Sunday, August 5, 2012


     In Mahabharata epic there is character called Jaynadrath. As the story goes , the Hero of the Bhagawat Geeta , Arjuna vowed to kill him before the sunset . The Jayadrath hides and Arjuna is unable to find him . So then the lord Krishna sent his Sudarshan chakra to hide the Sun . Now as the chakra covers the Sun , there is darkness . Thinking that the sunset has occurred , the Jandrath comes out from his hiding place and then the lord Krishna takes out the chakra , there is the Sun and the light and so Arjuna kills him . Metaphorically the Jandrath stands for our attachment to 'live' or survive. This attachment is the strongest of all the attachments . One can quit smoking , or the alcohol or salt in the diet , but the desire ti 'live' will continue . I have seen this in my medical practice many times , sometimes with surprise , sometimes with irritation and anger and sometimes with pity. I  treat many patients with chronic , disabling conditions and many times we in medicine can not help any more . Many a times it may cancer or advanced emphysema . I had one such incidence recently , and that reminded me of the other stories.
      I was called in on a patient for the shortness of the breath  .Before  I saw the patient , I looked in the computer for some old records .I noticed that she was diagnosed with a lung cancer about a year ago and had received radiation and the chemotherapy. I also saw the name of the pulmonary specialist and his recent note. So I ended up calling up both the oncologist and the pulmonologist . I came to know that he the pulmonologist had told her that he could not do much and so she was asking for 'second opinion '. So I was called in . This was a 63 years old female patient who had smoked fir several years . She had quit smoking several years before the diagnosis of inoperable cancer was made . The chest surgeon had seen her and felt that she could not benefit from the surgery , so she was treated with radiation and chemotherapy . She did OK with the radiation treatment , though had some side effects . But had bad reaction to the chemotherapy . So the chemotherapy was stopped . The oncologist did offer other treatment , but she did not do well. So now she was on no treatment.When I saw her she was short oh breath and had needed oxygen . She also had wheezing , the bronchospasm . I started her on treatment with medicines to improve the wheezing . I know that the steroids sometimes can do wonders . So when I stared her on the steroids , she did feel better, and her need for the oxygen went down and now she needed it only with long distant walking or sleep .This was partly due to emphysema and partly due to cancer and the scaring that had occurred due to radiation . She did not want any chemotherapy and wanted to consider 'alternative ' treatment . As it happened she was discharged home and did go to see a homeopathic medicine doctor and started some treatment . She did continue to come to me and also go to the oncologist . Due to the treatment of the COPD , she was feeling little better, though the cancer was not getting any better . As it happened , she was admitted to the hospital with irregular and fast heart beats and I had to cut back on the medicines for the COPD , as all of them can cause the increase in the heart rate . She had heard about the side effects of the steroids and wanted to cut them off , but unfortunately  she would become very short of breath with the reduced dose of the steroids . I had several discussions with her and her line in boy friend , who also was her POA , the medical power of attorney. So she never was DNR.
     As the time went by she continued to get worse and was more short of breath . We continued to do follow up CT scans to check on the cancer and it was getting worse . It was at times difficult to separate the changes due to cancer and radiation treatment , it was my feeling that the cancer was getting worse. She had also some fluid around the lung . It did not appear to be large and I did not drain it out . This was because , in past when we did drain it , it came back in less than one day and it did not appear to be large .
     She continued to get worse and was more short of breath . So I decided to do some tests to find out what if any could be done . I did CT scan and noticed that the abnormality on her right lung was getting worse . The fluid was more and the collapse of the lung was more , so called 'increase in volume loss' on the scan . I knew that the cancer was getting worse , and not much could be done . I did a new scan to check on the amount of  blood going to the lung and the air going to the lungs . The tumour was in the center of the right lung and my suspicion was that it was pressing on the circulation and the bronchus .It showed that the right lung was not getting any blood and there was no air going in to the right lung .I knew this when I ordered the test .The blood vessel going to the right lung was blocked by the tumor and so no blood was going to it and same was true of the bronchus . The tumor was pressing the bronchus from outside and so no air was going in . This was not a good news . I told her about this and called the radiation therapy doctor . He looked at the scans and called me . HE could not do anything . The next morning she was admitted to the hospital .I saw her and went over the findings with the patient and the family . In spite of the findings and the poor prognosis , she wanted everything done. As I had thought she needed to be put on respirator . I did call the chest surgeon . He had nothing to add. I did call another oncologist at the request of the family . He told the same thing In between her blood pressure dropped and her urine out put had dropped . Her kidney function also got worse .So I called the kidney doctor . By then I was having the problem with the oxygenation. Now she was on 100 % oxygen and still did not have adequate oxygen .I was speaking to the family and they wanted everything done . That night I got the call . Her blood pressure was low . She was on the medicines for the the dropping blood pressure and still no urine output and oxygen was low . I spoke to the family . Told them that with the given situation there was high possibility of the brain damage .They had the long discussion and decided to make her DNR .

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