WHY ? WE DON'T KNOW

   In medicine and in general our life we see things that can be explained on the basis of our knowledge or logic or science. I have often said that the GOD has kept us guising. The man thinks that we KNOW and then the God or an incidence tells us that we DON'T KNOW everything. Many years ago my professor of Preventive and Social medicine had a heart attack and I went to see him in hospital. In those days we did not have stents  and all the modern things that we have to treat the heart attack. He made a statement to me . 'I don't smoke , I don't eat meat and I eat lots of fish and I don't drink alcohol, I exercise  and my cholesterol is normal. I do or have high blood pressure or diabetes - I still have heart attack !'Since then we have much more understanding of atherosclerosis and heart attack and the risk factors but the basic statement is still true. We have no clue as to why some get sick and some don't. That brings me to the story for today. 

   I saw this male patient of about 70 years of age . He had been smoker and had COPD. He did not have much shortness of breath and he had routine chest X- ray and that was abnormal. So he came to me and then I did the work up. He had bronchoscopy and PET scan and breathing test and biopsy  and he had lung cancer . Based on the tests that we had done he had cancer that could be resected  and there was no evidence of spread of the cancer to any organs or the lymph nodes . So I sent him to thoracic surgery. and he also thought that he needed surgery So he had surgery and the cancer was out. The margins were clean and no blood vessels were invaded  and no lymph nodes showed any spread of the cancer . He was seen by cancer specialist and was told that he does not need any chemotherapy as there was spread . 

    More than a year went by and he was followed by VA cancer specialist and he was doing ok . He came to me  and he was doing fine . Then last time when he came to me he had laryngitis. He had lost his voice and so I was concerned  and I wanted to do CT scan and he told me that his cancer doctor had done the scan and that was fine and I did see the report and he had nothing on the CT scan to suggest any recurrence. So I sent him to ENT to check on throat- vocal cords . He had paralysis of left vocal cord! So ENT doctor did new CT SCAN - 1 month from the last one and he did it with contrast  and that showed that he had recurrence at the site of resection. Just to explain medical anatomy - the nerve that supplies to left vocal cord comes down and goes in chest and winds around left central part where there are nodes and blood vessels  and then goes back in neck and goes to vocal cord. So when there is cancer in middle of left central part this nerve can get caught and the vocal cord can get paralysed . So he had that and I did do biopsy  and he has recurrence. 

    So all the odds were in favor of so called CURE and then he had CT scan  and that did not show tumor and then in one month new CT scan did show the cancer !So do we really know or we are just medical statisticians ?

COVID UNCERTAINTY

     Since last March 2020, we have been indebted with information on COVID 19  and we still are learning. Last year when I was checking out there were atleast 15 different medications that were tried or given or had some 'promise' and as off today we have very few. Most of the medicines have been proved to be not very successful. But at many places people are still being treated with some of these medicines. Vitamin C and vitamin D are some of them. So some one asked me a question ,Can a fully vaccinated person transmit the virus? And I came across the answer  and may be a proof of the information. 

    I saw this male patient . I had seen him 3 years ago and he was a smoker and had COPD - smoking related lung disease. He had work up and when I did CT scan I found out that he had a kidney mass . I did further work up and send him to  urologist. He had surgery and it was kidney cancer. He did OK and came to see me once and then did not do follow up.After 3 years he came to me as he had abnormal CT scan of the chest. He had COVId infection  in a month  and then he was fine  and on march 1st he had his first shot of the vaccine. He had no major problem but he had chest x- ray as he has had some cough later on . The chest X- ray showed some abnormality and so he had CT scan of the chest . The CT scan showed  a mass or pneumonia. There were 2 spots and so he was sent to me . He has been smoker and had COPD. We decided to do the work up . He had CT scan and at the same time he had second test done for COVID 19.  and that was positive. He had no problems and he wanted to go back to work.So he did another COVID test  and that was negative. This was done in 6 or 7 days after the positive test . He also had his second dose of vaccine  and did very well and had no reaction to it . So this tells me that one could get infection even after having vccine . But patient may have no symptoms  and the course seems to be limited as he was negative in less than 7 days . 

