utilazation of medical resources and ethics
TRANSCRIPT
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To Treat or not to treat?
A health care reform debate
J. Alberto Martinez, M.D.
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Case presentation.
HistoryRS is an 85 Y.O. male referred emergently by an ophthalmologist for a severe corneal ulcer, left eye.
CC: Seven day history of decreased vision and discharge, left eye. Denies pain.
Patient is on his last few radiation treatments for throat cancer.
Mr. RS lives with a septuagenarian couple who are his friends and help take care of him.
Patient still smokes ½ pack of cigarrettes per day
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EXAMFragile, cachectic male able to ambulate slowly.
Able to cooperate, slowly, grumpily.
VA: OD: sc 20/25 OS: sc: HM
Poor blink OU
Normal anterior segment OD, well centered IOL
OS: Massive corneal infiltrate with bulging cornea. No seidel’s, deep anterior chamber, pseudophakic.
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Diagnosis and Treatment
Corneal ulcer, severe, probably associated with exposure keratopathy
TREATMENT?
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Initial TreatmentCorneal scraping for culture and sensitivity
Start VigamoX every 1 hour around the clock until fortified antibiotics ( Ancef and Gent) obtained. Shield
Assesed home condition, spoke with social worker, home friends to improve compliance, given patient’s general condition.
Daily follow-up.
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Clinical EvolutionInfiltrate appeared to get smaller over the next three days. Compliance appeared to be good. Difficulties with transportation.
Cultures were negative.
On the fourth day, the chamber collapsed
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Now What?To transplant or not?
No transplant: Ulcer may be sterilized, perforation would be vascularized, eye would eventually may become pthisical.
Transplant: 90% plus chances of saving the eye and eventually good vision.
Patient given the option: “he wants his eye”
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ETHICSShould we invest about $10,000 on this eye?
Patient’s quality of life would be essentially unchanged with a successful transplant.
Cost to SOCIETY.
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Treatment
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Treatment
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DiscussionUtilization of limited health care resources
Who makes the decision?