BARKING A WRONG TREE

      We often use this term , "barking the wrong tree ". I have personally experienced this type of behaviour many a times In medicine we often blame the Insurance company for the increasing cost of the insurance premium. But to some extent this is at least to some extent' barking the wrong tree '. The insurance company collects premium and distributes it to providers. It also has to pay it;s employees and the overhead to the agents and the advertisers and the claims management team etc. So whatever is left is the profit. So if they pay more for the overhead or for the medical expenses-health care claims, then they will have to 'increase' the premium as they have to have some profit.(especially to show it to their share holders )I do not deny that some of the CEO of the insurance company do make what I would feel as outrageous bonuses.But essential if we continue to 'blame' the Insurance company for the increasing cost of the health care, then we are 'barking a wrong tree'. But today I am not talking about the health care cost . I am talking about a patient.
     I was consulted on this 55 years old patient , who was admitted to the hospital for shortness of breath. As it happened he was having shortness of the breath for last 6 weeks and had made appointment to see me . He was to see me in a week before which he got worse and came to hospital . He had  a history of clot in the leg and it had travelled to lungs about 6 years ago . This happened after the knee surgery and so he was prone to it and was treated with' blood thinner', for 6 months . He did OK But then last year he was short of the breath. So was admitted to hospital and was again diagnosed to have clot in lung and clot in leg. So he was treated with blood thinner again . This time he was seen by a blood specialist . He stopped the blood thinner 6 months down the road. The work up to see if his blood clotted too quickly was mostly negative.
      So this time when he was admitted to the hospital , they suspected clot. Indeed he had a clot in the leg but the CT scan of the lung was negative for the clot in the lung. So when I was consulted , the admitting doctor also was thinking that all that we needed was to continue the blood thinner , may be this time for life long . In fact i myself made a comment to the patient , that "just because barrel of a gun is empty , does not mean that the gun did not fire. " We use this line when there is a clot in lungs but not in vein . But I was not sure as to why he was short of breath for LAST 6 WEEKS . It was possible that due to some clotting abnormality, he was 'throwing' clots in the lungs and that has caused his shortness of the breath. .But like as I usually do I made him walk. I walked with him . As we walked , I was talking with him. As we walked for may be 50 feet or so , I asked him if he wanted to continue or go back to the room .He told me that he was short of breath and was feeling little dizzy and felt he was sweating. I went back to the room and checked his oxygen . It was 100% and he sounded clear on his lungs . I told him that I don't think it was lungs that was causing his shortness of the breath , but it is possible . But I was concerned about his heart. So we ordered a CT Coronary scan . In this test they inject  a contrast and the 'pictures' are taken very rapidly, all most 64 pictures per second. This gives coronary anatomy.It is may be 85 % accurate (or may be more. )It was abnormal So we consulted a cardiologist . He agreed and did a cardiac cauterisation . One of the main artery was blocked 85 % with a plaque. The cardiologist put in a stent and the patient did well This was at such a location that it is called 'widow maker'.
       So I thought that he had a recurring clot in the lungs as the cause of his shortness of breath.But as it terned out his shortness of the breath was due to critical coronary artery disease. So I was "barking the wrong tree!!!!"