   Then I came across the data from CDC  and also some srtcle from British Medical Journal.They had 5800 cases among 77 millions vaccinated  and some were admitted  and some died.But  that should not surprise anyone . The vaccine is not 100% successful like any other vaccine . I also saw another study  on antibody titre in patients who had solid organ transplants and who were on immunosupressants. Only 17 % patients had antibody titer. So I am sure when antibody titers will be done in patients who had vaccine and got infected, we may get the answer . May be the antibody titers may not be high or adequate in atleast the patients who needed to be hospitalised . But we don't know that yet..

WHEN IS IT ENOUGH?

    I had a call from a physician asking me to see him as he wanted to do CT scan of the chest due to so called new recommendation on doing low dose radiation CT scan to diagnose cancer of lung . Several years ago we started doing CT scan of chest in current smokers and Ex smokers for 14 years to diagnose cancer of lung early . There was new article  and some added changes but overall it is about the same . But since it appeared  in Newspaper, he wanted to get it done . He had quit smoking 30 years ago and he would not fall in to the recommended patients that would qualify for the CT scan.But that brings me to the story for today. 

    I had seen this patient for last 3-4 years .She is 74 years old female who had smoked for many years and had quit several years - 18 years ago. She had bad emphysema and needed oxygen  and had not much of wheezing. She had shortness of breath and I had done CT scans  and she had some small nodule . We followed the CT scan for 3 years and there was no change in tiny nodules and the radiologist felt that it was benign.The last scan was 8 or 9 months ago and  I had plan to do yearly scan.She saw me  and had pain in belly and so I told her to see Gastroenterologist and also to talk to primary care physician. I told her to take antacid and also ordered a chest X- ray . The chest X- ray was reported as normal. She continued to have pain and the gastroenterologist could not see her for 4 weeks or more  and so when she still had pain ,she went to walk in clinic and they did CT SCAN of chest and also belly. The Ct scan of belly showed masses in liver  and the lungs had nodules that we had seen  and also had some lymph node enlargement . She was admitted  and then we did further work up . We did the PET SCAN  and that showed that the liver spots were hot and the lung nodules were warm not very hot . There was some uptake in lymph nodes in chest but again not very high . So we did the liver biopsy. The biopsy showed lung cancer that has spread to liver.

      I had done chest X- ray done less that 3 weeks before the CT scan  and that had shown nothing to suggest cancer. The PET scan also did not show very high activity in nodules  and also the size was increased,but not very much from the CT scan that was done 9 months ago. So where did the cancer arise  and why we did not see large tumor in lungs  and why the liver mass was 3 or 4 times the size of the nodule in lung where the cancer started  and lastly why was the chest X- ray unable to give even hint of anything happening. 

    And that is why my question - How often (doing a CT scan) is enough . The recommendations are to do once a year  and that would not  and did not catch the cancer early!

IT WALKS LIKE DUCK, QUACKS LIKE DUCK AND IT IS NOT DUCK

    We often say that if it walks like duck  and quacks like duck it is duck . But sometimes we have situations where our conclusion based on our experience is not right. We have seen this many a times where ordinary people, politicians and news media tell a story and then draw a conclusion and that tends to obvious -but on further investigations the conclusion drawn based on experience is proved to be wrong. The same thing happens in medicine  and that is my story for today. 

    I was seeing this patient for sleep apnea and may be mild asthma . He was obese and over period of few years of follow up he had mot lost any weight and had continued to be obese  and was using the PAP therapy and had no problem with it . He usually had no other complaints  and the asthma part was minimal and he used to use inhalers as needed. Then one day he came to see me . He had cough and shortness of breath and it all started 6 weeks before he saw me . He was seen by his family doctor  and was given antibiotics and some cough syrup . He did not improve and so was given steroids  and different antibiotics. He continued to have problem with cough and some shortness of breath. I saw him in office and he has low normal oxygen and he had bronchospasm and wheezes . I ordered a chest X-m ray and also started him on 2 different inhalers and also different dose course of steroids. I asked him to see me in 2 weeks . The X- ray came back showing a fluid accumulation. I called him  and ordered CT scan  and asked him as to how he was feeling . He was little better as far as wheezing was concerned and he had no fever . His shortness of breath was still there but was better. The CT scan was done and the findings surprised me. He had fluid around his lung  and also a spot on the lung. I called him and told him that we will have to do the work  and that may involve number of procedures and biopsy  and also may need additional consultations . I was concerned about cancer and the presence of fluid may be due to cancer and then he would not be early of surgically resectable cancer . So I admitted him and did drain the fluid  and the fluid was somewhat  locculated -had some different pockets  and the fluid did not show cancer . So we did PET scan and I did bronchoscopy  and there was no tumor . The PET scan which is suppose to pick up cancer in almost 85% of the cases did show that the nodule had some activity and so possibility of cancer was there . So we decided to do needle biopsy of the nodule. The only other option was to ask a chest surgeon to do biopsy under anesthesia . The needle biopsy was done  and it showed inflammation  and o cancer . 

