WEBVTT - 32 - Shortness of Breath 0:00:00.090 --> 0:00:04.080 From Kerkow media coming up on the show, the first 0:00:04.080 --> 0:00:07.100 patient I saw when I was an intern, I was 0:00:07.110 --> 0:00:09.690 at Duke University, I went down to the E.R. to 0:00:09.690 --> 0:00:12.639 admit my patient. She was twenty five. She'd come in 0:00:12.640 --> 0:00:15.990 the a couple of weeks before pregnant. She was second 0:00:15.990 --> 0:00:20.489 trimester tachycardic and short of breath, fast heart rate. Couldn't breathe. Well, 0:00:20.640 --> 0:00:22.950 she was told she was anxious from her first pregnancy, 0:00:22.950 --> 0:00:25.710 was sent home, came back. I was there to admit her, 0:00:25.890 --> 0:00:27.990 but by the time I got it, she'd already had 0:00:27.990 --> 0:00:30.630 a cardiac arrest and died. I went to her autopsy. 0:00:30.750 --> 0:00:33.270 I have pictures of it to this day. And she 0:00:33.270 --> 0:00:36.180 had huge blood clots. One, I never forgot that. You know, 0:00:36.540 --> 0:00:38.700 we've both seen a lot of interesting things in medicine, 0:00:38.700 --> 0:00:40.650 but that really got my eye that something like this 0:00:40.800 --> 0:00:43.589 not only takes the lives of older patients, but can 0:00:43.590 --> 0:00:45.659 take the lives of young people who seem to have 0:00:45.659 --> 0:00:49.739 no particular risk factors. Dr.. 0:00:52.140 --> 0:00:56.670 Having trouble catching your breath, slightly dizzy, maybe battling a 0:00:56.670 --> 0:01:01.470 small cough, perhaps, that it's probably nothing, right, for the 0:01:01.470 --> 0:01:04.770 patients or doctors listening, we're not trying to make you nuts, 0:01:04.770 --> 0:01:08.700 but these seemingly benign symptoms might be something that require 0:01:08.700 --> 0:01:12.839 a second look. And apparently part of this diagnosis process 0:01:12.959 --> 0:01:16.680 comes from perspectives that only come from doctors with years 0:01:16.680 --> 0:01:21.000 of experience. A pulmonary embolism has been deemed a silent 0:01:21.000 --> 0:01:24.660 killer because most often than not, it's diagnosed only in 0:01:24.660 --> 0:01:29.250 an autopsy. Yep, when it's too late. Well, today we're 0:01:29.250 --> 0:01:32.340 joined by a renowned doctor from Cedar Sinai whose research 0:01:32.340 --> 0:01:35.550 helps lift the curtain behind a disease that plays hide 0:01:35.550 --> 0:01:39.090 and seek. It's used to hiding and will only present 0:01:39.090 --> 0:01:42.510 itself if you seek it out. It's a sobering lesson, 0:01:42.510 --> 0:01:47.190 but it's highlighted with hope. This is medicine we're still practicing. 0:01:47.760 --> 0:01:52.550 I'm Bill Kurtis. So first, my co-host, the quadruple board 0:01:52.550 --> 0:01:56.720 certified doctor of internal medicine, pulmonary disease, critical care and 0:01:56.720 --> 0:02:00.880 neuro critical care, and my very best friend, Dr. Stephen Tayback. 0:02:00.900 --> 0:02:02.440 How are you doing, Steve Cable. 0:02:02.480 --> 0:02:03.050 Good to see you. 0:02:03.530 --> 0:02:05.780 We've got a special guest today that I know you're 0:02:05.780 --> 0:02:08.370 going to like because it's just right up your alley. 0:02:08.419 --> 0:02:12.560 That's a fact. Our special guest, Dr. Victor Tapson, he's 0:02:12.560 --> 0:02:15.320 a professor of medicine and director of clinical research at 0:02:15.320 --> 0:02:19.100 the Women's Guild Lung Institute. He's also associate director of 0:02:19.100 --> 0:02:23.060 the Pulmonary and Critical Care Division at Cedars Sinai Medical Center. 0:02:23.540 --> 0:02:26.960 He's authored more than two hundred peer reviewed manuscripts and 0:02:27.110 --> 0:02:29.870 a whole bunch of books and book chapters. We're lucky 0:02:29.870 --> 0:02:32.840 to have him here. Vic, I imagine this past year 0:02:32.840 --> 0:02:35.480 with covid has been quite a challenge. And I understand 0:02:35.810 --> 0:02:39.679 covid creates all kinds of blood clot issues in your patients. 0:02:39.690 --> 0:02:41.090 Has it been for the last year? 0:02:42.050 --> 0:02:44.299 It's been such a bill as it has for everyone, 0:02:44.450 --> 0:02:46.460 but because a lot of problems, a lot of them 0:02:46.460 --> 0:02:49.160 involve the lung, of course, and many of them actually 0:02:49.160 --> 0:02:52.700 involve specifically a blood clotting in the lung and blood 0:02:52.700 --> 0:02:55.790 clotting in other places, too. So we've been trying to 0:02:55.790 --> 0:02:57.800 figure out how to deal with how to treat it, 0:02:57.800 --> 0:03:00.380 how to diagnose it. It's been a trying, but I 0:03:00.380 --> 0:03:01.680 think we've made a lot of progress. 0:03:02.210 --> 0:03:05.450 Why does it cause blood clots? How does the virus 0:03:05.450 --> 0:03:05.900 do that? 0:03:06.380 --> 0:03:09.560 Well, it's interesting, but there's something that go into thulium 0:03:09.560 --> 0:03:12.619 cells that line your blood vessels. These are the cells 0:03:12.620 --> 0:03:16.520 that line the blood vessels, become very inflamed and irritated 0:03:16.700 --> 0:03:20.059 by this virus. And we get something called an endothelial IDUs, 0:03:20.060 --> 0:03:22.489 sort of. So these viruses get in there, they inflame 0:03:22.490 --> 0:03:24.770 the lining of the cell. And when that happens, it 0:03:24.770 --> 0:03:28.190 releases substances from inside the cells. One of them is 0:03:28.190 --> 0:03:31.790 called Tissue Factor. It can really get clotting going and 0:03:31.790 --> 0:03:34.430 it's more complicated than that. But we certainly learned that 0:03:34.430 --> 0:03:37.610 in many blood vessel linings, not just the lungs, this 0:03:37.610 --> 0:03:41.960 develops blood clots in their legs called gvt, and they 0:03:41.960 --> 0:03:43.700 break off and go to the lungs. We call that 0:03:43.700 --> 0:03:46.310 pulmonary embolism. And we've seen a lot of this and 0:03:46.310 --> 0:03:48.620 it's been difficult to try to decide who we should 0:03:48.620 --> 0:03:51.170 look for that because a fairly high percentage of patients 0:03:51.170 --> 0:03:52.220 with Koban do get it. 0:03:53.150 --> 0:03:56.290 Back in January, we had 10 deaths a day, and 0:03:56.330 --> 0:03:59.960 which is just unprecedented and morale was at an all 0:03:59.960 --> 0:04:03.380 time low and just the human tragedy of it. And 0:04:03.530 --> 0:04:07.910 the staff was just reeling every day from the terrible 0:04:07.910 --> 0:04:11.590 emotional trauma. What did you guys do over the hill? 0:04:11.910 --> 0:04:14.150 Over the hill? Because Cedars is over the hill from 0:04:14.150 --> 0:04:16.760 where we're at. How did you folks deal with the 0:04:16.760 --> 0:04:21.349 social devastation both to the patient's family and also to 0:04:21.350 --> 0:04:22.010 your staff? 