Friday, November 14, 2014


     The diagnosis of Asbestosis has a special meaning. It has medical and economical importance. As a lung specialist I often see patients whoa have suspected asbestosis or who have abnormal chest X-ray. In past we used asbestos at many different places and we had no understanding of the risk of the asbestosis.So when one inhales the asbestosis fibre , it goes in to the lungs.The asbestos fiber is indestructible.So the body can not destroy it and then it stays in the lungs. It can penetrate to the covering of the lungs called the pleura. So it continues to stay and 'irritate' the lung tissue and the pleura.This leads to Lung Cancer and the cancer of the pleura , called Mesothelioma. (Chronic irritation can lead to cancer. If there is a sharp tooth that causes repeated biting of the inside of the lip , it will cause the cancer. In the Kashmir (INDIA), there is a custom of using a 'hor burner' called Kangri around the belly.This is covered by a blanket. The repeated heating in that area of the belly causes skin cancer. The abdominal wall skin cancer is otherwise not seen as it does not get exposed to sunlight.)So this constant  irritation from the asbestosis fifer causes the cancer.
     Now that there is a economical compensation for getting exposed to asbestos , there is more incentive to 'find' asbestosis. The good part is that many patients who are esposed to the asbestos ,do not get the asbestosis and those who do get the asbestosis, do not get the cancer or bad scarring in the lungs.The bad or good part(as one looks at it) is that any time there is a diagnosis of asbestosis , there is compensation or at lest a claim for one . Thank God , we are not using asbestosis any more and at least have eliminated at least one deadly agent.But the story that I am going to tell is not of asbestosis.
      I saw this patient who was referred to me for the evaluation of abnormal chest X-ray. The patient was from formal USSR. He did not speak any or much English. So he was with his friend who did speak English.Even though we tend to think that we do not cut short, when we see patients who can not speak English, we do .It is not intentional , but I think we do cut down on what we think is non essential history.We don't miss medical history , but as to family history of occupational history, we cut it short. He was 2pack per day smoker and had some COPD.So when I saw the CT scan of the chest ,I was concerned. He had a pleural based mass .The mass was at the edge of the lung ,but the size was about 4 Cm. So In this smoker I was worried about the cancer. there was no old X-ray .I decided to do the PET scan and the bronchoscopy. The bronchoscopy was negative and did not help.The PET scan which is suppose to pick up 85% or more the cancers, was OK.So now the "chance ' of the cancer was low. So when he came for the follow up.I asked him on any motor vehicle accident to see if the density that I was seeing may have been related to trauma. The answer was no. He had done some odd jobs but there was no history of asbestos exposure. So I decided to do follow up CT scan . The CT scan was showing no change ,which was good news as it reduced the chance of cancer. So when he came for the follow up we started talking about the USSR.Then he told me that he was a POW or political prisoner and was incarcerated for more than 2 years. When I asked him about the prison conditions and the treatment of the prisoners, he told me that the guards kicked him routinely AND THAT TOO IN THE CHEST. It was so bad that he had bruised ribs. So this was the cause of his abnormal CT scan. The kicking or for that matter any trauma,can cause some inside bleeding and that can heal with a scar tissue. If the amount of bleeding is severe then one will have blood collection in the chest cavity and that may need to be drained. But small to moderate amount will leave the scar.So I had the answer in the third visit and it was not asbestosis.
    I did continue to do follow up and follow up CT scan , as he was a smoker , but over period of 3 years , nothing changed .There are other causes of such abnormality, seen on CT scan , but more about them at some other time.

Sunday, November 9, 2014


   I was reading a book and the topic  of the Death Penalty and the physician's role came in . As a physician we have been asked to treat patients and cure them and not 'kill' them . Long time ago I had seen a sitcom in which the husband is a physician who had to see a patient in ER with a gun shot wound . He had to operate and give him blood and save his life , so the State Attorney ,which happens to be his wife could prosecute him for a murder and ask for the death penalty.This is not only a good topic for the TV drama but also a great Ethical question. Should physicians assist in the death penalty?AMA does not feel that physicians should have any role in the execution of the convicted killers. In fact they came out with a policy statement -guideline in 1980.But today 38 states the death penalty is carried out by lethal injection and in 2006 a District Court recommended a physician's presence and they recommended (or ordered?) anesthesiologist to be the one .So I was thinking about it .What is our true role?Let me explain.
     In a day to day work we as physicians discuss the diagnosis and the treatment of various diseases and also the prognosis. This may be as simple as bronchitis or high blood pressure or asthma, or it may be a serious condition like acute heart attack and cardiogenic shock or respiratory failure.Even when a patient is admitted to the hospital with simple element, like hernia repair or pain in the belly, by law we have to ask for what is called 'Advanced Directives'.This the statement which tells the treating physician as to patients desire to do aggressive treatment in case of the need for it.We also deal with this issue while patient is in hospital,especially in ICU with critical illness,especially if he or she is snot doing well.Then we talk about DNR,DO NOT RESUSCITATE order.
     In some cases when the patient in spite of being on respirator and on no of life sustaining medicines ,is not doing well and when the physician feels that the prognosis is likely to be poor, then we do recommend 'stopping'the treatment , the so called Withdrawal of Life Support.
    So let me analyse.In some cases we discuss and decide (with help of patient) to with hold the life saving treatment and in other cases we also stop the life sustaining treatment . IN NO CASE WE DO ANY THING ACTIVELY TO HASTEN DEATH.But the out come is same.Let me give an example. If I see someone drowning ,and I do not help him,(presuming that I can swim and save him), and in other case I actively hold someones head under water.The out come is same .Are the acts same?When we decide that we are not going to help some one by putting them on respirator and let them die and in other case we stop the respirator and let them die, are we not doing the same ?( I know that we always make sure that the patient is comfortable and not struggling and use plenty of narcotics to  achieve the goal).
       Now that I have confused every one that is reading this blog , tell you one thing. I don't think many of us would ever be in position to assist in execution of death penalty , though many of us believe in it.I also feel fortunate to help patients make educated on the prognosis and limitations of the treatment , so that they can make educated descion and not emotional. I am sure I will revisit this topic sometimes in future.