Saturday, July 29, 2017


   I have been in medical practice for many years ,and over period of time I have seen lot of changes . The sole motive of the Insurance company is to control the cost and the sole motive of the regulations is to avoid fraud . But in doing so we have increased the cost of the health care and made it substandard and made it cumbersome . It is at a  point that I do not know a single medical person -nurse , respiratory therapist or physician, that is happy . I have one person just handling  the fax , one getting referrals, and one doing 50 % of time doing required forms for the DME- oxygen CPAP,nebuliser etc. The insurance companies deny claims and not pay and then any time -even a year down the road DEMAND the refund as they may have made mistake in paying when they should have denied and if we do not refund , then they cut it from next patent's bill!!.There is nothing I can do as no one care for the physicians -not even the physicians societies that I am a  member  of. But that is not my purpose of this blog . My problem is that these regulations and the behavior of the insurance companies has produced substandard care . That is the story about .

     I saw this young lady in my office . She was 59 years old and had some cough and shortness of breath. She had never smokes and was not taking any alcohol. She had no history of high blood pressure or diabetes or for that matter any other medical problem . She did not have asthma . Her chest X- ray was OK. On examination she was in no distress and her blood pressure was normal. She had no fever and her lungs sounded clear and her oxygen saturation was normal. She was little emotional as she was never sick in her life and now she was short of breath and had this cough that would not go away. Her heart rate was little high, but then she was quite emotional.

    So my impression was that most likely she had allergies and asthma . The chronic cough in non smoker , with normal chest X-ray is due to asthma and /or allergies in almost 80 % of the time . So I did the allergy blood test and the breathing test and did try her on inhaler for the asthma . I also did the walk test as many patients with asthma wheeze on walking or exercise. I also did what is called sum-maximal pulmonary stress test.
     She came for the follow up . Her allergy blood test was normal and the breathing test showed mild decrease in lung capacity , but did not show obstruction , which would have confirmed the diagnosis of asthma . Her walk test was OK and she did not wheeze and her oxygen saturation on walking was not decreased. Her stress test was abnormal and it was showing the problem to be HEART or cardiac.So I had asked for the echo cardiogram -or the ultrasound of the heart. She had called me in between and so I had also done the CT scan of the chest . The Ct scan showed some fluid /water around the both lungs .I did the CT scan to rule out any fibrosis -which was a long shot as differential diagnosis. The echo cardiogram done through the PCP office was reported normal. So when she came for the follow up I was puzzled. She was very short of breath . The inhaler had not helped . She could not even collect her mail without getting short of breath. And my tests had not shown any specific cause for it . Though she had some water around the lungs , everything else that could explain the cause of it was normal-the heart function.  She was so emotional that she started crying . She was never sick in her life and now she was so bad that she could not function doing day to dat activities . My tests were showing that most likely she had congestive heart failure and that had caused the water built up and so she was short of breath . But the ultrasound of the heart was normal . I was stuck .
     But like in my past medical life I take decisions based on MY heart than what tests show . So I told her that I am  going to get  her in the hospital and treat her for congestive heart failure with water pill and then see how she does . If she does not get better , then I will take out the water and may be do bronchoscopy to find out what was going on.
     I admitted her and started her on diuretic IV and ORDERED ANOTHER ECHO CARDIOGRAM , I saw her about 8 hours after she received the first dose of the diuretics . She was all smile -she hugged me and thought that I was the miracle man  as she was feeling so good that she has not felt in last one month. The echo cardiogram showed that her heart pumping action was 20 %!!!!!
This simply means one of the two things , one -the first echo was not of good quality or not interpreted properly  or secondly -n she developed the heart problem between the two echo. I tend to believe the first one . This is not the first time and it will be not the last time . The insurance companies want to save money . So doing and echo at radiology center or PCP office is much cheaper than a cardiologist consult and then doing echo in his office. So now a days routinely the echos are done by PCP or in a X-ray facility and they are not as good as done by cardiologist .

     So sometimes one has to go by what you feel than by the tests . She did very well after we treated her for congestive heart failure .  

Sunday, July 23, 2017


    In medicine and in life I often find that what could be considered as the TRUTH changes . medicine as such is as much science as art. So like in life or religion the search for the truth comes down to personal persistence .So one has to try hard and go withe the heart . That brings me to some patient;s story.

      I saw this patient , about 78 years old male who had lost 40 lbs of weight over period of 4 months . He had quit smoking 10 years ago and he had no cough or chest pain or shortness of the breath.The primary care physician sent him to Gastroenterology.   The specialist did the colonoscopy and the endoscopy The colonoscopy showed some polyps and they were benign. So he had no diagnosis as to why he was loosing weight. He had no fever , and no other  complaints.His cheat X-ray was reported as normal .
     And then one day he had  a bout of the cough and he noticed blood . His blood in the sputum continued for one day and so he called the primary care physician. He sent him to emergency room. In the ER they did CT SCAN of the chest. The CT scan showed that he had a mass in the middle part of the right lung and there was collapse of the right upper lobe . So I spoke to the patient and the family.
      He had normal chest X-ray. There was no evidence of cancer on the chest X- ray even though by looking back at the CT scan ,which had shown the mass or the cancer , I could not see the cancer , that was inoperable.
      I did the bronchoscopy and he has mass in the upper lobe -that was not seen on the CT scan , and it was causing the blockage of the right upper lobe and that had caused the collapse of the upper lobe.
    So I he had cancer of the lung and it had spread to the lymph nodes and had caused the collapse of the upper lobe , but NOTHING WAS SEEN ON PLAIN CHEST X-RAY!!

