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!
     

MEDICINE , FAITH AND RESPOSIBILITY

      I am a firm believer in GOD and also in medicines . Sometimes these 2 things seem to have cross roads. I do believe in chance  and also in probability. If I see someone with stage 4 lung cancer , there is high chance that the survival is limited .But I also know that there are patients who will beat all the odds-in both direction.This is the bell shape curve. Majority of the patient fall in the middle and some will die much sooner  and some will survive more than expected . But that does not mean medicine is wrong. We also see Faith being invoked when the disease is bad and these are the same people that may not have done prayer outside church or may not have helped someone in need. But what I wanted to say that just because one has firm faith does not mean one can neglect medical advice or medical odds.This brings me to today's story.
      I  had seen this 70 plus years old patient in office for cough. She was nonsmoker  and also did not drink alcohol. She had no major medical issues that just high blood pressure and that was well controlled .She had cough and she also had some shortness of breath.I did the work up and the breathing test did show some obstruction and so she did have some element of asthma. I also noticed that the oxygen transfer factor - called diffusion capacity as oxygen is transferred across the lungs in to blood, was reduced . Her chest X- ray had shown some 'chronic changes' . With her cough and shortness of breath and also the lower diffusion capacity, I decided to do high resolution CT scan of the chest .I was concerned that she may have scars or fibrosis in lungs . The CT scan did show fibrosis . I explained it to her that she has both asthma  and fibrosis. I also told her that the fibrosis could get worse  and she will be more short of breath. There were new medicines out  and if she has some worsening in next 3-6 months we could consider the medicines . The medicines were expensive though covered by insurance . The cost would be $30000 per year. But insurance covered the cost. She was followed by me for about 9-10 months  and she was stable . Then she stopped coming . Clinically she was stable. The cough was there but the shortness of breath was better and when I mentioned on medicines , she refused them and told me that the GOD will HEAL. Certainly she was not worse  and she was not interested in medicines or the oxygen use which she needed at night .
       I did not see her for long tome  and may be a year down the road she was hospitalizes .She was short of breath and had very small blood clot in lungs . She needed oxygen and then she was started on blood thinners . I told her that she has not done follow up. The fibrosis appear to be same. She was sent home  and then she came to my office for determining the need for portable oxygen . Her oxygen was very low  and I called her primary doctor  and told him that she needed oxygen ASAP. and I was sending her to hospital ER.I needed STAT CT scan to make sure there was no worsening of the clot . The out side radiology facilities sometimes can not accommodate such emergency and I was worried that if she needed more treatment , she will have to be in hospital. With HMO insurance I have to get everything approved from PCP. She had scars  and the clot was smaller and she was sent home. I was under the impression that she was started on oxygen . She was not . She came to my office next week  and was doing much better The oxygen was better and she was not as short of breath as she was when I had seen her a week ago. She did not have oxygen and she felt she will not need as the GOD will heal, Same thing that she had told me when I had mentioned newer medicines for fibrosis. I scheduled for a walk test where we walk patient for 6 minutes  and monitor oxygen and  decide if they need oxygen and how much. She needed oxygen  and I again talked to her on getting or considering the new medicines for fibrosis. When we talk about use of oxygen , her statement was same -I am fine  and the Lord will heal me.
       Certainly over course of last 2 years or so she has had some ups  and down  and certainly the GOD can heal. But one has to take responsibility and also have to DO efforts to get better . One can not expect high blood pressure or diabetes or pneumonia to be cured without taking medicines  and just praying. Prayers have a role  and it more in some cases  and less in others . But as human beings GOD wants us to do efforts on our part and then he will do HIS part .

DOES IT MAKE A DIFFERENCE ?

