ARE WE CONNECTED?

     I believe in reincarnation and I also believe in Law of Karma.I do not have any direct proof for it , though I often come across the situation that leads me to believe that both of them are real. The question that is always asked is ,is it nature or nurtured?The things that we see in different family members occurring , is it due to the simple 'chance' or is it because the environment under which the family members are brought up is same or is it due to some kind of relationships that we develop that continues beyond single life ?(which means is it due to the our karma and it's effects , which causes reincarnation).I often see patients whose spouse also start seeing me if they have lung problems. So I often wonder when I see sick patients , whose spouse also has significant pulmonary or other medical issues.
      The story that I am going to tell is one that is related to the patient in my last blog . The patient that I described had 3 lung cancers at 3 different times and sarcoidosis and then developed breast cancer and died of it.One of these days this patient told me that I was going to see her husband . I had known him for some years as he used to come with her.Now he wanted to see me . He was a 70 years old white male who had significant cough, mainly dry and some shortness of breath. He was getting tired.He had mild cough and had some crackers on physical examination. I did the chest X-ray and then the CT scan . It confirmed that he had pulmonary fibrosis.I had also sent blood for rheumatoid arthritis and some other conditions that can cause the fibrosis. The rheumatoid factor was positive .So he had rheumatoid arthritis and it had caused the fibrosis in the lungs.The breathing test that I did,,showed that the diffusion capacity-how the oxygen is transferred across the lungs in to the blood,was reduced . This was consistent withe the diagnosis of the fibrosis. I sent him to a arthritis specialist and he was started on treatment for the RA.He came to see me in 3 months and was OK but did not look very happy .He had lost some weight and still felt tired. But he had no fever . His appetite was good ,but he was not gaining any weight. I decided to do the Bronchoscopy. Sometimes these patients with the fibrosis and the one that are taking immuno- suppressants ,get atypical infections, like atypical TB.It came back negative. So I decided to do the follow up .He came to see him Had lost more weight and was feeling more fatigued and short of breath.I did the new diffusion capacity .It was not any worse . I had done the Echo cardiogram , to rule out cardiac cause and it was OK. I walked him in our office for 6 minutes,and he did OK. So I was not sure as to the cause of his weight loss. I had asked gastroenterologist to do endoscopy ,colonoscopy to rule out occult cancer and it was negative.So I did not know and he WAS WASTING away. And it struck me .I was surprised that I had not noticed it before. HE was loosing not only weight, but was also loosing the muscle mass. I sent him to neurologist and this time my hunch was correct .He had myopathy, a muscle disease in which his muscles were wasting and as he was loosing the muscle mass he was loosing weight.There was no treatment for his condition.
     In the past he was the one who would help his wife ,when she was short of breath. He was strong and big and had no problems. Now he was himself short of breath and was weak. He could not be of much help.In next less than a year he died .
     So the question that I had was was by any chance that these two were married and both saw me and I had diagnosed  the different conditions , that would lead to death finally.
     WAS THIS SIMPLY A CHANCE?

