SEEING THE TREE AND NOT THE FOREST

    Many a times we all do it .We are so focused on something that some other things which is in front of our eyes , we don't see. But I often feel that in medical practice to day has become so fragmented that we all have OUR OWN specialty and we have the blinders. So we do not see the patient , but we see the disease . What used to be done by good Family doctor in past is not done by today's PCP and the the specialist of today are only Specialist . In addition to that we have patients that have sometimes selective hearing . This brings me to today's story.

     I saw this older patient . She had lot cough and some shortness of breath , She had routine tests done and she was treated with medicines . She was told about pneumonia and was treated with antibiotics in past . She was in hospital and she was also seen by different specialists . She was seen by a lung specialist . He had done bronchoscopy and no specific etiology was found out and she was still having the cough and the congestion , so she was brought to me by her family. I reviewed the data and saw patient , She had usual problems like high blood pressure and some leg problems and neuropathy . She had not been smoker and the chest X-ray and the old CT scan did show the pneumonia.. We decided to do breathing test as some times asthma can cause recurrant  respiratory  infections. . We decided to do new CT scan and the decided to do new bronchoscopy . She had lost some weight and atypical infection like MAC can also cause such symptoms.. All the work up was OK , but I had done swallow study too . She had aspiration . Whenever she swallowed , the liquid went in lungs .So this causes chemical injury to bronchial tubes and lungs and that causes inflammation and that leads to infection . She also had very small diverticulum , which may have added to the aspiration problem . When I did the CT scan I had also noticed that her esophagus was dilated and so I had ordered functional test to see how it works , motility study . As I suspected , her esophagus was not contracting properly and so the squeezing of the food that happens to get food down towards stomach.So the reason for the recurrent pneumonia and the cough was aspiration. I told the family that this is going to recurring problem and only 100 % way to help this is to have feeding tube put in . Thew were not ready . They were stuck on the diverticulum and wanted to get it fixed and then the problem would go away. She was readmitted and then had another episode of aspiration . I called in a gastroenterologist and he decided to do endoscopy - I am not sure why . The family wanted  a surgeon to fix the diverticulum . I knew  this would not change , but had no choice and a surgeon was willing to 'fix'it .

     She had the surgery and 2 weeks down the road she had another episode of aspiration . I explained again to them . This time a different gastroenetologist was consulted . He decided to do endoscopy again ! I am not sure . She is doing better and was d/c and I am sure she will get another episode and will be back .
     Not the hospital doctor or the 2 different gastroenetologist told them what I told them and I am not sure what information we got from the endoscopes . The family is seeing TREE and can not see the Forest -and so do some others !

DO THE RIGHT THING

        I enjoy medicine -otherwise with today's demand on medical practitioner for non medical things and things that do not help patients , I would have stopped doing medicine..I also watch news and the political commentaries. In my life time I have never seen such a divide.It almost reminds me of OJ court trial. The conclusion drawn are diagonally opposite. I wonder if they were watching same proceeding or not . But I often get the same feeling when I see patient. This is not new .In past it has happened to me that I was asked to 'clear' a patient for surgery and I thought that the patient was terminal. He was thought to have incarcerated hernia and needed surgery . He was seen by hospital MD , surgeon and cardiologist and kidney specialist . When I saw the patient , his hernia was reducible and nor incarcerated , his heart was pumping at 10 % and he had kidney failure and he had water in lungs .Not only he DID NOT need surgery , he could not have SURVIVED THE surgery. So when I told this to the daughter , she was surprised as OTHER doctors had cleared him . I went see her again and showed her the labs and the heart reports and the chest X- ray .We made him DNR and he dies in 24 hours . This brings me to today/s story . 
       When I was passing in the hallway of the hospital , I came across an Indian male , who mistook me for some one else . His wife was admitted and so I hello to them . I came to know minimal things about her medical problems . I told them that I will let the physician -that they knew , and from behind mistook me for him -know that she is admitted. After about 3 days or so I got a call from hospital . The nurse told my secretary that I was to see a new consult . My office took the information . I was busy with office patient and then I got 2 text message to call the nurse . So I called . The same lady that I had seen socially 3 days ago , was the new patine. She was short of breath and they wanted me to see her . She was so bad that the nurse called me on my cell phone twice. I had no call from any other doctor -not even the Hospitalist MD. The nurse had called Rapid response team twice. I spoke to the nurse and got brief history and gave orders . I told her to do chest X- ray and a blood test to check on congestive heart failure and give couple of medicines and call me is she was not better in 1 hour . I also told her that I will see her at 5 pm , which was 2 hours from the call.