     We all have gone through life sometimes feeling that we could change certain things . When we were younger and did not get that A grade we thought we could have done something something and could have changed the grade - may be done more study or behaved better or something else . When we lost a tennis match , we felt we could have handled a serve better or done more practice. At that particular moment, we field the desperation and feel that our life is changed for ever with that one change or decision. But then when we look back at it after several years , these incidences have not made any major impact on our future life . I see the same thing sometimes in my patients . That brings me to today's story.
     I saw this patient in my office by chance.It was Friday and  I had a text from one my friends, who is a cardiologist that there was a patient who was short of breath and if I could see him soon. I normally do  not see patients in the afternoon on Friday .But I told him that I could make an exception and see him on same day- the Friday.So I told my office to call the patient and saw him at 2 pm. I am in the office on Friday but do not have scheduled patients, He came in . He was a 76 years old male who had acute bronchitis  and he was coughing and has wheezes. He was also short of breath.He came with his wife . He has been smoker in past and had quit may be 1-2 years ago and has had shortness of breath before . But after quitting smoking he had improved  and he did not need any medicines  and he had not been on any inhalers . He did not have any pulmonary function test in past or had any chest X- ray in recent past. I examined him and he had had significant bronchospasm and he was short of breath. He also had very low oxygen saturation on examination. So he needed a chest X- ray , a breathing test , oxygen  and antibiotics  and steroids . He also was going to need medications to be given by nebuliser to help the wheezes. I thought that it would be better if he is in the hospital. He was quite stubborn and did  not want to be admitted.So I called in prescriptions  and also told him to do chest X- ray ASAP as I would have changed my plan if he had pneumonia. I told him to call me or go to ER if he felt more short of breath. I also called a company to provide oxygen at home .
       The radiologist called me with the report that his chest X- ray showed a mass . I  had to call him with the news  as that meant that he may have cancer . I called him and told him of the findings  and told him that we will do CT scan soon .
    He had a CT scan and that did show a  mass.He had improved  and he was had been on steroids  and also nebulizer treatments  and also other inhalers and he was not short of breath. We did breathing test and I wanted to do bronchoscopy. He was not sure  and postponed the tests couple of times . The CT scan did show the mass and so I did PET scan and that also showed that the mass did pick up suggesting 90% chance of cancer .His breathing test showed that he had significant reduction in pulmonary reserve. I had extensive discussion done with him on several occasions,The options of therapy for the lung cancer is surgery or chemo or radiation. Due to poor breathing capacity he was not a candidate for the surgery. But he did not want me to do the biopsy and and wanted to see surgeon. So I sent him to one . The surgeon told him that he could not have surgery as the surgery and the resection of the part of the lung would leave him with need for respirator. . He decided to see another surgeon for the opinion . The opinion was again the same. Every time he had done something he would walk in my office  and wanted to talk to me  and I did for short time. I also told him to see radiation doctor . The mass was not very large and short course of radiation would have achieved the 'cure' in many patients . But he was bent on having surgery.
     One of the surgeon did biopsy of lymph node - I am not sure what that would achieve  and that was negative for the cancer.,He did have needle biopsy  and then when cancer was confirmed he did have radiation .He has continued to come to me  and he has clear lungs  and he has not been using any inhalers and nebulizers . He feels fine  and after almost a year of the treatment , he has no evidence of cancer .

  So it was very important for him to have surgery and he wasted time , money and also had some surgery that did not change much  and it did not change anything in his life -at least for 1 year so far. 

ANNOUNCEMENT

     I have started a YOU TUBE CHANNEL  to talk about various things . I will be adding one short video at least every week .
If you like this blog , PLEASE watch it , like it and subscribe to it .
Check it out under JUST-A-TALK .
I will continue to do the blog too .  

