eMedinewS
15th November 2014, Saturday

Dr K K AggarwalPadma Shri, Dr B C Roy National Awardee and National Science Communication Awardee. Limca Book of Record Holder (CPR). Gold Medalist

Dr KK Aggarwal

President, Heart Care Foundation of India; Senior Consultant Physician, Cardiologist & Dean Medical Education Moolchand Medcity; Editor in Chief IJCP Group, Senior National Vice President, Indian Medical Association; Member Ethics Committee Medical Council of India, Chairman Ethical Committee Delhi Medical Council, Hony. Visiting Professor (Clinical Research) DIPSAR; Limca Book of Record Holder in CPR, 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.twitter.com/DrKKAggarwal, www.facebook.com/Dr KKAggarwal

Chhattisgarh sterilization deaths: Accident or Negligence or Administrative Failure

To err is human; error of judgment is not crime; difference of opinion is not crime, failure of outcome is not crime; routine complications are not crime; mere deviation from standard practice may not be crime, BUT what a crime is "not taking standard precautions, neglecting the patient or not taking proper consent. This can only be found out after proper investigations.

I have written to MCI to take this case suo moto and investigate. Punish the doctor if he is guilty or protect him and restore the image of the medical profession if he is not guilty.

The human rights commission should also take this case suo moto and if they find the government is responsible for the mishap (buying sub standard drugs, setting targets for such surgeries, not providing enough safe infra structure for such camps) it should be taken to task.

Following MCI ethics regulations clauses are applicable in such mishaps

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 wilfully commit an act of negligence that may deprive his patient or patients from necessary medical care.

7.16 Before performing an operation the physician should obtain in writing the consent from the husband or wife, parent or guardian in the case of minor, or the patient himself as the case may be. In an operation which may result in sterility the consent of both husband and wife is needed.

7.22 Research: Clinical drug trials or other research involving patients or volunteers as per the guidelines of ICMR can be undertaken, provided ethical considerations are borne in mind. Violation of existing ICMR guidelines in this regard shall constitute misconduct. Consent taken from the patient for trial of drug or therapy which is not as per the guidelines shall also be construed as misconduct.

Supreme Court of India

What are defined situations of negligence?


In one of the judgments SCI enlisted some guidelines for the doctors and the hospitals. "1. Current practices, infrastructure, paramedical and other staff, hygiene and sterility should be observed strictly.” (SCI: 3541 of 2002, dated 17.02.2009, Martin F. D'Souza vs Mohd. Ishfaq: Markandey Katzu and G S Singhvi, JJ.)

Death does not mean negligence?

In Dr Suresh Gupta vs Govt. of Delhi (AIR 2004 SC 4091) case the doctor was accused under 304A. The patient died during surgery of nasal deformity due to wrong incision and subsequent bleeding, choking & death. The high court said that adequate care was not taken to prevent seepage of blood resulting in asphyxia. The Supreme Court said that cause of death was stated to be ‘not introducing a cuffed ET tube of proper size as to prevent aspiration. The Supreme finally concluded that it is a case of negligence as there was a lack of care and precaution but for this the doctor can be held liable in a civil case but it is not that reckless or grossly negligent as to make him liable in a criminal case. For conviction in a criminal case the negligence and rashness should be of such a high degree which can be described as totally apathetic towards the patient. (SCI: 3541 of 2002, dated 17.02.2009, Martin F. D'Souza vs Mohd. Ishfaq: Markandey Katzu and G S Singhvi, JJ.)

