Sunday, August 30, 2020


   In medicine we have seen many a times the sorrow  and the grief and sometimes some or all doctors feel that they help patients to relieve them in their miseries. I also feel that we do certain things to help alleviate the pain and suffering. But sometimes the problems are profound and sometimes simple . Someone with stage 4 cancer wants to beat it  and we know in our heart that that is not likely to happen, but we understand the request  and know that this is VERY difficult to fulfill .But sometimes we have very simple request and we still find it difficult to fulfill it. This brings me to the today's story. 

    I saw this patient who was a 78 years old female. She was diagnosed to have pneumonia  and so I was consulted . When I went to see her ,she was somewhat cachectic patient who was in bed. her caregiver was with her . She was looking good  and not sick and she also had her facial make up well done even though she was in hospital. I asked her some questions  and then the care giver told me that she can not talk and she can understand  and she will answer the questions with her PHONE. She could not write on paper . She was not a smoker  and she had not had any history of excessive alcohol intake. She was diagnosed to have ALS - also known as LOU GEHRIG'S disease.This is neurological disease  and there is slow or sometimes rapid progression of muscle weakness  and it disables the person. She had that and she was unable to do much and she had electric scooter  and also a wheel chair  and has kept up some motility . But the disease affected her jaw muscles and she could not  talk  and also could not swallow. So she had feeding tube inserted directly in stomach called PEG.She had taken water  and then she started with cough and so she had aspirated . So she had shortness of breath and she came to ER  and then chest X- ray wa done  and that showed that she had pneumonia. 

    She was comfortable  and did not need  oxygen supplementation and she had no shortness of breath and no fever.I had seen the chest X- ray and other tests  and she seems to be stable. She answered my questions on phone texting - writing  and the care giver was also giving me most of the answers. I examined her  and told them the aspiration  and also the precautions  and she also had hiatal hernia  and so I told them all the precautions that she needs to follow . Certainly she can not have any thing to eat . As usual I asked them if they had any questions . The care giver and the lady communicated with her very well even though she could not talk and so she told me that patient had a question. The patient could not talk and so she had to write on her phone  and it took some time . She showed me the phone -she had written 'CAN I HAVE A SIP OF WATER ?'

    A simple request  and I was not sure if I could grant it . I had big explanation and told her that she could take a 'chance' by doing it and she may have aspiration and pneumonia . But I did compromise .I told her that she can have a small ice cube on and off . My thought being that the ice will dissolve slowly and the amount of water that is in her mouth would be so small that it will  not cause problem..

Such a simple request and such a complicated answer!!  

Sunday, August 23, 2020


    All of us know that when there is birth,there is death.Anyone who is born, will die. But inspite of knowing this we all are not only prepared for it nor we want to accept it. I was listening to Swami Sarvapriyanand, he is in charge of hermitage in NY,when he narrated a story where this man complains to Lord of Death , that he never was given warning about death approaching. The Lord of Death answered that what do you think was the meaning of thinning hair line  and gray hair  and loss of teeth and wrinkles and sagging skin  and many other things that we notice  and ignore. I find the same thing in my medical practice. And I am not blaming anyone , but I feel that WE are never ready or accept it. My father dies at age of 88 years of age 11 years ago  and he was never sick before his last sickness, i was not prepared for it  and sometimes even today I think of him  and miss him. So I know this is common to all of us . That brings me to the story for today. 

     I have known this patient for many years . He was 78 years old male and he was morbidly obese and had COPD  and also sleep apnea.He came to me  and the work up showed that he had COPD  and OSA, and he had heart problem and high blood pressure. He also had congestive heart failure . I treated him and he was fine . He was very limited in his activity and he basically stayed home  and was taken care by his wife. He would walk in house to eat and take shower  and go to bathroom but no other physical activity and over period of years that I followed he got slowly worse. He was on oxygen  and then the need for oxygen increased  and then he needed 4-5 L oxygen all the time  and in spite of using oxygen, he was short of breath. I do chest X- ray every year and when I did X- ray  I saw a density that was not there in past X- ray. So I did CT SCAN of the chest  and that showed a mass . This was highly suspicious for lung cancer. I ordered PET scan  and that showed high uptake in the mass . His overall status was such that we could not do any invasive test and my feeling was if we get the biopsy positive for cancer we will treat it as cancer and if I am unable to get adequate tissue to get diagnosis of cancer I will still like to treat him for cancer . So I sent him to radiation doctor  and they agreed and gave him radiation under the diagnosis of cancer based on all the tests. 

     He did OK  and continued to live his usual life style. He had gained some more weight and also had swelling of feet.But otherwise he was fine. We did new CT SCAN and the cancer was improved  and there was small amount of scar tissue where there was cancer. Then I got a call that he was in ICU. He had confusion and altered mental status  and so family took him to ER  and he was admitted to ICU as he had elevated carbon di oxide. (The function of the lung is to take in oxygen and wash out or get rid of CO21 In lung disease early stages the oxygen and CO2 are normal , then oxygen drops  and patient need oxygen but CO2 is normal  and in advanced stages CO2 also goes up)The CO2 was so high that he had to be put on noninvasive respirator. He continued to be non responsive to verbal stimuli. The usual treatment was carried out and he did improve somewhat. I spoke to his family some of whom were in medical field , and tried to make him DNR as to me his prognosis was very poor with all the medical conditions  and also obesity and cancer of the lung and heart and lung problem and he would not have very productive life. . 

