Cure or Kill?

My fading years of practice still provides me with patients whose problems test my skills, patience and occasionally my knowledge. Experience gained over 40 years of practice and occasionally sheer serendipity comes to my rescue. The month of December saw me solving two such problems with the help of a combination of the factors told above and I consider them as the best New Year gifts received even before the old year ended.

It is required that I take permission to tell their stories, especially when they are alive and kicking as in these two instances and I have done so and I must thank them for permitting to do so. Let me begin with the first one, Mrs A.
Mrs A is mother in law of a close friend of mine. She is a well built lady in her mid eighties and spends time living for some months with each of her children and for a long time she was my patient until her elder son retired from the army and came to live in this city 5 years ago. Since then she is being cared for in the army hospital and in a private hospital whenever an emergency arose. With another son living abroad money is not an issue that came into the picture as far as care is concerned.

As it often happens with us GPs, patients leave us to what they think or what their children think, for better pastures, which often is true but not in this case as later events proved. Fifteen or so years ago, when she came under my care, she was an obese, hypertensive, seasonal asthmatic and had fairly well compensated heart failure due to leaking heart valves. She was also severely arthritic with painful hips. Averse to any form of regular exercise and fond of food it was no surprise she kept gaining weight and her hip pains only became worse. We took a risk and got one of her hips replaced and the cardiology opinion was that she was a high risk patient and ideally have her heart valves replaced and the surgeon felt it was not worth doing it considering she is being fairly well managed medically as far as her heart failure was concerned.

Four years ago, when she was not under my care she got her other hip replacement done! She had a stormy post operative period but made good recovery and now she has both hips replaced and was pain free. One would have thought she would exercise and get her weight down but as I said earlier she did not and her weight remained as before and when I occasionally saw her socially [as she is my friend’s mother in law] I felt her weight had only increased. Since last one year her health seemed to worsen and she has been in and out of hospitals for one reason or the other.

Six weeks ago, she was taken to a nearby hospital [with corporate ethos] and was admitted as she was complaining of weakness and was short of breath. Given her heart condition the diagnosis was obvious. She was in heart failure due to leaking valves. The cardiology team of that hospital is good and most of them are known to me but as I was not involved in her care I did not personally check with them as to the details of the treatment. What her son in law and my friend told me was that the cardiologist felt her heart failure was under good control and he advised her increased activity and she was discharged home.

This time the home she came to was the daughters. She continued to be unwell and kept telling her relatives that her end is near, so bad was her feeling! One evening, the son in law [my friend] came to my home and asked me to come and have a look at her before they took her back to the hospital.

I went with him to see her. She was lying flat on bed, a slab of pale flesh with deathly pallor. She looked very ill. She had constant feeling of nausea and was off food for the last week and was barely able to keep fluids. She also felt it impossible to even to get up and sit and the daughter was having a hard time nursing her. Quick examination showed her blood pressure under control, but her heart’s beating was irregular. Her feet were swollen and her lungs showed few abnormal sounds suggesting beginnings of fluid accumulation. She complained of discomfort in the pit of her stomach.

I wanted to see her records. The record keeping had stopped in the year 2006 when she was under my care. Rest were all hospital discharge summaries and prescriptions. I saw the latest prescription. This had 9 drugs. One to stabilize the heart, another to remove the fluid from her lungs, yet another to keep her blood pressure under control, a different one to prevent clotting, another to prevent the possible side effects on the stomach because of all these drugs and the usual masala of vitamins.

Digitalis is a time honored drug and has a fascinating history. The plant Foxglove from the leaves of which the steroid glycoside Digoxin was extracted, belongs to the family Sacrophulariaceae, was time honored native medicine in Europe for many centuries. It came to widespread use due to an accidental discovery by the 18th century English physician William Withering. A patient of his was very unwell with Dropsy [old name for fluid accumulation all over the body]. After visiting her, Wuthering came back home leaving her to die, so hopeless was her state. Few days later the patient, now recovered, visited him. The surprised Withering found out that she had consumed a concoction made out of the common garden plant, Foxglove! It to his credit that he published his meticulous observations and extract of foxglove, digitalis, came to be used universally in heart failure patients and has with stood the test of time and is in use even to this day.

This wonder drug however, has one major problem. The margin of safety between the therapeutic dose and the toxic one is thin and if one is not careful the drug can become from a life saver to a life taker!. This is especially true when used in the very young and the very old. The toxicity is on the stomach and worse, on the heart. In the stomach it causes severe gastritis manifested as loss of appetite and severe nausea and on the heart with irregular to very fast beating leading to failure, the very illness for which it is given!

Madam A had classical Digoxin toxicity! The drug was stopped and it took 48 hours for her to eat her first solid meal in three weeks. Her heart’s beating returned to normal and the deathly pallor was replaced by a cheerful expression. She began moving around the third day and was able to walk up and down the stairs of her home. Yesterday she made a long car journey to her other son’s place to a town some 6 hours away!

Mrs A escaped from certain death [if she had continued with digoxin].

This story has taken too much of time. Will do the other one sometime next week.