DO NOT ASK FOR THE DIRECTION TO PLACE WHERE YOU DON'T GO

     In medicine I have said that do not ask for the direction to a place where you do not want to go. As we are seeing aging population, this has become more and more common . Patient having some blood in stool will need work up . But then if the patient is very old - and very old can be determined by family and physician only - and say has dementia , is it worth finding the cause and doing million dollars work up with INVASIVE procedures which have some risk, when we know that we are not doing the treatment which is ideal like surgery. A good doctor may suggest certain work up and treatment and a good doctor will take in account not only the diagnosis , but also other factors. That brings me to story for today. 

    I saw this 85 years old female . She had pain in abdomen and so she went to walk in clinic and they did Ct scan of the belly - abdomen. (I am not sure  as to what was the thought process -or differential diagnosis that they did CT scan -but now a days that is a knee jerk reaction) .The scan showed no abnormality in abdomen or pelvis , but showed a nodule in the lung . She had a CT scan of chest in past - few years ago and that had shown a nodule  and she had seen a lung specialist 4 years ago. And he had told them to watch it , rather that doing additional biopsy etc . That had happened 7 years ago . So she was 78 years old . Again I was not the physician and not sure what was taken in to account when the decision was made. The size of the nodule was smaller and now after several years when CT scan of belly was done it appeared to show increase in size. So she was sent to me. She had not done CT scan of chest. 

   She was older lady but seems to understand very well and was accompanied by caring family. I looked at reports and also tried to find out any old reports that might help. I tried to check 2-3 hospital and radiology centers to see if there was any scan of the chest in last 3 years and could not find any. She had no pulmonary complaints. If the size seen on scan of the belly was correct the spot or the nodule had grown in last few years . So it was likely to be slow growing cancer or a scar cancer - cancer developing in old scar. Either way we needed work up . I often tell patients that we need to answer 3 questions - 1 Is it cancer 2 Has it spread  and 3 what kind of treatment we need / can do.  The treatment of cancer - if it is - is surgery-radiation-chemo. Here comes the point of making decision as to what kind of work up we should do. If the patient does not want surgery or it is felt that the surgery is too risky then how much should be the work up? Ideally we would do PET scan , Breathing test to assess lung capacity and biopsy. But if patient does not want any  treatment like surgery or chemotherapy, how much invasive work up we should do. If we don't want to go a place why should we ask for the direction to that place ? This lady did not want surgery and chemo and the family agreed . Then do we need to do biopsy ? I suggested doing a PET SCAN which can pick up cancer in may be 80-85% of the cases So I decided to do the PET scan and if that is positive , consider radiation treatment without biosy or just do follow up Ct scan in 3 months and see if it grows . 

    Again I would be curious as to what would AI suggest . 

RIGHT OR WRONG ?

     In life we often say that each one of us has opinion and sometimes we have 2 opinion especially if we are talking about politicians. But even normal people have different opinions and the same hold true in medicine. Most of the time we all have same opinion -may be because we all read the same book or have seen same study. No one will argue about treating high blood pressure or high blood sugars. But then we it comes to certain other conditions in elderly , we have different opinion. No one can state that his way is the only correct way. Take for example HBA1C , the indicator of diabetic control. In younger patients we like it around 6 or may be even less-close to as normal as it could be. But in elderly such a tight control is not good or could be detrimental. In elderly patient who may be living alone or who may be living with spouse who also may be elderly, it is more dangerous to have low blood sugar than high sugar . The low sugar can lead to unconsciousness and brain damage , while high blood sugar -not extremely high sugar is not that bad. This kind of thinking brings me to case for today. 

