ONE IN A MILLION

     We in medicine are many a times sure on our thinking and diagnosis. Again this is based on our education and experience and statistics. As I have mentioned in my previous blogs , the entire medicine is based on statistics. If I see someone with cough and fever and yellow sputum, I would diagnose as having bronchitis or pneumonia if on physical examination there are abnormality. We are correct in our thought process  and diagnosis  and planned treatment. We don't do the sputum culture to start antibiotics or which one to give. Again this is based on statistics. But sometimes we are wrong . and then we say or thin this is one in a million. That brings me to the story for today . 

    I have known this 90 years old male for last 90 years or so. He had mild lung problem like asthma and he had been on inhalers and was quite stable. One day I got a call from his physician that he did a CT SCAN and he has cancer. I was shocked . He was 90 years old  and he had not smoked for more than 30 years ago I had seen him 3 weeks ago and he was stable. His last chest x- ray done 15 months ago was OK . So I was surprised . But the CT scan had shown a mass and that definitely looked like cancer. I told my office to call him and set him up for PET scan and biopsy. My office called the patient  to set it up . He had a grand daughter  and we had to call her . But then I got a call from her and she told me that he had a fall and he was taken to ER and then was admitted .They were doing work up to make sure he did not have bleeding or stroke. The work up was ok and he was still littlle confused . He was in the hospital where I do not go. But the granddaughter wanted me to check the chart and make sure that what they were doing was OK with me. The lung specialist planned to do the biopsy like I had planned  and he did . There was narrowing and there was some susicion of cancer but then when he checked the pus came out from that area . I continued to check  and he had infection and no cancer was detected on biopsy. He was started on antibiotics  and he was discharged on IV antibiotics 

   I spoke to them on telephone as he was too weak and could not come to office. Hew as doing better and last chest X- ray was much better. So it looks like he did not have cancer but had lung abscess - infection and pus in lung that looked like cancer. 

   This kind of thing does not happen often but only one in million .

CONTRACT

     Now a days when you watch TV, we see several advertisements that are for replacement policies for Medicare recipients, that promise everything and more. The usual Medicare does not cover vision, dentistry and over the counter medications. But theses policies cover everything and they also 'give you money in pocket'. If one thinks about this with some intelligence, they will realize that one has to cut the cost somewhere.. Theses Insurance companies get money from Medicare and then they spend it for health care . But they have to have some overhead expense and also they need to show some profit for their share holders. So how can they do all that and promise things that are not covered by Medicare? The obvious answer is they MUST BE CUTTING SOME SEVICES OR PAYMNETS. Most of the patients do not think about this. This brings me to story for today. There are 2 such stories that I came across recently. Both are similar.

     I have known this patient for many years. She has been seen by me for last few years with shortness of breath and has been obese. She has Asthma /COPD and has been on medications. She had done sleep study and she has sleep apnea, the treatment for that is CPAP - pressurized mask for sleep. She has refused to use the CPAP. She also has heart problem and she has not lost any weight . She has atrial fibrillation and the heart rate has not been controlled. The cardiologist had suggested ablasion, but it was never done and she was not sure if she wanted that. So she needs oxygen and CPAP or BIPAP and also needs to lose weight . She has oxygen and recently she was in hospital. When I talked to her I asked her if she was using oxygen and she told me she does not as the oxygen cylinder is 'dangerous' to carry as it can explode if she has car accident and she is not going to put her and her grand kid's life in danger if she has car accident. So she does not take oxygen with her and so he has not done any exercise and she has not lost any weight.. Just as aside note - walking or the amount of exercise that she or patient like her can do will not add much to weight loss as the calories spent will be minimal. The main thing for weight loss is diet. e.g. 16 French fries consumption is equal to doing 31 minutes of bike riding or 52 peanuts is equal to 90 minutes of house work. So there is no dietary change and no exercise. I also asked her if she will be willing to use PAP as that has been shown to reduce the atrial fibrillation problem. She told me that she can use only minimal pressure -which will not do any good as that pressure is ineffective to control her sleep apnea . So I asked her as to what does she want me to do / The answer was she wanted PORTABLE OXYGEN CONCENTRATER -the one that she has seen on TV and she knows that Medicare covers it . The problem is that Medicare covers oxygen but does not cover all portable oxygen concentrator and when a patient has one home oxygen concentrator ,then Medicare will not pay for second. We had tried to get her the portable oxygen concentrator in past and the company that has contract with her Advantage policy had refused it. Simply stated I can tell that patient needs oxygen and the company will provide oxygen .But what device they will cover is up to them and when there is cost reduction by these plans they may not get what patients want. 

