Thursday, December 27, 2012


  As I said in last blog , I often see patients who are sick , or remarried or have complex family issues . The story that I am going to tell is not unusual, but was unexpected in this family , at least I thought so .
   I saw this 78 years old patient for allergies and asthma . He was fairly stable , except when he would get bad sinus infection . Then he would get lot of coughing and fever and even shortness of breath as he also had mild asthma . He was OK but then his healthy looking wife was diagnosed to have brain tumour and then continued to get worse . She died in very short time . It was a shock to him and me too. He had a friend and she helped him during his wife's illness .Within short time after his wife died ,he married her .She was same age as him and was married twice before . Her both previous husbands had died . She had no children of own . They were married and then both of them continued to come to me .As he got older , his health continued to deteriorate . He was diagnosed to have Parkinsonson's disease and then congestive heart failure . He was getting more short of breath. He was 84 years old and was not a candidate for any surgery . The new wife had sleep apnea and mild asthma .She was doing quite well . . But he was not well. I had admitted him few times and even when he came for follow up , he was unable to walk much without getting short of breath .
I had talked to them about respirator and CPR and other things , like 'life support '. He had told me that he did not want to be prolonged , but wanted to "give it a try .". This is always very difficult as doctors don't have 'crystle ball to know ' as to what is going to happen in future.
     Then it happened .He was admitted to the hospital with shortness of breath . He was in ICU. I saw him and talked to him and his wife . We decided that we wanted to do everything for now . In next hour or so he was put on respirator .He had pneumonia and congestive heart failure . The new echo cardiogram showed that his heart was quite weak . In next few days he continued to go down , with problem with blood pressure and urine out put and then with oxygenation . I was talking to the wife , who was medical power of attorney . I was not aware of any children . I had not seen any one even when his 1st wife died ,so I was surprised when I got a call from "his son". I talked to his current wife to whom he was married for  atleast 6 years . We were talking of withdrawal of life support as he was not doing well and he did not want to be just left alive if there was no hope . She agreed and then I got the phone call .The son wanted to come before he died . When I talked to the wife , she told me that this son had never called or kept in touch except when he wanted money . Over period of time he had given him thousand of dollars with the promise that he would return and he had never returned any . We postponed the withdrawal for one day and when the son arrived we ended up doing the withdrawal of life support . He died in less than 15 minutes .
      The son was quite mad that the father had left nothing to him in his will . He tried to challenge it and nothing got changed . He called me and wanted to know if his father was in 'sound mind ' I do agree that I have only one side of the story , though I feel that it is quite accurate . I am not sure where was the love . I do believe that the marriage was due to necessity and I do believe that the 'love ' did develop latter on , but I don't think that that the son had any love , other than for his money .

Wednesday, December 26, 2012


   I often see patients who have sometimes real complaints , at times fake complaints and at times about other family members . Sometimes it is funny , sometimes it is sad , but one thing for sure that I often hear only one side of the story . The stories that I am going to tell are such stories .
    I had seen him for many years . He was close to 90 years of age . His wife was 90 years old .He was diagnosed to have lung cancer about 6or 7 years ago . Taking in to account his age and lung capacity , he was not a good candidate for surgery and so was treated with radiation therapy . He did well and was considered 'cured ' of the cancer as there was no evidence of the cancer in follow up scans and since 7 years had passed , he was cured .One day he came with his wife as he did usually. As I entered the examination room , and asked him as to how he was doing , he answered, "my wife does not love me any more ". I asked him 'why do you think that way?' He told me as to what had happened last night .Night before his appointment , he could not fall asleep and at 1or 2 am he started having some vague chest discomfort . So he woke his wife and told her about it . She said ,"go to sleep for now ." . When he could not fall asleep , he woke her again . He told her that he still had the discomfort and he may die . She told him to turn on other side and die . and she will take care of his body in the morning . He did not like it and was complaining that she does not love him anymore ..When I asked her , she told me that when he can't fall asleep , he gos on complaining about things . Again after 60 plus years of marriage , she did love him .But he was telling me that she does not love him any more .