UNCONVENTIONAL CONVENTIONAL

      In medicine there are things that are conventional in certain situation ., but are not conventional under other circumstances. Some of the examples that I can give would be use of certain medicines that are not recommended or not used for certain diseases.are used under special circumstances. Albuterol, which is bronchodialater and used to treat asthma or COPD, is used to treat high potassium under certain situation.I came acrose one patient sometimes ago that may fall under same category.
      I saw this patient who came with a diagnosis of pneumonia. He was a66years old patient , who had quit smoking few years ago . He started with cough and it continued . He took over the counter cough medicines , but it did not get better. He then had an episode of coughing up of blood . He had also lost 5-8 lbs of weight . He went to a' walk in clinic' and they did chest X-ray. The chest X-ray showed 3 masses. They told him that the chest X-ray was not normal and they would treat him for pneumonia . But he needed to see a lung specialist . So he came to me . He had brought with him the X-ray. I saw it and knew that he most likely had Lung Cancer and not only he had cancer , but it was inoperable. I explained him my suspicion and the work up . I told him that we needed to answer 3 questions , 1Is it  Cancer, 2 Has it spread  and 3 What can we do for it. I did tell him that since there were 3 separate masses most likely it was inoperable. We did the work up . I ordered a CT scan and a PET scan and breathing test and a bronchoscopy.
     The bronchoscopy showed that there was a tumor blocking the right main bronchus , going to right upper lobe . I did the biopsy and it did confirm that it was lung cancer . I saw him in the office and discussed with him and his wife .The type of cancer that he had could be treated with chemotherapy as the best option of the choice. But the tumor was quite bulky and he had it in right upper lobe and right  middle lobe and left upper lobe. But there was also the tumor blocking the main bronchus partially . So in addition to sending him to a oncologist , I also sent him to a radiation doctor.
    He saw both doctors , but the radiation doctor wanted to treat this with chemotherapy and did not want the radiation . He did not call me . So the patient was scheduled to get a port put in . When he showed in the hospital to, get the port, his heart rate was 150 and the blood pressure was low . So instead of getting a port put in , he was admitted to ICU . I saw him , so did a cardiologist and the oncologist. He was started on medicines for the increased heart rate. In next 48 hrs he got many different medicines to control heart rate. Nothing worked . He continued the same rate and rhythm and the blood pressure was low . I could not give him any medicines as it would increase the heart rate. We had done a new CT scan as I was worried about fluid around the heart due to cancer. The fluid around the heart could cause blood pressure to drop.There was no fluid , but the tumors were there and the enlarged lymph nodes were pressing on the pulmonary artery .So I called the radiation doctor and asked them to reevaluate. He agreed and and started the radiation treatment . I also called the oncologist and asked them to give the chemo right away , and they did . Within 2 days of the 2 radiation treatments and one cycle of the chemotherapy , the heart rhythm became normal and the rate was normal too . He stayed in the hospital foe next 5 days and was discharged home . He was off oxygen and most of the medicines .
     I COULD BE 100% WRONG , but I believe that the radiation treatment and the chemotherapy effectively reduced the volume of the tumor enough to reduce the pressure on the heart and then in turn reduce the heart rate. So the radiation treatment ,which is normally not first line of treatment for his cancer, was used and it worked.The only other possibility is that the GOD intervened. (may be giving me the thought of trying to push for the radiation and chemotherapy !!)

