Electric vehicles and pollution

In the recent days i see a lot of ads in the newspapers about, e-bikes - pollution free electric vehicles. These ads tout the supposed advantage of economy, noiselessness and with an added benefit of helping the environment. There is an electric car also in production. Are these not mis-informations? In India, like in most countries around the world, majority of the electricity is produced from fossil fuels. So how do you cut pollution when you use electricity produced from fossil fuel to charge your vehicle? Less smoke, less noise, economical… acceptable with a pinch of salt. No pollution - not acceptable. But to most who read these ads this is not apparent. This is taken to advantage by the sellers. Is it ethical?

Free patients

In practice we see a lot of patients that we know at a personal level and treat them without any consulting fees. We spend more time explaining to them about the disease and clarifying their doubts then the usual run of the mill patients. But these are the people who become a failure to us. Failure in that, most of them do not comply with the advises as much as patients who wait their turn to see us and pay out of their pocket for the consultation. (Of course this applies to places like where i live where there is medical insurance is not popular). This is sad because the people who you really want to take care are the people who end up getting the least care. I have along list of such patients - a relative who is obese and constantly has under-controlled blood pressure, a colleague’s wife who has diabetes and gone to develop albuminuria, i can keep on making a long list. But the underlying theme in all these patients is, they do not pay for their consultation and do not comply. Is it because they do not wait for an hour in the waiting room (Because i see them right away) make them think that the doctor that they are consulting is not good? Is it because they are not paying for the advice, they do not feel that it is important? Or is it just the feeling that at anytime you can consult the doctor and he will take care of you despite not following any of his advice the reason for non-compliance? Whatever the reason, it is sad. So what i have started doing is not to give any undue advantage to people who i know. Collect the fees in most situations, advice them as i would to any patients and be strict that they comply . Even though this may make them feel bad at the beginning i feel that this is what is good for them in the long run.

Memorable patients

        In this post i write about two unforgettable patients. The first one was a patient in his forties a smoker with diabetes, hypertension and hyper-lipidemia. He went on to develop exertional angina. His electrocardiogram showed ischemia at rest and an echocardiogram revealed regional wall motion abnormalities in the areas corresponding to the ischemia. He was started on nitrates in addition to aspirin he was already on. He was not willing for angiogram or any other procedures. His angina worsened to a stage where he was hardly able to walk for five minutes before getting angina. The nitrates had been increased to the maximum and calcium channel blocker and beta-blockers had been added without much use. i expected him to go for infarction any day. He  asked me whether there was any other medications for relieving his chest pain.When i said there was none, he went for alternative treatment (Unani). He came after a few days and told me, that he was pain free and had stopped all the nitrates. I was happy for him but still expected him to be brought with infarction one day. He continues to smoke, has stopped all medications other than his anti-diabetics, including aspirin and is pain free. Not only that, his sugars are normal with nearly half the medications he had been prescribed. It is nearly five years now.This was one patient who brought me, belief in alternative medication. Each time i see him, i am surprised at what true alternative medicines can do. In this era of science and evidence medicine, it made me believe there are many things which can be learn from true practioners of alternative treatments.It also made me believe absence of evidence does not mean lack of evidence.
The second patient is a patient again a non-hypertensive, poorly-controlled diabetic, who came with three hours history of difficulty in speaking. On examination he had evidence of lower cranial nerve paresis (7, 9 & 10) with recurrent aspiration and dysarthria. He could not afford an CT of the brain at admission.So i started him on aspirin. He recovered dramatically and within eight hours he was totally asymptomatic. At this time the attendees were willing for a CT. The CT revealed a cortical infarct on the opposite side. So what he probably he had was a brain stem TIA with a old asymptomatic cortical infarct. He was taken against medical advice after the CT for alternative treatment.I was surprised. Usually patients go for these when the treatment they are taking fails, not when it is improving dramatically. I have found, for strokes these patients get nothing but a good physiotherapy.The problem is they stop the secondary prophylaxis and invariably end-up in recurrent stroke.This patient has not come back to me but i have seen many patients with ischemic strokes on alternative therapy going for recurrent stroke without aspirin prophylaxis.
So what is the conclusion. There are areas where alternative therapies hold big promises. There are areas where they fail miserably. The failure may be because of people who do not know these therapies practicing the art (Probably the main cause. You can get a degree in any of the alternative therapies by distant education in six months flat!) or because there is no real treatment in that system.It is our duty to find evidence for therapies where it seems to be obviously successful. Once we have positive evidence, more people will search for evidence and the ultimate benefit is of course to the patients of these chronic diseases.

