BACK TO THE SQUARE ONE

      The phrase of 'back to the square one' is very commonly used when we do something as a plan  and that does not work . This probably came from one of the board games  may be chutes  and ladder  when we are going to the higher squares  and suddenly we find our-self going down due to chute. The same things happen when someone is trying to solve the criminal case and the clues lead us to dead end  and then we are back to original level. The same thing happens in medicine , but not often. This brings me to the present story.
      I saw this lady for shortness of the breath. She had smoked  and had diagnosis of COPD  and in past she had lung cancer diagnosed  and she had treatment for it She also had breast cancer  and she had surgery and she was cured. I saw her  and did  act scan  and also breathing test and started her on oxygen. She was started on medicines for the COPD  and then the CT scan showed tiny nodule. I told her that we will need to do the follow up fort the nodule  and it was too small for the further work up to know the diagnosis. Doing bronchoscopy , or doing needle biopsy or doing PET  scan or asking surgeon open biopsy were not options as they would not have given the diagnosis. So we decided to do the follow up . I continued to see her for next year and we did couple of CT scans  and they did not show any any change or growth . She did not come to me for follow up a year. Then she  had shortness of breath and she was hospitalized.I was asked to see her . She was very sick and she had to be in ICU for short time  and even after getting out of ICU. She had new CT scan done  and that was abnormal . The nodule that we had seen was same but she had new 'mass' in rt middle part . She was not in very good shape for biopsy and so we did PET scan  and that did show that the mass was likely to be cancerous -had increased uptake of the glucose.She was never a candidate for the resection  as she had advanced COPD and the location was such that she could not have had resection or entire lung and then also she would not have been cured. I did do bronchoscopy  and I had to get help from anesthesiologist and she did OK . I did see narrowing of the middle part of the right lung and i though that she may have external pressure from cancer or it may be narrowed due to cancer itself. I did do the biopsy and other things  and they came back with 'atypical cells but not conclusive for cancer.
      She was getting better  and i told her that we need new biopsy but she needs to be better  and so after 2 weeks i had do EBUS - biopsy with help of ultrasound , This was done and they came showing no cancer . I knew the CT scan , I knew the PET SCAN  and i also knew her history. She had 2 different cancers  and she also had OXYGEN dependent COPD.So now what I can I do to get to the diagnosis? As you can see every time we did a test thinking that we will get the diagnosis we were back to the square one.
     So I had a surgeon to review her scans  and he called me stating that the situation was very difficult, but he felt that he could do some biopsies  and get the diagnosis. He saw her and did a procedure called Mediastinoscopy  and biopsies came back showing no cancer. So he did see her again and did biopsies through chest  and they also came OK. So she came back to me  and she was hurting from the surgery and we had no diagnosis. I asked radiation doctor to see her and see if they can do radiation WITHOUT the tissue diagnosis of cancer. They were not very happy to do such a treatment without the proof for cancer . This is not like giving antibiotics.
     So I decided to do new CT scan in 3 mo this The month before she was to have new CT scan done she was in hospital  and I saw her . She had developed fluid collection around the lung - same side as was the mass. I did new CT scan  and that did show the fluid  and also that the mass has increased. So there was no question that she had cancer . But we had no proof. So I called the same surgeon  and told him the situation . I was concerned that she had fluid due to cancer and just taking it out once may not be enough.She was also on blood thinner . So I asked the surgeon to do the  catheter insertion to drain the fluid  and do some additional biopsies.
    He did do the catheter and did  not do he biopsies .The fluid was sent for cancer cells  and they came back as No cancer . So we were back to square one - same place that we started after  5 procedures to get the answer. So now I  again called the radiation doctor and asked if they could do radiation without the diagnosis OF CANCER..
   This time they agreed  and she got the radiation therapy without tissue diagnose of the CANCER . 

