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 . 

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