ELEPHANT IN THE ROOM

    In medicine sometimes we have extreme positions. The so called pendulum swings to he other direction.I have seen use of certain drugs for a certain condition as routine 'acceptable' treatment  and then suddenly it falls off the favorite train and then no one uses it . Theophylline is one such drug . 20 years ago there were several pharmaceutical companies that were making brand name theophylline  and now there is none. We also use a term  "The elephant in the room". This brings me to the story for today. 

     I saw this 90 years old patient in office and then she was diagnosed to have asthma  and also she was obese and may have had sleep apnea. But she did not want sleep study and so she was on oxygen which is not accepted treatment for sleep apnea now a days. But when the oxygen drops badly during sleep, one can not deny use of oxygen .She was admitted to hosp and she had  multiple problems . She had shortness of the breath and she had swelling in the legs and she has problem with her kidneys.So she was seen by hospital doctor and as expected they had called cardiologist and kidney specialist and pulmonary specialist . So when I saw her she was in hospital for she was in hospital for 3 days . I saw her and she had acceptable oxygen saturation at rest and she has significant edema in legs and her kidneys were not functioning well. She had clear lungs but no one had given her home inhalers which were prescribed for her asthma in past . So i started them. The cardiologist had seen and done echocardiogram  and the heart function was good and he has no other suggestion. The kidney doctor was giving her diuretics and her  her swelling was getting better  and she had some improvement renal function. What struck me in this patient was that her lungs were clear and the oxygen was fine and she still felt short of breath. Certainly it could be due to being 89 years old with low activity  and de conditioning and may be some heart problem and certainly may be even lung issues. But she also had anemia  and they had done the work up and she had problem with production of red cells.( think of red cells as a product of a factory. Let  us take an example of making shirts.So if there are less shirts available in market, then  it could be due to factory not making enough or that they are sold too quickly. - high demand or that there is not enough raw material . The same thing is true about red cells . The raw material - iron B12 or other r=things may not be enough or we have a loss of blood or it could be that the bone marrow the factory is defective.)So she had problem with production of red cells. That is not uncommon in patient with kidney problem. I followed her for few days . What I noticed is that in spite of inhalers and edema getting better and the kidney function improving she was still short of breath.And I also noticed that the anemia was not any better and was somewhat worse . Her hemoglobin -which carries the oxygen in blood was half the normal. So patients with anemia are short of breath as their system has to work harder to provide oxygen as the blood does not carry same amount of oxygen.So I finally called the hospital doctor  and asked her to give BLOOD TRANSFUSION. In past we used to transfuse even with much higher hemoglobin. But then we realize that that was causing problems in future  and so now the pendulum has swung to other extreme and no one thinks of transfusion even though this 90 years old lady was shortness of breath was perfect candidate for giving blood . So this was the big elephant in the room and no one was talking about it or treating it or may be no one could THINK about it .