INADEQUACY

    Some one had defined 'specialist'(in medicine) as "someone who knows more and more about less and less!" I feel it is so true . A cardiologist does not know about Pulmonary or at least does not want to be bothered about it and a  kidney doctor does not look at anything else but kidneys. But the medicine is growing so fast that one can not keep up to date on every new development in every subject. But my story today is about something else . Sometimes in practise of medicine we have all sorts of experts and they also come out empty handed. The line that I had liked in past was ,'Medical knowledge is vast and incomplete.'
     So this is the story of one of my patients. I had known her for few years . She was mid fifties and was a smoker . She had shortness of breath and also CO PD. so she was tested and was put on oxygen and medicines and was told to quit smoking . She had some kidney issues and so had an ultrasound   of the abdomen done and it showed some fluid in the lungs. So she called me . I did a chest X-ray and it did show large amount of fluid around the right lung. She was little more short of breath and so I decided to admit her. She then had a CT scan of the chest and the fluid was confirmed . There was no other abnormality to explain the cause of the fluid . So I drained the fluid . I drained 1200 ml of the fluid and sent it for various tests to find out the cause of the fluid collection. There was no infection , TB or bacterial . But the fluid did show CANCER cells. So I consulted an oncologist -expert in cancers. He ordered some tests , but we did not know the origin of the cancer -where did it start. Now a days we do many tumor  markers. The cancer cells look different that their parent organ cells. But they still retain certain characteristics of the original cells.Easy to understand would be breast cells . They will have 'markers' for female hormone, estrogen . I also give example of interracial marriages , where the children would show some characters of both the parents. So one can do many markers now a days  There are so many of them that I can not keep up with them and I have to depend upon other experts and their knowledge . So after testing many of them we still came out empty handed . I had ordered a PET scan . This scan is done by injecting glucose which is tagged with radioactive material. The glucose is picked by every cell in the body . Since the cancer cells are metabolically more active than the normal cells , they pick up more glucose and the this pick up is measured and one can diagnose or stste high probability of cancer . No test is 100%. So the PET is may bbe 88%. The PET scan showed abnormality only in pleura , where we knew that there was cancer. The major differential was between lung cancer and the mesothelioma. All of us know that if one has lung cancer there is no monitory gain , the treatment is different and the prognosis id different. On the other hand if it was mesothelioma , which occurs with asbestos exposure , there is monitory gain and the treatment and the prognosis is different. So I consulted a chest surgeon . I asked him to do 'open biopsy'. So an open biopsy was done and then bigger sample was given to the pathologist and the final diagnosis was ------still same .It is cancer , burt unable to state where it started and not sure if it is mesothelioma. The sample was reviewed by 5 local pathologists and now is sent out for 'expert' opinion. So in spite of all the experts we still DON'T KNOW' . This is what I call inadequacy of medicine .  

