SELF DESTRUCTION

      All of us know about the self destruction of the cassette in the episodes of Mission Impossible. In medicine we know there are many example of cell destruction . The red cells will die in 120 days from the time they are released in the circulation . The platelets , which are important  for the clotting have life of 7 days . Same thing happens with many tissues and many times There was a time when an experiment was done to see as to how long cells can continue to multiply if they are provided adequate nutritional support and environment in the Lab.In the beginning it was felt that the cells has unlimited ability to multiply. But then it was realised that when new chicken broth was added as nutritional support , thew were adding New Cells . Subsequent work showed that each cell has Fixed Limit. This is called Hafflick factor. When the skin of old mice was transplanted in younger mice the the cells lasted longer . However the limit was there.So this about the medicine , but the Self destruction that I am talking today is about behavioral destruction. I have seen this in my medical like. But this one of the story.
     I saw this 40 years old female in my office for chronic cough. She also had some shortness of the breath . She was in ER few times . This had started few months ago and she had seen a lung specialist I saw the old -2 months old Ct scan . It showed that she had Interstitial lung disease . I saw the old record . She had some lymph node enlargement and the lung specialist had done biopsy of the nodes and told her that 'everything was OK' .I decided to do new CT scan and the pulmonary function tests. The Ct scan did show that she was worsening in the inflammation in the lungs and breathing test did show that scars had affected the test. The process of transferring the oxygen is called diffusion and that is impaired when there are scars .This is called Diffusion capacity . I did do another broncoscopy and biopsy , but no definite diagnosis was established So I asked a chest surgeon to do the open biopsy . It showed specific reason for the inflammation and the scars . I had done all the tests to rule out that etiology called connective tissue disorder (Lupus or Rheumatoid arthritis etc )I started her on steroids and tried to send to Mayo clinic or other centers , but had problem with her insurance . She continued ti get worse. So I sent her for transplant evaluation . She was felt to be a good candidate, and they decided to start the work up , so that she can be put on Active list . The it happened . She was admitted for shortness of breath . Someone did a Drug test on the urine and it showed positive for cocaine .She got worse and needed 50 L oxygen .But she was not accepted for the transplant as she had used cocaine . They would not accept her till she is 6 months drug free .
                      THIS IS WHAT I CALL SELF DESTRUCTION ! 

SHEAR LUCK

      We often talk about people being 'lucky' . When we watched the super ball or NBA play offs , we see that some games are won not by dominance of one team over other team, but sometimes it's shear luck . Otherwise why would at buzzer someone throws a ball and it is nothing but the net . No one , not even the player who threw the ball in desperation, thought that it would go . But it did . So that is the luck ,In medicine also the luck plays the roll , Sometimes the patients are lucky and sometimes the doctors are lucky .But most of the physicians will not say so , and will take the credit for diagnosing something unusual or diagnosing something which was not indicated by the symptoms . But I know better . I don't think I can take any credits or discredits when things go unexpectedly right or wrong respectively. There is a saying by a physician who invented the antiseptic technique or the hand washing before the delivery, to reduce infection '.I dressed the wound and God healed it .'So true! I n the Hindu scripture it says , 'You have right to the action , but not to the fruits of the actions ,' This does not mean murderer is not responsible for his or her actions.This brings me to the today's story.
       I saw this patient in my office few months ago . He was a young man who had cough for several months . He had tried over the counter medicines and antibiotics and some other stuff. It had not worked . So he was referred to me . He was not a smoker and had really no past medical problems . He did appear to me to be anxious. I did chest x-ray and breathing test and allergy test . The x-ray was normal and the breathing test was almost normal . I could make a case for mildest form pf asthma , but it was OK . The allergy test did show allergies to molds. I did put him on some medicines and then he missed follow up . I thought that he may have gotten better or gotten tired of going to doctor as nothing was positive . But then one day he showed up. His mother had passed away and he was out of town when she got sick. He was so upset that he spent 6 hours with her when she had already died!He simply could not stand loosing her . I can relate to it easily as I have lost my mother last year.I told him the concept of life after death and the Astral world and told him some books to read . I restarted him on inhaler and send him to an allergist . The allergist did the allergy tests and gave him some medicines . I had not seen him for may be 7-8 weeks . The one day when I was going to my office from hospital. ,I got a call from the emergency room physician , He was in ER with shortness of breath. The physician wanted to know if I wanted to see him in office sooner or wanted to know if I had any suggestions. He had done the chest X-ray, cardiogram , blood test to rule out heart attach and congestive heart failure and regular blood count.All the tests were normal . His oxygen was normal but he had shown in ER with cough and shortness of the breath . I was in the car . I was not too sure as to his problem . He certainly was worked up by me and nothing was found out granted  it was 6 months ago.I don't know what happened , but I told the ER physician that since this was 40 years old patient , who had shown to ER with the complaints of shortness of breath,we should at least do CT scan to rule out clots . Mind you I did not think that the CT scan was highly indicated or was going to be informative . So the CT scan was done . I was in office when the ER physician called me . He said , 'You just saved this young man's life . He has significant clots in lungs , both lungs 'I gave some more orders and went to see him after the office . He was treated and was discharged . But I had DONE NOTHING. I happen to throw the ball at the buzzer and scored the 3 points to win .But I was really lucky , or may be the patient was really lucky. 