    So, then there is conflict The plans tell everyone on TV that they cover everything and MORE and in reality they have to cut cost to cover MORE and that is cut for every service - physicians , labs , radiology and also for DME that provides such equipment . The patients are told that if a physician writes a letter that 'it is medically necessary' then they will cover it. But reality is they WILL PROVIDE oxygen but not what patient wants .Patients watch TV have misconception and then don't do what is more important than just the equipment 

    

KARMA PAST OR PRESENT

      I have talked about the Karma many a times  and there are times when I see situations where I can not explain the things that I see on the basis of law of Karma.I do see husband and wife as patients  and they have lung issues and I am not sure if they got together due to Karma done in past life or they are creating new Karma in this life and that has the effects that I see as diseases. Certainly genetics can not play arole as they rae not genetically related to one another. This is not the first time but I have seen thu=is over and again . That brings me to the story for today .

   I  had seen this patient many a tomes and I also wrote about it in my previous blog. He was a smoker and had abnormal CT scan of chest .I did bronchoscopies and biopsies and they did not show cancer though I was convinced that he has cancer. To make the long story short, we did finally did surgery and then he was diagnosed to have cancer in the lung  and that started in SALIVERY GLAND !! I have never seen this before  and he did not have any cancer in salivary gland that we can detect. So as a fact he had salivary gland cancer that spread to lungs  and so essentially he was inoperable  and the chance of cure was not much .But he was treated with chemo and radiation therapy. He completed the treatments  and he has been off that for more than a year. He is doing good and he has no evidence of cancer. 

   Then his wife started seeing me . She was a smoker and she had some shortness of breath and also had some heart issues. She needed a cardiac process  and she needed pulmonary situation to be cleared . So I did see her and then did the work up ,She had breathing test and then chest X- ray and then CT SCAN of the chest . The CT scan did show a nodule about 1.2 cm  and so I did the work up . She had PET scan and the bronchoscopy. The PET scan did show some uptake but it was not very high . Due to her history of smoking I wanted open biopsy. The low uptake indicates slow growing cancer if it was a cancer. She saw a surgeon and he did do the surgery and it was a cancer . All the lymph nodes and margins were good and the chance of recurrence was thought to be very low. She did see oncologist - cancer specialist and she was not started on any treatment . But it was decided to do follow up CT scan to keep an eye on it .She had a new ct scan in 4 months after the surgery . SHE HAS SPREAD OF CANCER TO LIVER.!

  So her husband who had metastatic cancer  that too of very rare type seems to be cured  and the wife who had very small nodule and that too metabolically not very high growth, .He is cancer free and she has spread in 3-4 months  after so called surgery that was thought to be curative. Not sure I can explain this .

DISTRUST OR MISTRUST

     In medicine we come across many situations where I am surprised at the behavior of the patients or the relatives of the patients. I can understand that we all have different experiences in life and also we have different educations and we all are different individuals. So we will think differently and behave differently . But certain things are more accepted than others . So in this pandemic I have seen things that I did not think I had seen in past. So this blog is related to such opinions. 

