Never declare a patient dead under conditions of hypothermia

Never declare a patient dead under conditions of hypothermia

 Dr KK Aggarwal, Dr R N Tandon

A core body temperature below 95°F is hypothermia. Core temperature 90-95°F is mild hypothermia, 82 to 90°F is moderate hypothermia and core temperature below 82°F is severe hypothermia.

In conditions of severe hypothermia in children, body metabolism is suspended, which may protect against hypoxia. Patients with core body temperature 82°F have been known to survive anoxia for 12-18 minutes and up to 60 minutes or more at core body temperature 68°F. Sometimes, hypothermic patients can be successfully revived with CPR even with total resuscitation time of 9 hours. Because of dilated pupils, asystole, hypoventilation, absence of shivering, the patient appears dead. Because of failure to recognize this state, the patient may be declared dead.

Successful revival is also possible in adults because of the neuroprotective effects of hypothermia. Several hours of CPR may be required for this. Efforts to revive the patient should be continued till the core body temperature reaches 90-95°F i.e. bring the temperature from severe hypothermia to mild hypothermia or normal. If the patient still cannot be revived with CPR, then he/she can be declared dead.

The recent incident of a premature (22 weeks) newborn, who was alive, but allegedly declared dead at a private hospital in the National capital has captured headlines. The other twin was stillborn. While being taken for the funeral, the newborn was discovered to be alive and is now on life support system.

In light of this incident, IMA has issued an advisory that patients should not be declared dead under conditions of hypothermia. 

It is important to recognize hypothermia so that patient can be timely revived using all resuscitative measures, including rewarming, CPR.

Updated guidelines for treatment for patients with ventricular arrhythmias

Updated guidelines for treatment for patients with ventricular arrhythmias

Dr KK Aggarwal

The American College of Cardiology (ACC), American Heart Association (AHA) and the Heart Rhythm Society (HRS) have jointly published new guidelines for the management of adults who have ventricular arrhythmias or who are at risk for sudden cardiac death, including diseases and syndromes associated with a risk of sudden cardiac death from ventricular arrhythmias.

According to the guidelines, patients considering implantation of a new ICD or replacement of an existing one should be informed of their individual risk of sudden cardiac death and nonsudden death from heart failure or noncardiac conditions, and the effectiveness and potential complications of the ICD. In patients nearing the end of life from other illness, clinicians should discuss ICD shock deactivation as they reassess their patients’ goals and preferences.

Emphasizing on the role of shared decision making between patients and their doctors, the guidelines say that treatment decisions should also take into consideration, the health goals, preferences, and values of the patients.

The “2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death” have been published online October 30, 2017 in the Journal of the American College of Cardiology, Circulation and HeartRhythm.

(Source: ACC News Release, October 30, 2017)

Should doctors study art and literature?

Should doctors study art and literature?

Dr KK Aggarwal

Emotions make up an important core of the doctor-patient relationship. A patient who comes to the doctor is emotionally vulnerable. He/she is struggling with feelings of anger, sadness, despair, guilt, irritability, anxiety, fear, etc., which may at times manifest as negative behavior. Failure to recognize these emotions of the patients in the rush of the day and accordingly respond in an empathetic manner often result in disputes, which may even manifest as violence against doctors. 

Suppressing emotions or feelings can manifest as disease. The stress of holding in strong feelings can increase blood pressure and heart rate and increase muscle tension. On the other hand, disclosing or expressing deep emotions can boost immune function as well as mood and well–being.

As doctors we need to know and understand humanity. Art and literature are both expressions of emotions or feelings arising from human experiences. This way both help to understand the emotions of a person.

In this age of litigation, doctors are relying more and more on lab tests and imaging methods. By doing so, they may be losing out on one of the most important skills for a clinician i.e. observational skill. 

Simply knowing the facts is not enough to practice medicine today. Medicine is an art based on science. And it is an uncertain science at that. No two patients are alike. Also, diseases often do not present in a classical, text book manner. Doctors need to be alert to recognize all atypical signs and symptoms. Sir William Osler said, “Listen to your patient, he is telling you the diagnosis.” 

