Friday, June 19, 2020


  There is a saying that stitch in time saves none. If one does things in time then one does not have to worry about getting things worse. The saying is is related to clothes  but it also applies to our every action and every decision that we make or action that we do . It may be diabetes  and eating sugars or blood pressure  and salt intake. . If we do not do action in time  and the diabetes or blood pressure gets worse  and has complications , then acting in right way will not help us as much as if we would have taken precautions early. I have seen this in many patients and that brings me to today.s patient.
    I saw this patient who was 78 years old  and had some dementia . He came with family  and i could not figure out why he came to me . He had some abnormality , He was in hospital and he had pain the belly. He had CT scan of the belly done  and that showed some abnormality in lung and so had CT scan of the chest done  and that showed a very tiny nodule. He had seen primary care doctor  and he sent him to me . He had also seen Gastroenterology  and he was planning to do endoscopies . I had no reports  and I got them  and I was surprised He had very tiny nodule in lung  but had a mass in pancreas  and also in liver . The patient of the family did not know about it  and they were surprised . I explained it to them that he seems to have cancer that seems to have spread to liver and may be lung . The endoscopies will not help but he needs diagnosis of cancer by biopsy  and then we can decide as to the treatment . The Lung nodule was too small  and there was no way anybody could do biopsy of the nodule. So I decided to do the PET scan to know the extent of the cancer and scheduled him to have biopsy of the Liver
  He had the biopsy and that did confirm the diagnosis of cancer He had pancreatic cancer  and the biopsy did show that liver spread was confirmed . I saw them in office  and told them the diagnosis  and the treatment options of chemo . I also told them on chemotherapy and the side effects  and the 'prognosis' . I told them that the pancreatic cancer with spread to liver is not good news They decided to go ahead with chemo. I had told them to consider future choices  and also the poor prognosis  and DNR or Do Not Resuscitate status . Thew were not sure.
    He was admitted  in hospital  and he had received chemo and the blood counts were low . He had some pain and that was due to enlarging Liver metastasis.He was given pain medications  and that caused more confusion and I again talked to the familyb. I told them that in spite of treatment he was not doing well and the cancer had increased and they need to see the oncologist  and see they could consider radiation which has less side effects  and may be do no treatment ts .We also talked about the DNR .
    He was discharge  and then was readmitted  and it happened . I had expected it. He had cardiac arrest and they did CPR  and he had to be put on respirator  and also had rib fractures  and collapse of lung and had to have tube put in chest to re expand the lung. We had the discussion and they agrees after 3 days to make him partial DNR . Now the decision had to made to withdraw the machine - respirator . That was much more traumatic to his wife  and sons . But once someone is on respirator , we can not withdraw without doing the forms for withdrawal of LIFE SUPPORTS .
THIS IS I CALL STITCH IN TIME . If they had made the decision in advanced for DNR, we would ot have gone through he suffering for patient - the tubes , rib fractures, chest tube  and also the family to make the withdrawal decision . . 

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