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"The irony of it all," Cassie approaches Dana, hands deep in her scrub pockets. Trauma has a chokehold on her today. Her fourth pneumothorax (lung collapse) she’s seen today. She'd be lying if she said it wasn't therapeutic, doing procedures and stepping back to watch all that dangerous intrapleural cavity air exit. Medicine is strange. It’s torturous, yet full of relief.
She's heard that before, for other things.
Dana simply flicks her cigarette (which would be so hot to Cassie, if it wasn't her God-ordained duty to strongly warn against the act of smoking) and shoots her girlfriend a shit-eating grin. She's right. The charge nurse's chain smoking is either the clear opposite of health propaganda, or a message to the health system: we're stretched so thin we're killing ourselves to save others. That last one is probably it.
Cassie slides herself closer to Dana, tired elbows brushing against each other. They learned to tune out the ambulance sirens decades ago, one never a deterrent to their conversations.
"You good? Little girl with pneumonia pull through?" Dana asks.
"Don't change the subject," Cassie shakes her head. "But she's okay. ICU now. Baby with respiratory distress also okay."
Dana nods with relief, choosing to ignore the fact that all the cases Cassie has mentioned are related to things that could very much happen to her anytime soon, before sharply turning away to cough with effort. It sends a shiver down Cassie's spine, each repetition of inspiration (thoracic cavity volume increasing, lung pressure decreasing) coming from the nurse. She's doing a terrible job at hiding it, and it pisses Cassie off. As if Dana doesn't have enough stress on her system, a proud wearer of the adult-onset asthma label. Occupational asthma—just one of her many hospital battle scars. Her airways are narrowed, or constricted, from mucosal inflammation and smooth muscle hypertrophy, making it an extra challenge to overcome resistance to airflow. And it's much like Dana to keep the whole ER in check but accidentally leave her inhaler at home at least three shifts a week. (Cassie has a spare, always tucked away in her pocket. Because, of course she does.)
(Dana calls Cassie her "albuterol trolley". Her favorite source of source of the short-acting beta2-adrenergic receptor agonist (put simply, bronchodilator).)
She can see the muscles move, working overtime to try to expel the poison in Dana's lungs. On her inhale, the external intercostals extending the anterior and posterior dimensions of her thoracic cavity. Scalenes, sternocleidomastoid, major and minor pecs, serratus anterior, latissimus dorsi. Everything lifts, then everything comes crashing down on the forced exhale—antrolateral abdominal wall, internal and innermost intercostals. Phrenic nerve yelling for help—okay, does Dana want her diaphragm to give up on her, too?
They never talk about it. Mostly because they prefer to leave the medical speak at the hospital. But lately, Dana is becoming more and more precious to Cassie.
"You think I haven't heard you cough yourself crazy?" Cassie murmurs, smoothing out her ponytail. "Like you've been running marathons in your sleep. Your minute alveolar ventilation isn't even minute. It's a millisecond," she jokes dryly. Dana rolls her eyes to this. It was the pretty obvious clinical pearl in Cassie’s pre-med: smoking syndrome—cilia killed—mucociliary escalator unable to function—chronic cough the only way to stop mucus accumulation in the lungs. She liked learning all these things, liked to hear about all the little tricks up the body's sleeve that wanted nothing but to keep itself alive.
Take the airway epithelium, for example. It's lined with cilia and mucus, two elements that work in sync, in waves, to push pathogens up and away from the respiratory tract to keep everything clean and healthy. Smokers have shorter (or wors,e destroyed) cilia, which means it's more difficult for them to make contact with the mucus, decreasing the mucociliary clearance. Increased risk of lung disease makes ventilation failure more likely, and God only knows what a headache it is to intubate. And it doesn't end there.
Her macrophages will be deterred, making infection more of harder to kill. Exhalation will hurt, destroying her alveolar walls. Blood won't be able to pass through as many capillaries as before, leading to pulmonary hypertension. She could get heart failure. Carbon dioxide could pile up in her system and kill her.
Basically, everything would go to shit.
Cassie can trace the pathophysiology of Dana's self-inflicted morbidity, from her risk factors to her prognosis if she doesn't stop now (or better yet, twenty years ago), and it kills her to have the mental capacity to even imagine it. To helplessly grieve a sickness slowly setting in. And whose fault is it?
Well, it isn't Dana's. Not completely.
"There are enough COPD cases on the board," Cassie says, largely to herself. "We sure as hell don't need another one.
"We're all dust at the end of the day, Cass," Dana breathes out. The small, automatic (for now) movement is complex when broken down.
The lungs deflate, the muscles relax, the diaphragm moves upwards via the abdominal muscles, ribs move downward via the internal intercostals, intrathoracic volume decreases, until, finally, elastic recoil returns the lungs to rest.
There's a pitiful look in Dana’s eyes, saying something like, allow me this. I'm trying my best to do everything else right.
Cassie knows Dana is fully aware of everything she's saying. But she's willing to get a side-eye, or to be accused of being patronizing, if it means she at least tried. If it matters that Dana gets to hear this from the one who looks at her like she hung the moon.
"I don't want you to turn into dust," Cassie confesses. "Not yet, D. Not ever."
Dana faces her, eyes scanning the worry lines, the sides of Cassie's fringe, her stethoscope worn from years of use and fidgeting she doesn't notice she does. She knows she can be stubborn, out of necessity—to advocate for the patients in the ER, to keep the position she's fought tooth and nail to keep. She'll admit she sometimes does it on purpose. Like she can't believe someone's willing to take care of her, for a change.
She takes a deep breath (which hurts, she's gotta admit). "Are you gonna ask if you could refer me to someone? Because..."
Cassie looks at her, stunned. It's not like Dana to be so defensive, especially not to her.
"No, I'm..."
"...because I could take you up on it," Dana finishes, eyes on her grime-and-blood-covered shoes.
Cassie blinks.
"I..."
"Want me to repeat that for you, Doc?"
"I'm sorry, no, I'm just surprised," Cassie shakes her head, a smile escaping the corner of her lips. "You weren't showing any signs of indulging me."
"How 'bout now?" Dana tosses her cigarette before squeezing Cassie's hand. "If you could help."
"You're letting me? Letting me love you?" Cassie runs her thumb over Dana's palm.
"I'm letting you," Dana chuckles. "You make it easy."