Sunday, April 27, 2014


       I did write about the destiny and if we can change it or not .This was in connection to the question , "if we can not change the destiny , then how can we be held responsible?" As I stated in that blog, we can change anything if we have 'enough' time .and if we try 'hard' enough. The classical example that I could give was the one studying for any examination . If one starts studying for the examination only a day before the examination , then the destiny is not going to change . But if he starts studying long before the date of examination , he can change the outcome .This is very simple to understand , when it is an examination and we know when it is to take place . But the problem occurs when we don't know the date of the examination and so don't know if we acted in time, The story that I am going to tell is one such , where I did not know if we were acting in time .
        I had a call from a primary care physician on one Wednesday before Thanks Giving.He had seen a patient 49 years of age , who had acute bronchitis. He treated her with antibiotic. She continued to have significant cough and had now had some shortness of breath. He did  X-ray. It should fluid around the lung.So he called me , so I can get her in the hospital and take care of it.I could have done this as outpatient , but she was short of breath and I did not know as to the cause of the fluid . If it was due to pneumonia , than the treatment would be different , than if it was cancer.So I admitted her . She was a smoker , had no fever and was somewhat short of breath . So o the Thanks Givings day I did the procedure to take out fluid . I removed almost 1200 ml of the fluid.The report came back as cancer.I also did a CT scan of the chest after the fluid was taken out and it showed abnormality in right lower lobe . I did a bronchoscopy and she had significant narrowing of the lower lobe bronchus and the biopsy showed the cancer . So in essence she had a lung cancer and it had spread to the covering of the lung and the treatment of the cancer was going to be combination of radiation and chemothery. The question that I ofetn get is why can't we cut out the entire lung and explain it to them is that once the cancer spread to the covering of the lung , then taking out the lung , though it is possible technically , does not alter the outcome or the prognosis. I did consult the chest surgeon for recurring fluid collection and he put in a talcum powder . The talc causes the reaction and it stops the fluid recurring in more than 85% of the cases.
      So she was started on the treatment and did very well . She got the radiation , followed by the chemotherapy and she had some side effects , but overall did well . I continued to follow up . She had quit the smoking and had some COPD but was doing well. The oncologist continued to do the follow up scans and there was no evidence of the cancer recurrence . Due to the previous tumor, and the radiation, there was abnormality in the right lower lobe.Since she was doing so well, I had the question popped up again . Why can't we do the surgery . I did a another bronchoscopy and saw the narrowing of the bronchus , but there was no tumor and the biopsy was negative for the cancer . It was almost 20 months, since the diagnosis of the cancer was done . I spoke the oncologist.He had no plans to give any more chemotherapy.The patient was pushing for the surgery and I had no  answer as to why we should not do surgery . I told her that the surgery is possible , but if we agree to do it , there is still risk of recurrence and with major surgery it would be risky aand all the efforts would be wasted.
      I spoke to the surgeon and he saw the patient and talked to patient and the family . He told them that doing surgery was not conventional and there was risk of 'unwarranted ' surgery. By then it was 22-23 weeks ,almost 2 years . The family and the patient decided to do the surgery . The surgery was done . The lung was taken out and the pathology did show that cancer was still there , ( even though there was no clear cut evidence of it on the scans . So the patient and the family was very happy. But upon follow up in 3 months, with the scan  she had spread of the cancer to liver . She was restarted on the treatment , but did not do well. She died in about 6 months .
      So when we did diagnose the cancer we knew the destiny and did not know if we had enough time to change  it . Then when we decided to do the surgery, we thought that we werre going to change the destiny , But we were wrong . WE DID NOT HAVE ENOUGH TIME TO CHANGE THE DESTINY, AND OUR EFFORTS FELL SHORT!!!!!


