Wednesday, October 24, 2012

Case History : The Good, The Bad, The Ugly.....

What a week !

First I have Ananda Arumugam [ not his real name  ]walking into my clinic after an absence of 6 years. A post infarct patient who lost his job because his boss thought he could no 'longer deliver'. Now a 'boss' himself with twenty or so people depending on him.

Then there is CML, a young Chinese engineer,  just turned 32 year old and just married,  with advance lung cancer complicated by disemminated neoplasm to his pleural cavity [ sac  covering the lung ] resulting in fluid accumulation and partial collapse of both lungs; acute  blockade of his pulmonary circulation [ pulmonary embolism ] due to increased clotting activity [ increased thrombogenicity ]arising from the cancer situation; and if this is already not enough, a very tense and 'compressed heart' due to malignant fluid accumulation in between the heart and it's sac. We termed this 'pericardial effusion leading' to a 'tamponade.
This young man has advance cancer [ stage 4, ie disseminated ] and in real deep 'shit'.

I had to do an emergency evacuation of the malignant accumulated fluid by doing a pericardiocentisis [ pericardial tap] ...[ ]
That was just the beginning of things to come. He needed top notch specialist oncological treatment with the latest chemotherapy regime available. Two days after the pericardial tap, he went into respiratory failure due to the  dual additive effect of pulmonary embolism and his  lung's encroachment by disseminated  cancer. Needed to be actively ventilated to tide over the acute situation while the chemotherapy take its slow effect.
Prognosis ? G. O. K
Statistically speaking,probably two years at best, in the best of centres[ ]. Not great ! But this is the reality of life when you happened to be in a 'deep shit' like this.

Madam GkL, 61  year old Chinese lady arrived at our ER in 'extemis'. She was pulseless and not breathing. The ER Medical Officer noted 'ventricular fibrillaiton' on the EKG meaning she has a 'cardiac arrest'. [ ] The ER  in my hospital is one of the best place to have a cardiac arrest in the whole of KL and PJ! The staff  there are all superb at bringing back people 'who are actually ready to go to the other side' and pull back to 'this side of the realm'. After half an hour of active resuscitation and ventilation, GKL' heart comes back to sinus rthym. She was by now on artificail ventilation and my anaesthetist colleague was in charge of the 'breathing'.

"Sir, you wife has massive acute myocardial infarction and I am bringing her straight to the cath lab now to do an angiogram to look at the blockages and open them up with  balloons and then tacked them up with metal  wire-mesh  which would act as scarfolding, called 'stents'. We have no choice and time is of the is early days now for us to tell the effect of the cardiac arrest on the brain...that we have to assess later.............". One hour later in the wee hours of the morning she came out of the cardiovascular cath  lab with all her blockages opened  and three 'stents' implanted. That took care of the heart. [ ]..The effect of 'hypoxia' [ lack of blood flow, or no flow due to cardiac arrest ] on the brain need to be assessed the next day. Need to give her sometime

On the 3rd hospital day, she is still fully ventilated, brain function assessed by EEG showed minimal activities. Outlook is grim: a long term vegetative state as a possibility was on the card, 99.9 % probability. She has global 'hypoxic encephalopathy', the period of no 'oxygen and no blood flow to the brain' while arriving to hospital was too long. ]

I had a long discussion with her husband. He does not foresee a' vegetative' situation as something that his wife would have liked.

" Doc, you are Muslim and I am also People of the Book. Both of us believe in Him in our very own ways. What do you think I should do?............."

" We have done our utmost best, me as a doctor and you as her husband.....As a Muslim I entirely agree with your plan to bring her home and let God decide...but Sir, things will happen very quickly the moment we wound down her treatment and especially the active ventilation. At the moment she has no ability to breath by herself, the 'signals from the brain are not there' , so to speak..whatever we decide, let your Canada -based son and daughter  arrive at KLIA first tonight and see their mother still alive, after that I will unwind everything....I am not playing God of is just the small things that He allow us to play around know what I would be kinder for your children, in the long run...and I would do that, if you  and your children could come to an agreement all round....".

That is the Good, The Bad and The Ugly  handed to me on my plate this week.

At this juncture in my private and professional life, I wish I could  be involved more in all  my patients' spiritual life due to this feeling of 'mahabbah' for my fellow humans  but societal, medico-ethical considerations and political correctness, does not allow that 'boundary' to be traversed. A pity.....

Innalillah hiwainna ilai hirojiun....From Him we come, to Him we return.

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