VAST AND INCOMPLETE MEDICINE

   I watch evening news and many a times there are stories,which include police power abuse and also about medical negligence or missed diagnosis. Recent case in point is in case of Ebola in Texas.I do not no much more about Ebola or about the case in Texas.But the families always believe that the police are not careful in cases of criminal cases and doctors are not careful in cases of medical cases ,especially when the out come is bad.Even though I am sure that there are cases where the doctors are at fault.But I also believe that as in case of police ,the work of doctor is not easy . To get a line from Dr.Atul Gawande, the medical knowledge is wast and incomplete, it becomes difficult to be correct 100% of the time . I am going to tell a story of a patient that had so many complicating issues ,that it was impossible to have something definite diagnostic test than doing a intellectual educated guise work.
      I had seen this patient for many years. She was a smoker , who had quit .She had mild lung problem related to smoking in the past. But she was not bad . But when she saw me she had abnormal chest X-ray.She had some lung congestion or infiltrates and her lymph nodes in the chest were enlarged. The possibility of a condition called Sarcoidosis was entertained by me . In this disease patients do get the enlarged lymph nodes and they do get problem in the lungs Some patients ,<1%will get worsening and will get short of breath.She was quite concerned.I did the lung biopsy, and it did confirmed the diagnosis of the sarcoidosis..She was worried about cancer . So I sent her to a chest surgeon and he did a lymph node biopsy.It was positive for the diagnosis of sarcoidosis.She was happy and we decided to do the follow up.
     Over period of next couple of years , I did the several CT scans . They continue to show the enlarged node and the the lung congestion . The one of these days she had a nodule. I was not sure if this had anything to do with the sarcoidosis or it was a cancer. The further work up was neede . So we did the biopsy and then finally I sent her to a chest surgeon.He did the open biopsy and took out the part of the lung that had the tumor. The good part was that not only it was a cancer that was contained, and the nodes were negative for any spread of the cancer.She was happy . I just wanted to just point out that if in case of lung cancer, if the nodes are involved , patient becomes inoperable and incurable.But in the case of this patient, there was no way to know if the enlarged nodes were due to cancer or due to sarcoid. Even though in latter part our follow up we had PET scan.In PET scan ,tagged Glucose is given IV and images are taken. The glucose is picked up by metabolically active cells and by normal cells. The metabolically active cells pick up glucose more actively and so we can pick up cancer. The problem is that the infection or sarcoid will also pick up glucose more avidly and so it does not differentiate between cancer and sarcoid or infection.So you see the difficult?
    In near future she developed another nodule .I was not sure what to do other than do the usual work up . I did send her to a surgeon and it was taken out .And it did not stop there. She did well with this surgery.But then again developed a small nodule. Please realism that I followed her for may be 10 years or more.This time , the third time when she had new nodule and the nodes were same , I sent her to a surgeon. I am not sure why , but the he decided to do the biopsy of the lymph node and not the nodule . I was thinking that the nodule was cancer and the nodes were sarcoid .She also had develop breast cancer. To my surprise the nodes came back positive for cancer.and she HAD BREAST CANCER in the lymph nodes and the . So I was not sure why he did that but it was more helpful than the PET scan .
    So the difficulty that we have is no test is perfect and your intuition is not perfect and every time one can not do major surgery or do biopsy . So this is not a perfect science and like any other time we go by what is more common.She had 3 lung cancers and a breast cancer and Sarcoidosi , each one can cause the enlarged nodes and positive PET scan.
     The lady was given chemotherapy , continued to have problems and got metastatic breast cancer and died about year and half after the breast cancer diagnosis.
     

