Sunday, January 31, 2016


    We often say that something could go wrong , it could (Thank God not'' it will" ) But sometimes in medicine it is so true. I have seen and heard about the stories , which are sometimes referred as 'train wreck'. And I have personally seen them too . But sometimes the complications or what happens is helpful in making certain decisions . Just to give an example would be patient who has borderline pulmonary reserve to have lung surgery to take out a cancerous growth. Then he may have a scan showing spread or a appearance of skin lesion that terns out to be spread of the cancer.So now the decision is clear . Due to spread of the cancer , he is not surgical candidate . And it is also helpful to patient as well . If such a patient would undergo surgery and does not do well due to poor pulmonary reserve , and then develops spread, we would be more unhappy. Instead if we make decision to not operate we at least have quality of life . But the uncertainty in medicine is disappointing and at times frustrating. This is so true with one of my patients that I saw.

    So I saw this 70 some years old patient who came to hospital with generalized weakness. She was found to have low blood count . Her white cell count , red cell count or the hemoglobin and the platelet , which help in clotting , were all low . She was told few years ago that she had problem with the counts. But it got better and so she stopped going to the blood specialist . The counts continued to be OK for about 2 years and now she was in the hospital . She had low blood oxygen , so I saw her . I did CT scan and it showed some fluid around her lungs . So I did ultrasound of the heart and it was normal . She was worked up and found to have MDS , I this condition the bone marrow , which is the factory for all the blood cells , stops making them. She was started on treatment to improve the counts . I treated her for the low oxygen and with the treatment she got off the oxygen and her fluid got better. But the counts continued to be low . So she was given transfusions. I had talked to the family and the patient , telling them the poor prognosis. But as it often happens, unless this information comes from every doctor including the blood doctor, it will not have the effect .And then one night I got a call . She had difficulty breathing and her oxygen dropped She needed to be transferred to ICU . In next 6 to 8 hours it was clear that she had heart attack and she was in shock due to poor heart function. She was also confused and agitated. I am not sure why. But any way once the heart attack and it's side effects were seen, it was easy to make decision I had the discussion with the family and with her MDS and now the heart attack , we decided to do the comfort care. The MDS which had not gotten better and in itself carried poor outcome , was not enough to make decision . But now an unexpected heart attack made it easier to make decision .  

Wednesday, January 27, 2016


    I have been sometimes asked if I would be interested in doing telemedicine . I feel that I am doing the telemedicine at times for long time and even today , though without getting paid for it . When patients call me or my office and have some complaints , I look at their charts and based on the information provided on telephone and the information that I have from the past , make a decision. It may be as simple as giving an antibiotics or as complicated to ask him to go to ER. But the modern day telemedicine is to advice patients or 'consumer'  on possible diagnosis , it's work up and may be treatment. And these are not my 'known ' patients , but brand new patients that I have never seen or examined . I do not feel comfortable with the idea , though I do that too with friend and friend'd friends all the time . I don't think this is good medicine . But I thought about this when I came across the patient who was treated as if it was telemedicine . I often say that if it was possible to do the diagnosis and the treatment this way, computers would take over. But sometimes I feel that doctors are behaving like computers.

    I saw this 70 years old patient , who was referred to me for chronic cough and abnormal chest x-ray. He was having cough for about 2-3 months and was treated with antibiotics and cough medicines . The cough persisted and so he had a chest X-ray done and it was abnormal so then the CT scan was done and when it showed multiple nodules , he was referred to me . He had no fever and though his appetite was reduced , he had not lost any weight . The cough was dry and he was minimally short of breath. He was non smoker . We had no old CT scan. So I decided to do Bronchoscopy . My initial impression was the possibility of atypical infection called MAC or Mycobaterium Avium Complex . It is in the same family as Regular TB . But it is not contagious and treatment is different. His bronchoscopy and the biopsy and the TB culture came back negative . He had multiple nodules , so if they were spread of a cancer --metastatic cancer , he was not surgically resectable stage. But I decided to send him to a surgeon and at the same time have radiologist do a needle biopsy . In between ,I am not still clear why, he was sent to a cancer doctor. I am still not sure as to who sent him to cancer doctor. But he did go to cancer doctor and she sent him to a surgeon from her own group . He sent him to radiologist for a biopsy. IDID NOT GET CONTACTED OR GET ANY NOTES. All these doctors belong to same group. He had the biopsy . None of these doctors saw him in office , but he was told that he did not have a cancer.

