Blissful Life

Category: mbbshacker.blogspot.com

  • “Risks” vs Risks

    Decision making is almost always complicated by uncertainties. The more information that can provide context, the more stakeholders that are part of the decision, the better the chances of reaching a good decision.

    In the past few weeks, world leaders have had to make very difficult decisions. Lock down entire country? Put money into healthcare? Risk economic disasters to prevent health disaster?

    I guess the biggest problem they would have faced in making these decisions is uncertainty. Because medicine is a field of uncertainties. The first thing a doctor learns when helping patients is that they can never be sure of anything other than the fact that they have to act. Diseases, cells, organisms, molecules, environment, human behaviour – there are a lot of moving parts in medicine. Parts that you can’t control. Parts that you can’t even predict.

    A doctor is a performance artist who uses an imperfect science to help alleviate suffering. In Osler’s words, “Medicine is a science of uncertainty and an art of probability”. I’ve been fascinated by the range of dilemmas a thinking doctor faces in routine practice. When choosing who gets a ventilator they get to act God. When choosing what information to convey to the spouse of a person newly diagnosed with HIV, they get to play the Supreme Court. And not to forget the countless times they get to act human when seeing raw humanness play out in various scenarios – first breastfeeding of a newborn baby, last bye-byes before surgery (oh, thinking of it, I’ve never seen a family wave bye-bye in India. Maybe I’m watching too much of medical TV series), pain that persists even with the strongest painkillers, so on.

    We were talking about uncertainties. Yes. That’s what makes life really difficult in the field of medicine.

    Let’s take one specific question. The use of masks by public during COVID-19 pandemic. Should they wear it? Should they not?

    Let me break it down.

    What do we know about how the virus is transmitted? Just enough. We think it is through respiratory droplets and contact.

    What does that mean? A respiratory droplet is any drop that comes out of a person’s nose or mouth. It could come out while coughing, sneezing, even while laughing, or shouting. Contact is, well, contact. Touch. Touch anywhere where those respiratory droplets could have been. Surfaces, hands, wherever.

    Okay. So we know how the virus comes out of a person. But how does it enter someone else? No points for guessing that the respiratory tract is a major route for entry of respiratory viruses into someone. That includes mouth and nose. But turns out respiratory viruses can enter body through eyes too. (Warned you about uncertainties, didn’t I?) Luckily for humans, the largest organ of our body – the skin – is also a very protective sheath that makes our hands, legs, and so on less likely to be ports of entry for the virus. (Like I tell the people who come to me scared of HIV because they touched someone infected with HIV, even if a bag of blood full of HIV falls on your bare hands, unless there is a cut on your skin, there is no need to be scared. Of course, they then ask about the possibilities of microscopic cuts. But that’s another story and this snippet of that story is included to make a point that there are “risks” and there are risks.)

    Now, what do we know about masks? The medical masks that we are talking about? They can definitely protect someone’s nose and mouth from other people’s respiratory droplets. But that’s all they can do. They cannot protect their hands. They cannot protect their eyes. And the mask itself gets contaminated while protecting the mouth and nose of the wearer (Important point. The external surface of the mask is where all those respiratory droplets, if any, should get caught).

    What do we know about people? We know that people touch their face a lot. You just touched your face while reading this article. Your nose is itching as you’re reading this sentence.

    When a human goes out during the pandemic to buy grocery, they have to deal with many things. Around them, there could be a large number of people who have never seen SARS-CoV-2 in their life. They could also be walking among asymptomatic carriers who are shedding their virus in respiratory droplets. They could be touching surfaces which a carrier coughed into 10 minutes before. They could be inhaling respiratory droplets from carriers. Respiratory droplets could land on their eyes. Droplets could land on their hands and they could then touch their eyes/nose inadvertently. Droplets could land on their masks and they could then touch their masks inadvertently. Their mask itself could be a makeshift one with towel that they hold in front of nose and mouth (where the external most surface is their own, pretty, hand). And that hand could then inadvertently touch their eyes/nose.

    Do you see the risks and the risks that masks mask (pun intended)?

    Yes, theoretically masks decrease the risk of transmission by a tiny bit. But practically, probably, they don’t.