Grass root facts

  • Camps are common, standardized and happen with the knowledge of government authorities.
  • Government pays incentives for patients, doctors and staff
  • Day care surgeries are done in conveyer belt fashion

Issues to decide negligence or accident

  • Proper consent
  • How many laparoscopes were used?
  • Time taken for laparoscope sterilization
  • Time between two surgeries
  • Type of anesthesia given
  • Type of drugs used
  • How many surgeries are done and in how much time
  • Qualification of the surgeon
  • Experience of the surgeon
  • Autopsy reports
  • CO2 used: quality
  • Quality of instruments used

Government steps on the tragedy

  • Meanwhile even as reports said that rusted equipment were used in the surgeries, a team of doctors from Delhi's premier AIIMS hospital is in Bilaspur to investigate what happened.
  • The medicines used have been sent to a lab in Kolkata for analysis
  • Autopsy reports are awaited

Media Trial

"Times Now" TV channel news at 7-15 p.m. on 13-3-2014 equated Dr. R K Gupta, surgeon, of Chhattisgarh as "Doctor Death", "Butcher of Bilaspur" and "Merchant of Death".

Comments by fellow colleagues

  • "Till the results of the enquiry are released the doctors should not be harassed. The medic should not project the negative image of the profession" : Dr Narendra Saini Honorary Secretary general IMA
  • "It is for the IMA to digest it and to be blind to it and to ignore it or to launch media blitz against this channel and to send a legal notice demanding within 72 hours an unqualified apology to be prominently telecast on the same channel, failing which the IMA should initiate appropriate legal proceedings. Please note that IMA has full locus standi to move on these lines because it represents the whole medical profession and ought to preserve its dignity and respect. Dr M C Gupta"
  • " http://scdrc.up.nic.in/judgement/A-1893-2008.pdf: "Held that the tubectomy was done free at a primary health centre as part of government’s family planning programme without payment of any money and hence it was not within the ambit of consumer act…………………………………." M C Gupta
  • The government has announced a relief of Rs. 2 lakhs only (Dr Mehra)
  • " Here in Chhattisgarh, government pay Rs. 1400 to the patient for sterilization operations and if operation fails then Rs. 30000 as compensation are to be paid. They are not consumers, still so many cases are going on in consumer court for the same and our treating surgeon keeps on attending the trials on behalf of govt. I don't understand why consumer court accepted these cases" Vicky Bansal
  • ”PAYING 30,000/- as compensation for failed tubectomy is in itself a wrong step as any procedure can fail. So what is the big deal?" Dr Sodhi
  • "We are talking of doctors & doctors alone. Please remember that this is a government programme, government doctors, government everything. There is something called vicarious responsibility. There is another thing which is "owning up responsibility". And finally there is something (though rare) called "shame". Another rare item is "moral ground" Do you all not feel that the health minister should own up responsibility and resign on moral grounds? Dr Sodhi

Questions which need to be answered (Dr Neeraj Nagpal)

  1. Is Surgeon responsible for deaths in a family planning camp?
  2. Is setting of targets for family planning responsible for such mishaps? 3.
  3. Is the team including nurses, helpers, OT assistants equally responsible?
  4. Should the nurses, OT technicians and helpers who were part of team also be arrested?
  5. Is arrest of Surgeon without finding cause of mishap correct?
  6. What are various reasons one can think as cause of 14 deaths in a family planning camp?: Lack of sterilization of instruments by paramedical staff/ Reaction to medicines or anesthesia used/ Chemical contaminant in CO2 used for insufflation/ Poor skill of surgeon leading to bleeding/ Carelessness of surgeon while operating/ Carelessness of surgeon in preoperative and postoperative care/ Mischief by someone who is part of surgical team
  7. Are Doctors pressurized to do more and more surgeries in Family Planning camps by their superiors?
  8. Does the concept of medical and surgical camps in sub optimal settings need to be abolished
  9. Should those who pressurize doctors to achieve 'targets' also be punished ?
  10. Should compensation awarded by Govt to deceased not be raised to 20 lacs or more in such a mishap ?
  11. How should such tragedies be avoided in future ?: Reduce number of surgeries which can be done in one camp to 10; Use minimum 3 Laproscopes and instrument sets for one camp; Qualified nurses and OT assistants to accompany doctor on such camps; Penalize superiors if more than 10 tubectomies are done in one camp; Abolish family planning camps totally or Punish surgeon severely to set an example.
  12. Should awards be given as incentive to surgeons who perform more surgeries in family planning camps?
  13. Is labelling the Surgeon 'Killer' by our print and electronic media appropriate ?
  14. After such media condemnation if it is found later the surgeon was not at fault? Should he be compensated by his employers/should he be compensated by the Press/ should he be compensated by his professional Associations who did not support him?

