IT WALKS LIKE DUCK, QUACKS LIKE DUCK AND IT IS NOT DUCK

    We often say that if it walks like duck  and quacks like duck it is duck . But sometimes we have situations where our conclusion based on our experience is not right. We have seen this many a times where ordinary people, politicians and news media tell a story and then draw a conclusion and that tends to obvious -but on further investigations the conclusion drawn based on experience is proved to be wrong. The same thing happens in medicine  and that is my story for today. 

    I was seeing this patient for sleep apnea and may be mild asthma . He was obese and over period of few years of follow up he had mot lost any weight and had continued to be obese  and was using the PAP therapy and had no problem with it . He usually had no other complaints  and the asthma part was minimal and he used to use inhalers as needed. Then one day he came to see me . He had cough and shortness of breath and it all started 6 weeks before he saw me . He was seen by his family doctor  and was given antibiotics and some cough syrup . He did not improve and so was given steroids  and different antibiotics. He continued to have problem with cough and some shortness of breath. I saw him in office and he has low normal oxygen and he had bronchospasm and wheezes . I ordered a chest X-m ray and also started him on 2 different inhalers and also different dose course of steroids. I asked him to see me in 2 weeks . The X- ray came back showing a fluid accumulation. I called him  and ordered CT scan  and asked him as to how he was feeling . He was little better as far as wheezing was concerned and he had no fever . His shortness of breath was still there but was better. The CT scan was done and the findings surprised me. He had fluid around his lung  and also a spot on the lung. I called him and told him that we will have to do the work  and that may involve number of procedures and biopsy  and also may need additional consultations . I was concerned about cancer and the presence of fluid may be due to cancer and then he would not be early of surgically resectable cancer . So I admitted him and did drain the fluid  and the fluid was somewhat  locculated -had some different pockets  and the fluid did not show cancer . So we did PET scan and I did bronchoscopy  and there was no tumor . The PET scan which is suppose to pick up cancer in almost 85% of the cases did show that the nodule had some activity and so possibility of cancer was there . So we decided to do needle biopsy of the nodule. The only other option was to ask a chest surgeon to do biopsy under anesthesia . The needle biopsy was done  and it showed inflammation  and o cancer . 

  So  the tests that I di to prove a cancer - it certainly looked like that - was not correct  and it looks like he may have had pneumonia and that caused the fluid  and he does not have cancer .. We have plans for doing follow up on chest X- ray and CT scans in future  and then we will know , but for now it looks like not a cancer . 

TELEMEDICE - NOT SO TELE

     With the pandemic the insurance companies have allowed to do telemedicine  and many physicians are doing it and some patients demand it and feel that that is alternative to going to physician's office. I have my own frustrations with certain problems and when patients want telemedicine visits. Say one is short of breath, what can I do by talking to patient or seeing him/her on screen without being able to examine lungs  and oxygen level and heart  and so on. So sometimes we have problems with telemedicine visits. But I came across one example where one can do telemedicine  and may be not do it. I know this statement is confusing and so let me tell you the story. 

   I had a call at midnight from some one that I know. His relative had some health issue and so he decided to call me . So I spoke to her. She is 36 years old female who had no major health issues . She had sudden left sided chest pain. It started in the front  and went through the chest to back and also had some jaw pain  and neck pain. She was not short of breath and had no fever . She had no history of asthma. I asked several questions and obtain the story. She was not contraceptive pills. She had no cough and she took ibuprofen and she still had minimal pain. The question was what was the problem and what should she do. I told her that there were 2-3 possible explanations. She may have musculoskeletal pain -simple. But I was more concerned about the serious diagnosis of blood clot in lung  which is possible in young person especially when they are on contraceptive. I was more concerned about pneumothorax - or air leak and collapse of lung . So I told her to go to ER right away.  I told her to let me know as to what happens in ER and told her to have them do CT scan of chest . 

   I got some more texts from them  and I was told that the ER physician did blood tests to rule oy heart attack - a possibility of such is so low in my mind that I did not think it was even there. The test was OK and so was the cardiogram . They did not do CT scan but did chest X- ray and he told them that it was OK . He told them that it was muscular pain  and they will do second blood test in 6 hours to make sure that there was no heart attack. I get a new text at 7 am . The radiologist had read the X- ray and there was a small pneumothorax - air leak - collapse of lung  and they were going to admit her for observation and new chest x- ray .

