Morning MEDtalks with Dr KK Aggarwal 2^nd July 2018

Watching late night competitive sports

Watching the World Cup can kill you if you indulge in late nights, beer, bad food and end up with  roller coaster excitement via triggering a heart attack. It is especially risky for men with an underlying heart blockages when watching their favourite teams, studies suggest – but winning ways could have an unexpected bonus for society.

Staying up late for games, lounging on a sofa for hours and snacking on fast food loaded with salt, fats and carbs all put more stress on the heart and affect blood pressure, not to mention the risk of a heart attack for soccer fans amid an emotional roller coaster as their teams battle it out in Russia.

Late nights, excessive drinking and snacking are not good for heart health.

During the 2002 World Cup, Hong Kong’s Queen Mary Hospital saw 22 admissions for acute cardiovascular events, while in the same period the following year there were 15 and in 2004 just 11.

Three landmark judgements that will change the practice of medicine

Practicing medicine has become very challenging today; more so because the doctor has to be equally well-versed in legal aspects as much as he is required to be proficient in his clinical knowledge. It all started with Anuradha Saha case with over 12 crore compensation that all doctors started talking about impact of medicolegal cases in clinical practice.

1. A doctor cannot delegate the duty of taking informed consent to his junior staff. Last year, the Supreme Court of Pennsylvania in Shinal vs Toms, 162 A.3d 429 (Pa. 2017)has held that “the duty to obtain informed consent belongs solely to the physician and that it is non-delegable… a physician may not delegate to others his or her obligation to provide sufficient information in order to obtain a patients informed consent. Informed consent requires direct communication between physician and patient, and contemplates a back -and -forth, face-to-face exchange, which might include questions that the patient feels the physician must answer personally before the patient feels informed and becomes willing to consent. The duty to obtain the patients informed consent belongs solely to the physician.”

2. The UK Supreme Court took quite the opposite stance to Samira Kohli vs Dr Prabha Manchanda on informed consent in the matter of Montgomery v Lanarkshire Health Boardin 2015. Subsequent to this judgement, Bolam test has legally become an ineffective tool to establish standard of care in cases of alleged medical negligence. It allowed the doctor the right to withhold information about risks associated with the proposed treatment, if he believes that the particular treatment is the only hope for a cure for the patient. Post-Montgomery judgement, doctors in the UK have now to take care now that “the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments”. The test of materiality would be whether “a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it." “The “therapeutic exception” is not intended to enable doctors to prevent their patients from taking an informed decision. Rather, it is the doctor’s responsibility to explain to her patient why she considers that one of the available treatment options is medically preferable to the others, having taken care to ensure that her patient is aware of the considerations for and against each of them.” This ruling has also taken away the therapeutic privilege of the doctor.

3. In the case of Dr Hadiza Bawa-Garba vs GMC, the UK Supreme Courtcharged Dr Hadiza Bawa-Garba and two nurses with manslaughter by gross negligence for the preventable death from sepsis of a 6-year-old boy with Down syndrome in 2011. Her name was erased from the medical register following an appeal by the GMC. She was held responsible for a sequence of failings.

1. “She did not recognize the early features of sepsis in the child and as such appropriate antibiotic treatment was delayed.
2. She appeared not to recognize the implications of seriously deranged blood gas results and failed to fully communicate the implications to her consultant.
3. When the child suffered a cardiac arrest there was a further problem as the patient was wrongly identified as another child for whom a DNACPR order applied.

Inquiry revealed that multiple errors and failings contributed to the mishap. No one cause could be found that led to the death of the patient.

1. Dr Bawa-Garba had only recently returned to work following maternity leave
2. She was covering the work of another registrar, with her supervising consultant teaching on a different site, and the two junior colleagues, for whom she had supervisory responsibility, had no pediatric experience.
3. She was expected to review unwell patients and perform procedures on six wards over four floors, field the GP calls and struggle without a functioning IT system.
4. The patient was shifted to a bed previously occupied by a patient with a DNR order; that change had been made without her knowledge. She was blamed for failing to recognize this.”

This judgement discounted system errors that may have contributed to the death of the patient. It also shows that “to err is human” can no longer be a defence, at least in the UK for the time being. But this is a case that is waiting to happen in India.

Diabetes pollution link

According to the journal Lancet Planetary Health, even low pollution levels can pose a health risk like diabetes and that reducing pollution may lead to a drop in diabetes cases.

The researchers looked at the particulate matter, airborne microscopic pieces of dust, dirt, smoke, soot and liquid droplets, to evaluate air pollution. In diabetes, pollution reduces insulin production and triggers inflammation, preventing the body from converting blood glucose into energy that the body needs to maintain health.

The Lancet Infectious Diseases: Study highlights diagnostic delays and inappropriate treatment of meningitis

Viruses are the most common cause of meningitis in adults aged 16 and older in the UK, according to new research published in The Lancet Infectious Diseases journal. Although generally seen as a benign condition, this new observational study shows that recovery from viral meningitis can be a long haul for patients, with many still experiencing memory and mental health problems months after they are released from hospital.

