eMedinewS12th November 2013, Tuesday

Dr K K Aggarwal Padma Shri and Dr B C Roy National Awardee

Dr KK Aggarwal

President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist & Dean Medical Education Moolchand Medcity; Editor in Chief IJCP Group, National Vice President Elect, Indian Medical Association; Chairman Ethical Committee Delhi Medical Council, Hony. Visiting Professor (Clinical Research) DIPSAR; Chairman (Delhi Chapter) International Medical Sciences Academy (March 10–13); Hony Director IMA AKN Sinha Institute (08–09); Hony Finance Secretary National IMA (07–08); Chairman IMA Academy of Medical Specialties (06–07); President Delhi Medical Association (05–06), President IMA New Delhi Branch (94–95, 02–04);
For updates follow at
www.facebook.com/Dr KKAggarwal

Is misconduct different from negligence?

The above is also clear from the following

1. Delhi Medical Council act (32): Complaint against medical practitioner.—

(1) "The Council may inquire into complaint against medical practitioner either suo motu or on the basis of any complaint made to the Council in respect of misconduct or negligence of any medical practitioner for the purposes of the Act through the Disciplinary Committee……………"

2. Delhi Medical Council act (21 (2)) talks about who can be punished

"If a registered practitioner has been, after due inquiry held by the Council or by the Executive Committee in the prescribed manner, found guilty of any misconduct by the Council or the Executive Committee, the Council may— issue a letter of warning to such practitioner; or direct the name of such practitioner (i) to be removed from the register for such period as may be specified in the aforesaid direction; or (ii) to be removed from the register permanently.

Explanation—For the purpose of this section a registered practitioner shall be deemed to be guilty of misconduct if— he is convicted by a criminal court for an offence which involves moral turpitude and which is cognizable within the meaning of the Code of Criminal Procedure, 1974 (2 of 1974), or in the opinion of the Council his conduct is infamous in relation to the medical profession particularly, under any Code of Ethics prescribed by the Council or by the Medical Council of India constituted under the Indian Medical Council Act, 1956 (102 of 1956) in this behalf.

3. DMC act (10 f) defines one of the powers, duties and functions of the Council as "to receive complaints from public (including patients and their relatives) against misconduct or negligence by a medical practitioner, to proceed for inquest, take a decision on the merits of the case and to initiate disciplinary action or award compensation and similarly to take action against frivolous complaints.

Note: This clause again differentiates misconduct and negligence and defines the punishment disciplinary action for misconduct and "award compensation” for negligence?

4. MCI act (7) defines the misconduct and (6) the unethical acts separately.

MCI Act 7.1 however covers misconduct if there is Violation of any of the MCI Regulations: If he/she commits any violation of these (MCI) Regulations. This covers when any negligence can become a misconduct.


8.1 It must be clearly understood that the instances of offences and of Professional misconduct which are given above do not constitute and are not intended to constitute a complete list of the infamous acts which calls for disciplinary action, and that by issuing this notice the Medical Council of India and or State Medical Councils are in no way precluded from considering and dealing with any other form of professional misconduct on the part of a registered practitioner. Circumstances may and do arise from time to time in relation to which there may occur questions of professional misconduct which do not come within any of these categories. Every care should be taken that the code is not violated in letter or spirit. In such instances as in all others, the Medical Council of India and/or State Medical Councils have to consider and decide upon the facts brought before the Medical Council of India and/or State Medical Councils.

8.2 It is made clear that any complaint with regard to professional misconduct can be brought before the appropriate Medical Council for Disciplinary action. Upon receipt of any complaint of professional misconduct, the appropriate Medical Council would hold an enquiry and give opportunity to the registered medical practitioner to be heard in person or by pleader. If the medical practitioner is found to be guilty of committing professional misconduct, the appropriate Medical Council may award such punishment as deemed necessary or may direct the removal altogether or for a specified period, from the register of the name of the delinquent registered practitioner. Deletion from the Register shall be widely publicized in local press as well as in the publications of different Medical Associations/ Societies/Bodies.

6. Under MCI the violation of any of the following can become a professional misconduct and liable to punishment provided the doctor’s conduct is infamous in relation to the medical profession particularly.

