Saturday, September 29, 2012


     We as human beings often wonder about the life and death.We can neither predict the 'time ' of birth or the time when someone is going to die.So we talk to fortune teller, horoscope reader and palmist, and so on . Sometimes we see people who should not be alive , live for long time , and those who should not die , die . So how is our "life " or to be specific duration of life determined ? There are many explanations.Some are so called scientific and some are philosophical. We sometimes say that the life is a wound up spring and when is is done unwinding , then we die . Then there is theory of reincarnation . We are born with certain seeds of 'karma' which will come to fruition in this life . Then there are some 'karma' which are added , that will come to fruition in this life . e.g. we ate too much or ate spoiled food , and we get sick . So when these karmic effect is done with, we die . This can be compared to annual plants , once they are done with flowering, then they are done .  So in my practice of medicine ,when  I  come across some patients those who should not have 'survived  ' but survive,  this law of karma comes to my mind . Only question sometimes remain is what is it that they are waiting for ?
     When I saw Dorothy, not her real name , she was 70 years old female who was some what short, fragile lady . She was accompanied by her daughter . She was a smoker and had emphysema . She was short of breath walking few feet . Many of my patients are similar or have very similar history . The reason I remembered at that time was that she was married to one of my patients, who also had emphysema and he was smoker too . This also is not very uncommon . Only unusual thing was that he was only 52 years old . So there was a difference of 18 years . She had  bad lung disease, needed oxygen , which she would take off when she would smoke .She was admitted to the hospital several times , During the work up one time , we did a CT scan of abdomen and found out that she had a aortic aneurysm. It was not very large , but needed to be watched . There was no way that she would be a good surgical candidate , so this was the only option .
   She continued to do OK , had finally quit smoking .and had reached 72years of age . She was admitted to the hospital .She was short of breath,and had some belly pain . We did CT scan of abdomen and found that the aortic aneurysm had increased in size . It was not 'leaking '.I called the surgeon , who had seen her in the past . He came and saw her , The aneurysm had reached such a level that he felt that the surgery was unavoidable . In those days there was no endovascular grafting , which is done now a days . (in this procedure no surgery is needed , but a graft is inserted under local anesthesia . ).He wanted to do the surgery next morning . She was transferred to intensive care unit for the safety reasons . She was scheduled for the surgery next morning at 7 am . I had talked to the family , the husband and the daughter . They understood the risk , but also knew that there was no other option , as we had postponed the  operation as long as we could and now the time had come to do it .
    I got a call at 3 am that night that her blood pressure had started dropping . I knew what had happened . HER ANEURYSM WAS LEAKING AND WAS GOING TO RUPTURE . They had called the surgeon , who had called the operating room . She was taken to surgery in next 30 mins and 'made ' it . She was on respirator ,for long time . We had  to do the tracheaostomy and it took about 4 weeks to get her off the respirator. She still had the trach. and as she was not eating and her weight had gone down to 60 lbs , we did a feeding tube . She was discharged to a nursing home with the feeding tube and trach. I continued to do office follow up . She went home in about 8 weeks . The trach was taken out as her breathing was better and we do take out the feeding tube after about 6 months as her caloric intake improved . She continued to live for another 18 months or so .
     On that eventful day when the aneurysm started leaking and then almost ruptured, she was in the best place that she could be ----the hospital intensive care unit . If she was home or even if she was on regular floor or if we had not done the CT scan of the abdomen , she would have died . And even with the surgery with her overall status she made it , only because the " THE TIME HAD NOT COME "!!!!!

