Saturday, November 26, 2016


    In my blog related to Health CARE I have used this term . The cook book medicine would be something that a computer would do , if it is used to diagnose or treat a patient . So one would ;ffed' in the information and then the computer will analyze the data and come to a conclusion and then advice the treatment for the disease that it diagnosed. In case of Health Care management the cook book medicine is different. One would follow certain 'decision tree' and then decide if a TEST is warranted. This would help to reduce the cost , if everyone follows the same rules and there is some protection from malpractice if these cook book format is used. But today I am talking about different type of cook book medicine which is followed, without a THOUGHT PROCESS. In hospital several Ct scans are done with no obvious thought process. So let me tell about this patient ,that I think where a cook book approach was done without THOUGHT PROCESS.
       I was seeing this 60 years old patient , who had COPD. She was a smoker and had continued to smoke in spite of the diagnosis of COPD. She was short of breath and needed oxygen at night as her oxygen level would drop at night , when she was asleep. She also had chronic pain and was disabled. She had pain in the belly and so as is done now a days , she had CT SCAN of the belly. The CT scan did not show any thing in belly or pelvis that could explain the pain , but showed fluid around a lung . So she called me. I ordered a chest X-ray and it did show significant fluid. She was short of breath and when I called her , she told me that she was more Short of breath now . So I decided to admit her .Next day I took out 1200 ml fluid . I did also a CT scan of the cheat. Now she needed to be on oxygen even during day time.The fluid came back positive for CANCER. But the pathologist was not sure as to the ORIGIN of the cancer. We did PET scan and the cancer was limited to the chest only. The main concern was about the chemotherapy. The surgery was out of question -for cure -as there was cancer in the fluid.The radiation had no role as it was not a localized cancer. The chemo was the only option and to select the  chemotherapy ,we needed to know EXACT TYPE of the cancer. So I called a chest surgeon. He did do open biopsy to get more tissue to do additional testing and also put in a catheter to drain the fluid. The biopsy was done but it took more than a week to come back and it turned out to be MESOTHELIOMA. But it took more than a week to get the final answer. The biopsies were sent for second opinion as the differential was between lung cancer and the mesothelioma. As the treatment and the prognosis and the monitory gains are much more or different with two diagnosis , the differentiation was very important.
    In the past the mesothelioma had no treatment and surgery was not an option. But now a days some surgeons do the surgery. It is extensive surgery. There are two kinds of surgeries, but in either case the surgery is EXTENSIVE. So when we got the diagnosis of mesothelioma was established for sure , she was told to see a surgeon at a referral center. I was some what surprised at the decision taken by the oncologist. This patient had advanced oxygen dependent lung disease and was NEVER a candidate for ANY kind of lung surgery, let alone extensive one for mesothelioma. So the patient did go and see the surgeon , who told the same thing that we knew , HE WAS NOT A CANDIDATE for the surgery.
     This is what I call COOK BOOK MEDICINE.When one does follow all the instructions in the recipe he does not use own thought , but follows the instructions exactly as told. But I hope medicine is not a computer making decisions. So surgical consult was a waste of time , money and time.   

Sunday, November 20, 2016


    I have often said that medicine is nothing but statistics, at least on day to day diagnosis and treatment. When we tell patients that you have bronchitis or pneumonia or even for that matters high blood pressure and we will treat 'it' this way or that way, we are using statistics. We don't know if the antibiotic that we are using is going to work in EVERY CASE or the blood pressure medicine that we selected is going to be the 'right' one for him or her . But we know that in 'majority ' of the cases 'it works' and so we use it. But there are exception to the rules or the statistics.These are the patients or the conditions that defies the all the odds.This is one of those stories.

        I saw this patient who was 75 years old. He never smoked and had no major problems other than high blood pressure. He had history of renal stones and so when he had pain in the belly, he went to ER.He had CT scan of the belly and it showed the stone, but somehow he passed it. But in doing the CT scan of the belly we include some lower part of the lungs and vise verse. So in the lower part of the lungs they saw a nodule. This was at the edge of the lung. So then he was sent to me . He then had a dedicated CT chest and it confirmed the nodule. There were no additional nodules or any other abnormalities.
     I saw him . His had no complaints and his lungs sounded clear. He had no swollen glands. So He had PET scan and it showed very low uptake. This meant the chance of cancer was quite low. He was quite concerned. So I did bronchoscopy. It was negative and no infection was there and  no cancer cells were seen. But I did not expect it to be positive as the nodule was way out of my bronchoscope reach. But there was about 6weeks between the Ct scan of the belly and the PET scan. The size of the nodule had gone down by 2 mm. He was quite concerned. So I sent him to a chest surgeon. The chest surgeon saw all the scans and the reports and felt that the possibility of cancer was very very low and advised to repeat the CT scan in 3 months. He came to me for follow up after the visit with the surgeon. He was quite anxious. I told him the criteria that we us and the chance of cancer in nonsmoker and with slight decrease in the size and negative PET scan uptake ---which is extremely low. But I realize that he was still concerned.
    So I spoke to radiologist . The radiologist told me the same thing , the chance of cancer was low and we should do follow up CT scan . But with the patient's anxiety , I asked him to do the needle biopsy. He agreed. So he had the biopsy.

     So here is a guy . who never smoked which makes his 'chance' of getting lung cancer 20 times less than smoker. He had slight decrease in size , again making the chance of lung cancer less likely. The PET scan was negative ,making chance of cancer may be less than 12 or 15%.But he still had lung cancer.

Saturday, October 29, 2016


   In our life we often talk about the first impression. If some one is going for an interview , we say you must make your first impression great or long lasting. We also say the 'my first impression was not good. ' So the first impression had great value In suspense stories or i movies , we have our first impressions as to who is the culprit . So first impression is very important as it is 'accurate ' in many instances or at least we believe that our first impressions are great and reliable . I am not sure if some one has done any study as to the accuracy of this statement . Nevertheless we depend  on the first impressions .
      In medicine also we have first impressions and we make decisions -consciously or unconsciously about the  reliability of a story or complaints. In my life time of practise of medicine I have been right on many occasions , based on my first impressions.So you must have realized that the story that I am about to tell is either one where I was right or dead wrong . Well it was both .
      I saw this 78 years old patient who was smoker in the office. She had smoked for entire adult life may be 60 years or more. She had exertional shortness of the breath. So she came to me . She had emphysema . She was not having much bronchospasm . I explain this to my patients this was , if the damage from the smoking is more to the bronchial tubes and they are inflamed, then these patients get 'bronchitis and have productive cough and they wheeze. On the other hand if the damage from smoking is  more to the air sacks or the alveoli where the gas exchange takes place , then they don't have much secretion and have no significant wheezes. So this lady had more of emphysema or damage to the air sacks and was not wheezing , but was short of breath and when I walked her she needed oxygen as her oxygen saturation dropped when she walked. So I told her to quit smoking and gave her some medicines and asked her to do follow up. I did see her once on follow up to discuss the test results and again to urge her to quit her smoking,
       I saw her in the hospital in somewhat unusual circumstances . She had leg pain and so the family physician ordered a MRI of the lower spine .It showed an abscess-collection of pus. So the radiologist was asked to drain it . When he gave her sedation , her oxygen dropped and he had to cancel the procedure and I was called. So when I saw her I did not recollect her as being patient that I had seen . I had seen her many months age and that too only twice . She was very frail 78years old and looked like she was chronically sick. She weighted 72lb . She was on oxygen and could not get out of bed . She needed pain meds round the clock. She was started on treatment and then the procedure was done . Her further course was somewhat unusual and challenging . She was on IV antibiotics. But every time the catheter stopped draining the pus and we removed it , she had recollection of the pus . We were unable to find out reason for the collection of pus in first place and let alone recollection. I had talked to her and the family several times and made her DNR. She was discharged to a nursing home .
     When we discharged her  she was barely able to get out of bed and walk 2 feet . She was still on IV antibiotics and still had a catheter . This was her fourth catheter . I saw her on follow up in office in next 4 weeks . I looked at her office chart and was about to ask her as to why she had not seen me for several months , when I realize that she was the same patient who was in the hospital and had needed 4 deranges.She came walking without walker or oxygen and was fully oriented and had clear lungs and good oxygen . So this brings me to my first impression . I knew she was sick and had bad disease , was my first impression and it was correct . Then when I saw her in the hospital she was worse and I felt that her prognosis and the chance of recovery was not that great . So I was partly right . But then she showed up in my office as if nothing had happened , and that proved my impression to be wrong .  

