NO RIGHT WAY

    In medicine there are more than one way to do things  and the AI will not be able to give one final way. In Mathematics, 2 plus 2 make 4  and that can not be changed and it is true under all conditions. In medicine sometimes we do things differently in different patient and there is no right or wrong way. I  saw 2 different patients  and they had very similar problems. And I will tell you one at time. 

The patient that I saw was that of my other patient, who had COPD and he had smoked for many years and he had quit ,but it had taken toll and he had COPD and he had shortness of breath and he  needed oxygen. I saw him and he had large mass and we did biopsy and he had cancer and he was not a candidate for surgery based on many factors like being on oxygen with advanced COPD and also the mass was invading the center of the lung . So we did radiation therapy and he did OK . Then his wife came to me. She was about 80 years old and had smoked many years ago. She saw her PCP  and had some cough and some shortness of breath and when she saw PCP her oxygen was low and she was started on oxygen and she had CT scan of the chest done and that was abnormal and so she was sent to me .

  She was elderly women and she has been on 3 L oxygen and she had some shortness of breath and she had not had any chest x- ray in recent past till she had the CT scan . The CT scan showed Aright upper lobe mass and that had invaded the hilum the center of the lung . She also had significant fluid around her lung  and she was short of breath. She had irregular heart beats and had not seen cardiologist but was on blood thinner. So I had high suspicion for cancer which had spread to lymph nodes  and also the fluid that was seen , was most likely due to cancer. She was on oxygen and had COPD  and she  did not want any chemotherapy same as her husband. So I had a choice . I could do bronchoscopy and biopsy and see if I can get the diagnosis of cancer  and then drain the fluid and see if there are cancer cells in it. If my bronchoscopy and biopsy does not give diagnosis then i will have to ask radiologist to do needle biopsy of the mass and if the fluid  reaccumulates then we have to have a catheter put in for periodic drainage. Since she was on blood thinner, we will have to hold it for 5 days every time we did any invasive procedure. So if I did all these procedures we will be stopping and starting blood thinner many times . So I decided to do thing that I thought was RIGHT for THIS PATIENT. 

  I called radiologist and asked him to do needle biopsy of the lung mass and at the same time put in catheter , under the presumption that the fluid was due to cancer and will come back if just drained and then will need drainage again or the catheter for periodic drainage. 

  THIS WAS THE RIGHT WAY FOR HER IN MY UNDERSTANDING . 

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MINE FIELDS IN MEDICINE

      I have heard this statement that when  Taliban terrorist left certain areas they left the place with mines  and they were unpredictable and can explode anyplace that we did not expect. I have felt the same thing in medicine. This is so true in case of cancer . I don't like when a patient diagnosed with cancer and have gotten treatment with chemotherapy, come for the follow up in my office and tell me that the oncologist told them that the cancer is gone. I know better that making such a statement and so does the oncologist. But patients like that and then when the cancer comes back, then we have hard time explaining the recurrence. And I call this as the mine field where we have no way of knowing all the mines -the metastasis -which are there, but not obvious. That brings me to story for today. 

 I had seen this young woman who had been diagnosed with breast cancer and she has had surgery and then radiation and then chemo. She had some abnormality in lungs and that also was breast cancer. She also had some bone spread. She was short of breath and so she had chest x- ray and she had fluid built up around her lungs and so she came to me. We did drain more than a litter and it showed cancer cells and so we did follow up chest x- ray in 3-4 weeks and the fluid had come back. So we did a catheter to drain fluid periodically at home. She did well and she had some chemotherapy changed and she was ok . The fluid drainage continued to be less and less. 

