Thursday, December 25, 2014


    Often in life we make decisions based on our previous experience .This is called Intelligence. So if we deduct based on our previous experience , then that is actually anything special, but when we act based on his experience , we think we are intelligent. If I have been burned with fire (which looks red ) , next time when we see something similar to the fire that we had seen ,then we deduct that it is fire and do not touch it.But it may be one of those 'fake' fire , that is seen in fake fire places. So then we are wrong . But when this happens in our regular life it may not be that bad. But when that happens in medical field , it may not be that benign.But unfortunately there is no 100% in life or for that matter in medicines . That is the reason same blood pressure medicine works differently in two different patients . But this is not that bad . When we talk about Life and Death , then it it very very important that we are correct as much as close to 100% as possible. Recently I had a patient that this holds so true.
     I have been seeing this patient who is relatively young. He is may be mid 40es. He has some developmental problems and some other diseases, but the reason that he is seeing my is for the lung problems. He had pulmonary fibrosis .I saw him may be 4 years ago or so. He is also obese and had dry cough. I did the CT scan and the pulmonary function tests and check on oxygen . His condition was bad . He needed to be put on oxygen and I tried steroids.I also treated his cough. He was put on oxygen. I tried to refer him to transplant centers, but due to multiple reasons , he was not accepted.So I continued to treat.He also had elevated pressure in the lung circuit, called pulmonary hypertension. So I started treating him for that.He has been doing well till earlier part of the year.But then he started having problem. He was admitted to the hospital and had pneumonia. His oxygen need went up and it was high enough that can not be provided at the home . I spoke to his mother, who is his POA, and told her that she needs to consider DNR status. But no decision was made and he got better. I discharged him on 6L oxygen .He would drop oxygen level to a critical level in less than 10 seconds if oxygen was stopped.But he was better than in the hospital , when he needed 40 and 50 L oxygen. But he was better at home . In next month or so he was readmitted . This time he had to be in the ICU. I had hard time getting oxygen up. He needed to be on pressurised mask and when it was taken off he would bottom down on his oxygen.I was successful in cutting down on his pressurised mask to high flow oxygen . But over period of next 10 days I was not in position to cut it down much from 40 L.I spoke to him and his family . I told them that not much could be done In my (educated) mind , his scar tissues were getting worse and not much could be done .No decision on DR was made. I ended up getting him to a special facility as this high rate of oxygen flow can not be provided at home or rehab. centers or any other place  other than hospital like facility. He looked OK but I had seen this type of patients in the past , who look OK , but don't get better and either end up on respirator or die. So I was not very hopeful.
    But in a 4weeks or so I saw him in my office, I was surprised . He was on 8L oxygen and he was running low oxygen ,when he walked , but then he was OK with 6 L.I decided to start him one new drug. He came with his mother and I talked to her about poor prognosis,but no decision was made. He was readmitted and not as bad as before . He needed 10 L oxygen . I have continued to talk to them on the prognosis and he was discharged this time on 6L oxygen . So in my experience he should not have done well 6 months ago , but he did and he is OK for now . So sometimes there are exception to the rules and our 'intellegence' may not be the most correct thing.
    The mother knew about the poor prognosis and still had /has the hope . I was basing my decision on my experience and felt desperate, when no decisions were made . I think the jury is still out.   

Wednesday, December 17, 2014


    I did write about the cost of health care in the past.This is the time of the year to renew the health insurance policy.The medicare replacement policy or other insurance policies need to be renewed.So I had to go to my insurance agent. I had called him about a month ago and since the 'new' policies don't open up till this month, I had to wait till I could get the new policies to review. Year before last I had a group insurance . The cost since then went up by 45%.Since last year to this year it went up by 33%.So in short it has doubled since 2012. I knew that the cost of health care insurance was not going to go down.(In spite of the claims otherwise.)But I was more interested in trying to find out the reason for this cost increase.And there are several reasons .In my view it is important to try to find the reasons as otherwise it is not going to be possible to reduce the cost . (I am not hopeful that this will ever happen).
     1) I was talking to someone who has coverage for 4 people and the cost of their family coverage is less than 25% of my cost.(which is foe 2)Their insurance plan is not as good as mine , but they got 40 %discount. So if the question is ,who is paying for the difference? This the first reason for the cost increase.
     2)There were several new drugs released in last 4 or 5 weeks. The 2 of them are for treatment of scar tissues in the lungs. This is called IPF,Idiopathic Pulmonary Fibrosis.The cost of these new drugs is , are you ready, $85000 per year.I can think of many patients that would need it and be benefited by these drugs.So if some one is paying the insurance premium of $1000 per month, which is $12000 per year, how would the insurance company going to come with the difference of $73000? The answer is the second explanation for the cost increase.
   3)The medicine has become the game of cat and mouse . Every time a new test is avaibale that pays more than the older one (whose reimbursement was reduced now), doctors tend to do the new tests more often than older tests .This is the 3rd cause .
   4) The cost for hospital employed doctors get more reimbursement for the same test , same service.The cost is at times 25% to 50 % more . Every one is aware of it , but no one is doing anything about it . More and more physicians are joining hospitals and so the cost is going up even though the services provided are same .
     I know there are several factors that contributes to the health care cost , the sad part is NO ONE IS DOING ANYTHING ABOUT IT.!!

Saturday, December 13, 2014


     I have been quite interested in the Quantum theory. This may have to do with the fact that in the Quantum theory ,every thing is interrelated . Two particles, miles apart ,will act as if they are connected by some force or information. So if one particles course is altered, then the other particle will also change the behavior .This is similar to the thought that we are all some way related and nothing happens by 'accidant'.There have been books written on the relationships of this behavior and the Hindu or TAO philosophy. One that comes to my mind was written several years ago, written by physicist, CAPRA. (TAO OF PHYSICS).  The other unexplainable behaviour of the particles is they could be at two places at the same time!This sounds impossible to the logical thinking mind . But it has been proved that this really happens.But we never knew that this can happen at cellular level. So it is one thing to have nonliving particles to behave as if they are related and exchange information, millions of miles apart and for a particle to be at two palaces at one time, but it is never thought or confirmed that this can occur at the cellular level. So when I came across this I was surprised at first, but then I felt that it was natural. If my behaviour is related and can affect behaviour of some one who is not in direct contact with me
    So let me tell you the quantum behavior at cellular level . This was observed and inferred in the plant who do Photosynthesis with the help of chlorophyll  and seen in bacteria called E.Coli. To have energy produced at a very efficient level, the transfer of information must occur at shortest  and best pathway. So the the "trial run" of the transfer occurs at various pathways at the same time.And then the plant find out shortest pathway.So it does not occur one pathway trial at a time , but all of them are checked at the same time and that is how the energy production is at 95%. (It is like I am driving on I4 and 17-92 state Hwy, at the SAME TIME to find out which one has less crowded and then take one that I can go faster.)
    This was also seen in bacteria .called E.coli. If the bacteria are put in a lactose medium, which they are not able to use for nutrition, then mutation occurs .But it was noted that the rate of mutation occurs at much higher rate than can be explained on the basis of random mutation. So the bacteria select position of hydrogen atom, in both position that based on the medium that the bacteria are put in , the hydrogen settles down so the mutation occurs.I know this is too complicated , but in short the bacteria behave,in two different way at the same time.
     I know this is of not interesting to many and not the most interesting to many ,I thought of writing as it intrigued me .

Sunday, December 7, 2014


       I used to think that in this world nothing could surprise me any more.Every day something new pops up.I have seen the drug free urine being sold for 'helping' those who use drugs and don't want to get caught on random  drug testing.I have heard about a company 'providing' disabled person in a wheel chair,  to get ahead in the 'lines of the Florida theme parks.'And many other that I would have not thought off few years ago. I do know that artificial insemination is done in castles all the times get better quality cattle. But I was talking to one my patients and what he told me was surprising.
      I was seeing this patient for the follow up of sleep apnea. Most of these patients have no major issues and are doing fine . Only some have issues with the mask or the amount of pressure of the CPAP etc.But for the purpose of the continuation of the care I see them every 6 to 8 months. So this was a stable patient with sleep apnea. His wife is also my patient and her problems are different. So I was chatting with them.I used to have a dog , which was German Sheppard. I knew that he had gotten a Rottweiler. So when I asked him about it , the story got interesting. He bought this one with all the 'papers'.So he had decided to breed it. But what I did not know surprised me . When he bought the puppy, he signed a contracts . According to the contract that was written by a retired judge, who does this as business, he has to breed this puppy with sperms of a show dog. This has to be done artificially and the expense has to be paid by this patient of mine. When the new little is born, then the previous owner will get one pup.(which she will sell with the same contract to a new owner).So the the business of the money making by breeding continues. He had paid $3000 for the puppy and spent another $3000 for the artificial insemination. But he told me that he can sell each puppy for significant amount of money , so he can make money himself !!
      I often talk about the Law of Karma and the Soul in Astral world. So I am not sure what kind of KARMA is this and what kind of souls will be attracted to the souls of puppy.
     Well I will hopefully find out the answer in future.

