Pinch of salt!

The importance of common salt, essential not just for life but for good health especially in hot times is unfortunately often overlooked. The balance and concentration of sodium in our body, is one of the most delicately monitored and finely tuned body functions and is kept constant concentration of 0.9%.

Salt, also known as table salt, or rock salt is a crystalline mineral that is composed primarily of sodium chloride (NaCl), a chemical compound belonging to the larger class of ionic salts. It is essential for animal life in small quantities, but is harmful to animals and plants in excess. Salt is one of the oldest, most ubiquitous food seasonings and salting is an important method of food preservation. The taste of salt (saltiness) is one of the basic human tastes.

Most people expect a straight flat answer to the question “ How much salt should we consume each day?”. The National Academy of Sciences, USA, recommends that Americans consume a minimum of 500 mg/day of sodium to maintain good health. Individual needs, however, vary enormously based a person's genetic make-up, lifestyle, place of residence, climate and presence of other diseases.

As salt or sodium tends to retain water, people working outdoors on hot summer days for instance need a generous intake of salt to keep their blood pressures and from getting dehydated. A manual labourer working under the hot sun may require as much as 15 g of salt for day. It is this craving for salt that makes us relish the well salted cucumbers and kakris in railway stations or on the road side.

Our body’s hunger for salt is also reflected in our seasonal food preferences. A well salted “nimbu paani” or “mango pana” is often our preferred drink in the daytime, pickles and papads, rich in salt, tend to go down well with “daal chawal” and drinks such as Bloody Mary that are served with “salt bridge” are welcomed before meals at this time of the year.

Low salt levels in the body, or hyponatremia, often manifests as undue fatigue, lethargy, muscle pain and muscle cramps. The blood pressure may fall and the pulse may be feeble. In severe cases it may even cause drowsiness and death.

Our kidneys play a crucial role in regulating the body’s salt balance, conserving it if our blood pressure dips or exceting it through urine if there is excess. Restricting salt intake is usually beneficial for people with high blood pressure and in edematous conditions such as heart, kidney or liver failure when the body tends to retain salt and water. Checking the serum sodium level (normal range 135-145 meq/L) periodically can help ensure that one is in the safe zone.

If you have to go oudoors often and are feeling listless and tired these days, an extra pinch of salt could revive the zest to life. Try and feel the difference. 

As published in HT City ( Hindustan Times) dated 17 June, 2012.

Beware of Unnecessary Medications!

An elderly lady who had tolerated her mild symptoms of abdominal gas for decades, was suddenly metamorphosed to a vegetative state thanks to an unusual side effect of a newly launched drug for gaseousness!. The disturbing video of this lady, with shaking of hands and twitching of face, shown to a gathering of doctors in a meeting in Lucknow recently evoked a uniform surprise “Gosh, I did not know this could also happen!”. Dr Debnandan further shared information gathered from the net that several such instances of an ailment resembling Parkinson ’s disease have been reported with this agent, the disorder becoming permanent in many.

Adverse reactions to medicines do occur in a minority and every doctor faces them from time to time. What constitutes a tragedy is when the reaction is grave or life threatening while the indication for prescribing the medicine was mild.

Take for instance the side-effect of constipation that comes with many draugs such as pain-killers, anti-spasmodics or anti-depressants. It does not pose a danger to life, and if anticipated, can be prevented by co-prescribing a fibre laxative like Isabgol.

Liver damage can however be a fatal complication of some drugs, especially ones used for treating tuberculosis. I recall looking after an eminent scientist who developed jaundice due to anti-tubercular medicines for a mild chest infection. By the time he was brought to us he was deeply jaundiced, developed liver failure, went into liver coma and passed away despite all efforts. Very careful serial monitoring of liver functions is therefore mandated when drugs with potential to harm the liver are prescribed.

Another side-effect we dread is suppression of the bone marrow, a condition in which the white blood cells, platelets and red blood cell counts fall precipitously predisposing the patient to fulminant infections or bleeding. An antibiotic chloromycetin often prescribedfor typhoid fever, used to be the commonest culprit, It occurs nowadays with anti-cancer drugs, but may also occur with certain medications like azathioprine used for treating ulceartive colitis and auto-immune hepatitis.

In this case atleast, help has come from the laboratory. A blood test now helps recognize individuals prone to developing this complication, either based on their genetic make-up (genetic polymorphism in our jargon) or the level of enzymes that inactivate the drug (TPMT enzyme assay). Although somewhat expensive (around Rs 3000/-) getting it done before starting the azathioprine adds a dash of safety and is now internationally recommended.

Unfortunately such tests are very few while the list and inventory of drugs and the catalogue of their serious adverse reactions is sky-rocketing! What means do we then have to make our lives safer?

A useful dictum is to give home remedies a try first and resist the tempation of popping a pill for every minor discomfort. Doctors need to avoid prescribing more drugs than absolutely necessay and remember that old trusted medicines are often safer than the new ones touted as magic cures.

As published in HT City( Hindustan Times) dated 10 June, 2012

Deodorants and Sweat Connection!

