Saturday, July 27, 2013


   I wrote about the drug reaction . Some of the drugs may be commonly used and the reaction may be unusual or the drugs may be unusual . But in every case there is a host and there is an agent . What I mean by that is that every body does not react to the same agent in the same exact way . So how we react to an situation is our individuality .. But then how do we react or more than how do patients react to a diagnosis or a bad news ?I do see patients with lung cancer, and as it happens to be in many cases the cancer may not be operable or resettable. This may be due to the spread of the cancer or it may be due to the age of the patients or other medical conditions , like bad heart or limited lung capacity or other causes that precludes the surgery .Even today , in the year 2013 , the resection or the cancer is the best treatment. Not the chemotherapy nor the radiation therapy . So when I tell patients that the cancer is not resettable , their  reactions are different. I am going to tell you couple of stories that the reaction stunned me and I was at the receiving end of the bad reaction .
      Several years ago I saw a 58 years old patient, who was a smoker . She smoked since age 12 or 13 years. She had persistent cough for more than 6 months and she thought that it was due to the smoking .  She took some over the counter  remedies But as the cough did not get better , but got worse and she noticed some blood .. So she saw the family doctor . He started the antibiotics for possible acute bronchitis and did the X-ray . The X-ray showed a mass . So she was referred to me . I did the work up In those days we did not do the PET scan , but did other scans , The scans suggested that the cancer had spread to liver , couple of ribs and gland called adrenal. I did the bronchoscopy and the biopsy of the mass blocking the right lower lobe bronchus . The biopsy showed that it was a Small cell cancer . The small cell cancer is non  resectable as such as the history tells us that  by the time  we diagnose it , it has already spread . So cutting it out does not prevent the recurrence . In this case we had scans to suggest wide spread .The patient came to my office  after the biopsy . Our office policy is such that we tell patients the results of each test when we get it . So she was aware of the scan reports . I discussed with her the diagnosis of the cancer , the type of cells and told her that the best treatment would be the chemotherapy . On our first visit I had told her about the 3 potions and what is the best treatment . So the news was not good and she knew about it before she came for the follow up . So I was not expecting the response that I got . She was MAD AT ME . She had some sore nose after the bronchoscopy , as we put the scope through nose . I had told her that it should improve . Then she told me that I don't care , as she is complaining about the nose and I did not care . I told her that I was more concerned about the inoperable cancer and how to treat it The she stood up and told me that she will like to see a different doctor , as I was not concerned about the  sore nose .I did not know what to do . I gave her couple of names and offered her to make the appointments .
    I really did not know why she reacted to my honest discussion as I always tell patients about options and the truth , but I am never harsh or heartless .  Then unexpectedly  the answer came to me . The patient worked in a hospital . And on of the coworker told me . She had a daughter , who was mentally challenged and was solely dependent upon the my patient for every thing . So she was upset with future . The future in which she would be gone and the mentally challenged daughter would be there and there would be no one to take care of her .So her anger was directed at the messenger and I happened  to be the bearer of the bad news .

