Monday, April 30, 2012


   I did get occasionally students who are 'pre-med'. This was one of those days when I had one of the students in my office .When I entered the room , I saw Mrs. Smith. She has been coming to me last few years. She started with some cough and then upon further investigations was found to have a small nodule on her  CT scan of the chest.I did follow it for some times, and it was stable, and she really did not need any further follow up. But she wanted to come and "make sure that every thing was OK."
    This was one of those follow ups. As I entered the room, she stood up and hugged me and thanked  me . Since her last follow up with me , lot had happened and she had lost her husband. Her husband had a brain tumour and had gotten radiation therapy . He was doing good   but then developed  leukemia. Then went to an oncologist and was quite sick. He was admitted to the hospital and started with pneumonia . When he started getting worse , I was called . I had seen him as her husband, but not as a patient before.
    When I saw him in the hospital, he was quite sick. I had to transfer him Intensive care unit and soon , within short time had to put him on respirator . He continued to do poorly and his blood pressure had dropped and he stop ed making any urine and continued to get worse. He was quite sick and I had talked to her several times . We were doing so bad that I was worried that we were doing 'futile ' care. I thought that continuing to do futile care and then do CPR and continuing to do more was not useful to say least and was  torture to say bluntly.I called her and then asked her to consider Do Not Resuscitate and consider 'withdrwal '. She came with her daughter and after extensive discussion , she agreed to do DNR and he died in net 3 hrs .
     Now I was seeing her and she was thanking me for taking care of her husband and advising her to do the 'right ' thing . There was nothing to do with her care as her last x-ray was clear . Then she asked me a question. She wanted my opinion . After the death of her husband she had gone to her daughter to stay fir some times.She was sitting on the sofa and there was a fire place and on the mantle was pictures of her 3 grand children . It so happened that their first  names  were such that three together made her husband's full name . (first name, middle name and the last name. ). Suddenly she saw her husband or his face , smiling at her . She called her daughter , and asked her if she saw her 'daddy' . She did not see him . But she promised her to get the copies of the 3 pictures. She took them home and put them on the fire place mantle. and she did see again her husband. She wanted to know if she was going 'crazy' . So I sat there and explained her the concept of 3 bodies. i.e. causal body, the astral body and the physical body and how the astral body is the replica of the physical body and may be what she was seeing was the astral body of her husband . I also told her that she needs to tell him to 'go ' and let him be free in the astral world.
      I did not do any medical advice to her and told her to come  for   the follow up in six or seven months , she made appointment to 'see' me in 4 months .

Thursday, April 26, 2012


    I did think I wrote clearly about the shlokas, 4, 5, and 6. But some people thought that it was not very clear. So I would like to clarify. Let me take an example of we trying to wake up early in the morning to do meditation. On one side we want to do it ,so as to improve our 'chances'of achieving some level of 'samadhi'.but then we don't want to get out of 'bed' and want to continue sleeping . In this 'fight ' we will have 2 sides , so when our mind (it's son, which is thought. )looks at  'both ' sides of this fight , it will realise that the devote had done the study of scripture, has changed his life and tells the Truth, does not do hoarding, has celibacy, does follow nonviolence, control of breath(pranayam), etc ,So when one looks at the different names that are taken by Duryodhan, we see all this ' names' reflecting  how we 'prepare ' for the samadhi.
      Now fof  the shloka ,7 and 8. In this one (8) he talking about who are going to 'fight ' from side of the 'mind '.They are Drona , Bhishma, Karna , Kripa, Ashwatthama,Vikarna-son of Son of Somadatta, and Jayadratha.
      As I stated before Drona represents the Saunskara or impressions from past lives. So naturally they will 'guide ' us in doing good things or bad things--habits. Most of is have more bad habits than good , so they will 'side ' on the side of mind and not intellect. So Drona went on side of Duryodhana .We also know that Bishma represents the 'Ego ' . The ego is nothing other than 'self ' attached to the body. So as long as it thinks that it is physical body , it will side on the side of the body , it's pleasure and the mind , which is looking for the same . i.e. the bodily pleasures.So Duryodhana is looking to Drona and Bishma for the help. Bhishma also represents the Asmita- which what makes us feel -"I AM ".
      Now about the other names
      Kripa- This according to Yoganand is the Avidya. ( how this is derived is difficult to explain, but to summarise, root krip to klrip--which means imagine--one who has false understanding of the matter. This is the MAYA .
      Karna--This means ' one who behaves and performs the actions that gives pleasure. 'Even though Karna was born of Kunti (power of dispassion ) and SUN , he was born before Kunti was united with the intellect or discrimination. So he was under the influence of the mind and so preferred the actions that would give bodily pleasure.
      Vikarna is repulsion or the Dwesha.
       Jyadratha--is Abhiniwesh. We have several attachments, to eat good food to listen to pleasing music or words, to take stimulants etc , But our greatest attachment is to our body and desire to 'live' This is strongest desire and that is the attachment to the body , no matter how old and disease ridden or painful it is .
      Son of Somadatta (Bhurishravas),This one represents the action that we do for the material things . So even though this is also action it is done for the purpose of material pleasure and so it is under control of Mind and Ego .
     Ashwatthama-- He is the son of the Drona and represents the latent desire. Drona is sauskara, may be the tendencies that are going to guide us now , while the Ashwatthama is latent tendencies or desires , that is why he is 'immortal ' . i.e. the latent desires do not die .

