SEPARATING FACTS FROM BELIEFS

   In our life we 'know' the fact and we have certain beliefs . But we have difficult time separating them . In one of the old Indian story there was a King who had a very smart assistant or adviser. For those who are Indians , I am talking about the AKABAR and the BIRABAL . So one day when they were walking in the city , the king saw a mother kissing her child , which happened to be a ugly looking child. So he made a  comment that how can she not know that child is ugly? Birabal said that she 'believes ' that her child is the most beautiful child . The king did not agree. So next day Birabal called the mother in the palace and asked her to bring the most beautiful child from the city  to the palace by that evening. The mother left the palace and then looked all over the city but could not find a child that she thought was better looking than her own child . Finally she took her own child to the palace . Birabal looked at the King and gave the mother gifts. So we tend to have difficulty when we want to separate the facts and our beliefs. It was said that president Clinton could 'compatmentalise' the different parts of his life . But really can anyone do that ? I do not like to talk about politics in my blogs , but I am amazed at the current state of politics . On one side people can't find any problems in their candidates or side irrespective of the issues that have come out including e-mails or IRS audits or our ambassador being killed ,or reporter's emails being tapped and so on . On the other side people who are supporting a candidate, can't find fault with statements like 'how good is Canadian health care system' or 'there is problem with corruption and lobbyist in DC , but I use it when it is to my advantage ' or many other . And to my surprise the people who believe in purity of thought believe in these candidates. (If a candidate states that there is increase in prostitution in our city , and I would like to get rid of it , but I have used their services when I needed it ,Do you think you would vote for him ?)I am also amazed at the attitude of one side when Lion was hunted and killed .One side which cares for the life of Lion but do not care for the life of unborn baby . And the other side which cares for the life of baby but have no problem with cruelty of killing the Lion or for that matter billions of animals that are slaughtered (approximately 10 billions  a year) to give us the 'food' . Those who are oppose to killing animals for fur,or for medical experiments , have not much problem with the way animals are killed daily .(For those who are interested there is a book The Ethics Of What  We Eat by Peter Singer and Jim Mason - this is' must' read).But that brings me to the medical story .
     I saw this young man , may be in mid fifties. He had quit smoking few years ago and was having increasing cough . He was treated by his doctor with antibiotics and then when he did not get better he had a chest X-ray . The X-ray showed congestion and small fluid and so he was treated with more antibiotics and then a repeat X-ray was done . It did not show improvement , but showed worsening . So he had a CT scan and then was sent to me . When I saw him he was quite Short of breath on physical activity , but oxygen saturation was good. I saw his CT scan and knew that most likely he had a cancer of the lung and the fluid was due to the cancer and that would make it inoperable. I could have done drainage of the fluid as an out patient and then the Bronchoscopy and the called the catheter insertion for the malignant fluid and then asked cancer specialist to see him . Doing it as an out patient would have taken may 3 weeks or so to get treatment started. I did not want to wait . So I admitted the patient , did drain the fluid next morning , had a surgeon see him do additional biopsy and put in a catheter to drain fluid periodically on 4th day of my first visit. (For recurring fluid collection we can put in catheter, that can stay in for several months and patient can drain own fluid as needed). We got him to see a cancer specialist 5th day and then the treatment was started . I was very proud of myself to have done this so quickly. I spent significant time answering all the questions . He was discharged . He walked in our office about 4 days or so after discharge, complaining that the catheter was clogged . I was not in the office and even if I was in the office , I could have done nothing . I spoke to him on telephone and told him to go to ER . I called the ER physician and told them the problem and the solution , namely to use certain drugs to unclog it . The ER physician did not do it , but decided to admit him . I went to see him at 5pm and the catheter was still clogged . He was seen by another lung specialist who ordered CT scan but did not do anything to catheter. I went in and unclogged the catheter. The next day he was OK . On third day I was told by the admitting physician that he wanted to change the lung specialist . he was not 'happy' with me as I could not help him in the office .
      I was little upset at first as I had done more than anybody else . I diagnosed and got him started him on the treatment as quickly as nobody would have done it or did it . I was the one who unclogged the catheter , though not in my office at 11 am , but at 5 pm . So why was he unhappy? The answer is in what I said in the title of the blog . He was MAD as he knew the outcome of inoperable cancer, that was aggressive . But he could not be mad at his smoking or the bad luck or the 11 years and 15 years old children . So HE could not SEPARATE the FACTS from his belief. This may be the same for the popularity of one candidate over others.We are all mad about the state that we are in . But we have difficulty to separate the facts from the fiction.Many of the things that we would like to change , are not practical or even possible. The TY anchors and the multimillion dollars contract talk show hosts have difficult time with this , He was only a unlucky patient!I 

