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 .

Wednesday, May 22, 2013


     The other day I was with some friends and were trying to read one of old "sant literature " or for those who know , sant Tukaram gatha . This saint is from the Maharashtra state in India and has many stories . One of his creation is called Tukaram Gatha , which has several Abhang, which for many is worship of the God . Somehow we went in to discussion on why the scientists do not believe in the GOD, and then I started thinking . Many who call them self scientists do not want to believe in existence of God . So is believing in the GOD is not scientific or being believing in science means one has to atheist? I have heard several arguments and I thought of dealing with some of them .
    1 If GOD is kind and merciful , then how come who have problems , murders, wars car accidents and children getting killed and cancers and son and so for .There are 2 problems with this thinking, one is that when we assign the GOD with all these attributes, like kind and merciful and forgiving etc , we are making Him Human being .So if he has 'good ' qualities  like human beings , then he will also have 'bad ' qualities . Then we can't blame Him . Secondly 90 % of the bad things that happen are 'our' doings . The wars are caused by us and every other bad deeds are done by us and then we blame him .If we 'behave ' then many of the bad things will go away Will it eliminate sorrow from the world , no but it will be better. This is call free will . This leads to the law of karma . We make decision on our own and this freedom to make decision giver us our future , good or bad , in this life or next life or next and next .
    2 How come what we were taught in past about the earth , universe is proved to be wrong by science .The things that were  mentioned in so called religious books are not necessarily spoken by or written by the God . This what happens when we take 'literal' meaning of the things that are written in the scripture . Take for example the story of the Adam and Eve . They were happy till they broke the law /rule of the God .And the rule is not one that is 'don't kill ' or don't lie ' , but the rule was 'o not eat the fruit from an apple tree " At least to a casual reader or observer this looks like a rule that 'parents ' lay down , no explanation, but just "Do as I say ". Would the God make such a rule , which does not make any sense , nor there is any moral value to it , other than HE MADE THE RULE . So  how can we make any sense out of this story? The explanation that I have ( and I liked ), is as follows . The Garden of Eden is the human body and the real garden . The fruit tree that was in the middle of the garden is the sex pleasure or may be the engagement in sense organ indulgence. There is nothing that says that we should not 'enjoy ' the beauty of the great things that the God created . But when we indulge in it we commit 'sin'. When the Adam and Eve started engaging in the act of sex for no other reason than lust , then we are breaking the law set by the God . ( most of us do this on multiple occasions and human beings are the only animals that engage in the sexual activity at any time of life cycle ).If you notice , in the story after 'eating ' the apple, they were ashamed of their body and covered the body.
     There are many other similar explanation in the other areas of the scriptures . May be we can talk about other questionable or confusing statements .