The deodorant spray, the next gen’s all too familiar “deo”, may be the cause of our excessive fatigue and exhaustion during hot summer days.

Deodorants, meant to tackle the bad body odour especially from the underarms, do so by two methods. One is by killing the germs that colonize in these warm moist sites and break down secretions into smelly substances. Almost all deos are therefore antiseptic agents of a sort, containing some form or other of spirit, natural oils and perfumes. They work to keep us feeling clean and fresh.

Many deos however are anti-perspirants as well, and work by blocking the secretion of sweat from the sweat- glands. This variety of sprays has become trendy as they make the skin look cool and dry even on sweaty days. They prevent the embarassing wet dark maps from appearing on the shirts, and make us stink less as there is less soaking of clothes with skin secretions.

While many use the terms deodorants and anti-perspirants interchangably, they are not the same. Anti-perspirants work to stop perspiration from occuring. Deodorants allow perspiration, and work to kill the bacteria that causes odor when we perspire.

While anti-perspirants keep the skin and armpits dry and clean, they block the body’s vital cooling mechanism, allowing it to get heated up. Heat stroke and heat exhaustion occur when the body’s temperature rises well above its normal of 37⁰C and it finds itself unable to dissipate heat into the atmosphere.

 From a purely natural standpoint, it makes more sense for us to use deodorants as it allows the natural process of sweating to continue, a mechanism by which the body keeps itself cool when the outside temperature rises.

If you feel unusually exhausted and tired by noon or evening, check your body spray and ensure that you are using the right one. Anti-perspirants could be bottling up your body heat and causing your symptoms.

Further, anti-perspirants contain aluminium, a chemical that has come under scrutiny for a variety of health problems. High aluminium levels have been linked to seizures, breast cancer, kidney disorders and Alzheimer’s disease. Although very small quantities of aluminium contained in anti-perspirant-sprays cross the skin and reach the inner tissues, there is speculation whether even these small amounts could accumulate and cause disease when used for several years.

Most human achievements have come with toil and the proverbial sweat. The deleterious effects of blocking this symbol of hard work can extend well beyound our bodies to our social perception of human effort too. 

As published in HT City( Hindustan Times) dated 3 June, 2012.

Beating the heat before it beats you

The month of May, when the mercury soars to 45^OC in the northern plains, can play havoc with your health, energy levels, mood and performance.The hot blast that strikes our face when we venture out in the afternoon these days  can dry up our body (dehydration) or cause excess body heating (heat or sun stroke), both of which can be quite serious.

Dehydration is the commoner one, and claims around 2 million lives globally every year, especially from developing regions. Children are more susceptible, and once grossly dehydrated, often find it impossible to regain health.

Symptoms and signs of dehydration include fatigue, headache, low BP, dizziness, fainting, dry mouth and reduced amounts of concentrated urine. It is often precipitated by an attack of vomiting or loose motions, or sometimes, a fast. Drinking large amounts of water (around 6-15 glasses a day) and increasing the intake of salt (through pickles, papads, salted nimbu paani or lassi) are the cornerstones of prevention and treatment.

The hot air also tends to dry up or dessicate the nose and skin. Sunscreens are not of much help here as they protect only from sunlight and are not the antidote for dry hot blasts.Bleeding from the nose is not uncommon; a simple measure is to smear a moisturizer on your nose membranes. Using a moisturizer on the exposed parts of the body, especially the face, and ensuring a good intake of fluids, helps keep the skin in good turgor.

Heat stroke is common during these dry hot spells when the body’s heat regulatory mechanism fails to maintain a balance between heat production and heat loss. When the outside temperature grossly exceeds the body’s (37⁰C), we are unable to dissipate heat into the atmosphere by sweating, panting or passing urine. Therefore, when the outside temperature is 45⁰C the body temperature rises causing the person to be pale, hot, irritable, confused or unconscious. Children and elderly are at greatest risk, as are athletes, construction workers, labourers or miliatary recruits.

Heat stroke, as it is called, is a medical emergency and requires moving the person to a cool shaded place, lying him down on the floor or ground, pouring water on the head and body, placing ice cubes under the armpits and moving him to a clinic or hospital.

The reason why schools and institutions close during the peak summer period is to protect children and youngsters from getting heat stroke. Further, milder manifestations of exposure to severe heat causes fatigue, poor concentration, dizziness, cramps and fainting, when students can hardly be expected to perform well in scholastics or sports.

The hot summers therefore provide a unique opportunity to stay indoors, munch on salads and cucumber, drink lots of salted nimboo-pani and mathha, swim in the early mornings or late evenings, and use the major portion of the day to catch up on all the pending reading. 

Keep consoling yourself that whatever goes up must, come down.someday. So will the soaring mercury!

As published in HT City (Hindustan Times) dated 20 May, 2012.

GET QUIZZING

Sample these questions: “Which country held a parliamentary meeting under water to draw the world’s attention to environmental issues?” What are trans-fats and why are they a health concern? What killed Michael Jackson and Elvis Prisley?, By what proportion do diarrheal diseases come down if hands are washed well before meals?”. These were some asked in HOPE Quiz finals held in Lucknow on 7^th May in which teams from 45 schools participated.

