Saturday, April 25, 2020


   Invention is not new to man kind. We often say ,'you don't have to invent wheel'. So the wheel was invented  and so many other things have been since then . The reason for me writing about the invention is nothing other than COVID . I am amazed at the new things that have been tried - invented due to COVID. But when I look at my own past I realized that all of us do some adapt to the circumstances  and in doing that we try different things. We do not always call it invention.I remember,when i learned about different chemical agents  and how they affect different things, i had thought of their use other than what they were used for. Benzine -a chemical agent dissolves fat. So I had thought about injecting it in fat belly and then after it has dissolved the fat , we can 'Drain' out the benzine  and fat  and that will give quick solution to obese  and stubborn  fat belly . Certainly I was 16 at that time  and had no clue of how toxic that would be.Then when i started learning about the vaccines  and I came to know the breast cancer in younger females , I thought of injecting Extract of resected breast tumor  and injecting in horse to het antibody containing serum, that would be effective in treating cancer. Certainly I had very little idea about tumor antigenicity and difficulties with such a naive idea . But we are doing something similar now with cancer immunotherapy.
    Then when I started my practice of medicine in Florida I came across a patient who had aspirated a tablet . The hospital did not have foreign body removal basket. So I ended up using ureter stone removal to do the job. ( ureter is duct that connect kidney to bladder) I was successful.
   You might be wondering why I am talking about this now. With COVID  I have seen so many new things that I can not even imagine why some one would think in that direction. When we had issue with ventilators in NY or we thought we may have issue about ventilators some physicians came with ONE VENTILATOR for 2 PATIENTS . In may earlier practice I had used 2 VENTILATOR for 1 PATIENT when one lung was very stiff as it was badly affected  and other was relatively normal. I am not sure if this was done by some one , but certainly not often for sure. So 1 ventilators for 2 patient was a novel idea  and it could work only because we have sophisticated ventilators. This would not have worked 20 years ago.
    The number of drugs that have been tried. I am not sure why these drugs were even considered . I can understand using any ANTIVIRAL DRUG as COVID is a VIRUS. But drug used for malaria or drug used for rheumatoid arthritis - the Hydroxychloroquine ? Why would some one consider it is beyond my imagination- and I know why it was considered . But I would have never thought of it . It gave us some hope  and as news media waited to prove how it will not work to create news or to blame the supporter of it's use, I have seen number of physicians use it  and use it successfully in earlier stage of the disease. (I will direct those of you who are interested to see my TOU TUBE VIDEO -JUST A TALK  to see why theses studies that did not show success are not the best studies)
   So I came across another idea that may have been the reason why President was talking about disinfecting from Inside . A biotech company from Cider Sinai, has come out with use of UV light . The Ultra violet light A has potential to kill bacteria and viruses. So how do you you get that UVA in the lungs? They have a catheter that has UVA emitting capability  and that is inserted through the breathing tube of the patient that is on ventilator. This is called by them as HEALIGHT . I am not sure if they have any data treating patient  and viral load measurement etc But certainly my hats off to the scientist who come out with inventions.
    A drug which is used in dogs for worm infestation called IVERMECTINE . So this has been used to treat COVID  and not much data on it .But I am ot sure why some one even think about using a medicine used in dogs  and that too for worms  and not for viral infection. But some one did !  

Saturday, April 11, 2020


     The medicine is changing fast and new medicines are invented  and used daily and many are good  and some will be gone in future. But with new  drugs we have new problems . Whenever there is new drug on the market the pharmaceutical company calls it ' Launching' the new drug . That stimulates many people to market it .The company has drug reps and their managers  and superiors  and ad campaign  and meetings  and studies etc This is the only way to 'educate ' physicians about the new drugs  and the indications , dose  and side effects etc. There are some drugs that have limited use  and number of patients that can use it are less. So the cost is high . These drugs, when the number of patients that have been diagnosed or have that disease, are less than 250,000 in US, then these drugs are called 'orphan drugs'.This brings me to today's story.
     I had seen this 74 years old patient 2 years ago . She had scars in the lungs  and she had the scars which were diffuse  and they were in both lungs  and since we did not know that cause of the Fibrosis, it is called Idiopathic Pulmonary Fibrosis, IPF. There was no treatment in past that was effective. We have tried many different drugs including steroids. Few more came  and were tried  and were proved to be not effective  and many patients with true IPF would die in 3-4 years . So may be 4 years  ago or so , 2 new drugs were approved  and they were suppose to slow the decline  and the studies did confirm that. The cost is $30000 or so per year! So we had something that we can offer. But the problem is there are many patients that DO NOT GET WORSE. The patient had fibrosis  and I did not know the cause of the fibrosis  and she did not want biopsy. She had fibrosis even 3-4 years  ago when she had CT scan done by some one else . So she had IPF . But she had not been evaluated by lung specialist . I did the usual tests  and she had reduction in her lung capacity  and she also had oxygen saturation dropping when she slept and walked  and so I started her on oxygen and talked to her about the new drugs - by now theses drugs were not NEW . She had some colon issues in past. The common side effect is nausea  and diarrhea.So she was very reluctant for the new medicines to be added. After follow up for almost a year she had nt gotten much worse . The problem with this diagnosis is that only few -may be 20-30 % get worse  and if the treatment is started earlier , then response is better. So I decided to start her on meds  and told her that she can go to Mayo clinic  and get an opinion .
          She went to Mayo clinic  and she saw number of physicians  and had SAME TESTS  repeated . She was told that she had Fibrosis but she did not have TYPICAL IPF They thought she should consider some other suppressant medications . I will  not go in details of the types conditions that could lead to fibrosis.The first line of treatment is steroids for the diagnosis that they thought she had and she has been treated with it . The steroids do not work for IPF. They told her her to stop the medication that I had started  and she had taken for less than month. The patient came to me  and wanted me to DECIDE AS TO WHAT TO DO . My problem was that Mayo did not do any new tests  and what they told her was their opinion and there was no proof for it  and I did not want to try something that would suppress the this older lady . I also knew that she had used steroids  and that would have been first line of treatment and also that she had this for few years .
I was stuck . The new drugs are approved for only Fibrosis of unknown etiology and not for fibrosis of any other etiology . My reason for starting her on the drug was simple .She had done steroids  and the CT scans were abnormal for number of years . So if she has other causes of Fibrosis , we can not use drug . She did not want much drugs anyway as she felt she had not worsened
    The problem and questions that we have is cost and indications  and the side effects. So at present movement We are going to do follow up on her CT scan and breathing test  and other things  and then decide. She does not want biopsy to get definitive diagnosis  and does not want drugs  and so this is the only options . . 

