REWARDS

     Many a times I am asked if patients care to know if patients care as to which physician they see. Now a days we have many HMO and patients enroll in to them based on the 'benefits',rather than which doctors participate in to it or if they can go to their previous doctors. I can not not say that every patient that I see or for that matter any other doctor sees , does care for their own doctors , but I can certainly state that majority of my patients would like to come to me rather than going to someone else , simply because of the new insurance plan .I think I am lucky to have these patients ,that care for me as much as I care for them . The story that I am going to tell is one such story , that touched my heart. Unfortunately the end was not sweet.
     I was seeing this 63 years old female who had smoked for many years . She had developed very advanced COPD and within short time after I started seeing her ,she was put on oxygen.She was short of breath walking 50 feet . She had significant cough and got recurrent respiratory infection . She also needed to be put on steroids on and off.I

    I continued to do the follow up and in next 2 years she was in the hospital few times . She continued to get worse , but had strong will power and did walk at times , but then ended up in a wheel chair. She knew that her disease was bad.She was on respirator twice and each time it was difficult to wean her off respirator. The second time she was on the respirator for 14 days and came very close to having tracheostomy. After that incidence , when she was about to be discharged , we talked about the DNR .She told me and the husband that she did not want to be ever put on respirator again. She would rather die , than go on respirator for test of her life --and I did feel that it was possible that next time she may not be in position to be weaned off.So we agreed that we would do everything medically possible but no artificial means .
     She was admitted to hospital once and did OK . The husband was a builder and the economy was not doing well , and the construction was down . So he could not survive , so he sold his house and moved to a place 80 to 90 miles from my office . It was much smaller place and he had gotten a job near by . He still continued to come to me and I continued to follow her.
    I had admitted her in our hospital , when the husband would call me, telling me that she was bad .It was one Saturday morning.I got a call from the husband that she was not doing well and needed to be admitted . I told him to take extra dose of steroid and get her to local hospital , if she was bad . She did not want to go to local hospital.She lived 80 to 90 miles from our hospital . So I expected her to take at lest 2 hrs. So I told the husband that I will make arrangement  for her to be admitted and I will see her when she is admitted . It was about 10 am . So I thought that by the time I am ready to leave the hospital , she should be arriving. I called the admitting office . As she was admitted to the hospital before , they had all the information about her . I also left the preliminary orders like blood count x-ray , steroids, and other orders , in case I had left the hospital before she came in.
        She was not in the hospital by 12-30 pm , I was going to wait for short time and call the husband on his cell phone and ask him on their where about.Then I got a call from some unknown telephone number. I called the number and it was sheriff, highway patrol.He asked me if I knew the patient . I said yes . He told me that while the husband was bringing her to our hospital , she died on her way to the hospital . He wanted to know if I would be willing to sign the death certificate.I said off course. I spoke to the husband , there was not much to add . He had asked her if she wanted to go to other emergency room or hospital , and she had told him 'no '. She did not want to be treated by anybody other than me.

IS IT BAD LUCK ,KARMA OR JUST A CHANCE ?

    I do believe in luck , bad (or for that matter good ) karma.I definitely believe in reincarnation . I still do not have answers to all the situation in life and can explain the out come or the so called bad luck that we all see and sometimes experience .Granted that if we bring in the law of Karma in bad situations  then we will be considered 'cruel' or not sympathetic . But in spite of all the problems that we would face trying to explain everything, I still believe in the law of karma . The reason I thought of all this when I met a patient of mine in the hospital recently.
   I had seen this patient , who is now over 70 years or so. I had seen her for abnormal X-ray chest almost 20 years ago. The further work up showed that she had lung cancer and then it was operated,with resection of the cancer. It was completely resected and she did not need any further treatment.I continued to do the follow up as there is always chance of recurrence and also the chance of second cancer. So she continued to come to me . In the couple of years that she came to me , she lost the job and then lost the health insurance.I still continued to see her and in fact diagnosed to have new onset of high blood pressure and did treat it. I had to treat her as her primary did not see her when she lost the insurance .
    One of these days I saw her in the hospital. She was not a patient ,but was visiting someone. The patient that I was seeing had lupus and renal failure and was on dialysis. She also had circulation problem and needed amputation. She was 30 years old and was bed bound and was in a nursing home.As it turned out she was daughter of my patient.
    I was seeing a another patient in the office that I had started seeing for only last 6 or 8 months. This was a 35 years old female who had chronic cough. As it turned out she had a another connective tissue disorder (lupus is one such ),called scleroderma. She had developed scar tissues in lung due to scleroderma and also had elevated pressure in lungs called pulmonary hypertension. She was bad and I started treating her , but with the young age I referred her to lung transplant program.She refused.So I was treating her , but I knew that her prognosis was very poor.SHE ALSO TURNED OUT TO BE MY PATIENT'S DAUGHTER!.
    So my patient had lung cancer and had 2 daughters who had bad disease, bad enough that they were likely to die soon. And they were all seen by me . I did not mention one more daughter that also had connective tissue disorder which was not bad ,
    The question that I have is "is this Karma ?"Is this shear chance? or all this was interconnected with each other with the circle of karma and the debt that all of us collect with interpersonal relationships in our 'every' life !!!!!
  I don't know the answer, but may be you do.