Sunday, May 19, 2013


  When I started the medical school , in the first term of clinical medicine , we started seeing patients . The interaction was what I was looking for  the most . But I was disappointed , when in in the beginning of the  term , We were told to get the demographic data . The name age , date of birth , race occupation and so on . I thought this was useless and wanted to jump to the chief complaints and then the history , examination . I felt that this simple information was useless . We were taught that this may give use the 'clue ' to the diagnosis . But I did not want to be Sherlock Homes and Watson , I wanted to be a Doctor , who had 'great diagnostic skills .'But soon I realized that this information may be useless in many cases ,( as these cases  may be straight forward,) it adds to the diagnostic tools . The case that I am going to tell is one such rare case .
    I had known this 58 years old lady for sometimes . , may be 2 or 3 years . She had mild asthma . This would get really bad when she got respiratory infection . Then she would need lot of medications , even needed steroids . She was also admitted to hospital on few occasions . She was reluctant to use medicines all the times as she was OK when she did not have infection. One day she called me , with the complaints of bronchitis . I started her on antibiotics and course of steroids . She felt little better , but still had lot of cough and low grade fever . So at the end of 7 days I ordered the chest X-ray . To my surprise , it showed the pneumonia . I decided to admit her , as she had not responded to the out patient treatment . She was started on intravenous antibiotics and we did the CT scan . I also consulted an infectious disease specialist . The CT scan showed  large area of consolidation with central air. This was suggestive of abscess- --or pus in the middle . We continued to watch her . She continued to have fever though low grade . Her cough continued and she was also short of breath . After 8 days or so of the treatment , there was no response . She still had 100 f temperature and was still not feeling good . No cultures were positive . I did a bronchoscopy , and it had not provided any answers .I talked to the  infectious disease  doctor and then decided to do the 'open biopsy ' . I discussed with patient and consulted a thoracic surgeon , to do open biopsy .
     The surgeon saw her and did agree to take her to surgery .The lobe of the lung was heavily consolidated and he took out the entire lobe , one third of the lung . After the surgery she did very well. The fever was gone and she was eating better and white cell count came down . The pathology on the lung showed 'pneumonia'. So in a way we were not any closure to the diagnosis  than before . She was better and doing fine , but we still did not know the cause of the pneumonia .
   Then I got the call from the micro. lab. The lung specimen was growing a mold called Trichosporium .This is a mold which can occur in soil and usually does not affect patient with normal immunity . So how did this lady got it ? On further questioning I came to know  that she had no place to stay on regular basis . She used to go to one or other friend and stay with them for short time . She would do household chores in return or help them  if they are sick or need some physical help . Few days ago she was staying with a friend who needed help with her horses . She fed them and massage them and other thing with the horses , whatever is needed on day to day basis . She did not have place to sleep in the house . So she did sleep in the stable on the floor . My feeling is that she inhaled the mold from the soil or the hay and then the mold invaded the lungs . May be because she had bacterial infection , may be because of asthma her 'clearance' was not good or may be she got steroid . This led to the infection .
     SO THE OCCUPATION OR WHAT KIND OF WORK ONE IS INVOLVED IS IMPORTANT IN THE DIAGNOSIS OF THE CONDITION . ( I don't think that knowing the type of work that she did would have made me think of this unusual infection or saved the surgery .)

Saturday, May 18, 2013


  I often wonder if we truly know anything . Our decisions are dependent upon our previous experience and probability. This is true in medicine and in any other situation . Brian Green , a physicist once said that according to the quantum theory , if we try to go through a wall , there is a probability that we will pass through it ,if we try it enough number of times .In legal terms ,possibility and probability are different . When we say possible it means the chance is anywhere from 1 to 100 % , but when we say probable , it means the chance is more than 50 %.We like to be confident in our life , medical or regular . But in reality we are dealing with probability and nothing more .I am going to tell a story today of a patients , in which I knew ( at least I thought I knew ) the probability , but missed  the possibility ,
      It was Wednesday , I had a call from my office. One of the primary care physician had called our office and wanted me to see this patient ASAP. He had a abnormal CT scan , which was showing a mass in the lung and it was most likely a cancer . I had a full schedule next day and next week . There was no way I could see him soon . So I decided to see him in the hospital as if I was seeing him in my office . He came with his sister .
     He came with his sister in the hospital . he was 54 years old male . He was a smoker and had quit smoking 8 or 9 years ago . He started with what looked like acute bronchitis . He had lot of cough , had fever and was wheezing . So he was treated with antibiotic . The fever was gone , but the cough continued . He got second course of the antibiotic .He got little better , but still had some cough . So then the primary care physician did a X-ray . It showed pneumonia . So now he got different antibiotic . The cough continued and he had blood in the sputum . So he had CT scan done . It showed the mass at the center of the left lung .So now he came to me . He also had a small nodule in the other lung .I had asked him mu 'usual ' questions , like high blood pressure , diabetes , TB , heart attack etc . Then when I explained him the possibility of cancer , I told him that we have to answer 3 questions . Is it cancer . Has it spread and lastly what can we do about it .(treatment choices , surgery , chemo or radiation ) From the look of the CT scan it was clear that he was inoperable . At that point he told me that he did not want chemotherapy and was not sure about the radiation . I told him to make educated decision and not an 'emotional ' one . Then he told me that he had HIV, and was on treatment and it was controlled . On further questions , I came to know that he had infectious polyneuropathy and at the time of the treatment the HIV was diagnosed .So his point was that with HIV , giving the chemotherapy may be a problem .I ordered PET scan , Pulmonary function test and a bronchoscopy and biopsy .I called office and then he was scheduled for all the tests .
    I saw the PET scan , which was one next week . It was bad news . The mass in the left lung was positive , but the entire lung had collapsed and there was fluid around the lung . There was activity in the spine , ribs and liver . There were lymph nodes which were positive too and there were other nodules in the right lung . I had to call him personally as it was quite bad I told him that I wanted to do MRI of the brain and the liver to rule out spread of the cancer .He agreed with the plan .But when my office called him to schedule the tests , he wanted to cancel all the tests that were scheduled earlier , the bronch , biopsy . the breathing test and wanted too do nothing .When my office told me about it , I told them to get him in the office next week .
   When he came to my office  he was quite rational l. ;He knew the difficulty that we would get in to with chemotherapy with his underlying HIV .The disease was all over and radiation would not be an option .So after the discussion , we decided to call Hospice . His sister asked me the question ---how long and with my educational guess I told him 6 months to 9 months
    He was in ER in next 10 days , with shortness of the breath . The ER MD talked to him and he was put on a pressurized mask. It did help . I also gave him steroids and breathing treatments. He was seen by me in ICU next afternoon . By then he was off the mask , his X-ray showed complete collapse of the left lung , but he was OK . We had the chat and I called the Hospice to see if he could be put in their unit . The time lapsed between  the ER presentation and my talk was 18 hours
   He was transferred to step down unit . He was doing OK . I got a call from the nurse at 1 am that he was short of breath . He wanted to be on the pressurized mask . I told them to put him on it and transfer him to ICU . The next call that I got was at 3 am . He was on the BIPAP , the mask and morphine for the comfort  and had cardiac arrest. He was DNR So no CPR was done and he died .
     I knew he was going to die soon . When I saw him for the first time I knew that he had inoperable cancer and thought that with his young age and treatment he would live for may be 18 months . Then with his PET scan abnormality , I thought that it would be 3 months . The n when he came to ER I thought that he would last couple of weeks . AND HE DIED IN FEW HOURS .

