Saturday, November 30, 2013


   I was reading a book . This one I had heard about sometimes ago and scanned it at one time . But I did not read it till few weeks ago . It is written by an Indian lady , Bhawanagari and the title of the book is The Laws of The Spirit world .This is some what unusual story . The author's two sons died in a automobile accident . Then she came to know from some one that the 2 sons wanted to talk to her . So they did what is called auto writing . The mother would put the pen to the paper and then it would write automatically . Sometimes she would ask questions and the sons or the spirits would answer .The book is interesting and makes one think .It supports some my thinking or or understanding . AT times it does not support my understanding . For example I thought that the way in which we come back is due to our Karmas and our attachments , and the way in which we are born in a particular family is due to our 'debt ' to other people and a chance for us to repay the debt . It also is conducive to have effects of  our Karma come to fruition . So it is very likely that we may have our relationships continue in next life as our attachments and debt is maximum with our close family members .Due to our attachments we really have no 'choice' in rebirth . But according to this book ,spirits have a choice and if they do not want to be reborn , they don't have to . The only reason they come back in physical world is to improve the soul .I can understand the latter part , that in spirit world we can not improve or uplift our soul quickly as we do not have physical body . Think about it . When we help some one on the earth , majority of the time we are helping the physical need . i.e. giving food to hungry , or providing shelter to homeless or helping sick .All these things involve physical or bodily help . It does not do anything to uplift spirit. So if we do not have physical body , how can we help to 'score ' good points to uplift ourselves ?
   The part that I do not agree is the one where it states that if we do not want to be born , we don't have to and that we can 'select ' our new mother ( not the father ).I thought that we 'develop ' 'debt' to each other and develop attachments , this is the 'force ' that brings us back in the same network of people . So in essence we will have same circle of people in each life to which new ones are added and some are deleted . The cycle ends when the sum of all the attachments is zero . and we do not have any desires left at the time of death . The book does not say any of these things .
   It has more moral laws and describes the spirit world which is similar to our world on the earth . It has hall of rest and a hall of learning and it ha s a record keeping place . I do not agree with this type of structure . Any way I think the book is good and it makes one think about our own life and behavior. 

Thursday, November 28, 2013


   Sometimes I feel that may be I am obsessed with the idea that critical thinking is important and I may be mistaken that I am the only one who does it . But then I come across a patient , that tells me that everyone is thinking about their system or specialty, and not thinking about the patient as a whole . In past we talked to the primary care physicians as they were actively involved with the care of the patients. But now a days no primary care physician is admitting patients to the hospital and do not come to see the patients . We now a days have 'new breed ' of physicians called hospitalist , many of whom are family physicians by training and as such are taking care of adult patients . In training , the family practice they are taught to to take  care of all the aspects of all the age groups and sex . So they have  training to deliver babies , take care of children , women and adults . But it is not a specialty to take care of complicated , very sick patients . This is not to say that they are not good doctors. I know of several family doctors that are so good that I would not hesitate to go myself or send my family members . Now a days there is a special training to be a hospitalist .May be things will improve . The story that I am going to tell is one such where physician extender providing care and each one looking at his or her own branch becomes an issue .      I was seeing this 71 years old lady for abnormal chest CT scan . It turned out that the  paitent's abnormal X-ray was due to an abnormal protein in blood that can cause enlarged lymph nodes . I was following the X-ray and I had ordered one .The chest X-ray showed fluid around right lung . This was new finding . I forgot to mention that she also had a leaky valve . So I started her on water pill and decided to do a blood test for congestive heart failure . As expected the test was abnormal and so as per my expectation she should have respond to the treatment . I was to see her in office . She saw the cardiologist . or the physician's assistant . He decided to change my water pill order and started her on two different water pills in much larger doses . I am not sure why did he do it . ( his note that I got did not show any rationale as to why he did it ) . She came to see me and was very weak . Her blood pressure was low and she was feeling worst than better . I told her to stop the new medication and ordered a blood test to check on her electrolytes .The blood test was done , but she felt so bad that she ended up in he ER and was admitted to a different hospital . I do not go to that hospital She was seen by kidney specialist and the same cardiology group and by different lung specialist . Her salt in the blood was very low and the lung specialist drained the fluid from around the lung . With the treatment she got better and was discharged .It was felt that the fluid was due to congestive heart failure , but no one tried to answer as to why she suddenly had congestive heart failure .
   She saw me after the discharge and I got the records and asked her to do follow up chest X-ray and asked her to see the cardiologist , not the PA . I personally called him and told him that we need to asses the leaky valve as may be it was getting worse and she may need the work up and surgery to fix it . She did see the cardiology PA again and nothing was done . She was readmitted . This time she came to the one that I go to . So I saw her . The story and the findings were same . She had low salt , fluid around the lung and very very high test for congestive heart failure . The same group of doctors and the PA saw the patient and I also saw her . The hospital doctor called me and wanted me to take the fluid out . My point was that we knew why she had the fluid and we needed to address as to how we can stop it from coming back . The kidney doctor started her on  pills of salt, 4 grams a day (while she was on salt restricted diet of 2 grams ).and started her on Intravenous saline . When I saw the patient her condition was not better and the blood test on congestive heart failure was higher . (normal 800, she came with 10000, and now it was 18000.) I called the kidney specialist . I told him my concerns , that her congestive heart failure  would get worse with this  treatment . He agreed , So I stopped the Intravenous fluids , cut down on the salt pills and did drain more than 1 liter of the fluid . I had noticed something else in her blood tests . I had talked to the cardiologist , but nothing new was panned by him as " echo cardiogram " was not bad . He did not know why the patient was being readmitted for congestive heart failure. As I was mentioning, I had noticed other blood abnormalities . Before I do the drainage of the fluid, I check to make sure that blood clots normally . Her clotting was not normal . I did do the drainage of the fluid , but also ordered the teat to see if her liver was normal . The usual blood tests for the liver were OK . She had no history of hepatitis or excessive alcohol intake . So there was no reason to suspect the liver disease . But with the abnormal blood tests for the clotting , no obvious cause for the worsening "congestive heart failure " , low sodium for which we did not have obvious reason , liver disease was a good possibility . The test confirmed that she had cirrhosis of the liver . I had started her on the different water pill , in anticipation of the liver disease , and she started getting better . In nest 3 days her sodium became almost normal .
     In next couple of days she was discharged . I gave a script to do blood tests every week to check on sodium .
     So we were thinking about congestive heart failure due to leaky valve and elevated blood test called BNP .Though she did have probably both of these conditions , her fluid , low sodium were due to liver disease . Treating low sodium with salt pills , or Intravenous saline or treating as Congestive Heart Failure , would not have helped. We got the diagnosis only after critical thinking.

Monday, November 25, 2013


     I used to tell nurses that one must do 'critical thinking ' One may ask as to what is difference between regular thinking and critical thinking? This was very important to me or to other doctors . We often get calls at night regarding patients . It is difficult to 'use' some one's eyes to know exactly what is going on . So it is very important to for a nurse to tell me exactly as to what is the problem and what is the possible diagnosis and what should be done . So I used to tell them on various cases and how to think and direct us to the right treatment . This then turned to be what is now called as SBAR. S stands for the 'situation ' B stands for background ( of the patient , like patient has history of congestive heart failure or GI bleed etc ),A stands for assessment (what is the impression of the nurse ) and lastly the R stands for the recommendation .(what is the nurse suggesting as the treatment ) . Now a days we have rapid response team or a nurse , who is a nurse from ICU and can give better assessment and advice . But what I want to do is consider this as a class to medical students.I feel that sometimes even many treating doctors . I am going to tell a story of a patient , that this will be obvious .

     I was called to see this young 50 years old female patient who was admitted with chest pain . She was nonsmoker and ha d not seen physician and was taking any medicines . She was not on birth control pills and was not sedentary . She had  a CT scan and it showed blood clot in the lungs . She was also anemic . She was admitted to hospital and the hospital doctor ordered 'blood thinner ' and gave her blood transfusion . I was also called to see patient . I did not not see any work up for the anemia or as to why this lady would get a blood clot in the lungs . When I asked her as to what was going on I realised that she was having heavy menstrual periods and that is why she had drop in her blood counts .I ordered the work up for both anemia and blood clot. I also called a hematologist , a blood specialist .He saw a patient and changed the blood thinner to a new one that does not need monitoring the blood thinner ( yes the one that is advertised on TV ) I talked to the patient next day , and then called the blood specialist . My concern was that with blood thinner on board, , she would bleed profusely with her next menses . So in my estimate , we needed  Gynecologist to check her out ( as the  pelvic ultrasound and it showed  enlarged uterus and big fibroid)  Using a long acting blood thinner without controlling the menstrual bleeding would not be a good idea .
   So this is critical thinking . Everybody knows that blood clots are treated with blood thinner and anemia needs blood transfusion and some work up . But to change the standard treatment to avoid complications that could occur withe the treatment . THIS IS CRITICAL THINKING .  .

