Sunday, March 30, 2014


     The other day I had a call from one of the hospital's doctors . He wanted to know as to what should he write on the death certificate as to the cause of death, in a case of a patient that I had seen with him . (The story of that patient could be itself a story).I t made me think as to why someone dies at a specific time . Some die at early age , when no one suspected and then others live long time with no obvious purpose,at least what we can see. Then I thought about the BIRTH. Why do you think we are born , at a specific time to specific set of parents , in a specific country and so on. Again this question arises only if we believe in reincarnation. Even if you do not believe in reincarnation , question still remains as to why we are born on this earth. One more question that could arise if we don't want to believe in reincarnation, is that where were we , before we were born?. This question may be the best proof that there is reincarnation. Otherwise the question comes as to why some of us are born rich and some of us poor ,some of us to good parents and some to bad parents . But that is a separate discussion.So now we still need to answer as to why we are born .I thought about it  and trying to put it in words.
       To understand the answer, we must try to understand as to what happens to us when we die.When we die , what actually 'dies ' is is a physical body . The body dies because the power that keeps it alive is gone . Think about a computer. If the batter dies then the computer does not work. It still has a the software and the hard disc and the keyboard.But the computer does not work . If we can get the battery recharged , then the computer will work . In case of the human body, if we can charge the battery , it will restart to . But unfortunately (or fortunately), the physical body decays , and then new charge will not work.So when we die , the 'causal body' leaves the physical body . Since we carry the impressions of our likes and dislikes , our experiences,and impressions of our 'DEEDS'--or what we call as Karma , is carried from physical body to a body call Astral body .The the bodies are tied together during our existence on the earth, and the two bodies , the causal and the astral bodies leave together. They have to be somewhere . That world is called Astral world. It has several levels and is a replica of the Physical world except that since it does not have physical elements , we can't see it.(as we only have physical eye and unless light reflect from an object , we can't see it with physical eyes.)
     In the astral world we are placed in a particular level based on our progress that we did in physical world. It is all most like going to casino. We can play only those games that we have money for and once we run out of money , we have to leave the casino.There are two differences though with this example, One is that we can 'spend' money in casino.and may be we can continue to get more money , may from a bank or credit card or borrowing it . In the astral world , our chips or the money is the good deeds that we did in physical world.In the astral world we can not make more money.(Can not get more good deeds to our pot. )What we call as good deeds ,are most of the time or may be all the time are related to the physical world.We can feed the hungry or provide a shelter or provide medicines to sick etc . This is all at physical level. But if we do not have physical body we can not do any of these Good deeds . So How can we improve upon our 'chips'?So in the astral world  we can not uplift our self very easily.SO TO GET BETTER AND IMPROVE OUR STANDING IN THE ASTRAL WORLD , WE MUST GO BACK TO THE PHYSICAL WORLD. This is the first cause for us to be born..So this is one of the driving force for us to be born.
     But then there is second and may be much more powerful force for us to be born.We do things in our life on physical world and it leaves us with an impressions and those impressions create desire and desire leads to action and action leads to impression . So this is called circle of mind . The desires and the impression DO NOT DIE with physical death. These impressions and the desires that they create are stored in the astral brain in an abstract form . Since in astral world we o not have the physical body , we can not ' ACT ' or 'FULFILL' these desires . So we must come back to physical world.Just to give example , I want to eat sweet food . I can not eat sweet stuff to fulfill the desire unless I have physical body .So we must GO BACK .
   The time and a place that we are born is determined by the strength of our desires and how deep are the impressions and at what level in astral world we are . I like sweets but the intensity of my desire may not be very strong and it mat take longer time for it coming to the surface and be strong enough for me to force to be born . We also develop 'connections .and create 'DEBT'.We are sons and daughters and we are fathers and mothers and we are friend and neighbor and we are husbands and wife. These relations create 'give' and 'take ' relationships . So we have attachments and create debts . These must be RE PAYED. So based on our deeds , desires , bondage and debts and attachments we 'select' our parents and place of birth , family and other thing including time .
This is like a matching game --may be like E-HARMONY .Whenever there is a conception , there is a 'spark' in the astral world , and several souls , with their astral and causal bodies are 'attracted 'to the fertilized egg. Only one succeeds. So to some extent it is voluntary , to some extents it is not . But ultimately we come down because we have connections that we could not cut , neutralize and we did not die without some desires left unfulfilled .THIS LEADS TO THE REBIRTH, THE TIME AND THE FAMILY.
     This is somewhat short explanation as to cause of birth.
      I hope to write about the "cause of death" in my future blog.  

