Saturday, July 16, 2016


    Some one had defined 'specialist'(in medicine) as "someone who knows more and more about less and less!" I feel it is so true . A cardiologist does not know about Pulmonary or at least does not want to be bothered about it and a  kidney doctor does not look at anything else but kidneys. But the medicine is growing so fast that one can not keep up to date on every new development in every subject. But my story today is about something else . Sometimes in practise of medicine we have all sorts of experts and they also come out empty handed. The line that I had liked in past was ,'Medical knowledge is vast and incomplete.'
     So this is the story of one of my patients. I had known her for few years . She was mid fifties and was a smoker . She had shortness of breath and also CO PD. so she was tested and was put on oxygen and medicines and was told to quit smoking . She had some kidney issues and so had an ultrasound   of the abdomen done and it showed some fluid in the lungs. So she called me . I did a chest X-ray and it did show large amount of fluid around the right lung. She was little more short of breath and so I decided to admit her. She then had a CT scan of the chest and the fluid was confirmed . There was no other abnormality to explain the cause of the fluid . So I drained the fluid . I drained 1200 ml of the fluid and sent it for various tests to find out the cause of the fluid collection. There was no infection , TB or bacterial . But the fluid did show CANCER cells. So I consulted an oncologist -expert in cancers. He ordered some tests , but we did not know the origin of the cancer -where did it start. Now a days we do many tumor  markers. The cancer cells look different that their parent organ cells. But they still retain certain characteristics of the original cells.Easy to understand would be breast cells . They will have 'markers' for female hormone, estrogen . I also give example of interracial marriages , where the children would show some characters of both the parents. So one can do many markers now a days  There are so many of them that I can not keep up with them and I have to depend upon other experts and their knowledge . So after testing many of them we still came out empty handed . I had ordered a PET scan . This scan is done by injecting glucose which is tagged with radioactive material. The glucose is picked by every cell in the body . Since the cancer cells are metabolically more active than the normal cells , they pick up more glucose and the this pick up is measured and one can diagnose or stste high probability of cancer . No test is 100%. So the PET is may bbe 88%. The PET scan showed abnormality only in pleura , where we knew that there was cancer. The major differential was between lung cancer and the mesothelioma. All of us know that if one has lung cancer there is no monitory gain , the treatment is different and the prognosis id different. On the other hand if it was mesothelioma , which occurs with asbestos exposure , there is monitory gain and the treatment and the prognosis is different. So I consulted a chest surgeon . I asked him to do 'open biopsy'. So an open biopsy was done and then bigger sample was given to the pathologist and the final diagnosis was ------still same .It is cancer , burt unable to state where it started and not sure if it is mesothelioma. The sample was reviewed by 5 local pathologists and now is sent out for 'expert' opinion. So in spite of all the experts we still DON'T KNOW' . This is what I call inadequacy of medicine .  

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