Medicine's Subtle Art Gives A Man The Chance To Breathe Again

Dec 8, 2014
Originally published on December 9, 2014 4:57 pm

Bob Smithson had been in the critical care unit at Brigham and Women's Hospital in Boston for more than a week. He had a rare neuromuscular disease, and his 78-year-old body was being kept alive by tubes that delivered air to his lungs and food to his stomach.

Then Bob's wife, Pat, got some really disturbing news. The hospital's medical staff wanted Bob to have a tracheostomy, a surgical procedure that would carve a hole in his neck and allow doctors to keep him on a breathing machine indefinitely.

Some patients who get a tracheostomy never breathe on their own again. And Pat feared that Bob would be one of these patients. "I just could not bear it," she says. So she made an appeal to Dr. Allan Ropper, the neurologist who had admitted Bob to the hospital. And that's when Ropper made a decision that couldn't be supported by any medical textbook.

A Rare And Sometimes Deadly Disease

The events leading to that decision had begun a year earlier in the couple's two-story house in Cohasset, Mass. "We were having dinner with some very good friends," Bob says. "One of our friends happened to be a doctor, and he said, 'Why are you dropping your head, Bob?' "

Bob had no idea why his head was lolling forward. Neither did his doctor friend. Before long, other symptoms appeared. Bob had trouble swallowing and he had double vision.

Eventually a local neurologist identified the cause: myasthenia gravis. It occurs when the body's immune system attacks the connections between nerve and muscle. That weakens muscles, including those that control eye movement, swallowing and even breathing.

Doctors treat myasthenia with drugs that improve the transmission of nerve impulses and suppress the immune system. But the disease is rare enough that many doctors have never seen a case. So Bob's neurologist sent him to Ropper, an expert on the disease.

From the start, Ropper knew Bob might be headed for big trouble. "Myasthenia is known to be a very fickle disease," Ropper says. "It can get bad very quickly. It has a substantial mortality rate, particularly in an individual his age."

Ropper started Bob on several medications. But his patient's muscles continued to weaken. "He was spending more and more of the day holding his head up by putting his arm under his chin," Ropper says. "That was enough to say, 'You need to be in the hospital.' "

From Bad To Worse

Pat began spending her days with Bob at the hospital and nights at a Holiday Inn. Late one evening, she got a call. Bob was being moved to the intensive care unit and wanted to see her.

Pat took a cab back to the hospital. "I sat in a chair and put my arms round his legs, and we sort of stayed until the morning," she says.

Before long, Bob was heavily sedated, full of tubes and unable to talk or even write messages. "I thought, well, if it was me, I'm sure Bob would be right there," Pat says.

After Bob had spent more than a week in intensive care, Ropper realized that his patient had arrived at a critical juncture. "He was beginning to get a pneumonia and was really in the kind of spiral that is very feared," Ropper says.

The medications weren't working. From time to time, doctors would turn off the ventilator to see if Bob could breathe on his own. He couldn't.

A Critical Decision

And Bob was becoming despondent, Pat says. She feared that one more setback would be too much for him, and for her. So when surgeons suggested the tracheostomy, Pat balked. To her, the procedure amounted to a statement that her husband wasn't going to leave the hospital alive.

Ropper understood her reaction to the tracheostomy. "It's done all the time," he says, "but it signifies that you're in it for the long haul and things are going to get bad."

A good neurologist learns how to "interact with the person inside the brain," Ropper says in his book Reaching Down the Rabbit Hole. So when Pat asked whether the procedure was absolutely necessary, he decided to try something unorthodox, something that reflected his understanding both of Pat and Bob, and of the disease that had brought them to this point.

Ropper knew that weeks earlier, Bob had stopped getting a myasthenia gravis drug called Mestinon because it no longer seemed to be working. And during his decades in practice, Ropper had noticed that some patients who stop taking Mestinon for a while regain their ability to respond to the drug.

"So I said, 'Don't do the tracheostomy; put him back on the Mestinon," Ropper says. It was a decision based as much on art as on science, he says.

Bob started getting Mestinon again on a Friday. Ropper told the surgeons to wait until Monday to see if Bob responded.

And on Sunday, Pat says, a team came by to test her husband's lungs one more time. "When they took him off the ventilator, he breathed," she says. "He took that breath."

Bob would spend another week in intensive care and months regaining his strength. But a year after the dinner where his head began to loll, Bob and Pat had another party with the same guests. This time, Bob had no trouble holding his head up. "It was such fun," Pat says. Bob adds: "Had we not had a doctor like Dr. Ropper, I'm not sure where I'd be today."

