Saturday, September 25, 2021

DISTRUST OR MISTRUST

     In medicine we come across many situations where I am surprised at the behavior of the patients or the relatives of the patients. I can understand that we all have different experiences in life and also we have different educations and we all are different individuals. So we will think differently and behave differently . But certain things are more accepted than others . So in this pandemic I have seen things that I did not think I had seen in past. So this blog is related to such opinions. 

   I saw this 78 years old lady and her daughter who was may be 58 years old . They came to me for pulmonary follow up. In my routine for this pandemic has been to ask them on signs and symptoms of COVID and now that we have vaccine to ask them if they are vaccinated . So they had no symptoms of COVID infection on our screening questions  and so I was seeing them in office. So when I sked her as to the vaccination for the COIVD , they said they did not have it. So I asked why did you not get it ? The answer surprised me .The daughter told me that they don't trust such shots . So I asked why don't you trust this , Everyone is taking vaccine. She answered that 'In past they have been used as scape goats (African Americans) for medical experiments and so they do not want vaccine'. I did not go in detail. But I am not sure what is cause of this distrust. But I did tell them that if you see the lines that are shown on TV news of the people that are waiting to get vaccines ,it is mixed population - the Asians were much higher than Caucasians  and Hispanic and African Americans were less . But everyone gets same vaccine .

  The second story is of a Hispanic patient. She is 85 years old and has some lung issues and she was admitted to hospital with COIVD pneumonia. On further work up she was also noted to have clots in lungs and she has significantly low oxygen and she was on BIPAP -oxygen given under pressure . She did not want to be put on respirator. So I was talking to the patient and the daughter on daily basis. On the first day she refused the Remdesivir which is a standard treatment for the COVID . So I called the daughter and then the patient agreed The reason was she did not trust any medicine or the vaccine that was related to COIVD . So we did start her on treatment and she continued to need  high oxygen flow . Then the daughter asked me if she could get flax seed capsules and elderberry capsules . So she did not want the standard treatment for the COVID as she had DISTRUST in the medical treatment even though that had some data as to the effectiveness - but had MISTRUST in theses over the counter products WHICH HAD NO DATA  as to the effectiveness !!!!

Sunday, August 15, 2021

PANDEMIC AND HEALTH CARE

       We started with COVID 19 pandemic last year in 2020 and since then medical practice has been affected . We have issues with patients not showing up for follow up when it is utmost important to do follow up  and do follow up tests  and then some showing up when they should not. When I wanted to doo scans to make sure that there was no cancer and patients don't want to do it due to fear of catching COVID, there is nothing I can do but to pray. Fortunately I have not had anyone who had cancer that did not get diagnosed sooner due to not showing up for the scan. But many other factors have played role in frustrations for the medical community with the pandemic and I have not seen that being addressed or even mentioned by news media or our own medical societies . All that they are interested is in FREE CARE FOR ALL. One has to understand that there is nothing FREE-someone is paying for it .We have had issues with supplies that we need to do tests not provided leading to cancel tests . Which means we have to no income and we have to get authorization from insurance company or PCP for doing tests  at a different date  and then getting patients upset as the tests were postponed. So the tests are not done and there is no income ,but the person who does the test is still employed and has to be paid .The list of issues that are going on and have been there for more than a year is long but I wanted to tell one quick story about other issue that I mentioned earlier.

    I think we have COIVID INFORMATION FATIGUE . We have enough information about the disease and it's spread and treatment and complications -that I think anybody could do doctorate in COVID . but still sometimes I come across patients that surprises me . I have a patient who has COPD - the disease that is primarily caused by smoking . She is 75 years old and has been on oxygen due to her condition. She had a routine follow up with me . She is usually accompanied by her family. In spite of the diagnosis of COPD which is caused by smoking ,she has continued to smoke and quit only recently. She came to office and my office and my office told me that I have to do telemedicine follow up. So they were asked to wait in car . SHE WAS POSITIVE FOR COVID and her daughter who came with her to my office was also positive . 

     My patient was vaccinated but her daughter and her son and her son in law were not vaccinated  and one of them is in medical field and works in hops with respiratory problem patients! So in spite of 10 posters on my office front door and check in window and waiting room , they came to my office .Another health care problem with pandemic . 

