Monday, September 3, 2012


    We as human being expect people to say words  like  'please',  'thank you 'etc. When people do not say these words,and do call them words as many a times they are mere words ,we get upset. But there are times when we do not expect someone to say it and people say it .  we are left asking a question  'for what ' , though we do not say it loudly. Many times  we say these things when we don't mean it . So when I received the greeting card from Martha , I was not only surprised, I did not know how to react .
     I saw Tom in my office for abnormal chest x-ray. He was 81 years old male who was referred to me for abnormal x-ray. He had persistent cough . So he went to his primary care physician and was treated . When the cough did not improve , he had the chest x-ray . It showed a patch of pneumonia . He was treated and the x-ray was repeated . The x-ray did not show  improvement, so he was sent to me .
    He was accompanied by his daughter . He was a retired cop. His wife had passed away 3 years ago and his daughter had moved with him . He had no major medical history. He had high blood pressure.He had lost 15 lbs. He had mild memory loss . He still walked a mile without getting short of breath.. I ordered a CT scan and did pulmonary functions . The CT scan showed a collapsed of left lower lobe ( lower third of the left lung ). I did bronchscopy and it showed the tumour in the lower lobe . It was blocking the opening of the left lower lobe.This had caused the persistent pneumonia. I did the biopsy and it did come back positive for cancer. So I had a talk with him and the daughter.The breathing test was not normal . It did show reduction in the lung capacity . But it was still acceptable for cutting lower third of the left lung to get rid of the cancer . This would be the best treatment . The alternative would be to give him radiation treatment . The surgery is the only treatment which if successful , can cure the cancer . The other treatments can help , reduce the size of the tumour , but in most cases can't cure the cancer . After the discussion they agreed for the surgery .
    He had the surgery . Unfortunately at the time of surgery , the surgeon noted that the tumour was stuck to the central area , and the central lymph nodes  were involved . The fissure that separates the lower lobe from upper was incomplete and the tumour had spread to the upper lobe as well . This was not obvious on the CT scan . He had no choice but to take out entire left lung . The post operative course was not very good . He was on the respirator and we had difficulty weaning of it . Every time we went down to 4 breaths ,he would get short of breath, and we had to sedate him . I did try for next 10 days . I knew that if we could not wean him off the respirator by 2 weeks or so, we will have to do tracheostomy . I did discuss this with the daughter . After that we made him DNR. DO NOT RESUSCITATE .
    On the 13th day , it happened . He suddenly became short of breath, and his blood pressure dropped . I did a chest x-ray and it showed left chest full of air . The stump had ruptured . (When the lung is taken out, the main bronchus is cut and sutured . It heals and we don't have problem . But in this case due to the respirator , which 'gives' breath of air, it causes increase pressure  with the breath . Due to increase stiffness of the remaining lung the stump ruptured , and that caused the drop in oxygen and the blood pressure .) We put in a chest tube to allow the air that was leaking , to get out . But this did not help . Now the air that the respirator was pushing in with each breath , was leaking out.and the right lung was not getting enough air . So we were unable to oxygenate well . I talked to the daughter . I had done what I could . The surgeon had called to take  him to the surgery , as it was only option . After the discussion the, daughter refused the repeat surgery.Her feeling was that 'he had gone through enough '. Her point was well taken as  even if we were successful in closing the air leak, he was going to be on the respirator, and would have needed tracheostomy. I called the surgeon and cancelled the surgery and made him DNR and he died in next couple of hours . The daughter was present in ICU.
    Ten days had gone since Tom had died .  I was in the office. My secretory told me that the daughter had come to talk to me . I called her in . She handed me a card . It was a 'thank you ' card and she had her personal note in it . She wanted to thank me personally .
    For next 5 years , she came personally and gave me the 'thank you ' card !!!!!

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