NEVER NEVER 100%

    In medicine we go by statistics. Take a simple example of bronchitis or pharyngitis. In medicine we see a patient and if the complaints and the physical examination fit =s in to the diagnosis then we treat with antibiotics. We don't necessarily do a throat culture or blood count or X- ray etc. as investigation. We just treat it and we get to be correct most of the time . Out=r decision is based on statistics and we are correct most of the time . The bad part is nver 100 %. This is a story of a patient when we did not get to be right and still we felt good.

    I saw this patient 68 years old who was a current smoker . He had some cough and he had no other complaints. He had had chest x- ray  and that was OK but he had had a CT scan in past that had shown abnormality . The old CT scan was from 2 years old . I got hold of  the report of the CT scan and that had shown a nodule. he had not had the new or follow up scan  and so I decided to do new CT scan . The CT scan showed that the nodule had increased by quite a bit . To be exact the nodule was 9mmx6mm and now it was 16mmx11 mm We did the bronchoscopy and also did the PET scan . The PET scan uptake was mildly increased, The breathing  test showed adequate lung capacity. The PET scan uptake was minimally increased but we can see that in very slow growing cancer as the metabolic activity of theses cells is not very high and so the uptake could be low..I discussed the case with patient and the family . I also called a chest surgeon. The surgeon was sure that he had slow growing cancer and I also felt the same thing and the problem was only 100 % test is to do open biopsy. 

   He has the open biopsy and the report showed no CANCER and it was a scar with lots of inflammation. So that was good .I was happy that he did not have cancer we don't have to worry about recurrence, but we were 100 % wrong. So in medicine there is no 100 %  right or wrong!!

LEARNING CURVE

     In medicine we have certain diseases called as Syndrome. Theses are the symptoms or signs that are bundled together and we OBSERVED them in a patient and then in other patients together . e did ont know why certain things were together but we knew they were together  and so they were coined tern a syndrome Over period of time we knew the cause for the disease  and then found out why different organs seemingly unrelated were involved. When a new disease pops up we have a learning curve. The most recent example is that of COVID. We started with many assumptions  and then as we saw more patients , we realizes that what we thought as the right thing was not right and was wrong . The use of BIPAP or noninvasive ventilation is classical and so is use of steroids. We were told that we should not use steroids and then a study came out that use of steroids reduced mortality and morbidity and now in every patient we use steroids .But I feel that we are still in a phase of learning curve - may be it is flattened but it is still there. 

      That brings me to the story for today. I saw this new patient who was having intermittent fever for last 2-3 months  and so his PCP did out patient CT scan of chest and then when he got the report, he was asked to be admitted for further work up and doing a bronchoscopy. I saw him He was a 68 years old male patient who had lymphoma  and that was diagnosed many years ago and he had some radiation and then chemo. He was treated in Italy  and also here .He had COVID infection around X-muss and did not have much problem getting over the infection. He then had the vaccination for COVID. He continued to do ok but had some low grade fever off and on. He had no weight loss and he had good appetite and he never had very high fever. I talked to him and his wife  and then he was started on broad spectrum antibiotics  and we did do new CT scan to rule out any blood clots. I did do a bronchoscopy and there was not much of abnormality and I sent samples for bacteria and mold and TB and also cancer cells. He had test for COVID and that was negative . He had no positive microbiological culture. But then he had fever again. He had some additional studies  and a new COVID test. And that was positive this time. So I was not sure what to make out of it . The tests done 4 days apart one positive and one negative. I spoke to the infectious disease specialist and we decided to start him on treatment for COVID. But we also did antibody titer for COVID. AND HE HAD NO ANTIBODIES FOR COVID. So after having the COVID infection and having vaccine for COVID, he did not produce the antibodies and so he probably was having persistence of virus in body  and that was causing low grade fever off and on. This is my conclusion. 

                                This is my learning curve - and based on that we have treated him. 

Disappointment

   The life is full of success and failures  and we have many disappointments , may be in our own life or job or kids or team that we follow for any game and so on. But sometimes we expect certain things and then the final outcome is worse that what we expected . This in MY VIEW is due to Hidden and unseen KARMA -FALA - Fruit of our past Karma that we are not aware of. Again this is my view based on what I understand of The Law of Karma. But in medical life we don't want it but we have to face it. This is the story of one such disappointment.

     I had a call from PCP . He had seen a patient who had cough and he treated  and then when it did get better, he did chest x- ray. He not only ordered the X- ray he did personally see it. He was not happy as he thought he saw something  and the radiologist had not reported it and so he did CT scan and he was right. The lady had a mass - or suspected cancer. So he called me and I saw her in office .We did the work up which is to do the PET scan and there was increased in the uptake of the glucose in the mass. she had breathing test and that showed that she has good lung capacity in case we needed  to do surgery and cut the part of the lung that has cancer . I was happy to some  extent as even though she had cancer - most likely , she was resectable  and hopefully the surgery would be curative . So i sent her to a thoracic surgeon. He saw her and she was scheduled for surgery. In between she was seen by neurologist as she had some tremors of one of the hands . He did do a MRI of the brain - which is rather routine than for any specific suspected diagnosis . To his surprise she had a mass in the brain. So the chest surgery was cancelled or put on hold. I came to know about it when we called her to find out on date of surgery.She was sent to oncologist and a neurosurgery. But we had no definite diagnosis of cancer. So I called her and scheduled her for needle biopsy of the lung mass. I also called radiation therapy doctor to see her. 

