Morning MEDtalks with Dr KK Aggarwal 27th August 2018

Total volatile organic compound (TVOC) levels are an important indicator of the overall air quality in a building. Volatile organic compounds (VOCs) are gaseous molecules that can be sampled quickly and non-invasively from breath. They can originate either from within the body (endogenous VOCs) or from external sources such as diet, prescription drugs and environmental exposure (exogenous VOCs).

TVOC level is a measurement of the sum of all of the volatile organic compounds found in an air sample. It does not distinguish between chemicals that may be toxic and those that are not, so in addition to looking at the TVOC levels, the levels of the individual chemicals found in the air sample should be evaluated.

There are no regulatory standards for TVOCs so these levels should serve as a guideline.

Breast milk donation is the new wave and a concept. We often hear about the need for blood donations, but there is also a need for breast milk donations. Mayo clinic is asking for breast milk donations for fragile infants. Giving milk, can save a life. To be a donor a woman must be in good health, a non-smoker and willing to give at least 200 ounces of milk. Human Milk Banking Association of North America (HMBANA) has 26 non-profit member milk banks in the United States and Canada. HMBANA dispensed more than 5 million ounces of donor milk from more than 9,000 donors in 2016—which was a 20 percent increase over the prior year.

Milk banks are responsible for screening donors and processing, pasteurizing, and dispensing the collected milk. Hospitals decide which babies qualify, and it’s only given with a doctor’s prescription. This is used for the highest-risk babies in the most critical time.

Johnson & Johnson kept regulator in dark. The Indian arm of Johnson & Johnson suppressed key facts on the harmful aftermath of surgeries conducted on hundreds of patients in the country using faulty hip replacement systems it imported and sold. It did not inform the national regulator about the exact number of patients who used these devices, the adverse reports following such surgeries and the corrective operations subsequently conducted. It also did not provide any compensation to those affected. These findings form the core of a report prepared by an expert committee set up by the Union Ministry of Health & Family Welfare. The committee, which was set up on February 8, 2017, submitted its report on February 19, 2018. The Government is yet to implement the recommendations.

The report states that over 3,600 patients with the faulty implants remain untraceable, and that at least four deaths have been reported from those who underwent surgeries using these devices.

The committee has recommended that J&J be made liable to pay at least Rs 20 lakh to each affected patient, and that the reimbursement programme for revision surgeries should continue until August 2025.

J&J imported and sold ASR XL Acetabular Hip System and ASR Hip Resurfacing System in the country — these devices were globally recalled in 2010.

The committee concluded: “…the ASR hip implants were found to be faulty, which resulted in higher revision surgeries”; the “…accelerated wear of metal on metal implant leads to higher levels of cobalt and chromium in the blood which lead to toxicity… these metal ions damage tissues and further damage body organs” and “may also cause localised and systematic health problems”. All of this, the panel found, “results in increased pain and decreases mobility affecting their family and social life” and has “a negative impact on their self-esteem and mental health”.

J&J’s hip implant devices, manufactured by its subsidiary DePuy Orthopaedics Inc, were first cleared by the United States Food and Drug Administration (USFDA) in 2005. Following red flags on the rising number of revision surgeries, the firm recalled the devices on August 24, 2010. (Excerpts from Indian Express)

A miracle plant can cure diabetic ulcers, as reported in TOI Rajkot. Let us talk about the plant. The signs of Dushta Vrana (chronic wound) mentioned in the classics are Ativivrita (broad base), Bhairava (ugly look), Putipuyamansa (pus discharge), Gandha (foul smell), Vedana (pain), Dirghakalanubandhi (chronicity).

Sushruta has mentioned prognosis of diabetic wound as “krichrasadhya” (difficult to treat).

According to Acharya Sushruta among the 60 measures of wound treatment, “Kalka” (application of paste) is a measure indicated for non-healing wounds located in muscle and having slough. The paste performs both functions of “Shodhana” (cleaning) and “Ropana” (healing).

Katupila (Securinega leucopyrus) leaves have Kashaya rasa, which provides Lekhana (scraping) that helps to slough out necrosed tissue and preparing the wound for healing. Kashaya rasa has Grahi and Stambhana properties which helped to stop discharge from the wound. (J Ayurveda Integr Med. 2014 Jan-Mar; 5(1): 60–63.)

In 2016, researchers at Israel’s Tel Aviv University concluded that a large whey protein breakfast may help people manage type 2 diabetes.

Delhi High Court has directed MCI to frame sentencing policy for delinquent doctors

Advocate Ira Gupta: In the matter titled as “Ravi Rai versus Medical Council of India, WP (C) No.10506/2017 and WP(C) No. 10625/2017”, the Hon’ble High Court of Delhi vide order dated 20.08.2018 has directed Medical Council of India (MCI) to frame sentencing policy for delinquent doctors for the infractions committed by them and the said sentencing policy shall be a guidance for the Committee which are tasked with job of returning recommendations both, on the guilt and punishment to be accorded to a delinquent doctor.