    On the other hand, there are some real risks of people wearing masks to grocery shops.

    The first thing that happens is we all run out of masks. Including the health care workers and people who care for COVID-19 infected at home. (Of course this has already happened in many cities). These people are now at definite risk for contracting infections because they deal with definitely sick people and for very long durations which increases their exposure. Many of the health care workers do not become sick, but some of them do. When they become sick the entire system is demoralized. And we don’t want that to happen when we are about to face a pandemic that nobody is sure how to deal with.

    That is why WHO and CDC and others insist that masks should be used rationally.

    Does that mean, if we had unlimited supply of masks, it would be okay for public to wear it when going out to fetch grocery?

    If you are a person who wears a helmet while walking on the road, yes.

    Of course, how could I miss this, yesterday when I went to the grocer’s, I was wearing a helmet with the glass visor closed all the time.

    — Akshay S Dinesh (@asdofindia) March 28, 2020

    Okay. Update: I haven’t considered at all the chance that you’re an asymptomatic carrier who is spreading the disease to others. In which case, suddenly there is a non-trivial effect where masks prevent the respiratory droplets from getting out of you in the first place. Uncertainties here are the proportion of asymptomatic carriers and their infectivity.

    I really don’t know.
    Update on May 30: There is piling evidence that masks are useful for source control. And now that the pandemic is well distributed inside all countries, the calculations of risk also has to change. Right now, the governments would have had enough chance to ramp up PPE production and meet healthcare needs. Right now you are at a higher risk of being an asymptomatic carrier than you were at the beginning of the pandemic when overall prevalence was low. So, yes, wear a mask. It may not protect yourself, but it will protect others.

  • PGDMLE Paper 4 – Law & Medicine Some Emerging Issues

  • PGDMLE Paper 3 – Medical Professional, Patient & The Law – The Legal Relationship

  • PGDMLE Paper 2: Law and Health – an Interphase

  • PGDMLE Paper 1

    It's been a long time since I posted any question papers on this blog 😀

    I've been doing a distance course in medical law & ethics from National Law School Bangalore. I love the course. So much so that I didn't take exam the first time so I could extent the duration.
    This time I had to take at least two papers. (I'm taking four, and skipping dissertation for next time).
    This is paper 1 which is common to all diploma courses (among child rights, cyber law, and so on).
    I've ticked the questions I answered.

  • Lessons One Should Learn From Shehla Sherin’s Death

    If you do not avoid news like me, you would have heard about the tragic death of a 10 year old in Wayanad a couple of days ago. You can search the name and find the story on your own, but a few facts are established already.

    1. Shehla Sherin had her foot go into a hole on the floor of her classroom and was afraid a snake bit her in that incident
    2. There was delay in taking her to the hospital
    3. Anti-Snake venom was not administered at the local hospital, and the child was referred to a tertiary care center at least an hour away.
    4. Child died on the way.

    I won’t unnecessarily go into speculations on what other things happened on that fateful day, but having managed emergency department in a rural hospital for over an year, I will use this sad death to illustrate two very important lessons for every doctor.

    Lesson 1: Never take any complaint lightly, even if the circumstances lead you to think otherwise

    There are two ways patients can come in. There are people who exaggerate, and people who downplay. Take all symptoms seriously.

    There are no insignificant complaints. There are no insignificant findings. Whatever the patient tells you has to be taken seriously. Even if the patient asks you to not take it seriously. At the height of experience and confidence you might be able to predict that something isn’t as serious as it sounds, but be really really careful before making that decision.

    I had once a patient come to the casualty with a swollen foot. The patient had intellectual and speech disabilities and therefore there was no proper history. The bystander (who apparently takes care of the patient) told that “someone must have hit him”. My colleague suspected a snake-bite because of the way the swelling looked, but nevertheless ordered a whole blood clotting time test and a foot x-ray to rule out a fracture. My shift was about to start and while I was taking charge from my colleague I inspected the foot of this patient closely (in the x-ray room). I could see two small points of bleeding close to each other – fang marks!

