KARMA AND THE EFFECTS

           We had several mass killings in recent past and I was thinking about it . At the same time , I was reading Hindu script , which was written several hundred years before Christ.The one that I was writing about stated that 'IF ONE CAN CONCENTRATE UPON THE IMPRESSIONS THAT ARE CREATED BY THE KARMAS (FROM ALL THE LIVES)THEN HE/SHE CAN KNOW THE TIME OF DEATH." So this blog is about the Karma and it's effects . I have written about it in past.In Bible also it states that 'Reap as you Sow' The difference though is that in Hinduism, the seeds of Karma continue with multiple births and deaths , and the impressions of Karma or effects can occur in any life. This is different than the Christian belief  in which the effects ENDS with present life . So on the day of judgment , decision is made based on ONE life and if you have done more good than bad , then you go  to heaven and if have done more bad than good , you go hail . So every body is judged on the same day.So I am not sure as what happens in between . In Hindu concept the process is recurring and the NEXT life is based on all PREVIOUS lives. So when we continue to do Karma , we continue to accumulate the effects and this POT, full of all the Karmas that we have done in past lives , is called SANCHIT Karma . When we are born , we come with certain seeds or Karma that are going to come to fruition in Present life.This is called PRARBDHA  KARMA. We do more Karma in the present life and some of them will come to fruition in Present life and some will be stored as SANCHIT Karma to come to fruition in next lives.The current life Karma is called KRIAMAN Karma .
       In this law of Karma ,the EFFECTS or the Fruits of Karma occur AFTER the Karma is done . But in CHRISTIANITY when it is said that the Jesus died for our SINS , the Fruits happened before we did any sins or Karma.
       So for the Hindu concept of the Karma , the Karma has to precede the effects or the fruits of Karma , the effects of Karma ,can not be transferred to someone else ,(I can not suffer for the sins of my parents or my kids), there is no GROUP Karma . So when a group of people miss behave, EACH one has to get the fruits of his or her Karma and there is no group suffering due to group action. So in mass shooting each one of the victims had some unknown Karma from previous lives,that brought them to SAME DESTINY. The effects of the Karma is Recurring, and there is no final Judgment day.
       This concept is closely tied to the concept of reincarnation. One more difference is that just the Grace the God is not enough for getting rid of the Karma. Every one has to go through the effects of their Karma , the Surrendering unconditionally to GOD will help ,but not eliminate the effects . If one looks at the lives of many Indian saints , they all had very hard live,e.g.DNYANESHWAR,TUKARAM,MIRABAI . This has to do with completely neutralizing the effects of Karma from last ALL the lives , so there is freedom from rebirth. The only way to stop the KRIYAMAN karma -one that occurs with our every day life is to not be ATTACHED to the fruits -DO THE ACTION ,WITHOUT EXPECTING THE FRUITS OF THE ACTION.

ADVANCES IN MEDICINE AND THE NEW QUESTIONS WITH IT

      I am always amazed with the new inventions and new techniques in medicine. But some of them are so good and may be an advantage for the patient and for the physicians. But sometimes it adds to the problems . So few years ago I was talking to some one  who happened to little older . She had tried to get pregnant and was not successful . She had test tube baby - fertilization done out side the body , then selected embryos implanted in the uterus. Due to the advanced age of the mother, they were doing blood tests from the mother starting at age 10 weeks . The blood tests were done again done at periodic time . The mother's blood is tested for fetal DNA. This can help detect the Down's  syndrome and some other fetal abnormality . The amount of the DNA is increased as the pregnancy advances. So the mother's blood gets fetal DNA even though the two bloods don't mix. While I was thinking about this , i looked in to it and realize that similar thing could be done for cancer or tumors. So I looked in to it and was surprised that there were some scratchy studies done in the past .

     And then I came across the study where blood tests are being done for very small nodules in the lungs and some as small as 3 mm and some much larger as much as 30 mm . This is called 'liquid biopsy" The studies are being done for breast cancer and the lung cancer and urine for bladder cancer. So I now know local physician involved in this study. I am not sure what would come out , but I was excited to know that some one was doing the study .