Monday, September 24, 2012


    In practice of the medicine , we often tend to see things that reminds me of the story of ' 7 blind men and the elephant '.I also think of saying in one of the scriptures, which states that the the Truth is one and wise men interpret it differently. I have personally seen this and experienced it too . It reminds me of old story .
     In old days there was a train and it had 4 people in a compartment. There was an old lady , one young lady , and 2 young men . As the train was moving at night , the electricity went off ,and there was transient darkness. At that time there was a sound of kissing and it was followed by sound someone slapping . When the lights came back, the old lady thought that one of the young men kissed the young girl, and she slapped him . That was her truth. The young lady thought that how stupid are these men , I am here and they or at least one of them is kissing the old lady . That was her truth. The one man thought that the other man kissed the young girl, and I got slapped . So all three had thought that they 'knew' the truth.AND The REAL TRUTH was that one of the men kissed his own palm and slapped the other man .
    In medicine we often think that we 'know the truith'. And when the truth is out it comes as a surprise on at least some occasions .The story that I am going to tell is one such case .
    I saw this 67 years old male for cough that was going on for 2or 3 months .The primary care doctor had done a chest X-ray,and it was reported normal. He was treated with antibiotics.He was also give cough medicines and was even given a short course of steroids. He felt little better, but the cough continued . It was so bad that he had blood tinged sputum.So he was refereed to me .
    He was ex smoker and had quit smoking 5 years ago and was little obese .He had no fever nor had he lost any weight. He did have some shortness of the breath. On examination , he had some wheezing and rest of the examination was normal . I looked at the X-ray, and I thought that I saw a nodule in the left lower lobe .I was not sure if it was 'real ' , or I was imagining it .Anyway I decided to do a CT scan and also decided to do bronchoscopy . The Ct scan was a surprise , even I had not expected it . The CT scan showed a mass next to main wind pipe called trachea and it was partially pressing on the trachea. My bronchoscopy was completely normal, except for little bronchitis . I did not not see any tumour, even though the scan had shown almost 4 or 5 cms size mass . I know this can happen. The mass was out side of lung and the bronchial tubes . I called in a chest surgeon and he did the biopsy , which showed it to be the lung cancer .
    So when the primary care MD did the X-ray , and it was reported normal , he thought he knew the truth . When I saw the X-ray and thought that there was a nodule in the left lower lobe, I thought I knew the truth, and 'the real ' Truth was that he had a right sided lung cancer that was not seen in the lungs even with the CT can or the bronchoscopy.

Friday, September 21, 2012


    The other day I was in the hospital and saw that the hospital was asking patients to answer a questionnaire, in which they were asked about the treatment that they got in the hospital . They were also asked to evaluate the doctor as far as communication, care, and if he answered their questions or concerns. I was surprised to see some of the 'good ' and 'caring ' doctors get lower grade . I made a comment , that may be they need to ask extra question, "did you need any pain medication ?" . I hear about pain seeking patients everyday . Fortunately I am not directly involved in taking care of these patients, but do know that these patients do exist and get angry when they do not get the pain medicines.Theses patients will not be happy with the doctors, who would not give them the pain medicines. It is very difficult sometimes to really know the difference between the 'real' pain and just drug seeking behaviour. It reminded me of this patient that I had seen many years ago.
     I saw this 71 years old male with complaint of coughing blood . He was coughing hard and brought up blood tinged sputum. He was given an antibiotic and a cough medicine and was asked to see me . He had X-ray done and it was OK , and so he came to me .On questioning , I came to know that he was ex smoker and had quit smoking 5 years ago .He was retired, and had some cough for last 6 months . He had history of high blood pressure and arthritis . His examination was unremarkable .On reviewing his medicines I saw that he was taking long acting morphine called Oxycontin . I asked him as to why he was taking it . He told that he had back pain and was treated by family doctor first and the when the pain continued , he was refereed to orthopedic doctor . He had some X-ray and was given physical therapy and when pain continued was given morphine . I looked at the chest X-ray and noted some abnormality on the left side . It was close to the heart border. I was not concerned about the hemoptysis, but I was surprised by the back pain in this 71years old who needed narcotics to control the pain . I ordered the CT scan of the chest and also the CT scan of the lower spine .
     I was not surprised when the radiologist called me with 'wet' reading . He had a tumour in the spine and it was pressing upon the spinal cord . He also had a tumour in the left lower lobe . ( He also had swelling of the leg and I had done a scan to rule out clot called phlebitis and it was positive for the clot ).The main concern was the tumour pressing on the spinal cord . I started him on blood thinner and called a radiation oncologist , the doctor who treats cancer with radiation . He agreed with me and saw patient same day and started the treatment without diagnosis of the cancer . Due to the clot in the leg I had to treat it first. ( if the clot is not treated then it can travel to lung , which could be fatal  ) So we decided to continue the radiation treatment and the blood thinner fof next 3 weeks , then do the biopsy of the lung mass . We got the diagnosis of the lung cancer , which had spread to the spine and had caused the severe back pain , which needed narcotic.
    The 'clue ' to the diagnosis of tumour was that he did not look like some one who was drug seeking and  had real bad pain , which needed the narcotic . I was glad that I could differentiate between the two behaviours.