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Another excellent grand rounds

This time the grand rounds was held in Africa at one of my favorite blog spots.
It had a few good articles that were worth pondering about. The one by rlbates on hematomas in plastic surgeries. Makes us understand some logical reason (hypotensive anesthesias to create a bloodless field during surgery) can go wrong due to a better logical explanation. (After closing the wound and blood pressure coming to normal small bleeders not cauterized during surgery bleeding and causing hematomas).
The other article (Extend the spirit of Christmas) which makes us start thinking why we get the helping mentality only during festive seasons and make us feel that, the same attitude should last throughout the year.
I liked ‘good suggestions’ and ‘resolutions for doctors and patients’ which made me think of those suggestions and new year resolutions seriously. Simple yet very much necessary. The ones about brain fitness in ‘expensive brains’ was also great. Susan’s article on ‘night of trauma’ takes us through the agony of human life, death and suffering. All in all more exposure to me to these fantastic writers. If any of you visiting my blog have the time, do visit to ponder further.

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I wish all my blog friends a happy, safe and prosperous new year.

Vicious Circle

Why do most of the practitioners in towns maintain medical records? Everybody knows that this is the most important document both to the patient and the doctor. For the patient this is not only going to record all his health problems, but also small details that will help avoid future troubles like tremors to Salbutamol or extra-pyramidal reaction to Metaclopramide or drug idiosyncrasies. It saves the patient of remembering all these and narrating to each new doctor he meets along his life. To the doctor it documents all his actions. So it is helpful in many ways. It helps him to have a more complete picture of the patient. It helps him to defend himself in a court if something gos wrong - provided he has done all the right things. It helps him to think before acting knowing that he is documenting what he is doing instead of doing things reflexively. There is more chance for a doctor to keep himself up to date when he habitually documents then one who does not. Last but not the least, without records there is no statistics. This is one of the major reason for a country like India where infections are rampant, is unable to produce good quality scientific papers. In countries where medical records are mandatory like in USA, they are able to generate lot of data on the disease incidence, its progression, its response to medicines, number of patient who meet treatment goals (like HbA1C in diabetes, LDL levels in hypertriglyceridemia, blood pressure in hypertension),etc…So how come such an important document is not maintained as scrupulously or not at all in majority of the cases?
This happens, i think when the doctors are not paid adequately. When they are not paid enough, their motivation to give complete care comes down. Say a patient comes to a doctor with fever. The doctor’s job ideally does not end with treating the present fever. It should also extend in educating the patient on ways of preventing its spread to family members, ways to prevent it recurring in the future, etc… Not only that - the ideal doctor needs to screen him for presence of other problems like symptoms and signs of other common disease like diabetes, depression, coronary artery disease, high risk behaviors and what not(Like smoking, consuming alcohol, sedentary life…). You will be surprised at the number of condition that each person has, that needs to be addressed. There is so much that need to be educated.To do a complete physical examination after a detailed history, document it and work-out a plan for the current disease and the other underlying problems, it is going to cost a minimum of 45 minutes (In post-graduate exams a long case is given this much time to just assess the patient which most of the time is barely enough and there is no discussion with the patient of his disease and the treatment plan). If a doctor is going to be paid Rs 40 or 50 for a consultation ($1 compared to about $100 in USA), where is he going to get the motivation to do a complete examination and maintain a record? He barely has time to treat the present problem, leave alone future problems and spending on documenting it and retrieving it at future visits. Of course it is legally mandatory to maintain these records. Not every law is followed in India. How many of us wear seat belts in India? So some doctors who are a bit more motivated do one of the following things to maintain a quasi-health record - writing behind the prescription a short history,findings and treatment plan or asking the patient to buy a note and bring it for each visit and to any doctor he goes where the treatment notes are written in that or computerized records (Very few due to the fact it is going to cost a lot of money and time to maintain it). The written records are mostly useful only to the doctor who wrote it, since he only understands the scribble of notes and its significance. In cities, the doctor charges a higher fees and mostly works in a bigger set-up where the trouble of maintaining and retrieving records are done by the hospital. So he can afford to be meticulous. Given proper compensation for the time spent, i think any doctor will be willing to treat completely rather that the presenting symptom alone.
So the next question is why is the doctor not paid adequately? Mainly because many patients cannot afford it and there are many other doctors and quacks willing to treat the present problem at a lesser price. So they choose to go for the short term relief. This is the vicious cycle. The patient cannot afford - doctor does not spend time / maintain record - patient is not treated completely - repeated visits to the doctor with more and more preventable disease. A totally unhealthy situation to both the concerned parties - the doctor as well as the patient. So where is the solution. Health insurance. When effective and economical health insurance can come into place, the doctor will get reimbursed and he is forced to maintain a record. This will improve the medical care and all patients can get equal treatment irrespective of their affordability provided they have a valid insurance. This will in a way subsidize medical care to patients with multiple problems. This is what is happening in developed countries that we are lacking. The problems of insurance companies deciding who will get how much care will be totally another devil which we have to face as and when it comes. So let us fhope for a better health care in India this new year.