Situations are

1. There is violation of duty of physician to their patients

a. Not seen a patient in emergency MCI 2.1.1: Obligations to the Sick (Though a physician is not bound to treat each and every person asking his services, he should not only be ever ready to respond to the calls of the sick and the injured, but should be mindful of the high character of his mission and the responsibility he discharges in the course of his professional duties. In his treatment, he should never forget that the health and the lives of those entrusted to his care depend on his skill and attention. A physician should endeavour to add to the comfort of the sick by making his visits at the hour indicated to the patients. A physician advising a patient to seek service of another physician is acceptable; however, in case of emergency a physician must treat the patient. No physician shall arbitrarily refuse treatment to a patient. However for good reason, when a patient is suffering from an ailment which is not within the range of experience of the treating physician, the physician may refuse treatment and refer the patient to another physician.

b. Doctor attending a patient when he is not fit

MCI: 2.1.2 Medical practitioner having any incapacity detrimental to the patient or which can affect his performance vis–à–vis the patient is not permitted to practice his profession.

c. Doctor relieving the secrets of a patient MCI 2.2 Patience, Delicacy and Secrecy: Patience and delicacy should characterize the physician. Confidences concerning individual or domestic life entrusted by patients to a physician and defects in the disposition or character of patients observed during medical attendance should never be revealed unless their revelation is required by the laws of the State. Sometimes, however, a physician must determine whether his duty to society requires him to employ knowledge, obtained through confidence as a physician, to protect a healthy person against a communicable disease to which he is about to be exposed. In such instance, the physician should act as he would wish another to act toward one of his own family in like circumstances.

d. Doctor exaggerating the prognosis of a patient

MCI: 2.3 Prognosis: The physician should neither exaggerate nor minimize the gravity of a patient’s condition. He should ensure himself that the patient, his relatives or his responsible friends have such knowledge of the patient’s condition as will serve the best interests of the patient and the family.

e. The doctor has neglected a patient MCI 2.4: The Patient must not be neglected: A physician is free to choose whom he will serve. He should, however, respond to any request for his assistance in an emergency. Once having undertaken a case, the physician should not neglect the patient, nor should he withdraw from the case without giving adequate notice to the patient and his family. Provisionally or fully registered medical practitioner shall not willfully commit an act of negligence that may deprive his patient or patients from necessary medical care.

Note only willful negligence is covered under misconduct.

f. Taking over someone else’s case MCI: 2.5 Engagement for an Obstetric case: When a physician who has been engaged to attend an obstetric case is absent and another is sent for and delivery accomplished, the acting physician is entitled to his professional fees, but should secure the patient’s consent to resign on the arrival of the physician engaged.

2. There is violation of the duties of a doctor in consultation

a. MCI 3.1 Unnecessary consultations Unnecessary consultations should be avoided. b. 3.1.1 However in case of serious illness and in doubtful or difficult conditions, the physician should request consultation, but under any circumstances such consultation should be justifiable and in the interest of the patient only and not for any other consideration.

b. Ordering unnecessary investigations MCI 3.1.2: Consulting pathologists/radiologists or asking for any other diagnostic Lab investigation should be done judiciously and not in a routine manner.

c. Not briefing the patient in time 3.2 Consultation for Patient’s Benefit: In every consultation, the benefit to the patient is of foremost importance. All physicians engaged in the case should be frank with the patient and his attendants.

d. Not punctual in consultation MCI 3.3 Punctuality in Consultation: Utmost punctuality should be observed by a physician in making themselves available for consultations.

e. Not briefing the patient properly or not divulging difference of opinions in time

MCI 3.4 Statement to Patient after Consultation 3.4.1 All statements to the patient or his representatives should take place in the presence of the consulting physicians, except as otherwise agreed. The disclosure of the opinion to the patient or his relatives or friends shall rest with the medical attendant.

