DISAPPEARING PATIENT

    When I diagnosed patient with asthma , I am often asked , how did I get it at such an old age or what can I do to 'cure' it , and many a times, what can I do to control it . I often tell patients that there is hardly any disease which is 'cured' . Take for example of high blood pressure, or diabetes .One has to take medicine to control high blood pressure or high blood sugars . He will have to take medicines for entire life . In short neither  high blood pressure nor diabetes are cured . Same is case with asthma , as long as one takes medicines, the asthma is well 'controlled ' , not cured . But there are exceptions to the rules . When asthma is allergic in origin , say allergies to cat ,and one avoids cats he may not get attack of asthma . You may be wondering where I am going with this as far as disappearing patient . Let me tell you a story of this patient .
     I saw this patient with asthma or COPD in one of the hospitals . He was  treated with medicines and seemed to have improved . He was on oral medicines , pills and was OK . I decided to to discharge him . He was given prescriptions and discharged home . I did talk to his primary care physician . That evening I got a call from the physician . The patient had gone home and the was feeling good , but as time went by , he started feeling bad and got short of breath .He called the primary care physician . The office was about to be closed .So he called me . I had no idea as to why he was short of breath ,When I had seen him in the morning , he was OK , his lungs were clear and his oxygen saturation was normal . So I could not add anything to his treatment on telephone . I told him to send him to the hospital , and told him that I will admit him . I called ER and told them to call me when the patient comes to ER . The admissions were done in ER , even though  there may be a 'direct admission ' .I got a call from the ER that he was in ER and the ER physician did not see him as it was direct admit under me , and so they called me  and told me about his arrival and told mre the room number that he will be admitted to . I decided to go the room in next 15 -20 mins .
     I went to the room directly , without going to the ER . He was not there . I asked the nurse , who was suppose to take care of him . She got the report , but the patient did not come to the room .I thought that patient may be still in ER , so I went to ER . He was not there . The patient was not seen by ER physician , so he could not tell me anything about the any medical issues that he may have had . In between I get a call from his son . He had heard that after the morning discharge from the hospital , he got worst and so was being admitted to different hospital , and so he wanted to talk to me about his father and wanted to know as to what was happening . I did not know where the patient was , and certainly had no idea as to his new medical problem . I called nursing super wiser . I also  called security guard . We decided to check all the elevators and even all the bathrooms . I was afraid that he may have passed out and no one knew . It would have been a major issue if he had passed out , even worse had died , and no one knew . He was to be found nowhere . I just thought of something . If his son was calling , then who drove him to the hospital ?I called his son . He told me about patent's sister who had picked him up from the hospital. I got her telephone number .and called her . To my surprised she answered . She was the one who had brought the patient to the hospital .Her  house did not have air conditioning .As the time went by with no AC , in Florida heat and humidity, he felt worse , called the PCP and then started to come to the hospital .The car was air conditioned , he felt better , When he came to ER , which was air conditioned , he felt better . When he was assigned the room , he was feeling so good that he decided to go home , instead of being readmitted . So it was the AC that made the difference . Unfortunately he did not tell anyone , which caused the major problem in the hospital . The end was sweet , but I added one more thing to my list of things that cause worsening of asthma , the air conditioning !!!!

CURSE IN DISGUISE

      It is often said that sometimes it is blessing in disguise , which means even though  certain situation may appear to be bad , it may be other way round and it may be good . That is why it is called blessing in disguise .But I am describing the exact opposite situation .Which means that the things on surface appear to be good , but in reality they are bad . I remember reading about a study . The people who were ' stood up ' at the time of wedding, were asked if that was the worst day in there life . Think about it . All the preparations are made for the wedding and then the bride or bridegroom does not show up and the wedding is cancelled . Would it be not the worst day in the life ?But the answer surprised the people who were doing the survey . Majority of the people felt that it was the best day in the life or may be the luckiest day in their life . They felt that if they would have gotten married and the had to get divorce , that would have been the worst situation . So getting 'stood up 'saved them the misery of undergoing the divorce.So it was the blessing in disguise .
      I am telling you short story that appears to be good , but was not good . I was seeing this patient who was close to 100 years of age . His wife was 96 or 97 years old . At one time both got admitted to the hospital . He had pneumonia and congestive heart failure . He did OK for a while , but then started getting worse. At that time his wife was admitted too . She had bad bronchitis and so we put both of them in the same room . As his condition continued to get worse , I talked to him and her and he was made DNR. In next 2 days he died . She was discharged in improved condition . She came to see me on follow up . She continued to do well . In next couple of weeks I saw a new patient , who happen to be her sister and who was year older than her . When I came to know that she was sister of my patient I said that you have great geans and are lucky. My patient stated that it was not that great and it was not blessing . She told me that her 'life partner ' was gone , her memory was not the greatest , her hearing was going down , so was her vision . So what good it was that she was 96 or 97 years old . I had no answer .
      I realised this , as I am seeing more and more patients who are in their nineties . One guy was mad as his driving licence was suspended and he had to depend upon others to go places . I visited India and saw a couple , husband is 93 and wife is 88 years old. She can't see, to a point that she can not watch TV or read a book . Her walking was difficult and she fell down few times .The husband has to do every thing in the house. I have known some older people who choke on food or are confined to house as they can't walk . So I really understand that just living longer is not a blessing . In fact what appears to be blessing is actually a curse in disguise .