Quizzing has always aroused the most excitement among students since HOPE startd reaching out to students in 2004. HOPE quiz 2012 started with an intra-school quiz that 75 schools of Lucknow hosted in April. The highest scoring 2 students were then invited to represent their school in a semi-final round, and from them the top 6 schools were chosen for the finals.

Most questions were aimed at assessing if the student had been reading the daily news-papers and probing inquisitively into health aspects. While almost everyone knew about the recent death of the great music maestro Jagjit Singh, few, for instance, knew that it was caused by brain hemorrhage due to uncontrolled high blood pressure? The issue assumes importance as high blood pressure is not uncommon among elders in most homes, and for students to be aware of the potentially fatal consequence of brain hemorrhage, if BP remains unchecked and ignored, may help prevent such events.

What students found most exciting was the video round, in which the template constituted short clips from movies. A scene from “Udan” depicted the hazardous influence of alcohol, tobacco and stress bringing on bullying and physical abuse. Another clip from “Vivah” was used to show how a carelessly fired rocket during Diwali, can enter a home through a window precariously left open, ravage a house, and plunge people into gloom.

In this keenly fought contest, St Agnes Loreto, represented by Bhavika Mehta and Advika Singh, emerged as the winner and Loreto Convent and La Martiniere for Boys as the runners up. But at the end of the day, everyone who attended the quiz was a winner as he went home with a handfull of new health messages that he would share with his friends and family back home.

As published in HT City ( Hindustan Times) dated 13 May, 2012.

Moonlight and the darker you

The suspicion that the moon might be affecting our moods and actions refuses to die down. A doctor colleague frantically approached me yesterday to seek help for an uncontrollable aggressiveness that he was experiencing towards his colleagues, patients, staff, and even his small child. When I opened the paper after having dispensed the usual advice to consult a psychiatrist, I realized that it was full-moon time, and that the moon had come as close to the earth as it possibly could.

One could argue that this was mere coincidence, but a possible link between the lunar cycle and its effect on mood and behaviour prompted me to explore the internet with Google throwing up 10 million results in a fraction of a second.

My suspicion was well founded as there were enough accounts. A police dispatcher recounted how full-moon nights were busy nights, when crime rates and murders soared, the police stations were full and people behaved aggressively. Back in the 1970s, a study published in the Journal of Clinical Psychiatry, found that homicides in Dade County, Florida appeared to rise and fall with the phases of the moon over a 15-year period. In other words, the murder rate rose with the full or new moon. A similar study from India was published in the prestigious Bitish Medical Journal in the 80’s from Patna.

 If the moon can cause tides in oceans by its gravitational pull, why can’t it affect our brains? Psychiatrist Arnold Lieber, theorizes that since humans are composed mostly of water (like the earth), our bodies might have "biological tides" in the brain that influence our emotions.

 Abnormal mood and behavior is often reffered to as ‘lunacy’, which is defined in the Merriam-Webster Online Dictionary as "intermittent insanity once believed to be related to phases of the moon." In fact, in England in the 18th century, a person who committed a murder during a full moon could plead "lunacy" and get a lighter sentence.

 Hospital workers also seem to notice increases in strange behavior with the full moon. A study published in the Journal of Emergency Medicine in 1987 found that 80 percent of emergency room nurses and 64 percent of physicians agreed that the moon affected their patients' behavior. In fact, the nurses were so overwhelmed by their workload during the full moon that they asked for bonus "lunar pay." The sections of staff who noted an association more often were mental health professionals, social workers and clinical psychologists.

 There are many however who pooh-pooh this theory as superstition. It is understandable as the moon’s presence in the sky often going unnoticed by most modern urban dwellers. But just as sailors and coastal fishermen swear by the lunar tides, the night sky may hold the key for some moody people  and observant policemen. 

As published  HT City( Hindustan Times) dated 6 May, 2012.

Medical etiquette

Why delivering good gratifying medical care is so complex is because it involves not just knowledge, skills and ethics but another vital component that is often overlooked, called medical etiquette.

Medical etiquette is simply good proper behaviour that is expected of physicians and nurses when dealing with patients. Simple, etiquette is usually not given much importance during medical training in this country and is hence often found woefully lacking in our professionals. Consequently, do not be surprised to meet a top-notched specialist with a string of degrees below his name, who may forget the etiquette of offering you a seat when you enter his chamber, and continue talking on the phone.

A resident doctor, who comes to train with us to become a superspecialist, is often grossly deficient in etiquette. In the busy and crowded OPD, I see him often examining a female patient in the presence of 10 unrelated spectators. In the ward, I see him doing an ascitic tap (drawing fluid from the abdomen) without putting screens around to ensure privacy. Another common gaffe is barging into the private cabin of a patient without an announcing knock or a “please may I come in?”.

While etiquette may not decide life and death, what it does decide is whether the patient feels comfortable, cared for and treated with dignity while in hospital. And as most of my genre gets to know by the time they reach my vintage, attempting to treat patients without ensuring their satisfaction is like driving a sedan without suspension.