0:04:22.250 --> 0:04:24.409 I can tell you, Stephen, I'm sure you did the 0:04:24.410 --> 0:04:26.719 same thing. It was very difficult, especially early in the 0:04:26.720 --> 0:04:29.150 pandemic when we weren't putting patients in the room. No 0:04:29.150 --> 0:04:32.029 one was coming in. And later the same thing Jan 0:04:32.029 --> 0:04:34.250 came along. It was much worse than over the summer 0:04:34.250 --> 0:04:36.980 for us to we didn't really notice a really high 0:04:36.980 --> 0:04:40.250 death rate the whole first year until that surge after 0:04:40.250 --> 0:04:42.800 the holidays. Then we noticed something a little different. I 0:04:42.800 --> 0:04:45.350 don't know if that was a variant California variant. We 0:04:45.350 --> 0:04:47.810 were getting some of the one one seven Bériot. I 0:04:47.810 --> 0:04:50.029 don't know the reason we didn't sequence everything right away. 0:04:50.029 --> 0:04:52.160 I could just tell you, though, we saw what looked 0:04:52.160 --> 0:04:55.040 like a difference to us and to handle those problems 0:04:55.040 --> 0:04:57.290 that you're mentioning, the emotional social issues, me was a 0:04:57.290 --> 0:05:00.440 lot of phone calls and we enrolled patients in clinical trials. 0:05:00.440 --> 0:05:03.200 And normally we would talk to them and say, well, Mrs. Jones, 0:05:03.200 --> 0:05:05.120 we wouldn't like to enroll in this trial. And I 0:05:05.120 --> 0:05:06.679 know your husband's on the phone. Let's tell you a 0:05:06.680 --> 0:05:09.650 little bit about the study. And it was not just 0:05:09.650 --> 0:05:11.750 like a usual study where we would fill them in 0:05:11.750 --> 0:05:15.800 on some details. We had tons of questions about Kojm therapy, 0:05:16.010 --> 0:05:18.320 everything from other members of our family, how they could 0:05:18.320 --> 0:05:21.170 prevent it. So it was a lot of communication, a 0:05:21.170 --> 0:05:24.050 lot of phone calls. And I think that's really important 0:05:24.050 --> 0:05:27.020 treatment during this kind of thing. And it was family members, 0:05:27.020 --> 0:05:30.640 the patients themselves, isolated patients, the rooms. You know, Steve, 0:05:30.710 --> 0:05:33.349 it was terrible. It was terrible. A lot of communication, 0:05:33.350 --> 0:05:34.219 a lot of handholding. 0:05:34.460 --> 0:05:36.890 So I probably can't say the name, but I have 0:05:36.890 --> 0:05:40.030 a friend of mine who spent 59 days in your 0:05:40.070 --> 0:05:44.750 ICU and was on the ventilator for a long, long time. 0:05:44.750 --> 0:05:48.830 And nobody was really too positive about how that was 0:05:48.830 --> 0:05:51.770 going to turn out. And you guys sent him home 0:05:51.770 --> 0:05:54.800 and he had to relearn to walk. And he lost 0:05:54.800 --> 0:05:57.380 all kinds of weight, of course, but you had to 0:05:57.380 --> 0:06:00.589 put him back home among his wife and all of 0:06:00.589 --> 0:06:02.510 us who love them. And we really appreciate it. 0:06:02.610 --> 0:06:04.609 I'm glad he did. Well, boy, I'll tell you and 0:06:04.610 --> 0:06:06.080 I'm sure Steve took care of some of the same 0:06:06.080 --> 0:06:08.839 kind of folks. We just had some very, very long 0:06:08.839 --> 0:06:12.979 hospitalizations that were complicated by subsequent to see someone in 0:06:12.980 --> 0:06:14.720 the ICU for a long time or whatever they have 0:06:14.720 --> 0:06:17.350 covered or whatever. And then they get a urinary tract infection, 0:06:17.370 --> 0:06:20.520 they get a bloodstream infection, they get another kind of pneumonia. So, yeah, 0:06:20.540 --> 0:06:22.909 just like you're saying, Bill, these were complicated patients in 0:06:22.910 --> 0:06:23.660 many cases. 0:06:24.380 --> 0:06:27.220 No question for you. The general public, I think, is 0:06:27.230 --> 0:06:29.750 very familiar with the idea that if you've had a 0:06:29.750 --> 0:06:31.549 knee replacement, you're going to need to be put on 0:06:31.550 --> 0:06:34.550 blood thinners. People have heard they've been on a long 0:06:34.550 --> 0:06:37.280 plane flight. They've heard of cases of people developing a 0:06:37.279 --> 0:06:37.909 blood clot. 0:06:37.910 --> 0:06:38.970 And I think it's 0:06:39.020 --> 0:06:41.330 it's just general knowledge that when you're on an airplane, 0:06:41.330 --> 0:06:44.210 you should get up and walk around the mechanism for 0:06:44.210 --> 0:06:49.120 blood clotting in the covid patients pathologically. Is it? Exactly. 0:06:49.170 --> 0:06:52.599 The same as those people who undergo a surgical procedure 0:06:52.600 --> 0:06:54.419 or those people who are on a long plane flight 0:06:54.570 --> 0:06:57.240 is a blood clot, a blood clot, or is there something, 0:06:57.240 --> 0:07:01.140 a nuance to covid patients that we've identified during this 0:07:01.140 --> 0:07:01.700 past year? 0:07:02.370 --> 0:07:05.190 I think it's a little bit different. I think people 0:07:05.190 --> 0:07:07.349 do form clots in their legs. They break off and 0:07:07.350 --> 0:07:09.750 go to the lungs. But we're seeing patients that came 0:07:09.750 --> 0:07:12.810 in the hospital, as you suggested earlier, are nurse coordinators 0:07:12.810 --> 0:07:15.840 drawing blood from cold patients. The two clot it off 0:07:15.840 --> 0:07:17.720 and this doesn't happen by the two keeps falling off. 0:07:17.760 --> 0:07:21.150 I can't get it quite literally easily. We're seeing something 0:07:21.300 --> 0:07:25.470 called micro thrombosis, small clots in blood vessels, blood clots 0:07:25.470 --> 0:07:27.630 in the lungs don't start in the lung. They start 0:07:27.630 --> 0:07:29.160 in the legs and they go to the lung where 0:07:29.160 --> 0:07:31.230 some of these patients getting clots in their lungs. It 0:07:31.230 --> 0:07:33.510 might even be building up inside to do some I 0:07:33.510 --> 0:07:37.190 don't think know blood clots for forming and veins that 0:07:37.200 --> 0:07:40.560 niobium that usually would stay open. And so I think 0:07:40.560 --> 0:07:43.590 it was different. Steve, I think this very pro thrombotic, 0:07:43.590 --> 0:07:46.590 as we call it, tendency Cauvin was causing problems and 0:07:46.590 --> 0:07:50.040 a little different way, not just big macroscopic clots in 0:07:50.040 --> 0:07:52.140 the leg veins breaking off and going to the lungs, 0:07:52.140 --> 0:07:56.190 but small clots even causing strokes, causing heart problems, causing 0:07:56.190 --> 0:07:59.280 kidney problems. So we're seeing multi organ problems and what 0:07:59.280 --> 0:08:03.180 we call micro thrombosis, because this organism seems to be 0:08:03.180 --> 0:08:06.570 much more pro thrombotic than the flu, more than nerves 0:08:06.570 --> 0:08:08.970 or SARS or some of the past infections we've seen, 0:08:09.630 --> 0:08:12.450 in addition to the treatment, I should say, of blood 0:08:12.450 --> 0:08:18.360 thinning anticoagulation. Have you folks done any research on antiinflammatory agents, 0:08:18.370 --> 0:08:22.020 immunotherapy that may have some impact on either prevention or 0:08:22.020 --> 0:08:23.530 treatment of blood clots? 0:08:23.550 --> 0:08:25.770 We haven't actually done some of the studies on some 0:08:25.770 --> 0:08:28.040 of the antivirals. In the early stages, the desert disappear. 