Saturday, November 23, 2013


   We now a days have many specialists . In past , we had family doctor and he took care of everything . If he refereed a patient to a specialist , and the specialist advised a test , the patient would go back to the family MD to make sure that the test that was ordered by the specialist was needed and should be done . That kind of trust is gone , but those family physicians are also gone .Even when the specialist saw the patient , he looked at the entire medical history of the patient . Now a days this has not remain so .It remind me of my residency training days . We had a radiologist who taught us the reading of X-rays . He used to put a chest X-ray on the screen or viewing box , and one of us had to go in front of the class and read it . You are already nervous and not sure about your ability to read a X-ray . I was asked to read one . I saw the X-ray . Did not see anything wrong or abnormal in lungs or heart or any other area .  Then he pointed out to the entire class that the X-ray abnormality . Even though it was a chest X-ray , and there was nothing wrong in the lungs or heart , the X-ray did show the fracture of both humerus . Obviously trying to concentrate on lungs I had missed the 'out side ' bone abnormality, which was as clear as bright Sun . Since then I have tried to see patient in it's entirety, rather than sticking to my speciality .
     The story that I am going to tell is one such story , where I spend more time trying to figure out as to what was happening with the patient , which other consultants had not .
      I saw this 61 years old patient in my office , sent by a cancer doctor . The patient had back pain and was to undergo a back surgery . The routine blood test showed that his white cell count was very high . So he was sent to the blood /cancer doctor . He did CT scans of chest belly , brain and some blood tests . The CT scan of chest showed a nodule and so he was sent to me . Patient had also seen a gastroenterologist for difficulty swallowing . He did the upper and lower endoscopies and told the patient , that nothing was wrong . Did not try to find out as to why he could not swallow . The endoscopy did not show any blockage or tumour , so his job was done . I had noticed some bulge in lower part of the neck . So I mentioned it to patient that we may need to have him see Ear Nose, Throat specialist . He told me he had seen one , who had told him that he 'scraped' his vocal cords and they were OK . He was smoker . He had lost 30 -40 lbs . He was unable to eat , swallow and had some shortness of the breath . His examination was positive for what I originally thought was a mass in the lower right neck . But on further examination , it appeared that the mass was deeper and it was pushing the what could be the right side of the thyroid upward . So the mass that I was seeing was the pushed up thyroid . The lungs were clear . The Ct scan also showed that there was a mass on the right side and it was pushing the thyroid . This mass was about 5 Cm in size and the nodule was 1.5 Cm . The mass was next to the 'hard ware ' that was put in when he had neck surgery . I called several doctors . The first one was the radiologist . He looked at the CT scan and told me the details of the findings , which gave me some idea as to how to proceed and why he was having the swallowing difficulties . Then I called the surgeon who had done the surgery and the gastrienterologist , who had done the endoscopy . He told me that there was no explanation for  his problem . I also called the ENT MD and discussed with him the CT scan finding . I decided to do the PET scan and the bronchoscopy . My thinking was that this smoker may have a small lung cancer , which had spread to the lymph nodes that were so big that they pressed his esophagus or the food pipe and so he could not swallow . I was not sure if it had anything to do with the neck surgery . The PET scan ,which picks up cancer in 85% of the cases . It was positive . The bronchoscopy was OK . So I had radiologist do the biopsy of the neck mass and it showed the cancer .
     I called the radiation oncologist , called the oncologist and the gasroenterologist . He will start radiation , chemotherapy and will need feeding tube to avoid worsening of his swallowing problem in the initial course of the therapy with the radiation therapy .     

Friday, November 22, 2013


    I have  almost always believed that when patient says something , we as physician should believe in it . I think patients know their bodies and can direct us to correct diagnosis , if we pay enough attention .Now there are exceptions to the rule . But in many cases patient will be right .Now there are patients who may have 'drug seeking behavior or they may be 'malingering ' . But these are exceptions to the rule . I have tried to practice , what I believe .So this one story is how I almost did not believe , but still follow my dictum and got the diagnosis .
    I was called for a consult on this 31 years old female who was admitted with cough and had diagnosis of pneumonia ..She was somewhat obese lady who had delivered about 9 or 10 months . She had gastric bypass for obesity and had lost more than 100 lbs , She had no other history . Her main complaint was that she had pain on left side . The CT scan done had shown no clot in the lung and had shown the pneumonia . Her physical examination showed that she was wheezing and could not take deep breath due to pain . She was started on antibiotics . She did not have much fever . I started her on a short course of steroids and continued the antibiotics .Sometimes when patients have pneumonia , they have pleurisy , and so they get pain . Next day when I saw her , she was better . I had also given her some inhaler and treatment for asthma type symptoms and she felt much better . We continued the same treatment for the next 2 days and then as she was better and had no fever and had all 'cultures ' negative switched her to oral medications and discharged  her .
     She was put on antibiotics and short course of steroids . She came back in in less than 2 weeks . She had completed the course of antibiotics and the steroids and then started with the pain , lot of cough and so decided to come to hospital . The chest X-ray was better and there was a repeat CT scan and that showed 'improvement ' in the pneumonia . Her white cell count was normal ( which goes up with infection) , her X-ray and CT scan was better and there was no positive culture . We restarted her on antibiotics and consulted Infection Specialist .He suggested to do a bronchoscopy . I did not think I was going to get any more information , but I did it . There was lot of inflammation in the bronchial tubes . All the cultures , including vial cultures and TB and mold , came OK . I did check on her immune globulin.Sometimes when patients have deficiencies of these special proteins , they can get frequent , unusual infections . But they came back as normal . By now her X-ray was almost normal and there was no wheezing . Her white cell count was normal . I had also done a test for lupus and it was OK too . Her cough continued and she now had pain on both sides of the chest due to coughing Now she started having headache . So I did sinus X-ray . It was normal too .So now I was lost . I had told her that she had pneumonia and may have asthma and the cough will continue for next 2-3 weeks. Once the inflammation was better then the cough will go away . The pain was muscular , due to coughing .So then started saying that she was having problem with the swallowing. She had never told me or any other doctors about this . When I asked her how long she had this problem , she told me 4 or 5 weeks .
     I was not sure what to do . We had planned to discharge her .and all her tests were OK and the finding that were abnormal were now normal . I almost thought that may be she is afraid to go home , may be there are issues at home or may be the new baby care is too much . But I reminded myself . I MUST PAY ATTENTION TO THE PATENT'S COMPLAINTS ! I ordered the swallow study . To my surprise , the study showed that she was ASPIRATING . Which means , when she was drinking the liquids , it was partly going in her lungs . I was shocked . I had no explanation as to why she was doing this . We see this quite commonly in elderly patients or patients with stroke or Parkinson's disease , but at age 31 one I had no thought I thought of myesthenia or multiple sclerosis .In  these conditions one could have swallowing difficulties . I ordered the test for Myesthenia Gravies and ordered the neurologist to see patient . I also asked for the MRI of the brain . The neurologist specifically asked to look for Chiari malformation  and he was right The MRI DID SHOW THE CHIARI 1 MALFORMATION .
     So the puzzle was solved . She had Chiari one malformation , in which it can press on certain nerves , which in turn can cause difficulty with swallowing and this can lead to aspiration . This caused the pneumonia . The recurrent aspiration of liquids (some are acidic ) caused the inflammation and so she continued to have the cough.    . 

Saturday, November 2, 2013


      I used to watch , and I still do watch sometimes the cartoon of Tom and Jerry . Each time one tries to cheat other or try to defeat other . But the things seem to be working much better for Jerry and go against Tom . Sometimes I feel the same way when I am treating patients . I try to find out 'best ' treatment for one condition and when it is successful I pat myself on my back . But then something else pops up . Then I try to do something for that condition and then third thing pops up.
     The story that I am going to tell you is one such story . This has no sad or great ending, but it 're enforces ' my belief in reincarnation .This is a 59 years old male patient that I saw few years ago . He had diagnosis of asthma . He had never smoked and was mildly obese . He had  problem with his aortic valve and surgical repair for the same .For whatever reason he was difficult to control . I tested him for allergies , and they came negative . I tested for Immune globulin , to see if he was lacking the immune proteins , that would continue to have inflammation and would make the asthma worse . The were normal . I tested for for an enzyme , lack of which can cause emphysema . It was OK too . After seeing him for 6 or 9 months I was not sure what else could be done . i had done CT scan and it had shown no major finding in lungs , but had hiatal hernia .He was hospitalized few times and may a times his symptoms started quite suddenly. There was no respiratory infection, which is common cause for asthma attack . It occurred that his asthma was due to the Hiatal Hernia . Due to hiatal hernia there is a weakness of the sphincter between the stomach and esophagus. This was causing the asthma worsening , according to me . I told the patient  my thought process and told him that we should consider fixing the hernia . This meant a surgery .He agreed . The surgery was done and his attacks of asthma improved . I cur down on his asthma medicines and now he was on only inhalers . We had stopped steroids. and other medicines and he was fine . I was very happy .
        All most a year had passed . He had seen me in office couple of times and was not admitted for long time . Then I got a call from the ER . He had chest pain , shortness of the breath and his blood pressure dropped . The wife had called 911 and paramedics took him to ER In the ER they found out that his left lung had collapsed . There were blisters or called blebs and one of them rupture and like a car tire his lung collapsed .The ER physician put in chest tube and it expanded his lung . He wanted to admit him . But the patient and his wife did not want to be admitted to that hospital as I don't go there . He was transferred to the hospital , that I go . He was fine . The chest tube was still leaking  air , telling me that the 'hole ' in the lung had not healed .When I reviewed the chart , I realized that when he collapsed the lung , his blood pressure had dropped . This was dangerous sign . I got the CT scan from the other hospital .It showed that he had number of blebs . So he could get similar episodes as these blebs could rupture. I discussed with the patient and his wife . I wanted to have him a surgery to fix the problem . I called the thoracic surgeon .He agreed and patient underwent surgery .The surgeon did a procedure where a talc is blown in . The talc causes inflammation and it acts as 'glue'.  In next few days he was discharged . I had known but forgotten to mention that he had similar episode 20 years ago on the right side and had surgery for it .
       He was admitted again in 4 months for atrial fibrillation , irregular heart beats and was tested and then put on blood thinner . His asthma was quite stable during all this time .He was doing OK for 6 months . And then I got a call from ER again. He had left sided chest pain and so as per my instructions he came to ER . The CT scan showed that he had collapsed the lung . DUE to the surgery that we did , there was no major collapse , but there was some air collection on medial side . He was OK and he was not short of breath , his Oxygen level was normal .I was not sure what else to do . I called the surgeon and he did a mini surgery and put in 2 chest tubes to suck out the air that had leaked . He did well and went home . I am afraid that he may get another episode. The only good part is that (hopefully) with his surgery , his lung can not collapse to cause major problems .
     But I am amassed that this nonsmoker  had aortic valve replaced , had bad asthma , that we control with hernia surgery , then he gets collapse of the lung , not once , not twice , but 3 times . (if you consider the one that occurred on the right side several years ago .)

