Saturday, May 9, 2015


    When I was growing up , I used to read a children's magazine ,called 'Chandoba' or 'Chandamama'. It was published in several languages. In those days there was no TV nor was video games and this was great. There is used to be a very popular story, called VETAL. As this magazine was Indian, the characters were Indian . We had famous king called Vikram and he was known for his generosity and intellect. In the story the King was asked by some Yogi to go to cemetery and bring back a dead body. The condition was that he can not say a word while doing this . In one of the stories that I remember, the king goes and picks up the body and the   or the VETAL starts talking. He tells him a story. At the end of the story ,he would ask a question and the king has to answer if he knew. If he does not answer then his head would explode. In the one of the stories , one of the laddie's brother has cut his head and her husband also had cut his head in a temple. The lady goes there and then the Goddess is pleased and tells her to put the head back on the torso and then thew will come to life again . By mistake she puts the head of brother on the torso of the brother and the head of brother on the body of husband . The question was who is her husband and and who is her brother. The VIKRAM has to answer as he knew the answer. He tells that the head is more important than the body , so the body that has head of husband is the husband. You must be wondering as to where am I going with this . I have in my medical life seen many occasions where this is so true. So let me tell you one of those stories .
       The first time I saw this patient , was when he was admitted to another hospital and was transferred to our hospital . He was a 70 or so years old male from South Africa , but was Indian looking and spoke one of the Indian languages . He was a smoker and had heart surgery and still continued to smoke . He had pneumonia and got very short of breath and so had to be put on respirator and then was sent to our hospital and I started seeing him. He was quite sick and I was not sure if he would survive. He ha congestive heart failure and COPD and pneumonia and anemia and some kidney issues. It took mare than 2 weeks to get him off the respirator. He was discharged and then saw me in the office . Over period of next 2 years he continued to see me and was hospitalised few times . Sometimes for congestive heart failure and sometimes for COPD . He also continued to have low blood counts and was worked up by gastroenterologist. He continued to smoke and needed oxygen , which he was reluctant to use as it meant he can't smoke. He was short of breath on walking . The heart problem and the low blood count contributed to it. He needed blood transfusions . He then decided to go to Mayo clinic to do some special procedure. And then the news came . He had bone marrow disease diagnosed in which the marrow does not make any blood cells . All our blood cells are made in bone marrow and in a disease called MDS the marrow function goes down and so the blood cells , white cells, red cells and platelets all of them are reduced . Reduced white cells make patient more susceptible to infection. Low platelets cause problem with clotting and make more prone to bleeding and red cells cause anemia and can cause shortness of breath. He was started on chemotherapy.
       He continued to get weaker had pneumonia and could not walk even 10 feet. He needed some transfusion , either red cells or platelets almost on daily basis. I talked to him and his family on daily basis . I knew the prognosis. In this 75 years old patient with weak heart , oxygen dependent COPD, and now blood count issues , the out come was poor . I wanted to see if they would agree for DNR, not to put on artificial support or  resuscitate. In spite of my several discussions they did not agree.
     Then one day it happened . He became unresponsive at about 8am . So a 'stat' CT scan of brain was done . It showed that he had bleeding in the brain. So a neurosurgeon was consulted. I saw him at 10 am. There were several family members present . I told them the poor prognosis .And to my surprise , thew wanted DNR and wanted Hospice consulted. Their plan was to take him 'home'and then withdraw the respirator, and let him go.
      So here is my point. Every other organ malfunction , heart , lungs , bone marrow, or kidney -could not convince them to make him DNR , But once the brain was gone , they wanted things ended in next few hours.

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