Wednesday, December 23, 2015


       We are often happy , proud and boast when we are right or feel YOU did help someone . But at times this sis not so , In medicine it happens more often than in other professions . Sometimes we suspect cancer and we work to find or may prove that we are right. But when we get the diagnosis we are not happy as the diagnosis is not the best diagnosis. and the prognosis is not good. I had similar experience recently . The key in this story is different than I started this blog .

      So I saw this female who was about 70 years old who had chronic cough . She was seen by other doctors outside the country and had some investigations . She had no shortness of the breath and when I told her to cough all that she would cough would be spitting saliva . Her lungs sounded cleat and her X -ray was OK and the oxygen saturation was normal . I ordered the allergy blood tests and then did the breathing tests. It showed no obstruction or suggestion of asthma . I did try her on medicines for asthma and for allergies . She may be got little better but continued to have cough . Again it was only saliva and not real sputum . She was lost for follow up as she went out of town . I saw her again after a gap of few months . She had seen a cardiologist  as she was short of breath too . He did a echo cardiogram and then scheduled the stress test . So when she saw me she told me that she was quite Short of breath . I did make her walk as I do it in every patient when they complained of shortness of the breath . She could walk barely 30 feet. Her oxygen did drop little bit and she was not wheezing . But I could hear a loud murmur that I did not recollect hearing it . So I did a ct scan to rule out scars and send a note to the cardiologist . I wanted to tell them that her shortness of breath was real and was worse . I could not figure out as to why . But  a blood test was ordered . I got a text from the cardiologist that the stress  test was OK . Then came the diagnosis . Her hemoglobin was less than half the normal . So she was admitted for the work up and the blood transfusion . The further work up showed that she had acute leukemia . She was started on chemotherapy .
    So when I saw her for the first time , which was a year ago , my impression was that she did not have major issues , but I still did the work up . The last time when I saw her , I was quite concerned that SHE HAD something . though I could not figure out as to the cause of her shortness of the breath . But I knew that she had something . Unfortunately it turned out to be acute leukemia -not the best diagnosis and the prognosis .  

Saturday, December 19, 2015


      All of us know about the self destruction of the cassette in the episodes of Mission Impossible. In medicine we know there are many example of cell destruction . The red cells will die in 120 days from the time they are released in the circulation . The platelets , which are important  for the clotting have life of 7 days . Same thing happens with many tissues and many times There was a time when an experiment was done to see as to how long cells can continue to multiply if they are provided adequate nutritional support and environment in the Lab.In the beginning it was felt that the cells has unlimited ability to multiply. But then it was realised that when new chicken broth was added as nutritional support , thew were adding New Cells . Subsequent work showed that each cell has Fixed Limit. This is called Hafflick factor. When the skin of old mice was transplanted in younger mice the the cells lasted longer . However the limit was there.So this about the medicine , but the Self destruction that I am talking today is about behavioral destruction. I have seen this in my medical like. But this one of the story.
     I saw this 40 years old female in my office for chronic cough. She also had some shortness of the breath . She was in ER few times . This had started few months ago and she had seen a lung specialist I saw the old -2 months old Ct scan . It showed that she had Interstitial lung disease . I saw the old record . She had some lymph node enlargement and the lung specialist had done biopsy of the nodes and told her that 'everything was OK' .I decided to do new CT scan and the pulmonary function tests. The Ct scan did show that she was worsening in the inflammation in the lungs and breathing test did show that scars had affected the test. The process of transferring the oxygen is called diffusion and that is impaired when there are scars .This is called Diffusion capacity . I did do another broncoscopy and biopsy , but no definite diagnosis was established So I asked a chest surgeon to do the open biopsy . It showed specific reason for the inflammation and the scars . I had done all the tests to rule out that etiology called connective tissue disorder (Lupus or Rheumatoid arthritis etc )I started her on steroids and tried to send to Mayo clinic or other centers , but had problem with her insurance . She continued ti get worse. So I sent her for transplant evaluation . She was felt to be a good candidate, and they decided to start the work up , so that she can be put on Active list . The it happened . She was admitted for shortness of breath . Someone did a Drug test on the urine and it showed positive for cocaine .She got worse and needed 50 L oxygen .But she was not accepted for the transplant as she had used cocaine . They would not accept her till she is 6 months drug free .
                      THIS IS WHAT I CALL SELF DESTRUCTION ! 

Saturday, December 5, 2015


      We often talk about people being 'lucky' . When we watched the super ball or NBA play offs , we see that some games are won not by dominance of one team over other team, but sometimes it's shear luck . Otherwise why would at buzzer someone throws a ball and it is nothing but the net . No one , not even the player who threw the ball in desperation, thought that it would go . But it did . So that is the luck ,In medicine also the luck plays the roll , Sometimes the patients are lucky and sometimes the doctors are lucky .But most of the physicians will not say so , and will take the credit for diagnosing something unusual or diagnosing something which was not indicated by the symptoms . But I know better . I don't think I can take any credits or discredits when things go unexpectedly right or wrong respectively. There is a saying by a physician who invented the antiseptic technique or the hand washing before the delivery, to reduce infection '.I dressed the wound and God healed it .'So true! I n the Hindu scripture it says , 'You have right to the action , but not to the fruits of the actions ,' This does not mean murderer is not responsible for his or her actions.This brings me to the today's story.
       I saw this patient in my office few months ago . He was a young man who had cough for several months . He had tried over the counter medicines and antibiotics and some other stuff. It had not worked . So he was referred to me . He was not a smoker and had really no past medical problems . He did appear to me to be anxious. I did chest x-ray and breathing test and allergy test . The x-ray was normal and the breathing test was almost normal . I could make a case for mildest form pf asthma , but it was OK . The allergy test did show allergies to molds. I did put him on some medicines and then he missed follow up . I thought that he may have gotten better or gotten tired of going to doctor as nothing was positive . But then one day he showed up. His mother had passed away and he was out of town when she got sick. He was so upset that he spent 6 hours with her when she had already died!He simply could not stand loosing her . I can relate to it easily as I have lost my mother last year.I told him the concept of life after death and the Astral world and told him some books to read . I restarted him on inhaler and send him to an allergist . The allergist did the allergy tests and gave him some medicines . I had not seen him for may be 7-8 weeks . The one day when I was going to my office from hospital. ,I got a call from the emergency room physician , He was in ER with shortness of breath. The physician wanted to know if I wanted to see him in office sooner or wanted to know if I had any suggestions. He had done the chest X-ray, cardiogram , blood test to rule out heart attach and congestive heart failure and regular blood count.All the tests were normal . His oxygen was normal but he had shown in ER with cough and shortness of the breath . I was in the car . I was not too sure as to his problem . He certainly was worked up by me and nothing was found out granted  it was 6 months ago.I don't know what happened , but I told the ER physician that since this was 40 years old patient , who had shown to ER with the complaints of shortness of breath,we should at least do CT scan to rule out clots . Mind you I did not think that the CT scan was highly indicated or was going to be informative . So the CT scan was done . I was in office when the ER physician called me . He said , 'You just saved this young man's life . He has significant clots in lungs , both lungs 'I gave some more orders and went to see him after the office . He was treated and was discharged . But I had DONE NOTHING. I happen to throw the ball at the buzzer and scored the 3 points to win .But I was really lucky , or may be the patient was really lucky. 

Thursday, November 26, 2015


  I wrote about the change of mind and how most of us do not change the mind . This is true for general public as well as people who consider themselves as open minded and learned . This was obvious to me when I witnessed the Indian election and when I read Musafir. This reminded me of the previous incidence . On an average we don't see physicians in politics , though we do have some now. I had ameeting with a physician who was elected to Florida house. We were about 10 physicians and had a meeting with him . His talk was quite eye opening. Let me explain as to what he said . Usually physicians are taught and act in such a way that there are no two opinion s . If I see a patient with a lung mass on CT scan , I am taught to consider it as a lung cancer and in my mind the possibility of other diagnosis is very low . So I will tell the patient same and work it up same way . I can not consider any OTHER SIDE . On the other side lawyers have different point of view. Say case of divorce or tenant -landlord . Who so ever pays him more money , he will consider that side to be correct and defends it . So for him it is easy to be a politician. So we physicians are nor flexible . We do not change our mind. So I am going to tell a story of not changing our mind .
     I was asked to see this patient on second opinion. This was a 64years old female. who was admitted to ICU. She had a history of high blood pressure and diabetes . She also had history of heart attack. She came out of a supermarket and had chest pain and then became short of breath. She became more short of breath and so the people around called 911. The paramedics came and then they had to put her on a pressurized mask and then they took her to ER. She was quite bad and so she was intubated and put on respirator. She was admitted to ICU . She improved and so the respiratoe was weaned off and she was taken off it . She did ok for few hours . But she got more short of breath in next 6 hours and had to be put back on the respirator. The family was upset and decided they wanted to have second opinion .The physician called me and told me that the lady had Pneumonia and respiratory failure and the family wanted second opinion and I could see patient and then take over . He also told me that she will need Bronchoscopy as we did not know tha cause of the pneumonia . The infection disease consultant was seeing the patient and had started her on 3 antibiotics to treat pneumonia I talked to the patient's husband. She had heart attack and the cardiologist had done cardiac catheterization in recent past and told them that they could not do much about the blockages .I saw the chest X-ray . It looked like to me as congestive heart failure. The X-ray had improved and then gotten worse. Her history of chest pain and sudden onset of shorness of the breath, lack of fever , all pointed to me that she did not have pneumonia , but had congestive heart failure. I ordered blood test for heart attack and congestive heart failure. The BNP , blood test for congestive heart failure was elevated , almost 30 times . She also had may be a heart attach . I also ordered echocardiogram and it showed her heart function to be 20%. So in my mind she had a HEART TATTACK, and had congestive heart failure and DID NOT have PNEUMONIA . she DID NOT NEED BRONCHOSCOPY OR THE 3 ANTIBIOTICS. I explained it to the family and convinced them to continue the same physicians. They agreed . I did see the chart and she had improved . All the cultures were negative and still she had bronchoscopy and the antibiotics were continued and she was still being treated for pneumonia . She did get off the respirator.
    I am still convinced that she did not have pneumonia , but I could not convince the original physician or the consultant , that she had congestive heart failure inspite of all the history and the findings and the blood tests .NO CHANGE IN MIND!!.   