Sunday, September 29, 2013


   In last blog I wrote about the new tests that are now available for us to diagnose the diseases and extent of the cancer .But these tests cost money and how we order them and how often we order and what information comes out of them that is useful for the treatment or telling the prognosis of the disease is very important . All of us know how we value the money . If I am spending 'my ; money for myself , I am very careful . If I am spending 'my ' money for someone else (say buying gift for a friend ) then I am careful , but not as much as I would be if I was spending for myself . And lastly when I spend someone else  money for a third party I care least . This last one is the politicians spending our money for some cause that will bring them more votes . I think in medicine I should add one more . When we spend somebody else's money for some other person and make money for our-self , then I am more likely to be more liberal than any other time . The case that I am going to tell is one such case , though I can't say for sure if it was the 3rd or 4th cause for  ordering of the test .
   I saw this 74 years old male with the diagnosis of pneumonia . He had cough , shortness of breath and had fever . He was congested and the X-ray did show pneumonia . He also had a history of laryngeal cancer and it was treated few years ago with radiation . He had follow up with the cancer doctor 2 or 3 months ago and no tests were ordered . He had not seen the throat doctor (ENT MD ) in last 12 months . He also had history of the Parkinson's disease . I did start him treatment and did a CT scan . The scan showed a "mass like density-consolidation right lower lobe of the lung ". The clinical picture was that of infection . But with his history of cancer , smoking in the past , and the CT scan finding , I had to rule out cancer . So I did the bronchoscopy . The bronchoscopy was negative for any tumor and all the biopsy , cultures came back OK . I spoke to him and his wife and told them that I was happy withe the findings. Due to the size of the abnormality seen on the CT scan , 6 cms ,I wanted to do follow up CT scan . If it was pneumonia , then it should get better and if it did not then I would worry about cancer and do a scan called PET  scan .
     He was discharged and I saw him in office for a follow up . I forgot  to mention that I had also a swallow study and he was not normal . The thin liquids were going down to lungs instead of the esophagus . So the cause of the pneumonia was the aspiration .He was doing good . Had no fever. Had minimal cough. I ordered the follow up CT scan in 2 months . He was suppose to see me after the follow up CT scan .
     He was admitted to the hospital with fever of 102 f and I saw him again . He had the follow up CT scan and the consolidation , which was 6 cms , was only 2 cms . "Significant improvement " was the report of the radiologist . I had seen it , but patient ended up in the hospital with fever . I did the new swallow study and it did confirm that he was aspirating . But patient and the wife did not want feeding tube and the speech therapist felt that we could change the consistency of the food and give one more try . He had fever due to aspiration and that caused the pneumonia . He responded to the antibiotics .When I looked in the computer  I noticed that the oncologist had done a PET scan , one week before the CT scan that I had ordered . The  PET scan had shown some uptake in the area of concern and the radiologist felt that the uptake was consistent with the pneumonia .I was not aware of the fact that he had seen the oncologist and they had ordered the PET scan . I wish that the PET scan was not ordered without doing the CT scan . The cancer does not go down in size from 6 cms to 2 cms . So if the oncologist or their nurse practitioner would have checked with the patient on the CT scan that was ordered , and waited for the results of the CT scan , then they would have seen that there was no need for PET scan and we would have not 'wasted ' $3000 for the PET scan .
     I am not sure if the PET scan was ordered by the doctor or their assistant. I am also not sure if the PET was ordered , due to lack of information or it was due to some other reason . But one thing for sure , it was done and  we wasted the money .

Friday, September 27, 2013


    I have been practicing medicine for a long time . Many patients and doctors are not aware of the fact that many tests that we order today or the treatments that we expect on day to day basis , were not there short time ago , like 30 years ago, There was no CT scans or MRI or PET scans , the stents that we expect for coronary artery blockage were not there .The simple Ultrasound examination came for common use in mid seventies , Ct scan in eighty and so on . So I often wonder how we functioned as 'good doctors ' in those (?good old days .)days . Were we smarter, or did we miss lot of stuff . Did we develop keen diagnostic sense , in absence of these super helpful tests .( like blind patients have other senses develop better than ordinary person ).So I am going to tell a story , where this is illustrated in the best way .
    This was a 72 years old male patient , who was admitted to the hospital with irregular heart beats , called atrial fibrillation . He was seen by the emergency MD , then the hospitalist and then by a cardiologist . Pt was worked up and the put on blood thinner and the heart medicines to control the heart rate and then discharged . He had 'routine ' blood tests , the chest X-ray and all was well . He had some arthritis of the hip and some back pain . He came back to the hospital with intractable hiccup . So again was seen by the ER doctor , hospital doctor , and was worked up and had a neurologist evaluate him too . The CT scan of the abdomen was done and a tumor was seen in the liver . The biopsy was ordered and I was called to see patient . The CT scan of the chest  was done  and  it showed a mass in the lung as well . Mind you this 'mass ' was not seen on regular X-ray . So the liver biopsy was done and I did the biopsy of the lung mass . Both showed the cancer and also indicated that it started in the lung . I was quite concerned about the extent of the cancer and so I ordered a bone scan and then MRI of the brain . To my surprise the bone scan was positive and even the MRI also showed 'multiple nodules consistent with metastasis '. I did the MRI of hip and spine and all showed the cancer . This is a guy who was in hospital 2 weeks ago , and was seeing his family doctor on regular basis and was getting regular physical examination and blood test every so often . But none of them were able to detect such a wide spread cancer . WE did not know and we would have NEVER KNOWN  the extent of the spread without these modern day tests . Our clinical sense was useless , until we did the first test of CT scan of the liver .
    So should we be doing these tests in every patient all the time ? I don't think so , but I don't have a perfect answer . There are number of studies looking at low dose CT scan done on regular basis in 'high risk patients '. But what about other cancers and what about the expense and the radiation exposure ? I truly don't know    

Sunday, September 22, 2013


   We as human beings want to be right all the times . May be it is related to our ego , when we are right , it gets satisfaction  or may be we enjoy telling " I told you so ", or may because we think we are smarter than other people. It does not matter , as to why we want to be right , but one thing for sure , we like to be right . It becomes more important if we are making money , like in investing in 'right' stock ' or 'real estate ' . or when people appreciate  our prediction being right .In medicine it nourishes my ego . I have written some incidences ,where i was very happy that my diagnosis was correct (and others had not suspected it ) , But today I am going to tell a story that was different .
    I had known this 80 years old female for last 3 or 4 years . I had seen her for pneumonia and then followed her periodically , though not that often . But I also saw her husband . He was coming to me for last 5 or 6 years .He had atypical TB called MAC . I treated him for a year with 3 different medicines and his CT scan had improved  . He hated the medicines due the side effects . But took them as I had told him . There is always a chance that the infection can come back , so I continued to do the follow up . He was 4 years older than her  and she always came with him and always had questions for me .
    Then it happened . She had some belly pain and her doctor ordered CT scan of the belly . With CT scan of the belly , some lower area of the cheat is also included . The belly was OK and her pain was gone , but the left lung showed some fluid  around it .So she came to me . She had no shortness of the breath, no fever or any other complaint . She was 'fine '. I did the CT scan of the chest and it showed the same fluid around the lung and no other findings, that could tell more as to why she had the fluid . I decided to do the thoracentesis , in which I take out the fluid by putting in a needle and catheter in the chest .She was going on a vacation and was anxious to get this done . So  I did it soon and took out 1000 ml of the fluid .She went out of the country for 2 weeks . The fluid showed the characteristics of inflammatory fluid . There was no cancer or TB . But cancer can not be ruled out 100 %by one test . So when she came for follow up I did a  new X-ray , It showed the fluid . The fluid that I had removed and the X-ray that had improved , was now cloudy and the fluid was back . I was not happy The fluid had come back in less than 3 or 4 weeks . I did not want to do the procedure again .So I suggested that she should see a chest surgeon . She wanted me to do. second tap .I agreed to it . The second tap yielded the same findings . The same levels of proteins , and no cancer or infection . She agreed to do a follow up X-ray . The X-ray was done . And it showed the fluid was there .This time I had taken out 1200 ml of fluid . I had talked to her several times and was telling her to get the 'open ' biopsy . My point was that , we did not know what was causing the fluid and we needed to 'fix' the fluid . In such case the chest surgeon would do the biopsy , and then put in a talcum powder . This causes adhesion and so the fluid stops coming back .We had no choice . I was worried that she had cancer , but was hoping that it would be an inflammation . She had no symptoms , so this could be a nonspecific chronic inflammation .
    She agreed and was seen by the surgeon . The operative note stated ,"clear fluid , no cancerous growth , proteinacious  material seen and biopsy done ."She did have talc put in and then in about 3 days was discharged .
    The biopsy came back as MESOTHELIOMA !! I had thought of cancer as the cause of rapidly accumulating fluid . But mesothelioma s not on my mind . So I was partly right , but not happy .

