Sunday, February 17, 2019


          There is saying that the Honesty Is the Best Policy , but is  it really true?In life we have incidences where the honest answer may be crude or cruel or not pleasing . In Ganapati ATHARWASHIRSH, it is state the 'I will say Pleasing and Truth'. In personal relationships between the husband and wife and children and friend, this is true.But even in many other aspects of our life we don't have ti lie but we can still say truth without hurting the other person or the relationship.Sometimes we can not tell our boss what we 'feel ' about him or his decisions. We still can say the fact or the truth. In medicine this holds very well. I have come across this on number of occasions. This more often happens when we have a patient who has cancer . This brings me to the today's story.
      I had seen this 75 years old lady who was smoker and had some lung issues . Over course of my follow up she developed a mass in the lung . In all probability it was cancer and so we did do the work up and then i sent her to surgeon  and it was taken out. She did well- had some problem post op. But overall did OK. She needed oxygen after surgery , that was arranged at home . She was doing better and then may be 18 months or so after the surgery , when we did the follow up CT scan she had a mass . We had her see radiation  and oncologist . She had needle biopsy and then the recurrence of the cancer was diagnosed. She had localized mass and so she received radiation. She then saw oncologist , who decided to start her on some chemo . In spite of the chemo she developed new nodules and so the chemo was changed . Now she had multiple nodules in both lungs  and radiation was not option and so she had continued the chemo. She has been old  and has some dementia . She has COPD  and does need some oxygen .She was admitted to hospital with multiple issues , including anemia related to chemotherapy and also had low salt and worsening kidney function and also had swelling of the legs . Further work up showed that she had clot in the legs  and  for some unknown reason (at least to me ) someone ordered a CT SCAN of the belly and that showed a mass in colon.
She was in no shape to do any invasive procedures for diagnosing colon cancer , but more than that , diagnosing colon cancer would alter any treatments . Due to fear of bleeding from colon mass if she was started on blood thinner and with her low blood counts , we decided to do insert a filer in one of the blood vessel so that clot from legs would not travel to lung- embolism..
   When the radiologist went to insert the filter he realized that the entire blood vessel was filled with clot. So he could not do the procedure. But more of  a problem was that the clot occurred in the blood vessel as it was compressed by external tumor. So the narrowed blood vessel developed the clot and that was blocking the drainage  and so she had swelling of the legs . So then we had a catheter inserted in that blood vessel and clot busters were started . Now she will have to be on blood thinners too.
      So we have 80 years old patient  who has spread of a lung cancer , who also has anemia  and kidney failure and oxygen need for COPD , and has possible colon cancer and the a tumour that is pressing on one of the major veins that has clot. You get the picture. No matter how successful we are in treating the clot , her long and may be even short term prognosis is not very good . I did try to talk to her family as she has some dementia about this . But the cancer doctors and their nurse practitioners have not said a word about bad prognosis and so we are doing the bandage approach without being able to treat the underlying cause of the problem . The need to be honest but not blunt  and compassionate but still telling truth.

Sunday, February 10, 2019


     Many years ago I was talking to a state elected congressman, who happened to a physician. He was telling the difficulties that physicians have to a good politicians and why the lawyers have no problems. Many of the politicians are lawyers. His point was that we physicians have single tract mind . If a patient comes with history of smoking and has coughed up blood and has abnormal CT scan of the chest showing a mass, we KNOW that it is highly likely to be a cancer and we KNOW only one way to do the work up.We will not tell to just watch it grow unless off course the patient is demented or has lots of co morbidity.But even though we may not do the tests or the work up due to the circumstances , we are very certain that the mass is cancer and we do not entertain any other thought. Now take an example of a lawyer. There is a divorce case and custody battle or case of tenant and land lord.Who so ever pays the money the lawyer is on his side and he will argue if needed in court that his client is right. There is no one side which right . But for medicine , high blood pressure is to be treated and there is no argument or 'other side ' , Same with high blood sugar or any other number of cases that I can tell . So the physicians are taught to have one particular way of thinking and we do not have to change our opinion due to some one paying me more money. So we can not be good politicians who can listen to both sides and can be swayed by one or other arty that gives them more money. But that brings me to the story for today .
       In medicine I am seeing more and more older patients and it is not uncommon for me to see few 80 years plus  and some 90 years plus patients.This has changed me and my decisions  and also the way in which one can approach the same issues that we had before. I saw this patient who was 90 years old . He has coronary artery disease and had high blood pressure and also was short of breath. He had some COPD ,  and needed some bronchodialater -medicines to treat his wheezing or bronchosasm.But on further investigation I realizes that he also had elevated pressure in lungs or what is called pulmonary hypertension.The medicines that I could offer for that were expensive and are special pharmacy medicines , which means they are to be ordered through the drug company and need right heart catheterizing to be done . The cost runs $30000 -year $30000 -I did not make mistake in adding a extra 0 .So the company wants to be sure that there is elevated pressure and the value is high enough to need treatment. So he needed cardiac catheterizing. The cardiologist was not in favor of doing an invasive procedure in this 90 years old patient . But the patient wanted it and so finally it was done . It did confirm the diagnosis of elevated pressure and I tried to start him on medicines .Due to the high cost of copay, I could get only one drug started and he did do little better.
So at each step of the decision I was 'OPEN' to treat or not treat this patient as the benefit of these medicines and the cost and the side effects may not be of value in this patient.
    In few months he continued to be stable  and had to be on oxygen 24 hrs a day and also was short of breath . The he developed more shortness of breath and the chest X- ray done did show worsening of the congestive heart failure . We had to pit him in the hospital and he had some fluid. In average patient I would drain it with a catheter insertion. But in his case - who was 93 years old now I was very hesitant to do such a procedure and decided to try to just 'watch' it with medicines being given .
So even though I KNOW the best way , I am WILLING to wait and watch . This s a change in my though process . BUT I WILL NEVER BE READY FOR THE POLITICAL ADVENTURE !!!!