Friday, April 25, 2014


       I remember the time when the movie called The Close Encounter , came out in theaters . There were long lines for the tickets . Now the similar  movies with better cinematography have come out . But this one was one that I remember very well . But what I want to write today is not the 'THIRD KIND',but the encounter of Lord of Death . In Hinduism , we have a concept of the Lord of Death. In fact one of the scripture called .Kathopanishad , was a discourse given to a young boy by the Lord of Death, about what happens to 'us' after the so called death .it is very interesting to know that each religion has different concepts about life after death. But to my knowledge , there is not much known or talked about signs of death approaching . I have read some books that talk about it . I want to share a story with you about a patient that had close encounter.
     I had seen this 63 years old patient with advanced CO PD. He was a smoker and had significant damage to his lungs . He was on oxygen and also had lot of vascular problems . He had a enzyme deficiency , called Alpha 1 Antitrypsin (also called AAT), But he did not want replacement for it , which is normally given intravenously.He was referred to a cardiologist and had some stents put in . He also had aortic aneurysm and was seen by vascular doctor and I sent him for the lung transplant evaluation.Couple of centers rejected him , but one decided to work him up.He had some nodule in the lung and had several endoscopes as he also had abnormal chest CT scan . I had followed this for sometimes and there was no change , but he still had bronchoscopies with new techniques.He was admitted to hospital and was quite short of breath . In spite of treatment he still 'felt' short of breath. I gave him some tranquilizers, to take care of anxiety. This seemed to have worked . I also talked to him about noninvasive ventilator at home . This a respirator that gives breaths, with a pressurized mask.. He was reluctant , but agreed . He was discharged. I called his insurance company doctor to get approval . But then he was readmitted . I had a call from the transplant doctor , on the last day of his hospitalization that they had decided to not accept him for the transplant . I did tell this to his wife , but did not want to tell him this at that time .
     On readmission he was OK . I was not too sure what had brought him back but his salt in blood was low . So we started him on IV saline  and he got better . On the 3rd , I went to see him . It was Saturday.I saw him . He looked uncomfortable . He was little short of breath or was breathing little faster . But  his oxygen saturation was good , his blood pressure was normal and his heart rate was normal . He had just gotten back in bed from the bathroom and I thought that the faster breathing was due to the exertion . But I was not too sure . I asked ,if anything else bothered . He told me that he had some stomach pain . He had upper endoscopy less than 2 weeks ago . and also had follow up CT scan with the vascular doctor less than 3 weeks ago . When I checked the labs , I noticed that his blood count had dropped , but then he also had quite a bit of fluid, which could dilute the counts. On examination, his lungs were clear and he had mild tenderness in belly.I was not sure . I called the nurse and tried to call his wife on telephone . I wanted to know if she had told him about the transplant rejection  and also wanted to ask her about the CPR and code status. I knew something was wrong . I ordered the repeat blood count , and ordered the CAT scan of the belly to check on the aneurysm .Could not get any one to answer at his home . So I went to his room again and asked for her cell number . He took his own phone and placed the call . I spoke to her and told her that I was concerned about his condition and I was doing the CT scan stat  to rule out problem with the aneurysm .I also asked her about the code status , and she told me that she had told him about he rejection from transplant team and they had discussed and decided that he would be DNR. I gave him the phone and he reconfirmed the DNR . I left the floor after signing the forms and went to next floor to see other patients . It may be 15 or 20 minutes .that had passed that I heard hospital operator calling cardiac arrest from his room. I ran up stair and the nurse was in the room and other 4 or 5 people were there.The nurse had informed them that he was DNR , so no CPR was done . He was put on 100 % oxygen and was barely breathing . The transport from radiology was there to take him down for the CT scan that I had ordered I tried to call his wife and no one answered at home . I did not have her cell number as he had called it for me . I picked up his cell phone dialed the last number dialed . She did not answered. I looked at the other numbers that he had called and called one that he had called earlier . It turned out to be his daughter. I could not tell her that her father was dying .She did not live locally . I was in the room for about 20 to 30 minutes watching his agonal  breathing . Then I left .Told the nurse to call me when his wife would arrive. I came to talk to them . Some how she had known as the nurse was able to contact her after I left.
      I knew that something was not right . I also knew that there was a possibility of aneurism rupturing. I also knew that he may end up being coded . BUT I DID NOT KNOW IT WAS GOING TO BE THAT SOON --MY CLOSE ENCOUNTER .      

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