Thursday, September 19, 2013


  We in medicine or even in the general conversation  often say that it is not a gospel truth. So what do we mean by that ? I have used the phrase in my explanation of test results or medical prognosis with the same phrase . But I have found out one fact , when a test is new it is more likely to be more accurate in diagnosis of a disease or predict prognosis . But as we get more experience , we realized that the test is not as good as we thought it to be .Every time a new test comes out we think it to be a gospel truth , but as we gain more data , the reliability of the test goes down . Take for example the test  called PSA . When we started doing it to diagnose the prostate cancer , we thought that it could diagnose the cancer i overwhelming cases , may be 95 %. Now that we have been doing it for long time we have realized that it is not as good and then we also know that at mild elevation it is less accurate than at very high elevated level .The story that I am going to tell , is one such case of high expectation that did not turn out to be true /
    I saw this 63 years old white female for abnormal X-ray . She was admitted with the diagnosis of the pneumonia . She was a smoker . She had cough for long time , which she had attributed to her smoking . But it persisted and then her primary care physician did a chest X-ray and it was reported to show pneumonia . She was started on antibiotics . The X-ray did not get better and so I was called in I did the CT scan and it was looking more like a mass than like pneumonia . I did the bronchoscopy and biopsy . I did not see any tumor when I did look inside , but I still did the biopsy . It did not show any cancer . She did not tolerate the procedure very well . Her oxygen saturation had dropped and she started wheezing and was quite short of breath . I had to give her medicines and nebuliser treatment .She had bad CO PD . I had discussion  with her I told her that I was quite concerned about cancer , but did not have the diagnosis . She seemed to have very  poor lung capacity and so was not a candidate for the resection of the tumor or do open biopsy .So the other option remaining to get the diagnosis was to consider a needle biopsy . Unfortunately the tumor was not at the edge of the lung and the 'chance ' of collapse of the lung with the biopsy . And she had hard time with the bronchoscopy ,she certainly could not have tolerated the collapse of the lung . So after the discussion we decided to do the follow up as out patient and do the PET scan , which was new at that time . The PET scan is a biological scan . When we do Ct scan , we are looking at the structure of the various organs. But does not tell us as to what is the abnormality . PET scan shows the metabolic activity . Every cell needs glucose for the metabolic activity . So in the PET scan glucose tagged with nuclear material is injected . The uptake of the glucose is more in the cancer cells or infection or inflammation. So depending upon the uptake we can diagnose cancer . So we did the PET scan . It was positive in the lung spot , suggesting that it was 'most likely ' cancer  But it also showed that there was uptake in the left breast . The lung tumor was in the right lung and the breast uptake was on the other side .. So one possibility was that she had breast cancer and it had spread to the lung . The PET scan was suppose to be great tool . in diagnosis of cancer , may be 95 % . In a way I was happy . Please note that some nodes in the chest was also  showing uptake . So if she had lung cancer it was not operable . The prognosis with unresected lung cancer is worse compared to breast cancer , as latter responds to the chemotherapy . I sent her to a surgeon .
     The surgeon called me in next couple of days . SHE DID NOT HAVE BREAST CANCER .  As it turned out to be , she had breast abscess and not a breast cancer . The pick up that we saw on PET scan was not due to cancer , but due to infection . So PET scan was not gospel truth and it fooled us . She did have lung cancer .    

Thursday, September 12, 2013


      Today's medicine has become so specialized that no one wants to take care of the patient in it's entirety. I have noticed this last few years more  than in the past.I often see notes stating that " OK with me for the discharge ". But if one looks at the patient , then it is realised that there are many things that are going on which would be obvious to causal observer , like blood count may not be normal or need for oxygen may be high or something else. But at times the boat is missed .The story that I am going to tell is one such , in which case everybody did their job , but patient did not get the benefit from it .
     It was Saturday, and I had a new consult . The diagnosis was 'pleural  effusion ' patient had fluid collection around the lung . I don't like these types of consults on a weekend . This has nothing to do with the patients , but the difficulties that I have  getting things done on weekends If I decide to do the drainage of the fluid , then I need to get ultrasound tech to help me . On weekends there is only one in the hospital He may be busy doing ultrasound in ER or one for the admitted patients or in OB So I have to arrange it according to their schedule . They are very helpful and bend backward to to help me , but still at times it takes time . In any case I went to see the patient. She was a 47 years old female who was recently discharged from the other hospital with similar problem She had history of a heart valve replaced few years ago and was on blood thinner called coumadine . This is given to prevent a clot forming on the mechanical valve . The blood thinning prevents the clot formation, but also makes patient prone to bleeding .She had also history of hepatitis c . She was admitted to other hospital and was seen by a cardiologist , a gastroenterologist and a lung specialist . She had a large fluid collection and the lung specialist had drained a liter of the fluid 2 days ago She was discharged and was admitted to the hospital in less than 3 days .
      I saw her . She was as such comfortable , not short of breath at rest , but got short of breath on doing any activity .I reviewed the new X-ray and new labs , but also looked at old data Patient was seen by the same cardiologist who had seen her in the other hospital In his note he had written one line ,"cardiology stable " The note was dictated by his nurse practitioner  and there was nothing new in it than what was dictated in the other hospital . There were no diagnostic test or treatment suggestions . The admitting doctor had dictated the not , but in the plan of care , the plan was to get different consults . When I saw the patient she also had gastroenterologist's note She had some fluid in the belly and he had put her on some diuretics When I saw the patient , she also had fluid in the belly . The problem was more complicated than I had anticipated . Draining fluid was the least of them . The question was why ? Why did she have fluid , why did it come back that soon , what was the reason for the fluid in the belly and were the two related ?For me to drain the fluid I had to stop the blood thinner in the pill form  , put her on shots of the blood thinner . But she also had low platelets , which also help clotting . If the fluid came back so quickly , what good it wound do to  drain it again, unless I could treat the 'cause ' of it's formation In between I had requested the report of the CT scan of the belly It did confirm that she had fluid in the belly . She also had liver abnormality( that I had suspected ). So now it was more complicated , but it was becoming more clearer as to what was her diagnosis .
      My feeling was that she had hepatitis c , and now it had caused the liver disease, may be cirrhosis and it caused the fluid in the belly . There may be a hole in the diaphragm  and the fluid in the chest or around the lung was relate to the liver disease . The platelet count was low , due to liver disease and taking out fluid from either the chest or belly , would not help her She was going to need more than just a fluid drainage . She needed treatment for the liver disease . May be procedure to reduce the pressure in the liver , which had caused the fluid or may even a liver transplant . I did not think that there was a constriction of the heart , which might explain some of the symptoms . But it needed to be ruled out .
      I called liver transplant MD , had him look at the CT scans and .other labs and told him the story . He agreed to transfer the patient and then work her up and treat her .  

Thursday, August 22, 2013


     As a lung specialist I often see patients with the complains of shortness of the breath . I have mentioned  many common causes of the shortness of the breath . I saw a patient recently saw a patient which had one more not very common cause .
     I saw this 67 years old female , who was referred to me by a cardiologist . She had shortness of the breath and some difficulty swallowing . She was seen by her primary care physician and had X -ray done . She had history of high blood pressure and was little obese . She also had hypothyroidism , low function thyroid , which I see in may be 30-40 % of the females that I see . She was referred to a cardiologist and he did the work up . She had echocardiogram , and a stress test and both were normal . The cardiac cause for the shortness of the breath was ruled out . So with her other complaints , he decided to referred to me and a gastroenterologist . So I saw her . There was not much in her history . I was sure that her lung would be 'clear ' as if there were some findings , they would have been picked up by these 2 physician . So I was thinking about doing the breathing  tests and some other work up .I had not examined her yet .
    So when I started examining her . I put my hand on her neck . I normally check for the lymph nodes and the thyroid . I was surprised . I felt a  Hugh thyroid , some what firm . It was extending way out of it's normal position . I knew why she was short of breath and may be why she had some difficulty swallowing . I asked her if she knew about her thyroid . She told me that she had a condition called Hashimoto's thyroiditis . This is a condition where patients get inflammation of thyroid and it enlarges . It may be tender . This is a condition , where there are antibodies against the thyroid and then they attack the thyroid and then over period of time , patient gets low functioning thyroid as the thyroid is damaged . So the history of low functioning thyroid was true , but the cause for it was not common . When thyroid has this problem and then it is under functioning , it becomes big . In case of this patient it was HUGH . I told her about her about my diagnosis . I was worried about the enlarged thyroid pressing on the trachea , the wind pipe and causing the shortness of the breath .I ordered the CT scan of the neck and the chest , as I was worried that the enlarged thyroid might be inside the chest . I got the CT scan reports . Both the suspicions were correct . There was big thyroid and it had deviated the trachea and it was so big that it was extending to the chest .
    I called a thyroid surgeon for the surgery .This is one of these unusual causes of the shortness of the breath where there is a mechanical cause out side the lungs and lungs themselves are OK .

