MAY BE YOU CAN'T CHANGE FATE ??

     We act in our life with desire  and advice that we can change the fate or outcome. We want to eat healthy food and not smoke and not drink too much of alcohol and not do drugs . I do believe that this is good behavior and everyone should try to do what is right . In medicine we also act and advice patients that certain way of treatment or work up will help us in getting good or desired outcome. I still remember , when many years ago one of my professor of preventive and social medicine had a heart attack . In those days not much was known on heart attacks , but we still knew that smoking and not doing exercise  and cholesterol were main culprit and we also knew that diabetes and hypertension were also risk factors. So when I saw him after his heart attack he made a comment to me saying that he does not smoke and does not drink and has no hypertension or diabetes and he still had heart attack . This type of unexpected medical elements are known to someone who ahs been in practice for long time but what I am talking today is the out come of the treatment or we not getting expected outcome. 

    I saw this patient in hospital. I had seen her sister and one more family member  and one of them had cancer. She has been smoker  and she had quit smoking and then she had shortness of breath .She had 2 years ago heart attack or tales chest pain and was found to have blockages and had stents  done . She was seen by PCP and that was telemedicine follow up and he gave her antibiotics and she did not get better and was still short of breath .So she came to hospital and had abnormal chest x- ray and then had a CT scan done and that showed a mass at the central part of the lung . If one can imagine lung with a stock like a fruit, then this mass was exactly at the stalk area. The main bronchus and the main artery all go in the lung at that area  and the mass or the tumor was pressing on the bronchus and it was narrowed . So there was a high suspicion for cancer and they called a cancer specialist . I was also consulted . I saw her and when I saw her I knew that this was not good . She also had a second mass  and she had shortness of breath  and she was on minimal oxygen supplementation.. The cancer doctor had ordered a biopsy of the lung mass. I explained to her and her husband that I was quite concerned  about a cancer  and that too will nor be operable  and the position was bad and that may compromise the air  and blood going to the one lung . I also ordered a PET scan. She did not feel good on the next day and so the biopsy was postponed  and so was the PET scan. Then the next day she had problem  oxygenation and so we had to increase the oxygen and that continued to get worse  and so I transferred her to ICU.I again talked to the husband and the patient and I also called radiation doctor to see if he could start emergency radiation without the diagnosis of cancer as otherwise that was going to get worse . They felt that getting a stent to open up airway would be better . So we consulted one of the interventional lung specialist . She was transferred to another hospital . As it happened, she had a heart attack and she was started on blood thinner and she had gastrointestinal bleeding  and then she vomited  and had cardiac arrest  and she was on ventilator  and continued to get worse. 

     So we did all the right things , Oncologist was consulted and Pulmonary was consulted  and we also called radiation doctor and then interventional pulmonologist. We had cardiologist see her when she had heart attack  and inspire of that she did not have good outcome. That is what we call fate.

DIFFERNTIAL DIAGNOSIS

   When I was in medical school, we had a visiting professor named DR, French .His father had written a book on Differential Diagnosis. The book had various causes of certain symptoms. So if one looks  at the cause of headaches, we will see many causes of headaches from simple tension headache to sinus infection to brain tumor. So it gave a list of possible causes of certain symptoms. One has to understand that the physician or the medical student has to take a detain history  and do physical examination and then narrow it down to 'few' causes.  In those days the lab tests  and radiology was not that advanced  and the Ultrasound examination and CT scan  and PET scan  and angiography etc. were not there. So everything was CLINICAL. Now a days we have many tools at our disposal and that has changes things and helped  and also made it worse. We are depending upon TESTS and not on history and physical examination and then we are going on wrong track. That brings me to the story for today. 