CHANGE OF MIND AND MEDICINE

  I wrote about the change of mind and how most of us do not change the mind . This is true for general public as well as people who consider themselves as open minded and learned . This was obvious to me when I witnessed the Indian election and when I read Musafir. This reminded me of the previous incidence . On an average we don't see physicians in politics , though we do have some now. I had ameeting with a physician who was elected to Florida house. We were about 10 physicians and had a meeting with him . His talk was quite eye opening. Let me explain as to what he said . Usually physicians are taught and act in such a way that there are no two opinion s . If I see a patient with a lung mass on CT scan , I am taught to consider it as a lung cancer and in my mind the possibility of other diagnosis is very low . So I will tell the patient same and work it up same way . I can not consider any OTHER SIDE . On the other side lawyers have different point of view. Say case of divorce or tenant -landlord . Who so ever pays him more money , he will consider that side to be correct and defends it . So for him it is easy to be a politician. So we physicians are nor flexible . We do not change our mind. So I am going to tell a story of not changing our mind .
     I was asked to see this patient on second opinion. This was a 64years old female. who was admitted to ICU. She had a history of high blood pressure and diabetes . She also had history of heart attack. She came out of a supermarket and had chest pain and then became short of breath. She became more short of breath and so the people around called 911. The paramedics came and then they had to put her on a pressurized mask and then they took her to ER. She was quite bad and so she was intubated and put on respirator. She was admitted to ICU . She improved and so the respiratoe was weaned off and she was taken off it . She did ok for few hours . But she got more short of breath in next 6 hours and had to be put back on the respirator. The family was upset and decided they wanted to have second opinion .The physician called me and told me that the lady had Pneumonia and respiratory failure and the family wanted second opinion and I could see patient and then take over . He also told me that she will need Bronchoscopy as we did not know tha cause of the pneumonia . The infection disease consultant was seeing the patient and had started her on 3 antibiotics to treat pneumonia I talked to the patient's husband. She had heart attack and the cardiologist had done cardiac catheterization in recent past and told them that they could not do much about the blockages .I saw the chest X-ray . It looked like to me as congestive heart failure. The X-ray had improved and then gotten worse. Her history of chest pain and sudden onset of shorness of the breath, lack of fever , all pointed to me that she did not have pneumonia , but had congestive heart failure. I ordered blood test for heart attack and congestive heart failure. The BNP , blood test for congestive heart failure was elevated , almost 30 times . She also had may be a heart attach . I also ordered echocardiogram and it showed her heart function to be 20%. So in my mind she had a HEART TATTACK, and had congestive heart failure and DID NOT have PNEUMONIA . she DID NOT NEED BRONCHOSCOPY OR THE 3 ANTIBIOTICS. I explained it to the family and convinced them to continue the same physicians. They agreed . I did see the chart and she had improved . All the cultures were negative and still she had bronchoscopy and the antibiotics were continued and she was still being treated for pneumonia . She did get off the respirator.
    I am still convinced that she did not have pneumonia , but I could not convince the original physician or the consultant , that she had congestive heart failure inspite of all the history and the findings and the blood tests .NO CHANGE IN MIND!!.   

