John

Meet John

John is a 60-year-old mechanic who has smoked a pack of cigarettes daily since he was about 16. He also likes to have one or two beers each night after work. He has had a chronic or smoker’s cough for several years. Two months ago his phlegm or  sputum changed from whitish to streaked with blood. His wife, Mary, finally persuaded him to go to the doctor, who promptly ordered a chest X-ray. Unfortunately this showed a shadow in the top of John’s left lung. Because of the possibility that the shadow might represent lung cancer, John’s doctor then referred him to a chest surgeon. He advised John that he needed to undergo an examination of the lungs by  bronchoscopy and also of the space in front of the heart inside the chest by  mediastinoscopy. During these examinations, the surgeon would take a small piece of tissue or  biopsy to determine if there was cancer present, what type it was, and if it had spread to the  lymph nodes.

“The surgeon told me that if it had spread to the nodes, then there was no point in me undergoing an operation to remove the cancer, that I’d be better off having some radiation. But if we’d caught it early, then my chances were pretty good that I could have part or all of my lung removed. But I’d need to have the first biopsy operation under general anaesthesia.”

Preparation

Although John considers himself ‘fit’ for a 60-year-old, his family doctor had found that John’s blood pressure was a little high. When examining John’s lungs, the doctor also heard a few squeaks and wheezes, characteristic of a long-term smoker. Because of these findings and the concern that John might have cancer of the lung, both the family doctor and the surgeon wanted John to be evaluated further by a  physician or  internist.

Two weeks later, John goes to see the physician, who takes a detailed history, asking specially about John’s exercise tolerance.

“Well, I reckon I’m pretty fit,” replies John, “despite what the X-ray might show. I can still show those young blokes a thing or two. Look at these hands – they’re not like that from sitting around drinking cups of tea or playing on computers.”

“How many flights of stairs can you climb?”

“Don’t know, don’t have any in the house”.

“What happens when you get a cold?”

“Never used to get them – but the last couple of winters, I’ve had some nasty bouts. Doc kept me in bed for a week last year, filled me up with antibiotics and stuff. Breathing wasn’t too good then.”

“How many cigarettes do you smoke in a day?’

“Oh, a pack or more.”

“How many is that?”

“Probably 30 or so.”

“That’s quite a few over the years.”

The physician asks more detailed questions and then examines John, paying particular attention to his heart and lungs. He also checks John’s blood pressure, looks in his eyes and tests his reflexes. John’s blood pressure is slightly high, but his heart is beating regularly and sounds normal when the physician listens to John’s chest. However, he does hear abnormal noises coming from John’s lungs – a combination of crackles when John breathes in and wheezing when he breathes out.

John then undergoes some more tests, including blood tests, an electrocardiogram, breathing tests, and a  CT scan of his chest. The blood tests are to look at the numbers of the various blood cells, as well as some of the chemicals in the blood, including glucose, potassium, and calcium. The electrocardiogram is to check on how John’s heart beats and if there are signs of any previous damage, such as a heart attack or  myocardial infarction (MI). The breathing test, or pulmonary function test, is to assess the size of John’s lungs and how well they function – for example, the extent to which John’s wheezing affects the flow of air from his lungs. The CT scan is to provide a more detailed X-ray picture, because of the possibility of cancer.

All of John’s doctors have told him that he must stop smoking. This is because of the abnormal noises in John’s lungs and because he is going to have an anaesthetic.

At the hospital

The afternoon before surgery, John enters the hospital, some 200 km from home. This is because he lives so far from the hospital and he needs some additional treatment for his breathing. This treatment includes having a drug to dilate the passages of the lungs or bronchi and some physiotherapy. John arrives at the hospital at four o’clock and is soon settled into the ward. His wife, Mary, accompanies him. She is very nervous about the whole thing but doesn’t dare say so.

On admission, the nurse checks John’s blood pressure, pulse, and temperature. Then the surgical resident is called to admit him.

At half past five, Dr. Constantin, the anaesthetist, comes to visit John. Dr. Constantin will be caring for John the following morning when the surgeon performs the bronchoscopy and mediastinoscopy. Dr. Constantin is carrying a binder – John’s  hospital record or  chart. Included in this record are the results of the tests, plus copies of the letters from John’s family doctor and the surgeon.

After introducing himself to John and Mary, Dr. Constantin asks John,

“Have you ever had an operation before?”

“I had my tonsils out when I was – oh, seven or eight. Can’t remember much about it but I do remember a terrible smell – and being bloody sick after. Don’t think I’ve had any others……. have I, Mary?”

“No, dear,” Mary says.

“Fortunately things have changed a bit since then,” says Dr. Constantin, “you probably had  ether and it was terrible stuff. We don’t use it any more; we’ve got much better drugs these days. Tell me, what’s your general health like?”

“Oh, pretty good,” replies John.

“And you’ve obviously smoked a bit,” comments Dr. Constantin, looking at the nicotine stains on John’s fingers. “Have you managed to stop?”

“I’ve tried, but after 40 years I’m finding it a bit difficult. Reckon I should have given up years ago, but you know what it’s like. Been smoking since I was sixteen. I’ve been pretty good though – I’ve only had two or three over the last couple of days. But the worst of it is I’ve been coughing up a bit more phlegm.”

“Great – that means the puffer medications started by your physician are working. I’ll have a listen to your chest now, and then go and look at your chest X-ray. We’re going to get the physiotherapist to see you this evening, and we’ll continue the puffer medications to help your breathing. We want to see if we can’t clear out a bit of that phlegm that’s sitting in the bottom of your lungs. With chronic smoking it tends to stay there but sometimes it can cause a few breathing problems during and after the anaesthetic.”

“Is that serious?” asks John, looking a bit worried for the first time.