Recent updates on the case.

  1. Drug company which supplied those drugs had been earlier booked for five cases and all cases are still running but government didn't ban it before. Now after Bilaspur incident government banned that pharma company and this company was operating from a residential house still government bought all medicines like ciprofloxacin ibuprofen given to all camp patients.
  2. Post Mortem report says no surgical fault seen; waiting for chemical lab report. No signs of inflammation present at surgical site.
  3. An urgent notice by the government to ban these drugs with immediate effect in all government hospitals shows the actual reason for death in camps.
  4. Government suspended few doctors on using branded medicine and here in this case using generic government supply also get the doctor arrested. Thinking where we doctors stand today?
  5. Health officials are equally responsible but they arrested only a senior doctor who was about to retire in one year. Very unlawful. IMA must come forward and put doctor view in public and raise issues related to safety of cheap generic medicines. (Vicky Bansal, Medical officer)

News Around The Globe

  • Rare mutations that shut down a single gene are linked to lower cholesterol levels and a 50% reduction in the risk of a myocardial infarction (MI), according to a study published in the November 12 issue of the New England Journal of Medicine.
  • Angiotensin-converting enzyme inhibitors (ACEIs) were associated with a 57% reduced risk in the chance of developing amyotrophic lateral sclerosis (ALS) in patients who were prescribed ACEIs greater than 449.5 cumulative defined daily dose (cDDD), compared with patients who did not use ACEIs, according to a study published online by JAMA Neurology.
  • Two studies published in the American Journal of Medicine raise questions about the traditional management of patients who have been discharged from the hospital after a myocardial infarction (MI). They found that beta-blockers have no mortality benefit in contemporary treatment of MIs.
  • Dual antiplatelet therapy duration gets the focus as the American Heart Association meeting kicks off this weekend. The landmark Dual Antiplatelet Therapy (DAPT) Study will "anchor" Sunday's opening late-breaking clinical trial session of trials addressing duration.

Dr KK Spiritual Blog

Alcohol Takes Your Power of Judgment Away

Under the influence of alcohol, you may lose your power of judgment. I recall one of my friends who shot himself under the influence of alcohol after his wife refused to cook food for him and his friends at 11 pm. When he said, “mujhe khana do nahin to mein khood ko shoot kar lunga”, to which she said, “shoot kar lo” and he shot himself.

Under the influence of alcohol, your crime becomes less severe. In the present gang rape case, all the accused persons were under the influence of alcohol but they were not caught at the same time. If they were caught with alcohol in their blood, their crime would have become less severe than what it would have been if alcohol was not found.

If alcohol is the major culprit than the person who invites people to drink alcohol should be punished as he was very well aware that he was inviting others to drink alcohol and after drinking alcohol, when they lose their judgment power and they may misbehave with others and indulge in violence.

If you invite people at home for alcohol party, it is your duty:

  1. Not to serve more than 80 ml of alcohol
  2. Not to serve alcohol to people who have come without drivers and are going to drive back
  3. Or take their keys in your possession and get they dropped after the party
  4. Never serve alcohol to drivers and other peoples who are going to drive.

Drunken man is like a snake or an injured lion. Never heart ego of a person who is under the influence of alcohol. He may hurt you. In Ayurveda, there are three types of people Vata Pitta and Kapha. People with Vata personality can get drunk with limited amount of alcohol and people with Kapha personality can be sober even after a large drink of alcohol.

Under the influence of alcohol a person usually does not speak a lie and hence starts speaking truth which can provoke others if it does not go well with them.

However, if a drunken man commits a crime or is confronted with a powerful muscular man or a policeman, he often comes back to his senses.