Saturday, October 22, 2016


     In medicine like in many things in life or other sciences we have rules and they do apply in many cases or under many circumstances . But we also talk about exception to the rule. In medicine we have the same thing . When we see a patient and try to diagnose the disease that may be causing the symptoms. So when we see some one with high blood pressure we  don't try to work every patient for etiology for the elevated blood pressure . Again if we see very young patient with elevated blood pressure we WILL DO tests to find any cause of the elevated blood pressure -so called secondary hypertension.In medicine we are often told that the cause of symptoms is more likely to be due to ONE diagnosis , rather than 2 or 3. So this is one of the stories where there was a exception to this rule .
      I saw this patient who was seen by number of physicians before me . He came to see me referred by a family doctor. When I went the room in my office to see him , he was lying down on the examination table. In my practise this is very unusual as most of my patients are sitting in a chair ,waiting to be seen . So this was a 65 years old male who was referred to me for the evaluation of abnormal CT scan of the chest . He was admitted to the hospital in recent past his first primary doctor with chest pain . He was seen by a cardiologist and the had heart catheterization  and it showed the blockage and so a stent was put in. He was discharged in spite of him complaining that he still had chest pain . So in less than on week he went back to the ER with chest pain and he was readmitted. Again the cardiologist saw him and told him that his heart was OK and no further work up was needed. He was discharged and the primary care physician saw him in office . The pain was still there and so he did a CT chest . The CT chest showed number of small nodules and some abnormality in bones including spine. He was sent to a lung specialist . As I understand he was told that he needed to do follow up on CT scan in future. He still had lot of pain and so he decided to change physician . The new MD sent him to a orthopedic doctor who ordered MRI of spine . It showed abnormality in vertebra. But no further action was done. He was now referred to me . He was not sitting in a chair as he was hurting badly and there were no additional tests ordered. I saw the CT scan report and it clearly specified that patient had bony abnormality in ribs and spine that was 'consistent with metastasis '. Patient was smoker had quit smoking NOW . So most likely he had some kind of CANCER that had spread to the bones and it was causing the chest pain .
     I decided to admit him . My worry was two fold . One is the pain control and other was the abnormality seen in first thoracic vertebra . If something would happen to this vertebra , he may be paralyzed . So I talked to radiation oncologist . I did further work work up in the hospital . The CT scan of the abdomen and the pelvis did not show any source of the cancer. The bone scan confirmed the spread of the cancer to several bones . I also got the old history that he had prostate cancer 5 years ago and had surgery and radiation treatment. But the PET scan showed increased up tale in several lymph nodes. It also showed some uptake in colon .So I consulted a chest surgeon who did the biopsy of the lymph nodes in the lung and it showed the LUNG CANCER . So we had the diagnosis . But the question was does he have second or even third cancer ? Remember the rule in medicine is not to look for more than one diagnosis . So here we had diagnosis of lung cancer , which could explain the entire picture . was elevated PSA -a blood test that indicates possibility of prostate cancer . We had done bone biopsy and it was OK But it was not done from the exact place where the bone scan was showing abnormality . So I decided to ask radiologist to redo it , but this time with help of CT scan . So the biopsy was from possible metastatic lesion . It showed prostate cancer . So he had 2 different cancers . The pain was not from the lung cancer ,but was from the prostate cancer spreading to bones .I am not sure if he has third cancer colon We have not done colonoscopy yet .


Thursday, October 6, 2016


     Now a days it is fashionable  to talk about the targeted treatment or approach in the patient care . I often wonder as to what did the physicians did in the past . Was it not targeted  or was it not patient care ? But in the commercials that I see on the TV , especially on cancer treatment I see the word used frequently. But I do not find any difference or at least not anything better. But I find more often treatment being given per BOOKS rather than targeted to individual patients. So the treatment that is offered is more often determined by COMPUTER medicine rather than by Human being who happens to be physician. So one of the story that I am going to tell is one example of this targeted (?) therapy.
    I have known this 78 years old male patient who was smoker for entire adult life . He had COPD ,related to smoking. He was getting more short of breath and then had to be put on oxygen . He still continued to smoke . The when he was hospitalized he had a CT scan of the chest done and it showed a small nodule . The size was around 1cm. With his given condition and the given size , diagnostic procedures to get the biopsy would have been impossible . We can do bronchoscopy , a PET scan or needle biopsy, or open biopsy . But the given oxygen dependent COPD and small size we could not do any definitive test to get the diagnosis.So I decided to do follow up CT scan . The new Ct scan was done in 3 months and the nodule had grown and it was now 1.5 cm . In between he had developed  swelling of the feet and further work up showed that he had Liver problem . As it turned out  he was drinking 5-8 drinks a day and it had caused cirrhosis of the liver. So now we had to treat it . Medicines did help the swelling. Then he was admitted to hospital with shortness of the breath and the new CT scan done showed clot in the lungs . So now he needed blood thinner.. I spoke to radiologist about doing the biopsy of the nodule. I had done the PET SCAN and it did show increase activity suggesting that this nodule was most likely to be cancerous.. The radiologist felt that it was too risky to do biopsy due to the recent clot and the location . So I talked to the patient and the family and it was determined that we will wait and do follow up on the scan . He was discharged to rehab place . He came to see me in the office . He was still quite weak and short of breath,but felt better. So after discussion we decided to ask RADIATION ONCOLOGIST to consider radiation treatment without the diagnosis of the cancer , but based on PET scan finding and the growth seen on CT scans. So I got a note from him. He wanted a biopsy of the lymph node that was shown to be hot on PET scan but was not enlarged .
       He was readmitted and this time he had fracture of vertebra and needed treatment. So I decided to do new CT scan and it showed the nodule and did not show any enlarged nodes. So in span of 4 months the nodule was bigger and no lymph nodes were seen. So I thought that radiation oncologist would agree to do the radiation treatment without the biopsy . I did not feel that lymph node biopsy would be positive or give any additional information to alter the treatment. But the radiation oncologist insisted on the biopsy . So I called 2 different doctors who do such biopsies. Both of them looked at the CT scan and the PET scan and felt that they could not do the biopsy as the nodes were too small and it was too risky.
      So I have this patient who has oxygen dependent COPD , cirrhosis of liver , clot in the lung and vertebral fracture and had aortic aneurysm. So it would be 'targeted 'therapy if we could give him radiation to the nodule rather than looking at the PET scan and feel that if the lymph nodes are positive , we would need different field of treatment .
    By the way patient for now has decided to go with Hospice 

Saturday, October 1, 2016


        The modern day medical care is considered comprehensive . The ICU have started collaborative  rounds , which includes physician,nurse, case management, respiratory therapist . pharmacist and some other. The idea behind this concept is that such collaboration will help improve patient care and it will be comprehensive . So now a physician present in ICU 24/7 will help critically ill patent's outcome. This now implemented in ICU across the country. Certainly it will improve some care in some patients and it will also increase the cost of health care as billing will be changed and most likely it will be higher. But what I would have like to think is better care by individual physicians and better communication among patients and doctors and among different physicians. I often see computer generated notes which are neither accurate nor informative and tends to state things that are exaggerated especially the Time spent . If one would add the recorded time in the notes , there would be no time left in a day of 24 hrs. But my question is why do we have such a behaviour and the thought process ? I want to talk about couple of patients in this regards.
     I saw this patient for pneumonia. He was 84 years old and had not smoked for many years . His chest x-ray showed pneumonia and some fluid around the lung . So I did CT scan and it showed fluid . So I drained the fluid and it was positive for lung cancer . I called oncologist and they saw him promptly . But a month went by and no treatment was started as they were trying to decide on which drug regimen protocol to use . Patient got more short of breath , and that was in spite of regularly draining the fluid with a inserted catheter. So he as admitted and it showed a clot in the lung and now more /new fluid on the other lung. So the ER doctor called  at 10 or 11 pm. I started him on intravenous blood thinner . and ordered to check the legs for a clot in the legs. The incident of such clot in patients with cancer is very high and they may need treatment life long or as long as the cancer is there. I also knew that he may need the drainage of the fluid and may need putting a catheter to drain it as needed -just like he had it on other side . The treatment for cancer was not yet started  and that may also need insertion of a port . So essentially he would have needed -potentially 3 different surgical procedures in near future. This meant we will have to hold the blood thinners. Taking this account I had started the blood thinner that could be stopped and the blood thinning would return to normal in less than 6 hrs.
     The next morning I went to See the patient and was surprised to note that the IV blood thinner that I had ordered were discontinued and a pill was ordered. This new pill takes effect immediately and patients can be discharged quickly. But it takes 2 full days to reverse the effect of blood thinning. So while he is on this pill no surgical procedure could be done and will have to be off it for 2 days . I had to change the orders again as we needed to have catheter inserted for fluid and a filter to prevent clot travelling from leg to lungs and get port inserted to give chemotherapy. So why the oncologist give pill?
     The patient got all three procedures done and then about 4-5 days down the road we started the pill and he went home I think the problem is that the thought process that I went through when I started the IV blood thinner was not done by the oncologist , nor was my note seen and it was a knee jerk reaction to start the pill which is correct treatment in most but not in all . 

Saturday, September 24, 2016


       I had a chance to attend the lecture of Dr Atul Gawande, the famous writer who has written some books and the last one is BEING MORTAL. His lecture was recently arranged by Florida Hospital and being in medicine and quite familier with the topic , I decided to go . The lecture was attended by many ,the hall was full and he had standing ovation. I have known the mortality of life for long time and have seen the effects of aging in my patients and relatives and myself. So the topic was not new nor was the contains. But what I have found out in my own experience is that it is the most difficult task in medicine. So this is one of the two stories.
       I saw this 86 years old male in the hospital for shortness of the breath. He had high blood pressure and question of the heart problem . When I saw him he had some fever and cough and he was short of breath. His wife was in his room . His ability to walk was reduced and his wife had to help . She looked little younger than him , may difference of 10 years. So the chest X-ray was done and the diagnosis of pneumonia was made . He was treated with antibiotics . He also needed oxygen and some additional treatment. We also did the echo cardiogram and it showed some narrowing of the heart valves , some elevated pressure in lungs . At his age this was not unexpected . I often tell patients that as the doors in older house do not close tightly or get stuck , the doors or the valves in heart either become sticky and narrowed or leaky. I did swallowing test and it did show some problem , but he did not too badly. So improved and was discharged home .
      I saw him in the office and did the breathing test. It showed reduced lung capacity and so he was put on some inhalers to help open the bronchial tubes. He was readmitted with the congestive heart failure in next 2-3 months . He was treated and discharged , but this time he was weaker and needed physical therapy and needed to be sent in a rehab center for 2 -3 weeks . We repeated the swallow study as my suspicion was that he was aspirating food and liquids and so he was having the lung problem. This was worst and indeed he was aspirating. But the speech therapist thought that he may do OK with certain precautions. He was seen in my office and we did  check up on his need for the oxygen . He could walk short distance and his oxygen dropped . So we had to put him on oxygen . So I saw him in the office in next 4 weeks and he was doing OK . He needed to increase the flow of oxygen when he would walk. Higher the flow is needed , larger the oxygen cylinder is needed. The smaller ones would not last longer duration . So the choice is to drag the larger cylinder or don't walk much. Dragging larger cylinder foe 87 years old is not easy. SO then I talked to him about his expectations  and CODE STATUS.He told me he had not give a FULL THOUGHT and will talk it over with his wife and let me know .
     Two weeks down the road he was again admitted with another bout of pneumonia -most likely aspiration.I saw him and saw his CT scan and talked to him treatment and repeating the swallow study . I also told him that he may need feeding tube if the swallowing function is not normal and worst. He did not say much . So I again asked hin about CODE STATUS. I told him that he needs to make decision before it is too late His answers was same , ' I will discuss with my wife and let you know.'
    So if years old with all this problems can not make the decision then how do we expect younger one to do it? There are 3 other doctors involved in his care and not a single one has talked to him about this . May be if all of us in health care would talk at same wave length it might change , but who has TIME!!!!!! 

