EXCEPTION TO THE RULE

     In medicine like in many things in life or other sciences we have rules and they do apply in many cases or under many circumstances . But we also talk about exception to the rule. In medicine we have the same thing . When we see a patient and try to diagnose the disease that may be causing the symptoms. So when we see some one with high blood pressure we  don't try to work every patient for etiology for the elevated blood pressure . Again if we see very young patient with elevated blood pressure we WILL DO tests to find any cause of the elevated blood pressure -so called secondary hypertension.In medicine we are often told that the cause of symptoms is more likely to be due to ONE diagnosis , rather than 2 or 3. So this is one of the stories where there was a exception to this rule .
      I saw this patient who was seen by number of physicians before me . He came to see me referred by a family doctor. When I went the room in my office to see him , he was lying down on the examination table. In my practise this is very unusual as most of my patients are sitting in a chair ,waiting to be seen . So this was a 65 years old male who was referred to me for the evaluation of abnormal CT scan of the chest . He was admitted to the hospital in recent past his first primary doctor with chest pain . He was seen by a cardiologist and the had heart catheterization  and it showed the blockage and so a stent was put in. He was discharged in spite of him complaining that he still had chest pain . So in less than on week he went back to the ER with chest pain and he was readmitted. Again the cardiologist saw him and told him that his heart was OK and no further work up was needed. He was discharged and the primary care physician saw him in office . The pain was still there and so he did a CT chest . The CT chest showed number of small nodules and some abnormality in bones including spine. He was sent to a lung specialist . As I understand he was told that he needed to do follow up on CT scan in future. He still had lot of pain and so he decided to change physician . The new MD sent him to a orthopedic doctor who ordered MRI of spine . It showed abnormality in vertebra. But no further action was done. He was now referred to me . He was not sitting in a chair as he was hurting badly and there were no additional tests ordered. I saw the CT scan report and it clearly specified that patient had bony abnormality in ribs and spine that was 'consistent with metastasis '. Patient was smoker had quit smoking NOW . So most likely he had some kind of CANCER that had spread to the bones and it was causing the chest pain .
     I decided to admit him . My worry was two fold . One is the pain control and other was the abnormality seen in first thoracic vertebra . If something would happen to this vertebra , he may be paralyzed . So I talked to radiation oncologist . I did further work work up in the hospital . The CT scan of the abdomen and the pelvis did not show any source of the cancer. The bone scan confirmed the spread of the cancer to several bones . I also got the old history that he had prostate cancer 5 years ago and had surgery and radiation treatment. But the PET scan showed increased up tale in several lymph nodes. It also showed some uptake in colon .So I consulted a chest surgeon who did the biopsy of the lymph nodes in the lung and it showed the LUNG CANCER . So we had the diagnosis . But the question was does he have second or even third cancer ? Remember the rule in medicine is not to look for more than one diagnosis . So here we had diagnosis of lung cancer , which could explain the entire picture . was elevated PSA -a blood test that indicates possibility of prostate cancer . We had done bone biopsy and it was OK But it was not done from the exact place where the bone scan was showing abnormality . So I decided to ask radiologist to redo it , but this time with help of CT scan . So the biopsy was from possible metastatic lesion . It showed prostate cancer . So he had 2 different cancers . The pain was not from the lung cancer ,but was from the prostate cancer spreading to bones .I am not sure if he has third cancer colon We have not done colonoscopy yet .

     THIS THE EXCEPTION TO THE RULE !

