Professional Specialist's Personal Opinion on Phra Dhammajayo's Health

The specialist who diagnosed and treated Luang Por Dhammajayo, and issued a medical certificate for his condition, offers his professional opinion on the Abbot's condition. The specialist is currently under investigation for issuing the medical certificate in the hospital's name without the hospital's permission. However, that is only a technicality. His expertise on the field of medicine has not been questioned, as he has many years of practical experience to support him. The following are his words:

There have been questions doubting Most Venerable Dhammajayo’s illnesses. Is he actually Ill? What exactly is he suffering from? Today, I will attempt to explain his medical conditions.  I will be using information from the press release by Wat Phra Dhammakaya, medical certificates that the media publicized without permission on 20th May 2016, and my 20 years of experience as a medical doctor and vascular surgeon.

1. The Abbot has deep vein thromboses (DVT), or occlusions in the popliteal vein, deep/superficial femoral vein, common femoral vein, external/internal iliac vein, and common iliac vein. Magnetic resonance venography (MRV) reveals that the right common iliac artery is putting pressure on and occluding the common iliac vein.  These findings are consistent with iliac vein compression syndrome (May-Thurner syndrome), which is the cause of DVT in this patient.  MRV reveals that the left femoral vein is completely occluded. When a patient has a DVT, the venous system remodels itself to compensate by optimizing smaller, collateral veins to deliver blood back to the heart.  In order to bypass the occluded femoral vein, MRV reveals the development of collateral veins from the left lateral thigh to the left hip and inferior vena cava back to the heart.

2. A secondary complication from long term DVTs is chronic venous insufficiency (CVI).  CVI presents with lower extremity swelling, chronic and acute pain, skin color changes, and thickening and hardening of skin on the legs and ankles (lipodermatosclerosis).  As CVI progresses, venous stasis ulcers may arise on the distal (far) end of the extremities due to lack of blood flow.  The photo shows a venous stasis ulcer near the radial side(change to medial or lateral side, or if you can’t figure it out just say ankle) of the ankle caused by CVI, which is different from a diabetic induced ulcer. Diabetic ulcers are normally located on the bottom of the feet, and present with numbness and tingling of the feet (peripheral neuropathy).  CVI induced venous stasis ulcers allow infection to spread more rapidly to other parts of the body and leg. If the infection is not well contained, or the leg becomes swollen enough to completely block blood flow, the tissues in the leg will necrose and die, ultimately leading to amputation.  As this patient has both diabetes and CVI, venous stasis ulcers become more chronic and harder to heal.  Thus any cut or wound could lead to infection and increase mortality risk.

3. The Abbot has acute collateral venous thromboses present in many locations on the lateral side of the thigh. MRV illustrates this and ultrasound shows the thrombosis in the collateral vein in the same location as in MRV. Ultrasound reveals a new occlusion due to the hypoechoic, or darkened nature, of the clot on the scan.  Newly formed clots make it increasingly more difficult for blood to return to the heart, worsening edema and pain.  Increase in pain, swelling, and darkening of the skin are signs of PCD (phlegmasia cerulea dolens).  PCD can also lead to permanent blockage, necrosis of tissues, (venous gangrene) and possible amputation.

Another fatal complication of DVTs is an acute pulmonary embolism (PE).  A PE occurs when part of a clot breaks off and travels to block the blood vessels in the lungs. If the clot is small enough the effects are minute, but if the clot is large it can cause hypoxia and be fatal.  Fatigue can be one presenting symptom of a PE.  Luang Por Dhammajayo has a history of getting acutely fatigued due to multiple etiologies.  One of these causes could be multiple small pulmonary emboli in his lungs.  The press release did not reveal the results of an MRA of the pulmonary veins (which reveals PEs), thus we cannot exclude this from the Venerable’s list of medical complications.

4. The Abbot is a 72 year old elderly monk whose medical conditions include diabetes mellitus (DM), hyperlipidemia (HLD), and hypertension or high blood pressure (HTN).

