Saturday, February 6, 2021

CAUSE AND THE EFFECT ??

   In every walk of life we have cause and effect .But sometimes we do not have the perfect explanation. One sees this in everyday evens and we do not even question it. We drop a glass object to the floor, it will break . The wood floats and the iron sinks . But the boat made of steel floats  and so the scientists have found the reasons for such things . But in medicine we have no CAUSE for many outcomes  and effects . In medicine we call it IDIOPATHIC . So we don't know why some people have elevated blood pressure  and so we call it Idiopathic hypertension If someone has Fibrosis in lungs  and we do not know what caused the fibrosis , we call it Idiopathic Pulmonary Fibrosis  or IPF. But this is well accepted  and no one thinks any other way or questions. But sometimes we see common things and have no answer . Certainly there is always a reason but we are unable to answer it and then the patients get frustrated as they have no way of PREVENTING IT .That brings me to the story for today. 

    I have known this patient for many years and she has been ex-smoker and had quit many years ago. Over period of time she worsened . She had diagnosis of COPD  and she was on meds  and still she continued to worsen over period of years, She needed oxygen and slowly we adjusted medicines and she was on all the medicines that we could use. She was also started on oxygen and nebulizes medicines and also steroids. She had some cardiac issues and they seem to be stable. Overall she was doing OK. One of theses days she was admitted  and then had some worsening due to pneumonia. I checked her blood oxygen and carbon di oxide  and she had elevation of carbon dioxide. So we started her on what is called non-invasive -ventilator. This has been done now a days for COPD patients for last few years. This helps the patient's own breath and this supplementation or the help improves the breathing and carbon dioxide  and then the shortness of breath. So she was started on it  and did well for more than a year. One day I get a call that she became unresponsive  and so was taken to ER I went to see her in ER  and the Er physician had already put her on respirator with a tube in her trachea. I reviewed the data . She was using her own machine and in spite of that she had ELEVATED carbon dioxide to such a level that she became unresponsive . So we had no choice of doing INVASIVE VENTILATOR  and that did help. Over period of next 4 days we were slowly in position to reduce the support from the machine  and we did take her off the ventilator. She did OK  and she was started on the noninvasive ventilator at night and just oxygen during day time . I watched her for 3 dyas and she did just fine . We had done many tests . She had CT scan of brain to make sure she did not have stroke  and she did not , We did CT scan of chest and she did not have clot or pneumonia . We did culture of blood  and sputum and treated her with antibiotics  and all the work up was negative  and she did not have sepsis. So why did she have respiratory failure even when she was doing everything right ? 

    I DON'T KNOW  and I will never know .

     Why did her lungs quit suddenly and then in 4-5 days recovered , I don't know . But one thing that I DO KNOW is that I have seen such patients in past and will again see such patients where we do not have the cause that precipitated  the event. 

Saturday, January 30, 2021

EXPECT UNEXPECTED

    We often talk about any  situation when something goes wrong, as Murphy's Law, 'If anything can go wrong, ,it will!' Nothing is exception to this statement  and medicine is also not exception.But I often say that sometimes it is better to not know everything, but know what patient DOES NOT HAVE. So when I see some patients and have some symptoms  and I can not find exact reason for it , I tell them that I don't know what you have , but it is not serious. That brings me to the story of one my patient.

    He was a young male and has not been smoker.He was fine till one day when he was working on a house . He was hard working - physically hard working male and he used to buy homes and work on them and then sale them. So one day when it was little cold in Florida, he was working on a house. He was out side and so he had a jacket and was working  and he noticed that he felt hot and took out the jacket and he noticed that he was sweating . He had some shortness of breath. No major chest pain. He saw his primary care physician and was told to get COVID test done . He had no fever and no cough and no other problems . He did the test  and that was OK . He was told to see me or may be he decided to see me. I asked him on any chest pain and he did tell me that he had some chest pain but it was short lasting but now he has some more shortness of breath.I examined him  and his blood pressure was normal, he had no fever and he had good oxygen saturation  and his lungs were clear and he had no wheezing like asthma.He had normal heart sounds and there was nothing abnormal on physical examination.I thought that his symptoms were atypical and did not look like lung problem ,but he was short of breath on doing things that he could do without efforts in past.I thought that he could still have mild asthma , but it was not very clear cut.So I decided to do work up. He had COVID test and that was negative. He had no cough and no fever  and lungs were clear. I ordered CT scan of chest and a breathing test  and also pulmonary stress test. I gave him  an inhaler to help breathing in case he had asthma. The breathing test was normal  and the CT scan showed some abnormality. He had what was described as 'ground glass densities' The ground glass densities is very small areas of ' haziness' The window glass is clear and the shower glass door is not clear . So that is called ground glass density. I could not figure out as to what might have caused this  and infection could be one of them  and so I spoke to him and he told me that he was little better but was still short of breath and he had no new complaints . I ordered some antibiotics and told him that he needs to see cardiologist ASAP as I was concerned that he may have heart problem , the sweating and shortness of breath and some chest pain all could be due to coronary artery disease . So I called a cardiologist to see him soon. He was seen in 1 day and the cardiologist was convinced that he HAD SEVERE CORONARY ARTERY DISEASE. and wanted to do cardiac cath. to find out any blockage. But all the slots were filled in the lab. and so he admitted him of Friday, the day that he saw and did procedure on Saturday. HE HAD  SEVERE BLOCHAGE IN THE CORONARY ARTERIES  AND NEEDED surgery!