COMPUTER AND MEDICINE

   I have now seen models of computerized medicine or the decision made by the computer . Our brain does work as computer, but at times we do have instincts.And they do work better than the well thought out computer program.Many years ago I was reading a book called 'MIND Control' written by Jose Silva.It stated that we have intuition as children, but as we grow older, we are told to think 'logically' and as we develop logical thinking , we loose intuition.The computers work logically .There is no intuition in the computer decision making.It is all logic. Off course the logical thinking is programmed by the human beings.
   In medicine ,when we make decisions ,many a times it is not completely based on logical thinking, but it is based on 'feeling'. The patients that I am going to tell is one such story.
   I have been seeing this 68 years old female.She was a smoker and in 2010 I diagnosed her as having a lung cancer . She also had a history of a lung cancer in 2004. In 2004 she had a surgery and had part of her left lung removed. In 2010, after the new cancer was detected ,I referred her to a surgeon.She had a new surgery and at that time the surgeon did what is called a wedge resection . This is to save lung,by limiting the amount of the lung that can be removed, as much as possible.There is a risk that the resection margins may show cancer cells under microscopic examination ,which necessitates additional treatment and recurrence rate is higher.But as patient looses less lung , the shortness of breath is less.So this lady had 2 lung surgeries . I was following her with follow up CT scan.She had continued to smoke , had shortness of breath on exertion, and had significant cough. Few months ago the CT scan showed the increase in size of a nodule by 2 mm in span of 1 year.So I did a bronchoscopy and a PET scan. The PET scan is a biological scan . In this scan we check the glucose uptake in the spot, comparing it to the normal tissue.As cancer cells and infections have higher metabolic rate,the glucose uptake is much higher than normal lung tissue.The PET scan uptake was there but at much lower level than seen normally with cancers. So I decided to do follow up on the CT scan. The CT scan was done in 4 months.The nodule had grown by 5 mm and repeat PET scan now showed the uptake to be very high, highly likely to be cancer. I did check the breathing test and it showed adequate lung reserve. She had continued to smoke and had significant cough and was short of breath. But the nodule was still small and so in short ,she was surgical candidate. I was quite skeptical as to her ability to tolerate the 3rd lung surgery. But I had no choice but to refer her to a surgeon. Patient was not very old , had adequate lung capacity and was willing to have the surgery. So I sent her to a surgeon. I also sent her to a radiation doctor for the opinion,as if the surgery can not be done, then we could treat her cancer with radiation treatment.
     The surgeon saw her and so did the radiation doctor . Both felt that the best option was to give radiation and not the surgery. So my " FEELING "was correct ,or at least all 3 of us felt same.So if this was a computer decision, then she would have had surgery and may not have done well .    