ALTERNATIVE MEDICINE AND ME

    I practice type of medicine , which is known to everyone as medicine . In reality,it is called allopathic medicine .There are several other types of medicines which are practiced in India, which are quite common and practiced quite regularly. These are Homeopathic , Aurvedic and many more .In India these are not 'week end 'courses but are 4 years college courses. They do have materia medica and the medicines used are produced commercially and are easily available .I do not know much about it , but it is very common to use herbs and regular use food articles . Theses do have many uses and I do tell patients about their use. These are from ginger, turmeric , clove garlic , eucaliptus etc.Many of these are available in health food stores and also in regular or Indian grossery stores.I do not recommend or prescribe any of them , do tell patients to use these and they seem to help at least symptoms if not cure them .
     But there are other things which fascinate me and these are not scientifically proved , but people tend to claim success, and I feel that they need to be investigated . These are Recky, (I may be misspelling the word ), photo therapy , acupressure , acupuncture . etc. I have a personal story that can't beat any of these things .
      You might have heard about Chinese meridians . They are similar to Indian Nadies .This is a story of stimulating them . I used to do exercise with free weights . I must have done something wrong as one day I started having pain in my shoulder.It was so bad that I could hardly lift my arm . When I got in to my car I could not raise my hand enough to put keys in the ignition . On that day I had to do a procedure --an endoscopy . I had major problem as I could not raise my hand . At dinner table , i could not pass the salt ,let alone any other pot .
     Next day was a holy day and I went to a temple . As I was standing in line to offer my prayers , a friend of mine was next to me . He is a physical therapist . He noticed my problem and asked me about it . I told him about the problem and also told him that I had gone to an orthopedic surgeon . The surgeon examined me and told me to take ibuprofen . He did not feel that anything major was wrong and any additional intervention would be needed .The physical therapist told me that he could help me and if I want, he could come to my house that evening and give me the treatment . I agreed.
    He came to my house .I was under the impression , that he would give some physical therapy . Instead he took out a box . He had this meridian locater and was going to stimulate it . He found out 3 different spots , two in leg and one in my elbow area.I knew about meridians . So I was not surprised, but I was surprised to see that 2 of the points were in leg. He did the treatment and left. By the time he had left , I was  much improved, may be 50-60%. Next morning when I woke up , I was 80-90 % better. I saw the orthopedic surgeon in the hospital. He was awair  of this technique, but did not feel it was any effective .
   To analyse the whole situation , as I do it all ways , I had taken Advil twice , and not done any exercise, So it could be the effect of the anti inflamatory drugs . But to me the improvement was too quick and significant ,very close to the this new treatment , that I feel that it was related to stimulation of meridian .
   I do believe that  there are lot of 'fake' alternative treatments, but there are effective real treatments too. The difficulty is that we do not have definite double blind studies, that could prove it .

