Friday, November 24, 2017


     IN our life we face the situations ,in which e know what to do , but can not Do it. I am sure no one is an exception to this rule..We know we should not indulge in too much food , but we do .Yesterday was Thanks Giving -so all can see what I mean by this. We know we should exercise , but we don't and there are many other situations where we know what is good and what is right and we still are unable to do it.But in medical practice we see this all the time too. I know and the patient knows that smoking is bad , but still continues to do it ,and the obesity-everyone knows that one must loose the weight , and it never happens. If one considers obesity is a disease, then the 'cure rate' is zero. Even for those who do loose weight, the 5 yer survival or the disease free interval-terms that we in medicine use for cancer- is also zero. In both these conditions,the addictive nature of smoking or eating is very strong and the fault does not always lies with patient. The surroundings -stress,habits of spouse and the environment do play role.But sometimes we can put blame on patient and patient only. I am telling a story of such a patient.
            I saw this patient -72 years old , who had sickle cell anemia. She had episodes of crisis many times . In sickle cell anemia the red cells , which carry oxygen and have hemoglobin in them , are not shaped normally. They look like sickle. And when such a cell tries to go through very tiny blood vessel , it gets stuck and then is destroyed and that causes the attacks of pain . The pain could be anywhere in the body and sometimes patients can get addicted to pain medicines. They do have low hemoglobin.. In some of these patients when these episodes happen frequently,-may be in blood vessels of the lungs , the pressure in lung circuit-pulmonary pressure increases.This is called pulmonary hypertension. This is similar to one that can happen in patients who get frequents clots in lung.So this needs treatment .So when I saw this lady , she had same problems that she was admitted for in past several times . She had several echo cardiograms done in past 2 or 3 years before I started seeing her . She had the usual problems , high blood pressure and the anemia and the pain and mild problem with kidney function. I did order new echo cardiogram as in past she had elevated pressures. The normal pressure is less than 30 . 2 years ago the pressure was high 30es and the increased to 48 and then mid fifties. So there was trend of worsening pressure in lung blood vessels. The new echo cardiogram showed the pressure to 67. Clearly she needed treatment. So I asked cardiologist to do the right heart catheterizing and check pressures directly. This required as the echo cardiogram is good but not 100% accurate and the drugs that are used to treat are very expensive --$40000 per year. So the catheterizing was done and it did confirm the elevated pressure. So I started her on medicines . One of the medicines is Viagra .(it is interesting how the drug companies change the name and the price , So the same VIAGRA when used for pulmonary hypertension id called REVATIO, and the cost is much higher too.).

      We need to do some tests to assess that progress of the disease as we can not do heart catheterizing frequently . So we do check the distance that one can walk in 6 mins,which is very simple and can give us the idea about the improvement . We also need to do other tests . I have seen this patient many times in hospital where she comes in for pain or sickle cell crisis . But SHE HAS NEVER COME TO MY OFFICE TO DO SOME OF THE TESTS  that are needed.. Her pressure continues to be elevated and she continues to be on 2 different drugs . But without certain tests and close monitoring of the blood tests and other things , I can not add more medicines . Every time I talk to her ,she promises me that she will come to office and we have scheduled her for the tests and she never shows up.She does have many more medical problems now than when I started seeing her . Sh has also seen other lung specialist in between. But not in their office . .   

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