Sunday, September 4, 2016


     We in medicine have algorithm and diagnostic tree to make decision in case of simple or complicated cases and diseases . So some people are doing 'tele medicine ' . But my problem is that the computer can not diagnoses it nor treat it. The problem that I have is there is more to medicine than just knowing the diagnosis. One needs to know the patient and the family and the other factors. So I am writing this story to tell.
      I saw this 90 years male patient for abnormal chest x-ray. He had quit smoking 54 years ago and had no major problems other than high blood pressure. He was in good health and did not have any shortness of breath. He did have some vague chest pain and so the chest X-ray was done and then it showed abnormality . So the CT scan was ordered and he was sent to me .He was OLD but was completely oriented to and fully with the program. He came with his wife who was in wheel chair. She was also quite well as far as understanding is concerned. The CT scan showed a mass in the right lower lobe of the lung. So I told them the routine 3 questions, Is it Cancer , and has it spread and lastly the treatment options . So I also told them that we will need to do the PET scan to know the 'extent' of the disease , i.e. spread, and will need bronchoscopy and may be needle biopsy to 'know' the tissue type which would help in determining the treatment options . So the surgery was mentioned and I myself was not sure that this 90 years old would be a surgical candidate. But I had to mention it.Both of them of the opinion that he would not be considering the surgery as option of treatment. Then we talked about the chemotherapy and the radiation treatment as other options . We left is at that without making any final decision. I told them on the need for biopsy . At that time the wife asked me if there was an option of 'doing nothing' . Before I could answer the patient turned to her and said , 'why , why would I consider no treatment?No I want to get treatment. 'So we did the bronchoscopy and I did see the tumor. It was blocking the right lower lobe and the middle lobe was also seem to be involved in the tumor process. I did do the biopsy and he had some bleeding though I could control it with epinephrine and saline.  I was reluctant to do more biopsy. The PET scan that was done came back with bad news . He had PET scan that showed the pick up not only in the lung tumor , but also in the lymph nodes in the lungs and in the RIBS and in the bones of pelvis /hip. So essentially not only he was inoperable , but also had 'wide spread ' cancer and the prognosis was not very good.
      The biopsy came as 'possible cancer' but could not state as to exactly where did it come from and overall it was iffy at best. So I called them in the office to discuss as to the further work up ans /or treatment . The options of radiation treatment and or chemotherapy was discussed . For chemo to be given we would have needed more definite tissue diagnosis . So we will have to do a needle biopsy.After telling them the PET scan findings, it was decided that we will go for radiation treatment and do no further biopsies. I made arrangements to see the radiation doctor.
      2 days down the road I got a call from the ER physician that he was in ER with shortness of the breath and the chest X-ray showed a large fluid collection around the right lung. He did have small fluid on PET scan done may be 10 days ago . He was quite bad and I had to do a procedure to take out the fluid that same evening at 6-7pm. When I talked to him about the overall disease and the plan of the treatment ,since he now had one more problem to deal with. He told me to cancel the radiation treatment consult , which was to take place next day. He also wanted to be DNR and was considering HOSPICE.
    All the things that happened in this patient and how the decision was changed on number of occasions can not be done by computer. We might get options of treatment choices but not the definite decision without a physician explaining the options and choices made by patient and the family with the input by doctors.

Sunday, August 14, 2016


     I love to read and I do get enough material to read. I like to keep in touch with new development in medicine . But in doing so I sometimes come across certain thins that come out of research that amazes me . It reminds me of one of the episodes of Seinfeld. In the episodes he says that some people want to find out cure for cancer or may be AIDS, while others find out seedless grapes !Some of the stories that I read belong to such class as seedless grapes . So let start on some of the medical things that I have seen or heard in last few months.
    The FDA approved a drug few months ago for ---are you ready - for 'DOUBLE CHIN' .So this drug called 'KYBELLA'. So this drug which is given as injection to reduce the fat in double chin . As I read it , there was a mention that number of injection may be needed . The question popped in my mind how many would you need to reduce xxxx, never mind .
    The next one was seen by me as a study. Since I saw it I have told it to many of my patients and they all laughed and I was trying to find out for the reason for the results that the researcher got. These researcher did survey and followed patients with diabetes and other heath issues . The patients were asked if they thought that their 'spouses' were nagging . They were also asked to score the happiness in their married life . I am not sure how the nagging 'scores' were done , but the conclusion was very interesting . When the men the study felt that their wives were more nagging and  had negative opinion about the marriage, their diabetic control was better than in men who thought that their wives were not nagging and the married life was good . But exactly opposite was true  in women . So if the women thought that their husbands were more nagging and their married was not happy , their diabetic control was poor !
    I had some questions . How do you score nagging and how do you grade marriage . And may be the nagging wives will be more upset about keeping scores and saying that the marriage was not happy.! The reason for the result may that the wives's nagging may be causing the husbands to eat better and may be forced to exercise and that may help diabetes . On the other hand the wives when nagged and had less satisfaction in their marriages , ATE to relieve the tension and reduce frustration and so the diabetic control was poor .
     So now that I talked about the food and eating and overeating, let go to my next invention. So  do you realize that 86 % of African American women are overweight or obese ? This is also a major issue in Hispanic and whites . So recently FDA approved a device to help this. It is clear that we can not control our food intake . So this GENIUS came out with device . A tube is inserted in the stomach and it can be attached to suction . So you can eat anything and as much as you want . Then attach the stomach to suction and it will 'suck' it out before it is absorbed and adds inches and pounds to you.
    I have few more but may be in next blog.

Saturday, August 6, 2016


   I love stories that have mystery , I also love movies where one can not predict the end .But the problem with these stories is that once we know the end , we can not read it again . There is no fun in reading such story , when we know what is going to happen . The same is true of the movies. In medicine when some one says patient is interesting , it is because we did not know the diagnosis. But sometimes finding the diagnosis is not the end of story. And we don't know what to do .Today I am talking about a mix of these 2 problems .
     I was asked to see a patient for abnormal chest CT scan . I saw this 48 years old patient who came for not feeling good and having black stools. He was a homeless person. He was a smoker 2 packs a day and 18 cans of Beer a day alcoholic . In spite of all this he came because he was not feeling good. The work up was done . It included CT scan of the chest .It showed couple of nodules . So I was called in to see patient . He looked cachectic and so I asked him as to if he had lost weight .Again it would be easy to understand if a homeless person had lost weight. But some one who can smoke 2packs per day and drink 18 cans of beer should not loos weight due to lack of food. He had lost 40lbs of weight. Weight loss is an indicator of cancer in many cases , at least in many patients . So I asked him if he was not eating well. He told me that he could not swallow. The food sticks in throat  was his answer. So I ordered the swallow study and CT scan of the neck. The swallow study showed no problem with the food pipe or esophagus. Son at least he did not have cancer of the esophagus. But the CT scan of the neck was abnormal.
     We called the throat doctor-ENT specialist .I had also decided to look inside the lung -bronchoscopy. He had lung nodules and so I also ordered the PET scan . In PET scan tagged glucose is injected and whole body is scanned to see the uptake of the glucose . The glucose is picked up by every cell in the body and the 'pick up' is higher in cancer cells and inflammation . So it helps the diagnosis of cancer.When I did the bronchoscopy, I saw A MASS INVOLVING THE RIGHT VOCAL CORD AND extending above it . I did not do biopsy as I felt it was too risky to do it with mild sedation. The PET scan did not show any 'pick up' in lung nodules but did show the pick up in throat mass. So I called the ENT surgeon .
    With the vocal cord cancer , radiation treatment can be done . But due to Location of the cancer ,patients usually can not swallow well with radiation, so they need FEEDING TUBE . He would have also needed food like Ensure or BOOST to feed through the feeding tube . He would also need daily transportation to get radiation. So now we are faced as to how to manage this in a homeless man . To add to our trouble the surgeon could not do the biopsy for next 10 days. So if we discharge him we don't know if if he would show up for the follow up and the biopsy.
    So this takes me to my original point . NOW we KNOW the diagnosis , but WHAT NEXT? 