Saturday, July 24, 2021

TREAT OR NOT TREAT

   In out life we often have to make decision daily as to do things this way or that way . Take this road or do highway. order this food or that food . Take a phone call from this person or not . But in medicine we make the decision which is some times more complex that ordering topping on pizza. In many cases the flexibility of decision is not there. If I see elevated blood pressure or blood sugar, there is no question about if we should treat it or not .We treat it -period. But in certain other condition, we have to make a decision. This brings me to the story for today. 

   I saw this 91 years old male patient for the cough . He had cough off and on for 3-4 months  and he had no shortness of breath or other complaints . He was not a smoker and though was 91 years old , he was overall OK . He had some memory problems but lived by himself  and had not lost weight or had fever . He did not have history of asthma or gastroesophageal reflux - the 2 most common causes of chronic cough The Chest X- ray was done  and that had nothing impressive but some upper lobe scars. So I did some more testing . I di CT scan of chest and that showed some upper lobe scars  and some other abnormality that could go for Old TB. I was concerned  and so I did not do breathing test  and instead I gave him an inhaler for possible asthma  and I asked him to do sputum for tb bacteria. I had planned for doing the breathing test, but his sputum came showing that it was growing TB bacteria. This was preliminary  and the final report in case of TB can take as much as 6 weeks . Some times we can get report in 3-4 weeks if the TB bacteria is of type that grows fast . I had planned to do breathing test but I cancelled it till I get the culture. 

    I called the patient and the son and told them that the sputum is growing something and to be on safe side keep him indoor. Then they came to see me after 2-3 weeks . By then I had received the identification of the bacteria . It was atypical TB . The Mycobacteria is a family name  and the Mycobacterium Tuberculosis is the one which is contagious and MUST BE treated and isolate in the first few days  and also family close contact will be needed to be checked . But the mycobacteria are not like that. They do need prolong treatment and have similar symptoms ,but they are not contagious.So when they came to see me ,I had to decide on the treatment . I had 2 choces one was to treat this 91 years old patient with 3 MDICINES for 18 months or not to treat but watch it . tHt medines used can have liver problem , eye problem . So I had to talk to them . Her was a 91 years old patient who had sputum growing atypical TB  and had no complaints other than some cough. 

          TO TREAT OR NOT TO TREAT ?WAS MY QUSTION. . 

I decided to watch him with new CT scan and new sputum check and clinically. 

Sunday, July 18, 2021

NEVER SAY NEVER

    We have a saying in medicine . We never say never in medicine. I have written many a times on unexpected and surprises that we see in different patient. But in spite of knowing that we never say never in medicine , things seem to come as surprise  and then we say "there is exception to every rule". That brings me to the story for today . 

  I had known this lady for many years . Her husband was may patient and he had cancer of the lung and when we diagnosed it he had spread of the cancer to liver and he did survive for 4 years or so . She started seeing me after he had died . She had also smoked and she had COPD  and we did the work up. She then developed lung cancer. She was 'lucky' and we had diagnosed the cancer in time - or at least we thought. She did ok but when the surgery was done she had some of the lymph nodes showing spread of cancer. So we did have her see oncologist and had treatment with chemotherapy. She continued to do OK and she had COPD  and she had shortness of breath and needed oxygen .She also had gained weight and she had sleep apnea . I had told her after the diagnosis of the cancer  and the need for the treatment to 'prevent' the recurrence that the recurrence happens most in first year and then less in second  and least in third year after the diagnosis. After 3 rd year the chance of recurrence is not there  and so you are cured if there is no evidence of cancer after 3 years . 

   Five years had gone by after the surgery and she had new scan. She had CT scan and then PET scan. That was abnormal and so she came to me. Five years had gone by since we had diagnosed cancer and she had surgery. So the possibility of old cancer coming again was low or not there . But patients who have one cancer have high chance of having second cancer is high and then depending upon the type of cancer the treatment may be different. The abnormality was in such a location that simple way to do the biopsy was not possible . I spoke to interventional radiologist and he did not feel he could get it and suggested that biopsy with ultrasound guidance through a bronchoscope was better choice . But the interventional pulmonologist did not feel EBUS or navigational bronchoscopy could get the diagnosis. I did ot want open biopsy as this was not a curative surgery and she was oxygen dependent COPD . So the risk was higher . But I had no choice  and so she did see the surgeon and had a biopsy  and it was NOT A NEW CANCER but it was the SAME CANCER that was taken out 5 years ago. 