   So in this case the primary care physician was right in doing the CT scan and he did find out the cancer and sent her to me . I did do the work up and was happy that we could sent her to thoracic surgery for cutting out cancer. No one had suspected brain metastasis at the time when we all - the primary care - myself - thoracic surgery suspected it. I don't think the neurologist suspected it either. So this was great disappointment - what was thought to be curable cancer was now only treatable cancer  and chance of cure was reduced to minimal.

PREDICTABALY UNPREDICTABLE

      In our life we have things that we expect and they do happen and then things that come as absolute surprise. So we have things that are predictable  and we know that things are going to unfold in certain way and so we have expectation and our mind is ready for it and so the impact is not that much. But when we have things happen which we did not expect , and then we face them we are not expecting them and so we are not prepared for them and we are shocked. So that brings me to the story for today. 

     I have been seeing this patient for many years and he has had multiple problems but main was pulmonary fibrosis . He also had aortic valve problem and I ha =d told him that needs to be fixed and he  saw cardiologist and they did not feel it was that bad . After about 1 or 2 years they felt that the valve needed to be repaired  and so he was admitted . He had check up for carotid artery and he was found to have narrowing and so he had stent and then he had stroke. . So then he partially recovered from it. His wife helped him and he had missed follow up and after a gap of 8 months ,he came to see me. He was doing OK from my stand point and had some limitations on walking. But is wife was with him After the visit was done , he asked me if I could help his wife. I said sure , what is the problem. He told me that she ha shortness of breath and so she went to ER and had CT scan and that was abnormal. The Ct scan showed a large mass. So I agreed to see her in 2 days as emergency. I had neve seen her and since she was in ER and was not admitted , I presumed that she was OK . I saw the CT scan before she came to my office. I knew that the mass was large and was not in best position and so I had scheduled her for biopsy. She came for the appointment  and when I saw her and checked her she was not in the best shape, She was diagnosed to have COPD  and has been on oxygen and she was short of breath and when I checked her , her heart rate was vey high and her oxygen was very low. The heart rate was 170 and so I increased the oxygen and told them that she will need to be admitted . The mass was close to major blood vessel -pulmonary artery going to right lung and it was encasing the artery and also the bronchus . So that was bad to start with and I had anticipated difficulty with getting biopsy and also the treatment part. Certainly she was not surgical candidate  and the option of treatment was radiation and chemotherapy. But now with the heart rate issues and oxygen problem I was not sure as to how much can be done at this stage . 

    So I was aware of the fact the CT scan was not very great for the treatment but did not expect that we will have such a difficulty now even without even having done work up. This is predictably unpredictable.

ONE IN A MILLION

     We in medicine are many a times sure on our thinking and diagnosis. Again this is based on our education and experience and statistics. As I have mentioned in my previous blogs , the entire medicine is based on statistics. If I see someone with cough and fever and yellow sputum, I would diagnose as having bronchitis or pneumonia if on physical examination there are abnormality. We are correct in our thought process  and diagnosis  and planned treatment. We don't do the sputum culture to start antibiotics or which one to give. Again this is based on statistics. But sometimes we are wrong . and then we say or thin this is one in a million. That brings me to the story for today . 

    I have known this 90 years old male for last 90 years or so. He had mild lung problem like asthma and he had been on inhalers and was quite stable. One day I got a call from his physician that he did a CT SCAN and he has cancer. I was shocked . He was 90 years old  and he had not smoked for more than 30 years ago I had seen him 3 weeks ago and he was stable. His last chest x- ray done 15 months ago was OK . So I was surprised . But the CT scan had shown a mass and that definitely looked like cancer. I told my office to call him and set him up for PET scan and biopsy. My office called the patient  to set it up . He had a grand daughter  and we had to call her . But then I got a call from her and she told me that he had a fall and he was taken to ER and then was admitted .They were doing work up to make sure he did not have bleeding or stroke. The work up was ok and he was still littlle confused . He was in the hospital where I do not go. But the granddaughter wanted me to check the chart and make sure that what they were doing was OK with me. The lung specialist planned to do the biopsy like I had planned  and he did . There was narrowing and there was some susicion of cancer but then when he checked the pus came out from that area . I continued to check  and he had infection and no cancer was detected on biopsy. He was started on antibiotics  and he was discharged on IV antibiotics 

   I spoke to them on telephone as he was too weak and could not come to office. Hew as doing better and last chest X- ray was much better. So it looks like he did not have cancer but had lung abscess - infection and pus in lung that looked like cancer. 

   This kind of thing does not happen often but only one in million .