In all fairness, it is the British, whom we all love to hate, who brought in the concept of propriety and courtesy in general life as well as in profession. Etiquette, a French word, while meaning much the same, conveys a hint of style, in addition.

Officers of our defence forces exemplify this British legacy best in the country. They adhere to time, are dressed appropriately for an occasion, are well mannered, show the right measure of the right kind of courtesies towards seniors, ladies, colleagues (and enemies too!). This etiqutte does not come naturally. For most, it has been the result of years of grooming in their academies, training and at postings.

This British legacy was once strong in Indian medical schools too. It was, in fact, so strong that an Indian doctor would also rub and warm his hands before examing a patient in the swealtering Indian heat, just as was expected of a British doctor to do in freezing England. .But the general courtesies that thay taught us, often referred to as “bed-side manners” has all but evaporated in the summer heat!

American medical institutions are increasingly recognizing the need for formally incorportaing medical etiquette in the training of their doctors. Indian doctors need it too, perhaps even more desperately. And officers of the defence services can chip in a good bit to hone our etiquette. 

As published in HT City( Hindustan Times) dated 29 April, 2012.

Why expect nurses to be superhuman?

Although one cannot imagine a hospital without nurses, their importance in the delivery of care often goes unrecognized.

It is not uncommon to hear of instances when a very critical patient with little hope of survival, has been successfully operated upon by a team of highly specialized doctors, brought back to life as it were by a group of intensivists in the ICU, and then, after several weeks in hospital when hope has mounted, suddenly dies due a wrong injection or infection from a catheter due to nursing lapse. What relatives experience at such times is a deep sense of betrayal and anger, that soon replaces the gratitude and appreciation that the previous few weeks of heroic achievement had earned.

And what compounds matters in busy hospitals is that nurses neither have the time nor the training to provide emotional support to grieving relatives at this stage, ensuring that they go back with permanent bitter memories and impressions of this hospital.

To be fair to nurses, just too much is expected of them and just too little effort goes into looking after them. Most hospitals run woefully short of nursing staff, resulting in overburdening the few.

Consider their case. A regular eveing or night nursing shift comprises 2 nurses who are expected to look afte 30 (in some 60)  sick patients over 6 to 8 hours. At first sight it may look simple, but here is the list of what they are expected to do in this period: take over the stock of medicines and details of patients from their colleagues of the previous shift (30 min), check each patient’s vitals (pulse rate, BP, respiration and temperature 4 to 6 hourly (@ 10 mins x 30 patients = 300 minutes), distribute medicines ( highly individualized) to 30 patients 2-6 hourly (90 mi), give injections (to 20 odd patients), draw blood samples for tests (from around 10 patients), start IV fluids or change IV bottles ( around 15 patients), shift patients for procedures such as surgery, endoscopy or radiology (10 patients), assist doctors in minor procedures such as ascitic or pleural taps (10 patients), supervise diet, complete discharge formalities and expalin instructions to those who are leaving, and the list goes on. On top of all this, every time a patient’s condition deteriorates, they have to assist with resiscitation (30 mins) and respond to SOS calls (quite frequent as 50% of the ward consistes of very sick patients).

If you calculate what they actually achieve during their shift, you will be surprised how they indeed manage. Where then is the time to administer TLC (acronym for tender loving care), talk and establish rapport with patients and relatives, sponge and clean them, and do all that good nursing is all about?

It is unfair to expect nurses to perform as super-humans all through their careers. While the complexity of medical care has increased several fold over the last 5 decades, the ratio of nurses to patients have hardly changed. Strengthening this pillar is essential if hospital care has to improve to the next level. 

As published in HT City (Hindustan Times) dated 22 April, 2012.

Pray for Ruby

Ruby is finally set to undergo surgery for a blocked and ulcerated food-pipe that has plagued her for 12 long years. Inshallah, if all goes well, this 30 year old frail 40 kg girl might get another chance to live life with grace and vigour, when a loop of intestine replaces her gullet and allows her to eat normal food.

Her problems had begun suddenly twelve years ago when she had accidentally swallowed sulphuric acid, used to clean floors and commodes that her father had kept in a clear water bottle. She still shudders to think of the intense burning, choking and pain, the swelling around her mouth and the agony of drips in hospital. A week later she had noticed difficulty in swallowing food that had progressed to obstructing even the passage of her saliva. She had withered rapidly from a 55 kg energetic girl to a skin-and-bony 20 kg in three months and had become so weak that she needed hospitalization and drips again and again.

It was around then that her association with us started when she had come with a badly damaged food-pipe through which even water would not trickle down. We had managed to pass down a thin wire and dilate the stricture with bougies and balloons to initially allow liquids, and then a bit further to let semi-solids such as sooji, khichri and custards into her stomach. She soon picked up a few kilos and got back on to her feet.

Then the socio-economic factors came into play. Her parents found her protracted illness too expensive, and decided to concentrate on their two other children, leaving Ruby to her fate. Her marriage of a few months broke up. She soon found herself struggling to stay alive, earning Rs 3000/- per month from a lodge as a part-time caretaker, and spending most of it on her 2 weekly dilatation sessions and her special liquid feeds.

