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".