The German

The German

I recently saw one of my regular patients. She is now in her late sixties. She was born in the former East Germany a few years after the end of the second world war, but her family had been able to move to West Germany. She had immigrated to the United States after getting married to an American soldier posted there.

She had two sons from this marriage. Unfortunately, her marriage ended in a divorce and she brought up her two sons on her own. She worked as a waitress.

The older son was single and lived with her. Her younger son had joined the army, but was murdered several years ago. She had no grandchildren and no other close family in the United States.

She had developed several medical problems, but kept working long hours as a waitress. On her most recent visit, I greeted her in German, “Gutten Tag Fraulein” (good day miss). I had learnt this from Google translate. Frau, not Fraulein, she corrected me. I am not so little anymore, and Fraulein is for the younger single women.

We laughed together. At the end of her visit, I asked her how her family made it to West Germany. I have read about the Berlin wall, and how many people were killed trying to cross the border in those days.

It was the early 1950’s she told me. The Russians and their East German allies were starting to close the borders as large numbers of East Germans were crossing into West Germany. The Berlin wall had not yet been built and crossing the border was still legally allowed if someone needed medical treatment on the other side.

Her mother came up with a plan. They had a family friend who was an ambulance driver who also wanted to defect. He would drive the family across the border in his ambulance on the pretext of getting my patient (who was seven at the time) medical care.

The family of five (my patient’s parents and her brother and sister) got in the back of the ambulance. The children were seated on a stack of down comforters. My patient’s skin was dyed yellow by her mother to make her appear to have jaundice and look sick. She also had a note from her family doctor.

The border in those days was manned by Russian soldiers. On the West German side were American soldiers. It was still the early days of the cold war and at that time she tells me the Russians and Americans were often friendly.

They got to the border and went through the check point. Just as they were about to get through, a Russian officer approached. The ambulance driver panicked and hit the accelerator. My patient was thrown at the back door of the ambulance and it opened and she fell out. She fell into a puddle and stained her dress. She remembers hitting her head and her mother screaming. The ambulance had stopped on the other side of the border. There were three Russian soldiers and perhaps twenty Americans, all heavily armed.

The little seven-year-old girl was not hurt, but the yellow dye was peeling from her skin and all the soldiers were watching. She picked herself up and walked across the border back to her mother. The Russians did not interfere.

Were you scared, I asked my patient? It happened so quickly, that she said that she did not have much time to think. Her family made a new life in West Germany, where she grew up. She eventually moved to the United States after her marriage.

What an amazing story, I said. She just gave me a smile.

                                          The Berlin wall under construction August 1961

The Virus of John Cunningham

The Virus of John Cunningham

A few years ago, I was seeing a new patient in the Infectious Disease clinic. It was an African American male in his early forties. He had recently been admitted to the hospital with pneumonia. This was also found to have advanced HIV infection. His pneumonia was treated and he had been referred to me for further treatment of his HIV infection.

He was an extremely nice man, but was not sure how or when he got the virus. He did not use drugs, held a steady job and was married with three children. His wife was negative for the infection even though he had likely been infected for many years prior to marrying her.

On the first visit, he was accompanied by his wife. She was Caucasian and much younger than him. She appeared very devoted to him and was quite concerned about him. They were accompanied by their youngest child, a two-year-old daughter.

I explained the disease to them in detail as well as the precautions that they need to take in order to prevent him from passing the infection to his wife. I then started him on a cocktail of medications after explaining their potential side effects.

My patient started his regimen. He was very compliant and his virus levels fell rapidly and soon became undetectable. His immune system also started to recover. I was quite excited and remember congratulating him on a subsequent visit.

However, one week after that visit, he came back to the clinic. Strange things were happening to him. His wife told me he could not remember things and was dropping objects. His speech had become slurred and he was having difficulty walking.

Alarmed, I admitted him to the hospital and ordered an MRI of his brain. His MRI showed multiple patchy white areas on his brain. These were the likely cause of his symptoms. At this point I thought it best to transfer him to our nearby teaching hospital, as they would have more facilities to make a diagnosis. A few days later, I received a call from the Infectious Disease Professor who was taking care of him. They had made a diagnosis of Progressive Multifocal Leukoencephalopathy or PML for short.

