Tukur Tukur

Tukur Tukur

The following story is from my earlier days as a school boy before I became a doctor. It is a tribute to a person that I have had a great deal of admiration and respect for, the late Mr. Khalil Mahmud, (3/7/1929 to 1/29/2006). He was a great man, and this is just one of my many fond memories. May he rest in peace.

I had grown up in the small town of Zaria in Northern Nigeria in West Africa. My dad taught at the local university there.

Our primary school was within the University, but when we moved to secondary school in seventh grade (which we called Form one), we had to go to a local school in town.

Our local school was called Barewa College. It was a school originally built as a boarding school for the male children of ‘Elites’ in Northern Nigeria. It was designed in the best traditions of a British public school. By the time we started going there, it had lost a lot of its luster, but we still took pride in the fact that several of Nigeria’s leaders had graduated from there.

I became a day student there, and a car pool was made to ferry myself and other classmates to the school and back. It was a good 30-minute ride away. I would be crammed in a car with four other boys. Two of those boys were American brothers.

Their Father grew up in Boston, Massachusetts. He was an extremely smart African American man, and got a full scholarship to Harvard in the 1950’s. He however chose to go to the smaller Brandeis University. They had a better program on Islamic studies and he was a convert to Islam.

In the 1960’s, he moved to Nigeria in West Africa with his wife. In Nigeria, he eventually had four sons, the older two would be in the car pool with me. He had become the University Librarian, which was a very senior position in the University.

He was very distinguished in appearance, with a full beard and an extremely soft voice. I can still hear him speaking in that authorative but very soft New England accent. He was a very kind person.

He drove a white Peugeot 504 station wagon which had an extra back seat and was more comfortable than the smaller Volkswagen Beetle my dad had. His driving style was different too. He was a very good driver, but in complete contrast to his very sedate appearance, he could drive quite fast.

I recall one particular day about 35 years ago. We were running late. He was driving fast. As was his habit, he had his window rolled down. Normally in warm West Africa, this would be a good thing, but this was the Harmattan season, which was our winter. Cold air would come down from the Sahara creating a dusty haze in the air. We felt really cold.

Mr. Mahmud did not seem bothered with the cold air. He had grown up in Boston, and when I visited Boston in winter many years later, I realized that our Harmattan was probably just like a balmy day for him.

As I mentioned earlier, we were running late. This could have consequences for us. If we did not get to the morning assembly in time, we could be called to the Principal’s office and be punished.

It was at this point someone suggested taking a shortcut. Instead of going down the highway, we could cut through the village of Tukur Tukur. This was a typical village in Northern Nigeria. A haphazard collection of mud houses just north of our school. It had a large rocky hill (also called an Inselberg) overlooking it. I thought this was a bad idea as I was not even sure there was a road going through the village.

Mr. Mahmud did not give it a second thought. He swung off the highway on to the dirt track leading to the village. While he was absolutely calm, my heart was in my mouth as we sped towards the cluster of mud houses. It was early morning and the village was deserted.

Tukur Tukur village from the Inselberg in the 1970's

We were rapidly driven through the narrow spaces between those village houses. The only way I can describe that experience is that I was reminded of it when I later saw stock car racing in the United States. We darted in between the narrow spaces expertly with plumes of dust in our wake, and finally got to the school.

We got to school on time. We ran to the assembly and stood up to say the national anthem. The village of Tukur Tukur still exists as does my old school Barewa College, but I doubt if anyone can drive as quickly or as expertly through that village as we did on that morning many years ago.

E Pluribus Unum

E Pluribus Unum

One of the patients being seen in my Internal Medicine clinic was a young woman in her twenties. She was coming to see me for the first time for routine care. She was generally healthy and had no problems. Her name was however unusual. It appeared to be Middle Eastern in origin.

When I saw her, she looked no different from most other young woman in our area.  I was however curious about her unusual name. During the course of our exam, I asked her how she got her name. Oh it is Afghan, she said.