Sunday, December 23, 2012


   I did mention some incidences of physicians who neglected their own health , not sure if it was due to'fear' or shear neglect or feeling of invincibility.In any case their diagnosis gets delayed and outcomes are not all ways favourable . The next story is that of someone I knew.
   This physician was a lung specialist . He was quite overweight or even obese . (now a days if body -mass-index is 25 to 30 , it is called overweight , if it is more than 30 , it is called obese .)He had some shortness of breath and some neck pain . Our job involves misuse of neck . We hold phone by our shoulder and twisting neck , we do many procedures with neck being bent all the time and even writing or working on computer does same thing. This leads to arthritis  of neck . He did CT scan of cervical spine and found out that he had pinched nerves . He had attributed his shortness of breath to being overweight .He had the spine surgery . His pain was better , but the weakness in arms continued to get worse . So now the further work up was done and it showed that he had ALS. In this disorder there is degeneration of spinal column and this leads to weakness and then paralysis , which continues to get worse and one can become quadriplegic . In advanced case they will need respirator and a feeding tube . Once the diagnosis is established , the prognosis was clear and so was the treatment . We as physicians advice tracheostomy to help handle secretions and feeding tube to avoid aspiration and the respirator . HE SAID NO TO EVERYTHING , KNOWING FULLY WELL THAT HE WILL DIE WITHOUT THIS HELP . In this case the diagnosis was not that delayed and even if it was done few months earlier , it would not have changed the outcome , and this brave physician decided not to go through 'torture ' of treatment .(Stephen Hawkins has same thin and he has full support ).

Saturday, December 22, 2012


22.When we surrender oneself to you , then we get all the pleasures .When you protect us , why should I have any fear.
23.When you roar, people in all 3 worlds start shaking in fear.
24.When we chant your name , ghosts will not dare to come close.
25.When we chant your name all diseases and all problems will go away.
26.When one devotes to Hanuman, with mind,action, speech,and concentration,(DHYAN),he will get rid of any difficulty.
27.You consider King Rama who is also Yogi, as supreme and you are all ways ready to do any work for him .
28.Anyone who tells you his desire,he gets what he desires and gets long life.
29.Your fame or bravery is known in all 4 Yugas.(Kruta, Treta ,Dwapar and Kali)and because of of you the entire world is enlightened .
30. You (who is loved by Lord Rama ) protect Yogis and devotees. You destroy the rakshashas.
31.Mother Janaki gave you a boon that you can give 8 sidhis(miraculous powers ) and 9 different types of monitory things .
32.You have magical chemical called Rama and so you live for ever.(there are in Indian scripture there are few people who are thought to live for ever , Hanuman is one of them ).
33.Worship or chanting for you goes to Lord Rama and it eliminates sorrow from many lives.
34.At the end of life, with devotion to you ,one goes to Ayodhya(place where Lord Rama was born ), and being born there is considered to be devotee of Hari (Lord Krishna ).(Rama is reincarnation of Lord Vishnu , so is Lord Krishna )
35.One does not need to worship any other Devata ---god as devotion to Hanuman will give all happiness.
36.When one thinks of Haanuman , all difficulties go away .
37.Controller of the all senses , Lord Hanuman , Victory to you, bless me like any teacher would do .
38.When one repeats these 40 shlokas 100 times.he will be free from all bandages and will achieve great happiness.
39. When one reads this Hanumanchalisa , his desires will be fulfilled .Lord Shankar is witness to this fact .
40.Tulasidas is devotee of Hari and Lord (please) reside in my heart (for ever ), This is my request.

O removal of all difficulties , ,son of Wind Hanuman , tour look is very auspicious .O protector of gods and the earth , please reside in my heart along with Lord Rama, Lakshuman , and (mother )Sita .