Saturday, December 6, 2014


    I deal with life and death and the attachment to our own body.I am no exception to the rule . I often Say that the 'worst' or may the highest attachment that we all have is the attachment to the body. Smoking, alcohol drugs or sex are strong addictions or the attachments, but nothing compared to the attachment to the body.In fact when we talk about the 'sin' that we all did or ;inherited' from Adam,is the attachment to the body and 'thinking that we are the body and not the soul.Even though we know that the body is 'mortal', we still treat it as if it lives for ever and it continues to be there after death.
    When my father died,I wanted to cremate a picture or 'our family' with his body.I was adamant about it and would not back out. But then there were other people who felt otherwise. ;They' felt that it was not 'good' to burn the picture of live people. So ultimately I backed off. So I did not get the family picture creamed with the body.So I was thinking about the 'body' as the soul and the other who opposed it thought it in the same way. The picture is not me and nor is the body.The reason I am writing this today is due to a patient that I saw.
    He is a 71 years old male with history of bronchial asthma and sleep apnea.He came for the follow up. I have to write in my notes that the patient is using the CPAP and it is helping him.This is required to get the supplies for the CPAP. So I asked him if he is using it. His answer was ,Yes , daily. Then we were talking to him , he told me that he could not use it in the beginning, and when he would turn on side,it would bother her wife. So I asked as to how she is taking it now.He told me that she passed away few months away. But before she died ,they started sleeping in such a way that her feet were at the head side so the CPAP would not hit her head ,but the feet. That sounded good , and I thought telling other couples about this trick.Then he told me that she had died and he wanted himself to be buried next to "HER" IN THE SAME WAY. Her feet where his head would be .I can understand the emotions , just like I had , but thinking about this after few months , May be be it is LOVE , may be it is misunderstanding or may be it is ATTACHMENT to the body.

Friday, November 14, 2014


     The diagnosis of Asbestosis has a special meaning. It has medical and economical importance. As a lung specialist I often see patients whoa have suspected asbestosis or who have abnormal chest X-ray. In past we used asbestos at many different places and we had no understanding of the risk of the asbestosis.So when one inhales the asbestosis fibre , it goes in to the lungs.The asbestos fiber is indestructible.So the body can not destroy it and then it stays in the lungs. It can penetrate to the covering of the lungs called the pleura. So it continues to stay and 'irritate' the lung tissue and the pleura.This leads to Lung Cancer and the cancer of the pleura , called Mesothelioma. (Chronic irritation can lead to cancer. If there is a sharp tooth that causes repeated biting of the inside of the lip , it will cause the cancer. In the Kashmir (INDIA), there is a custom of using a 'hor burner' called Kangri around the belly.This is covered by a blanket. The repeated heating in that area of the belly causes skin cancer. The abdominal wall skin cancer is otherwise not seen as it does not get exposed to sunlight.)So this constant  irritation from the asbestosis fifer causes the cancer.
     Now that there is a economical compensation for getting exposed to asbestos , there is more incentive to 'find' asbestosis. The good part is that many patients who are esposed to the asbestos ,do not get the asbestosis and those who do get the asbestosis, do not get the cancer or bad scarring in the lungs.The bad or good part(as one looks at it) is that any time there is a diagnosis of asbestosis , there is compensation or at lest a claim for one . Thank God , we are not using asbestosis any more and at least have eliminated at least one deadly agent.But the story that I am going to tell is not of asbestosis.
      I saw this patient who was referred to me for the evaluation of abnormal chest X-ray. The patient was from formal USSR. He did not speak any or much English. So he was with his friend who did speak English.Even though we tend to think that we do not cut short, when we see patients who can not speak English, we do .It is not intentional , but I think we do cut down on what we think is non essential history.We don't miss medical history , but as to family history of occupational history, we cut it short. He was 2pack per day smoker and had some COPD.So when I saw the CT scan of the chest ,I was concerned. He had a pleural based mass .The mass was at the edge of the lung ,but the size was about 4 Cm. So In this smoker I was worried about the cancer. there was no old X-ray .I decided to do the PET scan and the bronchoscopy. The bronchoscopy was negative and did not help.The PET scan which is suppose to pick up 85% or more the cancers, was OK.So now the "chance ' of the cancer was low. So when he came for the follow up.I asked him on any motor vehicle accident to see if the density that I was seeing may have been related to trauma. The answer was no. He had done some odd jobs but there was no history of asbestos exposure. So I decided to do follow up CT scan . The CT scan was showing no change ,which was good news as it reduced the chance of cancer. So when he came for the follow up we started talking about the USSR.Then he told me that he was a POW or political prisoner and was incarcerated for more than 2 years. When I asked him about the prison conditions and the treatment of the prisoners, he told me that the guards kicked him routinely AND THAT TOO IN THE CHEST. It was so bad that he had bruised ribs. So this was the cause of his abnormal CT scan. The kicking or for that matter any trauma,can cause some inside bleeding and that can heal with a scar tissue. If the amount of bleeding is severe then one will have blood collection in the chest cavity and that may need to be drained. But small to moderate amount will leave the scar.So I had the answer in the third visit and it was not asbestosis.
    I did continue to do follow up and follow up CT scan , as he was a smoker , but over period of 3 years , nothing changed .There are other causes of such abnormality, seen on CT scan , but more about them at some other time.

Sunday, November 9, 2014


   I was reading a book and the topic  of the Death Penalty and the physician's role came in . As a physician we have been asked to treat patients and cure them and not 'kill' them . Long time ago I had seen a sitcom in which the husband is a physician who had to see a patient in ER with a gun shot wound . He had to operate and give him blood and save his life , so the State Attorney ,which happens to be his wife could prosecute him for a murder and ask for the death penalty.This is not only a good topic for the TV drama but also a great Ethical question. Should physicians assist in the death penalty?AMA does not feel that physicians should have any role in the execution of the convicted killers. In fact they came out with a policy statement -guideline in 1980.But today 38 states the death penalty is carried out by lethal injection and in 2006 a District Court recommended a physician's presence and they recommended (or ordered?) anesthesiologist to be the one .So I was thinking about it .What is our true role?Let me explain.
     In a day to day work we as physicians discuss the diagnosis and the treatment of various diseases and also the prognosis. This may be as simple as bronchitis or high blood pressure or asthma, or it may be a serious condition like acute heart attack and cardiogenic shock or respiratory failure.Even when a patient is admitted to the hospital with simple element, like hernia repair or pain in the belly, by law we have to ask for what is called 'Advanced Directives'.This the statement which tells the treating physician as to patients desire to do aggressive treatment in case of the need for it.We also deal with this issue while patient is in hospital,especially in ICU with critical illness,especially if he or she is snot doing well.Then we talk about DNR,DO NOT RESUSCITATE order.
     In some cases when the patient in spite of being on respirator and on no of life sustaining medicines ,is not doing well and when the physician feels that the prognosis is likely to be poor, then we do recommend 'stopping'the treatment , the so called Withdrawal of Life Support.
    So let me analyse.In some cases we discuss and decide (with help of patient) to with hold the life saving treatment and in other cases we also stop the life sustaining treatment . IN NO CASE WE DO ANY THING ACTIVELY TO HASTEN DEATH.But the out come is same.Let me give an example. If I see someone drowning ,and I do not help him,(presuming that I can swim and save him), and in other case I actively hold someones head under water.The out come is same .Are the acts same?When we decide that we are not going to help some one by putting them on respirator and let them die and in other case we stop the respirator and let them die, are we not doing the same ?( I know that we always make sure that the patient is comfortable and not struggling and use plenty of narcotics to  achieve the goal).
       Now that I have confused every one that is reading this blog , tell you one thing. I don't think many of us would ever be in position to assist in execution of death penalty , though many of us believe in it.I also feel fortunate to help patients make educated on the prognosis and limitations of the treatment , so that they can make educated descion and not emotional. I am sure I will revisit this topic sometimes in future.

Thursday, October 30, 2014


    When I used to drive on interstate in this town , I used to see a billboard, making an announcement that "we do miracles".I could never understand as to why a hospital would like to claim to do miracles as many of the religious leaders can't claim the same.Then I was reading a book by a surgeon named Atul Gawande.He has written 4 books and written several articles related to the medicine and related topics. In one of his book he states that the medical knowledge is vast and incomplete.I could not agree more .In one of the books where he talks about medical malpractice,he described a case of melanoma , a deadly skin cancer.The case describes a patient who had melanoma and it was taken out and there was a difference of opinion between two pathologists and the doctor claimed that he asked patient to consider 'wider and more resection'. But patient refused and then developed wide spread metastasis. So the doctor got sewed.This reminded me of one of my patients.We doctors claim to know everything and the hospitals claim to do miracles. So it is not of surprise that patients expect that we will 'know everything ' and can' predict 'every outcome.
      I was called by this doctor about a patient that he wanted to me to see. The patient was having a cough and so the doctor treated her . She was a nonsmoker and had no other medical history.When she did not respond, he did chest X-ray. Then he did a CT scan .The scan showed a small mass in the center of the chest.He wanted me to see patient ASAP. I checked with my office and they gave her an appointment within 5 days of the call. I was thinking that she probably has a benign thing called THYMOMA. This gland called Thymus is present in early infancy.And then it disappears in adulthood. Some people continue to have it or in some patients it enlarges or even becomes cancerous.In a patient who had not smoked this was the most likely possibility. So when she came to my office ,I came to know that several years ago she had uterine cancer. She was followed by the oncologist.When I saw the CT scan , I also saw a small mass on the center of left hill um.I was concerned about it .I was worried about may be a lymph node cancer called Lymphoma.I decided to do the PET scan that picks up cancer in almost 90 %. She was also scheduled for bronchoscopy.The PET scan was done and then before she was to have the bronchoscopy,she got very short of breath and her oxygen was very low . So she was admitted to the hospital Another CT scan of the chest was done .It showed that there was also a congestion in the left lower lung.The lung was still inflated. The other areas of the abnormality were same . When I saw the PET scan it showed increased activity in the center of the chest , left middle part and also on right side and also in the lymph node in the neck.I did the bronchoscopy and I saw the tumour in the left main bronchial, completely blocking it. This was not expected.I could not do biopsy as I felt it was too risky.The appearance was was that of a tumor called carcinoid. These tumor bleed on doing the biopsy. So then a surgeon saw her and did the biopsy under anesthesia . I also had radiologist do biopsy of the lymph node in the neck. So we got multiple biopsies and enough tissue to analyse as to the type pf the cancer. We continued to have diagnosis of "adenocarcinoma",a type of a cancer which can arise in several different organs. The best that they can tell us is that it could be uterine in origin or lung as the origin of the cancer. So we still did not know . (FORGET about doing a miracle,we can't even tell where did the cancer start.)
      That is why the medical knowledge is vast and incomplete.  