Saturday, March 22, 2014


    I see patients and know that some of them have serious disease and will not make it for long time . Usually when I see patients with wide spread lung cancer , I know that they will not be alive for years . Based on the growth pattern I can see that they may be there for few months or may be couple of years . There are times when with smaller nodules and new Radiation treatment I have even seen cure.But there are surprises . I saw recently saw some incidences , where my judgement was not best .
   I had seen this lady for long time . She was a retired nurse, that I had seen in the hospital as a nurse . She had dry cough and her primary care physician ordered a chest X-ray and it showed abnormality and so she saw me . She had pulmonary fibrosis. I did the breathing test and chest CT scan and confirmed the diagnosis. I was reluctant to start any steroids .So I decided to watch. And many years passed by . She continued to have cough , but did not get worse either with X-ray or the breathing test. I must have followed her for at least 15 years or so . Then she had some colon problem and then was diagnosed to have colon cancer. She was operated and really did well . The only thing that was new was that we did a cardiology work up before the surgery and it showed that she had narrowing of the aortic valve and mild coronary artery problem . Sh was 87years old and we decided to to do no additional procedures. She did very well and was out of the hospital in less than 7 days. I continued to do the follow up.She was getting old and her activity level was down . Her husband who was also our patient, was also having some problems but doing overall OK.
     Then I had a call from the hospital one morning , may be at 11 am . She was admitted with shortness of the breath. It was more than 3 years since her colon surgery. She was 90 years old .She was awake and was short of breath. But still was conscious and oriented. Her oxygen level was low and she was on 100% oxygen. She had loud murmur of the aortic valve narrowing and the crackles , which partly were due to the fibrosis and (as I thought, partly due to water in lungs .) She was not putting out any urine . As I saw her and discussed the care with the family , the kidney specialist saw her . I discussed with him and we decided to start her on diuretics to get more urine out put,so that the water from her lungs would be reduced ..I talked to them and made her DNR . We decided to do only medicines . She agreed and so did the family . She was quite awake and in spite of being short of breath , talked to me .I talked to the nurse and her primary care doctor.
     I was leaving the hospital at 12-30 pm or so and I got a call from the nurse , she had just passed away.I knew that she was not going to survive for long , but I did not expect that she was going to go in less than 2 hours!!!

Friday, March 21, 2014


   I often see patients , where I think about the diagnosis and try to work up to get to the  diagnosis. Unfortunately the answer does not go well as it may be indicative of bad outcome.So the happiness that we got the diagnosis does not last that long.The story that I am going to tell is one such case.
   I saw this patient few months or a year ago.She was seen by me for abnormal chest X-ray and CT scan. The CT scan showed some lymph nodes enlargement. I was not impressed , but decided to do follow up on it. I then got additional history , that explained it very well . She had something called monoclonal gamapathy.The minor lymph node enlargement can be seen in this condition.I was going to do just follow up on scans .
   Few months down the road ,she had belly pain and her primary care physician did a CT scan of the belly.It was OK as far as belly organs are considered, but had fluid around the lungs.So she came to me .I was not sure as to why she had fluid , but thought of heart as she had a murmur.I ordered a blood test for the diagnosis of congestive heart failure.and started her on a water pill.The test came back as elevated suggestive of the diagnosis of congestive heart failure.So the treatment was was correct.She was seen by cardiology nurse practitioner ,and he increased the  dose and that caused the drop in blood pressure and she ended up in the hospital . She went to a hospital,where I don't go .She was seen by another MD and he did take out the fluid  twice . IT showed the findings to be consistent with the diagnosis of congestive heart failure.She was discharged.
    She was again admitted in the hospital with similar problem . Since she knew that I don't go the other place ,she decided to come to our hospital .She had low sodium (salt content)and kidney failure. The fluid was worse and the blood test for heart failure was 10 times higher.I spoke to the kidney specialist and started her on larger dose of diuretics.I was not sure as to why she was getting the fluid back all the time . Her cardiologist was seeing her , but it was not clear as to why she had the heart failure.I spoke the cardiologist as most of the time she was seen by his nurse. I did do a liver scan and it was abnormal and so I thought that she had a liver disease .I started her on different treatment and she got better. She was discharged .
   She came to me and continued to have ups and down . So I called the cardiologist and asked him to see her personally and may be do a cardiac cath, She did have a leaky valve . I was not too sure if she needed that valve to be repaired .
   The cardiologist saw her and told her that she should go to Mayo Clinic. She made the appointment. But got admitted to the hospital . This time she was sick and had multiple issues.Had significant worsening of kidney function and her blood pressure was low. Then she had complete shut down of the kidney. Her lungs were filling with water. She needed more oxygen.
    We still did not have the diagnosis . Going to Mayo was out of questions she was too sick. I decided to do a biopsy of fat pad from her belly . The surgeon called me asking as to why I wanted such a biopsy in this sick patient . My problem was convincing the family that she had something that was not going to get better. I needed the diagnosis. So I asked for the biopsy.
   The patient did not want to do any aggressive treatment or go on machines.But I had to get the family members convinced . The biopsy was done . She continued to get worse and then the family did make the decision of doing 'comfort care'.I talked to them ,did write DNR, Do not resuscitate order and checked the computer for the biopsy report. SHE DID HAVE WHAT IS CALLED AMYLOIDOSIS!. In this condition this material gets deposited in various organs and also the heart and that caused the heart failure. So we did get the diagnosis , but it was not helpful to the patient.  

