STATIASTICS

    Many years ago I had heard comments about statistics. I am sure you can add to the list . Some of them are interesting. One was ,' there are lies and then there are lies , and then there is statistics!'. The other one was, 'if you put one hand in boiling hot water and other in ice cold water, then statistically you are at comfort'. So sometimes when we in medicine talk about chance , or probability or possibility , we truly are talking about what happens to majority . But by no means this is 100% but we in medicine  get our opinion further confirmed as majority of the patients behave as we knew from the statistical data. I  have been always puzzled as to why in a study all the patients don't behave same way . The sugar is sweet and everyone who tastes it will say the same thing . Then why a particular cancer in particular stage behaves differently in different patient ?These thoughts came to my mind when I saw this 74yeras old patient recently.
      He is a 75 years old male whom I saw several years ago . He was maybe 60 years old at that time and had come to me for an abnormal cheat x-ray. So I did a CT scan and then a biopsy. The CT scan showed that he had a mass in the right lower lobe and there were number of lymph nodes in the chest that were enlarged. This indicated spread of cancer to these nodes and made him inoperable . The biopsy confirmed the lung cancer . So he was treated with radiation and chemotherapy. Per my 'thinking' -which was based on the statistical data of this type of cancer in inoperable stage,- was that  he was not going to last mare than 2 or 3 years. I had told him that and he had known it to from other sources including oncologist. Certainly we all read the same books and know the same data. But he did not die . So I continued to follow him and he did OK .Few years passed by and it was more than 10 years that he not only did not die , but had no evidence of the cancer. Then it happened. His CT scan was abnormal. So I did a bronchoscopy. He had new cancer . So he was started on new chemotherapy. We could not do more radiation . So I followed him up and he continued to do well . May be it was 2 more years and he coughed up blood. So I did a bronchoscopy . His chemo was stopped as he had no evidence of cancer . My bronchoscopy showed that he had recurrence of the right sided cancer and there was a different cancer on left upper lobe . The interesting part was that in spite of me seeing the cancer - a new one - on left side , the CT scan did not show any cancer, not did PET scan showed the cancer. ( another statistical data which was not right ). So he was given different chemo . This time he got quite sick. He could not eat and developed weakness in the legs and had number of other issues . He also had pneumonia and swelling of the legs . He was so weak that he could not even stand up . So I told him and to his wife that there was no sense in continuing the chemo and made him 'no code' . He was discharged to extended care facility. He needed help and the wife could not have taken care of him at home . I did not think he was going to last more than few weeks . So I forgot about him . He showed up in my office about 7 or 8 months down the road . He was walking , and eating well and was doing OK.So I did another CT scan and as it was abnormal did another bronchoscopy. He had recurrence of the cancer on left , but none on right. I had stopped counting as to how many times he was cured or told that he was cured and had new cancer or recurrence of the cancer . Statisticaly this is impossible . He has defied  all the odds. 

ONE STEP AHEAD (OR BEHIND)?

      When one goes to a physician , they expect that the physician will be one step ahead of the treatment or the diagnosis. And most of the time it works . But at times it is a frustrating and the story that I am going to tell is one such . As a physician we like to help , anticipate and treat or prevent the problem that may arise. So it is quite frustrating when we come across the surprise . So this is such a case that in spite of every one we did not anticipate the outcome .
      I saw this 45 years old male that had chronic cough . As usual I did the allergy testing and the breathing test . The allergy test did show some allergies and the breathing test showed that he had mild asthma. So I put him therapy for the asthma and he did improve . In next few months he was seen by me for one or two times and then was lost for follow up . He had some personal issues and so was out of town and was doing well and so postponed the follow up . He came back to me as he again had some cough . His lungs sounded clear , and so I sent him to an allergist. Then he had further allergy testing . When he went back to him he was told about the allergy shots . At that time he was having shortness of the breath . So he was given steroid shot . He continued to feel shot of breath , so he decided to go to ER. There was nothing positive in the ER on examination or chest X-ray . But I decided to do CT scan .The CT scan showed that he had clots in the lungs and he also had pneumonia . So the pneumonia was not seen on plain X-ray and he had no fever. He was admitted and was started on blood thinner . He was anemic and so I did the work up and I also did the work to find out as to why he would get clots. I also called a blood and a cancer specialist . We treated the pneumonia and then he was discharged. He was followed up by me and the oncologist . He was readmitted in less than 10 days as he had fever . in spite of the antibiotics . So he was treated for the pneumonia and was seen by infection specialist . I ordered the scan of sinuses as I was not convinced that the fever was due to pneumonia. He did have bad sinusitis , so I called the ENT consultants . They saw him and did not do anything different. They told him to see them in the office. He was doing better and was discharged. I saw him and he was still weak and was seen by all the consultants as out patients. I did follow up CT scan and it showed that the pneumonia was better . He was feeling better and had no fever and was back to job .
        So when I saw him in the office I was happy that finally he was doing better and we had done well with him , anticipating the clot in first place , then the sinus infection and then the follow up on Ct scan etc He looked OK and told me that he had much improved energy . The I saw him and noticed a lump in the neck . It was lymph node enlargement. He had shown it to his PCP and he told him to watch  it . I was not going to do that. I ordered an antibiotic and CT scan of neck . I told him to see ENT doctor  ASAP .The next thing that happened was that he was admitted and  had a biopsy of the enlarged lymph node and HE HAD LYMPHOMA.
   

