JUDGEMENT DAY

    I was brought up in my medical education in much different way than how the medical education is done today.In seventies we did not have ultrasound , CT scan or PET scan. We did not have stents to open up blocked arteries  and there were limited blood tests. We physicians relied on our 'clinical sense'.Now a days I see nurses walking with laptops  and so also the hospital doctors . Before patient is seen , they see the data in computer , sometimes entered by the nurses and others. So the 'DIRECTION' of thought process is 'predetermined' . The history and clinical examination have become secondary and many of my patients when they are admitted  and seen by different physicians , have told me that the stethoscope is not used on daily visit.And I do agree that with modern day CT scan , X- ray and MRI and different blood tests and Ultra Sound examination and  other tests , the clinical examination and the sense have become secondary. But being 'old timer', I still do the things MY own -old way. And this does pay. I do not have nurse practitioner or PA to give me 'help' or give me the direction .So my opinion is unadulterated.This brings me to my today's patient.
      This was a 50 years old male patient that saw me for the first time . Due to the computer entry or so called EMR - Electronic Medical Records , I do some reversal in asking questions . So he was nonsmoker , nonalcoholic patient who had no other history than HIV. He was fine till about a month ago and or may be less. He started having shortness of breath and so he went to ER and was admitted to hospital that I  don't go . He was seen and worked up by hospital doctor and was also seen by lung specialist and also by cardiologist.  He had CT scan of the chest and the ultrasound of the heart and many other tests  and blood tests He was told that he had emphysema - the disease that patients get -damage to lungs -when they are smokers. He was given an inhaler and discharged home . He had no improvement in his shortness of breath, but he was sent home . He came to me sent by his PCP. I did the history  and physical examination. He could not sleep as he had more shortness of breath when he was supine  and would wake up short of breath  during night.He could not walk to keep his garbage out at curb and he had some dry cough. His examination was unremarkable. His oxygen saturation was 97% which normal and good in spite of being short of breath  and only thing that was abnormal was his heart rate -it was high at 130 to 135.
     I reviewed his reports from the hospital records  and the CT scan had shown one bleb - which  made them to tell him that he had COPD -emphysema. He did not have emphysema. He had ultrasound of the heart and it showed minor abnormality . His pumping action was mildly reduce at 45% instead of 55 to 60 % being normal. I told him that he did not have COPD  and i was concerned that he has heart problem . I ordered some tests in my office -breathing test and walk test and pulmonary stress test. I personally called a cardiologist and told him to see ASAP.
     He came for the pulmonary stress test in next 3-5 days. I had given him a different inhaler  and he told me that it had not helped and he could not sleep at all last night and had to sit in chair as he could not lie down in bed . His oxygen saturation was same - normal and the heart rate was high and the lungs were clear. He had seen the cardiologist and he was told that they will do the cardiac stress test , but they did not think he had heart problem.I told him that I was going to admit him as I  was sure that this is cardiac and only way to sort it out was to get him in the hospital.
     So he was back in the hospital within less than 3 weeks of his last one . I ordered number of tests , but I ordered another ultra sound of the heart even though he had one just 4 weeks ago, I called the cardiologist and told him to see him personally  and not depend upon PA.A blood test called BNP , which goes up in congestive heart failure was 8000, the normal is 800. . The echocardiogram showed that his heart function was 20 % and he had 'Severley Leaky ' aortic valve . In spite of knowing this I could not hear any murmur. ( that is the inadequacy of physical examination ) The cardiologist did the cardiac cauterization  and the diagnosis of leaky valve was confirmed and he was transferred for replacement of the valve . (There were few more things that we did due to his HIV , but they were not related or causing the shortness of the breath)
      So the hospital doctor and the 2 cardiologist  and one lung specialist could not or did not think about the heart problem , may be being misdirected by TESTS  rather than history which was classical for shortness of the breath due to heart problem . 

THREE STRIKES AND ?????