     I have seen this male patient for last few years  and he had smoked many many years ago and had COPD.. Over period of time he had gotten worse  and he was on oxygen and he also had cardiac problem - Atrial Fibrillation. He had few episodes of increased heart rate and i had to admit and then he had ablation and he did better. He lived by himself  and he was some what noncompliant with follow up. I checked his blood oxygen and carbon dioxide  and as expected he had elevation of CO2. In the early part of lungs not working or doing their job- which is to take in oxygen and wash out carbon di oxide, both these are normal. As the disease advances, the oxygen lack starts and then patient needs oxygen . As disease gets worse, the CO2 starts getting elevated. So in his case the oxygen had dropped  and CO2 was now elevated . The sum of these 2 gases in blood is constant ( one of the laws of partial pressure of gases in a mixture) So when CO2 increases the oxygen drops  and if we can reduce CO2, the oxygen will increase. So I started him on a machine - NIV -Non Invasive Ventilator . So he has been on it for a year and seems to have done better . His compliance was not great . I would have liked him to use it for 8 hours or more and he was using it for 4 hours  and that to not daily. So one day he had a fall in bathroom and so he came to ER . He was slightly confused  and had tremors  and the ER physician did CT scan of the brain  and admitted him for altered mental status  and may be TIA - mini stroke. NOONE BOTHERED TO CHECK BLOOD CO2.when we did do the check on it his CO2 was more than the double of normal value. and having oxygen supplementation his oxygen level was too high. THAT WAS THE CAUSE OF HIS CONFUSION AND  THE Fall. We have respiratory center in brain and it is stimulated by LACK of oxygen and Elevated CO2. So when the oxygen level drops , we breath more to compensate for it  and same with CO2 elevation. But with COPD patients the sensitivity to elevated CO2 is gone  and the patients breath only due to lack of oxygen. The elevated CO2 acts like sedative  and cause altered mental status. When one takes away lack of oxygen, the patients will not breath much . So one has to be careful as to how much oxygen should be given. In this case if one would have done HISTORY , they would have known that he was on home NIV  and that means his CO2 must be elevated  and they would have checked blood CO2  and that would have helped .But the knee jerk reaction was to do CT scan of the Brain. Certainly doing a CT scan in any patient with fall  and altered mental status is indicated  and appropriate, but checking blood oxygen and CO2 levels would have clinched the diagnosis .So the differential diagnosis has a list of many conditions that could cause the fall and the altered mental status  and the HISTORUY would have narrowed it down  and on the top of the list would have been retention of CO2!

FAMILY MATTERS

       I have tried to avoid talking about the pandemic with COVID as there are so many who have written and talked about it that my blog would be nothing new . But what I have realized in this pandemic is that the disease is not as simple as other diseases that we have encounter in out routine medical practice. It has many faces  and it is possible that we may be having "training on job "type of situation. I had state it in past either on my YOUTUBE CHANNELL or in one of the blogs or may be in some group discussions that out  mortality was high in the beginning as we did not try simpler way of providing oxygen  and respiratory support. Now we are not doing that and the mortality is reduced. So i have stated many times that this reminds me of old Indian Story of 7 blind men and Elephant. There were 7 blind men and they had not seen an Elephant . So they asked their teacher to describe the elephant . So the teacher took them to a place where they could touch the elephant  and 'know' for themselves how the elephant may look like. So one blind man who was touching the back of the elephant said that the elephant is like a wall , The other one who was holding the tail stated that No it is like a rope and thisrt one who was touching the legs stated that no ,no it is like a pillar  and so on. So each one was touching some part of the elephant and felt that he 'knew' how the elephant looks like. That brings me to today's story.

   I have known this patient 74 years old for last several years . When I saw her for the first time she had what looked like a pneumonia  and so she was admitted  and I saw her . She had pneumonia, but it was due to obstruction of a bronchus with a cancer  and she also had COPD -lung disease due to smoking . So I treated her and had her see a chest surgeon and he operated her and the cancer was resected  and she did well and did not need any further treatment in form of chemotherapy or radiation. She was followed and she had no problem . Then early part of last year she was admitted  and she had pneumonia  and I was called again and i saw her . We treated her with antibiotics and she had CT scan  and then I did Bronchoscopy to make sure that she did not have cancer and she did not . We did do follow up CT scan in 3 months  and she had complete resolution of the pneumonia  and CT scan was clear. Last month her husband got sick day before the Thanks Giving  and went to walk in clinic  and was diagnosed with COVID . He did not want to go to hospital and decided to get treatment as out patient and watch . She was OK  and then on Friday after Thanks Giving ,she got sick and she went to ER and was admitted to hospital. I saw her and she needs minimal oxygen and she had no fever and she was not short of breath . The chest X- ray did show that she had pneumonia  and her COVID test was positive. But she also had diarrhea  and so she was dehydrated  and her kidneys were not functioning normally. So we started her on treatment for regular pneumonia a nd also for COVID . The infectious disease specialist also saw her  and she was on steroids , oxygen and Remdesvir. I watched her every day and she was stable for 4 days  and was to complete the treatment t in one more day. And her condition got worse  and she needed more oxygen , So now she was on 12 L oxygen and then next day the chest X- ray got worse and oxygen dropped  and so we transferred her to ICU  and she needed to be on PAP - machine that generated pressure to deliver oxygen -- which we were not using due to fear of spreading COVID only 3 months ago. She continued to need it for 4 days. Shas done better but still not completely out of wood. So she did all the right things . She went to ER when she had problem , got hospitalized and was seen by specialist and was started on treatment with current medications and seemed to improve -only to crash after the treatment was completed I am not sure how to explain this . 