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Transcript

DAVID GREENE, HOST:

Today in Your Health, should unvaccinated children be allowed in day care? We'll explore that question a moment. First, a medical mystery of sorts and the doctor who solved it. Medicine has become a lot more scientific in the past century, but decisions can still be as much art as science, especially when they involve the brain and the nervous system. NPR's Jon Hamilton brings us the story of one medical decision. It begins in a house in Cohasset, Massachusetts.

JON HAMILTON, BYLINE: Bob Smithson lives here with his wife, Pat.

BOB SMITHSON: We were having dinner with some very good friends. One of our friends happened to be a doctor. And he said why are you dropping your head, Bob?

HAMILTON: Bob, who is 79, had no idea why his head was lolling forward, neither did his doctor friend. And Bob's wife, Pat, says before long other symptoms appeared.

PAT SMITHSON: The next day he couldn't swallow.

HAMILTON: And he had double vision, so Bob went to his primary care doctor who called the neurologist.

BOB SMITHSON: And the neurologist said I think he's got a very rare sickness.

HAMILTON: Myasthenia gravis - a disease that can leave muscles dangerously weak. It occurs when the body's immune system attacks the connections between nerve and muscle. Doctors treat myasthenia with drugs that improve the transmission of nerve impulses and suppress the immune system. Bob's neurologist referred him to Allan Ropper, an expert on myasthenia at Brigham and Women's Hospital in Boston. Ropper says he knew Bob might be headed for trouble.

ALLAN ROPPER: Myasthenia's known to be a very fickle disease. It can get bad very quickly. It has a substantial mortality rate, particularly in an individual his age.

HAMILTON: Ropper started Bob on several medications, but his patient's muscles continued to get weaker.

ROPPER: He was spending more and more of the day holding his head up by putting his arm under his chin or using a collar and to me that was enough to say you need to be in the hospital because you're on the brink of decompensating.

HAMILTON: A nice way of saying his body was barely able to function without help. Pat was spending her days at the hospital and sleeping at a Holiday Inn. Late one night, she got a call. Bob was being moved to the intensive care unit and wanted to see her. She took a cab back to the hospital.

PAT SMITHSON: I sat in a chair and put my arms around his legs and we sort of stayed until the morning.

HAMILTON: Pretty soon Bob was heavily sedated and full of tubes. One delivered air to his lungs, another sent food to his stomach.

PAT SMITHSON: He can't talk now. He can't write. I thought well, if it was me, I'm sure Bob would be right there.

HAMILTON: More than a week passed and Ropper realized that his patient had arrived at a critical juncture.

ROPPER: He was beginning to get a pneumonia, which is common from being intubated and on a ventilator. And was really in the kind of spiral that, as clinicians, is very feared.

HAMILTON: The medications weren't working, at least not yet. From time to time doctors turned off the ventilator to see if Bob could breathe on his own. He couldn't, but Pat still believed her husband was going to get better, until she got some really disturbing news.

PAT SMITHSON: One of the doctors came back after the rounds and said we've decided that he has to have a tracheotomy.

HAMILTON: Surgery to make a hole in his neck for a breathing tube - Ropper says for some patients the tube is permanent.

ROPPER: It's a big step. It's done all the time, but it, you know, signifies that you're in it for the long call and things are going to get bad.

HAMILTON: Bob had become despondent, and Pat was afraid one more setback might be too much for him and for her.

PAT SMITHSON: I just could not bear it. I said please just ask if Dr. Ropper can come. If he says it's OK I'll rest on it.

HAMILTON: Ropper understood what was going through Pat's mind.

ROPPER: She felt like the end was near. This meant, you know, that he was going to be a wreck(ph).

HAMILTON: So he paid a visit to the Smithson's.

PAT SMITHSON: He came in, walked over to Bob, said, Bob, we're going to try something.

HAMILTON: Ropper knew that weeks earlier Bob had stopped getting a medicine called Mestinon because it no longer seemed to be working. But over the years, Ropper had noticed that after patients stopped taking Mestinon for a while their bodies become more likely to respond to the medication again.

ROPPER: So I said don't do the tracheostomy. Put him back on the Mestinon.

HAMILTON: That was on a Friday. Ropper told the surgeons to wait until Monday to see if Bob responded. And on Sunday, Pat says, a team came by to test her husband's lungs one more time.

PAT SMITHSON: When they took him off the ventilator, he breathed. He took that breath. He took that breath.

HAMILTON: Bob would spend another week in intensive care and months regaining his strength. But a year after the dinner where his head began to loll, Bob and Pat had another party with the same guests.

PAT SMITHSON: It was the most fun, wasn't it?

BOB SMITHSON: Had we not had a doctor like Dr. Ropper, I'm not sure where I'd be today. And Pat was always with me 100 percent of the time.

HAMILTON: Jon Hamilton, NPR News. Transcript provided by NPR, Copyright NPR.