    So the telemedicine on just telephone  not video -with me  and my suspicion was correct , but to confirm the diagnosis we needed DIRECT VISIT to physician and ER. 

ATTACHMENT

      I have been in medical practice for many years  and I have myself changed in my thought process. But the main thing does not seem to change . We all want to LIVE. We often say that we have no attachment for living if we have suffering. But I have often seen that NO ONE is ready even under extreme conditions. That brings me to my story for today. 

    I had seen this elderly patient few years ago . Her problems were not major from my stand point and after doing follow up for 2 or 3 times ,she stopped coming. Then after 4 years of gap she came to me . She came with her daughter . She is 82 years old female  and had some shortness of breath and she went to er  and she had chest X- ray done and that showed larger fluid collection on rt side . She was admitted and they consulted lung specialist and he decided to put in a catheter to drain it . Normally we drain fluid and then based on response  and findings of the fluid we decide if patient needs further intervention. But for whatever reason she had the catheter inserted  and then she was discharged . The daughter came with her and she was draining the catheter at home  and when I asked her if they ever established diagnosis , she did not know , though she did know that cancer was suspected. I looked the work up done at the hospital and realized that no diagnosis of cancer was done  and part of the problem was the daughter's refusal to do additional biopsy since the fluid itself did not show cancer cells. She was weak and cachectic  and she was not eating and had lost weight. She was so weak that she could not walk .They had seen oncologist  and they did not like him / her and so they had not done follow up . She had no home help and no direction as to how often to drain the fluid. 

    I talked to them and looked at the reports from her hospitalization. She di have tumor in the covering of the lung and so from such a biopsy . So she did not have it. I told them that one can not get much treatment without knowing the diagnosis of cancer and what type. So i asked a surgeon to do the biopsy and at the same time consider talc powder instillation to stop the fluid from coming back. She agreed and the biopsy was done  and the diagnosis of cancer was established . She came to see me  and she had worsened. She had lost more weight and there was not much fluid left to be drained  and in spite of that she was short of breath and had no appetite and had low oxygen. I spoke to her grandson and also to daughter  and after discussion they decided that they could  not do any treatment and that it will be futile. So at their request i called hospice . They wanted comfort care only. 3 weeks went by and I get a call from the daughter , she had talked to oncologist and they wanted to start her on treatment immunotherapy . So they had cancelled Hospice and they wanted me to get her oxygen and some other stuff from other company .

    (I have often stated that if you ate vegetarian do not go to stake house ,if you go to oncologist they will do chemo/immunotherapy)So none is truly ready 

CAUSE AND THE EFFECT ??

   In every walk of life we have cause and effect .But sometimes we do not have the perfect explanation. One sees this in everyday evens and we do not even question it. We drop a glass object to the floor, it will break . The wood floats and the iron sinks . But the boat made of steel floats  and so the scientists have found the reasons for such things . But in medicine we have no CAUSE for many outcomes  and effects . In medicine we call it IDIOPATHIC . So we don't know why some people have elevated blood pressure  and so we call it Idiopathic hypertension If someone has Fibrosis in lungs  and we do not know what caused the fibrosis , we call it Idiopathic Pulmonary Fibrosis  or IPF. But this is well accepted  and no one thinks any other way or questions. But sometimes we see common things and have no answer . Certainly there is always a reason but we are unable to answer it and then the patients get frustrated as they have no way of PREVENTING IT .That brings me to the story for today. 

    I have known this patient for many years and she has been ex-smoker and had quit many years ago. Over period of time she worsened . She had diagnosis of COPD  and she was on meds  and still she continued to worsen over period of years, She needed oxygen and slowly we adjusted medicines and she was on all the medicines that we could use. She was also started on oxygen and nebulizes medicines and also steroids. She had some cardiac issues and they seem to be stable. Overall she was doing OK. One of theses days she was admitted  and then had some worsening due to pneumonia. I checked her blood oxygen and carbon di oxide  and she had elevation of carbon dioxide. So we started her on what is called non-invasive -ventilator. This has been done now a days for COPD patients for last few years. This helps the patient's own breath and this supplementation or the help improves the breathing and carbon dioxide  and then the shortness of breath. So she was started on it  and did well for more than a year. One day I get a call that she became unresponsive  and so was taken to ER I went to see her in ER  and the Er physician had already put her on respirator with a tube in her trachea. I reviewed the data . She was using her own machine and in spite of that she had ELEVATED carbon dioxide to such a level that she became unresponsive . So we had no choice of doing INVASIVE VENTILATOR  and that did help. Over period of next 4 days we were slowly in position to reduce the support from the machine  and we did take her off the ventilator. She did OK  and she was started on the noninvasive ventilator at night and just oxygen during day time . I watched her for 3 dyas and she did just fine . We had done many tests . She had CT scan of brain to make sure she did not have stroke  and she did not , We did CT scan of chest and she did not have clot or pneumonia . We did culture of blood  and sputum and treated her with antibiotics  and all the work up was negative  and she did not have sepsis. So why did she have respiratory failure even when she was doing everything right ? 