    We immediately told the bystander that this is not “someone must have hit him”, it is a snake bite, and that the patient will die unless something is done immediately. This bystander did not look like they liked the patient very much because they asked me “please do whatever you can here itself, don’t refer us to higher center”. We knew that the best we could do was given anti-snake venom (which we immediately started doing) but the patient might require blood products which weren’t available and required referral. So, we took a stand and sent the patient as soon as the ASV went in.

    There was this other patient who came at noon on a different day with severe chest pain, as if he was going to die the next moment. He was a smoker and alcoholic with a very good chance of having a heart attack. He wouldn’t even lay still for us to get a proper ECG, and whatever leads we could obtain looked like there were ST elevations all over. The MI protocol kicked in, we gave all the painkillers, anti-coagulants, and sent the patient to the nearest cardiology center. News later was that he was just having severe gastritis due to alcoholism. But, we did what we should have done.

    We’ve had a patient with vague headache/chest pain admitted for observation die on us under strict observation. I’ve had a patient with diarrhea go into dehydration and shock. I’ve had a lady who could perceive fetal movements but have no fetal heart activity on ultrasound. We’ve had a person with cellulitis of lower limb go into septic shock and die while we were on rounds. We’ve had a bystander who missed anti-epileptic medication die after getting seizures and aspirating. I’ve examined a kid with high fever who had febrile seizure on the way out. We’ve had a kid admitted for being dull after vaccination die in front of us, despite our best efforts. We’ve had a child in waiting area who wasn’t breathing well arrest by the time they were identified by a patient care worker to be requiring urgent attention. I’ve had a patient with vague thigh pain turn out to be deep vein thrombosis and die next day.

    Always have the worst outcomes in mind when making decisions. Be mindful about patients who you haven’t even seen yet. Communicate a lot. Err on the side of cautiousness.

    Never be afraid to wake seniors up from sleep. When in doubt, ask for help. If you are not sure about something, check it again. If something happens while you could have done something which you didn’t, you’ll regret that your entire life. And that is a pain.

    Lesson 2: It is a privilege to have access to the miracles of modern medicine. When you have the power to use things, please also have the courage to.

    There is always going to be a risk. It is risk that makes the work of a doctor exciting. If you’ve chosen to be a doctor, there is no way you can avoid risk. Even if you become a dermatologist, you can land up in soup. As a doctor, the only way to avoid risk is by quitting professional life and meditating inside a cave.

    Risks shouldn’t hold you back from attempting something that’s required for your patient. I got this lesson the first time when I was still an intern, and was in KR Hospital’s Medical ICU. I was trying to insert a catheter into someone’s jugular but I was going too superficial. My senior then told me “Always remember, what you’re doing is for the benefit of the patient. You’re only going to harm them by not doing it confidently. The patient will die if they don’t get this line. So you may as well put it in boldly.”

    There is a definite role for experience and knowledge in being able to build the confidence to do things. But neither of that will come unless you want to do those things for your patient. If you are shy of cutting, you can never be a surgeon. If you are scared of side effects, all the pharmacology you know is absolutely of no use.

    Too many doctors think that by not committing something they’re keeping themselves safe. But their fake sense of safety comes at the cost of the patient’s suffering. Laws of medical negligence apply to acts of omission as well as they apply to acts of commission. With all your training you may as well do something and fail, than be a mean coward. That’s what your license is for.

    Use anesthesia (ketamine + midazolam, if you will) when draining breast abscess. Give powerful analgesics when people are in pain (don’t give diclofenac for MI/fracture. Give something like pentazocine). Use second line and third line drugs when the first line fails. Give aminophylline or magnesium sulphate for COPD/Asthma. Steroids and immuno-suppressants are in various guidelines for a reason – use them when indicated. Even newborns may need anti-epileptics. Benzathine Penicillin is the best available cure for Syphilis. “Higher antibiotics” are not reserved for higher centers. Use vasopressors (and for heart’s sake not fluids) in hypotension where failure needs to be considered. Use nitroglycerine to control high blood pressure. Use heparin. Use atropine. Use adrenaline. Use BiPAP. Resuscitate. Use oxygen. Use fluids. Give vaccines. Conduct deliveries. Splint fractures. Suture large wounds. Intubate and bag till the ventilator in referral center. Use all the things you’ve learnt to deliver care. That’s why you’re a doctor.

