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