PML is a deadly disease that is associated with severe immunosuppression that occurs in advanced HIV patients. The disease is caused by a virus, known as the JC virus. JC stands for John Cunningham and is the name of the first patient in whom this virus was isolated. This virus is harmless in most people except those with advanced immune deficiencies, such as in cancer or HIV infection, in which case it can be fatal.

John Cunningham was the first patient in whom this disease was described. He was a 36-year-old military veteran who had developed a cancer. While receiving chemotherapy for the cancer, he developed inexplicable neurological problems and subsequently died. A virus was isolated from his brain tissue and was given his name. The year was 1970.

Fifteen years later, the JC virus made a resurgence amongst advanced HIV patients. It often surfaces when the immune system is starting to recover after HIV therapy is started, as it happened in my patient. There is no specific treatment. My patient continued to decline and was moved to a nursing home. He died there a few weeks later.

I thought hard about this patient’s treatment and if I could have done anything differently. There was nothing I could find. I spoke to his distraught wife afterwards and did my best to comfort her. She would now have to bring up their three children on her own.

John Cunningham would never have imagined that his name would become immortal by being given to the cause of the very illness that took his life, and that of many others.

                                           White patchy areas of PML on an MRI of the brain.

The Mule

The Mule

It was another day as an Infectious Disease physician. I had received a consult call from the Intensive Care Unit (ICU) at our local hospital. It was for an infection of the abdomen.

The patient had an interesting history. He was a Hispanic man in his forties. He had developed a sudden onset of abdominal pain and then collapsed unconscious. He was rushed to the Emergency Room.


In the hospital, he had a CT scan of his abdomen. The radiologist spotted something unusual. His report said that the abdomen was full of small round objects, which the radiologist thought may contain an illicit substance. One of these objects possibly had ruptured causing the abdominal pain and collapse.


He was rushed to emergency surgery and multiple bags containing a white powdery substance (likely illicit drugs) were removed. One of those bags had ruptured leading to an acute overdose and infection in the abdomen. He had to have a colostomy after those bags were removed. He was smuggling drugs, and was what is known in popular slang as a “Mule”. The Police were also called and they called in the State Bureau of Investigation (SBI).


It transpired that he had just returned from a trip to Colombia. He did not speak English, so a Spanish interpreter had to be used. When I saw him, he was not very co-operative. He had a colostomy in place and was awake and alert. I gave advice on antibiotics and I left.

Two days later the United States government shut down. It was one of those unusual occasions that the congress did not agree with the president and did not approve the funding to keep the government running. At that time, our hospitalist team that was taking care of this patient had asked me to give final antibiotic recommendations as they were planning to discharge the patient.

It was at this point that I got a call from our patient’s nurse. It was a request to speak to me from an SBI agent that was assigned to this patient. I went over to the hospital. The SBI agent was a smartly dressed young man. He was exceedingly polite.

He asked me if the discharge could be postponed. He explained to me that because the patient had a colostomy, they could not take him to a regular prison at discharge. He would have to go to a hospital prison. The nearest one was several hours away, and because the government had shut down, they were not accepting any new inmates. If the patient was discharged into his custody, he had nowhere to take the patient.


I told him that I would speak to the hospitalist team. The hospitalist doctor met me and asked me very directly if there was any indication for continued hospitalization from a medical perspective. I told him that I could think of none. He told me that he had other sick patients waiting for beds and he had no choice but to discharge the patient.


I went back to the SBI agent and told him the news. He was quiet for a while, then said that he would have to release the patient. This information distressed me and in an attempt to reassure me he said - “don’t worry, we are going to keep a very close eye on him”.

Later, I was speaking to one of his nurses, and she told me that she had heard (I am not sure from whom), that the drug lords would be punishing our patient for losing the drugs. Those drugs were several bags of heroin, with a street value of over half a million dollars. What kind of punishment, I asked? Oh they will probably kill him or his family members in Colombia if they can't find him, she replied.

