COVID AND TELEMEDICINE

    Telemedicine has been there for sometimes now. But Most of the Insurance companies were not paying for any medical service that is done without direct contact -in person -patient care. I have done antibiotics  and other medicines advice and prescription without getting paid  and that is fine b. But I still don't like to do Telemedicine as substitute for patient bein seen with direct contact. There is difference between watching a movie on TV or computer and attending in person a Broadway play Or attending a basketball game in arena V watching it on TV is not same. But now a days in hospital many consultants are not only allowed to do telemedicine for COVID positive patients , and are encouraged to so . In the beginning it was to save on PERSONAL PROTECTIVE DEVICE . But it has continued. This story is related to that 

   I have known this patient for few years. She is in her early seventies  and has had COPD - smoking related lung damage  and also had weak heart . Her pumping action of the heart was 25% at one time . She had a device inserted called ICD and she had improved . She needed the battery change and so she had COVID test done and that was negative  and she had the procedure . Every patient that has any procedure .surgery, endoscopy done in hospital, has to have negative COVID test She had some problem after the procedure  and she was kept in hospital for 24 hours .She was sent home and then in 2 days she has some shortness of breath and so she came to ER. She had as expected COVID test  and that was positive . I am not sure how she had COVID when she had not gone out of house after discharge. She had many reasons to be short of breath - bad lungs and weak heart. But since COVID test was positive everything changes. Infection Disease specialist was called  and new COVID routine ordered were done by the specialist . He did not see patient . It was telemedicine consult  and she was started on Rendesvir  and steroids were started . The hospitalist also had seen patient. I have known her and so I was called  and I SAW HER IN THE ROOM  AND EXAMINED HER . I also saw CT scan and did not feel COVID had anything  to do with her symptoms  and if it was not for COVID she would be treated for lung and cardiac diseases. She did better with the treatment that I had started or may be due to the treatment of COVID .In any case she was better . But one day I saw her  and she told me she had bad night  and could not sleep and she could not be supine  and walking 5 feet she was short of breath. I asked her if she was seen by Infection Specialist doctor   and hospital doctor. She told me that it was telemedicine call from specialist and when she told her that she was more shor of breath, he told her that we will take it day by day. The hospital doctor saw her very briefly  and was talking to her from door . I saw her and knew what had happened . She was getting lot of fluid as ROUTINE for last 3 days  and with her weak heart she was not able to tolerate it  and so she was in congestive heart failure . I stopped her fluids  and gave her medicines to have more urine . When i checked her next day , she was like new person. Within less than hours of getting medicine she felt like pressure was relieved .

    She continued to improve  and new chest X- ray had nothing to show anything to suggest COVID worsening in lungs . So the Infection specialist  and hospital doctor who did telemedicine  and did not check patient miss the real reason for the shortness of breath. The routine set of orders sometimes need to be changed . 

SAFE DRIVING

    To get a driving license one must take a driving test and also do written test to show that one has enough knowledge of driving  and safety and rules and regulations . But we know that just because one got the driving permit does not make him or her safe driver  and many a times one accident can ruin the insurance risk and also damage the car and also sometimes life . I am often reminded of this when I see certain patients  and I also tend to explain patient on risk of accidents. So this is the story of a patient but it applies to may of today's patients as we are seeing aging population  and also certain patients who recover from stroke who in past may not have survived . 

     I saw this 94 years old patient in my office for congestion and cough . I had known him as husband of one of my patients  but he was not my patient . He came with his daughter as he had lost his wife who was my patient in recent past . He had mild high blood pressure and no other major problems and I had known him to be the care giver for his wife who was fragile and sick  and never thought of his age . He was having cough for last 6 months and has been treated with antibiotics and cough meds by PCP  and he has had 3 courses of antibiotics  and he has done little better but he still had cough and congestion  and so they decided to come to me .He was not in any distress  and his blood pressure was good and his oxygen saturation was on low normal side. He did sound congested and he had what looks like productive cough, but he was not able to cough up easily. He did not have any chest X- ray and so I ordered chest X- ray and also set him to get breathing test . He had no problem swallowing , but I ordered the swallow study . I also gave him some mucous thinning medicine  and also ordered nebulizer treatments  and also put him on medicines -bronchodilator The reason to do the swallow study was my previous experience . In many elderly patients , -even though they may not have problem swallowing- they have some aspiration- food or liquids going wrong way in wind pipe-trachea and then lungs .  

