NO TWO OPINIONS

     Many years ago I was talking to a state elected congressman, who happened to a physician. He was telling the difficulties that physicians have to a good politicians and why the lawyers have no problems. Many of the politicians are lawyers. His point was that we physicians have single tract mind . If a patient comes with history of smoking and has coughed up blood and has abnormal CT scan of the chest showing a mass, we KNOW that it is highly likely to be a cancer and we KNOW only one way to do the work up.We will not tell to just watch it grow unless off course the patient is demented or has lots of co morbidity.But even though we may not do the tests or the work up due to the circumstances , we are very certain that the mass is cancer and we do not entertain any other thought. Now take an example of a lawyer. There is a divorce case and custody battle or case of tenant and land lord.Who so ever pays the money the lawyer is on his side and he will argue if needed in court that his client is right. There is no one side which right . But for medicine , high blood pressure is to be treated and there is no argument or 'other side ' , Same with high blood sugar or any other number of cases that I can tell . So the physicians are taught to have one particular way of thinking and we do not have to change our opinion due to some one paying me more money. So we can not be good politicians who can listen to both sides and can be swayed by one or other arty that gives them more money. But that brings me to the story for today .
       In medicine I am seeing more and more older patients and it is not uncommon for me to see few 80 years plus  and some 90 years plus patients.This has changed me and my decisions  and also the way in which one can approach the same issues that we had before. I saw this patient who was 90 years old . He has coronary artery disease and had high blood pressure and also was short of breath. He had some COPD ,  and needed some bronchodialater -medicines to treat his wheezing or bronchosasm.But on further investigation I realizes that he also had elevated pressure in lungs or what is called pulmonary hypertension.The medicines that I could offer for that were expensive and are special pharmacy medicines , which means they are to be ordered through the drug company and need right heart catheterizing to be done . The cost runs $30000 -year $30000 -I did not make mistake in adding a extra 0 .So the company wants to be sure that there is elevated pressure and the value is high enough to need treatment. So he needed cardiac catheterizing. The cardiologist was not in favor of doing an invasive procedure in this 90 years old patient . But the patient wanted it and so finally it was done . It did confirm the diagnosis of elevated pressure and I tried to start him on medicines .Due to the high cost of copay, I could get only one drug started and he did do little better.
So at each step of the decision I was 'OPEN' to treat or not treat this patient as the benefit of these medicines and the cost and the side effects may not be of value in this patient.
    In few months he continued to be stable  and had to be on oxygen 24 hrs a day and also was short of breath . The he developed more shortness of breath and the chest X- ray done did show worsening of the congestive heart failure . We had to pit him in the hospital and he had some fluid. In average patient I would drain it with a catheter insertion. But in his case - who was 93 years old now I was very hesitant to do such a procedure and decided to try to just 'watch' it with medicines being given .
So even though I KNOW the best way , I am WILLING to wait and watch . This s a change in my though process . BUT I WILL NEVER BE READY FOR THE POLITICAL ADVENTURE !!!!