   I saw this 78 years old lady and her daughter who was may be 58 years old . They came to me for pulmonary follow up. In my routine for this pandemic has been to ask them on signs and symptoms of COVID and now that we have vaccine to ask them if they are vaccinated . So they had no symptoms of COVID infection on our screening questions  and so I was seeing them in office. So when I sked her as to the vaccination for the COIVD , they said they did not have it. So I asked why did you not get it ? The answer surprised me .The daughter told me that they don't trust such shots . So I asked why don't you trust this , Everyone is taking vaccine. She answered that 'In past they have been used as scape goats (African Americans) for medical experiments and so they do not want vaccine'. I did not go in detail. But I am not sure what is cause of this distrust. But I did tell them that if you see the lines that are shown on TV news of the people that are waiting to get vaccines ,it is mixed population - the Asians were much higher than Caucasians  and Hispanic and African Americans were less . But everyone gets same vaccine .

  The second story is of a Hispanic patient. She is 85 years old and has some lung issues and she was admitted to hospital with COIVD pneumonia. On further work up she was also noted to have clots in lungs and she has significantly low oxygen and she was on BIPAP -oxygen given under pressure . She did not want to be put on respirator. So I was talking to the patient and the daughter on daily basis. On the first day she refused the Remdesivir which is a standard treatment for the COVID . So I called the daughter and then the patient agreed The reason was she did not trust any medicine or the vaccine that was related to COIVD . So we did start her on treatment and she continued to need  high oxygen flow . Then the daughter asked me if she could get flax seed capsules and elderberry capsules . So she did not want the standard treatment for the COVID as she had DISTRUST in the medical treatment even though that had some data as to the effectiveness - but had MISTRUST in theses over the counter products WHICH HAD NO DATA  as to the effectiveness !!!!

PANDEMIC AND HEALTH CARE

       We started with COVID 19 pandemic last year in 2020 and since then medical practice has been affected . We have issues with patients not showing up for follow up when it is utmost important to do follow up  and do follow up tests  and then some showing up when they should not. When I wanted to doo scans to make sure that there was no cancer and patients don't want to do it due to fear of catching COVID, there is nothing I can do but to pray. Fortunately I have not had anyone who had cancer that did not get diagnosed sooner due to not showing up for the scan. But many other factors have played role in frustrations for the medical community with the pandemic and I have not seen that being addressed or even mentioned by news media or our own medical societies . All that they are interested is in FREE CARE FOR ALL. One has to understand that there is nothing FREE-someone is paying for it .We have had issues with supplies that we need to do tests not provided leading to cancel tests . Which means we have to no income and we have to get authorization from insurance company or PCP for doing tests  at a different date  and then getting patients upset as the tests were postponed. So the tests are not done and there is no income ,but the person who does the test is still employed and has to be paid .The list of issues that are going on and have been there for more than a year is long but I wanted to tell one quick story about other issue that I mentioned earlier.

    I think we have COIVID INFORMATION FATIGUE . We have enough information about the disease and it's spread and treatment and complications -that I think anybody could do doctorate in COVID . but still sometimes I come across patients that surprises me . I have a patient who has COPD - the disease that is primarily caused by smoking . She is 75 years old and has been on oxygen due to her condition. She had a routine follow up with me . She is usually accompanied by her family. In spite of the diagnosis of COPD which is caused by smoking ,she has continued to smoke and quit only recently. She came to office and my office and my office told me that I have to do telemedicine follow up. So they were asked to wait in car . SHE WAS POSITIVE FOR COVID and her daughter who came with her to my office was also positive . 

     My patient was vaccinated but her daughter and her son and her son in law were not vaccinated  and one of them is in medical field and works in hops with respiratory problem patients! So in spite of 10 posters on my office front door and check in window and waiting room , they came to my office .Another health care problem with pandemic . 

TREAT OR NOT TREAT

   In out life we often have to make decision daily as to do things this way or that way . Take this road or do highway. order this food or that food . Take a phone call from this person or not . But in medicine we make the decision which is some times more complex that ordering topping on pizza. In many cases the flexibility of decision is not there. If I see elevated blood pressure or blood sugar, there is no question about if we should treat it or not .We treat it -period. But in certain other condition, we have to make a decision. This brings me to the story for today. 