THE MODERN DAY MEDICINE

     Every time I look around the technology amazes me . The other day I went with a real estate agent to look at some properties . She would dial a number and the cell phone would open the 'lock' on the box that contained the keys to the property. We did not have to call the listing agent or he did not have to come to the place. The listing of the properties and the information is on the computer is old  development. But when we used to give 'lectures' , we had to get slides in the past and then we had to take our computer and use it for the slides. But now we can take it with us or email it .But this kind of technology progress is exponential. or geometric proportion.In comparison to that medicine has progressed less fast. But in spite of that when I see medical inventions in thoughts or drugs or equipments, I am amazed.every day when I read medical news . So this blog is related to that fact.
      When I was in medical college , I had read about vaccination. I was in India and Tetanus was not uncommon . The vaccination was advised , but we used to see the patients who already had high risk of getting  tetanus, we used tetanus serum . These were antibodies that were developed when horse was given the vaccination and then his blood was drawn and the serum was prepared. I was in medical college and had seen one of my friend's sister diagnosed and die of breast cancer. So I had a primitive idea. Why not inject 'tumor extract ' in horse and then the horse will develop antibodies against the tumor. Then we can inject those antibodies in the patient , which will kill the tumor. Off course this idea was to primitive and never would have worked . But all of us now know about use of antibodies in treatment of cancer.
     But then I heard about a a new treatment for elevated LDL cholesterol. All of us know about the satins, in use of treatment of high lipids. But then I saw a study of the treatment of elevated lipids by antibodies against an enzyme that is required for the lipid metabolism. I don't want to try to explain the exact way it works. .but it suffices to say that when this enzyme is attacked by the antibodies against it, the production of LDL cholesterol is reduced. So now the antibodies are used to treat the disease or condition,rather than satins.
     When I was in the medical college , I had  thought about the treatment of obesity or to be specific, treatment of fat belly. As we know many patients have not much fat on extremities , but the abdominal fat is major issue. The studies have shown that the abdominal fat is the cause of the problem. I did not know this in past . But I had thought about taking care of the abdominal fat by developing a solvent , that could be injected locally and then it will dissolve the fat and then one can suck the liquid out. I had no idea as to possibility of any agent or what could be safe and can be not only injected, but also sucked out . I don't think any agent is available even today. But the other day I read a new drug being approved by FDA, called Kybella. This was approved to treat "double chin. IT is an injectable medicine and may need to be given few times to be effective. (It reminded me of Seinfeld episode , or monologue, where they are talking about seedless water melon(or grapes).he states that when other people have 'desire to 'cure' AIDS or Cancer , some one was thinking and working on seedless melon!)

MEDICO-SOCIAL ISSUES

   We in medicine often talk about socioeconomic issues and how it affects various aspects of health care, It is well known that the socioeconomic differences do make difference in patient seeking medical help , the time of diagnosis, acceptance of treatment and the outcome . It also makes difference in preventive medicine. But there is another problem in medicine . This one I call socio-medical. The medical conditions are treated , but we in medicine often face social conditions , that we have to address or at least take in to account the social problems when treating the medical conditions. When we diagnose a patient with cancer and they need radiation treatment , sometimes we find problem in out patient treatment plan . These radiation treatments are given on daily basis, 5 days a week , each time the time needed is couple of hours. But there is a need for some one to bring them to radiation center. And we find NO ONE in family to do the jab. Then the patient gets transferred to rehab center or some such facility, approved and paid by medicare. So essentially WE are PAYING for it and I am not sure if this is essential medical care or essential social care.
      This I have seen in many other conditions , when we need to keep some of these patients in other facilities when one could easily treat some if not all of these patients as out patients ,patients staying home . But I came across a patient some times ago ,that made this issue worse and I felt like writing about it. I saw this 68years old female , who had smoked all her like and gave up smoking ,about 3 years ago . She was on home oxygen and over period of last year she continued to get worse and could do less and less ,as far as physical activities are concerned. She was pretty much room bound , if not bed bound . She was then referred to Hospice. But then she was sent to hospital .The diagnosis was COPD, but real reason was different. She was comfortable , but could do hardly any activity. She could not get out of bed or even turning in bed . We started treating her , but pretty soon we realised that she was not going to get any better. So when we talked about the discharge planning, I realised the problem and as to why she came to hospital; .She was leaving on one of her relatives and that person could not 'keep' her anymore.This was due partly to her deteriorating physical condition and partly duo to other reasons. She had her own kids, and they lived near by , but they had 'no space' in their house.
       So she had no place to go . We worked with the social service , but she had no physical therapy potential as she could not even get out of bed on own .The hospice could not help as she could not be accepted in their in patient facility as she was not 'dying' .So this is the socio-medical problem . We are going to face it more often as we are seeing 'aging' population and kids getting older and unable to care for the older parents.
     May be society has a solution. I had thought about a" social bank ". It is not my original idea. But it is not only great , but practical. A small group like a church can 'set up ' bank . When some one needs a help, So if one family needs his or her parents to be taken to doctor or physical therapy or radiation treatment, and he does not have time, some one who has time can do that job . So in the church 'bank' one gets balance of +2 hours or whatever time he spent and the other person gets debt or negative balance.So in future positive balance person can 'cash in ' his balance from the person who has negative balance . And ideally it could be done among many families . Only one condition --every body has to be HONEST. 

