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Sunday, July 23, 2017

Does medical science believe in miracles?

July 2012: Mr Abdul Rehman Shaikh,  75 year old male was hospitalised in the ICU with sudden paralysis of the right side of the body. A diabetic since 20 years and ischemic heart disease with a poor cardiac function since 10 years, his regular activities had already reduced  due to a poor heart conditioning. And now to increase his morbidity, he had had a stroke, which affected his left or dominant side of the brain. He lost his speech, the power to move his right hand and leg, control over his bladder and bowel movements, but not his power to live. He was discharged after a few days in a bed ridden state with a poor chance of long term survival. 
But the worst was far from over. Within a few days, he was back at the hospital with a gangrene of the foot. The blood supply to the leg was found to be very poor due to long standing diabetes. As a result of this, his left foot had to be amputated. His heart which was already compromised, couldn't take it further, and he suffered a cardiac arrest in the hospital. Due to the resuscitation efforts of the medical personnel, Mr Shaikh did survive, but suffered extensive irreversible damage to his brain. The doctors did manage to get him off the ventilatory support, but he had slipped into a vegetative state for life. He now had a feeding tube,a breathing tracheostomy tube to aid the removal of his tracheal secretions and a urine catheter. He barely opened his eyes, neither responded to anybody's touch nor call, and was mechanically fed by the nurses. The doctors had given up hope completely this time and sent him home with no chances of survival. 

July 2017: 5 years have passed. Every 6 months, he is brought by his daughters to the hospital for a routine physical checkup, a change of tubes, and a battery of investigations. 
The results always amaze the doctors. They find no deterioration in any parameters. The sugars are well controlled, the lungs are breathing normally, the heart is pumping with the same force as before, there is not a trace of a bed sore and not an iota of infection in the urine. Neurologically he may be the same, but we are still hoping for Abdul Rehman Shaikh to get up and talk to us. 

This is not a miracle but a dedicated effort by the near and dear ones to keep the hope alive. On one hand we have sons who ask us on just the second day of ventilatory support, "Doc, should we remove the respirator and take our papa home" and on the other hand we have a certain Mr Shaikh's daughters who despite the doctors giving a 'no chance' certification, have persevered with their efforts. 

*Names have been changed to protect the identity

Tuesday, June 27, 2017

Dialysis: A life saving machine

A 70 year old diabetic lady, hitherto active and leading a normal lifestyle, is admitted in the Intensive care with sudden difficulty in breathing since 2 days. After running a few tests, she is diagnosed with Acute kidney failure because of an infection in her urine. She has been advised an urgent lifesaving dialysis but her relatives outright refuse to go ahead with it. Their concern is that once started, she would require dialysis on a regular and lifelong basis. 
To convince someone for dialysis remains one of the commonest challenges faced by Internists and Nephrologists. In a country where quacks sometimes decide the course of medical therapy, where pharmacists prescribe scheduled drugs and where relatives are in charge of the fate of patients, saving lives is becoming more and more difficult. 
What is dialysis? Simply put, it is an artificial kidney. Our kidneys normally function to remove the waste products through the urine. When there is a kidney failure, dialysis takes up the function of the natural kidney and cleanses the body with the help of a machine. 
Broadly put, our kidneys may fail in 2 ways: 
1. The healthy kidneys stop working suddenly due to a recent crisis event. 
2. The kidneys are gradually damaged over a long period of time. The body adjusts to this and maintains its milieu till a crisis develops and the kidneys fail.
It is important to note that kidney failure occurs only when both kidneys fail to function. In both the above situations, dialysis may need to be done for the reasons mentioned above. Also, dialysis doesn't help in kidney recovery but it just substitutes for the failed kidneys. But, it needs to be emphasised here that in the first case, since the kidneys were healthy prior to the illness, dialysis is only for a short period of time while in the second case, dialysis could probably be a lifelong affair.                              That brings us to a few important questions. Shouldn't saving a life be the topmost worry on the minds of the near and dear ones rather than worrying about whether the dialysis will be a lifetime headache? Don't the relatives have any responsibility ethically and legally towards the patient? Is only the doctor answerable for a wrong decision taken for a patient? 

And in our 70 yr patient, who eventually died because she was denied a chance to live, can the relatives be tried in court for negligence and malpractice??

Friday, September 18, 2015

Superbugs: Born to kill

Antibiotic resistance: The ability of bacteria and other microorganisms to resist the effects of an antibiotic to which they were once sensitive. It is also known as 'drug resistance'. 
This makes the medications less effective and as a result of which higher doses of drugs are needed which would result in more side effects. Organisms which are resistant to multiple drugs are called 'Multi drug resistant -MDR' or "Superbugs".  

Antibiotic resistance is a serious and growing global problem: a WHO report released April 2014 stated, "this serious threat is no longer a prediction for the future, it is happening right now in every region of the world and has the potential to affect anyone, of any age, in any country."