Saturday, November 21, 2015


     I was visiting India and did not have a chance to do much on the blog . But before I left for my trip, the political season in US was in full force . When I was in India there was election in state of BIHAR . What struck me the most was that INDIA and the USA are 2 large democracies and though the population and the nature of the constituents is different, the overall there was more similarity than differences. I also noticed that the news media , at least print media is liberal or progressive and people who are interested in 'status co' are liberal . This parallels my experience in US. Before I left , I was asked by one liberal doctor, 'which one of the jokers in GOP you are supporting?' These so called jokers included very successful governors who had turned around the economy in theit states , there were doctors and CEO. But that was not enough for this doctor and no matter what,  he was going to support the other party candidate , no matter who so ever it might be . I did not say a word., as I KNEW THAT NO MATTER WHAT I SAY I CAN NOT CHANGE HIS MIND .
       I also realizes this when I read a book written by one Indian auther who is considered very intelegent and smart . He was CEO of many companies and has written several books . One of the books that I read was MUSAFIR - A TREVELER . I happen to read it He collects several books on a subject and then does a abstract writing . , He also wrote a book on economics . Certainty his presentation is brilliant . But views are one sided. He is not an economist and has travelled to many countries but not lived out side India. . The opinions that one can form by watching CNN and ABC , CBS AND MSNBC are going to be very different than one that are formed by Fox news audience . One can not employ same tactics to improve economy in USA as they would do it it in India or Brazil. I have seen the 'misery index economy ' and seen the supply side economics work . So when one argues that it does not work I will not agree in late 70es and early 80es . I also the effects of cutting taxes .. I think it may not work in India , But I thought that by writing a lengthy e mail explaining how it DID WORK or how it may work would change his mind , But I was wrong One can not do brain surgery by reading a book on brain surgery. It is easy to write a book and form an opiniop on the topics that one has never experienced .But it is very difficult to accept that one could be wrong . . So I conclude that ONE CAN NOT ACHANGE ANYBODIES MIND , EXCEPT MAY BE BY OFFERING BRIBE .
      I also saw similar opinion on the election in India . People that I thought were good and educated and honest were supporting corrupt politicians . I could not believe when one 25 years old asked me how I would define Bribe . On top of that he was defending the bribe by saying that the one who takes bribe has to also give bribe and so he is helpless. Such a thought process is detrimental to the development of the country. I hope I was not seeing the majority and this will change .
      I KNOE THAT THIS A NON MEDUCAJ BLOG, But medical story on this topic in my  next blog..

Sunday, October 25, 2015

Grace of God -2

         So in the last Blog I described the case where I saw someone that was not at the best level of health and mentally . Again I do not want to take anything from the family as I know everyone of us would like our loved ones to live for ever . Very few of us are 'ready' to let go , and that too when they are very very old and unconscious. So I understand the behavior of the relatives. But what I don't understand is WHY the disparity .So let me tell the other story.
        I saw this 42 years old female for chronic cough . She was anon smoker and had some cough going for long time , may be 2-3 months . She had never smoked . Had no other medical history , other than she had melanoma resected out few years ago . Her physical examination was normal . Her lungs sounded clear and there was no other abnormal findings . The chance of asthma and allergies is very high in patients who are nonsmoker and have chronic cough as main complaint. So I told her the differential diagnosis . I ordered the blood test for allergies , a chest X-ray and breathing test . I gave her sample of inhaler and a short course of steroids . She called me in 2 weeks . She had cancelled the follow up , the breathing test and had not done the blood test . She was feeling great and her cough had gone away . So she had concluded that it was due to allergies and she thought that she would rather go to allergist and do testing , rather than doing blood test for me .My office gives me the charts of all patients that miss the appointment or cancel the work up , like CT scans or breathing tests etc . So We called her and told her to do at least chest X-ray that I had ordered. She did the X-ray . The radiologist called me with the report . It showed LARGE mass in the lung . So I called her and got her to do CT scan. The CT scan showed the same findings . I saw her day after the CT scan was done . She came to me with her husband . I told them that in all probability it Wes Cancer . We need to answer 3 questions , Is it Cancer , Has it spread , and What can we do about it . So I ordered a PET scan , which is accurate in about 85 to may be 88% of the time in picking up the cancer. The Pet scan and the breathing test was scheduled for next day and the Biopsy was day after . The PET scan showed that the mass was highly active and there were lymph nodes and there were 2 skin nodules . All these findings made her inoperative .
      I am not going to talk about the diagnosis or the treatment . What I was bothered with this experience is that this 43 years old female who had done all the right things in life and had her all faculties in tact and significant life left , has inoperable cancer .
                                       HOW DO YOU EXPLAIN  THAT?

Saturday, October 24, 2015


     I see many patients in my practice that have gotten the short end of the stick . And then there are patients that happen to be 'lucky'. I have often wondered as to why certain things happen to some patients. That leads to the so called bad luck or the theory of reincarnation and the laws of Karma . But even though I know the theory and believe in the reincarnation and laws of karma , it does not stop me from getting surprised and wonder about the God's plan . I thought about it when I saw recently some patients.
     First one was a84years old male who was admitted with possible pneumonia . He had significant dementia and was sleeping most of the time . He did answer some questions , but did not know where he was . He did follow some commands . or instructions I knew that he had pulmonary fibrosis and may have some other medical problems. His mantle status and advanced dementia and the age would make him more prone to aspiration , food and the liquids going wrong way and in lungs at times . So I ordered a CT scan and swallow study. The swallow study did confirm my suspicion that he was aspirating. So the speech therapist ordered some instructions . The CT scan did confirm that he had fibrosis . But it also showed a mass in liver . The radiologist wrote in the report that he was concerned about the primary cancer of the liver. I spoke to the family several times and try to get him to be DNR .He was unable to walk . He was sleeping most of the time and did not know where he was and he also had pulmonary fibrosis which caused him to need oxygen all the time . There were some restrictions or modifications on his food as well due to aspiration. But the family did not want to make him DNR and wanted all the work up . So I ordered the PET scan which picks up cancers may be 85 to 88% of the times . The PET scan was positive . So the radiologist felt that he had cancer of the Liver . Another round of talk was done with the family . They wanted biopsy to confirm it . So we had to do the biopsy . Interestingly enough he had history of heart problem and heart attack and stents . So he was on blood thinner . So we had to hold the blood thinner for 5 days before the biopsy could be done . The biopsy was attempted , and it turned out that HE DID NOT HAVE CANCER , BUT HE HAD AN ABSCESS -collection of pus . He was on antibiotics for pneumonia , so we readjusted the antibiotics .
       So here is my question . This patient who was older , had heart disease , had dementia , had aspiration , and had pulmonary fibrosis and could not walk , and he did not have cancer . So with the treatment of infection he was going to be OK if there was anything to be OK with him . And then the next one that I will tell in my next Blog will point out the problem that I sometimes have with the diseases . What is the purpose of beating all the odds of cancer in this patient ? What does God thinks and why does this happen in patients that we mortals can't seem to see the benefit and then when we wish someone not to have fatal disease , they have it . You will get it when I write my next blog soon . 

Friday, October 2, 2015


      I had written in the past about the Emperor's new clothes. This term has been used in medicine for number of diseases, but it was used for pulmonary embolism many years ago . It was so true in past as we did not suspect in the diagnosis in past and so when it presented with some unusual symptoms, we missed it . But exactly opposite thing has happened.For last few years we do CT scan to diagnose pulmonary embolism . Now a days almost anybody and everybody who comes to hospital ER gets a CT scan with minimal or no symptoms suggestive of clots in the lungs. So we tend to diagnose more. The number of CT scans done has gone up by 1000%, again 1000%, not 100%. So it is unusual to miss the diagnosis of pulmonary embolism. But sometimes when we come across certain things quite often , we tend to not pay attention to them. This brings me to some stories that I am going to tell today.
      I saw this new patient who was 57 years of age I saw her in office as a new patient .She was a nonsmoker who had a diagnosis of asthma in the past and was given the inhaler She was using and was OK for a while . But then started having more shortness of the breath . So she saw her PCP and he promptly referred her to cardiologist. The cardiologist did number of tests . He did cardiogram and then the echocardiogram and then did the stress test. She also had holter monitor , which is continuous recording of the cardiogram . All the work up was negative and she was told that heart was OK and healthy. So she went back to PCP and so now she came to me . She was short of breath and also had passed out about 3 times in last 2 -3 months. 3 days before she saw me she was taking out her dog and passed out  and found herself on the side walk . She looked OK but when I checked her oxygen saturation it was 91%. Her lungs were clear and she had no wheezing . I got hold of her cardiac test and they were OK . I made her walk for 50 feet and her oxygen saturation dropped to 85%(normal is greater than 95%)and she was quite short of breath.I knew what the problem was . SHE WAS THROWING CLOTS . I decided to admit her and ordered the CT scan and it did show the clot. She had plenty of them  I had started her on blood thinner even before doing the CT scan . I did call the cardiologist . He decided to do a new procedure in which a catheter is inserted in the artery going to lung and then a clot buster is slowly dripped in . This dissolves the clot more quickly .She did very well .
     So the shortness of breath , passing out and the drop in oxygen with lungs sounding clear were all the clues to the diagnosis. But it took much longer to get to it !   

