Friday, November 23, 2012


    I have often said that treat patient as a patient , not only from your speciality stand point , but as a patient , who has medical problem . We all sub specialist are physicians first and specialist or sub specialist latter .We all do medical training , first as Internal Medicine ,so we should be in position to diagnose , if not treat everything in an expert way . We may not know be in position to know all the details of the treatments of all the diseases , but we should be in position to help diagnose . The case that I am about to tell is one such case .
    I had known this 70 years old patient for few years . I had diagnose him to have a lung cancer . Fortunately for him he was operable . We were in position to operate and resect the cancer . I did continue to see him for a while . He continued to do well and was followed by Cancer doctor , an oncologist .
    When I saw him after a gap of 2 years , it was because he was short of breath . It had started suddenly and his oxygen was low . I saw him and did CT scan . It surprisingly showed a metallic object in right bronchus . He had lost 2 lobes out of three  lobes . So he was left with only one lobe , which was blocked by something and so he was short of breath and oxygen was low . I did a bronchoscopy    and saw the obstruction . IT WAS A PILL .I tried to take it out , but was unable to do so with his oxygen dropping . Finally we had to do it under anesthesia . .He did well and was discharged . I saw him once in my office . He did not see me for almost more than year and a half . He came to office as the oncologist had done a CT scan and it showed fluid around the lung . He was mildly short or breath. On examination the lungs sounded clear . There was mild reduction of air going in the right lung . The CT scan had shown a pocket of fluid on the top part and 2 other pockets on the lower part .When I started to check his blood pressure , I noticed that his arm was swollen on left side . I asked him about it . He noticed a week ago and it got gradually worse . He had kidney issues and his kidney function was quite compromised .So when he saw the kidney doctor , he called the cancer doctor and he had test (called Doppler ) to rule out phlebitis or a clot in the arm , that could explain the swelling . It was normal . So then CT scan was done and it showed the fluid and he was asked to see me to take out fluid . I asked him on the cause of the swollen arm , and he did not know . I asked him if any other test was ordered , to find out the cause of it ,he said no . I was surprised.I was not sure what was the cause of the swelling, but suspected that there must be a blockage to the blood flow return deeper that what was tested . But I was not sure why  there was no swelling of the right arm as the deeper structure called SVC , drains all the blood back from both upper extremities and head . So if it is blocked , why there was no swelling of right arm ?
    I called a vascular surgeon , but when my secretary called the office , they got appointment after 3 weeks . I called a cardiologist , who does vascular studies , but he was out of town . So I called his associate and he agreed to see the patient . He saw the patient and did the Doppler of the same left arm and did echo cardiogram . He told him that his heart was OK and the swelling was not due to heart and may be due to kidney problem . I was not happy . I called a radiologist who also does lot of vascular interventions . He was very helpful . I told him that I was suspecting the blockage of the SVC .He looked at the CT scan that was done earlier and told me that my hunch  was most likely correct .. Unfortunately he could not do the study and treatment on Friday . I decided to admit the patient on Sunday and he agreed to do the procedure .
   I am glad to tell that the test was done and there was blockage of the SVC and he did stent it and the swelling got resolved in 3 days .
   I had said it in the past , " your eyes can't see what your mind can't think ."Otherwise I am not sure why it took so long and 4 doctors to solve the problem .

