DO WE REALLY KNOW ANYTHING ?

  I often wonder if we truly know anything . Our decisions are dependent upon our previous experience and probability. This is true in medicine and in any other situation . Brian Green , a physicist once said that according to the quantum theory , if we try to go through a wall , there is a probability that we will pass through it ,if we try it enough number of times .In legal terms ,possibility and probability are different . When we say possible it means the chance is anywhere from 1 to 100 % , but when we say probable , it means the chance is more than 50 %.We like to be confident in our life , medical or regular . But in reality we are dealing with probability and nothing more .I am going to tell a story today of a patients , in which I knew ( at least I thought I knew ) the probability , but missed  the possibility ,
      It was Wednesday , I had a call from my office. One of the primary care physician had called our office and wanted me to see this patient ASAP. He had a abnormal CT scan , which was showing a mass in the lung and it was most likely a cancer . I had a full schedule next day and next week . There was no way I could see him soon . So I decided to see him in the hospital as if I was seeing him in my office . He came with his sister .
     He came with his sister in the hospital . he was 54 years old male . He was a smoker and had quit smoking 8 or 9 years ago . He started with what looked like acute bronchitis . He had lot of cough , had fever and was wheezing . So he was treated with antibiotic . The fever was gone , but the cough continued . He got second course of the antibiotic .He got little better , but still had some cough . So then the primary care physician did a X-ray . It showed pneumonia . So now he got different antibiotic . The cough continued and he had blood in the sputum . So he had CT scan done . It showed the mass at the center of the left lung .So now he came to me . He also had a small nodule in the other lung .I had asked him mu 'usual ' questions , like high blood pressure , diabetes , TB , heart attack etc . Then when I explained him the possibility of cancer , I told him that we have to answer 3 questions . Is it cancer . Has it spread and lastly what can we do about it .(treatment choices , surgery , chemo or radiation ) From the look of the CT scan it was clear that he was inoperable . At that point he told me that he did not want chemotherapy and was not sure about the radiation . I told him to make educated decision and not an 'emotional ' one . Then he told me that he had HIV, and was on treatment and it was controlled . On further questions , I came to know that he had infectious polyneuropathy and at the time of the treatment the HIV was diagnosed .So his point was that with HIV , giving the chemotherapy may be a problem .I ordered PET scan , Pulmonary function test and a bronchoscopy and biopsy .I called office and then he was scheduled for all the tests .
    I saw the PET scan , which was one next week . It was bad news . The mass in the left lung was positive , but the entire lung had collapsed and there was fluid around the lung . There was activity in the spine , ribs and liver . There were lymph nodes which were positive too and there were other nodules in the right lung . I had to call him personally as it was quite bad I told him that I wanted to do MRI of the brain and the liver to rule out spread of the cancer .He agreed with the plan .But when my office called him to schedule the tests , he wanted to cancel all the tests that were scheduled earlier , the bronch , biopsy . the breathing test and wanted too do nothing .When my office told me about it , I told them to get him in the office next week .
   When he came to my office  he was quite rational l. ;He knew the difficulty that we would get in to with chemotherapy with his underlying HIV .The disease was all over and radiation would not be an option .So after the discussion , we decided to call Hospice . His sister asked me the question ---how long and with my educational guess I told him 6 months to 9 months
    He was in ER in next 10 days , with shortness of the breath . The ER MD talked to him and he was put on a pressurized mask. It did help . I also gave him steroids and breathing treatments. He was seen by me in ICU next afternoon . By then he was off the mask , his X-ray showed complete collapse of the left lung , but he was OK . We had the chat and I called the Hospice to see if he could be put in their unit . The time lapsed between  the ER presentation and my talk was 18 hours
   He was transferred to step down unit . He was doing OK . I got a call from the nurse at 1 am that he was short of breath . He wanted to be on the pressurized mask . I told them to put him on it and transfer him to ICU . The next call that I got was at 3 am . He was on the BIPAP , the mask and morphine for the comfort  and had cardiac arrest. He was DNR So no CPR was done and he died .
     I knew he was going to die soon . When I saw him for the first time I knew that he had inoperable cancer and thought that with his young age and treatment he would live for may be 18 months . Then with his PET scan abnormality , I thought that it would be 3 months . The n when he came to ER I thought that he would last couple of weeks . AND HE DIED IN FEW HOURS .
  SO DO YOU THINK WE KNOW ANYTHING AT ALL --REALLY?????
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THE CONNECTION - THE BODY AND MIND