Tuesday, September 11, 2012


      I have known people , that remember their loved ones after their death in different ways .Many have pictures , some have tapes , and many others have different means of remembering them . The story that I am going to tell is one such story .
       I saw this 55 years old male with persistent cough. He was a smoker, 1 pack a day for almost 40 years . He was treated by primary care for a while and when the cough did not get better, he ordered a x-ray.It showed 'pneumonia ' . He was treated with more antibiotics. He did not improve , so was referred to me . His examination was unremarkable, except for some wheezing.I looked at the x-ray. It did not appear like simple pneumonia. There appear to be a volume loss, which means , that the size of upper lobe was smaller , I was concerned about the tumour blocking the bronchus and causing the cough , pneumonia, and persistence of the  symptoms .
      I ordered the CT scan . It did confirm my suspicion . There was centrally located tumour.I did the bronchoscopy. It did show the cancer and biopsy confirmed the diagnosis of the cancer . Due to the location of the tumour, he was inoperable. I did further work up and unfortunately the cancer had spread to the liver . So the only option remaining was to do radiation treatment and chemotherapy . He and his wife were very optimistic . 'We will beat the cancer ' , they told me . The wife was a nurse , and worked at the hospital where I practiced . So she was medically knowledgeable.They had a 15 years old son .
       The radiation was completed and chemotherapy was going on . He had lost significant weight . His appetite was poor and nausea made it difficult to eat.He was admitted to the hospital with nausea and inability to keep food or liquid down .I saw him and knew that it was more than just effect of chemotherapy.I ordered the Ct scan of the belly . It showed the intestinal blockage .I was hoping that it would resolve on it's own , though by looking at the CT scan I knew that it was due to cancer . Since he did not get better, I had no choice but to call  surgeon. He was operated and it showed that there was cancer in the small intestine and it was blocking . The surgery did help and he was better , But the cancer had spread and was worse in spite of all the  treatment .I have seen many lung cancers , but never seen cancer going to small bowel and causing obstruction. I had along talk with the wife and made him DNR . I knew that not much could be done .
      He died in next 3 weeks. I talked to the wife , she was expecting it and took it well
      Six or eight months had passed , I was sitting at the desk , writing my notes . I saw her,the wife . I asked if everything was OK. She said 'fine'. I started talking to her .When it came to her husband , she told me that they had done the cremation . When we talked about the memories , she told me something that shocked me . He had total knee replacement . Before he died he had told her two things . One was to get married to his close friend, who had helped them , including taking care of the young son and second take home the 'artificial knee ' home and' keep it as his memory.'

