THE SYSTEM DOES IT WORK

       In every aspect of the life we often say that the system works . If a murder is solved after several years , we say that the system works. We have been witnessing the political drama unfolding in DC.
I am not sure if the system is going to work - either way whatever your political view may be - Democrats are feeling that the system did not work in 2016 election and the republicans feel that same way about the Democratic party candidate  and the FBI and the DOJ behavior.But I am talking about the day to day life where we come across things  and feel that the system did not work. All of us have 'misconception' about our ability and be often 'feel' that we do not get what we 'deserve'. But I am talking about much simpler things like DEATH CERTIFICATE. That brings me to the today's story.
       I saw this patient 5 years ago. she was 38 years old , obese  and had multiple medical problems . To my recollection she was not working and she had medical disability at that young age . She was not a smoker nor was alcoholic , but had bad hand dwelt in her life . She had Lupus a deadly disease in some  and many who have that diagnosis. She also was obese  and she had TB-yes tuberculosis  and had part of the lung taken out . In patient with Lupus,patient have multiple organ involvements - from skin to lung to kidney to pressure in lung circuit. She had scar tissues in her lungs  and also had chronic pain and also had obesity  and sleep apnea. She was short of breath and she did not do much exercise  and had not lost much weight . The combination of all these factors had led to shortness of breath. I am sure if she could loose some weight ,  and exercise she may have have been that short of breath, Fortunately her fibrosis or scar tissue in her lungs though bad was stable. The pressure in lung circuit - called pulmonary pressure was mildly elevated . Her oxygen would drop bellow critical number and so she needed oxygen when she would walk . But being young , she did not like the idea of carrying the oxygen and so she was not using it most of the time . The oxygen transfer factor that we measure, was less than one third of normal and so no wonder she needed oxygen and was short of breath. She had sleep apnea  and was not using the pressurized mask that she should use . But in all in spite of all these she  was stable  and we did not  and could not change any medicines .
     One day I got a call that she was in ER . In last 5 years or so that I took care of her , she was never in ER or hospitalized. I saw her in ER. She was quite short of breath and  needed high flow oxygen delivered with pressurizes mask. Her husband was bed side . She had respiratory infection and that caused the pneumonia  and since she was compromised ,she had acute respiratory failure . The ER doctor had started her on antibiotics  and steroids  and CT SCAN was planned soon . I discussed the situation with them  and she was to be admitted to ICU. I told them that if the things do not work out she will be intubated  and put on respirator and then we will see how she responds . With given pulmonary compromised the weaning off the respirator would be difficult if not impossible.
       As I thought she was intubated  and she had many other problems that are associated with sick patient . I would not discuss them at this time . But at the end of 17 days she was on maximum support on the respirator and she was on 100 % oxygen and high pressure  and also had problem with blood pressure  and also with blood count and she was not waking up..The discussion was on going with family on the poor out come and so finally we talked about the HOSPICE  and withdrawing the life support . We knew that the end was near with or without life support . So may be on day 20 or so we stopped the respirator  and she passed away. We now a days have ICU doctor  and also Hospitalist and so I did talk to husband but did not expect death certificate to be brought to me .
    15 days after this event my office staff told me that the husband was in my office to talk to me . I was not sure as to what was the reason . But I thought that he may have come to have  'closure' as he had not known all the problems that she had even though I had had told them when I met him in ER  and then in ICU. I brought him in and he told me that they do not have the body to do the funeral. I was shocked . The lady dies more than 2 weeks ago . He told me that the hospital doctor mentioned a 'fall' in the death certificate  and so the case was sent to medical examiner . Since the county did not have their own it was sent to different county ME . I did not know the name or the person. So I was not sure as what and how I can help. But I told him to call the ME office  and tell them to call me to clarify any medical issues that may be holding the release of the body. I gave him my cell number. I git a call from the him that the ME secretary told them that she could not do anything  and if I wanted I can call them . But it was up to ME . They would not call me . So I got the number  for the ME office  and called them I could not talk to ME but I explained the situation to the secretory and told her to have ME call me if he still has any  questions or concerns before releasing the body.
     A day latter  I had death certificate brought to me  and I signed it  and told office staff to call the husband  and inform him that  it is done.  So the system should have worked and the family should have gotten the body much sooner . But it did not , but finally the system DID WORK - BETTER LATE THAN NEVER. 

