Friday, January 30, 2015


       The medicine has evolved. In the past when the diagnosis of AIDS was made, it was a death sentence.Now a days we can treat and can control the disease that many patients with HIV can live long life . We can diagnose fetal genetics analysis to know more about defects without waiting till end of the pregnancy and avoid the threat of abortion .(which can occur when we did take out amniotic fluid to analyses for fetal defects, there is a risk of abortion.). Now a days we can do this very early (may be as early as 14 weeks.)with mother's blood.But sometimes we are left to the mercy of 'fate' or God.I thought about this when I was taking care of a patient .
      I saw this 74 years old patient , who had a chest pain and then went to see his family doctor. There was no fever and he did not have much cough. He had chest X-ray,that showed he had pneumonia and so he was admitted.I saw him and looked at his chest X-ray. It showed the pneumonia and showed some fluid around the lung. He had no elevation of white cell count as is normally seen in pneumonia or any infection. The fluid did not appear to be large .He was nonsmoker and so I decided to watch it with follow up chest X-ray in next day or so , with antibiotic treatment. I ordered the CT scan in next day or so and I was surprised . The CT scan showed large fluid. I could not believe the difference between the chest X-ray and CT scan . I decided to take out the fluid the same day even though it was weekend .I drained 1200 ml of fluid ,which was bloody . I had the discussion with him and his wife as I was quite concerned about cancer.
       As expected the fluid did come back positive for cancer. This meant that the fluid needed to be treated as with cancer it is likely to come back again. We normally put in a catheter , which can drain the fluid as needed .Or We can do instillation of the talc powder.I called a chest surgeon and a cancer specialist. The cancer specialist, oncologist, wanted 'more' tissue so that we can know 'MORE ACCURATE' tissue diagnosis. Now a days we are doing tumor markers and this has changed our way of thinking and it does give us better understanding of the type of cancer and also the choice of treatment. So I asked the surgeon to do additional biopsies to get more tissues and he did it . The patient and his wife were explained in detail our plan . So the new biopsies were done . It took additional 5 days to get the final diagnosis . The pathologist told me that the cancer was there , and the cells have changed so much that IN SPITE of all the new stains and the marker , they could not tell me for sure that it started in lungs or not , though 'MOST LIKELY" it was lung cancer. So once again in spite of our modern day medicine we were left with the decision to our old way of thinking!!

Saturday, January 24, 2015


      I have written about the destiny and if we are able to change it. I had said that the problem with the question related to destiny , is that one that we don't know what exactly is the destiny.Then we don't know if we have enough time and thirdly if our efforts are enough or not . So one may think 'something' as a destiny and try to change it . In reality the change that he or she thinks they are trying for , may be the real destiny .If if fact the destiny is different that what we think , our efforts may be inadequate or we may not have enough time to change it . But for a second consider that we DO KNOW the destiny and we don't even try to change and the time is limited . Today I am going to tell a story of a patient where I felt the situation is as I described before.
      I was consulted on this young patient who was about 35 years old and had smoked for her entire adult life . She was admitted with shortness of the breath.She had lot of cough and was wheezing. She also had fever.
She also had history of high blood pressure and had developed kidney failure and then when they stopped working , she needed to be put on dialysis . She had refused to stop smoking and was not following restriction of  fluid /water intake .I started her on steroids and other breathing medicines . Asked her to not smoke and follow the water restriction. She did not follow any of my advise and continued to smoke and continued to eat and take as much of water as wanted. Her neck veins were very prominent and I had thought that it was due to excess fluid in the body as she did not have urine out put.But it continued even after dialysis . So I did Echo cardiogram. It showed that the pressure in the lung circulation(pulmonary pressure) was 75. Normally this pressure is 25. I explained this to patient .I also told her that this is serious and it will need further work up and treatment. The medicines that we use costs almost $100,000 per year. So we are needed to do definite test . This is a test where we put a catheter in the right side of the heart and the measure the actual pressure.It took another 2-3 days to convince her to get this done . When this one was done the actual pressure was more than 100. This is considered very high and needs CONTINUOUS INTRAVENOUS DRIP of a medication. This would need a special access line .She flatly refused. So I had no choice but to try pills, which are special pharmacy drugs and can be obtained after forms are completed .But it would take 3 weeks and may be more since she had not signed the forms. She wanted not to take the medicines for the COPD , wanted to stop the steroids and not take the inhalers.So I had to stop them.She continued to smoke.
       I have told her that this is serious condition and she could die with or without the treatment. I also told her that the smoking will make this worse. I also told her that pressure will go up and this can kill her. So I (think) I know the Destiny.But it is not 100%. I do know how we can try to change the destiny. But I also know that the efforts are LESS and I am not sure if we have ENOUGH TIME.

