Saturday, September 24, 2016


       I had a chance to attend the lecture of Dr Atul Gawande, the famous writer who has written some books and the last one is BEING MORTAL. His lecture was recently arranged by Florida Hospital and being in medicine and quite familier with the topic , I decided to go . The lecture was attended by many ,the hall was full and he had standing ovation. I have known the mortality of life for long time and have seen the effects of aging in my patients and relatives and myself. So the topic was not new nor was the contains. But what I have found out in my own experience is that it is the most difficult task in medicine. So this is one of the two stories.
       I saw this 86 years old male in the hospital for shortness of the breath. He had high blood pressure and question of the heart problem . When I saw him he had some fever and cough and he was short of breath. His wife was in his room . His ability to walk was reduced and his wife had to help . She looked little younger than him , may difference of 10 years. So the chest X-ray was done and the diagnosis of pneumonia was made . He was treated with antibiotics . He also needed oxygen and some additional treatment. We also did the echo cardiogram and it showed some narrowing of the heart valves , some elevated pressure in lungs . At his age this was not unexpected . I often tell patients that as the doors in older house do not close tightly or get stuck , the doors or the valves in heart either become sticky and narrowed or leaky. I did swallowing test and it did show some problem , but he did not too badly. So improved and was discharged home .
      I saw him in the office and did the breathing test. It showed reduced lung capacity and so he was put on some inhalers to help open the bronchial tubes. He was readmitted with the congestive heart failure in next 2-3 months . He was treated and discharged , but this time he was weaker and needed physical therapy and needed to be sent in a rehab center for 2 -3 weeks . We repeated the swallow study as my suspicion was that he was aspirating food and liquids and so he was having the lung problem. This was worst and indeed he was aspirating. But the speech therapist thought that he may do OK with certain precautions. He was seen in my office and we did  check up on his need for the oxygen . He could walk short distance and his oxygen dropped . So we had to put him on oxygen . So I saw him in the office in next 4 weeks and he was doing OK . He needed to increase the flow of oxygen when he would walk. Higher the flow is needed , larger the oxygen cylinder is needed. The smaller ones would not last longer duration . So the choice is to drag the larger cylinder or don't walk much. Dragging larger cylinder foe 87 years old is not easy. SO then I talked to him about his expectations  and CODE STATUS.He told me he had not give a FULL THOUGHT and will talk it over with his wife and let me know .
     Two weeks down the road he was again admitted with another bout of pneumonia -most likely aspiration.I saw him and saw his CT scan and talked to him treatment and repeating the swallow study . I also told him that he may need feeding tube if the swallowing function is not normal and worst. He did not say much . So I again asked hin about CODE STATUS. I told him that he needs to make decision before it is too late His answers was same , ' I will discuss with my wife and let you know.'
    So if years old with all this problems can not make the decision then how do we expect younger one to do it? There are 3 other doctors involved in his care and not a single one has talked to him about this . May be if all of us in health care would talk at same wave length it might change , but who has TIME!!!!!! 

Sunday, September 4, 2016


     We in medicine have algorithm and diagnostic tree to make decision in case of simple or complicated cases and diseases . So some people are doing 'tele medicine ' . But my problem is that the computer can not diagnoses it nor treat it. The problem that I have is there is more to medicine than just knowing the diagnosis. One needs to know the patient and the family and the other factors. So I am writing this story to tell.
      I saw this 90 years male patient for abnormal chest x-ray. He had quit smoking 54 years ago and had no major problems other than high blood pressure. He was in good health and did not have any shortness of breath. He did have some vague chest pain and so the chest X-ray was done and then it showed abnormality . So the CT scan was ordered and he was sent to me .He was OLD but was completely oriented to and fully with the program. He came with his wife who was in wheel chair. She was also quite well as far as understanding is concerned. The CT scan showed a mass in the right lower lobe of the lung. So I told them the routine 3 questions, Is it Cancer , and has it spread and lastly the treatment options . So I also told them that we will need to do the PET scan to know the 'extent' of the disease , i.e. spread, and will need bronchoscopy and may be needle biopsy to 'know' the tissue type which would help in determining the treatment options . So the surgery was mentioned and I myself was not sure that this 90 years old would be a surgical candidate. But I had to mention it.Both of them of the opinion that he would not be considering the surgery as option of treatment. Then we talked about the chemotherapy and the radiation treatment as other options . We left is at that without making any final decision. I told them on the need for biopsy . At that time the wife asked me if there was an option of 'doing nothing' . Before I could answer the patient turned to her and said , 'why , why would I consider no treatment?No I want to get treatment. 'So we did the bronchoscopy and I did see the tumor. It was blocking the right lower lobe and the middle lobe was also seem to be involved in the tumor process. I did do the biopsy and he had some bleeding though I could control it with epinephrine and saline.  I was reluctant to do more biopsy. The PET scan that was done came back with bad news . He had PET scan that showed the pick up not only in the lung tumor , but also in the lymph nodes in the lungs and in the RIBS and in the bones of pelvis /hip. So essentially not only he was inoperable , but also had 'wide spread ' cancer and the prognosis was not very good.
      The biopsy came as 'possible cancer' but could not state as to exactly where did it come from and overall it was iffy at best. So I called them in the office to discuss as to the further work up ans /or treatment . The options of radiation treatment and or chemotherapy was discussed . For chemo to be given we would have needed more definite tissue diagnosis . So we will have to do a needle biopsy.After telling them the PET scan findings, it was decided that we will go for radiation treatment and do no further biopsies. I made arrangements to see the radiation doctor.
      2 days down the road I got a call from the ER physician that he was in ER with shortness of the breath and the chest X-ray showed a large fluid collection around the right lung. He did have small fluid on PET scan done may be 10 days ago . He was quite bad and I had to do a procedure to take out the fluid that same evening at 6-7pm. When I talked to him about the overall disease and the plan of the treatment ,since he now had one more problem to deal with. He told me to cancel the radiation treatment consult , which was to take place next day. He also wanted to be DNR and was considering HOSPICE.
    All the things that happened in this patient and how the decision was changed on number of occasions can not be done by computer. We might get options of treatment choices but not the definite decision without a physician explaining the options and choices made by patient and the family with the input by doctors.