Thursday, November 22, 2018

COLLATERAL DAMAGE

     In medicine I see all sorts of things , some routine and some not so routine . Being a firm believer in reincarnation , I try in my own mind wonder as to the cause of the miseries and also how people behave..I am not enlightened enough or may be enlightened at all , that I can explain everything and my hope is that one day I will meet someone who is enlightened  and guide me to be enlightened . Until then I use common sense and power of deduction .Many years ago I had asked some one that I thought was better than me about this question . In criminal code , the judges were given guideline as to what punishment would be appropriate for particular crime. So is there a Sacred Book that will tell us to the punishment that one could expect if he deviates from the RIGHT thing . So if I take a pen from the hospital or a towel from hotel etc what are the consequences of my action ? So if I am aware of the reaction to my action , I can better decide as to do it or not. But there is none . I have heard that the SUICIDE is one action that has very strong or bad reaction . I do not know why .But this brings me to the story of a patient today .

       I saw this patient , may be 71 years ole for chest congestion . He has been smoker in past and he had mild high blood pressure that was well controlled with medicines . He had cancer of the throat - larynx , and so he had surgery and he had to use a hand held machine for speech . He was doing well . But had noticed some chest congestion and he had cough and then he would get short of breath . When I saw him in office , he came with his wife . His lungs sounded clear and he had good oxygen saturation and e was quite comfortable . His PCP had done chest X- ray and that was fine . He had the laryngectomy stoma -when the larynx is removed there is a hole in the front of the neck and one breathes through it rather than nose or mouth .The purpose of the nose and the hair in the nose and the mucous membranes in nose and the throat is to 'filter' the air and make it warm .So the dust and the cold air does not go to the lungs . When you bypass the nose and the throat , this advantage is lost . So the bronchial tubes get dried out and the mucous becomes thick and dried. This will cause problem as one can not cough up thick mucous easily . So I told him to use humidifier as much as possible for the laryngeal stoma and also put him on nebuliser treatments with medicines that could open the bronchi and help the secretions. He did very well . I continued to do follow up and he was stable patient for more than a year .

    One day he called me and asked me for an antibiotic. He was congested . So I did call in antibiotics , but I also told him to do more nebuliser treatments  and also started him on steroids. He got better but he again called me in 2 weeks and wanted to have more steroids and antibiotic . He had similar problem again . So I  saw him and he was OK and I did again the same thing . He got better .
3 weeks passed by and he called me again . He has am problem . This time I told him to come to ER as I was not sure why he was having same problem all the time . So he came to ER . I saw him in ER .He looked about the same . The lungs were clear and he had good oxygen saturation . The blood pressure was OK and even the chest X- ray was OK . There was no pneumonia or any other abnormality . He had no fever and he was comfortable. I decided to admit him and treat him for respiratory infection..We could also watch him , give nebuliser treatments round the clock and steroids and the antibiotics  too. We can also suction the airways if needed . He was not very happy . He was feeling fine and all that he wanted was antibiotics and some steroids.

       I saw him at 6 pm and that was the last time I saw him . At 1 am he had cardiac arrest and he had CPR  and he died .I was shocked and so was the wife . I called her at 1 am and told her to come to the hospital ASAP . She did but it was too late . I spoke to wife again next morning and then she came to my office to thank me when I had not done anything . ( I think in her mind I ADMITTED him  and so she did not have the burden of guilt if he had gone home .)
       I also saw her in hospital one time and she hugged me and again thanked me . She looked OK She was still mourning but who would not after loosing a spouse of 40 years plus . Then one day a nurse told me . She reminded me of this patient and asked me if I remembered the patient. HOW could I forget /

   She told me that his wife committed  suicide  and shot herself ! 

Saturday, September 22, 2018

HOW AND WHY IN MEDICINE

       In medicine we often asked the question as to how does someone get cancer and why does this happens . The common diseases like high blood pressure or diabetes , no one asks this question . In pneumonia or Tuberculosis , we know the answer of how , but not why . One can say in case of Diabetes , that the insulin lack causes the diabetes , But we do not have the answer to 'why' . In high blood pressure we do not have any answer as to how and why . In case of cancer  we know NOTHING . We do have bits and pieces on to how cancer develops . We know that chronic irritation or tobacco increases the 'chance ' of getting cancer . But we still don't have the answer as to how and why . But today I am talking about a patient where there is how and why , but in a different way .