She was advised surgery several times over this period, but had declined. Firstly, there was the issue of expense. Second, no family support. And third, she was mortally scared of losing her voice as she had met someone who indeed had after this kind of surgery.

What then triggered this change of mind now? With her indomitable spirit, she has enrolled for a graduation course that she is pursuing after the day’s work. Further, a benevolent soul, touched by her story, has offered to sponsor her surgery. She, on her part, has finally decided to take the risk and turn the corner. Her ambition now is to leave the unpleasant past behind and create her own future and become independent.

Corrosive injury to the food-pipe is still a common problem in India. While some are due to accidents, many occur from suicidal intent in a fit of desperation. Most victims are able to live normal lives with few sessions of endoscopic dilatation, but some like Ruby need more help. 

As published in HT City (Hindustan Times) dated 15 April, 2012.

Time to fight spring allergies

Spring is the time when allergy reaches its peak every year with sneezing, stuffy or running nose, scratchy eyes, a nagging cough or itchy skin. More severe allergic symptoms include urticaria or angry hives on the skin and breathlessness or wheezing.

Global observations show that allergies are on the rise year after year; 2011 set a record and experts expect 2012 to be worse. This increase has been attributed to increased levels of carbondioxide in the atmosphere due to global warming, that feeds plants and leads to greater release of pollen in the atmosphere.

The culprit is usually pollen that comes either from grass or from tress. Pollen from blooming plants are carried by the wind and brought on to our bodies where some of them trigger allergic reactions. As they enter the body through the nose and wind-pipes, they often selectively trigger reactions at these sites.

While many allergy experts recommend testing to find out the exact cause like identifying species of plant pollen that causes your symptoms, many feel that this exercise has scant practical value. Being ubiquitously distributed in the wind, it is impossible to selectively protect yourself from a type of pollen, can you? Ragweed and tiger grass are common culprits but the ability of winds and storms to carry pollen as far as 400km makes matters difficult.

Here are 6 tips that could come handy:

1.  Take anti-allergic medications to suppress allergy when required. Some medications cause sedation and should be taken only at night. You should avoid driving when you take them. Few are non-sedating, can be taken in day-time. Find out which one suits you best and stick to it. It is better to take them regularly for a few days still the phase has passed.

2.   Keep your doors and windows closed. As the culprit is usually pollen, and is brought on by the wind, keeping them away can help. “Fresh air” can often aggravate symptoms at such times while air-conditioning may provide relief.

3.   Limit outdoor activities. Contrary to popular belief, walks may aggravate symptoms due to increased exposure to pollens. Spending time in the gym may be a better option.

4.   Keep car windows up to reduce exposure to pollen and wind

5.   Take shower and change clothes frequently. It helps to wash off pollen from the body and reduce exposure to allergens.

6.  Carry anti-allergy medications with you at all times. I recommend that you carry both types – an anti-histamine tablet such as Avil, Cetrizine, or Allegra as well as a tablet of steroid (prednisolone or Betamethasone) that may be required in case of severe allergy such as wheezing due to spasm of the wind-piipes.

If you have had allergies in the past, you could be vulnerable at these times. Allergy can catch you unaware. It is wise to take precautions and be prepared. 

As published in HT City (Hindustan Times) dated 1 April, 2012.

Sudden cardiac arrests in youths

News-watchers were shocked to learn how a young robust 19 year-old Vishwanath, collapsed suddenly and died while playing football (soccer) recently in Bangalore. This happened at a time when soccer lovers were recovering from a similar incident in which the Bolton midfielder Fabrice Muamba, collapsed on the field from a sudden cardiac arrest (SCA) and had to be rushed to hospital.

The possibility that young, well-trained athletes at the high school, college, or professional level may die suddenly of heart disease seems incomprehensible. It is a dramatic and tragic event that devastates families and the community, especially as these young people seem to be the fittest in society.

SCA in young athletes triggered by vigorous activity occurs in 1 of 100,000 sportsmen annually. FIFA lists around 92 players who died while playing soccer, half of whom from SCA.YouTube contains an interesting video showingMiklosFeher slumpingsuddenly to the ground and dying, and another of Anthony van Loo who suffers a SCA but is revived by a timely thump on the chest by a coach.

The first recorded incident of sudden death of an athlete occurred in 490 BC when Phidippides, a young Greek messenger, ran 26.2 miles from Marathon to Athens, delivered the news of Greek victory and then collapsed and died. Today, the 2 sports that claim most lives from SCA are soccer and basketball.

Unlike people over 30 years of age in whom the cause is usually blockage of flow of blood by a clot or narrowing in the coronary, the causes in young athletes are:

1.  Abnormal thickening of heart muscles called hypertrophic cardiomyopathy, especially common in Afro-Americans, who indeed are more prone

2.  Developmental anomalies of coronary arteries, which can often arise from abnormal sites and may be prone to kinking

3.  Long QT syndrome (LQTS),an inherited heart rhythm disorder that can cause fast, chaotic heartbeats. The rapid heartbeats, caused by changes in the part of the heart that causes it to beat, may lead to fainting, which can be life threatening. In some cases, the heart's rhythm may be so erratic that it can cause sudden death. Young people with long QT syndrome have an increased risk of sudden death.