Wednesday, May 15, 2013


    We often talk about the connection between the body and the mind . Most of us have seen some connection at one or other time . I know sometimes we think it is as if the mind , which seems to be the weak component of the entire body seems to act in such a way that it seems to 'take over ' the course of the events .In our text book on a case of asthma . There was this guy , who had asthma . He was allergic to roses . Once he entered the conference room . There was a centerpiece with lots of roses . He noticed them and as the meeting progressed , he started feeling tight in the chest and finally had a an attack of the asthma . As the paramedics came to take him to ER , he realized that the roses were 'silk roses '.As the mind knew that he was allergic to roses , he had the attack , even though there was no physical allergen or stimulus . But I am  going to describe a case in which the mind -body connection that I have noticed in many cases is of  different  kind .
    Bill was my patient for long time . He was 63 years old when I saw him for the first time . He had dry  cough and further work up showed that he ha pulmonary fibrosis , scar tissues in the lungs . He had mildly reduced lung function .I did the usual work up and put him on some steroids .He did OK and I did reduce the dose and took him off the steroids . He continued to do well and continued to come to me . Over period of next 7 or 8 years he was about the same clinically . His lung capacity did go down , little more than what could be accounted for by the age . But he was OK , did the exercise  and was not short of breath .. His cough was Ok and he felt good . Overall he was stable .
    On one of the visits ,he told me that his wife had diagnosis of ovarian cancer . She had surgery and did OK , but needed  the chemo . She finished the chemo and was OK for about 9 months or so . He continued to see me had no change in his lung function and X-ray.He was not short of breath . The cough was minimal . The when he came to see me he told me the bad news . His wife had the recurrence of the cancer and she needed more chemo therapy . She had rough time with it .Over period of next 6 months she continued to get worse and then died . He seemed to take it well , may be because it happened over period of time or he may be expecting it .
    But in the next follow up he was feeling more short of breath , and when I did the lung functions , they were worse . I did the CT scan and it looked worse . I started him on larger dose of steroids and called him to check the oxygen level on walking . I mede him walk for the 6 minutes and he was quite short of breath and his oxygen level dropped I also ordered oxygen check at night and it was low too . So now I put him on the oxygen with sleep and on exertion .He was doing little better and did try to cut down the steroids . He did OK for may be about 3 or 4 months . But then he was again getting worse . He was more short of breath and his need for oxygen increased . I did increase the steroids , with no change .
    He was admitted to the hospital and ended up getting transferred to ICU . His 2 sons came from out of town , We had discussion with them and talked about the poor prognosis . I wanted to know if he wound like to be put on respirator . He and both the sons wanted to 'give it a try '. As I expected , he got more short of breath and went on respirator . On one of the days his lung collapsed . The oxygenation which was a problem got now worse . He had to be not only sedated m but to control the respiration , we had to 'paralyse ' him .I had a lengthy talk with the sons .We decided to stop all the treatment and did the withdrawal of the life support .
   He died in less than one year of the death of his wife .The guy who was stable for several years with the fibrosis , got worse after the death of the wife . Was is due to him giving up , or was there other cause for his deterioration , that we did not know and could not treat ? I feel that this was body-mind connection .