     In medical practice sometimes I wonder as why I end up seeing some patients . I do not seem to have much contribution to their specific care and still sometimes I am asked to see them and then it seems that they want to come to ma for follow up. The only way I can explain this is by law of Karma. Something sometimes that we had in past that brings them to me . I will tell you about one such patient .
      I saw this 76 years old male in my office . Due to language barrier he was accompanied by 3 other family members. Sometimes in medical office where the exam rooms are small, this is overwhelming . It also takes longer time to get to the real story. But here the family was well versed  with his medical problems and had the reports with them too. They were genuinely concerned. He was admitted with bleeding from the stomach , which turned out to be due to ulcer and then the work up was done . He was a smoker and heavy alcohol uses  and had liver disease due to excessive alcohol intake . The routine chest X- ray showed that he had spot on the lung and so a biopsy was done  and it showed lung cancer . Due to some blood abnormality , further work up was done  and diagnosis of prostate cancer which had spread to bones was done . So to summarize, he had alcoholic lever disease  and lung cancer and prostate cancer . He had seen oncologist and chest surgeon. So I was not sure as my role . But as I always do I saw the patient and told them on the need for the breathing test to make sure that he had adequate lung capacity to cut out part of the lung containing the cancer as that seemed to be the plan . But when I examined the patient, he had an enlarged lymph node in neck.So I told them that the biopsy of that node was very important as if it had cancer cells, there was no reason to do the resection. If the cancer has spread then the surgery would be futile.We scheduled him for breathing test and then the follow up .
       I did not see him for may be 6 weeks or so  and then one day they came back.He had missed the appointment for the breathing test. I had received no reports or any communications from the primary care doctor or oncologist or the surgeon. But the family had the reports . I was not sure as to what was the reason for their follow up. So he had surgery and the diagnosis of the cancer was confirmed .One lymph node was positive for cancer and it was close to food pipe or esophagus.The lymph node was there and they did not do biopsy but he was sent to ENT throat doctor  and had diagnosis of cancer of the lung. So now he had 3 cancers and liver disease and lung disease due to smoking and the lung cancer had spread to lymph node . So the chance of recurrence was high . They had planned radiation lung and tongue  and then chemotherapy. The family and the patient has several questions for ME . This is in spite of seeing the oncologist and radiation doctor and multiple other doctors .
    I was not sure why they came to me ,but I explained them the radiation side effects to swallowing and also the side effects of the chemo . They were not aware of some of the side effects, So I TOLD THEM TO TALK TO THE ONCOLOGIST AND RADIATION DOCTORS  AND told them he may have difficulty with swallowing and may need feeding tube.

PARADOX

     In medicine one does see number patients at the same time  and in sub specialty practice we see similar patient all the time  as there are limited number of common diseases . But even though the diseases are common each patient is different. But there are some differences in the disease process and differently the behavior  and the reaction of each patient.I see this everyday  and sometimes the contrast is so glaring that I have to  write it.
      So I saw this patient several years ago , She was 84 years old  and had severe COPD - damage to lungs due to smoking.She continued to smoke  and then was more short of breath. Then she needed to be on oxygen.Her chest X- ray changed  and she had a nodule  She did not want to do CT scan and was not interested in CT scan . She did not want o quit smoking . She became irregular in follow up and then would miss follow up . We did follow up and she finally agreed to do CT scan and she did have a nodule. She did not want work up and she was not a candidate for open Biopsy or even needle biopsy. She did not want any work up anyway. Over period of time I did not see her and then when I saw her the nodule had grown and she was also older and she had started to be in wheel chair.
She did not want to do CT scan and then when we did it the nodule had become a mass - bigger . Her daughter came in picture  and we had a a talk and we did not do much work up . Then she was admitted to hospital with pneumonia , She was sick and needed more oxygen and she was quite short of breath. and she was worse She had CT scan done  and had pneumonia  and had increase in mass .By now she was 90 years old .  She was very sick and no biopsy could be done as she could not have tolerated even bronchoscopy. She was seen by cancer specialist and they agreed that she was not candidate for much work up and also for much treatment given her dementia , oxygen dependent COPD.
     She was discharged home . We had discussion and she was seen by oncologist  and no further work up was done . She lost some weight and had more dementia . She did not come to see me . The daughter came to me to talk without any formal appointment. When I could not justify signing form to continue oxygen and other medications without seeing in office, she did come . She was cachectic  and she was followed by a group of oncologist and the daughter had taken her to different oncologist and radiation doctors in hope that they would offer her something NEW. They all wanted biopsy as chemotherapy could not be done without knowing exact nature of the cancer-tissue type The oncologist did not offer her any or she did not want any. The daughter walked in my office one day and had CD of CT scan that was done by different group of oncologist and they wanted to do biopsy. So she wanted  my opinion. I told her that I could take CT scan to radiation doctor as the mass was 11 cm now. She wanted to see what I would suggest. The radiation doctor called me and saw her and told her that the biopsy was needed. She was admitted for congestion and we went through the same discussion . She was 92 years , on oxygen all the time , had dementia  and could not walk even 20 feet . The 2 daughters were bedside  and I had my discussion including calling Hospice . One daughter wanted that but the other one that came to my office did not want to make her DNR or hospice  and wanted the biopsy . The biopsy was done  and the pathologist called me.She had CANCER . I talked to the daughter  and she was extremely surprised "Oh NO " she shouted . Now I was surprised . All the doctors she had seen in last 2 years had all told her that she has cancer .So why was the surprised and not willing to accept the inevitable?
       I saw this 73 years old female  and she had CT scan and she had a nodule . 9 mm She was non smoker and so we decided to do follow up on the CT scan. so in 1 year or more it went to 11 mm -increase by 2 mm . Sometimes this kind of variation may be due to sectioning . So I decided to do follow up. She was followed up by PCP  and did not come to me ,But then was admitted to hospital for pneumonia .I saw her ,. She had pneumonia in the same area  as the nodule and so it was difficult to assess  any change in the nodule. She was treated  and discharged. She came to me  and I did chest X- ray and it was improved . I ordered the CT scan and then the follow up. She did not do the CT scan and missed the follow up. The PCP called me  and wanted to to know if I wanted the CT scan or plain chest X- ray and I did CT scan . The Ct scan showed that the pneumonia that she had 6 months ago was gone and the nodule now was 15mm. So I called her and saw her in office . I told her that in roughly 3 years the nodule has grown from 9 mm to 15 mm and it could be very slow growing cancer and we need to do the work up. So I wanted to do PET scan  and Biopsy. I asked her how much active she is .She was working for 4 days a week and on average she was walking 10 miles a day .She had no cough , shortness of breath or weight loss or any complaints.But then she surprised me by saying that 'I am too old - how long I am going to live , is it worth doing all this work up etc'
          So this is 73 years old patient, who is working 4 days a week  and has no shortness of breath and is walking 10 miles a day  and has 15 mm nodule who does not want to do the work up. And the other lady is 92 years old is on oxygen all the time  and has dementia  and has mass of 11 cm  and her daughter wants her to do everything and not even consider DNR status . WHAT MORE PARADOX CAN YOU SEE . 