    As it happened he had a fall and he went to ER and was admitted . I had also done CT scan  and hat had shown some infiltrates - what one might see in pneumonia and I had started him on antibiotics. When he was admitted, by hospitalist, he had another CT scan -within less than a week - waste of heath care money-and it did not add to our information. I did the swallow study and also continued what I had started as oi=ut patient , The swallow study did confirm my suspicion that he had silent aspiration. He did not do that every time  and not same with all consistency.. So the speech therapist advised some instruction - some precautions to avoid the aspiration. Over period of next 3 days he got better and oxygen saturation improved and congestion improved  and he was ready for discharge . 

   So he had aspiration pneumonia when I saw him and that got worse when he was admitted  and he was discharged on precautions to prevent aspiration. But as i was saying one can drive safely for months ot years , and then one can get in an accident  and that may be devastating -economically or insurance or health wise. This is my concern when we talk about aspiration. One may do ok 10 times or 100 times or more , but one day or sometimes even everyday one may have SILENT ASPIRATION and that can cause chemical bronchitis - inflammation, that can lead to cough ,congestion and even pneumonia  and if it is bad - sepsis or death. This risk is there. Unfortunately there is no answer to this as we can not be doing feeding tubes in everyone who has this problem . Certainly if one has 3 accidents then the liscence to drive will  be suspended. Same way if one has 3 episodes of aspiration pneumonia, then we should consider SUSPENDING eating and do feeding tube . 

 

MEDICINE AND DR G

     Now a a days one can find anything on Google . One can search any song, any information, any news and anything and everything in medicine. This has lots of advantages . I can tell patients to check out certain things . e.g. portable oxygen concentrator - the machine that absorbs room air  and filters out nitrogen and produces oxygen So when someone asks me about the brands or cost, I tell them to check it out. Same with CPAP cleaning device - CPAP the machine that is used for sleep apnea. Or even I tell people to check out cost of medicines in Canadian pharmacy. So it is not uncommon for me to see someone who has questions based on Google search. Now a days many patients are told to ask their physicians certain questions  and that is also OK with me . I will tell you that people have done studies and they have timed physicians interrupting patients every 20 seconds or so - I ma not be exact in time but it is seconds and not even a minute for sure . So I am aware of that . But I have also known certain web sites asking patients to get second opinion. Again I have no problem with that either but the problem is getting second opinion for certain simple things-where there is no possibility of SECOND opinion is waste of money for sur and may be at times WASTE OF TIME. Say if Blood Pressure is 180/95 That is High Blood Pressure  and there is no second opinion - yeas one may have difference of opinion on which drugs to use or dose etc. but not about the diagnosis . This brings me to the story of the patient . 

     I saw this patient who had some cough going on for 2-3 months , The PCP treated it with antibiotics and some other medicines and he did not get better. So he had chest x- ray . He has no old x- ray in several years . The x- ray was abnormal and he had CT scan as he was ex-smoker The Ct scan did show a mass . So he came to me .We talked for 30 mins  and I explained him that we have to answer 3 questions 1 Is it cancer 2 Has it spread  and 3 What can be done -if it is cancer or suspected cancer . 

    We di the work up. We did bronchoscopy and did PET SCAN  and the breathing test The pet scan did show increased uptake  and that was suggestive of cancer - not 100% and it is never 100% . The bronchoscopy did not give us the diagnosis. The breathing test was Ok acceptable if we wanted to do surgery to resect the part of the lung. So I discussed with him and told him that the high possibility of cancer though we can never say 100%. I told him that we have 3 options 1 see chest surgeon and get an opinion to see if we should do open biopsy and take it out .2 Do needle biopsy which has some risk of collapse of lung and the chance of getting the diagnosis was not 100%  and if negative for cancer I would still consider open biopsy which is only thing that can give 100% diagnosis.3 Do only follow up CT scan in 3 months and see if the the mass increases . 

    To me there is no other option and there is problem with each of these options . The open biopsy may show that it is not cancer and we have done UNNECESSARY SURGERY, The needle biopsy has risk and diagnosis is not 100% ( I have seen recently couple of people with complications that needle them to be admitted to hospital )And wait and watch approach - has problem too. If it is cancer then in 3 months it can spread  and may become INOPERABLE. So ONE HAS TO ACCEPT THE RISK IN EACH OF THESE APPROACHES. 

   The patient after listening to all these wanted to get second opinion. I have no problem with SECOND opinion and I thought that the surgeon - a chest surgeon will be the second opinion. ut he was convinced that one must get second opinion based on his RESEARCH .!

(Just a foot note - there are other new procedures that can be done  and the diagnosis is not 100 % with them either.)

    

ARE WE EVER READY

      In medicine we often have health and sickness and also life and death situations or need for making such decision. This is not surprise at all. But sometimes for a physicians to bring up the topic of DEATH is not well received  and some time patients or the members of the family are not happy that I bring it up. 

