End (Edge) of life issues -

Sometime back, when I was a trainee, we used to get patients at the end of their life. They would come to us tired and dejected (and angry) after  treatment from premier hospitals all over the country; having tried various form of alternative therapies and charlatans. And we would evaluate them and send them back to their homes. Some saw the futility and accepted while some fought to be admitted and die in the ICU. Overall there was (is) singular lack of knowledge and guidelines for the patients, their relatives and also among the physicians and health care workers.

I looked around and found there were no institute or place for such people and their families for guidance. The few places that existed were religion affiliated and their outlook was not what was needed. After so many years; even today no such places exist.

In recent time this area of end of life issues and hospice care has seen advancement especially in United States. A great series of articles was published in the Dallas News which I would recommend to everybody. Excerpts

Nobody wants to die a slow, lingering death. But many Texans do. Half die in hospitals. One in five passes away in intensive care. Often, their last months of life are expensive, painful exercises in medical futility.


Health care reformers in Dallas and around the nation are pushing for a better way to help people at the edge of life.

Practitioners of "palliative care" combine traditional medicine with pain relief, spiritual counseling, and practical advice for patients and families.

These articles derive from the experiences of palliative care team at the Baylor University Medical Center in Texas.

Unlike hospice, palliative care can continue alongside aggressive, life-sustaining treatments. Palliative doctors, nurses and other clinicians guide patients and families through searingly painful choices, including decisions to avoid overly invasive care. They aim to help patients live as well as possible for as long as possible, and to help grieving families prepare for the inevitable.

Research indicates that such "comfort care" sometimes can prolong life more effectively than aggressive surgical, chemical or radiation therapies. It also can reduce medical expenses; Medicare spends 28 percent of its annual budget on care given in the last year of life.

She describes the families and their emotions so well, highly recommended reading includes video clips.

Mr. Bourque tried telling Michelle that her mom might not make it. The little girl set stuffed animals and a purple-and-orange squirt gun on her mother's emergency-room gurney like talismans.

The Bourques were medical people. Mr. Bourque, 44, was a pediatric ICU technician starting nursing school; Mrs. Bourque, 45, was a pediatric respiratory therapist. They couldn't kid themselves, but it wasn't clear how much their daughter understood.

They'd tried to spare her, and sensed that Michelle was trying to protect them, too. They all needed help to get through what was coming. But nothing else could happen as long as Mrs. Bourque was trapped in agonizing pain.

In this era when nothing is ever enough and the machines can breathe for you; pump your heart; feed you forever; but cannot think for you: read here the series by Lee Hancock.

Drug marketing and dichotomy

When I began my practice following residency I became aware of the cesspool that medical and associated profession have become. Each day was (is) a learning experience. Not that one is completely unaware of the ground realities- but first hand experience is humbling.

I was reading a blog post by Jim Sabin wherein he comments on an article on "Drug promotional practices in Mumbai: a qualitative study" in the Indian Journal of Medical Ethics (April-June 2007 issue) and surmises

All of the issues described in Mumbai are present in the U.S., but in India the pharmaceutical practices are more brazen. Federal and state regulatory capacity is significantly less in India than in the U.S. Perhaps more important, organizations - medical schools, hospitals, medical societies, and more - currently have less capacity to push back against commercial forces than comparable institutions in the U.S.

But the Indian media is sinking its teeth into the issue of commercial corruption of medical decision making (see, for example, "Are your drugs boosting your doctor's lifestyle?" in yesterday's Times of India here). The same ethical drama is playing out globally, just with different timing.

the ground reality and the extent is so so much worse that it is mind boggling. and to be frank the medics/doctors are ending up being bit players.

Pic from offside.com
Technorati Tags: Medical Ethics

Burnout in Medical Students

As every whining medical student knows- life as a medico is tough and trying. This was well documented and analysed in an article in Annals of Internal Medicine(abstract).

The article has been reviewed by Sydney Spiesel at Slate.com

The study included more than 2,000 students at seven medical schools and looked for evidence of burnout and suicidal thinking. About half the medical students reported the feelings that define burnout (emotional exhaustion, a feeling of a loss of personal identity, a sense of poor personal accomplishment). Many showed signs of depression and a decreased mental quality of life compared with peers not in medical school.

He attempts to explain the findings and further offers possible solutions to the problems as in

We need to be alert to the signs of burnout, depression, and suicidal thinking in medical students and to make available the mental-health services needed to help with these problems.

Even though the factors in India are quite different from the US medical schools esp. regarding the debt(largely subsidized); I would be surprised if the findings are much different. the full article is here.

(Thanks to Cartoonstock.com for the pic)

Lessons from Sharks on reducing infections.