BAD LUCK

   I have been asked many times as to the cause of cancer. We see have seen it in older  and younger people , we have seen it in fat and skinny people , we have seen it in people who have good habits  and bad habits.We have known some risk factors like smoking  and chewing tobacco, and people with exposure to chronic irritants. The sharp tooth has caused oral cancer and KANGRI the heated burner that people in KASHMIR out around their belly to keep warm has caused the cancer of the skin of belly wall.When radium was invented  and people used radium dial wrist watches , there was increase incidence of cancer of the wrist bone.So we know some causes but we do not have any idea as to why some get cancer  and why some don't.This brings me to the story of the patient for today.
     I saw this young women who has some vague chest pain . She was nonsmoker and had no h/o high blood pressure or diabetes or any cardiac problems. She was OK till then . So the family doctors did a chest X- ray. The chest X- ray was abnormal. and so she had CT scan of the chest  and that showed a large mass  and also a smaller mass. She was sent to me . She was very anxious  and was quite concerned . And rightly so as the mass was reported as as most likely as lung cancer in the report, which she had with her and had read it few times . She had noticed the right sided chest pain only 2 weeks ago  and she had no pain before that .She had no shortness of breath or any significant cough, She had not coughed up any blood . Her appetite was good, but she had lost some weight,but she had thought that due to the the problem that she had with eating . I explained it to her and her family that the possibility of lung cancer was high but may not be 100%. We should answer 3 questions -Is it cancer, Has it spread and lastly the choice if treatment if it is cancer.
   To answer these questions we needed the diagnosis of cancer.So we ordered PET SCAN which is good in detecting spread of cancer or presence of cancer - may be 85%of the time. I also ordered the breathing test. and also bronchoscopy. That showed narrowed bronchus  and so I did biopsy  and then the biopsy did come back showing cancer .
   The PET scan was done a day after the biopsy. So when I saw the PET scan report I was not happy. So I called the patient to see me . She had lung cancer and the PET SCAN showed that the cancer had spread to Liver and bones . The chest pain that she had was due to the spread of the cancer to the ribs . So she was not operable. I had called  chest surgeon to see if there was any chance of doing surgery - though it was before the PET SCAN,  and I had done it in spite of knowing that she would not be based on ct scan .
    She had come with her family and they wanted to know the prognosis  and why she had cancer . I had no answer to both the questions. So the nonsmoker,nonalcoholic lady was having lung cancer and that too had spread to other organs such that the prognosis was not very good .

PENDULUM HAS GONE TO OTHER SIDE

    In our life and in many a times we see the pendulum of opinion swinging . At one time coffee is bad then someone does research  and then tells us that coffee is good. High fat diet was bad for many years then came low carb is good  and high fat diet is good. I have seen this medicine too . We were told that steroids  are needed to treat COPD   and now it is OK not to use steroid inhaler. We are told that we have epidemic of narcotic use  and addiction .But when we look at it we realize that WE ALL are responsible for it .But then we got to have someone else to be blamed for it - may be then we can collect some money. So blame big pharma . As much as they are  responsible,we all are. I just want to mention that I do not  and did not prescribe these medicines. But with hospitals pushing doctors to get better patient satisfaction, the narcotics were prescribed  and they were more than what was  medically needed. The hospital reimbursement was dependent upon the patent's satisfaction. So we created the dependence  and the addicts . So now the pendulum has gone to another direction and that brings me to the story.
    One my my patient age 90 years plus called me on week end stating that she has chest pain on right side . She was doing weed whacker  and she fell down  and hurt the arm  and the skin -which was thin to begin with tore,She was also badly hurting on right side of the chest after the fall. . She went to ER  and they did chest x- ray  and not sure if they did CT scan. They gave her some medicine and discharged her . She wanted pain medication and the ER MD did not give her any . She was disappointed so she called me .I told her that with weekend , I could not do much ,but she can try some over the counter medications  and if not better then go back to ER again . And she did not feel better and so she went to different ER . The events were repeated . The ER physician gave her muscle relaxer - no pain medications  and discharged .She was having pain 'worse than labor pain' as she described it to me . I told her to come to ER where I can see her and let the ER doctor know that I will come and see her. I did ask her to call her PCP  and she had done it , but now a days no PCP goes to hospital, so that was not an option. She came to ER . I went to see her. The ER physician told me that she would not do any tests  as she told them that the 2 previous Er did all the work up. So I talked to her  and told her that we need to do X- ray of the ribs  and she agreed . We did the X- ray  and she has SIX RIB FRACTURES ! She needed to be admitted.
      The question is why did the ER physicians did not do rib X- ray , why did they not admit her  and lastly WHY DID THEY NOT GIVE HER PAIN MEDICATIONS?This old lady was not addict, she was not going to become addict and she had obviously pain starting after a fall. The answer is in the narcotics fear that we have created  and the hoops that physicians have to jump through to JUSTIFY narcotics prescriptions. So that is what I am calling as pendulum has gone to other side. 