   I had seen this patient for last couple of years and she was 75 years old female who had chronic cough  and so she had work up done and she was told to have got Fibrosis or so called IDIOPATHIC PULMONARY FIBROSIS. The disease is uniformly fatal. But in my experience that happens in 20-30 % of the patients  and some get worse rapidly and others slowly  and some never get bad enough. This is not what the medical literature will state. Again this is based on diagnosis by CT scan . Anyway she had fibrosis  and also it was or it had gotten worse. She was short of breath and had chronic cough and I did the work up and she needed oxygen  and she would drop her oxygen level even walking few feet and she needed oxygen 24 hrs a day . She had CT scan - High Resolution CT scan  and she had the typical findings of fibrosis  and so we did routine work up and then started her on a  relatively new medicine called OFEV . This I think was approved by FDA in 2014 or 2015 . She was doing OK and she continued to have problems Due to progressive nature of the disease, I discussed with her and the family on  lung transplant  and she wanted to go to a university center as some of her family was there. The appointment was postponed as the center was in another state. She continued to have very limited activity and was some what stable. She had some cough and she seems to be stable with Ofev . She had appointment with the transplant center after 6 months  and she decided that she did not want to have transplant as she felt 'she was too old '.She then had respiratory infection and she was more short of breath and so she was admitted . She had new CT scan and that again showed fibrosis, but also showed a new density at the edge of the lung . I was not too sure as what that was as it did not look like typical cancer. I asked her to get me old CT scan cd. I looked at it and in old CT scan that area did not show the density. So when she came to my office , she came with her son. I explained them the new findings  and told them that I am concerned about developing cancer . I also told them that if it is cancer she was not a candidate for invasive work up given her poor lung condition . The bronchoscopy would not get to the area as it was at edge of the lung . The needle biopsy - by putting in the needle from chest wall in to the lung was possible but there was very high risk of collapse of the lung as puncturing lung was a possibility . Certainly 'cutting it out ' by surgeon was out of question. So I ordered a PET scan and told them on what could be done as treatment if at alll we can do some without biopsy . 

    At the end of lengthy discussion I also told them that she needs to have living will and decision as to what she would like if she could not breath or her heart stops --the so called DNR status. OI told her that if she would go on ventilator, with her given lung capacity, it will be impossible to wean her off the ventilator. So then the family will have to make decision on so called "pulling the plug". So it will be better if she has discussion with them and make decision in advance. I also suggested that she should consider not going on respirator or make  herself DNR  by signing forms. She seemed to be receptive . But the son told her that he does not think she should be DNR  and we should do everything possible . I told her that that is why she should have discussion with family members. So that will avoid the conflict when the time comes.

   DO YOU THINK WE ARE EVER READY ?

RIGHT OR WRONG

    In life most of the time we have situations where average person or for that matter even kids know what is right and what is wrong. Even when child is caught with his hand in cookie jar , he tells mom that he was getting the cookies for mom. So we all know most of the time and there are some situations where the situation is not clear  and one could go either way and both things may be right. We in medicine have certain situations where we could go either way and will be considered right. Just to give an example, one at certain time in our life can decide not to go on respirator  and some may want to do it even with the odds against the survival and we can not fault the decision . I came across such a situation recently . 

     I was asked to see a patient in office for abnormal CT scan . I was told my office that there was a patient who had lung mass per primary physician and they wanted me to see him soon. So I saw the patient soon He was 89 years old male who had not smoked for 40 years. He had dementia  and so the family wanted to put him in day care for day time  and the center needed  chest X- ray  and it was abnormal. So the primary care did CT scan and that showed a mass and so he was sent to me . 

  When I talked to the family - the wife and daughter , the patient did not answer any questions  and he could not tell me the day or the month and also the name of the US president . He had bladder cancer many years ago and he had no pulmonary complaints He looked very comfortable  and had no idea as to what  was going on and why he was in my office. I reviewed the CT scan and talked to the family. He had what looked like cancer . As his bladder cancer was many years ago I felt that this was likely to be due to cancer of lung . So I told them that we normally like to answer 3 questions  Is it cancer , Has it spread  and What is the treatment choice. So I asked them as to what would be the choice of treatment . I told that  I don't think he would be a candidate for surgery due to dementia and age even though the stage of the cancer was resectable. The chemo would be very bad  and should not be considered. So the only treatment  that could be considered would be radiation . I   i also told them that DOING NOTHING would be also an option  and that may not be bad idea as with his dementia, not much could be changed and he was 89 years old . So the good patient and physician could do PET SCAN and offer radiation and good physician and patient or family could consider no treatment and no work up. Either way is right  and wrong 

WHAT CAN WE DO

     The health care is changing for many years . We used to have family doctors and primary care doctors used to take care of the patients in offices and also in hospitals and also 'answered' to the questions  and treated minor element on phone after hours . But that all ended with HMO - the so called Health Care Maintenance organization that in my opinion decreased the quality of medical care  and also reduced income for many and most physicians  and made money for 3 piece suits - the so called management of theses HMO. Now the dust has settled on that change  and we have gotten used to the change  and have accepted the obstacles that ordinary physicians have to face due to rules and regulations -that are primarily meant for reducing cost and not helping any patients,-we are seeing another problem . This has been brought to surface more due to COVID. This is aging population. So that brings me to today's patients . 