    I have been  a physician  for longer time than I have been not a physician . I have noticed several things about physicians . These are only my observations and may not be validated by others. We physicians are the only people who can neglect our family , who can neglect their health , and will be considered 'great ' physician . "HE IS SO GOOD THAT HE DOES NOT CARE IF HE HIMSELF IS SICK OR IT IS A HOLIDAY ETC " are the statements that we here and 'feel ' good . Son it is not a surprise that many a times diagnosis of illness is delayed  and we pay dearly for it . It may also have to do the facts that since we know the medicine , we are 'afraid ' of the diagnosis and , so avoid doing the tests that could make the diagnosis earlier . Let me give some examples .
    I was standing in a doctor's lounge , trying to eat before I had to go to the office . I had may be 5 minutes at most .In past and even today I sometimes eat in the car , while going to office and have stains of ketchup to prove it . But this time I was eating in the room and was with couple of female doctors . I saw a male surgeon walk in the lounge . I had called him for a consult few weeks ago and was told by the covering physician that he had open heart surgery --a coronary bypass . So I was happy to see him back . I told the other 2 female MD . and asked them if they knew that he had a bypass surgery .They had heard that he was 'out ' but did not know exactly as to why . They asked me if had problem with the heart before . I told them I did not know . How come he did not know that he had heart problem , they asked . I said , "two reasons , one he is a doctor and second is that he a male doctor . "When the surgeon came towards me I asked him about his health. As predicted , he never had any testing done . nor had he gone to physician for routine check up . (He is 67 yrs old .)
     The second story is that of a another friend of mine . He was a gastroenterologist . One day he called me asking me if I knew any good surgeon . I was surprised as he was himself a physician. He told me that he had hernia and needed a surgeon that operated in the hospital, that not too many people knew him .I told him couple of names and asked him as to what was the problem . He told me that he had vague belly pain and he thought that it was due to the hernia that he had . He did get an appointment with a surgeon , but did routine blood tests before going to him . To his surprise , his liver tests (blood enzymes )were not normal . So he did ultrasound of liver and then CT scan . HIS LIVER WAS FULL OF CANCER . Further investigation showed that he had cancer of the stomach . He died in less than 6 months after the diagnosis. His belly pain and weight loss was due to cancer and not due to hernia . (and I am sure he might have suspected it , but never thought of working it up like any good doctor would do ---like himself  and paid price for it )
    Just add a personal story , I had a hernia and I knew about it for at least 3 years before I decided to get operated . .(The size was such that at times I had to reduce it in public , making sure no one was watching.)I was scheduled for the surgery on Wednesday before Thanks Giving .I completed my "hospital rounds ". Then at one pm checked myself in , had surgery at 3 pm and went home at 6 pm . I was back to work on Monday . ( If I was allowed to start the work on Saturday by my wife I would have done that too )
    The next story is that of a young cardiologist. He had a dizzy spell and then passed out . The family called 911 and he was taken to a ER . CT scan of brain was done and it showed that he had bleeding in the brain . He had no medical history . He was transferred to other hospital , but he was gone . He was brain dead and family decided to stop everything . He was not even 50. I was talking to a ward secretary ,few days after this incidence . She told me a story which shocked me . One day this cardiologist was making round and this ward secretary asked him she could help him . (by getting charts or labs or calling RN etc . ) He said that if she wanted to help him she could get some ibuprofen as he had headache  . She gave him 400mg of Advil (which is usual dose ). He said , he needed 800mg to 1200mgs to relieve 'his' headache. She did give the dose . In retrospect if a patient came to me with a complaint of headache that needed such a large dose , I would have sent him for STAT CT scan of brain . My suspicion is that he had an aneurysm , that ruptured and he died of the bleed . COULD WE HAVE SAVED HIM IF THE CT SCAN WAS DONE EARLIER ?DID HE NEGLECT HIS OWN HEALTH ?----YOU DECIDE .