Sunday, August 11, 2013


    Many of us know that when we breath the Helium , our voice changes . We have tried this when we were kids , and it was funny to talk in a different voice , may like a duck . The reason is that the helium is less dense than the room air . This has been made use of in treating asthma . When we breath the 'lighter'  gas , then the resistance to the air flow is reduced . In case of asthmatic attack , the bronchial tubes are in spasm . So the  person who is in attack , has shortness of the breath . This feels like breathing through a straw . So when the patient is given the lighter gas , like Helium , the resistance to air flow ( or the gas flow ) is reduced and the shortness of breath is improved . This is a short term solution . As the treatment improves the narrowed airway, then helium is discontinued .But today the story that I am going to tell is very different .
     I had known this patient , we will call him John . He was diagnosed to have advanced COPD . This was due to his  smoking in the past . He was on oxygen all the time . He was diagnosed to have got a lung cancer about 3 years and since he was not a surgical candidate , to re sect the tumor , he got radiation treatment and that seems to have 'cured ' him . Recently he was having some more trouble . He had a respiratory infection , and he continued to feel poorly and more short of breath . We gave him an antibiotic and a another , added several courses of steroid and he was still not his 'usual' . I continued him on the steroid for long time and gave an appointment in 6 weeks or so . So when I saw him in office in less than 2 weeks , I was surprised . I asked him as to why he came so soon . His wife started telling me the reason . But she did not have to describe his problem , as when he started talking , I knew why he was in my office soon . His voice had changed . Now many a timed when patients have a lung cancer and the voice changes , we suspect an involvement of the nerve going to the vocal cord . The nerve that goes to the left vocal cord has a long route , It goes down in the chest , then winds around the left main bronchus and then goes back to the neck and goes to the vocal cord . So during the long course of the nerve , especially in the chest, it can get caught in the cancer process -spread and then the voice changes . But his voice change was not like that , but was more like the one that we have with the helium inhalation . They both had noticed it and so though he was not more short of breath , he decided to come to office . I listened to his lungs and they were clear and there was good air movement.  His oxygen level was OK too . But when I felt in the neck , I could feel the air in the soft tissues of the neck .
     THIS WAS THE CAUSE OF HIS CHANGE OF VOICE . He had ruptured  one of  the air sacks and the air had leaked  in to the neck . Some how it was causing the voice change . I am not sure how the voice change ocures, but I have seen it . So I decided to get him in the hospital . for the observation . Fortunately his lung had not collapsed , and he did not need much intervention. We did the CT scan of the chest and the CT scan of the neck , and it confirmed the diagnosis . He was released in 2 days , and is doing fine .The cancer that he had , had nothing to do with his voice change (thank God ).

Thursday, August 1, 2013


      I was reading the chapter 18 of the Bhagawat  Geeta , and I was stunned by the shloka 66. In this shloka the Lord Krishna states that "let go all other Dharmas, and remember me alone .I(If you do that ), I will free you from all sins .Do not grieve . "
      I am not sure why  all the scriptures are written in symbolic way, as anyone can interpret it as he or she wishes . Does this not sound like any other religion ?The christens believe that Christ is the only God and the savior , the Muslims believe that the Allah is the only God and Christ is 'messenger ' and every other religion believes that their religion is the only  one and their God is the only God to be worshiped , For me there is one more problem . When the Lord states that if you surrender to the God , then all the sins will be forgiven, then what happened to the Law of Karma . Does this not sound like the God father , if you surrender to Him , then he will 'take care ' of every thing . Is He claiming that the Hinduism is the ONE that everyone should follow and not worry about any other religion? From what I know about the Hinduism , it can not be the correct meaning.
      If my understanding of the real religion is correct , than this does not sound correct . Every one must pay the price for the action either in this life or next or next . If you read the life of Lord Krishna , , he had to repay all the debt , before he died .( as he was born as a human being). We also believe that everyone has a choice . We can follow different paths , and all the paths will meet the same goal of reaching Him . We can follow the path of knowledge , or devotion , or action , and we will achieve the same goal .So then how can one God be better or stronger or forgiving etc?\
      Let me try to explain . There are many meanings of Dharma . One of the meaning is the religion . But we also use it in other ways . When I say that the wood floats on the water as it is it's dharma or Gunadharma . The Snake will bite , even if you do not harm or threaten it as 'it is his Gunadharma ' , the character  or  nature . We also talk about the Dharma in other sense . I have a dharma to be a good father  or good husband or good son or good neighbor and a good citizen etc . So I have various duties , which sometimes are referred as Dharma . I have to follow these all different duties , as otherwise I am committing sin . One may say that in the same connection that for me to be a good husband or son or a family man , I must make money , have sex , 'collect' thing etc So these are our different Dharmas . The lord id telling us that ultimately one has to forget all these things , then and than only we can achieve Him . Does this mean we should not do any of the duties ? No . It means that we should do all the duties , but not get attached or involved or may be at one or other time 'give it up ' .We get attached to all these Dharmas ,and believe that it is our true nature . The LORD is telling us to forget it all and think about HIM and only HIM .Then all our sins that may occur when we don't do our duties , will be wiped out. Again he is not advising us to forget our duties . He wants us to consider our only 'real' duty to be one with Him .We mistakenly think that our body is our soul and so we feel that we must full feel it's desires etc . 
     The law of Karma will apply , but if we do things , act without the attachment , then the law of karma does not affect us . So if we continue to do our daily duties , without the attachments , we will not have committed  any sin I can describe this time of behavior in one line --one of the old song of Raj Kapoor , MUD MUD KE NA DEKH . . Enjoy the  good food , good music good beauty , but don't get attached , or turn around and think about it and get attached .

Saturday, July 27, 2013


   I wrote about the drug reaction . Some of the drugs may be commonly used and the reaction may be unusual or the drugs may be unusual . But in every case there is a host and there is an agent . What I mean by that is that every body does not react to the same agent in the same exact way . So how we react to an situation is our individuality .. But then how do we react or more than how do patients react to a diagnosis or a bad news ?I do see patients with lung cancer, and as it happens to be in many cases the cancer may not be operable or resettable. This may be due to the spread of the cancer or it may be due to the age of the patients or other medical conditions , like bad heart or limited lung capacity or other causes that precludes the surgery .Even today , in the year 2013 , the resection or the cancer is the best treatment. Not the chemotherapy nor the radiation therapy . So when I tell patients that the cancer is not resettable , their  reactions are different. I am going to tell you couple of stories that the reaction stunned me and I was at the receiving end of the bad reaction .
      Several years ago I saw a 58 years old patient, who was a smoker . She smoked since age 12 or 13 years. She had persistent cough for more than 6 months and she thought that it was due to the smoking .  She took some over the counter  remedies But as the cough did not get better , but got worse and she noticed some blood .. So she saw the family doctor . He started the antibiotics for possible acute bronchitis and did the X-ray . The X-ray showed a mass . So she was referred to me . I did the work up In those days we did not do the PET scan , but did other scans , The scans suggested that the cancer had spread to liver , couple of ribs and gland called adrenal. I did the bronchoscopy and the biopsy of the mass blocking the right lower lobe bronchus . The biopsy showed that it was a Small cell cancer . The small cell cancer is non  resectable as such as the history tells us that  by the time  we diagnose it , it has already spread . So cutting it out does not prevent the recurrence . In this case we had scans to suggest wide spread .The patient came to my office  after the biopsy . Our office policy is such that we tell patients the results of each test when we get it . So she was aware of the scan reports . I discussed with her the diagnosis of the cancer , the type of cells and told her that the best treatment would be the chemotherapy . On our first visit I had told her about the 3 potions and what is the best treatment . So the news was not good and she knew about it before she came for the follow up . So I was not expecting the response that I got . She was MAD AT ME . She had some sore nose after the bronchoscopy , as we put the scope through nose . I had told her that it should improve . Then she told me that I don't care , as she is complaining about the nose and I did not care . I told her that I was more concerned about the inoperable cancer and how to treat it The she stood up and told me that she will like to see a different doctor , as I was not concerned about the  sore nose .I did not know what to do . I gave her couple of names and offered her to make the appointments .
    I really did not know why she reacted to my honest discussion as I always tell patients about options and the truth , but I am never harsh or heartless .  Then unexpectedly  the answer came to me . The patient worked in a hospital . And on of the coworker told me . She had a daughter , who was mentally challenged and was solely dependent upon the my patient for every thing . So she was upset with future . The future in which she would be gone and the mentally challenged daughter would be there and there would be no one to take care of her .So her anger was directed at the messenger and I happened  to be the bearer of the bad news .

