KNOWN UNKNOWN

      I remember when the defense secretory Don Rumsfeld made a statement , in which he talked about 'known unknown and unknown known ' . At the first glance it sounded very confusing , but the on the second thought it became very clear as to what he was talking . In medicine there are known unknowns and there are unknown  known.  For example , if a patient is undergoing a surgery , we know what is his risk , based on lung or heart evaluation . But we may not anticipate any kidney problem that he may get in or a stroke that may occur in a elderly patient , that we may not anticipate .I am not sure if the case that I am going to describe fits in to this description . Knowing his or her heart issues is known risk , but not knowing his risk for stroke is unknown risk . The story is not exactly fitting in to this type of case .
     I saw this 65 years old male patient for 'pulmonary clearance ' for the spine surgery . He was a male patient , who had smoked his entire life except for last 5 years . He was having bad back pain for sometimes . The Internist had tried various medication and then done CT scan of the lower spine and referred him to an orthopedic doctor . He was tried on physical therapy , and some 'shots ' . His pain got little better , but came back and he was miserable . So the decision was made to the surgery . Due to his history of the smoking , he was sent to me for assessing his pulmonary risk.
    I saw him in my office . The Internist who referred him to me is one of those rare doctored who sends his notes with the patients . So it becomes easy to evaluate them . His lungs were clear . His oxygen was normal and in his history , there was not much of the complaint of cough or sputum . So his surgical risks would be good . But when I was examining him I noticed a large lymph node in his left side of the neck ,above the collar bone . I asked him about it . He was aware of it , but had not mentioned it to any of his doctors as it had not changed much in last 3 months , since he had noticed it . I was not very happy with the size and it felt firm to hard , suggesting that it may be cancerous . He had chest X-ray done , which was normal . I decided to call the internist and then after discussion I sent him to a surgeon . He did the biopsy . It showed a cancer . The tissue type was such that it could come from the lungs or many other organs . It could be the lung cancer or the throat cancer . I did do a CT scan of the lungs and CT scan of the neck . Both the scans came back normal . I decided to do bronchoscopy and send him to ENT doctor . I did not find the origin of the cancer in either throat or lungs Rest of the work was negative , he had no evidence of the cancer anywhere in the body . So we had a patient , who has definite cancer , but we don't know where it started and once the node was out , there was no presence of cancer in the body , as far as we could say .  I cleared him for the surgery . I was not sure as to what kind of treatment we could give him as we did not know how to asses the effectiveness of the treatment .How can we say that he is benefiting from the treatment , as with the node out there was no evidence of cancer that we could detect .
   I had follow up set for him in 4 months or so . He had surgery and his pain was much better . The surgery was uneventful no complications . I ordered a new CT scan . He was not very keen on doing it . But did it . IT showed a nodule ,a spot in right lung . I redid the bronchoscopy , did not see anything abnormal . I decided to do the needle biopsy of the nodule . IT came back as cancer , same type as was seen in the lymph node that was taken out almost 6 months ago .
    The mystery was solved .He had lung cancer, that spread to the lymph node , but the primary tumor was so small , that we could not see it with CT scan or with the bronchoscopy .

