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Propranolol in addition to amiodarone for treatment of electrical storm

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Dr KK Aggarwal    20 June 2018

Propranolol in addition to amiodarone for treatment of electrical storm: For hemodynamically stable patients with ventricular tachycardia in electrical storm, in addition to amiodarane as an antiarrhythmic co-administer propranolol rather than a beta-1 selective beta blocker.

Beta blockers reduce the adrenergic surge associated with frequent ventricular tachyarrhythmias requiring defibrillator shocks. However, there have been limited data to guide the choice of a selective or non-selective beta blocker in the management of VT, in particular electrical storm (three or more episodes of sustained VT within 24 hours).

In a randomized, double-blind study of patients with an implantable cardioverter-defibrillator (ICD) and electrical storm in which all patients received intravenous (IV) amiodarone and were randomized to propranolol (40 mg every 6 hours) or metoprolol (50 mg every 6 hours) for the first 48 hours, VT terminated significantly earlier in patients receiving propranolol (3 hours versus 18 hours with metoprolol) Ref: J Am Coll Cardiol 2018; 71:1897.

Irrfan’s emotions on battling cancer: “It’s been quite some time now since I have been diagnosed with a high-grade neuroendocrine cancer. I was part of a trial-and-error game. I had been in a different game, I was travelling on a speedy train ride, had dreams, plans, aspirations, goals, was fully engaged in them. And suddenly someone taps on my shoulder and I turn to see. It’s the TC: “Your destination is about to come. Please get down.” I am confused: “No, no. My destination hasn’t come.” “No, this is it. This is how it is sometimes.”

Delhi AQI improves

The AQI was between 441 and 447 from June 13 to June 15, which improved to 369 on June 16, indicating ‘very poor’ condition. On Sunday, it further came down to 289 while on Monday, it entered the ‘moderate’ category at 171.

Measures taken: All construction and demolition activities in Delhi were stopped till June 17. The agencies were also told to intensify other measures such as mechanical road sweeping, sprinkling water on trees, and implementing prohibition on open burning of waste.

AMR

Clostridium difficile, is one of those superbugs.  According to CDC data from 2015, approximately 453,000 cases of diarrhea and 29,000 deaths in the U.S. can be attributed annually to Clostridium difficile infection (CDI). CDI has become the most common healthcare-associated infection in the United States; and a hypervirulent strain (C. difficile 027/BI/NAP1) emerged in the early 2000s, resulting in even more morbidity, mortality, and costs.

Fecal transplantation: Replenish the good bacteria and control the disease-causing bacteria.  Fecal transplants have been incorporated into consensus guidelines for “people with two or more recurrences of CDI and for whom traditional antibiotic treatment has not worked.” Results have been far superior with fecal transplant as compared to antibiotic therapy, with resolution rates exceeding 80%

Diabetes

Diabetes

The study, published June 19 in the journal Annals of Internal Medicine, found evidence that a positive result for two standard diabetes markers in a single blood sample is a highly accurate predictor of diabetes and of major diabetes complications such as kidney disease and heart disease. Positive results for both glucose and HbA1c in one blood sample might be an acceptable alternative to the current two-sample standard.

Weather

Heat wave conditions are likely to prevail over parts of east India and coastal Andhra Pradesh during next 48 hours

Legal (Ira Gupta)

REFERRING THE PATIENT TO THE HIGHER CENTRE IS NOT A MEDICAL NEGLIGENCE

In the matter titled as “Suman Taneja versus Metro Hospital & Heart Institute & Others” bearing Complaint Case No. 1499/2015, the Hon’ble National Consumer Disputes Redressal Commission has vide judgment dated 02.02.2016dismissed the consumer complaint filed by the complainant seeking compensation of Rs. 2.5 Crores. While dismissing the said consumer complaint, the Hon’ble Commission has held that referring the patient to the higher centre is not a medical negligence and also that the doctors should not be dragged to court unnecessarily on frivolous grounds which prevent them from discharging their duty to a suffering person who needs their assistance utmost.

