Ep. 52 | Vivek Yadav, MD, Pulmonology & Critical Care, SGMC Health

Transcript

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- Welcome to another episode of What Brings You in Today? I'm Erika Bennett, and I'd like to start out by thanking all of our listeners for tuning in. Make sure to like and subscribe if you haven't already. And then of course, if there are any topics that you are interested in hearing more about, please let us know in the comments so that we can bring on a guest to address those. But today we are here with Dr. Yadav and he is a pulmonologist at SGMC Health. So Dr. Yadav, what brings you in today,

- I'm here to talk a bit about lung cancer screening, about the new tools that we have available at South Georgia Medical Center to help diagnose lung cancer effectively and at an earlier stage to help our patients and the community and to talk a bit about the risk factors and lifestyle changes we can do to reduce the incidences of lung cancer in the community.

- Perfect. All right. Lungs? Everybody's got 'em. I don't think we really think about them until we're maybe running or walking. Get out of breath. Right. So we can start before we hit on lung cancer and you know, lung health, let's talk about your background a little bit.

- I'm a dual trained pulmonologist and critical care medicine physician. Okay. Pulmonology is like respiratory medicine and critical care medicine is the intensive care medicine.

- Okay. - So I take care of patients in the outpatient and inpatient settings. In the outpatient, I practice as a respiratory care physician, as a pulmonologist, where I deal with problems like COPD, asthma, diagnostic aspects of lung cancer and various other pulmonary conditions like interstitial lung disease, pulmonary hypertension, and so on.

- Okay.

- I also take care of patients in the ICU and patients who are on ventilator. Were critically ill having multiple medical problems, organ failure,

- Respiratory

- Failure. So

- That's a pretty variety of patients you've got there. You know, you've got your pulmonologist side, but the critical it is care unit, it's a whole nother Yeah. Ballgame. How did you decide to, is that normal for a pulmonologist to dual specialize in critical care or how does that, how'd you decide to do that?

- That's an interesting question. Actually. In United States, this is a unique combination and majority of the pulmonologists that are training now, I would say at least 80 to 90% they have dual training.

- Okay.

- Because the programs are pulmonology and critical care medicine combined fellowships. So it's a three year integrated program where you get training in intensive care medicine as well as pulmonary medicine.

- It in regards to like hospital population of patients, do a large majority of patients who are hospital or hospitalized, do they, the pulmonary issues, is that normal to have both of those? Is that why that kind of tends to lead that way?

- I would say when patients are in the intensive care unit, majority of them need some kind of support in terms of breathing, and then large number of them are on ventilators. So it just makes sense that patients who are on ventilators, pulmonologists take care of them

- Because, - Because we have training in bronchoscopies management of ventilator, lung physiology, and I think that is where it came from. Okay.

- And what interested you in the lungs? What made you decide to pursue pulmonology?

- Essentially, my background is from India as a trauma surgeon. Okay. And then I've always seen how injuries can make people sick and can lead to multiple organ failures and how this can der the physiology of human body and essentially the diagnostic dilemma and the acuity of medicine at that time. When people are dealing with so many serious life-threatening conditions, the ability to diagnose, support and make them better, I think it's very rewarding.

- Yeah.

- At the same time, lung itself, pulmonology is a very cerebral field. A lot of conditions in the body can manifest in the lung. Like patients. I've seen rheumatoid arthritis getting diagnosed based on patient presenting with respiratory complaints.

- Hmm.

- A lot of interstitial tissue disorders, they can manifest as lung disorders, like cough, wheezing, shortness of breath. You would not think that

- Yeah,

- Patient has a systemic disease. It's only when you do the workup, you come to know that the patient is suffering from a systemic disease, which is a connective tissue disorder, but it manifested in the lung first.

- Okay. - So I just think that this is a very interesting and a very rewarding combination. You get to practice inpatient, you take care of the sickest people in the most difficult times, and you also have a nice variation where you can do office practice.

- Yeah.