   It was difficult for his wife to accept it even though she lived with him and he had not done much physically in last 2 years . He finally was made DNR  and then I called Hospice . We still continue to have discussions  and then after 3 more days they agreed for Hospice - comfort care . 


Sunday, August 16, 2020


   Withe COVID 19 , we have been doing telemedicine  and all the insurance companies are paying for it. I have often wondered as to the value of it. In certain cases this works fine , but then a telephone call that I make daily to many patients is not any different than doing telemedicine follow up that we are allowed and encouraged and get paid. I am not sure what is achieved by a cardiology nurse practitioner  calling patient for blood pressure follow up when she is or he is going to depend upon blood pressure reading done by patient at home or in a pharmacy. One could easily do same thing with simple phone call and then insurance companies would not pay for same call and same advice that was given . But now under the name of Telemedicine ,they will pay! I can understand follow up for sleep apnea as all that I see is compliance data  and that I can obtain from computer and ask patient on any problems related to mask or pressure.So that is required and there is not much more needed as physical examination. But I came across a patient  and that is the story for today. 

   I sa this patient may be 2 years ago and he has  had abnormal chest x- ray. He was smoker  and had quit many years ago . As usual I di the work up and he had PET SCAN and bronchoscopy and then breathing test  and then the suspicion  for cancer was very high and so I sent him to chest surgeon. He did not come back to me . He had surgery and it was cancer and he had part of the lung taken out and he also saw oncologist and no chemotherapy was needed. His son called me one day stating that he had coughed up blood  and he has he was afraid to go to ER and also worried to come to office. I had not seen him for 1 year and I was not sure as what had happened since I sent him to the surgeon. So I convinced him to come to office  and then did CT scan . The CT scan was OK  and there were no new lesions  and then I did bronchoscopy and I did not see any lesion and his coughing of the blood had stopped after first day and there was no evidence of any new or recurrent cancer. He has been followed by oncologist and they had done some scans too. So when he came for follow up after all the tests were done,, and it was not telemedicne follow up, i talked to him and the son. He was doing OK . He had sore tongue  and we had given him antibiotics  and I thought he may have had thrush. But I decided to look inside the mouth and I saw something. He had a lesion on his tongue. This was way at the back of the one side of the tongue.. If one had causal look he would miss it as it was on the side of the tongue  and at the back part. I told them that I am concerned about cancer of the tongue. I know how medicine works and so I called the PCP  and told that he must see ENT doctor ASAP. 

    He saw the ENT doctor  and had biopsy of the lesion  and it is cancer of the tongue. 

   I could not have detected this with TELEMEDICINE FOLLOW UP !

Saturday, August 8, 2020


      We often talk about evidence based medicine. I am in practice for many years  and I can tell that in medicine many a times we make decisions based on GUT FEELING. The medical societies often talk about this as clear cut and the people in Ivory Tower of medicine have no understanding as to how in medicine we have to make a decision.In my mind current COVID treatment is in same situation. When I looked at it last more than 20 different treatments were tried  and some with claimed success. One example is Hydroxychloroquine. But I am not talking about COVID in this article. 

   I saw this 72 years old lady many years ago and she had been smoker and she had COPD , She was seen and followed by her PCP  and she  when she had chest X- ray  and that was abnormal she was sent to hospital. We did the work up and she had advanced COPD due to smoking - the damage that happens due to smoking  and she needed oxygen 24/7  and she also had a cavity in the upper lobe  and that happened to be atypical TB . I started her on medicines for COPD  and oxygen and also treatment for the MAC or atypical TB. She did well and she improved  and I did see her for about a year. Her CT scan showed improvement  and she had no new complaints . She then was admitted with shortness of breath and so she was in hospital. I saw her, As expected she was admitted as COPD WORSENING. I had hard time believing that she had COPD worsening  and I was worried that this time it may be heart. So I did a ultrasound of the heart - echo cardiogram. It showed that her heart function was reduced.So I went with my GUT FEELING and that was correct at least I thought I was . We did treat her for both- COPD  and HEART PROBLEM  and she did improve. She was discharged. But before she was sent home, she had seen a cardiologist and she had stress test  and that was normal. 

    She did OK  and then she had an episode of shortness of breath that woke her up  and she was in ER  and as expected the ER physician told the family that she has pneumonia. She had no fever and the episode was somewhat sudden. She had no history suggestive of respiratory infection - not much cough and no sputum and the white cell count was normal. The chest X- ray did show some infiltrates or congestion. Knowing the history , I decided to treat her for heart problem . When the heart does not pump blood out normally, then the water backs up in lungs  and the Lungs which are like dry sponge becomes like sponge filled with water and then patient can not breath as the lungs are heavy. So I started her on water pill and she did improve in less than 24 hrs. The stress test had shown normal heart function, but in my GUT FEELING on both occasions this was HEART  and not LUNGS as the cause of her problems and the evidence based medicine would have suggested this as was COPD  and not heart problem. So I often respect Gut Feeling . By the way I did give her antibiotics for 2 days till I was sure that she had congestive heart failure.