    So at the end of 3 months he came to me . I had not gotten any reports and I was not aware that he had gone to different group of doctors and had work up done . When my office had called him in between , he had told my office staff that he was seeing a surgeon and is having a biopsy. So I gathered the information from all the doctors . When  I got the biopsy it stated "No malignant cells seen " .It did not state as to what did THEY SEE. So I faxed request to see if they could tell me as to WHT THWY SAW , not what they did not see. I never got the answer. I also could not figure out if they had done any TB culture . So this is the computer generated medicine . It had no thought process as to the possibility of MAC . So no cultures were done . No one bothered to tell patient as to what was diagnosis and what he should do next.
   I decided to do repeat bronchoscopy and called the surgeon and told him that if my bronchoscopy was unable to get a diagnosis , then he should do OPEN biopsy , not needle biopsy. With patient's luck , my second bronchoscopy confirmed the diagnosis of MAC .I started him on treatment and he did fine .

   But the reason to write this blog is to make a point that one has to see patient and make a calculated diagnosis. Otherwise the tests don't mean much , and we might as well have computer generated diagnosis and may be treatment too ! 

Tuesday, January 12, 2016


      In today's world people expect that the modern day medicine is perfect and every time patient goes to doctor , the modern medicine and the tools that we are given , will give us the answer every time . But I hate to break the bad news that even with the modern medicine and the CT scans and the MRI and many other tools , we are not 100% accurate. It reminds me of old story that was told to me by my teachers when I started thinking that I KNEW everything .Many years ago there was a surgical conference and a speaker was presenting data on stomach surgery. He told the incidence of the complications. So in question -answer part one young surgeon stood up and stated that he has done many surgeries that the speaker was talking , and he has not seen the complications that the speaker was talking about  . The speaker answered that Either he has not done Enough surgeries or He had the complications and did not Recognize them.In medicine it is the same . All of us come across the cases where in spite of all the investigations and tests we can not explain the problem . So then we are left with the guise work. I am going to tell a story today which falls in under the same category.
      I was consulted to see this patient who was 77years old and he got more shortness of the breath. He was on oxygen at home and had sleep apnea and also had heart problem and had cardiac bypass done . He was quite obese and was not using the CPAP for the sleep apnea. When I saw him he was on 100%oxygen and needed pressurized oxygen called BIPAP. Just to explain , simple oxygen is needed in many cases. Then high flow rate , then BIPAP and if it does not work out then respirator. .So he was close to last but one step . His blood pressure was low and had some vague suggestion of congestion in lungs . I thought that he may have pneumonia or congestive heart failure. I ordered the echocardiogram and started treatment with antibiotics . The cardiologist saw him and infectious disease specialist saw him and changed antibiotics . The blood pressure got little better and echocardiogram did not answer why his blood pressure was low or he needed so much oxygen . He slowly got better. But continued to need very high oxygen flow rate for several days . He was in ICU , looked comfortable , had no shortness of breath . The chest X-ray did not get much better ..But for whatever reason after 15days , his oxygen need got better and we could do CT scan. It showed Emphysema and some scars . but not much to explain why he needed such high oxygen. We did swallow study and it did show that he was aspirating. Which means the food or liquids that he was eating or drinking , was partly going in the lungs .
       So my educated guess was that over period of time he had done significant damage to the lungs and that had led to scar tissues and he must have had significant aspiration on the day of the hospitalization. This caused the significant inflammation and that took almost 3 weeks to heal as we had not given him any food or liquids by mouth . This allowed the healing. So he was able to come off the high flow oxygen.He was discharged on 3 L oxygen , while he had needed as much as 70 L flow in ICU .So my diagnosis was  only a educated thought process.