  So  the tests that I di to prove a cancer - it certainly looked like that - was not correct  and it looks like he may have had pneumonia and that caused the fluid  and he does not have cancer .. We have plans for doing follow up on chest X- ray and CT scans in future  and then we will know , but for now it looks like not a cancer . 

TELEMEDICE - NOT SO TELE

     With the pandemic the insurance companies have allowed to do telemedicine  and many physicians are doing it and some patients demand it and feel that that is alternative to going to physician's office. I have my own frustrations with certain problems and when patients want telemedicine visits. Say one is short of breath, what can I do by talking to patient or seeing him/her on screen without being able to examine lungs  and oxygen level and heart  and so on. So sometimes we have problems with telemedicine visits. But I came across one example where one can do telemedicine  and may be not do it. I know this statement is confusing and so let me tell you the story. 

   I had a call at midnight from some one that I know. His relative had some health issue and so he decided to call me . So I spoke to her. She is 36 years old female who had no major health issues . She had sudden left sided chest pain. It started in the front  and went through the chest to back and also had some jaw pain  and neck pain. She was not short of breath and had no fever . She had no history of asthma. I asked several questions and obtain the story. She was not contraceptive pills. She had no cough and she took ibuprofen and she still had minimal pain. The question was what was the problem and what should she do. I told her that there were 2-3 possible explanations. She may have musculoskeletal pain -simple. But I was more concerned about the serious diagnosis of blood clot in lung  which is possible in young person especially when they are on contraceptive. I was more concerned about pneumothorax - or air leak and collapse of lung . So I told her to go to ER right away.  I told her to let me know as to what happens in ER and told her to have them do CT scan of chest . 

   I got some more texts from them  and I was told that the ER physician did blood tests to rule oy heart attack - a possibility of such is so low in my mind that I did not think it was even there. The test was OK and so was the cardiogram . They did not do CT scan but did chest X- ray and he told them that it was OK . He told them that it was muscular pain  and they will do second blood test in 6 hours to make sure that there was no heart attack. I get a new text at 7 am . The radiologist had read the X- ray and there was a small pneumothorax - air leak - collapse of lung  and they were going to admit her for observation and new chest x- ray .

    So the telemedicine on just telephone  not video -with me  and my suspicion was correct , but to confirm the diagnosis we needed DIRECT VISIT to physician and ER. 

ATTACHMENT

      I have been in medical practice for many years  and I have myself changed in my thought process. But the main thing does not seem to change . We all want to LIVE. We often say that we have no attachment for living if we have suffering. But I have often seen that NO ONE is ready even under extreme conditions. That brings me to my story for today. 

    I had seen this elderly patient few years ago . Her problems were not major from my stand point and after doing follow up for 2 or 3 times ,she stopped coming. Then after 4 years of gap she came to me . She came with her daughter . She is 82 years old female  and had some shortness of breath and she went to er  and she had chest X- ray done and that showed larger fluid collection on rt side . She was admitted and they consulted lung specialist and he decided to put in a catheter to drain it . Normally we drain fluid and then based on response  and findings of the fluid we decide if patient needs further intervention. But for whatever reason she had the catheter inserted  and then she was discharged . The daughter came with her and she was draining the catheter at home  and when I asked her if they ever established diagnosis , she did not know , though she did know that cancer was suspected. I looked the work up done at the hospital and realized that no diagnosis of cancer was done  and part of the problem was the daughter's refusal to do additional biopsy since the fluid itself did not show cancer cells. She was weak and cachectic  and she was not eating and had lost weight. She was so weak that she could not walk .They had seen oncologist  and they did not like him / her and so they had not done follow up . She had no home help and no direction as to how often to drain the fluid. 