POVERTY IN ASKING

     I have often wondered as to the validity of asking for 'things' from the GOD. We almost treat the GOD as a human being , when we ask for things that are material things. If HE could 'Give' us something ,then He could 'take away' things from us ,and  then if he does punish or reward , then there is no difference between HIM and human beings. But this is just for the discussion. In any case I DO pray and DO ask for'things' from HIM . On top of that I do believe that the prayers work . (I did write  a blog on prayers in past. ) But today I thought about this due to a patient that I saw the other day. This was a 53 years old patient who came to me foe possible sleep apnea. In recent past the sleep apnea has gotten more importance and publicity in media . So more people are aware of it . Just to state the importance of the sleep apnea, sleep anea has relation to high blood pressure , diabetes, atrial fibrillation, stroke and many other things. S
      So this patient that I saw , had sleep apnea.He had sleep study done by his dentist and it did show the sleep apnea. But he decided to do nothing. Now he wanted to have treatment. So there was not much in the history or examination. So when we were talking , he told me a story.Several years ago he was separated /divorced from his wife and it was 31st of December. It was freezing and he could not continue to in the party at a friends place . So stepped out in the back yard. He was depressed and frustrated and did not know what to do . So he looked up and said,'GOD ,I can't do anything , YOU are in charge now'. And according to him the GOD said to him , "I AM ALWAYS IN CHARGE!"
      That brings me to  title of the blog. I reminded him of the story of Kramer in sitcom Seinfeld. In that episode Kramer is suing a corporation for hot coffee burns. The company executive are ready to offer him thousands of dollars for settlement.When Kramer comes in to discuss the settlement, the executive starts talking about it. So he starts with saying that Kramer can have as much coffee as he wants for the life .Before he could offer the monitory settlement, Kramer accepts it. So he never got the money. We act like that . HE can GIVE us much more than what we ask . So we ask for little things , when HE is willing to give much more. WE ARE JUST TOO POOR IN ASKING !!!!

FAILURE OR SUCCESS

         We in medical practice come across situation when we have to think and decide as to if our actions or decisions are a success or failure. I am often amazed as to how we evaluate a success or failure of our treatment or actions. I had come across an article in which they were talking about a chemotherapy for lung cancer.The chemotherapy agent was approved for treatment of the lung cancer. The study that the FDA looked at showed that the 'survival' was increased by may be 30 days. (It was long time ago and I do not remember the name of the agent or the exact prolongation of the time ,but it was not more than 30 days . )The cost of the treatment was enormous, may be $10000 or more. Is prolonging life for 30 days with metastatic cancer -irrespective of cost , a success ?To some it is and to others it is not . Look at Steven Hawkins, He is paralysed and has trach ,but still does so many things scientifically important in Astrophysics .So sustaining life was worth it for him. So we will call success.I had a patient who also had myopathy and did go on respirator at home for last 25 years. She had young kids and it was worth it and I call that a success. But today the story that I am going to tell is that of different angle .
        I saw this patient who was 65years old . He was a had abnormal chest X-ray and was smoker and so was sent to me . I did the work up and did the CT scan and bronchoscopy. He had a cancer of the lung. He had breathing test done and it showed 'adequate reserve' or the lung capacity for doing resection of the lung cancer. So I referred him to a surgeon .He was evaluated and he agreed to do the surgery. He had no other history except high blood pressure. So he underwent the surgery. The surgery went well .He had resection of the lung cancer. The surgeon had to resect 2 lobes out of 3 .He was doing OK post operatively. When lung is resected there is always some air leak and fluid leak as the lung has to heal .This usually takes about 7 -10 days to heal and then the tubes that are inserted to drain fluid and the air, are taken out. In this case the lung or the remaining lung would not heal. The fluid drainage was less , but air leak continued. The surgeon did couple of things, including going back in. But there was no change . So we decided to put a one way valve on the chest tube . This valve would allow the air to get out but not get in .
       So he was discharged and was followed by the surgeon . .Even after one month the air leak continued. So then he was referred to other university centers . He decided to go to one place . They did another surgery and the problem continued . So he went to still an another place and they did another surgery . They 'crushed' the chest wall and collapse the lung . This stopped the air leak. But this deformed the chest to such an extent , that his remaining lung was almost nonfunctional. As not much blood going to the remaining lung and it was deformed , it was causing recurrent infections. We had to treat it with antibiotic and most of the time intravenously.
       I was not too sure as to what could be done . I did the lung scan and it confirmed that the right lung showed very little air going to it and very little blood going to it . So essentially it was not 'contributing ' anything to the lung function, but was cause of all the problem. So I suggested to go to the surgeon who had done the last surgery ans see if he could take it out. He thought about it , but did not do much . But then he decided and saw the surgeon and did have surgery . It did not 'cure' anything and he was admitted to our hospital . Some of his problems are still there and the 'jury' is still out as to if this last surgery was a 'success'.By the way there was no cancer for last 10 years. So the 1st surgery was a"SUCCESS' ,or was it ?