Tuesday, April 24, 2012


    Sometimes when we see patients , and they ask about the 'prognosis ', we tend to think that we 'know ' the statistics and give an answer. And may be we are OK or right most of the times. But then sometimes we see patients that are so far from our 'understanding ' of the medicine or the statistics that we are proved wrong, and wonder why someone is so 'lucky ' or 'unlucky'. Then we ( at least me personally) tend to believe in the 'law of the karma ' . So today I am going to tell couple of stories of the patients that 'fit ' in this description.
    I was called to see this one patient who was post op. She was 68 years old and had belly pain .Further work up revealed that she had gall bladder problem and had stone in the duct of the gallbladder. So had the surgery to take the gall bladder, and the gastroeterologist did a procedure to take out the stone . The over all everything went well . But then 3rd day she got short of breath. So I was consulted . I saw her  in less than 15 mins , so no additional tests were done . She was mildly short of breath. She had quit smoking 20 years ago. She was wheezing a little bit and had lot of positive fluid balance. (her fluid 'intake ' was more than her ' output' ) . I ordered for the x-ray, some breathing treatments to help the wheezing and ordered for a 'water pill ' ( to improve urine out put.) I also ordered a blood test called  d-dimer. It is elevated in patients who has 'clotts' . in patients who have been not moving much tend to get clots in the legs and when it travels to lungs , it causes shortness of the breath and drop in oxygenation.The x-ray was normal and she responded to the water pill and felt significantly better in next 2 hours. However the blood test that I ordered came back elevated , meaning that there could be a clot somewhere. Sometimes it may be related to post operative status. But with the given history I could not let it go without any further work up . I almost felt guilty for ordering the test as by now she was off the oxygen and wanted to go home . I was forced to order a ct scan of the chest to rule out 'clot in the lung' As I expected the ct scan did not show any clot , this was 'good ' news , but it showed a mass in the lung . Mind you even when I went back and try to look at the previous x-ray I could not see the 'mass' . This means that she may have Cancer . She wanted to go home , so I discharged her and scheduled her for the further work up , which included a PET scan and a biopsy. She had Cancer and had good lung capacity  to resect it out . She was referred to a chest surgeon and a cardiologist . The cardiologist did a stress test to make sure that she did not have cardiac issues for the lung resection.
     She had the surgery and the cancer was resected , only thing which was not expected was that they had to take out entire lung, No cardiac problem or lung problems during post operative period . She was discharged and was doing well. When she went to the cardiologist, I have no idea why , but he ordered a holter monitor. This one records cardiogram for the 24 hrs period . She had absolutely no complained. To her and her cardiologist's surprise it was abnormal, It showed ventricular tachycardia and even some ventricular fibrillation !!!!THIS IS LIFE THREATENING AND SUDDEN DEATH CAN OCCUR.She had defibrillator put in , and is doing well.
     So now look at the 'Luck ' If I had not ordered the blood test, I would not have done the CT scan and the cancer would not have been detected , (as plain x-ray was 'normal '), and by the time she would have symptoms , it might have been to late.
      Not only that her cancer was detected unexpectedly, but the dangerous and lif threatening  arrhythmia was detected by 'accident ' . (remember that the cardiac stress test was 'normal ' ). So she must have had good or great luck .
     The one with 'bad luck ' next time.

Sunday, April 22, 2012


     I saw him in the office fof  the abnormal chest x-ray and some weight loss. He was referred to me by a family doctor , who was following him for last about a year. In that time he had lost some weight, may be 8 lbs. He was not a smoker and family doctor did blood tests , and chest x-ray. The blood tests did not show the reason for his weight loss, he was not diabetic , nor did he have anemia or thyroid problem.  He also did a nonspecific blood test called CEA , which is a tumour marker. This was also normal . The chest x-ray however did show abnormality, which was reported as " scaring , may be related to granulamatous disease, as in old tuberculosis. "So he was referred to me .
    He was 69 years old black male , came with his wife . He had no cough, no fever, no night sweats, to suggest TB. His examination was unremarkable . He was ex smoker, had quit smoking 8 years. . He did not have poor appetite. He did not have much cough, some left from his chronic bronchitis. When I asked him about history of TB , he told me that he was told about abnormal x-ray  in New York few years ago.He was told that it residual scaring from TB.
     I did the usual work up ,did cat scan of the chest and even though it showed 'scaring may be related to old TB , but also did a endoscopy--bronchoscopy , as I could not rule out 'scar cancer' i.e the cancer that develops in old scar. It came back negative. I was waiting for the TB cultures , so I told him to get me  old x-ray reports from New York. When I saw the old x-ray and compared them to the one which were done here, they looked unchanged .So the possibility of active TB was low and when I got the TB cultures negative , it was completely ruled out. He however continued to loos weight So I started to look for occult cancer,as it can cause weight loss. I did cat scan of the belly and send him to a gastroeterologist, to do colonoscopy. His work up came OK , No cancer was detected.
     When he came for the follow up, he looked weak and had  further lost weight , now almost 30 lbs. He had no other complaints , but he was not doing any exercise and when I saw him walk , he looked like an old   man walking with some difficulty. When I examined him , he had lost some fat , but what struck me most was the loss of muscle mass. It is not uncommon to loose muscles when one loose that much weight.But with his other symptoms, I thought of something. He was loosing MUSCLES. and so I thought of some kind of neuropathy(inflammation of nerves, which can lead to muscle loss ) or the myopathy , the muscle disease. The weight loss van be explained on the basis of loss of the muscle tissue.
     I ordered the muscle enzymes and send him to a neurologist . I had explained him and his wife about my thinking. I also called the neurologist and told him my concerns.
    Next week I got the call from the neurologist. He had done the investigation and had the diagnosis. He had ALS---amyotropic Lateral sclerosis, also known as Lu Garick' disease. So I was party correct , He had lost weight due to loss of the muscle mass, and it was due to ALS . In this disease patients get degeneration of neuronal cells in the spinal cord (anterior horn cells ). The unfortunate problem is that even though I now knew the cause of his weight I had NO TREATMENT, and prognosis was very poor , with the patients needing respiratory support and feeding etc .   