Sunday, July 14, 2013


    I wrote about the allergic reaction to commonly use medicine aspirin , and it almost killed patient . No one was at fault and no one made any mistake or wrong decision . There was no malpractice . But it was just a ' chance  '.Many a times common public can not understand , that this was just a bad luck .I am going to tell about an another case of similar situation .
    I was called at 9-30 pm to see a patient who was short of breath and then when I called them back ,I came to  know that he was being transferred to  ICU as the blood pressure was low . As I got in the car to go to see patient , I had called the admitting doctor . He told me that the patient was admitted to hospital at about 4 am that day and he had seen the patient that morning and he was doing OK . Now with the shortness of breath and low blood pressure he was being transferred to ICU . I called the ICU nurse and got some general idea . She had not assessed the patient as he was in  ICU  for less than 5 or 10 minutes . I gave some general ordered to get the labs going and managed the low blood pressure ..As I was getting in the parking lot of the hospital , I had realized that I was going to need a general surgeon to see patient that night, and that too ASAP . I called the surgeon .
     I went to ICU and evaluated the patient . He was 44 years old white male , who had flu like symptoms for about 2 or 3 days and he had taken over the counter remedies . He had some fever and some cough . When he did not get better , he came to ER . He also was having some belly pain . In the ER he had abnormal liver function and mildly elevated white cell count , suggesting infection .The admitting doctor had ordered the gall bladder studies and they came back negative . He was started on IV fluids and was given broad spectrum antibiotics .He felt little better . But then when new team came in at 7 pm and the nurse did her evaluation , she noticed low normal blood pressure . She called the doctor and got orders for some labs and more IV fluids . The next evaluation , his blood pressure was lower and so it was decided to transfer him to ICU and I was called .
    On examination he was quite tender in right upper quadrant of the belly , where liver and gall bladder are present . He had gotten lot of fluids and as his blood pressure was still low , we started him on medicines -to bring it up . By then the labs came back . He=s white cell count had further gone up and his liver tests were also worse . He was not responding to the blood pressure medicines and I had to add different medicine . He was not putting any urine and it showed in the blood chemistry . He was in kidney failure  too. I had anticipated it and had put a call to a kidney specialist too . The surgeon came in and so did the kidney specialist . We discussed the case , and decided to talk to his waiting family , the wife and a daughter . I felt that there was no choice but to open him up and see as to what was going on in the gall bladder or liver or for that matter in the abdomen . The concern that the surgeon was that , he may not tolerate the anesthesia or the surgery and may die on the table . We discussed the pros and cons of the choices that we had . In between I had decided that with his general condition worsening , we needed to put him on a breathing machine. The surgeon wanted to talk to a vascular surgeon , so he can come in the operating room , once he was little stable and assist him , in case there was a vascular issue that was causing the problem . The wife and the daughter wanted to see him . As I entered the ICU with family and the surgeon , I saw that his blood pressure was dropping and now the heart rate was dropping too . We called in  CODE . We tried to work on him for next 40 0r 50 minutes , but he never came out . He died . I was in ICU for about 2 hours . I had no idea as to what did he have . I explained it to the family and requested an autopsy . She agreed .
      The autopsy was done . I spoke to the pathologist . According to the pathologist patient had acute necrosis of the liver , most likely due to excessive use of Tylenol . There was no gall bladder problem , there was no vascular issues and certainly no major lung or heart problem . I had gotten the history of taking over the counter products , including several Tylenol. So the best conclusion that I could come with and the pathologist agreed , was that he took too many Tylenol and he also use to take 3 to 4 drinks a day . So the combination of the Tylenol and alcohol, both very commonly taken things , killed him  !!!!

Saturday, July 13, 2013


   In medicine we often use drugs and get 'used ' to it so much , that we don't even think twice about writing a script any time .But then comes a patient or we learn about an incidence that make us think twice. The story that I am going to tell today is one such .
    The Aspirin has been in the use for many years . It was invented in 1897. Felix Hoffman of the Bayer company , was credited for the invention . But then there was another chemist , who was Jewish , who claimed to be the one whose work was purged by Nazi, as he was a Jew . In any case it was marked for aches and pain and the fever . It was widely used in the flu epidemic and was thought to have helped . Though some believe that children died because of the use of aspirin . We use it today everyday . In fact it is used for heart attack and there are studies that show that it prevents colon cancer too . Since it is 'over the counter '  drug , we use it without any thought for the safety . If it was prescription drug , then we would have been seeing many TV ads on how it caused deaths or problem and 'how you may be entitle for the compensation'. So this is one such story .
    I was called  to see this patient , who was being admitted to ICU with respiratory failure . I spoke to the ER  doctor . Patient came to ER in respiratory distress , and they could not even intubate the patient . The ER doctor had to do emergency tracheostomy .I went to see the patient . He was a patient with a history of asthma . He had a cold and saw the primary care physician . He was given the prescription for an antibiotic . Patient went home and had not yet filled the prescription for the antibiotic . He felt like he had flue and so took the aspirin . Within very short time he started feeling like he could not breath . The wife called 911 . The paramedics came in less than 5 minutes . They put him on oxygen , gave him some shot and moved him to ER . HE continued to get worse and they could not put a tube down the throat in to main wind pipe ,to help him breath . When he was brought to ER , the ER doctor could not intubate him either ,as his throat was closing . So then he did tracheostomy .
    I examined him and the treated for asthma , though interestingly the asthma was not a problem at all .He really did not sound that bad . We weaned him off the respirator . We had consulted an ENT to fix his tracheostomy , as the one that he had done was done as an emergency procedure . He was off the respirator and the we had ENT do the repair of the tracheostomy . It took about 6 months to get it out . I still see him and his asthma is fairly stable .
    This was a typical case of severe allergy to aspirin . I am not sure if he had taken the aspirin before , but this time it almost killed him . He had a major reaction to  aspirin and he had swelling of his throat to such extent that if it was not for the ER physician or he was not brought to ER soon enough , then he would died
   I saw a case of acetaminophen killing a patient , recently , and I will talk about it next time ..

