Wednesday, December 30, 2020


     We act in our life with desire  and advice that we can change the fate or outcome. We want to eat healthy food and not smoke and not drink too much of alcohol and not do drugs . I do believe that this is good behavior and everyone should try to do what is right . In medicine we also act and advice patients that certain way of treatment or work up will help us in getting good or desired outcome. I still remember , when many years ago one of my professor of preventive and social medicine had a heart attack . In those days not much was known on heart attacks , but we still knew that smoking and not doing exercise  and cholesterol were main culprit and we also knew that diabetes and hypertension were also risk factors. So when I saw him after his heart attack he made a comment to me saying that he does not smoke and does not drink and has no hypertension or diabetes and he still had heart attack . This type of unexpected medical elements are known to someone who ahs been in practice for long time but what I am talking today is the out come of the treatment or we not getting expected outcome. 

    I saw this patient in hospital. I had seen her sister and one more family member  and one of them had cancer. She has been smoker  and she had quit smoking and then she had shortness of breath .She had 2 years ago heart attack or tales chest pain and was found to have blockages and had stents  done . She was seen by PCP and that was telemedicine follow up and he gave her antibiotics and she did not get better and was still short of breath .So she came to hospital and had abnormal chest x- ray and then had a CT scan done and that showed a mass at the central part of the lung . If one can imagine lung with a stock like a fruit, then this mass was exactly at the stalk area. The main bronchus and the main artery all go in the lung at that area  and the mass or the tumor was pressing on the bronchus and it was narrowed . So there was a high suspicion for cancer and they called a cancer specialist . I was also consulted . I saw her and when I saw her I knew that this was not good . She also had a second mass  and she had shortness of breath  and she was on minimal oxygen supplementation.. The cancer doctor had ordered a biopsy of the lung mass. I explained to her and her husband that I was quite concerned  about a cancer  and that too will nor be operable  and the position was bad and that may compromise the air  and blood going to the one lung . I also ordered a PET scan. She did not feel good on the next day and so the biopsy was postponed  and so was the PET scan. Then the next day she had problem  oxygenation and so we had to increase the oxygen and that continued to get worse  and so I transferred her to ICU.I again talked to the husband and the patient and I also called radiation doctor to see if he could start emergency radiation without the diagnosis of cancer as otherwise that was going to get worse . They felt that getting a stent to open up airway would be better . So we consulted one of the interventional lung specialist . She was transferred to another hospital . As it happened, she had a heart attack and she was started on blood thinner and she had gastrointestinal bleeding  and then she vomited  and had cardiac arrest  and she was on ventilator  and continued to get worse. 

     So we did all the right things , Oncologist was consulted and Pulmonary was consulted  and we also called radiation doctor and then interventional pulmonologist. We had cardiologist see her when she had heart attack  and inspire of that she did not have good outcome. That is what we call fate.

Saturday, December 19, 2020


   When I was in medical school, we had a visiting professor named DR, French .His father had written a book on Differential Diagnosis. The book had various causes of certain symptoms. So if one looks  at the cause of headaches, we will see many causes of headaches from simple tension headache to sinus infection to brain tumor. So it gave a list of possible causes of certain symptoms. One has to understand that the physician or the medical student has to take a detain history  and do physical examination and then narrow it down to 'few' causes.  In those days the lab tests  and radiology was not that advanced  and the Ultrasound examination and CT scan  and PET scan  and angiography etc. were not there. So everything was CLINICAL. Now a days we have many tools at our disposal and that has changes things and helped  and also made it worse. We are depending upon TESTS and not on history and physical examination and then we are going on wrong track. That brings me to the story for today. 