TARGETED TREATMENT

     Now a days it is fashionable  to talk about the targeted treatment or approach in the patient care . I often wonder as to what did the physicians did in the past . Was it not targeted  or was it not patient care ? But in the commercials that I see on the TV , especially on cancer treatment I see the word used frequently. But I do not find any difference or at least not anything better. But I find more often treatment being given per BOOKS rather than targeted to individual patients. So the treatment that is offered is more often determined by COMPUTER medicine rather than by Human being who happens to be physician. So one of the story that I am going to tell is one example of this targeted (?) therapy.
    I have known this 78 years old male patient who was smoker for entire adult life . He had COPD ,related to smoking. He was getting more short of breath and then had to be put on oxygen . He still continued to smoke . The when he was hospitalized he had a CT scan of the chest done and it showed a small nodule . The size was around 1cm. With his given condition and the given size , diagnostic procedures to get the biopsy would have been impossible . We can do bronchoscopy , a PET scan or needle biopsy, or open biopsy . But the given oxygen dependent COPD and small size we could not do any definitive test to get the diagnosis.So I decided to do follow up CT scan . The new Ct scan was done in 3 months and the nodule had grown and it was now 1.5 cm . In between he had developed  swelling of the feet and further work up showed that he had Liver problem . As it turned out  he was drinking 5-8 drinks a day and it had caused cirrhosis of the liver. So now we had to treat it . Medicines did help the swelling. Then he was admitted to hospital with shortness of the breath and the new CT scan done showed clot in the lungs . So now he needed blood thinner.. I spoke to radiologist about doing the biopsy of the nodule. I had done the PET SCAN and it did show increase activity suggesting that this nodule was most likely to be cancerous.. The radiologist felt that it was too risky to do biopsy due to the recent clot and the location . So I talked to the patient and the family and it was determined that we will wait and do follow up on the scan . He was discharged to rehab place . He came to see me in the office . He was still quite weak and short of breath,but felt better. So after discussion we decided to ask RADIATION ONCOLOGIST to consider radiation treatment without the diagnosis of the cancer , but based on PET scan finding and the growth seen on CT scans. So I got a note from him. He wanted a biopsy of the lymph node that was shown to be hot on PET scan but was not enlarged .
       He was readmitted and this time he had fracture of vertebra and needed treatment. So I decided to do new CT scan and it showed the nodule and did not show any enlarged nodes. So in span of 4 months the nodule was bigger and no lymph nodes were seen. So I thought that radiation oncologist would agree to do the radiation treatment without the biopsy . I did not feel that lymph node biopsy would be positive or give any additional information to alter the treatment. But the radiation oncologist insisted on the biopsy . So I called 2 different doctors who do such biopsies. Both of them looked at the CT scan and the PET scan and felt that they could not do the biopsy as the nodes were too small and it was too risky.
      So I have this patient who has oxygen dependent COPD , cirrhosis of liver , clot in the lung and vertebral fracture and had aortic aneurysm. So it would be 'targeted 'therapy if we could give him radiation to the nodule rather than looking at the PET scan and feel that if the lymph nodes are positive , we would need different field of treatment .
    By the way patient for now has decided to go with Hospice 

MYOPIA

        The modern day medical care is considered comprehensive . The ICU have started collaborative  rounds , which includes physician,nurse, case management, respiratory therapist . pharmacist and some other. The idea behind this concept is that such collaboration will help improve patient care and it will be comprehensive . So now a physician present in ICU 24/7 will help critically ill patent's outcome. This now implemented in ICU across the country. Certainly it will improve some care in some patients and it will also increase the cost of health care as billing will be changed and most likely it will be higher. But what I would have like to think is better care by individual physicians and better communication among patients and doctors and among different physicians. I often see computer generated notes which are neither accurate nor informative and tends to state things that are exaggerated especially the Time spent . If one would add the recorded time in the notes , there would be no time left in a day of 24 hrs. But my question is why do we have such a behaviour and the thought process ? I want to talk about couple of patients in this regards.
     I saw this patient for pneumonia. He was 84 years old and had not smoked for many years . His chest x-ray showed pneumonia and some fluid around the lung . So I did CT scan and it showed fluid . So I drained the fluid and it was positive for lung cancer . I called oncologist and they saw him promptly . But a month went by and no treatment was started as they were trying to decide on which drug regimen protocol to use . Patient got more short of breath , and that was in spite of regularly draining the fluid with a inserted catheter. So he as admitted and it showed a clot in the lung and now more /new fluid on the other lung. So the ER doctor called  at 10 or 11 pm. I started him on intravenous blood thinner . and ordered to check the legs for a clot in the legs. The incident of such clot in patients with cancer is very high and they may need treatment life long or as long as the cancer is there. I also knew that he may need the drainage of the fluid and may need putting a catheter to drain it as needed -just like he had it on other side . The treatment for cancer was not yet started  and that may also need insertion of a port . So essentially he would have needed -potentially 3 different surgical procedures in near future. This meant we will have to hold the blood thinners. Taking this account I had started the blood thinner that could be stopped and the blood thinning would return to normal in less than 6 hrs.
     The next morning I went to See the patient and was surprised to note that the IV blood thinner that I had ordered were discontinued and a pill was ordered. This new pill takes effect immediately and patients can be discharged quickly. But it takes 2 full days to reverse the effect of blood thinning. So while he is on this pill no surgical procedure could be done and will have to be off it for 2 days . I had to change the orders again as we needed to have catheter inserted for fluid and a filter to prevent clot travelling from leg to lungs and get port inserted to give chemotherapy. So why the oncologist give pill?
     The patient got all three procedures done and then about 4-5 days down the road we started the pill and he went home I think the problem is that the thought process that I went through when I started the IV blood thinner was not done by the oncologist , nor was my note seen and it was a knee jerk reaction to start the pill which is correct treatment in most but not in all . 

