Saturday, March 2, 2013


     I often talk about body , mind and intellect. everyone knows that the body and mind are different .But I am not talking about the philosophy. In medicine we need 'presence of mind '. We talk about this in case of emergency , but even in  ordinary situation a doctor needs presence of mind .But in some situation , we need presence of BODY. What I mean by that will be clear with the story that I am about to tell .
    I saw this young male patient , who was about 50 years old . He had a diagnosis of rheumatoid arthritis for last few years .He was doing OK , but then started having more cough . He had some cough for long time , but with his arthritis  as  main problem , he had not paid much attention.Now that it got worse , he had X-ray and then was treated by Primary Care physician and then was referred to me . I saw him and saw his X-ray , he had clear cut scar tissue in the lungs , fibrosis.I did do CT scan  of the chest to confirm my diagnosis . The CT scan did show extensive fibrosis. I also did bronchoscopy and biopsy and the the breathing test . All the tests confirmed the diagnosis of fibrosis . It was most likely related to the rheumatoid arthritis . Lot of patients are not aware of the fact that the rheumatoid arthritis can affect lungs .It can cause fibrosis , it can cause nodules in the lungs and sometimes  other problems too . I explained it to patient and his wife the diagnosis of scar tissues and it's treatment . We tend to treat it with steroids . We also sometimes use other immunosupressents to treat it . In many patients this does the job . The fibrosis does not get 'cured ', but it's progression can be stopped .
       I started him on large dose steroids , and told them that I will see them again and do the follow up tests like oxygen check on walking , breathing test , and even CT scan .I saw him sooner than planned , as he continued to get more short of breath and had worsening cough.I saw him and felt that he looked worse . Even at rest he was breathing little fast .When I had checked his oxygen first time it was OK . This time when I did it it was still acceptable , but lower than before . I warmed his fingers and checked it , and it was still low normal .I thought that the crackles that I was hearing on the lungs were more pronounced . I made him walk in our office . We usually do what is called 6 minute walk test . We walk patient for 6 minutes and watch blood pressure , pulse and oxygen saturation . This is to find out if the oxygen level would drop with exercise . If it does then patient needs oxygen at home . We put patient on oxygen and the check the saturation again to male sure that the oxygen flow is adequate . I did ask him to walk and he could walk 3or 4 minutes and his oxygen level dropped .I put him on oxygen , which he did not like , but I had no choice and I told him that neither had choice as his oxygen level was too low .I was concerned and so I upped his steroid dose and discussed with about adding a new drug called methotrexate .They agreed and I started him on methotraxate too . I asked him to see me in 3 weeks .
     I saw him in 3 weeks . He looked much worse . He was quite short of breath and could not do much walking even with the oxygen on and increase to 4 l.I did not know what else to do . I decided to admit him . I talked to his wife and told her that he was getting worse quite rapidly and I was going to try to to what else could be done . I also told her that if things don't get better , he may need to be on respirator . I admitted him in ICU  and put him on BI PAP, in hope that with applied pressure the oxygen would improve . I also called a cardiologist , to rule out any cardiac reason for his worsening shortness of breath . The cardiologist saw him and did ultrasound of the heart and it did not show any heart problem. As I expected he continued to get worse and I had to put him on respirator .I was talking to his wife daily and had told her the poor prognosis . Due to his young age I had to and wanted to try everything . As he continued to get worse , I decided to get second opion . I did not want to 'miss anything '.The other doctor had nothing to add or change in his treatment .
     It was Saturday . I had seen him in the morning and talked to his wife . Not much had changed . He was on respirator ,need for oxygen was worse and there was no possibility of weaning was not there on 10 the day of respirator .I was eating out in a restaurant, and I got a call from ICU . We had reached oxygen need to 100 % , which means that we could not increase it anymore . His wife was in ICU and I talked to her and told her the worsening. I wanted to to tell her in straight words that I can not do anything anymore . But cold not . She asked me if I could talk to her again after she had talked to her parents . Her kids were on their way to the hospital . I told her off course . It was 10-30 pm . I wanted to go home .But decided to go to the hospital . I wanted to talk to her face to face . I knew that I was not going to be in any position to change anything .I could have easily talked to her on telephone .But I felt that my "physical" presence was more important than my "mind " or "intellect". I went there . Her whole family was there , her both parents , her both kids,age 14 years and 16 years . She had decided to call it off . She wanted to stop all the treatment and so called "pull the plug". I knew that I could not 'save' him .(In fact I have stopped thinking that I  can save anyone ).But I had hard time accepting it due to his age or may be because of his young kids , who were close to my kids' age . I agreed .
    I knew I could have done this on phone as she had made up her mind , but presence  of 'physical body' was more important at this stage of game .

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