Saturday, July 6, 2013


    In recent past the technology has added to our understanding of the diseases process . We also can diagnoses the diseases better and treat better . The ultrasound came for the general use in most of the hospitals in mid seventies . Then came the CT scan and then the PET scans. We now can virtually see arteries going to heart --the coronary arteries without doing the cardiac  catheterization.. We can  biopsy of  almost any organ without cutting .And we almost don't need any autopsy to see any organ . New endoscopy techniques have added to our ability to get to the bottom of the diseases.. But I often feel are we really any better ? Are we not doing too many things ,and they do not  really help patients .This came to my mind when I saw couple of patients on follow up in my office .
    I had seen this patient in office for may be 2 or 3 years . He had large nodules in both lungs . He  was seeing other lung specialist . In fact he had seen 2 different lung specialists in last 5 years and they had done endoscopies .No cancer was detected . The CT scans had remained stable with no major change in the nodules . I had followed him for the asthma that he also had . He was doing OK and I had done the follow up on his CT scans. H e had missed his last 2 appointments and the he came to see me after a gap of about 8 or 9 months . He told me that he was fairly stable and his medications were renewed by his family doctors .But then he told me that he was hospitalized . and had many tests . I had not known this and he was admitted to the hospital ,that I don't go . I reviewed the hospital records . I saw his CT scans , not one but 3 and then he had 3 bronchoscopies . He also had CT scan of the Abdomen and number of other tests . The CT scans had not changed , when compared to older scans from 3 years ago . But the first  bronchoscopy and biopsy was non conclusive . So he had  a second one . That showed some abnormality . and so he had a third one with special type of biopsy . Through the scope and ultrasound is done and then a biopsy of lymph node is done . They also used another ultrasound technique to do the biopsy of the mass . Both these techniques are new , may be developed in last 3 years and still not done by 75 % of the endoscopists . One of the biopsies showed that he had a benign disease called sarcoidosis .This was not diagnosed by any of the special techniques, but by simple deep biopsy. The sarcoidosis is a disease , etiology of this is not known . It can affect any organs , but commonly we see the lungs involved . In some patients we see significant scars in the lungs and patients have chronic cough and may be short of breath . Not even one % patients die . I have seen may 2 patients who had progressive disease .
     So now I am wondering as to what did we achieve with 2 CT scans of chest , one of belly , 3 bronchoscopic , one of which was under anesthesia , and cost of thousands dollars .We did not have the diagnosis in the past , but now that we have diagnosis, did it change anything . Did he need any treatment that he was not getting ? If we would have continued to do follow up on his CT scans or even simple X-ray, would it not have sufficed ? We do have new technologies and they do help us in diagnosis . But we need to not loose the sight of risk -benefit ratio. This patient had masses on both sides of lung . They had not changed in at least 5 or 6 years . So the 'chance ' of cancer was very -very low or nonexistent . If indeed he had cancer, he would not have been  a surgically resectable stage . So did we spend all this money for nothing ? You have decide .

Thursday, July 4, 2013


   Recently there was a Supreme court case , where there was a  question, if children should get a adult organs. The decision was made that a child could get the adult lung . The patient got the adult lung and as it appears everything is OK . The question is how much limitation we in medicine we have , when it comes to transplant . I just was told by my office that one of my patients , about 50 years of age died .
     Ed was my patient for last 5 or 6 years . He had scleroderma and had some shortness of breath . He was doing OK for last several years , but recently , may be last year and a half , he was getting worse . As in many cases of scleroderma , he had some scar tissue in the lungs . We did the work up and his overall status was getting worse .We did the heart catheterization  and rest of the work up . In the span of 6 months he really got worse . I decided to refer him for transplant .He had to go out of town for the evaluation . AND they rejected him . He had mildly abnormal kidney function. This was contraindication for the transplant . So we had not much to offer . He continued to get worse and so  put him on hospice and he died . The medication that they use could worsen the kidney function in patients with scleroderma and then patient would need dialysis or renal transplant . So with our given technology , we could not help him .
     But there more to this than what this case illustrates . I often tell my patients that to get a new lung , someone has to loose one and which means someone must die .So we have quite a bit of limitations as to who gets the transplant and who is rejected . I have got patients that have been rejected due to previous cardiac history , or age or other issues . One of my other patient who needs lot of oxygen , 6 to8 l per minutes and he is short of breath on doing anything and he is less than 45 years old .But he was rejected for the transplants .
     There are many more cases that I have as patients that have been rejected for one or another cause . These causes range from the over weight to under weight , heart problems, kidney problem , psychiatric issues , family problems . This reflects more on our limitations and  the bad luck than true rationing , but in any case we in medicine do rationing all the time . This also applies to many other diseases and many other medicines use .