I had a fungal lung infection

I knew I was in trouble on August 21, 2018, when I was on a business trip. Lying in a hotel bed, I felt my body boiling hot. I had felt a chest pain a day earlier and just began a mild cough. When I got home the next day in the late afternoon, my temperature was 102. All symptoms suggested pneumonia.

I didn’t want to go to an emergency service in the evening. I made an immediate appointment on Doctor on Demand, a telemedicine service. A doctor went through all my symptoms through a video call and shared her diagnosis of pneumonia. She prescribed azithromycin, a common frontline antibiotic treatment for pneumonia. My wife rushed to a pharmacy to get the prescription right before it was closed for the evening.

The antibiotic dropped my temperature to 100. After the 5-day course of azithromycin, I went to see my family doctor. He took a chest x-ray, which showed a 3 by 6 centimeters mass in my left lung. The family doctor put me on another antibiotic, levofloxacin, and told me it would cover a broader spectrum of bacteria.

My fever lingered between 100 and 101 through these days. I started to lose appetite and weight. Fever should be gone already under a right antibiotic. Felt I needed a second opinion, I started to look for an appointment with a pulmonary doctor or lung specialist. I didn’t expect this to be a challenging endeavor. I had not used the healthcare systems for a long time beyond occasional visits with my family doctor. When I called for an appointment, Mayo clinic would see a new patient in November and the University of Minnesota Fairview Hospital told me to wait till October. Eventually, I got an appointment on Sep 5 with a pulmonary doctor at the St. John’s, a hospital in a neighboring suburb.

The pulmonary doctor felt the levofloxacin should have the infection under control, and she was puzzled by the lingering fevers. She ordered a CT scan on the same day to get more information. I got a call from the doctor on the same evening and was not prepared for what I heard.

She told me that the CT exam found a 7 by 7 by 5 centimeters mass along with several small masses in my left lung that were suspected for malignancy, or lung cancer. This would not exclude the possibility of lung infection, but the malignancy was the main concern. She suggested a CT-guided needle biopsy for a more definitive diagnosis.

This news was not easy to digest. The pulmonary doctor stayed late and sent me a copy of the CT report. I shared it with a few close doctor friends and my sister. The implication was serious. My sister, working for a large pharmaceutical company in New York, started to look for connections with the best cancer institutes in New York City. One doctor friend advised me to focus on getting a right diagnosis first and not worrying about the possible outcome. My wife and I hugged and reminded each other not to worry about the lung cancer just yet.

One problem we faced was where to get care. I might need care from oncologist, interventional pulmonologist and infectious disease specialists. I needed to go to a hospital, where all cares could be coordinated. The doctor at St. John’s was nice and responsible, but her hospital was small and unknown to us. Finally, we decided to go to the Abbott Northwest Hospital. It’s a larger hospital. A close friend worked there. She helped get an appointment on Sep 11 with a thoracic surgeon, who specialized in lung cancer.

A second problem was more complex. Lung cancer was serious, but the chance I had it was also small. I did not have its major risk factor of being a primary smoker or exposure to second-hand smoke. In addition, the mass grew from 3 by 6 centimeters to a much larger size from Aug 29 to Sep 5 – too fast for a tumor to grow. The needle biopsy recommended by the pulmonary doctor had a 20% chance to collapse the lung, or pneumothorax, which would require hospitalization. The problem was how to minimize the complication rate while getting a right diagnosis.

The fever still lingered around 100 to 101. After the 10-day course of levofloxacin, I went back to the family doctor. This time, he prescribed another antibiotic called doxycycline. This became an empirical approach of trying different antibiotics and hoping to catch the bug.

The thoracic surgeon ordered a PET scan before my appointment to get more information. The PET scan confirmed the findings on the CT report. The thoracic surgeon recommended a biopsy procedure via bronchoscopy, a procedure that causes less complication rate than a needle biopsy and has the flexibility to get more samples. The biopsy was scheduled on Sep 17.

After seeing the thoracic surgeon, I saw an infectious disease doctor at the same hospital, who prescribed another antibiotic, amoxicillin. It covered a different spectrum of bacteria. I was happy to try it after the doctor suggested that I might feel much better after 2 to 3 days. We scheduled another appointment following the biopsy. The relief, however, didn’t come after three days.