- And addition to that, you have tools like robotic bro endo, bronchial ultrasound. So there is a procedural aspect also to it. So I think it gives you a whole spectrum to practice.

- Yes. - I think, I think it's a unique combination.

- Yeah. All right. Well let's talk about, you mentioned cough, wheezing, asthma. What kind of symptoms, and maybe I just listed to them, would someone have where they might need to consider seeking medical advice? And does that typically start with your primary care provider? But what, when should someone be concerned

- In terms of symptoms? Any unexplained weight loss, any unexplained cough, which lasts more than four to six weeks. Any blood coming in the phlegm, any loss of appetite, any lumps or swelling that you find unusual and you observe in your body all these symptoms, they should not be ignored. And medical health should be sought early.

- Do you think people ignore them longer than they should? Typically

- Around here they do, unfortunately. Unfortunately they do. And a big thing now is preventive care, the U-S-P-T-F, United States Preventive Task Force, it it, it gives you the guidelines, what kind of preventive screening you have to do to detect diseases earlier.

- Yeah.

- And lung cancer is one of them. So

- Yeah.

- A lung cancer screening program is a nationwide recommendation by U-S-P-T-F. And it says that anybody who is in the age group of 50 to 80 years have smoked for more than 20 pack years and are currently smoking, or they have quit within the last 15 years. They qualify for an annual low dose CT scan of the chest.

- And what does that look like? What does that procedure look like? You go, is it, I mean, what kind, walk

- Me through it. It's a, it's a non-invasive procedure. Okay. It's just like a, I would say just like a bigger form of x-ray.

- Okay.

- You just have to lie down on the table. And then the CT scan machine CT scanner, it just scans your chest. You lay still for a few minutes and it takes a picture of your lungs. Okay. And if they detect any nodules, any spots that looks suspicious or that may warrant any invasive diagnostic workup, the physician can pick it up at an early stage. Okay. The idea is to detect lung cancer at the earliest possible stage because the treatment and the outcomes are entirely different. To give you an idea, if somebody is detected with lung cancer at stage one, the five year survival you're looking at is 60 to 70%. Okay. On the other hand, if it is stage four lung cancer, the survival five year

- Wow.

- Is just 10 to 12%. So this, this, this can kind of, this is the,

- It's huge to catch it early.

- This is correct. It's, it's a big deal actually.

- And tell us about, I know a lot of people probably avoid getting screamed because they don't wanna know. They don't wanna know that it's there because then what happens after that? Like all the things, if it is there, what they have to do. So tell us a little bit about that. Bronch, I can't even say it.

- You

- The

- The bronchoscopy?

- Yes. Bronchoscopy.

- Okay. Once we see these nodules on the CT scan, essentially there are different of going after them to find out what they are. Essentially we need a tissue sample, right. To find out whether they're cancer or their infection or they're something else. We can do it in a different number of ways. One is bronchoscopy.

- Okay.

- And I'll talk a bit more about it. The other way is to do a CT guided biopsy where the needle is pushed inside the lung after giving a local anesthesia. Okay. Under guidance of CT scanner. Okay. And the third thing is obviously surgical sampling where the chest is opened and there's a biopsy, actual biopsy done by the surgeon. Everything comes with its own pros and cons. And unfortunately all the procedures come with side effects. And the whole idea is to minimize the harm and the side effects by utilizing minimally invasive technique. That is where we utilize the robotic bronchoscopy. Okay. Because ion robotic bronchoscopy, which we have at South Georgia Medical Center, it's a cutting edge technology. It is the latest innovation in technology, which has been a game changer. What we do in that is we pass a very thin, flexible maneuverable tube through the airway. It has a tip which has a camera, so you can look where you're going and navigate it or steer it through all the smallest airways and get access to the most peripheral part of the lung, which is not possible with a traditional bronchoscope.

- Right.

- Because they were thick and as, I mean, human airway has 23 branches, 23 generations of human airway starts from the trachea, and then it branches and then branches. So there are 23 divisions. With the traditional bronchoscope, you can hardly get to the fourth or the fifth generation with ion bronchoscope, because it is so thin and it is more maneuverable, it is more flexible. You can navigate up till 10th or 12th generation of airway.

