Saturday, June 20, 2020

BLOG

   I HAVE BEEN DOING THIS BLOG FOR LONG TIME  AND I HAVE 2 OTHER BLOGS  AND A YOU TUBE CHANNELS
IF YOU LIKE THEOLOGY I HAVE A BLOG WHERE I HAVE DONE ORIGINAL HINDU SCRIPTURE 600 BC CALLED PANTANJALI SUTRA YOGA , THIS IS A WAY TO MIND CONTROL AND THE POWERS THAT ONE GETS  AND ULTIMATE NIRVANA.
AT THE END OF THIS SUTRA I HAVE STARTED SOME STORIES WITH MORAL POINTS.

WWW.PATANJALISUTRAYOGA.BLOGSPOT.COM

MY BOOK IS AVAILABLE ON AMAZON BOOKS E BOOK  AND PAPERBACK UNDER MY NAME KIRTANE

I HAVE ALSO STARTED NEW  BLOG ON SCRIPTURE CALLED  KATHOPNISHAD WHICH IS UPANISHAD.

YOU CAN READ IT

WWW.KATHOPNISHAD.BLOGSPOT.COM

MY YOU TUBE CHANNEL IS

JUST A TALK

IT HAS MEDICAL AND NON MEDICAL TOPICS LIKE ASTHMA , CANCER OBESITY  AND SLEEP APNEA AND ALSO REINCARNATION, MEDITATION, ORIGIN OF UNIVERSE ETC.

I HOPE YOU WOULD VISIT THESE BLOGS  AND YOU TUBE CHANNEL 

Friday, June 19, 2020

STITCH IN TIME ----

  There is a saying that stitch in time saves none. If one does things in time then one does not have to worry about getting things worse. The saying is is related to clothes  but it also applies to our every action and every decision that we make or action that we do . It may be diabetes  and eating sugars or blood pressure  and salt intake. . If we do not do action in time  and the diabetes or blood pressure gets worse  and has complications , then acting in right way will not help us as much as if we would have taken precautions early. I have seen this in many patients and that brings me to today.s patient.
    I saw this patient who was 78 years old  and had some dementia . He came with family  and i could not figure out why he came to me . He had some abnormality , He was in hospital and he had pain the belly. He had CT scan of the belly done  and that showed some abnormality in lung and so had CT scan of the chest done  and that showed a very tiny nodule. He had seen primary care doctor  and he sent him to me . He had also seen Gastroenterology  and he was planning to do endoscopies . I had no reports  and I got them  and I was surprised He had very tiny nodule in lung  but had a mass in pancreas  and also in liver . The patient of the family did not know about it  and they were surprised . I explained it to them that he seems to have cancer that seems to have spread to liver and may be lung . The endoscopies will not help but he needs diagnosis of cancer by biopsy  and then we can decide as to the treatment . The Lung nodule was too small  and there was no way anybody could do biopsy of the nodule. So I decided to do the PET scan to know the extent of the cancer and scheduled him to have biopsy of the Liver
  He had the biopsy and that did confirm the diagnosis of cancer He had pancreatic cancer  and the biopsy did show that liver spread was confirmed . I saw them in office  and told them the diagnosis  and the treatment options of chemo . I also told them on chemotherapy and the side effects  and the 'prognosis' . I told them that the pancreatic cancer with spread to liver is not good news They decided to go ahead with chemo. I had told them to consider future choices  and also the poor prognosis  and DNR or Do Not Resuscitate status . Thew were not sure.
    He was admitted  in hospital  and he had received chemo and the blood counts were low . He had some pain and that was due to enlarging Liver metastasis.He was given pain medications  and that caused more confusion and I again talked to the familyb. I told them that in spite of treatment he was not doing well and the cancer had increased and they need to see the oncologist  and see they could consider radiation which has less side effects  and may be do no treatment ts .We also talked about the DNR .
    He was discharge  and then was readmitted  and it happened . I had expected it. He had cardiac arrest and they did CPR  and he had to be put on respirator  and also had rib fractures  and collapse of lung and had to have tube put in chest to re expand the lung. We had the discussion and they agrees after 3 days to make him partial DNR . Now the decision had to made to withdraw the machine - respirator . That was much more traumatic to his wife  and sons . But once someone is on respirator , we can not withdraw without doing the forms for withdrawal of LIFE SUPPORTS .
THIS IS I CALL STITCH IN TIME . If they had made the decision in advanced for DNR, we would ot have gone through he suffering for patient - the tubes , rib fractures, chest tube  and also the family to make the withdrawal decision . . 

