Saturday, June 29, 2019


       In every aspect of the life we often say that the system works . If a murder is solved after several years , we say that the system works. We have been witnessing the political drama unfolding in DC.
I am not sure if the system is going to work - either way whatever your political view may be - Democrats are feeling that the system did not work in 2016 election and the republicans feel that same way about the Democratic party candidate  and the FBI and the DOJ behavior.But I am talking about the day to day life where we come across things  and feel that the system did not work. All of us have 'misconception' about our ability and be often 'feel' that we do not get what we 'deserve'. But I am talking about much simpler things like DEATH CERTIFICATE. That brings me to the today's story.
       I saw this patient 5 years ago. she was 38 years old , obese  and had multiple medical problems . To my recollection she was not working and she had medical disability at that young age . She was not a smoker nor was alcoholic , but had bad hand dwelt in her life . She had Lupus a deadly disease in some  and many who have that diagnosis. She also was obese  and she had TB-yes tuberculosis  and had part of the lung taken out . In patient with Lupus,patient have multiple organ involvements - from skin to lung to kidney to pressure in lung circuit. She had scar tissues in her lungs  and also had chronic pain and also had obesity  and sleep apnea. She was short of breath and she did not do much exercise  and had not lost much weight . The combination of all these factors had led to shortness of breath. I am sure if she could loose some weight ,  and exercise she may have have been that short of breath, Fortunately her fibrosis or scar tissue in her lungs though bad was stable. The pressure in lung circuit - called pulmonary pressure was mildly elevated . Her oxygen would drop bellow critical number and so she needed oxygen when she would walk . But being young , she did not like the idea of carrying the oxygen and so she was not using it most of the time . The oxygen transfer factor that we measure, was less than one third of normal and so no wonder she needed oxygen and was short of breath. She had sleep apnea  and was not using the pressurized mask that she should use . But in all in spite of all these she  was stable  and we did not  and could not change any medicines .
     One day I got a call that she was in ER . In last 5 years or so that I took care of her , she was never in ER or hospitalized. I saw her in ER. She was quite short of breath and  needed high flow oxygen delivered with pressurizes mask. Her husband was bed side . She had respiratory infection and that caused the pneumonia  and since she was compromised ,she had acute respiratory failure . The ER doctor had started her on antibiotics  and steroids  and CT SCAN was planned soon . I discussed the situation with them  and she was to be admitted to ICU. I told them that if the things do not work out she will be intubated  and put on respirator and then we will see how she responds . With given pulmonary compromised the weaning off the respirator would be difficult if not impossible.
       As I thought she was intubated  and she had many other problems that are associated with sick patient . I would not discuss them at this time . But at the end of 17 days she was on maximum support on the respirator and she was on 100 % oxygen and high pressure  and also had problem with blood pressure  and also with blood count and she was not waking up..The discussion was on going with family on the poor out come and so finally we talked about the HOSPICE  and withdrawing the life support . We knew that the end was near with or without life support . So may be on day 20 or so we stopped the respirator  and she passed away. We now a days have ICU doctor  and also Hospitalist and so I did talk to husband but did not expect death certificate to be brought to me .
    15 days after this event my office staff told me that the husband was in my office to talk to me . I was not sure as to what was the reason . But I thought that he may have come to have  'closure' as he had not known all the problems that she had even though I had had told them when I met him in ER  and then in ICU. I brought him in and he told me that they do not have the body to do the funeral. I was shocked . The lady dies more than 2 weeks ago . He told me that the hospital doctor mentioned a 'fall' in the death certificate  and so the case was sent to medical examiner . Since the county did not have their own it was sent to different county ME . I did not know the name or the person. So I was not sure as what and how I can help. But I told him to call the ME office  and tell them to call me to clarify any medical issues that may be holding the release of the body. I gave him my cell number. I git a call from the him that the ME secretary told them that she could not do anything  and if I wanted I can call them . But it was up to ME . They would not call me . So I got the number  for the ME office  and called them I could not talk to ME but I explained the situation to the secretory and told her to have ME call me if he still has any  questions or concerns before releasing the body.
     A day latter  I had death certificate brought to me  and I signed it  and told office staff to call the husband  and inform him that  it is done.  So the system should have worked and the family should have gotten the body much sooner . But it did not , but finally the system DID WORK - BETTER LATE THAN NEVER. 