The patient was discharged with his colostomy in place. He never showed up for his follow up appointments. I often wonder as to how he did.

                                                             CT Scan of a drug mule.

The Branded Felon

The Branded Felon

A new patient came into the infectious disease clinic to see me. He was a young man in his early thirties. He had been to multiple doctors for a rash. This rash was thought to be an infection and had come on spontaneously. It started on his shoulder and slowly started getting bigger. He had been put on multiple antibiotics, but they made no difference.


Then he developed a similar lesion on his nose, which also started getting bigger. Alarmed, he sought out an Infectious Disease doctor and came in to see me.


I examined him. The areas on both his nose and shoulder were red and angry looking. They looked like an obvious infection, but  he had not responded to antibiotics. The other unusual thing was the lesion appearing on the nose in an area completely separate from his shoulder.


The first thing I did was take a detailed history. He worked as a construction worker. About two weeks prior to developing the first lesion, he had been involved in digging up an old road. He had encountered pieces of rotten wood that had to be cleared. He had also inhaled a lot of dust at that time.


I suspected a possible fungal infection called blastomycosis. This is often found in rotten vegetation. When inhaled, it can cause a pneumonia, but in rare cases it can instead go to the skin. The only way to confirm this and make a diagnosis was a biopsy. I explained this to him.


He was agreeable to this but was concerned about the cost. He did not have any health insurance. I told him that the biopsy was absolutely necessary for a diagnosis and he consented to it.


I proceeded to do a biopsy of his shoulder lesion. As I was doing so, I asked him why had he not tried to get health insurance? He then said - “I used to have health insurance”. He told me further that he had been a computer programmer with a good job. What happened, I asked?


I met a girl online he said. They developed an online relationship. She lived with her parents and decided to run away from home to come and live with him. Her parents called the police and she was quickly traced to his home. She was only fifteen years old.


My patient told me that he had thought she was seventeen. He said that he never got into a physical relationship with the girl. However, when confronted with her angry parents, the girl changed her story and accused him of kidnapping her.


My patient was arrested and was faced with a lengthy trial and the possibility of many years in jail. He agreed to a plea bargain and admitted to inappropriate contact with a minor. He spent a few months in jail and then was released.

Unfortunately, he now had a criminal record and was a convicted felon. Even worse he was considered a sex offender and placed on the sex offender’s registry. In other words, wherever he moved to, his neighbors would be informed of his conviction. I guess this was the modern day equivalent of the middle ages custom of permanently branding a person for his crime.


He lost his job and consequently his health insurance. The only work he could find was as a construction worker digging up old roads. Nobody wanted to hire a person with his kind of record.


I finished up his biopsy and started him on anti-fungal medications. His biopsy confirmed the diagnosis of blastomycosis, and he responded to treatment. Three months later, his lesions were almost completely resolved. I have not seen him since.


I hope he is doing well today.

Blastomycosis lesion on the back.

The Ethiopian

The Ethiopian

There was a time that I used to volunteer at a local inner city free clinic. This was a clinic set up to serve people with no insurance and inadequate access to healthcare. This sometimes included recent immigrants.

I found my time at the free clinic very rewarding. The patients were often very appreciative. Most were routine and straight forward primary care patients. There was however one patient I remember that was particularly challenging.

She was a young woman in her twenties. She had immigrated from Ethiopia recently to join her sister in the United States. She herself was divorced and single, but was also a new mom with a six-month old daughter.

She was sick when she saw me. She had tremendous fatigue. She was jaundiced and had a protuberant belly, suggestive of advanced liver disease. She told me that she had developed an acute liver infection in Ethiopia while she was pregnant. She had seen doctors there but told me that they had been unable to come to a diagnosis.

She delivered a healthy daughter and subsequently came to the United States. Unfortunately, she found out that she did not qualify for Medicaid and she was unable to work or get any type of health insurance. She lived with her sister who brought her to the free clinic.

