Saturday, November 26, 2016


    In my blog related to Health CARE I have used this term . The cook book medicine would be something that a computer would do , if it is used to diagnose or treat a patient . So one would ;ffed' in the information and then the computer will analyze the data and come to a conclusion and then advice the treatment for the disease that it diagnosed. In case of Health Care management the cook book medicine is different. One would follow certain 'decision tree' and then decide if a TEST is warranted. This would help to reduce the cost , if everyone follows the same rules and there is some protection from malpractice if these cook book format is used. But today I am talking about different type of cook book medicine which is followed, without a THOUGHT PROCESS. In hospital several Ct scans are done with no obvious thought process. So let me tell about this patient ,that I think where a cook book approach was done without THOUGHT PROCESS.
       I was seeing this 60 years old patient , who had COPD. She was a smoker and had continued to smoke in spite of the diagnosis of COPD. She was short of breath and needed oxygen at night as her oxygen level would drop at night , when she was asleep. She also had chronic pain and was disabled. She had pain in the belly and so as is done now a days , she had CT SCAN of the belly. The CT scan did not show any thing in belly or pelvis that could explain the pain , but showed fluid around a lung . So she called me. I ordered a chest X-ray and it did show significant fluid. She was short of breath and when I called her , she told me that she was more Short of breath now . So I decided to admit her .Next day I took out 1200 ml fluid . I did also a CT scan of the cheat. Now she needed to be on oxygen even during day time.The fluid came back positive for CANCER. But the pathologist was not sure as to the ORIGIN of the cancer. We did PET scan and the cancer was limited to the chest only. The main concern was about the chemotherapy. The surgery was out of question -for cure -as there was cancer in the fluid.The radiation had no role as it was not a localized cancer. The chemo was the only option and to select the  chemotherapy ,we needed to know EXACT TYPE of the cancer. So I called a chest surgeon. He did do open biopsy to get more tissue to do additional testing and also put in a catheter to drain the fluid. The biopsy was done but it took more than a week to come back and it turned out to be MESOTHELIOMA. But it took more than a week to get the final answer. The biopsies were sent for second opinion as the differential was between lung cancer and the mesothelioma. As the treatment and the prognosis and the monitory gains are much more or different with two diagnosis , the differentiation was very important.
    In the past the mesothelioma had no treatment and surgery was not an option. But now a days some surgeons do the surgery. It is extensive surgery. There are two kinds of surgeries, but in either case the surgery is EXTENSIVE. So when we got the diagnosis of mesothelioma was established for sure , she was told to see a surgeon at a referral center. I was some what surprised at the decision taken by the oncologist. This patient had advanced oxygen dependent lung disease and was NEVER a candidate for ANY kind of lung surgery, let alone extensive one for mesothelioma. So the patient did go and see the surgeon , who told the same thing that we knew , HE WAS NOT A CANDIDATE for the surgery.
     This is what I call COOK BOOK MEDICINE.When one does follow all the instructions in the recipe he does not use own thought , but follows the instructions exactly as told. But I hope medicine is not a computer making decisions. So surgical consult was a waste of time , money and time.   

Sunday, November 20, 2016


    I have often said that medicine is nothing but statistics, at least on day to day diagnosis and treatment. When we tell patients that you have bronchitis or pneumonia or even for that matters high blood pressure and we will treat 'it' this way or that way, we are using statistics. We don't know if the antibiotic that we are using is going to work in EVERY CASE or the blood pressure medicine that we selected is going to be the 'right' one for him or her . But we know that in 'majority ' of the cases 'it works' and so we use it. But there are exception to the rules or the statistics.These are the patients or the conditions that defies the all the odds.This is one of those stories.

        I saw this patient who was 75 years old. He never smoked and had no major problems other than high blood pressure. He had history of renal stones and so when he had pain in the belly, he went to ER.He had CT scan of the belly and it showed the stone, but somehow he passed it. But in doing the CT scan of the belly we include some lower part of the lungs and vise verse. So in the lower part of the lungs they saw a nodule. This was at the edge of the lung. So then he was sent to me . He then had a dedicated CT chest and it confirmed the nodule. There were no additional nodules or any other abnormalities.
     I saw him . His had no complaints and his lungs sounded clear. He had no swollen glands. So He had PET scan and it showed very low uptake. This meant the chance of cancer was quite low. He was quite concerned. So I did bronchoscopy. It was negative and no infection was there and  no cancer cells were seen. But I did not expect it to be positive as the nodule was way out of my bronchoscope reach. But there was about 6weeks between the Ct scan of the belly and the PET scan. The size of the nodule had gone down by 2 mm. He was quite concerned. So I sent him to a chest surgeon. The chest surgeon saw all the scans and the reports and felt that the possibility of cancer was very very low and advised to repeat the CT scan in 3 months. He came to me for follow up after the visit with the surgeon. He was quite anxious. I told him the criteria that we us and the chance of cancer in nonsmoker and with slight decrease in the size and negative PET scan uptake ---which is extremely low. But I realize that he was still concerned.
    So I spoke to radiologist . The radiologist told me the same thing , the chance of cancer was low and we should do follow up CT scan . But with the patient's anxiety , I asked him to do the needle biopsy. He agreed. So he had the biopsy.

     So here is a guy . who never smoked which makes his 'chance' of getting lung cancer 20 times less than smoker. He had slight decrease in size , again making the chance of lung cancer less likely. The PET scan was negative ,making chance of cancer may be less than 12 or 15%.But he still had lung cancer.