Sunday, October 19, 2014


    It is that time of the year, when we get to 'choose; the health insurance .I can change my health insurance in November (private insurance ) and the new medicare enrollment will also start now.I was talking to some patients and some doctors and some nurses.I was surprised to realize how little many of us 'know' about the Medicare.So I thought that I will write as to how many insurance companies work.
    So let me start by saying that the medicare expense as part of Federal budget was 14% in 2013
The money comes from general revenue ,(41%),pay role taxes(38%),and the beneficiary contribution(13%).The government collects the money and then pays out as the 'claims' are submitted by the 'providers',such as hospitals,doctors labs and outpatient clinic and radiology centers.There is off course management cost , and that comes out of the expense.Now since the medicare is supported by the federal government, there is no limit to the expense.So each year the medicare expense continues to go up.This is where the HMO come in picture. The companies like Humana, Welcare, or Freedom and many more like to have the piece of the pie.So they go to the federal government and tell them that they will 'manage ' the health cost of the recipients. So Let us take number, though not accurate, it is for understanding purpose only. The federal government is spending $1100 per month per medicare patient. So these companies will accept payment of $1000 per month,per patient.Now the federal government is off the hook for the expense. If the expense is less than $1000  then Humanas or wellcare etc will make profit. If the expense is more than $1000, then they loose the money.But wait a minute, .The HMO have expenses too. They need to pay agents who sign up patients and the expense for advertisement, and the claim managements and the office and the other expenses. They also need to have some profit so they can stay in business.So they have to 'manage' all this in the amount less than the medicare was spending when it was done by the government.So how do they do it?
       They go to different providers and offer them contracts that are less than what they would have gotten if it came directly from the government. So they go to primary care physician and 'offer' him 'fix' amount of money per patient per month. Say $25 per month and then they assign say 100 patients . So the primary care physician gets $2500 1st of every month, irrespective of how many patients and how often he sees.So if a patient sees him 3 times a year , he gets same money as if he sees the patient 10 times a year. But then there a catch . The year end 'bonus; will depends upon how much is actual expense on 'his assigned  patients if the total expense is more than what insurance company wants , then the bonus less or gone .So this is" the carrot and stick approach."So now you can see that the primary care physician has motive to spend less money,which means less tests, less consultants ,less costly medicines and less hospitalizations.In a way this is good as it eliminates unnecessary tests and referrals. But it is not good as the referrals or expensive tests  are not ordered.Every provider gets pay cuts, may it be Labs or Radiology clinics or consultants.This very easy to understand . If the insurance company is going to get less money than what the federal government would have spent, and they have spend money too get patients to sign with them and they have to 'manage' providers and on top of this they have to show profit to their stock holders. So The actual money spent on 'health care; is anywhere from 70% to 85%.(under new law this has changed.)At one time one HMO was spending only 67 cents out of a dollar that they collected.THEY CALL IT MEDICAL LOSS RATIO!!.Most of the primary care physicians do this kind of contracts.But there  an another way of doing these contracts and that can be more daring and more lucrative.
       Some doctors feel that they can manage better than the HMO insurance company.So they now approach the HMO and get money from them and now HMO are off the hook if the expense is more than what they collect. Now the doctors manage it and so you can imagine. The money that was spent by government is more than the HMO spending and this 'risk contracts' doctors spend even less . So now everybody gets deeper cuts and less  tests and referrals are done.This is a reality. The patients don't understand as to why the consultants won't see patients without getting referral or would do a tests as if they do , they won't get paid.
     So if any one signs with the HMO ,does not matter which one ,the money spent on health is less.This does not mean that one will get inferior care . It definitely means that there would be more restrictions on your care. Which consultant you go, which radiology clinic you go , which lab does your blood tests, who gives oxygen or other equipments  etc are all predetermined .I am sure there are more questions than answers after reading, but get the answers before you sign. 

Friday, October 17, 2014


    The medical field is changing. I know that the doctors are not same and the patients are not the same . Patients go to a particular doctor not because they want to go and like him , but their insurance tells them to go to a doctors who are on their insurance plans. There are exception to the rule.I have many patients who would 'change' the plan if they can not come to me . But even today's doctors are different. When I talk to some new doctors, they would prefer to work 8 to 5 type of job.It is difficult to say the least. The medical life is different .When someone in non medical life spends too much time in his or her business, then we criticise him. We say that he is too much after money or he does not care about own family.But when a physician does this to take care of a patient, we say that he is 'caring'. We praise his behaviour and say that" he is so good that he does not care about his own family when it comes to his family."This is the medical paradox that I was telling. But this is not limited to the doctors only . Even the nurses and other medical support staff does this all the time . Today I am going to mention two such short stories.
      I was invited for a 'surprise '50th birthday of a nurse that I knew .I was told to come to the house and park the car 2 blocks away. She was working 12 hours shift ,7 to pm . So she was not likely to come home before 7-pm.So I decided to go around after 7-30 pm.I went in the house and there were about 20 other people . The nurse did not show up.So we contacted one of the nurses who  was also working with the nurse.She was to call us when this nurse would leave the hospital. We waited till 9 pm before we got the call and then the birthday girl arrived . There was a sick patient , who needed to be transferred to the ICU and she worked on him till he got the transferred.
      The second story is that of a respiratory therapist.I was seeing a patient who had respiratory failure. The patient was doing well and appeared to be ready for extubation, to take patient off the respirator.So I was sitting at the desk and told the respiratory therapist to do the test to see if he was ready . (they do blood oxygen ,carbon dioxide and check 'mechaniques'--to check the strength of the respiratory muscles.)The therapist went to do it I could see him from where I was sitting . He went in the room . I saw him stumbling and falling down . I ran to to the room .The other nurse came in too. We got him out of the room and put him in a chair. He was sweating and was cold and clammy. The nurse was putting a blood pressure cuff. I told her to grab 50%glucose . I got IV line and pushed the glucose while the nurse checked the blood glucose.I was not surprised when she told me that the glucose was 53 very low. The therapist woke up .I gave him couple of orange juices. I did not know he was diabetic and was taking insulin.He was so busy that he did not have time to eat the lunch.So his sugar dropped and he almost lost the consciousness. Like the other nurse who had birthday , he also did not care for his own health.

Wednesday, October 15, 2014


        I often see patients with the fluid around the lung or sometimes both lungs . When I try to explain my patients , i try to make it simple . I often tell them that there is always some fluid around the lungs , but it is so small that we can not see it on the plain chest X-ray.Now a days there are so many CT scans done that we see so many abnormality that need to be addressed. In past when we did only chest X-ray we did not appreciate these minor things . So as much as we can diagnose cancer at it's early stage, and can get cure , we also see things that means nothing on the long term,but we still have to do follow up and do more CT scans.The Ct scans do show more fluid as it is done when patient is lying supine and the fluid layers down and so looks worse.So many a times when I do not see much fluid on plain X-ray , I would elect to do follow up X-ray and 9 out of 10 times I don't have to do anything.(drain fluid ) I also tell patients that there is constantly fluid made and constantly absorbed.So when there is more production (as in case of infection , pleurisy or TB or cancer) or there is less absorption,(as in case of weak heart ,liver disease or kidney disease).But there are other causes of fluid too. But they are are so uncommon, that in usual ,cases I don;t mention them.Sometimes in case of patients who have had some kind of surgery, the possibility of 'blood' can be there.But today The case I am going to tell is one that is not uncommon.
      I saw this patient,who is almost 88 now. When I saw her she remembered me. She told me that I was the one who had 'drained'fluid after her heart surgery. When I checked old records, I realised that Indeed I had seen her almost 18 years ago. She had coronary artery disease and then had work up and then was advised to have a coronary bypass.She did  quite well and was discharged. She had a follow up chest X-ray.The chest X-ray showed fluid on the left side .In many cases of open heart, there is some fluid on the left side and it is simply due to the surgery. In most of the cases it is blood and the body tends to absorb it if given time. I have seen many patients that have had it and who were advised to have it drained and by just waiting , and doing follow up X-ray I have avoided the procedure in at least 9 out of 10 patients. I explained this to patient in general. But when i repeated the chest X-ray , it showed no improvement, but showed some worsening. So I decided to drain it.In past I had one or two patients , that needed to have surgery as there was significant blood.The fluid was not that worse , but I was concerned.
    So I did bring her in the ultrasound department and decided to do the drainage of the fluid. I did the ultrasound and marked the spot for insertion of the needle and then the catheter . When I inserted the needle , followed by the catheter, what came out shocked me . IT was a milky fluid . Normally the fluid is like clear water .In case of fluid with high protein , it is yellow .may be like concentrated urine.And then there is blood.But the milky fluid is very uncommon and indicates injury to or blockage of LYMPHATIC DUCT. In view of the recent heart surgery, the injury to the lymphatic duct was high. Most of the people don't know about the lymphatic system This system also drains fluid and drains to special glands, called lymph nodes.So sometimes in case of cancer of the lymph nodes, lymphoma, fluid can collect. But I have seen may be one case of the collection of such a fluid . So in this case it was related to the heart surgery. In most of the cases the leak stops automatically and nothing special needs to be done . In case of this patient I just did the follow up chest X-ray and the fluid was gone.I did not have to do anything more. 

