Sunday, January 27, 2019


     As a child we used to read a book called ISAP NEETY , Isap was a slave and he could talk to or communicate with animals . There used to be a another book called PNACHTANTRA . In that book also there were short stories and the animals could talk . Every story in these books had some moral to be concluded and that was stated at the end of the story . In one of the story there was lady who had a mongoose. That was her pet . She also had a infant child.She had to go out of the house to get some water from the well.The child was sleeping and so she decided to go out in back yard to fetch some water. It took her some time to come back.When she came back she saw the mongoose at the door of the room with blood on it's face . She concluded that the mongoose attacked the child when she was out. She threw the water pot at the mongoose which almost killed the mongoose. She ran in the room where the child was sleeping sound and there was  a dead snake next  to the child . So when she was out , snake came in the room and the mongoose saw the snake  and attacked the snake  and killed it . So the mongoose killed the snake  and not the child . But the lady jumped to conclusion. This is not uncommon for all of us . We JUMP to conclusion without having checked all the information. That brings me to story for today .
       I saw this hospital as second opinion He was 74 years old male who was primarily followed by VA.He was a smoker and inspite of diagnosis of COPD , he had continued to smoke.He also had coronary artery disease and had 5 stents. He also had circulation problem and had shortness of breath on walking 50 feet or less. His breathing test had shown severe compromise and the flow rate was 22%only. He was in hospital  and had CT scan done . The CT scan showed a nodule. The lung specialist that was called saw the patient and wanted to do Bronchoscopy . The patient was short of breath and the nodule was too small to have adequate sampling with regular bronchoscopy. So there is a relatively new technique called navigational bronchoscopy .The computer with help of CT scan 'guides' - navigates- to get to the small nodules that are not seen with the scope. In my experience , this needs anesthesia  and is not greatly successful in getting sample or diagnosis unless one is expert in doing it . The patient refused the procedure and so I was called in to see him . HE was obese patient  and had smoked and was fairly well aware of his medical problems. His fear of the procedure was that with anesthesia, he may end up on respirator and then will have difficult time to get off it .And in my opinion he was right.In addition to that he had 3 CT scans at VA and  he knew the results  and he thought that he had nodule in the past . Not only he was aware of the CT scan findings , but he had 'access' to the reports . I told him to pull up the reports in the computer and he was right . HE DID HAVE NODULE REPORTED - SAME AS WAS IN THE CT SCAN THAT WAS REPORTED IN NEW CT SCAN! So with his advanced lung disease, the nodule being there before I suggested to do follow up on the CT scan in 3 months and then consider PET scan . He was not a candidate for open biopsy  and the newer Radiation technique for smaller nodules is only 5 sessions and it has great cure rate. So if indeed he has cancer one could confirm the likelihood of it being cancer -nor 100% and no tissue type known - by PET scan and treat it .
     Just because there was a nodule does not mean cancer especially if he had it for a while . I agree that this still could be cancer but the diagnostic test should not cause more problems . So jumping to do a test was premature  and just like that lady was hasty in concluding that the mongoose hurt her child. 

Saturday, January 5, 2019


     We often use this term , PERSPECTIVE - Often it is stated that one should not forget perspective in life . In medicine we need to remember this more than in any other field. But I have felt that we HAVE FORGOTTEN it . I know how the things are done in past  and how they are done here . But I also know how things are done in other counties, including India  and how we are doing things here in US . I do not want anybody to think that I am  suggesting DEATH  agencies or more control on health care decision. But sometimes it is frustrating. I think the problem may be partly if not solely due to cost of health care is not being not paid by relatives - by the people who make the decision.It may be due to lack of understanding the ability or for that matter inability of the modern day medicine . But in any case we have a problem . The health care cost not the only thing to be considered in these matters , but also the suffering of the patient as well as the relatives who make the decision. I saw 2 patients recently  and that brought me to write this blog .
       I saw this patient few months ago . He is 78 years old and has the usual issues that many at that age have . He had hypertension and has had strokes and had developed dementia . He had atrial fibrillation in which the heart can throw clots and that can eat up the brain piece meal . This  leads to loss of brain tissue and that leads to dementia . So he did have dementia . But with the strokes he also had problem  the swallowing and so he had lost some weight and then the family agreed to have feeding tube for the nutritional reasons and also to give him some medicines which otherwise he could not swallow . He was tried on blood thinners to prevent clots  and he had blood loss and blood counts dropped . So he was taken off them . So on one side he had high risk of clots and so he should be on blood thinner , but on other hand he could not be on it as he had drop in his blood counts and so not being on the blood thinners the chance of getting mini strokes increased and that can make the dementia worse , On top of that he had developed severely leaky valve and that in tern caused the pressure in the lung to be increased . So he had aspiration pneumonia and had feeding tube and dementia and heart problems .
     I talked to his wife who was the medical power of the attorney and tried to have her agree for DNR- not to put on machines. He was seen by cardiologist and they stated that nothing could be done about his valve or the atrial fibrillation other than trying to control the heart rate. He did better with the antibiotics and then was discharged . He came back in  1month with episode of fall and low blood pressure and an abscess on the scalp. He had low blood counts again and needed to be transfused  and he was on antibiotics and he also had to have the surgery to drain the abscess. He was not only demented but was very uncooperative and would swing and try to hit doctors and nurses and would constantly curse. It is not his fault as he did not know much as he had dementia. I talked to the wife  and told her the limitation . We certainly can give antibiotics, which we did . We can transfuse him which we did . But the dementia and the aspiration and the leaky valve and the pressure built up in lung was not going to get any better . But she would not agree for DNR. The treatment is bandage approach as we are not treating the main problem dementia and stroke and the heart problem and so we treat the symptoms . But we are not 'helping' him or her . I am sure it is painful to watch our own relative 'suffer'  and be in hospital , but I do not know the reason for the not doing him DNR. She has  no liability for the bill  and may be the after life belief system  , may be fear of loosing husband - whatever it is , it is not helping her or him or the health care cost .