Saturday, May 18, 2013


  I often wonder if we truly know anything . Our decisions are dependent upon our previous experience and probability. This is true in medicine and in any other situation . Brian Green , a physicist once said that according to the quantum theory , if we try to go through a wall , there is a probability that we will pass through it ,if we try it enough number of times .In legal terms ,possibility and probability are different . When we say possible it means the chance is anywhere from 1 to 100 % , but when we say probable , it means the chance is more than 50 %.We like to be confident in our life , medical or regular . But in reality we are dealing with probability and nothing more .I am going to tell a story today of a patients , in which I knew ( at least I thought I knew ) the probability , but missed  the possibility ,
      It was Wednesday , I had a call from my office. One of the primary care physician had called our office and wanted me to see this patient ASAP. He had a abnormal CT scan , which was showing a mass in the lung and it was most likely a cancer . I had a full schedule next day and next week . There was no way I could see him soon . So I decided to see him in the hospital as if I was seeing him in my office . He came with his sister .
     He came with his sister in the hospital . he was 54 years old male . He was a smoker and had quit smoking 8 or 9 years ago . He started with what looked like acute bronchitis . He had lot of cough , had fever and was wheezing . So he was treated with antibiotic . The fever was gone , but the cough continued . He got second course of the antibiotic .He got little better , but still had some cough . So then the primary care physician did a X-ray . It showed pneumonia . So now he got different antibiotic . The cough continued and he had blood in the sputum . So he had CT scan done . It showed the mass at the center of the left lung .So now he came to me . He also had a small nodule in the other lung .I had asked him mu 'usual ' questions , like high blood pressure , diabetes , TB , heart attack etc . Then when I explained him the possibility of cancer , I told him that we have to answer 3 questions . Is it cancer . Has it spread and lastly what can we do about it .(treatment choices , surgery , chemo or radiation ) From the look of the CT scan it was clear that he was inoperable . At that point he told me that he did not want chemotherapy and was not sure about the radiation . I told him to make educated decision and not an 'emotional ' one . Then he told me that he had HIV, and was on treatment and it was controlled . On further questions , I came to know that he had infectious polyneuropathy and at the time of the treatment the HIV was diagnosed .So his point was that with HIV , giving the chemotherapy may be a problem .I ordered PET scan , Pulmonary function test and a bronchoscopy and biopsy .I called office and then he was scheduled for all the tests .
    I saw the PET scan , which was one next week . It was bad news . The mass in the left lung was positive , but the entire lung had collapsed and there was fluid around the lung . There was activity in the spine , ribs and liver . There were lymph nodes which were positive too and there were other nodules in the right lung . I had to call him personally as it was quite bad I told him that I wanted to do MRI of the brain and the liver to rule out spread of the cancer .He agreed with the plan .But when my office called him to schedule the tests , he wanted to cancel all the tests that were scheduled earlier , the bronch , biopsy . the breathing test and wanted too do nothing .When my office told me about it , I told them to get him in the office next week .
   When he came to my office  he was quite rational l. ;He knew the difficulty that we would get in to with chemotherapy with his underlying HIV .The disease was all over and radiation would not be an option .So after the discussion , we decided to call Hospice . His sister asked me the question ---how long and with my educational guess I told him 6 months to 9 months
    He was in ER in next 10 days , with shortness of the breath . The ER MD talked to him and he was put on a pressurized mask. It did help . I also gave him steroids and breathing treatments. He was seen by me in ICU next afternoon . By then he was off the mask , his X-ray showed complete collapse of the left lung , but he was OK . We had the chat and I called the Hospice to see if he could be put in their unit . The time lapsed between  the ER presentation and my talk was 18 hours
   He was transferred to step down unit . He was doing OK . I got a call from the nurse at 1 am that he was short of breath . He wanted to be on the pressurized mask . I told them to put him on it and transfer him to ICU . The next call that I got was at 3 am . He was on the BIPAP , the mask and morphine for the comfort  and had cardiac arrest. He was DNR So no CPR was done and he died .
     I knew he was going to die soon . When I saw him for the first time I knew that he had inoperable cancer and thought that with his young age and treatment he would live for may be 18 months . Then with his PET scan abnormality , I thought that it would be 3 months . The n when he came to ER I thought that he would last couple of weeks . AND HE DIED IN FEW HOURS .

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