CAN YOU PREDICT DEATH ?

      This is very interesting question. I am not talking about someone sick in ICU and is on respirator and falling blood pressure. I am talking about can we predict death in a regular walking -talking patient ,who has no cancer. But recently I came across a form that I had to complete where the first question was 'Is patient likely to die in one year?' This is recent and it was a patient who was to undergo minimally invasive cardiac surgery. As a lung specialist, I often get forms to ;CLEAR' the patients for various procedures or surgeries - endoscopies to cataract surgery to colon resection and so on. The risk of any surgery is increased when the patients have lung problems and the lung capacity is compromised. This brings me to the story for today.

     I have known this patient for many years . He was  70 years old patient, who had chronic cough . I had done the work up and that included breathing test and Chest x-ray . We even did the CT scan of chest . He had mild to moderate asthma or obstruction on his breathing test. The x- ray was ok and so I gave him inhalers to treat the asthma. He used it and came back and told me he does not know when to use as he did not find any change in cough. So he would  not use it. I also did swallow study to see if he was aspirating-food or liquid going wrong way -instead of going in food pipe , esophagus ,it would go in wind pipe or trachea. This would then trigger the cough reflex. He did have aspiration. But then again he did not feel he had any problem with swallowing. So he did not do anything . I continued to follow him for more than 5 years  and he did well with no hospital admission or major pneumonia. 

   Then he saw a cardiologist and they diagnosed him with a heart valve problem and they wanted to do minimally invasive heart surgery to fix it. I cleared him for the surgery and he did well. He came back to see me. He was doing good and had uneventful recovery from the heart surgery. He however had urinary retention and he was diagnosed with enlarged prostate and needed surgery to fix that. Just as a rule risk of lung problems is increased when the surgery is close to lungs Say for example amputation of a toe is much less risky that having lung surgery with compromised lungs. Now he needed prostate surgery. I cleared him for the surgery. He did well and then was to be discharged. And then HE ASPIRATED . The aspiration caused major pneumonia and his oxygen dropped . He developed respiratory failure and then was struggling. He and family made decision not to put him on respirator and so then hospice was called and he died . 

    So the patient that survied heart surgery dies after prostate surgery -CAN TOY PREDICT DEATH?  

IT IS SIMPLE FLU -IS IT ?

       We all have heard of Flu and how it is a viral infection and there is vaccine for that. The vaccine are good and prevent diseases. But in case of Flu it is 'hit or miss'. There are seasons when flu vaccine are not that effective and some others where it's effective,  In my last several years of practice I have seen Flu where people get better in 4-7 days and then there are some where the fatigue and cough and malaise continues for weeks.  But then there are some where the diagnosis is done in 1-2 days and then we use antiviral medicines and people get better. And then there are EXCEPTIONS to rule. Which brinhs me to the story for today. 

      I had seen this elderly male who was 82 years old and had a nodule on his chest x- ray. He came to me and had work up done . He had had hypertension and had chest pain and that was worked up and he had CAD coronary artery. He had work up and then had blockage and then had stents. During the work up he was found to have this new spot on the lung and so he came to me 

     We did the work up and then he had breathing test and also PET scan. He had descent lung capacity and the PET scan did show increased uptake suggesting the spot to be cancer. I had options of surgery - radiation treatment. He wanted to have it removed. I sent him to a chest surgeon and he agreed and the patient had the surgery. It was cancer and everything was good and he did not need any additional treatment like radiation or chemotherapy. 

    Over period of next few weeks he developed fluid around his lung and had some cough. He thought it was a set back and was worried - could it be cancer? I treated him with steroids and the fluid went down to minimal. He continued to do well. And then he had flu.

     He went to ER and was treated with antiviral medicines and he did not feel better . He saw primary care and was given steroids and antibiotics . He continued to have sough and could not eat well and lost weight. He was congested and had no energy . He could not do much waking and exercise . He used to go to gym before this Flu infection. He did not have fever and his oxygen saturation was normal . He came to me and he looked 'bad.' As mentioned no fever and no shortness of breath . But he looked mineable. I decided to hospitalize him . The standard rules don't apply as he had no fever - no shortness of breath and no pneumonia . The does not meet the criteria for hospitalization. But when you look at patient , the story was different. HE was old patient who had heart problem and had lost part of the lung with cancer and he was not recovering from this SIMPLE FLU quickly and he needed better care that can be done in hospital . I ADMITTED HIM !