      I saw this patient who was 68 years old and had some cough and then the primary care physician did the chest X -rat and then the CT scan , The CT scan showed a nodule . He was a nonsmoker . He had history of prostate cancer and it was treated and 'cured ' He also had tonsillar cancer and it was treated and he was 'cured ' He was not a smoker and he had no other major medical issues . His physical examination was unremarkable . He had clear lungs and the oxygen saturation was good. I did PET scan and also the Bronchoscopy . I also did the breathing test . The breathing test was good and was normal . He underwent bronchoscopy and it was normal . The nodule was too small for me to do any biopsy. The PET scan where glucose is injected and the uptake is majored . The higher the metabolic rte , higher is the glucose uptake and higher is the chance of cancer . The PET scan showed increased uptake though it was not very high . So i saw him in the office and discussed the various options . One option was to do a needle biopsy . The needle biopsy has some risk of collapse of the lung and the sample is small and so not 100 % if it does not show cancer . The other option was to do follow up of the Ct scan . The good part about it is that it may 'save' an unnecessary  surgery , but the disadvantage is that if cancer , 'waiting' may increase the chance of cancer spreading . The first Ct scan and the time that all this happened was almost 6 weeks . I sent him to chest surgeon . The surgeon did a new CT scan and it showed that the Nodule had increased by very small amount . But taking in to account the PET scan finding and the small but definite though small increase in size in short time , we decided to do the open biopsy .
      The surgery went well and he came back for the follow up . The pathology showed that he had MELANOMA which is skin cancer in lung . That meant that the melanoma - a skin cancer has spread to lung , But he had no history of the melanoma ,nor the PET scan had shown no activity or pick up anywhere but lung nodule. So the patient asked me as to how can he have the skin cancer spread to lung when there was no skin cancer in first place. HOW is this possible and WHY did this happen ?I do not have the answer . 

Friday, September 14, 2018

I DON'T KNOW

     In medicine we , physicians do not ever want to sat ,'I don't know.' nor the patients want to get answer from their that they don't know . But truthfully we do have patients where we truly don't have the answer or know what else to do .If the physicians don't  know the diagnosis or have answers , then what kind of hope patient has or what kind of treatment they can expect ?Recently I came across some patients where I had not much to say . My unfortunate problem is that there is no other physician who has answer.

      So I saw this 70 years old patient almost a year ago . He has been a smoker and had some cough . His primary care physician did a chest x- ray and it showed abnormality . So I saw the patient . I did the work up . He had claustrophobia and could not and refused PET scan . I had tried mild sedation , but he could not do it . He did have a CT scan and that showed a mass at the center of the left lung . I did the bronchoscopy and there was narrowing of the bronchial tube going to left lower part of the lung . I did do some biopsy and that came back OK . I did follow up and did new CT scan . He also saw thoracic surgery and it was felt that we will do follow up on the CT scan . The follow up CT scan continued to show the abnormality and it was not any better or worse. I did second bronchoscopy and that showed the same findings and so I again did some biopsy and it did not show any cancer. I sent him back to the surgeon and asked him to do bronchoscopy or any other biopsy that he could do . I was concerned about the cancer . He told me that only 100% way to get the diagnosis was to take out entire lung . The patient was not keen on it and I was not sure if that surgery would be curative in view of the CT scan findings. He did do the Bronchoscopy under anesthesia and he had the same findings and the deeper biopsies were negative for cancer . We did new CT scan and it showed increase in the mass .So I sent him to a different chest surgeon. The new surgeon did get the PET SCAN done and it did show that the mass was metabolically active . This was highly suggestive of  a cancer . There was no other area in the body that showed the uptake , which meant that if this was cancer , there was no spread of the cancer. So he suggested taking out entire left lung . He came to me with family . He agreed and so the surgery was done . The left lung was taken out He did well.
      He came back for the follow up with  his wife. The surgery was done in different hospital and I had not gotten the report . So when he came for the follow up , I git the pathology report. To my surprise the pathology showed that indeed there was cancer . But not like I had suspected . It was not lung cancer . It was SALIVARY GLAND CANCER THAT HAD SPREAD TO THE LUNG !!
He does not have any abnormality in the salivary glands and there is no cancer there. nor the PET SCAN ever showed any abnormal pick up in salivary glands . So when they ask me as to how can he have cancer of the salivary gland spread to lungs , when he does not have cancer in salivary gland , I had to say 'I  DON'T KNOW '.