    And if you feel you’re under-prepared for any of those things even after MBBS, work with sincere people in rural hospitals (like VMH or THI or BHS). Learn the skills. Learn the craft. Understand pain and suffering. Care for other humans. Become a good doctor. Then do whatever you want to.

    Epilogue

    I had a rule when I was working in ED – “Nobody dies when I’m on duty”. The only exception was patients admitted for palliative care. Imagine if every doctor in our country made rules like that for themselves.

  • Understanding Adrenaline Dosage

    Have you ever administered adrenaline for anaphylactic shock? I’ve never had the unfortunate need to. I’m sure anyone who ever does will forever remember the correct dosage. But for me, it is always a confusion. Every time I vaccinate someone at my clinic, I look up the dose of adrenaline just to be sure.

    The first problem is the dilutions. Dosages of adrenaline are (or were) mentioned in dilution. 1:1000 & 1:10000. There begins the confusion.

    Firstly, let us understand where the 1000 comes from in 1:1000. Have you seen a small vial of adrenaline? That is 1mL. It has effectively 1mg of epinephrine/adrenaline. But why is it called 1:1000? Because 1mL of water = 1g of water = 1000mg. So, the 1:1000 actually refers to 1mg of adrenaline : 1000 mg of water. Unnecessarily complex!

    All you had to say was 1mg in 1mL. And that is why this labeling is now being followed in some countries.

    So, there you have a small vial – a 1mL vial – with 1mg of adrenaline in it.

    Now, let us look at the other form epinephrine comes in. Epinephrine also comes in a big syringe of 10mL. But even this 10mL contains only 1 mg of adrenaline. The total amount of adrenaline in this 10mL form is the same as a small vial.

    What is different then? Well, when the volume increases without increase in amount, the concentration drops. The 10mL form is more dilute than the small vial. Can you guess the dilution? It is 1:10000 or more easily expressed as 1mg in 10mL.

    So, the first thing to internalize is that the small 1mL vial we see has 1mg of adrenaline (it may say 1.8mg of an adrenaline salt, but the effective amount of adrenaline is 1mg). And this is a concentrated form of adrenaline.

    What that also means is that the 1mg/1mL adrenaline is never used directly IV! The reason is that this can cause an arrhythmia or other damages to the heart muscles.

    If you’re bored reading text, watch this youtube video telling these same things.

    Now, the dilute form and the concentrated form are for slightly different uses. The concentrated form is given IM in anaphylactic shock. The dilute form is given IV in cardiac arrest.

    When giving IM adrenaline for anaphylactic shock, the dosage in adults is almost always 0.5mg (0.5mL of the concentrated vial). If you can remember this fact it is easy to calculate the pediatric dose as well. The adult dose can be thought of as if it applies to a 50kg person. So 0.5mg for 50kg = 0.01mg/kg and that is the pediatric dose. (This 50kg adult approximation applies for many other drugs in calculation of pediatric dose. Let me know in comments below about other drugs that can be calculated this way).

    When giving in cardiac arrest, in which case the dilute form (1mg in 10mL) is used, the adult dose is the entire 1mg (or 10mL) given intravenous and repeated based on the protocol you follow.

    That is all there is to know. Just a 0.5mg and a 1mg.

  • The Curious Case of Consultation Fees in General Practice

    Today as I was returning home in metro two lawyers occupied the seats next to mine. I was reading A Reader on Reading by Alberto Manguel. But I distinctly heard one of them tell the other “I have two cases tomorrow evening”. That set me thinking.

    Advocates have “cases” and so do doctors. Advocates have “clients” and so do doctors. (Some doctors call their clients patients because some clients are indeed patients. But some doctors call even their patients clients, appreciating the fact that ultimately the people who come to them are dignified individuals seeking a service and with autonomy in choosing service providers.)

    Advocates are also notorious for charging sometimes lakhs for an “appearance”. But here doctors have itt slightly different. Doctors also get called money-minded and unscrupulous, but they get called so for charging much less than what advocates usually charge. Why is this so?