Her case intrigued me as I have an Infectious Disease background and had also grown up in Africa. I took a detailed history on her. It seemed that she had developed some type of a liver infection possibly a viral hepatitis. However, for viral hepatitis to cause liver failure in such a short time was unusual. There were also parasitic infections endemic in that part of Africa such as “Schistosomiasis” of the liver that could over time cause liver failure.

Through the free clinic, I was able to test her for the common viral hepatitis A, B and C. These were all negative. The Schistosomiasis test was a send out test to the CDC which I tried to order, but was unable to do so. I however treated her empirically with an anti-parasitic medication. If this was from a Schistosomiasis infection, there was a possibility that her liver could improve after treatment.

There was another condition that is known as hepatitis E. It is widespread in parts of the third world including southern Asia and parts of Africa. It usually causes a very mild and self-limiting disease in most people.

However, hepatitis E can cause severe liver disease leading to liver failure in two types of people. One, people with immune deficiencies such as cancer, the other – pregnant women!

This was a well described phenomenon. This otherwise mild disease could cause severe liver disease leading to liver failure in pregnant women. Could this young woman have had that? I tried to test her for it, but there was no commercially available test that I could find. I would have to arrange to send the blood to the CDC.

Even if her liver disease was from hepatitis E, there was no specific treatment. Unable to make a diagnosis or offer any treatment, I referred her to our local public University Teaching Hospital, which often provides care for such uninsured patients.

I never saw this young lady again. I often wonder about what happened to her. I hope that this lady is doing well today.

For Family

For Family

In the course of my work as a physician I meet many remarkable individuals. Many of these people have made sacrifices for the sake of their family. This takes many forms and one afternoon I saw two different aspects of this.

 The first patient was an elegant widowed lady in her fifties who had been having trouble with anxiety lately. She had been widowed as a young woman in her early thirties. Her husband had died of cancer. She tells me that on his deathbed, she held his hand and promised him that she will take care of their children.

 At that time, she had three small children, the youngest of which was three years old. She worked hard as a single parent, working two jobs. She even went back to college and successfully graduated. She put all three children through college. Her older daughter and son were married with children.

 She worked a good job, and lived by herself in her own home. She had never re-married. Her children and grandchildren did spend time with her, but she often found herself alone at home. She felt that her children and grandchildren did not need her as much anymore.

 The second patient was an equally elegant woman in her sixties who was also having trouble with anxiety. Her husband had suffered a stroke and required her to be a full time caregiver at home. Added to that, she took care of her father who was in his nineties and also totally dependent on her. She was under a lot of stress because of this. She felt that she was needed all the time as neither her husband nor her father could function without her.

 In the space of one afternoon, I saw two remarkable women. One had sacrificed the best years of her life to give her children a good upbringing. Now that they were independent and with their own families, she was feeling a little left out. She however relished the success of her children. She would not have it any other way.

 The other woman was devoting her every waking minute taking care of her disabled husband and elderly father. When, I suggested a nursing home for them, she shrugged her shoulders and said no, she will take care of them as long as she has the ability to do so. She would also not have it any other way.

 One felt like she was not needed as much, and the other felt that she was excessively needed. My opinion is that both these women are very much needed and make our world a better place to live. They are also making a big difference to their families.

 I feel a deep sense of gratitude and respect for both these remarkable women.

The Other Man

The Other Man

Recently, I saw one of my long standing patients for a routine visit. I have been his physician for many years. He is quadriplegic and has been so for over 14 years. He had an accident when he was about 40 years old. He was a passenger in a car driven by a friend.

They were returning from a fishing trip. His seat belt had not latched on properly on that fateful day. He fell asleep, and unfortunately his friend who was driving also fell asleep at the wheel. The car ran off the road, and when my patient woke up in the hospital, he was paralyzed from the chest down. His friend who was driving was unhurt.

Months of rehabilitation followed. He was lucky that he still had some movement in his hands. He learnt to move around in an electric wheelchair. He even learnt to drive a specially modified van with hand controls. He had been married with two daughters before the accident. His mother subsequently also moved in with them. He had to close down a business that he had owned and gradually adjusted to his new lifestyle.

