Saturday, February 23, 2013


     I was reading an article on the Astrology . It was interesting article . In India lots of people follow the astrology , to guide them about  many things , in day to day life  as well as on special occasions .Each one of us is born on different time and based on the position of stars (planets), natal chart is prepared . Then 'educated 'people can 'predict ' or suggest certain things . So the question in the article was how can we predetermine the time that a new child is born . If one knows the auspicious time then c -section can be done to get the time of birth to  exactly what we want . But then question comes in as to what is the "time of birth " .Is it the time of conception ? or is it when the heart starts beating or is it when thee neural grove is formed .Or may be when the infant takes first breath or may be when the cord is cut , so now the child has independent existence.I do not want to talk about the Astrology , as it is too complicated , I do not know much and it will be impossible to tell anything in such a short blog .But when I was reading the article I felt that we can not determine or know the time of birth or death . It reminded me of one of my previous patients.
     I had a call from this family doctor . She had chronic cough and had tried to treat herself, and had no improvement. So she wanted to see me . I saw her the next day . She was 53 years old female who had never smoked and , had no history of asthma . On examination , she had some crackles on her lung examination and was mildly short of breath. Her oxygen saturation at rest was 92 % , which  is low for nonsmoker lady . I asked her if she had done chest X-ray . She had done it and brought it with her . When I looked at it I was shocked . It showed significant abnormality . It showed fibrosis, at least , that is what I thought .She had not thought much of the X-ray .I ordered the CT scan and did pulmonary function tests . My diagnosis was correct .She had significant fibrosis. I did the bronchoscopy and biopsy. It did confirm the diagnosis . In view of her younger age , (and her being physician ) she wanted to know as to the cause of fibrosis . In reality , the etiology does not matter as in most or all cases , the treatment does not change . I asked a chest surgeon to see her , who did 'open lung biopsy '. It again showed the same thing and we still did not know what exactly was the cause of the scar tissue. I had started her on steroids and she also needed to be on oxygen . She was refered to a center for lung transplant . She was out of her office for 3 weeks or so , but then decided to resume the office work . She needed to be on oxygen when she was seeing patients .
      She was evaluated by transplant team .But she started getting worse . It was not even 3 months since the diagnosis was made and she was more short of breath and needed more oxygen . She continued to get worse and I had to admit her . She was admitted to Intensive care unit . We tried various means to improve the oxygenation , with no improvement. Her son -age 22years and the daughter age 20 had come . I told her the patient that we had no choice but to put her on respirator . She did not want to . She asked me, "what good that would do " ?I had no good answer, other than that it will buy some time . In reality we had no treatment to improve her fibrosis .After a long discussion , she agreed to to be put on respirator , but with only one condition . I will stop the respirator in next 3 days , not one more and under any circumstances .I tried to tell her that if any improvement was going to occur ,it will take longer than 3 days . She would not change her decision . She made her children promise that under no condition she will be left on respirator longer than 3 days .
       I had no hope that she could be weaned off the respirator in 3 days .I was correct . she was completely dependent on the respirator . On the 3 rd day , the family approached me and wanted to take her off the respirator . I told them that I will call the transplant center and see if they could do something . The children did not want to break the promise . I still ended up calling the transplant center , , They did not have much to offer . So I had no choice but to do the withdrawal of the life support . She died in less than 2 minutes ,once I took her off the respirator . So she did "predetermined 'her own death !!!!

Tuesday, February 19, 2013


     I often see patients with bronchial asthma . The good part about treating asthma is that if medicines are taken on regular basis , the patients can live normal life as it is fully reversible . In past I used to tell patients that the asthma is like Hershey's commercial , Now you have it , Now you don't . When the patient has attack of asthma , there is obstruction  to the air flow and patient feels short of breath , but when it is treated , then there is no obstruction and there is no shortness of breath.The story that I am going to tell is one where patient felt both on their own .
      I saw this young female with some cough . She ha two young children and was very active . She was not very short of breath , but was having bad cough . On examination her lungs sounded clear , though diminished air entry was noted . I did the work up with allergy blood test and pulmonary function test . She did have several allergies.Her pulmonary function test showed that she had significant airflow obstruction . Her lung capacity was reduced to 60 %out of 100, but her airflow was only 29 %. I am not sure why she was not short of breath . The only possibility was that she was not exerting hard enough . In any case she had sever asthma .
      I started her on the treatment . Her cough was gone and she was feeling better .I did new breathing test and her lung capacity had gone up to 80% and the airflow was up to 65 %. This was significantly better that the first one , though it was not normal yet . I had started  her on a combination of two drugs , one a long acting bronchodialator , and the other one steroid . The first one opens up the narrowed bronchial tubes , while the other one reduces the inflammation . For whatever reason many patients  don't like the name of steroids.I try to explain to patients that the amount of steroid in the inhaler is very small and the amount that is absorbed is minimal . So there are no systemic side effects of the inhaled steroids . But still some people are reluctant to use it . I was not aware of the fact that this patient had stopped the medicine .I came to know about this latter on .
     She went to a Chinese doctor (?) and he gave her treatment with acupressure . She then stopped the medicines . She had to go out of country for some meeting . While she was there , she started with shortness of breath . She was so bad that she ended up in emergency room . She was treated with medicines , nebuliser treatment and also was given Intravenous STEROIDS . She was better and when she came back , she was on her medicines that I had started , She came for the follow up and told me the story .
     I told her that asthma is like Good marriage , there is no 'divorce ' or separation . So one has to take medicines all the times , in most cases .