Friday, April 25, 2014


       I remember the time when the movie called The Close Encounter , came out in theaters . There were long lines for the tickets . Now the similar  movies with better cinematography have come out . But this one was one that I remember very well . But what I want to write today is not the 'THIRD KIND',but the encounter of Lord of Death . In Hinduism , we have a concept of the Lord of Death. In fact one of the scripture called .Kathopanishad , was a discourse given to a young boy by the Lord of Death, about what happens to 'us' after the so called death .it is very interesting to know that each religion has different concepts about life after death. But to my knowledge , there is not much known or talked about signs of death approaching . I have read some books that talk about it . I want to share a story with you about a patient that had close encounter.
     I had seen this 63 years old patient with advanced CO PD. He was a smoker and had significant damage to his lungs . He was on oxygen and also had lot of vascular problems . He had a enzyme deficiency , called Alpha 1 Antitrypsin (also called AAT), But he did not want replacement for it , which is normally given intravenously.He was referred to a cardiologist and had some stents put in . He also had aortic aneurysm and was seen by vascular doctor and I sent him for the lung transplant evaluation.Couple of centers rejected him , but one decided to work him up.He had some nodule in the lung and had several endoscopes as he also had abnormal chest CT scan . I had followed this for sometimes and there was no change , but he still had bronchoscopies with new techniques.He was admitted to hospital and was quite short of breath . In spite of treatment he still 'felt' short of breath. I gave him some tranquilizers, to take care of anxiety. This seemed to have worked . I also talked to him about noninvasive ventilator at home . This a respirator that gives breaths, with a pressurized mask.. He was reluctant , but agreed . He was discharged. I called his insurance company doctor to get approval . But then he was readmitted . I had a call from the transplant doctor , on the last day of his hospitalization that they had decided to not accept him for the transplant . I did tell this to his wife , but did not want to tell him this at that time .
     On readmission he was OK . I was not too sure what had brought him back but his salt in blood was low . So we started him on IV saline  and he got better . On the 3rd , I went to see him . It was Saturday.I saw him . He looked uncomfortable . He was little short of breath or was breathing little faster . But  his oxygen saturation was good , his blood pressure was normal and his heart rate was normal . He had just gotten back in bed from the bathroom and I thought that the faster breathing was due to the exertion . But I was not too sure . I asked ,if anything else bothered . He told me that he had some stomach pain . He had upper endoscopy less than 2 weeks ago . and also had follow up CT scan with the vascular doctor less than 3 weeks ago . When I checked the labs , I noticed that his blood count had dropped , but then he also had quite a bit of fluid, which could dilute the counts. On examination, his lungs were clear and he had mild tenderness in belly.I was not sure . I called the nurse and tried to call his wife on telephone . I wanted to know if she had told him about the transplant rejection  and also wanted to ask her about the CPR and code status. I knew something was wrong . I ordered the repeat blood count , and ordered the CAT scan of the belly to check on the aneurysm .Could not get any one to answer at his home . So I went to his room again and asked for her cell number . He took his own phone and placed the call . I spoke to her and told her that I was concerned about his condition and I was doing the CT scan stat  to rule out problem with the aneurysm .I also asked her about the code status , and she told me that she had told him about he rejection from transplant team and they had discussed and decided that he would be DNR. I gave him the phone and he reconfirmed the DNR . I left the floor after signing the forms and went to next floor to see other patients . It may be 15 or 20 minutes .that had passed that I heard hospital operator calling cardiac arrest from his room. I ran up stair and the nurse was in the room and other 4 or 5 people were there.The nurse had informed them that he was DNR , so no CPR was done . He was put on 100 % oxygen and was barely breathing . The transport from radiology was there to take him down for the CT scan that I had ordered I tried to call his wife and no one answered at home . I did not have her cell number as he had called it for me . I picked up his cell phone dialed the last number dialed . She did not answered. I looked at the other numbers that he had called and called one that he had called earlier . It turned out to be his daughter. I could not tell her that her father was dying .She did not live locally . I was in the room for about 20 to 30 minutes watching his agonal  breathing . Then I left .Told the nurse to call me when his wife would arrive. I came to talk to them . Some how she had known as the nurse was able to contact her after I left.
      I knew that something was not right . I also knew that there was a possibility of aneurism rupturing. I also knew that he may end up being coded . BUT I DID NOT KNOW IT WAS GOING TO BE THAT SOON --MY CLOSE ENCOUNTER .      