    So I knew that this was not lung problem  and suspected it was heart, but was not sure . 

   So one must know  what it is not even if one does not know what it is.

Saturday, January 23, 2021

WHY?

   We do not the future  and that is why every newspaper and many magazines have weekly or monthly horoscope. We also have psychic readers and Taro card readers.People make lots of money telling people as to what is going to happen love life and job market and so on. But we in medicine have the firm but wrong belief that we can predict as to what is going to happen , the so called prognosis. But I have come to a firm conclusion that what we are doing is more of a statistics  and a chance  and probability and we could be wrong . But then I wish we could have some more TESTS that could bring us to 100% prediction of future. When I used to go for a movie in my earlier years  like 10 or 12 years of age,when hero was being followed by villon, my cousin used to shout warning the her that the villon was right behind him . But if hero knew that then the story would end right there , but in life we have similar situations. I guess then there won't be FREE WILL or Law of Karma.That brings me to the story for today . 

   I saw this patient for a short time . He was life long nonsmoker  and he had some cough and was admitted 3 months ago and had abnormal chest x- ray. The X- ray was abnormal  and so had a CT scan and has a small nodule less than 2 cm . The work up was done and had needle biopsy and he had cancer of the lung. He had never smoked  and he still had lung cancer. So he had further work up with PET SCAN  and there was no spread of the cancer and so he has surgery done in November . The cancer was operated and there was no suggestion of spread to lymph nodes and the borders were clean and nothing to suggest need for any additional treatment.He did well and recovered from the surgery and was doing good . Then he had some vague pain in the belly and he came tp hospital. He had CT scan of belly and also chest X- ray . The CT scan of belly was abnormal and had a mass that was pressing on the duct that drains the bile  and so he also had CT scan of chest and that showed a cavity. This was near the suture line of the previous operated cancer. So it looked like he had recurrence of the cancer that was taken out. The further work was started . 

     So 3 months ago or less he had no evidence of spread of cancer  and so had surgery and no test could have shown that in short period of 2 or 3 months he has now a cancer that has spread to a point that it is not possible to do much surgery. WOULD IT NOT BE NICE IF WE HAD SOME TEST THAT COULD PREDICT THIS OUTCOME ?

Sunday, January 17, 2021

MORTALITY

      Since we were born we know that we will die - well may be not when we are in our childhood , but certainly we know about the death even when we act as invincible as young adults.One can see this in the risks that are taken by teenagers. But at the same time we want to live for EVER. All the  TV  and radio commercials that we see are related to extend life expectancy and also how to look or feel young. This is from skin care products to various nutritional supplements which is billion dollar industry. And I see this in many of my patients. There is nothing wrong with the attitude that we must do everything to prolong life or make it better  and that is the role of medicines and physicians. But that thought process should not obscure the reality that everybody dies. That brings me to story for today. 

    I saw this patient 90 years old . He was diagnosed to have cancer of rectum.He was treated with radiations  and he was doing OK but the cancer was mot cured and so he was now on CHEMOTHERAPY. Then he was admitted with what looked like pneumonia  and then had further work up  and was found to have obstruction of lower lobe bronchus on right side and that was biopsied  and it was cancer  and to surprise it was not spread of rectal cancer,but it was new Lung Cancer. So ow the radiation therapy physician was called . He was not a candidate for surgical resection and so radiation was started and it was completed  and then he got more chemotherapy. He had the side effects  and was weak and had no appetite  and has drop in blood counts  and he had some shortness of breath. He also was confused  and he has reduced responsiveness. He had the full work up and had CT scan and consult with cardiology - he also had atrial fibrillation and so had cardiologist to look at him  and also infectious disease doctor  and lung specialist.- This is very typical now a days as primary care doctors do  not come to hospitals and the hospital doctors call various consultants. The CT scan showed collapse of the lower part of the lung  and this was related to the blockage from the cancer that was diagnosed 3 months ago and treated with radiation , but now he had more fluid around the right lung. I thought that this could be due to inability of lung to expand due to blockage from inside due to cancer or could be due to cancer spreading to the covering of the lung - pleura . In any case I felt that this was not good . He was severely anemic  and cancer doctor nurse also saw patient. I felt that there was not much that would change much by doing more interventions as diagnostic test. HE was 90 years old  and had 2 different cancers  and bot did not seem to have been cured  and also he had side effect from chemotherapy. My feeling was that we could treat him for fluid  and that may help him but beyond that doing additional therapy was not going to change much on long term.I also thought that since the  fluid was  locculated - had formed a pocket - may be due to radiation, putting a catheter would be better idea in this 90 years old patient. I did not feel doing more chemotherapy would change much . When I asked patient when he had improved in his mental status as to what he would like to do. He wanted to know why we can not do surgery on lung and rectum? I did not think he either understood or accepted the reality of having 2 cancers and the prognosis.