     But then I came across a study which was published recently and the lung cancer . They did the blood test in patients who were treated for the lung cancer and had NO EVIDENCE of the cancer. Those who had the positive blood test for ??tumor marker- had higher incidence of the recurrence of the cancer.But here is my problem . So if the blood test is positive and one has no evidence of the cancer , should we treat it with more chemotherapy or just watch it . The problem is that even though the blood test may suggest that some cancer cells are still in the body , not everyone comes with the recurrence , may be the body's immunity takes care of small tumor load. So treating everyone , we may be over treating , and that adds to the cost and the side effects .This problem was much worst when in past some did similar blood tests in high risk patient , who had no evidence of the cancer anywhere in the body, and the tests came back as positive . So now what do you do . Without the actual tumor , one can nor select appropriate chemotherapy and what kind of follow up can we done to see if patient is Responding or not. So when these tests are done we need something more or better to help patients and doctors to make these decisions. Otherwise we have tests and the reports , and no answers or treatment plan . And on top of that it adds to the anxiety on part of the patients and the family . It also may create problems with getting Health insurance and Life insurance .

       I know this blog is not a patient story , but I think it tells the real dilemma that will be added to medical decisions , when medicine is Art and Science combined in my opinion.  

MEDICINE -SCIENCE OR ART AND SCIENCE

                 I have been in medical practice for many years . More I see , more I realize that NOTHING is perfect. I guise that patients when they come to doctors do not read books and so the presentation of these patients is not always like it is  written in books. . So sometimes it is not perfect  or 2 plus 2 does not make 4. And sometimes you come across these patients in clusters. So this brings me to today's story.

                    I saw this 67 years old male patient for abnormal CT scan of the chest . He was a smoker and he had quit few years ago .He had some cough and he had some clear sputum . He had no fever and had not noticed any blood in sputum . He had though lost 15 lbs of weight in last 3 months and upon questioning , he told me that the food did not taste the same , and so he was eating less and so he lost weight . He did not have any excessive sweating at night . He had chest x- ray and then when it was noted to be abnormal , he had CT scan of the chest . The CT scan of the chest showed a cavitary area in the upper lobe . I told him and his wife that this could be cancer or infection . Or it could be TB . Sometimes we have a tumor blocking the secretions and then that can lead to pneumonia and then the middle part of the pneumonia can liquefy and that can look like this . But sometimes infection without tumor can also have similar appearance . Sometimes TB can look like this  and the RB is more common in upper part of the lung .
           So we did PET scan and bronchoscopy . The PET SCAN showed that the area in the upper lobe was quite hot and there were some lymph nodes that were hit too . These nodes were not seen enlarged on CT scan . I did the bronchoscopy and it did not show any blocking tumor or for that matter any abnormality . The abnormal area was quite large and was almost 10-12 cm and was occupying the entire upper lobe. So I did not do any biopsy . The breathing test did show some reduction in the reserve , but it was adequate for the surgery , in case we decided to take out the upper lobe. There were no cancer cells in the cytology of the samples that I collected .So I spoke to a surgeon and he saw the patient . He decided to do the bx of the lymph nodes first and then if negative , consider taking out the lobe .
        I was OK with it till I got a call from Lab on the samples that I had sent was growing TB like bacteria . So now I am now faced with the decision . This is a ex smoker and the positive PET scan could be due cancer or TB or infection . The lymph nodes could also be due to cancer or infection . Sometimes cancer and infection or atypical TB could be in same patient at the same time . So what should be the next step . Should we do the biopsy and the surgery to take out part of the lung > or should we treat the atypical TB and then do the follow up CT scan . The problem with this approach is the CT scan may not improve in 2 or 3 months. So no change in the CT scan does not mean that atypical infection is not the cause and it does not rule out or rule in cancer . Doing surgery in this patient and then if the surgery shows only Atypical TB , then we have done major surgery for medically y treatable infection , which can be cured by medicines in most cases and surgery in not needed. But it is  cancer and infection together, then the waiting is is not good option , but open biopsy is the only thing that can give us 100 % answer.

      This is what I call medical practice and the Watson -computer can not solve and it becomes art and the science together . 

MEDICAL MYSTERY OR ????

