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.)