  I had seen this 80 years old patient in office . He had diagnosis of lung cancer and then we had surgery and he did well and did not need any additional chemotherapy of radiation and did ok .He did have some shortness of breath and I saw him and the work up was ok .He came to me for few months and then stopped . After a gap of 3 years he came to me and had some shortness of breath and we did do new CT scan and that showed density next to  suture line. In past we had seen that density and followed it and it was stable for couple of years. This time it looked like it had increased. So, I saw him . By now he was elderly , fragile and had some dementia. He had reduced activity partly related to shortness of breath and partly related to aging , dementia etc. I did order new PET scan and new breathing test. The wife was a nurse  and she wanted everything done and wanted to see thoracic surgery - the same one who had done surgery 3-4 years ago . I ordered the tests and she saw him. He ordered a biopsy of the mass. I did PET scan and that showed very high uptake in the mass -suggesting that it is cancer . Certainly we did not know the exact diagnosis or what type. The physician who was to do the biopsy is in the same group as the surgeon. I had suggested asking radiation doctor to see him as I did not feel he would do well with surgery cutting out part of the lung and also he would do well with chemo. The wife wanted surgery as 'that is the BEST treatment for the cancer'. But the surgeon agreed with me and told her that doing surgery was too risky. I had suggested not doing any biopsy but just based on PET scan treat with radiation . But the surgeon wanted his group doctor to do lung biopsy. I asked them - if biopsy is positive - would you take chemo the answer was NO. I asked if the biopsy is negative for the cancer would consider radiation treatment based on PET scan? the answer was YES . So my question is why do a test that does not change the course of treatment in this elderly fragile patient.  

    There is no answer and he will have the biopsy and radiation treatment !! RIGHT OR WRONG.

  

GOOD OR BAD ?

      In medicine we make decisions  and then live by it. The decisions are made based on our understandings of the tests  and not all are available for all of us .Could AI make a different outcome - I don't know . I don't think so. So most of the time we are correct and sometimes we are not. So the new tests are developed .That brings me to the story for the today. 

     I saw this lady several years ago. She had mild asthma and she came to me and we did tests and then started her on medicines and she did well. But ew people have this thinking that they can 'cure' the decision and then they will not need medicines . It does not happen in many conditions, but still some think it in that way. So she went to allergist and he did tests and then continued the same meds. But she did not come back to me. She was stable and then after 3-4 years she had shortness of breath and she was admitted and I was called. She had a clot in lungs  and that made her short of breath. The asthma was stable . But when a CT scan was done, she had not only pulmonary embolism, but also ha =d a spot on the lung . This was not seen before  and she was concerned. She has been nonsmoker  and had new clot. So I decided that we will do the out patient work up. But at this time we wanted to have her treatment for the clot. The oncologist was also called and they concentrated on the clot rather that the spot on the lung. She was discharged  and then we did the work up as out patient. 

  She was treated with blood thinner /anticoagulation. She had follow up with her cancer doctor and no new tests were done .She came to me after 4-6 weeks . I ordered a PET SCAN As I have mentioned in my previous blogs the PET scan shows metabolic activity of the cells and is good in 85 % cases for picking up cancer. We decided to do bronchoscopy and we had to hold the blood thinner for 3 days and then the bronchoscopy was OK. We had done breathing test and I had asked her to see a chest surgeon too. The PET scan was showing that the spot on the lung was hot -it had pick up and so I had her see the thoracic surgeon. He saw her and no decision was made. She came to see me and by then it was almost 6-7 weeks from the PET scan. I saw her I was expecting that the surgeon would have done the surgery and then I will see her. SO when I saw her in office and no surgery was planned, I called the surgeon and scheduled her for new CT scan . The surgeon called me and he could not tell me why no surgery was planned , but he agreed that the spot needed to come out. The new Ct scan was done and she had the same spot with may be minimal increase.

    The surgery was done  and - and - there was no CANCER. It was a infarct related to the clot. With the clot part of lung had infarct and bleeding and so that did not get better with time. But it was not cancer. 

   So the decision made based on PET scan was correct , but the Good news was that there was no cancer  and Bad news was that she had surgery- a invasive procedure . 

  We have some new tests - CTDNA - circulating tumor DNA, Nodify etc. . We check the DNA of the cancer cells from simple blood test , we have antibody for cells and protein associated with the cancer etc. But NONE is 100% . Hope we will have it one day. 