    We often talk about the connection between the body and the mind . Most of us have seen some connection at one or other time . I know sometimes we think it is as if the mind , which seems to be the weak component of the entire body seems to act in such a way that it seems to 'take over ' the course of the events .In our text book on a case of asthma . There was this guy , who had asthma . He was allergic to roses . Once he entered the conference room . There was a centerpiece with lots of roses . He noticed them and as the meeting progressed , he started feeling tight in the chest and finally had a an attack of the asthma . As the paramedics came to take him to ER , he realized that the roses were 'silk roses '.As the mind knew that he was allergic to roses , he had the attack , even though there was no physical allergen or stimulus . But I am  going to describe a case in which the mind -body connection that I have noticed in many cases is of  different  kind .
    Bill was my patient for long time . He was 63 years old when I saw him for the first time . He had dry  cough and further work up showed that he ha pulmonary fibrosis , scar tissues in the lungs . He had mildly reduced lung function .I did the usual work up and put him on some steroids .He did OK and I did reduce the dose and took him off the steroids . He continued to do well and continued to come to me . Over period of next 7 or 8 years he was about the same clinically . His lung capacity did go down , little more than what could be accounted for by the age . But he was OK , did the exercise  and was not short of breath .. His cough was Ok and he felt good . Overall he was stable .
    On one of the visits ,he told me that his wife had diagnosis of ovarian cancer . She had surgery and did OK , but needed  the chemo . She finished the chemo and was OK for about 9 months or so . He continued to see me had no change in his lung function and X-ray.He was not short of breath . The cough was minimal . The when he came to see me he told me the bad news . His wife had the recurrence of the cancer and she needed more chemo therapy . She had rough time with it .Over period of next 6 months she continued to get worse and then died . He seemed to take it well , may be because it happened over period of time or he may be expecting it .
    But in the next follow up he was feeling more short of breath , and when I did the lung functions , they were worse . I did the CT scan and it looked worse . I started him on larger dose of steroids and called him to check the oxygen level on walking . I mede him walk for the 6 minutes and he was quite short of breath and his oxygen level dropped I also ordered oxygen check at night and it was low too . So now I put him on the oxygen with sleep and on exertion .He was doing little better and did try to cut down the steroids . He did OK for may be about 3 or 4 months . But then he was again getting worse . He was more short of breath and his need for oxygen increased . I did increase the steroids , with no change .
    He was admitted to the hospital and ended up getting transferred to ICU . His 2 sons came from out of town , We had discussion with them and talked about the poor prognosis . I wanted to know if he wound like to be put on respirator . He and both the sons wanted to 'give it a try '. As I expected , he got more short of breath and went on respirator . On one of the days his lung collapsed . The oxygenation which was a problem got now worse . He had to be not only sedated m but to control the respiration , we had to 'paralyse ' him .I had a lengthy talk with the sons .We decided to stop all the treatment and did the withdrawal of the life support .
   He died in less than one year of the death of his wife .The guy who was stable for several years with the fibrosis , got worse after the death of the wife . Was is due to him giving up , or was there other cause for his deterioration , that we did not know and could not treat ? I feel that this was body-mind connection .