Monday, November 19, 2012


   We as physician are asked about the prognosis . This is not a question when we diagnose things like high blood pressure or diabetes or asthma . But when we tell patients about cancer or poor heart function etc , then the question always arises as to what is the prognosis . This goes farther when the condition progresses and when the patient and the family realizes that the things are not going well or not getting better and are not likely to get better. This is the time when patients make decision on DNR. If the END is near then sometimes they decide to go with the Hospice . But as I mentioned in last blog , when these decisions are not made in advanced or they are made but we as doctors are not made aware of it , we end up having a mess . Once is patient is put on 'life support ' , taking him off is little difficult . There are state laws and regulations and there are hospital rule and regulations .When we have to take patient off the life support , it is called 'withdrawal of life support ' . In this process there must be an agreement between patient or his representative , and two doctors about the prognosis and to stop the futile efforts . If patient can not make decision (which is the case most of the time as he is on respirator and sedated ), then we have to get OK from his relatives . If patients have made decision about their representative it is easier .If there is no written representative , then there is rule as to who can make decision . The spouse is first in line , then children , then the parents and lastly siblings.The problem is when there are more than one child . The law needs 50% plus one to agree on the decision  to withdraw.So if there are 3 children then all must agree .(one and a half plus one ).
    I face this situation frequently in Intensive Care Unit . It is easier to make decision when we know patient or there is really terminal condition or condition is terminal . e.g. brain bleeding . But then there are times when it is not that clear . When a physician signs a form stating that the " condition is terminal and recovery is unlikely " he is acting as God . In my life time there may have been two or three cases when I have postponed the withdrawal for 24 hrs just to get a chance to wean down or get more evidence that with or without treatment patient will die . This has sometimes caused some friction with the family or other physician . I have weaned off some patients of the life support and avoided making decision as God .

Sunday, November 18, 2012


   We often talk about the 'living will '. The hospitals are required to ask every patient that comes to hospital if they have 'living will ' . The lawyers also do living will as part of estate planning . But no one talks about DNR. Many years ago I read an article written in  a medical gernal by a Harvard doctor (not medical doctor ) . It criticised medical community for not 'honoring 'her mother's 'living will ' and how she had to go through suffering . I was shocked that this Harvard professor was not aware of the difference between the meaning of living and the "true' DNR . Unfortunately this confusion is very common and it leads to more problems than help medical community .
    The living will states that "if my condition is determined to be terminal -----". So determines that the condition is terminal or not ? In the article that was written by the above mentioned professor, her mother was admitted to the hospital with the living will and in the middle of the night had a stroke . She was not breathing well , so the doctors decided to put her on respirator. This was done as a emergency decision in the middle of the night . The living will stated that she did not want to be revived ,if the condition was determined to be terminal . There was no way to know at that time in the middle of the time to state confidently that there was no way that she was going to survive or die .So the doctors had to make quick decision and they decided to put her on the respirator . If she would have recovered from the stroke then the decision would be applaud to be great , but when she did not improve then the decision was "wrong " and did not "respect her wishes " . per the author. This reminded me of one of the patients that I had seen .
    I was called in to see this patient .He was admitted to Intensive care unit . He was brought to ER with decrease level of consciousness.He was not breathing good , so was put on the respirator .When I saw him in the ICU, the nurse told that his wife was there , and was very mad .I saw him ,he looked OK and everything looked OK .I was not too sure as to why the wife was mad . I did not know exactly what made him sick . But he looked to be getting better . I asked her many questions ,and got the history . Then I came to know why she was mad .She had brought with her ,his living will 'Her point was that he had living will and the doctors in ER still put him on respirator . She was so mad that she told me that she would be 'suing'the doctors and the hospital . I explained her the situation and told her that he was doing quite well and I expected him to be off the respirator in next 24 hours . He was quite obese male , though young and most likely had 'sleep apnea ' . He also had what is called as 'obesity hypoventalation syndrome . ' This in past was also called Pickwick  syndrome , based on a character from a novel written by Charles Dickens . In this condition patients do not respond to carbon dioxide retention . Normally we have to main stimuli (to our respiratory centers )to breath , One is lack of oxygen and second is build up of carbon dioxide . (there are other stimuli too , but these are main ones in day to day life . )So these patients are very sensitive to sedatives and narcotics . I was not too sure what might have have happened, but my thinking was that he stopped breathing when he was given oxygen , which took away his stimulus to breath as he did not respond to build up of carbon dioxide . Anyway he did well and was taken off the respirator . He was discharged on 3 rd day . After he was taken off the respirator , I did call his wife and asked as to how she felt NOW , about the decision made by the ER doctors in spite of his living will . She was off course very happy .
     The living will is not as great a paper as it is made to be . It does convey the patients thought process about life in general . But one wants to be not put on any artificial life support under any condition , then he or she should consider DNR. . So it is not left to the doctor or paramedic or to the family members, who at times are left with guilt feeling . This is so important in patients who are very old or have end stage disease, like cancer or very bad lungs or heart or have dementia , in short quality of life is very poor .