Saturday, July 30, 2016


     I have been in medical practice for many years and sometimes I feel that nothing can surprise me . But many a times I come across patients that have a diagnosis that is not uncommon , but it surprises me or may be it touches the heart. Some one coming for pain in the belly and then finding out wide spread cancer, is one of them . I often wonder as to how come there were no other warning symptoms. So today I am going to tell a story of one such patient.
     I was asked to see this patient who had pneumonia. This older patient had history of bladder cancer and has seen by urologist several times . He had some surgeries and treatment with BCG. (I have never known as to how this BCG came out as the treatment for the bladder cancer . The BCG is TB vaccine . It was used in the past for the protection of TB and now we know that it does not do the job so we don't use it . But how could one might have thought to use the BCG - a TB vaccine to treat bladder cancer?) He came to the hospital with painful urination and difficulty with urination. So he had some urinary retention. But the routine chest X-ray showed some infiltrates or congestion in the lung. So he was started on treatment for the pneumonia and I was asked to see him . He had never smoked and had not much of respiratory related complaints. He had some cough and no fever and had some minimal shortness of breath. I did do the CT scan as there was fluid around the lung and he did not have typical history of the pneumonia . The CT scan showed same -pneumonia and the fluid . So I decided to take out the fluid . So with the ultrasound guidance I took out 1200ml fluid . I was quite concerned about this being due to cancer rather than due to pneumonia.
    He felt great after I took out fluid . (It is amazing to see how one can have that much fluid and have no major shortness of the breath). In between he was seen by the urologist and had some surgery to help the bladder issues and they told him that he will have to have urinary catheter left in for few weeks. So he was not very happy. I got the fluid report and there were NO CANCER cells. So he and his wife were happy and I was happy but surprised .So I called a chest surgeon to do additional biopsy from inside . He wanted to go home .So he wanted to wait  But there were other issues going on . So I did another chest X-ray. I knew what I was going to get . The fluid had recurred in less than 3 days! So now he agreed to do the additional biopsy that the surgeon had suggested .
     The biopsy is done by inserting a small scope through a small incision in the chest. It is called THORACOSCOPY. The biopsy showed the cancer , IT WAS A LUNG CANCER . He and his wife were not happy , neither was I . But I was happy that I had ordered the biopsy.
     He stayed in the hospital for another few days to get a port put in and then to start chemotherapy as out patient . We left a chest catheter in to drain the fluid periodically at home .
     I felt quite bad as he and his wife were quite depressed . He came with urinary problem and left with the diagnosis of inoperable lung cancer and 2 CATHETERS, which he was quite unhappy about! He asked me HOW CAN THIS HAPPEN?

Sunday, July 24, 2016


     So in last blog I told the literary meaning . And I also stated the story of BHISHMA. So haw can the time of death is more important than what we do in our entire life ?  The answer is in the real meaning of the word , night and day , and the fire or smoke and Uttarayan or Dakshinatan or Shukla paksh or Krushna Paksha .
     If we think about the  'war' as the war of disciple with oneself , then it becomes clearer . So when the Lord Krishna is  talking about the  fire , he is talking about the knowledge or the Kundalini power. The smoke covers the truth. When he states smoke , it means the mind is not clear and one has ignorance .So if one has never engaged in meditation or trying to arouse Kundalini Shakti , and lived in ignorance of thinking of the physical body as the reality and engaged in sense pleasure indulgence , he is not going to reach eternity. He will be reborn due to desires and the attachments to the physical body as none of the physical desires can be fulfilled without the physical body.
    The 'Light' and the ''Darkness' are also very easy to understand . The Light is the spiritual eye . When one is successful in the meditation , he will have the  experience of one with the God , and this when sustained with repeated practice , will lead to detachment from the physical body . When there is no attachment to the physical body or the sense indulgence , then there is no rebirth.
     The Daytime and night are similar. When the Day starts , we are' awake' and wake up from' Sleep'. So during  the sleep when we do not have any Knowledge of our surrounding, is compared to us sleeping in ignorance. This term is quite often used when we are told to 'Wake Up' by many politicians or religious leaders .
     The next one is waxing and waning of the Moon . The Lunar light is not it's own light . In the real world the Moon's light is the reflected light of the SUN. So if the Sun is the spiritual Eye and it sheds it's light on the Moon which is material world. (The moon is related to material worls where the energy comes from the Sun . So when the enlightenment 'increases' and our mind turns away from the material world , we will have MOKSHA, but when this light is reducing or getting dimmer , we will have the rebirth as then we are turning away from the Realization.
      Now the last one . When we watch the Sun rise in the East, we will notice that the sun moves Northward for 6 months and then southward for 6 months. In our body the upper part of body is north and the lower part is south. (Remember in case of DRONA in Mahabharata , when he defeated Drupada ,he gave him back the southern part of the kingdom. So it is little easier to have control over lower centers than upper centers)The six months are six centers and when one tries to meditate and get control over lower centers , procreation , excretion and hunger, he is moving NORTHWARD . So the SUN or the knowledge is moving northward . When we are paying attention to lower centers more and more , we are moving southwards. So if we continue to be more involved in these lower level activities, we have no chance of MOKSH.and 100% rebirth is guarantied ..


    I am not sure why all the scriptures are written in a mystic way , such that they become 'open' to interpretations or 'misinterpretation'. This is true of Hindu as well as Christen Bible. I have some explanations of the some of the verses of the Bible that are according to the Hindu belief. In revelation(4) it is stated that "I looked up and saw 24 elders sitting on a thrones" I think these are 24 principles that go in forming ASTRAL body. But if one reads the entire passage it is very likely that different people will come with different explanations, all of them could be valid. The translation of the 'words' is not the intended meaning.
         So today I thought of writing on GEETA ,chapter 8 ,verses 23 to 26. I have seen different explanations including on by  Swami  Chinmayanand. But the best one and what I like by Yoganand.
The word by word meaning is when the Lord Krishna is telling Arjuna the path which is taken at the time of death by different people. So He says that ,
"I will tell you the path taken by yogis that leads to 'freedom' and path that which leads to 'rebirth'.23

"Fire, Light, Daytime and Shukl Paksh ( bright half of Lunar month), Uttarayan (six months of Northward movement of the Sun),--following this path (at the time of death) men (or women) who 'know' God or Brahman will go to God or Brahman." 24

"Smoke , night time , Krushna Paksh, (dark half of Lunar month), and Dakshinayan (six months of Southward movement of the Sun)--following this path he will obtain Lunar light and will return to Earth."25

"These 2 paths -one of light and one of darkness are thought to be eternal. The path of Light leads to release,while the path of Darkness he returns".
      So if one takes the literally meaning of these verses , will have to conclude that the 'time of death ' is very important. So if one dies at 'wrong time ' then he will have rebirth . But if one dies at 'right time ' then he will get the MOHSHA . If you recollect the story of Bhishma in Mahabharata , he war injured and could have died except for his own control on the time of death. He was blessed with a boon from his father Shantanu that he and he only will decide the time of his own death. So when he is badly injured the 'time ' was not right ,it was DAKSHINAYAN -The Sun was moving southward . So he would not achieve the Moksha . So Bhishma decides to hold on to the physical body till the Sun starts moving Northward again. So it does not matter what one has done in entire life if one dies at 'wrong' time ! This does not make sense . So the real meaning is different . let me try to explain as I understand it .

Saturday, July 16, 2016


    Some one had defined 'specialist'(in medicine) as "someone who knows more and more about less and less!" I feel it is so true . A cardiologist does not know about Pulmonary or at least does not want to be bothered about it and a  kidney doctor does not look at anything else but kidneys. But the medicine is growing so fast that one can not keep up to date on every new development in every subject. But my story today is about something else . Sometimes in practise of medicine we have all sorts of experts and they also come out empty handed. The line that I had liked in past was ,'Medical knowledge is vast and incomplete.'
     So this is the story of one of my patients. I had known her for few years . She was mid fifties and was a smoker . She had shortness of breath and also CO PD. so she was tested and was put on oxygen and medicines and was told to quit smoking . She had some kidney issues and so had an ultrasound   of the abdomen done and it showed some fluid in the lungs. So she called me . I did a chest X-ray and it did show large amount of fluid around the right lung. She was little more short of breath and so I decided to admit her. She then had a CT scan of the chest and the fluid was confirmed . There was no other abnormality to explain the cause of the fluid . So I drained the fluid . I drained 1200 ml of the fluid and sent it for various tests to find out the cause of the fluid collection. There was no infection , TB or bacterial . But the fluid did show CANCER cells. So I consulted an oncologist -expert in cancers. He ordered some tests , but we did not know the origin of the cancer -where did it start. Now a days we do many tumor  markers. The cancer cells look different that their parent organ cells. But they still retain certain characteristics of the original cells.Easy to understand would be breast cells . They will have 'markers' for female hormone, estrogen . I also give example of interracial marriages , where the children would show some characters of both the parents. So one can do many markers now a days  There are so many of them that I can not keep up with them and I have to depend upon other experts and their knowledge . So after testing many of them we still came out empty handed . I had ordered a PET scan . This scan is done by injecting glucose which is tagged with radioactive material. The glucose is picked by every cell in the body . Since the cancer cells are metabolically more active than the normal cells , they pick up more glucose and the this pick up is measured and one can diagnose or stste high probability of cancer . No test is 100%. So the PET is may bbe 88%. The PET scan showed abnormality only in pleura , where we knew that there was cancer. The major differential was between lung cancer and the mesothelioma. All of us know that if one has lung cancer there is no monitory gain , the treatment is different and the prognosis id different. On the other hand if it was mesothelioma , which occurs with asbestos exposure , there is monitory gain and the treatment and the prognosis is different. So I consulted a chest surgeon . I asked him to do 'open biopsy'. So an open biopsy was done and then bigger sample was given to the pathologist and the final diagnosis was ------still same .It is cancer , burt unable to state where it started and not sure if it is mesothelioma. The sample was reviewed by 5 local pathologists and now is sent out for 'expert' opinion. So in spite of all the experts we still DON'T KNOW' . This is what I call inadequacy of medicine .  