Tuesday, December 18, 2012


   12.Lord Rama was pleased and he hugged him and praised him and told him that he (Hanuman ) is like my brother Bharata.
    13,14,15..The king of cobras , the SHESH, will sing your praises with his 1000(thousands of )mouths.(In Hind concept the Shesh Nag or Cobra is the bed of Lord Vishnu , and the lord Rama is reincarnation of Vishnu . when it is said thousand , it means many thousands. )But also Sanak (muni or rishi ) Brahmadev(creator of the universe)many Rhishis, Narad(the Indian scripture Reporter who can travel to earth or heaven )Sharada, ( who is Goddess of knowledge ),King of snakes , Yama (Lord of death )Kuber (treasurer of the heaven ), etc,poet Govind are unable to describe your greatness.
    16.You were instrumental in meeting of Sugriv and lord Rama, in turn (due to Rama's blessing ) Sugriv became the king.
     17 .Taking your advice , Bibhishan(becoming friend of lord Rama) became king of Lanka .
      18 The Sun which is .thousands of mile away ,looked like a sweet fruit to you and you jumped to get it .(this occurred when Hanuman was borned . When he started to go towards the Sun , lord Indra , the king of Gods, got concerned and threw his Vajra )
      19.You jumped the entire ocean. with the ring held in mouth given by lord Rama, to go to Lanka . ,but that is not a surprise.(as the distance between the earth and the Sun is far more than between Lanka and the India and you were blessed by the Lord Rama .)
      20.The difficult task becomes easier and winnable , with your blessings .
      21.You are the security guard for the lord Rama (so without your permission we can't get to Lord Rama .)You do not leave Him without His order .

Monday, December 17, 2012


   1.Jay to Lord  Hanuman ,who is knowledgeable and is like ocean of all the good qualities.Jay to that greatest of the monkeyes . He is enlightening all 3 lokas (the earth, the heaven and ,PATAL, which is bellow the earth .)
   2.He is the messenger of the Lord Rama and is home of the strength(that means all the strength starts from Him ).He is the son of Anjani and is known as or famous as son of Lord wind (PAWANSUT ).
   3. He is great warrior and his body is strong as Wajra.(famous weapon )Let him control our bad thoughts(and intellect) and promote good intellect.
   4.He has golden color.(which is shining ),so he looks great,with earring in the ears and has curly hair.( Hanuman was told how to 'identify lord Rama . He was told that one who identifies his golden undershorts , is the lord Rama . )
   5.He is holding aWajra like Gada and he is holding a flag in other hand .On his shoulder is the sacred thread called Janoyi. (in ancient time when the child became of age to start study or become student, there is a ceremony performed , in which he starts wearing this Janoyi ).
   6.He is reincarnation of the Lord Shiva(with his blessing , he is no other than Rudra ) and he is son of Monkey named Kesari . He is such great warrior that entire world bowes in front of him .
   7.He is very intelligent ,he is very smart, and is very eager to anything for the lord Rama.
   8.He is very keen on listening to the life story of lord Rama as Rama. Sita and Lakshuman are seated in his mind .
   9.He took very small size when was meeting Sita , and became big to set fire to the Lanka .
   10.He was huge , when he destroyed many Rakshashas and was very helpful in the work of  lord Rama.(in destroying Rakshsashas ).
  11. He brought medicine called sanjiwani and so Lakshman survived . This made Lord Rama very happy and he hugged Hanuman .(when during the war with Rawan ,Lakshman became unconscious. So to save his life they needed medicine to be brought from a far away mountain called Mandradri. Hanuman lifted entire mountain and brought it as try to find the medicine would have wasted the time . )

