Sunday, May 4, 2014


     When we talk about any surgery, we want to know if it is absolutely needed or not . If I state that some one's gallbladder needs to come out , I have state that doing so is going to help prevent an attack of gall bladder.Things are sometimes Crystal clear. If some one has lung cancer and surgery is recommended , no one has any questions. But there are situation , when we have to make decision to the surgery , where nothing on long term is going to change , but we still need surgery .The story that I am going to tell is one such.
      I saw this 72 years old male for pulmonary evaluation . He was diagnosed to have lung cancer, when he was admitted to hospital . The biopsy was done and the diagnosis of lung cancer was made . Patient was seen by radiation doctor and an oncologist As the work up was done , he was found to be inoperable and was treated with radiation therapy. He also got some chemotherapy.He was followed by the lung specialist. He had some fluid around his lungs and it was taken out by the previous lung specialist. He also had a bronchoscopy . There was no recurrence of the cancer. For whatever reason, he came to me for the further follow up. I looked at his old records and realized that the left lung , where he had the cancer,was contracted and almost nonfunctional . This most likely had occurred due to the previous treatment with the radiation and the chemo. So the lung was contracted and could not expand. And there can not be an empty space , so the fluid was coming back. Taking out fluid would not help anything , neither shortness of the breath , nor cancer. I did not do any procedure ,but did a scan that measures the blood flow and the air going to that lung . As I had expected , the left lung was getting 3 or 4% of the air and the blood . So in essence it was contributing nothing to the function of the lung.
     About 6 months after that , he was admitted to the hospital with car accident .He was driving at night and was hit by a car ,He broke couple of ribs and was admitted to the hospital . I saw him and looked at the chest X-ray . He also had CT scan of the chest and it showed that the fluid was little worse , but not much . He was also on blood thinner for his heart, atrial fibrillation ,irregular heart beats.I stopped the blood thinner in a fear of bleeding with trauma.I ordered the repeat blood counts. The next day when I saw him I had noticed that his blood counts had dropped . When I called the nurse about it , she informed me that the hospital doctor had ordered the transfusion . (not knowing what had caused the drop in the counts . I saw him . He was short of breath. There was not much air going in the left lung . I spoke to him and ordered stat chest X-ray . I also told him that most likely he had bleeding in the chest due to car accident and rib fractures and he bled due to being on blood thinner .I told him that I was going to call a chest surgeon and most likely he will need surgery.I transferred him to Intensive Care Unit .
     As was expected , his chest X-ray showed 'white out' of the left lung.I spoke to the surgeon. His breathing got worse and he had to be put on respirator . Patient and the family were told that he is going to need surgery , and it was not for his cancer , nor it was going to change anything as far his cancer was concerned , nor was it going to change his shortness of breath.(from his base line ). They wanted to know if this was needed surgery and what would happen if did not do it . I told them that if he continue to bleed, and then shortness would be worse .They agreed and he underwent the surgery . The blood was evacuated and did OK.He was on respirator for 10 days and then needed lot of physical therapy.
     The surgery was needed , but was not going to change anything that was his problem in the past . But it was necssary surgery, as without it he would have died.   

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