DR GOOGLE

    I have done my medical education many years ago and since then the medicine has grown and we have been able to keep with new developments . But now a days we have added the burden of computer educated generation where patients have seen . checked on computer and think they know the answers 

  We still have many patients that trust their doctors , but still we have sometimes problem and we have to explain things . It is difficult to wife off the slate which is not clean to start with and write new things .  Sometimes it is not fault with patients but with people surrounding  That brings me to the story for today.      I saw this 80 plus years old patient in office for shortness of breath . HE was smoker and had diagnosis of laryngeal cancer and that was treated and he was better and was in remission . He had COPD  and he has shortness of breath  and so he came to me . I asked him questions and I found out that he was admitted to hospital  and he had CT scan and that had shown nodule , the so called spot on the lung, He did not have any new Ct scan after the discharge 4 months ago.  So I ordered the new CT scan and that showed that the nodule had grown . That means that it was likely to be cancer . Since he had laryngeal cancer , there was possibility of new lung cancer or metastasis. So I ordered the PET scan . The  PET scan  picks up cancer may be 85% of the time . The PET scan showed activity in the lung nodule and also some activity in food pipe esophagus . We had done breathing test and he had severe compromised lung function. He was older and had bad lungs and enlarging nodule . So I asked interventional lung specialist to see him and do navigational bronchoscopy and biopsy . Ehen the biopsy was done it came back positive for cancer. She called me and the family and she wanted them to see cancer doctor - oncologist  and Gastroenetrologist.  I called the family as I wanted to discuss the further work up and treatment plan . I was told by family that they know it is cancer and what was I going to do . I insisted on bringing them in .

    I had discussion with them  and i was glad that they came . They were confused between oncologist and Gstro. I told them that he did not have great lung capacity and he was not a candidate for lot of invasive tests . But we needed to know if this spot - that had biopsy positive for cancer was ARISING IN LUNG or had started in esophagus and SPREAD TO LUNG . The distinction was very important as if there was no cancer of esophagus , then we could do short treatment of the lung cancer called stereotactic radiation and that will not cause much problem with h9 compromised lungs and has some cure rate . In contrast to that if he has had esophageal cancer, then treatment of the lung nodule will be not useful and then either chemo or localized radiation to esophagus will be needed  and that may cause difficulty in swallowing and need feeding tube - may be. These kind of things was not there when thy had checked on  Google. 

   I cleared him for doing endoscopy and when they left they were happy that they came. .  .

DECEPTION

      In medicine we have a trust in certain things . I f often say ,'if this is normal then that is not likely or not possible. And then we come across a case or 2 ,that proves us wrong. If  fasting sugar is 100 mg or less then you don't have diabetes , or if one is not a smoker ,then chance of having lung cancer is very low . The statements are true from statistical stand point.  This brings me to the story for today. 

  I had seen this patient many years ago . She was 70 years old female , who had been smoker and had smoking related lung disease -COPD. She also had a smaa nodule and that was stable for 2 years . So she was lost for follow up. I think she thought that she had stable nodules for 2 years and so it was less likely tat that was cancer and she had continued to smoke . She saw me again after a gap of 5 years. She had been  to hospital for various things including shortness of breath. She had continued to smoke . She had some cough and also no fever, weight loss  and no new CT scan of chest . She had couple of chest x- rays done and they had shown no nodule on right side but had shown some congestion and small fluid on left side in the lower part. 

    I ordered breathing test and a CT scan chest . She was again admitted and I was not consulted or informed and she had suspected stroke and that was cleared . she was discharged and then again readmitted with some cough and some shortness of breath. This time I was called in . She had a CT scan of the chest to rule out clot in the lungs  and the CT scan did not show any clot ,but showed a MASS in the left upper part of the lung which was compressing the bronchus and blood vessle going to left upper lobe of the lung . She also had mass lower down and also on right side next to the center of the lung and also there was another nodule or mass in right lower lobe. This was increased from the CT scan that was done 5 years ago. So here is a lady that had 2-3 chest x- rays of the chest which did not show any mass , but some congestion and some fluid on left LOWER part, now has masses in left upper lobe , left center , rt center and right lower lobe . NONE OF THIS WAS SEEN ON PLAIN CHEST X- RAY . 

     In all probability this is cancer But how much we rely on plain x- ray and now the CT scan showed so many things that were NOT EVEN SUSPECTED by looking at the chest x- ray. This is what I called deception. 