     I have seen this male patient for last few years  and he had smoked many many years ago and had COPD.. Over period of time he had gotten worse  and he was on oxygen and he also had cardiac problem - Atrial Fibrillation. He had few episodes of increased heart rate and i had to admit and then he had ablation and he did better. He lived by himself  and he was some what noncompliant with follow up. I checked his blood oxygen and carbon dioxide  and as expected he had elevation of CO2. In the early part of lungs not working or doing their job- which is to take in oxygen and wash out carbon di oxide, both these are normal. As the disease advances, the oxygen lack starts and then patient needs oxygen . As disease gets worse, the CO2 starts getting elevated. So in his case the oxygen had dropped  and CO2 was now elevated . The sum of these 2 gases in blood is constant ( one of the laws of partial pressure of gases in a mixture) So when CO2 increases the oxygen drops  and if we can reduce CO2, the oxygen will increase. So I started him on a machine - NIV -Non Invasive Ventilator . So he has been on it for a year and seems to have done better . His compliance was not great . I would have liked him to use it for 8 hours or more and he was using it for 4 hours  and that to not daily. So one day he had a fall in bathroom and so he came to ER . He was slightly confused  and had tremors  and the ER physician did CT scan of the brain  and admitted him for altered mental status  and may be TIA - mini stroke. NOONE BOTHERED TO CHECK BLOOD CO2.when we did do the check on it his CO2 was more than the double of normal value. and having oxygen supplementation his oxygen level was too high. THAT WAS THE CAUSE OF HIS CONFUSION AND  THE Fall. We have respiratory center in brain and it is stimulated by LACK of oxygen and Elevated CO2. So when the oxygen level drops , we breath more to compensate for it  and same with CO2 elevation. But with COPD patients the sensitivity to elevated CO2 is gone  and the patients breath only due to lack of oxygen. The elevated CO2 acts like sedative  and cause altered mental status. When one takes away lack of oxygen, the patients will not breath much . So one has to be careful as to how much oxygen should be given. In this case if one would have done HISTORY , they would have known that he was on home NIV  and that means his CO2 must be elevated  and they would have checked blood CO2  and that would have helped .But the knee jerk reaction was to do CT scan of the Brain. Certainly doing a CT scan in any patient with fall  and altered mental status is indicated  and appropriate, but checking blood oxygen and CO2 levels would have clinched the diagnosis .So the differential diagnosis has a list of many conditions that could cause the fall and the altered mental status  and the HISTORUY would have narrowed it down  and on the top of the list would have been retention of CO2!

Saturday, December 12, 2020


       I have tried to avoid talking about the pandemic with COVID as there are so many who have written and talked about it that my blog would be nothing new . But what I have realized in this pandemic is that the disease is not as simple as other diseases that we have encounter in out routine medical practice. It has many faces  and it is possible that we may be having "training on job "type of situation. I had state it in past either on my YOUTUBE CHANNELL or in one of the blogs or may be in some group discussions that out  mortality was high in the beginning as we did not try simpler way of providing oxygen  and respiratory support. Now we are not doing that and the mortality is reduced. So i have stated many times that this reminds me of old Indian Story of 7 blind men and Elephant. There were 7 blind men and they had not seen an Elephant . So they asked their teacher to describe the elephant . So the teacher took them to a place where they could touch the elephant  and 'know' for themselves how the elephant may look like. So one blind man who was touching the back of the elephant said that the elephant is like a wall , The other one who was holding the tail stated that No it is like a rope and thisrt one who was touching the legs stated that no ,no it is like a pillar  and so on. So each one was touching some part of the elephant and felt that he 'knew' how the elephant looks like. That brings me to today's story.

   I have known this patient 74 years old for last several years . When I saw her for the first time she had what looked like a pneumonia  and so she was admitted  and I saw her . She had pneumonia, but it was due to obstruction of a bronchus with a cancer  and she also had COPD -lung disease due to smoking . So I treated her and had her see a chest surgeon and he operated her and the cancer was resected  and she did well and did not need any further treatment in form of chemotherapy or radiation. She was followed and she had no problem . Then early part of last year she was admitted  and she had pneumonia  and I was called again and i saw her . We treated her with antibiotics and she had CT scan  and then I did Bronchoscopy to make sure that she did not have cancer and she did not . We did do follow up CT scan in 3 months  and she had complete resolution of the pneumonia  and CT scan was clear. Last month her husband got sick day before the Thanks Giving  and went to walk in clinic  and was diagnosed with COVID . He did not want to go to hospital and decided to get treatment as out patient and watch . She was OK  and then on Friday after Thanks Giving ,she got sick and she went to ER and was admitted to hospital. I saw her and she needs minimal oxygen and she had no fever and she was not short of breath . The chest X- ray did show that she had pneumonia  and her COVID test was positive. But she also had diarrhea  and so she was dehydrated  and her kidneys were not functioning normally. So we started her on treatment for regular pneumonia a nd also for COVID . The infectious disease specialist also saw her  and she was on steroids , oxygen and Remdesvir. I watched her every day and she was stable for 4 days  and was to complete the treatment t in one more day. And her condition got worse  and she needed more oxygen , So now she was on 12 L oxygen and then next day the chest X- ray got worse and oxygen dropped  and so we transferred her to ICU  and she needed to be on PAP - machine that generated pressure to deliver oxygen -- which we were not using due to fear of spreading COVID only 3 months ago. She continued to need it for 4 days. Shas done better but still not completely out of wood. So she did all the right things . She went to ER when she had problem , got hospitalized and was seen by specialist and was started on treatment with current medications and seemed to improve -only to crash after the treatment was completed I am not sure how to explain this . 

    Her husband decided to stay home for 1 week and then when he got worse , he came to ER  and had to be put on ventilator and continue to need ventilator for long time  and is sick  and has improved minimally.So he did not do what he should have done  and paid price for it .So I am not sure in this family matters who is right and who is wrong !! ,