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.  

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