Inspirational Story

Determination and Persistence

This is a real life story of engineer John Roebling building the Brooklyn Bridge in New York, USA back in 1870. The bridge was completed in 1883, after 13 years.

In 1883, a creative engineer named John Roebling was inspired by an idea to build a spectacular bridge connecting New York with the Long Island. However bridge building experts throughout the world thought that this was an impossible feat and told Roebling to forget the idea. It just could not be done. It was not practical. It had never been done before.

Roebling could not ignore the vision he had in his mind of this bridge. He thought about it all the time and he knew deep in his heart that it could be done. He just had to share the dream with someone else. After much discussion and persuasion he managed to convince his son Washington, an up and coming engineer, that the bridge in fact could be built.

Working together for the first time, the father and son developed concepts of how it could be accomplished and how the obstacles could be overcome. With great excitement and inspiration, and the headiness of a wild challenge before them, they hired their crew and began to build their dream bridge.

The project started well, but when it was only a few months underway a tragic accident on the site took the life of John Roebling. Washington was also injured and left with a certain amount of brain damage, which resulted in him not being able to talk or walk.

“We told them so.” “Crazy men and their crazy dreams.” “It’s foolish to chase wild visions.” Everyone had a negative comment to make and felt that the project should be scrapped since the Roebling’s were the only ones who knew how the bridge could be built.

In spite of his handicap Washington was never discouraged and still had a burning desire to complete the bridge and his mind was still as sharp as ever. He tried to inspire and pass on his enthusiasm to some of his friends, but they were too daunted by the task.

As he lay on his bed in his hospital room, with the sunlight streaming through the windows, a gentle breeze blew the flimsy white curtains apart and he was able to see the sky and the tops of the trees outside for just a moment.

It seemed that there was a message for him not to give up. Suddenly an idea hit him. All he could do was move one finger and he decided to make the best use of it. By moving this, he slowly developed a code of communication with his wife.

He touched his wife’s arm with that finger, indicating to her that he wanted her to call the engineers again. Then he used the same method of tapping her arm to tell the engineers what to do. It seemed foolish but the project was under way again.

For 13 years Washington tapped out his instructions with his finger on his wife’s arm, until the bridge was finally completed. Today the spectacular Brooklyn Bridge stands in all its glory as a tribute to the triumph of one man’s indomitable spirit and his determination not to be defeated by circumstances. It is also a tribute to the engineers and their team work, and to their faith in a man who was considered mad by half the world. It stands too as a tangible monument to the love and devotion of his wife who for 13 long years patiently decoded the messages of her husband and told the engineers what to do.

Perhaps this is one of the best examples of a never-say-die attitude that overcomes a terrible physical handicap and achieves an impossible goal.

Often when we face obstacles in our day-to-day life, our hurdles seem very small in comparison to what many others have to face. The Brooklyn Bridge shows us that dreams that seem impossible can be realised with determination and persistence, no matter what the odds are.

Rabies News (Dr A K Gupta)

What precautions should be taken while vaccinating by the ID route?

  • The ID injections must be administered by staff trained in this technique.
  • The Vaccine vials must be stored at +2°C to + 8°C after reconstitution.
  • The total content should be used as soon as possible, but at least within 8 hours.
  • The 0.1 ml. ID administration of cell–culture vaccine should create a wheal of at least 5 mm diameter with "peau de orange" appearance.
  • If ID dose is given subcutaneously then there is a possibility of poor immune response due to low antigen load. This may be life–threatening.

Cardiology eMedinewS

  • Anemia and chronic kidney disease (CKD) are independently associated with an increased risk of new-onset atrial fibrillation (AF), and the combination of the two risk factors is synergistic for AF onset, suggests a prospective cohort study published online November 11 in the American Journal of Cardiology.
  • Individuals who possess a mutation in the Niemann-Pick C1-like 1 gene (NPC1L1), the gene that encodes the NPC1L1 protein targeted by ezetimibe, have lower levels of LDL cholesterol and a corresponding lower risk of coronary heart disease compared with individuals who do not carry the mutation, suggests a study published online November 12 in the New England Journal of Medicine.