- Wow. So you're able to get deeper in the lung. Correct. Is that okay?

- Deeper and into more difficult to reach areas.

- Okay.

- You can actually access all the 18 segments of the lung. And not only that, actually maneuverability dexterity. When we use a traditional bronchoscope, the pulmonologist is holding the bronchoscope with one hand and they only have one hand to utilize the sampling needle or the forceps. In robotic bronchoscopy, we have a robotic arm that does the job and you have a console and a tracker. You can just maneuver it and advance the tube. Once you have located the spot with pinpoint precision, you lock the tube there and you have both the hands free Mm.

- To

- Do whatever you want to do.

- Yeah. Was it hard for you to learn maneuvering the robot?

- I think it's easier for the kids and

- Yeah, I've test drove the, the regular da Vinci that we have. And it is, it is interesting the kids, they can do it real easy, but it is cool how you can get that, that like 360 rotation and stuff that you cannot do with your, just your hands alone. So, well that's phenomenal. I mean, that's huge to be able to get there earlier and decide what it is earlier, I mean, in the past, did people just have to wait until it got,

- I - Mean, how did that, or did you not even detect it until it got,

- I would say detection was there, but first of all, the lung cancer screening program was not as widely implemented. Now that it has been implemented.

- Yeah.

- We are picking up lung cancer at a much earlier stage. Okay. Now coming to your second question, how would you diagnose if you did not have a robotic bronchoscopy? If they were very tiny spots, you would just get repeated CT scans.

- Okay.

- Just to watch them, whether they're growing or they're not growing. Some of the cancers can be slow growing.

- Yeah. - Or you would go for the CT guided biopsy. Now the problem with CT guided biopsy, there's a very high chance of developing a pneumothorax, which is like a puncture of the lung and air getting trapped inside the chest.

- Up - To 10 to 20% of people can get that pneumothorax. Okay. With robotic bronchoscopy, the chance of developing a pneumothorax is less than four or 5%.

- Okay. So

- There's a huge difference in the incidence of side effects.

- How does that make you feel being able to have these tools now that you can kind of diagnose earlier and treat earlier? Just as a physician?

- I mean, I, I feel immensely grateful to this technology. It is helping the people and it is helping our patients. You feel more confident that you can go after smaller nodules, which are located in difficult parts of the lung. Lung has a complex anatomy,

- But - With these tools we can actually access the most complex anatomy of the lung. As I said, you can get nodules in all the 18 segments and in the peripheral, one third of the lung, which is far away from the trachea where you start the bronchoscopy.

- So - This was something which was unimaginable, I would say five, 10 years ago.

- Yeah.

- So it has definitely empowered us. It has definitely given us more flexibility, more options. And it has actually, it has been reflected, the outcomes of lung cancer are improving. And the large part of it is because we are able to diagnose lung cancer at an earlier stage nationwide and at South Georgia Medical Center. I'm glad we have implemented this technology now almost for one year.

- Yeah.

- And we have had some excellent results. We have had, we have detected cancers in say one centimeter nodule, 1.2 centimeter nodule.

- Wow.

- Which is what, like 10 like this tiny in a, in the lung. So yeah, this is, this is a huge accomplishment and I'm glad we are able to offer this technology to the community.

- Yeah, absolutely. Let's talk a little bit about prevention for lung cancer and in general and how we can keep our lungs healthy. What's the best thing we can do to keep a our lungs in check?

- Yeah. Since we are talking about lung cancer primarily here, the biggest thing here is to stop smoking. 90% of the cases of lung cancer are in some way caused by smoking. Yeah. Now smoking can be, the person can be smoking themself or there is a spouse or

- Secondhand

- Or somebody who's secondhand smoke. Both of them are equally dangerous. If we can get rid of smoking, I think the incidence of lung cancer will go down significantly.