UNTITLED

    I was talking to a friend om mine . We were talking about SAT examination. He stated that that that is very important examination . I made a statement that at a particular time in our life ,things that appear to be very important , do not appear to be that important when we look back at it after several years. The SAT examination does determine which college we can get in . But many a times the college that we join may or may not  and in most instances does not make difference in our future. . When my son graduated from college and went to medical school, one of the guest made a comment that even the graduate of the medical college who stood LAST in the class is called MD. One my patent's son who was with GOOGLE and making ton of money -over a million dollars a year , was graduate of UCF  and his major was physics ! So sometimes we worry and get concerned  and get upset over things that on long term does not matter.That brings me to my today's story.
    I saw this patient about 71 years of age who had moved to Florida from some other state . She was diagnosed to have lung cancer  and had treatment for it  and was 'cured' . She was a smoker  and then she also had history of breast cancer and she had surgery and she was 'cured' of that too. She had smoked for several years  and had COPD. She was compromised  and had shortness of breath  and also had reduced lung capacity. I treated her and she was going better. She had  a CT scan of the chest  and it showed some changes related to COPD   and related to previous cancer but was thought to have them related to her previously treated cancer rather than new cancer. She continued to come for follow up for 6-8 months  and then did not come - very common now  a days since HMO have taken over health care  and 'RISK ' contracts  are becoming common and big business are 'buying the medical offices  and run them . They can not make money unless they cut the cost  and doing so they reduce follow up by consultants and do less testing .
     Then one day - about 1 year down the road,I was called to see her in the hospital as she was admitted for shortness of breath  and pneumonia. I saw her  and when I asked her questions I came to know that she had CT scan done as out patient (No one had bothered to  ask her and she had new CT scan in hospital and that was abnormal . So I wanted to do further work up .) She told me that she had routine chest X- ray and then it was abnormal  and so she had CT scan  and since that was also abnormal she had PET SCAN . So I got hold of the scan  and she clearly had very abnormal CT scan and also the PET SCAN . It looked like she had NEW LUNG CANCER  and the way in which the scans were , she would not be a surgical candidate for resection. Certainly her condition was bad  and from COPD stand point also she was not surgical candidate, She was on oxygen  and was very short of breath. After I treated her with medications , she did seem to improve and one day I did do bronchoscopy to get some tissue . She had hard time with the procedure  and the biopsy came by showing some abnormal cells but not conclusive for cancer.The daughter was not very happy as the PET SCAN was done 3 weeks before the hospitalization and now 10 more days were gone  and we still did not know the diagnosis of the cancer  and so no treatment was started.
     I told them that the condition was such that doing more invasive procedure at that time would put her in worst state  and she will be on ventilate and than we will not be in position to treat. So the best option was to treat her  and allow her to recover her from present illness and then in 4 weeks when she is better then do some additional procedure like doing biopsy of enlarged  and abnormal lymph nodes as reported on the PET SCAN There appear to be tumor wrapping around the  right bronchus  and that appear to be out side the main bronchus . So I asked a another physician to see her to that biopsy  and there were  problem with referrals  and the appointments got cancelled due to physician having emergency  and the primary not giving referral at right time . The daughter walked in my office twice  and asked me to help and was not happy .I called the both the offices  and made arrangements  and then she  had procedure by another physician as the the one that saw her in office was not available. This added to the frustrations  and then she came to see me. The biopsy done by this MD did not show any cancer and so we were at square one . She was not any better  and she was on oxygen  and the daughter was not happy that we did not have the diagnosis  and so there was no treatment started for CANCER. Our conclusion that she had cancer was based on PET SCAN which is almost 88% accurate. So I was convinced that she had cancer , but the biopsies were not showing . One thought that I had was to sent her for Radiation therapy  and asked them to see if they felt they could treat her WITHOUT THE DIAGNOSIS based on PET scan findings . But I decided to call a surgeon. He was very prompt  and he saw her  and did  2 different biopsies from 2 different sites on 2 different occasions.
     ALL THE BIOPSIES SHOWED NO CANCER !!!
     So the frustrations that patient and the daughter  and I had about not getting diagnosis IN TIME  and worried about the delayed treatment was real and now looking back at it not very important.
I am still not sure that she has or does not have cancer and I think only time will tell us. 