SUDDEN DEATH

    We all know or talk about somebody dying suddenly . Someone that was OK at one minute and is gone the next . This is commonly said to be the sudden death . In medicine we talk about sudden death, in which case person gets fatal arrhythmia , fatal , if untreated . That is the reason why we now a days see defibrillators in all the public places and even in police cars . But I am not talking about these cases . The are part of our life , especially medical . I am talking about different type of patients .These patients leave me speechless or may be the other way , that I tend to talk about them to anyone and everyone that is willing to listen to me .
     I knew this 62 years old lady , who had advanced  COPD , the one that you get when the lungs are destroyed by smoking. She was oxygen dependent and could walk may be 200 feet without getting short of breath. I had talked to her on many occasions about quitting smoking and she knew that she needs to , but had not been successful . She was on all the medicines that I could think , even the steroids .It was Sunday evening , I was to attend a graduation party  at 6 pm or so . I was thinking of going to Gym and then come home and go to the party , I got a call from the ER , My patient , let us call her Mary was in ER with pneumonia . She was short of breath and the doctor in ER had treated her with the oxygen , antibiotics , steroids and the other medicines . She was 'much improved ' but she needed to be admitted to the hospital. I had no choice but to go to the ER as I knew this patient quite well . In past she needed to be in ICU and needed a machine to breath . I went to the ER  .
     I saw her in ER . She was sitting at the edge of the bed . looked quite comfortable . , was on some oxygen and oxygen saturation was good . Her heart rate was normal , but her blood pressure was little low . Her X-ray showed pneumonia and her white cell count was elevated .Her mother was with her . I looked at the other data . spoke to both of them and spoke to the hospital doctor , who was going to admit her . I told him that she looked OK , but with her low blood pressure , not that bad (95/60 ), and her previous history , I would out her in ICU . I did my paper work , dictated my note and saw her again in ICU . She was OK , but I did mention to her and her mother that if she does not improve , or gets worse we may have to put her on respirator , to help her breath . She told me that she would agree for noninvasive way of treating , and did not want to go on any 'machine '. I was OK with that , as I was not expecting any major problem .I left the hospital .
    I was leaving for the party , when I got a call from ICU . She was not doing well and her blood pressure had dropped and her breathing was labored . I told them to start some other medicines and told them to put her on BIPAP , a noninvasive way ventilation . I spoke to the mother and the nurse , they did not want any machine , but agreed for the BIPAP. Over period of next 12 hours I continued to get several calls . Her blood pressure continued to be  a problem . In spite of different medicines that I tried it was barely 100. .She was not breathing well and had issues with carbon dioxide retention. She also had no urine out put .
   I saw her in ICU next morning . She looked horrible . She had no urine , was maxed out on medicines to improve her blood pressure , looked swollen , with all the fluid that we had given and none had gotten out as she had no urine .Her breathing was almost terminal .I spoke to her mother and her brother . I had no hope . I told them that even if I would do 'everything ' that I could do , including all machines , she was not going to survive . They agreed for the" comfort treatment only ".
   She died in next couple of hours . It was little over 16 or 18 hours ,that I was talking to her . She was sitting at the edge of the bed talking to me as she used to do in my office . I never thought or predicted that she would be gone in next few hours, and if some one would have told me that she was going to die , I would have told him or her  that they don't know what they are talking about .This I call SUDDEN DEATH . I don't think I am writing this as I DID NOT PREDICT THE OUTCOME , but I know we can never predict the BIRTH or the DEATH in any case .    

HOLY WAR , OWN RELIGION AND DUTY

    I read an article in one of the Indian magazine , called EKATA . It had a commentary on some of the shlokas in Geeta , ,pertaining to the Holy war , following one's own religion and the doing Duty. This was in reference to the shlokas in Geeta , 2-31 and 3-35. I did not agree with the explanation  . So I am writing this blog . Though this is a commentary on Geeta , it still gives my understanding of the concept of religion , duty and to some extent Heaven and the holy war .
   In the chapter 2 , of Geeta, shlokas 31 to 39 deal with the concept of The Righteous Battle . So which battle is considered righteous ?I think everyone of thinks that his cause is 'eight' and the battle that he or she is fighting is 'righteous'. If we take an example of the battle between King Shiwaji and the Mogul king , both sides believed that their cause was just and the God will be on their side . If we talk about the Israeli and Palestinian conflict or Indian and British or any other conflict , each side believes in it's cause and thinks that it is a right cause and so it is Righteous battle . So who is right ?. In Mahabharata, Arjuna and Panda was were fighting to get back the land that they had lost and at least to casual observer , it can not be considered a Holy war . So then why would Lord call the war Righteous ?My explanation is different .
    I think when Lord Krishna is talking about the war (at Kurukshketra with the Kaurawas ), he is not talking about the war between the two sets of cousins . The Lord Krishna tells Arjuna that as  warrior (Kshatriya ) , he must fight as it is religion of the warrior to fight in the battle . In India or in Hindu  religion, there are 4 types of people .or called 4 Verna. These are Brahman ,Kshatriya , Vaishya and shudra . Theses are not based on where one is born , but bases on level of your soul development . or predominance of different Gunas , that is Satwic, Tamasic ,and Rajasic .But the war that the Kshatriya should 'fight' is not with the enemy outside , but within oneself . So the war with bad habits or desires , or the wasanas .The warrior is one who fights and has some victory in the battle . He has some control over his desires or wasanas . But then he feels lost , feels hopeless as he has not achieved the mastery or experienced the Bliss that comes with the victory . So now he is questing the 'wisdom ' of fighting . At this time the Lord reminds the warrior or the Devotee that it is his duty to fight . So the 'HOLY WAR ' is the war between the man and the desires , wasanas and not outside war .
   In the shloka 3-35, the lord talks about the own religion or duty , stating that even though , sometimes own religion appears deficient , and religion of other appears more attractive , one must follow his own religion . Certainly he is not talking about other religions, like Christianity, or Muslim or any other religion . We refer to religion in different ways . Sometimes  we say that the wood floats on the water , as that is it's property or the religion . But the Lord is not talking about the properties . So what is he talking about . What is the 'SWADARMA ' --own religion ?
   We are born of HIM , the lord . We have soul which is reflection of the Lord . But because of the attachment to the body , sense organs and our thinking that we are not the soul , but we are the body . So our Real Religion is to be with one , where we came from . , which is the LORD himself . Trying to achieve this Union with the Lord is not easy . and we may find lot of difficulties with giving up sense organ pleasures .It is not easy to wake up early and do meditation or avoid indulging in to the eating , drinking or sex etc . So the ' SWADHARMA ' is to be one with the LORD . The PARADHARMA or the other religion is to get indulge in the bodily pleasures . So when one does not have great or long lasting success in the Samadhi o, then he starts thinking that the other religion is better . So the Lord is stating that our own religion is always better than other religion
     The lord also states that if you die fighting the war , then you will go to heaven and if you win or are victorious, then you will enjoy the pleasures as if you are in heaven . If this true literary , then there is no difference in the thought process of the suicide /homicide -bomber . In that thought the bomber thinks that either way he is going to enjoy the heavenly pleasures. . So I do not think he ,the Lord is talking about this meaning..
   If one dies fighting , then he will continue to have impressions , left by the practice of meditation and he will be born with advanced ability . So he will be in the Heaven , If one successful in this life , then he will have the greatest pleasure . This one is everlasting  bliss. So it is better than being in the Heaven . So following own religion than other religion is always better .