Saturday, March 8, 2014


   I have often said that the critical thinking is very important in medicine . Again treating cold or respiratory infection ,like bronchitis or pneumonia or sour throat etc does not need much critical thinking .Even computer with enough data can do it . But when the problem is recurrent or more serious , then the critical thinking becomes very important . I often see patients where computer generated medicine is used. (not that doctors use computer to make decision) But our thinking becomes limited as is that of computer.Heart rate is up/more give medicine to reduce it , without trying to find out why is the heart rate is up , and then treat it.The story that I am going to tell today is one such .
    I had seen this patient . She was a smoker and had persistent cough.The usual treatment for the cough did not help. So the doctor ordered the X-ray and it was abnormal . The CT scan was ordered .The patient was referred to me . The CT scan had shown that patient had multiple nodules , almost more than 100. With her history of smoking , I thought that this was most likely a lung cancer, that has spread.. I did a PET scan . As I expected it was positive in lungs . But there was also an uptake in colon. She underwent both a bronchoscopy and a colonoscopy . There was a tumor in her colon and biopsy from that was positive for cancer. The lung biopsy also showed that the cancer in the lung was a spread from the colon cancer .So she had a colon cancer which had spread to lung and there was no lung cancer .
    She was referred to an oncologist and was started on chemotherapy.Within next few months she was admitted to hospital on number of occasions .Sometimes it was due to shortness of breath, sometimes it was due to cough. Due to significant part of her lug being replaced by the cancer she was always short of breath and we could never get rid of her cough. In an attempt to treat it she was put on steroids and was on steroid most of the time . I was trying to reduce the steroids to zero and she would get admitted again. Her last 4 or 5 hospitalization she would come in with cough ,shortness of breath and fever . She wold be started on 3 different antibiotic as she was considered compromised host due to underlying cancer and being on chemotherapy.With repeated use of antibiotics , she developed what is called CDT colitis . The infectious disease consultant was seeing her . So I could not stop the antibiotics. But every time all the cultures were negative. We would reduce the steroids and then discharge her on oral steroids and antibiotics. In the hospital she would have no fever , but always had fever at home .
    I realized as to what was happening.The fever was not due to any infection , but it was due to cancer . So when we stopped the steroids , the fever came back and she was in the hospital. We would give her steroids and it would suppress the fever.The recurrent CDT , colon infection was due to recurrent use of antibiotics , and we could never clear it up as she was obstructed due to colon cancer. I decided to stop all antibiotics except for one for colon infection. and decided to continue steroids at low dose , but not to stop it .This has worked out so far .
    So the knee jerk reaction is give antibiotics whenever there is fever .But critical thinking was to find out if we really needed antibiotics and how can we avoid recurrent colon infection in patient with partial obstruction . 