Pediatrics eMedinewS

  • New data published in the November 13 issue of the New England Journal of Medicine pinpoint the main causes of head trauma in children in different age groups, as well as the frequency of traumatic brain injury (TBI). Researchers noted that the most common mechanism of injury was a fall from any distance (27%), followed by a fall while standing, walking, or running (11%); a collision with a stationary object when walking or running (6%); a motor vehicle crash (9%); and a bicycle crash (4%).
  • Abnormalities in brain structure could possibly explain depressive disorders starting in early childhood, suggests new imaging research. Study authors noted that children with preschool-onset major depressive disorder (MDD) had smaller anterior insula (AI) volumes than their healthy peers. The study was published online November 12 in JAMA Psychiatry.

Quote of the Day

  • A question that sometimes drives me hazy: am I or are the others crazy? ~ Albert Einstein

Wellness Blog

Myths

  1. The right skin cream can keep your skin looking young: For reducing wrinkles, the topical treatment with the best evidence behind it is retinoic acid (as in Retin-A). The best ways to keep wrinkles at bay are using sunscreen and not smoking.
  2. Antibacterial soap is best for keeping your skin clean: Many experts are concerned that the use of antibacterial soap could lead to more antibiotic-resistant bacteria. Antibacterial soap is not necessary for everyday use. Regular soap is fine. Thorough and consistent hand-washing, not antibacterial soap, is what helps prevent the spread of infection.

ePress Release

Exercise: a prescription

Stating why one should do exercises Padma Shri, Dr. B C Roy National Awardee & DST National Science Communication Awardee, Dr. K K Aggarwal, President Heart Care Foundation of India and Sr National Vice President Indian Medical Association laid down a few facts:

  1. Reduces the chances of getting heart disease. For those who already have heart disease, exercise reduces the chances of dying from it.
  2. Lower the risk of developing hypertension and diabetes.
  3. Reduce the risk for colon cancer and some other forms of cancer.
  4. Improve mood and mental functioning.
  5. Keeps the bones strong and joints healthy.
  6. Helps you to maintain a healthy weight.
  7. Help maintain independence into later years
  8. Age is no bar; there is abundant evidence that exercise can enhance health and well-being. But today for most watching TV, surfing the Internet, or playing computer and video games is replacing the helpful exercises.
  9. The minimum threshold for good health is to burn at least 700 to 1,000 calories a week through physical pursuits.
  10. Exercise improves health and can extend life. Adding as little as half an hour of moderately intense daily physical activity can help one avoid a host of serious ailments, including heart disease, diabetes, depression, and several types of cancer, particularly breast and colon cancers.
  11. Regular exercise can also help one sleep better, reduce stress, control weight, brighten mood, sharpen mental functioning, and improve sex life.

As per Harvard researchers a well-rounded exercise program must have all the four components-

  1. Aerobic activity
  2. Strength training
  3. Flexibility training
  4. Balance exercises

Aerobic activity: is the centrepiece of any fitness program. Most benefits of exercise revolve around aerobic cardiovascular activity, which includes walking, jogging, swimming, and cycling. One should work out at moderate intensity when performing aerobic exercise—brisk walking that quickens the breathing is one example. This level of activity is safe.

Strength training protects bone: Strength or resistance training, such as elastic-band workouts and the use of weight machines or free weights, are important for building muscle and protecting bone. Bones lose calcium and weaken with age, but strength training can help slow or sometimes even reverse this trend.

Flexibility exercises ease back pains: Muscles tend to shorten and weaken with age. Shorter, stiffer muscle fibres make one vulnerable to injuries, back pain, and stress. But regularly performing exercises that isolate and stretch the elastic fibres surrounding the muscles and tendons can counteract this process. And stretching improves posture and balance.