These shocking events and our growing understanding of the reasons behind SCA have generated considerable debate regarding our state of preparedness on the field. Developed countries have called for cardiac screening for all athletes undertaking vigorous sports. Anyone with a history of fainting or a family history of early cardiac events should undergo thorough evaluation.

We need to be better prepared at the venue. Coaches and players should be trained in resuscitation techniques. Anthony van Loo survived only because of timely action by his coach. It should also be mandatory to have hand-held defibrillators available on the field and people should be trained to use them. And the need for prompt transfer to ICU cannot be overstressed, if damage to the brain and other organs is to be prevented.

As published in HT City (Hindustan Times) dated 25 March, 2012.

DISPOSABLES ARE COSTLY

The “use-once-and-throw” habit that has come to characterize modern living has ushered in considerable individual safety that most of us have become familiar with, but for a price. Single-use syringes and needles for instance, have become a norm in all clinics and hospitals, with the old fashioned “heat sterilize and re-use” glass syringes going into disrepute and oblivion.

While this “u-o-t” phenomenon is being seen with other commodities like shaving razors, water bottles and shampoo pouches, its most profound impact is being felt in the health care industry. Numerous scientific studies have shown greater safety from transmissible infections such as HIV, Hepatitis B and Hepatitis C with the use of disposable single-use needles and syringes.

The cost and hastle of disposables are however beginning to be felt in tertiary care hospitals where several procedures that involve puncturing the body are performed routinely. In coronary angiography for instance, catheters or long special tubes are inserted in the patient’s groin and dye is injected through them near the heart to assess the patency of arteries. In gastroenterolgy, we routinely use long tubes or accessories that pass down endoscopes to take samples from the intestines, inject medicines into bleeding veins, or remove stones from the bile duct 

The vexing issue is whether all these elegant accessories need to be brand new for each patient, or whether they may be re-used with care.

The “u-o-t” approach is what wealthy litigant societies use and is safer. If a patient with obstructive jaundice for instance, has to have an endoscopic procedure called ERCP to get the offending stone removed from his bile duct, he would need at least 3  fresh accessories: a guide wire, a cannulotome to inject dye and widen the bile duct, and an extractor to pull the stone out, together costing aorund Rs 60,000/-. Add to that the hospital procedure charges and you would get a bill of around Rs 70,000/- , that most patients find hard.

This partly explains why the cost of the same procedure varies so widely between hospitals. Government as well as many affordable centres provide the same service at one-tenth the price and come to the rescue of people with limited resources whose choice is often between a scientific predictable treatment that he can afford and faith-healing.

Most Indian hospitals, caught in this dilemna, therefore re-use some accessories for some procedures. If defined guidelines are followed the risk of transmitting infection is low while the treatment remains within reach. American health care is so very expensive that an Americans without insurance cannot afford it, and the government, reeling under pressure has been trying desperately to reform.

Indian doctors are therefore perpetually caught in the crossfire between what is preached in books published in the west, and their ability to face reality and render the maximum good to maximum patients who throng their doors.

Between the ideal and the practicable, often falls the shadow!

As published in HT City (Hindustan Times) dated 11 March, 2012.

Parents under Exam Stress!

How wired parents get when their stressed kids take the board exams showed up yet again when they went on a ruckus over a question that appeared in the English paper asking students to provide an imaginary account of a bomb blast in a crowded place. Opinion seemed sharply divided with some parents on edge calling it “insensitive”, while ex-students terming it contemporary and relevant.

Parents argued that stressed to the hilt that exam-goers are at these times, asking them to imagine and describe a gory scene of a bomb blast would add to their children’s distress. Could not the paper -setters’ think of pleasant topics that could soothe their raw nerves?

Some students garnered their parents’ sympathy and mentally cushion them in the event of a less than expected performance. “It is all the insensitive board’s fault!” is what they are chanting along with their parents, having found a convenient scapegoat should it be necessay when the results come in.

Successful ex-students and teachers however had a differnt take on this topic. If the English paper was to test thier linguistic skills, what was wrong in testing them on issues a bit beyond the text book? Why do students and their parents expect “smooth” questions that seek answers that can be provided by rote? Is that the best way to test linguistic skills? Why then do we have students with adeqaute decoratve degrees in English who cannot speak, write, describe or narrate anything beyond what Jack and Jill didon that fateful day?

 Mrs Bhargava, a young smart school teacher, surprised me with her response when I posed this issue to her. “Contrary to what w expect, students actually perform better when asked such unconventional questions”, she said. “I have seen students write much better essays on issues such as corruption, scams, terrorism or elections than they do on the old-world topics such as honesty, beauty, gratitude and valour”, she said, making me wonder if we are indeed being separated from our present-day kids by the proverbial generation gap.