An interventional pulmonologist conducted the biopsy under general anesthesia on Sep 17. After asking the nurse to adjust my pillow in the OR, the next thing I remembered was waking up in the recovery room with my wife on my side.

The biopsy report came the next day. If the CT report on Sep 5 was “life threatening”, this report was indeed “life giving”. It confirmed that there was no malignancy in the biopsy sample. Instead, the doctor found large yeast forms with the shape of blastomycoses. In another word, I had a fungal lung infection. This explained why all those antibiotics had not worked – I did not have bacterial pneumonia.

I was feeling good about finally getting a right diagnosis until I started to read about fungal lung infection and blastomycosis. Fungal lung infection was a rare condition and misdiagnosis was common. In a report from Southern Saskatchewan Canada between 2000 – 2015, a total of 15 cases of blastomycosis were confirmed by lab report. Initial misdiagnosis occurred in nine cases and six of them died. The main cause of death was acute respiratory distress syndrome (ARDS) after the majority of lung infiltrated by the fungal infection.

The infectious disease doctor put me at ease after reading my biopsy report. There was an effective antifungal treatment for blastomycosis, which he started it with me right away on Sep 20. He also told me although my lung function was compromised, it was still in good shape with little risk for ARDS.  

After three days of antifungal treatment, my fever receded for the first time after a whole month. It was such a relief. Finally, I had the right diagnosis and treatment. It took a whole month, but it was not too late.

Throughout my career, I worked with doctors on new treatments for patients.  This was a humble experience navigating the healthcare system that I had thought I knew well but really didn’t as a patient. I was lucky to have close doctor friends, who kept me on the right track and avoided additional delays. My family, friends, and colleagues kept me focused on my health. They reminded me that I was in their thoughts and prayers when I faced uncertainties. I was happy to tell them finally I was on the mend.

I had an excellent insurance plan provided by my employer. It provided my access to specialists, diagnoses, and treatments with little out of pocket costs. I was grateful for getting all the care I needed for granted and recognized it as a privilege.  

Finally, I was wondering where on earth I got the fungal infection?

The Great Lakes is an endemic area for blastomycosis. The infectious disease doctor asked me about everything happening on my two trips in the boundary waters areas in the early summer this year, such as whether I broke any beaver dam. The last case that he diagnosed came from a group of four guys took woods from a beaver dam and burned them while camping and canoeing in the boundary waters. All four contracted fungal lung infection.

I became nervous with the line of questioning, worrying about not going to the boundary waters ever again. After thinking about the trips for a few days, I remembered one event. The blastomycosis lives in moist soil, decomposing wood, and leaves. When we were in boundary waters in June this year, we were mostly fishing and canoeing in its beautiful lakes. On one day, after a light rain, my friend and I grated the gravel and dirt road leading to his cabin. We had a lot of fun of dragging a scraper blade up and down the road a dozen time. This would have the best chance to expose me to the fungus than anything else we did during the trip.

It was a relief to know, after surviving this fungal lung infection, I could still enjoy the boundary waters, fishing, and canoeing. We just need to leave the gravel road, beaver dam and its fungus alone.

Postscript
The Minnesota Department of Health contacted me in December to collect information on my exposure to blastomycosis. They have a good summary of on the overall exposure information in the state of Minnesota: http://www.health.state.mn.us/divs/idepc/diseases/blastomycosis/statistics.html

Mending Hearts in Yunnan

Xiao Hua (“Little Flower”) was brought in by her parents to the First Affiliated Hospital of the Kunming Medical University in Yunnan (called “Yunda Hospital”). Her parents were migrant workers from Guizhou, a neighboring province.  They came with a hope that doctors here can “fix” their little girl who is now 5-month old. 

After a pre-birth echo exam, the doctor told Xiao Hua’s parents that there was a small hole between upper two chambers (called “ASD”) and a big one between lower two chambers (called “VSD”) in Xiao Hua’s heart. With these two openings, Xiao Hua’s heart mixed oxygen-rich blood from the lung with oxygen-poor blood circulating back from the body. Without repairing, Xia Hua would not grow properly because the defects would put more burden on the heart and lung and eventually damage their functions permanently.  