Sunday, July 14, 2013


    I wrote about the allergic reaction to commonly use medicine aspirin , and it almost killed patient . No one was at fault and no one made any mistake or wrong decision . There was no malpractice . But it was just a ' chance  '.Many a times common public can not understand , that this was just a bad luck .I am going to tell about an another case of similar situation .
    I was called at 9-30 pm to see a patient who was short of breath and then when I called them back ,I came to  know that he was being transferred to  ICU as the blood pressure was low . As I got in the car to go to see patient , I had called the admitting doctor . He told me that the patient was admitted to hospital at about 4 am that day and he had seen the patient that morning and he was doing OK . Now with the shortness of breath and low blood pressure he was being transferred to ICU . I called the ICU nurse and got some general idea . She had not assessed the patient as he was in  ICU  for less than 5 or 10 minutes . I gave some general ordered to get the labs going and managed the low blood pressure ..As I was getting in the parking lot of the hospital , I had realized that I was going to need a general surgeon to see patient that night, and that too ASAP . I called the surgeon .
     I went to ICU and evaluated the patient . He was 44 years old white male , who had flu like symptoms for about 2 or 3 days and he had taken over the counter remedies . He had some fever and some cough . When he did not get better , he came to ER . He also was having some belly pain . In the ER he had abnormal liver function and mildly elevated white cell count , suggesting infection .The admitting doctor had ordered the gall bladder studies and they came back negative . He was started on IV fluids and was given broad spectrum antibiotics .He felt little better . But then when new team came in at 7 pm and the nurse did her evaluation , she noticed low normal blood pressure . She called the doctor and got orders for some labs and more IV fluids . The next evaluation , his blood pressure was lower and so it was decided to transfer him to ICU and I was called .
    On examination he was quite tender in right upper quadrant of the belly , where liver and gall bladder are present . He had gotten lot of fluids and as his blood pressure was still low , we started him on medicines -to bring it up . By then the labs came back . He=s white cell count had further gone up and his liver tests were also worse . He was not responding to the blood pressure medicines and I had to add different medicine . He was not putting any urine and it showed in the blood chemistry . He was in kidney failure  too. I had anticipated it and had put a call to a kidney specialist too . The surgeon came in and so did the kidney specialist . We discussed the case , and decided to talk to his waiting family , the wife and a daughter . I felt that there was no choice but to open him up and see as to what was going on in the gall bladder or liver or for that matter in the abdomen . The concern that the surgeon was that , he may not tolerate the anesthesia or the surgery and may die on the table . We discussed the pros and cons of the choices that we had . In between I had decided that with his general condition worsening , we needed to put him on a breathing machine. The surgeon wanted to talk to a vascular surgeon , so he can come in the operating room , once he was little stable and assist him , in case there was a vascular issue that was causing the problem . The wife and the daughter wanted to see him . As I entered the ICU with family and the surgeon , I saw that his blood pressure was dropping and now the heart rate was dropping too . We called in  CODE . We tried to work on him for next 40 0r 50 minutes , but he never came out . He died . I was in ICU for about 2 hours . I had no idea as to what did he have . I explained it to the family and requested an autopsy . She agreed .
      The autopsy was done . I spoke to the pathologist . According to the pathologist patient had acute necrosis of the liver , most likely due to excessive use of Tylenol . There was no gall bladder problem , there was no vascular issues and certainly no major lung or heart problem . I had gotten the history of taking over the counter products , including several Tylenol. So the best conclusion that I could come with and the pathologist agreed , was that he took too many Tylenol and he also use to take 3 to 4 drinks a day . So the combination of the Tylenol and alcohol, both very commonly taken things , killed him  !!!!

Saturday, July 13, 2013


   In medicine we often use drugs and get 'used ' to it so much , that we don't even think twice about writing a script any time .But then comes a patient or we learn about an incidence that make us think twice. The story that I am going to tell today is one such .
    The Aspirin has been in the use for many years . It was invented in 1897. Felix Hoffman of the Bayer company , was credited for the invention . But then there was another chemist , who was Jewish , who claimed to be the one whose work was purged by Nazi, as he was a Jew . In any case it was marked for aches and pain and the fever . It was widely used in the flu epidemic and was thought to have helped . Though some believe that children died because of the use of aspirin . We use it today everyday . In fact it is used for heart attack and there are studies that show that it prevents colon cancer too . Since it is 'over the counter '  drug , we use it without any thought for the safety . If it was prescription drug , then we would have been seeing many TV ads on how it caused deaths or problem and 'how you may be entitle for the compensation'. So this is one such story .
    I was called  to see this patient , who was being admitted to ICU with respiratory failure . I spoke to the ER  doctor . Patient came to ER in respiratory distress , and they could not even intubate the patient . The ER doctor had to do emergency tracheostomy .I went to see the patient . He was a patient with a history of asthma . He had a cold and saw the primary care physician . He was given the prescription for an antibiotic . Patient went home and had not yet filled the prescription for the antibiotic . He felt like he had flue and so took the aspirin . Within very short time he started feeling like he could not breath . The wife called 911 . The paramedics came in less than 5 minutes . They put him on oxygen , gave him some shot and moved him to ER . HE continued to get worse and they could not put a tube down the throat in to main wind pipe ,to help him breath . When he was brought to ER , the ER doctor could not intubate him either ,as his throat was closing . So then he did tracheostomy .
    I examined him and the treated for asthma , though interestingly the asthma was not a problem at all .He really did not sound that bad . We weaned him off the respirator . We had consulted an ENT to fix his tracheostomy , as the one that he had done was done as an emergency procedure . He was off the respirator and the we had ENT do the repair of the tracheostomy . It took about 6 months to get it out . I still see him and his asthma is fairly stable .
    This was a typical case of severe allergy to aspirin . I am not sure if he had taken the aspirin before , but this time it almost killed him . He had a major reaction to  aspirin and he had swelling of his throat to such extent that if it was not for the ER physician or he was not brought to ER soon enough , then he would died
   I saw a case of acetaminophen killing a patient , recently , and I will talk about it next time ..

Saturday, July 6, 2013


    In recent past the technology has added to our understanding of the diseases process . We also can diagnoses the diseases better and treat better . The ultrasound came for the general use in most of the hospitals in mid seventies . Then came the CT scan and then the PET scans. We now can virtually see arteries going to heart --the coronary arteries without doing the cardiac  catheterization.. We can  biopsy of  almost any organ without cutting .And we almost don't need any autopsy to see any organ . New endoscopy techniques have added to our ability to get to the bottom of the diseases.. But I often feel are we really any better ? Are we not doing too many things ,and they do not  really help patients .This came to my mind when I saw couple of patients on follow up in my office .
    I had seen this patient in office for may be 2 or 3 years . He had large nodules in both lungs . He  was seeing other lung specialist . In fact he had seen 2 different lung specialists in last 5 years and they had done endoscopies .No cancer was detected . The CT scans had remained stable with no major change in the nodules . I had followed him for the asthma that he also had . He was doing OK and I had done the follow up on his CT scans. H e had missed his last 2 appointments and the he came to see me after a gap of about 8 or 9 months . He told me that he was fairly stable and his medications were renewed by his family doctors .But then he told me that he was hospitalized . and had many tests . I had not known this and he was admitted to the hospital ,that I don't go . I reviewed the hospital records . I saw his CT scans , not one but 3 and then he had 3 bronchoscopies . He also had CT scan of the Abdomen and number of other tests . The CT scans had not changed , when compared to older scans from 3 years ago . But the first  bronchoscopy and biopsy was non conclusive . So he had  a second one . That showed some abnormality . and so he had a third one with special type of biopsy . Through the scope and ultrasound is done and then a biopsy of lymph node is done . They also used another ultrasound technique to do the biopsy of the mass . Both these techniques are new , may be developed in last 3 years and still not done by 75 % of the endoscopists . One of the biopsies showed that he had a benign disease called sarcoidosis .This was not diagnosed by any of the special techniques, but by simple deep biopsy. The sarcoidosis is a disease , etiology of this is not known . It can affect any organs , but commonly we see the lungs involved . In some patients we see significant scars in the lungs and patients have chronic cough and may be short of breath . Not even one % patients die . I have seen may 2 patients who had progressive disease .
     So now I am wondering as to what did we achieve with 2 CT scans of chest , one of belly , 3 bronchoscopic , one of which was under anesthesia , and cost of thousands dollars .We did not have the diagnosis in the past , but now that we have diagnosis, did it change anything . Did he need any treatment that he was not getting ? If we would have continued to do follow up on his CT scans or even simple X-ray, would it not have sufficed ? We do have new technologies and they do help us in diagnosis . But we need to not loose the sight of risk -benefit ratio. This patient had masses on both sides of lung . They had not changed in at least 5 or 6 years . So the 'chance ' of cancer was very -very low or nonexistent . If indeed he had cancer, he would not have been  a surgically resectable stage . So did we spend all this money for nothing ? You have decide .

Thursday, July 4, 2013


   Recently there was a Supreme court case , where there was a  question, if children should get a adult organs. The decision was made that a child could get the adult lung . The patient got the adult lung and as it appears everything is OK . The question is how much limitation we in medicine we have , when it comes to transplant . I just was told by my office that one of my patients , about 50 years of age died .
     Ed was my patient for last 5 or 6 years . He had scleroderma and had some shortness of breath . He was doing OK for last several years , but recently , may be last year and a half , he was getting worse . As in many cases of scleroderma , he had some scar tissue in the lungs . We did the work up and his overall status was getting worse .We did the heart catheterization  and rest of the work up . In the span of 6 months he really got worse . I decided to refer him for transplant .He had to go out of town for the evaluation . AND they rejected him . He had mildly abnormal kidney function. This was contraindication for the transplant . So we had not much to offer . He continued to get worse and so  put him on hospice and he died . The medication that they use could worsen the kidney function in patients with scleroderma and then patient would need dialysis or renal transplant . So with our given technology , we could not help him .
     But there more to this than what this case illustrates . I often tell my patients that to get a new lung , someone has to loose one and which means someone must die .So we have quite a bit of limitations as to who gets the transplant and who is rejected . I have got patients that have been rejected due to previous cardiac history , or age or other issues . One of my other patient who needs lot of oxygen , 6 to8 l per minutes and he is short of breath on doing anything and he is less than 45 years old .But he was rejected for the transplants .
     There are many more cases that I have as patients that have been rejected for one or another cause . These causes range from the over weight to under weight , heart problems, kidney problem , psychiatric issues , family problems . This reflects more on our limitations and  the bad luck than true rationing , but in any case we in medicine do rationing all the time . This also applies to many other diseases and many other medicines use .

