Thursday, December 25, 2014


    Often in life we make decisions based on our previous experience .This is called Intelligence. So if we deduct based on our previous experience , then that is actually anything special, but when we act based on his experience , we think we are intelligent. If I have been burned with fire (which looks red ) , next time when we see something similar to the fire that we had seen ,then we deduct that it is fire and do not touch it.But it may be one of those 'fake' fire , that is seen in fake fire places. So then we are wrong . But when this happens in our regular life it may not be that bad. But when that happens in medical field , it may not be that benign.But unfortunately there is no 100% in life or for that matter in medicines . That is the reason same blood pressure medicine works differently in two different patients . But this is not that bad . When we talk about Life and Death , then it it very very important that we are correct as much as close to 100% as possible. Recently I had a patient that this holds so true.
     I have been seeing this patient who is relatively young. He is may be mid 40es. He has some developmental problems and some other diseases, but the reason that he is seeing my is for the lung problems. He had pulmonary fibrosis .I saw him may be 4 years ago or so. He is also obese and had dry cough. I did the CT scan and the pulmonary function tests and check on oxygen . His condition was bad . He needed to be put on oxygen and I tried steroids.I also treated his cough. He was put on oxygen. I tried to refer him to transplant centers, but due to multiple reasons , he was not accepted.So I continued to treat.He also had elevated pressure in the lung circuit, called pulmonary hypertension. So I started treating him for that.He has been doing well till earlier part of the year.But then he started having problem. He was admitted to the hospital and had pneumonia. His oxygen need went up and it was high enough that can not be provided at the home . I spoke to his mother, who is his POA, and told her that she needs to consider DNR status. But no decision was made and he got better. I discharged him on 6L oxygen .He would drop oxygen level to a critical level in less than 10 seconds if oxygen was stopped.But he was better than in the hospital , when he needed 40 and 50 L oxygen. But he was better at home . In next month or so he was readmitted . This time he had to be in the ICU. I had hard time getting oxygen up. He needed to be on pressurised mask and when it was taken off he would bottom down on his oxygen.I was successful in cutting down on his pressurised mask to high flow oxygen . But over period of next 10 days I was not in position to cut it down much from 40 L.I spoke to him and his family . I told them that not much could be done In my (educated) mind , his scar tissues were getting worse and not much could be done .No decision on DR was made. I ended up getting him to a special facility as this high rate of oxygen flow can not be provided at home or rehab. centers or any other place  other than hospital like facility. He looked OK but I had seen this type of patients in the past , who look OK , but don't get better and either end up on respirator or die. So I was not very hopeful.
    But in a 4weeks or so I saw him in my office, I was surprised . He was on 8L oxygen and he was running low oxygen ,when he walked , but then he was OK with 6 L.I decided to start him one new drug. He came with his mother and I talked to her about poor prognosis,but no decision was made. He was readmitted and not as bad as before . He needed 10 L oxygen . I have continued to talk to them on the prognosis and he was discharged this time on 6L oxygen . So in my experience he should not have done well 6 months ago , but he did and he is OK for now . So sometimes there are exception to the rules and our 'intellegence' may not be the most correct thing.
    The mother knew about the poor prognosis and still had /has the hope . I was basing my decision on my experience and felt desperate, when no decisions were made . I think the jury is still out.   

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