JUMPING TO CONCLUSION

     As a child we used to read a book called ISAP NEETY , Isap was a slave and he could talk to or communicate with animals . There used to be a another book called PNACHTANTRA . In that book also there were short stories and the animals could talk . Every story in these books had some moral to be concluded and that was stated at the end of the story . In one of the story there was lady who had a mongoose. That was her pet . She also had a infant child.She had to go out of the house to get some water from the well.The child was sleeping and so she decided to go out in back yard to fetch some water. It took her some time to come back.When she came back she saw the mongoose at the door of the room with blood on it's face . She concluded that the mongoose attacked the child when she was out. She threw the water pot at the mongoose which almost killed the mongoose. She ran in the room where the child was sleeping sound and there was  a dead snake next  to the child . So when she was out , snake came in the room and the mongoose saw the snake  and attacked the snake  and killed it . So the mongoose killed the snake  and not the child . But the lady jumped to conclusion. This is not uncommon for all of us . We JUMP to conclusion without having checked all the information. That brings me to story for today .
       I saw this patient.in hospital as second opinion He was 74 years old male who was primarily followed by VA.He was a smoker and inspite of diagnosis of COPD , he had continued to smoke.He also had coronary artery disease and had 5 stents. He also had circulation problem and had shortness of breath on walking 50 feet or less. His breathing test had shown severe compromise and the flow rate was 22%only. He was in hospital  and had CT scan done . The CT scan showed a nodule. The lung specialist that was called saw the patient and wanted to do Bronchoscopy . The patient was short of breath and the nodule was too small to have adequate sampling with regular bronchoscopy. So there is a relatively new technique called navigational bronchoscopy .The computer with help of CT scan 'guides' - navigates- to get to the small nodules that are not seen with the scope. In my experience , this needs anesthesia  and is not greatly successful in getting sample or diagnosis unless one is expert in doing it . The patient refused the procedure and so I was called in to see him . HE was obese patient  and had smoked and was fairly well aware of his medical problems. His fear of the procedure was that with anesthesia, he may end up on respirator and then will have difficult time to get off it .And in my opinion he was right.In addition to that he had 3 CT scans at VA and  he knew the results  and he thought that he had nodule in the past . Not only he was aware of the CT scan findings , but he had 'access' to the reports . I told him to pull up the reports in the computer and he was right . HE DID HAVE NODULE REPORTED - SAME AS WAS IN THE CT SCAN THAT WAS REPORTED IN NEW CT SCAN! So with his advanced lung disease, the nodule being there before I suggested to do follow up on the CT scan in 3 months and then consider PET scan . He was not a candidate for open biopsy  and the newer Radiation technique for smaller nodules is only 5 sessions and it has great cure rate. So if indeed he has cancer one could confirm the likelihood of it being cancer -nor 100% and no tissue type known - by PET scan and treat it .
     Just because there was a nodule does not mean cancer especially if he had it for a while . I agree that this still could be cancer but the diagnostic test should not cause more problems . So jumping to do a test was premature  and just like that lady was hasty in concluding that the mongoose hurt her child. 

PERSPECTIVE

     We often use this term , PERSPECTIVE - Often it is stated that one should not forget perspective in life . In medicine we need to remember this more than in any other field. But I have felt that we HAVE FORGOTTEN it . I know how the things are done in past  and how they are done here . But I also know how things are done in other counties, including India  and how we are doing things here in US . I do not want anybody to think that I am  suggesting DEATH  agencies or more control on health care decision. But sometimes it is frustrating. I think the problem may be partly if not solely due to cost of health care is not being not paid by relatives - by the people who make the decision.It may be due to lack of understanding the ability or for that matter inability of the modern day medicine . But in any case we have a problem . The health care cost not the only thing to be considered in these matters , but also the suffering of the patient as well as the relatives who make the decision. I saw 2 patients recently  and that brought me to write this blog .
       I saw this patient few months ago . He is 78 years old and has the usual issues that many at that age have . He had hypertension and has had strokes and had developed dementia . He had atrial fibrillation in which the heart can throw clots and that can eat up the brain piece meal . This  leads to loss of brain tissue and that leads to dementia . So he did have dementia . But with the strokes he also had problem  the swallowing and so he had lost some weight and then the family agreed to have feeding tube for the nutritional reasons and also to give him some medicines which otherwise he could not swallow . He was tried on blood thinners to prevent clots  and he had blood loss and blood counts dropped . So he was taken off them . So on one side he had high risk of clots and so he should be on blood thinner , but on other hand he could not be on it as he had drop in his blood counts and so not being on the blood thinners the chance of getting mini strokes increased and that can make the dementia worse , On top of that he had developed severely leaky valve and that in tern caused the pressure in the lung to be increased . So he had aspiration pneumonia and had feeding tube and dementia and heart problems .
     I talked to his wife who was the medical power of the attorney and tried to have her agree for DNR- not to put on machines. He was seen by cardiologist and they stated that nothing could be done about his valve or the atrial fibrillation other than trying to control the heart rate. He did better with the antibiotics and then was discharged . He came back in  1month with episode of fall and low blood pressure and an abscess on the scalp. He had low blood counts again and needed to be transfused  and he was on antibiotics and he also had to have the surgery to drain the abscess. He was not only demented but was very uncooperative and would swing and try to hit doctors and nurses and would constantly curse. It is not his fault as he did not know much as he had dementia. I talked to the wife  and told her the limitation . We certainly can give antibiotics, which we did . We can transfuse him which we did . But the dementia and the aspiration and the leaky valve and the pressure built up in lung was not going to get any better . But she would not agree for DNR. The treatment is bandage approach as we are not treating the main problem dementia and stroke and the heart problem and so we treat the symptoms . But we are not 'helping' him or her . I am sure it is painful to watch our own relative 'suffer'  and be in hospital , but I do not know the reason for the not doing him DNR. She has  no liability for the bill  and may be the after life belief system  , may be fear of loosing husband - whatever it is , it is not helping her or him or the health care cost .
      