GEETA CHAPTER1 SHLOK 9

  I have been always intrigued by the Geeta's1st chapter. In many of the series of first shlokas it appears that there is not much about the religion . In short they appear 'wasted' if one considers the Geeta to be a religious discourse on the battlefield. On the other hand many believe that these shlokas are introduction to the REAL battle field story and so they are part of MAHABHARATA and so the appear to be appropriate in the beginning of the Geeta. I wrote about the first 8 shlokas in past and in this blog I want to write about the 9th one . Please understand that this is not MY KNOWLEDGE and I am simply stating what I gathered by READING.
     In shloka 9 it states that "and many other warriors are present, they are well trained and have weapons and are here for my sake and will lay down their lives. " When I look at this one , in continuity of other shlokas it does fit in to the introduction of the war . May be it sounds like the speech that many Hosts give at the time of wedding stating important names first and to avoid omitting others ,state that and' many others who have come to attend this function taking out time from their busy schedule .'
    So who are these 'many other warriors?'Yoganand feels that these are the 6 enemies of the human beings that are mentioned here . These are KAMA, KRODHA, LOBHA, MOHA , MADA AND MATSARA.--LUST, ANGER,GREED, DELUSION,PRIDE AND ENVY OR MATERIAL ATTACHMENT. So are these 6 enemies represented by the 6 warriors in the Kaurav army?
   Kama-Lust-Usually we think of Kama as Lust or sexual desire , but in broader sense lust is intense desire for many materialistic things and so the DURYODHAN is the best example . But if we think about the story of Mahabharata and the incidence of Pandawas loosing in gambling there were many who came forward to undress Draupadi . So these are the one that  represent KAMA.
   Krodha or Anger -We all know that when we are angry , we can not think properly and make proper decision. We are told by elders to calm down and make decision. So in the Mahabharata , Duryodhana's brother Dushshasana is the example of anger . In Sanskrit meaning of the word Dushasana is 'one which is difficult to control.'
    Lobha or Greed- The greed could be for food or sex or money . But how do we develop the greed . We 'act' and then 'experience' pleasure and then we develop the likes and dislikes . If I eat something and I enjoy it I am attached to it and I develop GREED FOR IT.So even if I am not hungry I will indulge in eating . This attachment to the things that we like and repulsion to the things we dislike are represented by Karna and Vikarna .
    Moha or Delusion-Sometimes we use word Moha as attraction. And indirectly it is attraction . But the attraction is due to Delusion or not knowing the truth . The ego has the bodily attachment and has delusion. The soul does not have the delusion . This ignorance is the cause of Moha.So if we knew the truth , we may not have the attraction. If we fall in love with someone as they are good looking but then when we know their nature or views or behavior the attraction is gone .The same thing could be said about the food , which is tasting good but not good for the good health. In Mahabharata this Moha or delusion is represented by SHAKUNI . He was the one that had asked the Pandawas to play with the dice that were tainted . This is when the Pandawas lost everything in gambling. The delusion was that they could win .
    Mada or Pride- We are proud of our name , family  or education or job or family members . But when this goes beyond certain level it is intoxicating or unwise or bad . In Mahabharata Shalya is representing this quality. In reality Shalya was maternal uncle of last 2 Pandawas namely Nakul and Sahadev. He was brother of Madri. So he should have been on the side of Pandawas ,but due to the Pride ,he decided to fight from side of Kaurawas.
    Matsara or envy-This one is easy to understand as we all have it and display it all the time . We are envious of someone who makes more money or has better and bigger house or whose kids are smarter than ours. In the Mahabharata this is represented by Kritvarma. Lord Krishna belonged to the clan of Yadawas . Kritvarma was a Yadawa, but he became envious when the lady that he wanted to marry  , got married to Lord Krishna. So he was envious of Krishna and so decided to join Kaurawas to fight against the Krishna supported Pandawas .
    I know that this is not perfect explanation . But I thought this is as close as I can understand and accept.   

MOTILITY

   I have often talked about the lung diseases as I am a lung specialist . But as I often say the various organs in the body are related to each other like the various residents in a town . What one does affects every one other at one or other time . The obvious ones are the lungs and the heart. But recently - may be in last few years I have realized that the the Gastrointestinal system does affect the lungs mare than one way . Some of the elements may be related to patients living longer. Sometimes ago I saw this Indian patient . He walked in my office and had no appointment . He was working in a motel . When my office secretary asked him as to why he was in my office , he told her that the owner of the motel told him to come to me and I will take care of him . I started seeing him.
   He had a condition called scleroderma and he had no health insurance . So it was somewhat difficult to take care of him. But we managed . He had scar tissues in the lungs and also had circulation problem in the fingers and toes . He had chronic cough due to the scars in the lungs and was also short of breath . I did do CT scan at a discounted price from a radiology center and did complete pulmonary functions free. and treated him with meds . He had developed a ulcer on his ankle and had some ulceration on fingers . So I treated it with home remedies . I gave him Papaya cream and honey and asked him to soak both feet in hot water as long as he can to improve the circulation . All these things worked and the ulcers healed . After about 2 years of the follow ups , he got health Insurance and then he moved out of town , but continued to do the follow up with me .
    He was quite bad and I decided to refer him for transplant evaluation . I had done the check up on his heart as the scleroderma can cause the pulmonary pressure to go up . The heart check up was ok . The transplant evaluation as far as lungs were concerned , went well and they did think that he would be good candidate in ; near future'. But on further evaluation it was noted that he had problem with his esophagus. This is actually quite common .I had not done any work up on swallowing as he had no insurance and he had no GI symptoms. So  it came as a surprise and a disappointment . HE HAD ESOPHAGEAL MOTILITY problem .
     Normally the esophagus moves as contraction rings so the the food is squeezed down .  HE had no contractions . This can cause the food and the water to stay in the esophagus for prolongrd peroids of time and that can then regurgitate and go in lungs and can cause aspiration. This can further damage the already damaged lungs . This an absolute contraindication for the surgery and he was rejected fo transplant.
    Since then I have seen similer problem in some of the older patients without the scleroderma .Most of them presented as chronic cough, or recurrent pneumonia,  

STANDARD OF CARE ????