     More than  months passed by and i get a call from ER . She was in ER for shortness of breath. I spoke to the ER physician and told him to do the CT scan as she had 'white out' on right side - suggesting either the fluid or collapse of the lung. Sometimes the catheter may get clogged or may not be in 'right ' place. The CT scan showed that her right lung had collapsed . I  did bronchoscopy to see if her  right lung bronchus was blocked from 'inside' or it was due to pressure from 'outside' . If she had blockage from inside then I could put in radiation catheter and that would treat / burn the tumor and then that will help 'open' the obstruction. She did not have any tumor inside the bronchus, so she had pressure from outside . So we called radiation oncologist and she was started on radiation. 

    So she had breast cancer - that had spread to lungs - then had pleural fluid  and now mass that was pressing on the bronchus - just like new mines were discovered every so often. Then I had a call from Mayo clinic where she had gone for second opinion. The oncologist called me and told me that she had done MRI of the liver and SHE HAD MULTIPLE METASTASIS TO LIVER. Just like another mine exploding in her face .

CATCH BEFORE ---

    I n case of many medical conditions, if we catch in time , we have higher success. This is true even with infection . heart disease diabetes etc. . If we treat diabetes or high blood pressure early then we can prevent the complications that are associated with it. This is also true with cancer . In medicine we have tried to  diagnose earliest stage and then hope that we can achieve cure. We have stared  doing tests like DNA pieces of tumor in blood, this is called CTDNA . -Circulating Tumor DNA .But it is not a test that many labs do and even many physicians are not aware of it. It also raises some questions as to what to do if the test is positive. 3-4 years ago Medicare approved CT scan of chest as screening for early diagnosis of lung cancer in patients who recurrent smoker or ex- smoker for 14 years. This has certainly helped , but also has raised some anxiety when the CT scan shows some nonspecific abnormality  and needs follow up. But sometimes I feel that it's not always possible to 'CATCH' cancer early. The story that I am going to tell is one of that kind. 

   I saw this patient who was in mid or late eighties. He had quit smoking many years ago. He had quit smoking many years ago . he had some cough and usual treatment with cough medicines and antibiotics did not help. So, he had chest X- ray and then had more antibiotics . He then had CT scan and that was abnormal and so he came to me. He had some cough and no fever . He had no shortness of breath. There was nothing special in special examination. The CT scan showed  abnormality and had a cavitary area in lung . That could be an infection or cancer. So we decided to do further work up . We did PET scan. The PET scan shows where the glucose is concentrated and that depends upon metabolic activity of the cells. So it picks up in 8- plus % of the cancer. The PET scan showed increased activity in the cavitary area and also some lymph nodes. There was no evidence of any activity in any other areas , We did the EBUS - ultrasound guided biopsy through bronchoscope and that showed lung cancer -highly likely. I had discussion with patient and family and decide to send him for radiation treatment to the lession in lung. . Surgery was not an option and I had called and asked a surgeon to some additional biopsy and he had refused. He and his family did not want any surgery or chemotherapy so, radiation was the only option. I called radiation doctor and he gave him appointment 

  3 weeks had passed and he was admitted with weakness and hospital doctor had admitted. .When I was called in ,he was seen by cancer specialist and infectious disease doctor and also cardiologist. Tests were planned. He had chest pain and that happened to be due to spread of cancer. The cancer doctor had planned ordered bone biopsy . I talked to  patient and family they did not want any biopsy and so I called radiation doctor to consider radiation to bones where cancer  had spread . He agreed . 

   The PET scan done few days - weeks ago had not shown any spread outside the chest and now he had bone spread in many bones. I am sure cancer had spread tat time but out tests are unable to detect as the amount of cells must be bellow needed to be picked up. But with just given few weeks / days it showed on bone scan and CT scan. 

LIVING WILL AND DNR

    I have seen many patients that have living wills. Now a days if someone goes to hospital , they are asked if they have a Living Will. There is some misunderstanding about the Living Will. Some people  do not understand the difference between the Living Will and the WILL. If someone has gone to an attorney for estate planning they would have done the WILL which is their wish as to how the estate should be divided after their death. The Living Will has nothing to do with estate, but has to do with how one should  act in case they have sickness- how aggressive one should be have  terminal sickness. The living will does not mean DNR  which stands for Do Not Resuscitate. I had seen a letter to Editor in a medical magazine where she was complaining about the care that her mother got when she had stroke . That showed that she the Harvard professor did not understand the difference between DNR and having a living will.