On the recent visit, I asked him how things were going with his wife. Oh I got divorced and made her leave, he said. She was having an affair, he continued. She was also using the money from his disability income to make trips and have fun with this other guy.

I am so sorry to hear this I said to him. Who was the guy? He was one of my closest friends he replied. Apparently it was a friend of his he had taken into his home many years ago. This man had been effectively homeless at that time after his father had thrown him out of his house.

When my patient found out about the affair, he was so upset that he pulled out two handguns and pointed them at his friend and wife and asked them to come clean or he would shoot. I then asked him how he did that, as his hands did not have full strength. I thought holding guns in his hands may have been difficult. Oh, I can hold the guns and I have enough strength in my middle finger to pull the trigger, he said.

They admitted their affair and he asked both to leave his house. They did leave and now live together. His younger daughter chose to continue to live with him. His older daughter had gotten married and moved out. His mother also continued to live with him.

I said that it was so very sad that his friend who he had sheltered in his home for such a long time betrayed him in this way. Oh I am better off now he said.

He was then silent for a little while then said, “he was also the friend driving the car I had the accident in”. It took a while for this information to sink in.

So, this man, who my patient had taken into his home for so many years was responsible for the accident that caused my patient to be quadriplegic. He then continued to live off my patient’s disability income, living in his home, while also having an affair with his wife.

I said to my patient that this is so wrong! He smiled at me and without the slightest hint of bitterness, said - “this is life”!

Recently my patient died at age 54 from repeated infections that quadriplegic patients often get. May his soul rest in peace.

The Paraplegic

The Paraplegic

One of my patients was seeing me in the office. He was in his early fifties, and has been my patient for many years. He is paraplegic, with no sensation below his waist. He does not have bowel or bladder function and has a colostomy for his stools. For his urine, he self-catheterizes himself several times a day.


About 25 years ago, he was running his own business and was quite successful. He was athletic and socially active. One fateful Saturday, he was doing some work on the roof of his home. He accidentally fell off and lost consciousness. When he awoke in the hospital, he found that he had fractured his back, and his legs were paralyzed.



Months of surgeries and rehabilitation followed. He was now wheel chair bound, but learnt to drive again with hand controls. He had complications, notably a tendency to develop pressure sores in his lower back. He had multiple plastic surgery procedures for this. He gradually learnt to deal with his limitations and even got a part time job.



More recently, his problematic back ulcer had recurred leading to infection in the bone. He was treated with aggressive intravenous antibiotics and more plastic surgery procedures. He always maintained a stoic and positive outlook, which I greatly admired.

At this office visit, I was accompanied in the clinic by a young medical student. She happened to be in her third trimester of pregnancy. Noticing her pregnant state, my patient asked her when she was due.  In about a month she replied. He then asked what everyone asks – “is it a boy or a girl”? She laughed and said it is one or the other as she and her husband had decided not to find out beforehand. At this point, I asked my patient if he had ever had children.

He became quiet and then said no, he had not. I moved on with his visit and was refilling his medications, when he suddenly said – “I had to go to the doctor several times”. What do you mean, I asked? Did you have trouble having a child? You don’t understand, he replied. Those visits were to take care of pregnancies. “I murdered my children” he stated rather abruptly, albeit in a quiet voice.

Taken aback, I asked what he meant. As a young man he had several girlfriends, he explained. Some of these had become pregnant. At that time, he was not ready to become a parent and convinced his girlfriends to terminate the pregnancies. By his own count he had to do this five times.

After his accident, he lost his business. Subsequently his girlfriends left him. He now lives alone. I asked him why had he never mentioned this to me before. He replies in a matter of fact manner - because you never asked.

The Other Woman

The Other Woman

It was several years ago and I was doing a fellowship in Infectious Diseases. I was on the consult service and got a call on a new consult. This was on a young woman who used intravenous drugs. She had apparently used unsterilized needles to inject herself with heroin. In the process she had developed an infection in her blood which had involved the heart. The medical term was bacterial endocarditis. We had been consulted for antibiotic management.