3.4.2 Differences of opinion should not be divulged unnecessarily but when there is irreconcilable difference of opinion the circumstances should be frankly and impartially explained to the patient or his relatives or friends. It would be opened to them to seek further advice as they so desire.

g. Not taking the right decisions when required

MCI 3.5: Treatment after Consultation: No decision should restrain the attending physician from making such subsequent variations in the treatment if any unexpected change occurs, but at the next consultation, reasons for the variations should be discussed/explained. The same privilege, with its obligations, belongs to the consultant when sent for in an emergency during the absence of attending physician. The attending physician may prescribe medicine at any time for the patient, whereas the consultant may prescribe only in case of emergency or as an expert when called for.

h. Not briefing the specialist properly and the specialist not giving his opinion in writing

MCI 3.6: Patients Referred to Specialists: When a patient is referred to a specialist by the attending physician, a case summary of the patient should be given to the specialist, who should communicate his opinion in writing to the attending physician.

i. Not disclosing his fee

MCI: 3.7 Fees and other charges:

3.7.1 A physician shall clearly display his fees and other charges on the board of his chamber and/or the hospitals he is visiting. Prescription should also make clear if the Physician himself dispensed any medicine. 3.7.2 A physician shall write his name and designation in full along with registration particulars in his prescription letter head.

Note: In Government hospital where the patient–load is heavy, the name of the prescribing doctor must be written below his/her signature.

Note: From the above it is clear that for the council to take action it must be proved that the medical negligence amounted to professional misconduct under "patient must not be neglected" and this neglect was infamous in relation to the medical profession particularly, under any Code of Ethics prescribed by the MCI.

HC directs TN Medical Council to probe Doctor’s complaint

PTI: The Madras High Court recently directed the Tamil Nadu State Medical Council to consider and dispose on merit and as per law the complaints given by a doctor to probe and take action against those doctors responsible for "criminal negligence" in treating his father, who was suffering from cancer and died last year.

Allowing a plea by Dr Easwaran DNB, FRCS, Justice K K Sasidharan observed that any breach by medical professionals in their duty would give a cause of action to the aggrieved to initiate disciplinary proceedings for professional misconduct before the State Medical Council concerned.

Dr Easwaran, a surgeon, said in his petition that he took his father for treatment for cancer in a private corporate hospital here in April 2010. He alleged that the surgeon, anaesthetist, the medical superintendent and the hospital were highly negligent and the cancer recurred within a year. It was mainly on account of ‘botched up’ operation and the failure to give radiotherapy which was essential to prevent recurrence of cancer, he alleged.

Dr Easwaran, who was temporarily abroad, returned to India in January 2011, and found that the tumours were bigger. He got his father operated in another hospital in April 2011, but the cancer spread to other parts of the body and he died in January last year.

Easwaran said he complained to the Tamil Nadu Medical Council as well as Medical Council of India. Though the MCI asked the Tamil Nadu Medical Council to investigate the complaint within six months, the latter said it had no power to take action relating to medical negligence. Only in case of professional misconduct, action could be taken, it said.

Easwaran then moved the Court. Invoking the concept that a medical practitioner owed a duty of care to his patient and that the breach of such duty would amount to professional misconduct, Justice Sasidharan said the state medical council was not correct in its contention that it had no jurisdiction to initiate disciplinary action.

He then directed the council to consider complaints and dispose it of on merits without in any way being influenced by the present order, within six months.

cpr10 Mantra The CPR 10 Mantra is – "within 10 minutes of death, earlier the better; at least for the next 10 minutes, longer the better; compress the centre of the chest of the dead person continuously and effectively with a speed of 10×10 i.e. 100 per minute."

VIP’s on CPR 10 Mantra Video
Ringtone – CPR 10 Mantra Hindi
Ringtone – CPR 10 Mantra English

Understanding Indriyas

sprritual blog

As per ancient Indian literature, we have 10 Indriyas – 5 motor and 5 sensory. The motor Indriyas are called Karmindriyas and the sensory indriyas are called Gnanaindriyas. The motor indriyas involve the functions of elimination (anus), procreation (genitals), movement (legs), grasping (hands) and speaking (speech). The five sensory indriyas in sequence are smell, taste, seeing, touching and hearing.

The first motor indriya is linked to the first sensory indriya. Therefore, elimination is linked to smelling, procreation to tasting, movement to seeing, grasping to touching and speaking to hearing.