Xiao Hua’s case caught the attention of a team of doctors and nurses visiting from America. They are medical volunteers for Children’s HeartLink, an international non-profit group that works on improving treatment of congenital heart diseases in underserved parts of the world. Congenital heart diseases affect one in every 120 new births, and are the most common birth defects. There is a large disparity of CHD care around the world. Newborns in western countries are routinely screened for critical CHDs, and typically treated in their first year of life. Ninety percent of children with CHD were born in places that do not have adequate care for CHD. For example, Minnesota, a state in the US with four million population, has about 65,000 new births each year. The three pediatric heart centers operate on approximately 500 CHDs each year. In the province of Yunnan China, the population is about 40 million with 500,000 babies born each year. There were two hospitals that operate on 2,000 CHD cases a year, which serve half of the babies who might need surgeries. The partnership of YunDa with Children’s HeartLink aimed to improve capacity and quality of CHD care and serve Yunnan and neighboring provinces and countries such as Myanmar, Laos and Vietnam.

The American team was led by Children’s HeartLink’s Andreas Tsakistos and Dr. St. Louis, a pediatric heart surgeon from Children’s Mercy Hospital in Kansas City. The team has been working with the Yunda Hospital in the last four years to help them improve the overall quality to treat complex heart conditions. Xiao Hua’s procedure would not be complex for older children, but her young age and 6-kg body weight would push the limit of the local team to secure a safe and successful outcome.

Dr. Lee Pyles, a pediatric cardiologist from West Virginia University, examined Xiao Hua before the surgery with Dr. Wang Yu, the local echo doctor. They gave the go-ahead of the surgery with their confirmation of the diagnosis indicating the ASD was 5 mm and VSD of 10 mm, which are big holes for a small heart. Dr. Tao Jie led the surgery with his local team of heart surgeons and OR team with assistance from Dr. St. Louis and the perfusionist, Mr. Doug Zavidil from Children’s Mercy Hospital.

Pediatric heart surgery is the ultimate team sport in modern medicine. For Xiao Hua’s surgery, an anesthesia doctor put her to a deep sleep during the procedure. A team of perfusionists took over the function of the heart and the lung using a machine to maintain blood circulation in the body, letting the heart rest for the operation (called “bypass procedure”). The smaller the body is, the harder the procedure is for perfusionists to manage the margins of errors. For example, the blood volume for a 60-kg adult (132 lbs) is around 4,500 ml; for a 6-kg baby (13 lbs) is 450 ml. A small error of the bypass machine running at a wrong speed would have a 10 times impact in a Xiao Hua than in an adult. Mr. Doug Zavidil worked with the four-member local team on how Dr. St. Louis would typically choose instruments that specialized for small babies. During the procedure, they discussed constantly how to control the blood flow, temperature and medication to maximize the condition for the surgeons to operate.

Drs. Tao and St. Louis operated as if they had been partners for years. They communicated through an interpreter, although each seemed to know exactly what would be a next step. The surgical techniques for Xia Hua’s procedure are almost identical everywhere following standardized protocols and medical guidelines of international professional societies. The exchanges between Dr. Tao and Dr. St. Louis were more on their personal experience as cardiac surgeons. Dr. St. Louis routinely operates on small babies a few months of age with complex conditions. He is also among a few pediatric surgeons in America who specialize on pediatric heart transplant. Dr. Tao operates both on adults and children. He wants to take his team to operate on smaller babies like Xia Hua, and make it a routine procedure.

Xiao Hua was on the bypass machine for nearly an hour. The two openings inside her heart were patched by the two surgeons using the sack (called pericardium) that surrounds the heart. The perfusionists slowly waned Xia Hua off the bypass machine and let her heart take over. The electricity in the heart started first, each heart beat followed by a stronger pump of blood back into her tiny body. After the confirmation of all positive indications of the heart, the surgeons closed Xia Hua’s chest.  Xiao Hua is now a zipper baby, a term pediatric doctors like to call babies with a mended but healthy heart.

