Friday, September 5, 2014


       Many years ago I watched the movie called the Gambler.Kenny Rogers was a seasoned gambler and there was an amateur gambler who gets in trouble, So there was the song " You Got to know when to HOLD and you got to know when to FOLD. " I liked it very much for the meaning . I think it is a message for the life .I have used it in many situations.But it is so true in case of medical management. When we see patients in ICU who are very sick, we try everything that we can. We have lot of things to do as testing or try different treatments. But as time goes on and when we don't see any improvements , it may be time to stop the aggressive treatment or may be continue for little longer time . This is what I call either 'holding' or 'folding'.No one can state with certainty , as to when is a 'right' time to either Hold or time to Fold.I have faced the dilemma many times and sometimes I face it in situation when it is not impending as in ICU , but may be chronic or sub acute.The case that I am going to tell is one such.
        I had seen this young male who had chest pain . So he was admitted to the hospital . He had had a cardiology evaluation. He had a coronary CT scan . It did not show any significant coronary artery disease.He was discharged. He was OK for next 2 or 3 months and then he was having cough. The PCP treated him with different medicines . When he did not get better, he had new chest X-ray. The X-ray showed fluid around the left lung. So a CT scan was ordered and he was referred to me . He had large fluid collection around his left lung.When I looked at his old CT scan , he had tiny fluid on left .I took out mare than 1200 ml of fluid and it came back in less than 10 days . So we consulted a surgeon . He had surgery to look inside his chest and insert a catheter to drain fluid. The catheter can be left in for long time and we can drain it as needed, may be weekly or daily or whatever is needed.The biopsy turned out to be mesothelioma. The family was very smart and had done their home work . So they wanted to know if surgery was an option. I was not too sure . I knew that there were surgeons who did quite 'extensive' surgery.But was not sure as to the if he was a candidate. I knew the name of a surgeon and I gave it to him and he was also seen by an oncologist. He was started on chemo and had periodic follow up of scans and had drainage of the fluid. Due to tumour , the fluid was not free and we had to change the catheter couple of times . He did OK with the chemo and then was sent to the surgeon. But by now the CT scan showed spread of the cancer to liver . So he was not a surgical candidate. So other than continuing chemotherapy , there was no other choice . When I saw them , the patient and the family , I was surprised to see that they made decision to go with Hospice . In my mind this was the 'right; choice ,but was not too sure if they would ever consider Hospice , or ;giving up'. But I knew they knew when to "HOLD " and knew when to "FOLD". 

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