Chance, Destiny and Design

Compared with several tragedies claiming far more lives, the recent accidental crash of an air-ambulance killing several of its occupants and 3 residents has occupied a disproportionate chunck of media attention and evoked strange emotions from citizen.

At the heart of the issue is the human tragedy of a 20 year old young IIT aspirant boy suffering from acute liver failure whose chances of pulling through without a liver transplantation were minimal, and who was being air-lifted to a premiere hospital in Delhi for this heroic and costly treament. What adds to the sense of tragedy is that in a desperate bid to save thier dying son, the family had staked all their fortunes into his treatment (cost of air ambulance Rs 3 lac, cost of liver transplantation at Apollo hospital Rs 21 lac), and sent a young healthy cousin accompanying Rahul in the plane, who died as well, doubling the family’s toll.

Was Rahul, in hindsight, destined to die at this young age? He seems to have been unlucky on several counts: he was among the rare 1% (chance) to come down with hepatitis from every 100 who get exposed to the virus (A or E) that spread in summer months through water or food. He was further extremely unlucky to be among the rare 2% (chance) of young people who slip into liver failure and coma while suffering from hepatitis, from which 98% recover spontaneously.

And at the very last, when the family was striving desperately to save Rahul, his death while being air-lifted seems most unusual (one in a million chance) as civilian air-ambulance crashes are extremely rare, making the “Theory of Chances” look unconvincing.

Also, each desperate attempt by Rahul’s family to change the course of events seemed to have led to further losses. Apart fom Rahul’s cousin, another 7 people, mostly young with their own aspirations and futures, and unconnected with Rahul, died with him. These were 2 young doctors and a male nurse working in the emergency services of Apollo Hospital, Delhi, 2 pilots and 3 women living peacefully in their Faridabad homes, till Rahul’s fate got entwined with theirs.

When too many rare events occur in a cluster, and seem to defy the laws of chance, two lines of explananation begin to emerge: a “Conspiracy theory” in the West and the role of “Destiny” in the East.

While a “conspiracy” theory, in this case, would hardly have any takers even amongst the die-hard paranoids, most would invoke the role of “Destiny”, an ill-understaood phenomenon that accounts for whatever occurs beyond the fringes of chance.  “Destiny” cannot be explained it by the laws of science known to us today. When it begins to touch our lives, we often realize that it usually defies logical deductions, and often seems to have a design and a regulatory force that shapes it. Some may call this cosmic force, God.

As published in HT City( Hindustan Times) dated 29 May, 2011.

The White Coat

The familiar white coat worn by physicians as their distinctive dress for over 100 years, has been courting controversies lately.

It has been observed that patients who have their blood pressure measured in a clinic or hospital by a white-coat-wearing-doctor have higher readings than they do when measured at home by their relatives.  This is apparently due to the anxiety that the white coat and the hospital setting seem to evoke in patients, and has been termed “White Coat Hypertension”. Mature clinicians often routinely subtract a few points from these measurements when entering records in case charts or calculating the dose of anti-hypertensive medications to be prescribed.

Anxiety is also apparent in children who encounter pediatricians wearing the unfriendly white coat.  Kids often express their dislike for this dress by crying and screaming in protest. Casually attired personnel are more often allowed by small children to have access to their bellies or chest for examination. Many pediatricians across the world have folded up their white coats and taken to informal colourful dressing to get closer to their little patients and win their cooperation.

Sounds of protest are pouring in from psychiatrists as well, often portrayed as cold insensitive “clinical” people, dissecting human feelings and forcibly dragging their emotionally disturbed patients to the horrific “shock chambers”. Their reason for a changed dress code is to break their stereo-typed image.

The ‘white coat’ or the ‘lab coat’ is a knee-length overcoat worn by professionals in the medical field or those involved in laboratory work to protect their street close, symbolize professionalism and indicate a closeness to science. The modern white coat was introduced to medicine in Canada by Dr. George Armstrong (1855–1933) who was a surgeon at the Montreal General Hospital and President of the Canadian Medical Association. It was used in the late 19^th century by physicians to represent themselves as scientists, from whom they borrowed the dress, in contrast to quacks, faith-healers and butcher-surgeons who wore the black coats.

In sharp contrast to what the mutinous splinters might say of the white coat, opinion of patients and the public seem to be overwhelmingly and unwaveringly in its favour. A recent study conducted in the United Kingdom found that the majority of patients preferred their doctors to wear their white coats. Patients feel more confidence in doctors who are “professionally” attired than those dressing casually in jeans and T-shirts.