      Being in medical practice for so many years , I come across the patients that I can not fully understand the diagnosis. So sometimes I send them to Mayo Clinic or Shands Hospital at UF. I am in a way happy when they come back with no additional diagnosis or different treatment. But then I also feel bad that we can not CHANGE the disease. But sometimes I know the problem and I refer patients to other consultants and the patient comes back with some additional tests and no answers. I can understand the frustrations that patients go through. But I can not not tell my frustrations to patients or the family . I have also a problem when I explain the problems ans still the questions are the same. This brings me to the the patient of today.

      I saw this lady , 72 years old for chronic cough . It started many months ago and then the PCP gave her some antibiotics and then the cough medicines and the inhalers that are uses for asthma .It was OK and she still did have the cough and so she came to see me . She looked comfortable and did not have big or severe bouts of the cough when she was in my office . She had good oxygen saturation at rest. She had couple of family members with her. Her lungs had crackles on examination and that suggested to me that she had some fibrosis -scar tissue in the lungs . Whenever there is injury to lungs -from infection or chemicals or some unknown causes -there is chance of the healing leaving patients with scar tissues . The first symptom of the scar tissue  in the lungs is cough . The fibrosis can get worse quickly --6 months -was at one time called vanishing lung syndrome -or it can last many years and does not shorten the life . So it is unpredictable.
    So I explained them my initial impression . We did the CT scan and the breathing test and the oxygen check on walking . The scared  lung does not allow the oxygen transfer quickly when the demand go up and the circulation is rapid . So her CT scan was consistent with fibrosis and the breathing test did show that the diffusion capacity - the process of oxygen transfer was low at 32 % out of 100%. The walking also dropped the oxygen . So now I had to decide if there is any cause for the scars . The fibrosis for which there is NO CAUSE is called idiopathic or IPF , There are 2 new drugs that were approved only in 2015 and the cost is ONLY $50000 per year. They are not approved for the scar tissues that have a cause .So I did the work up . One of the causes of the fibrosis is conditions like scleroderma or rheumatoid arthritis or lupus. Some times in older patients there may be a problem with swallowing and the food or the liquid can go in to lungs and not in food pipe or esophagues . This can lead to chemical injury on repeated basis and that can lead to fibrosis .
       So I did the blood tests for the autoimmune diseases and did the swallow study. The autoimmune blood tests were strongly positive and the swallow study was abnormal , but not that bad . I did the tests that measures the contractions of the food pipe , as that is abnormal in some autoimmune diseases and so that leads to aspiration . This was severely impaired and the report stated 'consistent with connective tissue disorder '-one of the auto immune diseases . So in my mind the circle was complete . She had some auto immune process which impaired the contractions of the food pipe and that lead to aspiration - food and the liquids going in the lungs and causing the injury which healed with scar tissues and that caused the cough. Some of these auto immune diseases also can cause the scaring in the lungs without the aspiration .
    So I explained the situation to the patient and the family . I told them to see the Gasroenterologist and the Rheumatologist . I sent all the reports to both . The patient came back stating to me that Gastroenterologist did the endoscopy and it was normal . The rheumatologist did some tests and told her she was OK . The endoscopy can not diagnose the aspiration and the scars tissues and the strongly positive blood tests and the esophageal motility problem -all were pointing to the auto immune process. I did show them the reports and the explained them the whole things . And I still had the question -so why I am coughing ?

    I can not give an expensive medicine that has not been approved and proved to help scar tissues in this condition . So I my only way was to call them or send them my notes and my conclusions. 

GOING BEYOND

         

      When I was in my medical training, I used to write big notes and my Attending  physicians used to say that no one has time to read the long notes . I still do the long notes and there is a thought process in the notes , But now days , since the President Obama made it mandatory to have electronic medical records , I see longer and longer notes . That does not mean it has any information or the detailed thought process . Since these notes have been computer generated , there is lot material that was in older notes and even in the first note .So to find the REAL new information or the change in the patient , by reading these notes is very difficult. No one has time to read 8 page note . But the government has made it mandatory to have certain things included or documented ' , so we don't have choice . So there are these phrases that make no sense like smoking cessation -in house  and this is in patients who have never smoked .
       But I am not doing this  blog to complaints on EMR . But to tell you  the real difficulty when we have a patient who does not follow the medical advice . Or I want to NOT do something as I feel it is medically not  needed . Say I see someone who has clear cut cold  and patient wants antibiotics . There are several studies that have shown that the physicians are prescribing antibiotics much more often than it is needed -as in case of viral infection. I will have to write many more lines to justify why I am not giving the antibiotics. So many a times most will end up giving in and give a prescription for antibiotic rather than argue with patient and write few more lines to justify his or her decision. This brings me to today's story .