    Her husband decided to stay home for 1 week and then when he got worse , he came to ER  and had to be put on ventilator and continue to need ventilator for long time  and is sick  and has improved minimally.So he did not do what he should have done  and paid price for it .So I am not sure in this family matters who is right and who is wrong !! ,  

2 STEPS FORWARD AND 2 STEPS BACKWARD

   We sometimes say 2 steps forward and 1 step backward . But sometimes we have a different situation. We can't seem to go anywhere in life or the situation and we continue to depend upon FEELING rather than the fact. In medicine we often go by statistics or feeling and we do not want to accept it and feel that we are making scientific decision. But if we look at our usual decision in case of any patient's treatment is based on science as much as our feelings. Suppose I see a patient who is smoker  and has cough and blood in sputum and has no fever and has lost some weight, and has chest C- ray showing some spot, we consider cancer as highest possibility  and if that was in India and a nonsmoker  patient and same complaints , we will consider TB as the possible diagnosis as the first one. So we depend upon our experience  and past experience. But sometimes we have patients that has nothing typical and we struggle to decide  and we do tests to get to the bottom of the problem and then after work up are left with same ot more questions than when we started . This is one of those stories. 

   So I saw this 58 years old female who had a cough and the primary care physician had treated with antibiotics  and cough meds  and the cough continued and so she was sent to me , He had done chest X-ray and that had shown some congestion. She had CT scan ordered . The CT scan showed  multiple areas of congestion and she had no fever  and she had some bronchospasm  and some shortness of breath. I did further work up and did treat her with medicines for asthma  and did blood tests to find out the reason for the CT scan abnormality. We did allergy blood tests and also tests for autoimmune disorders like rheumatoid arthritis  and lupus  and also some blood tests for what is called hypersensitivity pneumonia -pneumonia due to allergies  and not infection. We also did breathing tests  and also did follow up CT scan . The scan did not improve  and so I did bronchoscopy and biopsy and that just showed inflammation and not much diagnosis of specific reason for it. So I did try steroids as treatment . I wanted to have her do open lung biopsy. She did see a chest surgeon but did not do the biopsy. After gap of 6 months or more she had COVID infection  and she was hospitalized. She did OK but needed oxygen and then when I saw her in office she had done well. . But the problem continued .So I sent her to the surgeon for the biopsy and she had the biopsy. She called me 7 days after the biopsy asking for my advice as to what to do now . I had not received the report as it was done in a hospital where I don't go. I checked the biopsy report in the computer  and could not make any decision as the pathologist had not given me any specific diagnosis. I called the pathologist  and spoke to him. He told me that it could be any number of things - that has caused the problem and I thought to m myself - I KNEW THAT EVEN BEFORE THE BIOPSY was done. He told me that he has sent the biopsy to Mayo clinic for second opinion  and it should be ready in 3-5 days . 

    I called the patient and told her to see me in 1 week in my office and discuss the diagnosis  and treatment. She came with her daughter . In the mean time I did get the Mayo clinic notes and opinion  and to my disappointment they had about the same opinion as I had before the biopsy was done .' It could be this or that or may be that and that also is possible'- was the report.    

     SO WE HAD NO BETTER UNDERSTANDING OF HER DISEASE NOW -AFTER THE BIOPSY THAN WE HAD IT BEFORE THE BIOPSY !

   This is what I called 2 steps forward and 2 steps backward.. Now I have to make CLINICAL DECISION.