0:08:28.290 --> 0:08:30.450 We completed a study on a drug called Burset NIB. 0:08:30.660 --> 0:08:33.540 There's something called a jack inhibitor. One thing we learn, 0:08:33.540 --> 0:08:36.060 as you know, in the Soviet era is that steroids 0:08:36.120 --> 0:08:38.390 seem to help. And why do they help? To help 0:08:38.400 --> 0:08:42.660 is cytokine storm. These patients get such immune responses and 0:08:42.660 --> 0:08:45.960 tremendous inflammation that steroids can tend to kind of shut 0:08:45.960 --> 0:08:48.209 that down and calm things down. It put them on 0:08:48.210 --> 0:08:50.160 steroids for a long time to early and then they 0:08:50.160 --> 0:08:52.470 get covered. Then they're in trouble because their immune system 0:08:52.470 --> 0:08:55.199 shut down, can fight the virus. Once they get covered. 0:08:55.290 --> 0:08:59.010 Steroids may help. And I think steroids probably help with thrombosis. 0:08:59.010 --> 0:09:01.620 But right now, the data don't prove that. One study 0:09:01.620 --> 0:09:04.950 published in February suggested that there's no real proof right 0:09:04.950 --> 0:09:07.770 now that steroids reduce the chance of getting a clot. 0:09:07.770 --> 0:09:09.930 But it's hard to ignore the fact that if you 0:09:09.929 --> 0:09:14.010 do the right study, they might because inflammation and coagulation 0:09:14.010 --> 0:09:16.860 or clotting are so intimately linked. One way we know 0:09:16.860 --> 0:09:19.410 that if look at obesity, obesity, we don't think of 0:09:19.410 --> 0:09:21.900 it as an inflammatory disease, but it is obesity is 0:09:21.900 --> 0:09:25.079 chronic inflammation. The more we see, the more information there is. 0:09:25.320 --> 0:09:27.510 A heavier you are, the more likely you are to 0:09:27.510 --> 0:09:29.970 be hospitalized if you got covid and the more likely 0:09:29.970 --> 0:09:31.800 you were to get a blood clot. So I think 0:09:31.800 --> 0:09:33.220 there's really something to that. 0:09:33.780 --> 0:09:37.350 Personally speaking to you and I, we live and breathe 0:09:37.380 --> 0:09:41.730 this type of issue in the ICU. Naturally, it's interesting 0:09:41.730 --> 0:09:44.670 to us. But was there something in particular that caused 0:09:44.670 --> 0:09:47.250 you to pull your focus and to dedicate your life 0:09:47.250 --> 0:09:49.990 to dangerous blood clots and pulmonary hypertension? 0:09:50.429 --> 0:09:52.520 I could see the first patient. I saw it with 0:09:52.620 --> 0:09:55.650 my arm. I was an intern. I was a Duke University. 0:09:55.860 --> 0:09:58.230 I went down to the E.R. to admit my patient. 0:09:58.559 --> 0:10:01.260 She was twenty five. She'd come in the last couple 0:10:01.260 --> 0:10:05.760 of weeks before pregnant. She was second trimester tachycardic and 0:10:05.760 --> 0:10:08.370 short of breath. Fast heart rate. Couldn't breathe well. She 0:10:08.370 --> 0:10:10.650 was told she was anxious from her first pregnancy, was 0:10:10.650 --> 0:10:13.260 sent home, came back. I was there to admit her, 0:10:13.440 --> 0:10:15.569 but by the time I got it, she'd already had 0:10:15.570 --> 0:10:18.180 a cardiac arrest and died. I went to her autopsy. 0:10:18.300 --> 0:10:20.849 I have pictures of it to this day and she 0:10:20.850 --> 0:10:23.720 had huge blood clots. I never forgot that. You know, 0:10:24.090 --> 0:10:26.270 we've both seen a lot of interesting things in medicine 0:10:26.350 --> 0:10:28.650 that really got my eye that something like this not 0:10:28.650 --> 0:10:31.350 only takes the lives of older patients, but can take 0:10:31.350 --> 0:10:33.689 the lives of young people who seem to have no 0:10:33.690 --> 0:10:37.700 particular risk factors sometimes. So it's always been fascinating to me. 0:10:38.040 --> 0:10:39.510 I've maintained my interest. 0:10:40.350 --> 0:10:44.250 It's one of the most misdiagnosed syndromes in medicine and 0:10:44.250 --> 0:10:48.490 one of the most highly litigated syndromes and pulmonary embolism. 0:10:48.960 --> 0:10:51.420 Why is it so hard to diagnose? Why is it 0:10:51.420 --> 0:10:54.990 that the general population of physicians out there, why is 0:10:54.990 --> 0:10:57.569 it that we're still missing so many of these cases? 0:10:57.600 --> 0:10:59.070 I think a couple of reasons are I can see 0:10:59.070 --> 0:11:02.069 the symptoms, as you know, are very nonspecific. But you're 0:11:02.070 --> 0:11:04.590 short of breath. You rarely have coffee. You might have 0:11:04.590 --> 0:11:06.960 a cough. You might, in rare cases, cough up blood 0:11:06.960 --> 0:11:09.809 not nearly as common with people. You're short of breath. 0:11:09.990 --> 0:11:12.510 You listen to the lungs, you don't hear anything. They 0:11:12.510 --> 0:11:14.440 sound normal. You don't hear wheezing like you do in 0:11:14.760 --> 0:11:17.790 your crackles, like a pneumonia or fibros. You don't hear 0:11:17.790 --> 0:11:20.460 decreased breath. Sounds like there's fluid in the lungs. Look 0:11:20.460 --> 0:11:22.949 at the chest x ray, chest x rays. Clear, clear 0:11:22.950 --> 0:11:25.200 x ray with a big polymorphism, you don't see pneumonia, 0:11:25.200 --> 0:11:27.760 heart failure. So people looking at your lungs, they look 0:11:27.760 --> 0:11:29.940 your arteries and maybe got a little asthma. Some I'm 0:11:29.940 --> 0:11:31.470 not sure what this is. And you're sent home. And 0:11:31.650 --> 0:11:34.679 we've learned from four or five autopsy studies, if you 0:11:34.679 --> 0:11:38.309 die from pulmonary embolism, more likely than not, you're not 0:11:38.309 --> 0:11:41.400 diagnosed until you're dead. And more likely than not, you're 0:11:41.400 --> 0:11:44.520 not even suspected until you're dead. So see that that's 0:11:44.520 --> 0:11:46.740 right on target and it's still a problem. So I 0:11:46.740 --> 0:11:49.780 think we I think we've raised awareness and I. We have, 0:11:49.780 --> 0:11:52.329 but we still see this still litigated and it still 0:11:52.330 --> 0:11:54.970 poses a huge problem. So you're absolutely right. 0:11:55.660 --> 0:11:58.179 So what is the best test at this point to 0:11:58.179 --> 0:11:59.469 diagnose this? 0:11:59.770 --> 0:12:01.750 One of the best tests off the bat? I'd say, 0:12:01.750 --> 0:12:03.220 Bill and I kind of see a tongue in cheek 0:12:03.220 --> 0:12:05.860 is using good clinical gestalt. And there's been a study 0:12:05.860 --> 0:12:08.500 that's been shown by one of my colleagues over in Belgium. 0:12:08.710 --> 0:12:10.480 She did a nice study that showed that you have 0:12:10.480 --> 0:12:14.290 these scoring systems as well as well score the revised. 0:12:14.290 --> 0:12:16.390 You need to score the perks for to maybe help 0:12:16.390 --> 0:12:19.000 you if you're suspecting whether you should do a test 0:12:19.000 --> 0:12:22.420 or not. And what Dr. Peñaloza showed was good stock 0:12:22.420 --> 0:12:24.990 is better, better even than any of these scoring system. 