Saturday, June 29, 2013


     We often see and talk about the  phrase ,'missing the boat'. Now a days the real estate prices are going up a little bit ,and when we will realize that we did not buy the real estate when we should have bought , we say we miss the boat . This is also said in case of stocks . But I don't think we ever say ( at least  not often ) that we missed the boat .But if we look at the medical conditions , it could be appropriately said that the patient or even doctor missed the boat . I have seen some unfortunate patients , that do seem to have missed the boat . They quit the smoking , and still get cancer . And when this happens after 5 or 7 years after quitting the smoking , then it certainly 'hurts'. The statistics states that it takes 13 or even 14  years the chance of developing cancer of the lung is same as nonsmoker .PLEASE note that nonsmokers do get lung cancers too. So it is never zero. I had a patient who had not smoked and had some fibrosis , scar tissues in lungs and had history of breast cancer , developed lung cancer . In fact I was shocked and even the patient was too . The yearly X-ray that I order on all my patients , except in those who have pure asthma , showed the mass in her case .This is not unusual . In fact there is a constant debate weather we should be doing X-ray or CT scans in smokers or ex-smoker .The argument is against it is that is  not cost effective as we may have to do too many X-ray to diagnose one cancer and so we may be spending too much to get one success. IN MY MIND IT IS COST EFFECTIVE TO THE ONE THAT I COULD DIAGNOSE THE CANCER IN EARLIER STAGE . In her case the cancer popped up in 11 months . And it was 9cms large . It was so large that she thought that I may be seeing her ruptured breast implant . She was inoperable . We gave her radiation and chemotherapy. But it did not make much difference . Again did we miss the boat ? There is no reason to do X-ray more often than yearly , as otherwise we may be increasing the amount of radiation and also the cost .But the story that I am going to tell is that of a patient , that I feel we missed the boat . I am not sure if it could have been prevented . But we did miss the boat .
     This was a 72 years old patient , who could not speak much English . She spoke creo. I saw her for the complains of cough and some shortness of the breath . She had high blood pressure and diabetes and was obese. She probably had sleep apnea too . This was her third admission . During her last admission , she had echo cardiogram and due to complains of chest pain had heart cauterisation. It had shown the blockage and so she had stent put in It was only 6 weeks and the work up for heart attack was negative . I thought that she had asthma and so I started her on inhaler and she felt better . She was discharged . She was readmitted and was discharged again , when the cardiac work up was negative .I saw her again as she was readmitted for the cough . She did not do follow up with me and had stopped her inhaler . The admitting doctor thought that her cough may be due to one of her blood pressure medicine .So he stopped it . She also had chest pain . But it was on both sides and id not sound like cardiac pain . But the cardiologist was consulted again and he wrote that it was non cardiac pain . Her chest x-ray was OK and her oxygen saturation was 100 %. I restarted her on some inhaler and ordered allergy blood test and also gave her on shot of steroids. The next day she was better . But that night I got a call that she was having shortness of breath and some chest pain . I ordered the treatment for asthma and did the test to make sure that it was not heart attack . Next morning when I saw her she had no problems , her lungs were clear and oxygen was 100 % with no oxygen supplement needed . I actually saw her at 2 pm . I was in dentist's office , when the nurse called me . She was short of breath had chest pain , again on both sides and her oxygen was low .The rapid response nurse was there . The had put her on 100% oxygen . I also told them to do stat X-ray and ordered the blood test for the heart attack . I also gave her a shot of steroid and the breathing treatment . It was 4-30pm and I saw her in next 15 minutes .
    When I saw her it was clear to me that she was in heart failure .They had called the cardiologist and his answer was there is nothing wrong with the heart and call the lung specialist . The X-ray confirmed that diagnosis , the blood test confirmed and the diuretic that I had ordered on telephone had helped her . We had her transferred her to ICU . The next day she was off the oxygen and was fine . I had talked to the cardiologist and he scheduled the heart  catheterization  .The cath showed that her heart function had gone down to 20 % and the stent had blocked .Other than giving her medical treatment , nothing much could be done .

Friday, June 21, 2013


    I talked about the weight loss calories , intake , spending , exercise and more . So now the question comes up , how to make a use of it in day to day life .So let me state some of the ways to make use of this information .
   1. Check the weight and if possible BMI. Weighing daily is useful . It gives us reminder about our weight and BMI and make s try harder , So WEIGHT DAILY and at the same time with same clothes on .
   2.Buy a pedometer . Do an average of your activity for a week and then add to it a REASONABLE number of steps . Make it a point that you will not go to bed unless the goal is achieved . Say you decide that you want to add 5000 more steps a day , in addition to your usual steps . YOU MUST DO IT EVERYDAY AND NO EXCEPTION.
    3 . Walking is good and if you do it more than once a day , it is better , Every time you exercise your metabolic rate goes up and remains higher for longer time than the duration of exercise . So doing it 3 or 4 times is better . If you can run instead of walking , then do it , as with running your metabolic rate goes higher than walking . So one may run for one or two minutes , then walk for 2or 3 minutes , and repeat it for total of 20 minutes .
    4. One must do 3 types of exercises on a daily basis .This is more important for people over 40 , or people who have not done exercise for a longer time ..The stretching , cardio and weight training . The stretching must be done daily . The cardio could be done 3 or 4 times a day to get cardio benefit . But if you want to loose weight, then you must do it as many times a week as possible .
     5 Carry some extra weight, if you are just walking . Do more leg exercise with higher weight than doing arms . Try to build muscles ,as this will help you to burn more calories .
      6. There are many diets and each probably has something to offer . My suggestion is to follow the diet that you can continue for the rest of your life . my suggestions are here , But these are the basic principles .
       a. Eat at least 6 to 8  servings of fruits and vegetables . Keep in freeze some of them , like carrots , cauliflowers  or celery or whatever you like Eat it as many times as you can . You may eat them in significant amount , before you eat main food .
        b. Drink at least 8 glasses of water a day . Drink a glass of water on waking up . You may want to drink a glass before you start .eating. The water and the vegetables with very little calories  , will stretch the stomach muscles and stimulate the satiety center and make you feel full .
       c. Try  to not eat simple carb .or pure sugars. These will  raise the blood sugar , which in turn will stimulate insulin secretion and that will create more fat . So check glycemic index of every food that you consume and either eat the one with low glycemic index or try to see if you can reduce the glycemic index . e.g the bagel  is high glycemic index food , but you can add peanut butter and lower the glycemic index .
       d.NO PROCESS FOOD . Avoid white rice , white bread, wheat pasta or white sugar , white potato . Brown rice , whole grain bread or pasta or sweet potato are better .
        e. I like to avoid animal proteins . Please see a DVD called Forks over knife.
       f . Please remember that 1 gram of carb is 4 calorie, 1 gram of protein is 4 calorie , but 1 gram of fat is 9 calorie . Soft drinks , sodas and alcohol are empty calories .   

Wednesday, June 19, 2013


       I tried to talk about some of the theory of the weight loss . Now we need to see how we can put these principles in practice , in our day to day practice . Let me tell couple of things before that . Let us say it is Thanks Giving and you start eating . .When you are finished you feel that you still can eat some more . But then you realize that you had looked at yourself in the mirror and wanted to start cutting back on the intake . So even though you could eat an extra piece of turkey ,you control the desire . But then 15-20 minutes pass by and now you feel that you have overeaten and your stomach is going to burst . So when you 'finished' eating , you did  not feel that full as much as you are feeling after 20 minutes . So what has happened ? This due to the satiety center . We have a center in the brain , that tells us that we are full . But it takes about 20 to 30 minutes for the satiety center to  get stimulated . So we feel more full after about 20 minutes of finishing eating .This can be used to loose weight . So if we eat slowly , then we will feel full and not overeat ..
      One more point is that this center gets stimulate by stretching of the stomach . This sends a signal to the center and then we are suppose to stop eating . IT does not matter as to what stretches the stomach . So we can make use of these two facts . One we can fill  our stomach with low calorie food , like any vegetables like cabbage , cauliflower , broccoli , or carrots , and it will stretch the stomach muscles and we will feel full. Secondly if we eat slowly and allow the satiety center to get stimulated we can avoid the overeating .
      One more thing to make use in loosing weight . I call it area under the curve . Let me explain . If I start running , my metabolic rate will go up . It happens very quickly . and it will continue to be up as long as you continue to exercise . So say my metabolic rate is 40 ,and when we start exercise, it goes to 60 , ( 60 calories per hour ).So when we stop the exercise , the metabolic rate goes down . But it can not go down to 40 , as soon as we stop . But body continues to burn at higher rate , though slowly reducing too baseline  of 40 . So WE CONTINUE TO BURN AT HIGHER RATE EVEN WHEN WE STOP THE EXERCISE . This is bonus for our calories spending .
      We can make use of these facts in our plan to loos weight and get healthier .