    

TRUTH AND NOTHING BUT THE TRUTH

    In medicine there is nothing which is permanent. When aspirin was discovered for fever , the 'warning' was that patients with heart problem should not use it. I have seen the changes in the thought process of many diseases. The asthma was defined as 'completely reversible airway obstruction.' And then we realized that there is more than just bronchoconstriction. We realized that there was component of inflammation and so then we started treating that .Now we are talking about casket of chain reaction in allergic asthma and how to block that . So ,I thought I will talk about the treatment that we were doing for asthma in past and ow we do not do it. Not that it's discontinued but, but we can not imagine that these treatments were done . 

   So let ma start by telling you that in early 1900, the asthma was treated with radiation therapy.. There are articles published in medical journals as to how to do it. There were 2 different techniques , one was to radiate nasopharynx and other was lungs and abdomen . I am not sure why radiate abdomen. But it was there and the success was good - 90 % doing good in first year and 40 % had longer lasting benefit !!The other was to take out blood from a vein and irradiate it and out in the body . This was also done with idea of 'killing ' antibody ??But that was also done to treat resistant asthma. 

    In India , there was a treatment that was there and is carried out even today . On a full moon day in a year - one particular full moon day only , south of city of Hyderabad, this treatment is carried out . The family that does this, has a special recipe and a 2 inch fish -MURREL  fish is swallowed coated with some spices on MRIGASIRA DAY.. The place is so busy that the government runs special bus service on that day  and thousands of patients are treated . 

   There is also treatment with auto blood . The blood is taken out and then 1/2 ml is injected in but area - intra muscular  shot . The idea is that it produces antibodies and that helps to cure the asthma 

  One other concept that is prevalent and studies have proved it to be wrong , is that if one gets a Chihuahua, the dog gets the asthma and the person is cured . Again there is asthma in the dogs but they do not 'get' it from human beings and certainly the human beings are not 'cured ' of asthma. 

PERSISTENCE PAYS

    In Medicine and in any other field persistence. If one wants to do a surgery -more one does he gets better . The same hold true for shooting baskets . But sometimes one has to dig deep to get to the bottom of the problem. In medicine that should be the rule. That brings me to the story for today.

  I saw this young lady for consultation. She was in her twenties. She had not been smoker and has been physically active , going to gym and not having any problems with breathing. But her boyfriend had noticed some wheezing when she was sleeping .So he told her to see me .She was young lady and had not been smoker and had no other health issues . She had good oxygen saturation and had clear lungs and no wheezing. She had no shortness of breath even when she was running on tread mill. So I was not sure as to what and how to treat . Here is a patient who has clear lungs and has no shortness of breath and only time there is abnormality is noticed is when she is sleeping and that too by her boyfriend . We did a chest x- ray and did breathing test. She had normal chest x- ray and the breathing test showed that she had asthma - obstructive pattern on spirometry. This happens when bronchial tubes collapse with exhalation. So I gave her an inhalers . She come back for the follow up. I asked her if she finds any difference. She told me she tried the inhaler for short time but she has no cough ,no shortness of breath and no wheezing and so how can she see the difference - difference in what ?I told her to use the rescue inhaler as needed in case she is short of breath or has bronchospasm. But I decided to do new breathing test in 3-4 months . She did the  test and the report was same . She had same obstruction . In the first test I had noticed abnormality in one part of the test called flow volume loop . That was seen in the second test too. I was concerned but I had not noticed any strider on trachea and so I was not sure what to make out of it. But this time she wanted me to clear her for surgery for breast augmentation. And I needed more test to make sure that she did not have problem with trachea -the main wind pipe. She was not very happy as I would not clear her unless she had done further testing . I did CT scan . And there it was .She had abnormal aorta  and and abnormal blood vessel crossing the trachea making it narrowed . That would explain the abnormality seen on flow volume loop and perhaps other part of the tests .Her trachea would collapse when she forcefully exhaled or when she was supine .My feeling is that the trachea may not be fully developed or may be not have enough cartilages and support and may be fibrous and so she had no problem when she exercised as that part could stretch  and no air flow obstruction could occur, but the test did show abnormality. 

  I have sent to a tracheal - chest surgeon  and he wants to do additional tests. The jury is out as she has not done the tests yet.She is thinking about it.