Balancing exercises prevents fall: Balance erode over time, and regularly performing balance exercises is one of the best ways to protect against falls that lead to temporary or permanent disability. Balance exercises take only a few minutes and often fit easily into the warm-up portion of a workout. Many strength-training exercises also serve as balance exercises. Or balance-enhancing movements may simply be woven into other forms of exercise, such as tai chi, yoga, and Pilates.

emedipicstoday emedipics

21st Perfect Health Mela 18th October 2014

Self-Assessment-Quiz

 

expert_choice
press release

Obesity reduces life expectancy

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Sameer Malik Heart Care Foundation Fund

The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number +91 9958771177 or by filling the online form.

Madan Singh, SM Heart Care Foundation Fund, Post CAG

Kishan, SM Heart Care Foundation Fund, Post CHD Repair

Deepak, SM Heart Care Foundation Fund, CHD TOF

Total CPR since 1st November 2012 – 101090 trained

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."

CPR 10 Success Stories

Ms Geetanjali, SD Public School
Success story Ms Sudha Malik
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Elderly man saved by Anuja

CPR 10 Videos

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IJCP Book of Medical Records

IJCP Book of Medical Records Is the First and the Only Credible Site with Indian Medical Records.

If you feel any time that you have created something which should be certified so that you can put it in your profile, you can submit your claim to us on :

 

Dr Good and Dr Bad

Situation: A patient with severe migraine wanted to know if xylocaine drops would help.
Dr. Bad: They have no role.
Dr. Good: You can try them.
Lesson: As an intranasal spray, 2% xylocaine drops can help migraine patients.

Make Sure

Situation: A patient on binasal oxygen developed nasal mucosal damage.
Reaction: Oh my God! Why was the oxygen given at the rate of 4 liters per minute?
Lesson: Make sure that oxygen via nasal catheter, is not given at a rate of >3 liters per minute.

eMedinewS Humor

Two boys are in the schoolyard bragging of how great their fathers are. The first one says, "Well, my father runs the fastest. He can fire an arrow, and start to run, I tell you, he gets there before the arrow".

The second one says, "Ha! You think that's fast! My father is a hunter. He can shoot his gun and be there before the bullet".

Twitter of the Day

Dr KK Aggarwal: Regular exercises increases HDL good Cholesterol
Dr Deepak Chopra: Perceptual experience & rationality are not fundamental reality which is consciousness, the source of both experience & reason

eMedi Quiz

Which of the following is present intracellularly in muscle cells:

1. Insulin.
2. Corticosteroid.
3. Epinephrine.
4. Glucagon.

Yesterday’s Mind Teaser: The buffering capacity of a buffer is maximum at pH equal to:

1. 0.5pKa.
2. pKa
3. pKa+1
4. 2pKa


Answer for yesterday’s Mind Teaser: 2. pKa

Correct answers received from: Dr Jainendra Upadhyay, Dr Avtar Krishan.

Answer for 13th November Mind Teaser: 4.Vertebral venous plexus.

Correct answers received from: Dr K V Sarma, Dr Jainendra Upadhyay, Dr Avtar Krishan.

Send your answer to email

medicolegal update

(Dr. K K Aggarwal, Padma Shri and Dr. B C Roy National Awardee; Editor eMedinewS and President Heart Care Foundation of India)

(Contributed by Dr MC Gupta, Advocate)

Q. I worked in a private medical college for two and half years as assistant professor. There was no written contract. I was selected for a government job. I resigned from the previous job with a request to relieve me immediately and to give me relieving certificate. No such certificate was given. I joined the government job. What should I do to get the experience certificate?


A. Written contract is not a must. An oral contract is legally valid.

You should send them a written request, under your signature but drafted by a lawyer, to give you the experience certificate. A properly drafted request would have high chance of being successful. If the previous employer ignores your request, you will be sure to get the required relief through court.

If you are forced to go to the court, it may be advisable to make the State government; the University; and, the MCI as co–respondents. A good lawyer would take care of this when drafting the request/representation for you.

medicolegal update
  1. Dear Sir, very informative newspaper. Regards: Dr Shagun

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