV remote. I felt like my 96 year-old father, bound to his chair in a nursing home. I need a walker, I thought. I was glad now that when we built the house the building code specified that the entire first floor to be wheelchair accessible. I had to take the stairs one at a time. Like climbing Everest. Step, pause, breathe. Step, pause, breathe. By five o’clock on Saturday I started to feel a little better, but still not well enough to eat a real dinner. I had some yogurt and cornflakes, with a banana. I could carry on a limited conversation with Roz and talk a bit on the phone. You look a little better, Roz said. Must be the antibiotics working, finally, I told her. I felt as if I’d eaten a huge Christmas dinner. Absolutely stuffed. By nine I was exhausted and ready for bed. I got into bed to read. I still had to sit straight up. I took more of the same medications and they produced the same effect. Nothing. They weren’t making me any better. They only kept me from dying. Something wasn’t right. I wasn’t thinking clearly at this point. Sunday morning. I stayed in bed until eight o’clock. I had been in bed for eleven hours. I had slept for perhaps three of them. It felt as if there was an animal in my lungs. They ached. There wasn’t any room in there. I wasn’t coughing. I didn’t have to clear my throat. No green stuff was coming up, as it usually did in the event of a lung infection. Everything was dry. I took the antibiotics again. I knew that on Monday morning I would have to go to a doctor. Either the infection was totally drug resistant or I had a huge tumor in my lungs. It was Sunday. Doctors’ offices were closed. I was starting to panic. Nothing I did made any difference. I was in a suffocating fog. I’m fucked, I thought. I sent a text to a doctor who had been recommended. I sent an email. I called his office and left a message. We turned on the TV about nine and watched the news. It took too much effort. I got ready for bed. Taking my shirt off drained the air I had in my lungs. I couldn’t breathe. It had become deadly serious. I had no more margin. I couldn’t ride this one out. If it got any worse I would die. I had used up the room you allow yourself when you say "I can tolerate this.” I was distancing myself from all this. If I moved I couldn’t breathe. I was sliding into shock. I was dying. I knew on some level that I was in serious trouble. Toleration of pain and discomfort was no longer the question. Survival had become the issue. I wasn’t thinking clearly. I knew these things instinctively. I had read that people died from asthma attacks. But they were smokers, I thought. I hadn’t smoked in twenty years. Kids without their inhalers die in the schoolyard. But I was not a kid. Adults die on the way to the hospital. That’s where I need to go now, I realized. I’d had enough. I was experiencing the last stages of an asthma attack that had been going on for four days. People stop breathing. That’s why they die. I was dying. I was terrified. I put on a sweat-shirt and walked across the room. I had to stop mid-way for breath. I wasn’t wheezing. There was no room to wheeze. I couldn’t fill my lungs enough to wheeze. I put my hands on my knees as I leaned forward to free my lungs and gasp, waiting for my breathing to stabilize. The room was spinning. I was fainting. My heart was racing out of control. There was no 'me' anymore. There was just an animal gasping at the end of life. This was past breathless now. I was suffocating. Roz found the number of an emergency medical service in Limerick, an hour and a half away. I was frightened that I wouldn’t make it there in time. I needed something closer. I got the operator on the phone. Hold while I get a nurse, she said. Please, I said. I can’t breathe. I hear that, she said quietly. I won’t be a minute. I’ll get back on the line with you. While I was on the phone Roz came in and rubbed my back to ease my panic. I could only speak two or three words at a time now. The nurse came on the line and made an appointment for me at ShannonDoc, in Ennistymon, ten minutes away. Can you make it there by ten-thirty? They have everything there, she said. They’ll be able to help you. Her voice was pitched low and lacked urgency. She was a professional used to dealing with people in shock. I only had to ride it out a little longer. Just a little bit longer. I had been saying that for the better part of a week. We left the house for ShannonDoc Emergency Services at 10:00 PM. It was very dark and very wet. ShannonDoc is staffed in turn by