Saturday, August 19, 2017

Gorakhpur Tragedy: Findings of the IMA Inquiry Committee

Dr KK Aggarwal
National President, IMA

The Gorakhpur tragedy, where many innocent lives were lost, has shaken the nation and stirred a debate in the country.

Taking cognizance of the seriousness of the situation, Indian Medical Association (IMA) HQs constituted an Inquiry Committee comprising of Prof KP Kushwaha, Former Principal & Head, Dept of Pediatrics, Medical College Gorakhpur; Dr Ashok Agarwal, National Vice President IMA and Dr BB Gupta, President IMA Gorakhpur Branch.

The committee also asked the following doctors to appear before it to present their case.

•  Prof Dr Rajiv Mishra, Principal BRD Medical College, Gorakhpur at the time of the incident
•  Prof Dr Satish Kumar, Head, Dept. of Anaesthesia, Medical College, Gorakhpur
•  Dr Mahima Mittal, Associate Prof, Dept. of Paediatrics, Medical College, Gorakhpur
•  Dr Kafeel Khan, Asst. Prof and Nodal Officer, Encephalitis Ward, Dept. of Paediatrics, Medical College, Gorakhpur
•  Dr AK Shrivastava, Superintendent in Chief, Nehru Hospital, Medical College, Gorakhpur

But, the above doctors failed to appear before the Inquiry Committee, which then decided to visit the Dept. of Pediatrics in the Medical College.

People there were hesitant to speak. The scope of the Committee was to only examine the working of the doctors as other issues such as lack of oxygen, inadequate staff and any structural deficiency were being investigated by the Chief Secy, UP Govt.

The committee also took note of the various reports published in the newspapers and other media. The following conclusions were arrived at:

•  Oxygen supply was interrupted for a short time on the night of August 10, 2017.
•  The liquid oxygen supplier had not been paid his dues since last 5-6 months.
•  Cleanliness of hospital and ward was unsatisfactory. Presence of dogs and rats in hospitals is not acceptable by any standards in the hospital premises.
•  The hospital was handling these cases and other critically ill patients much more than its capacity.
•  There is no facility in Gorakhpur and nearby districts to manage encephalitis.
•  There is a lack of staff – paediatricians, nurses and other paramedical staff – in PHCs/CHCs.
•  ICUs in 10 districts of Poorvanchal area are not functioning because of lack of staff and other resources.
•  No alert was issued by the hospital administration regarding shortage of oxygen, The traeting doctors should have been alerted seven days before the fresh oxygen supply was  not received.

According to the IMA, although there is no evidence of medical clinical negligence against Dr Rajiv Mishra and Dr Kafeel Khan, prima facie it appears that a case of administrative negligence against them cannot be ruled out. Hence, administrative inquiry and action may be taken against them.

The recent movie ‘Airlift’ was based on the true story of evacuation – airlifted - of several hundreds of Indians from Kuwait during the first Gulf war and brought back to the country.

Similarly, we read about ‘green corridors’ without any traffic disruptions being set up to transport harvested organs like heart to reach another hospital, where there is a patient waiting to receive the organ. It’s an emergency where time is of utmost importance.

Why can’t the same be done in situations such as the Gorakhpur tragedy, where an epidemic of encephalitis recurs every year and, many children lose their lives every year because of the illness?

In view of this tragedy, IMA has suggested the following to avoid similar situation in the future.

•  There should be a state policy to airlift such critically patients in a timely manner to nearby best facilities.
•  All patients denied treatment at government hospitals should be reimbursed for the cost of treatment in the private sector at pre-defined rates.
•  All hospitals should have back up of one-week supply of all essential drugs, investigations and oxygen.
•  IRDA has made it mandatory for all private hospitals to get NABH accreditation. The same should be extended to all government set ups.
•  Essential drugs and investigations, not non-essential drugs and tests, should constitute the bulk of the expenditure of the allocated budget to reduce the cost of treatment.
•  All payments for health care services should be made either in advance or in time.
•  Doctors are clinicians as well as administrators. It is important to make a distinction between clinical medical negligence and administrative negligence.