    I talked to them and looked at the reports from her hospitalization. She di have tumor in the covering of the lung and so from such a biopsy . So she did not have it. I told them that one can not get much treatment without knowing the diagnosis of cancer and what type. So i asked a surgeon to do the biopsy and at the same time consider talc powder instillation to stop the fluid from coming back. She agreed and the biopsy was done  and the diagnosis of cancer was established . She came to see me  and she had worsened. She had lost more weight and there was not much fluid left to be drained  and in spite of that she was short of breath and had no appetite and had low oxygen. I spoke to her grandson and also to daughter  and after discussion they decided that they could  not do any treatment and that it will be futile. So at their request i called hospice . They wanted comfort care only. 3 weeks went by and I get a call from the daughter , she had talked to oncologist and they wanted to start her on treatment immunotherapy . So they had cancelled Hospice and they wanted me to get her oxygen and some other stuff from other company .

    (I have often stated that if you ate vegetarian do not go to stake house ,if you go to oncologist they will do chemo/immunotherapy)So none is truly ready 

CAUSE AND THE EFFECT ??

   In every walk of life we have cause and effect .But sometimes we do not have the perfect explanation. One sees this in everyday evens and we do not even question it. We drop a glass object to the floor, it will break . The wood floats and the iron sinks . But the boat made of steel floats  and so the scientists have found the reasons for such things . But in medicine we have no CAUSE for many outcomes  and effects . In medicine we call it IDIOPATHIC . So we don't know why some people have elevated blood pressure  and so we call it Idiopathic hypertension If someone has Fibrosis in lungs  and we do not know what caused the fibrosis , we call it Idiopathic Pulmonary Fibrosis  or IPF. But this is well accepted  and no one thinks any other way or questions. But sometimes we see common things and have no answer . Certainly there is always a reason but we are unable to answer it and then the patients get frustrated as they have no way of PREVENTING IT .That brings me to the story for today. 

    I have known this patient for many years and she has been ex-smoker and had quit many years ago. Over period of time she worsened . She had diagnosis of COPD  and she was on meds  and still she continued to worsen over period of years, She needed oxygen and slowly we adjusted medicines and she was on all the medicines that we could use. She was also started on oxygen and nebulizes medicines and also steroids. She had some cardiac issues and they seem to be stable. Overall she was doing OK. One of theses days she was admitted  and then had some worsening due to pneumonia. I checked her blood oxygen and carbon di oxide  and she had elevation of carbon dioxide. So we started her on what is called non-invasive -ventilator. This has been done now a days for COPD patients for last few years. This helps the patient's own breath and this supplementation or the help improves the breathing and carbon dioxide  and then the shortness of breath. So she was started on it  and did well for more than a year. One day I get a call that she became unresponsive  and so was taken to ER I went to see her in ER  and the Er physician had already put her on respirator with a tube in her trachea. I reviewed the data . She was using her own machine and in spite of that she had ELEVATED carbon dioxide to such a level that she became unresponsive . So we had no choice of doing INVASIVE VENTILATOR  and that did help. Over period of next 4 days we were slowly in position to reduce the support from the machine  and we did take her off the ventilator. She did OK  and she was started on the noninvasive ventilator at night and just oxygen during day time . I watched her for 3 dyas and she did just fine . We had done many tests . She had CT scan of brain to make sure she did not have stroke  and she did not , We did CT scan of chest and she did not have clot or pneumonia . We did culture of blood  and sputum and treated her with antibiotics  and all the work up was negative  and she did not have sepsis. So why did she have respiratory failure even when she was doing everything right ? 

    I DON'T KNOW  and I will never know .

     Why did her lungs quit suddenly and then in 4-5 days recovered , I don't know . But one thing that I DO KNOW is that I have seen such patients in past and will again see such patients where we do not have the cause that precipitated  the event.