Saturday, October 11, 2014


     I believe in reincarnation and I also believe in Law of Karma.I do not have any direct proof for it , though I often come across the situation that leads me to believe that both of them are real. The question that is always asked is ,is it nature or nurtured?The things that we see in different family members occurring , is it due to the simple 'chance' or is it because the environment under which the family members are brought up is same or is it due to some kind of relationships that we develop that continues beyond single life ?(which means is it due to the our karma and it's effects , which causes reincarnation).I often see patients whose spouse also start seeing me if they have lung problems. So I often wonder when I see sick patients , whose spouse also has significant pulmonary or other medical issues.
      The story that I am going to tell is one that is related to the patient in my last blog . The patient that I described had 3 lung cancers at 3 different times and sarcoidosis and then developed breast cancer and died of it.One of these days this patient told me that I was going to see her husband . I had known him for some years as he used to come with her.Now he wanted to see me . He was a 70 years old white male who had significant cough, mainly dry and some shortness of breath. He was getting tired.He had mild cough and had some crackers on physical examination. I did the chest X-ray and then the CT scan . It confirmed that he had pulmonary fibrosis.I had also sent blood for rheumatoid arthritis and some other conditions that can cause the fibrosis. The rheumatoid factor was positive .So he had rheumatoid arthritis and it had caused the fibrosis in the lungs.The breathing test that I did,,showed that the diffusion capacity-how the oxygen is transferred across the lungs in to the blood,was reduced . This was consistent withe the diagnosis of the fibrosis. I sent him to a arthritis specialist and he was started on treatment for the RA.He came to see me in 3 months and was OK but did not look very happy .He had lost some weight and still felt tired. But he had no fever . His appetite was good ,but he was not gaining any weight. I decided to do the Bronchoscopy. Sometimes these patients with the fibrosis and the one that are taking immuno- suppressants ,get atypical infections, like atypical TB.It came back negative. So I decided to do the follow up .He came to see him Had lost more weight and was feeling more fatigued and short of breath.I did the new diffusion capacity .It was not any worse . I had done the Echo cardiogram , to rule out cardiac cause and it was OK. I walked him in our office for 6 minutes,and he did OK. So I was not sure as to the cause of his weight loss. I had asked gastroenterologist to do endoscopy ,colonoscopy to rule out occult cancer and it was negative.So I did not know and he WAS WASTING away. And it struck me .I was surprised that I had not noticed it before. HE was loosing not only weight, but was also loosing the muscle mass. I sent him to neurologist and this time my hunch was correct .He had myopathy, a muscle disease in which his muscles were wasting and as he was loosing the muscle mass he was loosing weight.There was no treatment for his condition.
     In the past he was the one who would help his wife ,when she was short of breath. He was strong and big and had no problems. Now he was himself short of breath and was weak. He could not be of much help.In next less than a year he died .
     So the question that I had was was by any chance that these two were married and both saw me and I had diagnosed  the different conditions , that would lead to death finally.

Thursday, October 9, 2014


   I watch evening news and many a times there are stories,which include police power abuse and also about medical negligence or missed diagnosis. Recent case in point is in case of Ebola in Texas.I do not no much more about Ebola or about the case in Texas.But the families always believe that the police are not careful in cases of criminal cases and doctors are not careful in cases of medical cases ,especially when the out come is bad.Even though I am sure that there are cases where the doctors are at fault.But I also believe that as in case of police ,the work of doctor is not easy . To get a line from Dr.Atul Gawande, the medical knowledge is wast and incomplete, it becomes difficult to be correct 100% of the time . I am going to tell a story of a patient that had so many complicating issues ,that it was impossible to have something definite diagnostic test than doing a intellectual educated guise work.
      I had seen this patient for many years. She was a smoker , who had quit .She had mild lung problem related to smoking in the past. But she was not bad . But when she saw me she had abnormal chest X-ray.She had some lung congestion or infiltrates and her lymph nodes in the chest were enlarged. The possibility of a condition called Sarcoidosis was entertained by me . In this disease patients do get the enlarged lymph nodes and they do get problem in the lungs Some patients ,<1%will get worsening and will get short of breath.She was quite concerned.I did the lung biopsy, and it did confirmed the diagnosis of the sarcoidosis..She was worried about cancer . So I sent her to a chest surgeon and he did a lymph node biopsy.It was positive for the diagnosis of sarcoidosis.She was happy and we decided to do the follow up.
     Over period of next couple of years , I did the several CT scans . They continue to show the enlarged node and the the lung congestion . The one of these days she had a nodule. I was not sure if this had anything to do with the sarcoidosis or it was a cancer. The further work up was neede . So we did the biopsy and then finally I sent her to a chest surgeon.He did the open biopsy and took out the part of the lung that had the tumor. The good part was that not only it was a cancer that was contained, and the nodes were negative for any spread of the cancer.She was happy . I just wanted to just point out that if in case of lung cancer, if the nodes are involved , patient becomes inoperable and incurable.But in the case of this patient, there was no way to know if the enlarged nodes were due to cancer or due to sarcoid. Even though in latter part our follow up we had PET scan.In PET scan ,tagged Glucose is given IV and images are taken. The glucose is picked up by metabolically active cells and by normal cells. The metabolically active cells pick up glucose more actively and so we can pick up cancer. The problem is that the infection or sarcoid will also pick up glucose more avidly and so it does not differentiate between cancer and sarcoid or infection.So you see the difficult?
    In near future she developed another nodule .I was not sure what to do other than do the usual work up . I did send her to a surgeon and it was taken out .And it did not stop there. She did well with this surgery.But then again developed a small nodule. Please realism that I followed her for may be 10 years or more.This time , the third time when she had new nodule and the nodes were same , I sent her to a surgeon. I am not sure why , but the he decided to do the biopsy of the lymph node and not the nodule . I was thinking that the nodule was cancer and the nodes were sarcoid .She also had develop breast cancer. To my surprise the nodes came back positive for cancer.and she HAD BREAST CANCER in the lymph nodes and the . So I was not sure why he did that but it was more helpful than the PET scan .
    So the difficulty that we have is no test is perfect and your intuition is not perfect and every time one can not do major surgery or do biopsy . So this is not a perfect science and like any other time we go by what is more common.She had 3 lung cancers and a breast cancer and Sarcoidosi , each one can cause the enlarged nodes and positive PET scan.
     The lady was given chemotherapy , continued to have problems and got metastatic breast cancer and died about year and half after the breast cancer diagnosis.

Monday, October 6, 2014


   As a child I learned the story of the crying wolf .I have thought about it on many occasions in life . We may be talking about the politics (it is always a crisis of some kind for some politicians), or your own son or daughter, or it may be in medicine, this phrase and the story is illustrative of our response.I have myself experienced this in my own decision making , even though I try to sort out my 'feeling' and the findings. Some ties it may have to do with the circumstances , but one must be careful.
      I had seen this elder,y patient , over 90 years of age,who was admitted to the hospital with the diagnosis of pneumonia. She had no fever nor did she have any elevated white cell count,( which is elevated in case of any infection)I saw her old chest X-ray done about 4 weeks ago.It was similar to the one done now. So I was not sure if she had indeed the pneumonia the diagnosis that she was admitted with.I wanted to do some investigations, but she was older , more than 90 years of age , and I was not too sure what did she want. I spoke to her and her son . She was not very keen on many "tests".But after discussions she was agreeable for the CT scan and an endoscopy. (Bronchoscopy.) Even though she was 90 plus she was quite clear in her thinking. She was allergic to many drugs and it was difficult to treat her. I did the CT scan and it did not add much . She had congestion , findings similar to the one seen on plain chest X-ray.The bronchoscopy also did not help. It showed no cancer , which was helpful .But the cultures were OK .The infectious disease consultant wanted to give 3 antibiotics.He did not want to stop any even though all the cultures were negative. I had no other choice as I did not know anything more.
      My plan was to do follow up X-ray in 3-4 weeks and then decide. But every day that I saw her, she had some complaint. One day the IV got out and they had hard time starting another one.Then she was constipated and the medicines thy gave her was not good and caused her to have abdominal pain. Then she had diarrhea.She did not want the breathing treatment and then felt that steroids were causing problem . Her physical findings were not any different. Her oxygen was OK and there was no fever and she sounded clear.The one day she got the laxative that she wanted and then felt like throwing up. She had 4 or 5 loose stools and may have been mildly dehydrated.Her blood pressure dropped and she almost passed out . I saw her in less than 10 minutes. She was fine and her oxygen saturation was OK and blood pressure was OK . I ordered some blood tests and new X-ray and gave her some fluids. The X-ray was better and labs were OK except one which was borderline for heart attack.Her ultrasound of the heart was normal and there was nothing to suggest heart attack on cardiogram.She continued to do OK , but every day had new complaint from stomach upset to constipation to diarrhea to problem with IV site and so on .
       One night the nurse called me stating that she had 'worked herself' up and was short of breath , The oxygen was OK, she sounded OK and blood pressure was normal She wanted an inhaler ,that she had stopped on her own before. I had respiratory therapist give her a nebuliser treatment and gave the inhaler . I also ordered new Chest X-ray. It was 1 am As soon as I hung up the phone I realised that I was brushing aside the complaints as she had complained too often . I called the nurse again .I ordered new cardiogram, blood test for heart attack and blood test for congestive heart failure. I also ordered IV Lasix, a diuretic.
       She did have the congestive heart failure and the X-ray and the blood test showed the congestive heart failure. So the diuretic helped . She was better.Next day I spoke to her and her son . She was doing much better and in next day or so was discharge to rehab unit.So I was about to be caught with the "crying wolf" and not doing the right thing . But I did OK.and so did the patient.