THE CHANGE OF MIND

     I was visiting India and did not have a chance to do much on the blog . But before I left for my trip, the political season in US was in full force . When I was in India there was election in state of BIHAR . What struck me the most was that INDIA and the USA are 2 large democracies and though the population and the nature of the constituents is different, the overall there was more similarity than differences. I also noticed that the news media , at least print media is liberal or progressive and people who are interested in 'status co' are liberal . This parallels my experience in US. Before I left , I was asked by one liberal doctor, 'which one of the jokers in GOP you are supporting?' These so called jokers included very successful governors who had turned around the economy in theit states , there were doctors and CEO. But that was not enough for this doctor and no matter what,  he was going to support the other party candidate , no matter who so ever it might be . I did not say a word., as I KNEW THAT NO MATTER WHAT I SAY I CAN NOT CHANGE HIS MIND .
       I also realizes this when I read a book written by one Indian auther who is considered very intelegent and smart . He was CEO of many companies and has written several books . One of the books that I read was MUSAFIR - A TREVELER . I happen to read it He collects several books on a subject and then does a abstract writing . , He also wrote a book on economics . Certainty his presentation is brilliant . But views are one sided. He is not an economist and has travelled to many countries but not lived out side India. . The opinions that one can form by watching CNN and ABC , CBS AND MSNBC are going to be very different than one that are formed by Fox news audience . One can not employ same tactics to improve economy in USA as they would do it it in India or Brazil. I have seen the 'misery index economy ' and seen the supply side economics work . So when one argues that it does not work I will not agree in late 70es and early 80es . I also the effects of cutting taxes .. I think it may not work in India , But I thought that by writing a lengthy e mail explaining how it DID WORK or how it may work would change his mind , But I was wrong One can not do brain surgery by reading a book on brain surgery. It is easy to write a book and form an opiniop on the topics that one has never experienced .But it is very difficult to accept that one could be wrong . . So I conclude that ONE CAN NOT ACHANGE ANYBODIES MIND , EXCEPT MAY BE BY OFFERING BRIBE .
      I also saw similar opinion on the election in India . People that I thought were good and educated and honest were supporting corrupt politicians . I could not believe when one 25 years old asked me how I would define Bribe . On top of that he was defending the bribe by saying that the one who takes bribe has to also give bribe and so he is helpless. Such a thought process is detrimental to the development of the country. I hope I was not seeing the majority and this will change .
      I KNOE THAT THIS A NON MEDUCAJ BLOG, But medical story on this topic in my  next blog..
      

Grace of God -2

         So in the last Blog I described the case where I saw someone that was not at the best level of health and mentally . Again I do not want to take anything from the family as I know everyone of us would like our loved ones to live for ever . Very few of us are 'ready' to let go , and that too when they are very very old and unconscious. So I understand the behavior of the relatives. But what I don't understand is WHY the disparity .So let me tell the other story.
        I saw this 42 years old female for chronic cough . She was anon smoker and had some cough going for long time , may be 2-3 months . She had never smoked . Had no other medical history , other than she had melanoma resected out few years ago . Her physical examination was normal . Her lungs sounded clear and there was no other abnormal findings . The chance of asthma and allergies is very high in patients who are nonsmoker and have chronic cough as main complaint. So I told her the differential diagnosis . I ordered the blood test for allergies , a chest X-ray and breathing test . I gave her sample of inhaler and a short course of steroids . She called me in 2 weeks . She had cancelled the follow up , the breathing test and had not done the blood test . She was feeling great and her cough had gone away . So she had concluded that it was due to allergies and she thought that she would rather go to allergist and do testing , rather than doing blood test for me .My office gives me the charts of all patients that miss the appointment or cancel the work up , like CT scans or breathing tests etc . So We called her and told her to do at least chest X-ray that I had ordered. She did the X-ray . The radiologist called me with the report . It showed LARGE mass in the lung . So I called her and got her to do CT scan. The CT scan showed the same findings . I saw her day after the CT scan was done . She came to me with her husband . I told them that in all probability it Wes Cancer . We need to answer 3 questions , Is it Cancer , Has it spread , and What can we do about it . So I ordered a PET scan , which is accurate in about 85 to may be 88% of the time in picking up the cancer. The Pet scan and the breathing test was scheduled for next day and the Biopsy was day after . The PET scan showed that the mass was highly active and there were lymph nodes and there were 2 skin nodules . All these findings made her inoperative .
      I am not going to talk about the diagnosis or the treatment . What I was bothered with this experience is that this 43 years old female who had done all the right things in life and had her all faculties in tact and significant life left , has inoperable cancer .
                                       HOW DO YOU EXPLAIN  THAT?