CONTRACT

     Now a days when you watch TV, we see several advertisements that are for replacement policies for Medicare recipients, that promise everything and more. The usual Medicare does not cover vision, dentistry and over the counter medications. But theses policies cover everything and they also 'give you money in pocket'. If one thinks about this with some intelligence, they will realize that one has to cut the cost somewhere.. Theses Insurance companies get money from Medicare and then they spend it for health care . But they have to have some overhead expense and also they need to show some profit for their share holders. So how can they do all that and promise things that are not covered by Medicare? The obvious answer is they MUST BE CUTTING SOME SEVICES OR PAYMNETS. Most of the patients do not think about this. This brings me to story for today. There are 2 such stories that I came across recently. Both are similar.

     I have known this patient for many years. She has been seen by me for last few years with shortness of breath and has been obese. She has Asthma /COPD and has been on medications. She had done sleep study and she has sleep apnea, the treatment for that is CPAP - pressurized mask for sleep. She has refused to use the CPAP. She also has heart problem and she has not lost any weight . She has atrial fibrillation and the heart rate has not been controlled. The cardiologist had suggested ablasion, but it was never done and she was not sure if she wanted that. So she needs oxygen and CPAP or BIPAP and also needs to lose weight . She has oxygen and recently she was in hospital. When I talked to her I asked her if she was using oxygen and she told me she does not as the oxygen cylinder is 'dangerous' to carry as it can explode if she has car accident and she is not going to put her and her grand kid's life in danger if she has car accident. So she does not take oxygen with her and so he has not done any exercise and she has not lost any weight.. Just as aside note - walking or the amount of exercise that she or patient like her can do will not add much to weight loss as the calories spent will be minimal. The main thing for weight loss is diet. e.g. 16 French fries consumption is equal to doing 31 minutes of bike riding or 52 peanuts is equal to 90 minutes of house work. So there is no dietary change and no exercise. I also asked her if she will be willing to use PAP as that has been shown to reduce the atrial fibrillation problem. She told me that she can use only minimal pressure -which will not do any good as that pressure is ineffective to control her sleep apnea . So I asked her as to what does she want me to do / The answer was she wanted PORTABLE OXYGEN CONCENTRATER -the one that she has seen on TV and she knows that Medicare covers it . The problem is that Medicare covers oxygen but does not cover all portable oxygen concentrator and when a patient has one home oxygen concentrator ,then Medicare will not pay for second. We had tried to get her the portable oxygen concentrator in past and the company that has contract with her Advantage policy had refused it. Simply stated I can tell that patient needs oxygen and the company will provide oxygen .But what device they will cover is up to them and when there is cost reduction by these plans they may not get what patients want. 

    So, then there is conflict The plans tell everyone on TV that they cover everything and MORE and in reality they have to cut cost to cover MORE and that is cut for every service - physicians , labs , radiology and also for DME that provides such equipment . The patients are told that if a physician writes a letter that 'it is medically necessary' then they will cover it. But reality is they WILL PROVIDE oxygen but not what patient wants .Patients watch TV have misconception and then don't do what is more important than just the equipment 

    

KARMA PAST OR PRESENT

      I have talked about the Karma many a times  and there are times when I see situations where I can not explain the things that I see on the basis of law of Karma.I do see husband and wife as patients  and they have lung issues and I am not sure if they got together due to Karma done in past life or they are creating new Karma in this life and that has the effects that I see as diseases. Certainly genetics can not play arole as they rae not genetically related to one another. This is not the first time but I have seen thu=is over and again . That brings me to the story for today .

   I  had seen this patient many a tomes and I also wrote about it in my previous blog. He was a smoker and had abnormal CT scan of chest .I did bronchoscopies and biopsies and they did not show cancer though I was convinced that he has cancer. To make the long story short, we did finally did surgery and then he was diagnosed to have cancer in the lung  and that started in SALIVERY GLAND !! I have never seen this before  and he did not have any cancer in salivary gland that we can detect. So as a fact he had salivary gland cancer that spread to lungs  and so essentially he was inoperable  and the chance of cure was not much .But he was treated with chemo and radiation therapy. He completed the treatments  and he has been off that for more than a year. He is doing good and he has no evidence of cancer. 

   Then his wife started seeing me . She was a smoker and she had some shortness of breath and also had some heart issues. She needed a cardiac process  and she needed pulmonary situation to be cleared . So I did see her and then did the work up ,She had breathing test and then chest X- ray and then CT SCAN of the chest . The CT scan did show a nodule about 1.2 cm  and so I did the work up . She had PET scan and the bronchoscopy. The PET scan did show some uptake but it was not very high . Due to her history of smoking I wanted open biopsy. The low uptake indicates slow growing cancer if it was a cancer. She saw a surgeon and he did do the surgery and it was a cancer . All the lymph nodes and margins were good and the chance of recurrence was thought to be very low. She did see oncologist - cancer specialist and she was not started on any treatment . But it was decided to do follow up CT scan to keep an eye on it .She had a new ct scan in 4 months after the surgery . SHE HAS SPREAD OF CANCER TO LIVER.!

  So her husband who had metastatic cancer  that too of very rare type seems to be cured  and the wife who had very small nodule and that too metabolically not very high growth, .He is cancer free and she has spread in 3-4 months  after so called surgery that was thought to be curative. Not sure I can explain this .