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The Art of Medicine

Breathing easier at the end of the day

Maurer, Brian T. PA-C

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Journal of the American Academy of PAs: April 2015 - Volume 28 - Issue 4 - p 66
doi: 10.1097/01.JAA.0000462063.16495.49
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To know even one life has breathed easier because you have lived. This is to have succeeded.”—Emerson

I pause from the medical article I'm reading and glance at my watch: 20 minutes until closing time.

Fifteen minutes ago I heard grown-up voices and the intermittent cry of a child from the waiting area. It certainly is taking a long time to process the last patient of the day. There must be a glitch of some kind.

I rise from my desk in the back office and glance down the corridor to see the medical assistant escorting a family down the long stretch of hallway. A woman dressed in traditional Middle Eastern garb leads the way, walking beside a girl who looks to be no more than 6. A man shuffles along behind, holding a toddler in his arms.

“Here,” the medical assistant says, thrusting the chart in my hands. “I don't know why they're here. I've been on the phone, dealing with their health insurance. They're from out of state.”

I introduce myself with a smile and glance at the encounter form. “This is Nur?” I ask. The mother nods her head. “What brings her here today?”

“She has been swimming in the pool lately. She has had two swimmer's ears over the summer. The last was in June. I didn't finish the antibiotic. Today she has fever and much phlegm. She always has much phlegm.”

I jot down a few key words. “Let's have her stand on the scale.”

The mother bends down to remove the child's shoes. The girl tips the balance beam at 55 lb. I record her vital signs: temperature, 99.4° F; pulse, 120; pulse oximetry, 95%.

“She can hop up on the exam table in Room 1,” I say, pointing to the doorway.

I pull off the child's embroidered coat and sundress, noting the prominent intercostal retractions on her chest. Her respiratory rate is in the low 40s. Honks and wheezes emanate from all lung fields.

I pop the stethoscope out of my ears. “How long has she been like this?” I ask.

“She always has cough—with much phlegm,” the mother says.

“Has she ever had to take neb treatments before—medicated mist from a machine? Ever used handheld inhalers?”

The mother shakes her head. “When we take her to the doctor, they say she has allergies. They say to give her cetirizine every day, but she always has cough with much phlegm.”

“Anyone in the family been diagnosed with asthma? Seasonal allergies? Eczema?”

“I have hay fever,” the man says.

“Your daughter has asthma,” I tell the parents. “Right now she's tight, not moving air all that well. I'm going to give her a treatment—it won't hurt—to help her breathe better.”

I dash out of the room, grab the necessary supplies, and return to set up the nebulizer.

Soon the child is inhaling the medicated mist. I hold the nebulizer in front of her mouth and in simple terms explain to her parents the pathophysiology of an asthma attack. Soon the child begins to relax; she's breathing easier now.

I turn off the machine and listen to the girl's chest. Air exchange is markedly improved. She slips her finger into the pulse oximetry monitor. It reads 98% now.

“I'm going to give you a machine like this one so you can give Nur breathing treatments at home,” I say.

The mother opens her mouth, then closes it.

“We bill your insurance for the cost of the machine,” I explain.

The father speaks up. “I am between jobs,” he says. ”We have moved to this area. I have a job interview on Monday.”

“We'll bill the insurance that you had for the children previously,” I tell him. “Don't worry about that now.”

They beam grateful smiles on their way out the door. The mother carries a new nebulizer machine in her arms with a sleeve of unit-dose medication and two prescriptions.

“I can't verify that kid's health insurance,” the medical assistant says, frowning.

“No?” I say. “Well, what more can be done on a Friday evening?”

We step outside and lock the door. I look up at the clear sky and take a deep cleansing breath. It never felt so good.

Copyright © 2015 American Academy of Physician Assistants