local doctors who offer emergency medical procedures to people who live locally. It is a pure survival outfit, designed to help people deal with immediate trauma before sending them on for more detailed treatment. We got there at 10:15. The receptionist told us that the doctor was making a house-call and would return in a few minutes. He knows it’s urgent, she said. She asked us to sit in the day room. There was no proper waiting room, with black leather chairs and magazines. This was Ireland making do. From the seventies, years before the days of The Celtic Tiger. A small, cash-strapped community in the west. It was miracle just to have this modest service. We sat down in a large day-room filled with mismatched tables and chairs, room for about forty people. It smelled musty. Dirty clothing was stacked on a sideboard. This was a room used during the day by poor people from the elderly community. They came here to have their dinner of boiled cabbage, boiled potato, boiled ham. We sat in front of a TV in the corner. We watched the final minutes of Geantrai, a traditional Irish music program with P.J. Hernon, Gerry Harrington, and Peter Horan, the legendary flute player. Peter Horan’s fingers were yellowed from cigarette smoke. He looked to be about a hundred years old, skeletal in a black suit and tie. We shut the TV off when the program ended. The nurse came in to tell us the doctor had called and would be there any minute. At 10:45 I was examined by a cadaverous doctor, a thin, grey-haired man of about fifty who did not offer to shake my hand. I am Doctor Nolan, he said, as he turned away from me to read the information forwarded to him from Limerick. He filled out forms. His attitude was dismissive. Maybe it was the stained sweatpants that I’d been wearing every minute for the past four days, or my hooded sweatshirt. Maybe he didn’t like Americans. Maybe he was dead tired. At least he was a doctor. Is this serious? I asked. He stopped writing and looked away. Yes. How serious? I asked. I don’t know, he said. He turned around and asked me to open my mouth so he could look in. Thank you, he said. He asked me to lean forward so he could palpate my neck. Thank you, he said. He looked in my throat and in my ears. Took my temperature but neither my pulse nor my blood-pressure. He took me into a room with florescent lights and a nebulizer ticking away against the wall. Please sit here, he said, pointing to a straight-backed metal folding chair. I sat. Thank you, he said. He put a plastic mask on me. This is Ventolin, he said. Just breathe normally. After two or three minutes I started to relax. I was breathing a delicious chemical mist. It had neither odor or flavor. It was cool and ambrosial. My back muscles eased and I could sit back in the chair and relax. Thank God, I thought. I’m not dying anymore. I can breathe. He came back in ten minutes. He turned the nebulizer off. How are you now, he asked. Much better, I said. I asked him how long the medicine would continue to work. I don’t know, he said. I looked at him in disbelief. I asked, Two hours? Four hours? One hour? Won’t the symptoms return? I asked him. Then what should I do? What do I do in the morning? In the morning, he said, surprised. You go to the hospital now. I was stunned. Is it that serious? I asked him. I don’t know, he said. They can make a thorough diagnosis there. Will I have to spend the night? I asked. Probably. Take these to Ennis with you, he said, handing me a small packet. Earlier that day my friend Robert had advised me to avoid Ennis Hospital if I could, and go to Galway Clinic instead, a new private facility. But Doctor Nolan seemed insulted. What’s wrong with Ennis? he asked me. I’ve heard some horror stories, I told him. He was quiet for a moment. Then he said, in his curiously flat affect, I work with them all the time and I haven’t ever heard a thing. What exactly have you heard? he asked me. I dodged the question. The thought of driving over an hour to Galway on a wet night in an emergency situation was daunting. Good, he said. That will be thirty Euros please. I paid him in cash. He handed me a receipt. He put the bills I’d given him on his thigh, stroking and flattening them, arranging each the same way, taking his time, facing them all in the same direction before methodically folding the bills into his day-glo pink plastic wallet. I certainly hope you will come to see me in my office in Lisdoonvarna, he said, turning away from me. I didn’t answer him. Roz drove the twenty miles to Ennis at