CRYING WOLF

   As a child I learned the story of the crying wolf .I have thought about it on many occasions in life . We may be talking about the politics (it is always a crisis of some kind for some politicians), or your own son or daughter, or it may be in medicine, this phrase and the story is illustrative of our response.I have myself experienced this in my own decision making , even though I try to sort out my 'feeling' and the findings. Some ties it may have to do with the circumstances , but one must be careful.
      I had seen this elder,y patient , over 90 years of age,who was admitted to the hospital with the diagnosis of pneumonia. She had no fever nor did she have any elevated white cell count,( which is elevated in case of any infection)I saw her old chest X-ray done about 4 weeks ago.It was similar to the one done now. So I was not sure if she had indeed the pneumonia the diagnosis that she was admitted with.I wanted to do some investigations, but she was older , more than 90 years of age , and I was not too sure what did she want. I spoke to her and her son . She was not very keen on many "tests".But after discussions she was agreeable for the CT scan and an endoscopy. (Bronchoscopy.) Even though she was 90 plus she was quite clear in her thinking. She was allergic to many drugs and it was difficult to treat her. I did the CT scan and it did not add much . She had congestion , findings similar to the one seen on plain chest X-ray.The bronchoscopy also did not help. It showed no cancer , which was helpful .But the cultures were OK .The infectious disease consultant wanted to give 3 antibiotics.He did not want to stop any even though all the cultures were negative. I had no other choice as I did not know anything more.
      My plan was to do follow up X-ray in 3-4 weeks and then decide. But every day that I saw her, she had some complaint. One day the IV got out and they had hard time starting another one.Then she was constipated and the medicines thy gave her was not good and caused her to have abdominal pain. Then she had diarrhea.She did not want the breathing treatment and then felt that steroids were causing problem . Her physical findings were not any different. Her oxygen was OK and there was no fever and she sounded clear.The one day she got the laxative that she wanted and then felt like throwing up. She had 4 or 5 loose stools and may have been mildly dehydrated.Her blood pressure dropped and she almost passed out . I saw her in less than 10 minutes. She was fine and her oxygen saturation was OK and blood pressure was OK . I ordered some blood tests and new X-ray and gave her some fluids. The X-ray was better and labs were OK except one which was borderline for heart attack.Her ultrasound of the heart was normal and there was nothing to suggest heart attack on cardiogram.She continued to do OK , but every day had new complaint from stomach upset to constipation to diarrhea to problem with IV site and so on .
       One night the nurse called me stating that she had 'worked herself' up and was short of breath , The oxygen was OK, she sounded OK and blood pressure was normal She wanted an inhaler ,that she had stopped on her own before. I had respiratory therapist give her a nebuliser treatment and gave the inhaler . I also ordered new Chest X-ray. It was 1 am As soon as I hung up the phone I realised that I was brushing aside the complaints as she had complained too often . I called the nurse again .I ordered new cardiogram, blood test for heart attack and blood test for congestive heart failure. I also ordered IV Lasix, a diuretic.
       She did have the congestive heart failure and the X-ray and the blood test showed the congestive heart failure. So the diuretic helped . She was better.Next day I spoke to her and her son . She was doing much better and in next day or so was discharge to rehab unit.So I was about to be caught with the "crying wolf" and not doing the right thing . But I did OK.and so did the patient.

WRONG DIRECTION ,RIGHT DESTINATION

     Sometimes we do things for long reason and get the 'right'answer.One does not want to go a wedding or to a party,but then he meets his dream girl. But in medicine , it rarely happens . I feel that we do too many tests, Some of them with normal results and are (at least my mind waste of money). This is more common in hospitals as no one wants to miss any thing and the physicians that are seeing patients , are not the ones that know patients and are not going to do out patient  follow up.So the tests get ordered.But the story that I am going to tell is one little unusual one.
   I had known this lady who was smoker. She had some COPD. I had taken care of her husband. He had COPD too . After taking care of him for few years, he died . Then she started coming to me more regularly.She was a smoker . She was hospitalised for pneumonia. We did a CT scan and it showed some scars and emphysema.She was doing better.But her platelet count  was low . So we did a further work up. At time I came to know that she also was drinking alcohol. So I did a liver test and it showed that she did have a liver disease related to alcohol . After extensive discussions , she agreed to stop smoking and drinking. It should be noted here that she had a colon cancer resected year and half ago. I continued to do follow up . She improved significantly .Her lungs got better. She hardly needed any inhalers. Her platelet counts improved and her liver function was normal.We continued to do follow upon her periodically.I do chest X-ray every year.
      She was also followed by an oncologist.So one day I get a call from him that he did a blood test and it was elevated suggesting of recurrence of colon cancer . So he did CT scan of belly and chest . The Ct scan of the belly was OK but the CT scan of the lungs showed that her lungs had abnormal density in right and left upper lobes . She had scars in left upper lobe , and it did look little worse. But the right upper lobe was new . I did PET scan and it showed the activity in right upper lobe . The left one where there was a scar was mildly active in that area, which could be scar or cancer. I did breathing test and a bronchoscopy.It was of no use.,did not help. So I asked radiologist to do the biopsy of right upper lobe . It showed LUNG CANCER and not colon cancer . (in my mind the possibility of colon cancer was almost zero ) I sent her to a chest surgeon . My thought was to take the cancer out. But the surgeon was concerned about the left side . He wanted the biopsy of Left side . So I agreed and the biopsy was done and it showed LUNG CANCER. So she had a lung cancer which had spread to other lung .I am not sure as to which side the cancer started.
     So the blood test that was done to do the follow up of the colon cancer was correct test to find out recurrent colon cancer, though the chance of recurrence was very very low. But there was truly no reason to do the CT scan of the lungs . So the test that was ordered which showed the cancer was not the right test , but it gave us the diagnosis of the lung cancer .