                   THAT IS WHY IN MEDICINE WE NEVER SAY NEVER!

Sunday, June 27, 2021

SOMETHING NEW

   Medical science is getting better every day. Certain things that we did not even imagine in past have developed  and even today it is very difficult to understand certain developments. But certain things which are easy to understand  and difficult to do are also there. In the treatment of cancer now a days blood cells called Lymphocytes are taken out from a cancer patient and are 'programmed '(??)  and then multiplied and then injected in the patient to take care of cancer. This process is easy to understand . But very difficult to actually know as to what is being done . What does a programming of a cell means ?But it is easy to explain. The new treatments for COPD are also such treatments where it is easy to understand  and easy to explain. That brings me to the story for today. 

  I have seen this patient for 3-4 years and she had episodes of respiratory infection when I saw her for the first time . She is in her early seventies and she never smoked . She had cough  and then I saw her . The chest X-ray was normal  and  treated her with antibiotics and the steroids .She did OK  and I did do breathing test and that came as normal . But she had cough and so she was started on treatment for asthma . She did OK and then she weaned herself of the medicines for asthma . She would get periodic episodes of cough and then she would see me and I would treat her with  steroids and inhalers  and she would linger for few days with persistent cough and then would get better . 

   This continued and then the cough got worse and then in spite of doing steroids and antibiotics and inhalers , she would still have bad coughing spells . I did do further work up and we did CT scan and that was normal. I also did measurement of immunoglobulin - These are proteins - globulins that are important for immunity and they prevent the recurrent infection. She did have low immunoglobulin. So I wanted to  give her replacement for the immune globulin . But her hematologist did not want to do that. In any case she continued to have cough and she was admitted few times for the control of her symptoms. Then  I decided to do the bronchoscopy. When I did the bronchoscopy ,I found out that she had problem with trachea and major bronchial tubes . Normally the trachea has cartilages and that gives trachea the support and it does not collapse. Theses cartilages are semicircular and  also extend to main bronchi . That act like scaffolding . But her trachea would collapse when she would exhale or cough  and that   was causing constant cough. So I told her that we need someone to do a stent  and see if that would work out.. She was seen by interventional lung specialist. But he felt that she would need  surgery and stents may not be enough. So I have to send her to Mayo clinic . 

    So such a stent placement was not there 10 years ago and even when they did do it 5 years ago it was in the infancy and also no  one would have thought of doing surgery on trachea in an adult patient few years ago . I still feel that the cause of this is lack of immune globulin leading to recurrent respiratory infections and damage that was caused by persistent inflammation. I feel that she would need replacement for that in future . Stay tune .

Sunday, June 13, 2021

INADEQUECY OF MEDICINE

     I have been in medical practice for many years and have realized that the medicine is never perfect or 100% . We can treat 2 people with same condition and same situation and same diagnosis  and still not get the same results. We have the same machine but the result of the same treatment is not the same. So someone may say that it may be due to the circumstances or that people are not like car or any other machine and so people have different outcome. Some may say that it is due to KARMA, Whatever may the cause, we know that we get different results. But then the question comes as to how we can anticipate as to who is going to have out of ordinary results and then avoid the same treatment and do something different in these exceptional patients. Yes medicine is trying to do that and I often feel that our tests are not adequate. That brings me to the story for today. 

   I saw this patient in office sent to me by radiation doctor. She was 70 years old female who had noticed a lump on mammography and so they had planned lumpectomy and then radiation . The radiation physician had ordered a chest x- ray as she was a smoker  and that showed abnormality. So she had CT scan done and that showed the abnormality and so she was sent to me. The original thought was that the abnormality may be due to scars. I saw the lady and she was current smoker  and I felt that the abnormality could be a lung cancer . So I did the work up and she had Bronchoscopy and PET scan and then a breathing test. I had no 100 % proof that the lung abnormality was cancer but on PET scan it was  showing increased activity and so I wanted to have her do surgery. Certainly she had breast cancer also and that needed to be taken out. So she had the breast cancer surgery and then the lungs . The lymph nodes were negative. (The lymph nodes  drain different areas  and so they can show the spread) So when the PET scan had no uptake in nodes the surgeon still did  the lymph node biopsy before taking out the cancer and that was also negative for the cancer spread. So she had the mass taken out and and that was a cancer and the nodes on further biopsy did not show any spread of cancer. She had some issues after the surgery and that needed to be fixed but overall she did OK . So she had breast cancer and then lung cancer - both notice at the same time  and taken out and no residual cancer as far as WE CAN TELL The pet scan had not shown any spread and the biopsy had not shown any spread. 