Sunday, September 9, 2012


     I have always felt that our spoken words have impact . In today's society  we have politician say things , promise things to get elected , and once in power they don't keep any promises , and the we never take them to the task . I have tried to keep my word , with my kids .Otherwise our kids have  have no role model. But even our spoken words can cause impact , and we need to be careful.
    I have had incidences in my life , where I said things inadvertently , without realising the impact of my words . There are several such incidences , that happen to us , but I Will tell you  one or two'
    I had seen a patient in the hospital , for the complaint of shortness of the breath. She was 50 years old female , who had history of breast cancer and came to the hospital with shortness of the breath . The reason to remember her name and the case is due to her ancestry , she was from Guiana and had her last name which sounded very much like one of the Indian names . When I met her husband , I realised that he indeed was 'Indian ' , except that he had no relation to India . His forefather had  or must have migrated to Guiana and he neither had Indian language nor religion or any affinity for India . (I have often wondered about the 'melting pot ' as the US is called and thought about what would happen to my grand kids ). Her X-ray showed that there was fluid around her lung on the Right side . With the diagnosis of the breast cancer , the possibility of this being related to the cancer spread , was quite high . I did do a CT scan and it confirmed the fluid . Under the ultrasound guidance I did put in a catheter and drained 800ml of fluid . It did show cancer cells confirming the diagnosis of spread of the cancer to the lungs . This was not good news . She was on chemotherapy.and in spite of that she had spread of the cancer .
      Normally we continue to treat the cancer in hope of preventing the recurrence of the fluid .If it comes back, then we drain it again or put in a chest tube to drain the fluid and put in talk powder.The talk powder acts as 'glu' and this prevents the fluid from recurring , as there is no space to accumulate . I talked to her and her husband . She was discharged .
    I did a follow up X-ray in 3 or 4 weeks and it did show that the fluid had increased . The time that it took to come back was too short for me to redo the drainage . We need some semipermenent 'fix'. .So I called a chest surgeon . She was readmitted and had the surgery . The talk was put in . Everything went well . She was discharged and was continued on chemotherapy .
     Then it happened . She was readmitted with the shortness of the breath . I had not seen her for the six months. She was doing fine , the chemo was doing OK and they were thinking that all was well . Noe with the  shortness of the breath, she was admitted . I saw her in the hospital . She looked OK when she was sitting in the bed , but least little activity , she got short of breath . Her oxygen level was normal . The x -ray showed abnormality which looked like the fluid was worsening . I did CT scan . It did show some fluid , but it was not 'free ' It had pockets . It also showed that there were tumour nodules on the covering of the lung called pleura. There was no way I could do any drainage of the fluid.So I called the surgeon , who had done the previous surgery , putting in the talk.
      I was not too sure if he could do much . One possibility was that he could go in and 'peal off  ' the pleura .The normal covering of the lung is loose , just like covering of tangerine. So it is easy to peal it off . But in case of the cancer spread, the covering becomes thick  like avocado, not very easy to peal it off .
    I had talked to the husband and told him about the difficulty that we were facing .I was home and was with my 5 year old son . We were watching some cartoons , when I got a call from the surgeon . I was talking to him , and I had forgotten that my son was in the same room . I was under the impression that he was watching the TV . The surgeon had seen her , had seen her CT scan and felt that he could not do much . "Can't do much , she is going to die " , he said . I told him that I had talked to the husband , and will sit with them and tell them that not much could be done and she is likely to 'die' .
       I hung up the phone and looked at my son . He was looking at me , with disbelief . He had heard every word and was shocked that 'his dad ' who is suppose to 'help patients' and 'save ' them was going to let the patient die .

        It took me several minutes to explain as to what was going on .
        My words had impact , without me realising it .