HOW MANY PEOPLE ARE NEEDED TO CHANGE A LIGHT BULB ?

      The question that I raised or we have heard in past as a joke.But sometimes in practical life we see the similarity. There is also saying that 'it was so simple that anybody could have done it but no one did it as everybody thought that some one will do it" I am not sure if that is due to procrastination.May be it is due to being lazy. What ever may be the cause, we see this quite often. Look at doing year end taxes. Ever year we see TV station showing the crowd at post office t 11th hour of April 15th. So why do people wait? But I am going to tell a story where I am not sure what is the cause of the passing the bug - may be ignorance , may be something else.
       I have seen this patient for a while . He had shortness of breath and some cough .So we did work up and found out that he also had sleep apnea and also he had low oxygen . He was also diabetic  and he also had some cardiac problems  and he had pacemaker put in..So he was followed by cardiologist. I did start him on a new medication for the fibrosis or scar tissue in lungs  and also on oxygen. He needed treatment with pressurized mask for sleep apnea ,but he did not like it. So one day he was in my office for the follow up. He was doing OK and I was not going to change any medicines . We did talk about retrying the the mask for sleep apnea.I was about to done and when I did look up at him, he was going to fall - he passed out . I put him on floor  and had my secretary call 911.He had pulse  and also oxygen was OK. The paramedic came in and his blood sugar was little low  and he woke up and was taken to ER.I was not called in and when I checked it he was doing OK  and was seen by cardiologist and he was discharged in 2 days . He was doing good .
     He came for the follow up in 3 months  and he was OK .I wanted to do new CT scan to check on his fibrosis. So I had my office schedule it . He was sitting in the chair and my secretary was talking to him and he rolled his eyes  and passed out . She called me  and we called 911 and i forced coke as much as he could take as he was diabetic  and I thought that he may have low blood sugar. He was taken to ER  and was admitted like last time  and I was not called . He was again seen by cardiologist and then discharged in 4 days. No CT scan was done. So I did CT scan and his fibrosis was stable .
    He had elevated PSA  and was told to have prostate cancer and was sent to Radiation doctor to treat the cancer. While in the office he again passed out and was admitted to hospital.I WAS CALLED THIS TIME - I am not sure why as his lung condition was stable. Again he was seen by cardiologist  and was told that he will need something called LOOP RECORDER ,to see if he had some irregularity of heart. I reviewed the old record.He had 2 echo cardiogram during previous hospitalization. IT HAD SHOWN THAT HE HAD defect in septum which separate the upper chambers of the heart. That had caused for the blood to go from left side where the pressure is higher to right side where the pressure is low . This leads to elevated pressure on right side  and less blood going to body . This can lead to the episodes of black out spells. I talked to him and called his regular cardiologist  and asked him if he could do the further work up and the treatment as the one that was seeing him was going to do the monitoring, which would not add or diagnose the problem, He agreed .    The patient was sent to a third cardiologist - pediatric cardiologist - as such defects are common in children and they are better at  diagnosing. So this third cardiologist did part of the cardiac catheterizing and called a 4th cardiologist to do additional procedure to make sure that he did not have blockage in coronary arteries . The diagnosis that was made in last 2 ultrasound of heart was confirmed . The hole in the chambers was there  and the blood flow was going from left to right side -normally there should none  and no mixing should happen-was confirmed.So now he was sent to 5th cardiologist to see what could be done . I was not sent any report. I was talking to patient to get update  and knew about the procedures that were done . I do treat elevated pressure on right side circuit of the heart to lung  and none of these cardiologist can 'FIX' the hole  and he will need heart surgeon to fix it.
     So it took 5 cardiologist to diagnose the problem!

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 .