THE CAUSE AND THE EFFECT

    The law of cause and effect is known to all of us from childhood to adult life . As a child we learned that if you touch a hot pot , we will get burns.Or if we don't get good grades , our parents are not going to be happy. As adults we know that if we do not follow the speed limits and get caught, we will get speeding ticket. But in spite of that we don't change the behavior all the time. We know that eating too much and getting obese is not good. But we still indulge and get fat. Some of these things are obvious,at least to most of us . But then there are things that are not either obvious or not accepted by some .Many years ago , when I was new in my medical practice , I met a cardiologist. He was older than me by may be 20 years . When I met him for the first in a parking lot , I told him that I was a lung specialist.He lighted cigarette and told me that smoking is harmful was all bogus and there was no proof that it causes any health issues .There was no way I was going to convince him otherwise .Now this is very obvious today and even in those days , it was known though may be not accepted by 5 or 10 % of the people.But then there are situations where the cause and effects are not known.
      I was told this story many years ago by some one . In India the rain fall was low and there was water shortage and the summer was hotter than before . So the Chief Minister ( Governor ) appointed a commission to investigate the cause . After meeting several times and spending lot of money they came with a report. They stated that "the cause of water shortage is that Indian couples are spending too much time in Bedroom" The Governor was stunned . He did not know what was the relationship of couples spending time in bedroom and water shortage.Then it was explained that when the couples spent too much time in bedroom, they had more kids and that caused increase in the population.When the population was increased, they needed more land to build houses . So they had to cut trees and so the forests were gone and this led to reduction in rain and increase in temperature. Sp sometimes the cause and effects are not obvious . I know I have a very long introduction in my story.
      I saw this Asian patient in ICU . he had pneumonia . He was a smoker and had cardiac issues and had bypass done and and also needed a heart valve replaced.He had other issues and We had a hard time weaning him of the respirator. I did couple of Bronchoscopies and had to give steroids and antibiotics. We came quite close to doing Tracheostomy. After 14 days of struggle, we weaned him off the and he did OK . There ware several days before he was out of ICU and then took few more days before he went home . I continued to see him as out patient. He continued to smoke and continued to have lung problems. Over period of next year and half, he continued to have more problems . He ha d blood loss from stomach and intestine and had congestive heart failure and anemia with drop in blood counts. He was admitted to hospital several times and even went to Mayo clinic. Then he was diagnosed to have a disease in which body (bone marrow ) does not produce enough cells. So the blood counts drop and he needed frequent transfusions. He continued to smoke, The he was started on chemotherapy. This caused his immunity to get worse and he ended up with an episode of sepsis . He ended up on respirator.We worked him up and were successful in weaning him off the respirator.
     So I have a question . Is there any relationship of him having all these diseases and continuation of smoking ? Certainly the cigarettes have many toxins and I am not sure if there is direct relationship between them and all the problems that he had , but then we don't know why the smokers have higher incidence of all sorts of cancers including breast cancer or bladder cancer.But I am sure that there some cause and effect between smoking and at least some of his medical problems .