0:12:25.000 --> 0:12:27.189 If you think someone might have P.E. and there's a 0:12:27.190 --> 0:12:29.740 reasonable chance they do, you've got to go for a 0:12:29.770 --> 0:12:32.560 simple blood test called a dimer. You can do dimer 0:12:32.559 --> 0:12:34.960 test is negative. It's very unlikely to have a clot 0:12:35.170 --> 0:12:38.380 if it's positive. You can't be sure it's nonspecific, but 0:12:38.380 --> 0:12:39.850 you've got to have a low threshold to go ahead 0:12:39.850 --> 0:12:42.660 and do a CT scan of the chest. And sure, 0:12:42.730 --> 0:12:45.550 you're going to maybe do too many CT scans expected. 0:12:45.550 --> 0:12:47.979 Too often you don't want to miss this diagnosis. So 0:12:48.160 --> 0:12:50.890 a good gestalt, I think, about the diagnosis and think 0:12:50.890 --> 0:12:54.429 about simple things like we've got an unexplained fast heart rate. 0:12:54.450 --> 0:12:57.190 Why is your heart rate 110 or 120? Maybe you 0:12:57.190 --> 0:12:59.980 are anxious, but maybe it's something else. Maybe it's your 0:12:59.980 --> 0:13:03.400 asthma inhaler, but maybe it's pulmonary embolism. So unexplained fast 0:13:03.400 --> 0:13:06.970 heart rate, unexplained shortness of breath, even someone's kind of anxious, 0:13:07.240 --> 0:13:08.890 a little bit shorter, but I've got to think about it. 0:13:08.890 --> 0:13:11.710 So once it comes to your consciousness, I think you're 0:13:11.860 --> 0:13:12.610 in better shape. 0:13:13.330 --> 0:13:16.120 So let me bring this into the mix, because this 0:13:16.120 --> 0:13:18.910 is the era of cost containment and you want to 0:13:18.910 --> 0:13:22.689 minimize testing. That's not necessary. And so using a score 0:13:22.690 --> 0:13:23.290 like the well 0:13:23.290 --> 0:13:24.280 score, which 0:13:24.280 --> 0:13:27.280 is supposed to help delineate who's the low risk, mid 0:13:27.280 --> 0:13:30.250 risk and high risk, and obviously, if it's a high risk, 0:13:30.400 --> 0:13:32.410 you're going to treat the patient. If it's a low risk, 0:13:32.559 --> 0:13:34.840 maybe you're going to let the patient leave your E.R. 0:13:35.080 --> 0:13:38.410 and certainly a seasoned practitioner such as yourself, your gestalt 0:13:38.410 --> 0:13:42.280 means a lot. But for a young practitioner who's making 0:13:42.280 --> 0:13:45.640 an assessment, who's relying heavily on a well score, and 0:13:45.640 --> 0:13:49.750 who feels pressure to minimize the amount of testing that 0:13:49.750 --> 0:13:52.810 they're ordering, what kind of a conundrum is that and 0:13:52.809 --> 0:13:53.890 where do we go with that? 0:13:54.340 --> 0:13:56.170 It is a conundrum and we do have to think 0:13:56.170 --> 0:13:59.020 about that for sure. And in the end, I think 0:13:59.020 --> 0:14:01.120 you should use these new scoring systems. I think the 0:14:01.120 --> 0:14:04.710 catch is use a scoring system together with a dimer 0:14:04.870 --> 0:14:08.199 in a body dimer is negative. You're almost always off 0:14:08.200 --> 0:14:11.740 the hook. If your suspicion is somewhat lower moderate, you're 0:14:11.740 --> 0:14:14.800 off the hook. If it's very high suspicion, probably nothing 0:14:14.800 --> 0:14:17.650 should supersede a very high suspicion. So I think what 0:14:17.650 --> 0:14:20.470 you do is you use those things together. And again, 0:14:20.560 --> 0:14:24.160 just don't ever second guess a really strong start feeling. 0:14:24.160 --> 0:14:27.010 But it's a problem. I think the tests testing make 0:14:27.010 --> 0:14:29.590 it better, make it easier. We're using artificial intelligence now, 0:14:29.810 --> 0:14:32.770 machine learning. We've done a couple of protocols. Now we've 0:14:32.770 --> 0:14:35.410 done with it. Are we able to predict code with 0:14:35.410 --> 0:14:37.720 a group we worked with coming up with an AI 0:14:37.720 --> 0:14:40.750 program without doing a COBA test? We were ninety nine 0:14:40.750 --> 0:14:43.810 point something percent accurate predicting covid. I think the same 0:14:43.810 --> 0:14:46.510 thing could be done with pulmonary embolism. And now now 0:14:46.510 --> 0:14:50.170 we've got A.I. artificial reading of CT scans, too. But 0:14:50.170 --> 0:14:51.820 I think that's going to come into the you may 0:14:51.820 --> 0:14:54.810 have seen something on TV using a robot who is 0:14:54.820 --> 0:14:57.640 taking histories from people. In the end, it was amazing. 0:14:57.820 --> 0:15:01.470 I think using machine learning, artificial intelligence, together with Gestalt, 0:15:01.540 --> 0:15:03.400 we're going to do a better job at saving money. 0:15:03.400 --> 0:15:05.560 But again, when it gets down to see I've been 0:15:05.560 --> 0:15:07.960 really lucky. No one's ever pressured me to save money. 0:15:07.960 --> 0:15:11.050 But we do want to use our common sense and try. 0:15:11.560 --> 0:15:14.780 But wait a minute. We're the patient here talking. Are 0:15:14.860 --> 0:15:19.960 you saying that there are considerations, perhaps with your relationship 0:15:20.110 --> 0:15:24.040 with some doctor's relationship with insurance companies that could affect 0:15:24.040 --> 0:15:27.430 whether or not you CT scan my dad if you 0:15:27.430 --> 0:15:30.490 have a well, let's say a minor suspicion that he 0:15:30.490 --> 0:15:31.360 might have a clot. 0:15:31.810 --> 0:15:34.210 Part of it is money and part of his resources. 0:15:34.210 --> 0:15:36.450 And for example, if you've got a busy day, there's 0:15:36.460 --> 0:15:39.280 one hundred people in there being seen. The CT scan 0:15:39.280 --> 0:15:41.830 is being used for all kinds of things. And so 0:15:42.010 --> 0:15:45.070 it's money and it's also using your resources carefully. But no, 0:15:45.090 --> 0:15:47.800 I would never think about money when I really thought 0:15:47.800 --> 0:15:50.680 someone that I think in general makes a good point. 0:15:50.690 --> 0:15:53.260 You've got to take that into consideration. But when it 0:15:53.260 --> 0:15:56.560 gets down to an individual patient to me, I will never, 0:15:56.560 --> 0:15:59.140 ever not get a test because I think it might 0:15:59.140 --> 0:16:01.030 cost me a little more if I have some doubt. 0:16:01.600 --> 0:16:05.170 But there is another consideration, and that is, if so, 0:16:05.170 --> 0:16:07.780 the public may say, well, if I'm a little short 0:16:07.780 --> 0:16:10.300 of breath, I'm having some chest pain. Everybody should just 0:16:10.300 --> 0:16:12.820 get a CT angiogram and and delineate. Is this a 0:16:12.820 --> 0:16:16.360 pulmonary embolism? Is it not? But the reality is the dye, 0:16:16.360 --> 0:16:19.060 the contrast that are being given with CT scans actually 0:16:19.060 --> 0:16:21.940 can have a deleterious effect. It can cause some kidney damage. 