Saturday, July 2, 2016


  I have been always intrigued by the Geeta's1st chapter. In many of the series of first shlokas it appears that there is not much about the religion . In short they appear 'wasted' if one considers the Geeta to be a religious discourse on the battlefield. On the other hand many believe that these shlokas are introduction to the REAL battle field story and so they are part of MAHABHARATA and so the appear to be appropriate in the beginning of the Geeta. I wrote about the first 8 shlokas in past and in this blog I want to write about the 9th one . Please understand that this is not MY KNOWLEDGE and I am simply stating what I gathered by READING.
     In shloka 9 it states that "and many other warriors are present, they are well trained and have weapons and are here for my sake and will lay down their lives. " When I look at this one , in continuity of other shlokas it does fit in to the introduction of the war . May be it sounds like the speech that many Hosts give at the time of wedding stating important names first and to avoid omitting others ,state that and' many others who have come to attend this function taking out time from their busy schedule .'
    So who are these 'many other warriors?'Yoganand feels that these are the 6 enemies of the human beings that are mentioned here . These are KAMA, KRODHA, LOBHA, MOHA , MADA AND MATSARA.--LUST, ANGER,GREED, DELUSION,PRIDE AND ENVY OR MATERIAL ATTACHMENT. So are these 6 enemies represented by the 6 warriors in the Kaurav army?
   Kama-Lust-Usually we think of Kama as Lust or sexual desire , but in broader sense lust is intense desire for many materialistic things and so the DURYODHAN is the best example . But if we think about the story of Mahabharata and the incidence of Pandawas loosing in gambling there were many who came forward to undress Draupadi . So these are the one that  represent KAMA.
   Krodha or Anger -We all know that when we are angry , we can not think properly and make proper decision. We are told by elders to calm down and make decision. So in the Mahabharata , Duryodhana's brother Dushshasana is the example of anger . In Sanskrit meaning of the word Dushasana is 'one which is difficult to control.'
    Lobha or Greed- The greed could be for food or sex or money . But how do we develop the greed . We 'act' and then 'experience' pleasure and then we develop the likes and dislikes . If I eat something and I enjoy it I am attached to it and I develop GREED FOR IT.So even if I am not hungry I will indulge in eating . This attachment to the things that we like and repulsion to the things we dislike are represented by Karna and Vikarna .
    Moha or Delusion-Sometimes we use word Moha as attraction. And indirectly it is attraction . But the attraction is due to Delusion or not knowing the truth . The ego has the bodily attachment and has delusion. The soul does not have the delusion . This ignorance is the cause of Moha.So if we knew the truth , we may not have the attraction. If we fall in love with someone as they are good looking but then when we know their nature or views or behavior the attraction is gone .The same thing could be said about the food , which is tasting good but not good for the good health. In Mahabharata this Moha or delusion is represented by SHAKUNI . He was the one that had asked the Pandawas to play with the dice that were tainted . This is when the Pandawas lost everything in gambling. The delusion was that they could win .
    Mada or Pride- We are proud of our name , family  or education or job or family members . But when this goes beyond certain level it is intoxicating or unwise or bad . In Mahabharata Shalya is representing this quality. In reality Shalya was maternal uncle of last 2 Pandawas namely Nakul and Sahadev. He was brother of Madri. So he should have been on the side of Pandawas ,but due to the Pride ,he decided to fight from side of Kaurawas.
    Matsara or envy-This one is easy to understand as we all have it and display it all the time . We are envious of someone who makes more money or has better and bigger house or whose kids are smarter than ours. In the Mahabharata this is represented by Kritvarma. Lord Krishna belonged to the clan of Yadawas . Kritvarma was a Yadawa, but he became envious when the lady that he wanted to marry  , got married to Lord Krishna. So he was envious of Krishna and so decided to join Kaurawas to fight against the Krishna supported Pandawas .
    I know that this is not perfect explanation . But I thought this is as close as I can understand and accept.   

Saturday, June 25, 2016


   I have often talked about the lung diseases as I am a lung specialist . But as I often say the various organs in the body are related to each other like the various residents in a town . What one does affects every one other at one or other time . The obvious ones are the lungs and the heart. But recently - may be in last few years I have realized that the the Gastrointestinal system does affect the lungs mare than one way . Some of the elements may be related to patients living longer. Sometimes ago I saw this Indian patient . He walked in my office and had no appointment . He was working in a motel . When my office secretary asked him as to why he was in my office , he told her that the owner of the motel told him to come to me and I will take care of him . I started seeing him.
   He had a condition called scleroderma and he had no health insurance . So it was somewhat difficult to take care of him. But we managed . He had scar tissues in the lungs and also had circulation problem in the fingers and toes . He had chronic cough due to the scars in the lungs and was also short of breath . I did do CT scan at a discounted price from a radiology center and did complete pulmonary functions free. and treated him with meds . He had developed a ulcer on his ankle and had some ulceration on fingers . So I treated it with home remedies . I gave him Papaya cream and honey and asked him to soak both feet in hot water as long as he can to improve the circulation . All these things worked and the ulcers healed . After about 2 years of the follow ups , he got health Insurance and then he moved out of town , but continued to do the follow up with me .
    He was quite bad and I decided to refer him for transplant evaluation . I had done the check up on his heart as the scleroderma can cause the pulmonary pressure to go up . The heart check up was ok . The transplant evaluation as far as lungs were concerned , went well and they did think that he would be good candidate in ; near future'. But on further evaluation it was noted that he had problem with his esophagus. This is actually quite common .I had not done any work up on swallowing as he had no insurance and he had no GI symptoms. So  it came as a surprise and a disappointment . HE HAD ESOPHAGEAL MOTILITY problem .
     Normally the esophagus moves as contraction rings so the the food is squeezed down .  HE had no contractions . This can cause the food and the water to stay in the esophagus for prolongrd peroids of time and that can then regurgitate and go in lungs and can cause aspiration. This can further damage the already damaged lungs . This an absolute contraindication for the surgery and he was rejected fo transplant.
    Since then I have seen similer problem in some of the older patients without the scleroderma .Most of them presented as chronic cough, or recurrent pneumonia,  

Saturday, June 11, 2016


   In medicine we talk about the standard of cars . What may be standard of care in one area may not be standard of care in another area. To give an example referring to a cardiologist may be a standard of care in one area where there may be 10 cardiologist, but in another area there may be none in 100 miles area so to manage on own by a family doctor is OK . Standard of care is what a medical community would do under given circumstances in a particular area or under given situation.So if some one has chest pain , we do work up to rule out heart problem. So today I am telling a story of a patient where we followed the so called standard of care and had more problems .
     I saw this 65 years old female who had some cough. The routine work up was done and her cough got better. but then due to the scare of cancer , she wanted a CR scan of the chest . I have seen patients with normal chest X-ray and abnormal CT scan showing cancer . So I did agree  to do the CT scan.The CT scan was done and it showed some some tiny nodules. The size of the nodule was so small that the usual tests that we do would be not effective in getting diagnosis. The usual test are Bronchoscopy , needle biopsy, PET scan or open biopsy .. With the size of the nodule less than 10 mm we can't do much . Now a days we are doing so many CT scans -almost 1000% more -that we are seeing these nodules and we are stuck with the follow up . I often tell patients that doing a chest X-ray is like looking at the sky at night and say looking at MARS. Doing a CT scan is like seeing the same MARS through powerful telescope. One is bound to see more details.So what is not seen on plain chest X-ray , will be seen on CT scan . So now I have to do follow up CT scan . The criteria which are established -the so called standard of care is to do follow up CT scan based on the size of the nodule . If it is 8 mm , then do CT scan in 3 months , if the nodule is 5 to 8 mm then do in 4 months and if the nodule is less than 5 ,mm then do the CT scan in 6 months . So I continued to do CT scans . Every time I did new CT scan it would show a new nodule and some old would either disappear or would be stable. (This sometimes can occur due to sectioning variation. I must have done follow up for more than 2 years and unfortunately due to new ones , I had to continue doing more CT scan . Again none of them were bi enough to do other tests .
     And then one day I did CT scan and this time it showed lymph node enlargement. So now I was not sure if she had a cancer of the lymph nodes or it was part some disease that was causing the nodules and now the enlarged nodes.I had to call her for discussion and she also came with number of family members . Had no choice but to recommend the biopsy . I did not want the needle biopsy as the sampling size is small and if we do not get 100% diagnosis , we will be stuck again . So I sent her to a chest surgeon .
       The happy ending is there . The biopsy showed SARCOIDOSIS. This is a benign disease and no disease !! 

