Wednesday, December 4, 2019

A friend and his illness
It was on 28th of august 2014 this incident took place. My close friend who lives nearby, Mr N dropped in to show his blood reports and the chest X Ray. As it was in the afternoon, he came to the main door of the house. There were two friends of mine sitting in the drawing room. Mr N also knew these two persons. On seeing them, instead of recognising and wishing, ' he gave them a vacant stupid looking smile' One of the friends asked him,' how are you? He replied,looking at me instead of that friend,'doctor'

I knew then something was amiss, that this is not normal behaviour. Took him to my examination room and asked him.'you know who those two are? He again gave me a vacant smile and obviously was at a loss.

He suffers from periodic mild episodes of bronchospasm and responds well to inhaled combination of bronchodilators and steroids. He had come two days before and as there was slight fever in addition to the wheeze, I was thinking of stating an antibiotic, but before that to make sure it was  not bacterial infection, I had asked for the tests which he had now come to show. He looked unwell and a quick check of his lungs showed wide spread sounds and he continues to have fever. This plus his odd behaviour led me to diagnose delirium due to lung infection despite fairly normal Xray and blood picture.

This was indeed an emergency and I rushed him to the hospital after getting in touch with Dr R who was the head of one of the medical units. He assured me that the resident at the emergency will take care of the patient. In the emergency  the work was fast and furious. The bedside PO2 showed level of 56 and the ECG was bizarre. This with the rattling chest in a 70 plus year old, the first thought was that he is in acute heart failure and my telling the young resident that he has this LBBB ECG pattern for many years did not convince him [I don't blame him one bit]. He went ahead and ordered the necessary tests, the results of which showed sodium levels of 120 and normal cardiac enzymes.
Now the doctors were convinced that this is no heart attack but an acute lung infection with spasm and electrolyte disturbance. Appropriate measures were instituted and naturally he was admitted in the ICU.

Now another drama began. I got a call from my friend at 10 pm that night. He said.'doc, am i going to die?'
I asked him why does he think so?
He said, ''they have put me in the ICU and the patient in the next bed has died just now''
''Didn't the doctor tell you what your problem is?''
He said, ''one young doctor told me that I have lung infection and electrolysis''
He meant electrolyte abnormality.
It took me fifteen minutes to explain what the problem is and why he is not going to die'

His last request was for me to use my influence and get him out of the deathly ICU.
After taking this promise from me thankfully he hung up.

Next day, my friend Dr R could only talk to me late afternoon when he could find some time. I told him my friend's request. He said, ''your friend though beter is not responding to inhaled steroids given through nebuliser also. I have started him on IV antibiotics and he needs to be in the intensive care for a few more days. I will shift him to the semi ICU as soon as possible where he will be more comfortable.

I thought I saw the end of my friend's problem. But I was mistaken. A call from him two days later. One problem with cell phone is that it's easy accessibility. He said, ''doc they are still keeping me here in this different ICU, and have not shifted me to the ward. Here too there are very sick patients. Next to me is one of them, he coughs non stop.I am afraid I will end up getting another and more serious disease if I continue to be here. '

His concerns were genuine and I told him I will look into this.

The problem we GPs face when a patient of ours get admitted to the hospital, is communicating and following up with the consultant concerned. Many hospital have this ladder of hierarchy and the junior doctors bear the brunt of routine work and they generally cannot give accurate information and even if they do, they cannot often take decisions like this one shifting from semi ICU to the ward. Again I waited for my friend Dr R to return my call..

I had to wait till late evening to get his call. I told him the problem. He up dated me like this,''I had to begin oral steroids and Mr N's diabetes has gotten out of control and now I am struggling with his infection, asthma and diabetes. You please advice him to put up with the discomfort for two more days and I will shift him to a room''.

I called my friend next morning and asked him, How are you? He said,'' they want me to be in this place for two more days, they have put a mobile screen around my bed now'' Hope this will protect me from getting infected'' I couldn't help but laugh, usually such screens are put around the bed of a very seriously sick patients so that the other occupants need not witness the gory scenes that some times occur in these ICU wards. In my friend's case it is the reverse so that he need not see the others's serious condition. That much credit for my influence.

He duly recovered and came home.

He has had three similar episodes and the last one was three weeks back. But fortunately not that serious as the first one, all the same needing oral steroids,antibiotics,worsening of diabetes and use of insulin. At the time of writing I have taken him off insulin and have tapered his prednisolone to 5 mgs a day and put him back on old dose of metformin.

A pulmonology consult last year was of no help. Looking for any pre existing cause also showed no results. His IgE levels are normal and his lung function is near normal

why does he gets these in this characteristic pattern, remains an enigma.

And when he falls ill, I feel it would have been better that I fell ill instead! because of the tension I go through.

Taking unbiased care of close friends and relatives is always  difficult. The worse thing is that, they don't know this and will not allow us to get some one else to take care of them.

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