Friday, March 14, 2008
My parents were smokers; in the case of my dad, it was three or four packs a day for forty years before he just up and quit one day, cold turkey, many years ago (not soon enough to avoid the need for home oxygen at the end of his life. But still...) Mom smoked far less, and quit the same day he did. After my grandfather's heart attack, he quit, too; but usually kept an unlit Tareyton in his mouth -- the kind with the cardboard tube on the end -- to chew on. Until his stroke.
Of course I took it up. Stole packs from my dad's pockets and sneaked with eighth-grade friends down to the swamp behind Reed College, smoked and coughed until we got the hang of it, and proceeded to be cool. I blew great smoke rings, learned the "French Inhale," could light a match in a matchbook with one hand, pop a flame with my fingernail, or on my shoe. I didn't smoke much until college, and then it was only five or ten sticks a day. I kept it up, I'm embarrassed to say, through med school and even -- more's the shame -- while a surgical intern. Somewhere there's a picture of me at the VA Hospital, working on a chart, wearing my whites, cigarette polluting coolly from my hand.
On the day I got married I quit but began again three months later, when I shipped off to Vietnam. Cigarettes were so cheap over there, I really couldn't afford not to. The last cigarette I ever had was when the stewardess (flights back to The World were on Pan Am jets -- "Freedom Birds," we called them) announced we were about to land at Travis AFB. Skrunked it out, and that was that.
I mention all this to confer authority when I say what a terrible thing it is to do. How easy it is to tell smokers when operating, and when caring for them afterwards. Not to mention when first seeing them from across the room, or hearing them. Lady who looks twice her age, facial skin wrinkled like a scrotum in winter, voice sounding like shifting gears without the clutch. Guy with a chest over-expanded by trapped air, honking up crud into a brown and stiff tissue. Holding it with yellow fingers.
Put smokers to sleep, they cough on their breathing tubes; the gooey crap that needs to be sucked out of their lungs to keep their oxygen levels up looks rotten, thick in pus. Brown, or green, or black. Or red, sometimes. The corruption thus vacuumed out streaks the tubing for a foot or two, slime from a dying slug. A smoker bucks like a horse untamed when waking up, straining sutures scarily. Many a time I've leaned on an incision to keep it from coming apart, a desperate sort of single-stroke CPR, waiting for the anesthetist to get them calmed down. When still in training, I had a smoker-patient wake up with such a convulsive cough that it popped every single stitch, pk-pk-pk-pk-pk-pk, like a tommy-gun, which is what led to taking up the leaning maneuver (as well as a change in suturing methods.)
Smoking retards healing. It increases the risk of leaks where we sew bowel, and of wound dehiscence or late herniation. If you want much in the way of cosmetic surgery and you're a smoker, fergit it until you quit. The chance of successful limb-salvage surgery -- bypass grafts around blockages and hooked to small distal vessels -- is greatly reduced in smokers; welcome to Stumptown. (I used to live there.) In hospitals, particularly on surgical floors and in ICUs, evidence of the hazards of smoking is everywhere. Opening a chest and seeing a normal lung, pink as a baby's tongue, fluffy as a feather, is as rare as it is beautiful.
When I worked at that VA hospital, I saw guys holding cigarettes in stubs of former fingers, sucking smoke into a tracheostomy. Rules be damned: people sneak out to stair wells or onto fire escapes to smoke after surgery. And lie about it after, oblivious to their smell. It's rough. The good news is that, in regards to surgery and anesthesia, the effects are lessened to some degree even with a week of abstention. Much longer is much better.
My advocacy does have limits. I thought it cruel and stupid when an attending refused to let a patient, dying of lung cancer, have the pleasure of a smoke. What's done is done. Give a guy a break.
[The post was written a while back, before this.]