Tuesday, September 22, 2015


       In medicine there is a term used called 'standerd of care' . One who is not in medicine , might wonder as to what is standard of care and how can standers of care can change . The easiest way to understand is to understand the circumstances under which medicine is practiced . So presume that there a doctor who is practicing medicine in a remote town . He will do much more on his own -not refereeing the patient to far out center for treatment or care. If the CT scan or MRI is not easily available , he may not order it as often as done by some one in city where several CT scanners or MRI centers are easily available.So the standard of care that one has to follow is different for different areas of the country , and also the education of treating physician. So who decides the 'standard of care'. There is no one person or a medical society decides it . But there are guidelines for almost every disease. Everybody knows that the HBA1C should be monitored in patients with diabetes. But the point that I am going to make is not about the usual standards that are set by various societies or communities. What bothers me  is that now a days the standards are set by the INSURANCE COMPANIES OR HMO, and nor necessarily by these medical societies . This brings me to today's story or may be I thought about this due to a patient that I saw . 
       I saw this 70 years old male for shortness of the breath . He was a smoker for many years and has been diagnosed to have COPD. He was little obese and had reduced the physical activity. He was started on medicines and was doing OK . He had quit smoking only one or two years ago. He had all the blood tests done , not only once but several times. But when I asked about chest X-ray , it was not done for several years . In fact he could not remember as to when one was done . He never had breathing test done. As a routine I ordered the chest X-ray and breathing test and oxygen check . As expected he had severe compromise in the pulmonary reserve.The oxygen was low and it would drop with walking , so he needed to be put on oxygen with walking. The chest X-ray showed 2 nodules. So I had to do the CT scan . The CT scan showed the 2 nodules and it was suspicious for Cancer. So I did the PET scan and it showed there was increased uptake in the nodules . So it was very likely that the nodules were cancerous. My bronchoscopy was poorly tolerated and so I did the needle biopsy. It confirmed the diagnosis of cancer. He was not a candidate for resection due to very poor lung condition. So only option of treatment was radiation treatment. 
    This is the story which made me think . He would have not been candidate for surgery even in the past . He had 2 nodules and he had quite advanced disease  which did not come in suddenly . So diagnosis of the cancer did not alter the out come . But what surprises me is that every one of these patients get check on their blood tests . But there was no requirement for doing the X-ray or the breathing test , so most of the patients don't get chest X-ray done . Now a days there is a change and even a ROUTINE CT scan for high risk patients is recommended and approved . But that will increase cost . So up till now this is not a standard of care according to HMO and so it is not done routinely. So the standard of care is set by the Insurance company in this instance . 

Friday, September 18, 2015


   One of the main difference between the Hindu religion and the other religions -at least perceived by the followers of other religions, is that the Hindu religion believes in reincarnation. The concept of the reincarnation exists in Christianity too , but conventional teaching is made simple and uncomplicated so as to get more people to follow the religion. The Hindu religion is quite complicated and some what difficult to understand. It is simple to understand that if one does 'Good things' the GOD will be pleased and then one is allowed to go to Heaven .On the other hand if one does "more BAD than GOOD", then he will go to Hell. So all that one has to do is 'get passing grade' may be 51% to get entry in to heaven . There is nothing about 'Law of Karma'  or the 'attachment to body' or 'desirer' and bondage due to them and rebirth. So it becomes difficult to talk about it as we have too many questions and not satisfactory answers. I have known this for long time and have myself several questions that no one has been able to give satisfactory answers. To just give an example , Why do some animals sleep in owner's bed and other end up in pound. What about the thousands of animals that are bred for food and have 'no life' .What do you think about the fertilised and frozen human embryos, do they have 'soul' . And many other . But this came to surface when one my patient asked me something related to this subject.
    I have known this patient for many years. She a young lady and had gall bladder surgery. After the surgery she was on the respirator and could not wean off it. So I was consulted . She had no past history and was not taking any medicines. She definitely had no previous lung problem. Her lungs sounded clear and her chest X- ray was normal. I tried to wean down and she would be OK up to certain reduction on the respirator , but then it would become difficult . I suspect muscular weakness , called myopathy. So I consulted neurologist , who cold not imagine myopathy in this mid forties patient without any previous history. He did not feel that was the problem . So I called the surgeon and deed the muscle biopsy. The surgeon was reluctant to do biopsy , but then agreed and it was done . The biopsy showed myopathy. So she has been on respirator for last 25 years . In the early part of her diagnosis she was on respirator for 12 to 14 hours . It gradually increased and now she need to be on the respirator for 24/7. She was little depressed. So with her last visit we talked about the present life , reincarnation , and many other things . I told her to read a book . The name of the book is 'Many lives -many Masters'. She not only read it , she took notes and gave me a letter. Without going in to the details of the content of the letter, I will tell you what she asked me . What did I do wrong that I have myopathy and I am on respirator for rest of my life.
    I don't have the answer ,( though I can give some general answer.)
    I had thought about this and wished we had a book like the Human Laws , where we know what is the punishment for Say for example stealing or killing or assault. But we don't know what will happen if I take a pen from the work place or some more serious bad action. But one thing for sure, we are attached to THIS life and attached to people around it and the desires that arise due to our MIND, INTELLECT, AND THE SENSE ORGANS AND THE ACTIONS that we do . I will tell a story .
      There was this swami or saint , who had discarded everything and was not attached to anything mortal. He had meditated and had achieved highest levels of SAMADHI . So he knew that when he dies he will not be reborn. He was on his death bed and he told his disciples that when he leaves his mortal body , and reaches NIRVANA , there will be a loud sound of bells ringing. So he died and there was no sound . All the disciples were perplexed . So one of the senior disciple had an idea. There was tree of berries out side his bedroom window  The saint could see it from his bed . The disciple went out and plucked few berries and opened them . In one of them there was an fruit insect. He killed it . AND THERE WERE RINGING OF THE BELLS. So the explanation was that when the saint dies , his attention was diverted to the berry and he had transient DESIRE to eat it , exactly at the time of death . So he had to come back to FULL FILL the desire.
     The story was that of old lady . She had cataracts and doctors had advised her to get it operated. But she had lost her husband and then she lost her son . So she told her friends that 'she wished that she was not alive to SEE all this .and what was the use of having the eyesight?'So one of the saint told her that these kind of thoughts could lead to BLINDNESS in the NEXT LIFE . So to know  the co relation between the desires and attachment to the next life , is very difficult but not impossible . 

Monday, September 7, 2015


      I was reading a magazine called SWAROOPYOGA . This is published in India and covers Hindu religion . Most of the articles are written by the Founder of the magazine , Madhawanand.But one of the articles had mentioned the conversion of Hindus. In past and even today this is a practice that is followed by Christians and Muslims . The conversion is carried out under pressure and by force by Muslims and in other ways by Christians.The Hindus do not 'convert' anybody as we believe that each one of us has choice and each one of us can 'follow' our own path at the 'level' that we are at. But I am not writing this to talk about the conversion. I am writing this one to point out the similarity between the Christianity and the Hindu concept . This is MY VIEW and not necessarily mentioned by teachers of the Christianity.
     So in HINDU religion we have AUM - TAT- SAT. This is often repeated by Hindus . In Christianity there is a mention of the The Father -The Son -and The Holly Ghost. These two are essentially the same . In Hindu concept the GOD is INFINITE and has no qualities.At the 'begining' of the universe HE splits in to the SPIRIT and the NATURE. The spirit pervades all the and everything in the universe. In Hindu concept the first Sound is AUM. So the SAT IN HINDU concept corresponds to the THE FATHER , from whom every thing originated and is Unchangeable and has no specific qualities. The TAT in Hindu concept corresponds to THE SON , which is Universal consciousness or the SPIRIT without which nothing exists . And the AUM is the HOLLY GHOST in Christianity and is the MOTHER NATURE or PRAKRUTI of Hinduism . This is also the first Sound and is said by various names in different religions. AUM is HUM in Tibetans ,AMIN of the MUSLIMS and the AMEN of the Egyptians, Greeks, Romans,Jews and the Christians.
     The Hindu religion happans to be the oldest of all the religion. In ancient times the as our knowledge increased we added months and the month of MARCH was the first month corrosponding to the Indian first month Chatrya. But more about this in the future blog. 