FINE PRINT

      We are always told to look at the Fine Print . The Dish Network  tell us to look at the Fine Print when we sign contract with cable company and now that the cable companies are in cell phone business, they are telling us to read the Fine Print. So we are always ask to see and read the Fine Print.But one may say what is there in medicine that we need to read Fine Print. When we see patients , many of have tendency to see what is important to our field or specialty. And many  and most physicians have PA or nurse practitioners and they do the notes and the consultants tend to get biased and don't do much on their own . Even the hospital doctors - the hospitalist have the same problem . They do not have their own patients  and the ER doctors or ER pa or nurse practitioners tell them the story and then they admit or their PA or nurse practitioners admit the patients I am not complaining  but just stating the facts . I  still do the same old way. See my own patients  and also read the Fine Print  and sometimes it takes more time but it is more satisfying  and rewarding.This brings me to the today's story.
           I was asked to see a patient who came to hospital for shortness of breath and some chest pain. He was a 51 years old male  and was quite heavy. He was never a smoker  and drank socially only.He had shortness of breath and he felt that started 4 weeks ago only . The ER physician did the work up .He had high blood pressure and he also had other work up done. He was admitted to ICU and hospital doctor saw the patient and then the cardiologist saw the patient . The patients that are admitted are seen by ICU doctors who in many case are lung specialist . So he also saw him . There was no reason to call another lung specialist.But his cousin was a physician and patient called him and he asked them to call me . Si I saw him . He had had clear lungs  and his lungs sounded clear  and his CT scan was OK . He had further cardiac work up and all the work up was negative .
     When I saw him I thought that he may have asthma  and so I started him on inhaler. But when I saw him and looked at the blood tests,I noticed couple of abnormalities. He had elevated proteins  and had one particular type of cells elevated. So I did mention it to them and then and did some additional blood tests .
    I saw him for 3 days more  and then when he was cleared for discharged by cardiologist , he was to be discharged. I had mentioned the need for work up in my notes  and also told the patient  and his wife. No further work up or  any mention of the abnormality or need for work up was done by hospital physician or cardiologist or ICU physician .Finally I ordered hematologist to see patient .
     He was discharged  and saw the hematologist as out patient and he has diagnosis of CLL chronic lymphocytic leukemia.So I read the Fine Print and that helped the diagnosis.
   
     