    So we all know that we are going to die  and are not mortal but even at age 90years  and with 2 cancers one is not ready for inevitable end of life.

Saturday, January 9, 2021

MAYO CLINIC

      I have been in medical practice for many years  and have seen very easy patients and diagnosis  and some patients who are difficult and some diseases which are difficult . I have sent some to Mayo Clinic for opinion and see what would they do in such patients. As far as i recollect I have not had any glaring change in my diagnosis or my decision in patients that I have sent there. This is GOOD for me and my confidence but not GOOD for patients as they did not get any different treatments . There have been some cases where I have disagreed with their opinion  and I do tell this to patients. But if they do not have any treatment option and I want to try something, I have told patient to try what I am suggesting and then decide in due course of time. But sometimes I come across patients that want second opinion and I know that there is no SECOND OPINION. This brings me to the story for today.

    I saw this patient who was sent to me by a surgeon who also does some family medicine practice . The patient was nonsmoker for many years and was not living close to me of the surgeon. He was in another area 2-3 years ago and had some chest discomfort and so he had a CT scan  and that had shown very tiny nodule and then he had no further work up. He had some cough and so the PCP did the chest X- ray and that was abnormal and so he did new CT SCAN  and that showed a mass - rather larger 5 cm size mass. So he was sent to me . I di explain it to him on the high possibility of cancer and did start the work up. I did PET scan and berthing test and also bronchoscopy . Even though the mass was larger it was not seen from inside at the time of bronchoscopy and the samples came back negative . I had expected that and I had told him on doing needle biopsy . I saw him in office on each time and also talked to him many times. He seemed to understand  and was ready and then I get a call from radiology that he has refused the biopsy  or did not want to schedule it . I talked to him again and he seemed to have agreed  and then he did not get it done  and I was told that he wants to go to Mayo Clinic. I feel that if he has cancer we are delaying the diagnosis  and the treatment  and I had also told him that if he feels he does not have cancer, we could repeat the CT scan  and see if the mass has reduced in size or not. I have seen some patients in which the tests point towards cancer but they are not good candidate for biopsy or they refuse the work up and the follow up CT scan shoes improvement. But it is rare. and the Mayo Clinic is not going to do anything different - either do the biopsy or wait and do new CT scan. 

Sunday, January 3, 2021

TIME AT LARGE AND SMALL SCALE

    The time as we know  and experience is different than the time that was told to us by Einstein. We presumed that the time is independent unit  and then Einstein proposed  and proved that the SPACE -TIME is constant and only thing which is unchanging is speed of light. So when the object is moving in SPACE the time is shortened compared to an object which is stationary. So the space - time unit is constant. If the movement is more ,the time shortens. If some on takes a watch in an ordinary plain and flies around the earth, then the watch similar to the one which is on the plain will run faster as the watch on plain time is shorter. Certainly at the ordinary speed , we do  not have ability to perceive the difference but it is there and can be proved . The unit of time that we are used to see is hours  and minutes and seconds and then micro and milliseconds etc. The unit of the time that was describes to be the SMALLEST that can be measured is called PLANCK SECOND  and is defined as time it takes photon - a particle of light to travel PLANCK DISTANCE  . So then came Planck unit and Planck constant for quantum theory etc. Certainly at a larger scale we have millions and billions and trillions etc. But in Indian mythology which was known or created we have much more time measurements than what has been thought out by science .We have both micro level time and macrolevel time measurement . I am amazed at the thought process of these measurements.