Sunday, January 18, 2015


In the last blog I wrote about the health and social problems that occur with the advanced age .This one is different one . As long as the human being are there we have this problem. Many years ago I had read or seen a video of a clip describing difference between men and the women . It stated that the majority of the female brain was occupied with chocolate and shopping and in males it is sex and football . The exaggeration aside , this has some truth in it. This obsession of men (not all ) is the AGE OLD problem that I was talking about. The story that I am going to tell is one such story.
     I had seen this 68 years old male patient , who had cancer of the lung diagnosed about 18 months ago . It was inoperable , and so was treated with chemo therapy and then radiation. He developed some weakness in the right arm and so the work up was done and a brain metastasis was detected. They were going to treat it with gamma knife, but then due various other reasons,he needed to be taken to surgery and had the tumour removed from the brain .He received additional radiation treatment to prevent any recurrence that may occur after the surgery . He was admitted to the hospital with fever and was found to have blood infection and was started on treatment . He needed 6 weeks of intravenous antibiotics. But when the antibiotics was stopped , he had fever up to 103 and came to ER. He had 103 F fever and his blood pressure was little low around 98mm. He obviously had another blood infection.(in the next few days it was determined that he had not only blood infection , but also infection on his heart valves.)I saw him in the ER and was talking to the ER nurse about his various problems . He had some difficulty passing urine and needed to be have a catheter put in .So when I told the nurse about his diagnosis of inoperable cancer and brain spread and needed surgery and additional radiation and the sepsis, she made a comment that struck me . She said ,"But that did not stop him from hitting on me ".He had asked her out for a dinner date !.
   I do understand the positive attitude and the benefits even in inoperable cancers , but this was more than just positive attitude.

Sunday, January 4, 2015


    I am sure those of you who are reading this blog , must be thinking about various problems,like STD or prostitution or problem related to money or greed.But I am talking about the problem that we in medicine and the general public is facing more and more.THE AGING POPULATION . This came to my mind when I saw 'few' patients in their nineties. The problem is complex and it has many facets from health issues , to mental problem and the memory loss to loss of companionship.So let me tell you about the patients that triggered the thought or may be got more intense.
    I was seeing this patient who was 99 years old and his wife , who is also my patient 96 years old and her sister who was 98years old I just causally mentioned to them that you all have 'good genes' The wife just smiled and did not say much..He had COPD and was on oxygen too. He got bad pneumonia and then got worse and so I had to admit him . Within 2 days of his hospitalisation, his wife got sick and though had only acute bronchitis , due to her age I had to admit her too. During the hospitalisation , I did check his heart as he was not getting better.I did echo cardiogram, an ultrasound of the heart. It showed that his heart was weak. He was followed by a cardiologist in the past , but no recent echo cardiogram was available.Again with his advanced age the cardiologist and the wife and I decided that not much work could be done. I made him DNR and he celebrated his 100th birthday . He continued to get worse and then died. The wife did OK and was discharged.
     In next 3 months , her sister got sick. She needed to be admitted and got really worse.She also had some dementia.So after discussion with her I made her DNR and called Hospice.She was discharged and died in next 2 days after the discharge
     I saw her in next 2 or 3 weeks..She was doing OK ,but looked depressed.When I asked her as to how she was doing, she said,"Do you remember what I was saying few months ago,"I was not sure as to which part of our conversation she was referring to . So she answered , that it was related to the GOOD GENES that I had commented about.She said, " Having good genes is not a blessing.I lost my life long partner, my only sister died and I am loosing my memory and can't see well .So how I am going to enjoy these good genes?" I had no answer.
    It is one thing to get old and accept the reality of the aging process. But it becomes very difficult , when either the patient or the family does not want to accept it.But I will talk about it in the next blog.