Facts of the case

1. Mr. Rai, on sustaining an injury to his lower limbs and lower back, was admitted to the Fortis Hospital on 19.06.2016, under the supervision of Dr. Maichand, Senior doctor, and Dr. Kakran.
2. On 19.06.2016, an X-Ray was carried out vis-a-vis Mr. Rais right foot followed by CT-Scan of the same foot on 20.06.2016.
3. An X-Ray of Mr. Rai’s left foot and backbone was conducted on 20.06.2016. On that very day, a CT-Scan of Mr. Rais backbone was also carried out. The diagnostic test carried out revealed that the bone in the right foot had broken into many parts. In other words, it was a condition of comminuted fracture. Consequently, a decision was taken to perform a surgery on Mr. Rais right foot. He was informed that the surgery would involve fixation of screws, followed by a plaster-of-paris cast.
4. The X-ray of the left foot and the backbone revealed that Mr. Rai had suffered a fracture in these two parts of his body as well.
5. Mr. Rai undertook two physiotherapy sessions despite the X-ray showing that he had fractured his spinal cord. The Physiotherapist, Dr. Dipti Jha, indicated that she was not informed that Mr. Rai had suffered a fracture in the left foot and the spine.
6. The anaesthetist, Dr. Yatish Sharma, was also informed only about the fracture in the right foot.
7. Prior to the surgery, the right foot was marked, as the plan was to perform surgery only on that foot.
8. The WHO-Check list, though, showed a marking made on the left side, the case record at page 52 showed that certain parts had been scored out. According to the DMC, both suggested tampering of records.
9. No consent of Mr. Rai was obtained, prior to the surgery with regard to the possibility of the operation being performed on the left foot. The DMC found that there was “un-displaced” fracture calcaneus on the left foot, which would have united or fused after eight (8) weeks, even if surgery was not performed.
10. Dr. Maichand had admitted before the DMC that he and Dr. Kakran worked as a team and that even before the surgery, a decision was taken by the two of them to operate the left foot, in case excessive swelling was found on the right foot. It was also found by the DMC that Dr. Maichand had not conveyed this aspect either to Mr. Rai or the Anaesthetist, Dr. Yatish Sharma.

Issue before the Hon’ble High Court of Delhi

1. First, whether MCI was right in exonerating Dr. Maichand completely?
2. Secondly, whether punishment accorded to Dr. Kakran was commensurate with the extent of its culpability?

Judgment of Hon’ble High Court

“25) As a result of these acts of omission and commission, Dr. Maichand, in my view, not only contributed to the avoidable trauma but also to the surgery being performed on Mr. Rai’s left foot, which as per findings recorded by the DMC, would have healed after eight weeks, even if no surgery was performed. An aspect which was not disputed by Dr. Maichand in his deposition before the DMC. Furthermore, as alluded to above, Dr. Maichand’s negligence, exposed Mr. Rai to trauma of not only having to undergo the surgery, which was not required to be done, including screws being inserted in the left foot which would have healed, even otherwise, naturally within eight (8) weeks, but was also, exposed him to the danger and after effects of receiving anaesthesia in a fractured spinal cord and undergoing physiotherapy sessions.

26) Therefore, for the foregoing reasons, I am unable to persuade myself that the decision of the MCI, insofar as Dr. Maichand was concerned, was correct. The MCI has, in fact, glossed over the findings of fact, recorded by the DMC, in its order. Thus, I am inclined to set aside MCI’s order dated 23.08.2017, insofar as Dr. Maichand is concerned.

27) As regards Dr. Kakran, the only grievance of Mr. Rai is with regard to the punishment accorded to him. In this context, I had asked Mr. Singhdev, who made submissions on behalf of the MCI, as to whether any policy had been formulated by the MCI, with regard to punishments to be accorded to delinquent doctors for infractions committed by them.

28) Mr. Singhdev informed me that no such policy had been formulated. In my opinion, this aspect needs to be looked at, urgently, by MCI. MCI must have a sentencing policy in place for guidance of its Committees which are tasked with job of returning recommendations both, on the guilt and punishment to be accorded to a delinquent doctor. The sentencing guidelines should take into account the aggravating and mitigating circumstances, including but not limited to whether or not the delinquent doctor is a first time offender or a repeat offender. MCI, is directed to report on this aspect of the matter within the next three months.

29) Having said so, in my view, the best judges of the conduct of a professional are his peers. The only area available to a Court for interfering with the punishment accorded to a delinquent doctor by his peers is where the punishment given is grossly inadequate or grossly disproportionate.”

Video to watch: TEDx Talks

Dr KK Aggarwal: Modern day doctor-patient relationship

https://www.youtube.com/watch?v=i9ml1vKK2DQ

Dr KK Aggarwal

Padma Shri Awardee

President HCFI

Vice President CMAAO