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Miracle cures - 1

Some of the diseases that present to us have instant cures. These pleasantly surprise the patient in that, it almost looks like magic, while it is just science.Hypoglycemia - this is one of the commonest presentation for magical cures. Diabetic brought in altered sensorium, sometimes unconscious, blood sugar shows sugar of 35 or 40mg/dL. (If sugars are high the patient is in trouble - something more sinister may be a hyperglycemic coma maybe a stroke) Give 25% Dextrose, within a few seconds, patient opens his eyes and in a few minutes wants to know how he landed up in the hospital. The lowest sugar i have seen in an adult is 22mg/dL. The only thing that should not be forgotten is renal and hepatic insufficiency other than oral hypoglycemic over dosages. The hepatic cause, i will never forget because once i saw a diabetic with recurrent hypoglycemia with biochemically normal liver and renal functions. On his third admission for hypoglycemia, there was a just palpable liver and an ultrasound showed a tumor. So that tumor - whatever - primary hepatoma or secondaries was preventing compensatory gluco-neo-genesis and was causing recurrent hypoglycemia.

The second condition that lends itself for miracle cure is hypokalemia. Suspected when patient presents with sudden onset quadri-paresis. It does not hurt to do a serum Potassium, if facility is available. A Ringer lactate infusion makes the quadri-paresis disappear. If it does not, patient is going to be in trouble - maybe an Acute inflammatory Demyelinating Polyneuropathy. And of course we should never forget to do a thyroid function to rule-out thyroid disease.

Drug-induced extra-pyramidal syndrome with bizarre, abnormal movements of face relieved by an intra-venous dose of Pheniramine maleate does give immediate relief to all parties involved- the patient, attendees and the doctor who gave the anti-emetic which precipitated the symptoms

Hysterical disorders with dramatic symptoms of unconsciousness, aphasia, “status epilepticus” and what not gets cured with a whiff of spirit of ammonia.

Seizures stop with an intravenous dose of Phenytoin most of the time but the recovery of consciousness is not as rapid and hence does not lend itself to dramatization.

i am sure injection of Flumazenil for benzodiazepine over dosage, or relief of myasthenic symptoms by a small dose of intra-venous edrophonium gives as much dramatic results. But i have never seen these being done.

As i remember more of them i am going to add those in a different post.

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Unsatified Patient

There are certain patients that irritate you. It may be because of their arrogant behavior, may be the negative comments for everything you do or may be because for some unknown reason you just dislike them. You hate it when they come. It is quiet understandable when they are really sick like running a high fever or when going through pain. Probably any of us will behave in a similar manner in these situations. When you are physically and mentally weak, even the smallest provocation is enough to bring any body’s worst character. But these are not the people i am not talking about. i am talking about people who basically have a negative way of looking at everything and trying to put down others. Take for example a patient i recently saw. This person presented to me with left side hemi-paresis (12h old) and at admission had a power of 3/5. A CT of the brain confirmed the presence of an infarct. With standard therapy (Of course aspirin, what else) he went back 72 hours later with a power of 4+/5. He comes back three days later and you can hardly make-out the weakness. He was quiet unsatisfied. He was unsatisfied that he has not come back to normal. i explained to him that this itself was quiet a remarkable improvement and neurological improvement gradually occur over a period of four weeks. He was not convinced and kept complaining back that he was the same as when he got admitted. There was no use in showing the documentation, that his power was indeed weaker at admission and had improved now. Luckily for his type of presentation, there is nothing sophisticated / expensive that could have been done that was missed-out but still we have an un-happy patient. These of course was just an example and we see quiet a few of these patients that are not satisfied even after proper explanations. (Lay people are not going to understand about a disease progression / improvement and if proper explanations are not given, definitely they are going to be un-satisfied). These people make me feel un-happy. One patient is enough to get you off your good mood for hours together. These patients put me in a soup. Whether to continue treating them or to refer them to some other hospital. We are supposed to treat even our enemy equally as we would treat our closest friends. Of course i will never ill-treat these patients in any way. That is wrong. But you loose interest in taking care of them. You just do what is necessary and nothing more. Previously i used to tolerate these hassles and continue treating them. I used to justify that we should not be emotionally disturbed by their behaviors. Of late, i tolerate it to certain limit and if they continue to bother i explain to them the reason for their referral and refer them off. I consider doctor-patient relationship is a long term affair. It is best if both the parties involved can sync. Otherwise it is going to be a trouble for both, especially so in treating chronic diseases. But the decision for me to start referring these patients was a late one. I always used to feel that i had to treat anyone who seeks me even if i do not like them. It always was an issue that took a lot of time to resolve for me. Now it is resolved for good. This i think is good for both myself and the  patients involved.  They may get some one who satisfy them and i will not be bothered.

