When Breathlessness Wasn't in the Lungs
There are consultations that begin with a symptom but end with a story.
This was one of them.
It started with a phone call as I was getting ready to leave for work.
"Doctor, can I bring my mother? She needs nebulisation."
I apologised and explained that I didn't have nebulisation facilities in my clinic.
"Bring her anyway," I suggested. "Let me examine her first. Sometimes breathlessness isn't asthma. It may be something else, or perhaps we only need to review her inhaler technique."
There was a pause.
"No, Doctor," the caller insisted. "She's very breathless."
The call ended.
The following morning, at around 7:30 a.m., my phone rang again. I was already dressed and preparing to leave for Kalutara.
"Doctor, can I bring my mother now?"
"I'm just about to leave," I replied.
There was silence for a moment.
Then, in a voice filled with desperation, she pleaded,
"Please, Doctor... I need a doctor."
Something about those words made me stop.
"If you can bring her immediately," I said, "I'll wait."
A few minutes later, a three-wheeler pulled into the clinic.
A middle-aged daughter helped her elderly mother out of the vehicle. The old lady was frail, walked slowly with difficulty, and appeared exhausted.
"Sorry for disturbing you, Doctor," the daughter said. "She's terribly breathless. We even took her for nebulisation yesterday, but it didn't help. The doctor there said she doesn't have asthma."
She handed me a stack of clinic records.
Mrs. Mary Donna was 95 years old.
She had a history of ischaemic heart disease, hypertension and hyperlipidaemia. Her medications included aspirin, antihypertensives, a statin, furosemide, and amitriptyline.
She was fully conscious, alert and remarkably sharp for her age.
"Doctor," she said quietly, "I can't breathe."
Yet something didn't fit.
She had no cough. No fever. No wheeze. No chest pain. No leg swelling.
Her oxygenation was satisfactory. Her pulse was mildly elevated, and her blood pressure was slightly high. A recent full blood count showed a haemoglobin of 10 g/dL—only mildly anaemic and certainly not enough to explain such severe breathlessness.
As I examined her, I noticed something else.
Whenever I looked directly at her, she seemed to breathe even faster.
Her face carried an expression that was less of physical distress and more of fear.
I paused.
"Amma," I asked gently, "are you frightened of something?"
She looked at me for a few seconds before answering.
"Doctor... every night I see a black figure standing beside my bed."
The room fell silent.
"Who is he?" I asked.
"I don't know."
"What does he look like?"
"He has his hair combed backwards. He's wearing a black tweed jacket and black trousers."
"Does he speak to you?"
She slowly shook her head.
"No... he just stands there... looking at me."
There were no voices. No confusion. No evidence of delirium. It appeared to be an isolated visual hallucination in an elderly lady whose cognition remained otherwise intact.
I reviewed her medications carefully.
At ninety-five, every unnecessary tablet carries a cost.
I discontinued medications that were no longer offering clear benefit, including furosemide and amitriptyline, both of which could contribute to adverse effects and increase her risk of falls. Given her overwhelming anxiety and poor sleep, I prescribed a very short course of alprazolam with clear instructions for cautious use.
More importantly, I reassured her.
I explained that there was no immediate life-threatening illness causing her breathlessness. I encouraged her daughter to spend time with her, keep her comfortable, and bring her back if anything changed.
As the daughter helped her mother back towards the waiting three-wheeler, she lingered behind for a moment.
Quietly, almost in a whisper, she asked,
“Doctor... do you know who she is seeing?”
I looked at her, waiting for the answer.
“It must be Papa.”
Her father.
“He passed away many years ago.”
For a few moments, neither of us spoke.
After they left, I sat alone in the consultation room thinking about the encounter.
Medicine teaches us to search for pneumonia, heart failure, pulmonary embolism and anaemia whenever someone says, “Doctor, I can’t breathe.” And rightly so.
Yet that morning, the symptom that had sounded like a respiratory emergency had led me somewhere entirely unexpected.
Was it simply anxiety? An adverse effect of medication? An ageing brain conjuring vivid images from fading memories? Or was there another explanation that medicine has yet to understand?
I never found out.
Mrs. Mary Donna is yet to return to my clinic.
Sometimes I still wonder what happened after that morning.
Whether the black figure continued to stand silently beside her bed...
Or whether, on one quiet night, he finally stopped coming.
I suppose some stories are never meant to be explained. Some are simply left where they belong—in the quiet space between medicine and mystery.