an exasperating 45 miles an hour. In all fairness it was past her bed-time and it was a very wet night. My mouth was dry and we stopped for a bottle of water on the way. I was able to leave the car and walk to the store. I would live, I thought. In the parking lot a boy got out of his car smoking a cigarette. I looked away when he asked how I was doing. Roz dropped me off at the entrance to the Emergency Room at Ennis General Hospital. The entrance to the E.R. was a locked back door, opened by a security guard. I waved the envelope and walked into a dim hallway. People have been known to die on a gurney in Ennis General, waiting a hallway for treatment in the E.R. Last year my friend Robert went there running a low-grade fever and a badly infected hand. After waiting for eight hours he was told to come back in the morning. The E.R. walls were painted a glossy tan verging on orange. Bright fluorescent lights reflected off the walls. It was late in the day and there were bits of paper and some wet places on the floor. I was told to sit on a shabby chair in the ward itself. Nurses buzzed by. Nobody suggested I was in the way. I was beginning to have a hard time breathing. The ward was a long room crowded with beds. Curtains on rails divided the room into spaces for treatment. From anywhere in the room you could hear anything said in another space. There was only room in this part for about five beds. In one bed an old man lay motionless. The curtain had not been closed. Ireland’s hospitals are woefully understaffed. They are under-nursed, under-doctored, under-funded and under-paid. It isn’t their fault. They have to make do with limited funds from a government that would rather feed the road-building industry than care for its sick. I was given a peak-flow meter and told to puff. I registered about 180. That’s low, the nurse said. I was beginning to wheeze. I started to tense. It was becoming difficult to breathe. Roz had parked the car and stood behind me now, rubbing my back. After a few minutes we were taken to the farthest corner of the E.R. Roz helped me onto the gurney. I couldn’t lean back and breathe. Roz had to find the back adjustment. Sitting straight up I felt much better. First some more nebulizer, the nurse said. I just had one, I told her. She looked at me with a half-smile. You’re going to want a lot of these, she said. Her name was Margaret and she lived up the road in Lissycasey, where they had lovely sessions. She asked me if I’d brought my flute. She’d be with me on and off for the next three hours. Machines were hooked up, nebulizers burbled. Dr. Acktor, a dark man from India, the first line doctor, inserted a heparin lock, a shunt, in my right arm. He felt my forehead. You will be all right, he said, in his clipped Indo-British accent. Margaret hooked up the nebulizer again. I was wheeled to the X-ray room. There was not a bit of chrome in this old facility. Plenty of dark wood. Everything seemed dated and on the verge of breaking. An air of poverty hung about the place. I was wheeled back. At one point a nurse came into our space and asked where all the sheets had gone. Margaret told her they were all used since five o’clock. It was Sunday. They both laughed. The X-ray showed nothing abnormal. More blood levels noted, pulse machinery beeping away (ok at 100 PPM), BP normal, more burbling nebulizers. Dr. Kamal Abbas, the attending doctor from Sudan, came in after an hour and felt for tumors, lumps, pain, or swelling. He asked more questions. Dr. Abbas is tall (over 6'3"), beautiful, a very handsome, gentle man. He had a lilting accent and a grey tooth in the front of his mouth. Imagine coming from the heart of poorest Africa to be a doctor in Ireland. I wondered what Martin, my racist neighbor, would make of Dr. Abbas’ gentle hands? I was at serious risk of a heart attack, I was told. What I had gone through could have been critical. I had waited far too long. I didn’t know, I said. I thought I had a simple lung infection. Dr. Abbas gave me an ampoule of hydrocortisone through the lock in my arm, more nebulizer, more tests. After still more questions about my medical history, and another course of nebulizer, I could breathe and talk. I was trembling from the meds. But I could walk across the room and not get breathless. I could swing my arms over my head and keep breathing. Dr. Abbas told me that I didn’t have to stay overnight if I didn’t want to. Thank you, I said. But come back first thing in the morning if you don’t feel everything is just right, he