Doctors need to broaden their horizon and avoid limiting their thinking. Study of art is one way they can do this.

Studying art or exposure to art, both visual and literary, can help doctors improve their observational skills during “inspection – the first step in patient examination” by training their eye to notice details that they might have otherwise not noticed to become better diagnosticians. Art also enhance their critical thinking and helps doctors to better understand facial expressions of the patient leading to a positive doctor-patient interaction.

Bill Kirkup, a public health physician wrote in 2003 in the BMJ, “We have lost something of the art of medicine in a headlong rush to embrace the science” (BMJ. 2003 Aug 16; 327(7411): 401).

Developing visual skills in art observation can help doctors, including medical students, to pick up more subtle clues to diagnosis and sharpen their diagnostic acumen and also communicate more effectively with their patients.

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

Who can give consent?

Who can give consent? Dr KK Aggarwal Informed consent is an integral and crucial part of medical treatment today. It is not only a procedural requirement, but also a legal requirement. Not taking consent is gross negligence. Consent has to be taken before starting a treatment or a procedure. For consent to be valid, it should be voluntary i.e. given without coercion, informed and the patient should be competent to understand the information given. Consent indicates a respect for patient autonomy, a very important principle of medical ethics. This means that patients have the decision making capacity and doctors need to respect their right to make decision regarding their care. And, no doctor treats a patient without informed consent. Who can give the consent? Informed consent must ideally be taken from the patient himself/herself. In a traditional Indian setting, if the husband is hospitalized, the wife, at times, may not be taken into confidence by the relatives about the gravity of the situation or otherwise. Most often, it is one of the family members who usually sign the consent in such cases. If the patient is unconscious, then the spouse should authorize one person as a legal heir to take legal decisions, in case the spouse does not want to take decisions or is not informed. In an emergency situation when the patient is not able to give consent, then treatment may be given without consent, if there is no other person available to give consent. But, the onus lies on the doctor to prove that the treatment given was lifesaving. The facts of the case must be documented. The Medical Council of India (regulation 7.16) states that “Before performing an operation the physician should obtain in writing the consent from the husband or wife, parent or guardian in the case of minor, or the patient himself as the case may be. In an operation which may result in sterility the consent of both husband and wife is needed”. The MCI should revisit the regulation 7.16 and come out with a clause of “next of kin” consent or “surrogacy” consent, which should also include “all legal heirs” and not just one as part of the consent. Disclaimer: The views expressed in this write up are entirely my own