Friday, August 31, 2018

LUCK

      I was reading an article from one of the Indian magazine . It was about the statistical probability and the prayers. But the question that arose in my mind is can you change the destiny with efforts or prayers? There is  story of a king in Mahabharata , where the king knew that he was going to die of snake bit .So he gets out of his Kingdom and becomes easy  pray for the snake . This brings me to my today;s story .

    I have known this patient for several years . He had bad lungs and had sleep apnea .He was obese and had cardiac issues . He had open heart surgery too . he was doing OK . But he had multiple problems . One day he was hospitalized for pneumonia and then he had pus collection in the pneumonia -what is called lung abscess . He needed antibiotics for long time . He improved , but the chest X- ray and the CT scan continued to show the abnormality I continued to do follow up for several years . I had also done Bronchoscopy and all the work up was negative for cancer . This  continued for 5 years . Then he had back problem and went for surgery . He had major problem and was in and out of hospital and needed antibiotic . He did improve . The a year down the road he was in hospital for heart problem . I did  see him and did CT scan of the chest . It showed the same abnormality , which was due to old abscess may be 4-5 years ago . But there was a new nodule . So we decided to do some work up . He was ot in the best shape , but we did follow up CT scan and then the PET scan . The nodule increased in size and so I did send him to Radiation doctor . . We decided to do the biopsy . The needle biopsy was done and it showed the lung cancer . It was very small and so we did radiation treatment called steriotactic radiation. He did well and the repeat CT scan and then the pet scan did not show any cancer . He did OK for next 5 months . Then one day he had nausea and vomiting and felt weak and could not do much walking and so he came to hospital.
I saw him and then the work up was done . He had no sign of the cancer where he had biopsy confirmed cancer , but the other nodule - which has been stable for few years was minimally enlarged . But he had nodules in Liver . We did additional work up and he has cancer in spine and liver and lung . The biopsy was done and it was confirmed that he had what looked like lung cancer , but the type of cancer that he had this time was different than the first one that we treated 6 months ago .

     He was seen by radiation doctor and cancer specialist . Next 2 weeks down the road his condition deteriorated to a point that we decided to put him on Hospice .

    So we watched the nodule and it was stable and we treated the cancer that we diagnosed , but we could not  'change' the outcome or may be destiny  or LUCK !!! 

Friday, August 3, 2018

COMPUTERS AND MEDICINE

      Recently I came to know about the old IBM building new IBM computer for medical diagnosis. The thought process of making a diagnosis is like computer . The history is like data fed in to computer and so is the physical examination and then the computer will make some 'Differential Diagnosis 'or the various possibilities , based on the data fed . The possibilities in Differential Diagnosis are listed in order of probability. So the number one would be most likely and the last one on the list would be least likely. So the precess is similar when we do not use computer and use the Human Brain as the computer.. We do not us the computer in day to day medical life and we do not need one and  it may be time consuming and may be even confusing . I was told that the new IBM computer is more accurate than the best of best clinicians . My issue with this process is the problem of the Data that is fed . The computer gives the diagnosis based on information that is given to the computer. The human brain is same . If we as physicians do not put in or get accurate information , the diagnosis can not be accurate. This brings to my my today's story.