KNOWN UNKNOWN

      I remember when the defense secretory Don Rumsfeld made a statement , in which he talked about 'known unknown and unknown known ' . At the first glance it sounded very confusing , but the on the second thought it became very clear as to what he was talking . In medicine there are known unknowns and there are unknown  known.  For example , if a patient is undergoing a surgery , we know what is his risk , based on lung or heart evaluation . But we may not anticipate any kidney problem that he may get in or a stroke that may occur in a elderly patient , that we may not anticipate .I am not sure if the case that I am going to describe fits in to this description . Knowing his or her heart issues is known risk , but not knowing his risk for stroke is unknown risk . The story is not exactly fitting in to this type of case .
     I saw this 65 years old male patient for 'pulmonary clearance ' for the spine surgery . He was a male patient , who had smoked his entire life except for last 5 years . He was having bad back pain for sometimes . The Internist had tried various medication and then done CT scan of the lower spine and referred him to an orthopedic doctor . He was tried on physical therapy , and some 'shots ' . His pain got little better , but came back and he was miserable . So the decision was made to the surgery . Due to his history of the smoking , he was sent to me for assessing his pulmonary risk.
    I saw him in my office . The Internist who referred him to me is one of those rare doctored who sends his notes with the patients . So it becomes easy to evaluate them . His lungs were clear . His oxygen was normal and in his history , there was not much of the complaint of cough or sputum . So his surgical risks would be good . But when I was examining him I noticed a large lymph node in his left side of the neck ,above the collar bone . I asked him about it . He was aware of it , but had not mentioned it to any of his doctors as it had not changed much in last 3 months , since he had noticed it . I was not very happy with the size and it felt firm to hard , suggesting that it may be cancerous . He had chest X-ray done , which was normal . I decided to call the internist and then after discussion I sent him to a surgeon . He did the biopsy . It showed a cancer . The tissue type was such that it could come from the lungs or many other organs . It could be the lung cancer or the throat cancer . I did do a CT scan of the lungs and CT scan of the neck . Both the scans came back normal . I decided to do bronchoscopy and send him to ENT doctor . I did not find the origin of the cancer in either throat or lungs Rest of the work was negative , he had no evidence of the cancer anywhere in the body . So we had a patient , who has definite cancer , but we don't know where it started and once the node was out , there was no presence of cancer in the body , as far as we could say .  I cleared him for the surgery . I was not sure as to what kind of treatment we could give him as we did not know how to asses the effectiveness of the treatment .How can we say that he is benefiting from the treatment , as with the node out there was no evidence of cancer that we could detect .
   I had follow up set for him in 4 months or so . He had surgery and his pain was much better . The surgery was uneventful no complications . I ordered a new CT scan . He was not very keen on doing it . But did it . IT showed a nodule ,a spot in right lung . I redid the bronchoscopy , did not see anything abnormal . I decided to do the needle biopsy of the nodule . IT came back as cancer , same type as was seen in the lymph node that was taken out almost 6 months ago .
    The mystery was solved .He had lung cancer, that spread to the lymph node , but the primary tumor was so small , that we could not see it with CT scan or with the bronchoscopy .