ARE WE AFRAID TO DIE?

     I t amazing to me how we all TALK about different things, but then when we are faced with the situation in our own life , we don't walk the talk . In Hindu philosophy or the religion , we are told that this world is not our HOME , and the this physical body is mortal , while the soul is immortal. We are all afraid to die or leave this mortal body. We are told that one should not eat meat or drink alcohol. So in the temple we do not allow serving alcohol or meat. But when I attend the social function out side the temple , one and all of the people who are on boards and are presidents and are on various committees freely drink alcohol and eat meat. I have seen in my life many patients who are ready to die even when they don't have terminal illness. Some of these are older and some have lost their long term spouse and may be feel that they will be united with the spouse. I really don't know. But the we come across many that are really suffering with significant illness but are not ready to dye.  I don't have reason for it . But I thought about this when I came across a patient in recent past.
      I started seeing this young patient , may be 55 years old in the hospital , She was an ex-smoker and had some cough . She was admitted to the hospital and then had work up gone . She had CT scan and the bronchoscopy. She needed some special biopsies to diagnose cancer of the lung . In spite of the young age , due to the spread of the cancer and the location of the tumor, she was not a surgically resectable stage . So the radiation and chemotherapy was given. She did OK , But after one of her chemotherapy treatment she was admitted with she had fever and low blood count and was admitted . This time she did not want previous doctors and so I was asked to see her . I knew that she needed treatment for possible infection , but in addition she needed treatment for her Chronic lung disease related to her smoking in past .
    She did well and did few more courses of chemo therapy . I saw her many times and was pleased to see her husband involved in her care. She had a job and was productive, Over period of next year or so her condition continued to get worse. She was more short of breath and had constant cough. I did do bronchoscopy and she had significant narrowing of the opening of one of the segment of the lung .She was not getting better and so she decided to go to memorial hospital in NY. They had no suggestion. I did check on amount of air and blood going to each lung and sure enough the right lung was contributing less than 30 % So no wonder she was shot of breath. I send her to another doctor to see if he could put in a stent in the narrowed bronchus and improve the function. He could not . Now she was needing more than 10 L of oxygen , In past her need was 3-4 L . Such a high flow need eliminated walking . After a great discussion , they agreed for DNR. She did not want to go on respirator. I decided to try something NEW-OLD thing . Several years ago we use to put a catheter in the wind pipe and deliver oxygen through it directly in to the trachea or the wind pipe. This reduces the oxygen need . I have not done one of these catheter insertion in several years , so I had to talk to 5 different people to see who could do it. And finally it was done . Her oxygen need went down to 3-4 L from 10 -14L.So she could go home . Things were going well for a change , and she was home for may be 3-4 weeks , She was readmitted and was short of breath The usual treatment of antibiotics and steroids and oxygen and other stuff was done . She seemed to get little better.
    The one night I got a call that she was quite short of breath . Her oxygen was borderline and her carbon di oxide was going up . This is a sign of the lungs not working,.This was not a surprise to me, But what surprised me was the nurse telling me that she  and her husband had changed their mind and wanted to go on respirator. So she was put on a respirator. In spite of the respirator , they had difficult time , so I went to see her at 4 am . We decided to not only heavily sedate her , but to paralyze herThe thing did get better , may be 5% . and we continued to have discussion with the family . On fifth day the family along with my impute decided to stop everything.
     So in spite of the suffering that she was going through , the family and she decided to go through the futile effort. And I understand ,May be I would have made the same decision.   .

