Saturday, February 23, 2013


     I was reading an article on the Astrology . It was interesting article . In India lots of people follow the astrology , to guide them about  many things , in day to day life  as well as on special occasions .Each one of us is born on different time and based on the position of stars (planets), natal chart is prepared . Then 'educated 'people can 'predict ' or suggest certain things . So the question in the article was how can we predetermine the time that a new child is born . If one knows the auspicious time then c -section can be done to get the time of birth to  exactly what we want . But then question comes in as to what is the "time of birth " .Is it the time of conception ? or is it when the heart starts beating or is it when thee neural grove is formed .Or may be when the infant takes first breath or may be when the cord is cut , so now the child has independent existence.I do not want to talk about the Astrology , as it is too complicated , I do not know much and it will be impossible to tell anything in such a short blog .But when I was reading the article I felt that we can not determine or know the time of birth or death . It reminded me of one of my previous patients.
     I had a call from this family doctor . She had chronic cough and had tried to treat herself, and had no improvement. So she wanted to see me . I saw her the next day . She was 53 years old female who had never smoked and , had no history of asthma . On examination , she had some crackles on her lung examination and was mildly short of breath. Her oxygen saturation at rest was 92 % , which  is low for nonsmoker lady . I asked her if she had done chest X-ray . She had done it and brought it with her . When I looked at it I was shocked . It showed significant abnormality . It showed fibrosis, at least , that is what I thought .She had not thought much of the X-ray .I ordered the CT scan and did pulmonary function tests . My diagnosis was correct .She had significant fibrosis. I did the bronchoscopy and biopsy. It did confirm the diagnosis . In view of her younger age , (and her being physician ) she wanted to know as to the cause of fibrosis . In reality , the etiology does not matter as in most or all cases , the treatment does not change . I asked a chest surgeon to see her , who did 'open lung biopsy '. It again showed the same thing and we still did not know what exactly was the cause of the scar tissue. I had started her on steroids and she also needed to be on oxygen . She was refered to a center for lung transplant . She was out of her office for 3 weeks or so , but then decided to resume the office work . She needed to be on oxygen when she was seeing patients .
      She was evaluated by transplant team .But she started getting worse . It was not even 3 months since the diagnosis was made and she was more short of breath and needed more oxygen . She continued to get worse and I had to admit her . She was admitted to Intensive care unit . We tried various means to improve the oxygenation , with no improvement. Her son -age 22years and the daughter age 20 had come . I told her the patient that we had no choice but to put her on respirator . She did not want to . She asked me, "what good that would do " ?I had no good answer, other than that it will buy some time . In reality we had no treatment to improve her fibrosis .After a long discussion , she agreed to to be put on respirator , but with only one condition . I will stop the respirator in next 3 days , not one more and under any circumstances .I tried to tell her that if any improvement was going to occur ,it will take longer than 3 days . She would not change her decision . She made her children promise that under no condition she will be left on respirator longer than 3 days .
       I had no hope that she could be weaned off the respirator in 3 days .I was correct . she was completely dependent on the respirator . On the 3 rd day , the family approached me and wanted to take her off the respirator . I told them that I will call the transplant center and see if they could do something . The children did not want to break the promise . I still ended up calling the transplant center , , They did not have much to offer . So I had no choice but to do the withdrawal of the life support . She died in less than 2 minutes ,once I took her off the respirator . So she did "predetermined 'her own death !!!!

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