Friday, April 20, 2012


    4,5, AND 6 . These shlokas have names of the warriors on the side of the Pandawas, namely Bhima Arjuna, Yuyudhana, Virata, Drupada, Dristaketu, Chekitana ,Kashiraj ,Purujit, Kuntibhoja,Shaibya,Yudhamannyu,Uttamojas, Son of Subhadra, (Abhimannyu )and the sons of Draupadi.
    Theses names are not all known to the readers of Mahabharata , certainly we know Bhima and Arjuna and some others , but Chekitana?, Purujit? . at least I was not aware of the importance of these names to be mentioned in these shlokas. So why are they mentioned?
    The answer comes from the meaning of these names . We may also have to look at the way we can do meditation , what are the things that are required to attain the highest levels of the ' samadhi' and how at each step we have opposition from our attraction from sense organ indulgence.
    Bhima ,is the son of 'Wind ' or Air, and it indicates control of 'Prana' or the 'life force . As we know the control of our breathing is essential part of achieving the highest levels of 'samadhi ' So Bhima is on the side of ' good '.
    Arjuna , represents the 'fire' element and it is at the lumbar center or the Manipur chakra. This has special importance. If one  remembers the structure of the Astral spine and the causal spine then we realise that  , our physical sensations are carried from the periphery to the spinal centers , from there the ascend to the brain , in it's various parts depending upon the location of origin of the stimulus. During the meditation  i.e. samadhi,  the goal is to ' withdraw ' our sensory input and try to 'cross the energy from physical to astral to causal spine . This opening between the astral spine and the causal spine is at the level of Manipura chakra.' That is why this stage is very important.
   Let me state the Sanskrit meaning (as per Yogananda ),of the different names which are mentioned in these shlokas. Yuyudhana is devotion to the God, Virataa is samadhi, Drupada is dispassion Dristaketuis resistance -mental (to the various temptations ). Chekitana is memory (that develops with repeated attempts of meditations and pleasure that we get when we achieve certain closeness with the God ),Kashiraj is the intellect to know 'good ' from 'bad ' .,Purujit is interiorization,  Kuntibhoja is good posture ( which is required for achieving the Samadhi )Shabya persistence or Adherence , Yudhamannyu is control of the life force.Uttamojas is celibacy, Abhimannyu the son of subhadra,is self control and the 'sons of Draupadi ' are the awakened 5 centers.
  I do not have enough knowledge of the Sanskrit verbs to explain ,but one can find them in books by Yogananda. Please let me state that I understood this from the Master Yoganand, and like the explanation.
     In the attempt to perceive the God , we need to go through certain behavioral changes and then certain changes in our thought and attempts at the proper meditation . The levels that we go through are gradually 'higher' and 'higher' and finally we feel on e with him . i.e Nirwikalpa Samadhi.There are are certain things that are called "Yama" and these are the changes in our behaviour and then in actions that we have to do . These are Ahinsa(nonviolence, this has to be direct and indirect and must be in physical action and also in thought ) Satya ( truthfulness again in action and in the thought. ), Astyey ( not to steal or indulge in sense organ , rather than doing it for survival.there are many different things that can be given as examples. Overeating to stealing from 'nature ', all of this is stealing ). Brahmachary (celibacy).Aparigraha(limiting possession or not have hoarding.All the Yams are moral conduct and avoiding immoral conducts . The Niyamas are the rules or 'way ' to achieve the Samadhi . These are Sauch (cleanliness ), Santosh ( satisfaction )Tap ,Swadhyay (study of scriptures and continuation of attempts to do meditation, Ishwarpranidhan
      To get to it we need proper Posture(asan ),control of breathing (pranayam) ,interiorization of mind(pratyahar).,concentration on the God (dharana )and finally the union with the God (samadhi).                        .

Tuesday, April 17, 2012


     I saw her as one of the new patient on one Tuesday. She was referred to me by an allergist. Patient was 37 years old white female , who had cough far 3-4 months. So her primary care physician referred to the allergist. The allergist did the allergy tests , did chest x-ray, and even tried treatment for the 'acid reflux' . The allergy tests were negative, and still she was tried on nasal steroid, and other allergy medicines. Nothing worked. When I asked on the x-ray report, she said 'it showed pneumonia ' and so she was treated with antibiotics. No repeat x-ray was done. I was surprised as to why was she referred to an allergist and not to 'lung specialist ', like me .
    When I examined her I noticed a faint rash on her arms . I asked her about it . Then she said " now I remember why I went to the allergist. I have this rash, and the over the counter pills for the allergy , like claratin and Zyrtec did not work. so  I was referred to her. ". I asked her about the any shortness of the breath. She said " I have been always short of breath, I thought it was due to my weight. " She was quite obese, but when I asked her , she was little more short of breath than before. This could have been due to 'deconditioning ', as her activity level was quite low . Her examination otherwise  unremarkable . When I got hold of the old x-ray, it did show some 'congestion ' i.e. infiltrates , in lower lower part of the lungs . I did cat scan and the breathing test . The ct scan showed same findings, the infiltrates, and the breathing test did show reduced lung capacity, especially, the DLco, the diffusion capacity. ( how the oxygen goes across the lungs ). was lower . I decided to do the bronchoscopy and biopsy. (looking inside the lungs and biopsy. )  I also ordered some blood tests . I felt that she was 'weak' and was not sure what I was the diagnosis , but due to rash , her shortness of the breath, and the lung infiltrate and her weakness, was worried about some sort of connective tissue disorder.
   The biopsy showed some 'inflamation' and the blood tests were positive. They gave the diagnosis. She had quite elevated muscle enzymes and other tests were diagnostic for what is called 'Dermatomyositis '.

   In this disease patients have rash, have some muscular weakness, and other abnormalities . The treatment is steroids . She was put on it and referred to rheumatologist and did very well, except that she never lost any weight .

Sunday, April 15, 2012


   Saraswati was readmitted to the hospital.I was called again . I saw her for the first time , when she was admitted few months ago . In last year she was in the hospital 4 or 5 times.When I saw her for the first time she was admitted with the fluid around the lung and was short of breath. I drained the fluid and did the work up . It turned out that she had a liver disease, cirrhosis of the liver . When I got the additional history , the husband told me that she had hepatitis in India . She had gotten worse in recent past . She was not a smoker and never drank alcohol . She was 'Hindu ' and ended up marrying a christen . The husband was quite stubborn , but loved his wife very much . She was 69 years  and was not in the best of the health.Her real name was Saraswati --name of a  Goddess  of  Money and he being Cristen changed to Sarah.
   Her hospital course was very intense,as the diagnosis was not established before . We took out the fluid from around the lung , we also did drained fluid from the belly . We did liver scan , cat scan of the chest and the belly. We also ended up doing liver biopsy to confirm the diagnosis of cirrhosis of the liver . She also had some kidney issues. , was anemic with low blood count and had low platelet count and blood did not clot normally . Most of these abnormalities were due to the liver disease.
     I had explained the grave nature of the disease and the poor prognosis to her and the husband . She was OK with it and accepted it quite well. He was not at all comfortable with idea of poor out come . She was older and  liver transplant was not an option 25 years ago . We had every speciality MD see her , Gastroenterologist , cardiologist , kidney specialist , blood doctor and myself, lung specialist .We discharged her on medication , fully well expecting that she will be readmitted .
    So over period of time she was in the hospital few times . Each time her condition was getting little worse in spite of the medications .
     Now she was in the hospital and this time she was in Intensive Care Unit.I saw her and talked to her husband. She had same problems , but all of them were worse . Her kidney function was wore, her liver chemistry was worse and her blood counts were worse too.
    We again had same group of doctors see her . Her liver was giving   up  and the level of ammonia --the liver is suppose to get rid of it - was climbing . Over period her urine out put dropped and accumulation of waste products, called BUN and cratinine were climbing. Her billirubin was getting worse .I had several conversations with the husband . I had told him in the beginning subtle way and when this was not effective , told him in no uncertain terms. She now was hypotensive ( blood pressure was low ) needed to be put on respirator and needed dialysis, as had no urine out put . She also needed transfusions repeatedly and was almost comatose due to 'waste products ' accumulating in the blood . Every time I tried to talk hi about making her  DNR--Do Not Resuscitate- he would say same thing 'Don't you believe in the Jesus, He can perform miracles . ' I had no answer to this  line of thinking . Granted that The God can do miracles , but if he did it every time it would not be 'miracle ' and no n one  would die .
      It was month of December and now she was in the hospital for 40 days . Her blood pressure was low , needing medicine to keep it up for 5 days and she was on dialysis for last several days . Sometimes we had to stop the dialysis as her blood pressure would drop with the fluid being taken out. We also needed transfusion and respirator support, and intravenous feeding was limited due to fluid balance issues. We had 'ethiques committee meetings , but he was not listening to any one and was not ready to accept that his wife--whom he refused to call Saraswati -her real name -Sarah - was not going to survive . I tried to tell him that he was being 'selfish '  and his wife was suffering . ( I was going to use word 'torture' , but I avoided it ).
  It was 25th of December and I was making my rounds . The patient load was light , but still lot of 'sick ' people were still in the hospital . ( At the time of these days only very sick patients continue to stay , rest of them want to get out as quickly as they can . )I spoke to him again . NOTHING HAD CHANGED . She continued to 'Hang in ' . I took him aside . I told him  that for practical purpose we were keeping her alive  with machines and dialysis and medicines . But more so that HE WAS HOLDING HER . If he would not resist she will go . I also told him that we should make her DNR and continue what we were doing --medicines, dialysis, transfusion , feeding etc , but if her heart stops or blood pressure drops then we will not do CPR or 'shock ' her . I don't know why , but he agreed to the DNR , but made me promise that we will not hold any treatment. I did that , but then said , "I want you to do me a favour. I think that she is 'there ' because you are 'holding ' her , if YOU could 'tell ' her that YOU will be OK , and she can 'GO ' she will go , ". He was not sure as to what I believed and definitely did not believe in 'this kind of thinking ' .  I  told to do it for me .  He agreed .
    We went in the room . He held her hand . and told her that 'she can go and he will be OK . '
     Saraswati died in less than 10 minutes, after his statement !!!!!!!