India is the world's antibiotic popping capital, recording the highest number of such pills consumed annually- 13 billion, as against 10 billion in China and 7 billion in the U.S.  

What are the Indian causes for such an emergence of resistance ? 

1. Self medicating oneself by indiscriminately prescribing some irrational antibiotic. 
This is generally done by patients to save themselves the trouble of visiting a doctor. Very rarely does one succeed in treating in this manner. 
The worse situation arises when the patient self medicates and stops the antibiotic without completing the entire therapy. Perfect recipe for developing drug resistance. 

2. The other group of patients would rely on their local B Pharm chemist to dispense them some antibiotic rather than visiting a doctor. It is termed as OTC- Over the counter. This is one of the reasons why the FDA has come down hard on these retail chemist outlets. 

3. Doctors are equally to blame for this rising incidence of resistance. When the patient visits his or her General Practitioner or Family Physician with say a Viral Fever, he is prescribed an antibiotic for a few days knowing full well that an antibiotic has no role in a Viral illness.  If the fever doesn't subside, an anti malarial is added to the treatment without subjecting the patient to a battery of tests to confirm the diagnosis. Doctors are sometimes also guilty of starting Anti tuberculous treatment without sufficient evidence of the disease. 

4. Once the patient is hospitalized, the Consultant takes over the case. He generally starts with a higher and broad spectrum antibiotic since he doesn't want to take any chances. This attitude over a period of time aggravates the resistance problem and thus we see the emergence of the Superbugs. 

There is an urgent need to formulate guidelines. It is a common practice in the West to start with basic antibiotics like Co-Trimaxozole while in India we would prefer to start straightaway with a 3rd or 4th generation Cephalosporin. 

  • Antibiotics should only be used when needed and only when prescribed. 
  • Health care providers should try to minimize spread of resistant infections by using proper sanitations techniques including handwashing or disinfecting between each patient. 

  • Prescribing the correct antibiotic is important and doses should not be skipped. 
  • The shortest duration needed should be used. 
  • Narrow-spectrum antibiotics should be used rather than broad-spectrum antibiotics when possible. 
  • Cultures should be taken before treatment when indicated and treatment potentially changed based on the susceptibility report.

"It is not the human body that is resistant, it's the organism which gets resistant". 

Friday, January 30, 2015

Flu: Can we fight it?

Influenza, commonly known as flu, is a viral illness characterized by fever, runny nose, cough and muscle pains. Most often it is a self limiting ailment lasting for less than a week.

Only 16% of patients with Influenza were prescribed Antivirals whereas as many as 30% were prescribed antibiotics. Unfortunately, we know that if you go to a Physician for a flu, you are more likely to leave with a prescription for antibiotics that you don't need than for an antiviral that might do you some good. 

If antivirals are started within 48 hrs of onset of symptoms, there will be an improvement of 30 hrs in time to getting better but if they are started after 48 hrs, there is not much benefit.

The problem might be a consequence of a lack of familiarity with antivirals and confusion over when to use and when not to use them. Also, there is a "deeply ingrained tendency" to prescribe antibiotics for sick patients because they need something or because of the perception that patients are going to be happier.
Inappropriate usage of antibiotics has thus led to a major crisis in antibacterial resistance.

Another very important reason is that clinicians 'don't want to risk missing anything'. Even if they know that out of 99 influenza cases, fewer than one will have a bacterial superinfection, physicians don't want to have not treated that one person who develops bacterial pneumonia as a complication of flu. It is true that flu predisposes to bacterial pneumonia, but it is not true that giving an antibiotic will prevent it, because the patient is likely to be infected with a different bacterium from the one targeted by the antibiotic. And if you treat 100 patients who don't need an antibiotic, you are probably going to send one to the hospital with a rash. If several develop diarrhea you will do far more harm than good.


Prevention is better than cure they say. A shot of the Influenza vaccine at the beginning of the cold season is recommended for everybody above the age of 6 months especially those at high risk - Immunocompromised, asthmatics, diabetics, etc. But the prevention rate is a measly 23%. The virus has a very high tendency to mutate and change its form. As a result, the antibody produced against the virus fails to destroy it. Also, the improper maintenance of the cold chain for preserving the vaccine has led to the high failure rate. Despite all this, the vaccine should be administered as advised since the benefits however small they seem, far outweigh the zero risk. The vaccine protects against certain strains of influenza, including the B viruses, which can cause severe disease and complications in infants, young children, and the elderly.

"Someone told me that they didn't want to take a flu shot because they didn't want to put a foreign substance in their body. What do they think they do at dinner every night?"

The flu is very unpredictable when it begins and in how it takes off.

Excerpts from Medscape

Saturday, November 22, 2014

Drug patents: The battle goes on…..

The war between Generics and Brands doesn't seem to die down. In our last discussion, 
we had concluded that the basic difference between these two is the pricing, a marginal difference in the efficacy of both the variants and the safety profile was but obviously assured. Probably that was what we were made to believe.