THE TRUE COST OF HEALTH CARE

    I have known that EVERYONE understand the money, from small child to old adult. When I tell patients about why they are short of breath, I tell them to think about the income . I tell them that if the income is reduce then they will be short of money. ( may be other than millionaires ). If the income reduced to less than half, then they will be very short of money to a point that they will have to cut down on many usual activities like eating out in fancy restaurants or going to a movies etc. So if the lung capacity is reduced they will be short of breath . I have not had any one ask me to explain after this talk . But we often complain about cost of many things -we say that health care is expensive or we are spending too much for defence budget. I do agree . This month when we were looking at the policies for individual health care policy , there is only one insurance company in State of Florida which does offer . The cost for $3759 deductible policy was $1700 per month , That is is even with no health problem . So that is outrageous . May be because we are paying for 'others' as they may have pre-existing condition . So we do not think too deep as to the cause of the high health care cost or cost of medicines . The same is true for defence. Majority of the cost for defence is personal and not weapons . This hit home as we just signed for new health insurance for year 2019 , but also I came across a patient .

      So I saw this patient few months ago . She is 68 years old and has had many problems like seizures after a brain surgery and had asthma and diabetes . I saw her as she came with pneumonia. She had pneumonia in right upper lobe . The pneumonia occurs in most cases when we inhale or aspirate bacteria  and it is common in lower lobes . The TB is more common in upper lobes . She was comfortable and did not have fever and had minimal sputum . We did CT scan and that showed that she had a mass in the right center and that was pressing on blood vessels and the bronchus in that area ,So I did a bronchoscopy and she had a tumour  and that was blocking the right upper lobe bronchus and so she had pneumonia , The biopsy showed that it was a CARCINOID . The carcinoid is a tumour that some call it BENIGN tumour that can SPREAD or some call it MALIGNANT tumour that grows very slowly -even sometimes it takes years . I called radiation doctor and cancer doctor . I wanted radiation treatment as this lady also had liver problem and some other issues and I was not very keen on chemotherapy. The oncologist wanted additional biopsy  and so we did it  and it did not change the diagnosis . ( The carcinoid could look like small cell cancer of the lung  and the treatment would have been different if it was small cell cancer).So she was discharged and started on chemo .
      She was readmitted with elevated blood sugar and number of other problems after chemotherapy . She was in ICU and then did well and was transferred out of ICU. She was weak and so physical therapy was started . She was doing good except for the need for the PT . So we asked her to be transferred to rehab unit for 2-3 weeks, Every thing was approved , but she continued to be in hospital . I was not sure as to the hold up . Her lungs were clear and she was not on oxygen and she had no shortness of breath and all the intravenous medicines were stopped and her kidney function , blood count and blood pressure were OK. So I was not sure . I contacted the case management  and the answer I git was what made me write this one . The rehab unit gets paid certain amount which includes the cost of the drugs /medicines. She was getting chemotherapy - one daily  and one every so often . The cost of only one of the drugs that was given daily was -are you ready - $17000!The rehab unit was not going to get any money to do the rehab and her stay if they paid the chemotherapy cost . So they refused to accept her . So SHE IS KEPT IN HOSPITAL FOR 5 DAYS  and the cost of the health care continues to rise .
    (I suggested to hold the chemo for 2 weeks if the oncologist and the patient will agree as i do not think it will alter the outcome in this patient with carcinoid that I am sure has been there for last few months if not years )
    

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 ! 

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 . 

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 '.