      I saw this patient in my office for abnormal chest x- ray and the CT scan . She was 71 years old and had quit smoking about 10 years ago . she had gone on vacation and was at height of 5000 feet . She got short of breath and so she cut short the vacation and then got down to lower level , She felt better and so she stayed there . She came back to the town and then saw the PCP . The PCP did chest x- ray as she still had some cough. She had no fever and had no chest pain , Her shortness of the breath was better , but not normal. The chest x- ray was abnormal and so she got the antibiotics and the she had a CT scan done . The CT scan showed a mass and a consolidation  or pneumonia . so she was sent to me .
         She came with her husband . She looked ok and did not appear to be short of breath . She sounded clear on her lung examination and her oxygen saturation was good . I knew by looking at her CT scan that she had cancer , that most likely was blocking the secretions and so she had the pneumonia . I knew that she needed the PET SCAN and the biopsy to get to the diagnosis of the cancer . But she and her husband were not convinced . She wanted to wait for some time to do any further testing . She felt that her problem was due to high altitude and it was better . So I agreed to wait for 'short' time of 2 weeks . I told them that if it was not cancer , it should get better in 2 -3 weeks . So we agreed  for 3 weeks . Mind you I had to write few more lines to 'document ' as to why I was not doing the scan and the biopsy sooner .
         So we did the PET SCAN and I was surprised . The spot on the lung was hot and most likely cancerous , but there were 'other spots ' in the lung and in the bones . so I called her and scheduled her to see radiation doctor and the radiologist for the biopsy . I did do bronchoscopy and she had the some changes that were consistent with cancer , but my biopsy came back suspicious , but not conclusive . so I called radiologist to do the additional biopsy . I had to again document this . she refused the Biopsy and she also refused the appointment with the radiation doctor . I was worried that bone spread to spine and the hip would cause the fracture and major problem .

       Again I had to document . I also called her PCP and again I had to document . So I was doing all this chart charting -may be 10 times and not going anywhere . So I called her to come to my office with her husband and the daughters .

      This is a very nice patient . But some how she was not getting what I was telling her . We did finally got the diagnosis of the cancer and got her to appropriate doctors for the treatments . She always hugs me and shakes my hand and thanks me for taking care of her. But that does not eliminate the need for the DOCCUMENTAION . If she would have done  things that I wanted her to do and done them sooner , I would have much documentation than what I did .

But I guise that is the modern day medicine --more documentation than patient care !!!
 

UNCERTAINTY PRINCIPLE

   In physics there is uncertainty principle. But I think it applies to medicine more . We expect certain things and at the end of work we get something else . I recently saw some patients and in each of them I was surprised after I did the work up. We always know that when we start working up a patient with certain complaints or problem, we have some idea as to what may be the final diagnosis or the outcome . If we did not have the idea as to what is the likely diagnosis , then we would not have the direction in which to do the work up.This is called the differential diagnosis. In other science it is called hypothesis. But sometimes the out come is so different that even the physician who ordered the tests is surprised.

