EVERY GOOD THING HAS TO COME TO END

      I have talked about  many of may patient without  disclosing any identity, Sometimes i have to change their age , sex and other part of the story , keeping intact the core of medical story intact. I also talk about things that have happed in distant past and not current. I have seen patients that have defied the medical odds.. So I am going to tell you couple of stories when the GOOD THING did come to end . 

     I had seen this patient several years ago . After a simple gall bladder surgery, she could not come off respirator. I was called in and I checked her and then consulted a neurologist as I felt that her lungs were fine and the problem was in her respiratory muscles. The neurologist saw her and did not feel there was any neurological cause and told me that it was my problem. I called the surgeon and asked him to do muscle biopsy and the biopsy showed that she had a very rare form of myopathy. She remained on respirator for fo years to come. Over period of time she did get worse and needed feeding tube and became bed bound. Every time I talked to her , she had to write her answer as she had tracheostomy and she would write the number of years that she was seeing me . After 34 plus years , when she was admitted to ICU with pneumonia, she requested me to be disconnected from the respirator. After long discussion, she was she was taken off the respirator and passed away peacefully. ALL GOOD THINGS MUST COME TO END. 

I will tell ypu about couple of my other patients next time. 

RIGHT AND WRONG OR NEITHER

   In medicine we have situations where WE feel most of the time ,things are right or wrong. If I see a patient with blood pressure is elevated, I think it is RIGHT TO TREAT WITH MEDICINES. It is NEVER RIGHT not to treat high blood pressure. The same is true of elevated blood sugars and pneumonia and asthma and so on. But sometimes a good doctor and good patient can make decision which are different, but they both could be right. This brings me to case for today. 

   I had seen this patient 88 years of age , who had quit smoking many years ago . She had no major complaints , but had some cough and so her primary doctor did chest x- ray and then send her to me 

     She had work up and we did CT scan chest and that showed a nodule . The nodule was not the cause of her cough, but I had to do the work up . So we suggested doing a PET scan and a bronchoscopy. The PET scan showed that there was some uptake of the glucose in that nodule , but not very high. So the possibility of cancer was low though not zero. We discussed the situation. We could do a needle biopsy or a navigational bronchoscopy and biopsy or open biopsy - the open biopsy would be 100 % . She did  not want any invasive procedure. So we decided to do new scan in 3 months . 

    She did new scan in 3 months and that showed that the mass was same size .She had refused any additional invasive procedures , and the nodule had not grown, we decided to do new scan in 3-4 months. I did new scan, and she came for the follow up. The nodule had grown Now I had a problem . A slow growing cancer may have low uptake on PET scan as the metabolism of cells is not very high compared to normal cells .The growth means there was most likely a slow growing cancer. So we again had the same discussion- do a needle biopsy . do navigational bronchoscopy or do nothing. This time I had one additional suggestion . The lady and her family did not want any biopsy and so I suggested asking radiation doctor and see if based on the growth and PET SCAN if they could treat it as cancer WITHOUT BIOPSY. 

   So Doing nothing could be RIGHT, Doing biopsy also could be right and doing radiation WITHOUT BIOSY  is also right.