    I came up with various possible reasons. One, the huge lawyer fees that we hear about usually are in big courts for defending big crimes. Perhaps the stakes are really high in those situations. To add to that, a court case is usually once in a lifetime situation for most people and one they probably have never encountered before. Therefore the clients are in a much more vulnerable situation and would be willing to pay a lot.

    This “high stakes” reason appears correct because there is similarity in healthcare. When you go to a hospital with a heart attack, you don’t care how much the hospital charges are going to be, you just want your (chest) pain free life back. But when you have a cold (which is probably the 14th time you are having it in your lifetime), you know it is going to be better in a few days and there is no real reason to spend lots of money.

    That probably explains why the market rates in general practice is very small. People usually present with simple illnesses and a sense that their illness is a simple one. Therefore there is not much value they are seeking from the doctor – most clients are in for quick relief from symptoms, if possible.

    Therein lies the complexity of general practice too. I’ll explain that in a bit, but first let us look at one more difference between lawyers and doctors. Lawyers take money from clients and work for clients by being sharp witted and coming up with strong legal arguments. But their “appearance” is in front of a judge. The favorable outcome is defined by the client but realizing that outcome requires very little of the client’s participation. Usually, the judgement made by the judge also unequivocally settles the judgement on the lawyer’s performance.

    Now let us talk about general practice. In general practice, your client does not just pay you, but also has to work with you for their own success. There is no third person involved. The client has to believe in the doctor, has to believe in the advice given by the doctor (that the advice is for their own good), has to follow the advice strictly, and also has to make a judgement about how good the entire process have been. This is where the previous point comes in.

    The reason why clients come to a general practitioner is often for quick relief from their symptom. Most of the time in medicine there is no quick relief which is also good. For example, painkillers are quick relief from pain due to strain. But the good thing to do maybe in many cases to take rest and allow body to recover. Common cold may slightly improve with nasal decongestants, but overuse maybe harmful. Sometimes sticking to medicines which cause nausea, vomiting, diarrhea or many other tolerable side effects are required in the face of greater dangers like multi-drug resistant tuberculosis.

    Sometimes the right thing to do in the view of a doctor maybe different from what the client thought would be the right thing to do. This would not be a problem for a lawyer as the client does not have a role in deciding the success of the lawyer’s approach to the “case”. But when doctors are in this situation they have to use all the skills they have in convincing the client about why there needs to be a change of expectations. And the success of the treatment itself relies on this “winning over” of the client.

    And after all that exercise, the client has to pay. ICUs, OTs, and emergency departments have it easy. There is a lot of money to be paid, but most of the work is done by nurses or doctors and the sick person usually just has to lie down on a bed (conscious or not). General practice? Totally different ball game.

    With that context, how much is a reasonable consultation fee in general practice? 50? 500? 1000?

    Before locking our answer, let us look this from another side. The general practitioner is a small entrepreneur. The GP has a home and has a life. The GP needs to make money to survive. But the GP is also a doctor. No conscientious doctor can do injustice to their profession or their clients. They cannot simply symptomatically treat diseases without thinking about root causes. Diseases have to be managed correctly. Counseling is an important aspect of treatment. And all of that requires time – time to be spent in consultation. And time is money.

    The question on consultation fee thus has to be somehow linked to the consultation duration. What is the minimum time a doctor should spend with their client to fulfill their obligation/duty? There can of course not be a single answer to this as every consultation is different. But practically, from my experience, in a single person clinic the doctor (who is the single person) has to spend at least 20 if not 30 minutes in a consultation for there to be some quality.

    How much of that can be delegated? Whom to delegate to? Of course in a single doctor clinic the only person to delegate to is the client themselves. Can clients prefill questionnaires about their health condition? Can clients read informational pamphlets instead of having to listen it directly from the doctor? Does trust suffer in attempting such time saving measures? These are all questions with no definite answers.

    Does building a healthcare team help? It can definitely help. At Restore Health we have a multi-disciplinary team where a lot of tasks are shared. But still there is considerable amount of time spent by each person of the team in providing care to a client. And we charge 500 in general practice consultations. Are there people who think that is too much? Definitely, yes. Including sometimes our own doctors. But there are times when we have saved the client a lot of money and good health and spent considerably more time in the process. We do not have “dynamic pricing”.