Consent Revisited: Inability to manage complications leads to violence

Consent Revisited: Inability to manage complications leads to violence Consent, as we know, is the authorization or grant of permission by the patient for treatment or any diagnostic, surgical or therapeutic procedure to be carried out by the doctor. A doctor has to take consent from the patient before proceeding with his treatment. It is ethical and in today’s scenario, a legal requirement. Any act done without permission is “battery” or physical assault and is liable for punishment. A valid consent has three components: Disclosure, Capacity and Voluntariness i.e. provision of relevant information by the doctor, capacity of the patient to understand the information given and take a decision based on the adequate information without force or coercion. This is informed consent. Any permission given under any unfair or undue pressure makes the consent invalid. The Hon’ble Supreme Court of India has defined ‘adequate information’ in the landmark case of Samira Kohli vs Dr Prabha Manchanda. This includes “(a) nature and procedure of the treatment and its purpose, benefits and effect (b) alternatives if any available (c) an outline of the substantial risks and (d) adverse consequences of refusing treatment.” No doctor practices medicine without taking informed consent. Yet we read and hear of incidents of violence against doctors from all parts of the country. So, are we going wrong somewhere? Are we doing something wrong somewhere? “Medicine is an art based on science”, said Dr. William Osler. Complications, adverse events or untoward incidents may occur at any time during the treatment. What is important here, how competent, we are, as doctors, or how competent is the hospital or the clinical establishment, in managing these complications or untoward incidents in a non-emergent situation. Not being able to manage complications leads to violence. The patient should be informed of every possible complication that may occur during this treatment, however rare they might be; even a complication rate as low as 0.1% might be 100% for that particular patient. No surgery can be called as a ‘minor’ surgery. Mistakes are made, but we believe that nothing will happen either to us or the patient. As I wrote few days back, it’s the case of "Kya pharak padta hai" to "bahut pharak padta hai". If nothing goes wrong, then "chalta hai". But, if something does go wrong or an unanticipated event occurs, then this becomes unacceptable “chalta nahi hai”. The key word here is ‘anticipation’. Anticipate what all can happen in the course of a treatment and be prepared to handle them or keep your patient informed. For example, you may need to shift the patient in an emergency to a higher care center and your establishment does not have an ambulance. Outsourcing an ambulance will delay patient transportation, and in an emergency situation, the longer the delay, more agitated are the patients or family members and may become violent. Let’s take another example. You might need the services of a specialist, say a urologist, neurosurgeon, or a nephrologist. If your hospital does not have these specialty doctors on its staff, then subsequent delays in procuring their services will increase risk of violence. Should you have these services and other such facilities as standby? Yes, everything must be on standby. The standby fee is 25%, while presence fee is 100%. This may increase the cost of treatment. The time has come when the patient must know that safety comes at a price in bigger hospitals. Inform the patient and the family members beforehand, let the patient choose and accordingly the consent should be taken. Safety of the patient is very important and should be our primary objective. A small set-up may not have all facilities as their bigger and better equipped counterparts. These smaller set-ups should keep the patient and/or family members informed about this lack of facilities and take consent. Good communication can reduce the rapidly increasing problem of violent attacks on doctors and healthcare establishments. ‘Adequate information’ for consent should include not only the competency of the doctor to treat the case, but also include the competency of the doctor and/or the hospital to manage any emergencies or untoward incident in a non-emergent situation. Any breach in this duty is negligence. This, I believe, is an area which we need to work on. It is the inability to manage complications that leads to violence. As doctors we SERVE our patients and the community and provide • Service which we have professionally trained for, which is • Excellent i.e. anticipated • Responsible, give our 100% to the patients and take responsibility • Value – Group; each member of the group knows the duties of another, so no gap in service may result • Enthusiasm: A positive happy atmosphere This is how we can avoid incidents of assault and violent attacks on doctors from happening. Dr KK Aggarwal National President IMA & HCFI Recipient of Padma Shri, Dr BC Roy National Award,Vishwa Hindi Samman, National Science Communication Award & FICCI Health Care Personality of the Year Award Vice President Confederation of Medical Associations of Asia and Oceania (CMAAO) Past Honorary Secretary General IMA Past Senior National Vice President IMA President Heart Care Foundation of India Gold Medallist Nagpur University Limca Book of Record Holder in CPR 10 Honorary Professor of Bioethics SRM Medical College Hospital & Research Centre Sr. Consultant Medicine & Cardiology, Dean Board of Medical Education, Moolchand Editor in Chief IJCP Group of Publications & eMedinewS Member Ethics Committee Medical Council of India (2013-14) Chairman Ethics Committee Delhi Medical Council (2009-15) Elected Member Delhi Medical Council (2004-2009) Chairman IMSA Delhi Chapter (March 10- March 13) Director IMA AKN Sinha Institute (08-09) Finance Secretary IMA (07-08) Chairman IMAAMS (06-07) President Delhi Medical Association (05-06)