Saturday, April 14, 2012


     We talked about the literary meanings of the first 8 or so shlokas. Now the real meaning . (that I understand , as was told by Yoganand. ) To get perspective on these one must understand the characters in the Mahabharata and their real meaning as was stated in the past . One must also , to some extent know the general concepts of Hinduism and how there are 3 bodies, how they are made and their composition. We will also talk about various stories that go with these characters and how they  are related to the meaning and how they play in the evolution of the soul and it's uplifting, so that finally we can be with HIM and escape from cycle of birth and death.
1. The war that occurred did occur, but the war that is refereed in the Geeta is the war that occur inside us , between good and bad  , and between the right and wrong. e.g. we need to loose , or one is diabetic and should not eat sugary things , but we 'succomb ' to the temptations  and do what we should not do . So in the first shloka the 'battle field ' is our body and the fight is between our attachment to 5 sense organs (may called lust ) and the desire to control them with the meditation .
       Drithrashtra signifies 'mind ' , as we know the 'mind ' is 'blind ' . It does  not take in to account the consequences of our actions.In the previous example--we will gain weight and the diabetes will be out of control etc . and we eat . The intellect is the one which more rational. So the fight is between 'mind ' and the 'intelect ' .We have 5 sense organs and  5 organs of actions. (smell , touch, see. here, taste and speech, hands for the grasping, legs for locomotion, procreation and excretion. ) The 'children ' of the blind mind are 10 defects of each of these 10 , and so these are the 100 sons of Drithrashtra or the Kaurawas. As one recollects the Pandu represents the Intellect or Buddhi and their 5 children are the 5 pandawas, born when the intelect is 'united' with the 5 'chakras  and the control over 5 great elements.
    So the real meaning of the first one is that the blind mind asked how are the all the attachments (through mind works) are doing in the fight with the intelect and it's meditation efforts controlling the 5 chakras.
   2. The king of all the attractions, the lust , the desires etc, is the Duryodhana. So when we are looking for the help , our actions are directed by our previous experiences and the impressions that we carry from our previous actions. e.g If we had eaten pizza in past and liked it , then when we are hungry ( or even when we are not hungry , but we see pizza we want to eat it ---engage in the action of eating. . )These are called impressions or ' Saunskara ' , that are carried in the astral body from one life to other. The Dronacharya represents these 'past impressions ' . These could be good or bad . So why is Dronacharya on the side of 'bad ' ?The answer is that most of us have more attachment to the sense organ desires and less to the good habits . Also when we are fighting we are likely to have more undesirable impressions than good ones. (that is the reason we are still 'fighting ' and not successful . ) During these times the past impressions are likely to take side of the bad or desires.
   So the real meaning of this one is that the Son of the blind mind -king of the desires  turned to the past impressions ( to guide him in the fight with the good actions . )
   3. He -Duryodhana said that the army of sons of the Pandu is arranged by your student, son of Drupada. If one considers the Pandu the intelect or Buddhi to be guiding us in the fight, we need to know who is going to help and how do we improve the chances of the success. The answer is repeated efforts to control our sense organs and have pure actions and do meditation .So the army of Pandawas is going to be the good habits and the qualities that will be discussed latter related to meditation . In this shloka the name Drupada comes in . Many may not know him and only some may remember him . (so why is he mentioned here, if it;s just the another name? ) The answer is that Drupada was childhood friend of the Drona. Drupad is dispassion for the material enjoyment. In the Mahabharata story, these two friends were together in earlier part of their life , but then the Drupada became the king of state called Panchal. Then Drona wanted some cows  , and went to the king Drupad and he did not help him and drove him out. So then Drona got angry and called his students at that time , --the Kaurawas and the Pandawas , The Arjuna went and defeated Drupada and was caught and then Drona released him , but allowed him to 'rule ' only 'southern ' half of the kingdom. Drupada was defeated but not going to quit. So he did a 'Yadnya ' , and got blessing from it and then had a son called Drishtadyumna (meaning -calm inner perception ) He was also taught by Drona . And he is the one who is now on the side of the Pandawas and is guiding rest of the army in the battle .
   So now when one tries to meditate and try to run away from doing bad things , his previous habits and the impressions that they have left (Drona ) will try to disturb it , ask him to help him . In the early part of our efforts we are not likely to be successful but likely to succumb to old habits and impressions and loose the battle and will be 'bound ' by them . (This the defeat of the Drupada-dispassion for material things, by previous impressions -Drona . ) Now with more efforts and ' sacrifice ' ---Yadnya-, we will be successful . When we loose in our earlier efforts we do not go back to level 1 , but continue to have some control left , usually in the lower levels --so called southern part of the kingdom --which is our body . With efforts we are successful and this 'fruit ' of our effort will help us and guide us . One may ask why do we need 'help ' if we are successful . The answer is , just because we are successful once , does not mean that we will be free of all the attractions. (one can look at any Rhushi-sage from Vishmamitra to Durwas to know that we need to continue the efforts and be vigilant all the time . )
   So the real meaning is that the inner calmness which comes after great sacrifice and efforts will guide the  us in the battle against bad impressions and bad habits .