Saturday, April 19, 2014


Sometimes I come across patients that have a what appears to be a simple problem, though we make it complicated and then go on wrong pathway . So then the answer appears to be simple and we 'feel ' very 'prowd ' of our self , and pat on the back , may be too prematurely . This happened to me recently. This just reminds us that we are not in control.
     I had seen this 85 years old female for may be 2-3 years . She had bad lungs and some other usual problems like , high blood pressure and arthritis . Her ambulation was some what limited and she was on oxygen at night . From my stand point she was doing as well as a 85 years old would be doing . She had a regular follow-up with me every 2-3 months. .Her follow up with me was about a month away , and I had  call from the primary care MD . She had seen the family doctor for the shortness of breath or may be it was a regular follow up . She had some cough, and some shortness of breath. So the primary care physician gave her antibiotics. And some cough syrup. He had a chest x-ray done and it showed pneumonia. So she was treated with more antibiotics. The follow-up was done at the primary care physician and she was again treated and had another follow-up x-ray done. The follow-up x-ray continued to show more congestion and now had a small amount of pleural fluid. Subsequently a CAT scan was ordered, and the CAT scan showed that patient had pneumonia with pleural effusion. Subsequently the doctor called me and possibly to see as soon as patient was developing pleural effusion and/or pneumonia was not getting better. I gave her the appointment soon.
       I saw the lady in my office. She had not much in the respiratory distress definitely had some increased cough. When I examined her lungs had some congestion on the backside. She had at least 3+ pedal edema. I checked her oxygen saturation and that was 95 percent on 2 L oxygen which he usually used at homes.I looked at the CT scan , and realised that the patient was not having unresolved pneumonia , but was in congestive heart failure.I talked to the patient and the daughter who was with patient . I told them that I would like to admit patient and treat her for the congestive heart failure . I told them that the fluid that we were seeing in the lung was due to the congestive heart failure and not due to pneumonia .She was reluctant ,and told me that she was in the hospital 3 months ago and had cardiac work up done and it was OK. I did get that report pulled up and she was correct . Her heart function was normal . This time eon examination , she had heart rate which was fluctuating between 120 to 145. It was irregular . I explained it to them that I still felt that she had heart problem . She agreed to get in the hospital , but talked to me about code status . She did not want to be put on any machines . So I signed the DNRforms .
     She was admitted to the hospital and we started treating her rapid heart rate and gave her diuretics . Her heart rate was controlled and the edema was also getting better . I did new echo cardiogram . And it showed that the heart function had dropped down to about 25%, which in past was 60 % , which is normal . The cardiologist saw her and some more adjustment was done in her medications . She was much better and was about to be discharged . The nurse called me and told me that she wanted to see me again , as she had forgotten to ask me a question . I went back to the room and she told me that she wants to be discharged home with HOSPICE . I was OK with that . The Hospice saw her and she was discharged home .It was Friday that she went home . I wanted to see her in office in 2 weeks . I wanted to check on her electrolytes in one week . I got a call from the Hospice on Monday that she died on Sunday .
     So here I was . patting myself that I diagnosed the patient correctly and treated her correctly and she had improved , and how smart I was to do this in spite of last cardiologist saying that she had no cardiac issues and her heart was OK , just 3 months ago . But the Luck , the God . whatever you can call was laughing at me as her destiny was determined and SHE KNEW IT !!!!

