Friday, January 20, 2017


     I have been in medical practice and sometimes feel that nothing can surprise me. But then comes across the situation where I feel that This one is new or I did not expect this.Sometimes it is patients behavior , sometimes it is other doctor's behavior and sometimes it is the diagnosis. Patients may feel that physicians are not 'involved ' in patients feeling or diagnosis. But Many do and I for one do more than I had thought.May be when we don't expect and get a different diagnosis, then we remember more. This brings me to the Case that I was going to tell.
    I saw this years old male in the office for abnormal chest x-ray . Patient was ex smoker and had quit smoking several years ago.He was pushing a golf cart and it hit his chest. He was out of state and had some pain , but then he for better with Tylenol and so did not go to doctor or ER. Then he was little short of breath. So he saw the primary care physician. The physician ordered a chest X-ray and it was abnormal and so did CT scan and send him to me . The chest X-ray showed the fluid around the lung and then the CT scan showed that it was inoculated. Normally there is very very small amount of fluid around the lungs , primarily to may be allow lungs to expand and contract-like lubricate. But in this case it was not free to go all around the lungs , but was forming a pocket and it was pressing on the lung. If it was a' free fluid' I could 'drain' it with a needle or catheter. But with fluid forming a pocket , I had to have surgeon do the drainage by doing the surgery. So I send him to a surgeon. He agreed with my suggestion and wanted to get cardiologist to 'clear' him for the surgery.        So after all the things were done he underwent the surgery and the pocket of fluid was drained but in doing so he had to 'peel' the covering the lung. This let an air leaking from the lung. Normally we see this quite commonly and so it was not a concern. But then the patient developed pneumonia and irregular heart beats. The oxygen dropped and he had to be watched in ICU. The air leak continued even when he got better. I have seen one patient where this air leak continued for weeks and he needed 2 more surgeries. So I was not concerned , nor was the surgeon. But when this continued for days and weeks . I was not sure as to what could be done. Now a days there are newer techniques to put in one way valve in the bronchial tube. But this needs lot of time under anesthesia to 'localize' correct bronchus -the one that is leaking the air. So I called intervention lung specialist to do this . Just to let you know how rare this is , I have never seen this procedure needed or done . There was another option that I have seen being done is do surgery and cover the 'hole' with pleura.So he was transferred to another hospital . The new lung specialist saw him and felt that he was 'too sick' to try to do the valve . So after another 10 days when the air leak did not stop ,he was taken for second surgery.
      What they found out was shocking to me . HE HAD CANCER IN THE COVERING OF THE LUNG and so the lung was unable to expand and so had continuation of the air leak. I did not anticipate nor did the first surgeon. That was shocking . I had always thought that surgery was 'final' verdict on cancer. So I was shocked to learn that the second surgery showed cancer .  

Sunday, January 15, 2017


       Sometimes I see patients that I can not figure out as to why they have so many problems or why certain things happen to certain people. Many years ago I went to see one of my professors, who taught us Preventive and Social Medicine, who was hospitalized for heart attack. He was 50 some years old and had heart attack. He said that 'I don't smoke , I don't drink, I do not have high blood pressure or diabetic ,then why did I get the heart attack.'I did not have answer.I find myself in such situation many times . So the story that I am going to tell is one such case.
     I had seen this patient for several years and she had many major problems and I had treated her and referred her to Mayo clinic and UF. She had repeated episodes of coughing blood and many other issues. I could not find any reason and nor did Mayo Clinic. But the UF did find some abnormal blood vessels and did cauterization of the same. She continued to have same problem and so I sent her back to get the cauterization  done . So this would have been her 4th or so procedure to stop the bleeding. She went there and had the procedure done on Friday and came back on Saturday. She was fine on Sunday.She started having shortness of the breath on Monday and so she called 911 and they brought her to the ER on Monday evening. So I get a call from the ER MD that she was there and the chest X-ray showed 'complete collapse 'of the left lung. She was put on BIPAP. She was admitted to ICU. So the ICU doctor called me and told me that she was admitted and she wanted to see me. So I saw her in the morning of Tuesday. She had second X-Ray and the left lung was still collapsed. I saw the notes of 3 doctors and saw their plan. Patient needed Bronchoscopy. My suspicion was that after the cauterization, she must have had some bleeding and had some blood clots that blocked the left bronchial tube and so the secretions could not come out. So the lung collapsed. So she needed to have the bronchoscopy and sucking out of the blood clots or the mucous to 'open' the lung. She did not want to be intubated and put on respirator. But without doing that it was impossible to do the procedure. The suction channel of the bronchoscope was too small and we might have gotten in trouble. So I called a chest surgeon and he agreed to do it and the patient agreed.So the bronchoscopy was done under anesthesia and had to be left on respirator. I saw the new chest X-ray and it had shown 50%improvement but was not 100%clear. So I decided to do the bronchoscopy again. The patient agreed and so I did the bronchoscopy.
       What I saw surprised. Her left bronchial tube was quite narrowed. There were plenty of mucous plugs and I lavage with saline . But my main concern was that the narrowing of the bronchus. My concern was that unless that we treated , she would get the collapse of the lung again. But I had to confirm it first as the narrowing was MY IMPRESSION. No one else had suggested it , nor at UF nor in ICU nor the surgeon who did the brochoscopy. So I spoke to the radiologist and ordered High resolution CT scan . It showed that left bronchus was quite narrowed, it was less that half the size. I called a interventional lung specialist and asked him to look at the CT scan and he agreed . So he did the balloon dilatation of the left bronchus and then we got her of the respirator.
      So this patient had complications to the treatment ,which I have not heard any other patient getting it. The disease is rare, the treatment is rare and the complication that occurred is I guises is rare

