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 !

Friday, May 25, 2018

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 . 

Saturday, May 5, 2018

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. 

Saturday, April 14, 2018

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 ???

    

Saturday, March 17, 2018

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 !!!