REALITY

     It is often said that something appears to be such and such , but the reality is ----different.In Hindu scriptures it is stated the truth is one and wise men interpret it differently.But when we use the term reality or truth it differs in different conditions. Let me start with a joke that I had heard . There were 4 people travelling in a train. There was a young girl and two young males and a older woman. As the train entered a tunnel , the lights went out briefly. There was a sound of kissing and it was followed by a slapping sound. The older woman thought that one of the boys tried to kiss the girl and she slapped him . This was her reality. One of the boys thought that the 'other'boy kissed the girl and the girl slapped me . That was his truth. The girl thought that how stupid these boys are . Here I am young and beautiful and these boys are kissing the old lady, So that was her reality.AND the real (!) 'reality' was that one of the boys kissed his own hand and then slapped the other boy.So what appears to be such and such , may not be so .So then one may say that if we 'see' something , then we know as to the reality. But then look at the sky. It is blue .So is it real blue? But then we know that the reason sky 'appears ' to be blue is due to certain color bands being reflected . And some one's shirt is red , is it really red . If you ask a colorblind person ,he will not agree with you . Then when we look at something through eyes of a chameleon it will be a broken image , hundreds of them . So what is a reality.So whose "reality" is true or real ?
     But there is more to the truth or reality. When the Hinduism declares that this world is not and there is only one real thing or truth,they are not talking about the thing that we see or the sound that we hear and so on.The definition of the reality or the truth is that thing that does not change , is the truth or the reality . So if I look at a dog , and to me it is real. But is it changing? If it changes then it can not be the truth ,as the truth does not change .The dog is changing every second, even if we can not perceive it until certain time is lapsed . We are getting old , but we can not recognise it till few years are gone . So this can not be the truth.So there has to be something which does not change from time to time.In this world , we see different things and every one of them is changing from second to second.But all these things have to come from something . That something can not be reality, if it changes in to different things . So if the entire universe came from the singularity, it can not change in to multiple things,So if we see different things , there is something behind them which is the reality . Something that we can not see or hear it or smell it or touch it . But it is there . And that is the reality . That is the truth.It is beyond our sense perception , it is beyond out mind's imagination and it is beyond our intelligence. Only thing that we can do is perceive it , by what means , I do not know .
   

THE DOUBLING TIME

    The doubling  time is a term I have used . I do know that the many lawyers like to use this in suing doctors . But what I am talking about is the use of doubling time in following the abnormal CT scans.In past we really did not have much idea as to the growth pattern of the cancers . But as we have followed more and more patients and are doing more CT scans , we now have some way of estimating the growth patter of the cancer. The interesting part is that the same tumor may not have same rate of growth at the same site or at other site , the metastatic tumor .So we have no 100 % test to know.To understand the doubling time we must first understand the origin of cancer.The body has great mechanism and it does not allow the growth of cells when it is not needed.So if I have a cut in my skin , the cell will start growing and as soon as the gap is filled then the growth will stop . This happens automatically.When the cell continues to grow and there is no control on the multiplication of the cells , then it is cancer. This is very simple explaination, and not the perfect one . But this comes as close to the real one.So if we believe that the cancer starts in one cell getting out of control. and continues to grow and DOUBLES , then again multiplies ,and becomes 4 , and then 8 and so on .So when we talk about the doubling time , we are not talking about time taken to double , but the time taken to double volume ,is called doubling time .So we are not talking about 1cms becoming 2cms , but the volume becoming double . The lung cancers have widely variable doubling time.It may be as fast as 45 days to as slow as 400 days.This means that the tumor may double in month and a half or year and the half . So this does not help much . But then majority of cancers will double in 3 to 4 months.So that is where we have some recommendations as to doing the follow up CT scans . But the case that I am going to tell is one which lies outside these patterns.
       I can remember many cases but I am going to tell about some . I was following this. semiretired nurse for shortness of the breath . She had history of breast cancer and it was operated and she was fine . But then was short of breath.The further work up revealed that she had developed inflammation and asthmatic reaction . On further work revealed that she was allergic to hays that is fed to the horses , and it was causing the inflammation and the scar tissues . I told her to stop taking care of the horses and she improved . So I was doing follow up on CT scans and breathing tests.She did well for next 3 or 4 years . So I was then doing yearly X-ray , rather than CT scan. One year I did the chest X-ray and it showed 9 cms size lung mass. She had no symptoms . So when I told her about it ,she thought it may be the breast implant leaking .We did the CT scan and it confirmed the lung mass and then the biopsy confirmed the lung cancer . So this cancer must have had very rapid growth patter as otherwise it could not have grown to this size so quickly.
       The other case that I will tell in future is one where a plain X-ray was reported normal , and the patient had wide spread cancer in less than 3 months . In one other case there was a spread of lung cancer ,that we could not find out in spite of CT scan of the lung.So the doubling time good for many patients or may be most patients , but is not 100%.  
        