UNCERTAINTY PRINCIPLE AND THE ASTROLOGY

      I was talking to some friends recently and the subject of Narendra Dabholkar came in.Mr. Dabholkar was recently murdered and the murderer is not yet caught. I never met him , but had seen him on one of the interviews . He had u tube video, where he stated that one should not call astrology a "science". I am not sure how much study of this science he did , to call it fraud and not a science. One certainly can understand his argument. In the science there is hypothesis and no matter who does the experiment or where it is done , the results are reproducible. So this is not so with Astrology . So he does not believed it to be a science. There are two problems with this  argument. One is that there is something called 'free will. Which means one can 'change' the out come in most of the situation , either with little efforts or with lot of efforts. So one can do nothing and then the outcome would be as predicted or if the effort falls short then the outcome would be same as predicted .But if we try hard, then the outcome would be changed and then the prediction would be changed.So there is no one hundred percent in any situation. So what Mr.Dabholkar said is not incorrect, but it has simple explanation, which he tends to neglect.
     But the second and may be more important for those who question religion and put 100%faith in the science, is that neither science can predict things 100% of the time .Many years ago Laplace , a scientist proclaimed that if we know speed and position of a particle, then we could predict it's "future" position. But as it turned out, he was wrong. NO ONE CAN PREDICT WITH CERTAINTY THE "FUTURE" POSITION OF THE PARTICLE. There were several attempts and explanations for this and then was the birth of quantum theory.So as soon as one tries to look at the position of the particle , it changes its speed and then it becomes impossible to predict the future.. So the predictions are purely based on 'probability' and not certainty.This is exactly what I was saying. The course of our life is predetermined as long as there is no interference from 'free will' or the efforts . If that interference occurs , then the so called future is changed . So the 'destint' is not predetermined as long as we do not try to change . Same is true of astrology . It is based on probability. The predictions have too many variables and too many influences from outer sources . So this can make some predictions exactly 'right ' or 100%wrong.
      

YOU GOT TO KNOW WHEN TO HOLD ------

       Many years ago I watched the movie called the Gambler.Kenny Rogers was a seasoned gambler and there was an amateur gambler who gets in trouble, So there was the song " You Got to know when to HOLD and you got to know when to FOLD. " I liked it very much for the meaning . I think it is a message for the life .I have used it in many situations.But it is so true in case of medical management. When we see patients in ICU who are very sick, we try everything that we can. We have lot of things to do as testing or try different treatments. But as time goes on and when we don't see any improvements , it may be time to stop the aggressive treatment or may be continue for little longer time . This is what I call either 'holding' or 'folding'.No one can state with certainty , as to when is a 'right' time to either Hold or time to Fold.I have faced the dilemma many times and sometimes I face it in situation when it is not impending as in ICU , but may be chronic or sub acute.The case that I am going to tell is one such.
        I had seen this young male who had chest pain . So he was admitted to the hospital . He had had a cardiology evaluation. He had a coronary CT scan . It did not show any significant coronary artery disease.He was discharged. He was OK for next 2 or 3 months and then he was having cough. The PCP treated him with different medicines . When he did not get better, he had new chest X-ray. The X-ray showed fluid around the left lung. So a CT scan was ordered and he was referred to me . He had large fluid collection around his left lung.When I looked at his old CT scan , he had tiny fluid on left .I took out mare than 1200 ml of fluid and it came back in less than 10 days . So we consulted a surgeon . He had surgery to look inside his chest and insert a catheter to drain fluid. The catheter can be left in for long time and we can drain it as needed, may be weekly or daily or whatever is needed.The biopsy turned out to be mesothelioma. The family was very smart and had done their home work . So they wanted to know if surgery was an option. I was not too sure . I knew that there were surgeons who did quite 'extensive' surgery.But was not sure as to the if he was a candidate. I knew the name of a surgeon and I gave it to him and he was also seen by an oncologist. He was started on chemo and had periodic follow up of scans and had drainage of the fluid. Due to tumour , the fluid was not free and we had to change the catheter couple of times . He did OK with the chemo and then was sent to the surgeon. But by now the CT scan showed spread of the cancer to liver . So he was not a surgical candidate. So other than continuing chemotherapy , there was no other choice . When I saw them , the patient and the family , I was surprised to see that they made decision to go with Hospice . In my mind this was the 'right; choice ,but was not too sure if they would ever consider Hospice , or ;giving up'. But I knew they knew when to "HOLD " and knew when to "FOLD".