WE KNOW , BUT STILL HURTS

    In medical practice , we can predict many things and sometimes we are wrong.The possibility that we would be wrong is smaller that we are going to be right. Again if we knew 'everything' , we would be God . But with the modern day medicine, with all the tests that we have , we can predict more accurately than in past. There are many factors that can affect the outcome and can change out chance of being right. But sometimes we are right and it still hurts.I have seen many patients that I thought will not do well, and did not do well. But sometimes the the contact that we have is so short , that I don't think for long time on these cases and don't wright about them . The case that I am going to wright is one where I knew I was facing uphill battle and did not think much till it happened .
     I had seen this 75 years old patient in my office.He was on oxygen when he came to my office.He was seen by another lung specialist.He was diagnosed to have lung issues and was put on oxygen and some other medicines.He had brought with me old X-ray from 4 or 5 years ago. I reviewed the CT scan done by the hospital and when other MD was seeing him . He was told to have COPD in the beginning and was treated with medicines . Then he was found to have elevated pressure in the lungs and was put on Viagra.I was not sure if they had told him that his major problem was not COPD though he had smoked ,but it was scar tissues in the lungs. I could see that even 4 or 5 years ago he had some scars.I ordered new CT scan and a walk test to see how much oxygen he would actually need . He walked may be 30 feet and oxygen dropped . We continued to increase the oxygen and by may be 4 minutes , we needed 8 to 10 L and he was still not greater than 90%.(which is considered low.)I told him not to walk more than 30 feet.I told him about the diagnosis and told him that not much could be done .I could try some new medicines, but they would not be successful. But he was reluctant for additional medicines.
      He was admitted to hospital in next 10 days. He was short of breath, but main problem was his blood pressure was low and he had low sodium. He was given water pills and they had caused him to be dehydrated and so the blood pressure was low and sodium was also low.I had to give him lot of fluids and steroids and very high oxygen flow . He was put on 100%oxygen with 60L flow (compared to 10 L at home ) The blood pressure was an issue for 2-3 days . But then the oxygen continued to be problem. I could not wean him down . I talked to him several times . We talked about going to special place called SELECT or go to Hospice . He told me that he had no relatives . He was writing a book on Bible,and wanted to complete it.He did accept the fact that he was 'bad' and may not make it for long time.He finally agreed to be DNR. It came as a surprise to me that after struggling for more than 2 weeks , we could reduce his oxygen. I had given /tried several medicines in desperation. Either they were working or it was just a 'chance'.He agreed to go home with Hospice .
     He was on 8 L and I had told them to have as high as 12 L oxygen.And 4 days down the road , I got the call from Hospice , that he passed away.I knew that this was going to happen , and I knew that it would not be that long . But 3 days ? It hurts.

ACCIDENTAL DISCOVERY

    In medicine and for that matter in other fields , there are accidental discoveries . The old example was that of discovery of penicillin.Some other drugs have been discovered by shear chance . Some chemotherapeutic agents belong to this category( cisplatinum). Then there are accidental uses of the drugs. A medicine that was used for allergy,was noted to cause increase in appetite and cause weight gain.So it is used not for the allergy, but to improve appetite and weight gain (Periactine).This is true for non medical inventions too. Sticky note is one such invention.But what I wanted to tell today is not that kind of accidental discoveries , but some other kind ,where no one knew or expected , a disease , and it was diagnosed by accident. I had written a story of a pregnant lady, who came to hospital and became unconscious and none of the doctors suspected pregnancy with it's bad effect called eclamcia.It was by accident that some one ordered the pregnancy test and the pregnancy was diagnosed and once the c-section was done patient got 'cured'.So the story that I am going to tell is similar to that.
      I saw this 90 years old patient in my office . He had diarrhea and had lost 20lbs weight. So the primary care physician did CT scan of the belly and it showed some abnormality in the lungs. Since the bottom of the lungs are not 'flat', but are curved, when they try to go to the top part of the belly, (liver) they will have some pictures of the lungs . So he had a CT scan of the lungs . The CT scan of the lungs showed a nodule in the lungs. So with the weight loss , i decided to do a bronchoscopy. My concerned was not to diagnosis lung cancer though it was a possibility, my concern was to atypical infection called MAC. So he came to do this procedure as out patient. He was put in a procedure room ,after the nurses did the history and some examination . They did notice the low heart rate. But they were waiting for me . When I entered the room ,I noticed that his heart rate was ,30 .His blood pressure was 1410/70 and his oxygen saturation was 97%. He was comfortable and had no complaints.When I looked at the monitor , I realised that he had a heart block ,i.e. only every other beat was conducted.So even though he had no symptoms related to this low heart rate, he needed a pacemaker. Needless to say that I canceled the procedure and called the cardiologist . I admitted the patient to ICU and started him on intravenous drip of a drug that did improve his heart rate, He had  pacemaker inserted and is did fine .
        So if he was not on monitor and if I had not scheduled his procedure, then his heart block may have remained undetected, at least for some time .