Disclaimer: The views expressed in this write up are entirely my own

Immunization in infants and children a must to avoid hearing disabilities

Childhood hearing loss goes undetected mostly due to lack of awareness and appropriate interventions

New Delhi, 18 August 2017: As per recent reports, about 5% of the world's population suffers from disabling hearing loss, of which 32 million are children. About 6.3% of the Indian population suffers from hearing impairment and this percentage includes roughly 50 lakh children. As per the IMA, most of these hearing problems can be prevented through immunization against various diseases, by controlling noise pollution, and regulating the use of certain medicines.

Deafness is primarily of two kinds. Nerve deafness is caused due to sound pollution and problems during birth. Conductive deafness is a result of socio-economic factors such as poor hygiene and lack of treatment, leading to chronic infection and deafness.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, “It is alarming to note that the number of infants and youngsters with hearing impairment has increased substantially over the last few years. Hearing impairment is not recognizable easily during infancy and therefore is highly neglected. The need of the hour is to educate people and create awareness that hearing loss can be combated through early identification and appropriate intervention. Apart from congenital defects, hearing loss can also be the result of external factors. It is imperative to control these with support from a good healthcare system and control over noise levels.”

Universal Newborn Hearing Screening (UNHS) is a medical test for early detection of congenital hearing loss. India still lacks such a system that can identify congenital hearing problems in infants.
Adding further, Dr Aggarwal, said, “There is a lack of communication, low awareness, and lack of understanding about the importance of early diagnosis and intervention in case of a hearing loss. Delay in identifying this condition can affect language acquisition, social interaction, emotional development, and education in children. Neonatal hearing screening for every newborn is a must and highly recommended.”

Here are some ways to prevent hearing loss in infants.

  • Avoid any shock and trauma to the ears as it can cause severe damage to the ear drums resulting in loss of hearing.
  • Ensure that water does not enter the infant’s ears while bathing.
  • Get them medically tested as early detection can lead to better treatment outcomes.
  • Never insert any sharp object in the infant’s ears.
  • Keep them away from loud music or other sounds as this can impact their hearing capability. Loud music causes acoustic trauma.
  • Make sure that children are immunized against infections like measles, mumps, rubella, and meningitis as per schedule. These infections can also cause hearing loss in children.

Friday, August 18, 2017

Will we be ready to tackle future epidemics?

In the public debate on the Gorakhpur tragedy, several reasons were put forth as to why these deaths occurred. That several factors collectively led to this tragedy is the undeniable truth. Rather than trying to pinpoint who is to be blamed, our focus instead should be preventing further outbreaks in the future.

Dealing with the aftermath of a tragedy is important as also, how we choose to deal with it. And the question that we all should be asking ourselves in this regard is “what can we do to prevent future epidemics” and not “what should have been done and was not done”.

Will we be ready to tackle future epidemics? The answer to this depends on what corrective measures we take today.

A long-term strategy needs to be formulated to deal with such outbreaks. A well-planned surveillance and response system should be in place, which can be mobilized quickly when needed. We need better investment in preparedness.

We have to work together to stop the next outbreak, not only in Gorakhpur, but also any epidemic in the country. Dengue, for example, occurs in epidemic proportions every year.

The Indian Medical Association (IMA) has suggested the following to avoid more incidents like the Gorakhpur tragedy.

·         There should be no shortage of staff – doctors, nurses and other supporting staff. Staff deficit affects patient care. Shortage of staff should be supplemented with the services of locum doctors.
·         Private doctors can be hired, but only for locum jobs, not as regular doctors.
·         The practice of “moonlighting” as is prevalent in the US should be allowed in India.
·         There should be a uniform system for Govt. doctors: either practice is allowed or it is not allowed.
·         All patients who are denied treatment at government hospitals should be reimbursed for the cost of treatment in the private sector at predefined rates.
·         All hospitals should have back up of at least one-week supply of all essential drugs, investigations and oxygen.
·         To reduce the cost of treatment, essential drugs and investigations - not non-essential drugs and tests - should constitute the bulk of the expenditure of the allocated budget.
·         All payments for health care services should be made either in advance or in time.
·         Insurance Regulatory and Development Authority (IRDA) has made it mandatory for all private hospitals to get NABH accreditation. The same should be extended to all government set ups.
·         Every death should be audited to find out the probable cause of death and whether it was a preventable death so that future such deaths can be prevented from occurring.
·         In any case of negligence, one should differentiate between administrative negligence and medical negligence.

