I have known practical problem in every field and then sometimes there are solutions and sometimes there are none. I remember of a joke where the Government officer is asking for the proof of being alive ,before approving the passion, when the person is standing in front of him, And the height of stupidity in following the rules is that he makes a statement that ;you have the certificate fir this year ,but where is the one for last year?' In medicine that problem is similar, That brings me to the story for today.
I had known this lady for long time .She was more than 90 year sold now and she had history of breast cancer. She also had sleep apnea and she was on PAP positive -airway -pressure mask for that. She also had asthma .She had some problem and so had chest X-ray and that showed a density . So we did CT scan and she had a nodule . A nodule is something which is density less than 2.5 cm. The cancer specialist were called in and I was also called in The cancer specialist wanted to do needle biopsy to get the diagnosis -as to if it was cancer and if it was , what kind so they could treat her. I had known her and so I talked to her and asked her if she ever would consider surgery or chemotherapy? She said no. The small nodules when PET scan is positive , we consider surgery , as that is the best treatment for cancer. In her case we did PET SCAN and that did show uptake in the nodule and so it was most likely to be cancer. So then I suggested short course of radiation -pin point radiation- called stereotactic radiation . This is done in 5 days and the cure rate is good .She agreed .
I thought we are done .She did OK for few months and then she had cough and shortness of breath and the X- ray showed fluid around her lungs . So she had that taken out and that showed cells of lung cancer. So she had lung cancer that had spread to pleura - covering of the lungs. Now the question was what should we do about the fluid . In patients with cancer the fluid tends to come back . So I suggested putting in a catheter that can stay for up to a year and we can drain fluid periodically, at home with a vacuum bottle and she does not need to have procedure done over and over again. She agreed and we did the catheter. We arranged for a nurse to help her and she was sent home.
The problem started after the discharge . She lived alone and was 93 years old. The Medicare denied to pat for the nurse to come to her place and drain the fluid . Normally we have family members who can do this job ,But here she had no one at home and the friends that she had were also older. I had sever calls from her and her relatives who were out of state. I called social service and case managers at the hospital and could not get any way to approve the nurse going there. Finally someone suggested getting Hospice to help . Certainly she would qualify - she had lung cancer and the fluid was related to that and she was 93 years old and no chemo was planned and her life expectancy was limited . So she was perfect candidate for the Hospice service .She did not want to be with Hospice , but we had no choice .
This is practicle problem in Medicine.