     I was asked to see 2 different patients - happened to be in 2 rooms next to each other . One was 91 years old and other was 02 years old . Bothe of them were awake, alert and orientated . They both had a fall and that was not related to any black out spell or dizziness or anything unusual in the house. They both had rib fractures on right side. Fortunately they did not have much fluid or blood related to rib fractures  and had no puncture of the lung. They were admitted  and I saw them . They were pretty much with the program  and they were not in any respiratory distress. Their oxygen level was normal. So I spoke to the families and told them that we will watch them for a day or so and ask them to take deep breath and that will prevent collection of secretions  and then that can lead to pneumonia. The body does not do anything that causes pain and so with rib fracture of ribs, the patient automatically takes shallow breaths as deeper breaths will cause pain. But this shallow breathing and not coughing as coughing also causes pain , will lead to secretions not being cleared and then getting infected  and that causes pneumonia . So all that we as physicians do is to give pain medicines  and ask patients to take deep breaths every hour or so. So as per my plan they should be ready for discharge in 24- at the most 48 hours. 

     But as it happens the things don't work out as we like it to. The patients did well . The pain control was good  and the oxygen continued to be good breathing room air  and they did get out of bed and walked with physical therapy. So in my estimate they were ready for the discharge. But the problem was with the age. Both the families felt that they could not go to their prehospitalization level of living. They needed more physical therapy. So they had to be discharged to physical therapy unit. So now comes the COVID problem. We had to have COVID test done  and that has to ne negative . One family did not like one unit that was approved on her HMO insurance  and so we had to look for another one.So what could have been treated as out patient in younger patient, needed hospitalization. What I thought will be only 1 or 2 days became 5 days in one  and 6 days in other. 

HOSPITALIST AND MODERN DAY MEDICINE

         I have been in medical practice for many years and I did practice medicine when the family practice physicians did go and see patients in hospitals. Then the HMO insurances under misguided thought process decided that 'employing' some physicians who do not have office practice  and do only hospital practice can 'save money' -the sole goal of Insurance company. I still remember that the family doctors complained about this  and then the insurance company decided to 'allow' these physicians to see patients while they were in hospitals , but they will mot be paid. Now you tell me who would see the patients manage  and take risk  and not get paid . So they stopped seeing their own known patients in hospitals a nd thet lead to crop of new group of physicians called hospitalist. This is suppose to help health care. In my view they have added NO BETTER CARE  and have increased EXPENSE. But I am not writing this blog for my view but want to tell about everyday problems that people like me face as consultant. So let me give stories of 2 different patients.

    I have known this patient for long time  and he had sleep apneas and I used to see him every 6 months . When he came to me last time, I was talking to him and realized that he had diverticular abscess - collection of pus due to infection in colon . He had no lung issues  and I admitted him and did work up and got him started on treatment and drained abscess and he was seen by people that could manage this condition- surgeon, infection specialist. He was discharged  and I did not want to see him as his problem was not related to my specialty .By the way he had seen gastroenterologist before I had seen him and decided to hospitalize him. 

     I had forgotten about him  and then the wife called me  and wanted to know if I was out of town as I did not see him. I called her and found out that after the discharge , he was OK  and then in 3 weeks he had seen infection specialist  and he did new CT scan of belly and that showed clot in lungs and so he was admitted . So this time he had LUNG PROBLEM  and he was admitted by hospitalist  and I did not get notified or called to see him. He was discharged  and the patient and the wife had lots of questions like why did he get it . how long the treatment  and the time gap between his CT scan of abdomen and the then the hospitalization. I had no answer as I had not seen him and I had to check the hospital computer  and with the modern day computer generated notes I had hard time getting the information . So I had spent time to get information that was very difficult to get and may not be 100% correct. The hospital doctor - THE HOSPITALIST are not seeing him and have no office  and they can not be approached by this patient, so it becomes responsibility for people like me who have to reconstruct the story based on someone else notes. In this case it was not that difficult but in my other patient I have gotten 6 phone calls on 3 different days for the questions related to hospitlazation when I was not consulted .