     I will tell story of the other patient where persistence on my part gave the diagnosis. 

Sunday, July 9, 2017


         The next one of the 6 enemies is the MOHA or the Delusion. Our entire life is full of delusion . If one considers the difference between the EGO and the SOUL, we will realize that ego is pseudosoul. The soul under the influence of delusion is is ego. When the soul which is immortal and unconditioned confines or appear to be confined within the physical body, is called EGO. The ego is BORN and Conditioned. Under the effects of the delusion or MOHA one does thins or acts differently than he would if he was guided by Intellect.

          In MAHABHARTA, the SHAKUNI MAMA is the representative of the delusion. He was known to be deceptive and create illusion or delusion. Upon the advice of the Shakuni , the Duryodhana asked Pandawas to the geme of Gambling . The deception that was used by the Shakuni worked and the under the influanec of the delusion the Pandawas lost . They not only lost their kingdom , but also the DRAUPADI, their wife. In the symbolic way the Draupadi is KUNDALINI shakti . The Pandawas lost the contol over the KUNDALINI under the influence of the delusion. So when one feels that HE or SHE is the BODY and confined to the limits of the body that is delusion

.            The next one is MADA or the PRIDE.The pride is I , ME ,AND MINE . Because of the pride we do things that at times are deceitful ,cruel and immoral.The 'I' in us makes us do things and act in such a way that otherwise we would not do. The PRIDE in MAHABHARATA, is represented by SHALYA . The Shalya is the brother of Madri the mother of the NAKUL and SAHADEO. So he should have joined the Pandaws in the battle between the PANDAWAS and the KAURAWAS. But the DURYODHANA bribed him with flattery and with gifts . The SHALYA was coming to join the war, Duryodhana arranged the big welcome and the feast of food and gifts and the flattery . The SHALYA thought that it was PANDAWAS and then he came to know that the host was no there than the Duryodhana. he still could hve joined the PANDAWA'S side , but withe PRIDE and the EGO and the delusion , he joined the Duryodhana side. We see it all the time how the fights among the friend and the siblings and the business partners never get resolved due to the PRIDE .

        The last one is MATSARA or ENVY. We all know this quite well. We can not enjoy if something good happans to someone as 'it did not happen to us'. In fact it is due to MATERIAL ATTACHMENT. So if someone gets promotion in job or gets recognised for his or her work or courage etc , we are not happy as we are attached to the same material things. This is the MATSARA or envy. In MAHABHARAT this is represented by KRITVARMA . Hewas the only YADAWA,who belonged to the sama clan as KRISHNA , But KRISHNA was respected , adored and was on the side of PANDAWAS. He became the enemy of Krishna , when the bride that HE WANTED to marry was married to Krishna . This meterial attachment and not having the same success in getting recognizes as was KRISHNA , he decided to join the side of KAURAWAS.

Tuesday, July 4, 2017


      In the last one we talked about the first of the six enemies of the mankind which was KAMA OR LUST . The next one is KRODHA or ANGER. In today's world one need not saay anything more about the anger . The road rage , so common that we hear about it everyday. The anger in politics is seen everyday and has paralyzed the function of the government .
      In MAHABHARATA, the anger is represented by DUSHHASAN. We all know the famous story from the epic of how he dragged DRAUPADI and tried to disrobe her . When the Pandawas lost in gambling and in doing so they lost their wife too. So she was brought to the Darabar and then DUSHHASAN tried to disrobe her . She asked Lord KRISHNA to help her as none of her husbands would or could get up to help her. The Lord Krishna provided her with unending saries . This dded was done in anger . Whenever there is anger it paralyses rational ,intellectual thought process. Some one had said that that getting angry is punishing our self for the mistake of the someone else. The anger can come due to greed, lust ,disappointment and can lead to violence either physical or verbal . Even if anger is justified , say for example when terrorists killed hundreds of innocent victims in the name of religion , one should allow a rational thought process and channel it in such a way that we can catch such terrorists before they can do another act of violence and prevent it in future.

     The next enemy is LOBHA or GREED. In today's world we see it all the tie in our politicians and in common day to day life . People that have billions of dollars will cont to do things that are illegal , immoral and unethical to get MORE. Otherwise how do yo explain the selling of uranium mine to Russians or collecting billions of dollars under the name of charity and spending less than 10 % for the charity. At our level we see this when we see people indulging in food at party or drink at a party. We all eat MORE than we need and we drink much more than we need and can handle .
In MAHABHARATA, this greed is represented by KARNA and VIKARNA. Karna is representative of RAGA which is attachment to things that we like and repulsion from the things that we don't like. This attachment is so strong that it leads to GREED. The funny part of this equation is that we are never satisfied when we get what we want . This is called CIRCLE OF MIND . When we DO an action , it leads to IMPRESSION , which leads to DESIRE and the desire leads to ACTION which again causes the impression and so on and so for. When we do repeated actions , the impressions that it leads to are much DEEPER and the DEEPER the impressions , more intense is the DESIRE . So satisfing the DESIRE does not lead to calmness but in contrast it leads to more intense DESIRE. These desires are stored not in our physical brain , but are stored in abstract form in our ASTRAL
AND  CAUSAL BRAIN.When the physical body dies the desires are not gone as they are still there in astral and causal bodies . So we are reborn to SATISFY our desires . When these desires are not satisfied , we get ANGRY -KRODHA and under the impression of anger we loose the rational thought process and ACT violently.
    I will try to do other ones in next blog.