STATISTIC AND MEDICINE

   If I would say to any person , that medicine is nothing but  statistic, they would laugh at me . Well may be not laugh , but would disagree with the statement. But if one looks at the way the medicine is 'practiced ' , he will have to agree that medicine is based on statistic and is practiced most of the time , if not one hundred % of the time with statistic in mind.Take for example of  acute bronchitis or case of pneumonia The treatment that I would give, will be based on statistical data as to which antibiotic will work 'best' with given circumstances . If the patient has COPD or is alcoholic or has HIV , we will select different antibiotic .Same is true of most of the other diseases , even the chronic conditions as high blood pressure or diabetes or rheumatoid arthritic etc. We have studies that have shown that certain drugs work best with certain conditions. We even have data as to which a better drug for Asian or African American patient.But sometimes we have to 'think 'differenly '. If this was not the case then we might as well ask "computer " to prescribe the treatment .The story that I am going to tell is one such case .
      It was 4-45 pm , I was in my office and was about done with the patients and the 'charts ' ,messages and the paper work. I got a call from the ER. One of my colleges was admitting a patient to ICU , with clot in the lungs . His blood pressure was little low and so he was going to be in ICU. I went to see the patient . He was 78 years old male with history of high blood pressure . He had artrhitis of the hips and had surgery done recently . The surgery went well and he was transferred to a rehab unit.. In cases of hip and knee surgery , there a high risk f developing a 'clott' in the leg veins and it can  'travel' to lung . This complication is called pulmonary embolism and can be fatal.So to prevent it we put patients on small dose of blood thinner .He was discharged on one such blood thinner . Two days after the discharge , he was not doing well and the nurse had noticed a swelling of the lags . In the begging it was thought to be due to recent surgery and limited activity . But then he became short of breath and so was sent to ER.In the emergency room he had a CT scan done and it showed pulmonary embolism .His blood pressure was low and he also had a clot in the legs . When I saw him some additional blood tests done . When we put patients on blood thinner , called Warferin --coumadine, we monitor a blood test called INR. He was not on this drug , but his INR was prolonged as if he was on it . The therapeutic level at which the clots do not occur , (statistically), is between 2.5 and 3 or so . His level was more than 3 and he still had clots , both in legs and in the lungs I was surprised. I did some more tests . I had my tentative diagnosis.I started treating him with medicines and fluid and oxygen . (I am avoiding the derails of medical part ). The test reports came back and my hunch was correct .
     He had developed  allergy to the blood thinner that he was getting and so he was 'clotting ' inside blood vessels . This random clotting caused the problem . It consumed the 'factors '(chemicals ) needed for the clotting and so he was bleeding too or oozing blood . The good news is hat patient improved and went home . The treatment that we gave him was a different blood thinner to help resolve the clots .
  Statistically patient should not develop clots with adequate amount of blood thinner , but he did and the treatment with other blood thinner was the treated though sadistically one does not need blood thinning agent if INR is therapeutic . The case occurred when we were not very 'familier ' with this condition called HIT , which is very well known now,  but one has to think about it , which I did and did get the reward. i.e.patient survived !!!!

PUT YOUR THINKING CAPS

      We often are told to 'put thinking caps '. This is so true when we talk about medicine . Unfortunately today thinking is left to the tests that are ordered or the computer for the 'pathway' for the diagnosis. Many a times if there is no test to be ordered then patients are told "everything from -------(cardiac or pulmonary or gastroenterologist etc ) is OK ".Many a times we don't try to find out if there is any reason that can be treated. I do see patients that are out of shape and have what I call 'deconditioning 'i.e. opposite of conditioning. This can happen to many of us as we decrease our activity as we are too busy or we have arthritis or we are too lazy . I don't tell anybody , without doing 'tests' that they are out of shape .This is a story of one of my patients , where 'thinking ' not a new test or a new scan helped .
      I knew this 79 years old male for a long time . He had severe COPD. , from smoking in the past . He had some increase in shortness of the breath .I did the work up and found out that he had a narrowing of the aortic valve .He was seen by a cardiologist and was advised to have surgery. I was concerned about it,as he had very bad , advanced lung problem. I told him that his shortness of will not improve much or dramatically as lungs are not going to improve . I did 'clear' for the heart surgery . He did very well after the surgery and in fact his shortness of breath also improved .
     He continued to do well. But then about 8 or 9 months down the road he started feeling shortness of breath. His lungs were clear and his oxygen was good and when I made him walk for 6 mins , he got short of breath , but oxygen did not drop.I did the breathing test and it was actually little better than before . So I came to dead end . I had sent him to a cardiologist , who told him that " the heart was OK ". I was stuck . So when he came to see me and was still was short of breath , I suggested him to see a different cardiologist .The 1st cardiologist had not done any test and I was concerned about the heart . I talked to this new cardiologist and told him my concerns . He saw the patient , and called me . He told me that he will be doing a echo cardiogram , but did not feel it will show any thing significant . He told me what he thought was the cause of his shortness of the breath .The patient was put on a drug called beta blocker . This can cause lung problem in some patients (which was not the case in this patient ) ,but it can decrease the heart rate .o when this patient was exercising ,beta blocker would not allow his heart rate to go up , which is essential for  providing more blood that is required to avoid shortness of the breath . So when he reduced the dose of the medicine ,his shortness of breath improved . So a minor change ,changed the shortness of the breath .
      So put your thinking caps, whenever you are faced with what looks like a difficult problem .