WRONG TEST RIGHT RESULT

    I have seen this in life and in medicine , that one does wrong thing , but gets right result. We sometimes call it side benefits . But this does not happen too often , thank God. So recently I had a case in which this was obvious .
   I had seen this 70 years old patient foe chronic cough and some shortness of the breath. He had history of heart problem and was treated by a cardiologist and his heart was OK . So he came to me . He was not in distress and his lungs sounded clear and so I did the tests like Breathing test , oxygen check on walking and some allergy work test . I also did pulmonary stress test. All the tests came back OK except breathing test which showed mild asthma. I started him on an inhaler and gave him steroids . He got better and came for follow up once and then did not come back . I got a call from his PCP telling me that he had several bouts of cough . He had stopped the inhaler as he felt that it did not help. Interestingly enough the steroids helped and in the 5 months that he did not see me , he had taken 3 or 4 courses of steroids . Each time it worked , but as soon as steroids were stopped , the cough came back. So the PCP called me . I told her to do high resolution CT scan and the decided to do bronchoscopy. I also told her to do longer duration of steroids at smaller dose.
I was not too sure if bronchoscopy would add anything to the diagnostic scope. But I have done few bronchoscopy in past for persistent cough and did not get any different information that I did not have before the bronchoscopy.
   The CT scan came back OK . There were no damaged bronchi or what is called bronchiectasis . There was no scar tissue . So I did the bronchoscopy . The bronchoscopy showed significant inflammation. Which can explain cough and why he responded to treatment with steroids.  So I was not sure as to why the treatment for asthma did not work . Anyway I also ordered blood tests to check on Immuneglobulin. There are 5 of them and each one has a specific function. I have seen few cases in which reduction in some of them patient had persistent cough and inflammation. This was along shot. But to my surprise his all immune globulins came back very low . This condition is called CVID .It will need further work up and treatment with immunoglobulin  every month or more often.  

UNCERTAINTY PRINCIPLE

    We often say that something could go wrong , it could (Thank God not'' it will" ) But sometimes in medicine it is so true. I have seen and heard about the stories , which are sometimes referred as 'train wreck'. And I have personally seen them too . But sometimes the complications or what happens is helpful in making certain decisions . Just to give an example would be patient who has borderline pulmonary reserve to have lung surgery to take out a cancerous growth. Then he may have a scan showing spread or a appearance of skin lesion that terns out to be spread of the cancer.So now the decision is clear . Due to spread of the cancer , he is not surgical candidate . And it is also helpful to patient as well . If such a patient would undergo surgery and does not do well due to poor pulmonary reserve , and then develops spread, we would be more unhappy. Instead if we make decision to not operate we at least have quality of life . But the uncertainty in medicine is disappointing and at times frustrating. This is so true with one of my patients that I saw.

    So I saw this 70 some years old patient who came to hospital with generalized weakness. She was found to have low blood count . Her white cell count , red cell count or the hemoglobin and the platelet , which help in clotting , were all low . She was told few years ago that she had problem with the counts. But it got better and so she stopped going to the blood specialist . The counts continued to be OK for about 2 years and now she was in the hospital . She had low blood oxygen , so I saw her . I did CT scan and it showed some fluid around her lungs . So I did ultrasound of the heart and it was normal . She was worked up and found to have MDS , I this condition the bone marrow , which is the factory for all the blood cells , stops making them. She was started on treatment to improve the counts . I treated her for the low oxygen and with the treatment she got off the oxygen and her fluid got better. But the counts continued to be low . So she was given transfusions. I had talked to the family and the patient , telling them the poor prognosis. But as it often happens, unless this information comes from every doctor including the blood doctor, it will not have the effect .And then one night I got a call . She had difficulty breathing and her oxygen dropped She needed to be transferred to ICU . In next 6 to 8 hours it was clear that she had heart attack and she was in shock due to poor heart function. She was also confused and agitated. I am not sure why. But any way once the heart attack and it's side effects were seen, it was easy to make decision I had the discussion with the family and with her MDS and now the heart attack , we decided to do the comfort care. The MDS which had not gotten better and in itself carried poor outcome , was not enough to make decision . But now an unexpected heart attack made it easier to make decision .  

TELEMEDICINE ????

    I have been sometimes asked if I would be interested in doing telemedicine . I feel that I am doing the telemedicine at times for long time and even today , though without getting paid for it . When patients call me or my office and have some complaints , I look at their charts and based on the information provided on telephone and the information that I have from the past , make a decision. It may be as simple as giving an antibiotics or as complicated to ask him to go to ER. But the modern day telemedicine is to advice patients or 'consumer'  on possible diagnosis , it's work up and may be treatment. And these are not my 'known ' patients , but brand new patients that I have never seen or examined . I do not feel comfortable with the idea , though I do that too with friend and friend'd friends all the time . I don't think this is good medicine . But I thought about this when I came across the patient who was treated as if it was telemedicine . I often say that if it was possible to do the diagnosis and the treatment this way, computers would take over. But sometimes I feel that doctors are behaving like computers.