Friday, April 13, 2012


     I have seen HIV cases for many years. Some cases are easy, and obvious and the diagnosis is even expected by the patient. And then there are cases it hits you suddenly . In the past we in medical profession were not aware of the incidence and were not expecting it . But then as the time went on and we saw many different presentations of the HIV , it became less of a ' mystery ' or unusual case . Never the less I still remember many of those unusual cases , simply because of the presentation. In those days diagnosis of HIV was death sentence '. And so it was very difficult to talk about it. The story that I want to tell occurred in early 80es.
    I saw a new patient , who  was referred to me by one of the family doctors. Patient was complaining of cough and so the doctor did chest x-ray. The x-ray came back abnormal . So he was asked to see me . He was 35 years old male , who had smoked in the past , but had quit 10 years ago. He was not alcoholic and had never used 'drugs' . He had mild asthma and worked as 'friut inspector '. He was having some cough, not much sputum, and questionable night sweat and weight of 5 lbs. He had brought in his x-ray and it showed some 'congestion ' in both lungs . i.e. bilateral diffuse infiltrates. His physical examination was normal . I did not feel any lymph node enlargement. At most I heard some crackles in lungs .
     There were no old x-ray available for the comparison. So my feeling was  that he may have  a condition called sarcoidosis .In this condition patients develop nonspecific inflammation in the lungs and they also develop lymph gland swelling in the chest and common symptom , if at all , they have any is dry cough. Sometimes thy may be short of breath.
     So I decided to do ct scan of the chest and scheduled him for the 'endoscopy ' (bronchoscopy- to look inside lungs and do biopsy ). The ct scan confirmed the chest x-ray finding and the bronchoscopy was uneventful . It was Thursday and  it was going to be Easter week end . So I was trying to finish the work in the office . And I got a call from the pathologist. Usually we get these calls only when it is cancer or something questionable or unusual and the pathologist wants additional history.
     When I picked up the phone , he asked me the history . and told him what my presumptive diagnosis was. He said ' well what I am seeing is not sarcoidosis, but I am seeing PCP. ' I was speechless. PCP pneumonia all most exclusively occurs in immune compromised patient, like HIV. My patient did not 'fit ' in to the typical patient that would get HIV and the PCP pneumonia. My second problem was how to tell patient . The weekend was coming and I wanted to treat him and tell him the diagnosis of PCP and do the test for confirming the HIV. But I COULD NOT DO IT IN THE TELEPHONE . So what could I tell him on the telephone, that too on Easter weekend? .
     I decided to call him and tell him the truth, but not the 'whole ' Truth . ( I had heard cases where patients had committed suicide after knowing the diagnosis . ) I had to be careful . I told him that I got some reports from the tests and I could not treat him at home . The medicines needed to treat  the type of pneumonia he had were given intravenously and so he needs to be in the hospital . He agreed.
    In the hospital, I told him the type of pneumonia and possibility of HIV and need to the test to confirm the diagnosis. He agreed . And then he told me something that I had not asked him , nor did he volunteer before. He told he that he was homosexual.
  I was somewhat surprised but not fully . But then what he asked me was more than what I could have anticipated or handled .
    His parents did come to the hospital , flew in from CT . I had to sit with them on the Easter Sunday and tell them the diagnosis. It was very hard . But after all the information was told to them , they accepted it.

(This  type of the story  may not be that may occur today , as many parents have told their parents about the 'lifestyle' and HIV patients live for many years and HIV is not a death sentence , that it used to be .)

Thursday, April 12, 2012


     I have seen actual Geeta shlokas and their translation . I have seen many speakers give lecture on Geeta. I have never seen anyone discussing chapter one and it's first 8 or 10 shlokas. If one reads them and reads the meanings , the translation of Sanskrit to English or any other language , one wonders why would the God ''waste '' time describing names of the ' WARRIORS ' in these part of the Geeta . It t almost feels like beginning of  the basket ball game . "  6-10 power forward, from -------is ------- " . Let me give the word by word meaning of these shlokas and then tell the real meaning of these .
     1 Dritharashtra asked, "on the holy grounds of Kurushetra my sons and Pandu's sons have gathered , eager to fight, what did they do ? "
     2 Sanjay said, "At that time seeing the army of the Pandawas, drawn up for the battle and going to the Dronacharya , prince Drurodhana spoke these words."
     3 "O master( teacher ) behold, the mighty army of sons of Pandu arranged in the battle by your talented student  son of Drupada."
     4 There are in this army heroes with  mighty bows and equal to Bhishma and Arjuna, such as Satyaki and Viraja and Maharathi.
     5 Drishtaketu , Chekitana and the valiant king of Kashi and Purujit.Kuntibhoja and Saibya, the best of men,
     6 And mighty Yudhamanyu, and valiant Uttamauja,Abhimanyu, the son of Shubhada,and the 5 sons of Draupadi, -all of them great warriors.
     7 " O best of Brahamanas, and now our side principle warriors  , generals of my army, I will mention them for your information --"
     8 Yourself and Bhishma and Karna and Kripa , who are always victorious in the war  Ashwathama, Vikarna and Burishwara, the son of Somadatta.

Wednesday, April 11, 2012

I AM RELATED TO --------

   We have a policy in our office . We do help other doctor's family members . They can get in quickly if it is an emergency and try to get samples  etc . I can not do it all the time , but we try . I expect the same from other doctors if I would need any help . This is called professional courtesy. Sometimes it happens and some times not . So this is a story of one of my patients.
   I saw her for the shortness of the breath . Sometimes we have to do investigations to find out the reason for the shortness of the breath and other times the diagnosis is obvious or even clear or known to the patient . This one was the latter case.
   She was 60 years old white female , who was lifelong smoker. She had chronic cough, which had gotten worse, and she was also wheezing. She had continued to smoke and knew what was the diagnosis. She had chronic obstructive lung disease . When I saw  her I had noticed that her name -last name was same as a doctor that I knew and was in practice within less than half a mile of my office. So  I asked her if she was related to him . She was very firm , when she said 'no '. I gave her medicines and schedule her for lung function tests and some blood tests and advised her to stop smoking .
    She was seen by me in next few months few times . Her breathing test showed quite significant drop in her lung capacity and she continued to smoke. every time I saw her she would ask for the samples and I would give her some . Unfortunately these medicines are quite expensive . e.g. one inhaler is $ 200. and it lasts only a month . ( by the way we can get it for $40 in Canada )
   She would complain of the cost of medicine , but I could do nothing about the cost of the medicine . At the one of the office follow up she asked me to close the door . I did . She started saying in low voice , " you remember you had asked me if I was related to Doctor. XXXX. " When I said 'yes' , she continued, " I am , related to him , I mean I was related to him . I am his ex wife . I have no relation left with him , I don't want him to have any relation with my children . " I was not sure where this conversation was leading to . She continued , " I saw that you give discount to the relatives of other doctors. I am related to Doctor xx , could you write off my balance?"
   i was speechless . I have written off some balance many times, 'related ' or 'unrelated ' to doctors. In this case too I did it .

