You only die once

Chapter 1B A chance

Chapter 1B

A chance

I reflect on my patients all the time. It tends to consume me and it surely isn't great for the 'soul'. The odd thing is I rarely reflect on my patients who sail through their treatments. I reflect on the ones who nearly died and the ones who had died. Certainly not good for the 'soul'.

When is a decision right? When is a decision wrong? Is there even a right decision?

With 20 or more years in my practice as a haematologist and oncologist, I guess I am in some position to talk on this topic, especially after my life and death situations (many more to relate in the next chapters).

Just a year ago, one of my patients was in worse dire straits than me. He had leukaemia and we were deep into treatment already, nine months to be exact. He was already in remission (no sign of the leukaemia) but he could relapse anytime (the leukaemia returns). As such, we continued to treat him with cytotoxic chemotherapy. It has been shown as a group of patients, it is advantageous to continue therapy and it would improve the cure rate.

So, he had his seventh course of therapy. Unfortunately, he had a bout of fever and was admitted a week later. This was November two years ago (Covid-19 started one month later in China). His chest X-ray showed a small area of opacity, indicating infection. He was comfortable and breathing normally. We started the usual antibiotics. A repeat CXR two days later showed deterioration although he was still feeling well. By Day 4, his CXR had worsened a lot more and he needed supplemental oxygen. At that juncture, I pushed all the panic buttons. Maximum antibiotic cover, even antiviral. Respiratory and Infectious Disease consultants were called in. By Day 6, he was on a ventilator helping him to breathe, with numerous medications and devices attached. He was really in bad shape.

By Day 14, he was on maximum support. (Well actually above maximum as we had gone beyond the recommended maximum.) There was nothing more we could do. I saw him many times a day, making minute adjustments and hoping it would change the outcome. His family was warned that his survival was next to none.

Most of the times at a juncture like this, we would throw in the towel. But, despite his severe lung infection, his other systems were fairly untouched. He needed loads of sedation just to keep him quiet enough in order to be able to ventilate his lungs. His liver and kidneys were perfect. (We never caught a bug and assumed it was viral. If he had gotten sick two months later, we would probably have called it Covid-19. None of us treating him got sick without much precautions, so he didn't have Covid-19, I would assume.) I wasn't willing to throw in the towel yet.

Another week, little changed. Then he showed signs of improvement coming into the third week. Gradually, he improved over the next two months. Then another event occurred.

As unpredictable as life itself, as I walked into his room, he suddenly experienced desaturation (oxygen level fell drastically) and almost arrested. Code blue had to be initiated. We extubated and reintubated him. Apparently, the endotracheal tube was blocked with secretions. The physiotherapist had just attended to him and possibly loosened thick secretions that blocked his tube. He nearly died again.

In a week, he was extubated and could breathe on his own with supplemental oxygen. After being in ICU for three months and in the ward for another month, he was discharged. With the lung changes on X-ray and scans, we were really uncertain if he would recover fully. A year later, he can exercise for an hour every morning. (I can't even do that myself.) He seemed to have fully recovered. His leukaemia has remained in remission.

A miracle? God's intervention? Good medication? Why when we try hard, do many still succumb? Why did he live? Answers we do not have.

All I know is that when we quote chances of survival, it is for a group of patients with similar conditions (similar, not exact conditions). If you are quoted a chance of 10%, you would think death is inevitable. But in reality, we don't know for an individual. Why do the 1 in 10 survive?

He is the one in 10 or 100 that survived.

If you are quoted 80% chance of survival, cure, or remission, the same applies. Why do 2 in 10 not do well? Science and medicine are imperfect because what we need to know is much more than what we know. I caution my patients that if you fall into the 2 of 10, then you would not do well. This is really how it is. LIFE.