Friday, September 4, 2015


      I often say that the cause of down fall of most of the mankind is due to Money, Sex and ?? . One can add anything as the third thing. I add In Laws , when I am talking to the ladies and majority of them agree with me . It is amazing to see how the money is the root cause of the problem and so is Sex . But we all knowing it can't seem to avoid it . I do not mean to say that we should not try to make money or try for more or never enjoy sex . But make sure that we don't get to a point that we start doing things that are not moral . Just look around us . Many politicians and religious leaders came down due to the greed for the money or sex. The ancient Indian sage Vishwamitra. He had done great penance and was about to reach the highest level of liberation . And then appeared the Menaka, the very beautiful dancer from the Haven and the Sage was lost. He ended up getting involved and all the hard work that he had done was gone in span of one moment. Do you remember the presidential candidate Hart or the other one Edwards?Both had affairs and their political careers are gone . How about the congressman Jefferson Clinton who was found to have $200000 in freezer or the Florida congressman who had homosexual relationship?
   One might ask what does it have to do with medicine ? Now that they are publishing medicare reimbursements to each physician, we have known the income of some of the doctors. Though this is not a good indicator as it does not take in to account the expense that occurs in doing testing. The oncologist give chemo therapy. The cost of the drug may be $10000 and the medicare may give $10200. So the actual income may be $200 but the reported income is $10200. But then I also see cardiologist who make $5 millions . There was neurologist who got over $ 500000 in income from pharmaceutical company . This is greed ---or at least I think it is . So it does not surprise me when I came across a study which made me write this blog .
     The study was conducted I think by CVS-CARE MARK of their employees. They did a study in which the employees were encouraged to quit smoking . The cost of taking care of the smoker was more than $4000.So they offered incentive to quit smoking. So they were divided in different groups. One group was offered money if they quit smoking . So they got money if they had quit for 14 days , 6 months and 12 months . So if they had not smoked for one year they got $800.There was another group . (In all there were 4 groups ,but I won't go in details )In that group employees were asked to pay a deposit at the beginning of the study and they got it back with the 'reward' if they continued not to smoke . These were compared to a group of employees who were offered 'coventional' help.  So do you want to take a guise as to the final results ?
     The group enrolment in which employees did not have to put up any money had the highest enrolment. Not too many people opted for putting own money. The success was great with employees who were rewarded when they continued to not smoke .So every one knows that smoking is bad , but till some one offered money,no one quit as conventional therapy was not as successful as in the group when the money was offered.SO MONEY MAKES ALL THE DIFFERENCE., not even own health!!!

Wednesday, September 2, 2015


      In physics we have uncertainty principle. In that situation we 'don't know' the out come till the event occurs.But I think in medicine also we have the same . But why talk about the medicine , we face it in every walk of the life . We appear in an examination ,and we 'don't know' if we passed or failed till the result of the examination is declared. So there is uncertainty. If we apply for a job and have an interview, we don't know if we got the job or not till we get the letter.So the uncertainty principle goes apply in every place . But we don't realise this as the 'out come' is predicted and some of the predictions are as close to 100% as possible .So there is no uncertainty in say some one smart and studious takes the examination. we know he is going to pass. So we don't think there is any 'uncertainty' in him or her passing the examination. That brings me to the medical uncertainty.
     I saw this 73 years old male patient, who was referred to me for abnormal chest X-ray. He was a nonsmoker and had no major complaints . But he had read 'somewhere' that one should get chest X-ray. So he had chest X-ray done . It was abnormal and so the primary care physician ordered the CT scan . The CT scan was abnormal and showed a lung mass. So he was referred to me . He came with his wife . So I saw the CT scan and showed him the pictures and showed him the mass. I told him that topically this kind of mass  in all probability will turn out to be i usually tell patient that we need to answer 3 questions. 1 Is it cancer ,2 Has it spread and lastly 3 What is the treatment opiton . So I explained them the need to do the work up To get the diagnosis I suggested the Bronchoscopy and if needed needle biopsy or Open biopsy to resect it out , if it is resectable and has not spread. So I told them that we will do the PET scan to see if it has spread. (In PET scan we inject glucose tagged with nuclear material . The glucose is picked by every cell in the body . The metabolic activity of the CANCER cell is higher than the normal cells , so they pick up glucose more avidly. So the scanner measures the activity and one can 'predict ' the chance of the mass being cancer ) .We did the PET scan  and the breathing test. His PET scan was positive , suggesting that the mass was cancerous. and the breathing test was showing 'adequate ' reserve for the resection of the mass . He did not want any biopsy . So I sent him to a surgeon for consideration of surgery . He saw 2 different surgeons and both told him and his wife that he needs to have surgery and the lung resected. He and his wife were convinced that this mass was a fungus or 'mold' and we were all wrong . The pharmaceutical companies have corrupted the system and we were brained washed and he did not believe that he had cancer as he had no symptoms. He also had number of books and articles written by 'doctots ' that had proven how they cured this as it needs anti fungal .
       I saw him and his wife several times and we continued to have discussions and new CT scans . The mass has grown little bit but not massively . But I can not convince them that he needs biopsy or resection . So after almost one year we are at the same place as we were a year ago. So this is the 'uncertainty' in medicine . I am sure that he has cancer . He and his wife is convinced that he has fungal infection. And till we do open biopsy we don't know what it is .(Unless he comes with wide spread cancer in next few months )!

Sunday, August 23, 2015


   In our life we 'know' the fact and we have certain beliefs . But we have difficult time separating them . In one of the old Indian story there was a King who had a very smart assistant or adviser. For those who are Indians , I am talking about the AKABAR and the BIRABAL . So one day when they were walking in the city , the king saw a mother kissing her child , which happened to be a ugly looking child. So he made a  comment that how can she not know that child is ugly? Birabal said that she 'believes ' that her child is the most beautiful child . The king did not agree. So next day Birabal called the mother in the palace and asked her to bring the most beautiful child from the city  to the palace by that evening. The mother left the palace and then looked all over the city but could not find a child that she thought was better looking than her own child . Finally she took her own child to the palace . Birabal looked at the King and gave the mother gifts. So we tend to have difficulty when we want to separate the facts and our beliefs. It was said that president Clinton could 'compatmentalise' the different parts of his life . But really can anyone do that ? I do not like to talk about politics in my blogs , but I am amazed at the current state of politics . On one side people can't find any problems in their candidates or side irrespective of the issues that have come out including e-mails or IRS audits or our ambassador being killed ,or reporter's emails being tapped and so on . On the other side people who are supporting a candidate, can't find fault with statements like 'how good is Canadian health care system' or 'there is problem with corruption and lobbyist in DC , but I use it when it is to my advantage ' or many other . And to my surprise the people who believe in purity of thought believe in these candidates. (If a candidate states that there is increase in prostitution in our city , and I would like to get rid of it , but I have used their services when I needed it ,Do you think you would vote for him ?)I am also amazed at the attitude of one side when Lion was hunted and killed .One side which cares for the life of Lion but do not care for the life of unborn baby . And the other side which cares for the life of baby but have no problem with cruelty of killing the Lion or for that matter billions of animals that are slaughtered (approximately 10 billions  a year) to give us the 'food' . Those who are oppose to killing animals for fur,or for medical experiments , have not much problem with the way animals are killed daily .(For those who are interested there is a book The Ethics Of What  We Eat by Peter Singer and Jim Mason - this is' must' read).But that brings me to the medical story .
     I saw this young man , may be in mid fifties. He had quit smoking few years ago and was having increasing cough . He was treated by his doctor with antibiotics and then when he did not get better he had a chest X-ray . The X-ray showed congestion and small fluid and so he was treated with more antibiotics and then a repeat X-ray was done . It did not show improvement , but showed worsening . So he had a CT scan and then was sent to me . When I saw him he was quite Short of breath on physical activity , but oxygen saturation was good. I saw his CT scan and knew that most likely he had a cancer of the lung and the fluid was due to the cancer and that would make it inoperable. I could have done drainage of the fluid as an out patient and then the Bronchoscopy and the called the catheter insertion for the malignant fluid and then asked cancer specialist to see him . Doing it as an out patient would have taken may 3 weeks or so to get treatment started. I did not want to wait . So I admitted the patient , did drain the fluid next morning , had a surgeon see him do additional biopsy and put in a catheter to drain fluid periodically on 4th day of my first visit. (For recurring fluid collection we can put in catheter, that can stay in for several months and patient can drain own fluid as needed). We got him to see a cancer specialist 5th day and then the treatment was started . I was very proud of myself to have done this so quickly. I spent significant time answering all the questions . He was discharged . He walked in our office about 4 days or so after discharge, complaining that the catheter was clogged . I was not in the office and even if I was in the office , I could have done nothing . I spoke to him on telephone and told him to go to ER . I called the ER physician and told them the problem and the solution , namely to use certain drugs to unclog it . The ER physician did not do it , but decided to admit him . I went to see him at 5pm and the catheter was still clogged . He was seen by another lung specialist who ordered CT scan but did not do anything to catheter. I went in and unclogged the catheter. The next day he was OK . On third day I was told by the admitting physician that he wanted to change the lung specialist . he was not 'happy' with me as I could not help him in the office .
      I was little upset at first as I had done more than anybody else . I diagnosed and got him started him on the treatment as quickly as nobody would have done it or did it . I was the one who unclogged the catheter , though not in my office at 11 am , but at 5 pm . So why was he unhappy? The answer is in what I said in the title of the blog . He was MAD as he knew the outcome of inoperable cancer, that was aggressive . But he could not be mad at his smoking or the bad luck or the 11 years and 15 years old children . So HE could not SEPARATE the FACTS from his belief. This may be the same for the popularity of one candidate over others.We are all mad about the state that we are in . But we have difficulty to separate the facts from the fiction.Many of the things that we would like to change , are not practical or even possible. The TY anchors and the multimillion dollars contract talk show hosts have difficult time with this , He was only a unlucky patient!I 