Friday, April 11, 2014


   I wrote about the time of birth and my thoughts on why we are born . There are many questions that remain unanswered.But I thought about writing on time of death . Why is it that someone that we never thought would die , dies next minute ?Or someone who we think will die soon 'lingers' for long time . I see this all the time in medicine and we all do see this in our life too . I have some thoughts .These are based on some of the same concepts that I had in my previous blogs .
     As much as we are born  to complete our desires, why do we die with more desires left unfulfilled ? This would be a natural question . The simple answer is that the Desires are never fully fulfilled . Think about it . If we desire to eat Pizza or drink alcohol or have sex , has it ever happened that we eat pizza and now have NO DESIRE to eat pizza ? or never have desire to drink alcohol or have sex ? So desires are fulfilled only for short time , just like the itching on the skin . More we scratch , more we itch and more scratching is needed . So when we do Karma , we have effect of them and the impressions bring us back to next life . So we are born with "fixed " no of 'seeds' that will come to fruition in this life and we create more Karma that leave with impressions .So when we are born , there are certain karma that have left us with impressions , that have left us with desires , that will come to fruition.. Some of these karma will be strong enough that they will come to fruition in this life , while others will be carried to different life , and these will determine our new birth , family , life and our relatives and our so called life .So when we are born , time that we are going to die is determined . The time is determined by the amount of seeds of karma that are going to come to fruition . So once that is done then we are gone .It is just like 'annual plants ' or the banana tree. Once the flowering is done the plant is gone . So the question would be , why some people die in few days after birth or few years  and some die after many years , even when we don't see any purpose of living ?.I think that even though we do not see any purpose there is always some reason . The loss of a young child in some one's life , is not without purpose . It may be due to some Debt that the two parties  i.e. the parents and the child , that had to be repaid . Or in case of older person , who lives with a stroke , fully dependent life , he and his care gives are doing some 'give  and take ' . either due to previous karma or creating new karma .
      We create many karma this life and some of them will have effects in this life . Smoking , excessive drinking ( alcohol ), drug use , all these are examples of the karma that come to fruition in this life.So the question would be can we change the time of death , can we postpone our demise?The answer is yes but very seldom.This based on the not my ability , but what I have read in books of evolved souls . In the book written by Yoganand , his GURU was asked to prolong some one's life . HE the GURU ,  UKTESHWAR did not want to do it . ( the thought is one is holding them back in this world ).But he did it for few months . The life has to come from somewhere . So as I understand one can 'borrow ' the time from next life and get an extension in this life , though it is very difficult and limited and can be done by only few , who are highly evolved souls .
     So to summarize we come with fixed years of life span , based on what karma are going to fruition  in this life . Once this is over we are gone . We create new ones , that may come to fruition in this life , and very rarely we can get extension.
    I am sure when you read this you will have questions , and I will have some more too .
    May be you will have some answers too . so let me know .  

Wednesday, April 2, 2014


      I was going through the last blog and thought  that some of the questions were may need clarification . One of the questions that may arise is if our 'give ' and 'take ' makes more attachments and in turn brings us back to the physical world, then it is likely that we will continue to have same souls in our different lives . This is true , but just because we are related in this life , does not mean we are creating more debt in this life . We see this on many occasions.The relations that we have simply related to our birth in a  specific family may mean nothing as far as closeness or give and take is concerned . So we may develop new relationships and have new debt.
     Secondly if 'conception' creates a spark in the astral world , then a soul is attracted to the fertilized egg, then what happens to the soul if the egg is fertilized outside the uterus , in a test tube ?When the egg is fertilized in a test tube (in vitro fertilization ), the so called parents are not decided , so then which soul will be attracted ?.The parents are not decided , so the environment that the soul will be born in is not decided till the fertilized egg is implanted in the uterus There is also another problem in modern society. In today's world , fertilized eggs are stored , frozen for long time , till decision is made as to implant them or throw them , destroy them . So how would a soul be attracted to it and then if not implanted in uterus and develops in to a human being , then it will be "trapped " in a frozen egg and that does not sound like any progress or a choice that a soul will desire .( or may be it does ).
      I don't know the answer to it . But it brings us to the million dollar question as to when doe the soul enters the fertilized egg? I do not know and I have not gotten any answer to it from learned people . I have my own thoughts and I would love to know what you think and why . Since the KUNDALINI, the coiled up energy , which stay es dormant , rested in lower part of spine ,I think may be the astral body and causal body , soul , enters the body when the neural grove if closing . I have no way of knowing if this right or if there is any evidence for this theory . But this was one of the thoughts that came to me . I know sometimes there are more questions than answers . But we can think about this in clowning , or in case of twins and in case of  many other circumstances .