    I DON'T KNOW  and I will never know .

     Why did her lungs quit suddenly and then in 4-5 days recovered , I don't know . But one thing that I DO KNOW is that I have seen such patients in past and will again see such patients where we do not have the cause that precipitated  the event. 

EXPECT UNEXPECTED

    We often talk about any  situation when something goes wrong, as Murphy's Law, 'If anything can go wrong, ,it will!' Nothing is exception to this statement  and medicine is also not exception.But I often say that sometimes it is better to not know everything, but know what patient DOES NOT HAVE. So when I see some patients and have some symptoms  and I can not find exact reason for it , I tell them that I don't know what you have , but it is not serious. That brings me to the story of one my patient.

    He was a young male and has not been smoker.He was fine till one day when he was working on a house . He was hard working - physically hard working male and he used to buy homes and work on them and then sale them. So one day when it was little cold in Florida, he was working on a house. He was out side and so he had a jacket and was working  and he noticed that he felt hot and took out the jacket and he noticed that he was sweating . He had some shortness of breath. No major chest pain. He saw his primary care physician and was told to get COVID test done . He had no fever and no cough and no other problems . He did the test  and that was OK . He was told to see me or may be he decided to see me. I asked him on any chest pain and he did tell me that he had some chest pain but it was short lasting but now he has some more shortness of breath.I examined him  and his blood pressure was normal, he had no fever and he had good oxygen saturation  and his lungs were clear and he had no wheezing like asthma.He had normal heart sounds and there was nothing abnormal on physical examination.I thought that his symptoms were atypical and did not look like lung problem ,but he was short of breath on doing things that he could do without efforts in past.I thought that he could still have mild asthma , but it was not very clear cut.So I decided to do work up. He had COVID test and that was negative. He had no cough and no fever  and lungs were clear. I ordered CT scan of chest and a breathing test  and also pulmonary stress test. I gave him  an inhaler to help breathing in case he had asthma. The breathing test was normal  and the CT scan showed some abnormality. He had what was described as 'ground glass densities' The ground glass densities is very small areas of ' haziness' The window glass is clear and the shower glass door is not clear . So that is called ground glass density. I could not figure out as to what might have caused this  and infection could be one of them  and so I spoke to him and he told me that he was little better but was still short of breath and he had no new complaints . I ordered some antibiotics and told him that he needs to see cardiologist ASAP as I was concerned that he may have heart problem , the sweating and shortness of breath and some chest pain all could be due to coronary artery disease . So I called a cardiologist to see him soon. He was seen in 1 day and the cardiologist was convinced that he HAD SEVERE CORONARY ARTERY DISEASE. and wanted to do cardiac cath. to find out any blockage. But all the slots were filled in the lab. and so he admitted him of Friday, the day that he saw and did procedure on Saturday. HE HAD  SEVERE BLOCHAGE IN THE CORONARY ARTERIES  AND NEEDED surgery!

    So I knew that this was not lung problem  and suspected it was heart, but was not sure . 

   So one must know  what it is not even if one does not know what it is.

WHY?

   We do not the future  and that is why every newspaper and many magazines have weekly or monthly horoscope. We also have psychic readers and Taro card readers.People make lots of money telling people as to what is going to happen love life and job market and so on. But we in medicine have the firm but wrong belief that we can predict as to what is going to happen , the so called prognosis. But I have come to a firm conclusion that what we are doing is more of a statistics  and a chance  and probability and we could be wrong . But then I wish we could have some more TESTS that could bring us to 100% prediction of future. When I used to go for a movie in my earlier years  like 10 or 12 years of age,when hero was being followed by villon, my cousin used to shout warning the her that the villon was right behind him . But if hero knew that then the story would end right there , but in life we have similar situations. I guess then there won't be FREE WILL or Law of Karma.That brings me to the story for today . 