Tuesday, September 23, 2014


     Sometimes we do things for long reason and get the 'right'answer.One does not want to go a wedding or to a party,but then he meets his dream girl. But in medicine , it rarely happens . I feel that we do too many tests, Some of them with normal results and are (at least my mind waste of money). This is more common in hospitals as no one wants to miss any thing and the physicians that are seeing patients , are not the ones that know patients and are not going to do out patient  follow up.So the tests get ordered.But the story that I am going to tell is one little unusual one.
   I had known this lady who was smoker. She had some COPD. I had taken care of her husband. He had COPD too . After taking care of him for few years, he died . Then she started coming to me more regularly.She was a smoker . She was hospitalised for pneumonia. We did a CT scan and it showed some scars and emphysema.She was doing better.But her platelet count  was low . So we did a further work up. At time I came to know that she also was drinking alcohol. So I did a liver test and it showed that she did have a liver disease related to alcohol . After extensive discussions , she agreed to stop smoking and drinking. It should be noted here that she had a colon cancer resected year and half ago. I continued to do follow up . She improved significantly .Her lungs got better. She hardly needed any inhalers. Her platelet counts improved and her liver function was normal.We continued to do follow upon her periodically.I do chest X-ray every year.
      She was also followed by an oncologist.So one day I get a call from him that he did a blood test and it was elevated suggesting of recurrence of colon cancer . So he did CT scan of belly and chest . The Ct scan of the belly was OK but the CT scan of the lungs showed that her lungs had abnormal density in right and left upper lobes . She had scars in left upper lobe , and it did look little worse. But the right upper lobe was new . I did PET scan and it showed the activity in right upper lobe . The left one where there was a scar was mildly active in that area, which could be scar or cancer. I did breathing test and a bronchoscopy.It was of no use.,did not help. So I asked radiologist to do the biopsy of right upper lobe . It showed LUNG CANCER and not colon cancer . (in my mind the possibility of colon cancer was almost zero ) I sent her to a chest surgeon . My thought was to take the cancer out. But the surgeon was concerned about the left side . He wanted the biopsy of Left side . So I agreed and the biopsy was done and it showed LUNG CANCER. So she had a lung cancer which had spread to other lung .I am not sure as to which side the cancer started.
     So the blood test that was done to do the follow up of the colon cancer was correct test to find out recurrent colon cancer, though the chance of recurrence was very very low. But there was truly no reason to do the CT scan of the lungs . So the test that was ordered which showed the cancer was not the right test , but it gave us the diagnosis of the lung cancer .

Sunday, September 21, 2014


    The law of cause and effect is known to all of us from childhood to adult life . As a child we learned that if you touch a hot pot , we will get burns.Or if we don't get good grades , our parents are not going to be happy. As adults we know that if we do not follow the speed limits and get caught, we will get speeding ticket. But in spite of that we don't change the behavior all the time. We know that eating too much and getting obese is not good. But we still indulge and get fat. Some of these things are obvious,at least to most of us . But then there are things that are not either obvious or not accepted by some .Many years ago , when I was new in my medical practice , I met a cardiologist. He was older than me by may be 20 years . When I met him for the first in a parking lot , I told him that I was a lung specialist.He lighted cigarette and told me that smoking is harmful was all bogus and there was no proof that it causes any health issues .There was no way I was going to convince him otherwise .Now this is very obvious today and even in those days , it was known though may be not accepted by 5 or 10 % of the people.But then there are situations where the cause and effects are not known.
      I was told this story many years ago by some one . In India the rain fall was low and there was water shortage and the summer was hotter than before . So the Chief Minister ( Governor ) appointed a commission to investigate the cause . After meeting several times and spending lot of money they came with a report. They stated that "the cause of water shortage is that Indian couples are spending too much time in Bedroom" The Governor was stunned . He did not know what was the relationship of couples spending time in bedroom and water shortage.Then it was explained that when the couples spent too much time in bedroom, they had more kids and that caused increase in the population.When the population was increased, they needed more land to build houses . So they had to cut trees and so the forests were gone and this led to reduction in rain and increase in temperature. Sp sometimes the cause and effects are not obvious . I know I have a very long introduction in my story.
      I saw this Asian patient in ICU . he had pneumonia . He was a smoker and had cardiac issues and had bypass done and and also needed a heart valve replaced.He had other issues and We had a hard time weaning him of the respirator. I did couple of Bronchoscopies and had to give steroids and antibiotics. We came quite close to doing Tracheostomy. After 14 days of struggle, we weaned him off the and he did OK . There ware several days before he was out of ICU and then took few more days before he went home . I continued to see him as out patient. He continued to smoke and continued to have lung problems. Over period of next year and half, he continued to have more problems . He ha d blood loss from stomach and intestine and had congestive heart failure and anemia with drop in blood counts. He was admitted to hospital several times and even went to Mayo clinic. Then he was diagnosed to have a disease in which body (bone marrow ) does not produce enough cells. So the blood counts drop and he needed frequent transfusions. He continued to smoke, The he was started on chemotherapy. This caused his immunity to get worse and he ended up with an episode of sepsis . He ended up on respirator.We worked him up and were successful in weaning him off the respirator.
     So I have a question . Is there any relationship of him having all these diseases and continuation of smoking ? Certainly the cigarettes have many toxins and I am not sure if there is direct relationship between them and all the problems that he had , but then we don't know why the smokers have higher incidence of all sorts of cancers including breast cancer or bladder cancer.But I am sure that there some cause and effect between smoking and at least some of his medical problems .

Saturday, September 13, 2014


      I was talking to some friends recently and the subject of Narendra Dabholkar came in.Mr. Dabholkar was recently murdered and the murderer is not yet caught. I never met him , but had seen him on one of the interviews . He had u tube video, where he stated that one should not call astrology a "science". I am not sure how much study of this science he did , to call it fraud and not a science. One certainly can understand his argument. In the science there is hypothesis and no matter who does the experiment or where it is done , the results are reproducible. So this is not so with Astrology . So he does not believed it to be a science. There are two problems with this  argument. One is that there is something called 'free will. Which means one can 'change' the out come in most of the situation , either with little efforts or with lot of efforts. So one can do nothing and then the outcome would be as predicted or if the effort falls short then the outcome would be same as predicted .But if we try hard, then the outcome would be changed and then the prediction would be changed.So there is no one hundred percent in any situation. So what Mr.Dabholkar said is not incorrect, but it has simple explanation, which he tends to neglect.
     But the second and may be more important for those who question religion and put 100%faith in the science, is that neither science can predict things 100% of the time .Many years ago Laplace , a scientist proclaimed that if we know speed and position of a particle, then we could predict it's "future" position. But as it turned out, he was wrong. NO ONE CAN PREDICT WITH CERTAINTY THE "FUTURE" POSITION OF THE PARTICLE. There were several attempts and explanations for this and then was the birth of quantum theory.So as soon as one tries to look at the position of the particle , it changes its speed and then it becomes impossible to predict the future.. So the predictions are purely based on 'probability' and not certainty.This is exactly what I was saying. The course of our life is predetermined as long as there is no interference from 'free will' or the efforts . If that interference occurs , then the so called future is changed . So the 'destint' is not predetermined as long as we do not try to change . Same is true of astrology . It is based on probability. The predictions have too many variables and too many influences from outer sources . So this can make some predictions exactly 'right ' or 100%wrong.

Friday, September 5, 2014


       Many years ago I watched the movie called the Gambler.Kenny Rogers was a seasoned gambler and there was an amateur gambler who gets in trouble, So there was the song " You Got to know when to HOLD and you got to know when to FOLD. " I liked it very much for the meaning . I think it is a message for the life .I have used it in many situations.But it is so true in case of medical management. When we see patients in ICU who are very sick, we try everything that we can. We have lot of things to do as testing or try different treatments. But as time goes on and when we don't see any improvements , it may be time to stop the aggressive treatment or may be continue for little longer time . This is what I call either 'holding' or 'folding'.No one can state with certainty , as to when is a 'right' time to either Hold or time to Fold.I have faced the dilemma many times and sometimes I face it in situation when it is not impending as in ICU , but may be chronic or sub acute.The case that I am going to tell is one such.
        I had seen this young male who had chest pain . So he was admitted to the hospital . He had had a cardiology evaluation. He had a coronary CT scan . It did not show any significant coronary artery disease.He was discharged. He was OK for next 2 or 3 months and then he was having cough. The PCP treated him with different medicines . When he did not get better, he had new chest X-ray. The X-ray showed fluid around the left lung. So a CT scan was ordered and he was referred to me . He had large fluid collection around his left lung.When I looked at his old CT scan , he had tiny fluid on left .I took out mare than 1200 ml of fluid and it came back in less than 10 days . So we consulted a surgeon . He had surgery to look inside his chest and insert a catheter to drain fluid. The catheter can be left in for long time and we can drain it as needed, may be weekly or daily or whatever is needed.The biopsy turned out to be mesothelioma. The family was very smart and had done their home work . So they wanted to know if surgery was an option. I was not too sure . I knew that there were surgeons who did quite 'extensive' surgery.But was not sure as to the if he was a candidate. I knew the name of a surgeon and I gave it to him and he was also seen by an oncologist. He was started on chemo and had periodic follow up of scans and had drainage of the fluid. Due to tumour , the fluid was not free and we had to change the catheter couple of times . He did OK with the chemo and then was sent to the surgeon. But by now the CT scan showed spread of the cancer to liver . So he was not a surgical candidate. So other than continuing chemotherapy , there was no other choice . When I saw them , the patient and the family , I was surprised to see that they made decision to go with Hospice . In my mind this was the 'right; choice ,but was not too sure if they would ever consider Hospice , or ;giving up'. But I knew they knew when to "HOLD " and knew when to "FOLD". 