Interesting article in the Wall street journal health blog

The ocean is full of slow-swimming creatures covered with algae and barnacles. But some slow-swimming sharks stay pretty clean.

A University of Florida researcher thinks that has to do, at least in part, with the microscopic pattern of shark skin, which makes an inhospitable environment for the critters that want to make a home there.

The researcher, Anthony Brennan, hopes to make products whose surfaces mimic that property, and he’s working with a couple of Denver businessmen on a company called Sharklet Technologies. This morning’s Denver Post has a story on the business.

The company says it’s already figured out how to make silicone surfaces with a sharklike pattern that’s resistant to the growth of bacterial films. Sharklet hopes to sell the technology for use on things like catheters, a common source of hospital-acquired infections.

It’s early days still for the technology, and it’s unclear whether it will get off the ground...

Hope that this cool idea works out! Urinary tract infection following catheter insertion is certainly a frequent complication in hospitalized patients. The concept of preventing infection by disabling bacterial adhesion and migration (biofilm formation) is gaining grounds with few other materials being tried out.

(image from the Denver Post)

From the Denver Post via WSJ health blog.

Richard Wright - Shine ON...

Richard William Wright died on the 15th of September 2008 following cancer at the age of 65. He was the lead pianist, keyboardist, lyricist and one of the original members of the band Pink Floyd. Wright had the lowest profile of any member of a band known for their disinclination to seek individual attention. He kept the details of his illness private as well.

Pink Floyd was (is) my favourite rock band.

He also had two solo albums Richard Wright's Wet Dreams(1978) and Broken China to his name. And this song is one my favourites from his albums.

Rest in peace Rick Wright ..and sail on across the sea!!

Internet Companies sued for Sex Selection Ads

Given the fact that male to female ratio in India is grossly skewed having reported a child sex ratio of 927 girls to 1000 boys in the
2001 census, against a world average of 1045 women to 1000 men.

In some
States this is even worse including in Punjab, Haryana, Gujarat, Himachal Pradesh, Delhi,
some districts of Tamil Nadu, Maharashtra and recently Karnataka, the
sex ratio has declined to about 900 girls per 1000 boys in the 0-6 age
group. In some districts, the ratio has plummeted to less than about
850 to 1000 boys.

The preference for male child continues and in recent times has been assisted by mail order/ internet companies who are able to defy safeguards by operating from outside the country. So it was just a matter of time that someone pointed this out. This news was published in the New York Times today.

Microsoft, Google and Yahoo were issued notices by India's Supreme Court on Wednesday, following a complaint that they were promoting techniques and products for the selection of an unborn child's sex through advertising and links on their search engines.

There is a deliberate attempt by these companies to target Indian users with advertisements that claim to help in the selection of a child's sex, said Sabu Mathew George, the petitioner in the case, in a telephone interview on Thursday. Read the rest of the article here.

Update: Internet giants Google and Microsoft have pulled adverts for sex selection products and services considered illegal in India after being threatened with legal action, activists said Thursday.(from Yahoo news)

WHO issues a surgical checklist.

A lot has been written about surgical errors during operation including incidents of left behind surgical instruments, wrong site surgery, operating on wrong patients and so on.


The WHO has issued a checklist which it hopes will go a long way in reducing such errors by enforcing a 'time out' when all personnel participating in a procedure will check and mark on the checklist ensuring compliance of necessary formalities. Such checks are further made at the end of procedure.

I agree that such checklists and timeouts will be quite helpful in reducing the number of errors but surgeons are resourceful and dogged of determination; they will find a way around this.

As an aside if you have read books by Atul Gawande you will be aware of his fascination for idea of checklist similar to those used by the Aviation industry(very effective) to reduce medical errors. His Harvard group and folks at IHI and The International Society for Quality in Health Care have been quite active at getting this off the ground.

WHO Safe Surgery Saves Lives ChecklistTechnorati Tags: surgical complications

Second opinion at a distance

There is an interesting piece of new in todays USA today about taking second opinion for health conditions online from experts. You send your medical records with or without your primary doctor's help via internet to Experts( places providing paid service) and get their opinion after a week or so.

Online second-opinion services offer patients consultations from specialists based on the medical records that they fax, mail or send via the Internet. The average cost, payable upfront via credit card, is $500 to $1,500, depending on the number of radiology or pathology interpretations required. Patients then receive online access to a second opinion in about two weeks.

What I find very interesting is the amount of changes in treatment or diagnosis as per this article.

More choices, 'more peace of mind'

Not all remote second-opinion services require that a patient's local physician participate. The Cleveland Clinic, for example, delivers consultations directly to a patient, while POSC shares them with the physician first and then with the patient.