   SIMPLE FLU CAN BE BAD IN CERTAIN HOSTS - PATIENTS. 

IS IT EVER SAFE

     In medicine we have many terms used and one of them is 'cure rate' or recurrence rate. This is tru especially in cancer diagnosis. If we have a patient who has say 1 cm lung nodule  and we  do surgery and it is taken out , and we have no evidence of spread of the cancer at the time of surgery, we call it a success. But is it really a cure ?The answer is yes and no - many will be cured and some will have recurrence of the cancer . We usually do  follow up CT scan for 3 years as the majority will recur in 3 years and if there is no recurrence of cancer in 3 years then we are 'safe' and the chance of recurrence is very little. This brings me to the story for today. 

  I saw this lade few years ago. She was a nonsmoker and had kidney cancer taken out several years ago - 5- 6 years ago. She was followed by a cancer specialist and he did CT scan every so often . One of the CT scan showed some nodule - a tiny density . He told her there is not much and wanted to redo new CT scan . She came to me and I reviewed the scan and really she had very tiny nodules . At the given size not much could be done as diagnostic test. The bronchoscopy, of needle biopsy or open biopsy could not have ben done to get tissues diagnosis. The PET scan is good for cancers that are at least 8 mm in size . Sometimes we do get it positive for little smaller but then most of the time it comes back negative and then radiologist states - too small to be picked up on PET scan- and we have spent money and sometimes patients get wrong impression. So we decided to do follow up on CT scan . 

     I continued to do  new scans for 3 more years , which means the renal cancer now was diagnosed 8 years ago. But the last 2 scans were showing some growth - still less than 8 mm. Then the last one was 11 mm -one of the nodules -the one that was growing . I decided that she will need biopsy  She was having difficult time with appointment  for biopsy and she finally was scheduled for the biopsy. 

     AND THE BIOPSY SHOWED KIDNEY CANCER !

So the cancer took all most 9 years to recur in lungs . That is why we should call not a cure , but 'disease free time '. 

THE MESSAGE AND THE MESSEHGER

     We have a saying that don't kill the messenger. But sometimes the message is bad and not easy to accept, then people kill the messenger. In medicine I have seen it personally. In spite of advances in medical science, we have diseases that are simply bad  and no matter what treatment you offer, it is not enough and certainly no cure. I have had that experience in past and I am sure I will have that in future. This brings me to the story for today. 

    I saw this 70 plus years old male patient ,who had some cough and some shortness of breath. He had moved here from near by place and was seen by lung specialist and followed by them for 2-3 years. He was ex smoker and had not smoked for may be 10 plus years. He had breathing test done and CT scan done in past. He was started on inhalers and he was OK. Then he started coming to me . I saw him and then I felt that he did not have much of COPD or obstructive lung disease which is related to smoking, but had FIBROSIS. I did do new CT scan of chest - called NRCT -HIGH RESOLUTION CT scan and also did breathing test. The Ct scan showed fibrosis and that was significant. I got hold of old CT scan reports and he did have FIBROSIS IN OLDER CT SCANS ALSO. We di assessment for need for oxygen and he needed oxygen. So now he was on oxygen and I discussed with him on the diagnosis of fibrosis and told him that he had it in past and seems like he was getting worse ,and so we needed to start him on medicines for fibrosis. The problem with medicines for fibrosis is 3 fold . Number one is that it DOES NOT CURE OR REVERESE the process. It slows down the decline. I tell patient that the reduction in lung function continues and does not stop , but the rate of decline is reduced - it continues rob dollars but instead of $100 , it now takes only $50 or so. Then second issue is it does not reverse anything. So the damage which is there does not get better , And lastly , it is expensive. My be as much as $25000 per year. So we need forms to be completed and get patient approved and then copay and other things that are associated with these orphan medicines. There are 2 medicines for the fibrosis - now for last 3 months 3 . I ordered one and the insurance denied the coverage. I was not sure why and we appealed and went through circle of calls and transfer and did not come to any conclusion. Then I realized  that they covered other medicine and not one that I had asked for.

    In between there was a drug trial going for the medicine - same one but as nebulizer and not a pill and we got him in it . He continued to have cough and continued oxygen . He did not get worse on his breathing test, but he felt he was NOT GETTING BETTER OR CURED. I had to tell him that he is not going to be cured and the disease will continue to get worse INSPITE of medicines . 

   He was not happy and dropped out of the study and decided to seek second opinion.  

   The message was not good and so he did not like it .