      This brings me to my first patient . I saw this 70 some years old male patient who moved in from other state. He was told to have pulmonary fibrosis or scars in the lungs . He had some chronic cough and so he was seen by a family doctor and then when the cough persisted , he was sent to a lung specialist. He did the CT scan and then he was told that he had pulmonary fibrosis . He was followed for may be 3 years and then he moved here . He had new family doctor and so with the diagnosis of the fibrosis , he was sent to me . He was fairly stable . He had some cough , but it was not worse and he had some shortness of the breath,but that was stable too. His lungs had some crackles ,which are typical of fibrosis . So they sound like the sound that one would hear when one rubs the hair in 2 fingers . When I asked him on the last CT scan , he was not sure , but certainly it was not done in at least1 year .  Same was about the lung functions. To assess the extent of the fibrosis and it's effect on the lung functions ,I ordered the CT scan and the breathing test.
      The CT scan report came and I was surprised . IT showed the fibrosis , but it also showed a mass in one of the segments of the lung . IT was about the size of a Quarter coin . I called him up and told him about the possibility of the cancer and ordered the PET scan . When the PET SCAN report came I was more surprised . The PET scan showed the lung mass to pick up glucose , suggesting that it most likely was cancer , but it also showed a mass and the pick up in colon. So now we had a question , Is it colon cancer which has spread to lung , or Does he have two separate cancers,one in lung and one in colon . My problem was that he had such a bad lungs due to scar tissues , that doing a needle biopsy would certainly cause collapse of the lung . And in patients with scars , it might not be well tolerated or if tolerated , it might take long time to heal the lung .
      So he is having colonoscopy and bronchoscopy . Then I will decide , based on breathing test as to the treatment options. Should we do resection of colon cancer and the lung cancer , if he has two cancers . Should we do resection of colon cancer and treat the lung cancer with radiation , or should we treat both conservatively  i.e. lung with radiation and colon with laser or something like that where the risk of surgery is avoided .

    The jury is still out .
     But to make my point , when I saw the patient , I did not anticipate all these problems that I was  or he was going to face . I thought I was doing routine work up for patient who had established diagnosis of pulmonary fibrosis. 

THE DESTINY , LAW OF KARMA AND RELIGIONS

    I often come across stories about my patients and their families . I t is impossible to know the details of the family relations and the dynamics in short visit which is for medical follow up and not for psychiatric evaluations . But I am amazes at the different 'fate' that all of us have . With my interests in mystic 'sciences' like horoscope , I wonder about the Destiny and law of Karma . Why do people who do adopt children with good intentions have bad out come or fate where the adopted children do not behave with love and responsibility.

    In Hindu beliefs we have some explanation , but when I look at other religions , I do not know any explanations offered. In fact sometimes many questions remain unanswered. The Christianity believes that the Christ dies for our SINS . But how can HE die for the sins that I a doing now? So the answer could be that the GOD knows what sins I am going to do . But if that is true , then it means that I can not decide my own destiny and the the destiny is predetermined or fixed . If that is the case , then it means that I do not have any FREE WILL and then I can not be held responsible got he actions or the sins that I commit. This does not go well with the concept of the GOD .
    In contrast to that when we talk about the Law of the Karma, we talk about WE determining our DESTINY and the  destiny is in future and the Karma - good or bad -precede the destiny. So it does not involve the GOD .So we have free will. Some people will differentiate between the destiny and the future.So what is happening in immediate future is Destiny and what will happen in future is future. But sometimes we can not explain the bad out come of apparently good deed . How do you explain that ?The answer lies in the concept of Hindu religion . We believe that the Time is endless , it does not have the beginning nor end . The Universe comes in existence and it goes down to Unity -something that the science believes how the universe came to today's state .  The only difference is that theses cycles are endless . In fact they have calculated the time of each cycle. and surprisingly, it comes quite close to the calculations done by the scientist . So in these multiple cycles , we have multiple births and we are reincarnated. So the physical body dies , but the 2 other bodies , namely Astral and the Causal bodies continue along with the mind and the intellect and the ego and all the impressions and the desires and the attachments from ALL THE PREVIOUS LIVES. These attachments and the desires make US SELECT our parents or the environment that is conducive for satisfying them and paying back the debt of the bad karma or the SINS . So again God does not DO anything to punish us or die for our SINS but the Laws that have been created determine our destiny or future . We have free will and we can use it to change our future.
      So the effects of our Karma are going to be seen in our future and when we have them , we create new Karma and attachments and desires and that decides the future life and future lives . No one can suffer for us nor no one can take credit for our good actions . We get what we deserve , even though at times the things appear to be unfair. There is a tug of war between the effects of our previous deeds or Karma and our present efforts which comes out of our free will. The effect of the two is proportional to the strength of each force . If our free will is stronger than the effects of the karma our life will go in the different direction , than if the free will is weak . The we will see the full effects of our Karma .