Sunday, May 22, 2016


  I received a message from one of the reader of my blog, that liked one of my old blog entry on Mysticism in MAHABHARATA. So I was thinking about the mysticism not only in Hinduism , but also in Christianity.On the surface  many things that are written or said, appear to be open for interpretation or misinterpretation. The story of Adam and Eve.The question that I have is how valid is the statement that we are all sinner as we are born to Adam and Eve . This off course comes from the people who DO NOT believe in reincarnation.So Where do I come from and what sin did I commit that I am paying for it ? I do have explanation . But I will write about it latter. But today I thought about writing about the THE FATHER , THE SON AND THE HOLY GHOST in CHRISTIANITY and the same thing in HINDUISM . You can tell me how wrong or correct I am after reading this blog.
    In Christianity they always talk about the Trinity . It is also said that The Jesus Christ was the SON and he will save us. But no one talks much about the origin of the universe. So the FATHER is the SAT, The SON is the TAT and the Holy Ghost is the AUM. The SAT means the Truth, the Unchangeable, the ever lasting. When one refers to something as REAL , it does not mean that in our conventional way . The computer that I am using is real to us and is not imagination . But it changes every second , even though we can not recognize it at that time.(We can see it very easily if we check it in a year or two. )So the SAT means one that does not change and from this SAT everything originated.  Thia is why it is the FATHER . The SON is the thing that comes out of the FATHER. But to start the universe we need to have ENERGY and the Matter. So the UNIVERSAL CONSCIOUSNESS or the SON which pervades everything in this universe is the TAT--THAT.The first word or the creative vibration. This is AUM or the HOLY GHOST. The matter is inert and has on spirit or energy and that comes from the SON or TAT The union between the SPRITE and the Matter leads to the beginning of the universe. The AUM is mentioned in the Bible as the 'In the beginning was the word and word was with the GOD 'So in Hinduism we talk about the first sound is AUM . The AMEN of Romans , Greeks, Egyptians, Jews and Christians the AMIN of Muslims , all are same as AUM .
    So The SUPREM GOD does not move and does not change and is the ulimate reality and is the origin of the universe is the FATHER OR THE SAT. The SON is the all pevading consciuosness or the Sprit or the energy or the TAT without which inert mattaer can not DO anything ,is the TAT. And lastly the HOLY GHOST is the AUM or the first sound or the matter or the mother nature.    

Tuesday, May 17, 2016


      I was reading a book which was suggested to me by several people . The name of the book is WHEN THE BREATH BECOMES AIR .' This was written by Paul Kalanithi . When I went to library to check it , I realized that it was quite popular book . There were 50 plus people ahead of me . This is a story of a neurosurgeon who was diagnosed with metastatic lung cancer at age 36 and died of it. The book it written by him and published by his wife after he died . Couple of points that I want to make is that 1 it is quite depressing book especially towards the end , and I did expect it . Even though I see this every day I was not very happy with the end even though I knew the end . Secondly I felt that too many physicians FEEL that working HARD and neglecting family is OK. I am not surgeon ,but I have heard that in all the surgical branches there is hard work and rude behavior and it is carried from residency and then in practise . (I want to make it very clear that Dr Kalanithi was not rude )But why is it OK to work 16 hrs?(In my residency time I did do 34 hrs straight too ).This may be the cause of stress and suicide. But the reason I started this blog was to tell you about my patient.
       So I was consulted on this 35 years old female who was having some shortness of the breath and question of pneumonia . When I talked to the patient and her family , I realized that I was dealing with a sad story.She never smoked and did not drink alcohol and about 20 months ago she was diagnosed to have a stomach cancer . By the time it was diagnosed , it was inoperable. So she was given chemotherapy and she did OK , She was in 'remission '. But then as many times happens , she had recurrence . She was given radiation and chemo and continued to struggle The cancer had gone to bones and brain and lungs. She was short of breath and needed oxygen . Due to the spread of the cancer to boned , she was needing blood transfusion every other day . I reviewed her chest X-ray and the Ct SCAN AND FELT THAT THE CANCER WAS NOT ONLY IN LUNGS , BUT WAS BLOCKING THE LYMPH DRAINAGE . This was making lungs 'stiff' .The lungs  which are normally like dry sponge , are now filled with water -or in this case due to cancer and these stiff lungs needed much more energy to open or expand them and that resulted in shortness of the breath . This fluid in lungs also caused the oxygen transfer to be poor and needing oxygen .So there was not much I could do . Just like in case of Dr Kalanithi , sometimes we can not offer anything but prayers .
      Even though I believe in reincarnation and the Law of Karma , I am not sure how I can explain this or accept it I still call it BAD LUCK !!!

Sunday, May 8, 2016


   I have always wondered about the speech or the language.  when different people speak English they speak in different way or have different accent. I think that the accent is based on the person's mother tongue.. (Is it called mother tongue as the father does not get a chance to speak?)So when a Hispanic speaks English it is different that when I Frenchman speaks. I for that matter can distinguish different accents of people from India . This is how the CHINAYA SUZUKI thought about the music. He felt that the music was a language and as we don't have to teach a child a language or it's peculiar accent , we don't have to teach a child a music if he or she can hear it frequently. But I am not talking about this part of the language , or the speech . I am talking about the origin of speech .
    The other day I saw this patient with respiratory failure . She had been a smoker and had rheumatoid arthritis . She came to hospital with shortness of the breath and then needed significant oxygen .When I saw her in ER , she was mildly short of breath and was talking OK. She may have had pneumonia , but when I saw her old X-ray , I knew that she had fibrosis , or scar tissue in lungs , probably from her rheumatoid arthritis. So I knew that we are going to have some tough time in weaning her oxygen . But she did OK , did get little better. But then the hospital doctor called me one morning telling me that she was confused and he did not have idea as to the reason for it . So when I saw her and examined her I was surprised . She was NOT CONFUSED ,but had Expressive Aphasia. SHE COULD NOT EXPRESS . She could move her all extremities. But when I showed her a pen , she could not name it and was saying yes to every question. So I knew that she most likely had stroke . I ordered a CT scan of the brain and asked a neurologist to look at her . CT scan of the brain showed abnormal area in the frontal lobe . The neurologist had no specific diagnosis.
     The speech is formed as a result of coordination of various areas in the brain. Broka's area and the Wernikoff's area are the 2 known area and the frontal lobe stroke most likely caused the aphasia .When we see something, we know what it is and the word is formed . When we listen to a sound we know what it means and when we touch , we know what we feel .
  For those who are interested in Hindu Religion , there are 4 different speeches , They are called PARA. PASHYNTI MADHYAMA AND VIKHARI. The last one is spoken speech . May some day I will try to explain what the other 3 mean .

Friday, April 15, 2016


    When the EMR , or electronic Medical records were introduced , it was thought that we will have better care. In fact the federal government paid physicians to participate in it . So many physicians got it. Those like myself who did not participate in it got reduced payments for the services than those who did get EMR . So now that we have it is the quality improved? In my estimate it has not only not improved , but has gotten worst. In the hospitals we HAVE to do EMR and I spend at least one and half hour extra doing it . On top of that I often see more things in the records than actually has been done .
    I get notes from other physicians . Many of them are 6 pages . When I go through them I find that 4 new lines , every thing else is same as was in previous last 5 notes . This is due to EMR. The notes are Generated by the computer and the physicians pit in minimal new information and rest is carried from old note which was generated on first visit. In one of the notes one physician who started labeling problems with alphabets rather than numerical numbers, at the end of the note he ran out of the alphabets and had to label AA,BB etc. Were there more than 26 problems that this physician addressed in 15 minutes visit? But the reason I am writing this today is due to one of the patients that I saw .
     I was consulted on this 48 years old patient for the diagnosis pf pneumonia . He had no fever , no t much cough , but the cheat X-ray showed some congestion. So he was started on antibiotics and I was asked to see him.He also had low blood count and so a blood doctor was also consulted. He had also history of heart disease and so a cardiologist was also asked to see him . I saw the patient . He had history of a disease called sarcoidosis and when I asked him as to how it was diagnosed , he told me that he had 'OPEN LUNG BIOPSY' . When I examined him . he had big belly. On examination he had enlarged liver and spleen and had fluid in belly. I had ordered CT scan of the chest and the Ultrasound of the belly. The CT scan showed that he did NOT have pneumonia and the mild congestion that was seen on plain chest x-ray was related to previous lung biopsy . The ultrasound of the abdomen DID show that he had cirrhosis of the liver and enlarged spleen and fluid .
    I did some further investigations. I called gastroenterologist and told the patient and his wife that he will need to see a liver specialist for consideration of liver transplant .
    I went back and looked at the EMR entries of one hospital doctor 3 different blood doctors and one cardiologist . EVERYONE had put belly examination as NORMAL on several different times . Some of these entries were done AFTER we had the US report showing enlarged liver and spleen . This the ' EMR and CUT and PASTE notes .   

Saturday, April 9, 2016


    In medicine as in any other field we all are product of advertisement. Every one today is concerned about cholesterol , even a 80 years old patient who has end stage lung disease and controlling the cholesterol would make no difference in his shortness of breathing for sure and probably in his survival. But he continues to be given statins and he also spends lot of money for the medicines that I am not sure is going to help. I would like to have someone do a study on these kind of patients who have significant co morbidity or are very old , to see if lowering cholesterol is beneficial or not. But then there is no benefit in doing this study for the pharmaceutical companies. But then there are known killers and we pay no attentions. This is primarily due to media bias. The two most common disease get attention in media are heart disease and breast cancer . But then there is no excitement in Influenza. That is what I am talking today .
    The flu is common and most of the people do not  need or seek treatment and get better. But then physician like me see the sick ones and some get so sick that they are in intensive care unit and even die.
    It was 6-30 pm and I was about finished with my patients and I had couple of notes to be finished . So I was happy . Then I got a call from one of the hospital doctors, asking me if I could see a new patient who was 'sick'. It was a27 years old Hispanic patient who had her first delivery and was found to have low oxygen and so this hospital doctor was asked to see her . In tern he asked me to see her . They had thought about some unusual conditions like amniotic fluid embolism. In this condition at the time of delivery the fluid from the sack enters the mother's blood and gets in lung and causes all sorts of problem . The bad part is that there is no real treatment. So I went to see her . When I saw her she not complaining of shortness of breath or any chest pain. Her respiratory rate was high and her oxygen saturation was low . Her lungs were congested and her chest X-ray was bad . It showed pneumonia . In this young lady who had just delivered a baby , I thought of vomiting and aspiration . But then there was no history of vomiting .She was in ER day before with symptoms of cold or flu and had 'rapid flu test' . It was negative and so she was sent home . Her history was suggestive of flu . So I started her on treatment and called infection specialist. I also transferred her to ICU . I was worried about the pneumonia and flu causing respiratory failure. I was right and she did get worse . There was no embolism. She was in ICU for 4 or 5 days . needed high flow oxygen. But she slowly got better and after in the hospital for 10 days she was sent home.
   So flu almost killed this lady. But with shear luck she got better . Recently I have had 2 more otherwise healthy patients in ICU and needed to be in the hospital foe 12-14 days. I also heard of 35 years old male loosing life due to flu.  

