TO EARLY TOO LATE

    We often have situations when we are told that one is too early or too late. Many a time when the diagnosis of cancer is done , we sometimes have to say it is too late. But sometimes I h seen patients, I have to say either too early or too late. I have recently 3-4 patients that this has happened  and the problem is that it is not anybody's fault. If there is some it is bad luck . 

      I had seen this patient for last few years . When I saw him for the first he was smoker and he had quit.. He had exertional shortness of breath and he came to me  and he had COPD. the lung disease that is caused by smoking . By then he had quit smoking for few years  and so i did the work up. He had the  medications started  and I did do a CT SCAN  and he had a bleb or bullous. The damage to lung tissue can cause  a blister or like a grape area which has not much going to that area  and that causes problem. If it is larger then it can press on normal lung tissue  and that can lead to more shortness of breath. So the CT scan did confirm a larger bleb and I thought that if we can get it cut , it would help the remaining lung to expand  and that may help the breathing problem. Certainly there  was a risk in surgery  and it may not help also. But if that bleb would rupture, it would cause collapse of the lung and more issues which would have to be dealt as emergency.He wanted to get a second opinion and so he went to Mayo clinic  and they did agree that that needed to be taken care  and they also found out some opening in the septum of the heart's upper chamber  and they felt that that needed to be  closed  and so they did that and then he had the bullectomy. He did very well and the shortness of the breath was better. He continued to work and saw me periodically.

        About 3 years ago, he started having problem and then we did additional work up . He  had new tests  and his breathing test was getting worse  and that decline was noted  and so I did adjust the medications  and he had also gained some weight and so i also did the sleep study and also asked him to see cardiologist. He had sleep apnea  and he was started on CPAP  and he did better . He also joined gym and some diet and did better. The cardiology work up was OK  and he lost some weight and was doing better. He was also sent to Lung Transplant evaluation and they felt he was bad but not bad enough to have lung transplant and so they decided to watch him . For last 6 months or more he had done follow up with me  and also heart doctor and also lung transplant . He continued to get worse  and then my work up showed some infections  and so we did treat him . I had done few CT scans  and did also bronchoscopies . The some of the unusual infections were treated by Infection specialist  and that was going on for 6-8 months  and he continued to be followed by all of us. He was felt to be a candidate for transplant , but may be little too early  and so he was just followed up. 

    He continued to have good  and bad days  and i saw him few times  and then I received a note from transplant doctor . The note stated that he had cardiac problem and taking it to account his age  and cardiac problem and other issues he will not be a good candidate for transplant and they were closing the file . I had not seen him recently and so I  called him  and came to know that he was in the hospital where I do  not go. So I pulled up his hospital records. He had more shortness of breath  and he saw cardiologist and they admitted him for high heart rate . They did the work up and his heart had worsened  and he had weak heart muscles  and they did start him on medications. He decided to see Mayo clinic  and they sent me a letter that he had too many problems including getting old  and he will not be good candidate for transplant . 

   So 3-4 years ago he was a good candidate but it was little too early , now he is not a good candidate as it is too late. I have seen this happen too many times I will write about other patients next time.