Saturday, June 1, 2019


      The question that I raised or we have heard in past as a joke.But sometimes in practical life we see the similarity. There is also saying that 'it was so simple that anybody could have done it but no one did it as everybody thought that some one will do it" I am not sure if that is due to procrastination.May be it is due to being lazy. What ever may be the cause, we see this quite often. Look at doing year end taxes. Ever year we see TV station showing the crowd at post office t 11th hour of April 15th. So why do people wait? But I am going to tell a story where I am not sure what is the cause of the passing the bug - may be ignorance , may be something else.
       I have seen this patient for a while . He had shortness of breath and some cough .So we did work up and found out that he also had sleep apnea and also he had low oxygen . He was also diabetic  and he also had some cardiac problems  and he had pacemaker put in..So he was followed by cardiologist. I did start him on a new medication for the fibrosis or scar tissue in lungs  and also on oxygen. He needed treatment with pressurized mask for sleep apnea ,but he did not like it. So one day he was in my office for the follow up. He was doing OK and I was not going to change any medicines . We did talk about retrying the the mask for sleep apnea.I was about to done and when I did look up at him, he was going to fall - he passed out . I put him on floor  and had my secretary call 911.He had pulse  and also oxygen was OK. The paramedic came in and his blood sugar was little low  and he woke up and was taken to ER.I was not called in and when I checked it he was doing OK  and was seen by cardiologist and he was discharged in 2 days . He was doing good .
     He came for the follow up in 3 months  and he was OK .I wanted to do new CT scan to check on his fibrosis. So I had my office schedule it . He was sitting in the chair and my secretary was talking to him and he rolled his eyes  and passed out . She called me  and we called 911 and i forced coke as much as he could take as he was diabetic  and I thought that he may have low blood sugar. He was taken to ER  and was admitted like last time  and I was not called . He was again seen by cardiologist and then discharged in 4 days. No CT scan was done. So I did CT scan and his fibrosis was stable .
    He had elevated PSA  and was told to have prostate cancer and was sent to Radiation doctor to treat the cancer. While in the office he again passed out and was admitted to hospital.I WAS CALLED THIS TIME - I am not sure why as his lung condition was stable. Again he was seen by cardiologist  and was told that he will need something called LOOP RECORDER ,to see if he had some irregularity of heart. I reviewed the old record.He had 2 echo cardiogram during previous hospitalization. IT HAD SHOWN THAT HE HAD defect in septum which separate the upper chambers of the heart. That had caused for the blood to go from left side where the pressure is higher to right side where the pressure is low . This leads to elevated pressure on right side  and less blood going to body . This can lead to the episodes of black out spells. I talked to him and called his regular cardiologist  and asked him if he could do the further work up and the treatment as the one that was seeing him was going to do the monitoring, which would not add or diagnose the problem, He agreed .    The patient was sent to a third cardiologist - pediatric cardiologist - as such defects are common in children and they are better at  diagnosing. So this third cardiologist did part of the cardiac catheterizing and called a 4th cardiologist to do additional procedure to make sure that he did not have blockage in coronary arteries . The diagnosis that was made in last 2 ultrasound of heart was confirmed . The hole in the chambers was there  and the blood flow was going from left to right side -normally there should none  and no mixing should happen-was confirmed.So now he was sent to 5th cardiologist to see what could be done . I was not sent any report. I was talking to patient to get update  and knew about the procedures that were done . I do treat elevated pressure on right side circuit of the heart to lung  and none of these cardiologist can 'FIX' the hole  and he will need heart surgeon to fix it.
     So it took 5 cardiologist to diagnose the problem!