Disclaimer: The views expressed in this write up are entirely my own.

Dr KK Aggarwal

Smoking increases the chances of acquiring an erectile dysfunction

Lifestyle changes and quitting smoking can go a long way in reducing the risks

New Delhi, 17 August 2017: Studies indicate that men who smoke more than 20 cigarettes a day have 60% higher risk of erectile dysfunction (ED). About 15% of past and present smokers experience an ED. Other important factors that contribute to this condition include diabetes, high blood pressure, and high cholesterol, all of which can also get further exacerbated by smoking. As per the IMA, smoking also leads to reduced volume of ejaculation, low sperm count, sperm shape, etc.

ED is defined as a persistent difficulty achieving and maintaining an erection. The causes for this disorder can be both medical and psychological. Frequent ED is usually the sign of health problems which may require treatment.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "Sexual arousal in males is a complex process involving the brain, hormones, emotions, nerves, muscles, and blood vessels. ED can occur when there is a problem with any of these associated factors. Stress and mental health concerns have been known to worsen the condition. Sometimes, ED is the result of a combination of physical and psychological issues such as a minor physical condition that slows a person’s sexual response leading to anxiety. This anxiety can lead to or worsen ED.”

There are various risk factors which can contribute to ED. These include medical conditions, being overweight, certain medical treatments such as prostate surgery or radiation treatment for cancer, injuries, medications such as antidepressants, psychological conditions, and drinking.

Adding further, Dr Aggarwal, said, “Many men with ED have been able to improve their sexual function through lifestyle changes. It is imperative to give up smoking, lose weight, and exercise which will all help in improving blood flow. In case a medication seems to be the contributing factor, it is a good idea to speak to a doctor about adjusting the dosage or switching to another drug.”

The following steps can reduce a person’s risk of acquiring ED.

  • Start walking: At least 30 minutes of walking a day is linked with a 41% drop in risk for ED.
  • Eat right: Eating a diet rich in fruit, vegetables, whole grains, and fish can decrease the likelihood of ED.
  • Pay attention to vascular health: High blood pressure, high blood sugar, high cholesterol, and high triglycerides can all damage arteries in the male organ. Low levels of HDL (good) cholesterol and an expanding waistline also contribute.
  • Get slim and stay slim: Obesity raises risks for vascular disease and diabetes, two major causes of ED. Excess fat interferes with several hormones that may be part of the problem as well.
  • Build pelvic muscles and not biceps: A strong pelvic floor enhances rigidity during erections and helps keep blood from leaving the penis by pressing on a key vein.

Thursday, August 17, 2017

AES Update: This is not the time for a “blame game”

The recent tragic deaths of children due to encephalitis in Gorakhpur medical college have hit the headlines in the last few days. These deaths also generated a lot of debate on the issue. Unfortunately much of the debate centered on “finger pointing”. This is not the time for a “blame game”.

This is not the first outbreak of acute encephalitis syndrome (AES) in the region. Many such outbreaks have been occurring for several years now and each epidemic has taken a heavy toll of lives.

By now there should have been a state of the art hospital to manage AES patients. There should have also been a research facility to examine why the area is vulnerable to AES, establish effective surveillance systems, plan a response plan, predict future outbreaks etc.

This is the time to look to the future and not talk of the past or even the present outbreak. Drawing from the lessons of the past years, we must be able to anticipate such local outbreaks and be ready to respond to them systematically and in a timely manner to contain them. A research center focusing on AES will help to identify early warning signals for such impending outbreaks.