“Well, it doesn’t make things easy but I’m quite happy that I can deal with it safely. You might find, though, that your cough will be a bit worse after the operation and you may see a little blood in your sputum. That will be from where the surgeon took the biopsy in your lungs. And about your blood pressure,” says Dr. Constantin, “I see that it’s much better. You’ve obviously been taking the tablets the physician also prescribed for you.”

“Yes, Mary’s made sure of that. Today the nurse said it was 130 or something. What does that mean?”

“Actually, blood pressure has two numbers. The top number is called the systolic and measures how hard your heart is beating. The measurement today is pretty good and lower than the 160 it was before. The second number reflects how well your blood vessels relax between heartbeats and is called the diastolic. In your case, the second number was 90 when you saw the physician, which meant that you needed treatment before the operation. And now it’s 80, which is normal. I’m sure you know that blood pressure does go up a bit as we get older and can be higher if you’re tense when having it measured. But these days we like to make sure it’s closer to normal before the operation. Nevertheless, it’s something that I’ll be watching carefully during the operation. All your other blood tests are OK, including the various chemicals, such as your creatinine, which is a measure of kidney function. That sometimes can go up with high blood pressure. Now, I’d like to have a look at you – listen to your chest and so forth.”

Dr. Constantin first feels John’s pulse at the wrist, looks at his head and neck, and asks him to open his mouth and bend his neck forward and backward and turn his head sideways. He then taps the back of John’s chest, listening to the hollow, drum-like sounds. Then he takes out his stethoscope and listens all over John’s chest, to his heart and lungs.

“Tomorrow’s operation is a bronchoscopy, where the surgeon is going to pass a long tube down your  trachea or windpipe. I need to look after your breathing during the whole operation. I’ll start by giving you an injection in the vein in your arm. I’ll also be using some local anaesthetic in your throat.”

John replies quickly, “No way I’m being awake for this. I want to be good and out……”

“That’s not what I meant. You will be totally unconscious, but the local anaesthetic is so that you won’t have a really sore throat afterwards. And you actually are having two procedures tomorrow – there’s also the mediastinoscopy for which you will need a general anaesthetic.”

“Is there any danger to his lungs with the general anaesthetic, Doctor?” asks Mary. “I’ve read in a magazine that people with breathing problems should only have spinals.”

“Well, sometimes we do give spinals to patients with lung problems, but not for these two procedures. That’s because we would have to make you ‘numb’ up to your chin. And then you wouldn’t breathe very well. The other things I want to explain to you are what I’ll be doing and the positions you’ll be in for the procedure.”

“Positions?” asks John with a wry grin.

“For the first procedure, the bronchoscopy, you’ll be lying on your back with your head on a very small pillow. Once you’re anaesthetised and I’ve put the breathing tube in your throat, the surgeon will put the bronchoscope down through the breathing tube and see if he can get a sample of tissue. After he’s done that, he’ll take the bronchoscope out. He and I will then put a cushion under your shoulders, so your head will lean back more onto the pillow and the lower part of your neck will be clear of your chin.” Dr. Constantin proceeds to demonstrate. “This helps the surgeon carry out the second procedure, the mediastinoscopy. But this position means that you might be a bit stiff and sore the next day. You probably don’t lie around the house doing this.”

“I’ll say,” says John in an amazed tone. “I didn’t realise all of this went on.”

“And while the surgeon is working, I’ll be watching over you, keeping an eye on your blood pressure, heart rate and oxygen, in particular. Now, do you have any questions, either about what I’ve just explained or anything else?”

John looks at Mary and then back at Dr. Constantin. “No thanks, Doc, reckon I’ll be right.”

“OK. Last question from me,” says Dr. Constantin. “Do you need anything to help you sleep tonight?”

“A couple of beers would be about right.”

“I’d rather you didn’t,” replies Dr. Constantin. “I’ll leave an order for a sleeping tablet, just in case.”

“I’ll probably need it more than him,” says Mary in a quiet voice from the corner where she has been sitting.

After the anaesthetic

John’s operation has been completed successfully. The surgeon was able to get a good sample of tissue for biopsy and this is now being examined in the laboratory. Six hours since his return to the ward, John is well awake and has been coughing on and off for the last two or three hours. He is sitting on the edge of his bed, coughing and holding a small plastic bowl, which contains some mucus speckled with blood. Mary is rubbing his back, while passing him a glass of water each time he begins coughing.

There is a  pulse oximeter sensor on his index finger which keeps falling off with each bout of coughing. Mary replaces it each time and when everything is calm, the  monitor reads an oxygen saturation of around 95%.

John is receiving some additional oxygen through a fine plastic tube running under his nose. The tube has two little prongs, one under each nostril. It’s annoying but necessary.

When he first returned to the ward, John was quite comfortable and only coughing occasionally. But now the local anaesthetic in his throat has worn off and all those years of smoking are having their effect.

He has a small dressing over a small  incision at the base of his neck, from the mediastinoscopy. It is not worrying him particularly – certainly not as much as the cough. The nurses had suggested a little while ago that he take some codeine, but John refused, despite Mary’s protestations.

Just then, Dr. Constantin and the surgeon arrive. They explain that everything went very well and that there didn’t appear to be any obvious involvement of the lymph nodes in John’s chest.

“But we have to wait on the pathology results,” cautions the surgeon.

“You don’t look too comfortable, John. Have you had any pain-killer?” asks Dr. Constantin.

“No,” answers Mary.

“Well, I think you should have some. I’ll get the nurse to give you some codeine.”

“Thanks…..thanks very much,” says John.

“He’ll be right,” says Mary.

Soon after, the nurse arrives with two tablets and John dutifully swallows them.

“Thanks,” he says.