- And you, I mean I feel like we've made a lot of progress to stop decreased traditional smoking cigarettes and such. But I mean, are we still seeing this? How do you feel it's gonna continue with the prevalence of vaping and things like that?

- Vaping is equally dangerous. That's what I feel. Although the data is limited because it's a recent trend, but it's equally harmful. So I don't think if people think that somebody just thinks that I quit smoking and I'm starting vaping and I'm on a safer ground, I think that's a fallacy that's not true.

- Yeah. - Smoking of any form is injurious to the lungs and it is going to cause an increased risk of lung cancer. So that is one big thing.

- Yeah.

- In lifestyle modification that can reduce the incidence of lung cancer. And of course then secondhand smoking. And then there are some occupational exposures like exposure to heavy metals, exposure to asbestos, you know, people who work in shipyards, you know, in construction and wearing proper masks, protective equipment, protective gear, getting regular lung cancer screening done. If you, if you, if you fall in that category of high risk people and maintaining a healthy lifestyle, eating a balanced diet, exercising all the other stuff that applies to any other cancer.

- Right.

- Also applies to it.

- Okay. I know people like, don't wanna hear it about us, stop smoking. But here, well that's the, you're the second one to say it that I've heard today. So it does, impact has a big impact on your body.

- Yeah.

- Okay. What about just from the outpatient pulmonology? I know you mentioned like asthma and stuff like that. Is there anything that can be done? I feel like around South Georgia we have bad seasonal allergies, asthma situation, what do you see?

- Lot of vegetation and pollens and a lot of antigens in the air. Definitely it leads to a trigger of seasonal, you know, allergies. The people should seek medical help. They should use the inhalers that are prescribed on a regular basis, avoid any triggers, which can be different from person to person. Some people are allergic to say, you know, cold. Some people may be allergic to dust, some people may be allergic to smoke. So individual triggers are different. So they have to understand what triggers their asthma and they have to make an effort to avoid those triggers.

- Okay. And what exactly is asthma? I know this like what happens in your body when it trigger

- Asthma is essentially

- Occurs

- An allergic response where the airways, they have an intense inflammatory reaction that leads to a constriction of the size of the airway.

- Okay.

- Which leads to a decreased air flow. Because if the airway is this big because of inflammation, there is a muscle spasm and it becomes smaller. So the air has less room to move. It makes it immensely difficult for people to move air and to breathe. That is what asthma is. Okay. It's an allergic reaction basically.

- It's, it's just interesting how all these different components can impact your body.

- Yeah.

- Just these external factors. Okay. Well tell us about, let's talk a a little bit about medical education. 'cause I know you are involved in our internal medicine Yes. Residency program here at SGMC Health. So tell us about medical education and you know, kind of your role and what you like about it. And if you could give any advice to any medical students.

- I work as a core faculty in the South Georgia Medical Center. I am residency program. And my role is to train the next generation of physicians. I train them to think rigorously and integrate physiology, pathophysiology, pharmacology, clinical assessment, and a bedside physical exam together to come up with a comprehensive diagnostic plan and to become physicians who are empathetic, who understand what the patient needs. My philosophy revolves around this. I think every patient has the diagnostic riddle. The diagnostic riddle of every patient. The key to that is held by the patient.

- So

- Bedside assessment is the key. And often the patient is willing to tell you what you need to know as a clinician. Provided you are willing to listen. Data points like imaging, monitors, labs, they're just a supplement to bedside assessment.

- And

- They're not meant to replace it.

- Right. Yeah. They're

- Not meant to replace it. They're only meant to supplement it.

- So it's, you're like an investigator.

- Correct. - You know, when you're out on the field, like,

- And another aspect is if you get lost in the maze and the web of numbers and data points, we often lose the touch or the sight of the human being that we are treating.

- Yeah. - As I said, standing at the bedside will give you more information than scanning to the chart, looking at all the numbers, looking at the monitor. But you need to do a physical exam. You need to understand the cultural aspect, the background, who the person was when they're in ICU, they're intubated. They have a central line, they have monitors connected, they have a, like all the web of wires and tubes and all. But eventually you should be able to see the human being that is lying there.