Sunday, March 20, 2016


    Many years ago I had heard comments about statistics. I am sure you can add to the list . Some of them are interesting. One was ,' there are lies and then there are lies , and then there is statistics!'. The other one was, 'if you put one hand in boiling hot water and other in ice cold water, then statistically you are at comfort'. So sometimes when we in medicine talk about chance , or probability or possibility , we truly are talking about what happens to majority . But by no means this is 100% but we in medicine  get our opinion further confirmed as majority of the patients behave as we knew from the statistical data. I  have been always puzzled as to why in a study all the patients don't behave same way . The sugar is sweet and everyone who tastes it will say the same thing . Then why a particular cancer in particular stage behaves differently in different patient ?These thoughts came to my mind when I saw this 74yeras old patient recently.
      He is a 75 years old male whom I saw several years ago . He was maybe 60 years old at that time and had come to me for an abnormal cheat x-ray. So I did a CT scan and then a biopsy. The CT scan showed that he had a mass in the right lower lobe and there were number of lymph nodes in the chest that were enlarged. This indicated spread of cancer to these nodes and made him inoperable . The biopsy confirmed the lung cancer . So he was treated with radiation and chemotherapy. Per my 'thinking' -which was based on the statistical data of this type of cancer in inoperable stage,- was that  he was not going to last mare than 2 or 3 years. I had told him that and he had known it to from other sources including oncologist. Certainly we all read the same books and know the same data. But he did not die . So I continued to follow him and he did OK .Few years passed by and it was more than 10 years that he not only did not die , but had no evidence of the cancer. Then it happened. His CT scan was abnormal. So I did a bronchoscopy. He had new cancer . So he was started on new chemotherapy. We could not do more radiation . So I followed him up and he continued to do well . May be it was 2 more years and he coughed up blood. So I did a bronchoscopy . His chemo was stopped as he had no evidence of cancer . My bronchoscopy showed that he had recurrence of the right sided cancer and there was a different cancer on left upper lobe . The interesting part was that in spite of me seeing the cancer - a new one - on left side , the CT scan did not show any cancer, not did PET scan showed the cancer. ( another statistical data which was not right ). So he was given different chemo . This time he got quite sick. He could not eat and developed weakness in the legs and had number of other issues . He also had pneumonia and swelling of the legs . He was so weak that he could not even stand up . So I told him and to his wife that there was no sense in continuing the chemo and made him 'no code' . He was discharged to extended care facility. He needed help and the wife could not have taken care of him at home . I did not think he was going to last more than few weeks . So I forgot about him . He showed up in my office about 7 or 8 months down the road . He was walking , and eating well and was doing OK.So I did another CT scan and as it was abnormal did another bronchoscopy. He had recurrence of the cancer on left , but none on right. I had stopped counting as to how many times he was cured or told that he was cured and had new cancer or recurrence of the cancer . Statisticaly this is impossible . He has defied  all the odds. 

Thursday, March 10, 2016


      When one goes to a physician , they expect that the physician will be one step ahead of the treatment or the diagnosis. And most of the time it works . But at times it is a frustrating and the story that I am going to tell is one such . As a physician we like to help , anticipate and treat or prevent the problem that may arise. So it is quite frustrating when we come across the surprise . So this is such a case that in spite of every one we did not anticipate the outcome .
      I saw this 45 years old male that had chronic cough . As usual I did the allergy testing and the breathing test . The allergy test did show some allergies and the breathing test showed that he had mild asthma. So I put him therapy for the asthma and he did improve . In next few months he was seen by me for one or two times and then was lost for follow up . He had some personal issues and so was out of town and was doing well and so postponed the follow up . He came back to me as he again had some cough . His lungs sounded clear , and so I sent him to an allergist. Then he had further allergy testing . When he went back to him he was told about the allergy shots . At that time he was having shortness of the breath . So he was given steroid shot . He continued to feel shot of breath , so he decided to go to ER. There was nothing positive in the ER on examination or chest X-ray . But I decided to do CT scan .The CT scan showed that he had clots in the lungs and he also had pneumonia . So the pneumonia was not seen on plain X-ray and he had no fever. He was admitted and was started on blood thinner . He was anemic and so I did the work up and I also did the work to find out as to why he would get clots. I also called a blood and a cancer specialist . We treated the pneumonia and then he was discharged. He was followed up by me and the oncologist . He was readmitted in less than 10 days as he had fever . in spite of the antibiotics . So he was treated for the pneumonia and was seen by infection specialist . I ordered the scan of sinuses as I was not convinced that the fever was due to pneumonia. He did have bad sinusitis , so I called the ENT consultants . They saw him and did not do anything different. They told him to see them in the office. He was doing better and was discharged. I saw him and he was still weak and was seen by all the consultants as out patients. I did follow up CT scan and it showed that the pneumonia was better . He was feeling better and had no fever and was back to job .
        So when I saw him in the office I was happy that finally he was doing better and we had done well with him , anticipating the clot in first place , then the sinus infection and then the follow up on Ct scan etc He looked OK and told me that he had much improved energy . The I saw him and noticed a lump in the neck . It was lymph node enlargement. He had shown it to his PCP and he told him to watch  it . I was not going to do that. I ordered an antibiotic and CT scan of neck . I told him to see ENT doctor  ASAP .The next thing that happened was that he was admitted and  had a biopsy of the enlarged lymph node and HE HAD LYMPHOMA.

Sunday, February 14, 2016


     I t amazing to me how we all TALK about different things, but then when we are faced with the situation in our own life , we don't walk the talk . In Hindu philosophy or the religion , we are told that this world is not our HOME , and the this physical body is mortal , while the soul is immortal. We are all afraid to die or leave this mortal body. We are told that one should not eat meat or drink alcohol. So in the temple we do not allow serving alcohol or meat. But when I attend the social function out side the temple , one and all of the people who are on boards and are presidents and are on various committees freely drink alcohol and eat meat. I have seen in my life many patients who are ready to die even when they don't have terminal illness. Some of these are older and some have lost their long term spouse and may be feel that they will be united with the spouse. I really don't know. But the we come across many that are really suffering with significant illness but are not ready to dye.  I don't have reason for it . But I thought about this when I came across a patient in recent past.
      I started seeing this young patient , may be 55 years old in the hospital , She was an ex-smoker and had some cough . She was admitted to the hospital and then had work up gone . She had CT scan and the bronchoscopy. She needed some special biopsies to diagnose cancer of the lung . In spite of the young age , due to the spread of the cancer and the location of the tumor, she was not a surgically resectable stage . So the radiation and chemotherapy was given. She did OK , But after one of her chemotherapy treatment she was admitted with she had fever and low blood count and was admitted . This time she did not want previous doctors and so I was asked to see her . I knew that she needed treatment for possible infection , but in addition she needed treatment for her Chronic lung disease related to her smoking in past .
    She did well and did few more courses of chemo therapy . I saw her many times and was pleased to see her husband involved in her care. She had a job and was productive, Over period of next year or so her condition continued to get worse. She was more short of breath and had constant cough. I did do bronchoscopy and she had significant narrowing of the opening of one of the segment of the lung .She was not getting better and so she decided to go to memorial hospital in NY. They had no suggestion. I did check on amount of air and blood going to each lung and sure enough the right lung was contributing less than 30 % So no wonder she was shot of breath. I send her to another doctor to see if he could put in a stent in the narrowed bronchus and improve the function. He could not . Now she was needing more than 10 L of oxygen , In past her need was 3-4 L . Such a high flow need eliminated walking . After a great discussion , they agreed for DNR. She did not want to go on respirator. I decided to try something NEW-OLD thing . Several years ago we use to put a catheter in the wind pipe and deliver oxygen through it directly in to the trachea or the wind pipe. This reduces the oxygen need . I have not done one of these catheter insertion in several years , so I had to talk to 5 different people to see who could do it. And finally it was done . Her oxygen need went down to 3-4 L from 10 -14L.So she could go home . Things were going well for a change , and she was home for may be 3-4 weeks , She was readmitted and was short of breath The usual treatment of antibiotics and steroids and oxygen and other stuff was done . She seemed to get little better.
    The one night I got a call that she was quite short of breath . Her oxygen was borderline and her carbon di oxide was going up . This is a sign of the lungs not working,.This was not a surprise to me, But what surprised me was the nurse telling me that she  and her husband had changed their mind and wanted to go on respirator. So she was put on a respirator. In spite of the respirator , they had difficult time , so I went to see her at 4 am . We decided to not only heavily sedate her , but to paralyze herThe thing did get better , may be 5% . and we continued to have discussion with the family . On fifth day the family along with my impute decided to stop everything.
     So in spite of the suffering that she was going through , the family and she decided to go through the futile effort. And I understand ,May be I would have made the same decision.   .