BEING MORTAL

       I had a chance to attend the lecture of Dr Atul Gawande, the famous writer who has written some books and the last one is BEING MORTAL. His lecture was recently arranged by Florida Hospital and being in medicine and quite familier with the topic , I decided to go . The lecture was attended by many ,the hall was full and he had standing ovation. I have known the mortality of life for long time and have seen the effects of aging in my patients and relatives and myself. So the topic was not new nor was the contains. But what I have found out in my own experience is that it is the most difficult task in medicine. So this is one of the two stories.
       I saw this 86 years old male in the hospital for shortness of the breath. He had high blood pressure and question of the heart problem . When I saw him he had some fever and cough and he was short of breath. His wife was in his room . His ability to walk was reduced and his wife had to help . She looked little younger than him , may difference of 10 years. So the chest X-ray was done and the diagnosis of pneumonia was made . He was treated with antibiotics . He also needed oxygen and some additional treatment. We also did the echo cardiogram and it showed some narrowing of the heart valves , some elevated pressure in lungs . At his age this was not unexpected . I often tell patients that as the doors in older house do not close tightly or get stuck , the doors or the valves in heart either become sticky and narrowed or leaky. I did swallowing test and it did show some problem , but he did not too badly. So improved and was discharged home .
      I saw him in the office and did the breathing test. It showed reduced lung capacity and so he was put on some inhalers to help open the bronchial tubes. He was readmitted with the congestive heart failure in next 2-3 months . He was treated and discharged , but this time he was weaker and needed physical therapy and needed to be sent in a rehab center for 2 -3 weeks . We repeated the swallow study as my suspicion was that he was aspirating food and liquids and so he was having the lung problem. This was worst and indeed he was aspirating. But the speech therapist thought that he may do OK with certain precautions. He was seen in my office and we did  check up on his need for the oxygen . He could walk short distance and his oxygen dropped . So we had to put him on oxygen . So I saw him in the office in next 4 weeks and he was doing OK . He needed to increase the flow of oxygen when he would walk. Higher the flow is needed , larger the oxygen cylinder is needed. The smaller ones would not last longer duration . So the choice is to drag the larger cylinder or don't walk much. Dragging larger cylinder foe 87 years old is not easy. SO then I talked to him about his expectations  and CODE STATUS.He told me he had not give a FULL THOUGHT and will talk it over with his wife and let me know .
     Two weeks down the road he was again admitted with another bout of pneumonia -most likely aspiration.I saw him and saw his CT scan and talked to him treatment and repeating the swallow study . I also told him that he may need feeding tube if the swallowing function is not normal and worst. He did not say much . So I again asked hin about CODE STATUS. I told him that he needs to make decision before it is too late His answers was same , ' I will discuss with my wife and let you know.'
    So if years old with all this problems can not make the decision then how do we expect younger one to do it? There are 3 other doctors involved in his care and not a single one has talked to him about this . May be if all of us in health care would talk at same wave length it might change , but who has TIME!!!!!! 