Saturday, May 11, 2013


    We all know or talk about somebody dying suddenly . Someone that was OK at one minute and is gone the next . This is commonly said to be the sudden death . In medicine we talk about sudden death, in which case person gets fatal arrhythmia , fatal , if untreated . That is the reason why we now a days see defibrillators in all the public places and even in police cars . But I am not talking about these cases . The are part of our life , especially medical . I am talking about different type of patients .These patients leave me speechless or may be the other way , that I tend to talk about them to anyone and everyone that is willing to listen to me .
     I knew this 62 years old lady , who had advanced  COPD , the one that you get when the lungs are destroyed by smoking. She was oxygen dependent and could walk may be 200 feet without getting short of breath. I had talked to her on many occasions about quitting smoking and she knew that she needs to , but had not been successful . She was on all the medicines that I could think , even the steroids .It was Sunday evening , I was to attend a graduation party  at 6 pm or so . I was thinking of going to Gym and then come home and go to the party , I got a call from the ER , My patient , let us call her Mary was in ER with pneumonia . She was short of breath and the doctor in ER had treated her with the oxygen , antibiotics , steroids and the other medicines . She was 'much improved ' but she needed to be admitted to the hospital. I had no choice but to go to the ER as I knew this patient quite well . In past she needed to be in ICU and needed a machine to breath . I went to the ER  .
     I saw her in ER . She was sitting at the edge of the bed . looked quite comfortable . , was on some oxygen and oxygen saturation was good . Her heart rate was normal , but her blood pressure was little low . Her X-ray showed pneumonia and her white cell count was elevated .Her mother was with her . I looked at the other data . spoke to both of them and spoke to the hospital doctor , who was going to admit her . I told him that she looked OK , but with her low blood pressure , not that bad (95/60 ), and her previous history , I would out her in ICU . I did my paper work , dictated my note and saw her again in ICU . She was OK , but I did mention to her and her mother that if she does not improve , or gets worse we may have to put her on respirator , to help her breath . She told me that she would agree for noninvasive way of treating , and did not want to go on any 'machine '. I was OK with that , as I was not expecting any major problem .I left the hospital .
    I was leaving for the party , when I got a call from ICU . She was not doing well and her blood pressure had dropped and her breathing was labored . I told them to start some other medicines and told them to put her on BIPAP , a noninvasive way ventilation . I spoke to the mother and the nurse , they did not want any machine , but agreed for the BIPAP. Over period of next 12 hours I continued to get several calls . Her blood pressure continued to be  a problem . In spite of different medicines that I tried it was barely 100. .She was not breathing well and had issues with carbon dioxide retention. She also had no urine out put .
   I saw her in ICU next morning . She looked horrible . She had no urine , was maxed out on medicines to improve her blood pressure , looked swollen , with all the fluid that we had given and none had gotten out as she had no urine .Her breathing was almost terminal .I spoke to her mother and her brother . I had no hope . I told them that even if I would do 'everything ' that I could do , including all machines , she was not going to survive . They agreed for the" comfort treatment only ".
   She died in next couple of hours . It was little over 16 or 18 hours ,that I was talking to her . She was sitting at the edge of the bed talking to me as she used to do in my office . I never thought or predicted that she would be gone in next few hours, and if some one would have told me that she was going to die , I would have told him or her  that they don't know what they are talking about .This I call SUDDEN DEATH . I don't think I am writing this as I DID NOT PREDICT THE OUTCOME , but I know we can never predict the BIRTH or the DEATH in any case .    

