HOW DO YOU DECIDE?

   We have all known the difficulties in diagnosing some diseases or even simple disease which may not show typical signs or symptoms of the disease. But when one knows the diagnosis and still have problem in making decision. This is due to circumstances that are there. I am talking about that kind of situation today. 

   I had known and seen this patient for  many years. She was elderly and had mild asthma and had h/o breast caner. She was doing fine . She was quite stable till she had COVID , She was admitted to hospital  and had pneumonia and had need for oxygen . With usual treatment for COVID she did well and was discharged . But then was readmitted for irregular heart beats. She was seen by cardiologist. And medications were adjusted . She did OK but continued to have problem with heart rate .She had this problem in past and had been on blood thinner but then had gastrointestinal bleeding and  so she was taken off the blood thinner. She was discharged and readmitted  and the story repeats . The next admission to hospital she had developed fluid around her both lungs and needed oxygen supplementation. I saw her  and then decided to take the fluid out with catheter to get her better quickly as she was on diuretics - water pill . She did better , but had another echocardiogram - ultrasound of the heart and that showed that one of her heart valves was not working well and had elevated pressure in lungs called pulmonary hypertension. So the cardiologist decided -this time to talk to her about surgical repair. Certainly now a days there are less invasive surgeries to repair such valves , but it is still surgery and she would need additional invasive work up . She would need TEE Ultra Sound of heart looking by putting a probe in esophagus  and then checking the coronary arteries by doing cardiac catheterization. Though not much invasive these procedures do carry a risk. And if  heart catheterization shows' blockage then she will need intervention like stent  and she will need to be on blood thinner . If the blockage is significant that it cannot be fixed with stent ,then will need bypass surgery. So the question that I have is SHOLD WE DO THE WORK UP OR NOT ? And if needs arise for major surgery , should we do it ? Not an easy decision.   

PATCH WORK

    In our general life we are always to to make decisions as to do a 'temporary patch work or do permeant fix'. So the AC is broke and the tech tells you  we can get it working with some  minor or less expensive parts or we can change major things and that will be warrantied . With cheaper work there is no guaranty that things will last but it is less expensive.  The came thing may be for roof repair or car problems. I fell that in medicine  is the same. We see patients in office or in hospitals, that are admitted for some diagnosis and then we fix it but that does not change the underlying problems or treat it . Example will be someone admitted for pneumonia with underlying COPD in smoker . So, we treat pneumonia but the patient continues to smoke  and gets CIOPD worse. We did not address that. This is very clear cut. But I am going to tell you  the story of a patient where this extend to more that such obvious thing. 

  I have know this patient for many years. She had some COPD  and she also had some cardiac issues . She was quite obese and it was to a point that she could not get of her bed  on her own. She was admitted with swelling in her feet and she was short of breath and so she was admitted and we treated her . She had some fluid around her lungs . She was treated and then sent home . She was readmitted and has same thin  and we tried to treat her . In her 5th or 6th hospitalization, she had increased fluid around her lungs , mainly left lung. She was very heavy women. Normally I drain the fluid by inserting a needle. But I was not sure that if my needle was long enough to 'reach' the fluid . So I asked the radiologist to insert a catheter. He agreed , but when he tried to do it he could not get needle long enough and so he was not successful. I had to call chest surgeon. He did put in a catheter under anesthesia. Over period of days one day she got agitated and pulled out catheter. She was treated and discharged . She was back again with shortness of breath and she had low hemoglobin and then she was again sent home and she was  back in hospital and this time her salt in blood was low . 

   During every one of these hospitalization, the problems were same - shortness of breath, swelling of the feet ,fluid around her lungs and low hemoglobin etc. She never was able to get out of her bed , let alone getting to walk Her weight was same and she has nothing else changed . We did 'fix' the problems that we saw , but did we really FIX anything or was that the PATCH WORK - A TEMPERARY BANDAGE ?

WHAT WOULD AI DO ?

  Now a days we have news about AI - Artificial Intelligence. AI passed the Medical board- AI passed Bar examination and many other areas where AI is doing different things that we thought ONLY HUMANS can do. Sometimes we come across cases where on surface it may look same but one has to apply different approach to the differential diagnosis  and work up. That brings me to the patients for today. 

   I had seen these new patients . One was a young man who had been diagnosed with HIV and has been on medicines for last 4-5 years and had done well. But then he had some brain infection-meningitis - infection  of covering of the brain to be exact and was treated and did well. He had then pain in the belly and so went to ER and had CT scan of the belly done  and that was normal. But in the CT scan of the belly , there was some abnormality noted in lungs . 

    He was discharged and saw PCP and he noticed the abnormality in lungs and he had not seen lung specialist and so he was sent to me. When he had meningitis , he was on respirator and he had tracheostomy and also feeding tube  and he had not had CT scan of chest .So, it was difficult to know if the abnormality seen on CT scan of belly was new or old. I saw him and ordered CT scan of the chest , which was never done . That showed the same thing that was seen on CT scan of the abdomen .- he had a cavity - are of the lung where there is  lucency or air in the center of he congestion.