Controlling the senses is the fundamental principle in acquiring spiritual health. Senses in Indian mythology are depicted by horses, which are chanchal and are likely to go out of control. The control over 10 senses is required to become a yogi.

The Ashwamedha Yagna of ancient era of kings basically meant doing a sacrifice so as to be able to control one’s senses.

In internal Ramayana, Lord Dashrath represents a person who has control over his 10 senses. Here ‘Dash’ means ten and ‘Rath’ means horse.

During meditation also, one is taught to sequentially control one’s senses. For example, to be able to meditate, one must first pass urine and stool as in the presence of these urges, one will not be able to meditate. The second is to control one’s sexual desires. It is well known that sexuality and spirituality cannot go hand in hand. In any Shiv Mandir, Nandi, the bull, is always worshipped outside the temple and not inside the temple.

The next step in meditation is control on movements and that is practicing stillness followed by relaxing each every muscle representing control over grasping and then going to an inner journey of inner silence of controlling over the 5th motor indriya i.e. speech. Only after one has learnt to control the mortal indriyas, can one be able to control the 5 sensory indriyas in succession as mentioned above.

cardiology news

A mother’s love

A little boy came up to his mother in the kitchen one evening while she was fixing supper, and handed her a piece of paper that he had been writing on. After his Mom dried her hands on an apron, she read it, and this is what it said:

For cutting the grass: $5.00; for cleaning up my room this week: $1.00
For going to the store for you: $.50; Baby–sitting my kid brother while you went shopping: $.25
Taking out the garbage: $1.00; for getting a good report card: $5.00
For cleaning up and raking the yard: $2.00; Total owed: $14.75

Well, his mother looked at him standing there, and the boy could see the memories flashing through her mind. She picked up the pen, turned over the paper he’d written on, and this is what she wrote:

For the nine months I carried you while you were growing inside me: No Charge.

For all the nights that I’ve sat up with you, doctored and prayed for you: No Charge.

For all the trying times, and all the tears that you’ve caused through the years: No Charge.

For all the nights that were filled with dread, and for the worries I knew were ahead: No Charge.

For the toys, food, clothes, and even wiping your nose: No Charge.

Son, when you add it up, the cost of my love is: No Charge.

When the boy finished reading what his mother had written, there were big tears in his eyes, and he looked straight at his mother and said, "Mom, I sure do love you." And then he took the pen and in great big letters he wrote: "PAID IN FULL".


You will never how much your parents worth till you become a parent.
Be a giver not an asker, especially with your parents. There is a lot to give, besides money.

Advice: If your mom is alive and close to you give her a big kiss and ask her for forgiveness. If she is far away, call her. If she passed away, pray for her.

News Around The Globe


  • In the LowSALT CKD study published in JASN, low salt intake reduced excess fluid volume by 1 liter, lowered blood pressure by 10/4 mm Hg, and halved protein excretion in the urine, without causing significant side effects.
  • In a retrospective study of all 74 obese patients with kidney disease who underwent surgery in three major London teaching hospitals from 2007 to 2012, excess weight was lost in 61% of patients one year post–surgery, but there were 16 adverse events, including two deaths (3%) related to surgical complications. Acute kidney injury was most frequent (4%), followed by leak (3%), acidosis and elevated blood potassium levels (3%), postoperative chest infection (3%), vitamin deficiency (3%), failure (3%), and heart attacks (1%). The findings were presented at ASN Kidney Week 2013. (ASN News)
  • Adding risedronate (Actonel) to vitamin D and calcium supplements in patients taking anti–epileptic drugs (AEDs) increased bone mineral density (BMD), both from baseline and relative to a control group, as reported by according to Antonio Lazzari, MD, of the Boston VA Healthcare System, and colleagues in the November issue of the journal Epilepsia.
  • According to a new study published online October 22 in the Journal of the National Cancer Institute, exercising at levels higher than currently recommended during chemotherapy (up to 3 hours, 3 times weekly) is safe for highly motivated women with breast cancer, and will not interfere with the completion of chemotherapy or exacerbate symptoms.
  • Dolutegravir plus abacavir–lamivudine was safer and more effective through 48 weeks against HIV–1 infection than standard highly active antiretroviral therapy with a combination of efavirenz, tenofovir DF, and emtricitabine, according to results from a randomized, double–blind, phase 3 trial published the results in the November 7 issue of the NEJM.