  The Living Will records one's desire to use machines or artificial means of keeping one alive in case of need  and if one DOES NOT want them if the condition is determined to be TERMINAL. In contrast to that the DNR means one does not want to be put on any machines or Resuscitated. In case of Living will the physicians and the relatives have to decide if the condition is terminal - as the language states " in case of my condition is determined to be terminal --". This may take time to decide . Not every cancer  diagnosis is TERMINAL and not in case of heart attack or stroke ,patient dies or is terminal. If one does not want to be put on any life sustaining machines or means or resuscitated ,then they should sign DNR . There is DNR form that is VALID anywhere. The hospital DNR are valid for that hospital stay and that hospital only . But the COMMUNITY DNR is valid anywhere.

   One more form that everyone should have is medical surrogate - someone who is assigned by patient to make Health Care Decisions in case patient cannot make own decision. This person could be spouse , siblings  or children or even unrelated person .

  So in modern days one must have 2 forms Living Will and assigned  Medical Surrogate..

HOUSE AND OUR BODY

    In recent past we are seeing longevity increasing. I am seeing older patients in my practice. It is not unusual for me to see many patients over 80 years of age  and also I see patients older than 90 years of age every week. Some are weak and have some memory problem and some have many medical issues. Some are fully oriented and almost independent and some cannot do much on their own. Some of the families accept the aging process and have limited expectation, but then there are others who have unrealistic expectations. That brings me to the story for today

    I have seen  2 older women at one time Bothe were over 90 years of age . One has been seen by me for many years and she had some cardiac issues and she had some fluid around the lungs  and she also had sleep apnea and so i had done follow up. She started having some problem at night , she had some shortness of breath and she called me and then came to me. She was concerned that the her PAP -the pressurized device that is used for sleep apnea was not working well. I saw her and after examining her that the problem was not with PAP but was due to her heart valve having problem ,She had murmur and also was short of breath and was waking up due to water accumulating in her lungs . The chest x- ray that I did confirmed my suspicion . She was followed by a cardiologist and he had told her that she was fine . I echocardiogram and then had her see the cardiologist . She was diagnosed with severe narrowing of the aortic valve  and he suggested doing a surgery - relatively new type of valve repair called TARV . She did not want it and so we adjusted some medicines and she did ok. She did OK and then had a fall and has some bleeding in brain but did OK But she was getting weak  and so she had to start living with her daughtercard month passed by and she had pain the belly and she came to ER , She had Gall Bladder attack. She now was quite weak and was in no position to undergo gall bladder surgery. So we did a drain and she responded to antibiotics Her numbers - blood tests and oxygen and fever etch was better. But she was weak and tired and could not eat. She could not do any walking and needed help even getting out of bed . She and the family had made decision that she did not want any aggressive treatment. So we decided to try to discharge her home with meds .While I was talking to her and her family , I told them that the house that we have owned looks good and have no obvious  problems ,but the it is old  and slowly somethings go wrong . the paint is pealing and the roof may start leaking or the plumbing may be also an issue. The aging body is like old house  and even though one 'looks' good all the organs are old and they start giving out under stress. One has to understand that .Unfortunately not all patients and families either understand the limitations or accept it. 

SURPRISE

    In medicine I don't like surprises. The surprise is not good for patient  and not for the physician. But we do have them  and since we are not 'all knowing ' the surprises do occur. The story that I am going to tell you, is one of such patients. 