   I saw this patient for a short time . He was life long nonsmoker  and he had some cough and was admitted 3 months ago and had abnormal chest x- ray. The X- ray was abnormal  and so had a CT scan and has a small nodule less than 2 cm . The work up was done and had needle biopsy and he had cancer of the lung. He had never smoked  and he still had lung cancer. So he had further work up with PET SCAN  and there was no spread of the cancer and so he has surgery done in November . The cancer was operated and there was no suggestion of spread to lymph nodes and the borders were clean and nothing to suggest need for any additional treatment.He did well and recovered from the surgery and was doing good . Then he had some vague pain in the belly and he came tp hospital. He had CT scan of belly and also chest X- ray . The CT scan of belly was abnormal and had a mass that was pressing on the duct that drains the bile  and so he also had CT scan of chest and that showed a cavity. This was near the suture line of the previous operated cancer. So it looked like he had recurrence of the cancer that was taken out. The further work was started . 

     So 3 months ago or less he had no evidence of spread of cancer  and so had surgery and no test could have shown that in short period of 2 or 3 months he has now a cancer that has spread to a point that it is not possible to do much surgery. WOULD IT NOT BE NICE IF WE HAD SOME TEST THAT COULD PREDICT THIS OUTCOME ?

MORTALITY

      Since we were born we know that we will die - well may be not when we are in our childhood , but certainly we know about the death even when we act as invincible as young adults.One can see this in the risks that are taken by teenagers. But at the same time we want to live for EVER. All the  TV  and radio commercials that we see are related to extend life expectancy and also how to look or feel young. This is from skin care products to various nutritional supplements which is billion dollar industry. And I see this in many of my patients. There is nothing wrong with the attitude that we must do everything to prolong life or make it better  and that is the role of medicines and physicians. But that thought process should not obscure the reality that everybody dies. That brings me to story for today. 

    I saw this patient 90 years old . He was diagnosed to have cancer of rectum.He was treated with radiations  and he was doing OK but the cancer was mot cured and so he was now on CHEMOTHERAPY. Then he was admitted with what looked like pneumonia  and then had further work up  and was found to have obstruction of lower lobe bronchus on right side and that was biopsied  and it was cancer  and to surprise it was not spread of rectal cancer,but it was new Lung Cancer. So ow the radiation therapy physician was called . He was not a candidate for surgical resection and so radiation was started and it was completed  and then he got more chemotherapy. He had the side effects  and was weak and had no appetite  and has drop in blood counts  and he had some shortness of breath. He also was confused  and he has reduced responsiveness. He had the full work up and had CT scan and consult with cardiology - he also had atrial fibrillation and so had cardiologist to look at him  and also infectious disease doctor  and lung specialist.- This is very typical now a days as primary care doctors do  not come to hospitals and the hospital doctors call various consultants. The CT scan showed collapse of the lower part of the lung  and this was related to the blockage from the cancer that was diagnosed 3 months ago and treated with radiation , but now he had more fluid around the right lung. I thought that this could be due to inability of lung to expand due to blockage from inside due to cancer or could be due to cancer spreading to the covering of the lung - pleura . In any case I felt that this was not good . He was severely anemic  and cancer doctor nurse also saw patient. I felt that there was not much that would change much by doing more interventions as diagnostic test. HE was 90 years old  and had 2 different cancers  and bot did not seem to have been cured  and also he had side effect from chemotherapy. My feeling was that we could treat him for fluid  and that may help him but beyond that doing additional therapy was not going to change much on long term.I also thought that since the  fluid was  locculated - had formed a pocket - may be due to radiation, putting a catheter would be better idea in this 90 years old patient. I did not feel doing more chemotherapy would change much . When I asked patient when he had improved in his mental status as to what he would like to do. He wanted to know why we can not do surgery on lung and rectum? I did not think he either understood or accepted the reality of having 2 cancers and the prognosis.

    So we all know that we are going to die  and are not mortal but even at age 90years  and with 2 cancers one is not ready for inevitable end of life.