Saturday, January 7, 2017


    I have been in Medicine for so many years that nothing should surprise me. But as in Life , we have uncertainty or unpredictability in Medicine. Usually most of the cases behave as we think or predict. But then there are cases that we come across that throw us off completely. I had 2 of them recently. So the first one is my today's story .
    I had seen this male patient , about 70 for may be 2 years. He used to see another lung specialist for several years and then switches to me when the his own physician left private practice or his insurance. In any case he was doing OK for several years in spite of damages bronchial tubes and some COPD.I had given him antibiotics and done chest C-rays and done lung function tests. He was fairly stable . So when he came for a routine follow up I did not think much. He was doing OK, had some chronic cough and no fever . He had some episodes of dizziness. He had lost some weight , may be 15 LB  and had some decreased appetite. Patients with damaged bronchi , called Bronchiectasis , can get infection with atypical TB - called MAC . The symptoms are weight loss , low grade fever , decreased appetite, worsening cough etc. So I was thinking of doing CT scan and brochoscopy. But then I checked his blood pressure and it was low normal at 100. So I had him stand up and rechecked it . it dropped to 60 . So I was alarmed and decided to admit him . He agreed.
    I got him in the hospital and started him on IV fluids and ordered some blood tests to diagnoses low functioning Adrenals. I also ordered the CT scan. I was going to do bronchoscopy and treat him with medicines till we could get him to Endocrinologist. But then he had episode of irregular heart beats and I had to call heart specialist. With medicines the heart rate was controlled, but the blood pressure continued to be low. So I suggested cardiologist to change the medicine , but it never was done. The he had some nausea and the the hospital doctor ordered the CT scan and some X-ray. That suggested small bowel obstruction. So they called a surgeon. I was not convinced as he had good bowel movement. (He had colostomy)But the surgeon decided that he needed surgery and he had surgery. He continued to have issues with blood pressure and the heart rate some upchucking.
   I was speaking to the wife and was not sure if surgery had helped in any way . But then when his oxygen need went up and wife told me that he is bringing up stuff all the time , I knew that he was aspirating . The surgeon had thought that surgically there was no problem and wanted to give diet /food. I decided to do new CT scan and and put in stomach tube- NG TUBE. Immediately I got 1100ml fluid and the CT scan showed dilated esophagus. So I knew that the problem was not bowel obstruction, but food pipe-esophagus problem . This was coming up and going in the lungs and was causing damage and the pneumonia. With his oxygen low I transferred to ICU.
   He was little better in next 2 days and then he had problem with bowels and had stools coming out from the incision and so needed second surgery. This set him back and he now was on respirator. He was loosing weight and was having problem with blood pressure and heart rate . We continued to struggle and he continued to get weak . We could not do any further studies as he was too sick. By now he had lost 30 -40 lbs He could not eat or cough or do any physical activities . The family decided to make him DNR.
     So the patient that came to my office for regular follow up and was having low blood pressure and weight loss , and I thought that I could get him out of hospital in 3-4 days , stayed in hospital for more than a month and continued to get worse.