Saturday, April 4, 2020


   I know that everyone is saturated with the information on COVID -19. But I have seen many things on TV  and radio and in general public that I thought I will write some of the things. We all know that the the virus originated in China . The theory that it started with animal market is debunked as I understood there is no bat- horseshoe bat ?? within several miles of the city Wuhan china where this all started . But there is a virology lab. This does not matter for the pandemic but certainly matters for the future as if it did originate in lab  and  accidentally escaped and infected people that is worth concern for any and all virology Labs .
   I have heard also that we were not prepared for this emergency. I am not sure what any country could do for such a magnitude of cases  and such a virulent virus. We have several issues that caused the problem and not all the talking heads are talking about it. We also need to understand that the understanding of virus  and the way it spreads is changing every day. So let me give  an example . I had done classical music concert for a great artist . I had a call on Sundat to see if I could arrange it for Tuesday. Tuesday being week day I was not sure how many people can attend. So at the end of Monday evening we had only 30 people who agreed to come . In view of such a small number  and cost of renting hall and arranging mikes etc , I decided to do it in my house . I had 30 chairs  and I could do it easily in my house  and I had microphones etc . On Tuesday, 60 people showed up. So did I have enough chairs? NO , So do you think I was not well prepared ? I think this is what has happened  and we will never be prepared for what happened  with COVID .
     Let me explain. The COVID was thought to be a droplet spread virus. So when the infected patient who coughs or sneezes he throws out droplets  and they will settle down on surface - gravity effects . So way in which I can get it , is by touching the surface where droplet is there  and then having virus on may hand  and then when I touch my mouth or nose or eyes - mucous membranes , I will get infected , So if II wash hands, I will not get infected. So the mask will not protect . But things changed . NOW WE KNOW THAT THIS ONE CAN BE AEROSOL SPREAD . This means viral particles will float in air  and when one breaths the air which has these particles , he will get the infection. So the mask is helpful. THIS ALSO MAY WHY WE HAD MORE INFECTIONS THAN WHAT WE COULD EXPECTED BASED ON DROPLET TYPE OF SPREAD  AND POLICY FOR MASK USE.
    The need for more Ventilator or respirators . As I mentioned before I can never be prepared for 60 chairs in my house , same with any hospital and even government . If we have big stock pile of ventilator , who is going to pay for it . Private industry can not afford buying them and not needing them for years and then if not maintained then they don't work . Secondly the change of policy for who needs to be on Ventilator. When we see a patient with pneumonia who needs oxygen, we start oxygen at flow rate of 2 L per min. and then increase it to 4-5-6 . If that is not enough we continue to increase to 15 L . then we can switch to what is called HEATED HIGH FLOW - may be 40 Lor moreas needed. . If that is not enough then we try BIPAP slimier to what is used in patient with sleep apnea. The only difference is that it can be attached to 100% oxygen and also we can add rate and other things that ventilator can do .The advantage is we do not have to put tube down the throat in to lungs and sedate patient . SO IT DOES NOT NEED VENTILATOR . The problem is all theses steps that we normally use before using ventilator CAN NOT BE USED DUE TO AEROSOL NATURE OF SPREAD . So anybody who needs more than 6L oxygen gets on VENTILATOR.and anybody who is on ventilator needs sedation and needs to be in ICU . Now you know why we need so many ventilators.
    SO the question is what is in future ?I don't know . But one thing for sure it has  knocked out the economic boom that we have had. I am  an optimistic  and feel that in next 3 weeks or less we should be turning down or may be flattening of curve. As of today this  has not happened . But reasons that I believe we will start getting better after middle of April .