Sunday, April 9, 2017


   Long time ago , I was complaining about the car repair bill to a car .mechanic The cost of the part was not that high, but the cost of the labor was very high. So the answer that I got was not that unexpected.He knew that i was a Physician and that was translated in to to two conclusion, one that I did not have much knowledge of cars and secondly I had money. So he told me that the human body is old machine and there is no change in it for many many years , contrary to that  the automobile engine has changes significantly in last few years and it continues to evolve and change and so it is much more difficult and time consuming to diagnose a problem , so the labor cost is much higher than what I get to see a patient on follow up. I did tell him that if I make a mistake (or some family member or a lawyer conclude for his or her own monitory benefit that I made a mistake,)the patient could be harmed or can die. That is not so with the car . But I had no way of getting my car fixed without him, so I did not argue. This brings me to the story that I am going to tell today.

    I saw this patient 78 years old female for pain in the belly . It actually was flank pain rather than belly pain. The reason I was called in was due to her chronic cough and the possibility of scars in the lung , so called Pulmonary fibrosis. The husband was bed side all the time . So I saw her , She had never smoked and she had some cough . I checked her oxygen saturation and it was normal. On her physical examination, she had some crackers ,which are indicative of scars in the lungs. The CT scan of the belly had shown no new findings , but she had some tumor in the belly ,unchanged from 2014. No one knew the etiology of the small abnormality next to liver , which is on the right side and her pain was on left flank. She did have vertebral fracture and some artritis in the spine.
   So I ordered the CT scan of the chest to check on the fibrosis.I did not do any investigation on he flank pain as Gastroenterologist was consulted. The Gastroenterologist  decided to do endoscopy, which I did not think was going to add anything and it did not. But I was talking to the husband and he was getting frustrated as 'she was here twice and no one can find the cause of the pain.' And he was right . She was in the hospital twice and as out patient had complained to PCP for last one month. So I told him that I think the pain is due to the lumbar spine problem and not due to the gatrointesinal problem . I ordered MRI of the spine and it did confirm my suspicion . She had severe arthritis and fracture of the first lumbar vertebra ,so the pain was due to the fracture. We talked about the arthritis where she would need to see spine MD and the fracture where we could try a procedure where they inject cement in the vertebra and that gives pain relief in majority of the patients. She and the husband agreed .

      So the procedure was done by neurosurgeon.She did well. I saw her about 4 or 5 hours after the procedure and she was OK , But like any other procedure she was out on the oxygen . The procedures are done with light sedation or anesthesia. She had no chest pain or flank pain or shortness of the breath. I told the nurse that we need to wean down the oxygen as we wanted to get her home in the morning. The fibrosis was confirmed and I would have to do the further work up as out patient.
   I get a call from the nurse that she was fine , but her oxygen was low . So I ordered blood oxygen check and it came back alarmingly low .Again she had no complaints. I was not sure as to what may be the reason , but I was worried about a blood clot in the lung due to lack of physical activity . So I ordered a CT scan of the chest . But I was not sure if I could give her blood thinner as she had invasive spine procedure. So I called the neurosurgeon . ( I had 4 different phone calls before I got the right doctor).He had no problem using the blood thinner, but he did not think this was related to the procedure . We had problem with the IV access and so I had to change my order on the CT scan . But then we got good IV and we did the CT scan. I got a call from the radiologist that she did have clots but they were NOT BLOOD CLOTS but it was the CEMENT clots .

     During the entire span of about 6 or 7 hours , I had about 12 calla and spoke to 5 different doctors trying to get the things done .
     Yes the human body -the machine is old , but problems are NEW and by the way there is no extra labor cost that I can bill !

Saturday, April 1, 2017


   I have written about the inadequacy of the medicine in past . But when one is in practice of medicine for many years, he or she thinks that everything is routine. But then a patient shows up with what looks like routine case , and then when the final diagnosis is there , one meets with surprise. It has happened to me in the past and sometimes a new patient or an incidence reminds me of the inadequacy of the medicine. The story that I am going to tell is one such story.

       I had seen this 74 years old male patient for at least 5 years.He came to me for a cough and then I did the work up . He was not a smoker and had never smoked . He had some allergies and the cough was kind of chronic and intermittent. He had no other major medical history. He had no TB or diabetes or skin cancer or asthma . The only thing that was different he had was that he had cancer of the kidney few years ago and had one kidney taken out. I did the routine work up . I see chronic cough patients every day. So I did the allergy blood tests and the breathing test and tried him on some allergy and asthma medicines. He did better . But to history of the cancer , he was concerned and so I did or his PCP did CT scan of the chest . It showed a small nodule. So I decided to do the follow up. He had follow up CT scans periodically . First one in 4 months and then every 6 month intervals as there was no difference in the nodule.
    The last time I did the CT scan, the report showed that the nodule was same , but he had some plural-covering of the lung-thickening. It was not all around the lung but only in certain places and that to only at 2 or 3 places . The thickness was barely few mm.I did not know what to make out of this findings. I decided to do the PET scan and the bronchoscopy. He also had started to have some chest pain on the same side as the plural , while the nodule was on other side.
   The bronchoscopy was negative and did not add anything to the diagnosis. But the PET scan showed that the entire pleura was hot or lighted up. This means that something was going on in the pleura. So I sent him to a chest surgeon to do the biopsy of the pleura . He underwent the chest surgery and it showed MESOTHELIOMA!.I had suspected the cancer due to the findings on the PET scan , but never thought he could have mesothelioma. One he had no history of working with asbestos , which is almost exclusive cause of the mesothelioma and secondly he had the cheat pain only for short duration and did not need much pain medicines . But not every case is standard case. As we say sometimes , patients don't read books when they have complaints and have particular disease. .
        So this is what I call Inadequacy of medicine.