While anxious parents do deserve as much sympathy as their stressed out exam going children, they have heaped more flak to the CBSE board than they deserved. To start with, the question was not a compulsory one; any stressed-out student could choose the other option. Further, describing vivid, albeit imaginary scenes is often easier and more scoring than writing on abstract issues. And if education is what we are all trying to provide, then touching on and creating awareness on “real” topics is a step in the right direction. The feelings of a bomb blast surviver are more relevant today than that of a ship-wrecked sailor of 2 centuries ago.

And if our 17 year olds need to be protected from exposure to horror and violence, they should not be watching Bollywood movies but reading fairy tales instead.

By seeing parents behave unreasonably under stress, as on this issue, students are likely to do much the same.

As published in HT City (Hindustan Times) dated 5 March, 2012.

Hospitals- Love or Hate them!

Of the many things patients have taught me is why they like some hospitals and hate others. You will find streams of grateful patients in a shabby government hospital for in stance, while there would be many who would choke on their drinks in a party with the mere mention of that hospital’s name.

The factor that seems to sway opinion most is the final outcome of an index patient; if he was brought in moribund and finally walk out, then all the dirty linen, the “paan” stained corridors, the constant drone of mosquitoes and the rude words from nurses are often forgiven, and the hospital assumes the symbol of a new life.

If the end goes awry, as often it does in a referral hospital where critically ill patients are shunted to, the hospital becomes blotched in the minds of relatives and friends across generations.

But how do first timers, who have often come in for a consultation or procedure react to a new hospital? The initial impressions often prove crucial. Was the entrance clean and welcoming, the process of registration short and sweet, the signange clear, and the waiting hall comfortable and relaxed?

It is the non-medical staff forming the point of initial contact, which often makes or mars opinions. Were they in uniform? Were they receptive and helpful? What often puts people off is to find a group of clumsily clad employess seated behind the counter desk, chewing tobacco and chatting amongst themselves, while anxious relatives wait in crowded lines to have their concerns addressed, quite like the “enquiry counter” in a railway station.

Why a hospital finds it hard to please everyone however is the MWYP or “My WOW your PUH” factor. I see this happen every day in our wards and endoscopy suites. Patients coming from poor backgrounds who have slept on dirty floors of other hospitals or their homes are often “wowed” by the tiled floors, the concealed bright lighting, the laundered bedsheets and a large bed for each patient in our hospital.

What catch the attention of patients coming from middle and upper class homes however are quite the opposite: smelly wet toilets, stained bedsheets, reused mouth guards and a shabbily-clad orderly squeezing his arm while a frowning nurse, without wearing gloves, digs a needle in his forearm to draw a blood sample! 

For many patients, the long wait in the waiting-hall becomes a horrid unforgettable experience: congested and stuffy, no vacant seats, no digital display to know if your turn has come (or will ever come), no announcements, no magazines, no TV.... a long and painful wait laden with expectations that their final meeting with a specialist will end in a solution to their problem and transform their lives!

Thronging attendance is no vindication of a government hospital’s efficiency as the poor and desperate have no other place to go. Taking aim to reduce “Puhs” will increase the “Wows” and enhance the quality of our care.

As published in HT city (Hindustan Times) dated 26 February, 2012.

ARSENIC MENACE

Around 10 million people in India are unknowingly consuming high levels of arsenic in their water, with many showing signs of chronic poisoning. A recent investigation showed that the ground water (wells, deep tube wells) of several parts of eastern Uttar Pradesh and Bihar contain far higher levels of arsenic than is considered safe and permissible for human consumption.

The plight of people residing in these regions came to light due to the dark spots and patches on their skins and by their rough and scaly palms and soles. People from adjacent regions could smell there was something wrong with inhabitants of some villages and declined marrying into these homes out of fear of some infection.

While the disease is not infectious, arsenosis, as it is called in medical science, is a disease that is being increasingly recognized across the world. Geographical regions with high arsenic content in ground water and human inhabitants of the regions showing a characteristic disease pattern have been reported from 30 countries.

The first reports from India came from West Bengal and adjacent parts of Bangladesh n 1986 by Prof DN Guha Mazumdar, an eminent scientist from Kolkata who drew the attention of the World Health Organization to the blight. People residing in high arsenic zones showed, apart from the characteristic skin changes, involvement of the lungs, eyes, nerves, liver and blood vessels, and suffered from anemia. Mothers from these regions had a 6-fold higher rate of still births. Further cancers occured more frquently here, especially of the throat and bladder.

Normal drinking water contains around 50 -100 ug of arsenic per litre. Levels above 200 are considered unsafe for the human body. The ground water of several villages has been found to have ten times these levels, sometimes crossing 2000 ug/L. Consumption of high levels of arsenic causes excess accummulation of this metal in different organs of the body leading to their slow damage.

Many of the affected people often drop out of work due to weakness, anemia and degeneration of nerves. Swelling of the feet and ankles is common. Involvement of the lungs causes chronic cough and breathlessness adding to their frailty.

 It is not uncommon to see people in their forties and fifties with skin patches and rough palms, languising at home, often labelled as lazy or depressed, unable to cope with strenuous work and earn their livelihhod. Their children often grow up to suffer the same fate as do their offsprings.