Saturday, May 4, 2013


    I read an article in one of the Indian magazine , called EKATA . It had a commentary on some of the shlokas in Geeta , ,pertaining to the Holy war , following one's own religion and the doing Duty. This was in reference to the shlokas in Geeta , 2-31 and 3-35. I did not agree with the explanation  . So I am writing this blog . Though this is a commentary on Geeta , it still gives my understanding of the concept of religion , duty and to some extent Heaven and the holy war .
   In the chapter 2 , of Geeta, shlokas 31 to 39 deal with the concept of The Righteous Battle . So which battle is considered righteous ?I think everyone of thinks that his cause is 'eight' and the battle that he or she is fighting is 'righteous'. If we take an example of the battle between King Shiwaji and the Mogul king , both sides believed that their cause was just and the God will be on their side . If we talk about the Israeli and Palestinian conflict or Indian and British or any other conflict , each side believes in it's cause and thinks that it is a right cause and so it is Righteous battle . So who is right ?. In Mahabharata, Arjuna and Panda was were fighting to get back the land that they had lost and at least to casual observer , it can not be considered a Holy war . So then why would Lord call the war Righteous ?My explanation is different .
    I think when Lord Krishna is talking about the war (at Kurukshketra with the Kaurawas ), he is not talking about the war between the two sets of cousins . The Lord Krishna tells Arjuna that as  warrior (Kshatriya ) , he must fight as it is religion of the warrior to fight in the battle . In India or in Hindu  religion, there are 4 types of people .or called 4 Verna. These are Brahman ,Kshatriya , Vaishya and shudra . Theses are not based on where one is born , but bases on level of your soul development . or predominance of different Gunas , that is Satwic, Tamasic ,and Rajasic .But the war that the Kshatriya should 'fight' is not with the enemy outside , but within oneself . So the war with bad habits or desires , or the wasanas .The warrior is one who fights and has some victory in the battle . He has some control over his desires or wasanas . But then he feels lost , feels hopeless as he has not achieved the mastery or experienced the Bliss that comes with the victory . So now he is questing the 'wisdom ' of fighting . At this time the Lord reminds the warrior or the Devotee that it is his duty to fight . So the 'HOLY WAR ' is the war between the man and the desires , wasanas and not outside war .
   In the shloka 3-35, the lord talks about the own religion or duty , stating that even though , sometimes own religion appears deficient , and religion of other appears more attractive , one must follow his own religion . Certainly he is not talking about other religions, like Christianity, or Muslim or any other religion . We refer to religion in different ways . Sometimes  we say that the wood floats on the water , as that is it's property or the religion . But the Lord is not talking about the properties . So what is he talking about . What is the 'SWADARMA ' --own religion ?
   We are born of HIM , the lord . We have soul which is reflection of the Lord . But because of the attachment to the body , sense organs and our thinking that we are not the soul , but we are the body . So our Real Religion is to be with one , where we came from . , which is the LORD himself . Trying to achieve this Union with the Lord is not easy . and we may find lot of difficulties with giving up sense organ pleasures .It is not easy to wake up early and do meditation or avoid indulging in to the eating , drinking or sex etc . So the ' SWADHARMA ' is to be one with the LORD . The PARADHARMA or the other religion is to get indulge in the bodily pleasures . So when one does not have great or long lasting success in the Samadhi o, then he starts thinking that the other religion is better . So the Lord is stating that our own religion is always better than other religion
     The lord also states that if you die fighting the war , then you will go to heaven and if you win or are victorious, then you will enjoy the pleasures as if you are in heaven . If this true literary , then there is no difference in the thought process of the suicide /homicide -bomber . In that thought the bomber thinks that either way he is going to enjoy the heavenly pleasures. . So I do not think he ,the Lord is talking about this meaning..
   If one dies fighting , then he will continue to have impressions , left by the practice of meditation and he will be born with advanced ability . So he will be in the Heaven , If one successful in this life , then he will have the greatest pleasure . This one is everlasting  bliss. So it is better than being in the Heaven . So following own religion than other religion is always better .