Saturday, August 15, 2015


     I have always known that there is unpredictability of life or in life . I have seen that in medical practice many a times and around me in people that I know . One of our close friends daughter was married to a doctor . His son had persistent pain after a basketball injury and needed narcotics to control the pain . So further work up was done and it turned out to be a bone cancer of the pelvic bone . He got radiation treatment and then the chemotherapy . He was OK but the chance of  cure is very rare. One of the days when he was going for the chemotherapy, the father took his motorcycle to get a oil change . Some one hit him and he died on the spot . The kid died latter on of his cancer . This is the uncertainty of the life .But this could be considered as bad luck . But today I want to tell you a story of one of the patient to let you know on the uncertainty in medicine.
     I was consulted on this some 60years old patient, who was admitted with the fluid around the lungs . I saw the patient. Her history was that of a patient who does not believe in the current medical system or the treatment and would prefer 'natural' cure or at the treatment. She was out of country and was diagnosed to have a cancer of the cervix. She did not want the surgery or any additional treatment. This diagnosis was done about year and a half . She was back in US . But continued not to go to see a physician .In last 4 weeks , she developed swelling of the legs and swelling of the left arm and some shortness of the breath. So she came to the hospital .She had CT scan of the chest and the belly and the pelvis. The scans showed that she had fluid around the  lungs. She also had several lymph node enlargement in the chest , neck and in the belly . She also had abnormality in liver and tumor in the pelvis . She had hard nodes in the groin and they were pressing on the venous drainage and so she had swelling . In short she had what I would call "wide spread metastatic cancer ."
      We had discussion with her and her several family members. We talked about conventional treatment with chemotherapy, but also talked about 'alternative ' treatment with things like antioxidants and many things that are talked about ,like sour sap leaves it's pulp and pyknoginole and shark cartilage and many other things. We drained the fluid and then since it was positive for cancer cells , put in catheter on both sides to drain the fluid . We were draining about 300 ml to 400 ml a day. She agreed for the chemotherapy .After the 2 cycles of the chemotherapy, her swelling was gone .I could not feel any lymph nodes. and the fluid drainage was minimal. she was walking without any shortness of the breath. Now the need for the drainage was less than once in 10 to 12 days .
     When I saw this lady she had incurable , wide spread cancer and I was not sure how she was going to do . She had avoided all the available treatment . Now agreed for all the treatment and RESPONDED. The jury is still out on the long term prognosis . But certainly  how she responded was unpredictable !

Saturday, August 1, 2015


     We often talk about how some one broke up relations with some one and broke his or her heart. In that sense we feel that the 'emotions' come from or originate in heart. In reality all the emotions come from brain. But some how we attribute the heart as the site of 'love' and 'feeling'. Even when we talk about various "Chakras" in the the Hindu philosophy, we talk about lower Chakras and the the 'highest ' Chakra. The lowest is located at coccygeal level , then the next one at sacral and then at  Lumbar level and so on . The one situated at the level of the heart is considered at the higher level than the coccygeal level. When I explain the improvement in our 'goals' that occur in our thinking , with the practice of the meditation,we often say that the attention towards the procreation or excretion or even hunger, is inferior to the attachment that we have with heart. So our term of the broken heart is emotional one . But what I am about to say has nothing to do with this conventional 'broken heart'. But it has to do with medical condition called broken heat syndrome.
     So let me tell you a story about the broken heart patient that talked to recently. She is lady that know for long time . She is about 62 years old and has no major medical history. She goes to Gym and does lot of weight training and also does power walk, sometimes as much as 5 miles. Her brother ,who is well educated lost his job and could not find full time job . So he moved in with her and then after a while got part time job. One day when this lady came home late , she could not find her brother in his room and the car was still in the drive way.So when she looked for him , she found out that he had shot himself and committed suicide. So the next day her all relatives came home. The very next day or so at night she woke up and could not breath. She was feeling pressure on her chest and started coughing clear sputum. So she woke her family as one of them was a cardiologist . The called 911 and then she went to ER. Further work up showed up that she had congestive heart failure and her blood test for heart attack was positive . The cardiologist was consulted and they did the Echo cardiogram and it showed that the pumping action of her heart was reduced to 25%. This was completely unexplainable and so they decided to do a cardiac cauterisation to find out if she had any blockages in the coronaries. The heart cath showed that coronaries were 'clean' and there were no blockages. She was improving and was sent home . HER DIAGNOSIS WAS 'BROKEN HEART SYNDROME' .
       So this as also called Takotsubo disease. This usually is preceded by EMOTIONAL event , like in this case her brother had committed suicide. The emotions cause (may be ) spasm of the coronaries and this leads to some release of the enzymes , which leads to positive blood test for the heart attack. The spasm of the coronaries leads to weakening of the heart muscles, but there is no long term damage. Most of the patients recover in short time , in a week to few weeks.
      So emotions DO trigger a heart weakness .So may be HEART is real location of EMOTIONS and not the brain after all.  

Sunday, July 26, 2015


      We often use this term , "barking the wrong tree ". I have personally experienced this type of behaviour many a times In medicine we often blame the Insurance company for the increasing cost of the insurance premium. But to some extent this is at least to some extent' barking the wrong tree '. The insurance company collects premium and distributes it to providers. It also has to pay it;s employees and the overhead to the agents and the advertisers and the claims management team etc. So whatever is left is the profit. So if they pay more for the overhead or for the medical expenses-health care claims, then they will have to 'increase' the premium as they have to have some profit.(especially to show it to their share holders )I do not deny that some of the CEO of the insurance company do make what I would feel as outrageous bonuses.But essential if we continue to 'blame' the Insurance company for the increasing cost of the health care, then we are 'barking a wrong tree'. But today I am not talking about the health care cost . I am talking about a patient.
     I was consulted on this 55 years old patient , who was admitted to the hospital for shortness of breath. As it happened he was having shortness of the breath for last 6 weeks and had made appointment to see me . He was to see me in a week before which he got worse and came to hospital . He had  a history of clot in the leg and it had travelled to lungs about 6 years ago . This happened after the knee surgery and so he was prone to it and was treated with' blood thinner', for 6 months . He did OK But then last year he was short of the breath. So was admitted to hospital and was again diagnosed to have clot in lung and clot in leg. So he was treated with blood thinner again . This time he was seen by a blood specialist . He stopped the blood thinner 6 months down the road. The work up to see if his blood clotted too quickly was mostly negative.
      So this time when he was admitted to the hospital , they suspected clot. Indeed he had a clot in the leg but the CT scan of the lung was negative for the clot in the lung. So when I was consulted , the admitting doctor also was thinking that all that we needed was to continue the blood thinner , may be this time for life long . In fact i myself made a comment to the patient , that "just because barrel of a gun is empty , does not mean that the gun did not fire. " We use this line when there is a clot in lungs but not in vein . But I was not sure as to why he was short of breath for LAST 6 WEEKS . It was possible that due to some clotting abnormality, he was 'throwing' clots in the lungs and that has caused his shortness of the breath. .But like as I usually do I made him walk. I walked with him . As we walked , I was talking with him. As we walked for may be 50 feet or so , I asked him if he wanted to continue or go back to the room .He told me that he was short of breath and was feeling little dizzy and felt he was sweating. I went back to the room and checked his oxygen . It was 100% and he sounded clear on his lungs . I told him that I don't think it was lungs that was causing his shortness of the breath , but it is possible . But I was concerned about his heart. So we ordered a CT Coronary scan . In this test they inject  a contrast and the 'pictures' are taken very rapidly, all most 64 pictures per second. This gives coronary anatomy.It is may be 85 % accurate (or may be more. )It was abnormal So we consulted a cardiologist . He agreed and did a cardiac cauterisation . One of the main artery was blocked 85 % with a plaque. The cardiologist put in a stent and the patient did well This was at such a location that it is called 'widow maker'.
       So I thought that he had a recurring clot in the lungs as the cause of his shortness of breath.But as it terned out his shortness of the breath was due to critical coronary artery disease. So I was "barking the wrong tree!!!!"

Wednesday, July 22, 2015


      In medicine there are things that are conventional in certain situation ., but are not conventional under other circumstances. Some of the examples that I can give would be use of certain medicines that are not recommended or not used for certain diseases.are used under special circumstances. Albuterol, which is bronchodialater and used to treat asthma or COPD, is used to treat high potassium under certain situation.I came acrose one patient sometimes ago that may fall under same category.
      I saw this patient who came with a diagnosis of pneumonia. He was a66years old patient , who had quit smoking few years ago . He started with cough and it continued . He took over the counter cough medicines , but it did not get better. He then had an episode of coughing up of blood . He had also lost 5-8 lbs of weight . He went to a' walk in clinic' and they did chest X-ray. The chest X-ray showed 3 masses. They told him that the chest X-ray was not normal and they would treat him for pneumonia . But he needed to see a lung specialist . So he came to me . He had brought with him the X-ray. I saw it and knew that he most likely had Lung Cancer and not only he had cancer , but it was inoperable. I explained him my suspicion and the work up . I told him that we needed to answer 3 questions , 1Is it  Cancer, 2 Has it spread  and 3 What can we do for it. I did tell him that since there were 3 separate masses most likely it was inoperable. We did the work up . I ordered a CT scan and a PET scan and breathing test and a bronchoscopy.
     The bronchoscopy showed that there was a tumor blocking the right main bronchus , going to right upper lobe . I did the biopsy and it did confirm that it was lung cancer . I saw him in the office and discussed with him and his wife .The type of cancer that he had could be treated with chemotherapy as the best option of the choice. But the tumor was quite bulky and he had it in right upper lobe and right  middle lobe and left upper lobe. But there was also the tumor blocking the main bronchus partially . So in addition to sending him to a oncologist , I also sent him to a radiation doctor.
    He saw both doctors , but the radiation doctor wanted to treat this with chemotherapy and did not want the radiation . He did not call me . So the patient was scheduled to get a port put in . When he showed in the hospital to, get the port, his heart rate was 150 and the blood pressure was low . So instead of getting a port put in , he was admitted to ICU . I saw him , so did a cardiologist and the oncologist. He was started on medicines for the increased heart rate. In next 48 hrs he got many different medicines to control heart rate. Nothing worked . He continued the same rate and rhythm and the blood pressure was low . I could not give him any medicines as it would increase the heart rate. We had done a new CT scan as I was worried about fluid around the heart due to cancer. The fluid around the heart could cause blood pressure to drop.There was no fluid , but the tumors were there and the enlarged lymph nodes were pressing on the pulmonary artery .So I called the radiation doctor and asked them to reevaluate. He agreed and and started the radiation treatment . I also called the oncologist and asked them to give the chemo right away , and they did . Within 2 days of the 2 radiation treatments and one cycle of the chemotherapy , the heart rhythm became normal and the rate was normal too . He stayed in the hospital foe next 5 days and was discharged home . He was off oxygen and most of the medicines .
     I COULD BE 100% WRONG , but I believe that the radiation treatment and the chemotherapy effectively reduced the volume of the tumor enough to reduce the pressure on the heart and then in turn reduce the heart rate. So the radiation treatment ,which is normally not first line of treatment for his cancer, was used and it worked.The only other possibility is that the GOD intervened. (may be giving me the thought of trying to push for the radiation and chemotherapy !!)