YOUR AND MY MONEY AT WORK

       In US we have health care crisis  and  the cost is way out of hands . We are spending money that we don't have . We have patients that DEMAND work up and we have physicians that order too many tests as they are afraid of malpractice  and want to make more money . We have hospital which has cost which is out of this world. and the medicines  are so costly that even well to do patients  can't afford. Lawyers are advertising on TV to sue anybody for any reason  and are looking for any bad out come  and or bad side effects . No wonder the cost of health care is out of hand . And to make it worst NO ONE CARES  and no party or politician has any clue how to fix it . Some believe that competition will reduce cost , others believe that government taking over will fix the problem and neither is ready for listening to others  or TALK to people like me - not any physician's associations -none of them have  any understanding how we practicing physicians work and face problems .
     This brings me to today's patient story . I have known this patient for last few years . She has mild  asthma  and recently I was thinking that her problem was due to heart problem and the the work up did confirm that she has leaky valve  and irregular heart beats  called atrial fibrillation that was contributing to her shortness of breath. She was followed by cardiologist and she is doing better. So the other day I had a call from the hospital that she was admitted . I went to see her . She had some upper respiratory symptoms  and she saw her primary care physician  and he gave her some antibiotics  and then ordered chest X- ray . The X- ray was OK and the fever was gone . But she was still 'congested '  and so she  and her daughter decided that she should come to ER. They did not call primary care any other doctor. As it is USUAL now a day ER did the CT SCAN of the chest . She had no fever  and had normal oxygen saturation and normal white cell counts. The CT scan was OK.
I saw her . She was started on 2 antibiotics by hospital doctor. Her lungs were clear and she had no fever and the CT scan did not show  any pneumonia . She was comfortable  when I saw her and did not need oxygen . But as a 'routine she had CT scan and as a routine she was started on IV antibiotics. I was consulted  and so was cardiologist and kidney specialist . She had mildly abnormal renal function and she was followed by them as out patient . The nasal smear came back positive for a virus --COMMON COLD VIRUS !!!

   So she had cold and she was admitted for 2 days . She was hospitalized for 'observation . This means hospital makes more money rather than regular hospitalization . The hospital doctor makes money  and so does the cardiologist and kidney doctor  and I . So we have spent lots of money for treating COMMON COLD !!!