Sunday, March 2, 2014


        We often use term 'it is Gospel truth "when we are talking about what we think it is a FACT .But many a times what we think as a fact or truth, turns out to be not so . In one of the old Hindu scriptures , called PATANJALI SUTRA YOGA , it state that there are different 'proofs ' , that we believe One is Direct . one is Indirect and last one is 'WHAT IS HEARD (FROM LEARNED EVOLVED SOULS ).The direct one is simple to understand. If I see somethings , I can 'trust' it . This is not 100%.I may 'see' something and conclude something , which may not be the truth.Our eyes can not be fully trusted. Anyone who watches the crime dramas know this very well . The Indirect is also simple to understand . If I see  a cooking burner coil to be red , I will conclude that it is hot . I do not have to to touch it . If I see smoke , I will conclude that there is a fire . But I could be wrong in both these instances.What I thought as smoke (my eyes thought it was smoke ) may be fog /smog and so there may be no fire . The last one is what we here from evolved souls . THIS IS GOSPEL TRUTH. The unfortunate fact is that we use this term too loosely.The story that I am going to tell is one such story , where we thought we knew , when in fact we still don't know .
      I saw him in recovery room . He is an executive , educated and well connected guy. He had a cough going on for sometimes . So after couple of antibiotic courses he had an X-ray . It showed pneumonia . He was treated with different --so called stronger antibiotic .The follow up X-ray failed to show any improvement and his cough was still there . So he had a CT scan .The CT scan showed a abnormal area of consolidation or pneumonia or mass . So he had a PET scan . It was positive , which means possibility of cancer was high. So he decided to see a thoracic surgeon . The surgeon took him to surgery. He did a bronchoscopy . The bronchoscopy showed that there was a blockage of a bronchus with what he thought was a "impacted meat ". He did the biopsy.The biopsy did show ' meat fibers '.I was called in to see patient and do follow up.
   He continued to have cough and was wheezing. So I started him on medications.He had follow up X-ray and then a CT scan . The CT scan did not show any improvement . So I talked to the surgeon,and did the bronchoscopy. I saw what looked like a tumor to me . I did the biopsy , but it came back as necrotic tissue . I spoke to the surgeon and told him that I can not remove (if it was meat ) nor could do lager biopsy. (I felt that it has to come out or he needed to to do biopsy under anesthesia .) He did the repeat biopsy and this time the pathologist read it as "malignancy ,most likely metastatic melanoma."So now see , we have 3 different reports , The first one , possible meat , second one , necrotic tissue , and the third one was melanoma . There are tumor markers . The melanoma markers were negative , but the pathologist felt that it still could be melanoma .
   After the discussion it was decided that in any case it must come out . So he had resection of the lobe of the lung that contained the tumor . It was reported as "spindle cell tumor , could be sarcoma."This was the final diagnosis .
    This what I was calling the Gospel truth . The pathologist and the cancer doctor and the the radiation oncologist , (forget about me and the surgeon ) still do not know if this a lung cancer or sarcoma or ???????

Saturday, March 1, 2014


    I had written about a case ,where one of my patients had 2 separate lung cancers at the same time . We decided to take them out one at a time . It was felt that she was inoperable as cancer from one side had to go to other side via blood and which means that the cancer will pop up sometimes soon . We did unconventional things and decided to operate one side at a time and we were lucky . The 2 cancers though appear similar in gross way , turned out to be different on tumor markers . The other findings on PET scan were also thought to represent spread of the cancer , but at the time of surgery turned out to be OK . So I was happy .
   It has been over 2 years and there was no evidence of recurrence. She was still going to the oncologist . The oncologist decided to to the CT scan . I had done the follow up CT scan on her before and I used to do it without using contrast . This time the oncologist decided to do it with the contrast . Then I had a call from him that it showed nothing new in the lungs , but there was one enlarged lymph node . The location was somewhat odd ,not easy to biopsy. So he did the PET scan . It showed that the node was hot , which meant that it was likely to be due to cancer . I reviewed  both the CT scan and the PET scan . There was no question that the node was picked up on PET scan .The previous scans were without the contrast . The contrast does make lymph nodes look more prominent. But in spite of the technical differences I also thought that the node was enlarged. I also could not overlook the high  uptake on PET scan .
   I discussed this with the patient and her husband . The only option that we had was to do the biopsy.(The other option would be to to do nothing and do follow up CT scan and PET scan in 3 months .)She agreed for the biopsy via bronchoscope . This is somewhat new technique . Through the bronchoscope ultrasound guided biopsy was done . The biopsy showed NO CANCER!
   I am pleased with this .But I will do a follow up scan in 3 months . My thinking was simple . The recurrence occurs most of the time in the first year .Some in second year and very few in the 3rd year . It would be very unusual to have the cancer recurrence only in one isolated lymph node without any other areas showing the cancer .
  Again I am very happy that the biopsy was OK .But I will continue to do the follow up and hope that logical thinking will pay off rather than looking at the test results as if they are Gospel truth.