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.