As long as their water is not detoxified of arsenic, the dwellers are doomed for generations, except when some children migrate to cities and inadvertently escape the scourge. Boiling water does not help in this case as there are no germs to kill by heating.

And the inhabitants can do very little by their own to save themselves and their families. Only a vigilant and caring governemnt can help with testing, identifying and detoxifying the water in these doomed regions.

As published in HT City (Hindustan Times) dated 12 February, 2012.

Are parents the real culprits of exam stress?

Indian children, being loyal to their parents in contrast to their Western counterparts, are often diffident to blame them for their misery during exams. In Manthan 2012, an inter-school debate organized by HOPE Initiative, in which 100 high-school students from 43 schools participated, several children finally admited to what their teachers had always suspected: the main source of stress during exam times was in fact, their parents.

Researchers have noted that the phenomenon of exam stress occurs more often in the Eastern hemisphere, especially in countries such as India, Japan and Korea. It has its origin in the aspiration of parents to see their children better-settled and financially secure. Paradoxical as it may sound, this parental desire that claims several hundred lives every year by suicides, often stems from their concern for the welfare of their children, a sentiment that abounds in Indian parents. It also has roots in unfulfilled desires or yearning to see their children climb up that extra step in the socio-economic ladder. You cannot really blame a struggling clerk serving a beaurocrat to want to see his son become an IAS officer one day!

 What seems to often go awry is the parent’s ability to understand or explore what his child wants to do, is good at doing or interested in achieving. In short, it is often a case of communication failure within the home. The child often finds that his profession has already been decided for him by his parents sometimes even before he was born, and all that remains for him to do is to struggle through school and college and fit into the picture that his parents have imagined of him. If an enginner they want him to be, so must it be even if his aptitude is for literature rather than for maths or physics.

Interestingly, what drives parents to drive their children is their perception of financial insecurity. Exam stress occurs more often in homes where parents are in salaried jobs rather than in affluent business homes. Children of Indian immigrants to USA are much more stressed to perform in exams, manifesting that same spirit of struggle than their American counterparts.

It is time for parents to realize that undue and unreasonable pressure on their children to score more in exams can often be counter-productive and shattering. Bridging the communication gap and finding out what their kid wants to make of his life should be a good starting point. An objective assesment of his aptitude and capabilities will often help him choose a career that he can then pursue with motivation, zest and success.

One of the most wonderful aspects of modern times is the array of opportunities that are available today. Limiting the choice to becoming a doctor, an engineer or a beurocrat is out-dated and unproductive. Children often know what is best for them. If only we listen!

As published in HT City (Hindustan Times) dated 5 February, 2012.

Are you indulging in medical shopping?

The line that divides “second opinion” from “medical shopping” is a blurred one.

“Second opinion” is the seeking of another medical opinion to verify or validate what the first doctor had diagnosed or advised, and is often quite a valuable step. Most in their normal senses would not seek another opinion for a common cold. On the contrary if the diagnosis is of a sinsister kind such as cancer, or if the  treatment advised is of the risky or expensive kind, such as a heart surgery, it is quite natural for a patient  to seek a confirmation or endorsement by another expert in the field. Indeed, good physicians and surgeons often advise their patients to consult a second physician so as to get convinced of the unpleasant diagnosis and then return with greater motivation to embark on a treatment that is challenging.

The diagnosis of cancer is certainly one such situation. It often comes as a shock and evokes a sense disbelief and denial in patients with thoughts like “it just can’t be true, I just had symptoms of indigestion” or “it cannot be happening to me”. A second evaluation by a competent doctor re-confiring the diagnosis helps the patient to accept the unpleasant truth.

A similar situation often occurs with patients undergoing coronary angiography for evaluation of heart symptoms. Detection of narrowing of arteries comes as unpleasant news, but if all 3 arteries are found to be thinned out and the cardiologist advises coronary bypass surgery rather than angioplasty, the patient usually gropes for a second opinion before subjecting himself to the operation.

Medical shopping on the other hand is quite akin to what we do while buying vegetables, going from one grocer to another enquiring the rates of cauliflowers, seeing their size,  and at times bargaining, before making our purchase. There are people who in their contrived habit of seeking the cheapest will enquire about the cost of endoscopy in 5 centres before going in for one. It may not always be the price, but the popularity of the doctor or the market-stature of the clinic instead.

Once a “noveau riche” businessman’s wife in her 40s, brought her 12 year old daughter, who had been complaining of abdominal pain for a month, to me. The child seemed to be in no distress as she sat smilingly across the table. As I went through her history and scanned the results of the innumerable ultrasound and CT scan tests she had gone through, the mother proudly told me that she had consulted 18 of the top pediatricians, surgeons and gastroenterologists of the city before coming to me.

I discovered in the course of history-taking that the pain came in the mornings before school, and once allowed her to stay back home, it subsided, permiting her to accompany her mother later to the shopping mall. I could see the disappointment in her face as she left in a huff with her daughter to seek their 20^th medical opinion.

As published in HT City (Hindustan Times) dated 29 January, 2012.