TO TREAT OR NOT TO TREAT

   In medicine we have many of us who are nonflexible. I f i check blood pressure on a patient and the recording is 150 / 95 , there is no question in my mind or for that matter in any physicians' mind as to treat or not treat. The high blood pressure must be treated ,we will treat it.If the blood sugar is high we treat it though it may depend upon age of the patient - but if the sugar is high, then we will treat it. Ig we see 80 years old person and fasting blood sugar is may be 110 we may not treat it but if the patient is 30 years old we will treat it . So there is some variation in treating diabetes . The same holds true in case of elevated lipids - cholesterol - though most of the cardiologist have lost the flexibility and treat even 90 years old with same medications  and that may be due to combinations of factors like insurance company asking us to do check marks  and then pharmaceutical company pushing for the drugs  and so on. But most of us weigh the benefit V  risk. The story that I am telling story  today is one such patient. 

    I saw this 84 years old patient. She had chronic cough and the PCP had treated with meds and antibiotics and cough meds and steroids, She had a chest X- ray done  and that was showing some chronic changes . She came to see me with her daughter. The cough was going on for more than a year. I did a CT scan and the breathing treatment. The CT scan showed damaged bronchi and mucous plugging  and and some other abnormality . I decided to do Bronchoscopy  and also some sputum culture for acid fast bacteria. The bronchoscopy showed that she had damaged bronchi and mucous  and the cultures came back showing bacteria called MAC. (If you want to know on MAC please see my YouTube  channel  under JUST A TALK on MAC or check out NTM )This is bacteria which  grows in damaged lungs  and also causes more damage. And patients have chronic cough sometimes blood in it and low grade fever  and night sweats and weight loss etc. Her sputum cultures also showed MAC . So under ideal conditions she NEEDS treatment . The problem is that the treatment consists of at least 3 drugs for 18 months . One of the drug can affect Liver and other one has potential for eye. So we monitor liver and eyes . So I discussed with her and her daughter on the treatment  and the medications and follow up and the monitoring etc. After the discussion they decided that they did not want the treatment . I agrees with them with one condition. WE HAVE TO MONITER HER with CT scan  and  clinically. There is a possibility of worsening if untreated . 

     So we have a disease  and we decided not to treat taking in to account her age her symptoms and understanding of the disease  and risk of worsening. And I have some older patients that WE have decided to watch  and they have done well without the treatment .  

MIND OVER MATTER

     In past I have stated that 'The eyes does not see what Mind does not sees' have seen several examples of this statement when I take care of patient. It may be memory problems which are not picked up by patients or their families to the doctors or nurses not seeing what is in front of them as their mind did not think. I had mentioned of patients that was sleeping  and the family sitting around  and thinking that she is doing 'fine' and the nurse also thinking gthe same and also the doctor who saw her .Then when I ordered the blood oxygen - carbon dioxide to know that she was in serious trouble due to elevated CO2 which acts as sedative. I THOUGHT OF ELEVEATED COO2 in this patient with poor lung capacity and so I COULD SEE it . But somehow others did not THINK OF it and so they did not SEE it. The story that I want to tell you is similar .

     I saw this young man who had seen other doctors  and had come to see me as second opinion. He has been having shortness of breath for almost one year and he complained about it to his PCP. He was non smoker and he did not seem to have any cough or wheezes . He had no chest pain and this had creeped up over period of time . So the PCP sent him to a cardiologist . The cardiologist with his blinders did the cardiac work up. He did the tests to rule out cardiac issues as the cause of shortness of breath, He had Echocardiogram  and stress test. He was seen  and then after the tests he was not called with reports  and as expected he thought that the tests were OK. He had follow up 3 months after the first visit with the cardiologist. When he saw the cardiologist, the cardiologist went over the tests  and realized that his pulmonary artery pressure was elevated. Let me explain this medical thing. The blood from which the oxygen has been taken out  and retuned through veins to right side of the heart . The Right side of the heart called Right Ventricle pumps it to the lungs where it gets the oxygen and then it goes to Left Side of the heart . The Left side chamber called Left Ventricle pumps to body . So we have 2 circuits -one right side of heart to Lungs and other Left side pumping to body . The blood pressure that we measure  is the pressure that left ventricle generates when it pumps to body but the Right side pressures  cannot be checked without doin g Echocardiogram. The normal blood pressure is 120 to 140  and the normal Right side pressure is 25. So his pressure on right side was 60 . This is called PULMONARY HYPERTENSION. 

      I am not talking about the diagnosis of pulmonary hypertension and the work and the treatment, but I wanted to point out that the cardiologist who saw him first time and did the work up had also read the echocardiogram which had shown elevated pulmonary pressure . But the elevated pressure was SEEN and the REPORT was dictated by the same cardiologist . So why was that not noted at the time of report generation ? The answer is YOUR EYES DON'T SEE WHAT YOUR MIND DOES NOT THINK !!

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 .