The ICU team took over after the surgery. The post-surgery care for Xia Hua was as important as the surgery itself. The heart was on medication to help maintain its function. Her breathing was assisted by a ventilator while the lung regained its function. The Children’s HeartLink team included Dr. Arif Somani from University of Minnesota, ICU nurse Karin Mayo from Children’s Healthcare of Atlanta, Nurse Beth Lang and Respiratory Therapist Kimi Lucas from Children’s Mercy Hospital. They worked with the local team led by Dr. He and head nurse Yang from transferring Xia Hua from the OR to the ICU. The two teams had many exchanges on how to manage Xia Hua on and off the ventilator and how to manage post-op pain. There are differences in routine practices between the two healthcare systems, changing minds can be as hard as changing hearts. Children’s HeartLink has been successful in establishing partnership during its training visits between medical volunteers and local teams based on building trust, on-site collaboration and communicating on common goals on quality improvement.

During the week of Children’s HeartLink visit, the two teams operated together on five children for heart surgery. Dr. Edgard Bendaly, a pediatric interventional cardiologist from Sanford Hospital in South Dakota worked with the local interventional team on a dozen more children’s whose heart defects could be repaired through minimally invasive procedures using catheters and closing devices.

Xia Hua’s parents met Dr. St. Louis outside the ICU. They wished to get a photo of Xia Hua with the entire HeartLink team. However, many team members were gone to different places during the one-week visit. Xia Hua was safely transferred from the ICU to a regular unit and discharged from the hospital after 10 days. Perhaps her parents wish could be met when the team returns to Yunnan next year. Their wish reminded a quote from Dr. Kumar, a pediatric cardiologist who works with HeartLink in India, “Parents everywhere want the same for their children: a relief from suffering and a promise of a long and healthy life.”

Dr. Tao Jie and Dr. St. Louis operated together during the Children’s HeartLink visit in YunDa Hospital in Nov 2017

 Mr. Doug Zavadil assisted the YunDa perfusionist team operated the bypass machine during surgeries.

Dr. Pyles examined Xia Hua after her heart surgery.

My experience as a Chinese American working in the medical device industry

My friend asked me to participate in a career development panel at first annual conference of the Minnesota Chinese Association for Science and Technology (mncast.org). It’s an honor and a good opportunity for self-reflection.

I thought about lessons I learned from my mentors, colleagues and my working experience after I came to the US in 1991, and starting my first job in the medical device industry in 2000.

Thirty years ago I entered college, majoring biomedical engineering. This is a field of improving our health through medical technologies. My training in math, engineering and physiology took me to my first job with the Guidant Corporation. I worked on cardiac pacemakers and ICDs, implantable devices that mitigate health issues of the heart. I joined Inspire Medical Systems in 2008, a twin cities-based startup company. We’ve developed the first FDA approved implantable device for treating obstructive sleep apnea, a chronic condition that affects 18 million Americans. Sleep apnea has been found to cause daytime sleepiness, cardiovascular functions, and neurocognitive disorders. Now the Inspire device has been implanted in more than 2,000 patients.

My reflection today is more related to being a Chinese American working in the Medical Device Industry

Think Independently (独立思考)

To solve a new medical problem is like coming to a new country, we encounter challenges that we have never faced in our lives before. We try to follow paths that have been shown to be successful. There are times, however, we need to make decisions on our own. The ability, skill, and recognition to think independently helped me to make the decision to leave a multi-national corporation for a small start-up of three people at the time. It has been a rewarding journey in the last 9 years.

Take Initiatives (迈一步)

It is hard to take initiatives when we worry about others may not understand you. It is easier and safer to stay in our comfort zone. Take initiatives helped me to expand my career path from being a good scientist to leading a team for bigger challenges. It’s a step I am glad that I took early in my career.

Pursue Your Passions (追求梦想)

I want to share two personal passions today. I play table tennis at the Shoreview Table Tennis Club (see svtt.info, we need new members) every Wednesday. Every Tuesday night, I dreamed about beating my friend FL the next day. FL just retired this year. He has been mercilessly beating me for the last 13 years. This reminds me a definition for passion, which is the pursuit of happiness through suffering. I think this year may be the year, as FL is slowing down in his forehand attack.

The second passion for me these days is to improve early diagnosis of congenital heart diseases in rural China. When diagnosed early, kids with a congenital heart defect can live a normal life after a surgery. Late diagnosis can miss the treatment window or leave poor outcome even with the best surgeon. Delayed diagnosis of congenital heart disease is still common in rural China and other parts of the world that lack of access to good healthcare. We have started a nonprofit organization this year that dedicate to this cause. Our name is One Heart Health (onehearthealth.org). I hope you will go to our website and support us when you can. 