Tuesday, April 10, 2012


    I have seen many patients , that want to live, in spite of 'bad ' diagnosis, and poor prognosis. But this one was unusual .
    Susan was my patient  for long time . She had advanced  chronic obstructive lung disease. She was on oxygen 24/7 . At most could walk 30 to 50 feet. And she was admitted with abdominal pain . Further work up with the scan etc showed that she had acute gall bladder attack . We had no choice but to do the surgery . In those days there was no option of "small incision "i.e. lap choly. surgery . So we had high risk of being on respirator post operatively. As expected she was on respirator, and it became very difficult to wean her off . After 12 dyes we had to do 'trachostomy' . We continued to wean her off , we were doing not too badly , but she was quite scared and was dependent on the respirator and almost addicted. When we would cut down the support from the respirator, she continued to do well . But once we told her about the cutting of the support or that she was on her own , she would get panicky .So I decided to do a trick . I continued the respirator , but there was no support from it . After 2 days ,I told her that she was not on the respirator support, but breathing on her own , she got mad , and anxious , but was latter on happy . I did discharge her home with the tracheotomy.
  I saw her in the office in couple of weeks. She was short of breath, but had learned  to 'talk' with the trach. She was in a wheel chair , but she and her husband were happy to to be home. At the end of the follow up she talked to me and made me promise that I would never ' put her through ' the respirator etc . I had to ask her , " Susan if it means you will die , do you still want to be  not on respirator ?" The answer was firm 'yes ' and the husband agreed .
   I was suppose to go go out of country on vacation. My flight was at 8 pm. I was still going to make rounds in the hospital and then hand over to the 'covering ' physician at  1or 2 pm , get ready and go . At 6 am I got a call from the emergency room . Susan was in Emergency Room and was short of breath. I saw her , she was not bad but was short of breath. I talked to her and her husband. We decided to  admit her in Intensive care unit. Did some orders. She did not want to be on respirator. I told her that I was going to be out of town for next 3 weeks. After I finished my hospital rounds I went back to the Intensive care unit and saw her . she was little better. Still quite short of breath, but still with 'progam '. , knew what was going on . Her husband was in the room . She stretched her hand and I held it . Her other hand was held by her husband. She put her finger on the trach, and tried to talk . Her voice was very low. So I had to put my ear very close to her . She said in low but firm voice/tone ,"Doc , Please , please let me die , Do something, so I will die , before You go out of the country. I don't trust anybody but you . " I had already written orders for the comfort and told the covering physician . So I 'promised ' her that she will not be on any 'life support' .
      My flight was at 8 pm . I was to board at 7 pm as it was international flight . I called the ICU and spoke to the nurse taking care of Susan .

Sunday, April 8, 2012


   We noticed in past about the ' meaningless' stories in the Mahabharata. In the epic we are told that the king Shantanu  falls in love with the Ganga , the river/ lady. He wants to marry her , but she has a condition , unless the king agrees to it , no marriage . The condition is that the king Shantanu will never question he r the Ganga about her actions. The love had blinded the king and he agrees to the condition and they are married . Soon after the marriage the Ganga gives birth to a baby, which she drowns in the river Ganga. Shantanu can not ask any questions as he had agreed to her condition of not questioning her actions. This is continued for next 6 boyes( totle7 )and Shantanu is helpless. When the 8th child is born the Ganga starts walking towards the Ganga river , Shantanu questions her actions. She takes the boy with her and  disappears in the river Ganga. This one is named Bhishma and at the request of the king, is returned to the king Shantanu.
    Now the king Shantanu falls in love with daughter of a fisherman called Matsyagandha or Satyawati. Her body odour was that of 'fish' and was foul , so she was called Mastsyagandha, She had a child through sage Parashar, who in turn blesses her and now she smells like fragrance of lotus. The son that was born was none other than author of the Mahabharata, sage Vyas. Satywati would not marry king Shantanu as she feels that 'her' son would not have any chance of becoming king after Shantanu dies. So Shantanu decides to let go the idea of marriage . But then Bhishma comes to know  the problem that his father is facing and decides to 'never marry'. So the the king Shantanu gives him a boon , that he can decide when he wants to die.
   So now Shantanu and satyawati are married and have 2 boyes, named Chitrangada and Vichitravirya. Chitrangada dies at very early age and Vichitravirya can not produce any offspring . So then Bhishma  snatches 2 girls (princes) and marries them to the vichitravirya. The kingdom is in need of new king and since Vichitravirya is impotent, sage Vyasa decides to 'help' . When he enters the bedroom ( my way of describing ) one closes the eyes with fear, (Ambika)  , so the child born is  blind , the other one turns 'white with the fear, (Ambalika) , so the child born is 'white or anemic . They also had third one , (who was put in by Ambika )a maid , she gives birth to normal child . So the blind one is Dritharashtra, the pale one is Pandu and the son of the maid was Vidur. . the Drtharashtra is married to Gandhari and has 100 sons and his second wife is Vaishya and has one son -Yuyutsu. The story on the other side is bit more complicated and  interesting . Lord Krishna's father gives away a daughter to a king (Kuntibhoja ) and her name is Kunti. She was serving a sage named Durwas   He was pleased with her service, and gives her 6 mantras . By chanting these mantras she can invoke 6 different 'gods' and can have a child through them . Kunti decides to 'try ' out and through the 'sun ' she gives birth to a son , named Karna. As she was not married  she decides to give it up and pots him in a box and floats him in a river, which is  picked  up by a charioteer . After marriage to Pandu, she  has to use remaining mantras as Pandu is 'cursed that he will die  if he has intercourse.So by invoking 3 different 'gods'  (Yama, Wind and Indra, the king of 'gods' ) she has 3 boyes, named Yudhisthir, Bhima and the Arjuna, the hero of the Bhagawat Geeta. Remaining 2 she gives to the other wife and  she has 2 sons ( from the Doctors of the gods called Ashwinikumars . )They are called Nakul and Sahadewa.
    The Arjuna is victorious and 'wins ' Draupadi ' and tells the good news to his mother , she tells him to 'divide ' among all the brothers . So now the Draupadi becomes the 'wife ' of all 5 Pandawas- the sons of Pandu .
   The Pandawas and the 100 sons of Drutarastra, called , Kaurawas are taught by the teacher named Dronacharya,. He is called Dronacharya as he was conceived in a'Drona' a bowl made of dry leaves .
   If one is not amused and confused by  this  story , there are more stories and complications in the latter part of the story . But what I would like to do is to try to start with this information and try to understand . I would like to take first 10 or  11 shlokas of the Geeta and try to explain the meaning of it . I have not seen much commentary on these shlokas by any one except The Yogananda and what I understand is his explanation and not my own .
   Just to start , I want to tell what each of these characters represent and then do the Geeta shlokas..
    The king Shantanu is the Parabrahma-the Father , the creator.
     The Ganga represents  the Universal consciousness--The Holy Ghost
     The Bhishma represents universal Ego -AHANKAR.
      The Satyawati represents primordial nature as the matter.
      The sage Vyas is the "consciousness cloaked in relativity".
      The Chitrangada is the Mahat Tatwa , the 24 principles that go in to formation of the universe. (24 elders sitting on the  throne   in the 'Revalation')
      The Vichitravirya is Divine Ego.
    The ' White ' Pandu is 'clear' intellect, Bhudhdhi.
     The 'blind ' Dritarashtra is blind mind .
     The Ambika  is 'perception  without clear discrimination or discernment.'
      The Ambalika is 'perception with discrimination '.
     The 100 Kaurawas are 100 'defects' of 5 sense organs and 5 organs of actions .
    (10 of each one , )
      The Pandawas are the results of union between the 'dispassion ' and the 5 great elements--the space (akash ) , wind ( vayu ) , energy ( teja ), the water (aap ) and  the earth (pruthwi). The Madri , the 2nd wife of Pandu is attachment to dispassion .
   The Gandhari is the power of Desire, so when it unites with the 'blind ' mind we have various sense organ and organs of action tendencies and the defects.
    The Dronacharya is 'stored up impressions '. (from our actions this and previous lives. So he 'teaches ' , or make us do both good and bad things.
   The 8 'children of the Ganga -the consciousness- Maha Prakruti- also called d Holy Ghost  are 6 governing intelligences ( of 3 micro and 3 macro universes---causal , astral and physical )one spirit pervading entire universe. The reflected spirit called Abhas chaitanya when unites with the matter it creates feeling of separate existence, so called the Ahankar or Ego. Since we do not see the 6 governing intelligences or the spirit they are 'drowned ' in the 'universal consciousness.' (Drowned by the Ganga )
   The Draupadi is the Kundalini- the energy or may be the Brahmanadi , which is coiled up in the lower part of the spine. The 5 Pandawas represent 5 Great elements in the universe, but in the human body they represent 5 chakras or 5 centers. So when one controls each of these elements or chakras, the Draupadi 'meets ' and ascends , so she is 'married'  to 5 Pandawas.
    This is quite complicated , but when one takes in to account the bizzar story , this will help .
 Once again this is what I got by reading Yogananda and like it .