Saturday, June 13, 2020

COVID AND BRAHMAM

    When we look at the God or the so called Brahmam id described as all pervading, limitless omnipresent etc In the religious words, it has no limit from what is called DESH,-KAL,-VYAKTI -means space ,time and identification.As one can imagine everything anything that we know has space limitation , time limitation and specific identification limitation.But the God or Brahmam has none of these limitation.What is chair is not a pot is the last limitation.. In these days we feel the same about covid  and that brings me to the story of patient for today.
    I was called to see this 67 years old male for shortness of breath and a clot in lungs. He was a male patient who had no history of smoking or drinking alcohol and had history of well controlled high blood pressure. He had some calf pain few days ago and then on the day of admission. He used to walk 3 miles  and he started having shortness of the breath and so he decided to come to hospital. He also had right sided chest pain and he had then CT chest  and that showed large clot in the right lung and some on left side as well. He had history that his daughter had coagulation factor problem and she has significant clots  and was in ICU few years ago. So the siblings  and parents were tested  and he had same problem but he was not treated for the problem as he did not have any problem .So from the history of his own illness and the history of the coagulation problem  and also the ct chest it was clear that he had pulmonary embolism  and he had it most likely due to certain coagulation factor problem. He had no fever and no cough and no exposure to anybody with covid  and he had no symptoms of upper respiratory infection. So he really did not have anything to suggest COVID infection. But one of the things that we know is that in patients with covid , they do get blood clots . So automatically test for covid was ordered . This meant that he will be transferred to the floor where the hospital kept all covid and suspected covid patients . The test takes sometimes 2 days to get results . HE REFUSED. He did not want to be on covid ward while waiting for the results .
    So now the question came up as to what to do .We have been so much afraid of covid - rightly so in many instances that we are going overboard  and have lost all the common sense. I saw a cardiologist washing potato chips bag and a salad dressing single serving bag. So the covid is like God pervading all our actions  and seems to present every where !
    

Sunday, June 7, 2020

TO BE OR NOT TO BE

     The famous line from Hamlet, is not uncommonly experienced or can be applied in medicine, by both physicians and patients. Sometimes it is very easy to make decision and sometimes it is not so easy. If I see a patient with Asthma ,who has shortness of breath and wheezes, I have very easy decision. I must start him on certain treatment . The patient also has not much difficult decision . Sometimes I do see patients who do not like to take medicines  and feel if they avoid allergens or take allergy medicines, then they will not need prescription drugs. But majority of patients who have symptoms , it is very easy to start medications. But then we see patients where the decisions are not that simple,the question arises as to which path one should take it.Say I see some one with a mass or a spot on the lungs  and I feel we should do open lung biopsy or do surgery to take it out and find out if it is cancer. So for me this is easy if I think the chance of cancer is high. But for patient it may be not that easy . This is a major decision as it involves major surgery and it may not turn out to be cancer after surgery.So in some cases decision is simple for physician and and patients  and in some cases easy for physician and not so for patient . The third possibility is where it is difficult for patient and physician also.So that brings me to the case for today.
     I had seen this 69 years old patient with spot on the lung . As usual we did the work up. The bronchoscopy was negative to get the diagnosis  and the PET SCAN did show that the spot was hot or had increased uptake suggestion cancer. The Pulmonary Function Test or the breathing test did show that she had good reserve to cut out out part of the lung. So I suggested seeing surgeon and she did see one  and he also told her to do the surgery and so she had surgery and indeed it was cancer of the lung. So as one can see I  suggested surgery - easy for me , the patient did agree for the surgery - some what easy -may be not as easy for her as was for me , but not very difficult. The surgery though did show that some of the lymph nodes were positive for spread of cancer. So I suggested doing radiation . The cancer spread to lymph nodes increases the chance of recurrence  and so I suggested it  and it was easy for me based on the data that I know. She did see the radiation doctor  and she got radiation . Again somewhat easy for patient to accept or make the decision. I had also told her to see medical oncologist.I wanted to know if in addition to giving radiation to kill some cancer cells that may have been left in some of the lymph nodes,if there was a need for chemotherapy. Here comes the difficult decision. The oncologist saw her  and suggested her to get in a TRIAL'She called me . The trial of new drugs is done when we do not have 100% evidence of benefit of using the drug . So this is a investigation to see if the medicine will help to reduce incidence or recurrence. In this trial, some patients will get the new medicine that is being tested to see if it works  and other patients will get NO MEDICINE OR SO CALLED PLACEBO . So the patient called me to know what she should do. In this case the decision is very - very difficult for me  and also for the patient as we will not know if patient is getting the drug or placebo I am not sure if the oncologist will know it or not - as is the case in some of the double blind studies (where both patient and physicians do not know to avoid having any bias).
     I don't know . WHAT DO YOU THINK YOU WOULD DO ?