Sunday, December 16, 2012


     The Hanumanchalisa is 40 shlokas , which were written by Tulasidas.It is a song related praise of Lord Hanuman . It has 40 shlokas , which is why it is called 'chalisa '.The Lord Hanuman is the so called 'monkey face Indian god. His mother was Anjani, and father was  Kesari . He is also the son of  "wind God ". So in an indirect way he is 'half brother ' of second of the Padawas , BHIM .In Indian mythology there is symbolism . One  reason we have Gods with different faces, is that we believe that there is a reflection of The GOD in every one of us. This has to do the fact that there is nothing that was not made by the God . So there is nothing outside Him . So if he made us,  we must have element of Him . This hold true for everything in this world . The second reason is symbolism . When the Hanuman was borned he was very notorious or naughty . He was bothering everyone with his mischievous . His mother was worried . She was told by one rhishi , that when Hanuman will meet Lord Rama , he will turn around , will become devotee of Lord Rama and will calm down . In my view Hanuman represents our mind , which very active and moves from one object to other , just like the monkey . So the Hanuman represents our mind . When we concentrate our mind on the God , then the it quietens down . So when we 'meet ' Lord Rama then we stop being notorious , and become the devotee .
   The 40 shlokas start with a 'doha', may be called a mini prayer. It says that the feet of Lord are like lotus and the dust from them is like pollens from the lotus. Let these particles of the dust , clean the ' mirror ' of my mind .(that is why I pray ) . I will describe the success of the lord Rama , who can give all 4 fruits of action .(FAL CHARI--4 fruits are DHARMA , ARTH, KAMA , MOKSHYA--RELIGION, MONEY, FAMILY LIFE AND ETERNITY OR RELEASE FROM THE CYCLE OF LIFE AND DEATH ) I am aware of the fact that my (physical ) body is stupid, I do not have intellect.So knowing this I want to think of lord Hanuman .I pray to him that he would give me the strength, intellect , and the knowledge.
    I will start with the meaning of 40 shlokas in next blog .

Friday, December 14, 2012


    We as physicians are often blamed for being late , and many a time rightly so . It is amazing that we can do things that well without in trouble. Sometimes I go to see patient and he is in CT scan . Then he or she may be in endoscopy or surgery and then we have to come back sometimes in few hours. One time I was consulted for a patient who after open heart surgery to replace a valve and he had 'air embolism ' . He was still on respirator . As such I was not going to do much except to make sure that the oxygenation was adequate . But when I went to see patient, he was in a hyperbaric chamber . The treatment for the air embolism was to give oxygen under high pressure . This would help to absorb the air that went in the blood .This was to be given for 12 hours or so .There was no way that I could wait in the hospital till he came out of hyperbaric chamber. So sometimes it is impossible to be always in time .
    But this is a different story , where I was not that late .
    It was Wednesday . I have morning hours . I  see patients between  8 am to 12 noon . But it never ends at 12 noon I end up with double bookings and then by the time I am done it is 1 pm or so . So I like to move . As much as patients hate the doctors being late , I hate patients being late . If patient shows up late then I have a difficult time adjusting to the schedule . On that day I was doing fine . I was in time , there was not much double booking and so I was only 15-20 mins late . Then it happened . The lights went off . The power was gone and so the computers were gone and the phones were dead . How dependent we are on these modern things . We did have our printed schedule ,so we knew the list of the patients . One of my long time patient was my next patient . She was never 'no show ' . I was surprised when she did not show up . But I was too busy , to think about it . We had opened blinds ,and were using cell phones. She showed up about one hour late . We still did not have the power . She was put in the room . My secretary told me that she had an accident and she was shaken . I went in the room . She looked OK . I asked her what had happened . She told me the story . About a block from my office she lost the control of her car and hit a electricity pole . Then the police came in , the report was made and so she was late . Fortunately  she  was not hurt.The pole that she hit was the cause of we loosing the power !