She was a young girl, in her early twenties. In appearance, she was very slim, and almost wasted. She had very poor dentition which is often a sign of crack cocaine use. Her heart had a loud blowing systolic murmur, a classic sign of endocarditis. Her heart Echocardiogram had also confirmed a vegetation on a heart valve and her blood cultures were positive, confirming her diagnosis.


I could not get much history from her. She was sedated as she had been withdrawing from drugs. I looked up from examining her and I suddenly noticed an older man sitting quietly in a corner of the room. I had missed seeing him earlier. He was a dark complexioned Asian man, very well dressed, probably in his fifties. He was wearing a Fedora hat. He saw that I had seen him and asked me how she was doing. I told him that she will need intravenous antibiotics for a few weeks and should recover.


I stepped out of the room and saw the patient’s nurse. I took her aside and asked her, who is that man in the room with her? Oh that is her boyfriend she said. He has been visiting her every day.


Two weeks later, I was in the Infectious Disease clinic, and a Pakistani immigrant woman was brought in for a follow up. She was a tragic case. She was brought in on a stretcher. She was in her late forties. About two years previously, she had developed neck pain and was found to have an abscess from tuberculosis in her neck. In the process of draining that abscess she became paralyzed from her neck down. The Infectious Disease clinic was treating her tuberculosis, but she remained paralyzed, essentially a quadriplegic.


I had been born in Pakistan and tried to speak to her in Urdu, her mother tongue. She was well educated and had gone to college in Pakistan. She had three teenage children and a husband that lived at home with her.


She was pleased to talk to me in Urdu and introduced me to her husband who had accompanied her. As I was being introduced to her husband, I was startled to see the same man that I had seen with the young drug addict. He recognized me too, but we kept our conversation focused on the care of his wife. She had completed her course of treatment for Tuberculosis, but her paralysis remained. There was nothing more that the Infectious Disease clinic could do.


I felt sad at the turn this lady’s life had taken. She was still relatively young, but effectively bed bound.


A few months later, this lady died. I do not know what happened to the young drug addict or the husband. I pray that my quadriplegic patient is resting in peace.

A Man in a Fedora Hat

The Teacher

The Teacher

One of my regular patients is an 84 year old retired school teacher.  She had been widowed a few years ago, and soon after that became wheel chair bound after a stroke. She lived in a nursing home. She had taught high school all her life. Her husband had run a successful motorcycle dealership.

She had two children, but her son had died of a heart attack in his 50’s a few years ago. Her daughter and grandchildren lived nearby. Despite her physical limitations, her mind and memory were quite sharp, and my conversations with her were always very illuminating. She had been a teacher after all.


On one visit, she was brought into the office by a young woman who was an aide working for the Nursing Home. My patient told me a story about when she was a young college student in the 1950’s. She and a friend decided to fly to Cuba for a weekend from Florida. The first night they spent there, fighting broke out with the communists trying to get control of the Island. She and her friend were able to evacuate on a flight out the next day. Apparently trips like these to Cuba were not so unusual in those days.


Intrigued, I asked her about more stories of those days. She told me that her life was otherwise unremarkable, but as a student she was president of the foreign languages club. One of her close friends and fellow club member was an Iraqi foreign student named ‘Fouad’, who eventually went back to Iraq.


She did not keep in touch with him and does not know what happened to him after he went back to Iraq. He had been one of two Iraqi foreign students that were active in the foreign languages club. She had become close friends with him at that time because of their mutual love of foreign languages.


At this point, the aide with her spoke up and said, “I have been to Iraq”. I was with the army for two tours there, she said.  She had been shot at, and survived an Improvised Explosive Device explosion that hit her Humvee amongst other experiences. Her direct contact with Iraqi’s had been limited.


To both of them, I remarked on the fact that their individual experiences with Iraqi people were so different. They both agreed.