    I saw this second patient at the same time . Hw was 78 years old and has had minor stroke  and had some cough  and had no fever . He had cough and he had seen Primary physician and had chest X- rat done . He was treated with antibiotics and then he had no change in his cough and so had CT scan and that showed again a cavity. I saw him  and he had good oxygen and also had some cough. 

    So we have 2 different patients with same Ct scan findings , the age is different and the past medical history is also different. The etiologies of the problem could be very different in these 2 patient . In the first patient who has compromised immunity, due to HIV he could have Tuberculosis or Fungal infection etc. The older gentleman could have aspirated - food or liquid going down wrong way in the lungs instead of esophagus, leading to pneumonia and lung abscess.

   The same CT scan findings - some difference , one has the abnormality in upper part of the lung , other has it in lower part of the lung - the cause could be different and work up could be different too. Would AI pick it up ?  I did the work up and result in my future blog.

 

NO RIGHT WAY

    In medicine there are more than one way to do things  and the AI will not be able to give one final way. In Mathematics, 2 plus 2 make 4  and that can not be changed and it is true under all conditions. In medicine sometimes we do things differently in different patient and there is no right or wrong way. I  saw 2 different patients  and they had very similar problems. And I will tell you one at time. 

The patient that I saw was that of my other patient, who had COPD and he had smoked for many years and he had quit ,but it had taken toll and he had COPD and he had shortness of breath and he  needed oxygen. I saw him and he had large mass and we did biopsy and he had cancer and he was not a candidate for surgery based on many factors like being on oxygen with advanced COPD and also the mass was invading the center of the lung . So we did radiation therapy and he did OK . Then his wife came to me. She was about 80 years old and had smoked many years ago. She saw her PCP  and had some cough and some shortness of breath and when she saw PCP her oxygen was low and she was started on oxygen and she had CT scan of the chest done and that was abnormal and so she was sent to me .

  She was elderly women and she has been on 3 L oxygen and she had some shortness of breath and she had not had any chest x- ray in recent past till she had the CT scan . The CT scan showed Aright upper lobe mass and that had invaded the hilum the center of the lung . She also had significant fluid around her lung  and she was short of breath. She had irregular heart beats and had not seen cardiologist but was on blood thinner. So I had high suspicion for cancer which had spread to lymph nodes  and also the fluid that was seen , was most likely due to cancer. She was on oxygen and had COPD  and she  did not want any chemotherapy same as her husband. So I had a choice . I could do bronchoscopy and biopsy and see if I can get the diagnosis of cancer  and then drain the fluid and see if there are cancer cells in it. If my bronchoscopy and biopsy does not give diagnosis then i will have to ask radiologist to do needle biopsy of the mass and if the fluid  reaccumulates then we have to have a catheter put in for periodic drainage. Since she was on blood thinner, we will have to hold it for 5 days every time we did any invasive procedure. So if I did all these procedures we will be stopping and starting blood thinner many times . So I decided to do thing that I thought was RIGHT for THIS PATIENT. 

  I called radiologist and asked him to do needle biopsy of the lung mass and at the same time put in catheter , under the presumption that the fluid was due to cancer and will come back if just drained and then will need drainage again or the catheter for periodic drainage. 

  THIS WAS THE RIGHT WAY FOR HER IN MY UNDERSTANDING . 

 . 

MINE FIELDS IN MEDICINE

      I have heard this statement that when  Taliban terrorist left certain areas they left the place with mines  and they were unpredictable and can explode anyplace that we did not expect. I have felt the same thing in medicine. This is so true in case of cancer . I don't like when a patient diagnosed with cancer and have gotten treatment with chemotherapy, come for the follow up in my office and tell me that the oncologist told them that the cancer is gone. I know better that making such a statement and so does the oncologist. But patients like that and then when the cancer comes back, then we have hard time explaining the recurrence. And I call this as the mine field where we have no way of knowing all the mines -the metastasis -which are there, but not obvious. That brings me to story for today. 

 I had seen this young woman who had been diagnosed with breast cancer and she has had surgery and then radiation and then chemo. She had some abnormality in lungs and that also was breast cancer. She also had some bone spread. She was short of breath and so she had chest x- ray and she had fluid built up around her lungs and so she came to me. We did drain more than a litter and it showed cancer cells and so we did follow up chest x- ray in 3-4 weeks and the fluid had come back. So we did a catheter to drain fluid periodically at home. She did well and she had some chemotherapy changed and she was ok . The fluid drainage continued to be less and less. 

     More than  months passed by and i get a call from ER . She was in ER for shortness of breath. I spoke to the ER physician and told him to do the CT scan as she had 'white out' on right side - suggesting either the fluid or collapse of the lung. Sometimes the catheter may get clogged or may not be in 'right ' place. The CT scan showed that her right lung had collapsed . I  did bronchoscopy to see if her  right lung bronchus was blocked from 'inside' or it was due to pressure from 'outside' . If she had blockage from inside then I could put in radiation catheter and that would treat / burn the tumor and then that will help 'open' the obstruction. She did not have any tumor inside the bronchus, so she had pressure from outside . So we called radiation oncologist and she was started on radiation. 