AGING AND MEDICINE

     We in medicine have algorithm and diagnostic tree to make decision in case of simple or complicated cases and diseases . So some people are doing 'tele medicine ' . But my problem is that the computer can not diagnoses it nor treat it. The problem that I have is there is more to medicine than just knowing the diagnosis. One needs to know the patient and the family and the other factors. So I am writing this story to tell.
      I saw this 90 years male patient for abnormal chest x-ray. He had quit smoking 54 years ago and had no major problems other than high blood pressure. He was in good health and did not have any shortness of breath. He did have some vague chest pain and so the chest X-ray was done and then it showed abnormality . So the CT scan was ordered and he was sent to me .He was OLD but was completely oriented to and fully with the program. He came with his wife who was in wheel chair. She was also quite well as far as understanding is concerned. The CT scan showed a mass in the right lower lobe of the lung. So I told them the routine 3 questions, Is it Cancer , and has it spread and lastly the treatment options . So I also told them that we will need to do the PET scan to know the 'extent' of the disease , i.e. spread, and will need bronchoscopy and may be needle biopsy to 'know' the tissue type which would help in determining the treatment options . So the surgery was mentioned and I myself was not sure that this 90 years old would be a surgical candidate. But I had to mention it.Both of them of the opinion that he would not be considering the surgery as option of treatment. Then we talked about the chemotherapy and the radiation treatment as other options . We left is at that without making any final decision. I told them on the need for biopsy . At that time the wife asked me if there was an option of 'doing nothing' . Before I could answer the patient turned to her and said , 'why , why would I consider no treatment?No I want to get treatment. 'So we did the bronchoscopy and I did see the tumor. It was blocking the right lower lobe and the middle lobe was also seem to be involved in the tumor process. I did do the biopsy and he had some bleeding though I could control it with epinephrine and saline.  I was reluctant to do more biopsy. The PET scan that was done came back with bad news . He had PET scan that showed the pick up not only in the lung tumor , but also in the lymph nodes in the lungs and in the RIBS and in the bones of pelvis /hip. So essentially not only he was inoperable , but also had 'wide spread ' cancer and the prognosis was not very good.
      The biopsy came as 'possible cancer' but could not state as to exactly where did it come from and overall it was iffy at best. So I called them in the office to discuss as to the further work up ans /or treatment . The options of radiation treatment and or chemotherapy was discussed . For chemo to be given we would have needed more definite tissue diagnosis . So we will have to do a needle biopsy.After telling them the PET scan findings, it was decided that we will go for radiation treatment and do no further biopsies. I made arrangements to see the radiation doctor.
      2 days down the road I got a call from the ER physician that he was in ER with shortness of the breath and the chest X-ray showed a large fluid collection around the right lung. He did have small fluid on PET scan done may be 10 days ago . He was quite bad and I had to do a procedure to take out the fluid that same evening at 6-7pm. When I talked to him about the overall disease and the plan of the treatment ,since he now had one more problem to deal with. He told me to cancel the radiation treatment consult , which was to take place next day. He also wanted to be DNR and was considering HOSPICE.
    All the things that happened in this patient and how the decision was changed on number of occasions can not be done by computer. We might get options of treatment choices but not the definite decision without a physician explaining the options and choices made by patient and the family with the input by doctors.
       

SO WHAT IS NEW IN MEDICINE ?

