Chapter 1

The Red Zone

DISCLAIMER

This is my true story, with adjustments for artistic license.

To protect their privacy, I changed names and biographical details of any individuals depicted. All patients are fictionalized and inspired by my aggregate experience as a physician.

Any views expressed are mine alone, and do not represent the positions of my employers.

My writing is not graphic, but it does describe medical details.

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I woke Monday morning with a scratch in my throat. I ignored it. After dropping my kids off at preschool, I sent in the final tax forms to our accountant. We were due a large refund, so I wanted to get that done. I am the finance nerd in our household.

On Tuesday and Wednesday, I developed myalgias and temperatures in the 99 range. Nothing higher than 100, and no “real” fevers above 100.4. I was coughing up mucus, which was common with my asthma and a viral infection, but I did not need any additional inhalers beyond my regular regimen. I suspected I might have the flu. Typically, I contract infections from the little viral vectors in my household, but their noses were relatively clean this week.

If I have the flu, I could count on more than one hand the patients from whom I might have caught it last week.

It was a terrible influenza year, the worst since the 2009-2010 H1N1 season. The CDC estimated that the virus killed tens of thousands, hospitalized half a million, and sickened tens of millions of Americans. I had cared for some of them. Was I now one of them?

I carried on my meetings virtually that week, with an occasional cough. By Thursday, the myalgias improved, and my temperature was normal. On Friday, I had a few meetings, including a session with a therapist that I started seeing via telemedicine about a month previously. I was coughing noticeably, to myself anyway. By the afternoon I could feel a subtle tightness in my chest, indicating that my asthma was starting to act up. I needed an extra dose of my inhaler. That evening I decided to start some prednisone, so I could get through the weekend. I would give my pulmonologist a heads up on Monday that I had started it. This was not unusual for me at the tail end of a viral illness, to require a few days of oral steroids. My asthma action plan had kept me out of urgent care or the ED for many years. I had never been admitted for asthma.

I slept well Friday night and woke up on Saturday morning feeling like the prednisone was starting to help. I took another dose that morning, with plans for once daily dosing through the weekend. This was the weekend leading up to Birthday Week in my house; my son Wally was to turn eight, and my firstborn Brandon would turn ten.

In preparation, I baked birthday cakes with our four kids in the kitchen. At least two of them were fully dressed. Leo, my third son, was not one of them. We made two 8-inch rounds using birthday cake mix, then the kids had to wait for them to cool. After what felt to them like a week, but was in fact just an hour or so, the cakes were cool enough to decorate. One with chocolate frosting and the other vanilla, with sprinkles galore on both. I covered the cakes on the counter, anticipating we would eat them later.

Wally’s team had its last basketball game of the season at noon. I would take him to the game while my wife stayed home with the other three kids, who were now cozy on the couch. Following the activity of the cake-baking and decorating, I felt short of breath. I went upstairs to take another puff of my inhaler. After pausing at the top of the stairs to rest, I walked down the hallway to our bedroom and the en-suite bathroom. I blew out, then drew in a slow, deep breath through the spacer chamber with the inhaler attached. One puff, wait a minute, then a second. Not much relief. Putting my inhaler back in its drawer, I saw my peak flow meter, a device that allows patients with asthma to track changes in their pulmonary function easily at home.

Hmm. I’m still pretty winded. Maybe I should see what I blow on that thing.

I took in a deep breath, then blew out hard as I could on the mouthpiece of the device. The marker stopped well short of the red line—meaning I was in the danger zone. After two doses of oral steroids. And an extra dose of rescue bronchodilator.

Not good Ian

I was failing outpatient management of an evolving asthma exacerbation. I walked slowly downstairs and wandered over to my wife Kathryn. She was reading Gruffalo on the couch to Molly, our three-year-old little girl.

“His eyes are orange, his tongue is black; He has purple prickles all over his back,” it was Molly’s favorite line.

“I have purple prickles, Mommy!”

I said quietly, in Kathryn’s ear, “Honey, I think I probably need to go get seen.”

Distracted by the story, it took her a moment to register. “Oh, Ok...what should we do about basketball? And where do you think you’ll go?”

“Well, I think urgent care isn’t open yet...” I honestly didn’t know if it was, but I also knew I might need more than an urgent care, continuing “...so probably I’ll just go to the ED.” I planned to go to a nearby hospital with doctors I trusted, but which would not be my hospital.

I suggested I drop Wally off at the basketball game with his coach. Then Kathryn could come with the other three kids while I drove myself to the ED. This plan seemed more reasonable at the time than perhaps it was in retrospect.

Wally bounded over to the car, excited for his game. I walked behind him, easing myself into the driver’s seat. We made the brief drive to his elementary school and went into the gym. We found his team, and I left him at midcourt, getting down on my knees and looking him in the eye.

“Buddy, Daddy’s sad I’ll be missing the game. I’m proud of you, try your best. Mommy will be here soon, and your coach is right there,” as I made eye contact with his coach over his shoulder.

Slowly, I walked back to my car, feeling noticeably winded. I passed Jim on my way—he worked at a local university and was father to one of the teammates. At practices we talked about work and life; today I just said hello, continuing my measured walk to the car. I made my way out the parking lot, turning left in the direction of the hospital.

Halfway down the street, my wife passed me in our black Toyota Sienna, heading to the game. She waved, and I waved back. I could see past her into the middle captain’s seats, Leo and Molly secured in their car seats. The kids did not register me in passing. I figured I would see them for dinner. Hopefully they would save me some birthday cake.