DRUGS ,HOW FAR DO WE GO?

    I have been seeing more more demand for making the pot smoking 'legal' or as some would like to say 'decriminalise'.There are good people who argue tat it would make money ans save money for the state.But the main things that they are missing is that no drug is 'safe', not even legal 'drug' alcohol.Does that mean that I would like to go back to days of prohibition?NO ,not really.But we need to do something about the rapid growth of use of legal and illegal drugs . I have been medical practice for long time and I believe that the use of narcotics and illegal drugs is at it's higher level and the part that bothers me is that we all think it is OK. This thought came to me , which prompted me to wright this blog.
      I had seen this patient may be year and half or so ago.She was a 79 years old patient who was referred to me for the evaluation of the abnormal CT scan. She had a history of breast cancer and had routine chest X-ray and it showed some abnormality and so a CT scan was done . The CT scan showed number of tiny nodule .So she was referred to me .The patient was quite anxious and had a hard time with the situation and was scared, like anybody else would have been with concerned for recurrence of the cancer.The nodules were very small .So the usual procedures like bronchoscopy or needle biopsy or PET scan or open biopsy were not great option. But I decided to do bronchoscopy as the possibility of atypical TB called MAC was there, in my mind it was high on the list of possibilities.I also told her that if these are cancerous nodules,,nothing could be done to 'cure' them and if they were benign ,then nothing was needed to be done. So if the bronchoscopy was OK we will do follow up CT scan . I did the bronchoscopy .And I had thought it came positive for MAC -the atypical TB . This needs treatment with 3 drugs for a year.We also need to do monthly liver function blood test , and need to check eyes periodically .She was not happy with all this , but was 'relieved' that at least it was not cancer.
      Her follow ups continued to be OK as she was tolerating the medicines quite well, after initial problems. She was doing fine and the blood tests were normal. She had no problems and was very pleasant. So I was surprised when I saw her and she appeared to be mad . When I walked in the examination room, she told me that she was done with all the tests and medicines .I looked at her and then the chart . She was about to be completing her treatment in next month and her last CT scan had shown the improvement in the nodules.Then when I started talking to her the real cause of her frustration came out. Her son ,more than 50 years of age, had dies of drug overdose. it was overdose of methadone , which was prescribed to him . Again I don't know the details and he may have taken some more drugs , but methadone was main cause according to her. She has a daughter and she also has drug problem and is no help to this elderly patient and felt no remorse, when she told patient that 'every body dies one day'.
     Under the name of pain control we are giving more medicines and I am afraid that we will get more addicts.
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SO WHAT CAN YOU DO ?