Importantly, the findings also reveal substantial delays in diagnostic testing and unnecessary treatment in hospitals across England, which are associated with longer hospital stays.

1. The median time from admission to a lumbar puncture to distinguish between bacterial and viral meningitis was 17 hours - in a quarter of patients it took more than 29 hours. Ideally the puncture should be completed within a few hours
2. Lumbar puncture is often postponed until patients have been admitted to a ward.
3. Additional delays of several days can also occur if samples are sent to offsite laboratories for analysis.
4. Viral meningitis usually get better in a few weeks, while bacterial meningitis can kill within hours and requires urgent treatment with antibiotics.
5. Results showed that unnecessary treatment with antivirals was associated with longer hospital stays - with patients infected with viral meningitis who did not have treatment staying for an average of 3 days compared with 9 days in those treated with antivirals (because most had intravenous treatment requiring inpatient care).
6. The chances of having a pathogen detected in viral meningitis reduced by 1% for every hour delay in lumbar puncture following admission

Components of informed consent: Watch https://www.facebook.com/drkkaggarwal/videos/1878828148805146/

Participate in survey on Inflammatory bowel disease

https://docs.google.com/forms/d/1SAbiZpxKIqt6bWixE3J-1ZB7VPH-Z530tmAgseQLK4g/edit

Four-hour target in emergency departments 

Was introduced by the Department of Health for National Health Service acute hospitals in England. The original target was set at 100%, but lowered to reflect clinical concerns that there will always be patients who need to spend slightly longer in A&E, under observation.

Setting a target that, by 2004, at least 98% of patients attending an A&E department must be seen, treated, and admitted or discharged in under four hours.

The target was further moved to 95% of patients within four hours in 2010 as a result of the coalitions claims that 98% was not clinically justified.

Trusts which failed to meet the target could be fined.

In January 2017 it was announced that the target would in future only apply to "urgent health problems".

In January 2018 only 77.1% of patients were admitted or discharged within four hours, the worst ever performance for type one A&E departments.

1. Vale for COPD: (Reuters) - The US FDA has approved Pulmonx Inc’s valve to treat a severe form of obstructive lung disease, most often characterized by shortness of breath. The tiny, cylindrical valve is permanently implanted using a catheter in the affected part of a patient’s lung and regulates the airflow to the healthier parts.
2. Oxytocin shortage

Dear Dr Aggarwal, please see the following Public notice regarding stoppage of sales of Oxytocin from retail chemist shops & manufacture by private Cos. Only Karnataka State Antibiotic Limited Public sector co will be allowed to manufacture it. Ban comes to force on 1st July 2018

Oxytocin has been used medically for prevention of Post-Partum Haemorrhage as well as induction of labour and shortening labour promoting Active Management, of Third Stage of Labour preventing PPH. Oxytocin has been misused in Dairy for letting down milk to the maximum. Injections are given just before milking.  

Whether preparation with alternatives has been done in terms of training of health personnel engaged in conduction of delivery and dealing with complications of bleeding (PPH)& adequate availability of alternative medicines e.g. misoprostol. 

We need to check the situation on the ground. Bleeding is one of the significant causes of Maternal Mortality. Under no circumstances women should suffer from failure to access essential medicines that they need. Definite action is needed to prevent misuse of Oxytocin in Dairy animals as well as Antibiotics in animals, fish poultry to prevent emergence of Anti-microbial Resistance.

Any new product must have ensured safety, efficacy & affordability and rational use in the field conditions, which as you well know inspite of so many decades after independence are in dire need for improvement. (Dr Mira Shiva)

Letter to the editor

Work hour limitations in the case of pilots, truck or any vehicle driver or any factory/worker, or even the doctors must be limited to 8 hours as the fatigue starts setting in. If the employer wants quality out-put, there should not be more than 8 hours of continuous duty except for occasional and demanding conditions. In the case of medical practice, increase the number of resident doctors on duty and the rotation may be overlapping so that the successor does not have any difficulty in understanding the patient sickness.

The problem in India is that of non-availability of hands for putting on three shifts, while the funds may be with the employers to pay wages for the three shifts. Mind it, the employee doctors, pilots, drivers, and other office/factory workers have their social responsibilities towards family and society besides the advised sleep of 8 hours which must not be ignored when talking of capping the limit of working hours higher than the bearing capacity of the physiology of man.  

When, we in India shifted from socialist to capitalist economy the industrialists wanted to raise the working hours from 8 to 12 hours and it was opposed tooth and nail. (G C MathurConvenor-Trustee Treasurer, Binty)

FICCI Healthcare Excellence Awards

Due to increased interest for participation this year, and large number of individual requests for date extension, the Awards committee have agreed to extend the deadline for submission of application to 6 July 2018 till 1800 hrs. In case of any query, please feel free to reach out to us at +91 9654631600:  

Shobha Mishra Ghosh 

Dr KK Aggarwal

Padma Shri Awardee

President HCFI

Vice President CMAAO