   In medicine we talk about the standard of cars . What may be standard of care in one area may not be standard of care in another area. To give an example referring to a cardiologist may be a standard of care in one area where there may be 10 cardiologist, but in another area there may be none in 100 miles area so to manage on own by a family doctor is OK . Standard of care is what a medical community would do under given circumstances in a particular area or under given situation.So if some one has chest pain , we do work up to rule out heart problem. So today I am telling a story of a patient where we followed the so called standard of care and had more problems .
     I saw this 65 years old female who had some cough. The routine work up was done and her cough got better. but then due to the scare of cancer , she wanted a CR scan of the chest . I have seen patients with normal chest X-ray and abnormal CT scan showing cancer . So I did agree  to do the CT scan.The CT scan was done and it showed some some tiny nodules. The size of the nodule was so small that the usual tests that we do would be not effective in getting diagnosis. The usual test are Bronchoscopy , needle biopsy, PET scan or open biopsy .. With the size of the nodule less than 10 mm we can't do much . Now a days we are doing so many CT scans -almost 1000% more -that we are seeing these nodules and we are stuck with the follow up . I often tell patients that doing a chest X-ray is like looking at the sky at night and say looking at MARS. Doing a CT scan is like seeing the same MARS through powerful telescope. One is bound to see more details.So what is not seen on plain chest X-ray , will be seen on CT scan . So now I have to do follow up CT scan . The criteria which are established -the so called standard of care is to do follow up CT scan based on the size of the nodule . If it is 8 mm , then do CT scan in 3 months , if the nodule is 5 to 8 mm then do in 4 months and if the nodule is less than 5 ,mm then do the CT scan in 6 months . So I continued to do CT scans . Every time I did new CT scan it would show a new nodule and some old would either disappear or would be stable. (This sometimes can occur due to sectioning variation. I must have done follow up for more than 2 years and unfortunately due to new ones , I had to continue doing more CT scan . Again none of them were bi enough to do other tests .
     And then one day I did CT scan and this time it showed lymph node enlargement. So now I was not sure if she had a cancer of the lymph nodes or it was part some disease that was causing the nodules and now the enlarged nodes.I had to call her for discussion and she also came with number of family members . Had no choice but to recommend the biopsy . I did not want the needle biopsy as the sampling size is small and if we do not get 100% diagnosis , we will be stuck again . So I sent her to a chest surgeon .
       The happy ending is there . The biopsy showed SARCOIDOSIS. This is a benign disease and no disease !! 

THE FATHER,THE SON AND THE HOLY GHOST OR AUM TAT AND SAT

  I received a message from one of the reader of my blog, that liked one of my old blog entry on Mysticism in MAHABHARATA. So I was thinking about the mysticism not only in Hinduism , but also in Christianity.On the surface  many things that are written or said, appear to be open for interpretation or misinterpretation. The story of Adam and Eve.The question that I have is how valid is the statement that we are all sinner as we are born to Adam and Eve . This off course comes from the people who DO NOT believe in reincarnation.So Where do I come from and what sin did I commit that I am paying for it ? I do have explanation . But I will write about it latter. But today I thought about writing about the THE FATHER , THE SON AND THE HOLY GHOST in CHRISTIANITY and the same thing in HINDUISM . You can tell me how wrong or correct I am after reading this blog.
    In Christianity they always talk about the Trinity . It is also said that The Jesus Christ was the SON and he will save us. But no one talks much about the origin of the universe. So the FATHER is the SAT, The SON is the TAT and the Holy Ghost is the AUM. The SAT means the Truth, the Unchangeable, the ever lasting. When one refers to something as REAL , it does not mean that in our conventional way . The computer that I am using is real to us and is not imagination . But it changes every second , even though we can not recognize it at that time.(We can see it very easily if we check it in a year or two. )So the SAT means one that does not change and from this SAT everything originated.  Thia is why it is the FATHER . The SON is the thing that comes out of the FATHER. But to start the universe we need to have ENERGY and the Matter. So the UNIVERSAL CONSCIOUSNESS or the SON which pervades everything in this universe is the TAT--THAT.The first word or the creative vibration. This is AUM or the HOLY GHOST. The matter is inert and has on spirit or energy and that comes from the SON or TAT The union between the SPRITE and the Matter leads to the beginning of the universe. The AUM is mentioned in the Bible as the 'In the beginning was the word and word was with the GOD 'So in Hinduism we talk about the first sound is AUM . The AMEN of Romans , Greeks, Egyptians, Jews and Christians the AMIN of Muslims , all are same as AUM .
    So The SUPREM GOD does not move and does not change and is the ulimate reality and is the origin of the universe is the FATHER OR THE SAT. The SON is the all pevading consciuosness or the Sprit or the energy or the TAT without which inert mattaer can not DO anything ,is the TAT. And lastly the HOLY GHOST is the AUM or the first sound or the matter or the mother nature.    