Saturday, February 6, 2016


    I have seen this in life and in medicine , that one does wrong thing , but gets right result. We sometimes call it side benefits . But this does not happen too often , thank God. So recently I had a case in which this was obvious .
   I had seen this 70 years old patient foe chronic cough and some shortness of the breath. He had history of heart problem and was treated by a cardiologist and his heart was OK . So he came to me . He was not in distress and his lungs sounded clear and so I did the tests like Breathing test , oxygen check on walking and some allergy work test . I also did pulmonary stress test. All the tests came back OK except breathing test which showed mild asthma. I started him on an inhaler and gave him steroids . He got better and came for follow up once and then did not come back . I got a call from his PCP telling me that he had several bouts of cough . He had stopped the inhaler as he felt that it did not help. Interestingly enough the steroids helped and in the 5 months that he did not see me , he had taken 3 or 4 courses of steroids . Each time it worked , but as soon as steroids were stopped , the cough came back. So the PCP called me . I told her to do high resolution CT scan and the decided to do bronchoscopy. I also told her to do longer duration of steroids at smaller dose.
I was not too sure if bronchoscopy would add anything to the diagnostic scope. But I have done few bronchoscopy in past for persistent cough and did not get any different information that I did not have before the bronchoscopy.
   The CT scan came back OK . There were no damaged bronchi or what is called bronchiectasis . There was no scar tissue . So I did the bronchoscopy . The bronchoscopy showed significant inflammation. Which can explain cough and why he responded to treatment with steroids.  So I was not sure as to why the treatment for asthma did not work . Anyway I also ordered blood tests to check on Immuneglobulin. There are 5 of them and each one has a specific function. I have seen few cases in which reduction in some of them patient had persistent cough and inflammation. This was along shot. But to my surprise his all immune globulins came back very low . This condition is called CVID .It will need further work up and treatment with immunoglobulin  every month or more often.  

Sunday, January 31, 2016


    We often say that something could go wrong , it could (Thank God not'' it will" ) But sometimes in medicine it is so true. I have seen and heard about the stories , which are sometimes referred as 'train wreck'. And I have personally seen them too . But sometimes the complications or what happens is helpful in making certain decisions . Just to give an example would be patient who has borderline pulmonary reserve to have lung surgery to take out a cancerous growth. Then he may have a scan showing spread or a appearance of skin lesion that terns out to be spread of the cancer.So now the decision is clear . Due to spread of the cancer , he is not surgical candidate . And it is also helpful to patient as well . If such a patient would undergo surgery and does not do well due to poor pulmonary reserve , and then develops spread, we would be more unhappy. Instead if we make decision to not operate we at least have quality of life . But the uncertainty in medicine is disappointing and at times frustrating. This is so true with one of my patients that I saw.

    So I saw this 70 some years old patient who came to hospital with generalized weakness. She was found to have low blood count . Her white cell count , red cell count or the hemoglobin and the platelet , which help in clotting , were all low . She was told few years ago that she had problem with the counts. But it got better and so she stopped going to the blood specialist . The counts continued to be OK for about 2 years and now she was in the hospital . She had low blood oxygen , so I saw her . I did CT scan and it showed some fluid around her lungs . So I did ultrasound of the heart and it was normal . She was worked up and found to have MDS , I this condition the bone marrow , which is the factory for all the blood cells , stops making them. She was started on treatment to improve the counts . I treated her for the low oxygen and with the treatment she got off the oxygen and her fluid got better. But the counts continued to be low . So she was given transfusions. I had talked to the family and the patient , telling them the poor prognosis. But as it often happens, unless this information comes from every doctor including the blood doctor, it will not have the effect .And then one night I got a call . She had difficulty breathing and her oxygen dropped She needed to be transferred to ICU . In next 6 to 8 hours it was clear that she had heart attack and she was in shock due to poor heart function. She was also confused and agitated. I am not sure why. But any way once the heart attack and it's side effects were seen, it was easy to make decision I had the discussion with the family and with her MDS and now the heart attack , we decided to do the comfort care. The MDS which had not gotten better and in itself carried poor outcome , was not enough to make decision . But now an unexpected heart attack made it easier to make decision .  

Wednesday, January 27, 2016


    I have been sometimes asked if I would be interested in doing telemedicine . I feel that I am doing the telemedicine at times for long time and even today , though without getting paid for it . When patients call me or my office and have some complaints , I look at their charts and based on the information provided on telephone and the information that I have from the past , make a decision. It may be as simple as giving an antibiotics or as complicated to ask him to go to ER. But the modern day telemedicine is to advice patients or 'consumer'  on possible diagnosis , it's work up and may be treatment. And these are not my 'known ' patients , but brand new patients that I have never seen or examined . I do not feel comfortable with the idea , though I do that too with friend and friend'd friends all the time . I don't think this is good medicine . But I thought about this when I came across the patient who was treated as if it was telemedicine . I often say that if it was possible to do the diagnosis and the treatment this way, computers would take over. But sometimes I feel that doctors are behaving like computers.

    I saw this 70 years old patient , who was referred to me for chronic cough and abnormal chest x-ray. He was having cough for about 2-3 months and was treated with antibiotics and cough medicines . The cough persisted and so he had a chest X-ray done and it was abnormal so then the CT scan was done and when it showed multiple nodules , he was referred to me . He had no fever and though his appetite was reduced , he had not lost any weight . The cough was dry and he was minimally short of breath. He was non smoker . We had no old CT scan. So I decided to do Bronchoscopy . My initial impression was the possibility of atypical infection called MAC or Mycobaterium Avium Complex . It is in the same family as Regular TB . But it is not contagious and treatment is different. His bronchoscopy and the biopsy and the TB culture came back negative . He had multiple nodules , so if they were spread of a cancer --metastatic cancer , he was not surgically resectable stage. But I decided to send him to a surgeon and at the same time have radiologist do a needle biopsy . In between ,I am not still clear why, he was sent to a cancer doctor. I am still not sure as to who sent him to cancer doctor. But he did go to cancer doctor and she sent him to a surgeon from her own group . He sent him to radiologist for a biopsy. IDID NOT GET CONTACTED OR GET ANY NOTES. All these doctors belong to same group. He had the biopsy . None of these doctors saw him in office , but he was told that he did not have a cancer.

    So at the end of 3 months he came to me . I had not gotten any reports and I was not aware that he had gone to different group of doctors and had work up done . When my office had called him in between , he had told my office staff that he was seeing a surgeon and is having a biopsy. So I gathered the information from all the doctors . When  I got the biopsy it stated "No malignant cells seen " .It did not state as to what did THEY SEE. So I faxed request to see if they could tell me as to WHT THWY SAW , not what they did not see. I never got the answer. I also could not figure out if they had done any TB culture . So this is the computer generated medicine . It had no thought process as to the possibility of MAC . So no cultures were done . No one bothered to tell patient as to what was diagnosis and what he should do next.
   I decided to do repeat bronchoscopy and called the surgeon and told him that if my bronchoscopy was unable to get a diagnosis , then he should do OPEN biopsy , not needle biopsy. With patient's luck , my second bronchoscopy confirmed the diagnosis of MAC .I started him on treatment and he did fine .

   But the reason to write this blog is to make a point that one has to see patient and make a calculated diagnosis. Otherwise the tests don't mean much , and we might as well have computer generated diagnosis and may be treatment too ! 

Tuesday, January 12, 2016


      In today's world people expect that the modern day medicine is perfect and every time patient goes to doctor , the modern medicine and the tools that we are given , will give us the answer every time . But I hate to break the bad news that even with the modern medicine and the CT scans and the MRI and many other tools , we are not 100% accurate. It reminds me of old story that was told to me by my teachers when I started thinking that I KNEW everything .Many years ago there was a surgical conference and a speaker was presenting data on stomach surgery. He told the incidence of the complications. So in question -answer part one young surgeon stood up and stated that he has done many surgeries that the speaker was talking , and he has not seen the complications that the speaker was talking about  . The speaker answered that Either he has not done Enough surgeries or He had the complications and did not Recognize them.In medicine it is the same . All of us come across the cases where in spite of all the investigations and tests we can not explain the problem . So then we are left with the guise work. I am going to tell a story today which falls in under the same category.
      I was consulted to see this patient who was 77years old and he got more shortness of the breath. He was on oxygen at home and had sleep apnea and also had heart problem and had cardiac bypass done . He was quite obese and was not using the CPAP for the sleep apnea. When I saw him he was on 100%oxygen and needed pressurized oxygen called BIPAP. Just to explain , simple oxygen is needed in many cases. Then high flow rate , then BIPAP and if it does not work out then respirator. .So he was close to last but one step . His blood pressure was low and had some vague suggestion of congestion in lungs . I thought that he may have pneumonia or congestive heart failure. I ordered the echocardiogram and started treatment with antibiotics . The cardiologist saw him and infectious disease specialist saw him and changed antibiotics . The blood pressure got little better and echocardiogram did not answer why his blood pressure was low or he needed so much oxygen . He slowly got better. But continued to need very high oxygen flow rate for several days . He was in ICU , looked comfortable , had no shortness of breath . The chest X-ray did not get much better ..But for whatever reason after 15days , his oxygen need got better and we could do CT scan. It showed Emphysema and some scars . but not much to explain why he needed such high oxygen. We did swallow study and it did show that he was aspirating. Which means the food or liquids that he was eating or drinking , was partly going in the lungs .
       So my educated guess was that over period of time he had done significant damage to the lungs and that had led to scar tissues and he must have had significant aspiration on the day of the hospitalization. This caused the significant inflammation and that took almost 3 weeks to heal as we had not given him any food or liquids by mouth . This allowed the healing. So he was able to come off the high flow oxygen.He was discharged on 3 L oxygen , while he had needed as much as 70 L flow in ICU .So my diagnosis was  only a educated thought process.