Friday, December 7, 2012


   I often say that one does not have 'choice ' in determining when one is born , and when one dies . One does not have choice in determining as to who are his parents . In a way this accurate and to some extent it is good . But one can argue that sometimes one can determine the time of death , as in case of suicide . But I am talking about normal , natural death . But in medicine I have seen that sometimes patients can decide as to when they want to die .
    I had known this patient, Mary for long time . I treated her husband too . He was much older that her and one day he died in the hospital . He was also my office patient . So he had an appointment with me in the office that was made long before he was admitted to the hospital.. Unfortunately my office did not cancel it , in the computer and ended up calling his home to 'confirm ' the appointment . She was quite mad , as we did not 'know 'that he had died . I continued to treat her for her asthma.
    One day she was admitted to the hospital . I was called in to manage her asthma . She was not feeling good and was having very vague symptoms . She low grade fever , that many times could not be confirmed , as she would 'feel' warm and hot , but the temperature was normal .She also would have sweating and had some issues with the weight loss , which was not major . The family doctor and the infection disease specialist had done the work up and did not find a reason and felt that it was due to menopause . According to her she had menopause many years ago and these symptoms had started only recently . I was not too sure as to the cause of her complaints and her lungs were 'fine ' . I was little concerned about the possibility of a occult "lymphoma " , a lymph node cancer . (the cancer can spread to the lymph nodes , but when the lymph node it self starts the cancer it is called lymphoma . ). I did do the CT scan of the abdomen and there was some abnormality . I decided to call a surgeon and he opened her up and found out a tumour called CARCINOID . This tumour is one such tumour that can be called either 'a benign tumour that sometimes spreads or metastasises ' or it can be called a cancerous tumour that grows very slowly and rarely metastasises . 'It also sometimes can secrete chemicals that cause the symptoms that Mary was having . Mind you this happened about 22 or 25 years ago . At that time specific type of  scanning for this type of tumour was not there.
    She was cured ! (she did get similar symptoms latter on and we could not find source of any recurrence , but she did respond to the treatment of carcinoid  with drugs .) This turned around her feelings about me as a doctor and I was the only doctor that she trusted . Our relationship continued to grow as I saw her for several years . She was admitted to hospital with asthma and continued to have some fever . The primary care doctor treated her for 2 days and then called . I told her that most likely her fever was due to urinary tract infection and not lung infection . So I changed her antibiotic and did urine culture and it did come back positive for the bacteria that was not sensitive to the antibiotic that she was getting before I saw her . (though it was good antibiotic for bronchitis . )
   Next time she was admitted she had lower back pain and the doctor suspected urinary infection . The urine culture came OK and then I was called in , not because of lung problem , but it was a consult at her request . I found out that she had fracture vertebra and it was due to osteoporosis and had her do procedure , where they put a glue or cement . Her was 80 % gone . Again I was the hero .
   I continued to see her in the office . She was almost ninety . And she was admitted to the hospital . Had bad bronchitis, pneumonia . She also had bad heart for last 5 years and had irregular heart beats . Interestingly she had avoided being in the hospital in spite all these problems for last 3 years . I started he treating her , so did the cardiologist . Nothing had changed much in cardiology part , but I was quite limited in treating her for the lungs as her heart rate was continued to be a problem . She was not bad , but did not get better as was expected .On 3rd or 4th day I went to see her in her room . The nurse was with me . She was on medicine for her heart rate , but it was still up . She was awake , alert , fully oriented , was not in distress , but was quite congested . She was unable to cough up . I examined her and was talking to the nurse about change in her treatment , she stopped  me . She took my hand in her hand and said , "Doctor , how long we have known , each other . ( it was not a question but a statement .)There is no one that I trust more than you and I will really miss you . but it is time to depart ." I understood what she meant . She continued . " Please let me die peacefully . I just want to be comfortable ."
     I called her family , made her DNR , stopped her all labs, x-ray and work up . I did not stop her medicine. She died in less than 24 hrs !!!!!
  I do believe that the out of all our attachments in this world , (eating , sex , music drug addictions , ) attachment to the body or to 'live ' is most powerful and we can rarely get away from it .