Thursday, November 15, 2012


   I told you about the story of patient who came with testicular torsion , and was dressed up like a female . This made me think for a different diagnosis, as I thought that 'he ' was 'she'. He was dressed up as female due to 'nessecity '  and not as choice . The story that I am going to tell is of different kind.
   I saw this white male 75 years old . He was admitted to hospital with pneumonia. When I saw him he was in his room , with his wife and was in hospital gown . After taking the history and and talking to him and his wife , I felt that he was aspirating . Aspiration means food or liquid instead of going in to stomach ,it goes to lungs . This can happen after stroke or as some people get older . This is due to poor coordination of swallowing muscles.So I ordered the swallowing function test . This is done by the radiology and speech therapy team . It confirmed my suspicion . He was grossly aspirating and the speech therapist felt that he should not be allowed to eat , but should get a feeding tube . This tube is inserted in the stomach , and then patient is fed with a liquid like Ensure or Boost etc . I spoke to them and they agreed for it , only me telling them that this could be temporary . The plan was to do the stomach feeding tube  and then repeat the swallowing test in next 2-3 months .The he had the feeding tube inserted . His pneumonia was getting better . One day I was quite busy and could not see him in the morning . So I went to see him in the evening . He was not in the room . So when I asked the nurse as to where abouts of him , she said that he and his wife were walking around in the hallway . I went to see him and when I saw him I was surprised . He was walking with his wife , but he was wearing female night gown . i was not too sure as to why he was wearing the female gown . I asked his wife latter on . The answer was perplexing . He wanted to be a female at age 72 or 73 . and had told this to his doctor . He had also told this to his wife and it seemed like she had no objection . He was also prescribed female hormones to reduce facial hairs and develop breasts.
  I did see him in my office . He did come in femenine clothes . He still had aspiration , though it was little better . He did not want to continue the feeding tube , so we compromised . He was allowed some 'forms ' or 'consistenct ' food with reduced risk and he was also fed via the stomach tube .  He was diong this as his choice.

Monday, November 12, 2012


  I have seen many surprises in my medical life , but certain things one expects from certain age groups . I would not expect hardcore drug addiction in older patient ,At the same time I would not suspect cancer in younger patient . But things are not always that clear cut . The two short stories that I am going to tell , belong to such category .
     I was working in ER many years ago . It was late at night . We used to have 2 residents working in the ER , but after 1am or so if the ER was not busy , then one resident would go home .On that day I was suppose to stay till  morning .At about I was told that there was a lady who had come with 'lower abdominal ( belly ) pain '. So I went to see her .Normally at such odd time two types of patients come in , those who are so bad that they can't wait till AM ,or those who have no time otherwise to come to ER at other time .
    When I entered the room , I saw this young lady . From her dress I would have suspected that she was a prostitute .Her make up , her flashy dress was indicative of that . The first thought that came to my mind was that if she had lower abdominal pain , the she had gynaecological problem , called PID, pelvic inflammatory disease . In our ER we had separate Gyn ,resident. But I had to make sure that there was no medical cause of her belly pain . So I started asking questions . So where does it hurt,? I asked 'Down bellow '. 'Down bellow , where ' I asked . The answer was shocking . He said , 'Down bellow in my balls " I did not understand , So (s)he pulled pants down . She was not 'she ' but she was 'he'. He was pretending to be a female , so as to get 'clients '. He also was taking hormones , estrogen to get enlargement of the breasts  He did not do any sex change as he was not transvestite . When I examined him he had testicular torsion , twisted testicle , which can cause severe pain and needs quick surgery . Needles to say I called urologist and he was taken to the surgery .and did well.My other story in next blog .