EMPEROR'S NEW CLOTHES

       In the past we were old a story of Emperor The story was that of a emperor. He wanted to have a new clothes. But he wanted to have the best and the lightest clothes.So many tailors tried and failed . Then there was this shrewd tailor ,who accepted the challenge. He took the measurements and then stated in palace, had good food and enjoyed the life . He never stitched any clothes. So the day came in when the king was suppose to get new clothes . He pretend to dress the king with new clothes . There were no clothes , but he made all the actions . He convinced that the clothes were so 'thin' that no one could see them . So the king went in the city wearing nothing . But no one could say anything as the king was convinced that he had the most thin and the lightest clothes . Then a small kid who was standing to watch the parade ,said loudly,"why is king going in the streets naked ."
   This story comes to mind, when we see certain patients. So I thought of this phrase,when I saw this patient. I saw this lady who was 65 years old , She was a smoker and had usual smoker's complains. She had some cough , with minimal sputum. She had cheat X-ray and then had CT scan of the chest . The CT scan showed clear lungs , absolutely no abnormality. But the CT scan showed lymph node enlarged. There was single node enlarged, which was located under the division of the main bronchus. This is not the easiest place to do biopsy. (this could be biopsied with a ultrasound guided needle insertion through bronchoscope . This is a relatively new technique.) I talked to her about the choices . She refused to do any tests. I wanted to do a scan called PET scan . The PET scan picks up cancer ,may be 85% of the time. She did not want it.The PET scan was done after several attempts to convince her that this would help. The PET scan did show' increased activity ' in the lymph node . But showed no activity in any part of lung or any other lymph nodes or any where in the body..This is very unusual. But I had to do the biopsy . I called another doctor who does the special biopsy and he gave her an appointment . But on the day of his appointment , she did not show up . So we again called her . She did not want biopsy. She however agreed to do follow up CT scan . By this time the CT scan was more than 2 months old.  So doing CT scan in next 2 months was not a bad idea. In my mind the one isolated lymph node without seeing anything in lungs and no other nodes being enlarged , was not likely to be cancerous . And if it was cancerous , that was not a surgically resectable. cancer. We continued to have some problem getting her to do tests and follow up. After some efforts ,she did do a follow up CT scan , and it showed no change. So she was happy and so was I. But then she saw a cancer doctor for some other reason ,. As a routine he ordered some blood tests and it showed abnormality. So he called me . I convinced her to to have biopsy. She did agreed for the biopsy.
      She had the biopsy and it showed the lung cancer , The new scan did not show ANY ABNORMALITY IN THE LUNGS . But she had the lung cancer . This is mind boggling to me . So she has lung cancer showing in the lymph node , but there is no primary tumor seen even on CT scan or PET scan . This is what I called the Emperor's new clothes.