BAD LUCK

      I was reading a book which was suggested to me by several people . The name of the book is WHEN THE BREATH BECOMES AIR .' This was written by Paul Kalanithi . When I went to library to check it , I realized that it was quite popular book . There were 50 plus people ahead of me . This is a story of a neurosurgeon who was diagnosed with metastatic lung cancer at age 36 and died of it. The book it written by him and published by his wife after he died . Couple of points that I want to make is that 1 it is quite depressing book especially towards the end , and I did expect it . Even though I see this every day I was not very happy with the end even though I knew the end . Secondly I felt that too many physicians FEEL that working HARD and neglecting family is OK. I am not surgeon ,but I have heard that in all the surgical branches there is hard work and rude behavior and it is carried from residency and then in practise . (I want to make it very clear that Dr Kalanithi was not rude )But why is it OK to work 16 hrs?(In my residency time I did do 34 hrs straight too ).This may be the cause of stress and suicide. But the reason I started this blog was to tell you about my patient.
       So I was consulted on this 35 years old female who was having some shortness of the breath and question of pneumonia . When I talked to the patient and her family , I realized that I was dealing with a sad story.She never smoked and did not drink alcohol and about 20 months ago she was diagnosed to have a stomach cancer . By the time it was diagnosed , it was inoperable. So she was given chemotherapy and she did OK , She was in 'remission '. But then as many times happens , she had recurrence . She was given radiation and chemo and continued to struggle The cancer had gone to bones and brain and lungs. She was short of breath and needed oxygen . Due to the spread of the cancer to boned , she was needing blood transfusion every other day . I reviewed her chest X-ray and the Ct SCAN AND FELT THAT THE CANCER WAS NOT ONLY IN LUNGS , BUT WAS BLOCKING THE LYMPH DRAINAGE . This was making lungs 'stiff' .The lungs  which are normally like dry sponge , are now filled with water -or in this case due to cancer and these stiff lungs needed much more energy to open or expand them and that resulted in shortness of the breath . This fluid in lungs also caused the oxygen transfer to be poor and needing oxygen .So there was not much I could do . Just like in case of Dr Kalanithi , sometimes we can not offer anything but prayers .
      Even though I believe in reincarnation and the Law of Karma , I am not sure how I can explain this or accept it I still call it BAD LUCK !!!

EXPRESSIVE APHASIA

   I have always wondered about the speech or the language.  when different people speak English they speak in different way or have different accent. I think that the accent is based on the person's mother tongue.. (Is it called mother tongue as the father does not get a chance to speak?)So when a Hispanic speaks English it is different that when I Frenchman speaks. I for that matter can distinguish different accents of people from India . This is how the CHINAYA SUZUKI thought about the music. He felt that the music was a language and as we don't have to teach a child a language or it's peculiar accent , we don't have to teach a child a music if he or she can hear it frequently. But I am not talking about this part of the language , or the speech . I am talking about the origin of speech .
    The other day I saw this patient with respiratory failure . She had been a smoker and had rheumatoid arthritis . She came to hospital with shortness of the breath and then needed significant oxygen .When I saw her in ER , she was mildly short of breath and was talking OK. She may have had pneumonia , but when I saw her old X-ray , I knew that she had fibrosis , or scar tissue in lungs , probably from her rheumatoid arthritis. So I knew that we are going to have some tough time in weaning her oxygen . But she did OK , did get little better. But then the hospital doctor called me one morning telling me that she was confused and he did not have idea as to the reason for it . So when I saw her and examined her I was surprised . She was NOT CONFUSED ,but had Expressive Aphasia. SHE COULD NOT EXPRESS . She could move her all extremities. But when I showed her a pen , she could not name it and was saying yes to every question. So I knew that she most likely had stroke . I ordered a CT scan of the brain and asked a neurologist to look at her . CT scan of the brain showed abnormal area in the frontal lobe . The neurologist had no specific diagnosis.
     The speech is formed as a result of coordination of various areas in the brain. Broka's area and the Wernikoff's area are the 2 known area and the frontal lobe stroke most likely caused the aphasia .When we see something, we know what it is and the word is formed . When we listen to a sound we know what it means and when we touch , we know what we feel .
  For those who are interested in Hindu Religion , there are 4 different speeches , They are called PARA. PASHYNTI MADHYAMA AND VIKHARI. The last one is spoken speech . May some day I will try to explain what the other 3 mean .