- Yeah.

- What happened to them, why their physiology is deranged, why are they with you in the ICU? Obviously not a happy place.

- Yeah.

- And what you can do to get them out of the ICU for that, you should be able to see through those lines and tubes and look at the human being and what is the derangement in the physiology.

- I wanna come shadow you for a day where you can, where I can watch your investigative skills and action.

- No, you are, you're welcome.

- But I mean that's so true. And I think that's why a lot of those Grey's Anatomy, all the medical shows that are become very popular because it is, it's like a problem that you're having to solve and you're having to take so many different clues and put 'em together and find the answer. But

- Critical care medicine, I say is internal medicine at its best. It's medicine on steroids.

- Yeah.

- You have a whole set of problems to deal with. It can be immensely challenging, but at the same time it's immensely rewarding.

- Yeah. I was gonna ask what your most

- Rewarding of your job is. Yeah. When you see people who come in like struggling for their

- Life.

- Yeah. You know, you have a feeling sometimes that you nearly lost them.

- Yeah.

- And then you see them standing up, walking out, going to the floor. So the ability to do that, it's, it's an art. Yeah.

- And

- I think a lot of it, as I said, comes from being comprehensive, being detailed at the same time. You need to have quick thinking. You're making decisions in fractions of seconds.

- Yeah.

- So you have to have that mindset. And always, I encourage the residents and the medical students to read because your eyes can see only what your mind knows. So if you don't know, you will never able be able to diagnose your patients.

- Yeah.

- And your patients have you. That's it. There's no one else. That's right. So I tell them, people say that, you know, I want a doctor who I would want to care for my family if I fall, if they fall sick, I tell them I go, go a further step further. I want a doctor who I think to become a doctor who I think I would want for myself.

- Yeah.

- If I am in that position.

- Yeah.

- So that should be the philosophy. You should be able to think in that, that terms that, am I the person who I would want for myself if I was in this

- Position? Yeah.

- So you have to kind of read, evolve.

- How about sound? Do you spend reading these days? You still hitting the books up?

- I like, I like, I like reading. So Yeah.

- Yeah.

- I think on an average, I, I almost read almost. 'cause things

- Are change. I mean, things are changing vastly. I mean, just think about all the advancements you already talked about just in the long care. And

- When I'm not in the ICU, I spend at least two to three hours reading every day.

- Wow.

- At least two I would say,

- Okay, well if I'm ever in critical care, come, come check on me. I want you on my case. Okay. But we do appreciate you and I mean it's, I mean, it is fascinating. I love this conversation. I've seen you in the hallway several times, but I did not notice that about you. And I, I love it. 'cause it, it is comforting knowing that we have physicians of your caliber and up there on the floors taking care of our patients. So I

- Mean, it's a pleasure and an honor to serve the community here, to be a part of the community, to be a part of the medical staff here. And I think it's a privilege.

- Well, well thank you for that. And then last question is this one, it should be, you know, not as difficult as the others, but

- What is, you asked me too many difficult questions for

- Today. What is your favorite thing to eat here at SG

- Salads? I'm a

- Vegetarian. Okay. A salad.

- So

- The salad bar, you

- Had that salad bar. Yeah. It's pretty impressive. And we have a good, oh, the salad bar. We have a good salads in the physician lounge also. So I think,

- All right, so you're, you're speaking it and living it from the nutrition side.

- Yeah, but I need to exercise more probably.

- It's hard. You can't, you know, it's the ebb and flow. You can't do all of them perfectly all the time. Right. You just baby steps, keep it manageable. Otherwise it's just too overwhelming. And you just say, I'm not doing any of it. So. Well, we appreciate you so much for coming on today. Of

- Course. It was a pleasure.

- And we'll link some information below regarding some of the things we talked about here in case you have any more questions or need contact information. And again, we just thank you and thank you to our listeners for tuning in.

- Thank you.