    Perhaps there needs to be more thought put into showcasing all the value that is created by a GP and monetizing some of that at least. All this while treading on the right side of ethics and not breaking the delicate thread of trust that connects a client to a doctor. Who says general practice is not challenging?

    My train of thought was derailed when the train I was sitting in reached my destination. As I stood up to deboard, the lawyer next to me took my seat. Perhaps she was thinking about how much to charge her next client. Perhaps not.

  • Healthcare in Consumer Protection Act 2019, VP Shantha and why you should read the source

    There are good journalists and bad journalists. It is the reader’s duty to discern between what is right and what is wrong. The problem in the 21st century is that that duty is completely thrown into water under the guise of “forwarded as received”.

    There are a lot of articles in newspapers talking about dropping the world “healthcare” from the list of services under the consumer protection act of 2019. Many of them have fancy headlines suggesting that healthcare will not be a service that falls under the ambit of the new consumer protection act. At least some of them have written objectively stating where the word is dropped from without going into judgement on what this means.

    But many doctors are reading headlines and thinking that the consumer protection act will not apply to healthcare henceforth. What they need to read to know they are wrong is just one judgement by the Supreme Court in the “Indian Medical Association vs VP Shantha, 1995” case.

    That judgement was specifically about settling the question of whether healthcare is a service that falls under the definition of service as defined in the consumer protection act (the act of 1986). For ease of reference I will quote the definition from the old act:

    “ “service”
    means service of any description which is made avail­able to potential users
    and includes, but not limited to, the provision of 
    facilities     in connection with banking, financing insurance, transport,
    processing, supply of electrical or other energy, board or lodging or both,
    housing construction, entertainment, amusement or the purveying of news or
    other information, but does not include the rendering of any service free of
    charge or under a contract of personal service;    “

    Notice that healthcare is not specifically mentioned. Supreme Court read this definition and confirmed that healthcare is included in the broad definition of “service of any description” and spelled out conditions where it would be excluded.

    Now, here is the definition from the new act:

    ““service” means service of any description which is made available to potential users and includes, but not limited to, the provision of facilities in connection with banking, financing, insurance, transport, processing, supply of electrical or other energy, telecom, boarding or lodging or both, housing construction, entertainment,amusement or the purveying of news or other information, but does not include the rendering of any service free of charge or under a contract of personal service;” (emphasis for words that have been added)

    Where is the “healthcare” word dropped from then? Well, it is from the draft bill that was introduced.

    Now you can read the full judgement on how the new definition also includes healthcare in it.

  • Meftal-Spas vs Meftal-Forte for Menstrual Pain

    I was recently asked by someone whether Meftal-Forte is a better drug than Meftal-Spas for menstrual pain.

    I hadn’t heard about Meftal-Forte till then. So I looked up. 1mg told me both the drugs are manufactured by Blue Cross.

    The page about Meftal-Spas gives us what I knew already – it is a combination of Mefenamic Acid 250mg and Dicyclomine 10mg.

    The page about Meftal-Forte told me that it is a combination of Mefenamic Acid 500mg and Paracetamol 325 mg.

    Based on this, the quick answer is “No. Meftal-Spas seems to be better suited for menstrual pain in people who find relief by using it. But self-medication may not be the best way to manage menstrual pain.”

    The longer answer is that dicyclomine is an anti-spasmodic that is widely used with anecdotal evidence supporting its use in primary dysmenorrhea. Mefenamic acid is an anti-inflammatory drug that is indicated for use in primary dysmenorrhea. Paracetamol is not really indicated for primary dysmenorrhea. Therefore if forced to choose between these combinations, the one with dicyclomine makes more sense to be used in primary dysmenorrhea. But self-medication is mostly not the right thing to do because a lot of dysmenorrhea maybe secondary to things like endometriosis and maybe better treated by other drugs under the guidance of a family doctor or a gynecologist, and sometimes just mefenamic acid (in the right dosage) might be enough to control primary dysmenorrhea.