The latest incident involving 13 female deaths at the Bilaspur sterilization camp has served as an eye opener.
As a knee jerk reaction, the honorable doctor who performed the surgeries at the camp was apprehended and charged with negligence and homicide.

Investigations have now revealed the presence of zinc phosphide, a rodenticide, in Ciprocin 500 (antibiotic), which was prescribed to all the patients during surgery.
This generic drug was manufactured by Mahawar Pharma Pvt Ltd, a Chhattisgarh-based drug firm, a small drug company according to revenue figures disclosed by the company.
This company has a very small unit in Raipur. They have been in the business for over 30 years now but it's a small scale business and supply of medicines was restricted within the state.
Political connections might have helped the company, despite reports that it was blacklisted two years ago over sale of duplicate generic drugs.

This may be a stray incident involving generic drugs but it certainly cannot be passed off without learning a lesson or two.

Firstly, it is important to realize that even the leading pharma companies do manufacture generics. The quality would obviously be ensured with such products.

Secondly, it is always better to avoid medical procedures and treatments in camps. Due to the large numbers, sterility can often be compromised.

And lastly. Dear doctors, if you ever have to participate in a medical camp, please ensure that the medical and paramedic staff are competent enough, drugs are of a standard quality and the setup fulfills the basic needs of a medical centre. Even though you haven't charged for your services, you are still answerable to the consumer forum.

A couple of weeks back I happened to meet a doctor colleague of mine from the US. He had remarked.  " The fundamental difference between the health system in our country and yours is that we value human lives". His words still keep ringing in my ears. 

Monday, November 17, 2014

Cell Phones: Savior or……...

The cell phone has provided an amazing safety net for citizens of almost all cultures across the world. The lives saved by the proliferation of cell phone communication is phenomenal — emergency calls, quick first responders, warnings of severe weather are only a few examples. However, the potential role of cell phones as an additional factor in oncogenesis (cancer creation) can't be dismissed.

The largest-ever study on the topic—the International Interphone study, which was conducted by the International Agency for Research on Cancer (IARC) and funded in part by cell phone companies, published in 2010, failed to find strong evidence that mobile phones increased the risk of brain tumors.

The IARC released a report in 2013, suggesting that there is a possibility of brain tumors amongst users of  both mobile and cordless phones.

But, the latest research on the subject concludes that long-term use of both mobile and cordless phones is associated with an increased risk for glioma, the most common type of brain tumor.

The new study published online October 28 in Pathophysiology, shows that the risk for glioma was tripled among those using a wireless phone for more than 25 years and that the risk was also greater for those who had started using mobile or cordless phones before age of 20 years.

This increased risk is due to greater exposure to radiofrequency electromagnetic fields. The brain is the main target of these emissions when these phones are used, with the highest exposure being on the same side of the brain where the phone is placed.

Children and adolescents are more exposed to radiation than adults because of their thinner skull bone and smaller head and the higher conductivity in their brain tissue. The brain is still developing up to about the age of 20 and until that time it is relatively vulnerable.

Radiation exposure increases dramatically when cell phone signals are weak.

Girls and doctors tend to put the smartphone below the pillow.
"It's a bad habit to go to bed with your smartphone."

It's time we minimized our risks.
Using hands-free phones with the "loud speaker" feature and text messaging instead of phoning should always be encouraged in appropriate settings.

"Technology can be our best friend, and technology can also be the biggest party pooper of our lives. It interrupts our own story, interrupts our ability to have a thought or a daydream, to imagine something wonderful, because we're too busy bridging the walk from the cafeteria back to the office on the cell phone" - Steven Spielberg. 

Friday, October 31, 2014

Malaria: The Growing Menace

The growing incidence of drug resistance has become a cause of worry for the medical practitioners. Very soon we would be left with hardly any choices to combat the infectious agents. 

The common causes for this emerging resistance are:

  • Misdiagnosis
  • Incorrect choice of therapy
  • Inappropriate doses
  • Incomplete therapy

As much as we blame patients for stopping the therapy before its completion,  so also we should be blaming ourselves for incorrectly prescribing the treatment.   

I have laid down the basic guidelines for the outpatient therapy of uncomplicated Vivax and Falciparum malaria.  

As adapted from the "National Vector Borne Disease Program" (NVBDCP)- 2013:

Please make note that Primaquine needs to begin from Day 1 of therapy. 

Drug schedule for treatment of P falciparum malaria:

Thus, the cornerstone of malaria treatment is Artesimin based combination therapy (ACT)
ACT could either be a combination of Artesunate + Sulfadoxine-Pyrimethamine
Artemether + Lumefantrine.

As discussed above, Primaquine is a very integral part of the therapy in both Falciparum as well as Vivax malaria.

In Falciparum, it is given on Day 2 as a single dose of 45mg, to eradicate the gametocytes and thus prevent the further transmission of the parasite.

In Vivax, it is given from Day 1, 15mg per day for 14 days, to eradicate the hepatocyte stage seen only in vivax malaria.

"Together we can, together we will".