Saturday, September 8, 2012


      I did state about he God particle in past. The so called God particle is the Higgs Boson . I am not sure what it is , but certainly it is not God particle , in sense of it being God , It does not have charge or spin , but has weight . So it may be something that has some quality , and the GOD is 'without any quality'. ' 
      There are 2 other things that caught my eye, one is 'dark energy ' and the other is 'dark matter'. When I was thinking about both of them , I thought of their qualities and if it came close to anything that scripture describes . So let me start by saying that in scriptures , the space was created first, then the air , then the energy , then the water and lastly the earth. Each one of them have quality or qualities of the previous ones .e.g. the earth has all 5 qualities like one can see it, taste it, smell it , feel it ,and here it . The space is not abscence of 'everything' or'' nothing'' .But is something active.  When Hubble was looking at the space , universe , he observed that the galaxies were moving away from us . This was not as much a surprise as was the observation that the distant galaxies were moving faster than the nearer ones . If the distance was double ,then the speed was double. e.g. 100 million light years away galaxy was moving away at the speed of 5.5 million Miles per hour.while 200 million light years away galaxies were speeding away at 11 million miles per hour.The  logical conclusion was that the universe is expanding. The question is why ? When the matter present in the entire universe was measured it turned out that it was barely 5 % of what would be needed to explain this expansion .( one needs energy or matter to have such an expansion ). The invisible energy is called the 'dark energy' . (the matter which is not seen , but is present and contributes about 24 % of this is called Dark matter . )
          The dark energy has certain qualities . It is dark . means we can't see it , as it does not 'react' with any matter at all.It is distributed in the universe equally. or smoothly.. That means the presence of big or small objects or galaxies does not make a difference in the concentration . It is 'same ' all over.And lastly , even with the universal expansion , it does not get 'diluted '.That means the amount of dark energy continues to be same all the time and  every where.
        So now that we know the properties of the dark energy, does it have any similarity with anything that we know? If we think about the 3 'bodies ' that are described in the vedic religion , we know that there is 'causal ' body, there is 'astral ' bodyand there is 'physical ' body . When I talk about the body , I am talking about everything IN THE UNIVERSE , that has 3 bodies . That means there are 3 plains one is causal , one is astral and one is physical . We all can see and feel the physical universe . But we DO NOT SEE OR FEEL the astral or causal universe . The causal part of the universe is nothing but the 'energy'. If we narrow down the observation to our own human body , we know that inside the physical body , we have astral body, which is identical to the physical body , except that it does not have physical elements . It still has eyes , ears ,etc and also has mind , ego , intellect etc. Inside this astral body,  is CAUSAL body. The causal body is the Cause of the 2 other bodies . It is the source of the energy, for the 2 other bodies . To explain this , let me take an example of the computer. I am writing this blog , The energy needed to run this computer, is coming from the battery , but if the battery runs out , I have to 'recharge ' it . So I plug it in wall outlet for the electricity. But the electricity does not come from wall outlet, it comes from the power company, The power is generated from various sources. The power for the human body or the entire universe comes from the GOD. this the 'hidden ' ,'unssen' energy , we can  'feel' it,which means we have indirect proof of it but can't see it ,It does not react with matter ,( enenthough the causal body is inside the astral body , it is not affected by it), it does not get diluted , and it is equally present in same concentration all over the universe . So to me the dark energy is the CAUSAL energy of the causal universe .

Wednesday, September 5, 2012


    When I was in medical school , I was taught the basics of medicine .We were very young and were taught proper way of taking history and proper way of examining patients . We had to do this in every case even if the diagnosis is obvious. It may be due to lack of all the tests that are available today , like CT scan, PET scan , echo cardiogram or stress tests or many other tests , but we had to be sharp in our history taking and our examination skills. Thank God that I have not left this habit , now that we have every patient getting all these tests .The case that I am going to describe is one that is illustrative of this fact .
     I was called in for a consult in Intensive care Unit . Patient was a 70 years old patient , who was admitted to hospital , with multiple medical problems . She had stroke and was admitted to hospital about 6months ago and needed to be on respirator. As she could not be weaned weaned off the respirator, she needed tracheostomy. She could not eat , so had feeding tube put in . She also had urinary catheter and had a line for intravenous medicines . She was in a nursing home . She had a routine blood test done and it showed renal function worsening. On the day of admission her blood pressure dropped , and so she was sent to hospital ER and then was admitted to Intensive care unit .
     When I saw her it was 6-30 pm . and the admitting doctor had seen her . She was also seen by kidney specialist and infectious disease specialist . They had ordered no. of tests , Intravenous fluid, and no. of antibiotics. Their notes had differential diagnosis and even a mention that  if  she did not improve, she would need dialysis. I saw her , spoke to the nurse and examined her . She was on respirator with history of stroke , so was unable to talk or communicate much.
     The CT scan of chest and abdomen were ordered .I saw her and EXAMINED her . I told the nurse that she needed to change the urinary catheter .She told me that the catheter was working 'fine ' as there was urine coming out .I told her to change it anyway as it was blocked and if it was changed , her kidney function would be most likely be normal by AM. I left ICU .
      By next morning , when I saw her she had put out 3700ml of urine in 12 hrs. and her kidney function was almost normal . Her blood pressure was normal and she was 'fine'.
    When I was in medical school ,we had to do 4 phase examination . ,Inspection , Palpation , percussion and auscultation . It did not matter if patient had obvious hernia or we were doing chest examination .If we did not follow this sequence , and  that to a point of being seen by our teacher , he would hit on our hand . We must first 'inspect' then 'palpate ' then the last two . In the patient , that I mentioned , when I felt her abdomen , I felt huge , distended bladder. (All other doctors had written that there was feeding tube and there was no mention of any other findings and definitely not that of distended bladder. )She did not have 'sepsis' nor did she need any dialysis. All that she needed was simple change of her catheter.. So in the age of all the scans , and other tests that we have , we still need basics of examining patient.