SYMBOLISM AND CONFUSION

    I have mixed blog and I do write sometimes about the religion  and the practice of it . I do try to make a sense out of certain behavior or the practices which are done mainly in Hindu religion . But I also have certain opinions about the other religions too. This is my opinion and it has limited value. Just to give  an example , in Revelation, It states that i heard a sound  and i turned  and saw 7 golden candles . I interpret it as meditation and the 'sounds' that one perceives when in Samadhi status , and their relations to the 'chakra' that we have . Certainly one could have a different opinion. There are many other examples I can give . But that is not my purpose of this blog .I had an Email from someone about the old Blog that was related to Indian religious -POOJA , called Satyanarayan Pooja. So I thought that I will y try to explain not the Pooja but the thought process .
      The supreme being is nothing but SPIRIT or energy. It has no qualities  as it has no GUNAS. Unless one has GUNAS or qualities , one can not have Desires . I want to eat Pizza because I have desire . But the Supreme being has none . So HE can not have desire to create the universe.But then there is matter . The matter has Gunas  and  so has desire .But no SPIRIT or the energy and without the energy it can not start the process of creating universe.  So the process starts ONLY WHEN THE SPIRIT AND THE MATTER (PRAKRUTI ) come together , This is important to understand . The supreme GOD is not a GOD FATHER , So one can not kiss his hand  and get favors. But the creation when started has lower level gods  and they are more like positions that are controllers of the 3 inverses. So when we humanize the god - we praise the God , we offer him food we do in HINDUISM SHODASH POOJA - 16 elements of worship , , we are now making the God a human being. So if the God can be pleased, he can also get MAD or Punish for not doing right things . The interesting part about this is that we tend to apply our worlds principles  and then are not willing to accept the results .
      We our self do worship ,but sometimes we do it through priest or we also do it with CD rather than priest . We also pray for others when they are not praying for them self . how can that be effective?.
If one kills someone or kills someone through contractor is he not guilty in both cases ? Direct or Indirect , we are responsible for the action . we apply same rules to the worship .
   In ideal situation , our own KARMA  are responsible for the situations that we are facing and the degree of efforts that we put to change it will make or break it . We have to accept it . But at the same time god can intervene, but not the SPPREME GOD .  .  

DRUG ADDICTION REVISITED

    Now a days we have significant talk about the drug use  and drug addiction. The problem is old  and there are are different shades  and what we used to see in New York in seventies  and eighties is not seen that often. WE ALL ARE RESPONSIBLE FOR THIS . We may not like this statement, but in my mind it is accurate. In hospitals there were surveys from patients about the satisfaction. So to get have higher'scores', the hospital pushed doctors -not directly but indirectly -to give -offer- pain medicines. When I had hernia surgery,after the surgery I took only Tylenol  and Advil. I had prescription for narcotics and i never filled it. I stooped the pain medicines in 3 days. But in the hospitals we offered much stronger medicines  and narcotics  and patients did take them  and some came in to get the medicines only . Taking them for short time is OK But over period of time patients got addicted . Some were addicted  and demanded pain medicines  and some came to hospital and would not give good reports unless got the pain medicines . This part is now corrected . But now we have pot being made 'legal'.So more people are doing it and that is step one. The pendulum has swung on the other side . The government has new regulations  and now I see some doctors doing pain management practice  as it is lucrative. But the problem is not solved . Some of these people that get medicines from these doctors sell it  add then the addicts buy them. This brings me to today/s story .
       I saw this young lady for diagnosis of pneumonia .I went to see her . She was a young lady and
did tell me that she did use drugs.She was a smoker and did not drink alcohol.But she was on pain medicines obtained on streets. But she was not taking them as pills even though they were suppose to be taken orally. She had some cough and fever and she had some right sided chest pain . She came to ER  and she had chest X- ray done  and that showed pneumonia. So she was admitted. When I saw her she was comfortable  and she she seems to be honest about the drug addiction. She was admitted few months ago with sepsis and MRSA infection. She denied using cocaine and did not drink alcohol,She did smoke sometimes , When I asked her on her drug addiction she stated that she used Dilaudil pills.SHE DID NOT HAVE THEM AS PRESCRIPTION but she bought them on streets. She would dissolve them in water and then inject them intravenously to get effect quickly.
      This form of abuse is very dangerous. The pills taken by mouth or drugs used by intravenously or smoking pot or use of cocaine are all risky behaviors. But the injecting pills is especially dangerous . The pills are meant to be taken orally  and so the pill contains talc or other substance that is particulate- has small particles of talc or chalk. This is not completely dissolved in water and when injected gets caught in lung blood vessels - causing pulmonary embolism -smilier to blood clots getting trapped in lungs . This in significant quantity can cause death . 

     I explained this to her  and she seemed to understand. She looked like honest drug addict  and looked like she will try to kick the habit . When I looked at the chart the drug testing was positive for number of other things that she had told me she did not use!