A white coat ceremeony (WCC) is a relatively new ritual that marks one's entrance into medical school and, more recently, into a number of related health- professions. It originated in Columbia University’s College of Physicians and Surgeons in 1993 and involves a formal "robing" or "cloaking" in white lab coats.

Over the last century, the white coat has protected not just the clothes of doctors but their staure in society too, and given them their distinct identity to represent “care” and professionalism as well. Those who wear it must do so with suitable dignity and uphold what it represents.

As published in HT City (Hindustan Times) dated 22 May, 2011.

Funny Ways to Remember Serious Stuff

Ever wondered how a medico transfers information on 226 human bones, 605 muscles, 800 diseases and 1200 medications, contained in 40 kg of medical books, to his brain and stores it as memory?  It is through a very useful memory-aid technique called Mnemonics.

A mnemonic is a catchy verbal phrase, word, poem or song that helps a person remember something. Take for instance the tongue-twisting names of the 8 wrist bones: Pisiform, Triquetral, Lunate, Scaphoid, Trapezium, Trapezoid, Capitate and Hamate. How on earth would a young fresher remember them and in that order had it not been for the mnemonic “Please Take Lovely S’onia’.To The Coffee House”.  What adds to the fun in the anatomy class is the freedom to improvise and use the name of one’s favourite “S”from the class girls, thereby etching the names of the carpal bones to one’s memory for life.

Home-made Indian versions are often more exciting. Medicos across the Hindi speaking belt prefer “Sneh Lata Tinde Paka, Tinde Tho Kachhe Hain” to remember the same 8 names, albeit in an opposite sequence,

The word ‘mnemonic’ is derived from the ancient Greek Goddess of memory “Mnemosyme”. Experts describe 2 types of memory, the “natural” one that we use every day, and an “artificial” one that is trained through learning and practicing a variety of mnemonic techniques, the type that doctors use.

What makes mnemonics so amusing and memorable are their regional flavours and arbitrariness. Americans remember the names and sequence of the 12 cranial nerves that originate in the brain (Olfactory,Optic, Oculomotor, Trochlear,  Trigeminal,  Abducens, Facial, Vestibular/Auditory, Glossopharyngeal, Vagus, Spinal-Accessory and Hypoglossal) with “ Oh! Oh! Oh!, To Take a Family Vacation, Go Vegas After Hours”, while Europeans prefer “ On Old Olympus’s Towering Tops a Finn And a German Viewed Some Hops”.

Mnemonics seem more popular in medicine than in any other branch of learning, accounting for more than half of the million results that a google search throws up for the word, and help us remember details that have no logic. How does one remember the day of fever on which a skin rash appears in an exanthematous illness, but for the mnemonic “Very Sick People Must Drink Tea Twice” indicating Varicella (chicken pox) on day 1, Scarlet Fever day 2, pox (small pox) day 3, Measles, day 4, Diphtheria, day 5, Typhoid, day 6 and Typhus, day 7.

Perhaps a better known form of mnemonic is an acronym, a sequence of letters to remember as a word or a catchy sequence. The ABC of resuscitation in an emergency, for instance, stands for securing a free Airway, ensuring Breathing, and an adequate Circulation, while DUMBELS (diarrhea, urination, meiosis, bradycardia, excitaion of muscles, lacrymation, and salivation) denote the symptoms of poisoning.with an organophosporous pesticide.

Tailpiece: Heard of the anatomy teacher who coined the mnemonic “Possible To Remember The Names Of All My Kids” to remember the names of his 9 children?. .

As published in HT City ( Hindustan Times) dated 15 May, 2011.

Medical Accidents

If the thought of visiting a hospital makes butterflies flutter in your stomach, you are neither alone nor is the fluttering without cause!  Hospitals are accident prone zones, and often the news or memory of an adverse experience someone has had while in hospital might be the cause for your unconscious anxiety.

The World Health Organization estimates that an accident might be occuring in as many as1 in 300 patients admitted to hospital, ranking 10^th among the causes of hospital deaths. It accounts for approximately 30,000 deaths in the USA alone.  Compare this with 1 in a million (1,000,000) , the rate of accidents that occur in the airline industry, presently considered one of the safest.

Don’t get me wrong and start imagining that hospitals gobble up a large number of healthy lives of cheerful people going on a holiday. In most instances, these are critically sick people on the proverbial razor’s edge, who often tumble downhill after an intervention that retrospectively seems to have tilted the balance against them. Misadventure all the same!

What causes these accidents?