      I was called in on a consult for this patient who was 38 years old . He was diagnosed to have pneumonia by hospital doctor . When I saw him , his mother was bedside . He was a nonsmoker and did  not consume alcohol He was working in a office and had no dust exposure. He was sick for almost 6 or 8 months . He had gone to walk in clinic and was told to have bronchitis . He was given antibiotics and sent home . he continued to have problem and so he went to see family doctor . He was given cough syrup and some more antibiotics . The chest x- ray was ordered . He continued to feel poorly and now was short of breath . He went back to family doctor and was given an inhaler. He was told to do CT scan . His copay was too high and he did  not do it . The shortness of breath got worse and so he came to ER and was admitted . In ER the CT scan is done and he was told to have pneumonia. I saw the patient . He had some congestion on the back side of the lungs. He was on oxygen . When I saw the CT scan I was more concerned . The CT scan had extensive congestion ,in both lungs . It was not like typical pneumonia . So I was not sure  as to the cause . He did not have much fever .
    I ordered the blood oxygen and when it came back with low oxygen , I decided to transfer him to ICU. He was also anemic and he told me that he knew that and was told to take iron . ( I was not sure why a young male would get iron deficiency anemia  ) I ordered number of tests and antibiotics . I also called the infection disease consultant . They ordered more and ordered HIV or blood test for AIDS . So I talked to them . While taking history , I had asked him as to the sexual history as the thought of AIDS causing the anemia and the chronic sickness and atypical pneumonia had crossed my mind . He had told me that he did not use any drugs and he had not had any sexual exposure in last 20 years . So I was shocked when the test for the AIDS came positive .Thai solved all the mystery. The anemia and the chronic sickness, and the atypical pneumonia etc were all related to HIV .

      So the Brain computer of mine did not get the data of some risk factors was not 'entered ' . But the Infectious Disease doctor , did not pay any attention to that information and just went with 'instinct' . The instinct was correct ! 

Saturday, July 21, 2018

HISTORY-PHYSICAL-LAB

       In medicine that I learned we had to do first history then physical examination and then do or order tests. Now a days the process is reversed . I still remember when one of the functions that my wife was attending, some one had transient blackout .. some one called 911. The lady was fine , but she was taken to hospital ER . I was in the hospital and my wife called me . So I went t Emergency Room . When I went to ER she was being brought to ER . So I was there from the very beginning . As the patient was brought in the ER , she was taken to one of the room right away. The nurse came in and she  gave her the gown , She checked the blood pressure and the oxygen and started the IV line . Then the tech came in and drew blood . Then the cardiogram was done , Then she was taken to radiology and chest X-ray was done and then the CT scan of the chest was done . I was there all the time . All the time this was done , there was no physician seen or she had seen him/her.
   Since I have access to the medical records, I checked them and the blood tests and the CT scan and the chest X- ray - all were OK . So I told them that the tests were OK . Then came the ER physician .
He asked not more than 2 questions , told me and the family that all the tests were OK and ideally he would put her in for 'observation' for a day . The patient did not want to stay and so she was discharged . No history was taken to see why she had blacked out . The process of HISTORY- PHYSICAL-TESTS - was reversed . The tests were ORDERED based on what was told by ambulance paramedics , then the doctors came in and hardly did the history or physical examination.
     This brings me to the today's story. I saw this patient who was 66 years old female. The reason for the office consult that we were told was abnormal CT scan of the chest . She was a current smoker
and she had CT scan done and it was 'abnormal' So she was sent to me . I asked her as to why was the CT scan done . She had lost 30-35 lbs of weight , So the PCP did CT scan of chest and ABDOMEN- belly and Pelvis. The CT scan of the belly and pelvis was OK . But the CT scan of the chest showed 2 tiny nodules , 2mm and 4 mm . 25 mm make an inch , so they were very very small . So Small that hardly any test would tell us the diagnosis. . So I asked her as to why she has lost weight - is she not eating or she has no appetite or she has problem with swallowing  etc . She told me that she has good appetite , but she throws up every time she eats and she feels that food gets stuck and then when she vomits she gets the relief . . I did further inquiry and then examined her and then told her that I was not concerned about the nodules , but I was concerned about the HISTORY OF vomiting and food getting stuck . I was worried that she may have esophageal cancer .
      I ordered the tests to check the esophageal and told her that she needs to see gastroenterologist ASAP. I told her that the nodules were so small that Bronchoscopy , or PET scan or needle biopsy or open biopsy  were of no use in getting the diagnosis and so we will have to repeat the CT scan in 4-6 months . She had very strong family HISTORY of cancer and Lung cancer and so she wanted me to d beonchscopy .So I ordered it , but also did the X- ray of the esophagus .
    The bronchoscopy was K nd the X- ray of the esophagus showed that it was narrowed at the end and it was not having any contractions . So the food was not MOVING down . So she will need the gastroenetologist to check it out to see what could be done .
      So it was HISTORY that made me ORDER A TEST  and not the other way around . 

Friday, June 15, 2018

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 !