Thursday, August 28, 2014


    In medical practice , we can predict many things and sometimes we are wrong.The possibility that we would be wrong is smaller that we are going to be right. Again if we knew 'everything' , we would be God . But with the modern day medicine, with all the tests that we have , we can predict more accurately than in past. There are many factors that can affect the outcome and can change out chance of being right. But sometimes we are right and it still hurts.I have seen many patients that I thought will not do well, and did not do well. But sometimes the the contact that we have is so short , that I don't think for long time on these cases and don't wright about them . The case that I am going to wright is one where I knew I was facing uphill battle and did not think much till it happened .
     I had seen this 75 years old patient in my office.He was on oxygen when he came to my office.He was seen by another lung specialist.He was diagnosed to have lung issues and was put on oxygen and some other medicines.He had brought with me old X-ray from 4 or 5 years ago. I reviewed the CT scan done by the hospital and when other MD was seeing him . He was told to have COPD in the beginning and was treated with medicines . Then he was found to have elevated pressure in the lungs and was put on Viagra.I was not sure if they had told him that his major problem was not COPD though he had smoked ,but it was scar tissues in the lungs. I could see that even 4 or 5 years ago he had some scars.I ordered new CT scan and a walk test to see how much oxygen he would actually need . He walked may be 30 feet and oxygen dropped . We continued to increase the oxygen and by may be 4 minutes , we needed 8 to 10 L and he was still not greater than 90%.(which is considered low.)I told him not to walk more than 30 feet.I told him about the diagnosis and told him that not much could be done .I could try some new medicines, but they would not be successful. But he was reluctant for additional medicines.
      He was admitted to hospital in next 10 days. He was short of breath, but main problem was his blood pressure was low and he had low sodium. He was given water pills and they had caused him to be dehydrated and so the blood pressure was low and sodium was also low.I had to give him lot of fluids and steroids and very high oxygen flow . He was put on 100%oxygen with 60L flow (compared to 10 L at home ) The blood pressure was an issue for 2-3 days . But then the oxygen continued to be problem. I could not wean him down . I talked to him several times . We talked about going to special place called SELECT or go to Hospice . He told me that he had no relatives . He was writing a book on Bible,and wanted to complete it.He did accept the fact that he was 'bad' and may not make it for long time.He finally agreed to be DNR. It came as a surprise to me that after struggling for more than 2 weeks , we could reduce his oxygen. I had given /tried several medicines in desperation. Either they were working or it was just a 'chance'.He agreed to go home with Hospice .
     He was on 8 L and I had told them to have as high as 12 L oxygen.And 4 days down the road , I got the call from Hospice , that he passed away.I knew that this was going to happen , and I knew that it would not be that long . But 3 days ? It hurts.

Sunday, August 24, 2014


    In medicine and for that matter in other fields , there are accidental discoveries . The old example was that of discovery of penicillin.Some other drugs have been discovered by shear chance . Some chemotherapeutic agents belong to this category( cisplatinum). Then there are accidental uses of the drugs. A medicine that was used for allergy,was noted to cause increase in appetite and cause weight gain.So it is used not for the allergy, but to improve appetite and weight gain (Periactine).This is true for non medical inventions too. Sticky note is one such invention.But what I wanted to tell today is not that kind of accidental discoveries , but some other kind ,where no one knew or expected , a disease , and it was diagnosed by accident. I had written a story of a pregnant lady, who came to hospital and became unconscious and none of the doctors suspected pregnancy with it's bad effect called eclamcia.It was by accident that some one ordered the pregnancy test and the pregnancy was diagnosed and once the c-section was done patient got 'cured'.So the story that I am going to tell is similar to that.
      I saw this 90 years old patient in my office . He had diarrhea and had lost 20lbs weight. So the primary care physician did CT scan of the belly and it showed some abnormality in the lungs. Since the bottom of the lungs are not 'flat', but are curved, when they try to go to the top part of the belly, (liver) they will have some pictures of the lungs . So he had a CT scan of the lungs . The CT scan of the lungs showed a nodule in the lungs. So with the weight loss , i decided to do a bronchoscopy. My concerned was not to diagnosis lung cancer though it was a possibility, my concern was to atypical infection called MAC. So he came to do this procedure as out patient. He was put in a procedure room ,after the nurses did the history and some examination . They did notice the low heart rate. But they were waiting for me . When I entered the room ,I noticed that his heart rate was ,30 .His blood pressure was 1410/70 and his oxygen saturation was 97%. He was comfortable and had no complaints.When I looked at the monitor , I realised that he had a heart block ,i.e. only every other beat was conducted.So even though he had no symptoms related to this low heart rate, he needed a pacemaker. Needless to say that I canceled the procedure and called the cardiologist . I admitted the patient to ICU and started him on intravenous drip of a drug that did improve his heart rate, He had  pacemaker inserted and is did fine .
        So if he was not on monitor and if I had not scheduled his procedure, then his heart block may have remained undetected, at least for some time .

Thursday, August 21, 2014


    I have been seeing more more demand for making the pot smoking 'legal' or as some would like to say 'decriminalise'.There are good people who argue tat it would make money ans save money for the state.But the main things that they are missing is that no drug is 'safe', not even legal 'drug' alcohol.Does that mean that I would like to go back to days of prohibition?NO ,not really.But we need to do something about the rapid growth of use of legal and illegal drugs . I have been medical practice for long time and I believe that the use of narcotics and illegal drugs is at it's higher level and the part that bothers me is that we all think it is OK. This thought came to me , which prompted me to wright this blog.
      I had seen this patient may be year and half or so ago.She was a 79 years old patient who was referred to me for the evaluation of the abnormal CT scan. She had a history of breast cancer and had routine chest X-ray and it showed some abnormality and so a CT scan was done . The CT scan showed number of tiny nodule .So she was referred to me .The patient was quite anxious and had a hard time with the situation and was scared, like anybody else would have been with concerned for recurrence of the cancer.The nodules were very small .So the usual procedures like bronchoscopy or needle biopsy or PET scan or open biopsy were not great option. But I decided to do bronchoscopy as the possibility of atypical TB called MAC was there, in my mind it was high on the list of possibilities.I also told her that if these are cancerous nodules,,nothing could be done to 'cure' them and if they were benign ,then nothing was needed to be done. So if the bronchoscopy was OK we will do follow up CT scan . I did the bronchoscopy .And I had thought it came positive for MAC -the atypical TB . This needs treatment with 3 drugs for a year.We also need to do monthly liver function blood test , and need to check eyes periodically .She was not happy with all this , but was 'relieved' that at least it was not cancer.
      Her follow ups continued to be OK as she was tolerating the medicines quite well, after initial problems. She was doing fine and the blood tests were normal. She had no problems and was very pleasant. So I was surprised when I saw her and she appeared to be mad . When I walked in the examination room, she told me that she was done with all the tests and medicines .I looked at her and then the chart . She was about to be completing her treatment in next month and her last CT scan had shown the improvement in the nodules.Then when I started talking to her the real cause of her frustration came out. Her son ,more than 50 years of age, had dies of drug overdose. it was overdose of methadone , which was prescribed to him . Again I don't know the details and he may have taken some more drugs , but methadone was main cause according to her. She has a daughter and she also has drug problem and is no help to this elderly patient and felt no remorse, when she told patient that 'every body dies one day'.
     Under the name of pain control we are giving more medicines and I am afraid that we will get more addicts.

Thursday, August 14, 2014


    There are times when I often wonder what else could do or is there anything that I can do to change the outcome.Someone had said that if you do certain things repeatedly , it becomes habit, and when you do it more often it becomes second nature. I think  I can say that about smoking. I also talk about the circle of mind. Let us say I have never tasted a Pizza and you bring in a pizza and ask me to try it. When I see the pizza , I would have no reaction or desires I have never seen pizza. But then you tell me try it as ' it's great.'So I try it and I like it or dislike it . So eating pizza leaves an impression.So next time when I am hungry or passing by pizza place , I would recollect that the pizza was good or bad and that would cause to buy it . Eating it will leave impression and then that will create desire to eat it again and so on and so forth.This is circle of mind .Action causes impression and impression leads to desire and desire leads to action.This is worst with smoking and that is my today's story.
       I saw this young 40 years old patient, with abnormal chest X-ray.She had lung mass. As usual I did the biopsy and the breathing test . She had a cancer and the lung capacity which was OK . She was a smoker and had the reduction in the lung capacity, but it was acceptable for the taking out the cancer. We had thought that she will need a lobe to be taken out ( approximately 2/3 rd of the lung , may be 2 lobes . But when the surgeon went in , the tumour was quite close to the center and he had to take out entire right lung .This was her only chance to may be give her a chance of cure.She did well and no major problem .She was given radiation treatment to prevent the recurrence. I followed her for long time after the discharge .She had quit smoking for may be 4 months or so. Then she started the smoking again . She had reduced lung capacity as she had lost the lung and she did not start with the normal lung capacity.She also had the cancer , but it did not matter , She was smoking. I must have followed her for few years and then she was lost for follow up .
    Then I got a call from a general surgeon , asking me to see a patient that I had seen before . She had routine mammogram and it had shown abnormality and so a biopsy was done . It showed a cancer . So she needed surgery . He wanted to me to 'clear' her for surgery as she had lost one lung and was a  current smoker. I saw her .She was still smoking . There was no evidence of recurrent lung cancer . Her lung capacity was lower . But I cleared her for surgery.It was breast cancer . She had no problem post surgery. She was started on oral  chemo. She continued to smoke . I must have talked to her several times and it made no effect. She continued to smoke .
    Three years passed . She had problem with acute bronchitis and was short of breath. So needed to be admitted. The routine chest X-ray done showed a abnormality in the remaining lung. She had CT scan and it confirmed that she had a lung mass. With her history of 2 different cancers the possibility of new lung cancer was high , and the possibility of spread of breast cancer was there.I did do the bronchoscopy and got nowhere. She was too short and I did not see ant tumor to the biopsy and deep biopsy were out of question with her shortness of the breath. I spoke to radiologist to see if he could do needle biopsy . He did not want to take a chance as she had only one lung and if it would collapse after the biopsy , she would probably could not tolerate and may die . So I spoke to the oncologist and we decided to do radiation as he 'felt' that possibility of lung cancer was higher than breast cancer. She continued to smoke and died in less than a year.

