Sunday, July 26, 2015


      We often use this term , "barking the wrong tree ". I have personally experienced this type of behaviour many a times In medicine we often blame the Insurance company for the increasing cost of the insurance premium. But to some extent this is at least to some extent' barking the wrong tree '. The insurance company collects premium and distributes it to providers. It also has to pay it;s employees and the overhead to the agents and the advertisers and the claims management team etc. So whatever is left is the profit. So if they pay more for the overhead or for the medical expenses-health care claims, then they will have to 'increase' the premium as they have to have some profit.(especially to show it to their share holders )I do not deny that some of the CEO of the insurance company do make what I would feel as outrageous bonuses.But essential if we continue to 'blame' the Insurance company for the increasing cost of the health care, then we are 'barking a wrong tree'. But today I am not talking about the health care cost . I am talking about a patient.
     I was consulted on this 55 years old patient , who was admitted to the hospital for shortness of breath. As it happened he was having shortness of the breath for last 6 weeks and had made appointment to see me . He was to see me in a week before which he got worse and came to hospital . He had  a history of clot in the leg and it had travelled to lungs about 6 years ago . This happened after the knee surgery and so he was prone to it and was treated with' blood thinner', for 6 months . He did OK But then last year he was short of the breath. So was admitted to hospital and was again diagnosed to have clot in lung and clot in leg. So he was treated with blood thinner again . This time he was seen by a blood specialist . He stopped the blood thinner 6 months down the road. The work up to see if his blood clotted too quickly was mostly negative.
      So this time when he was admitted to the hospital , they suspected clot. Indeed he had a clot in the leg but the CT scan of the lung was negative for the clot in the lung. So when I was consulted , the admitting doctor also was thinking that all that we needed was to continue the blood thinner , may be this time for life long . In fact i myself made a comment to the patient , that "just because barrel of a gun is empty , does not mean that the gun did not fire. " We use this line when there is a clot in lungs but not in vein . But I was not sure as to why he was short of breath for LAST 6 WEEKS . It was possible that due to some clotting abnormality, he was 'throwing' clots in the lungs and that has caused his shortness of the breath. .But like as I usually do I made him walk. I walked with him . As we walked , I was talking with him. As we walked for may be 50 feet or so , I asked him if he wanted to continue or go back to the room .He told me that he was short of breath and was feeling little dizzy and felt he was sweating. I went back to the room and checked his oxygen . It was 100% and he sounded clear on his lungs . I told him that I don't think it was lungs that was causing his shortness of the breath , but it is possible . But I was concerned about his heart. So we ordered a CT Coronary scan . In this test they inject  a contrast and the 'pictures' are taken very rapidly, all most 64 pictures per second. This gives coronary anatomy.It is may be 85 % accurate (or may be more. )It was abnormal So we consulted a cardiologist . He agreed and did a cardiac cauterisation . One of the main artery was blocked 85 % with a plaque. The cardiologist put in a stent and the patient did well This was at such a location that it is called 'widow maker'.
       So I thought that he had a recurring clot in the lungs as the cause of his shortness of breath.But as it terned out his shortness of the breath was due to critical coronary artery disease. So I was "barking the wrong tree!!!!"

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