   I saw this patient for abnormal CT scan .The lady was a smoker and had quit 2 years ago and had some persistent cough and so had chest X- ray done and then CT scan. The CT scan did show a mass in the central part of left lung . I saw her and I knew that in all probability it was cancer and the bad part was that due to the location of the mass - dead center of the lung where main bronchus enters the lung - it was not operable. I did the Pet scan and the miss did pick up glucose and was hot and then I did bronchoscopy. It showed that there was a mass in the bronchial tube and that was partially blocking the tube. In such cases the surgery is not possible as there may not be enough bronchial tube to resect / cut. If the cancer is also in central lymph nodes then also surgery will  not be successful. The biopsy came back as SMALL CELL CANCER. The small cell cancer is treated with chemotherapy and sometimes radiation .She was seen by both the physicians - radiation and also oncologist and received treatment.

   She was seen by me few times and she needed oxygen and had done overall OK Then one day she was short of breath and so came to ER and the x- ray showed complete whiteness of the left part of the chest . In X- ray there are only 2 colors - air is black and everything else - fluid - tumor - collapse of lung - all look white . The CT scan was done and the left lungs was collapsed and there was fluid around it . The natural conclusion was that the fluid was due to cancer and that had caused the collapse of the lung. The treatment would be to drain the fluid and then the lung expands. 

   The catheter to drain the fluid - which was though to be very large - was inserted. But then only small amount of fluid came out. The X- ray barely changed - the lung continued to be collapsed . I was nnot happy and that was not expected . But what had happed was that the lung had collapsed DUE TO EXTRISIC PRESSURE from the tumor on the covering of the lung and so the fluid was secondary  to that and the lung was unable to expand . So the catheter did not help much. So, now only option was to do new chemo and may be radiation and see if the lung would expand . The chance of lung opening is not very good . 

   When we see chest x- ray with fluid and collapsed lung in 90% of the time when we drain the fluid the lung expands , but the surprise that the lung could not expand was not a good news for the patient. 

ONE AFTER OTHER

    In medicine we have some of theses saying that is true in majority of cases , but there are exception. The patients have not heard them and so sometimes we have problem . What may be true in many patients or cases , may not apply for one  of the patients. We in medicine go by probability  and that is statistics The 2 words that we talk are 'probable' and 'possible'. Anything and everything is possible , but not everything is probable. The probable is what can happen in majority of cases - say more that 50%. But possible means it can happen but not more than 50 % . So if it can happen 1 in a million it is still called possible though not probable. That brings me to the story for today. 

  I saw this patient in my office . She had a lung nodule and that was less than an inch in size. We did the work up and she had bronchoscopy and PET scan and also breathing tests. She was a smoker and has some shortness of breath, The CT scan had shown the nodule and it also had shown another nodule of 6 mm in size. 25 mm make an inch . The PET scan showed that the larger nodule was positive and the smaller one was not picking up any activity. Certainly that could be a scar or cancer , but with not enough number of cells it was negative on the PET scan. The lungs functions were showing some compromise  and she still had enough reserve to have part of the lung taken out . 

  She did have lung surgery and the nodule was cancerous and all the other things - like lymph nodes, margins and covering of the lung etc. were ok and so she had a high chance of having 'cure. 'She was sent to an oncologist and he told her no need for any additional treatment and she had her family were happy. She was happy . He did new CT scan in 3 months  and that was OK but the smaller nodule had grown by 2-3 mm , So the oncologist wanted to do PET SCAN in 3 months . She saw me and I saw the CT scan and the growth though only by 2 mm was bothersome . So I called the surgeon and pushed for having new PET SCAN done sooner . The PET scan was done  and she had pick up in the nodule though faint. I talked to the surgeon. Interestingly enough her lung function had not gone down much in spite of having a part of the lung removed . So the surgeon did do second surgery and took out the nodule that had grown  and IT WAS CANCER . The good part -if there is anything good about having cancer - was that it was a different  type of cancer . If it was of same type then that means she had a spread of a cancer in first place and that would not have been a good news . So she seems to have had 2 separate independent lung cancer starting at the same time - something that we don't see commonly . Or to state it differently, it is possible but not probable to have 2 lung cancers in the same lung at the same time . But she did !!