Different measures of treatment

It was a black Monday for the family of my lung cancer patient, Madam Ng.

She had woken up early in the morning gasping for breath and her family called for a private ambulance to take her to see me.

But the estimated response time of the ambulance would be up to an hour.

Her family decided to call 995 for a civil defence ambulance, which by local regulations, cannot take the patient to a private hospital.

Madam Ng landed in a restructured hospital where she was promptly attended to by the emergency room doctor.

At 9am, I received a call from the doctor, who informed me that Madam Ng was very sick.

Her heart was racing at 160 beats per minute and her blood pressure was low.

An X-ray of the chest showed that the heart looked enlarged.

An emergency ultrasound scan of the heart confirmed that there was a large collection of fluid around the heart, squeezing it and preventing it from pumping properly.

The human heart, which is made up of muscle, lies within a sac called the pericardium.

There is usually very little fluid in this space between the sac and the heart.

When the amount of fluid builds up in the space, the heart cannot function properly.

This condition, called cardiac tamponade, is a medical emergency. If the fluid is not drained in time, the patient can collapse from heart failure.

‘The family would like me to consult you before I proceed to drain the fluid,’ the doctor said.

I agreed that he should go ahead, as drainage of the fluid would almost certainly give the patient instant relief.

Some time later that morning, I received a call from another doctor, who was looking after Madam Ng in the intensive care unit.

‘Your patient is still very sick. She has been seen by the cardiothoracic surgeon who advised a pericardial window,’ she explained.

This is a surgical procedure that creates a ‘window’ that allows the fluid to drain from the heart into the chest cavity, where it would not cause so much harm.

I was rather confused. Didn’t the patient just have a pericardial tap in the emergency room?

In this procedure, a needle or catheter is inserted into the pericardial sac to remove fluid.

Why was there still water surrounding the patient’s heart?

As it turned out, she did have the tap but only 55ml of fluid had been taken out.

This appeared to be a rather small amount so I suggested that the patient be referred to an interventional radiologist, for more pericardial fluid to be drained and for this to be done under direct imaging of a computed tomography (CT) scan.

This procedure would be less risky, considering that she was so ill.

My comments were duly noted by the doctor at the other end of the line.

But the family did not agree to the pericardial window as the patient was very ill.

At 8pm the same day, her son called me.

‘My mum is very breathless and I think she is going to die,’ he wailed on the phone.

There was really nothing I could do except offer to arrange for Madam Ng to be transferred back to Mount Elizabeth Hospital.

After a brief consultation with the family, her son called back to confirm the decision to activate the transfer.

I called my friend, Dr Winston Jong, a senior anaesthetist who practically runs the hospital’s intensive care unit, and asked him to organise the transfer.

I briefed him that the patient was critically ill and that she should be brought directly to the CT scan room, upon arrival.

In the meantime, I alerted Dr Peter Goh, the interventional radiologist, to be on stand-by for the patient’s arrival at about 10pm.

The ambulance pulled into the reception bay at 9.50pm and Madam Ng was on the CT scan table soon after.

Under CT guidance, a catheter was safely inserted into the pericardial cavity to drain the fluid. Within minutes, 400ml of fluid flowed into the collection bag. More fluid drained out over the next few hours.

I walked into the intensive care at 10.15pm and saw the patient propped up in bed and beaming from ear to ear.

‘I’m hungry,’ she announced. ‘When can I eat?’

I grinned back at her.

The family members were relieved but inwardly indignant that Madam Ng had suffered from a day of breathlessness when the procedure to relieve it took less than an hour.

How could this have happened? There are no easy answers.

Treatment delays can occur anywhere.

It is a question of availability of resources and how actively the attending doctor ‘pushes’ for patients in critical condition to have priority.

The doctors I had spoken to on the phone were trained and well-qualified; they cannot be faulted medically.

But patients and their families want more.

They expect doctors to give 100 per cent for their mother, to make sure that doctors treat her as they would their own mother.

It may not be realistic, but the son, the husband, the father in all of us, we expect it all the same.

This article first appeared in "Mind Your Body", a Straits Times Supplement.