Human errors account for around 40% and can arise from simple errors like entering a patient’s blood group or allergies incorrectly in the file, to more complex errors like chosing and performing a wrong operation that proves    overwhelming for the patient. Human errors are ubiquitous and occur in every organization that depends on human beings, but their imapct and consequences are never felt more than in the airlines and medical industries. The quality of recruits, their training, commitment, wellbeing (both professional and personal), monitoring and supervision are key factors.

It is not difficult to observe how quality can be compromised at several levels. The recent media exposes of “fraudulent” pilots, who did not qualify through merit and did not receive adeqaute training, yet made their way into the airlines industry, sent shivers down our spine. The concern it generated probably stems from imagining ourselves on board a flight 10 km up in the skies with the flight’s controls in the hands of an untrained pilot, flying us to a collective doom. Human medical errors may not cause “mass” deaths but “serial” misadventures, some of which may turn fatal. In hospitals, disaster often strikes when the paths of an ill-fated patient and a careless overworked doctor cross! 

Technical errors are the 2^nd most common. If you recount the last 10 airline accident news-reports, you will realize that most occurred due to technical snags with engines or “systems” letting them down; the recent Pawan Hans helicopter crashes are a case in point. Hospitals are no exception; despite measures that are locally feasible, malfunctions in hi-tec equipment do occur.  Senior doctors point out that in the old days medicine was ineffective but safe whereas today's powerful treatments are effective but risky.

The 3^rd cause is “Organizational Failure”. The airlines industry is much ahead in monitoring and tracking quality of performace of all categorie of its staff in an ongoing continuous mode, an area where hospitals are lagging far behind. The institutes of mangement and hospitals could work together and find solutions to some of these vexing problems.

As published in HT City ( Hindustan Times) dated 8 May, 2011.

Are Artificial Sweeteners helping you lose Weight?

If you have been trying to reduce weight by substituting sugar with low-calorie artificial sweeteners, and not shrinking much, you are not alone!  Recent data shows why things may not be working out as well as we had imagined.Sugar containing sweets do cause rapid rise in blood sugar levels, something that diabetics need to avoid. A wide range of sugar substitutes are now available to add a measure of sweetness to their lives and for their taste buds. They can now eat all types of mithai, kheer, pastries baked goods, soft drinks, candy, puddings, canned foods, jams and jellies, dairy products, and scores of other foods and beverages. Artificial sweeteners are attractive alternatives to sugar because they add virtually no calories to your diet. In addition, you need only a fraction compared with the amount of regular sugar you would normally use for sweetness.

If however losing weight is your target, artificial sweeeteners have not delivered as well as predicted. Despite the switch to these expensive products, the needle on your weighing machine may seem stuck for months, or worse, move further right.

Doctors at the Mayo Clinic have been trying to study this unexpected phenomenon, and are pursuing several lines of research. Some artificial sweeteners enhance appetitite thereby making you eat more. There could be a psychological element too, as you may be eating 2 pastries instead of one, once you are aware that they are low-cal.  

Another explanation is that the brain needs to sense sugar in the blood to turn off hunger; as artificial sweeeteners are calorie-less, hunger persists making us gorge more, making the other components in a pastry, such as starch and fat, push our weight up.

There are 3 broad groups of sweeteners in use today. The 1^st group is artificial sweeteners, and include Acesulfame potassium (Sunett, Sweet One), Aspartame (Equal, Sugar Free Gold, NutraSweet), Neotame, Saccharin (Kaltame, Sweet'N Low) and Sucralose (Splenda, Sugar Free natura). While some give an after-taste they are generally safe, contain no calories, and do not cause tooth decay.

The 2^nd group is that of sugar alcohols (polyols) that occur naturally in certain fruits and vegetables but can be manufactured as well.  They are not intense sweeeteners, contain some calories (though much less than sugar) and are considered “healthier”.  Examples are Erythritol, Lactitol, Mannitol, Sorbitol and Xylitol. They may cause loose stools and could be of help to habitual constipators.

The 3^rd group consists of natural sweeteners such as date sugar, grape juice concentrate, honey, maple sugar, maple syrup, molasses and agave nectar. They contain calories, as does your refined sugar, and cause tooth decay, but serve the dual functions of a sweetener and a flavouring agent, especially for some dishes.

If I have left you wondering which one to choose, here is my advice. Don’t stick to one but try a mix-and-match approach to suit your palate and your needs. Balance will still remain the key. Bon appetite!

As published in HT City (Hindustan Times) dated 1 May, 2011.