GRACE OF GOD

     I see many patients in my practice that have gotten the short end of the stick . And then there are patients that happen to be 'lucky'. I have often wondered as to why certain things happen to some patients. That leads to the so called bad luck or the theory of reincarnation and the laws of Karma . But even though I know the theory and believe in the reincarnation and laws of karma , it does not stop me from getting surprised and wonder about the God's plan . I thought about it when I saw recently some patients.
     First one was a84years old male who was admitted with possible pneumonia . He had significant dementia and was sleeping most of the time . He did answer some questions , but did not know where he was . He did follow some commands . or instructions I knew that he had pulmonary fibrosis and may have some other medical problems. His mantle status and advanced dementia and the age would make him more prone to aspiration , food and the liquids going wrong way and in lungs at times . So I ordered a CT scan and swallow study. The swallow study did confirm my suspicion that he was aspirating. So the speech therapist ordered some instructions . The CT scan did confirm that he had fibrosis . But it also showed a mass in liver . The radiologist wrote in the report that he was concerned about the primary cancer of the liver. I spoke to the family several times and try to get him to be DNR .He was unable to walk . He was sleeping most of the time and did not know where he was and he also had pulmonary fibrosis which caused him to need oxygen all the time . There were some restrictions or modifications on his food as well due to aspiration. But the family did not want to make him DNR and wanted all the work up . So I ordered the PET scan which picks up cancers may be 85 to 88% of the times . The PET scan was positive . So the radiologist felt that he had cancer of the Liver . Another round of talk was done with the family . They wanted biopsy to confirm it . So we had to do the biopsy . Interestingly enough he had history of heart problem and heart attack and stents . So he was on blood thinner . So we had to hold the blood thinner for 5 days before the biopsy could be done . The biopsy was attempted , and it turned out that HE DID NOT HAVE CANCER , BUT HE HAD AN ABSCESS -collection of pus . He was on antibiotics for pneumonia , so we readjusted the antibiotics .
       So here is my question . This patient who was older , had heart disease , had dementia , had aspiration , and had pulmonary fibrosis and could not walk , and he did not have cancer . So with the treatment of infection he was going to be OK if there was anything to be OK with him . And then the next one that I will tell in my next Blog will point out the problem that I sometimes have with the diseases . What is the purpose of beating all the odds of cancer in this patient ? What does God thinks and why does this happen in patients that we mortals can't seem to see the benefit and then when we wish someone not to have fatal disease , they have it . You will get it when I write my next blog soon . 

EMPEROR'S OLD CLOTHES

      I had written in the past about the Emperor's new clothes. This term has been used in medicine for number of diseases, but it was used for pulmonary embolism many years ago . It was so true in past as we did not suspect in the diagnosis in past and so when it presented with some unusual symptoms, we missed it . But exactly opposite thing has happened.For last few years we do CT scan to diagnose pulmonary embolism . Now a days almost anybody and everybody who comes to hospital ER gets a CT scan with minimal or no symptoms suggestive of clots in the lungs. So we tend to diagnose more. The number of CT scans done has gone up by 1000%, again 1000%, not 100%. So it is unusual to miss the diagnosis of pulmonary embolism. But sometimes when we come across certain things quite often , we tend to not pay attention to them. This brings me to some stories that I am going to tell today.
      I saw this new patient who was 57 years of age I saw her in office as a new patient .She was a nonsmoker who had a diagnosis of asthma in the past and was given the inhaler She was using and was OK for a while . But then started having more shortness of the breath . So she saw her PCP and he promptly referred her to cardiologist. The cardiologist did number of tests . He did cardiogram and then the echocardiogram and then did the stress test. She also had holter monitor , which is continuous recording of the cardiogram . All the work up was negative and she was told that heart was OK and healthy. So she went back to PCP and so now she came to me . She was short of breath and also had passed out about 3 times in last 2 -3 months. 3 days before she saw me she was taking out her dog and passed out  and found herself on the side walk . She looked OK but when I checked her oxygen saturation it was 91%. Her lungs were clear and she had no wheezing . I got hold of her cardiac test and they were OK . I made her walk for 50 feet and her oxygen saturation dropped to 85%(normal is greater than 95%)and she was quite short of breath.I knew what the problem was . SHE WAS THROWING CLOTS . I decided to admit her and ordered the CT scan and it did show the clot. She had plenty of them  I had started her on blood thinner even before doing the CT scan . I did call the cardiologist . He decided to do a new procedure in which a catheter is inserted in the artery going to lung and then a clot buster is slowly dripped in . This dissolves the clot more quickly .She did very well .
     So the shortness of breath , passing out and the drop in oxygen with lungs sounding clear were all the clues to the diagnosis. But it took much longer to get to it !