COVID AND TELEMEDICINE

    Telemedicine has been there for sometimes now. But Most of the Insurance companies were not paying for any medical service that is done without direct contact -in person -patient care. I have done antibiotics  and other medicines advice and prescription without getting paid  and that is fine b. But I still don't like to do Telemedicine as substitute for patient bein seen with direct contact. There is difference between watching a movie on TV or computer and attending in person a Broadway play Or attending a basketball game in arena V watching it on TV is not same. But now a days in hospital many consultants are not only allowed to do telemedicine for COVID positive patients , and are encouraged to so . In the beginning it was to save on PERSONAL PROTECTIVE DEVICE . But it has continued. This story is related to that 

   I have known this patient for few years. She is in her early seventies  and has had COPD - smoking related lung damage  and also had weak heart . Her pumping action of the heart was 25% at one time . She had a device inserted called ICD and she had improved . She needed the battery change and so she had COVID test done and that was negative  and she had the procedure . Every patient that has any procedure .surgery, endoscopy done in hospital, has to have negative COVID test She had some problem after the procedure  and she was kept in hospital for 24 hours .She was sent home and then in 2 days she has some shortness of breath and so she came to ER. She had as expected COVID test  and that was positive . I am not sure how she had COVID when she had not gone out of house after discharge. She had many reasons to be short of breath - bad lungs and weak heart. But since COVID test was positive everything changes. Infection Disease specialist was called  and new COVID routine ordered were done by the specialist . He did not see patient . It was telemedicine consult  and she was started on Rendesvir  and steroids were started . The hospitalist also had seen patient. I have known her and so I was called  and I SAW HER IN THE ROOM  AND EXAMINED HER . I also saw CT scan and did not feel COVID had anything  to do with her symptoms  and if it was not for COVID she would be treated for lung and cardiac diseases. She did better with the treatment that I had started or may be due to the treatment of COVID .In any case she was better . But one day I saw her  and she told me she had bad night  and could not sleep and she could not be supine  and walking 5 feet she was short of breath. I asked her if she was seen by Infection Specialist doctor   and hospital doctor. She told me that it was telemedicine call from specialist and when she told her that she was more shor of breath, he told her that we will take it day by day. The hospital doctor saw her very briefly  and was talking to her from door . I saw her and knew what had happened . She was getting lot of fluid as ROUTINE for last 3 days  and with her weak heart she was not able to tolerate it  and so she was in congestive heart failure . I stopped her fluids  and gave her medicines to have more urine . When i checked her next day , she was like new person. Within less than hours of getting medicine she felt like pressure was relieved .

    She continued to improve  and new chest X- ray had nothing to show anything to suggest COVID worsening in lungs . So the Infection specialist  and hospital doctor who did telemedicine  and did not check patient miss the real reason for the shortness of breath. The routine set of orders sometimes need to be changed . 

SAFE DRIVING

    To get a driving license one must take a driving test and also do written test to show that one has enough knowledge of driving  and safety and rules and regulations . But we know that just because one got the driving permit does not make him or her safe driver  and many a times one accident can ruin the insurance risk and also damage the car and also sometimes life . I am often reminded of this when I see certain patients  and I also tend to explain patient on risk of accidents. So this is the story of a patient but it applies to may of today's patients as we are seeing aging population  and also certain patients who recover from stroke who in past may not have survived . 

     I saw this 94 years old patient in my office for congestion and cough . I had known him as husband of one of my patients  but he was not my patient . He came with his daughter as he had lost his wife who was my patient in recent past . He had mild high blood pressure and no other major problems and I had known him to be the care giver for his wife who was fragile and sick  and never thought of his age . He was having cough for last 6 months and has been treated with antibiotics and cough meds by PCP  and he has had 3 courses of antibiotics  and he has done little better but he still had cough and congestion  and so they decided to come to me .He was not in any distress  and his blood pressure was good and his oxygen saturation was on low normal side. He did sound congested and he had what looks like productive cough, but he was not able to cough up easily. He did not have any chest X- ray and so I ordered chest X- ray and also set him to get breathing test . He had no problem swallowing , but I ordered the swallow study . I also gave him some mucous thinning medicine  and also ordered nebulizer treatments  and also put him on medicines -bronchodilator The reason to do the swallow study was my previous experience . In many elderly patients , -even though they may not have problem swallowing- they have some aspiration- food or liquids going wrong way in wind pipe-trachea and then lungs .  