About a year ago, I examined a pregnant woman (24+3 weeks of gestational age) who had an acutely swollen leg for one day. The previous day she had gone to see her obstetrician. An ultrasound was performed, and her obstetrician told her she was fine. She wasn’t satisfied, so she came to me for a second opinion. I performed an ultrasound on her vascular system and found a clot in her left leg vein. The image of the clot from the ultrasound was still black (hypoechoic), indicating that it was an acute DVT, and it occluded all the way from the popliteal vein, common/superficial femoral to the common/external iliac vein of the left leg. I referred her back to the obstetrician for treatment. After the delivery, she was fine and recovered fully, but the baby happened to die from a subdural hematoma that could have been caused from anticoagulation medications to slow clotting and internal bleeding (used for DVT prevention).  Both the baby and mother ran the risk of excessive bleeding from anticoagulation.  From this case we are able to understand that anticoagulants do not come without risks, and some medication side effects may be fatal.  No medication is without risk, and in medicine it is the physician’s job to carefully weigh the risk benefit ratio for each individual patient.  This is why medicine is an art, and not a black and white science where one treatment protocol works in every case.

For example, if a patient were forced to walk too soon, a clot that has not firmly attached itself to the vessel walls might break off and travel to the heart, causing a pulmonary embolism (PE), which can be lethal. However, if the patient stays non-ambulatory for a prolonged period of time, this causes muscle atrophy (weakening) and makes the patient more prone to falls and difficulty ambulating.  This is why it is crucial that such a patient is monitored closely and continuously by an experienced team of medical practitioners.

Writing this reminds me of when I was a resident surgeon at Ramathibodi hospital. In my last year as chief resident, a healthy-looking middle aged patient came in with a DVT in his left leg with cellulitis and infection. Almost the whole leg was dark green in color from phlegmasia cerulea dolens (PCD) causing venous gangrene, so he had to have an above the knee amputation. A few days after the amputation, he became extremely lethargic and pulmonary MRI/MRA showed multiple PEs in bilateral lung fields. He died unexpectedly 7 days later. The autopsy report found PEs in his pulmonary arteries along with an antibiotic resistant infection in his leg. The acute cause of death was from a pulmonary embolism. The first time I saw Luang Por Dhammajayo’s left leg, which was very swollen and dark red in color, it reminded me of this very patient. Luang Por Dhammajayo has a very severe condition. During my career as a vascular surgeon, I have never seen a patient with May–Thurners syndrome (complete occlusion of the iliac vein) before.  May-Thurner’s syndrome is very rare and complications of DVT can be life threatening.

In conclusion:

1. The Abbot has complete occlusion of the left common femoral vein from chronic compression by the right common iliac artery (May–Thurner syndrome), making it difficult for blood in the lower extremity to return to the heart.

2. The Abbot has severe chronic venous insufficiency (CVI) of the left leg due to May-Thurners syndrome. His leg is acutely edematous and painful, with venous stasis ulcers. The Abbot is at risk for an infection that may lead to amputation.

3. The Abbot has DVTs, or occlusions in the popliteal vein, deep/superficial femoral vein, common femoral vein, external/internal iliac vein, and common iliac vein. He is at risk for PEs and venous gangrene which also increase the possibility of amputation.

4. The Abbot has chronic medical conditions of diabetes mellitus (DM), hyperlipidemia (HLD), and hypertension or high blood pressure (HTN).  He is also advanced in age, which is always a risk factor for acute and life-threatening medical complications and increased sensitivity to medication side-effects.

5. The Abbot has acute on chronic fatigue due to multiple etiologies.  Multiple minor PEs cannot be ruled out in this patient.  An MRI/MRA would be needed to confirm this diagnosis.

It should be quite clear to everyone whether Luang Por Dhammajayo is ill or not, and what his medical problems are. Therefore it is inappropriate to accuse him of faking any condition, or to assume that his medical certificates are forged. If any governmental agency does not have confidence in my medical abilities and professional opinion, they are welcome to send their own specialists to erase any remaining doubt. The actions that have been done up to this point by the said governmental agency is considered a complete violation of the basic human rights of a patient. I REPEAT. The Abbot is HUMAN.

Thus, I agree with the supporters and followers of Luang Por from all over the world who are petitioning for justice and submitting letters stating that a human rights violation has been made, including his supporters in the United States of America who are collecting names to be presented to the White House. To those who are committing this international crime of violating the human rights of a medically ill person, it's never too late to turn back. It is better to hit the reset button and do the right thing than to simply say we have passed our deadline and cannot undo anything at this time. It is inhumane to view a 72-year-old Buddhist monk who has spent his entire life doing good deeds as an enemy who is undeserving of basic human rights.

Dr. Pairoj Songkunatham MD, Board of Surgery