THE FAMILY NAME

    I see patients with cancer quite frequently . Unfortunately, most of the patients that I see are not resectable .This may be due to various reasons . Sometimes when patients present to the doctor , the cancer has already spread to other organs , making it inoperable . Sometimes patients may have poor lung capacity , so even though the tumor may be resectable , patients may not be in position to tolerate the surgery or resection of the part of the lung . When the patients are  not candidate for the resection , the chance of 'cure ' is very small . The radiation therapy or chemotherapy can not cure the cancer in most cases . I do know some patients that got cured with either radiation or chemotherapy .So many a times patients ask me as to the prognosis . They want to know as to 'how much time ' they have . I am lost for the words . I don't want to take away the hope but at the same time I don't want to lie . And frankly I really can't predict the out come in specific patient, though I am fully aware of the statistic and can easily state what happens to majority of the patients . So I often make a statement . I say that that the cancer is like a family name . They all have similar characteristics . The are bad and they spread and will kill . But as is the case of family name , even though there are common character , not all the family members are same in their behavior . But then in some cases you turn out to be completely wrong .The case that I am going to tell is one such case .
        I knew Mary for long time . She was a smoker and had emphysema . Every time she came to office , she would promise me that she was quitting the smoking .One day she had some belly pain and it got worse . She saw gastroenterologist and he ordered ultrasound of the belly and did endoscopy . The endoscopy was OK but the ultrasound showed that she had masses in the liver highly suspicious for cancer . Her pain was quite severe and she was admitted to the hospital for the pain control .I was asked to see her . Further work up showed that she had multiple nodules in the lung , not seen on plain x-ray , but seen on CT scan , highly likely to be due to spread of cancer . The liver biopsy was done and it confirmed the cancer . They had hard time deciding as to where the cancer originated . But it looked most likely to be from pancreas . She was seen by the oncologist , cancer specialist . She had a port put in for giving chemotherapy . From the complaint of pain to the time that we got diagnosis was less than 2 weeks .She was discharged

       She was readmitted in less than one week , with multiple complaints . When I saw her , her belly looked bigger and she was mildly confused . I did MRI of the brain , and it was OK .She was given fluid and she did get better . Due to the increase in belly sise I did new CT scan of the belly . IT showed fluid in the belly and the liver tumors had increased in  size. This was in less than 3 weeks .  I knew that nothing was going to help . I talked to the daughter and the patient and decided to refer her to Hospice . There was nothing that we could do ,that could change her prognosis .
      She died in next 4 days , less than 5 weeks after the 1st complaint.




 

MAHABHARAT AND SYMBOLISM --JANDRATH

     I learned from reading from various sources as to the general idea and how these stories have similarity and use of similar objects to have similar conclusions . The story of Jayandratha is one such story . Once you know the different objects being used to symbolize certain , then it becomes easier to find the real meaning .
     In the story of Jayandratha , Arjuna declares that he is going to kill Jandratha before the Sunrise . So Jayandratha hides and Arjuna can not find him . As the time passes, every one is worried . So then lord Krishna covers the Sun with his Sudarshan chakra . So every one thinks that sunset has occurred . Jayandratha comes out  from his hiding place . Then the lord Krishna removes the chakra . There is bright Sun out . Arjuna kills the Jayandratha .
   To understand the meaning of this story , one has to know what the Jayandratha represents . We have several attachments in our life . We are attached to food , music or relatives or drugs , alcohol etc . We feel that we can not 'give up ' any of this easily . But we know that under various circumstances , we can give up these things . We know many people that have given up smoking , alcohol or relationship with spouse or parents or relatives There was story about the mother's love and attachment to the child . This from the Birabal and Baadashaha stories . Once they had a debate , which is stronger , mother's love or our own life . The Badashaha the king felt that it was mother's love , while Birbal felt it was attachment and desire to survive .So settle the debate they brought in a female monkey and her child . They were put in a tank where there was a small pillar in the center .. They started filling the tank with the water . As the water started rising , the mother monkey climbed the pillar and held the baby monkey as high as she could . But when the water came as high as mother's mouth , she quickly put baby down and tried to stand on it . So the attachment to our body or to survive is stronger than anything else .That is why. the most difficult of these is the attachment to our own body .We can not get detached from our body , may be because we most of the time think our self as our body .and not 'independent ' of it . This attachment is Jayandratha .As long as we think of body as 'I' we can not kill the desire or the attachment to the body , When we get the enlightenment or when the Sun comes out ( Sun represents the knowledge ). So when the Sun is out Jayandrath hides . But this is temporary . When the Sun goes out we are back to the bodily attachment. So we need help from the God and with his help once and for all kill the Jayandratha .When the Sun came out , which means when Arjuna got enlightenment , he could kill the bodily attachment .