Facts of the Case:

On 14.05.2015, at about 5 AM,  Mr. Anil Taneja, 57 yreas of age  (since deceased herein referred as a “Patient”) approached Metro Hospital & Heart Institute, Haridwar (OP-1) for chest pain as an emergency. Dr. Abhilash Kumar Gupta,(OP-2) a cardiologist examined him and diagnosed as a case of Inferior Wall Myocardial Infarction (IWMI). The patient was kept under observation in CCU, prescribed few medicines including Injection Mirel 18 mg worth Rs. 29,500/-.  But, shockingly OP-2 refused to treat him with routine stenting, because he was to leave for holiday. The attendants of patient begged mercy to OP-2 to save the life of the patient but, no avail. Due to the negligent attitute, valuable golden time was wasted. Therefore, patient had to run to another hospital in Dehradun from Haridwar covering a distance of 52 kms. Ambulance was not available immediately; it has to come from Dehradun. Due to heavy traffic, it took four hours; patient with attendants reached Himalayan Hospital, Dehradun at around 01:00 p.m.   Thus, it was clear failure of OP- 1 and OP-2 to perform their professional duty and ethical obligation to attend the patient in the emergency. The patient died at 03:20 A.M.  Therefore, it was alleged that had the patient been treated properly by OPs at 05:00 a.m. on 14.06.2015 itself, he would have been alive today. Therefore, complainant Smt. Suman Taneja filed this complaint under section 21 (a) (i) of the Consumer Protection Act, 1986 on 21.12.2015. The complainant prayed for approximate total compensation of Rs. 2.5 crores. The complainant placed reliance upon few medical literatures.

Arguments on behalf of the complainant

  1. The counsel submitted that, the conduct of OP-2 inter alia, is violation of Rule 2.4 of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 that provides:

“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 on act of negligence that may deprive his patient or patients from necessary medical care.”

     2.      The counsel further argued that, OP-2 violated the Hippocratic Oath. For the emergency treatment, the act of OPs is against the Apex Court’s verdict in Parmanand Katara Vs. Union of India, 1989 (4) SCC 286, held, “law courts will not summon a medical professional to give evidence, unless the evidence is necessary.”  The counsel further contended that, this instant case is covered by principles of res ipsa loquitur. The OP-2 being a specialist in cardiology working under the expert like Dr. Puroshattam Lal (OP  4) failed to perform  stenting immediately, which any other prudent cardiologist would do.

Judgment of the Hon’ble Commission

“7. We do not find any force in these arguments. Patient suffered IWMI, it was a cardiac emergency and he was in a critical stage. After diagnosis, the OP-2 rightly treated the patient by thrombolysing agents. Due to non-availability of cardiologist, he has referred the patient to the higher centre. Referring the patient to the higher centre is not a medical negligence.

8. No doubt, the OP hospital is a Heart Institute, but has few cardiologists. The   hand written Case summary clearly reveals, that it was a case of CAD/acute IWMI + RVMI with shock. The patient was thrombolysed with reteplase with explained reasons. The primary (Percutaneous Coronary Intervention) PCI was not done due to non-availability of cardiologist, with explained consent and patient was referred to higher centre. It should be borne in mind that, every cardiologist is not capable or experienced to the extent to perform PCI.  Therefore, we do not find the OPs breached in their duty of care or there was deficiency on the part of OP2 who referred the patient to higher centre due to non-availability of cardiologist. As per medical record, the patient was given proper care during the emergency. The lab investigations also revealed high blood urea (141 mg) and creatinin 1.8 mg, thus there was renal impairment also. Ideally, PCI would be conducted within 6 to 48 hours after thrombolisation and after normal renal function test. Therefore, we are of considered view that, the decision taken by OP2 to refer patient to higher centre was proper.

9. We rely upon the landmark judgment from the bench comprising Hon’ble Justices Dalveer Bhandari and H S Bedi of Hon’ble Supreme Court  in the case Kusum Sharma & Others Vs. Batra Hospital & Medical Research Centre & Others (2010) 3 SCC 480; dismissing a complaint held that

“Consumer Protection Act (CPA) should not be a "halter round the neck" of doctors to make them fearful and apprehensive of taking professional decisions at crucial moments to explore possibility of reviving patients hanging between life and death." Also said that “Doctors in complicated cases have to take chance even if the rate of survival is low. A doctor faced with an emergency ordinarily tries his best to redeem the patient out of his suffering. He does not gain anything by acting with negligence or by omitting to do an act,” It further observed as, "It is a matter of common knowledge that after some unfortunate event, there is a marked tendency to look for a human factor to blame for an untoward event, a tendency which is closely linked with the desire to punish,”

10.    Doctors should not be dragged to court unnecessarily on frivolous ground which prevents them from discharging their duty to a suffering person who needs their assistance utmost. On the basis of forgoing discussion, we are not satisfied that the damage had been caused by OP-2’s deficiency or negligence. Therefore, the instant complaint is dismissed at admission stage.”

Happy Wednesday

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