Incence and Asthma

25 years ago I used to make many house calls. I do hardly any now. Those days the emergency care in out of office hours was provided by us general practitioners and a large percentage of these calls were from those suffering with acute asthma. Asthma then as it is now is a serious disease and our visits meant a great deal to the patients and often was life saving. They were also the days when there were no inhaled bronchodilators and corticosteroids which have virtually eliminated emergencies of the kind we saw then. This city as it is now even then had a high incidence of asthma. There were also fewer institutions and doctors to provide emergency care. It was thus common place those days to drive 20 kms and back after making a house call. It was not difficult to drive as the traffic was thin and road users were less aggressive. I cannot imagine doing the same with the chaotic traffic of today.

This was also an essential part of our lives and these house calls helped us to get to know our patients better. It begets a special relationship when you share a cup of tea with the patient’s husband/ wife/ father after the visit before you started back on your lonely drive back home. You could also subtly assess the economics of the household by the way they lived. Though what the patient paid or could pay fell far short of our expectations, the indirect professional rewards made these house calls worth making.

When the call in question came, it was past 11 pm and I was just drifting off to sleep. It was the frantic voice of my friend and patient Arif that I heard, he said, ‘doc, my wife is having an attack of asthma, if you don’t do something quick she will die’. I asked him to give her a tablet of Alupent [a popular remedy those days]. He said he had already given that and it has had no effect and he stressed the need for me to hurry.

It is no exaggeration that acute asthma can kill if not relieved urgently and it was experience of many of us to have witnessed such deaths. I pulled a pair of trousers over my pajamas, told wife where I was going and not to expect me for another two hours [the house was 15 kms away], took the ever-ready kitbag containing all the essential equipment and went to the car. Took the car out and came on to the main connecting road.

Here I must describe how this extension was 25 years ago. The main road which is now a bustling wide road and the commercial hub with traffic round the clock was a barely motorable road which became narrower at both ends where it met the high way. There were no streetlights worth the name. The houses on either side were few and far between. Now if you add to this scenario a constant drizzle very few would venture out. It was November and Bangalore was colder then than it is now. This was the scene when I went out to make this house call. A km down the road I felt the characteristic wobble of my car indicating a burst tire. I had a car that went by the name of Gazel, a version of the popular standard herald car of those days. For a doctor, especially a GP, his car is his best friend. But I cannot say this to my Gazel. The amount of trouble I had with this car, no enemy [even imaginary one] could cause. That is another story which I will narrate some other time.

I had to take the car to the side of the road for an inspection. The rear tire was indeed flat and I had no option but spend some precious time changing the tire. They were pre cell phone days and I had no way of getting in touch with Arif to give the news of my delay. The best way is to change the tire as quickly as possible and be on my way. This was not as easy as it sounds. For one it was pitch dark, there was a cold drizzle and I had only a flickering torchlight to go by. There was no choice. I went back, opened the boot, took out the tire wrench and the jack and turned. That was the first time I noticed the presence of the Dog Doberman. The dark shape merged perfectly with the background. Unlike the other breeds Doberman attacks first and barks later. This dog fortunately just stood there staring at my torchlight and my hands that held the tire wrench and the heavy jack. I let go the jack which fell to the ground with a thud. The sound brought out the fighting instinct in that dog; he let out a huge bark and jumped. At the same time I also jumped and took a swipe with my wrench. Fortunately both of us missed the target and he landed on the car and gave a painful yelping bark and I hid behind the other part of the car away from him. He started sniffing the fallen jack, satisfied that it is no enemy and finding none else he let out another howl. This brought out a chorus of barks from all the dogs in the neighborhood, both strays and the domesticated. I also could see several strays running into join the battle. Thankfully for me the strays were friendly to me but were hell bent on attacking the Doberman. I could now safely retreat to a distance and watch the battle in the dim light.

