Friday, January 31, 2020


     I have written about the old patients  add the 'Age Old Problem'. But we can not avoid this problem and each one needs different approach . My problem is that in modern day medicine , the hospital doctors  and even many primary care physicians do not have the time .So it it ends up to some of the consultants who tend to spend more time to do things that is sometimes their specialty. I have seen this time  and again and the problems are not same though similar.
    I recently saw 2 different patients Both have passed their 90th birthday . Both had some dementia  and limited mobility and one of them had not gone out of the house for 2 years or so. one of then had some cardiac issues  and also had cardiac issues. He had some lung issues  and had seen lung specialist  and then no new tests were planned . He had heart rate problem and so the cardiologist decided that he needed a pacemaker . So he had a pacemaker inserted  and things went well  But then he had problems with breathing . His oxygen dropped  and he had to be started on oxygen and then he continued to have more and more need for oxygen . So I was called in . Withing a very short time after they called me for consult, lot of things happen . The patient was DNR,not to be put on respirator or had CPR done. But then the family decided to change their mind  and so they put him on  a machine that delivers oxygen with pressure  and he had new chest X- ray and also was given some medications. I had not seen patient and I was called again in less than 15 minutes that the patient did not want the pressurized mask  and the family decided that he will be again DNR  and no machines . But now the problem was that once you resend the DNR  and start the 'life prolonging machine', we can not just stop it. We need to do what is called 'withdrawal of life support.'So we need family / patient to agree  and sign forms  and we need 2 physicians to sign the forms . I came in and saw the patients  and discussed the case with nurse  and cardiologist and also to several family members  and also to patine. They all agreed  and I signed the forms  and changed him to a special oxygen delivery systems.
      So we went back and forth and he was DNR, and then i started him on some medicines . I thought that he had some chronic lung problems  and he may have aspirated - fluid or food going wrong way in to lungs - and we do see that in elderly patients not uncommonly,  and so we started treatments. To make the long story short he continued to do better  and he did recover to his base line level.
     I will talk about the other patient in my next blog.


Sunday, January 12, 2020


    I have often used this term and many other use it too. The vicious circle could be in any form. When one likes a particular food - say ice cream, we eat it  and we like it and we love it . So there is an impression after eating ice cream  and then when we are hungry or even when I am nor hungry, but see ice cream, we want to eat it and that leads to action and that again leads to impression  and hat again leads to action.This is vicious circle . But the one that I am talking about today is different one  and we do see it sometimes in medical life. We have seen patients that get in trouble with certain actions  and then get in trouble  and then get better  and get better and they do the same action and then the circle continues.
       This brings me to today's patient. I have known this patient for many years . She has been smoker and she was a nurse . She had diagnosis of COPD  and she continued to smoke . She also had arthritis and she was on pain medications. She had stopped working and she was in hospital few times I saw her few times  and she was treated  and discharged . She was not regular in doing office follow up, but she was in hospital in between and so I continued to do the follow up. She continued to smoke.
      One time she was admitted  and she had pneumonia  and she had significant cough and bronchospasm and she was not getting better and she could not cough up the secretions well. So I did the bronchoscopy . I saw something in the bronchial tubes  and thought that she may have aspirated part of her bridge form partial dentures. But trying to take out was difficult as she had problem with oxygen saturation and also she had significant bronchospasm. I called a surgeon and he did do bronchoscopy with anesthesia, so the respiration could be supported  and he found out that she had beckon pieces on lung. She got better and I did swallow study and she ha some problem and she had some arthritis in neck and that may have caused the problem . The speech therapist told her to see ENT doctor  and then she was discharged .Next few years she continued to smoke  and was readmitted several times and was treated . I had a suspicion that she was having problems due to her continuation of smoking and also respiratory infection and may be aspiration. I did few swallow studies  and she had some abnormality  and the speech therapist and they felt that she had abnormality and not bad to do much . My feeling was that she may do OK and then when she would aspirate that would cause chemical bronchitis.That would cause problem with COPD  and with recurrent problem she had more secretions  and then needed more medications . This caused more damage .But she would not follow up in office  and would not do nay precautions for aspiration .
     Then she was admitted  again  and she did better  and was to be discharged  and she did not have a place to go  and so she was waiting in hospital. And then she had worsening of COPD.  and so I was called  and i knew what had happened She had aspirated !! I did the treatment and also the CT scan and that did confirm that she had aspirated  and developed pneumonia when she was in hospital and the new swallow study did show aspiration. She was told by speech therapist to do certain precautions - not to drink liquids . She did not follow them . I used to see soda in her room  and soft drink cans  and she was drinking them . NO PRECAUTIONS . She improved  and went to rehab . But I am quite sure that she will be back in hospital as she continues to smoke  and has aspiration and does not follow precautions. This is the vicious circle that I was talking about . 

Wednesday, January 1, 2020


   When one goes to college we have various degrees that we get based on the subjects that we learn . So when the subjects are classified as art related we have different teachers  and different degree . So some colleges are art colleges  and some are science colleges  and some are engineering colleges  and some are medical colleges. History or language study are not science  and the Engineering is not a Art . But medicine is Art and Science. Many a times it is science  and may not look like art at all . But most of the time it is both and when we make decisions , we are using ART Part of it  and think based on Science part of the knowledge. Recently I came across some patients  and I had to fall back on art and not much help from science part of medicine.
     I saw this patient in my office who had been seen by me for several years . She has COPD  and she is on oxygen and also has sleep apnea  and some other problems . She was out of town  and then she had some worsening of the shortness of breath. She was short of breath in past and then we had checked the need for oxygen and she needed it  and then when she got better and was feeling good we did another test and she was better and so the oxygen was discontinued .She did have oxygen but she had stopped using it  and when she started feeling bad, she came to me  and we did another test and she was short of breath with walking for 6 minutes.Her oxygen did drop and so she needed the oxygen. In medicine we have to do 6 minute walk test where patient walks for 6 minutes and we monitor oxygen and if the saturation goes down to 88% then patient needs oxygen , So we arranged for new oxygen . We also did additional work up and so I did CT scan of the chest  and it showed some abnormality , there was a nodules or the spot. It was not very solid but , it was there . So I did additional work up. We did new breathing test  and also the bronchoscopy and also a PET SCAN .
     These tests were suppose to make our decision making life easier. The science part of medicine. But it added more questions  and problems . The PET scan picks up cancer in may be 80 % of the cases. The bronchoscopy did not show any tumor  and the tests that I did did not show cancer cells , but the nodule was small and it was much deeper . But the PET scan showed some lymph nodes in chest and also in armpit. Based on these findings , I decided to do couple of things .I sent her to chest surgeon  and My concern was that she may have cancer  and with her COPD  and shortness of breath and need for Oxygen made her difficult patient to cut out part of the lung containing the nodule.I also asked her to see breast surgeon and radiologist to do biopsy of the lymph node in arm pit.
   She did see the chest surgeon and he wanted to do the biopsy and then consider resection of the spot. But then the reports of my bronchoscopy came back , the TB culture can take up to 6 weeks  to be final. She had atypical TB called MAC.In patient with this infection patient can have some uptake on PET scan.. To add to the problem, the lymph node biopsy from armpit did not show much - certainly no cancer. So now we have to make a decision We have patient with COPD  and has limited lung capacity and need for oxygen  and has PET positive spot and also some nodes enlargement and also has MAC . So I have to make decision based on art of medicine  and the science part of medicine - the CT scan the PET SCAN , the bronchoscopy and the biopsy of node etc have not helped yet .
    I am collecting more sputum for TB cultures  and also we have surgeon will do biopsy of the chest lymph nodes  and then decide.