Sunday, July 12, 2015


     Every time I look around the technology amazes me . The other day I went with a real estate agent to look at some properties . She would dial a number and the cell phone would open the 'lock' on the box that contained the keys to the property. We did not have to call the listing agent or he did not have to come to the place. The listing of the properties and the information is on the computer is old  development. But when we used to give 'lectures' , we had to get slides in the past and then we had to take our computer and use it for the slides. But now we can take it with us or email it .But this kind of technology progress is exponential. or geometric proportion.In comparison to that medicine has progressed less fast. But in spite of that when I see medical inventions in thoughts or drugs or equipments, I am amazed.every day when I read medical news . So this blog is related to that fact.
      When I was in medical college , I had read about vaccination. I was in India and Tetanus was not uncommon . The vaccination was advised , but we used to see the patients who already had high risk of getting  tetanus, we used tetanus serum . These were antibodies that were developed when horse was given the vaccination and then his blood was drawn and the serum was prepared. I was in medical college and had seen one of my friend's sister diagnosed and die of breast cancer. So I had a primitive idea. Why not inject 'tumor extract ' in horse and then the horse will develop antibodies against the tumor. Then we can inject those antibodies in the patient , which will kill the tumor. Off course this idea was to primitive and never would have worked . But all of us now know about use of antibodies in treatment of cancer.
     But then I heard about a a new treatment for elevated LDL cholesterol. All of us know about the satins, in use of treatment of high lipids. But then I saw a study of the treatment of elevated lipids by antibodies against an enzyme that is required for the lipid metabolism. I don't want to try to explain the exact way it works. .but it suffices to say that when this enzyme is attacked by the antibodies against it, the production of LDL cholesterol is reduced. So now the antibodies are used to treat the disease or condition,rather than satins.
     When I was in the medical college , I had  thought about the treatment of obesity or to be specific, treatment of fat belly. As we know many patients have not much fat on extremities , but the abdominal fat is major issue. The studies have shown that the abdominal fat is the cause of the problem. I did not know this in past . But I had thought about taking care of the abdominal fat by developing a solvent , that could be injected locally and then it will dissolve the fat and then one can suck the liquid out. I had no idea as to possibility of any agent or what could be safe and can be not only injected, but also sucked out . I don't think any agent is available even today. But the other day I read a new drug being approved by FDA, called Kybella. This was approved to treat "double chin. IT is an injectable medicine and may need to be given few times to be effective. (It reminded me of Seinfeld episode , or monologue, where they are talking about seedless water melon(or grapes).he states that when other people have 'desire to 'cure' AIDS or Cancer , some one was thinking and working on seedless melon!)

Wednesday, July 8, 2015


   We in medicine often talk about socioeconomic issues and how it affects various aspects of health care, It is well known that the socioeconomic differences do make difference in patient seeking medical help , the time of diagnosis, acceptance of treatment and the outcome . It also makes difference in preventive medicine. But there is another problem in medicine . This one I call socio-medical. The medical conditions are treated , but we in medicine often face social conditions , that we have to address or at least take in to account the social problems when treating the medical conditions. When we diagnose a patient with cancer and they need radiation treatment , sometimes we find problem in out patient treatment plan . These radiation treatments are given on daily basis, 5 days a week , each time the time needed is couple of hours. But there is a need for some one to bring them to radiation center. And we find NO ONE in family to do the jab. Then the patient gets transferred to rehab center or some such facility, approved and paid by medicare. So essentially WE are PAYING for it and I am not sure if this is essential medical care or essential social care.
      This I have seen in many other conditions , when we need to keep some of these patients in other facilities when one could easily treat some if not all of these patients as out patients ,patients staying home . But I came across a patient some times ago ,that made this issue worse and I felt like writing about it. I saw this 68years old female , who had smoked all her like and gave up smoking ,about 3 years ago . She was on home oxygen and over period of last year she continued to get worse and could do less and less ,as far as physical activities are concerned. She was pretty much room bound , if not bed bound . She was then referred to Hospice. But then she was sent to hospital .The diagnosis was COPD, but real reason was different. She was comfortable , but could do hardly any activity. She could not get out of bed or even turning in bed . We started treating her , but pretty soon we realised that she was not going to get any better. So when we talked about the discharge planning, I realised the problem and as to why she came to hospital; .She was leaving on one of her relatives and that person could not 'keep' her anymore.This was due partly to her deteriorating physical condition and partly duo to other reasons. She had her own kids, and they lived near by , but they had 'no space' in their house.
       So she had no place to go . We worked with the social service , but she had no physical therapy potential as she could not even get out of bed on own .The hospice could not help as she could not be accepted in their in patient facility as she was not 'dying' .So this is the socio-medical problem . We are going to face it more often as we are seeing 'aging' population and kids getting older and unable to care for the older parents.
     May be society has a solution. I had thought about a" social bank ". It is not my original idea. But it is not only great , but practical. A small group like a church can 'set up ' bank . When some one needs a help, So if one family needs his or her parents to be taken to doctor or physical therapy or radiation treatment, and he does not have time, some one who has time can do that job . So in the church 'bank' one gets balance of +2 hours or whatever time he spent and the other person gets debt or negative balance.So in future positive balance person can 'cash in ' his balance from the person who has negative balance . And ideally it could be done among many families . Only one condition --every body has to be HONEST. 

Friday, July 3, 2015


     I have often wondered as to the validity of asking for 'things' from the GOD. We almost treat the GOD as a human being , when we ask for things that are material things. If HE could 'Give' us something ,then He could 'take away' things from us ,and  then if he does punish or reward , then there is no difference between HIM and human beings. But this is just for the discussion. In any case I DO pray and DO ask for'things' from HIM . On top of that I do believe that the prayers work . (I did write  a blog on prayers in past. ) But today I thought about this due to a patient that I saw the other day. This was a 53 years old patient who came to me foe possible sleep apnea. In recent past the sleep apnea has gotten more importance and publicity in media . So more people are aware of it . Just to state the importance of the sleep apnea, sleep anea has relation to high blood pressure , diabetes, atrial fibrillation, stroke and many other things. S
      So this patient that I saw , had sleep apnea.He had sleep study done by his dentist and it did show the sleep apnea. But he decided to do nothing. Now he wanted to have treatment. So there was not much in the history or examination. So when we were talking , he told me a story.Several years ago he was separated /divorced from his wife and it was 31st of December. It was freezing and he could not continue to in the party at a friends place . So stepped out in the back yard. He was depressed and frustrated and did not know what to do . So he looked up and said,'GOD ,I can't do anything , YOU are in charge now'. And according to him the GOD said to him , "I AM ALWAYS IN CHARGE!"
      That brings me to  title of the blog. I reminded him of the story of Kramer in sitcom Seinfeld. In that episode Kramer is suing a corporation for hot coffee burns. The company executive are ready to offer him thousands of dollars for settlement.When Kramer comes in to discuss the settlement, the executive starts talking about it. So he starts with saying that Kramer can have as much coffee as he wants for the life .Before he could offer the monitory settlement, Kramer accepts it. So he never got the money. We act like that . HE can GIVE us much more than what we ask . So we ask for little things , when HE is willing to give much more. WE ARE JUST TOO POOR IN ASKING !!!!