    So she had breast cancer - that had spread to lungs - then had pleural fluid  and now mass that was pressing on the bronchus - just like new mines were discovered every so often. Then I had a call from Mayo clinic where she had gone for second opinion. The oncologist called me and told me that she had done MRI of the liver and SHE HAD MULTIPLE METASTASIS TO LIVER. Just like another mine exploding in her face .

CATCH BEFORE ---

    I n case of many medical conditions, if we catch in time , we have higher success. This is true even with infection . heart disease diabetes etc. . If we treat diabetes or high blood pressure early then we can prevent the complications that are associated with it. This is also true with cancer . In medicine we have tried to  diagnose earliest stage and then hope that we can achieve cure. We have stared  doing tests like DNA pieces of tumor in blood, this is called CTDNA . -Circulating Tumor DNA .But it is not a test that many labs do and even many physicians are not aware of it. It also raises some questions as to what to do if the test is positive. 3-4 years ago Medicare approved CT scan of chest as screening for early diagnosis of lung cancer in patients who recurrent smoker or ex- smoker for 14 years. This has certainly helped , but also has raised some anxiety when the CT scan shows some nonspecific abnormality  and needs follow up. But sometimes I feel that it's not always possible to 'CATCH' cancer early. The story that I am going to tell is one of that kind. 

   I saw this patient who was in mid or late eighties. He had quit smoking many years ago. He had quit smoking many years ago . he had some cough and usual treatment with cough medicines and antibiotics did not help. So, he had chest X- ray and then had more antibiotics . He then had CT scan and that was abnormal and so he came to me. He had some cough and no fever . He had no shortness of breath. There was nothing special in special examination. The CT scan showed  abnormality and had a cavitary area in lung . That could be an infection or cancer. So we decided to do further work up . We did PET scan. The PET scan shows where the glucose is concentrated and that depends upon metabolic activity of the cells. So it picks up in 8- plus % of the cancer. The PET scan showed increased activity in the cavitary area and also some lymph nodes. There was no evidence of any activity in any other areas , We did the EBUS - ultrasound guided biopsy through bronchoscope and that showed lung cancer -highly likely. I had discussion with patient and family and decide to send him for radiation treatment to the lession in lung. . Surgery was not an option and I had called and asked a surgeon to some additional biopsy and he had refused. He and his family did not want any surgery or chemotherapy so, radiation was the only option. I called radiation doctor and he gave him appointment 

  3 weeks had passed and he was admitted with weakness and hospital doctor had admitted. .When I was called in ,he was seen by cancer specialist and infectious disease doctor and also cardiologist. Tests were planned. He had chest pain and that happened to be due to spread of cancer. The cancer doctor had planned ordered bone biopsy . I talked to  patient and family they did not want any biopsy and so I called radiation doctor to consider radiation to bones where cancer  had spread . He agreed . 

   The PET scan done few days - weeks ago had not shown any spread outside the chest and now he had bone spread in many bones. I am sure cancer had spread tat time but out tests are unable to detect as the amount of cells must be bellow needed to be picked up. But with just given few weeks / days it showed on bone scan and CT scan. 

LIVING WILL AND DNR

    I have seen many patients that have living wills. Now a days if someone goes to hospital , they are asked if they have a Living Will. There is some misunderstanding about the Living Will. Some people  do not understand the difference between the Living Will and the WILL. If someone has gone to an attorney for estate planning they would have done the WILL which is their wish as to how the estate should be divided after their death. The Living Will has nothing to do with estate, but has to do with how one should  act in case they have sickness- how aggressive one should be have  terminal sickness. The living will does not mean DNR  which stands for Do Not Resuscitate. I had seen a letter to Editor in a medical magazine where she was complaining about the care that her mother got when she had stroke . That showed that she the Harvard professor did not understand the difference between DNR and having a living will.

  The Living Will records one's desire to use machines or artificial means of keeping one alive in case of need  and if one DOES NOT want them if the condition is determined to be TERMINAL. In contrast to that the DNR means one does not want to be put on any machines or Resuscitated. In case of Living will the physicians and the relatives have to decide if the condition is terminal - as the language states " in case of my condition is determined to be terminal --". This may take time to decide . Not every cancer  diagnosis is TERMINAL and not in case of heart attack or stroke ,patient dies or is terminal. If one does not want to be put on any life sustaining machines or means or resuscitated ,then they should sign DNR . There is DNR form that is VALID anywhere. The hospital DNR are valid for that hospital stay and that hospital only . But the COMMUNITY DNR is valid anywhere.

   One more form that everyone should have is medical surrogate - someone who is assigned by patient to make Health Care Decisions in case patient cannot make own decision. This person could be spouse , siblings  or children or even unrelated person .

  So in modern days one must have 2 forms Living Will and assigned  Medical Surrogate..