Saturday, August 9, 2014


     I have seen many patients with complaints of chronic cause.I often make a joke when I say," Your cough and cold is my bread and butter". So I see many patients with the complaints of cough.When these patients are nonsmokers and their chest X-ray is OK , most of the time it is due to one of the 3 causes,Asthma,or allergies with post nasal drip or gastroesophageal reflux.So most of the time I worked them up for one or all three and treat as therapeutic trial and they get better.But sometimes I come across unusual cause for the cough.So this one was one of the unusual cases.
       I had seen this relatively young lady , may be about 55 years old.She was young but had long history .She was complaining of chronic cough.When I got in to details of the history, she told me that she was non smoker and had bad pneumonia and then had very stormy course.She was on respirator and could not be weaned off the respirator and so needed tracheostomy.Then she was diagnosed with a condition called POLYMYOSITIS . In this condition the muscles get very weak and this is related damage to the muscles by own body and the treatment is with steroids and immuno-suppressants. So she was started on the steroids , and then switched to immuno suppressants got better and was off the prednisone . Her cough was there when she had pneumonia and though the pneumonia got better, the cough continued. She was treated with different medicines. Her X-ray was OK.I was thinking in terms of ASTHMA, as the steroids can suppress the asthma and when the steroids are taken off the asthma can flair up. But due to be on immunosupressants I did CT scan of the chest.The CT scan showed some damaged bronchi and some scars.The were most likely due to previous pneumonia. But I was concerned and so I decided to do bronchoscopy to make sure there was no unusual infection.
     The surprise came when I did the bronchoscopy. She was coughing significantly in spite of quite a bit of sedation. When I entered the Trachea, her coughing would get worse. There was a abnormal tissue growth just bellow the vocal cord ,with 2 green colored threads coming out from it . It was so close to the vocal cord that I could not do any biopsy.I thought that It was related to the tracheostomy. It looked like there was some retained sutures and it had caused the excessive tissue growth.AND THIS MOST LIKELY WAS THE CAUSE  OF THE COUGH !!

Thursday, July 31, 2014


   I did write about the prayers and it's powers and how it may be working. I was reading an article written many years ago and I thought about it and liked it . It may be an explanation as to why some prayers seem to work, whole others seem not to work.This is similar to the destiny, and how it works.Let me explain.
     When we do sincere prayer ,with full faith and trust , it create positive  deeds. This can be compared to making more money , as it adds to our bank balance of good deeds. But just like the bank balance of money . it can be used for various expenses.If I suddenly get $100,000 , then I can decide to buy new car or new clothes or I can pay off some of my old debt, or I can decide to put some in a bank or invest in something for the future dividend.The same thing can happen for the fruits of our prayers. Some may be used or spent for 'giving' us success. (as if our prayers are answered.)This like me spending some money foe buying new car.Some of the fruits of the prayers will be spent in paying for avoiding the effects of the bad deeds that we might have done and which might have come to fruition in near future.And finally some is left in our bank account of good deeds . The problem is we do not have control on haw this is done in case of effects of good deeds, unlike in case of money, where we have full control. So we can not decide how to 'spend' it , nor we know how much is needed to nullify the effects of past bad deeds ,nor we know how much is needed to get success in what we are praying for . So we don't always see success ,our prayers are not answered ,and sometimes they are . I can not not understate the law of karma in any of these .This may be the deciding factor as to how much of effects of good deeds are used for each of the 3 things that I stated above.There are things that we have done in past or past life , effects of which will manifest and can not be avoided no matter what.And there are things that we can change with some efforts . Then there are some where lot of efforts are needed to change the outcome . So the question is how much is enough?If I want to but Rolls Rice and I have only $20,000, can I buy it? The answer is no .
       So this may be the answer to the question as to why some prayers are answered and others seem to go unanswered. 

Saturday, July 26, 2014


    We are all looking for one and only one thing, happiness.So what gives us the happiness?I have often said that the real happiness is not out side our mind , but in our own mind.Let us say that I like Pizza and it gives me happiness in eating it . So I think that the pizza is the source of the happiness, But when I start eating the pizza , the happiness that I get from eating the first slice is not the same. So when I eat 10th slice I am about to throw up and not getting the happiness that I got with the first slice . So then the happiness is not in PIZZA but it is in my MIND . This is same for many other things , including having sex or listening to a particular music and so on. So why do we feel the happiness.
      There was a story of a king that had heard when I was growing up.He was unhappy.So many doctors came and gave him different medicines , but it did not help.So the king continued to be unhappy.So then came a doctor. He said to the king that the treatment was simple. The king needed to wear a shirt worn by a HAPPY MAN. So the king sent his guards to all over the city , in search of a happy man . They went searching for the happy man one house at at time . Some one was not happy because he had lost a loved one , some one had broken up with spouse, some one had lost job ans so on and so forth. So at the end of day they ran out of houses to go . So the next day they decided to go to the outside of the city . It was early morning . The Sun was rising and a man was sitting on  the banks of a river on a stone doing nothing.The guards came to him and asked him if he was happy.The man answered YES without any hesitation.So they took him to the king. The king asked him the same question, are you happy. The answer was the same unequivocal yes. So the king asked him to to give him his shirt. The man said ,'I don't have shirt, I don't need one '. No wonder he was happy.So the story that I am  going to tell is story of one such happy man.
         I knew this guy , who worked in the hospital where I went . He worked in a housekeeping. I knew him as I saw him everyday in the hospital . He would say hello and I would respond . Then he knew that I was going to Gym , so then he started giving me advice on the body building. He also started telling me about the diet to 'build' muscles.Sometimes he would ask me about health issues.But not too often . He was planning to retire in next couple of years. He told me how much money he had in retirement plan.It was less than what many doctors make in one or two months.But he was happy and never complained about work or life or for that matter anything.
       One day when I was waiting for elevator, he came out of the elevator and  stopped me . He told me , he needed $100. He had to pay some tax. There was no way I could have said that I don't have it . I gave him the money. He had promised me that he will return the money.I continued to see him off and on in next few months . He never said anything about the money . The amount was too small anyway. Then one day he asked me if I could spare few minutes . He too me to credit union bank ,asked the cashier how much did he have in the account. Then asked her to give me $5.Over period of next year, he did this few times . There was no way for me to keep a track of how much he gave me . I am sure that he did give me all $100.I have talked to him after that sometimes Same talks ,same happy attitude, never sad face or complaints. Never asked me for any money.He retired and started doing part time work. This a guy, who had hardly any money, needed $100,but had conscious to return it, and was still very happy. And I see every day people , doctors , who have 10 times more money and are still unhappy .So the happiness is state of mind and not dependent on amount of money that one has nor on any external sources. 

Sunday, July 20, 2014


       I was attending a lecture on Hinduism.The swami coated a shloka from the Bhagawat Geeta, in which the lord Krishna says that whenever there is disappearance of the religious values and increase in non virtuous  behavior., the Lord comes to the earth to 'save' the religion.This is called the AVATAR.In Hindu mythology , there are number of times that the God comes in this world to help good and take care of evil.The Indian believe that there are many saints or swami , who are reincarnation of the lord or Avatar. But there are 10  Avatars which are well known . These are called  Dash avatar. The  God can come in any form in this world. It does not have to be in human form. This concept is seen only in Hinduism and not in any other religion . This may be due to the Indian concept that the everything that is in this world has reflection of the God. Let me explain . If we believe that this entire universe was created by the God and there is nothing which came without him, then everything has to come from him , which means everything has to have HIM in it. I van make a wooden  table. Then I can get a piece of wood, which is not part of me and make a table out of it . The wood is not part of my body . But if the God made the wood , it has to come out of Him as there is nothing outside of Him.So it is not surprising that the Avatars are of various kinds and not all are in human forms.
       So how do you explain this . Well there are various types of Avatars, We believe that all of us of the element of the God, so when someone gets to a higher level, or becomes a Saint, then he is like Avatar, but not a complete Avatar. They are 'born ' to increase the understanding of the religion and increase the good behavior.Then the Avatars like we have the forms which are less than Human beings , are also Avatars . But they are on the earth for only one purpose ans again are not 'complete' Avatars.But what is interesting about the ten Avatars. The first is a FISH form , the second is the TURTLE, the third is Varah , and fourth is mix form of LION and Human.(called NARASINH), then is VAMAN, then is PARSHURAM , then is RAM , and then is Krishna and then BUDHDHA  then is KALA KI.It is interesting to know that in every cycle, there were human beings. But the form that the GOD came in to save the world, was in different forms .Please remember that the there Avatars were not complete . So the 1st one was in form of fish, the 1st life form that came on the earth. The second was the form of turtle , evolution from the aquatic form . The third was an animal form , further evolution , then came half man -half animal , the Narasinh,.Then came a short human being, another evolution, then was the human being with weapons, the Parshuram , then was the king RAMA , another step in evolution.Then was the Lord KRISHNA. So there appears to be a progression in the different forms , almost like what is described in Davin's theory of evolution. I am not sure if this just by chance or well thought out progression or REALLY, REALLY what happened.
       I just wanted to tell you that this is not my idea, but I had read it some where and thought that it was thought provoking . And if the HINDUS thought about this many years ago , they certainly knew about the evolution , long time before the Davin thought about it.The difference between HINDUIS and other religions is that , Hindus believe that all of us have element of the GOD , and all of us have ability to as close to the GOD as was JESUS. Certainly it is not easy and not even one in million may get to it , but in the world of quantum world, where everything is based on probability, we can be as good as JESUS, may not be in this life , but may be in 100 lives down the road.