A few months ago, our school teacher died peacefully in the nursing home. Around the time she died, travel restrictions to Cuba were being eased. Iraq on the other hand is a war zone and not a place most people would travel to. I thought about how circumstances change with time and history keeps marching forward. 

Cubana airlines from the 1950's.

The Prior Authorization

The Prior Authorization

Another day at the office, that I am a physician in a small town. It is Monday morning and I am running late. My nurse herds me quickly towards my first patient.


The patient is a 42 year old man with a history of Diabetes. He lost his job as a construction worker 3 years ago and consequently lost his insurance. He recently got a new job and regained insurance and has come to see me. He has completely neglected his Diabetes in those years. He is married and a devoted father to two young children.


My nurse comes to me to tell me that his hemoglobin A1C is 9.6%. This is a test that we do in the office that gives us an average of his sugars over the last 3 months. Normal is 6.5% or less.


I have several medications available to me. Each on average can reduce his hemoglobinA1C by 1%. Appropriate diet can add another 1%. Thus for a 3% drop, I will need two medications and an appropriate diet.


One medication is the generic Metformin which is usually the first medication tried on Diabetics. There are also several newer medications that get at the root cause of Diabetes, but these are not generic. They are available in combination with the Metformin (which is included at no additional cost). At random I pick one that will be one pill once a day. I give him all this information on Diabetes and the proper diet to follow and send him on his way.


An hour later, my nurse tells me that the pharmacy has called and this drug requires a ‘prior authorization’. A ‘prior authorization’ is used by insurance companies to keep costs in control, by trying to restrict some of the newer and more expensive drugs. Now the nurse has to get on the phone with the insurance company to try to get this approved. 


It takes 45 minutes to get someone on the phone. Usually it is someone with no medical training, who follows the insurance company’s standard algorithm. ‘Has he had a trial of Metformin alone for at least a month’ they ask? No, the doctor feels that he will need more than just Metformin answers the nurse. They said that they will send their decision in two days. We get a letter the next day that the request has been denied and he needs a trial of generic Metformin alone first.


Many thoughts come to my mind. How is it that an insurance company is legally able to alter a physician’s medical decision? Interestingly if the patient has a poor outcome, it is almost impossible to legally sue the insurance company.


So I put my patient on Metformin alone, knowing that it probably will not be sufficient.  My nurse wasted 45 minutes yesterday, and will waste another 45 minutes next month. The insurance company will save on the cost of the medication for about a month.  One study assessed that prior authorizations cost US doctors approximately $ 31 billion a year.


I wish there was a better way!

The Battered Child

The Battered Child

It was another busy day at the clinic. One of the patients being seen is an HIV patient in his late twenties. I had first seen him several years ago. At that time he was not doing well. He was first diagnosed with HIV at age 17, but because of multiple reasons, did not start treatment.


Five years later he was admitted to the local hospital. The HIV had destroyed his kidneys and he was put on dialysis. His immune system was destroyed to the point that he had no detectable T cells (normal is greater than 1,000).


I did an HIV resistance test on him and with the help of our HIV pharmacist, came up with a regimen of medications that was not only effective, but was also dosed appropriately for his renal failure.


He made steady progress, and within a few months his T cells had recovered to well above the 200 AIDS threshold. During this time, he continued on dialysis and was generally doing quite well. 


A few months ago he told me that he was on the waiting list for a renal transplant. I subsequently got a call from a doctor at our nearby teaching hospital, that he had received his kidney transplant. 


His entire regimen had to be changed as he was on anti rejection medications which interact with a lot of HIV medications. The dosages also needed to be adjusted as his new kidneys started functioning. Of course we would also have to keep in mind his original resistance test.


He did very well. His new kidneys started working and his new HIV regimen kept his virus undetectable and also his T cells remained good, despite the anti rejection drugs that can reduce the T cell counts. He is now in college and working part time as well.


At his appointment, I asked him if he knew where his kidneys came from.  ‘It was a baby’ he said. I was taken aback!


It was a battered baby he explained further. Her parents had battered her so badly as to cause brain death. Her grandparents had then made the painful decision to donate her organs. 