THE SYSTEM DOES IT WORK

       In every aspect of the life we often say that the system works . If a murder is solved after several years , we say that the system works. We have been witnessing the political drama unfolding in DC.
I am not sure if the system is going to work - either way whatever your political view may be - Democrats are feeling that the system did not work in 2016 election and the republicans feel that same way about the Democratic party candidate  and the FBI and the DOJ behavior.But I am talking about the day to day life where we come across things  and feel that the system did not work. All of us have 'misconception' about our ability and be often 'feel' that we do not get what we 'deserve'. But I am talking about much simpler things like DEATH CERTIFICATE. That brings me to the today's story.
       I saw this patient 5 years ago. she was 38 years old , obese  and had multiple medical problems . To my recollection she was not working and she had medical disability at that young age . She was not a smoker nor was alcoholic , but had bad hand dwelt in her life . She had Lupus a deadly disease in some  and many who have that diagnosis. She also was obese  and she had TB-yes tuberculosis  and had part of the lung taken out . In patient with Lupus,patient have multiple organ involvements - from skin to lung to kidney to pressure in lung circuit. She had scar tissues in her lungs  and also had chronic pain and also had obesity  and sleep apnea. She was short of breath and she did not do much exercise  and had not lost much weight . The combination of all these factors had led to shortness of breath. I am sure if she could loose some weight ,  and exercise she may have have been that short of breath, Fortunately her fibrosis or scar tissue in her lungs though bad was stable. The pressure in lung circuit - called pulmonary pressure was mildly elevated . Her oxygen would drop bellow critical number and so she needed oxygen when she would walk . But being young , she did not like the idea of carrying the oxygen and so she was not using it most of the time . The oxygen transfer factor that we measure, was less than one third of normal and so no wonder she needed oxygen and was short of breath. She had sleep apnea  and was not using the pressurized mask that she should use . But in all in spite of all these she  was stable  and we did not  and could not change any medicines .
     One day I got a call that she was in ER . In last 5 years or so that I took care of her , she was never in ER or hospitalized. I saw her in ER. She was quite short of breath and  needed high flow oxygen delivered with pressurizes mask. Her husband was bed side . She had respiratory infection and that caused the pneumonia  and since she was compromised ,she had acute respiratory failure . The ER doctor had started her on antibiotics  and steroids  and CT SCAN was planned soon . I discussed the situation with them  and she was to be admitted to ICU. I told them that if the things do not work out she will be intubated  and put on respirator and then we will see how she responds . With given pulmonary compromised the weaning off the respirator would be difficult if not impossible.
       As I thought she was intubated  and she had many other problems that are associated with sick patient . I would not discuss them at this time . But at the end of 17 days she was on maximum support on the respirator and she was on 100 % oxygen and high pressure  and also had problem with blood pressure  and also with blood count and she was not waking up..The discussion was on going with family on the poor out come and so finally we talked about the HOSPICE  and withdrawing the life support . We knew that the end was near with or without life support . So may be on day 20 or so we stopped the respirator  and she passed away. We now a days have ICU doctor  and also Hospitalist and so I did talk to husband but did not expect death certificate to be brought to me .
    15 days after this event my office staff told me that the husband was in my office to talk to me . I was not sure as to what was the reason . But I thought that he may have come to have  'closure' as he had not known all the problems that she had even though I had had told them when I met him in ER  and then in ICU. I brought him in and he told me that they do not have the body to do the funeral. I was shocked . The lady dies more than 2 weeks ago . He told me that the hospital doctor mentioned a 'fall' in the death certificate  and so the case was sent to medical examiner . Since the county did not have their own it was sent to different county ME . I did not know the name or the person. So I was not sure as what and how I can help. But I told him to call the ME office  and tell them to call me to clarify any medical issues that may be holding the release of the body. I gave him my cell number. I git a call from the him that the ME secretary told them that she could not do anything  and if I wanted I can call them . But it was up to ME . They would not call me . So I got the number  for the ME office  and called them I could not talk to ME but I explained the situation to the secretory and told her to have ME call me if he still has any  questions or concerns before releasing the body.
     A day latter  I had death certificate brought to me  and I signed it  and told office staff to call the husband  and inform him that  it is done.  So the system should have worked and the family should have gotten the body much sooner . But it did not , but finally the system DID WORK - BETTER LATE THAN NEVER.