said in his lovely Sudanese accent. I will be fine, insh’ Allah, I said to him. He laughed and patted my back. We shook hands and he walked away. He’s lovely, I said to Margaret. Yes, he is, she said. A very lovely man. It was not a busy night in the E.R. Everybody was helpful and supportive. I was not bothered with forms. Although the building is ancient in this age of shiny new hospitals, and the machinery is dated and simple, I had been very well cared for. The people I saw were kind and skilled. They took their time. They were casual in just the right way to ease my panic. I trust these people now. Knowing they are just a half hour away is a comfort. I was sent on my way with cautionary tales and a prescription for new meds, including a tapering dose of steroids and some new inhalers. I was deeply relieved that they allowed me to leave the hospital for a night at home. I slept soundly from 2:30 AM until 6:30 AM. I could sleep no more. My body was tingling from all the medication and from the thrill of oxygen in my lungs. I could breathe. I was alive. I wheeze as I sit and write this first draft, the day after. Sometimes it sounds as if there is somebody else in the room with me. I am not used to the noise of my own breathing. I have to learn to live my life as an asthmatic now, as a person with life-threatening asthma, facing the risk of death. I spent four days surviving a critical asthma attack. It was not a simple chest infection. It was Chronic Obstructive Pulmonary Disease. COPD. I am forever joined to an acronym. Although I am a bit wheezy now, the asthma is under control. I got four hours of deep sleep last night and a half hour nap today. I am regaining my strength. I had ignored the developing symptoms, among them the suddenness and severity of the onset. I had survived a classic killing asthma attack. I was very lucky. The attack probably started when I played some flutes that had been stored for a year and kept in moldy cases. I ignored the mold and played away, never imagining the consequences. For three weeks I was living in our musty old American house filled with the odors of mold and ancient squirrel urine. It was very hot (35ºC/95ºF) and the humidity was so high (85-90%) that if you put your arm on a wooden surface it would stick to it. There was no air movement. I wrongly attributed my malaise to the unpleasant climatic conditions, many late nights, and too much traveling. At the time I attached no importance to my frequent puffs on the inhaler. Things are different now. I know how careful I have to be. How much care it will take to regain my good health and to stay healthy. And although I love my meds, I cannot wait to live without them. The medicine that doctors love to prescribe, that seems so helpful at the moment, are harmful in the long run. I look back and see that I have been an asthma-medicine junkie for forty years. There is no way I can go through four days like this again and survive. I was deaf to what my body was telling me. Arrogance and denial go hand in hand with those of us so convinced of our apparent youth and strength. The margin that I used to have between life and death, so wide a month ago, has narrowed. I have become a man my own age. Postscript: It is nearly two weeks now since my visit to the ER. I have learned that asthma isn’t only a lack of oxygen, as I had thought. It is the body’s response to too much O2 and not enough CO2 in the blood. I have learned to breathe through my nose and to sip air rather than gulp it through my mouth. I sleep with a nasal strip on my nose to keep it open and for two more weeks I will sleep with my mouth taped shut. I have finished my course of oral steroids and I haven’t used Ventolin in seven days. I am puffing the preventive inhaler once a day and soon it will be every other day. Although my lungs are still irritated I am playing the flute again and spending time in the gym. I don’t know if I will ever again be able to ride a hundred miles on the bike or bench press two-hundred pounds. I know that some things will never be the same. But I can finally face my forty year addiction to asthma and to asthma medicine. And that's a very good thing.
ANTICHOLINERGIC COGNITIVE BURDEN SCALE Developed by the Aging Brain Program of the IU Center for Aging Research Drugs with Possible Anticholinergic Effects Drugs with Definite Generic Name Brand Name Generic Name Brand Name Complete References: Boustani MA, Campbell NL, Munger S, Maidment I, Fox GC. Impact of anticholinergics on the aging brain: a r