Anticipation and preparedness will enhance efforts to control and prevent future outbreaks of AES. All stakeholders have equally important roles to play in prevention of any epidemic.

Some key points on AES

·         Encephalitis is inflammation of the brain parenchyma. It presents clinically as neurologic dysfunction (altered mental status, behavior, or personality; motor or sensory deficits; speech or movement disorders; seizure)
·         Viruses are the most commonly identified infectious causes of encephalitis. Around 10% cases may be due to Japanese encephalitis, scrub typhus and herpes simplex each. Enterovirus and other viruses also cause AES. Bacteria, fungi, and parasites may also cause encephalitis. In many cases of encephalitis, the etiology remains unknown despite extensive evaluation.
·         The WHO’s guidelines for JE surveillance recommend syndromic surveillance for JE meaning that all AES cases should be reported (NVBDCP, 2009).
·         The NVBDCP 2009 guidelines on management of AES have recommended classification of a suspected case as follows:
o    Laboratory-confirmed JE: A suspected case that has been laboratory-confirmed as JE.
o    Probable JE: A suspected case that occurs in close geographic and temporal relationship to laboratory-confirmed case of JE, in the context of an outbreak.
o    Acute encephalitis syndrome (due to agent other than JE): A suspected case in which diagnostic testing is performed and an etiological agent other than JE virus is identified.
o    Acute encephalitis syndrome (due to unknown agent ) A suspected case in which no diagnostic testing is performed or in which testing was performed but no etiological agent was identified or in which the test results were indeterminate.
·         The incidence is highest among infants <1 year. 
·         Status epilepticus, cerebral edema, fluid and electrolyte disturbance, and cardiorespiratory failure are some of the complications of AES.
·         ICU care is essential for patients with severe encephalitis (i.e., those with seizures, cardiorespiratory compromise, coma, or severe neurologic compromise) with close cardiorespiratory monitoring and careful attention to neurologic status, fluid balance, and electrolyte status.
·         Prognosis of viral encephalitis depends upon the age of the patient, neurologic findings at the time of presentation and the etiopathogen.
·         The case fatality and morbidity is very high among various viral encephalitis especially in JE or enterovirus encephalitis.
·         Survivors of childhood encephalitis should be monitored for long-term sequelae.
·         Scrub typhus encephalitis: Curable with doxycycline or erythromycin if diagnosed early. Look for fever, rash, local black eschar in the legs with enlarged, lymph nodes.
·         Japanese encephalitis: Mortality is 20% in the best of the centers. Preventable by vaccination.
·         Herpes simplex encephalitis: Can be diagnosed due to temporal lobe localization and can be managed with antivirals.
·         Lichi encephalitis is manageable with intravenous glucose.
·         Enteroviral encephalitis has limited therapeutic options. Intravenous immunoglobulin (IVIG) is often administered despite a lack of convincing evidence for efficacy.
·         All children who present with suspected encephalitis should be treated with acyclovir pending viral studies.
·         Empiric treatment for bacterial meningitis pending bacterial cultures also may be warranted if bacterial meningitis cannot be excluded.
·         Empiric treatment with doxycycline or erythromycin should be given till scrub typhus is ruled out.
·         Prevention strategies include hand hygiene, appropriate management of pregnant women with active herpes simplex virus lesions, routine childhood immunizations, JE vaccine, traveling immunizations, and insect control and avoidance measures. Control of culex mosquito.
·         All children who are hospitalized with encephalitis should be placed on airborne, droplet, and contact precautions at the time of admission, pending identification of a pathogen.

Dr KK Aggarwal

Fatty liver can lead to liver cancer in the long run

It is important to follow a healthy diet free of alcohol to prevent build-up of fat in the liver

New Delhi, 16 August 2017: Studies indicate an alarming increase in the number of people suffering from fatty liver. As per available statistics, 1 in 5 people in India have excess fat in their liver and 1 in 10 have fatty liver disease. This is a cause of concern as fatty liver can lead to liver damage and even liver cancer if undiagnosed and untreated. As per the IMA, about 20% of those with non-alcoholic fatty liver disease (NAFLD) are likely to get liver cirrhosis in 20 years. This percentage is akin to that among alcoholics.