     We continued to follow her and she had a follow up PET scan about 8 months after the original scan and that showed that there was activity in the nodes . So now the question was is it cancer and if it is then is is RECURRENCE OF THE LUNG CANCER or BREAST CANCER .The breast cancer is notorious in it's tendency to come back after several months and sometimes years .So she did have additional biopsy and it was not breast cancer but it was recurrence of Lung Cancer.

   So we had done a PET scan , which is suppose to be 85% accurate in picking up cancer  and that was negative . She had the same lymph node biopsy before taking out lung cancer and that also did not show the cancer spread . Then she had additional sampling of the same nodes  at the time of surgery to take out lung cancer and that was also negative . And now in less than a year - just 8 months she has the same nodes showing the spread of cancer. So the tests that we did were not adequate to pick up the cancer !

   Just a note - some labs are doing what is called circulating tumor DNA - a blood test that will pick up certain DNA of the tumor to predict recurrence of a cancer earlier that it is obvious on scans. So this may be a future .But if CTDNA is positive then the question is How do you treat?

Sunday, May 30, 2021

ELEPHANT IN THE ROOM

    In medicine sometimes we have extreme positions. The so called pendulum swings to he other direction.I have seen use of certain drugs for a certain condition as routine 'acceptable' treatment  and then suddenly it falls off the favorite train and then no one uses it . Theophylline is one such drug . 20 years ago there were several pharmaceutical companies that were making brand name theophylline  and now there is none. We also use a term  "The elephant in the room". This brings me to the story for today. 

     I saw this 90 years old patient in office and then she was diagnosed to have asthma  and also she was obese and may have had sleep apnea. But she did not want sleep study and so she was on oxygen which is not accepted treatment for sleep apnea now a days. But when the oxygen drops badly during sleep, one can not deny use of oxygen .She was admitted to hosp and she had  multiple problems . She had shortness of the breath and she had swelling in the legs and she has problem with her kidneys.So she was seen by hospital doctor and as expected they had called cardiologist and kidney specialist and pulmonary specialist . So when I saw her she was in hospital for she was in hospital for 3 days . I saw her and she had acceptable oxygen saturation at rest and she has significant edema in legs and her kidneys were not functioning well. She had clear lungs but no one had given her home inhalers which were prescribed for her asthma in past . So i started them. The cardiologist had seen and done echocardiogram  and the heart function was good and he has no other suggestion. The kidney doctor was giving her diuretics and her  her swelling was getting better  and she had some improvement renal function. What struck me in this patient was that her lungs were clear and the oxygen was fine and she still felt short of breath. Certainly it could be due to being 89 years old with low activity  and de conditioning and may be some heart problem and certainly may be even lung issues. But she also had anemia  and they had done the work up and she had problem with production of red cells.( think of red cells as a product of a factory. Let  us take an example of making shirts.So if there are less shirts available in market, then  it could be due to factory not making enough or that they are sold too quickly. - high demand or that there is not enough raw material . The same thing is true about red cells . The raw material - iron B12 or other r=things may not be enough or we have a loss of blood or it could be that the bone marrow the factory is defective.)So she had problem with production of red cells. That is not uncommon in patient with kidney problem. I followed her for few days . What I noticed is that in spite of inhalers and edema getting better and the kidney function improving she was still short of breath.And I also noticed that the anemia was not any better and was somewhat worse . Her hemoglobin -which carries the oxygen in blood was half the normal. So patients with anemia are short of breath as their system has to work harder to provide oxygen as the blood does not carry same amount of oxygen.So I finally called the hospital doctor  and asked her to give BLOOD TRANSFUSION. In past we used to transfuse even with much higher hemoglobin. But then we realize that that was causing problems in future  and so now the pendulum has swung to other extreme and no one thinks of transfusion even though this 90 years old lady was shortness of breath was perfect candidate for giving blood . So this was the big elephant in the room and no one was talking about it or treating it or may be no one could THINK about it .