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.