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Rabies News (Dr. A K Gupta)

If for some reason, IDRV cannot be given in deltoid region, what are the alternative sites?

IDRV can be given in deltoid region, suprascapular, anterior abdominal wall and the upper part of thigh.

cardiology news

(Dr KK Aggarwal, Group Editor in Chief, IJCP Group of Publications and eMedinewS)

  • European Union (EU) regulators have recommended narrowing the indication for drugs containing the lipid–lowering agent acipimox. Acipimox should be used only as an additional or alternative treatment for type 2b and type 4 hyperlipoproteinemia when lifestyle changes and other medicines are not adequate, according to the Pharmacovigilance Risk Assessment Committee (PRAC) of the European Medicines Agency (EMA).
  • Platelet expression of a protein that affects thrombin receptors is enhanced in blacks, compared with whites, and potentially explains some race–related variation in platelet activation and, by extension, thrombus–mediated ischemic risk, suggests a laboratory study published today in Nature Medicine. According to the authors, the findings underscore that racial differences in clinical responses to antithrombotic drugs need to be taken into account, particularly in the case of drugs designed to inhibit thrombin activity.
cardiology news

(Dr KK Aggarwal, Group Editor in Chief, IJCP Group of Publications and eMedinewS)

  • According to results from a 6–month longitudinal cohort study published online November 11 in Pediatrics, the Asthma Symptom Tracker (AST) performs well for monitoring the status of asthma symptoms in the pediatric population over time. The AST had moderate test–retest reliability and good validity, determined by a high correlation of scores with Asthma Control Questionnaire scores. With each 1–point decrease (worsening) in the 25–point AST score, children had a 13% higher use of oral corticosteroids and were 23% more likely to have an unscheduled acute care visit for asthma.
  • Chromosomal microarray testing is ideal for narrowing down the diagnosis in most patients presenting with multiple congenital anomalies, according to a study presented at the annual meeting of the American Academy of Pediatrics. According to Dr. Demmer, a pediatric clinical geneticist at Levine Children’s Hospital, Charlotte, N.C, for children presenting with a suspected syndrome, problems with growth, or a development or autism spectrum disorder, microarray is "really our go–to test right now." Also, if chromosomal testing demonstrates a certain karyotype, such as a translocation, then microarray testing is the best approach for determining if it is a balanced translocation. If a marker chromosome is detected, microarray will identify it.
cardiology news

Warning signs of worsening heart failure

If you have heart failure, call your doctor if you notice any of these signs:

  • Sudden weight gain (2–3 pounds in one day or 5 or more pounds in one week)
  • Extra swelling in the feet or ankles
  • Swelling or pain in the abdomen
  • Shortness of breath not related to exercise
  • Discomfort or trouble breathing when lying flat
  • Waking up feeling short of breath
  • Coughing or wheezing
  • Increased fatigue
  • Mental confusion
  • Loss of appetite
cardiology news

Total CPR since 1st November 2012 – 71933 trained

Media advocacy through Web Media

ECG not reliable marker for predicting heart disease

Doing an ECG is of little use in predicting future heart problems for people who are examined because of chest pain, said Padma Shri & Dr. B.C. Roy National Awardee, Dr. KK Aggarwal, President, Heart Care Foundation of India. Both angina and heart attacks increase during winter months.

Chest pain is the most common reason people seek medical attention for possible heart trouble, and an ECG, is a common test for such people. ECG can be normal in the first six hours even in frank heart attacks. Missing the diagnosis of heart attack on ECG is the commonest mistake done in the emergency rooms.

The most important parameters still remain is the classical history and physical findings.

1. A chest pain which can be pinpointed by a finger is not a heart pain.
2. Pain lasting less than 30 seconds is not a heart pain.
3. Heart pain is diffuse in the center of the chest lasting more than minutes and manifests as heaviness, burning, discomfort, heaviness or pain often precipitated by physical or mental exertion.

