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Sunday, July 23, 2017

Does medical science believe in miracles?

July 2012: Mr Abdul Rehman Shaikh,  75 year old male was hospitalised in the ICU with sudden paralysis of the right side of the body. A diabetic since 20 years and ischemic heart disease with a poor cardiac function since 10 years, his regular activities had already reduced  due to a poor heart conditioning. And now to increase his morbidity, he had had a stroke, which affected his left or dominant side of the brain. He lost his speech, the power to move his right hand and leg, control over his bladder and bowel movements, but not his power to live. He was discharged after a few days in a bed ridden state with a poor chance of long term survival. 
But the worst was far from over. Within a few days, he was back at the hospital with a gangrene of the foot. The blood supply to the leg was found to be very poor due to long standing diabetes. As a result of this, his left foot had to be amputated. His heart which was already compromised, couldn't take it further, and he suffered a cardiac arrest in the hospital. Due to the resuscitation efforts of the medical personnel, Mr Shaikh did survive, but suffered extensive irreversible damage to his brain. The doctors did manage to get him off the ventilatory support, but he had slipped into a vegetative state for life. He now had a feeding tube,a breathing tracheostomy tube to aid the removal of his tracheal secretions and a urine catheter. He barely opened his eyes, neither responded to anybody's touch nor call, and was mechanically fed by the nurses. The doctors had given up hope completely this time and sent him home with no chances of survival. 

July 2017: 5 years have passed. Every 6 months, he is brought by his daughters to the hospital for a routine physical checkup, a change of tubes, and a battery of investigations. 
The results always amaze the doctors. They find no deterioration in any parameters. The sugars are well controlled, the lungs are breathing normally, the heart is pumping with the same force as before, there is not a trace of a bed sore and not an iota of infection in the urine. Neurologically he may be the same, but we are still hoping for Abdul Rehman Shaikh to get up and talk to us. 

This is not a miracle but a dedicated effort by the near and dear ones to keep the hope alive. On one hand we have sons who ask us on just the second day of ventilatory support, "Doc, should we remove the respirator and take our papa home" and on the other hand we have a certain Mr Shaikh's daughters who despite the doctors giving a 'no chance' certification, have persevered with their efforts. 

*Names have been changed to protect the identity

Tuesday, June 27, 2017

Dialysis: A life saving machine

A 70 year old diabetic lady, hitherto active and leading a normal lifestyle, is admitted in the Intensive care with sudden difficulty in breathing since 2 days. After running a few tests, she is diagnosed with Acute kidney failure because of an infection in her urine. She has been advised an urgent lifesaving dialysis but her relatives outright refuse to go ahead with it. Their concern is that once started, she would require dialysis on a regular and lifelong basis. 
To convince someone for dialysis remains one of the commonest challenges faced by Internists and Nephrologists. In a country where quacks sometimes decide the course of medical therapy, where pharmacists prescribe scheduled drugs and where relatives are in charge of the fate of patients, saving lives is becoming more and more difficult. 
What is dialysis? Simply put, it is an artificial kidney. Our kidneys normally function to remove the waste products through the urine. When there is a kidney failure, dialysis takes up the function of the natural kidney and cleanses the body with the help of a machine. 
Broadly put, our kidneys may fail in 2 ways: 
1. The healthy kidneys stop working suddenly due to a recent crisis event. 
2. The kidneys are gradually damaged over a long period of time. The body adjusts to this and maintains its milieu till a crisis develops and the kidneys fail.
It is important to note that kidney failure occurs only when both kidneys fail to function. In both the above situations, dialysis may need to be done for the reasons mentioned above. Also, dialysis doesn't help in kidney recovery but it just substitutes for the failed kidneys. But, it needs to be emphasised here that in the first case, since the kidneys were healthy prior to the illness, dialysis is only for a short period of time while in the second case, dialysis could probably be a lifelong affair.                              That brings us to a few important questions. Shouldn't saving a life be the topmost worry on the minds of the near and dear ones rather than worrying about whether the dialysis will be a lifetime headache? Don't the relatives have any responsibility ethically and legally towards the patient? Is only the doctor answerable for a wrong decision taken for a patient? 

And in our 70 yr patient, who eventually died because she was denied a chance to live, can the relatives be tried in court for negligence and malpractice??