    I went see her at 5 pm I looked at the chart to see as to what was happening . I saw the chest X- ray. and I saw the blood reports and then went to see the patient. There were family members and the nurse . She was little better . I told them that I felt that in my opinion she had episode of congestive heart failure and with new medicines she should improve in next 4-6 hours . I ordered medicines for the congestive heart failure and also for wheezing that she had . I did not get any call from the nurse after that . I went to see her next day and she was like new person . I readjusted her medicines . I reviewed the chart . She was seen by cardiologist , Infection specialist , blood doctor and hospital doctor . I did not see any mention of the things that happened yesterday in any of the notes other than hospital MD and the infection specialist , who had called me personally after he saw the patient .
If one would look at the cardiologist note only ,he would not know that she went in congestive heart failure.  There was no mention of the problem that she had , that was related to HEART .So 2 people seeing same patient , have very different view of the patient . 

KARMA AND LUCK

      I came across a book that had discussion on KARMA .I liked some of the discussion that was done and some I did not agree . But overall it is a good book. I have talked about the Karma and the principles governing the Law of Karma. in the past . But I will summarize them before I talk about some new points. There is no patient story in this blog.
        The Karma is ACTION. To understand this one must realize that sometimes the INACTION can be ACTION. Sometimes the Action may not be obvious as it is MENTAL or not DIRECT. .So let me explain . If i am walking see someone in an accident and I walk away without helping . That not doing anything -inaction - is ACTION . This is simple to understand. Now the Mantle Action. I am think harm or lustful for someone once , because we had fight , it is not an Action .But if I continue with the same thought everyday it will become Action . (according to the book's author this is not action ). And lastly Indirect action is also Action . The claim that I do not kill chicken or pig and so I am not doing the Action of Killing is not right thinking . It is an Action .
        The action or the Karma that we do is called KRIYAMAN Karma .Some of it will have effect in this life and rest is stored as SANCHIT KARMA or 'Stored Actions'. So with several lives , we collect or store millions of Karma and not all can come to fruition or have effect in present life . So the Karma that are to come to fruition in this life -that happened in past lives -, is called PRARBDHA. This determines the 'outline' of our present life . In Hindu religion 4 actions or PURUSHARTH are described ,namely ARTHA-MONEY ,KAMA-DESIRES ,DHARMA-RELIGION AND MOKSHA-ETERNITY OR NIRVANA . The first 2 namely ARTH or money that we can make and KAMA or desires that we get fulfilled in this life are to some extent predetermined  and the to follow DHARMA or do our duties and try to achieve MOKSHA or eternity is in our hands . But we continue work for Money and Fulfillment of our desires.
           This does not mean that we can not WE can not CHANGE any outcome in our present life, But it is like swimming against the current and so our efforts must not only Match the force of the past Karma -PRARABDHA , but outperform it. If we do not try in this life ,thinking that our future is predetermined , we are CREATING new Karmas that will determine our next or future lives . So we must try and that may change some of the weak effects or the reaction to our previous life's  ACTION .So this effects of past life Karma determines our LUCK to major extent and some is determined by our present life Actions. 