    As it happened he had a fall and he went to ER and was admitted . I had also done CT scan  and hat had shown some infiltrates - what one might see in pneumonia and I had started him on antibiotics. When he was admitted, by hospitalist, he had another CT scan -within less than a week - waste of heath care money-and it did not add to our information. I did the swallow study and also continued what I had started as oi=ut patient , The swallow study did confirm my suspicion that he had silent aspiration. He did not do that every time  and not same with all consistency.. So the speech therapist advised some instruction - some precautions to avoid the aspiration. Over period of next 3 days he got better and oxygen saturation improved and congestion improved  and he was ready for discharge . 

   So he had aspiration pneumonia when I saw him and that got worse when he was admitted  and he was discharged on precautions to prevent aspiration. But as i was saying one can drive safely for months ot years , and then one can get in an accident  and that may be devastating -economically or insurance or health wise. This is my concern when we talk about aspiration. One may do ok 10 times or 100 times or more , but one day or sometimes even everyday one may have SILENT ASPIRATION and that can cause chemical bronchitis - inflammation, that can lead to cough ,congestion and even pneumonia  and if it is bad - sepsis or death. This risk is there. Unfortunately there is no answer to this as we can not be doing feeding tubes in everyone who has this problem . Certainly if one has 3 accidents then the liscence to drive will  be suspended. Same way if one has 3 episodes of aspiration pneumonia, then we should consider SUSPENDING eating and do feeding tube . 

 

MEDICINE AND DR G

     Now a a days one can find anything on Google . One can search any song, any information, any news and anything and everything in medicine. This has lots of advantages . I can tell patients to check out certain things . e.g. portable oxygen concentrator - the machine that absorbs room air  and filters out nitrogen and produces oxygen So when someone asks me about the brands or cost, I tell them to check it out. Same with CPAP cleaning device - CPAP the machine that is used for sleep apnea. Or even I tell people to check out cost of medicines in Canadian pharmacy. So it is not uncommon for me to see someone who has questions based on Google search. Now a days many patients are told to ask their physicians certain questions  and that is also OK with me . I will tell you that people have done studies and they have timed physicians interrupting patients every 20 seconds or so - I ma not be exact in time but it is seconds and not even a minute for sure . So I am aware of that . But I have also known certain web sites asking patients to get second opinion. Again I have no problem with that either but the problem is getting second opinion for certain simple things-where there is no possibility of SECOND opinion is waste of money for sur and may be at times WASTE OF TIME. Say if Blood Pressure is 180/95 That is High Blood Pressure  and there is no second opinion - yeas one may have difference of opinion on which drugs to use or dose etc. but not about the diagnosis . This brings me to the story of the patient . 

     I saw this patient who had some cough going on for 2-3 months , The PCP treated it with antibiotics and some other medicines and he did not get better. So he had chest x- ray . He has no old x- ray in several years . The x- ray was abnormal and he had CT scan as he was ex-smoker The Ct scan did show a mass . So he came to me .We talked for 30 mins  and I explained him that we have to answer 3 questions 1 Is it cancer 2 Has it spread  and 3 What can be done -if it is cancer or suspected cancer . 

    We di the work up. We did bronchoscopy and did PET SCAN  and the breathing test The pet scan did show increased uptake  and that was suggestive of cancer - not 100% and it is never 100% . The bronchoscopy did not give us the diagnosis. The breathing test was Ok acceptable if we wanted to do surgery to resect the part of the lung. So I discussed with him and told him that the high possibility of cancer though we can never say 100%. I told him that we have 3 options 1 see chest surgeon and get an opinion to see if we should do open biopsy and take it out .2 Do needle biopsy which has some risk of collapse of lung and the chance of getting the diagnosis was not 100%  and if negative for cancer I would still consider open biopsy which is only thing that can give 100% diagnosis.3 Do only follow up CT scan in 3 months and see if the the mass increases . 

    To me there is no other option and there is problem with each of these options . The open biopsy may show that it is not cancer and we have done UNNECESSARY SURGERY, The needle biopsy has risk and diagnosis is not 100% ( I have seen recently couple of people with complications that needle them to be admitted to hospital )And wait and watch approach - has problem too. If it is cancer then in 3 months it can spread  and may become INOPERABLE. So ONE HAS TO ACCEPT THE RISK IN EACH OF THESE APPROACHES. 

   The patient after listening to all these wanted to get second opinion. I have no problem with SECOND opinion and I thought that the surgeon - a chest surgeon will be the second opinion. ut he was convinced that one must get second opinion based on his RESEARCH .!

(Just a foot note - there are other new procedures that can be done  and the diagnosis is not 100 % with them either.)