You only die once

Chapter 3B A mystery that must be solved

Chapter 3B

A mystery that must be solved

A very good doctor friend related this story to me. This happened in his busy oncology practice. He was different from other oncologists I am familiar with. He was old-school. Sort of jack-of-all-trades type. Trained locally in a less developed country. He told me that he always remembered a nice small poster that was on the door of one of his colleagues. It read, "We have done so much with so little, so we can do everything with nothing." I always reflect on this. It means that expectations are way beyond what is possible.

He was called to Casualty at about 9 am. One of his patients had been brought in in a very distressed state with severe breathing problems. She could hardly talk. A relative was with her and related her story. She had been well since her last chemotherapy session more than a month ago. Her last check up a week ago was all good. Nothing was amiss. She had gone to bed and woke up fine that morning. She had her breakfast as she normally would at 7 am without anything untoward. At 7.30 am, she felt unwell and feverish. At 8 am, she started feeling breathless and it got worse as she was driven to the hospital.

When he examined her, she was on maximum oxygen support with a mask at 15 litres per minute. She was breathing 30 breaths per minute. Her oxygen level was 85% (normal is 95% and above). She was sweating profusely with a temperature of 39 degrees Celsius. Her lungs were filled with crackles, indicating that her lungs were filled with 'water'. This made it difficult for her to breathe, almost like drowning in your own liquid. The cardiologist, respiratory physician, and later, even the infectious disease consultant was called in. A fellow oncologist was consulted as a second opinion. Her ECG did not indicate a heart attack, yet her heart function was bad with less than 25% function left on the Echocardiogram. Her chest X-ray was near white out. (Normally, the lungs would be mostly black indicating air. When it is white, it means there is liquid or something solid denser than air present, blocking the X-rays from passing through.)

What was wrong with her? It just didn't fit any picture. Her heart suddenly failed but it was not a heart attack. An infection? So fast? Almost unheard of. Related to her treatment for breast cancer? Possible? But if this was a reaction, it would have occurred when the medication was still in her system. Her last treatment was a month ago. An allergic reaction? To what? Affecting her lungs and heart so suddenly? Poisoning? No one else was sick. The family all had the same breakfast. Only she was sick. Nothing fit. A mystery. But her life depended on solving the mystery.

The good doctor talked to her family. By that time, she was already in the Intensive Care Unit. A ventilator was being set up. He told them there was no real answer as to what had happened. She had been put on antibiotics, antiviral, and heart failure medication. Other medications to support her were at the maximum. They would have to put her on a ventilator and life support. Exactly what had happened was still uncertain. It was 10 am.

In the mist of all the sobbing, they requested the very best for her. Continue treatment no matter what. She had chosen to treat her breast cancer and was doing well. She knew there was no guarantee with treatment. But at that crucial moment, she had no choice. The doctor was alone in needing to make a decision for her. How to treat her?

She was put on life support and despite ventilation at maximum, her oxygenation was just at borderline to sustain life. She was in absolute dire straits. She could collapse at any moment. His fellow colleagues sharing in her care concurred with the grim prognosis.

He had to chance it. She was at death's door. He expressed it as 'only a few strands of hair are seen'. He gave her a whopping dose of steroids. The highest ever dose that we use in severe reactions. It could worsen her condition if she had a bad infection. It would have untoward side effects. But in his mind when 'only a few strands of hair are left', he didn't have a choice.

To most nurses and the doctors, it was like Lazarus. Within hours, at 3 pm, she was more stable. Within a day, her lungs started to clear and her oxygenation improved. She survived and was actually discharged after a week. Three years later, she continues to come for her three monthly visits completely well.

What happened? To this day, he said he does not know the actual truth. No one will.

He had postulated that nothing would be so fast unless it was a marked immune response. There has to be a trigger. With fever as the starting symptom, he postulated it was a viral infection of some sort. She had finished her treatment about a month ago. That may have left her system primed for an abnormal reaction, like a recall. Thus, her body mounted a massive reaction to fight an infection that would likely be mild to any other person. How sure can he be? Nope, he was not sure. In his own account, when 'strands of hair are all that is left', there isn't a choice. Is there?

In life, we like to have choices and to make decisions. However, there are times we cannot. We can only trust those who make them for us. Our parents make decisions for us when we are children. Teachers, politicians, and law enforcers make decisions for us, though we don't really think about it.

A Nobel Prize winner for medicine (for cancer research) was on CNN being interviewed. He was asked, "Your father is a doctor, physician. Why didn't you follow in his footsteps?"

His answer was serious and true and yet so apt. "My father has to be right all the time. If he is wrong, people might die. In research, you mostly fail and once in a while, you are right."

In medicine, science is only as good as it is. What we know today is more than yesterday. But what we want to know in medicine is like what we want to know about the universe and yet we only know basically very, very, very little. Yet life and death decisions are made in an instant, sometimes to save a life.

If she had died, would he be sued? Deregistered for acting on a hunch? Today, life has changed. The 'Americanised' way of thinking. Protocols, SOPs, no deviation. Protect the system, the establishment, yet coin the term 'corporate social responsibility' (means get advertisement by spending the money you get from others and use the poor souls who are begging). (I will come back to this in a later Chapter.)

Like my good doctor friend, I do believe that as long as we are doing things for the sake and betterment of the patient (and at times the family), we have to do what we think is right and "God help us all".

P.S.: His expression of 'a few strands of hair are left' puzzled me. So, one day I cornered him and he explained, "Imagine someone buried alive and all you can see is the few strands of hair. You pull on those few strands hoping you can pull him out of the earth." 🤔Hmmm. Rather dramatic thinking...

References:

Immune checkpoint inhibitors win the 2018 Nobel Prize. Biomed J. 2019 Oct; 42(5): 299–306.

https://en/wikipedia.org/wiki/James_P_Allison

Thank you for reading till this far. Much appreciated. Hope you have enjoyed the ride so far. Everyday I will post a new chapter. Many have asked me to quicken it. Will check the chapters and posts as fast as I can. Still got a day job. Chapter 4 will be here tomorrow.  🙏🏼