Friday, April 6, 2012


    This one incident happened sometimes ago , may be a year ago , and reminded me of the above saying, " your eyes don't see what your mind does not think " . Let me explain.
    It was Saturday. Time was noonish . I was done with my 80% of the hospital round. So going home by 1pm to 1-30 pm was still possible. (which meant I will not be eating my Saturday 'lunch ' at 4 pm. )So I was happy. And then I got paged . The call came from one of my patient's son. 'Doc , Did you not see my father ?' I was not sure , who was he talking about . So I had to ask . his father was admitted to hospital last night , when he fell down . He was 844 years old patient of mine , who had been a heavy smoker . He had bad Chronic obstructive lung disease. and though was quite limited in physical activity , he was doing well. He was on oxygen . He had bad balance and fell down . So the son brought him to the hospital. He was admitted , after all different ct cans were done. No major injuries were noted on the CT scan   of the chest , brain or the belly. He was on regular medical floor , complained of pain , got pain meds and then had respiratory arrest. (or cardiac arrest ). So then he was put on respirator, (breathing machine). The admitting doctor saw patient for the short time and ordered him to be transferred ti Intensive Care Unit and  other lung/Intensive care specialist. Now the son was calling me to know what was happening .
    The other doctor saw him and dictated the note . It stated he saw patient for 90 minutes . The patient wa put on respirator by the respiratory therapist . This doctor put in a central line , which caused lung collapse, so a chest tube was inserted to expand the lung. In between this time his blood count had dropped and his blood pressure also dropped . The note stated all this with each diagnosis , after which statement stating that cause for each , e.g. low blood pressure , cause not known , drop in blood count , cause not clear , respiratory failure , cause not clear, etc . I told the son that I have to be officially called in on the consult to see  patient , as otherwise I can not see patient and told him to call the hospital doctor and tell him to call me . I was called to see him officially in next 5 minutes and I saw him  in Intensive care unit . I had known him from before ,and the son had told me the story, and Had seen the notes . So it took me less than 10-15 minutes to examine him and talk to the nurse.
     I called the son , after I put a call to the chest surgeon . I told the son , that his father broke ribs , when he fell down and had bleeding inside the chest, which in turn caused drop in his blood count and drop in his blood pressure and in this elderly  patient  , he had respiratory failure.The son was medically knowledgeable, and asked me . " the how come hi ct scan was normal ? " My answer was , I know what happened, and I don't care what CT scan showed . it is possible that it was 'too early '   yesterday to pick up this bleeding yesterday. I was ordering new x-ray and calling a chest surgeon as he will need surgery "
    As I expected the new x-ray showed the 'fluid' with rib fractures and I had to transfuse him 8 units of the blood. After we stabilised the patient the surgeon took him to surgery , he found large collection of the blood and fracture ribs .  postoperative he continued to have problems , mot of them relater to his advanced age , his bad lungs and other co morbid conditions. We did take him off the respirator and he did need feeding tube. We  did discharge him to nursing home for the rehab.
    To me this story  elestrate the saying that you can't see (even if it is in front of you) what your mind can not think!!

Tuesday, April 3, 2012


   Last time we talked about the reincarnation and we can plan our future, ourselves and not depend upon anybody or even the God. ( though He controls it all the time .)It is our own deeds that leave us with the impressions  and that leads to new desires and that creates the new situation in our life. The interaction between different people will create new bonds ( and bandages ) and 'debt ' and that will lead to new encounters in new life , if these ' debts ' are not repaid by the end of present life . So if I have  prolong relations with some one e.g. parents or children or spouse , then we are likely to "meet " again, if not in this life then in another life and the another.
     Now this does not mean that we do not have any choice or once we have these contacts we continue to have these things all the time . We may not have same relationship in every life and so depending upon our attachment we will have different 'time ' of the contact and then that will decide our future life.
      So the counterargument that no one can 'predict ' any future is partly correct as our life is dependent upon our own actions and our own attachments. But in this world every thing is interrelated.This is exactly same as seen in quantum theory . If a photon particle starts from a distant star, let us say 100  light  years away, and it will reach  Orlando and an another photon is going to reach London . As long as we do not interfere with either photon , we are OK . But if we interfere with one , it will change course  of the other, even though they are separated by millions of miles and have no direct contact with each other. So in this universe , everything , is interconnected.

