THE CASE OF PERSISTANCE

    Sometimes one can not stop saying  that it is not my problem or that is not my specialty. Today what I see most of the times is  doctors saying that 'this is not cardiac issue or not surgical or not ----put any speciality issue. Then someone has to to take charge and find out as to what may be the problem.
    This happened in case of Ed.
     Ed was my patient for sometimes. His problem related to my field was very minimal . He was quite obese, weighed about 280 lbs, and had BMI ( body mass index ) of 39. Just for the information , BMI of 25 or less is considered normal. and more than 35 would be considered morbidly obese. He had 'sleep apnea '. He had sleep study and this was confirmed , ad he was advised to use pressurised mask called cpap.
unfortunately he could not tolerate it . So I had no choice to consider use of oxygen with sleep . This is  not recommended by American association of sleep society. But sometimes if the oxygen drop is very low or occurs for prolonged time I tend to use it . So from ' my standpoint ' there was no major problem . I was seeing him every 5 to 6 months.
    He was admitted to the hospital for low blood count , and I was consulted as he was short of breath . He did have some obstructive disease and was on some inhalers, but increase in shortness of the breath was due to drop in hemoglobin , which carries oxygen , and when it is lower amount of oxygen carried is less and then patient feels short of breath.  So I saw him . There was not much for me to do as such , as he was also seen by the cardiologist, who had declared.( through his nurse practcener ) that there was nothing  'wrong ' with his heart, and no specific treatment change was needed from his stand point. He was also seen by hematology, a blood specialist, who was following him for long time , as he had drop in his blood counts in the past and needed  'iron ' shots. There was no specific 'cause ' of his low blood count was found by them and he was told this was due to " chronic  disease " .(To my knowledge he had no 'chronic disease ' that could cause the anemia. )
      So after I saw the patient I could not sit without doing any work up to find out why Ed had anemia. So I ordered iron level , and it did come back low . So I called the hematologist and asked him if I could get Gastrointestinal doctor to see him and do ' bone marrow ' aspiration . (Bone marrow is the source of the all the blood cells-- one can call it blood cell factory, so if one wants to know the cause of low blood counts we can go to the source of them and see if the factory is not producing enough or the problem is some where else ). The bone marrow was showing low iron . So now the question was where was he loosing the iron/ blood .
     When I spoke to the GI specialist to rule out loss of the blood through gastrointestinal tract, his answer " we did check his colon and stomach 10 months ago and everything was OK. " I was not very happy with the answer , so I  convinced him look at the patient and redo endoscopy to check out stomach . He did do it , it was OK and he 'signed off the case ' as " From GI stand point patient was clear ". So I decide to do examination of the small intestine . ( stomach and colon were clear, so only logical thing left was to check the small intestine .) I also called the GI MD and asked him to do , what is called the capsule endoscopy , . in which patient swallows a ' capsule ' and it send pictures to a camera worn by the patient around the belly .  The small bowel  x-ray did show some abnormality in the 1st part of the small intestine and when he had the capsule test it SHOWED A SMALL TUMOUR IN THAT AREA .
     I was very happy that I had followed this closely . But my happiness did not last much long, as when he came to office for the follow up , he was not very happy . He was referred to a surgeon to take out the tumour, who told him that " he was too high risk for the surgery " and he should go to Mayo Clinic . He could not go to Mayo as it was not on his 'Insurence Plan '.So after all the effort we were back to square one .
     I had to do some thing. He had called the GI MD , with no success. I knew someone who did minimally invasive surgery as well as other special endoscopic procedure . I am very glad to let it know that this was successful and he removed the small intestinal tumour through endoscope.
    IT WAS BENIGN ( CALLED HAMARTOMA ) AND NOW PATIENT DOES NOT NEED EITHER IRON OR BLOOD TRANSFUSION.