The commotion brought the lights on in many houses and one of them realized that it was their dog’s cries of anguish. Mongrels [stray dogs] are good fighters and the Doberman was outnumbered. Out came the gentleman of the house calling out, ‘tiny, tiny, where are you, come in my pet’. The dog retreated into the compound and both the master and the dog went in, completely ignoring me and my predicament. This did not bother me, as I knew how my upper class countrymen behave in such times. Seeing only a hapless human, the canine pack quietly retreated leaving me to do my tire-replacing job. With the slippery conditions, placing the jack at the right place was no easy task, and must have taken much more time than usual. With grimy hands and anxiety in my heart I drove the distance to Arif’ s house.

I found him restlessly pacing up and down the verandah of his house. ‘What took you so long? you left the house an hour ago, I called your home and bhabhi [sister meaning my wife] told me you had left, she must be worried, I will call and tell that you are OK’, Without waiting for me to say anything he went to call my home. I knew she wouldn’t be upset but the thought of her waking up once again was not pleasant. I went into the house.

There was a pungent smell coming out of the patient’s room that had spread to the whole house. My tired nose started twitching and the irritating fumes made me cough, by then Arif arrived having assured his bhabhi that her husband is safe and at his assigned job. I asked him,’ what is this obnoxious smell?’ He said that is his mothers doing, after waiting for you so long she went and put something into the fire and this smelly vapor is supposed to help my wife’. Here I must tell you a bit about Arif ‘s mother. Being a mother of 8 children and innumerable grand and great grand children, she is the matriarch of the whole clan and her word is the law in that home. We have a love hate relationship, having crossed swords many a time with the same intention of healing the sick, she her way and I my way. Now, this way of effusing pungent fumes in an asthmatic’s room is tailor made to worsen the asthma. Those days I had even shorter fuse than now and my encounter with the Doberman had made my mood foul. I couldn’t help making some acerbic remark about the old lady little realizing that she was standing just next to the door we were entering. She said to me without mincing words, ‘ are you going to stand there making unwanted remarks or are you going to see the patient and give her some relief, you have taken your time to reach here, Allah ka marzi [thanks to merciful Allah], she is still alive’. Though angry enough to give a fitting retort, I held my tongue, as the patient was indeed very sick. There was much labored breathing with wide spread fine ronchi [sounds made when there is obstruction to the free flow of air] in her lungs with a tinge of blue in her tongue indicating insufficient oxygenation. The fast heart rate was due to a combination of breathing difficulty compounded by the thumping dose of alupent.

I loaded the syringe with Aminophylline and began the slow IV. After this was over, gave her dose of Betamethasone again IV. Now was the time to wait and see what relief one would get or what side effect I was going to produce with the aminophylline, a dangerous drug at the best of times. No immediate adverse reaction to the drug occurred in the first ten minutes and I heaved a sigh of relief. Now I could take stock of the surroundings. I noticed the closed windows and the stuffy and smelly air in that room. I went and opened the windows and let in some fresh air. By now the son and the mother had removed the Chula [earthen stove containing burning charcoal] with the dhoop [name of the incense] to some far corner of the house and the smell became considerably less. The matriarch was nowhere to be seen. I waited another ten minutes. The patient was significantly better and was actually able to smile at me. The atmosphere was much less tense and I could feel relief all-round. Another ten minutes of wait Syeda [Arif‘s wife] quietly went to sleep virtually free from the terrible spasm. The relief was so spectacular that it was difficult to believe that she was the same patient whom I saw 45 minutes ago.

Now I made my preparations to go. It was now the turn of the matriarch. She had already heard of my ordeal on the way, had seen the near miracle of her daughter in law’s recovery. She said in chaste Urdu, ‘doctor saab, I consider it a favor if you stay and have a cup of tea with us’. I was not that crass as to refuse this peace offer. We had a cup of much deserved hot tea and after thanking the old lady, I returned home to wake up my wife, the fourth time that night.