Positive reinforcement key to help patients quit smoking

Positive reinforcement key to help patients quit smoking Doctors should say 'Thank you for not smoking' to patients and avoid the use of discouraging remarks New Delhi, 30 June 2017: As part of its commitment to working closely with all National Health Programmes alongside the government, the IMA has urged individual doctors to counsel their patients who smoke about quitting smoking. It has, however, said that such counseling should be done in a manner that turns a negative situation into a more positive action. According to statistics, more than one-third (35%) of Indian adults use tobacco in some form or the other. Of these, 21% adults use only smokeless tobacco, 9% only smoke and 5% smoke as well as use smokeless tobacco. Additionally, about 52% of the adults are exposed to second-hand smoke at home.
The National Tobacco Control Programme aims at making the public aware of the harmful effects of tobacco use, controlling tobacco consumption, and minimizing related deaths. Tobacco use has many adverse health effects and is a major preventable cause of morbidity and mortality. Smoking not only increases the risk of various diseases but also reduces the quality of life, and increases health care utilization and cost.
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, "Campaigns on tobacco control convey the message 'smoking kills' with the intention of highlighting the potentially life-threatening health consequences of this habit based on the assumption that this would deter people from smoking or using tobacco products. However, many of these campaigns do not reinforce these messages in a positive manner. It is time to alter the tone of such public health campaigns from negative to positive. Quite often, we rebuke patients for failing in their efforts to quit smoking and tell them they may die if they do not quit. A statement worded in this manner can inadvertently sound discouraging to the patient."
People should know the dangers of smoking or using tobacco products. However, rather than adopting a critical approach, this message should be conveyed through positive communication for a more fruitful impact. Any violent communication should also be avoided.
Adding further, Dr Aggarwal, said, "It is best to avoid the 3Cs of violent communication - Condemn, Criticize, and Complaint. A nonviolent communication approach should be used instead to help and support patients in their efforts to quit smoking. It is important to say 'Thank you for not smoking' to the patients. Appreciate their hard work and perseverance in trying to quit this deadly habit. This way, they would know that they have your support and will in turn have trust and faith in you. Empathetic and supportive communication can increase the chances of patients adhering to lifestyle modifications." There is a very strong relationship between a doctor's communication skills and the patient’s capacity to follow through with medical recommendations, self-manage their medical condition, and adopt preventive health behaviors. It is imperative for a doctor to adopt a positive approach to explain, listen, and empathize with the patient. This in turn can have a profound effect on the biological and functional health outcomes.

Genesis of medical accidents

Genesis of medical accidents Patient safety is of prime concern in day-to-day practice. But despite, all precautions, medical accidents do occur. Medical accident is an unforeseen or an unintended occurrence. Most medical accidents are preventable. Hence, it is important for us to analyse why medical accidents occur. Several factors contribute to medical accidents. Fatigue, sleep deprivation, poor communication, inadequate preoperative planning are some common reasons for medical accidents. Distraction is another very important factor in medical accidents. Smart phones are a major source of distraction for the operating team in the OTs including the anesthetists or in critical care areas. Doctors may talk and attend to their mobile phones during a surgery and may communicate through a nurse or a junior who works as a bridge between the surgeon and the caller or may check or send e-mails or text messages. Mobile phone distractions adversely affect the performance of the entire team with greater likelihood of accidents that otherwise would not occur. E.g. an accidental injury to the intestine during an appendicectomy. Hands-free phone can be as distracting as talking on a hand-held mobile phone. The role of the navigator or the person who sits in the front passenger seat of a car can be an apt analogy here. It is a rule that he or she should not sleep or talk on the phone but stay alert. Besides navigation, he has to stay awake with the driver, especially on long drives, and also help the driver stay awake. Majority of car accidents are caused by human errors and are a result of distracted driving. It is important to concentrate on the task at hand and not let distractions take away the focus and cloud one’s judgement. Dr KK Aggarwal National President IMA & HCFI Recipient of Padma Shri, Dr BC Roy National Award, Vishwa Hindi Samman, National Science Communication Award & FICCI Health Care Personality of the Year Award Vice President Confederation of Medical Associations of Asia and Oceania (CMAAO) Past Honorary Secretary General IMA Past Senior National Vice President IMA President Heart Care Foundation of India Gold Medallist Nagpur University Limca Book of Record Holder in CPR 10 Honorary Professor of Bioethics SRM Medical College Hospital & Research Centre Sr. Consultant Medicine & Cardiology, Dean Board of Medical Education, Moolchand Editor in Chief IJCP Group of Publications & eMedinewS Member Ethics Committee Medical Council of India (2013-14) Chairman Ethics Committee Delhi Medical Council (2009-15) Elected Member Delhi Medical Council (2004-2009) Chairman IMSA Delhi Chapter (March 10- March 13) Director IMA AKN Sinha Institute (08-09) Finance Secretary IMA (07-08) Chairman IMAAMS (06-07) President Delhi Medical Association (05-06)

