Friday, August 17, 2012


     I often see patients that defy the medical expectations . At times we see patients that don't do as well as we thought and at times some get worse when we expect them to do well . I feel that everything has it's own way of response , good or the bad . Everybody is 'born ' with a so called 'timer ' .When the timer runs out of the time , the person dies . When the spring unwinds , then the time ends . Philosophically , when the karma that are going to come to fruition in this life have come to fruition , then the life ends . As seen in annual plants  when the have given the flowers , they are done .. We can not predict when someone is going to be born and we can not state with certainty when someone is going to go . The story that I am going to tell is one such case . As in all my stories names are not true names and certain things are changed to hide identity.
     I had known this 80  years old lady , with asthma  for some times . Most of the time when she would call , she was in trouble . Usually she was OK , but at times  needed antibiotics or steroids to control her symptoms . She also had rheumatoid  arthrttis  and did see a rheumatologist . She did have a primary care physician , but for all practical purpose I was her primary care doctor. Her husband had died and she lived with her son and the daughter in law . They usually brought her to me . This time when she was brought to me , she quite sick . She had fever and in spite of out patient antibiotics , she was still having fever , She was also short of breath. So with age , and her shortness of breath , I admitted her .She was started on intravenous fluids and antibiotics  and steroids . She got little better but her fever persisted .So I did CT scan . The CT scan showed the pneumonia , but also showed fluid around the lung . Normally I drain the fluid from the around the lung by doing the ultrasound of the chest and finding the right spot to insert the needle and the catheter to drain the fluid . This one on CT scan looked difficult . It was not possible to drain the fluid with the needle as it was not 'free' . It had formed pockets  . So I called the chest surgeon. This a story which occurred several years , In those days small incision chest surgery was not done . (Today we do a procedure called VAT , where a very small incision is done and a scope is inserted and with the help of video the surgery is done . Due to small incision the recovery is rapid . )Due to her age and other medical problems the surgeon decided to put in a chest tube . This is done bedside , under local anesthesia . This is done quite frequently without any major problems . I was not in the hospital at that time . The plan was to see if we can drain the fluid , (which was thought to be infected , causing the persistent fever . ) and hope to avoid a major surgery .
      As it happened , when the chest tube was inserted ,  the patient became short of breath and started coughing up blood . Her blood pressure dropped and so a code was called in . She was intubated and resuscitated . She continued to have blood coming to come out of her wind pipe and the chest tube . The surgeon took her to the surgery in next 10 minutes . She was operated upon and made it . She was transferred to intensive care unit and over period of time she recovered . She was discharged and continued to do follow up with me for next 7 or 8 years .
     What happened at that time ? . She had developed the adhesion in the chest , most likely due to infection and inflammation . Normally the chest cavity and it's covering are like a pillow and a pillow cover . So when the fluid accumulates between the lung ( pillow ) and the covering (the pillow cover ) we can put a needle or a tube and drain it . In this case , due to adhesions , the lung was stuck to the chest wall at one point . When the surgeon put in the chest tube , he did not go in the space but ended up tearing the lung which was attached to the chest wall . This caused the the shock , the bleeding from the lung etc . She would not have made it if the surgery was delayed for even short time , But with her luck , the surgeon was right there and he took her to operating room and she did well !
      So the time had not come yet !

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