FINAL PATHWAY ??

   Recently i came across some cases in my friends  and colleagues where I can not explain how  and why . Let me tell you on these patients . We recently lost a physician who was very young and had never smoked . He ad lung cancer and that did spread to brain and he died  in spite of all the treatments that he could get at various centers. Then there is elderly friend our our family who also never smoked and had lung cancer diagnosed. She is lucky and it was detected early and so she had surgery and it is in early stages  and there is good chance (Why good chance  and not 100 % chance ?) that she will be cured . And there was another case of a  cancer in a another physician who was completely unselfish , devoted her life to God  and community and again never smoked or had alcohol . She also dies of cancer. We all see this  and experience this in our life  and fail to understand why this happens.Some people ask me as to why some one gets cancer . And certainly there are definite causes and risk factors like smoking and also chemicals  and pesticides. In absence of obvious causes how do you explain the cancer and suffering that it brings in . And then why a stage 1 cancer is cured in some  and not in others . We have technology that can tell us -sometimes- as to who may recur  and who may not , buy not always So what is the answer to all these questions ?
      I DO NOT HAVE PERFECT ANSWER OR EVEN AN ANSWER .!
      But I may have some possible explanation based on my faith and Law of Karma  and reincarnation. I am sure this will not be acceptable to all  and also those who may accept the Reincarnation also may have difficulty to explain why would someone get CANCER and suffering .
The Law of Karma states that EVERY Karma has a fruit  and one will ave to accept it sometimes -in this life or next or next. We are reborn for several reasons .
 1 We must pay the debt that we have accumulated with other individuals .
2 We have to have to accept the fruits of our actions
3 We must fulfill our unfulfilled desires  and we not do that without PHYSICAL BODY .
4 We need PHYSICAL body if we want to UPLIFT  our self . (when we help someone which is Good Karma - most or all of then are related to helping physical body , e.g. food shelter, sickness,or any comfort .
    So we must have physical body and to have NEW physical body after death of old physical body there has to be Rebirth. But then the question arises as to who wants to suffer  and who will have Desire to suffer ?
    To answer this one must understand that the Karma is done every second with MIND and BODY . When the two come together then the Karma is complete . The intention behind the MENTAL or Physical Karma will determine the Effect or the fruit . If I have transient bad thought about some one  and O do not ACT on then it may not or will not have ant fruit . But if I continue to have a thought ALL the time -say lust or some other it will create enough impression that I will have to fulfill it in pr there will be fruit to the thought. If I have a physical action which happened but there was no Thought behind it -I kick some one by accident and I had no intention of the kicking - I will not have much fruit , but if I have intention of kicking someone and I act on it , then I will have Fruit to it .
    One more thing to remember is that our PRESENT life is sum of effects of many Karmas  and not one Karma . So there are many forces and effects that determine the final effects  and so the FINAL EFFECT  may not be such that we can RECOGNIZE THE ORIGINAL KARMA - as it is sum of many karmas .
     This may explain the things that happen to us that we can not explain easily based on our ACTIONS in this life or even if we believe in Reincarnation , can not TRACE to one isolated Karma , that could have caused it .
   

LIMITATIONS

    In  past I have always stated that there is a limitation in medicine. I was taught to do physical examination before ordering tests . But even before one could put his hand on patient to examine , we were suppose to take history.Now a days then things have changed  and most of the physicians that I see and meet  do reverse way . They sit at the computer and see the X- ray and the labs  and the 'other notes' and then go to see the patients. Some times there is not much of history or even physical examination . They depend upon  nurse practitioners or ER physicians who in tern depend upon their nurse practitioners .I am still old timer and do my OWN history and physical Examination. But I have realized that the history and physical examinations also has limitations  ans sometimes we get diagnosis with TESTS rather than history or examination .This brings me to today's patient