Her kidneys came to my patient. Her heart went to someone else as did her corneas and so on. Because she was an 18 month old baby, it took some time for those kidneys to grow in my patient until they became fully functional.


As this information sunk in, I asked my patient how he felt about this. He said when he first found out about the baby, he cried. He has talked to the grandparents via teleconference arranged by the hospital, and he told me that they are happy to see him doing well.


After the visit, I felt incredibly sad that this child’s life was ended so soon, in such a sad way, and yet feel a sense of gratitude to her for making such a difference to so many people.

Kidney ready for transplant

The Prayer

The Prayer

I was a third year resident in Internal Medicine at a large Teaching Hospital. I was in the middle of my Medical Intensive Care Unit rotation. This was one of the toughest rotations in our residency. It involved working in the intensive care unit with many critical and seriously ill patients.


I had a wonderful team. They were four young interns, and a fellow senior resident. This was an awesome team. Everyone was dedicated, hard working and extremely smart. It was fun to work with them, and my life was easy. We had excellent attending physicians as well.


One morning we were rounding on a very ill elderly obese woman. Her blood pressure had dropped to very low levels, to the point that she had become dependent on dopamine, a medication that maintained her blood pressure. However the reasons for this were not clear.


We need to put in a Swan Ganz catheter, our attending pulmonologist said. This is a special catheter that is put all the way into the heart and can tell us if her low pressures are coming from her heart or other reasons. The process of putting it is technically demanding.


My intern on that day was a smart young woman. She was a very hard working and dedicated person. We determined that while the patient had a triple lumen central line in place - in order to put in the Swan Ganz, we would have to change the access to a ‘port’ that will allow both the Swan Ganz as well as the central line. This was going to be tricky, as the patient was dependent on the access we had to maintain her blood pressure.


The attending told us to change the line to a port over a wire. In this process a thin wire is put in through the old line, then the line is withdrawn and the new port is placed over the line. This would be accurate and hopefully quick. The patient had no other intravenous access, and attempts to place another line had failed previously. Since changing a line over a wire is considered a fairly simple procedure, our attending left to see another patient. He would be back in 10 minutes to help us put the Swan Ganz in.


We put on our gloves and gowns, and stopped the dopamine drip. My intern carefully threaded the wire through the existing central line. The patient’s blood pressure started dropping immediately. We had a very experienced completely unflappable nurse assisting us. She started reporting the blood pressure as it dropped. 90, 85, 80.


The wire was in and I instructed the intern to pull out the line. She says to me – I don’t think this is right. The wire does not feel like it is properly placed. Please pull the line I reply. We don’t have much time. She pulls the line out and out comes the wire too!


This was a disaster. I had made the mistake of using a wire that was designed for the shorter port and not the longer central line that the patient had. Suddenly we had lost all intravenous access. 75, intones the nurse as the blood pressure continues to drop.  She raises the foot of the bed to try to maintain the blood pressure.


At this point, I said some colorful words under my breath and asked for another kit for a new line. My intern looked at me disapprovingly. Getting a new line can be difficult in normal circumstances, but in this situation seemed almost impossible. My intern hands me a new kit and says to me, it will be okay. She looks absolutely calm and I can see her silently saying a prayer. I am not a very religious person, but I felt an instant sense of calm.


I make the first stick and am immediately rewarded by a return of dark red blood indicating a successful attempt. I quickly thread the new port in and the nurse resumes the dopamine. The blood pressure which had dropped to 60 gradually starts climbing back again.


At this point our attending shows up. Oh good he says, you have the port in place, oblivious to the drama we just went through. He subsequently guided the intern in putting in the Swan Ganz catheter. I do not recall the eventual outcome of that patient, but we had stabilized her in the acute setting.


Afterwards, I marveled at the fact that we got the line back in so quickly. My intern said to me, “that is the power of prayer”. Now many people do not believe in prayer, but I have no doubt that her prayer at that time made a difference.


On that day, I learnt the immense power of prayer. I thanked my intern deeply.

Swan Ganz catheter