    I saw this 70 years old patient , who was referred to me for chronic cough and abnormal chest x-ray. He was having cough for about 2-3 months and was treated with antibiotics and cough medicines . The cough persisted and so he had a chest X-ray done and it was abnormal so then the CT scan was done and when it showed multiple nodules , he was referred to me . He had no fever and though his appetite was reduced , he had not lost any weight . The cough was dry and he was minimally short of breath. He was non smoker . We had no old CT scan. So I decided to do Bronchoscopy . My initial impression was the possibility of atypical infection called MAC or Mycobaterium Avium Complex . It is in the same family as Regular TB . But it is not contagious and treatment is different. His bronchoscopy and the biopsy and the TB culture came back negative . He had multiple nodules , so if they were spread of a cancer --metastatic cancer , he was not surgically resectable stage. But I decided to send him to a surgeon and at the same time have radiologist do a needle biopsy . In between ,I am not still clear why, he was sent to a cancer doctor. I am still not sure as to who sent him to cancer doctor. But he did go to cancer doctor and she sent him to a surgeon from her own group . He sent him to radiologist for a biopsy. IDID NOT GET CONTACTED OR GET ANY NOTES. All these doctors belong to same group. He had the biopsy . None of these doctors saw him in office , but he was told that he did not have a cancer.

    So at the end of 3 months he came to me . I had not gotten any reports and I was not aware that he had gone to different group of doctors and had work up done . When my office had called him in between , he had told my office staff that he was seeing a surgeon and is having a biopsy. So I gathered the information from all the doctors . When  I got the biopsy it stated "No malignant cells seen " .It did not state as to what did THEY SEE. So I faxed request to see if they could tell me as to WHT THWY SAW , not what they did not see. I never got the answer. I also could not figure out if they had done any TB culture . So this is the computer generated medicine . It had no thought process as to the possibility of MAC . So no cultures were done . No one bothered to tell patient as to what was diagnosis and what he should do next.
   I decided to do repeat bronchoscopy and called the surgeon and told him that if my bronchoscopy was unable to get a diagnosis , then he should do OPEN biopsy , not needle biopsy. With patient's luck , my second bronchoscopy confirmed the diagnosis of MAC .I started him on treatment and he did fine .

   But the reason to write this blog is to make a point that one has to see patient and make a calculated diagnosis. Otherwise the tests don't mean much , and we might as well have computer generated diagnosis and may be treatment too ! 

MEDICAL UNCERTAINTY

      In today's world people expect that the modern day medicine is perfect and every time patient goes to doctor , the modern medicine and the tools that we are given , will give us the answer every time . But I hate to break the bad news that even with the modern medicine and the CT scans and the MRI and many other tools , we are not 100% accurate. It reminds me of old story that was told to me by my teachers when I started thinking that I KNEW everything .Many years ago there was a surgical conference and a speaker was presenting data on stomach surgery. He told the incidence of the complications. So in question -answer part one young surgeon stood up and stated that he has done many surgeries that the speaker was talking , and he has not seen the complications that the speaker was talking about  . The speaker answered that Either he has not done Enough surgeries or He had the complications and did not Recognize them.In medicine it is the same . All of us come across the cases where in spite of all the investigations and tests we can not explain the problem . So then we are left with the guise work. I am going to tell a story today which falls in under the same category.
      I was consulted to see this patient who was 77years old and he got more shortness of the breath. He was on oxygen at home and had sleep apnea and also had heart problem and had cardiac bypass done . He was quite obese and was not using the CPAP for the sleep apnea. When I saw him he was on 100%oxygen and needed pressurized oxygen called BIPAP. Just to explain , simple oxygen is needed in many cases. Then high flow rate , then BIPAP and if it does not work out then respirator. .So he was close to last but one step . His blood pressure was low and had some vague suggestion of congestion in lungs . I thought that he may have pneumonia or congestive heart failure. I ordered the echocardiogram and started treatment with antibiotics . The cardiologist saw him and infectious disease specialist saw him and changed antibiotics . The blood pressure got little better and echocardiogram did not answer why his blood pressure was low or he needed so much oxygen . He slowly got better. But continued to need very high oxygen flow rate for several days . He was in ICU , looked comfortable , had no shortness of breath . The chest X-ray did not get much better ..But for whatever reason after 15days , his oxygen need got better and we could do CT scan. It showed Emphysema and some scars . but not much to explain why he needed such high oxygen. We did swallow study and it did show that he was aspirating. Which means the food or liquids that he was eating or drinking , was partly going in the lungs .
       So my educated guess was that over period of time he had done significant damage to the lungs and that had led to scar tissues and he must have had significant aspiration on the day of the hospitalization. This caused the significant inflammation and that took almost 3 weeks to heal as we had not given him any food or liquids by mouth . This allowed the healing. So he was able to come off the high flow oxygen.He was discharged on 3 L oxygen , while he had needed as much as 70 L flow in ICU .So my diagnosis was  only a educated thought process.