            So the verse in BHAGAWAT GEETA , which is often coated from Chapter 2 , verse 47-or misquoted . The verse states that one has Right to Action but not to the fruits-EFFECT- of the ACTIONS. The usual interpretation is that just because one tries does not mean he will get success . This is true , but the other meaning or the one which I like is that whenever there is Action or Karma , there is going to the fruit or reaction or effect of it . One can not say that I will not accept this or that fruit or effect . SO EVERY ACTION HAS REACTION -ONE CAN NEVER BE WITHOUT ACTION AS ONE CAN NOT STOP THINKING EVEN IF HE CAN STOP PHYSICAL ACTION. 

NEEDED TOOTH FERRY !

     I am against the price control in many situations . Th feeling that  'whatever market bears 'is the price was my opinion . But more I look at life , I think some regulations are required to avoid exploitation. I had a dog many years ago . One day when I returned home from going to beach on Friday and Saturday, he could not walk . I had to do something . So I called a veterinary doctor that I knew . He has seen me and come to my house and I have gone to his place may be once a year.at that time . He agreed to see my dog . He did X-ray and did give him a steroid shot ( which I thought was only thing that was needed ) , He also did Give me some shampoo and some steroids pills . My bill was $467. I was shocked as I knew the cost of the medicines and the cost of X- ray . I did not say anything nor did I ever took my dog to him again. He did tell me that people are willing to spend lot of money on their pets than on their kids . When in next year or so my dog needed back surgery , I had another shock . This time I was told as to how much each test would cost .Again my shock was that the doctor charged me for disposing of the needle too ! Having a pet is by 'choice and so may be if one does not want to spend money, he should not have pet . But that brings me to my today's story.

       I saw this 63 years old male . He had some cough and had bad bronchitis . He was in hospital and I saw him and treated him and as 'usual' he had CT scan in ER. It showed a nodule as small as 9 mm or so . He had quit smoking more than 20 years ago , so for the practical purpose he was non smoker -after 14 years of quitting smoking, the incidence of lung cancer is same in  ex smoker as in nonsmoker . Taking in to account the age and the size of the nodule I decided to do the follow up n the CT scan . The new CT scan showed increase in the nodule -almost double. So I did a PET SCAN .
    The PET scan did show uptake in the nodule suggesting that it was likely to be cancer . I did do a bronch and then saw in office . The bronchoscopy did not show any lesion and the cytology -pap smear of the lung was negative . But the size of the nodule was so small that I had not expected it to be positive . So now I talked to him and the wife . He had good lung capacity and he would have tolerated the resection of the nodule .So my first choice was to send him to a surgeon and then have do the surgery. Now a days robotic surgery is done , which has very small incision and the recovery is very quick. The other choice was to do needle biopsy and then if positive consider either resection by surgeon or do Steriotactic Radiation. This relatively new technique. This is used for nodules -- cancerous nodules that are less than 2.5 cm or inch . The radiation is given in higher than usual dose and it is more precise and only 5 treatments ts or sessions are needed . Some times this can be done in patients who are very high risk for open biopsy or resection due to poor lung capacity or age or other conditions like heart problem etc . The good news is that this treatment is almost as effective as resection . Some times we can do this without having  definite diagnosis of cancer . 

    I spoke to him and his wife and wanted to send him to surgeon . So I was shocked when he told me he would prefer either doing nothing and watching it --which I was against or seeing radiation doctor.. I was talking to him and he told me that 'Doc I have spent $46000 for getting new teeth and I want to use them !'So this 83 years old patine had to spent that much money more than an average cost of new car - to get new teeth.

       IS THERE ANY DENTIST WHO CAN JUSTIFY SUCH A COST - 20 TIMES MORE THAN WHAT HEART SURGEON MAKES FOR DOING BYPASS ???

    

THE ATTACHMENT

        We have number of  attachments in life.Some have attachment to smoking and some to alcohol, some to drugs and some for some other. Many patients tell me that the smoking is very difficult to quit . so there are lots of attachments and we have difficult time quitting them . But the attachment to the BODY is the one that is the worst and none can not leave it till end. Even the best and learned one can not get detachment from it. I have seen this all the time . I am no better , but most of us want to LIVE and not LEAVE the body no matter how disease reddened it may be . That brings me to the today's story.