This was an unexpected answer for me. How did you get an Afghan name, I asked? She replied that her father was from Afghanistan. When the Soviets invaded Afghanistan in 1979, he had fled with his family. He was sixteen years old at that time. The family first went to Germany and was able to eventually migrate to the United States and settle here.

Her father met her American mother and married her. He had four children with her, but unfortunately the marriage failed. My patient was brought up by her American mother, but kept her Afghan name.

On that day, I was also being shadowed by a medical student. After the patient left, he came up to me and said that his father had fled the Afghan war too. He was sixteen at that time as well. Oh, I asked, was your father from Afghanistan too? No he was Russian he replied.

Now I was confused. I said, "but the Russians are the ones that invaded Afghanistan"! He then explained to me that his paternal grandfather was forcibly conscripted into the Soviet army in the 1950’s during the Soviet invasion of Hungary. He did not want his children to have the same fate. When his son turned sixteen, the Afghan war had started and young Russians were being drafted into the army again. Many were being killed in action. The grandfather wanted to prevent his son from being forced to join the army.

He decided to get him out of the country, but getting out of the Soviet Union was not easy. His grandfather was able to devise a plan to get his young son out and away from the Soviet Union and thus avoid being drafted into the army. The young man eventually came to the United States. He went to college, got married to an American woman and had three children, the oldest of whom was my medical student. He was also in his twenties.

In that afternoon, I saw a meeting between the children of people from the opposite sides of the Afghan war. However both of these children were now American. The phrase that came to my mind was the original motto of the United States of America "E Pluribus Unum", which means "Out of Many, One". Originally meant to denote the first 13 states coming together to form a nation, it is now often considered a reflection of the melting pot nature of the United States of America.

As I saw for myself, this also includes people from opposing sides of the war in Afghanistan. Now barely, a generation later they were one. E Pluribus Unum indeed!

The Quilt

The Quilt

In my career as a physician, there have been many patients that left a lasting impression on me. There is one that I will never forget. Here is her story.

It was many years ago, and I had just started my first job as an Attending Physician in a small town. One of my earliest patients in those days was a very pleasant lady in her sixties. She was a breast cancer survivor. As part of the treatment for this, she had undergone a mastectomy, followed by chemotherapy and radiation therapy. Just as her cancer went into remission, her husband died. She had never had any children, and continued to live alone in the small town that had been her home all her life.

The first time she saw me, I was a young doctor fresh out of residency. She had been widowed for about a year at that time. I remember her being excited that her hair had grown back after she had lost it due to the cancer treatment. She had been married for about forty years before her husband died. She missed him dearly, but the thing I remember most about her was her positive outlook. She always had a smile on her face.

I developed a great relationship with her. Her visits would often be extended beyond our allotted time as we talked about local traditions in the Southern United States. I have always been fascinated with the ‘South’ ever since I read ‘Gone with The Wind’ as a young student in Africa. Her family had lived in that small Southern town for many generations. She knew everything about Southern culture and traditions.

One day, she came to see me and told me that she felt a lump at her mastectomy site. Concerned, I quickly examined her. It was a small round nodule at the site of her surgery. I had a sinking feeling that the cancer could be coming back. I did my best to sound reassuring, and ordered a CAT scan on her.

The scan confirmed my worst fears. The cancer had come back. I braced myself and called her with the news. She responded very calmly and asked me what we needed to do. I quickly referred her back to her cancer doctors. They resumed her chemotherapy and radiation therapy. Unfortunately, this time, the cancer did not respond to the treatment. Eventually a decision was made that further treatment was futile.

She then came to see me. She had lost her hair again with all her recent treatment and was wearing a hat. She looked me in the eyes and said that she had a request. It was to please make sure she does not suffer. I will admit that this was a very difficult conversation for me. People often think that doctors see these things all the time, and it should be routine. It is not. I was visibly shaken.