When in doubt one should do an exercise stress test and if negative these patients should be reassessed for risk factors.

If the patient is at high risk even with negative treadmill, he/she should undergo risk reduction management for prevention of future heart attacks.

High risk patients are smokers plus presence of blood pressure, obesity, high cholesterol and diabetes.

About HCFI : The only National Not for profit NGO, on whose mega community health education events, Govt. of India has released two National Commemorative stamps and one cancellation stamp, and who has conducted one to one training on" Hands only CPR" of 71933 people since 1st November 2012.

The CPR 10 Mantra is – "Within 10 minutes of death, earlier the better; at least for the next 10 minutes, longer the better; compress the centre of the chest of the dead person continuously and effectively with a speed of 10×10 i.e. 100 per minute."

today emedipics

Students form various schools took active part in the 20th MTNL Perfect Health Mela 2013

press release

To err is human

today video of the day20th MTNL Perfect Health Mela Press Conference with Marwadi Yuva Manch, Faridabad

20th MTNL Perfect Health Mela Press Conference at Marwah Studio, Noida

Cultural Evening at IMA

eMedi Quiz

Interscalene approach to brachial plexus block does not provide optimal surgical anaesthesia in the area of distribution of which of the following nerve:


Yesterday’s Mind Teaser: In all of the following conditions neuraxial blockade is absolutely contraindicated, except:

1.Patient refusal.
3.Severe hypovolemia.
4.Pre–existing neurological deficits.

Answer for yesterday’s Mind Teaser: 4.Pre–existing neurological deficits.

Correct answers received from: suresh srinivasan, Dr.Arun Gupta, DR.A.K.GAJJAR, Dr. P. C. Das, Dr. V.P. Thakral, drajayhemnani, Dr.K.Raju, Dr MONICA GANDHI, Dr Jainendra Upadhyay, Dr Arpan Gandhi, Dr Chandresh Jardosh, Dr K P Chandra, DR AVTAR KRISHAN, Dr B K Agarwal,

Answer for 10th November Mind Teaser: 1.Mapleson A.

Correct answers received from: Dr.K.V.Sarma,, Muthumperumal Thirumalpillai, Dr K P Chandra

Send your answer to ijcp12@gmail.com

medicolegal update

Click on the image to enlarge

medicolegal update

The International Food Shortage

Recently, a worldwide survey was conducted and the only question asked was: "Would you please give your honest opinion about the solution to the food shortage in the rest of the world?"

The survey was, not surprisingly, a huge failure. Because:

In Africa they didn’t know what "food" meant.

In Eastern Europe they didn’t know what "honest" meant.

In Western Europe they didn’t know what "shortage" meant.

In China they didn’t know what "opinion" meant.

In the Middle East they didn’t know what "solution" meant.

In South America they didn’t know what "please" meant.

And, in the USA they didn’t know what "the rest of the world" meant.

medicolegal update
medicolegal update

Click on the image to enlarge

medicolegal update

Situation: A patient was brought to the ICU in cardiogenic shock.
Reaction: Oh my God! Why didn’t you take him for emergency angiography and subsequent PTCA?
Lesson: Make Sure to perform an emergency diagnostic angiography and mechanical revascularization with PTCA in patients of cardiogenic shock. Results of NRMI–2 trial suggest that this intervention is much better than thrombolytic therapy in such patients.

medicolegal update

If we wait until our lives are free from sorrow or difficulty, then we wait forever. And miss the entire point. Dirk Benedict.

medicolegal update

Dr KK Aggarwal: Shorter acting calcium channel blockers linked to breast cancer http://bit.ly/15QdVeB #Health
Dr Deepak Chopra: Those who make wise choices in life should wind up happier & more successful http://tinyurl.com/mwjtqcs

medicolegal update
  1. Dear Editor, You have done well to highlight the importance of keeping spectacle prescription up-to-date in order to ease neck pain.Keeping your Rx eyewear up-dated provides vision that is not only clear but also stress-free that in turn helps you avoid facial wrinkles.Regards.Dr. Narendra Kumar

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