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.