   To start we have more than one system and there will be some variations in the numbers . So the smallest time in Hinduism is called TRUTI . This is the time it takes to TEAR A  SOFT PETEL OF A LOTUS . So this is TRUTI . 100 Truiti make on LAV

30 LAV make 1 NIMESH

15 NIMESH make 1 KAASHTHAA(8 SECOND)

30 KAASHTHAA  make 1 KSHAN 4 MINUTES)

6KSHAN make 1 GHADI (24 MINUTES)

2 GHADI make 1 MUHURT (48 MINUTES)

30 MUHURT make one DAY -24 HOURS 

28 DAYS make 1 MONTH 

2 MONTHS make 1 SEASON

3 SEASONS make 1 AYAN 

2 AYAN make 1 YEAR 

1 MONTH of Human is 1 PITAR DAY 

360 HUMAN YEARS =1 DIVINE YEAR

12000 DIVINE YEARS =1 DIVINE YOG (YOOGA) =1 HUMAN MANVANTAR =4320000 YEARS

71 DIVINE YUGAS =1 MANVANTAR 

14 MANVANTAR=1 DIVINE YUG=1 DAY OF BRAHMA =1 HUMAN KALP

4.32 BILLION YEARS =1 BRAHMA DAY

100 BRAHMA YEARS =2 PARARDH = 1 DAY OF VISHNU=311.04 TRILLION YEARS 

1 MANVANTAR is the life span of one MANU 

There are 14 MANUS and currently 7th MANU is ruling.

There are 4 YUGAS that we commonly know They are in proportion of 4:3:2:1

So SATVA TUGA IS 1728000, YEARS 

TRETA YUGA IS 1296000 YEARS 

DWAPAR YUGA IS 864000 YEARS KALI YUGA which is current YUGA is 432000 years. 

1 MANVANTAR IS =306720,000 YEARS 

There are 86400 seconds in a day but there are 17496 millions TRUTIES in  a DAY 

SO ONE TRUTI is 300th of a second . 

SO NOW YOU KNOW THE SMALLEST AND THE LARGEST MEASUREMENT IN HUNDUISM 

                      HAPPY NEW HUMAN YEAR 2021 !!


Wednesday, December 30, 2020

MAY BE YOU CAN'T CHANGE FATE ??

     We act in our life with desire  and advice that we can change the fate or outcome. We want to eat healthy food and not smoke and not drink too much of alcohol and not do drugs . I do believe that this is good behavior and everyone should try to do what is right . In medicine we also act and advice patients that certain way of treatment or work up will help us in getting good or desired outcome. I still remember , when many years ago one of my professor of preventive and social medicine had a heart attack . In those days not much was known on heart attacks , but we still knew that smoking and not doing exercise  and cholesterol were main culprit and we also knew that diabetes and hypertension were also risk factors. So when I saw him after his heart attack he made a comment to me saying that he does not smoke and does not drink and has no hypertension or diabetes and he still had heart attack . This type of unexpected medical elements are known to someone who ahs been in practice for long time but what I am talking today is the out come of the treatment or we not getting expected outcome. 

    I saw this patient in hospital. I had seen her sister and one more family member  and one of them had cancer. She has been smoker  and she had quit smoking and then she had shortness of breath .She had 2 years ago heart attack or tales chest pain and was found to have blockages and had stents  done . She was seen by PCP and that was telemedicine follow up and he gave her antibiotics and she did not get better and was still short of breath .So she came to hospital and had abnormal chest x- ray and then had a CT scan done and that showed a mass at the central part of the lung . If one can imagine lung with a stock like a fruit, then this mass was exactly at the stalk area. The main bronchus and the main artery all go in the lung at that area  and the mass or the tumor was pressing on the bronchus and it was narrowed . So there was a high suspicion for cancer and they called a cancer specialist . I was also consulted . I saw her and when I saw her I knew that this was not good . She also had a second mass  and she had shortness of breath  and she was on minimal oxygen supplementation.. The cancer doctor had ordered a biopsy of the lung mass. I explained to her and her husband that I was quite concerned  about a cancer  and that too will nor be operable  and the position was bad and that may compromise the air  and blood going to the one lung . I also ordered a PET scan. She did not feel good on the next day and so the biopsy was postponed  and so was the PET scan. Then the next day she had problem  oxygenation and so we had to increase the oxygen and that continued to get worse  and so I transferred her to ICU.I again talked to the husband and the patient and I also called radiation doctor to see if he could start emergency radiation without the diagnosis of cancer as otherwise that was going to get worse . They felt that getting a stent to open up airway would be better . So we consulted one of the interventional lung specialist . She was transferred to another hospital . As it happened, she had a heart attack and she was started on blood thinner and she had gastrointestinal bleeding  and then she vomited  and had cardiac arrest  and she was on ventilator  and continued to get worse. 

     So we did all the right things , Oncologist was consulted and Pulmonary was consulted  and we also called radiation doctor and then interventional pulmonologist. We had cardiologist see her when she had heart attack  and inspire of that she did not have good outcome. That is what we call fate.