PLACEBO AND PRAYERS

      I  was reading about the effects of the placebo and how it might work .There were several ;facts; that tried to explain on the mechanism of the effects of the placebo. We know for long time as to the effects of placebo. So the question arises as to how does the placebo works . There were several studies that showed that when patients were given a pill under the suggestion of it being antidepressant or sleeping pill , it seems to work. But what intrigued me more was that the capsules work better than the tablet and the color of the placebo capsule mattered too. The effect of red color capsule was different with the men and women. So how does this work . We know that certain chemicals are secreted by the brain , when we treat say for example depression . So how does these sugar pill cause effects to secret the same chemicals or is it that our 'mind ' stimulates that brain to secret these chemicals even though there is no real chemical in the pill to cause the secretion of say for example serotonin.
       The other interesting part was that if someone knows that the pill is not real medicine , then it would not work. The other fact was that the placebo did not work in all the patients, even when the patients did not know that that it was not real medicine .There was a story in which a patient got cured with the Hypnotism , which is nothing more that the suggestions given under certain state of the mind. But once the patient came to know that the disease was incurable with the usual medicines , the same Hypnotism did not work . The interesting pat about that story was that the doctor had suggested that the rash would be cured on only one arm and the rash was gone only on that arm , The rash did not get better anywhere on the body got better . The rash did not get better when the doctor knew that the rash was noncurable.So it seems that the one who gave the suggestions must also believe in the suggestion or the 'power' of the suggestions .
      So now comes the question about the power of the prayers . When we pray are we using the power of the suggestion and the mind or is it that the prayers work some different way? And when they work , what about the destiny or is it that the things were going to happen anyway . I have no clear answer. I think that there are mixed possibilities . I think that in some cases we can change the destiny by shear power of suggestions and the power of the mind. In some cases we can 'perform 'better with the confidence is better with our mind working with us . In some cases the destiny is there , as to what we want it to be . So we may think that the prayers work , but it was to happen anyway . Lastly the PRAYERS DON WORK. I think that when we pray, it is not power of suggestion or mind or the destiny is there , but it works in some mysterious way and if the prayers are sincere.
 

USELESS AND NEEDED SURGERY

     When we talk about any surgery, we want to know if it is absolutely needed or not . If I state that some one's gallbladder needs to come out , I have state that doing so is going to help prevent an attack of gall bladder.Things are sometimes Crystal clear. If some one has lung cancer and surgery is recommended , no one has any questions. But there are situation , when we have to make decision to the surgery , where nothing on long term is going to change , but we still need surgery .The story that I am going to tell is one such.
      I saw this 72 years old male for pulmonary evaluation . He was diagnosed to have lung cancer, when he was admitted to hospital . The biopsy was done and the diagnosis of lung cancer was made . Patient was seen by radiation doctor and an oncologist As the work up was done , he was found to be inoperable and was treated with radiation therapy. He also got some chemotherapy.He was followed by the lung specialist. He had some fluid around his lungs and it was taken out by the previous lung specialist. He also had a bronchoscopy . There was no recurrence of the cancer. For whatever reason, he came to me for the further follow up. I looked at his old records and realized that the left lung , where he had the cancer,was contracted and almost nonfunctional . This most likely had occurred due to the previous treatment with the radiation and the chemo. So the lung was contracted and could not expand. And there can not be an empty space , so the fluid was coming back. Taking out fluid would not help anything , neither shortness of the breath , nor cancer. I did not do any procedure ,but did a scan that measures the blood flow and the air going to that lung . As I had expected , the left lung was getting 3 or 4% of the air and the blood . So in essence it was contributing nothing to the function of the lung.
     About 6 months after that , he was admitted to the hospital with car accident .He was driving at night and was hit by a car ,He broke couple of ribs and was admitted to the hospital . I saw him and looked at the chest X-ray . He also had CT scan of the chest and it showed that the fluid was little worse , but not much . He was also on blood thinner for his heart, atrial fibrillation ,irregular heart beats.I stopped the blood thinner in a fear of bleeding with trauma.I ordered the repeat blood counts. The next day when I saw him I had noticed that his blood counts had dropped . When I called the nurse about it , she informed me that the hospital doctor had ordered the transfusion . (not knowing what had caused the drop in the counts . I saw him . He was short of breath. There was not much air going in the left lung . I spoke to him and ordered stat chest X-ray . I also told him that most likely he had bleeding in the chest due to car accident and rib fractures and he bled due to being on blood thinner .I told him that I was going to call a chest surgeon and most likely he will need surgery.I transferred him to Intensive Care Unit .
     As was expected , his chest X-ray showed 'white out' of the left lung.I spoke to the surgeon. His breathing got worse and he had to be put on respirator . Patient and the family were told that he is going to need surgery , and it was not for his cancer , nor it was going to change anything as far his cancer was concerned , nor was it going to change his shortness of breath.(from his base line ). They wanted to know if this was needed surgery and what would happen if did not do it . I told them that if he continue to bleed, and then shortness would be worse .They agreed and he underwent the surgery . The blood was evacuated and did OK.He was on respirator for 10 days and then needed lot of physical therapy.
     The surgery was needed , but was not going to change anything that was his problem in the past . But it was necssary surgery, as without it he would have died.