      I have seen this patient for last 10 years. He has been smoker in past and when I saw him he had breathing difficulties. Hr had diagnosis of COPD -smoking related lung problem . He was quite sick when I saw him  and he needed to be put on oxygen . He had severely reduced lung function and over period of the time he got worse and in one of the hospitalizations , he had to be put on respirator. . I was concerned as to how to wean him and if we could wean him off the respirator. But we did it . He was OK but needed to be on the oxygen all the time . He also had very limited walking ability . AS the time went on , he was in hospital few more times . The function of the lungs is to get in oxygen and get rid of carbon dioxide . When the lungs fail first thing is the oxygen drops . When the disease progresses , the carbon dioxide can not be washed out and patients start retaining it . So he started having that problem . That leads to sleepiness and fatigue and lack of energy. He started having that . So I talked to him and his wife . He was started on  breathing machine which can deliver breath and oxygen and it is done with a tight fitting mask . This helps the function of the lungs . We started him on that for the night . The machine helps the lings and the muscles of the breathing . So during day time they do not get fatigued and patient feels better . He did get better . He was on it for more than 3 years and was doing OK . He did need the machine to be adjusted due to carbon dioxide retention. Slowly his ability to walk was reduced and the lungs were failing . So he had to use the machine had to be used during day time too . So now he was on it during night and then may be 6 hrs during day time -not continuous but total 6 hrs during day time.

     There was not much I could change . We treated him for his respiratory infections and gave him steroids off and on and he did OK . He did ask me one day ''Am I going drown the drain slowly?"I could not answer yes , but I did tell him that not much can be changed .
     I do yearly chest X-ray and most of the time breathing test . His lung function was so poor that I did not do it again. The chest X- ray was done and it shows a mass . This was highly suggestive of cancer . It was not very small . So I called him and his wife . Our options of treatment or for that matter work up to get diagnosis . Even doing the bronchoscopy was very risky as he may end up having more problem. The needle biopsy was impossible and open biopsy was out of question. . So only thing we can do was to do PET SCAN . The PET scan id about 85% accurate in predicting cancer if the PET is positive.
     I talked to them several times about the limited or not much options and suggested consider radiation evaluation and HOSPICE . He did not know what to do and I have not completed any additional tests as he did not want it and did not want to consider HOSPICE YET !!

     THAT IS THE ATTACHMENT TO THE BODY !!!

EXCEPTION TO THE RULE

      In medicine we were told that when we see patients , and the patient has multiple complaints , try to find out one diagnosis . In most of the patients , one diagnosis explains all or most of the symptoms. Try not to have more than one diagnosis. Again this did not apply to the things that patients had it like hypertension and diabetes and the heart attack history. So if one comes in with shortness of breath and headache and fever  and say chest pain , try to find out one diagnosis to explain all the symptoms . Once one is in medicine for many years , he finds out that there is always exception to the rule. So the story of my patient that I am going to tell one such story .
         I saw this patient for abnormal chest CT scan  He had cough and had chest X - ray and it showed some nodule and so the PCP did chest CT scan and then the CT scan was abnormal and so he was sent to me . He was 70 years old male and had history of heart attack and had some high blood pressure. He had cough and some white sputum . He had not lost any weight and has no fever and no weight loss. He had cough for may be 3 months . He was not smoker . The CT scan showed multiple nodules . All of them were very small. they were like dots and some may be like small pea. The PET scan , which picks up cancer in 85 % of the cases of the cancer , has limit on the size and so these were too small to be picked up . The PET scan needs size of at least 8 mm, preferably 10 mm. The nodules were 3-4 mm . The needle biopsy of then nodules was impossible as they were too small. The open biopsy could be done , but which nodule and with the given size and the lack of any symptoms , we decided to d the bronchoscopy to rule out atypical TB called MAC.