TRUSTWORTHY

     We often talk about someone being 'trustworthy'. We use this word , weather we are talking about buying  a car ,or dealing in business or getting a maid service . But this is  more important when we are talking about a doctor or about medicine . Unfortunately as it occurs in any business , when we know someone or something , we either become overconfident or less confident . The story that I am going to tell is one such experience .
     I saw this patient , who had couple of episodes of coughing up blood . He was a 51 years old male who had smoked all his life and decided to quit after the 1st episode . It started as acute bronchitis , he had flu like symptoms and then started coughing quite badly , then noticed the blood . He neglected it first . The cough improved and he had no fever , and the x-ray done by his primary care physician was reported as normal .. But when he coughed up blood second time , and this time without severe bout of coughing , he got concerned ,and decided to come to me .
     When I saw him he had no other complaints , he was not short of breath , his lungs sounded clear ,and he had not lost any weight . He was working as a radiology technician  at local hospital .I explained him the various possibilities for coughing up blood with a normal x-ray, We decided to do CT scan , a breathing test as he was smoker , and scheduled him for a bronchoscopy . He was not very keen on doing the test, but did agree to do it when I told him that vocal cord tumor could be missed , unless we do direct visualization . The CT scan was OK . When I did the bronchoscopy , I saw a small tumor in the middle part of the right lung . I did the brushing and biopsy . The biopsy came as cancer of the lung . The patient would not believe that he could have cancer in spite of having normal CT scan . He asked me if the endoscopy or the lab. could have goofed up and the labeling on the biopsy could be wrong .I assured him that though theoretically it is possible it was not possible in his case . ( I had not done many biopsy on that day ).He was referred to a surgeon . The surgeon decided to repeat the bronchoscopy as the CT scan did not show the cancer and he did not want to take out part of the lung based on my observation As it turned out , he did not see any tumor . ( now think about it . The patient had full trust in the CT scan , more than what one should have , but did not have same trust in either my observation or the system of sending samples . The surgeon had more trust in his own observation than mine and I had more trust in what I saw . )
     I sat with the patient , in my office . I told him that I 'did' see the cancer , even though the surgeon did not and the biopsy that I did ,came positive for the cancer as I had suspected . I did not want to wait too long ,as in the whole process of working this out ,we were almost 3 months since the first episode of the coughing of the blood . I asked him to "do me a favor ". I asked him to allow me to do a repeat bronchoscopy , a third one . He was hesitant , but I told him my thought process and told him that if this one was OK then I would do follow up CT scan in 3 or 4 months . He agreed .
     I did do the bronchoscopy . I saw the cancer , I took the pictures and the biopsy came positive same as before , for the same kind of cancer .With this findings , when I contacted the surgeon , he agreed to take out the middle lobe of the right lung . The surgery went well and he did have very early stage of the cancer in the middle lobe .
    My thinking is that he had small cancer and the top part of it would become necrotic and dead and would fall off . I was lucky to see it and get the positive biopsy , but when the surgeon did it , the tumor had fallen off and he did not see anything . It was not large enough to be picked up on CT scan .If the surgeon would have done biopsy from that area , even though he did not see anything , he would have gotten it positive .
   So each one of us trusted our own ability or test , but not others . The radiology tech  had full faith in the CT scan but not in which we process the samples or in my observation .The surgeon was confident in his own ability , but not in mane and I was more comfortable and trust in my observation .

RESPONCE TO PRAYER

       I received this comment from Mr. D.P. Joshi from India and thought of sharing it with all .

Prayer is an attempt to change the outcome of an event. An event is a result of actions taken by so many people earlier in time; hence the final outcome is pre-decided by others already by individual actions. To that extent outcome, if already decided it can- not be changed, prayer or no prayer. If one prays that a girl should be born to a lady result is 50% pre-decided but exact result is decided at the time of conception. There is no way it can be changed by prayer either way. Of course it is a 50 % chance and to that extent one can be right.  However there is a distinct possibility of a change if one pays before the event is fixed by other events. In the dormant stage positive strong thoughts could make a change in the outcome. A prayer has definitely a chance of success if it is expressed before an examination giving the student a chance of improving his score but has no effect after the paper is written. I think prayer has a good chance of success if it reaches the party concerned in time, giving him an opportunity to alter inputs in a positive manner. One can- not deny that GOD has the final word about any outcome, but he would not use his powers normally. He has devised natural laws of all the games making a direct reference to him un-necessary. We may not be aware of all the natural laws that are different.

 

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