NAFLD is caused due to a build-up of fat in liver cells. The first stage of this disease is called simple fatty liver. Although excess fat builds up in the liver in this stage, it remains harmless and has no evident symptoms unless it develops into inflammation or damage. The second stage is called non-alcoholic stea to hepatitis (NASH) which is similar to alcoholic liver disease. However, those affected drink little or no alcohol.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, “NAFLD may progress to cirrhosis and is likely an important cause of cryptogenic cirrhosis. As little as two drinks per day in those who are overweight (and one drink per day in those who are obese) is associated in hepatic injury. Liver cancer is associated with cirrhosis due to NAFLD and heart disease is the most common cause of death among patients with this condition. NAFLD is not caused by alcohol but its consumption can make the condition worse. The disease can stop or reverse, especially in the early stages. Once it progresses to cirrhosis, the liver becomes unable to function causing symptoms like fluid retention, muscle wasting, internal bleeding, jaundice (yellowing of skin and eyes), liver failure.”

Some symptoms of NAFLD that emerge in the long run include fatigue, weight loss or loss of appetite, weakness, nausea, confusion and impaired judgment, pain in the centre or right upper part of the abdomen below the ribs, an enlarged liver, and patchy or dark skin on the neck or underarm.

Adding further, Dr Aggarwal, said, “NAFLD is often diagnosed after liver function tests produce an abnormal result and other liver conditions such as hepatitis are ruled out. However, NAFLD can be present even when routine liver blood tests are normal. One needs to make certain lifestyle changes to prevent the disease from progressing to a more serious stage and lower the risk of having a heart attack or stroke.”

Here are some simple lifestyle changes one can make to avoid this condition.
  • Maintain a healthy weight.
  • Consume a healthy diet rich in fruits and vegetables.
  • Get minimum of 30 minutes of physical activity every day.
  • Limit alcohol intake or avoid consuming it at all.
  • Only take medicines that are required and follow dosage recommendations.

Wednesday, August 16, 2017

Should a learning curve be allowed in medical education today?

Dr KK Aggarwal

For a doctor, it’s not enough to just know facts; application of that knowledge into clinical skills is even more important. Traditionally, medical students have relied on acquiring these skills by learning on real patients during their clinical postings as undergraduates and then as part of postgraduate training.

In this hands-on, often experimental, way of learning, raises ethical and legal concerns.

Mistakes are bound to occur during the learning process. We learn from our mistakes more than our successes. But patients today are empowered and enlightened. They are unwilling to accept this experimentation on their body. Primum non cere – “above all, do no harm” is fundamental to the practice of medicine.

We do cadaveric dissections to learn anatomy. But, surgical procedures are learned on live cases. When we learn something new, performance improves with experience... as also with a surgical procedure, where complication rates depend on the experience of a surgeon. There is therefore a learning curve.

An expert surgeon is defined by the number of similar surgeries done; complication rates, success rates, re-hospitalization rates are all factors that also define an expert surgeon. Patients today can ask the doctors to disclose these numbers before consenting to a procedure.

A single center study published in the year 2013 in the journal Circulation reported that
75-125 minimally invasive mitral valve surgeries were required to be performed by an average cardiac surgeon to gain mastery in the procedure. And, more than one such surgery per week was required to maintain good results.

In this age of digitization, all procedure-based skills should now be learnt via simulation lab. Although they are not a replacement for the actual patient-based operative experience, simulation labs provide a safe environment for learning. Practicing on a simulator, which has all possible simulations of a variety of real life clinical scenarios, ranging from low to high fidelity, shortens the learning curve and avoids “preventable” errors.

Learning by trial and error is no longer a feasible approach in this age of patient-centric medicine, where doctors have to work with patients as equal partners.

Simulation-based training is the need of the hour in both undergraduate and postgraduate studies and even continuing medical education, when students and doctors can refine their knowledge, skills, without compromising patient safety.

Disclaimer: The views expressed in this write up are entirely my own.