A Pediatric Cardiologist from West Virginia Practices Rural Medicine in China

I first met Dr. Lee Pyles on the airplane on our trip from Minneapolis to Lanzhou, China in 2008. Lee carried a giant suitcase, a roller bag and a big backpack. Lee grew up in West Virginia, and just moved back there recently after 15 years working with the University of Minnesota. In the nine years after that initial trip, Lee and I have traveled together to Lanzhou, Huining and Linxie in Gansu, Kunming and Xixuanbanna China.

Dr. Pyles is a pediatric cardiologist. During the training visits, Dr. Pyles performed echocardiograms (or “echo” for short) to verify diagnostics and confirm the plan for each surgery that the Children’s HeartLink team would work on with the local team. These patient exams were like a live classroom. Lee loved to teach. No detail was too small where it was critical.

It is a constant challenge for an echo doctor in China to see up to 100 patients a day, which is easily five times the volume in the US. It is a balance of serving a high volume of patients and maintaining the quality of diagnosis for each. Lee taught from his experience of understanding physiology to help the local team improve efficiency and quality.

On the first day of each training visit, members of both teams gather for a case conference to review all candidates for surgeries during the visit. Lee and I noticed the high percentage of pulmonary hypertension among children that were initially selected by the local team. Pulmonary hypertension in children with congenital heart disease (CHD) is caused by the high-pressured blood from the left ventricle of the heart that flows through an opening that called ventricular septal defect, to the right ventricle then into the lung. A prolonged high pressure can cause irreversible damage to the lung and the heart. When diagnosed early, closing the ventricular septal defect can avoid the permanent damage to the heart and lung with a curable outcome. When not diagnosed in time, pulmonary hypertension associated with the damaged heart and lung function increases the risk during surgery and recovery and may mean the patient has missed the window for treatment altogether.

It is rare to see pulmonary hypertension among children with CHD in the U.S. and other developed countries these days. The murmurs generated by the heart defect are recognized by trained pediatricians during early childhood checkups. In a place like Gansu and Yunnan province in China, however, many children from rural areas may not see a doctor for years after birth. Lee and I have visited several rural counties in Gansu and Yunnan working with local doctors to find these children and help improve the diagnosis of CHD in rural communities. We have developed a telemedicine system for a health workers to record and transmit heart murmurs via smartphone for review and consultation by a heart specialist in another location.

Many of the children Lee and I met in China had not seen a U.S. doctor before in their lives. Doing echo exams with their cooperation was no small feat. The young ones might bite their tongue, staring at Lee’s big nose. The infants and toddlers could cause riots. Lee could always see the trouble ahead and went to his big suitcases to fetch a toy. These made-in-China toys were big hits with the babies. Their moms were also impressed when they heard the toys were all the way from America.  Lee still travels with all his suitcases whenever we go to China.

Note: Thank you, Ryn W, for helping with the editing. 

Mobile Health Revolution - Killer Apps

There is a concern for the mobile health movement --- is this a hype? As seen in the recent interview of Dr. Eric Topol by John Nosta. The reason for the concern is the expectation of killer apps or home runs, and Dr. Topol did list a few. 

This is not different from the early days of internet or the dotcom era when the search for killer apps fed by funding frenzy that led to a bubble. Our experience with the internet has been one of an evolution over time, and a revolution after 15 years with many successes that offer valuable products. Google first appeared as a useful website to find information on the internet, which was limited at the time, and it was certainly not a revolutionary force changed our lives. Over time, its offers on search and map did become an integral part of our lives, a revolution completed. There are now so many internet services have transformed our lives, I am not sure if anyone is still try to conclude which are killer apps of the internet.

I believe mobile health will be very similar to the internet revolution. Initially, we will be looking for killer apps or home runs. Dr. Topol will have to tell the story of the airplane passenger saved by the iPhone ECG many times. This is also the time to ask questions about what issues/challenges faced by healthcare today can be addressed by mobile technology.  

It was fascinating to read the blogs by Dr. Janice Boughton on Why is American Healthcare So Expensive. Some of them are written like a nicely organized customer needs list when we began to design every new product in the medical device industry.  The challenges faced by Dr. Boughton everyday cry for better connection with medical information of her patients and devices that can help her in routine procedures so she can focus on cases truly demand her expertise.

