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 .

EMR ANAD HEALTH CARE

    When the EMR , or electronic Medical records were introduced , it was thought that we will have better care. In fact the federal government paid physicians to participate in it . So many physicians got it. Those like myself who did not participate in it got reduced payments for the services than those who did get EMR . So now that we have it is the quality improved? In my estimate it has not only not improved , but has gotten worst. In the hospitals we HAVE to do EMR and I spend at least one and half hour extra doing it . On top of that I often see more things in the records than actually has been done .
    I get notes from other physicians . Many of them are 6 pages . When I go through them I find that 4 new lines , every thing else is same as was in previous last 5 notes . This is due to EMR. The notes are Generated by the computer and the physicians pit in minimal new information and rest is carried from old note which was generated on first visit. In one of the notes one physician who started labeling problems with alphabets rather than numerical numbers, at the end of the note he ran out of the alphabets and had to label AA,BB etc. Were there more than 26 problems that this physician addressed in 15 minutes visit? But the reason I am writing this today is due to one of the patients that I saw .
     I was consulted on this 48 years old patient for the diagnosis pf pneumonia . He had no fever , no t much cough , but the cheat X-ray showed some congestion. So he was started on antibiotics and I was asked to see him.He also had low blood count and so a blood doctor was also consulted. He had also history of heart disease and so a cardiologist was also asked to see him . I saw the patient . He had history of a disease called sarcoidosis and when I asked him as to how it was diagnosed , he told me that he had 'OPEN LUNG BIOPSY' . When I examined him . he had big belly. On examination he had enlarged liver and spleen and had fluid in belly. I had ordered CT scan of the chest and the Ultrasound of the belly. The CT scan showed that he did NOT have pneumonia and the mild congestion that was seen on plain chest x-ray was related to previous lung biopsy . The ultrasound of the abdomen DID show that he had cirrhosis of the liver and enlarged spleen and fluid .
    I did some further investigations. I called gastroenterologist and told the patient and his wife that he will need to see a liver specialist for consideration of liver transplant .
    I went back and looked at the EMR entries of one hospital doctor 3 different blood doctors and one cardiologist . EVERYONE had put belly examination as NORMAL on several different times . Some of these entries were done AFTER we had the US report showing enlarged liver and spleen . This the ' EMR and CUT and PASTE notes .   

KNOWN KILLER

    In medicine as in any other field we all are product of advertisement. Every one today is concerned about cholesterol , even a 80 years old patient who has end stage lung disease and controlling the cholesterol would make no difference in his shortness of breathing for sure and probably in his survival. But he continues to be given statins and he also spends lot of money for the medicines that I am not sure is going to help. I would like to have someone do a study on these kind of patients who have significant co morbidity or are very old , to see if lowering cholesterol is beneficial or not. But then there is no benefit in doing this study for the pharmaceutical companies. But then there are known killers and we pay no attentions. This is primarily due to media bias. The two most common disease get attention in media are heart disease and breast cancer . But then there is no excitement in Influenza. That is what I am talking today .
    The flu is common and most of the people do not  need or seek treatment and get better. But then physician like me see the sick ones and some get so sick that they are in intensive care unit and even die.
    It was 6-30 pm and I was about finished with my patients and I had couple of notes to be finished . So I was happy . Then I got a call from one of the hospital doctors, asking me if I could see a new patient who was 'sick'. It was a27 years old Hispanic patient who had her first delivery and was found to have low oxygen and so this hospital doctor was asked to see her . In tern he asked me to see her . They had thought about some unusual conditions like amniotic fluid embolism. In this condition at the time of delivery the fluid from the sack enters the mother's blood and gets in lung and causes all sorts of problem . The bad part is that there is no real treatment. So I went to see her . When I saw her she not complaining of shortness of breath or any chest pain. Her respiratory rate was high and her oxygen saturation was low . Her lungs were congested and her chest X-ray was bad . It showed pneumonia . In this young lady who had just delivered a baby , I thought of vomiting and aspiration . But then there was no history of vomiting .She was in ER day before with symptoms of cold or flu and had 'rapid flu test' . It was negative and so she was sent home . Her history was suggestive of flu . So I started her on treatment and called infection specialist. I also transferred her to ICU . I was worried about the pneumonia and flu causing respiratory failure. I was right and she did get worse . There was no embolism. She was in ICU for 4 or 5 days . needed high flow oxygen. But she slowly got better and after in the hospital for 10 days she was sent home.
   So flu almost killed this lady. But with shear luck she got better . Recently I have had 2 more otherwise healthy patients in ICU and needed to be in the hospital foe 12-14 days. I also heard of 35 years old male loosing life due to flu.