Saturday, June 15, 2013


       I mentioned some of the things which are important in understanding how to loose weight ..The basic principle is that one has to take in less calories than what we spend . This is not as simple as it looks . One of the misunderstanding about the weight loss is about exercise .. When I see patients , common excuse is that I can not run or jog and so I can not spend enough calories .Let me make it very clear that if I run 1 mile or jog 1 mile or walk run mile , in all these cases I will spend the same calories . THE RUNNING DOES NOT SPEND MORE CALORIES provided the distance is same . The calories spent is related to the distance and not how quickly you do it . So if I run a mole , I will spend "X' calories , say in 10 minutes , I if I walk a mile in 20 minutes , then I would have still spent same 'X' calories. So someone is short of breath walking 1 mile , he can do the mile by walking 1/4th mile at a time 4 times a day , Then he would have spent same calories if he would have run one mile in 10 minutes .
      I am sure you  know someone , who eats more than what you do and still does not seem to gain weight .So then question arises , how come he or she does not gain weight and I gain eat , even when I eat 'hardly anything ' ?The answer is kind of mixed . Many a times I see people who claim to eat very little and exercise , and don't loose weight . On more questioning I realize that the 'very little ' that they eat is not that little or the exercise that they do is not that much or does not 'spend' the same calories , that they consume . Let me give an example . The 31 minutes of bicycling will burn same calories that one will get by eating 53 peanuts!!or how about eating 16 French fries will give same calories that you burn by doing 'housework ' for 90 minutes .There are more examples , but you get the point . IT IS SIMPLY NOT FARE !!. There are hidden calories in many things that we eat and don't realize .
    Let us assume that we are very careful and we eat exactly the same calories that this other 'lucky' person eats and we both do same exercise . But he or she does not gain weight and we do . The answer may be in the %body fat. Let me explain . You weigh 180lbs . and your friend weighs 180lbs You have % body fat of 30 % and your friend has % body fat of 20 %. Fat cells do not contribute much to basal metabolic rate . Our body has lot of water , but if we consider that both have same amount of water , than you have 70 % of cells that are burning calories and your friend has 80 % of the cells that are burning calories actively . So your basal metabolic weight is lower than that of your friend . Naturally he does not gain weight ,but you do . Remember that the muscles burn calories not fat . So more muscular one is , more calories he will burn . So TO LOOSE WEIGHT ONE MUST BUILD MORE MUSCLES . So even though the weight is same the ability to burn calories is different .
   So now the question is how do we burn more calories . The answer is simple . ONE HAS TO DO MORE CALORIE BURNING EXERCISE. If you walk , and walk for 30 minutes , but cover only a mile you may have to walk more distance to spend more calories than one who covers a mile in 15 minutes . So if you can not walk faster, then if you carry more weight , you will loose more calories . It takes more work or takes more calories for a 180lbs man to walk 1 mile than  that needed by 150lbs man to walk 1 mile . So if you carry with you more weight , 10lbs or more , you will burn more calories than if you just walk without those extra weights .
   Suppose you go to gym . and do the 'weights' .If you lift 5lbs of weight you will burn 'x' calories and if you lift 10lbs then you will  burn 2 x calories .But there is a limit as to how much can you lift with bicep curls . So the key to burn more calories is to lift more weight , and higher . If you do leg press , then I can bet you that you can lift significantly more weight than toy can do with biceps or deltoids . So even though good looking biceps are more appreciated as they are noticed that the quadriceps , it is more beneficial to do more leg press and burn more calories .

Saturday, June 8, 2013


    I know there are many diets for weight loss and many advice columns . There are commercial institutions that do a descent job of giving people some success. I do not claim to know anything special or have done something personally that has worked , but I do believe that certain principles are important to know and follow .  I will start with some basic understanding and then expand upon it to see if one can follow certain principles and do their own plan . So let us start .
    BMI -- This is used to determine if one is overweight or obese or morbidly obese .It is calculated by knowing the height in meter and weight in kilograms .So it is the weight in kilogram divided by height in centimeters. square  . So we can not quickly calculate it as we are not used to metric system . So it is better to use table that will tell you the BMI .If the BMI is less than 25 , you are OK ,( my BMI is24).if it is 25 to 30 , you are overweight . If the BMI is more than 30 then he or she is obese . I have seen patients who have BMI of 70 !!!.
    Percentage body fat - This can be calculated by various techniques . Again there are weighing scales that will calculate body fat percentage , when you stand on them . There are others that you need to hold in your hands to get body fat . Less than 20 % is good , less than 25 % is acceptable . But this will play role in weight law game . So it is important to know it .
     Glycemic index -- This is important to know as it will help one to 'select ' the proper food to be incorporated in your diet , based on the glycemic index. When we eat food , it is absorbed and the blood sugar goes up . The different foods do not increase the blood sugar  by same amount . This is called the glycemic index . The amount of ups and downs are important in the weight control , so it is important to know the glycemic index . If one eats 100grams of carbohydrate as potato (not 100 grams of potato , but 100 grams of carbohydrates from the potato . ) then the sugar rise would be different than the amount of sugar rise that would have occurred with 100 grams carbohydrates from soft drink --coke . The pure sugar in coke will raise the blood sugar quickly and then the body will secrete the insulin and the sugar will come down. The sugar rise that will occur with the complex carbohydrate like potato is more slow and sustained than sharp rise and fall that occurred with coke which contains simple carbohydrate. When the sugar drops down with insulin , then one will feel hungry and the we eat more . Also the insulin is lipogenic and it will deposit or make more fat .
     The thyroid problem -- I have seen too many people giving excuse of abnormal thyroid function as cause of weight gain or inability to loos weight . Though it is true that low function thyroid will make metabolism slower and so the patient will gain weight, it is not the cause of persistent weight gain or inability to loose weight . The problem is not with the Thyroid GLAND  but is with the other gland , namely the salivary glands .
     Use of steroids - This is a real problem . We tend to use the steroids in treating many conditions , including the asthma or colitis .or arthritis or any other inflammatory conditions . This will  cause weight gain by promoting appetite , retaining salt and water and   changing the distribution of the fat in . the body.
      Quitting smoking - Many patients will gain weight when they quite smoking .This may be partly due to improvement in the sense of smell and this in turn will make one eat more as food tastes better . It also could be due to smokers 'munching ' on food as they have more free time as they are not smoking
       Metabolic rate --Our body needs calories to function . Even when I am sitting doing nothing , my heart , brain , kidney etc are still working and so I am burning calories . This is called Basal Metabolic Rate . It goes up with any activity. So we need to make a use of  this .knowledge in weight loss . .
       I will talk about how to make use of this knowledge in next blog .

Monday, May 27, 2013


    I was talking to some of my friends , that I have known for last 40 years or so . All of them are doctors . While talking to them I realized that none of them 'enjoy ' the practice of the medicine as much as they did several years .This may be due to government rules and regulations , which has increased over period of the time or may be high handedness of the insurance company or may be because of the hospitals gobbling the private practices or may be even due to the uncertainty that is brought in by the new Obama care . Whatever may be the reason , but there is less enjoyment in the practice of medicine . But then when I was thinking about it I realized that in life there is always less pleasure in doing things that gave us pleasure in past . One of the friends was also asking as to how many marriages are happy marriages. I asked him a question as to what is happiness ?He was not happy with the question as he could not answer . I was trying to point out that the pleasure does not come from the object out side .Let me explain . Let us say I enjoy eating pizza . So if I start eating it the first slice of pizza will 'give ' pleasure , when I eat second or third or tenth slice of pizza , the pleasure is not same .So if the pleasure is in eating pizza , then the amount of happiness that I get by eating pizza, should be same with first or tenth slice . Think about it , if pleasure is in having sex , then it should not matter if it is rape or regular encounter between husband and wife . (for that matter is the pleasure same comparing many years ago to now ?) So if the pleasure is outside us , then every one should enjoy or feel happy with any food at any time or having sex with any one or every one should enjoy all kind of music .So the source of happiness is in our mind and not in external source .So now we realize  that this the law of diminishing return . This is also seen in biology . If you stimulate a muscle then  response is less with successive stimulus . This is seen in every place in body , does not matter if we are talking about mind or body or may be even intellect .
      So if we talk about happiness , then we should be talking about our own mind and not he outside source . It reminds me of a story of a king . The king was sick . So several doctors came and tried to treat him . He did not get better . So then a saint came in . He talked to the king and realized that it was not a physical illness but mental illness. So he advised that if the king would wear a shirt worn by a 'happy 'man then he would be cured . So the king sent his soldiers to look for a happy man . They went house by house to look for the happy man . Every house had some problem. Someone had some cancer , blood pressure or diabetes . Some houses had problems with kids or parents or job . NO ONE WAS HAPPY . Finally in desperation they ended up going outside of the town . They found a man who was sitting on a big rock , looking over waters and enjoying the morning sun . The soldiers asked him if he was happy . He answered 'yes'  So  they took him to the king . The king asked him same question , if he was happy . He said yes . So then king asked him to give his shirt to him . The man answered 'he does not have a shirt , why do you need a shirt ?'
      So if you look for the happiness outside of you , then there is law of diminishing return .