In Harlow's case, her physician "welcomed" the idea of a second opinion. Harlow says she opted for the whole-breast radiation treatment, based on the report from Lawrence Schulman, a leading oncologist at Dana-Farber Cancer Institute,

"In about 5% of the cases, we actually change the diagnosis of the patient. In 85% to 90% of the cases, we alter the treatment," says Jonathan Shaffer, managing director of e-Cleveland Clinic. "What we are able to do is give the patient more treatment options and hopefully give the patient more peace of mind," he says.

Shaffer says people are beginning to realize the convenience of e-health technologies. "It continues to grow every year."

Considering the rapid progress in internet technology and telemedicine these are bound to increase. Radiology is quite in the forefront. But is it viable in the long run?

Quite a majority of cases are such where the diagnosis and the treatment is not in doubt and the physician is quite comfortable in following through the treatment. It may happen that the patient remains unsatisfied and may want a second opinion or alternative treatment. And why not? after all it is his money and body. He might remain dissatisfied with the second opinion as well.

Physicians have been taking second opinion unofficially and consultations officially whenever they are unsure about management of a particular disease or presentation; but will they follow up on perceived unsolicited advise?

Do not expect the primary physician to follow and carry out the advice given by the Case manager /Second opinion provider unless he himself (or herself) co-initiated the consult. It is quite apparent that the second opinion will also be a medical consultation with its attendant liability and responsibility unless waived off by the patient( and then that has its own consequences).

The need for second opinion arises more in evolving fields like Oncology or where there are multiple treatment options under evaluation. For example- If the patient remained unconvinced by the doctor providing second opinion then what? back to square one..Patients need to have faith in their doctors and the doctors need to have knowledge to get that trust.

Whatever shape it takes in future; there is money to be made and does fill in a perceived need so will catch on.

Read the complete article from USA Today.

Pic from http://www.flickr.com/photos/luca_eos/

Reversible Vasectomy

At present Vasectomy is the only reliable method of male contraception. While it is relatively simple procedure and quite cheap besides the fact that the government pays you to get it done, yet it is not that popular. 

The reasons for that is the irreversibility of the procedure and the perception of loss of 'manhood'. Male desiring further children have to undergo recanalization which are not always successful and is expensive ( vas may block again, antibodies to sperm may develop etc.). So any reliable alternat e  method  is bound to be popular and in the  news. from rediff.com

Once upon a time, a scientist, rather an engineer-cum-doctor, toyed with an idea -- what if there were a male contraceptive? What if a simple injection to a male prevented unwanted pregnancy?

His ever-active brain started thinking and years of research followed. And after 30 long years, RISUG (Reversible Inhibition of Sperm under Guidance) was born.

The credit goes to Indian biomedical engineer Dr Sujoy K Guha and his group at the Indian Institute of Technology-Kharagpur,

In this situation a method of reversible blockage or sperm inhibition would be a wonderful thing; increasing the usefulness and acceptance of male contraception. This is where the method of RISUG comes in. Though still in advanced trial stages it is quite promising. It consists of partial blockage of the vas deferens lumen(the conduit passing sperm from the testes to the ejaculate) using polyelectrolytic compound and can be effective upto 8-9 years. The block can be reversed when desired by flushing using solvent or local stimulation.

The method is pioneered by Dr. Guha at IIT Kgp. In case you need to know more you can visit the Risug site or

Reversible inhibition of sperm under guidance - Wikipedia, the free encyclopedia.

(Pic from iitkgp )

Malpractice trial- A Physicians story

Great story from an Obstetrician who was sued.  How he came to terms with the verdict and the doubts it created in his mind. The true final verdict of my malpractice trial..

I was reading

I just finished Grisham's latest novel The Appeal. His latest book is much better than his last few offerings which I found a bit dull. The story reolves around desperate measures to influence the legal procedure, tort reforms and a mega corp willing to bend any rule for profit.

Set in the state of Mississippi,U.S. having a supposedly tort friendly judiciary a mega corp is accused and convicted of dumping carcinogenic waste into the environment. In order to overturn the verdict and avoid paying the huge compensation awarded the billionaire owner plots to influence the appeal process and the judges involved (I wont go into the details of the plot as you may want to read the book). The novel has interesting side forays into difficulties of being trial lawyers, false & misleading advertising campaigns, medical malpractice and injuries from aluminium baseball bats. Do we have cricket bats made of aluminium or are they banned by ICC?
Just as I finished reading this book I came across this piece of news

The family of a boy who suffered brain damage after he was struck by a line drive off an aluminum baseball bat sued the bat's maker and others on Monday, saying they should have known it was dangerous.

coincidence or author's inspiration?

Technorati Tags: book review, tort