0:16:22.270 --> 0:16:25.330 And you don't want to, in a cavalier fashion, start 0:16:25.330 --> 0:16:28.360 scanning everybody that comes in because you don't want to 0:16:28.360 --> 0:16:31.960 miss a pulmonary embolism and wind up causing a certain 0:16:31.960 --> 0:16:35.260 percentage of patients to have serious kidney damage. That may 0:16:35.260 --> 0:16:38.410 or may not be reversible because you wanted to be 0:16:38.410 --> 0:16:42.730 super meticulous about making sure you're scanning everybody. So so 0:16:42.730 --> 0:16:45.970 medicine granted should not be it. Certainly in this country, 0:16:45.970 --> 0:16:48.700 we should not be thinking resources first by any means. 0:16:49.230 --> 0:16:51.810 But we do want to be judicious in our testing 0:16:52.020 --> 0:16:55.050 because some of the testing can have some negative impact 0:16:55.050 --> 0:16:56.460 on our patients well-being as well. 0:16:57.030 --> 0:16:58.770 You've got a screen. You've got you're absolutely right. You've 0:16:58.770 --> 0:17:01.200 got to look at that and look at the kidney test. 0:17:01.380 --> 0:17:03.570 If it's too high, we can't do the CD. There 0:17:03.570 --> 0:17:05.730 is another test you can do called the BQE and 0:17:05.730 --> 0:17:09.479 the ventilation perfusion scan. Very good test. Not as accurate 0:17:09.480 --> 0:17:11.850 as a CT scan, especially if the X-ray is already 0:17:11.850 --> 0:17:14.820 abnormal or the patient has other kinds of lung problems. 0:17:14.970 --> 0:17:16.950 But still a good test. But you got. Yeah, you're right. 0:17:16.950 --> 0:17:19.680 But look, the lab tests make sure that that's normal 0:17:19.680 --> 0:17:22.409 or near normal or you can't do this and you 0:17:22.410 --> 0:17:25.650 may have to empirically treat someone you think they might 0:17:25.650 --> 0:17:27.869 have until you can do a scan. You may have 0:17:27.869 --> 0:17:29.939 to wait a day sometimes to get the kidneys better. 0:17:30.910 --> 0:17:33.190 So can I just ask you guys about the treatment 0:17:33.190 --> 0:17:34.060 for just a second, 0:17:34.060 --> 0:17:35.409 because logic tells 0:17:35.410 --> 0:17:39.100 me that if you guys treat a blood clot with 0:17:39.100 --> 0:17:42.370 a blood thinner, it would seem that that is going 0:17:42.369 --> 0:17:45.220 to reduce the size of the blood clot. Right. Kind 0:17:45.220 --> 0:17:47.709 of thin it out. And it would seem that it 0:17:47.710 --> 0:17:51.369 could then get dislodged and actually move into a more 0:17:51.369 --> 0:17:52.900 destructive location. 0:17:53.410 --> 0:17:55.540 They do a couple of things. They don't actually break 0:17:55.540 --> 0:17:58.720 the clot down themselves, at least the ones we usually use. 0:17:58.900 --> 0:18:01.870 They prevent the body from forming more clot, which is helpful. 0:18:02.080 --> 0:18:05.350 They allow the clock to stabilize by keeping it from growing. 0:18:05.470 --> 0:18:07.869 It sticks to the wall and is less likely to 0:18:07.869 --> 0:18:10.720 break off as it stabilizes like this. The other thing 0:18:10.720 --> 0:18:13.959 it does is by thinning the blood, it allows the 0:18:13.960 --> 0:18:17.200 blood to flow better. So these remaining channels you have open, 0:18:17.350 --> 0:18:19.900 you get blood through better. You've got a blocked off artery. 0:18:19.900 --> 0:18:21.970 The heart can't pump the blood as well. If you 0:18:21.970 --> 0:18:24.370 can open up some channels by making the blood thinner, 0:18:24.400 --> 0:18:26.710 it gets through better so it can help even without 0:18:26.710 --> 0:18:30.010 affecting the clot directly. But it takes time for your 0:18:30.130 --> 0:18:34.030 own body's fiber optic system or clot busting system to 0:18:34.030 --> 0:18:36.490 kind of break down these clots in the blood thinners 0:18:36.490 --> 0:18:38.110 will give you a time for that to happen. But 0:18:38.320 --> 0:18:41.050 it does happen. You can treat someone and they may 0:18:41.050 --> 0:18:44.199 still have another blood clot or form one. But generally speaking, 0:18:44.200 --> 0:18:47.109 once they get on, that clot stabilizes and size doesn't 0:18:47.109 --> 0:18:50.890 get bigger. And one thing we've learned is blood thinners 0:18:50.890 --> 0:18:53.740 save lives. It's one of the dogmatic things we can 0:18:53.740 --> 0:18:55.480 say about blood clots is as soon as you get 0:18:55.480 --> 0:18:58.300 someone on the blood thinner, their chance of dying gets lower. 0:18:58.300 --> 0:19:01.119 It's been shown in one nice research study by a 0:19:01.119 --> 0:19:04.480 colleague published in Chest, one of our journals in 2010. 0:19:05.010 --> 0:19:07.149 If you're on a blood thinner with an at an 0:19:07.210 --> 0:19:10.869 adequate level within twenty four hours, your chances of dying 0:19:10.869 --> 0:19:13.030 are far, far lower than if you're not. 0:19:13.540 --> 0:19:16.660 And once you're on a blood thinner, very often my 0:19:16.660 --> 0:19:20.129 dad and his case, I think warfarin. Was that excessive? Yeah. 0:19:20.290 --> 0:19:22.659 We didn't have the docs at the time that your 0:19:22.660 --> 0:19:24.530 father was first placed on uncommitted. 0:19:24.580 --> 0:19:28.630 OK, but basically once you're on blood thinners, you kind 0:19:28.630 --> 0:19:30.790 of stay on blood thinners. Is that the case? 0:19:31.030 --> 0:19:33.190 We're doing that more and more nowadays. Why don't we 0:19:33.190 --> 0:19:36.879 try to divide clots into what we call promote and unprovoked? 0:19:36.880 --> 0:19:39.370 That's a little bit simplified. But the bottom line is, 0:19:39.369 --> 0:19:41.889 if you have a really good reason for a clot, 0:19:41.890 --> 0:19:45.129 you have a hip replacement and you get a blood clot, 0:19:45.310 --> 0:19:49.240 usually will treat you for three months, sometimes six, unless 0:19:49.240 --> 0:19:52.240 you have other risk factors. If you fly from Paris 0:19:52.240 --> 0:19:54.430 to L.A., actually get a clot. We know the plane 0:19:54.430 --> 0:19:57.070 flights increase the risk of clotting, but to me, that's 0:19:57.070 --> 0:19:59.690 a minimal increased risk. I've flown my four million miles 0:19:59.690 --> 0:20:01.899 of American Airlines. I've never had a clot, I think. 0:20:01.930 --> 0:20:05.470 But people are more susceptible, increase their risk, lower the threshold. 0:20:05.730 --> 0:20:08.050 They may get a clot, someone that's the only reason 0:20:08.050 --> 0:20:10.720 they get a clot because they're flying. I'd be inclined 0:20:10.720 --> 0:20:13.480 to treat them long term. I wouldn't say forever, but 0:20:13.480 --> 0:20:16.780 I'd say indefinitely. Forever's a long time. And what we 0:20:16.780 --> 0:20:19.220 can do now that we've learned with these new drugs 0:20:19.220 --> 0:20:22.390 that Steve mentioned, called the Doakes, is we can drop 0:20:22.390 --> 0:20:24.940 the dose at six months and reduce the risk of 0:20:24.940 --> 0:20:28.330 bleeding dramatically and still offer protection. So no kind of 0:20:28.330 --> 0:20:31.690 a new paradigm is to consider many patients treat them longer. 