Saturday, April 6, 2013


     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 .

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