She saw that I was upset, and then she is the one who tried to comfort me. She said that she was looking forward to re-uniting with her husband. She had led a good life, and had no regrets. I promised her then that I will do everything to always keep her comfortable. She smiled and patted my hand. She said that she is going to get me a present. I protested, that getting presents should be the last thing on her mind at this time. She just smiled.

A few weeks later, she came to see me with a large bag. What is this, I asked? It is a quilt for you she said. I made it myself. You made a quilt for me I asked in amazement? It is a tradition in the South she said. Quilts are works of art and are often passed down from one generation to the next. They are created by sewing two layers of fabric together with an interior padding.

Her quilt was an impressive collection of small squares of multi colored fabric neatly stitched together in a pattern. She had made this by hand herself. It was beautiful.

I cannot take this, you do not need to do this, I protested. She smiled at me and said, I know. I just want you to have something to remember me by. And so, I kept the quilt.

A few weeks later, my patient fell ill and I admitted her to the hospital. I took care of her in her last days and did my best to make sure her transition was as comfortable as possible. She died peacefully. I hope she remains at peace and is back with her husband.

The quilt has remained with me everywhere I have moved. It remains one of my most prized possessions.

PTSD

PTSD

Recently, I was seeing one of my regular patients in the clinic. He was a well-built extremely athletic looking man in his early fifties. A couple of years ago, he had retired from the United States Army. He had been a special forces soldier.

He now lived with his wife with whom he had been married for a few years. This was his second marriage. His first marriage had ended in a divorce many years ago. His opinion was that this was in part due to his frequent and prolonged deployments overseas. He had no children or step children.

On his visit, he was having palpitations and difficulty sleeping along with frequent headaches. I did a detailed work up. This included multiple lab tests as well as an electrocardiogram. Everything came back as normal.

I then said to him that these could possibly be symptoms from stress and anxiety. He could have Post Traumatic Stress Disorder (PTSD) from his time in active military duty overseas. Were you ever in a war zone, I asked?

He laughed. For over twenty-five years, his life had been about deployments from one war zone to another. Some of these were obscure places as he was a special forces soldier. He explained to me that sometimes he would be sent on missions to places that never made news headlines.

Now, I was curious. What kind of missions, I asked? He then described one mission in which he was part of a mine clearing unit in a country in Southern Africa. He said that while they took precautions, it was still a dangerous task. He loved his work though, and told me that those two years he spent in the African Bush were very memorable.

He remembered another assignment in a Central African country. He was in the middle of the jungle along with a platoon of other United States special forces. They were on some kind of peace keeping mission and were on patrol one day, when they saw a small plane circling and appeared to come down to land nearby. The platoon decided to investigate. They came upon a landing strip in the middle of the jungle.

There was a small plane that had landed there. Surrounding the plane were some heavily armed men, carrying Uzi submachine guns. They were Israeli mercenaries that had come to pick up a shipment of illegally mined diamonds.

The Israelis and the Americans looked at each other. Both sides were heavily armed. His platoon decided that it was none of their business as to what the Israelis were doing and backed off.

There you go, I said. All those stressful situations are probably causing you symptoms of PTSD. He disagreed with me.

He said that at his military discharge, he had a very thorough medical checkup. He even had a Psychiatrist evaluate him specifically for PTSD, and he was given a clean bill of health. Unlike some veterans, he had very fond memories of his military days.

So, what happened after you got back, I asked? He moved back in with his wife and started adjusting to civilian life. He had to learn to do groceries and cut the grass in his yard for example. It is a good life he told me, but he would sometimes have arguments with his wife. She can get angry very quickly, he said.

He then admitted to me that it was sometimes stressful being around his wife. He could not often understand the reasons why she got upset. Being in a war zone is a piece of cake compared to being around an angry wife, he told me.

Aha, I said to him, I think I have your diagnosis. You have PTSD from your wife. He looked at me quizzically. You mean that what twenty-five years of being in a war zone did not do, a couple of years living with a woman has done?

That was a joke, I clarified, and we both laughed.

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.