Monday, April 2, 2012


     It was 9am and my cell phone rang. Very few people , other than most of the physicians , know my cell phone number. In spite of the lack of the caller ID I decided , I did pick it up . It was one of my Friends or the aquatints that was calling me . He wanted me to see his son . His son was sick and was taken to one of the ERs and was discharged home with the diagnosis of 'dehydration ' . I am not an internist, and normally evaluate patients with pulmonary problems only . But with this 'friend calling me , to his own 'son ' , I could not say 'no' . I my schedule was full, so I told him to bring him to my office at 4-15 pm . and also told him to bring as much as possible information or records from the emergency room .
       I was so busy that I had forgotten about the conversation , till he showed up . He was my last patient. The father and the son were in the examination room , when I entered it . I knew the brief story . But I asked him anyway . The son was 25 years old , and went to supermarket , did the shopping and came out . He did not feel good, so sat on the bench outside. And then passed out . Someone noticed it and 911 was called and he was taken to the local emergency room . In the ER they did cardiogram, did blood tests, including blood tests to rule out heart attack( mind you in this 25 years old patient ) and test to rule out 'drugs ' . All the blood tests were normal. So they told him " you are dehydrated " and gave him intravenous fluid .
    As a lung doctor I was not too sure what I could do in the morning and now in spite of the story and the labs , cardiogram  etc  I was not sure if I knew what was the cause of the him passing out. But I had to know . The rare possibility of increased pressure in the lung circulation called  pulmonary hypertension did cross my mind and I was going to do the work up to rule it out , but that was my last choice as there was no history suggestive of it . I was sitting facing the patient and I thought that he was shifting the position little too frequently and may looked little uncomfortable.( or may be I was grasping for the straw). So I asked him if there was any problem . H e said no , but when I asked him if he was 'hurting ' , he answered 'yes --a little bit ' . So I told  the father to step out. I told him to pull the pants down and show me where he was hurting. And I got my answer. HE HAD SWELLING IN THE UPPER PART OF TESTICLE , he had what I thought was  epididymitis .
     I called the father in the room , told my findings and told him that due to the significant sudden pain when he sat down , he passed , what we call 'vaso vagal response '. ( due to pain a vagus nerve is stimulated which causes drop in the heart rate and the blood pressure which in turn causes passing out ).
   I called local radiology clinic to a 'stat ' ultrasound ' of the testicle and call me with the report. and call a urologist to see him in the morning , gave him an antibiotics.
    There was no testicular twisting and my hunch was correct , HE DID FINE.

Sunday, April 1, 2012


    It was middle of the week. It was 11 am . I had office at 1pm . but due to semi emergency , the office had scheduled new patient at 12-30 pm . If I have no opening in next 2 or 3 weeks we sometimes schedule patients at 12 -30 pm. So it was going to be busy day. And I got page from the ER and at the same time got a call from another doctor . There was a patient in ER , that was being admitted ti Intensive care and I was consulted . The ER doctor wanted to give me the 'short' story and so did the admitting MD . I spoke to both of them .
     This was a 32 years old female who came to hospital or was brought in , to the hospital and then became   unconscious . So for the airway protection was intubated and was put on respirator and I was asked to help out. (when patient is unconscious, they could vomit or could not swallow their saliva and it could go in the lungs, called aspiration . To protect the patient we put patient on respirator even if their respiration may be OK. )So I was going to ER. , but then I was told that she was being transferred to ICU , so I went to ICU.
     When I went to ICU there was no new information . There was no one with her and there were no telephone no. on the chart, that I could call. She was 32 years old black woman and was on respirator. Her blood pressure was quite elevated and rest of the vital signs ,like heart rate ,  temperature , etc was normal . Her physical examination , including lungs and heart was normal . Her blood count her electrolytes, her chest x-ray all was normal . And to my surprise her drug screen was negative . ( whenever someone is found to be unconscious 1st that comes to mind is drug overdose , and then low blood sugars or the stroke .In younger patient stroke is very less likely and drug overdose is more likely. ) Her ct scan of the brain was normal .and now I was not sure what we were dealing with. Except for being very 'large ' woman, and elevated blood pressure and some swelling  in both legs there were no positive findings. I thought of 'encephalitis ' --which is infection of the brain. This is little difficult to diagnose , but  MRI can be helpful . I consulted the neurologist and infectious disease specialist and started her on treatment for encephalitis. (the common cause is herpes encephalitis. )I also requested for the lumbar puncture .( by examining the csf , the fluid which flows around the brain and the spinal cord, the infection of the brain , or more specifically the meningitis can be detected. )
    The lungs were OK and I did not have to do much . The other 2 consultants came and agreed with plan and did not add much to the treatment . But even though they did not add , there agreement withe the plan of treatment was great help . So next day there was no change , in spite of the treatment . The MRI of the brain  was normal . and the CSF , the spinal fluid was normal . So we had no diagnosis. Some how I had an idea. I knew that , she came to the hospital on her own .So she must have had her own clothes  and may be some Identification or some contact information . So I called the security and got all the patient's belongings . I was successful in getting a phone no . and got hold of her mother . The mother came to the hospital quickly . But that was of no help , as she had no new information, other than the daughter had high blood pressure. We had sedated patient and done good control of the blood pressure .
     we were coming to dead end in all the directions . Every time I thought we were doing some progress we had no success. The encephalitis , the drug overdose etc were proved to be not correct .
      I decided to look at all the report again . Sometimes looking at the data again or looking at it together may give me some 'clue' . So when I was looking at the labs , I saw a "pregnancy ' test being ordered . Our computer system does show test that are ordered and the results are pending . I was not sure who had ordered the pregnancy, and why . But when I went back to the labs. after looking at all the x-ray reports, I was shocked . THE PREGNANCY TEST WAS POSITIVE !!! This means she was pregnant and because of her obesity and lack of the history , we did not know it . ( even the mother did not know that the daughter was pregnant. )
    I called the ob-gyn on call and she was taken to operating room for the c -section and had a baby boy . The post operative course was short . She was awake and so we took her off the respirator and she did well and went home in next 2 days. ---on no medicines. I never knew if the patient knew that SHE WAS PREGNANT.