I will resist the urge to ask or answer what are home runs so far for the mobile health revolution. The force of this movement is coming from engaged healthcare consumers wanting useful tools to manage their own health, is coming from early adopting healthcare givers embracing improved productivity, and finally is coming from payers need to dramatically reduce cost to make healthcare available and affordable for everyone.

Mobile Health Revolution - Lifestyle Change

We have made long strides in reducing mortality associated with cardiovascular diseases in the last 30 years. As a biomedical engineers, I would proudly attribute the success to ICD, cardiac pacemaker, and many other interventional procedures and new drugs that save lives. Once a while, there is an inconvenient argument that suggests the successful campaign on anti-tobacco use may have played as an important role as all of advances in medical technologies. That will be a difficult debate without a lot of data for cause-effect, but there is no debate that lifestyle is the most important factor that influences lifelong health.

In today’s calling to reduce overall healthcare cost, innovations that improve our lifestyle is also the biggest opportunity for mobile health solutions.

First to share a personal anecdote. I started to record daily weight about 10 years ago. After enough entries, I began to plot them, and monitored the trend more closely. To my disappointment, the weight did not drop. However, the standard deviation, or the day-to-day change, reduced overtime. The frequent monitoring provides a feedback to adjust diet, and remind me not to have that second piece of apple pie.

I see a good mobile health solution here. The App I am using today (‘My Weight HD’ or the FitBit system) provides some but an incomplete solution. I like to have a weight scale that sends data wirelessly to my cellphone after each weight. I need an App that provides simple tools to annotate, analyze and trend. This is a solution I would happily pay now, because I know it will help me keep a healthy weight, and avoid paying a lot more in the future in care for high blood pressure, diabetes, or sleep apnea. In the last 10 years, I did not lose any weight, but thanks to that little excel sheet, I did not gain any weight either.

The revolution in mobile health is in its solutions to empower healthcare consumer to be more knowledgeable about our own health, and provide tools for us to manage our own health. It is that one apple a day that keeps doctors away, one of the most effective way to reduce healthcare cost.

iPhone ECG

It was exciting to hear the iPhone ECG was approved by the FDA early this month. This device has two electrodes that are built in a case for an iPhone, which can then record, display and also transmit ECG over a mobile network.

Mobile ECG or telephonic ECG are not new. There was a Nokia phone with ECG recording that was tested more than 10 years ago in a clinical study to see if EMR service can save time and improve outcome for heart attack. These studies later supported the current guideline from AHA that requires pre-hospital ECG for emergency services in patients with symptoms of heart attack. It makes sense when signs for ischemia can be identified from ECG, the information can save precious time in getting patients to a hospital that can provide treatment immediately.

I am more excited about the possibility of having an over-the-counter version of the iPhone ECG, which is not available now, but may become available next year. It is not immediately clear yet how the iPhone ECG will be used. Here are some thoughts …

I used to attend the international electrocardiography society conference when I was a graduate student in the late 90s. For several years, the theme for the conference has been “Was ECG still relevant?”. It was an irony for an ECG expert society to ask that question, but in reality, the ECG has become obsolete in most of cardiac services. Echocardiography, CT and MRI provide much more precise diagnostic information for treatment. I don’t expect the iPhone ECG to improve the diagnostic capability over the existing 12-lead ECG systems. That’s not the future.

The future of iPhone ECG is in its potential to provide services to empower us as a consumer for healthcare. In an early post, I argue that one of the reasons we cannot leave health care to a free market is because we are not equipped with enough knowledge to choose doctors or care providers freely. The health equipment shelf at Walgreen today has very few items, thermometer, glucose meter, blood pressure cuff, and none comes with a service. When we get sick today, there is very little choice but going to see a doctor. The trend of rising healthcare cost is not stopping. Recently, we have seen a new trend in the US for consolidation of large hospital systems that integrate diagnostics and treatment. That’s bad news for consumers.

iPhone ECG by itself will be limited to provide diagnostic value, but I see a future that a slew of health equipments that are available in consumer products. There will be independent diagnostic services that can help you become more knowledgeable about your conditions, and when you do decide to go to see a doctor, instead of waiting in the lobby for an hour, your doctor can't wait to see your iPhone.