Saturday, February 27, 2021


      I have been in medical practice for many years  and I have myself changed in my thought process. But the main thing does not seem to change . We all want to LIVE. We often say that we have no attachment for living if we have suffering. But I have often seen that NO ONE is ready even under extreme conditions. That brings me to my story for today. 

    I had seen this elderly patient few years ago . Her problems were not major from my stand point and after doing follow up for 2 or 3 times ,she stopped coming. Then after 4 years of gap she came to me . She came with her daughter . She is 82 years old female  and had some shortness of breath and she went to er  and she had chest X- ray done and that showed larger fluid collection on rt side . She was admitted and they consulted lung specialist and he decided to put in a catheter to drain it . Normally we drain fluid and then based on response  and findings of the fluid we decide if patient needs further intervention. But for whatever reason she had the catheter inserted  and then she was discharged . The daughter came with her and she was draining the catheter at home  and when I asked her if they ever established diagnosis , she did not know , though she did know that cancer was suspected. I looked the work up done at the hospital and realized that no diagnosis of cancer was done  and part of the problem was the daughter's refusal to do additional biopsy since the fluid itself did not show cancer cells. She was weak and cachectic  and she was not eating and had lost weight. She was so weak that she could not walk .They had seen oncologist  and they did not like him / her and so they had not done follow up . She had no home help and no direction as to how often to drain the fluid. 

    I talked to them and looked at the reports from her hospitalization. She di have tumor in the covering of the lung and so from such a biopsy . So she did not have it. I told them that one can not get much treatment without knowing the diagnosis of cancer and what type. So i asked a surgeon to do the biopsy and at the same time consider talc powder instillation to stop the fluid from coming back. She agreed and the biopsy was done  and the diagnosis of cancer was established . She came to see me  and she had worsened. She had lost more weight and there was not much fluid left to be drained  and in spite of that she was short of breath and had no appetite and had low oxygen. I spoke to her grandson and also to daughter  and after discussion they decided that they could  not do any treatment and that it will be futile. So at their request i called hospice . They wanted comfort care only. 3 weeks went by and I get a call from the daughter , she had talked to oncologist and they wanted to start her on treatment immunotherapy . So they had cancelled Hospice and they wanted me to get her oxygen and some other stuff from other company .

    (I have often stated that if you ate vegetarian do not go to stake house ,if you go to oncologist they will do chemo/immunotherapy)So none is truly ready 

Saturday, February 6, 2021


   In every walk of life we have cause and effect .But sometimes we do not have the perfect explanation. One sees this in everyday evens and we do not even question it. We drop a glass object to the floor, it will break . The wood floats and the iron sinks . But the boat made of steel floats  and so the scientists have found the reasons for such things . But in medicine we have no CAUSE for many outcomes  and effects . In medicine we call it IDIOPATHIC . So we don't know why some people have elevated blood pressure  and so we call it Idiopathic hypertension If someone has Fibrosis in lungs  and we do not know what caused the fibrosis , we call it Idiopathic Pulmonary Fibrosis  or IPF. But this is well accepted  and no one thinks any other way or questions. But sometimes we see common things and have no answer . Certainly there is always a reason but we are unable to answer it and then the patients get frustrated as they have no way of PREVENTING IT .That brings me to the story for today. 

    I have known this patient for many years and she has been ex-smoker and had quit many years ago. Over period of time she worsened . She had diagnosis of COPD  and she was on meds  and still she continued to worsen over period of years, She needed oxygen and slowly we adjusted medicines and she was on all the medicines that we could use. She was also started on oxygen and nebulizes medicines and also steroids. She had some cardiac issues and they seem to be stable. Overall she was doing OK. One of theses days she was admitted  and then had some worsening due to pneumonia. I checked her blood oxygen and carbon di oxide  and she had elevation of carbon dioxide. So we started her on what is called non-invasive -ventilator. This has been done now a days for COPD patients for last few years. This helps the patient's own breath and this supplementation or the help improves the breathing and carbon dioxide  and then the shortness of breath. So she was started on it  and did well for more than a year. One day I get a call that she became unresponsive  and so was taken to ER I went to see her in ER  and the Er physician had already put her on respirator with a tube in her trachea. I reviewed the data . She was using her own machine and in spite of that she had ELEVATED carbon dioxide to such a level that she became unresponsive . So we had no choice of doing INVASIVE VENTILATOR  and that did help. Over period of next 4 days we were slowly in position to reduce the support from the machine  and we did take her off the ventilator. She did OK  and she was started on the noninvasive ventilator at night and just oxygen during day time . I watched her for 3 dyas and she did just fine . We had done many tests . She had CT scan of brain to make sure she did not have stroke  and she did not , We did CT scan of chest and she did not have clot or pneumonia . We did culture of blood  and sputum and treated her with antibiotics  and all the work up was negative  and she did not have sepsis. So why did she have respiratory failure even when she was doing everything right ? 

    I DON'T KNOW  and I will never know .

     Why did her lungs quit suddenly and then in 4-5 days recovered , I don't know . But one thing that I DO KNOW is that I have seen such patients in past and will again see such patients where we do not have the cause that precipitated  the event.