Monday, September 3, 2012


    We as human being expect people to say words  like  'please',  'thank you 'etc. When people do not say these words,and do call them words as many a times they are mere words ,we get upset. But there are times when we do not expect someone to say it and people say it .  we are left asking a question  'for what ' , though we do not say it loudly. Many times  we say these things when we don't mean it . So when I received the greeting card from Martha , I was not only surprised, I did not know how to react .
     I saw Tom in my office for abnormal chest x-ray. He was 81 years old male who was referred to me for abnormal x-ray. He had persistent cough . So he went to his primary care physician and was treated . When the cough did not improve , he had the chest x-ray . It showed a patch of pneumonia . He was treated and the x-ray was repeated . The x-ray did not show  improvement, so he was sent to me .
    He was accompanied by his daughter . He was a retired cop. His wife had passed away 3 years ago and his daughter had moved with him . He had no major medical history. He had high blood pressure.He had lost 15 lbs. He had mild memory loss . He still walked a mile without getting short of breath.. I ordered a CT scan and did pulmonary functions . The CT scan showed a collapsed of left lower lobe ( lower third of the left lung ). I did bronchscopy and it showed the tumour in the lower lobe . It was blocking the opening of the left lower lobe.This had caused the persistent pneumonia. I did the biopsy and it did come back positive for cancer. So I had a talk with him and the daughter.The breathing test was not normal . It did show reduction in the lung capacity . But it was still acceptable for cutting lower third of the left lung to get rid of the cancer . This would be the best treatment . The alternative would be to give him radiation treatment . The surgery is the only treatment which if successful , can cure the cancer . The other treatments can help , reduce the size of the tumour , but in most cases can't cure the cancer . After the discussion they agreed for the surgery .
    He had the surgery . Unfortunately at the time of surgery , the surgeon noted that the tumour was stuck to the central area , and the central lymph nodes  were involved . The fissure that separates the lower lobe from upper was incomplete and the tumour had spread to the upper lobe as well . This was not obvious on the CT scan . He had no choice but to take out entire left lung . The post operative course was not very good . He was on the respirator and we had difficulty weaning of it . Every time we went down to 4 breaths ,he would get short of breath, and we had to sedate him . I did try for next 10 days . I knew that if we could not wean him off the respirator by 2 weeks or so, we will have to do tracheostomy . I did discuss this with the daughter . After that we made him DNR. DO NOT RESUSCITATE .
    On the 13th day , it happened . He suddenly became short of breath, and his blood pressure dropped . I did a chest x-ray and it showed left chest full of air . The stump had ruptured . (When the lung is taken out, the main bronchus is cut and sutured . It heals and we don't have problem . But in this case due to the respirator , which 'gives' breath of air, it causes increase pressure  with the breath . Due to increase stiffness of the remaining lung the stump ruptured , and that caused the drop in oxygen and the blood pressure .) We put in a chest tube to allow the air that was leaking , to get out . But this did not help . Now the air that the respirator was pushing in with each breath , was leaking out.and the right lung was not getting enough air . So we were unable to oxygenate well . I talked to the daughter . I had done what I could . The surgeon had called to take  him to the surgery , as it was only option . After the discussion the, daughter refused the repeat surgery.Her feeling was that 'he had gone through enough '. Her point was well taken as  even if we were successful in closing the air leak, he was going to be on the respirator, and would have needed tracheostomy. I called the surgeon and cancelled the surgery and made him DNR and he died in next couple of hours . The daughter was present in ICU.
    Ten days had gone since Tom had died .  I was in the office. My secretory told me that the daughter had come to talk to me . I called her in . She handed me a card . It was a 'thank you ' card and she had her personal note in it . She wanted to thank me personally .
    For next 5 years , she came personally and gave me the 'thank you ' card !!!!!