0:20:31.690 --> 0:20:34.270 If someone comes in, they have a plot and their 0:20:34.280 --> 0:20:36.930 only risk factors, they're obese. We might say, well, we'll 0:20:36.940 --> 0:20:39.010 keep you on this drug. We'll drop the dose in 0:20:39.010 --> 0:20:41.350 six months. If you lose weight, we'll take you off. 0:20:41.420 --> 0:20:42.980 But if you don't want to keep you on the slopes, 0:20:43.060 --> 0:20:45.730 there's a lot more versatility nowadays with these new drugs. 0:20:48.540 --> 0:20:51.090 OK, well, we're going to take about a 30 second 0:20:51.090 --> 0:20:53.550 break here, and when we come back, I'd like to 0:20:53.550 --> 0:20:56.990 talk a little about pulmonary hypertension. We'll be right back. 0:21:04.180 --> 0:21:07.980 A moment of your time, a new podcast from Kerkow Media. 0:21:08.710 --> 0:21:10.090 Currently twenty one years old 0:21:10.330 --> 0:21:14.020 and today, like magic, be defended from her fingertips down 0:21:14.020 --> 0:21:14.260 to the 0:21:14.290 --> 0:21:14.800 blood to take 0:21:14.800 --> 0:21:16.389 care of yourself because the world 0:21:16.390 --> 0:21:17.530 needs you and your 0:21:17.859 --> 0:21:19.659 every do gooder that asked about me was ready to 0:21:19.660 --> 0:21:20.470 spit on my dream. 0:21:20.470 --> 0:21:23.560 Fingers who are facing you can feel like your purpose 0:21:23.560 --> 0:21:24.550 in your worth is 0:21:24.550 --> 0:21:27.359 really being done to stop me from playing the piano. 0:21:27.369 --> 0:21:30.190 She buys walkie talkies, wonders to whom she should give 0:21:30.190 --> 0:21:30.760 the second day. 0:21:30.930 --> 0:21:31.570 Don't love 0:21:31.570 --> 0:21:34.379 humans. We never did. We never will. We just find 0:21:34.390 --> 0:21:34.910 what you do. 0:21:34.930 --> 0:21:37.780 If rock-climbing is that you can only focus on what's 0:21:37.780 --> 0:21:41.260 right in life. And so our American life begins. 0:21:42.280 --> 0:21:45.640 We may need to stay apart, but let's create together 0:21:45.880 --> 0:21:50.590 available on our podcast platforms. Submit your piece at Kerkow Dotcom, 0:21:50.590 --> 0:21:51.879 slash a moment of your time. 0:21:56.770 --> 0:22:00.970 All right, Vic, pulmonary hypertension. I'm assuming that is high 0:22:00.970 --> 0:22:05.050 blood pressure specifically in the lungs. How is that different 0:22:05.050 --> 0:22:06.639 than plain old high blood pressure? 0:22:06.850 --> 0:22:09.760 So high blood pressure. You measure your blood pressure, your arm, 0:22:09.760 --> 0:22:12.490 it's it's 120 over 80 when the heart's squeezing. It's 0:22:12.490 --> 0:22:15.790 120 when it's relaxed, it's eighty. And in the lungs, 0:22:15.790 --> 0:22:19.240 you have a separate circulation. Normally in the lungs, the 0:22:19.240 --> 0:22:22.690 pressure's much lower because the blood vessels are very dispensable. 0:22:22.690 --> 0:22:25.180 They can open up, they can handle more flow. The 0:22:25.180 --> 0:22:29.020 pressure might be twenty over ten, much lower pressure. Different 0:22:29.020 --> 0:22:31.180 things can make this pressure go up and we call 0:22:31.180 --> 0:22:32.350 that pulmonary hypertension. 0:22:32.859 --> 0:22:34.960 Now, I had a patient of mine who's become actually 0:22:34.960 --> 0:22:35.889 a very good friend of the 0:22:35.890 --> 0:22:37.510 family, and 0:22:37.630 --> 0:22:41.470 she had a pregnancy and right after she delivered suddenly 0:22:41.470 --> 0:22:45.250 became short of breath and she was diagnosed as pulmonary hypertension. 0:22:45.490 --> 0:22:47.770 One of my competitors at the hospital said, you know, 0:22:47.859 --> 0:22:50.230 you have two years to live and you better get 0:22:50.230 --> 0:22:53.230 your affairs in order. And then I walked into the 0:22:53.230 --> 0:22:55.240 room and I said, OK, well, things have changed now. 0:22:55.510 --> 0:22:59.020 And we obviously put her on some of our newer medications. 0:22:59.020 --> 0:23:03.010 It's been ten years and she's doing great. So maybe 0:23:03.010 --> 0:23:06.730 give a little bit of history about the earlier prognosis 0:23:06.880 --> 0:23:09.220 and where we are today in terms of 0:23:09.250 --> 0:23:10.540 the hope and the better 0:23:10.540 --> 0:23:12.760 outcomes that we're seeing relative to pulmonary 0:23:12.760 --> 0:23:15.130 hypertension. Well, Steve, I'm glad you were there to reassure her, 0:23:15.130 --> 0:23:18.010 because you're absolutely right. Things have really changed. Mortality actually 0:23:18.010 --> 0:23:21.219 dropped over the years. Just in a very brief nutshell, 0:23:21.369 --> 0:23:25.090 kind of five classes of permanent protection once called pulmonary 0:23:25.090 --> 0:23:27.550 arterial hypertension. It's the kind of young women tend to 0:23:27.550 --> 0:23:31.000 get more commonly than men unknown cause Group two is 0:23:31.000 --> 0:23:34.510 from chronic heart disease. That's much more common in older folks. 0:23:34.510 --> 0:23:38.200 Gets to FART'S and get heart has more trouble pumping attention. 0:23:38.200 --> 0:23:41.919 Group three, you have emphysema, lung fibrosis, scarring in the lungs. 0:23:42.130 --> 0:23:44.679 You destroy many of these millions of blood vessels in 0:23:44.680 --> 0:23:46.840 your lungs and the pressure goes up. You have to 0:23:46.840 --> 0:23:50.410 just treat the underlying disease. Group four is blood clots. 0:23:50.560 --> 0:23:53.530 About one in one hundred patients with pulmonary embolism, like 0:23:53.530 --> 0:23:56.500 we were talking about, will go on and get chronic 0:23:56.500 --> 0:23:59.169 pulmonary embolism. And that's got to be treated differently in 0:23:59.170 --> 0:24:01.690 the group. Five is kind of the muscle group. One 0:24:01.690 --> 0:24:04.810 is the one I suspect your patient had. It can 0:24:04.810 --> 0:24:08.550 be what we call idiopathic pulmonary hypertension, young women probably 0:24:08.560 --> 0:24:11.050 for women, for every man it gets it unknown cause 0:24:11.050 --> 0:24:14.200 sometimes brought out by pregnancy. And in the old days, 0:24:14.200 --> 0:24:16.929 we had no treatments. First patient I saw in nineteen 0:24:16.930 --> 0:24:19.659 eighty two, his name was Gary. There's a minister for 0:24:19.670 --> 0:24:22.930 South Carolina again. I was an intern. He had severe 0:24:22.930 --> 0:24:27.520 pulmonary hypertension of unknown cause. Our attending physician very insightfully 0:24:27.520 --> 0:24:30.100 sent them to Berkeley Griffith in Pittsburgh who had already 0:24:30.100 --> 0:24:32.800 done about a seven or eight heart lung transplant. Gary 0:24:32.800 --> 0:24:35.500 got a heart lung transplant and survived a good three 0:24:35.500 --> 0:24:38.320 or four more years after that. Now, we rarely have 0:24:38.320 --> 0:24:41.110 to do heart lung transplants, my judgment. And if we do, 0:24:41.109 --> 0:24:44.730 patients do much better nowadays. The idea is we have 0:24:45.010 --> 0:24:49.090 medications we've studied for the years. It was nineteen ninety six. 0:24:49.090 --> 0:24:53.820 We published the first paper on using prostacyclin drug IVI 0:24:54.010 --> 0:24:56.889 pulmonary hypertension to be published in England Journal. We studied 0:24:56.890 --> 0:25:00.310 eighty patients and 40 of those patients didn't get the drug. 0:25:00.460 --> 0:25:02.919 Eight of them died within 12 weeks. The patients that 0:25:02.920 --> 0:25:05.080 did get the drug all survive. We learned a lot. 0:25:05.200 --> 0:25:07.810 We started doing more and more treatment with that drug 0:25:07.810 --> 0:25:10.359 IV with a pump twenty the two we came up 0:25:10.359 --> 0:25:13.210 with another drug pill and so on. Over the years. 