CONDITIONAL LOVE

    I often say that to get to The GOD we need to have 'unconditional 'love .Most of the times we say that we love someone or something , it is neither unconditional nor it is ever lasting.Wnen mother loves the child --son or daughter , it is one love that comes close to the unconditional love . The love between the husband and wifeis is based on many conditions . In fact with the birth of a child the love is reduced , as part ofthe love  goes to the son or the daughter. I do see many patients that do get married , for convinience after the death of 1st spouse for many reasons . To avoid lonliness, security, safety etc are some of them.. Not in every case these marriages are accapted by the children . Sometimes they 'encourage' it , but in many cases don't accept it all the way.I am going to tell the story of a patient that I came across sometimes ago .
    I saw this 84 years old lady for the cough andit turned out tobe mild asthma . She was followed by me and was doing fine . One day I was consulted to see apatient with the same last name . It was not uncommon name , so I did not think much about it . But when I entered the room I saw my  patient . This new patient was her husband . He was diagnosed to have got melanoma . This is skin cancer and it was taken out . But it had recurred and so he was getting chemotherapy . He was doing poorly , and now he had a episode of passing out . The CT scan of the brain was naormal (except for some loss of brain tissue to aging ) . He was 89 years old . The CT scan of the chest showed many masses , suggestive of spread of the cancer. So I was asked to see him to see if biopsy could be done and diagnosis be established . I spoke to him . He had some dementia .He could not answer many simple questions to me .I asked the family , the wife , who was my patient, and the 2 daughters that were present. They did not want any any further chemotherapy . The side effects were quite severe and they did not feel it helped , as otherwise he would not get all these new lessions in the lungs . I told them that if they did not want any treatment , there was no reason to put him through a invesive procedre . He was dischrged .
      I thought that the case was over ,till I get a call from the wife . Patient was seen by the oncologist and he convinced them to get needle biopsy , which was done and it showed a cancer , but not definate melanoma . So now the oncologist wanted new biopsy . So the wife and the daughters wanted to discuss with me . I saw them and asked them if a PET scan was done . It was not done .I asked whythey were asking for the direction to the place that had no intention to go ? ( why do a biopsy , if they are not interested in the treatment .)He was having quite a bit of pain in hip and low back .I decided to do the PET scan to see if there was spread of cancer, so we can think of pain controll and /or hospice . The PET was positive in Hip and pelvic bones . So now the question was , should we do radiation for the pain controll or do nothing . I sent him to a radiation doctor and he called me and felt that the PET scan bnormality was due to arthritis and not cancer and did not need any treatment . I saw patient and his wife and the daughters in the office . After extensive discussion , I refered him to Hospice .
      He died in next month or so . The wife came for her follow up . I asked her as to how the things were as she had lost her husband . She said not very good , but she was trying . I presumed that it must be due to loss of long time spouse . But at that time I came to know the real story . She was married to this guy for 8 or 9 years only . She had lost her husband and he had lost his wife . They knew each other for many years and no one had any objection to them getting married . Her kids and his daughters were very happy that they were getting married . So the daughters that I met were not her daughters , but they were his daughters . There was no problem till he was alive . The all got along well . They all made the decision to make him DNR and get him to Hospice .But now that the husband was  gone , the things changed . The daughters took all his pictures and personalitems , not nesseraily expensive . She did not get anything as his 'memory'. So there was no problem and there was 'love ' till the father was alive ( or they needed some one to take care of the old father ) Now thta he was gone , who cares for the emotions for this old lady ?

NEW YEAR THOUGHTS , WISHES AND REALITY

  HAPPY NEW YEAR .
        Year 2013 started today . I do wish -like everybody else , that this will be better than last one or for that matter any other year in past . Like the saying ,"better is yet to come ." But then a thought came to my mind . We are keeping a count , since we know . But is it really a year 2013 or is it 2million and something or 2 or 10 or 15 billion and some thing ?According to one thought there are 'YUGAS ' and these continue for ever .  some lasting for 475000 years. The other thought was that as the earth moves around the Sun, the entire solar system moves around a different star, in 60000 years . So this is divided in to 30000 each way . I have no idea as to what is reality, and it really does not matter .
       So what is Happiness ? Or to be more specific , what makes one happy . Many of us know the story of 'happy man and his shirt '. If you don't know it , here is a short version . There was this king , who had everything that we think can give happiness . He had power , money , and good family and loving citizens . But he was not happy . So he invited many doctors . Each one advised a medicine . None made any difference. Lastly a new doctor came and told him that if he could were a shirt worn by a 'happy man ' , he would be cured . The king sent all his men to look for the happy man . When they asked a question , "are you happy ?" . then answer was discouraging . Some one was sick or family member was sick or they had lost job or had no money or had some other problem . The king's men could not find anyone who was happy . Finally in desperation they went out of town . The saw a man sitting on a stone , looking at the water of arrive , the sun was rising and this man was sitting there , doing nothing . So he was asked the same question .His answer was , "Yes I am happy ." surprised them . The took him to the king . The king asked him the same question , are you happy and he said yes . So then the king asked him to give his shirt. The man replied that he did not have one . This was a surprise to the king , but soon he realised what the doctor was trying to convey .
        The happiness is a state of mind and not of body . The happiness is not in external source but is internal to our mind . If the happiness came from the outside sources , then the 10th slice of pizza should give same happiness as 1st or everybody would love opera or classical or hard rock music . Or rape would be as pleasant as regular sex . Now it is clear that the happiness is the state of mind . AND SO I HOPE THAT WE ALL WILL ACHIEVE IT IN YEAR 2013 !!!!!!!