    There are times when I often wonder what else could do or is there anything that I can do to change the outcome.Someone had said that if you do certain things repeatedly , it becomes habit, and when you do it more often it becomes second nature. I think  I can say that about smoking. I also talk about the circle of mind. Let us say I have never tasted a Pizza and you bring in a pizza and ask me to try it. When I see the pizza , I would have no reaction or desires I have never seen pizza. But then you tell me try it as ' it's great.'So I try it and I like it or dislike it . So eating pizza leaves an impression.So next time when I am hungry or passing by pizza place , I would recollect that the pizza was good or bad and that would cause to buy it . Eating it will leave impression and then that will create desire to eat it again and so on and so forth.This is circle of mind .Action causes impression and impression leads to desire and desire leads to action.This is worst with smoking and that is my today's story.
       I saw this young 40 years old patient, with abnormal chest X-ray.She had lung mass. As usual I did the biopsy and the breathing test . She had a cancer and the lung capacity which was OK . She was a smoker and had the reduction in the lung capacity, but it was acceptable for the taking out the cancer. We had thought that she will need a lobe to be taken out ( approximately 2/3 rd of the lung , may be 2 lobes . But when the surgeon went in , the tumour was quite close to the center and he had to take out entire right lung .This was her only chance to may be give her a chance of cure.She did well and no major problem .She was given radiation treatment to prevent the recurrence. I followed her for long time after the discharge .She had quit smoking for may be 4 months or so. Then she started the smoking again . She had reduced lung capacity as she had lost the lung and she did not start with the normal lung capacity.She also had the cancer , but it did not matter , She was smoking. I must have followed her for few years and then she was lost for follow up .
    Then I got a call from a general surgeon , asking me to see a patient that I had seen before . She had routine mammogram and it had shown abnormality and so a biopsy was done . It showed a cancer . So she needed surgery . He wanted to me to 'clear' her for surgery as she had lost one lung and was a  current smoker. I saw her .She was still smoking . There was no evidence of recurrent lung cancer . Her lung capacity was lower . But I cleared her for surgery.It was breast cancer . She had no problem post surgery. She was started on oral  chemo. She continued to smoke . I must have talked to her several times and it made no effect. She continued to smoke .
    Three years passed . She had problem with acute bronchitis and was short of breath. So needed to be admitted. The routine chest X-ray done showed a abnormality in the remaining lung. She had CT scan and it confirmed that she had a lung mass. With her history of 2 different cancers the possibility of new lung cancer was high , and the possibility of spread of breast cancer was there.I did do the bronchoscopy and got nowhere. She was too short and I did not see ant tumor to the biopsy and deep biopsy were out of question with her shortness of the breath. I spoke to radiologist to see if he could do needle biopsy . He did not want to take a chance as she had only one lung and if it would collapse after the biopsy , she would probably could not tolerate and may die . So I spoke to the oncologist and we decided to do radiation as he 'felt' that possibility of lung cancer was higher than breast cancer. She continued to smoke and died in less than a year.

CHRONIC COUGH-ANOTHER UNUSUAL CAUSE

     I have seen many patients with complaints of chronic cause.I often make a joke when I say," Your cough and cold is my bread and butter". So I see many patients with the complaints of cough.When these patients are nonsmokers and their chest X-ray is OK , most of the time it is due to one of the 3 causes,Asthma,or allergies with post nasal drip or gastroesophageal reflux.So most of the time I worked them up for one or all three and treat as therapeutic trial and they get better.But sometimes I come across unusual cause for the cough.So this one was one of the unusual cases.
       I had seen this relatively young lady , may be about 55 years old.She was young but had long history .She was complaining of chronic cough.When I got in to details of the history, she told me that she was non smoker and had bad pneumonia and then had very stormy course.She was on respirator and could not be weaned off the respirator and so needed tracheostomy.Then she was diagnosed with a condition called POLYMYOSITIS . In this condition the muscles get very weak and this is related damage to the muscles by own body and the treatment is with steroids and immuno-suppressants. So she was started on the steroids , and then switched to immuno suppressants got better and was off the prednisone . Her cough was there when she had pneumonia and though the pneumonia got better, the cough continued. She was treated with different medicines. Her X-ray was OK.I was thinking in terms of ASTHMA, as the steroids can suppress the asthma and when the steroids are taken off the asthma can flair up. But due to be on immunosupressants I did CT scan of the chest.The CT scan showed some damaged bronchi and some scars.The were most likely due to previous pneumonia. But I was concerned and so I decided to do bronchoscopy to make sure there was no unusual infection.
     The surprise came when I did the bronchoscopy. She was coughing significantly in spite of quite a bit of sedation. When I entered the Trachea, her coughing would get worse. There was a abnormal tissue growth just bellow the vocal cord ,with 2 green colored threads coming out from it . It was so close to the vocal cord that I could not do any biopsy.I thought that It was related to the tracheostomy. It looked like there was some retained sutures and it had caused the excessive tissue growth.AND THIS MOST LIKELY WAS THE CAUSE  OF THE COUGH !!
     