0:25:13.330 --> 0:25:17.260 Now we've got about fourteen pulmonary hypertension drugs. We combine them. 0:25:17.380 --> 0:25:19.510 We often have people on one or two or three 0:25:19.510 --> 0:25:21.800 at a time and we've just done so much better 0:25:21.800 --> 0:25:23.830 than we used to do. So just like you told 0:25:23.830 --> 0:25:26.980 your patient, nowadays we can tell people that they can 0:25:26.980 --> 0:25:29.080 do well, have a normal life. We don't really like 0:25:29.290 --> 0:25:32.170 getting pregnant again if we try to talk them out 0:25:32.170 --> 0:25:34.629 of it. But patients can live a much more normal 0:25:34.630 --> 0:25:35.710 life now than they used to. 0:25:36.840 --> 0:25:38.910 Doctors, how do you test for this? I mean, you 0:25:38.910 --> 0:25:41.159 can't put a cuff around the lung, so how do 0:25:41.160 --> 0:25:44.680 you know that someone has hypertension specifically in their lungs? 0:25:45.090 --> 0:25:47.639 It is harder. And it's it reminds me a lot 0:25:47.640 --> 0:25:50.520 of a more chronic form of something like pulmonary embolism, 0:25:50.980 --> 0:25:53.670 where you often come in the emergency department suddenly short 0:25:53.670 --> 0:25:56.820 of breath, something just happened with pulmonary hypertension. It's often 0:25:56.940 --> 0:25:59.790 slowly over months, someone notices I can't walk. My dog 0:25:59.790 --> 0:26:02.660 is for a little short of breath walking up the steps. 0:26:02.910 --> 0:26:06.930 So you see almost uniformly chronic shortness of breath is 0:26:06.930 --> 0:26:11.399 worsened over time, usually at least months. And again, there's 0:26:11.400 --> 0:26:13.409 a failure to diagnose. And a lot of cases you're 0:26:13.410 --> 0:26:16.440 told you gain weight, you're just you're deconditioned, et cetera. 0:26:16.770 --> 0:26:19.119 But what you do, one of the key tests while 0:26:19.140 --> 0:26:22.400 you examine someone and if you carefully listen, your loud 0:26:22.470 --> 0:26:25.830 heart sounds, you hear this blood's being pumped into the lungs. 0:26:25.830 --> 0:26:28.590 The pulmonic valve, one of the heart valves, is slammed 0:26:28.590 --> 0:26:31.250 shut by this high pressure. You're allowed second heart stop. 0:26:31.470 --> 0:26:33.630 You can pick that up. You do more tests. If 0:26:33.630 --> 0:26:36.120 you don't hear that, you still think about doing echocardiogram. 0:26:36.300 --> 0:26:39.330 And echocardiogram is the kind of the pivotal test that 0:26:39.330 --> 0:26:41.100 gives you a really good clue. If you've got it, 0:26:41.140 --> 0:26:43.920 then we do a heart catheterization to prove it. But 0:26:43.920 --> 0:26:46.980 you're right. But you got to suspect it first. Then 0:26:46.980 --> 0:26:49.830 do consider doing an echocardiogram and you'll be most of 0:26:49.830 --> 0:26:50.310 the way there. 0:26:51.240 --> 0:26:54.540 Are there any thoughts about what predisposes one individual to 0:26:54.540 --> 0:26:56.040 this disease versus another? 0:26:56.250 --> 0:26:59.050 Well, I think there's truly some genetics with this group. 0:26:59.070 --> 0:27:03.900 One pulmonary hypertension. It's often undiagnosed unknown cause it can 0:27:03.900 --> 0:27:07.590 be due to certain connective tissue diseases, lupus, scleroderma, things 0:27:07.590 --> 0:27:09.390 like this. It can be from a hole in the heart. 0:27:09.390 --> 0:27:13.380 Congenital heart disease, HIV, we learned, can cause from hypertension. 0:27:13.380 --> 0:27:16.980 But again, in terms of predispositions, the classic patient that 0:27:16.980 --> 0:27:21.360 gets pulmonary hypertension is unknown. Cause probably has genetic some 0:27:21.359 --> 0:27:26.370 genetic abnormalities, bumper to gene mutation, one mutation, certain mutations 0:27:26.369 --> 0:27:29.700 that some people have, we don't completely penetrate. You might 0:27:29.700 --> 0:27:33.660 get this mutation. Not yet. We're still understanding, learning more 0:27:33.660 --> 0:27:36.240 about the genetics. But certainly what I can say is 0:27:36.630 --> 0:27:39.330 just because someone gets it doesn't mean other people in 0:27:39.330 --> 0:27:42.090 the family will. I've taken care of many families with 0:27:42.090 --> 0:27:46.030 pulmonary hypertension. One was notably a young woman, forty years old, 0:27:46.030 --> 0:27:49.590 that got pulmonary hypertension. And two years later, we diagnosed 0:27:49.590 --> 0:27:51.720 her eighty year old grandfather with the same kind of 0:27:51.720 --> 0:27:54.660 pull my hypertension. So it's fascinating. But what we can 0:27:54.660 --> 0:27:58.470 tell our patients and reassure them is the vast majority 0:27:58.470 --> 0:28:00.570 of them will not get it. If they have a 0:28:00.570 --> 0:28:03.000 family member that has so well, it may be genetic. 0:28:03.180 --> 0:28:05.970 It doesn't mean everyone going to actually get the disease itself. 0:28:06.630 --> 0:28:09.840 So because it's on your radar, probably more than everybody else's, 0:28:10.080 --> 0:28:13.470 are you seeing more pulmonary hypertension in covid and post 0:28:13.470 --> 0:28:17.040 covid Long Pollaers or is there not that association? 0:28:17.119 --> 0:28:19.410 It's a great question, Steve. You know, I think it's 0:28:19.410 --> 0:28:22.139 a little early to know. So far, we haven't seen 0:28:22.140 --> 0:28:24.869 much of it. We've seen patients who have chronic scarring, 0:28:24.869 --> 0:28:27.960 lung problems that could easily get pulmonary potentially if this 0:28:27.960 --> 0:28:31.230 keeps progressing. So far, though, we haven't seen we've seen 0:28:31.230 --> 0:28:33.600 this blood clotting problem we talked about, but so far 0:28:33.600 --> 0:28:36.960 we haven't seen or proven that patients are going to 0:28:36.960 --> 0:28:40.620 get chronic pulmonary embolism with pulmonary retention or getting any 0:28:40.620 --> 0:28:43.590 other form of, like Group three from chronic scarring. But 0:28:43.590 --> 0:28:45.390 I think it might be too soon to know that 0:28:45.390 --> 0:28:47.670 maybe the next six months or year we'll learn more 0:28:47.670 --> 0:28:49.500 about this. If it takes longer to evolve. 