PS: Of course i do not refer anybody when they are sick just because we do not get along. i treat them until they are well enough to be referred.

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Compromise

I always used to feel whether i am giving the best possible care to the patients i am treating. Take for example a common disease like diabetes. The patient needs so many tests like HbA1C, microalbumin, lipid profile, electrocardiogram periodically other than the regular blood sugar checks. If the patient can afford, then there is no question about the quality of treatment, he can have all these and we can see to that he/she is detected of any abnormality at a very early stage and proper precautionary medications / life style changes started. But what happens if the patient cannot afford as it frequently happens. Then cost rationing has to be done. Blood sugar is the least that can be done regularly. Though the standard of care requires HbA1C to be done, it seldom done because of the cost (Rs 250 compared to Rs 60 for fasting and post-prandial sugars) involved. So when a patient comes who cannot afford much, i always feel guilty that i may be missing out early evidence of renal compromise (Microalbuminuria), silent myocardial ischemia or the ubiquitous dyslipidemias. So what do i do in these situations? Explain to the patient the importance of doing these investigations either to find associated diseases or detect early potentially treatable complications of diabetes. i feel that the expense is well worth compared to the complications it can lead to and the compounding of expense to treat the complication, leave alone the added suffering. Some of the patients are willing to go through the tests once they hear these explanations. Most do not want the tests because they either think these are unnecessary (so digging their own grave) or really they cannot afford it (very few). In these patients, i have to go by the available information - clinical and investigative and hope for the best. When i initially started my practice, i used to feel quiet guilty that i am not helping them avoid preventable complications. I used to feel it is somehow a failure on my part. It took me a lot of time to realize that there are many things beyond our control - Out of which ignorance and low socio-economic status will top the list in India.

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What not to prescribe

This post is about the usage of drugs that is more and more being molded by the pharma industry. Not one day goes without the addition of a new brand and not a month without the addition of a new molecule. The question is should we go for the latest. This can be decided only after knowing for which disease we are talking about.
If it is the question of antibiotics, obviously an effective antibiotic with most narrow spectrum need be given. This is where our pharma friends come and ‘help’ us. They promote only drugs which are the latest and most powerful. They have visual aids which tell the indication of the drug. So you will see the visual aid showing Gatifloxacin and Gemifloxacins for URI. When a lie is told too many times, we may tend to believe it as the truth. Think about the general practioner who has finished his MBBS about 15-20 years before, he will tend to accept what is being repeated promoted as the truth. Unluckily for us there are no compulsory periodic licensing exams to keep ourselves up to date. So it is common to see the prescription pattern becoming dependent on the way the pharma wants it to go. Then we should not be surprised that Co-amoxi-clauv being used for common cold very commonly. Pathetic. Who to blame? - The pharma industry for misleading us or ourselves for not being up-to-date. I guess it is both. Finally who suffers? Of course the patient, who assumes that the doctor, knows best. In metros, when a patient goes to a big hospital and waits for an hour to meet the consultant paying big money for the appointment, they are not satisfied with a Paracetamol for the URI. The doctor writes a prescription worth at least his consultation so that the patient is satisfied. So a fission bomb is prescribed where TLC would do.
What I hate more is, doctors who are (supposedly) reputed, trend setters, using broad spectrum, powerful antibiotics which could have been taken care of a common, cheap molecule. Of course the patient gets relief nearly at the same time as the cheap, appropriate molecule would have worked compared to the all powerful, latest molecule. What it has paved way is, for community level drug resistance and rise in medical cost for the common man.
When the question of drug use is about a chronic non-infectious illness, it should be the drug which has the least side effect moderated to the patients affordability be prescribed. If you see the efficacy of various drugs in a class across the board, we will see that there are not many differences between individual drugs. So why bother about the hair-splitting differences between Losartan and Telmisartan. If the patient can afford, go for Telmisartan or any other later sartan. If he/she cannot afford go for Losartan. The same applies for other drugs like Glibenclamide Vs Glimepiride, Lisinopril Vs Ramipril…. That is the reason; all guidelines suggest the class of drug for a particular indication instead of a specific drug. While the difference in efficacy is small, the difference in cost is enormous. Ten tablets of Glibenclamide (Daonil 5mg by Aventis) costs Rs 6.60 while the same number of Glimepiride (Amaryl 2mg by Aventis) costs Rs 103. If a patient cannot afford much, we should not be writing Glimepiride just because no one is promoting Glibenclamide and because Glimepiride is the latest.
i want to conclude by saying, that we should use the drug for its indication and not for what the pharma person says. Importantly there is no alternative to keeping ourselves up to date.