Sunday, January 31, 2016


    We often say that something could go wrong , it could (Thank God not'' it will" ) But sometimes in medicine it is so true. I have seen and heard about the stories , which are sometimes referred as 'train wreck'. And I have personally seen them too . But sometimes the complications or what happens is helpful in making certain decisions . Just to give an example would be patient who has borderline pulmonary reserve to have lung surgery to take out a cancerous growth. Then he may have a scan showing spread or a appearance of skin lesion that terns out to be spread of the cancer.So now the decision is clear . Due to spread of the cancer , he is not surgical candidate . And it is also helpful to patient as well . If such a patient would undergo surgery and does not do well due to poor pulmonary reserve , and then develops spread, we would be more unhappy. Instead if we make decision to not operate we at least have quality of life . But the uncertainty in medicine is disappointing and at times frustrating. This is so true with one of my patients that I saw.

    So I saw this 70 some years old patient who came to hospital with generalized weakness. She was found to have low blood count . Her white cell count , red cell count or the hemoglobin and the platelet , which help in clotting , were all low . She was told few years ago that she had problem with the counts. But it got better and so she stopped going to the blood specialist . The counts continued to be OK for about 2 years and now she was in the hospital . She had low blood oxygen , so I saw her . I did CT scan and it showed some fluid around her lungs . So I did ultrasound of the heart and it was normal . She was worked up and found to have MDS , I this condition the bone marrow , which is the factory for all the blood cells , stops making them. She was started on treatment to improve the counts . I treated her for the low oxygen and with the treatment she got off the oxygen and her fluid got better. But the counts continued to be low . So she was given transfusions. I had talked to the family and the patient , telling them the poor prognosis. But as it often happens, unless this information comes from every doctor including the blood doctor, it will not have the effect .And then one night I got a call . She had difficulty breathing and her oxygen dropped She needed to be transferred to ICU . In next 6 to 8 hours it was clear that she had heart attack and she was in shock due to poor heart function. She was also confused and agitated. I am not sure why. But any way once the heart attack and it's side effects were seen, it was easy to make decision I had the discussion with the family and with her MDS and now the heart attack , we decided to do the comfort care. The MDS which had not gotten better and in itself carried poor outcome , was not enough to make decision . But now an unexpected heart attack made it easier to make decision .  

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