     I love to read and I do get enough material to read. I like to keep in touch with new development in medicine . But in doing so I sometimes come across certain thins that come out of research that amazes me . It reminds me of one of the episodes of Seinfeld. In the episodes he says that some people want to find out cure for cancer or may be AIDS, while others find out seedless grapes !Some of the stories that I read belong to such class as seedless grapes . So let start on some of the medical things that I have seen or heard in last few months.
    The FDA approved a drug few months ago for ---are you ready - for 'DOUBLE CHIN' .So this drug called 'KYBELLA'. So this drug which is given as injection to reduce the fat in double chin . As I read it , there was a mention that number of injection may be needed . The question popped in my mind how many would you need to reduce xxxx, never mind .
    The next one was seen by me as a study. Since I saw it I have told it to many of my patients and they all laughed and I was trying to find out for the reason for the results that the researcher got. These researcher did survey and followed patients with diabetes and other heath issues . The patients were asked if they thought that their 'spouses' were nagging . They were also asked to score the happiness in their married life . I am not sure how the nagging 'scores' were done , but the conclusion was very interesting . When the men the study felt that their wives were more nagging and  had negative opinion about the marriage, their diabetic control was better than in men who thought that their wives were not nagging and the married life was good . But exactly opposite was true  in women . So if the women thought that their husbands were more nagging and their married was not happy , their diabetic control was poor !
    I had some questions . How do you score nagging and how do you grade marriage . And may be the nagging wives will be more upset about keeping scores and saying that the marriage was not happy.! The reason for the result may that the wives's nagging may be causing the husbands to eat better and may be forced to exercise and that may help diabetes . On the other hand the wives when nagged and had less satisfaction in their marriages , ATE to relieve the tension and reduce frustration and so the diabetic control was poor .
     So now that I talked about the food and eating and overeating, let go to my next invention. So  do you realize that 86 % of African American women are overweight or obese ? This is also a major issue in Hispanic and whites . So recently FDA approved a device to help this. It is clear that we can not control our food intake . So this GENIUS came out with device . A tube is inserted in the stomach and it can be attached to suction . So you can eat anything and as much as you want . Then attach the stomach to suction and it will 'suck' it out before it is absorbed and adds inches and pounds to you.
    I have few more but may be in next blog.

SO NOW WE KNOW , WHAT NEXT ?

   I love stories that have mystery , I also love movies where one can not predict the end .But the problem with these stories is that once we know the end , we can not read it again . There is no fun in reading such story , when we know what is going to happen . The same is true of the movies. In medicine when some one says patient is interesting , it is because we did not know the diagnosis. But sometimes finding the diagnosis is not the end of story. And we don't know what to do .Today I am talking about a mix of these 2 problems .
     I was asked to see a patient for abnormal chest CT scan . I saw this 48 years old patient who came for not feeling good and having black stools. He was a homeless person. He was a smoker 2 packs a day and 18 cans of Beer a day alcoholic . In spite of all this he came because he was not feeling good. The work up was done . It included CT scan of the chest .It showed couple of nodules . So I was called in to see patient . He looked cachectic and so I asked him as to if he had lost weight .Again it would be easy to understand if a homeless person had lost weight. But some one who can smoke 2packs per day and drink 18 cans of beer should not loos weight due to lack of food. He had lost 40lbs of weight. Weight loss is an indicator of cancer in many cases , at least in many patients . So I asked him if he was not eating well. He told me that he could not swallow. The food sticks in throat  was his answer. So I ordered the swallow study and CT scan of the neck. The swallow study showed no problem with the food pipe or esophagus. Son at least he did not have cancer of the esophagus. But the CT scan of the neck was abnormal.
     We called the throat doctor-ENT specialist .I had also decided to look inside the lung -bronchoscopy. He had lung nodules and so I also ordered the PET scan . In PET scan tagged glucose is injected and whole body is scanned to see the uptake of the glucose . The glucose is picked up by every cell in the body and the 'pick up' is higher in cancer cells and inflammation . So it helps the diagnosis of cancer.When I did the bronchoscopy, I saw A MASS INVOLVING THE RIGHT VOCAL CORD AND extending above it . I did not do biopsy as I felt it was too risky to do it with mild sedation. The PET scan did not show any 'pick up' in lung nodules but did show the pick up in throat mass. So I called the ENT surgeon .
    With the vocal cord cancer , radiation treatment can be done . But due to Location of the cancer ,patients usually can not swallow well with radiation, so they need FEEDING TUBE . He would have also needed food like Ensure or BOOST to feed through the feeding tube . He would also need daily transportation to get radiation. So now we are faced as to how to manage this in a homeless man . To add to our trouble the surgeon could not do the biopsy for next 10 days. So if we discharge him we don't know if if he would show up for the follow up and the biopsy.
    So this takes me to my original point . NOW we KNOW the diagnosis , but WHAT NEXT?