THE FAMILY NAME

    I see patients with cancer quite frequently . Unfortunately, most of the patients that I see are not resectable .This may be due to various reasons . Sometimes when patients present to the doctor , the cancer has already spread to other organs , making it inoperable . Sometimes patients may have poor lung capacity , so even though the tumor may be resectable , patients may not be in position to tolerate the surgery or resection of the part of the lung . When the patients are  not candidate for the resection , the chance of 'cure ' is very small . The radiation therapy or chemotherapy can not cure the cancer in most cases . I do know some patients that got cured with either radiation or chemotherapy .So many a times patients ask me as to the prognosis . They want to know as to 'how much time ' they have . I am lost for the words . I don't want to take away the hope but at the same time I don't want to lie . And frankly I really can't predict the out come in specific patient, though I am fully aware of the statistic and can easily state what happens to majority of the patients . So I often make a statement . I say that that the cancer is like a family name . They all have similar characteristics . The are bad and they spread and will kill . But as is the case of family name , even though there are common character , not all the family members are same in their behavior . But then in some cases you turn out to be completely wrong .The case that I am going to tell is one such case .
        I knew Mary for long time . She was a smoker and had emphysema . Every time she came to office , she would promise me that she was quitting the smoking .One day she had some belly pain and it got worse . She saw gastroenterologist and he ordered ultrasound of the belly and did endoscopy . The endoscopy was OK but the ultrasound showed that she had masses in the liver highly suspicious for cancer . Her pain was quite severe and she was admitted to the hospital for the pain control .I was asked to see her . Further work up showed that she had multiple nodules in the lung , not seen on plain x-ray , but seen on CT scan , highly likely to be due to spread of cancer . The liver biopsy was done and it confirmed the cancer . They had hard time deciding as to where the cancer originated . But it looked most likely to be from pancreas . She was seen by the oncologist , cancer specialist . She had a port put in for giving chemotherapy . From the complaint of pain to the time that we got diagnosis was less than 2 weeks .She was discharged

       She was readmitted in less than one week , with multiple complaints . When I saw her , her belly looked bigger and she was mildly confused . I did MRI of the brain , and it was OK .She was given fluid and she did get better . Due to the increase in belly sise I did new CT scan of the belly . IT showed fluid in the belly and the liver tumors had increased in  size. This was in less than 3 weeks .  I knew that nothing was going to help . I talked to the daughter and the patient and decided to refer her to Hospice . There was nothing that we could do ,that could change her prognosis .
      She died in next 4 days , less than 5 weeks after the 1st complaint.




 

MAHABHARAT AND SYMBOLISM --JANDRATH

     I learned from reading from various sources as to the general idea and how these stories have similarity and use of similar objects to have similar conclusions . The story of Jayandratha is one such story . Once you know the different objects being used to symbolize certain , then it becomes easier to find the real meaning .
     In the story of Jayandratha , Arjuna declares that he is going to kill Jandratha before the Sunrise . So Jayandratha hides and Arjuna can not find him . As the time passes, every one is worried . So then lord Krishna covers the Sun with his Sudarshan chakra . So every one thinks that sunset has occurred . Jayandratha comes out  from his hiding place . Then the lord Krishna removes the chakra . There is bright Sun out . Arjuna kills the Jayandratha .
   To understand the meaning of this story , one has to know what the Jayandratha represents . We have several attachments in our life . We are attached to food , music or relatives or drugs , alcohol etc . We feel that we can not 'give up ' any of this easily . But we know that under various circumstances , we can give up these things . We know many people that have given up smoking , alcohol or relationship with spouse or parents or relatives There was story about the mother's love and attachment to the child . This from the Birabal and Baadashaha stories . Once they had a debate , which is stronger , mother's love or our own life . The Badashaha the king felt that it was mother's love , while Birbal felt it was attachment and desire to survive .So settle the debate they brought in a female monkey and her child . They were put in a tank where there was a small pillar in the center .. They started filling the tank with the water . As the water started rising , the mother monkey climbed the pillar and held the baby monkey as high as she could . But when the water came as high as mother's mouth , she quickly put baby down and tried to stand on it . So the attachment to our body or to survive is stronger than anything else .That is why. the most difficult of these is the attachment to our own body .We can not get detached from our body , may be because we most of the time think our self as our body .and not 'independent ' of it . This attachment is Jayandratha .As long as we think of body as 'I' we can not kill the desire or the attachment to the body , When we get the enlightenment or when the Sun comes out ( Sun represents the knowledge ). So when the Sun is out Jayandrath hides . But this is temporary . When the Sun goes out we are back to the bodily attachment. So we need help from the God and with his help once and for all kill the Jayandratha .When the Sun came out , which means when Arjuna got enlightenment , he could kill the bodily attachment .