Sunday, July 13, 2014


      I have been in medical practice for many years. The medical practice has changed in last few years. Many doctors are feeling that patients are more educated and demanding .I feel that educated patient is better than uneducated patient.This does not mean that all the patients are good or bad. I like patients knowing their diagnosis, getting interested in the treatment and know the prognosis. I have had good patients most of the times . I think many or may be most would come to me if given choice . So when someone says 'thank you' ,i like it and it makes my day.I have been given few strawberries, from their backyard to pecans that some one bought for me as they thought that I would love to eat. I have had 84 years old husband of my patient come to my office and show me how to build a stage for a play and offer to do it when I am participating in a play. I have been given books , scripts and many other things as gesture of their good will and expression of their gratitude.I REALLY REALLY DO APPRECIATE ALL THIS AND FEEL PRIVILEGED TO HAVE THESE KIND OF PATIENTS . But the story that I am going to tell is little different.
     I was called to see this patient ,who was admitted to the hospital with respiratory infection.It was 5 pm and I was not very keen on going to the hospital late in the evening. But the patient was one of the doctor's relative . He called me at 5 pm. He had seen her ,the patient 3 days ago for sore throat and given her an antibiotic.She was not feeling any better and so he decided to admit her . So I had no choice but to see her .When I went to see her , I was glad to have gone to see her . She was admitted to regular ward.She was 18 or 19 years old and had no other history. She was not a smoker or alcoholic or drug addict.She had no previous history.She was quite short of breath and her oxygen saturation was low. When I saw her the chest X-ray was done and when I saw it ,I knew as to why she was short of breath.The X-ray showed extensive pneumonia.I called the referring doctor, who was her relative and also put a call to infectious disease doctor. I transferred her ti intensive care unit and after the cultures ,put her on 3 antibiotics.I spoke to the infectious disease MD and he agreed with the antibiotics that I had started . I called the parents and  told them the seriousness of the diseases.I told them that she may get worse and we may have to put her on ventilator.I was however was hopeful that we had started her on treatment soon enough and she being young and with no other previous history, she would improve.I was wrong.She continued to get worse and also had other issues . She was mildly anemic and had developed kidney problem.She ended up on the ventilator and continued to get worse . Her need for the oxygen was getting worse and I had to sedate her . As the need for oxygen and ventilator support got worse that we had to paralyze her.With the need for ventilator getting worse and her lungs becoming stiffer , it blew up and collapsed and we had to put in a chest tube to treat collapsed lung. We had all sorts of consultants on case and we must have put in 4 chest tubes at different times .She needed tracheotomy as we could not wean her down the ventilator for more than 2 weeks. She had several tubes and catheters and lines,that she was on constant sedation drip.All the cultures were negative and the antibiotics were not effective . I had done the bronchoscopy and it did not add any thing to our understanding of her diagnosis. I had started her on steroids and before I  had done some blood tests for a condition called Wagner's disease. This was a long shot and I had thought about it due to the kidney issues and lung infiltrates.Withe cultures being negative I was not sure as to what was happening.
     To my surprise ,the test came back positive . I don't know how many times I must have called the parents and told them that I am not sure if she was going to" make it "We also had to do feeding tube . She was in ICU for may be 6 weeks .I had started her on large dose steroids and she had gotten little better, but not enough. So with the consultation with the kidney specialist, we started her on immunosupresants .There was a risk. Risk of infection ,but also that suppressing ovulation. This was effective and slowly we started seeing an improvement. She did have tracheotomy and was on ventilator and we were able to wean down the support.I was talking to the family on daily basis. This may have been due to the language barrier.The mother did not speak English at all and I did speak her mother tongue fairy well.She was off the respirator and had started feeding on own. Physical therapy was started.She was discharged .and was followed by the kidney doctor. The continued her medication for the Wagner's disease, and steroids were reduced .       She did very well and was off the steroids. She became a nurse and started working in the same ICU where she was admitted for almost 2 months.She got married and moved to PA. I had seen her parents few times , but it was in a social meeting where there were hundreds of people. So the talk was not much. Then I had a call that she was in town and wanted to see me  and if she could come to my house . I said OK and she came to my house . When we opened the door ,I was pleasantly surprised.SHE HAD HER TWINS WITH HER !!. She was off all the medicines and got pregnant and the kids were healthy. She came to my house to personally thank me . This was the biggest reward to me.(from the GOD) 

Saturday, July 12, 2014


      We often say , "what a coincidence".But I think we sometimes use this when we are not expecting and we are surprised to see something ,rather than real coincidence.Or may be both do hand in hand. We are surprised and it is truly coincidence.I was talking to a friend of mine from New Jersey.One of my classmate's daughter was dating a another young man.As they started getting little more serious, he came to see the father of the girl.So the usual conversation progressed,the father asked the boy as to what does his father do ?So the boy answered that he was a physician. Since both of them were Indians , the father asked as to which medical school he went to. It was the same medical school that the father had attended. So he asked the name of the father of the boy. As it turned out , the father of the boy was the classmate of the father of the girl and both knew each other quite well.So the kids of two friends were dating each other and they did not know that the two parents knew each other. Is this a coincidence or did it become coincidence as it was not expected? The story that I am going to tell is one such story.
    It was Saturday .So I was going to go to the hospital late.I got a call on my home phone line . The caller asked if it was xxxxx"s residence .So I said yes . Then he told me that he was so and so and was visiting Orlando. He was from Washington and had some free time and wanted to know if he could come to my house.He got my telephone number from telephone book.We  both were Indians and spoke same language and he somehow knew of me .I agreed and gave the direction to my house. I went to the hospital and when I came home he had just arrived.
     He was a 55 years old , who owned a business and had sold it a larger company.He was consultant for the company. So he was visiting the local manager. He told me about his family and asked me about mine and then we had a lunch. Around 4 pm he left. His manager was living on our side of the town and he got direction from me.(this was at the time when cell phone weighed 10 lbs!!).I have not heard from him again.
      That night I had a call from ICU for a new patient. It was 1 or 2 am and this was a 21 years old girl, who had a cardiac arrest.I had to go to see  the patient.I went to ICU. She was 21 years old , who was at home with her boyfriend and had a cardiac arrest. Many a times in these cases it is a drug related cardiac arrest . The Saturday night, boyfriend -girlfriend together, cardiac arrest, I had seen these cases many a times. But in these cases the boyfriend (or girl friend) usually 'dumps' the patients in ER and are no where to be found.In this case He was there and to my surprise the urine drug screen --testing urine for the drugs was negative .The girl was unconscious,not breathing over the set rate of the machine.The X-ray showed mild congestion.Most of the times when someone loose the consciousness,they may vomit and can get aspiration,i.e.stomach contents going in the lungs . So I started her on the antibiotics. I also ordered the echo cardiogram , ultrasound of the heart and then talked to the family . The both parents were present along  with the boy friend.I told them that main thing was to see how her brain recovers. It may take some time.In between we will 'support'her on respirator.
     The next day I saw her . She was still unresponsive .I got the echo cardiogram report. And I was surprised It showed that her heart was very weak.The pumping action was 10 %.So most likely she had weak heart , which was not known , and that caused the cardiac arrest. (sometimes a viral infection can affect the heart and make it weak. This is reversible in many patients.)But in case of this young girl it  caused cardiac arrest and it has caused the brain damage . Unless the brain recovers , nothing can be done . So the days passed . We had neurologist see her and she had brain wave recording. After about 7 days , there was no change and she was not breathing on her own and brainwave recording was very very slow and was not encouraging.I was  talking to her parents and family.We talked about the prognosis and poor out come.We talked about the withdrawal of the life support.It was very hard for me even when the patients are 'old'. This was a 21 years old patient.I was not too sure how can I console them . In these types of situations , no matter what one says , it is not going to be enough. You can not reduce the grief.But I did bring in the Indian philosophy or the concept of the soul being immortal and the concept that as we change the clothes , the soul changes the body.So the father asked me if I was Indian(Hindu). I answered yes. So then he stated that his 'boss' was Indian too.So asked for his name . He said 'you would not know him as he is not local'.I knew. I asked him if he was from Washington ,and his name was xxxx.I was not surprised when he said yes.
     So the guy who came to my house, whom I had not seen or known before, was his boss. And the manager that he went was the father of this 21 years old patient who was dying(or was dead).
                                   THIS IS COINCIDENCE.