Thursday, February 14, 2013


    When I diagnosed patient with asthma , I am often asked , how did I get it at such an old age or what can I do to 'cure' it , and many a times, what can I do to control it . I often tell patients that there is hardly any disease which is 'cured' . Take for example of high blood pressure, or diabetes .One has to take medicine to control high blood pressure or high blood sugars . He will have to take medicines for entire life . In short neither  high blood pressure nor diabetes are cured . Same is case with asthma , as long as one takes medicines, the asthma is well 'controlled ' , not cured . But there are exceptions to the rules . When asthma is allergic in origin , say allergies to cat ,and one avoids cats he may not get attack of asthma . You may be wondering where I am going with this as far as disappearing patient . Let me tell you a story of this patient .
     I saw this patient with asthma or COPD in one of the hospitals . He was  treated with medicines and seemed to have improved . He was on oral medicines , pills and was OK . I decided to to discharge him . He was given prescriptions and discharged home . I did talk to his primary care physician . That evening I got a call from the physician . The patient had gone home and the was feeling good , but as time went by , he started feeling bad and got short of breath .He called the primary care physician . The office was about to be closed .So he called me . I had no idea as to why he was short of breath ,When I had seen him in the morning , he was OK , his lungs were clear and his oxygen saturation was normal . So I could not add anything to his treatment on telephone . I told him to send him to the hospital , and told him that I will admit him . I called ER and told them to call me when the patient comes to ER . The admissions were done in ER , even though  there may be a 'direct admission ' .I got a call from the ER that he was in ER and the ER physician did not see him as it was direct admit under me , and so they called me  and told me about his arrival and told mre the room number that he will be admitted to . I decided to go the room in next 15 -20 mins .
     I went to the room directly , without going to the ER . He was not there . I asked the nurse , who was suppose to take care of him . She got the report , but the patient did not come to the room .I thought that patient may be still in ER , so I went to ER . He was not there . The patient was not seen by ER physician , so he could not tell me anything about the any medical issues that he may have had . In between I get a call from his son . He had heard that after the morning discharge from the hospital , he got worst and so was being admitted to different hospital , and so he wanted to talk to me about his father and wanted to know as to what was happening . I did not know where the patient was , and certainly had no idea as to his new medical problem . I called nursing super wiser . I also  called security guard . We decided to check all the elevators and even all the bathrooms . I was afraid that he may have passed out and no one knew . It would have been a major issue if he had passed out , even worse had died , and no one knew . He was to be found nowhere . I just thought of something . If his son was calling , then who drove him to the hospital ?I called his son . He told me about patent's sister who had picked him up from the hospital. I got her telephone number .and called her . To my surprised she answered . She was the one who had brought the patient to the hospital .Her  house did not have air conditioning .As the time went by with no AC , in Florida heat and humidity, he felt worse , called the PCP and then started to come to the hospital .The car was air conditioned , he felt better , When he came to ER , which was air conditioned , he felt better . When he was assigned the room , he was feeling so good that he decided to go home , instead of being readmitted . So it was the AC that made the difference . Unfortunately he did not tell anyone , which caused the major problem in the hospital . The end was sweet , but I added one more thing to my list of things that cause worsening of asthma , the air conditioning !!!!

Friday, February 8, 2013


      It is often said that sometimes it is blessing in disguise , which means even though  certain situation may appear to be bad , it may be other way round and it may be good . That is why it is called blessing in disguise .But I am describing the exact opposite situation .Which means that the things on surface appear to be good , but in reality they are bad . I remember reading about a study . The people who were ' stood up ' at the time of wedding, were asked if that was the worst day in there life . Think about it . All the preparations are made for the wedding and then the bride or bridegroom does not show up and the wedding is cancelled . Would it be not the worst day in the life ?But the answer surprised the people who were doing the survey . Majority of the people felt that it was the best day in the life or may be the luckiest day in their life . They felt that if they would have gotten married and the had to get divorce , that would have been the worst situation . So getting 'stood up 'saved them the misery of undergoing the divorce.So it was the blessing in disguise .
      I am telling you short story that appears to be good , but was not good . I was seeing this patient who was close to 100 years of age . His wife was 96 or 97 years old . At one time both got admitted to the hospital . He had pneumonia and congestive heart failure . He did OK for a while , but then started getting worse. At that time his wife was admitted too . She had bad bronchitis and so we put both of them in the same room . As his condition continued to get worse , I talked to him and her and he was made DNR. In next 2 days he died . She was discharged in improved condition . She came to see me on follow up . She continued to do well . In next couple of weeks I saw a new patient , who happen to be her sister and who was year older than her . When I came to know that she was sister of my patient I said that you have great geans and are lucky. My patient stated that it was not that great and it was not blessing . She told me that her 'life partner ' was gone , her memory was not the greatest , her hearing was going down , so was her vision . So what good it was that she was 96 or 97 years old . I had no answer .
      I realised this , as I am seeing more and more patients who are in their nineties . One guy was mad as his driving licence was suspended and he had to depend upon others to go places . I visited India and saw a couple , husband is 93 and wife is 88 years old. She can't see, to a point that she can not watch TV or read a book . Her walking was difficult and she fell down few times .The husband has to do every thing in the house. I have known some older people who choke on food or are confined to house as they can't walk . So I really understand that just living longer is not a blessing . In fact what appears to be blessing is actually a curse in disguise .