0:28:50.160 --> 0:28:52.320 I can't help but bring my dad back into this. 0:28:52.320 --> 0:28:54.600 And I know both of you guys have had to 0:28:54.600 --> 0:28:57.150 deal with this quite a bit. And that's the balancing 0:28:57.150 --> 0:29:00.570 act between the treatment that you would like to administer 0:29:00.720 --> 0:29:05.550 for a variety of these diseases and someone's kidney function 0:29:05.550 --> 0:29:09.240 and whether or not they're capable of withstanding the treatment 0:29:09.240 --> 0:29:12.660 that would be best for dealing with pulmonary hypertension or 0:29:12.660 --> 0:29:16.920 any other lung issues. Have there been any advancements in 0:29:16.920 --> 0:29:20.100 the last number of years that helps you navigate those 0:29:20.100 --> 0:29:20.940 balancing act? 0:29:21.330 --> 0:29:24.330 Yeah, I think the idea of of kidney function and 0:29:24.330 --> 0:29:27.990 liver function, too, is a balancing act because the kidneys 0:29:27.990 --> 0:29:31.860 and liver are so important for metabolizing certain drugs. Some 0:29:31.860 --> 0:29:34.260 drugs are tablas almost exclusively by the kidney, some of 0:29:34.260 --> 0:29:36.810 the liver, some by both. What we don't want is 0:29:36.810 --> 0:29:39.930 a beneficial drug to build up in the bloodstream and 0:29:39.930 --> 0:29:42.209 cause problems because you got too much of it. And 0:29:42.210 --> 0:29:44.880 we usually fine tune these drugs and we try treat 0:29:44.880 --> 0:29:47.730 them up to a certain dose. For example, for Pulman hypertension, 0:29:47.730 --> 0:29:51.120 but not beyond that. So a careful physician is going 0:29:51.120 --> 0:29:53.790 to check a patient's blood test periodically every three to 0:29:53.790 --> 0:29:57.300 six months, making sure that kidney functions OK, liver function 0:29:57.300 --> 0:29:59.460 is OK, and we don't have to make adjustments, but 0:29:59.460 --> 0:30:02.460 we do have new drugs. Now, for example, the proximally 0:30:02.460 --> 0:30:07.560 drug that I've inhaled, oral subcutaneous, one of the strongest 0:30:07.560 --> 0:30:11.100 medicines we have for Pulman hypertension. And that drug, fortunately, 0:30:11.130 --> 0:30:13.920 is not metabolized by the kidneys and you can use 0:30:13.920 --> 0:30:16.680 it indiscriminately in patients that have kidney problems. So in 0:30:16.680 --> 0:30:18.690 the blood clotting world, we learn you have to be 0:30:18.690 --> 0:30:21.750 a little careful. The docs, these newer drugs that Steve 0:30:21.750 --> 0:30:24.180 alluded to earlier, one of them, you have got to 0:30:24.180 --> 0:30:26.520 stop if the kidney function gets too severe, the other one, 0:30:26.520 --> 0:30:29.760 you're probably OK even with severe renal failure if you 0:30:29.760 --> 0:30:30.570 dose it carefully. 0:30:31.050 --> 0:30:33.840 So, Vic, before we leave, I just wanted to ask you, 0:30:33.840 --> 0:30:35.979 over the course of the last, let's say. Three or 0:30:35.980 --> 0:30:39.610 four years, what are the biggest breakthroughs that have helped 0:30:39.610 --> 0:30:42.640 you with your specialty? And as a warning, I'm going 0:30:42.640 --> 0:30:44.760 to ask you for the next three or five years, 0:30:44.770 --> 0:30:46.110 what are your expectations? 0:30:46.390 --> 0:30:48.150 I think in the past, if you want to go 0:30:48.160 --> 0:30:50.800 ten years, the Doakes, we used to use this drug 0:30:50.800 --> 0:30:54.280 called Coolman, you mentioned earlier, difficult drug. I mean, we 0:30:54.280 --> 0:30:56.920 used it for 50 years. Good drug. But you give 0:30:56.920 --> 0:30:59.620 someone an extra dose of Tylenol every day for three days. 0:30:59.830 --> 0:31:01.750 Their blood gets way too thin. You put them on 0:31:01.750 --> 0:31:03.850 a different drug, it gets too thick. They eat too 0:31:03.850 --> 0:31:06.670 much greens, their blood gets too thick. The dough acts 0:31:06.700 --> 0:31:09.820 a very few drug and a few critical drug interactions, 0:31:10.060 --> 0:31:12.550 you know, but but very few. They're much easier to 0:31:12.550 --> 0:31:14.890 use than we used to. And we don't need to monitor. 0:31:14.890 --> 0:31:17.350 We don't need a blood test. We don't get INR 0:31:17.590 --> 0:31:19.780 every week, every two weeks or every month with these 0:31:19.780 --> 0:31:23.410 new drugs. So these drugs have really revolutionized practice, made 0:31:23.410 --> 0:31:26.290 them much easier in the blood clotting around another area. 0:31:26.290 --> 0:31:29.440 And pulmonary embolism has been we're learning how to treat 0:31:29.440 --> 0:31:32.980 blood clots that are really big ones, causing big problems 0:31:33.160 --> 0:31:36.580 without using high doses of dangerous drugs that can cause 0:31:36.580 --> 0:31:40.000 bleeding without using clot busters or TPA. We can use 0:31:40.000 --> 0:31:42.670 lower doses by putting an I.V. or catheter in the 0:31:42.670 --> 0:31:45.250 lung and putting low doses in the lung or even 0:31:45.250 --> 0:31:47.830 just putting a Katharyn in suctioning the clot out. We're 0:31:47.830 --> 0:31:50.650 still learning when that's necessary. We don't want to overdo it. 0:31:50.830 --> 0:31:53.140 So those have been big advances, too. And the blood 0:31:53.140 --> 0:31:55.900 clotting work in pulmonary hypertension. We've had new drugs. We 0:31:55.900 --> 0:31:59.450 have three classes of drugs. Now, the prostate annoys the 0:31:59.450 --> 0:32:03.340 endothelium receptor antagonist and the PD five inhibitors. And a 0:32:03.340 --> 0:32:05.980 nice paper was just published in the journal. The new 0:32:05.980 --> 0:32:09.630 drug called Aricept even has a little bit different mechanisms. 0:32:09.760 --> 0:32:12.250 And we've got several other drugs like this that may 0:32:12.250 --> 0:32:15.790 be coming soon. So I think that we've just kept pace. 0:32:15.790 --> 0:32:17.560 I kind of feel like we're surfing and just staying 0:32:17.560 --> 0:32:19.720 on the edge of the wave, just able to kind 0:32:19.720 --> 0:32:21.250 of keep up with some of these diseases. 0:32:22.210 --> 0:32:24.700 Vic, thank you so much for joining us today. We 0:32:24.700 --> 0:32:28.390 certainly appreciated it. How can our listeners follow you if 0:32:28.390 --> 0:32:29.290 they want to connect? 0:32:29.620 --> 0:32:32.170 I'm on Twitter, Tapson. I don't get a chance to 0:32:32.170 --> 0:32:33.610 get on it as often as I like to, but 0:32:33.610 --> 0:32:36.280 I try to say something profound every once in a while. 0:32:36.490 --> 0:32:39.400 My email address, the typical Cedar's email address. Victor Don 0:32:39.400 --> 0:32:41.290 Tapscott Xpress, Doug 0:32:41.710 --> 0:32:44.650 Vick, thank you for joining us. And of course, Dr. Tayback, 0:32:44.920 --> 0:32:47.980 my good friend. Thank you for doing these shows. We're 0:32:47.980 --> 0:32:51.820 Still Practicing is produced and edited by AJ Mosley music, 0:32:51.820 --> 0:32:55.210 but we're still practicing as composed and performed by Celeste Anorectic. 0:32:55.720 --> 0:32:57.880 Don't forget the hit that follow button so you don't 0:32:57.880 --> 0:33:00.550 have to hunt around for a next episode. We'll catch 0:33:00.550 --> 0:33:13.330 you next time, everybody. From Kerkow media media for your mind.