Sunday, June 28, 2015


         We in medical practice come across situation when we have to think and decide as to if our actions or decisions are a success or failure. I am often amazed as to how we evaluate a success or failure of our treatment or actions. I had come across an article in which they were talking about a chemotherapy for lung cancer.The chemotherapy agent was approved for treatment of the lung cancer. The study that the FDA looked at showed that the 'survival' was increased by may be 30 days. (It was long time ago and I do not remember the name of the agent or the exact prolongation of the time ,but it was not more than 30 days . )The cost of the treatment was enormous, may be $10000 or more. Is prolonging life for 30 days with metastatic cancer -irrespective of cost , a success ?To some it is and to others it is not . Look at Steven Hawkins, He is paralysed and has trach ,but still does so many things scientifically important in Astrophysics .So sustaining life was worth it for him. So we will call success.I had a patient who also had myopathy and did go on respirator at home for last 25 years. She had young kids and it was worth it and I call that a success. But today the story that I am going to tell is that of different angle .
        I saw this patient who was 65years old . He was a had abnormal chest X-ray and was smoker and so was sent to me . I did the work up and did the CT scan and bronchoscopy. He had a cancer of the lung. He had breathing test done and it showed 'adequate reserve' or the lung capacity for doing resection of the lung cancer. So I referred him to a surgeon .He was evaluated and he agreed to do the surgery. He had no other history except high blood pressure. So he underwent the surgery. The surgery went well .He had resection of the lung cancer. The surgeon had to resect 2 lobes out of 3 .He was doing OK post operatively. When lung is resected there is always some air leak and fluid leak as the lung has to heal .This usually takes about 7 -10 days to heal and then the tubes that are inserted to drain fluid and the air, are taken out. In this case the lung or the remaining lung would not heal. The fluid drainage was less , but air leak continued. The surgeon did couple of things, including going back in. But there was no change . So we decided to put a one way valve on the chest tube . This valve would allow the air to get out but not get in .
       So he was discharged and was followed by the surgeon . .Even after one month the air leak continued. So then he was referred to other university centers . He decided to go to one place . They did another surgery and the problem continued . So he went to still an another place and they did another surgery . They 'crushed' the chest wall and collapse the lung . This stopped the air leak. But this deformed the chest to such an extent , that his remaining lung was almost nonfunctional. As not much blood going to the remaining lung and it was deformed , it was causing recurrent infections. We had to treat it with antibiotic and most of the time intravenously.
       I was not too sure as to what could be done . I did the lung scan and it confirmed that the right lung showed very little air going to it and very little blood going to it . So essentially it was not 'contributing ' anything to the lung function, but was cause of all the problem. So I suggested to go to the surgeon who had done the last surgery ans see if he could take it out. He thought about it , but did not do much . But then he decided and saw the surgeon and did have surgery . It did not 'cure' anything and he was admitted to our hospital . Some of his problems are still there and the 'jury' is still out as to if this last surgery was a 'success'.By the way there was no cancer for last 10 years. So the 1st surgery was a"SUCCESS' ,or was it ?

Thursday, June 25, 2015


       In the past we were old a story of Emperor The story was that of a emperor. He wanted to have a new clothes. But he wanted to have the best and the lightest clothes.So many tailors tried and failed . Then there was this shrewd tailor ,who accepted the challenge. He took the measurements and then stated in palace, had good food and enjoyed the life . He never stitched any clothes. So the day came in when the king was suppose to get new clothes . He pretend to dress the king with new clothes . There were no clothes , but he made all the actions . He convinced that the clothes were so 'thin' that no one could see them . So the king went in the city wearing nothing . But no one could say anything as the king was convinced that he had the most thin and the lightest clothes . Then a small kid who was standing to watch the parade ,said loudly,"why is king going in the streets naked ."
   This story comes to mind, when we see certain patients. So I thought of this phrase,when I saw this patient. I saw this lady who was 65 years old , She was a smoker and had usual smoker's complains. She had some cough , with minimal sputum. She had cheat X-ray and then had CT scan of the chest . The CT scan showed clear lungs , absolutely no abnormality. But the CT scan showed lymph node enlarged. There was single node enlarged, which was located under the division of the main bronchus. This is not the easiest place to do biopsy. (this could be biopsied with a ultrasound guided needle insertion through bronchoscope . This is a relatively new technique.) I talked to her about the choices . She refused to do any tests. I wanted to do a scan called PET scan . The PET scan picks up cancer ,may be 85% of the time. She did not want it.The PET scan was done after several attempts to convince her that this would help. The PET scan did show' increased activity ' in the lymph node . But showed no activity in any part of lung or any other lymph nodes or any where in the body..This is very unusual. But I had to do the biopsy . I called another doctor who does the special biopsy and he gave her an appointment . But on the day of his appointment , she did not show up . So we again called her . She did not want biopsy. She however agreed to do follow up CT scan . By this time the CT scan was more than 2 months old.  So doing CT scan in next 2 months was not a bad idea. In my mind the one isolated lymph node without seeing anything in lungs and no other nodes being enlarged , was not likely to be cancerous . And if it was cancerous , that was not a surgically resectable. cancer. We continued to have some problem getting her to do tests and follow up. After some efforts ,she did do a follow up CT scan , and it showed no change. So she was happy and so was I. But then she saw a cancer doctor for some other reason ,. As a routine he ordered some blood tests and it showed abnormality. So he called me . I convinced her to to have biopsy. She did agreed for the biopsy.
      She had the biopsy and it showed the lung cancer , The new scan did not show ANY ABNORMALITY IN THE LUNGS . But she had the lung cancer . This is mind boggling to me . So she has lung cancer showing in the lymph node , but there is no primary tumor seen even on CT scan or PET scan . This is what I called the Emperor's new clothes. 

Sunday, May 17, 2015


    As a physician I come across many patients. When I was a medical student and started learning the 'History taking', I had to write demographic data,then the occupation and then chief complaints. Each of this has a meaning, as I was taught. The name tells us the religion, cast, origin etc. This is important as certain diseases are common in certain people. African American and sickle cell disease is well known . Certain age groups have certain diseases as common , congenital heart disease is not going to be seen in 70 years old ,or cystic fibrosis is not seen in 70 years old and 15 years old is not going to have heart attack. The demographic is important as in certain part of India kidney stones were common , the area was called 'stone belt' . In US , there are areas where certain fungal diseases like Histoplasmosis is very common. So if the chest X-ray is abnormal , one might think of Histoplasmosis. The same is true of the occupation. There are many occupation where the Lungs are affected. The silo filler disease,Bird breeder's disease or hair dresser's disease would be some examples. So ideally as a medical student we were suppose to ask the occupation of each and every patient. In my practice with the modern day medicine, very rarely this information is of great help in the diagnosis of the disease. But many a times I do ask as to what the patients do . Some times I use this information to encourage them to  write their stories ,so as to keep busy. So sometimes we come across unusual occupations.
      I used to see this elderly patient . She was about 78 and had worked up to age of 70 . I had never asked her as to the occupation. Sometimes these older patients start having memory issues and part of the time it is accentuated by depression. So I tell them to buy a digital voice recorder, and record the old memories . This may include funny stories of their children or the experiences that they may have had when they were working. This recorder can be attached to a computer and then one can can 'burn' a CD . In my mind this is of great value as it revives the memory and such original voice recordings for the grand children.So when I asked this lady as to what did she do . she told me that she worked for a funeral home . So I said I you must have some experiences that were funny or scary or at least interesting ,.So why don't you record them.She told me some of them . One time she had to take a dead body to Georgia from Florida in her van . I can't imagine or may be I don't want to even imagine such an en devour.
       On of my other patient  that I saw only in the hospital for pneumonia, had a another story. I saw this 45 years old patient who was admitted with pneumonia. He was a smoker , but had a regular pneumonia He had no health insurance. So I was asking him some questions.He had told me that he was a businessman., when he had a phone call . He told the caller to call back. But after that call he seemed to be upset . So I asked him as to if anything was bothering him . He told me that he was being 'harassed' by IRS. So I asked to tell me as to what had happened. The answer was a surprise to me . He had a business and owned a limousine. It was 'equiped ' with every thing. He would pick up a client and the escort, and then he would drive around . The client and the escort would have 'fun' in the limo. itself without having to rent a motel room and then he would drop them off. He made good money , but then his partner bought expensive car and then IRS audited. That started the trouble he had to close the 'business'?. So this was the oldest business with new twist !! 

Saturday, May 9, 2015


    When I was growing up , I used to read a children's magazine ,called 'Chandoba' or 'Chandamama'. It was published in several languages. In those days there was no TV nor was video games and this was great. There is used to be a very popular story, called VETAL. As this magazine was Indian, the characters were Indian . We had famous king called Vikram and he was known for his generosity and intellect. In the story the King was asked by some Yogi to go to cemetery and bring back a dead body. The condition was that he can not say a word while doing this . In one of the stories that I remember, the king goes and picks up the body and the   or the VETAL starts talking. He tells him a story. At the end of the story ,he would ask a question and the king has to answer if he knew. If he does not answer then his head would explode. In the one of the stories , one of the laddie's brother has cut his head and her husband also had cut his head in a temple. The lady goes there and then the Goddess is pleased and tells her to put the head back on the torso and then thew will come to life again . By mistake she puts the head of brother on the torso of the brother and the head of brother on the body of husband . The question was who is her husband and and who is her brother. The VIKRAM has to answer as he knew the answer. He tells that the head is more important than the body , so the body that has head of husband is the husband. You must be wondering as to where am I going with this . I have in my medical life seen many occasions where this is so true. So let me tell you one of those stories .
       The first time I saw this patient , was when he was admitted to another hospital and was transferred to our hospital . He was a 70 or so years old male from South Africa , but was Indian looking and spoke one of the Indian languages . He was a smoker and had heart surgery and still continued to smoke . He had pneumonia and got very short of breath and so had to be put on respirator and then was sent to our hospital and I started seeing him. He was quite sick and I was not sure if he would survive. He ha congestive heart failure and COPD and pneumonia and anemia and some kidney issues. It took mare than 2 weeks to get him off the respirator. He was discharged and then saw me in the office . Over period of next 2 years he continued to see me and was hospitalised few times . Sometimes for congestive heart failure and sometimes for COPD . He also continued to have low blood counts and was worked up by gastroenterologist. He continued to smoke and needed oxygen , which he was reluctant to use as it meant he can't smoke. He was short of breath on walking . The heart problem and the low blood count contributed to it. He needed blood transfusions . He then decided to go to Mayo clinic to do some special procedure. And then the news came . He had bone marrow disease diagnosed in which the marrow does not make any blood cells . All our blood cells are made in bone marrow and in a disease called MDS the marrow function goes down and so the blood cells , white cells, red cells and platelets all of them are reduced . Reduced white cells make patient more susceptible to infection. Low platelets cause problem with clotting and make more prone to bleeding and red cells cause anemia and can cause shortness of breath. He was started on chemotherapy.
       He continued to get weaker had pneumonia and could not walk even 10 feet. He needed some transfusion , either red cells or platelets almost on daily basis. I talked to him and his family on daily basis . I knew the prognosis. In this 75 years old patient with weak heart , oxygen dependent COPD, and now blood count issues , the out come was poor . I wanted to see if they would agree for DNR, not to put on artificial support or  resuscitate. In spite of my several discussions they did not agree.
     Then one day it happened . He became unresponsive at about 8am . So a 'stat' CT scan of brain was done . It showed that he had bleeding in the brain. So a neurosurgeon was consulted. I saw him at 10 am. There were several family members present . I told them the poor prognosis .And to my surprise , thew wanted DNR and wanted Hospice consulted. Their plan was to take him 'home'and then withdraw the respirator, and let him go.
      So here is my point. Every other organ malfunction , heart , lungs , bone marrow, or kidney -could not convince them to make him DNR , But once the brain was gone , they wanted things ended in next few hours.