PRAYERS,REVISITED

   I did write about the prayers and it's powers and how it may be working. I was reading an article written many years ago and I thought about it and liked it . It may be an explanation as to why some prayers seem to work, whole others seem not to work.This is similar to the destiny, and how it works.Let me explain.
     When we do sincere prayer ,with full faith and trust , it create positive  deeds. This can be compared to making more money , as it adds to our bank balance of good deeds. But just like the bank balance of money . it can be used for various expenses.If I suddenly get $100,000 , then I can decide to buy new car or new clothes or I can pay off some of my old debt, or I can decide to put some in a bank or invest in something for the future dividend.The same thing can happen for the fruits of our prayers. Some may be used or spent for 'giving' us success. (as if our prayers are answered.)This like me spending some money foe buying new car.Some of the fruits of the prayers will be spent in paying for avoiding the effects of the bad deeds that we might have done and which might have come to fruition in near future.And finally some is left in our bank account of good deeds . The problem is we do not have control on haw this is done in case of effects of good deeds, unlike in case of money, where we have full control. So we can not decide how to 'spend' it , nor we know how much is needed to nullify the effects of past bad deeds ,nor we know how much is needed to get success in what we are praying for . So we don't always see success ,our prayers are not answered ,and sometimes they are . I can not not understate the law of karma in any of these .This may be the deciding factor as to how much of effects of good deeds are used for each of the 3 things that I stated above.There are things that we have done in past or past life , effects of which will manifest and can not be avoided no matter what.And there are things that we can change with some efforts . Then there are some where lot of efforts are needed to change the outcome . So the question is how much is enough?If I want to but Rolls Rice and I have only $20,000, can I buy it? The answer is no .
       So this may be the answer to the question as to why some prayers are answered and others seem to go unanswered. 

HAPPINESS

    We are all looking for one and only one thing, happiness.So what gives us the happiness?I have often said that the real happiness is not out side our mind , but in our own mind.Let us say that I like Pizza and it gives me happiness in eating it . So I think that the pizza is the source of the happiness, But when I start eating the pizza , the happiness that I get from eating the first slice is not the same. So when I eat 10th slice I am about to throw up and not getting the happiness that I got with the first slice . So then the happiness is not in PIZZA but it is in my MIND . This is same for many other things , including having sex or listening to a particular music and so on. So why do we feel the happiness.
      There was a story of a king that had heard when I was growing up.He was unhappy.So many doctors came and gave him different medicines , but it did not help.So the king continued to be unhappy.So then came a doctor. He said to the king that the treatment was simple. The king needed to wear a shirt worn by a HAPPY MAN. So the king sent his guards to all over the city , in search of a happy man . They went searching for the happy man one house at at time . Some one was not happy because he had lost a loved one , some one had broken up with spouse, some one had lost job ans so on and so forth. So at the end of day they ran out of houses to go . So the next day they decided to go to the outside of the city . It was early morning . The Sun was rising and a man was sitting on  the banks of a river on a stone doing nothing.The guards came to him and asked him if he was happy.The man answered YES without any hesitation.So they took him to the king. The king asked him the same question, are you happy. The answer was the same unequivocal yes. So the king asked him to to give him his shirt. The man said ,'I don't have shirt, I don't need one '. No wonder he was happy.So the story that I am  going to tell is story of one such happy man.
         I knew this guy , who worked in the hospital where I went . He worked in a housekeeping. I knew him as I saw him everyday in the hospital . He would say hello and I would respond . Then he knew that I was going to Gym , so then he started giving me advice on the body building. He also started telling me about the diet to 'build' muscles.Sometimes he would ask me about health issues.But not too often . He was planning to retire in next couple of years. He told me how much money he had in retirement plan.It was less than what many doctors make in one or two months.But he was happy and never complained about work or life or for that matter anything.
       One day when I was waiting for elevator, he came out of the elevator and  stopped me . He told me , he needed $100. He had to pay some tax. There was no way I could have said that I don't have it . I gave him the money. He had promised me that he will return the money.I continued to see him off and on in next few months . He never said anything about the money . The amount was too small anyway. Then one day he asked me if I could spare few minutes . He too me to credit union bank ,asked the cashier how much did he have in the account. Then asked her to give me $5.Over period of next year, he did this few times . There was no way for me to keep a track of how much he gave me . I am sure that he did give me all $100.I have talked to him after that sometimes Same talks ,same happy attitude, never sad face or complaints. Never asked me for any money.He retired and started doing part time work. This a guy, who had hardly any money, needed $100,but had conscious to return it, and was still very happy. And I see every day people , doctors , who have 10 times more money and are still unhappy .So the happiness is state of mind and not dependent on amount of money that one has nor on any external sources.