Saturday, June 29, 2013


     We often see and talk about the  phrase ,'missing the boat'. Now a days the real estate prices are going up a little bit ,and when we will realize that we did not buy the real estate when we should have bought , we say we miss the boat . This is also said in case of stocks . But I don't think we ever say ( at least  not often ) that we missed the boat .But if we look at the medical conditions , it could be appropriately said that the patient or even doctor missed the boat . I have seen some unfortunate patients , that do seem to have missed the boat . They quit the smoking , and still get cancer . And when this happens after 5 or 7 years after quitting the smoking , then it certainly 'hurts'. The statistics states that it takes 13 or even 14  years the chance of developing cancer of the lung is same as nonsmoker .PLEASE note that nonsmokers do get lung cancers too. So it is never zero. I had a patient who had not smoked and had some fibrosis , scar tissues in lungs and had history of breast cancer , developed lung cancer . In fact I was shocked and even the patient was too . The yearly X-ray that I order on all my patients , except in those who have pure asthma , showed the mass in her case .This is not unusual . In fact there is a constant debate weather we should be doing X-ray or CT scans in smokers or ex-smoker .The argument is against it is that is  not cost effective as we may have to do too many X-ray to diagnose one cancer and so we may be spending too much to get one success. IN MY MIND IT IS COST EFFECTIVE TO THE ONE THAT I COULD DIAGNOSE THE CANCER IN EARLIER STAGE . In her case the cancer popped up in 11 months . And it was 9cms large . It was so large that she thought that I may be seeing her ruptured breast implant . She was inoperable . We gave her radiation and chemotherapy. But it did not make much difference . Again did we miss the boat ? There is no reason to do X-ray more often than yearly , as otherwise we may be increasing the amount of radiation and also the cost .But the story that I am going to tell is that of a patient , that I feel we missed the boat . I am not sure if it could have been prevented . But we did miss the boat .
     This was a 72 years old patient , who could not speak much English . She spoke creo. I saw her for the complains of cough and some shortness of the breath . She had high blood pressure and diabetes and was obese. She probably had sleep apnea too . This was her third admission . During her last admission , she had echo cardiogram and due to complains of chest pain had heart cauterisation. It had shown the blockage and so she had stent put in It was only 6 weeks and the work up for heart attack was negative . I thought that she had asthma and so I started her on inhaler and she felt better . She was discharged . She was readmitted and was discharged again , when the cardiac work up was negative .I saw her again as she was readmitted for the cough . She did not do follow up with me and had stopped her inhaler . The admitting doctor thought that her cough may be due to one of her blood pressure medicine .So he stopped it . She also had chest pain . But it was on both sides and id not sound like cardiac pain . But the cardiologist was consulted again and he wrote that it was non cardiac pain . Her chest x-ray was OK and her oxygen saturation was 100 %. I restarted her on some inhaler and ordered allergy blood test and also gave her on shot of steroids. The next day she was better . But that night I got a call that she was having shortness of breath and some chest pain . I ordered the treatment for asthma and did the test to make sure that it was not heart attack . Next morning when I saw her she had no problems , her lungs were clear and oxygen was 100 % with no oxygen supplement needed . I actually saw her at 2 pm . I was in dentist's office , when the nurse called me . She was short of breath had chest pain , again on both sides and her oxygen was low .The rapid response nurse was there . The had put her on 100% oxygen . I also told them to do stat X-ray and ordered the blood test for the heart attack . I also gave her a shot of steroid and the breathing treatment . It was 4-30pm and I saw her in next 15 minutes .
    When I saw her it was clear to me that she was in heart failure .They had called the cardiologist and his answer was there is nothing wrong with the heart and call the lung specialist . The X-ray confirmed that diagnosis , the blood test confirmed and the diuretic that I had ordered on telephone had helped her . We had her transferred her to ICU . The next day she was off the oxygen and was fine . I had talked to the cardiologist and he scheduled the heart  catheterization  .The cath showed that her heart function had gone down to 20 % and the stent had blocked .Other than giving her medical treatment , nothing much could be done .

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