   I saw this 91 years old male patient for the cough . He had cough off and on for 3-4 months  and he had no shortness of breath or other complaints . He was not a smoker and though was 91 years old , he was overall OK . He had some memory problems but lived by himself  and had not lost weight or had fever . He did not have history of asthma or gastroesophageal reflux - the 2 most common causes of chronic cough The Chest X- ray was done  and that had nothing impressive but some upper lobe scars. So I did some more testing . I di CT scan of chest and that showed some upper lobe scars  and some other abnormality that could go for Old TB. I was concerned  and so I did not do breathing test  and instead I gave him an inhaler for possible asthma  and I asked him to do sputum for tb bacteria. I had planned for doing the breathing test, but his sputum came showing that it was growing TB bacteria. This was preliminary  and the final report in case of TB can take as much as 6 weeks . Some times we can get report in 3-4 weeks if the TB bacteria is of type that grows fast . I had planned to do breathing test but I cancelled it till I get the culture. 

    I called the patient and the son and told them that the sputum is growing something and to be on safe side keep him indoor. Then they came to see me after 2-3 weeks . By then I had received the identification of the bacteria . It was atypical TB . The Mycobacteria is a family name  and the Mycobacterium Tuberculosis is the one which is contagious and MUST BE treated and isolate in the first few days  and also family close contact will be needed to be checked . But the mycobacteria are not like that. They do need prolong treatment and have similar symptoms ,but they are not contagious.So when they came to see me ,I had to decide on the treatment . I had 2 choces one was to treat this 91 years old patient with 3 MDICINES for 18 months or not to treat but watch it . tHt medines used can have liver problem , eye problem . So I had to talk to them . Her was a 91 years old patient who had sputum growing atypical TB  and had no complaints other than some cough. 

          TO TREAT OR NOT TO TREAT ?WAS MY QUSTION. . 

I decided to watch him with new CT scan and new sputum check and clinically. 

NEVER SAY NEVER

    We have a saying in medicine . We never say never in medicine. I have written many a times on unexpected and surprises that we see in different patient. But in spite of knowing that we never say never in medicine , things seem to come as surprise  and then we say "there is exception to every rule". That brings me to the story for today . 

  I had known this lady for many years . Her husband was may patient and he had cancer of the lung and when we diagnosed it he had spread of the cancer to liver and he did survive for 4 years or so . She started seeing me after he had died . She had also smoked and she had COPD  and we did the work up. She then developed lung cancer. She was 'lucky' and we had diagnosed the cancer in time - or at least we thought. She did ok but when the surgery was done she had some of the lymph nodes showing spread of cancer. So we did have her see oncologist and had treatment with chemotherapy. She continued to do OK and she had COPD  and she had shortness of breath and needed oxygen .She also had gained weight and she had sleep apnea . I had told her after the diagnosis of the cancer  and the need for the treatment to 'prevent' the recurrence that the recurrence happens most in first year and then less in second  and least in third year after the diagnosis. After 3 rd year the chance of recurrence is not there  and so you are cured if there is no evidence of cancer after 3 years . 

   Five years had gone by after the surgery and she had new scan. She had CT scan and then PET scan. That was abnormal and so she came to me. Five years had gone by since we had diagnosed cancer and she had surgery. So the possibility of old cancer coming again was low or not there . But patients who have one cancer have high chance of having second cancer is high and then depending upon the type of cancer the treatment may be different. The abnormality was in such a location that simple way to do the biopsy was not possible . I spoke to interventional radiologist and he did not feel he could get it and suggested that biopsy with ultrasound guidance through a bronchoscope was better choice . But the interventional pulmonologist did not feel EBUS or navigational bronchoscopy could get the diagnosis. I did ot want open biopsy as this was not a curative surgery and she was oxygen dependent COPD . So the risk was higher . But I had no choice  and so she did see the surgeon and had a biopsy  and it was NOT A NEW CANCER but it was the SAME CANCER that was taken out 5 years ago. 

                   THAT IS WHY IN MEDICINE WE NEVER SAY NEVER!