    I was asked to see this new patient in the hospital . She was 72 years old patient who was having dry cough and so she saw her PCP . he gave her some medicines  and then did chest X- ray and then told her that she has allergies  and she should take some over the counter medicines for allergies . She continued to feel poorly and did see PCP and there was no change in treatment . Then she saw cardiologist as she was  also having some swelling of the feet and shortness of the breath. He gave her some medicines  and was going to do some more tests . But then when she was checking out at front desk , she was noticed to have significant shortness of breath . So she was admitted and I was called in . She had some lung scan done to rule out clots  and that was OK. But she has some fluid around the right lung. So the CT scan was ordered.
   When I saw her she was having dry cough . This was going on for last 2 months . She was getting short of breath for 3-4 weeks . She had worsening edema in legs . She had never smoked  and she had lost some weight , When I asked her about that she told me that she feels 'full'  and so could not eat more . On examination she had reduced air entry on lower part of right lung and she had edema . When I examined her belly , it was obese  and I felt it was 'tight' or firm . I could not feel much  and I did note that in my note . The CT scan showed 2 spots on lungs one on each side  and fair amount of fluid on right side. I told her the possibility of cancer and decided to do the procedure where upon I take out fluid . I took out more than 1000ml of fluid  and I ordered PET scan . The PET SCAN picks up cancer in body . It is about 88 to may be 90 % . The PET scan is done where glucose is injected  and the glucose pick up by cells is recorder . The cancers have higher metabolic rate  and so the cancer cells pick up glucose at much higher rate than the background . Since it is metabolic or biological scan we do not see the structure or the anatomy . So it is accompanied by CT scan . The lung Marses were positive suggestive of cancer. But to my surprise there was big tumour in pelvis  and it was 14 cm  and it was positive . She also had some fluid in belly. She had told me that she had hysterectomy and her ovaries were taken out partially . So it was a shock to me that she had cancer in pelvis . The fluid came back positive for ovarian cancer,

      So in spite of taking adequate history and examination, I did not anticipate the diagnosis . So sometimes one needs to get diagnosis which was not suspected . 

HONESTY IS IT THE BEST POLICY

          There is saying that the Honesty Is the Best Policy , but is  it really true?In life we have incidences where the honest answer may be crude or cruel or not pleasing . In Ganapati ATHARWASHIRSH, it is state the 'I will say Pleasing and Truth'. In personal relationships between the husband and wife and children and friend, this is true.But even in many other aspects of our life we don't have ti lie but we can still say truth without hurting the other person or the relationship.Sometimes we can not tell our boss what we 'feel ' about him or his decisions. We still can say the fact or the truth. In medicine this holds very well. I have come across this on number of occasions. This more often happens when we have a patient who has cancer . This brings me to the today's story.
      I had seen this 75 years old lady who was smoker and had some lung issues . Over course of my follow up she developed a mass in the lung . In all probability it was cancer and so we did do the work up and then i sent her to surgeon  and it was taken out. She did well- had some problem post op. But overall did OK. She needed oxygen after surgery , that was arranged at home . She was doing better and then may be 18 months or so after the surgery , when we did the follow up CT scan she had a mass . We had her see radiation  and oncologist . She had needle biopsy and then the recurrence of the cancer was diagnosed. She had localized mass and so she received radiation. She then saw oncologist , who decided to start her on some chemo . In spite of the chemo she developed new nodules and so the chemo was changed . Now she had multiple nodules in both lungs  and radiation was not option and so she had continued the chemo. She has been old  and has some dementia . She has COPD  and does need some oxygen .She was admitted to hospital with multiple issues , including anemia related to chemotherapy and also had low salt and worsening kidney function and also had swelling of the legs . Further work up showed that she had clot in the legs  and  for some unknown reason (at least to me ) someone ordered a CT SCAN of the belly and that showed a mass in colon.
She was in no shape to do any invasive procedures for diagnosing colon cancer , but more than that , diagnosing colon cancer would alter any treatments . Due to fear of bleeding from colon mass if she was started on blood thinner and with her low blood counts , we decided to do insert a filer in one of the blood vessel so that clot from legs would not travel to lung- embolism..
   When the radiologist went to insert the filter he realized that the entire blood vessel was filled with clot. So he could not do the procedure. But more of  a problem was that the clot occurred in the blood vessel as it was compressed by external tumor. So the narrowed blood vessel developed the clot and that was blocking the drainage  and so she had swelling of the legs . So then we had a catheter inserted in that blood vessel and clot busters were started . Now she will have to be on blood thinners too.
      So we have 80 years old patient  who has spread of a lung cancer , who also has anemia  and kidney failure and oxygen need for COPD , and has possible colon cancer and the a tumour that is pressing on one of the major veins that has clot. You get the picture. No matter how successful we are in treating the clot , her long and may be even short term prognosis is not very good . I did try to talk to her family as she has some dementia about this . But the cancer doctors and their nurse practitioners have not said a word about bad prognosis and so we are doing the bandage approach without being able to treat the underlying cause of the problem . The need to be honest but not blunt  and compassionate but still telling truth.