    The bronchoscopy was negative for cancer and the other tests on the lavage and the bushings were also negative for cancer and the TB or any mold .So we decided to do the follow up on the CT scan . I followed him for year and half and the CT scans .Some of the nodules disappear and some got smaller.. His cough was better and he had no other problem . He came for the follow up. I did Ct scan after 2 years  and it showed that one of the remaining nodule has grown . So I did PET SCAN . The PET scan did show activity in that nodule . He also had some other smaller nodules and they did not get picked up on PET scan..I did do new bronchoscopy and the work up was negative for cancer . But I was concerned and so We did needle biopsy of the nodule that had grown . It was cancer - type of  a cancer that is treated with chemo.But at the same time I got the report on the bronchial lavage , it showed MAC - atypical TB .

     So we had 2 different diagnosis. -both of them will need treatment at the same time.   

UNUSUAL CASE

     In my practice I have seen unusual cases . Some patients came for the complaints that are related to mu field -pulmonary medicines and the diagnosis was non pulmonary. Some came for pulmonary complaints and the diagnosis was not what was normal or usual . But some times I see patients , that have no pulmonary complaints and still they are referred to me  and then it becomes a challenge. The patient that I saw recently , was one such patient .

     When I see new patients I do things differently than what many do or what we were told to do . In medical school , we are told to start with chief complaints and then history of present illness and then past medical history, family history and personal history and the review of systems and then examination . I start with past history etc and then before examination I ask as to why they are in my office . So I saw this 67 years old patient . He had no significant past history except high blood pressure. H e was not  a smoker and did not drink alcohol  much . He  was otherwise healthy. So when I asked him as to why did he come to me , he answered that his primary care doctor told him that if anyone can help , it would be me. This followed by him telling me that so far he has seen 12 different doctors. So I asked as to what was the problem , he answered that HE HAS HICCUPS ALL THE TIME .! I was not sure as to how this was lung or pulmonary problem.. Granted  that the hiccup is spasm of the Diaphragm.and the Diaphragm is part of respiratory system . But this connection is too remote . Any way he had seen several primary care physicians as he had moved from Tampa. He had seen more than one ENT doctors and Gastroenterology  physicians. No treatment was successful . The hiccups were worse at night though they did occur during day time too. I asked him if he had any swallowing difficulties and he had none . But then he told me that he had some  doctor in Tampa do a study for it . Interesting enough and good for a change - he had the report. Normally I have to be detective in finding as to what kind of test was done and where was it done in most cases. I would say 70 % of the time . It is so time consuming that now a days my office checks couple of computer data on all new patients . Any way the answer was right there .

    He had what is called Esophageal Motility Study .In this test a probe is put in to food pipe or esophagus and the contraction of the esophageal muscles is recorded. The esophagus is like a sleeve and it has circular muscles and the wave of contraction of these muscles squeezes the food down . I have seen many patients that have the problem with this function of the esophagus. Typically we see this in disease called Scleroderma.. When I looked at the report , HE HAD NO CONTRACTIONS . This was the answer of his problem . The test was done the result was abnormal , but no treatment or co relation with his complaints were made. So when he ate solid food , it did not get pushed down and got stuck in food pipe or the esophagus . To dislodge it the diaphragm went in spasm and that is why he had hiccups. During day time he may not have been eating much or as much as dinner time as he was still working . Also he was upright and the gravity helped the food to go down. But after the evening meals, at 8 pm or so , he was going to bed at 9-30 or 10 pm and he was supine and then he got food stuck and so had more hiccups. At least this is my explanation. I explained him my thought and told him that he has to see a Gastroenterologist and there was no real treatment for this . There are some surgeons who do a surgery and it may be effective . I told him to go on liquid diet for 10 days and not have any food or even liquids after 6 pm . My thought was that if there was no solid food , then it will not get stuck and then the spasms of the diaphragms will not be there . But he was not very receptive to my idea and agreed to do it for may be 2-3 days .

       The jury is still out as he did not see Gastroenterologist for a month and I am not sure if he can offer any medical treatment .