Sunday, May 3, 2015


        In past we were concerned about many diseases. We had very few antibiotics and very few diagnostic tests, like CT scan , Pet scan or foe that matter even ultrasound. The Ct scan became available for 'average 'hospital in early 80.So we had to diagnose medical conditions with 'clinical' skills and the treatment was equally limited . The antibiotics were limited and treatment of TB was quite difficult. The treatment consisted of injections and pills that were too big and to be taken too often and caused stomach upset. So in patients with TB , who had poor appetite and weight loss , it was more difficult to treat. So now it has become simpler to treat the condition, but what I came across recently was surprising.
       I saw this patient in the office few months ago. He was referred to me for the pulmonary evaluation. He was a 40 years old male with history of smoking. He was having cough for last couple of months and he had chest X-ray done. He was smoker and the chest X-ray was abnormal and so the CT scan was done and so he was referred to me . He had some sputum and no blood in it . He had some fever and was treated with antibiotics. He had poor appetite and had lost some weight. The CT scan showed that there were abnormal cavities in the upper lobes. This could be due to various things. The one possibility was that he had damaged lung in that area ,like emphysema and then it got infected. The other possibility was that he had atypical TB called MAC. And the other one could be that it was cavitary cancer, the cancer in which the center got liquefied.He came with his wife . He also had 2 kids at home.
     I ordered skin test forTB and told him that we may have to do Bronchoscopy. As it turned out when we tried to schedule the tests, his insurance would not allow us to do anything at the hospital that I normally go . So I still ordered the tests that I thought were needed and told patient that he needs to see different lung specialist. I called the other lung specialist personally and left message. When he came back to show me the TB skin test, he told me that the other doctor gave him appointment after 3 weeks. The skin test was negative. I had sent the sputum for TB. I called the lung doctor and left second message. In between I got a call from the lab. His sputum was positive foe TB. Now I did not know as to treat him or do any additional treatment, while waiting for the further identification on the TB bug.I called the health Department and left message . I got a call from the other lung specialist . He did not want to see patient at all. His point was that he did not want to see suspected TB in the office with all the other old and may be 'compromised' patients. I had not had call from the health department . So I called the Infectious Disease specialist. I told them the story. I wanted to see if they could see him soon. They told me that they don't see TB patients any more and they refer them to health department. They gave me different telephone number for the different health department office. So I called them and left message. I got call back from them in less than 10 mins. They took all the information and promised me to not only take care of the patient , but also of his family. (the family members will be needing testing and treatment). I had already given him the prescription for 3 drugs for the TB and done the all the testing done for the TB.
       The 'new' things that I came to know with this experience, is that since the health department treats the TB , no other doctor want to even see patient , let alone treat it.
      As I write this story, I am glad to tell the last twist to this story. This patient did not have the Regular, contagious , infectious TB after all. But the final cultures showed that he had atypical TB , called MAC or Mycobacterium Avium Intracellularae!!!!(which is treated by all the pulmonary and infection specialist doctors.)

Wednesday, April 22, 2015


     I am now in practice of medicine for long time . I was talking to a student yesterday , when I told him that I would like to have better doctors in the future, as when I will need them , I want to be confident about their ability to diagnose and treat any condition. I am some what disappointed in today.s medicine. This does not mean that every one is not good or does not know medicine.But it reflects MY opinion about the current state of MEDICAL PRACTICE. No one gets paid to THINK ,and so gets paid to DO tests or it is easier to order tests. This may have to do with medical malpractice fear or demand by patients or any other reason. But result is same. Now many business entities are taking over medical practices and it is going to get worse as these Businessman do not know medicine and are in to medicine to MAKE MONEY . But what I am writing today is something little different . When I have a difficult case , I would refer him or her to centers like Mayo Clinic or Shands hospital or some other local or out of state reputed center.But when they can't help the patient any more than what I can do , then what?Let me tell you couple of stories.
     I saw this patient with possible unresolved pneumonia .He was about 42 years of age and had a history of brain tumor and surgery for it done .He also needed a shunt to drain the fluid from around the brain ,as otherwise the pressure build up around the brain will be detrimental. He was worked up by me and as it turned out he had scar tissues in the lungs . He was also obese and had some pressure built up in lung circuit, call pulmonary hypertension. I started him on oxygen and then the therapy for pulmonary hypertension. Till last October -November , there was no specific treatment for the scarring in the lungs .I had tried some steroids and it did not help I tried to get him for lung transplant .But due to various reasons he was rejected He did OK for couple of years and then started getting worse. I did put him on new therapy for fibrosis . But he continued to get worse. He was seen by one center in past and they could not do anything more. So I called other center, to see if they could do any thing. They agreed to see him. But over period of 3 months he continued to get worse and his need for oxygen continued to get bigger. After extensive concussion he was sent to Hospice and he died.I knew that I could not do anything more and I also knew that Mayo could not have done anything more. But then that is my question. What do you do when there is no further road. It is easies for doctors and probably for patients , when the diagnosis is cancer, as every one KNOWS and ACCEPTS the inevitability of the death with that diagnosis.But  when we have other diagnosis , and we can 't help and on one can answer or help, then that is what I was calling the DEAD END ROAD. The only good part is that many a times the problems are not fatal like chronic cough, and the best thing thing of all is ,it boosts my confidence ,when these patients come back with no major change in their treatment.
     So it brings me to one of my favorite statements , Medical knowledge is vast and incomplete.

Sunday, April 5, 2015


      I was reading an article on the role of physicians in telling the "bad news" to the patient or their family. Whenever there is a diagnosis of cancer or whenever there is bad prognosis, we a physicians have to tell it to patient and their family members. I sometimes have to tell the patients or their family same thing again and again. I am not sure if it is due to sometimes  patients 'blocking ' it out or may be the information is not clear or may be there is a wishful thinking. I came across a patient that I really felt bad , really could not explain why 'bad things' happen to good people.
     This was a patient who was a young male. He was referred to me for persistent cough, or that is what I thought. When I entered the room he was coughing a lot . I actually could hear it even before I entered the room. I started the my interview and the usual questions about the high blood pressure, diabetes, and asthma etc .He was smoking 3 -4 cigarettes a day and was sick for may be 4 weeks. He was treated with antibiotics and cough medicines and he continued to have cough. So chest X-ray was done and it showed possible pneumonia and some fluid around the lung. So a CT scan was ordered and he was referred to me . The CT scan was done and they brought the report with them . (He was accompanied by his wife. )The chest CT scan report was bad. There was significant fluid , much worse than was seen on plain chest X-ray.And the fluid was causing pressure on the lung and significant part of the lung was collapsed.From the other findings seen on the CT scan, it  was obvious to me that we were dealing with most likely a lung cancer.He was short of breath and coughing and I felt that to work up done quickly we should admit him. He was going to need number of tests and to do them as out patient, it would have taken long time . ( in addition to the scheduling issues that would occur, we would need 'refferel' to do every test.)So I spoke to patient and his wife and decided to admit him .
    He was admitted  and his chest X-ray showed complete collapse of the lung. THERE WAS NOT MUCH AIR GOING IN THAT LUNG. So I did the procedure to take out the fluid . I too out more than 1200 ml of fluid and his chest X-ray showed no improvement.So I consulted  a chest surgeon to put in a catheter to drain the fluid and do any additional biopsies to get the diagnosis. The fluid that I had sent did show the cancer cells , most likely lung cancer.I had told the patient and his wife in my office about the suspicion of lung cancer. They had asked me if it would be operable .I had told them that once the fluid is showing the cancer cells , it can not be operated to cure the cancer. So after the fluid came back, I sat with them and told them and explained that the treatment would be chemotherapy and not surgery.  I called the oncologist and and he had the catheter put in . We talked about the results of the surgery . He had tumor in the covering of the lungs all over, So I again talked to them about the chemotherapy and the radiation treatment . The question came again as to if we could do surgery . I had hard time answering that for two reasons , one was I had told them the answer few times and he had just introduced his 12 and 16 years old "kids" to me . I had to be very careful about the words that I spoke , but I still had to tell them the reality. This is what I call as the big job. I wish that the patient would not have asked me the SAME question again , But he did and I had to answer it .