UNPREDICTABILITY

     I have always known that there is unpredictability of life or in life . I have seen that in medical practice many a times and around me in people that I know . One of our close friends daughter was married to a doctor . His son had persistent pain after a basketball injury and needed narcotics to control the pain . So further work up was done and it turned out to be a bone cancer of the pelvic bone . He got radiation treatment and then the chemotherapy . He was OK but the chance of  cure is very rare. One of the days when he was going for the chemotherapy, the father took his motorcycle to get a oil change . Some one hit him and he died on the spot . The kid died latter on of his cancer . This is the uncertainty of the life .But this could be considered as bad luck . But today I want to tell you a story of one of the patient to let you know on the uncertainty in medicine.
     I was consulted on this some 60years old patient, who was admitted with the fluid around the lungs . I saw the patient. Her history was that of a patient who does not believe in the current medical system or the treatment and would prefer 'natural' cure or at the treatment. She was out of country and was diagnosed to have a cancer of the cervix. She did not want the surgery or any additional treatment. This diagnosis was done about year and a half . She was back in US . But continued not to go to see a physician .In last 4 weeks , she developed swelling of the legs and swelling of the left arm and some shortness of the breath. So she came to the hospital .She had CT scan of the chest and the belly and the pelvis. The scans showed that she had fluid around the  lungs. She also had several lymph node enlargement in the chest , neck and in the belly . She also had abnormality in liver and tumor in the pelvis . She had hard nodes in the groin and they were pressing on the venous drainage and so she had swelling . In short she had what I would call "wide spread metastatic cancer ."
      We had discussion with her and her several family members. We talked about conventional treatment with chemotherapy, but also talked about 'alternative ' treatment with things like antioxidants and many things that are talked about ,like sour sap leaves it's pulp and pyknoginole and shark cartilage and many other things. We drained the fluid and then since it was positive for cancer cells , put in catheter on both sides to drain the fluid . We were draining about 300 ml to 400 ml a day. She agreed for the chemotherapy .After the 2 cycles of the chemotherapy, her swelling was gone .I could not feel any lymph nodes. and the fluid drainage was minimal. she was walking without any shortness of the breath. Now the need for the drainage was less than once in 10 to 12 days .
     When I saw this lady she had incurable , wide spread cancer and I was not sure how she was going to do . She had avoided all the available treatment . Now agreed for all the treatment and RESPONDED. The jury is still out on the long term prognosis . But certainly  how she responded was unpredictable !

BROKEN HEART

     We often talk about how some one broke up relations with some one and broke his or her heart. In that sense we feel that the 'emotions' come from or originate in heart. In reality all the emotions come from brain. But some how we attribute the heart as the site of 'love' and 'feeling'. Even when we talk about various "Chakras" in the the Hindu philosophy, we talk about lower Chakras and the the 'highest ' Chakra. The lowest is located at coccygeal level , then the next one at sacral and then at  Lumbar level and so on . The one situated at the level of the heart is considered at the higher level than the coccygeal level. When I explain the improvement in our 'goals' that occur in our thinking , with the practice of the meditation,we often say that the attention towards the procreation or excretion or even hunger, is inferior to the attachment that we have with heart. So our term of the broken heart is emotional one . But what I am about to say has nothing to do with this conventional 'broken heart'. But it has to do with medical condition called broken heat syndrome.
     So let me tell you a story about the broken heart patient that talked to recently. She is lady that know for long time . She is about 62 years old and has no major medical history. She goes to Gym and does lot of weight training and also does power walk, sometimes as much as 5 miles. Her brother ,who is well educated lost his job and could not find full time job . So he moved in with her and then after a while got part time job. One day when this lady came home late , she could not find her brother in his room and the car was still in the drive way.So when she looked for him , she found out that he had shot himself and committed suicide. So the next day her all relatives came home. The very next day or so at night she woke up and could not breath. She was feeling pressure on her chest and started coughing clear sputum. So she woke her family as one of them was a cardiologist . The called 911 and then she went to ER. Further work up showed up that she had congestive heart failure and her blood test for heart attack was positive . The cardiologist was consulted and they did the Echo cardiogram and it showed that the pumping action of her heart was reduced to 25%. This was completely unexplainable and so they decided to do a cardiac cauterisation to find out if she had any blockages in the coronaries. The heart cath showed that coronaries were 'clean' and there were no blockages. She was improving and was sent home . HER DIAGNOSIS WAS 'BROKEN HEART SYNDROME' .
       So this as also called Takotsubo disease. This usually is preceded by EMOTIONAL event , like in this case her brother had committed suicide. The emotions cause (may be ) spasm of the coronaries and this leads to some release of the enzymes , which leads to positive blood test for the heart attack. The spasm of the coronaries leads to weakening of the heart muscles, but there is no long term damage. Most of the patients recover in short time , in a week to few weeks.
      So emotions DO trigger a heart weakness .So may be HEART is real location of EMOTIONS and not the brain after all.  

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.