IMA’s viewpoint on the Delhi budget 2017

IMA’s viewpoint on the Delhi budget 2017 With an allocation of Rs 5,736 crores for the health care, budget highlights indicate that healthcare infrastructure is a key priority for the AAP government. New Delhi, March 8, 2017: AAP ruled Delhi government allocated more than half of this planned expenditure on healthcare, education and civic infrastructure development. This is the second consecutive year that healthcare and medical infrastructure has been a priority in Delhi budget. Focus on sanitation and natural resource improvements also shine through the budget. To promote eco-friendly public transport system, subsidy to battery-operated vehicles was proposed. Action plan for cleaning of Yamuna River and the water sector also got a generous allocation of Rs 2,100 crore. 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, “Focus on primary healthcare especially in quality-healthcare lacking regions of the city seems to be the top agenda and rightfully so. A significant proportion of the total budget outlay seems to be allocated to improving medical infrastructure so we expect to see multiple reforms and initiatives in this area. Focus on waste management through waste disposal reforms is also a welcome move. Proper standards of hygiene are imperative in the control measures against infectious diseases and last year’s Dengue, Chikungunya and flu outbreaks are a testimony to this fact. It seems clear that the government is taking good lessons from past mistakes.” “A shortage of hospital beds has been on the radar and on the list of promises since last year’s budget. This year the promise comes full circle with 15,000 additional beds being rolled out in major medical facilities. Moreover, the city’s primary healthcare has always struggled to catch pace with the tertiary facilities; however, the proposal to build over 1,000 mohalla clinics will have a reinforcing impact on primary healthcare and will surely seek to bridge this care gap”, adds Dr K K Aggarwal. Following are some key highlights with respect to healthcare: • Number of beds in Delhi Government hospitals will be increased from 10,000 to 25,000. • Patient capacity to be increased by adding seven hospitals and remodeling 10 existing hospitals. • A dedicated allocation of Rs 15 crore for medical tests. • Government tie up with 21 private laboratories to provide 13 expensive tests like MRI, CT scan, PET-CT which will reduce the unavailability and long queues at hospitals. • Plan to roll out 5 de-addiction centers. • Focus on improving air quality and resources for waste management • 150 mohalla clinics to be fully functional by the end of the year. Currently, 110 such clinics are functional across the city. • 150 polyclinics with a variety of specialties to be rolled out by the end of the financial year.

Patient Solidarity Day and need for Universal Health care for all

Patient Solidarity Day and need for Universal Health care for all

Dr KK Aggarwal

National President IMA

In consumer market, the consumer is the most important and in healthcare, a patient is our asset and that too, the most important one. As doctors, we need to lend our ears to his sufferings, practice empathy and not sympathy and be available to him at all times of need. We need to maintain the honor and dignity of the medical profession and treat patients with the same dignity, honor and due respect. 

In September 2015, the 194 Member States of the United Nations agreed to develop and put in place practical actions and national frameworks to achieve Universal Health care and other targets, as part of the 2030 Agenda for Sustainable Development (Resolution A/RES/70/1).

On this Patient Solidarity Day (PSD), Saturday 3rd December 2016, the Indian Medical Association (IMA) calls on our members, state and local branches, institutions and stakeholders to support the call for universal health coverage (UHC) for all. UHC can be defined as affordable, high-quality and accessible healthcare for everyone

Sustainable, patient-centered UHC will need significant efforts and firm commitment over the next 14 years from the key actors in the healthcare system: governments, the pharmaceutical industry, healthcare providers and patients’ organizations.

Patient-centered UHC means that all people receive the health services they need, without suffering financial hardship.

The following are the core principles of universal health coverage

·         Accessibility: All patients have the right to access the healthcare they need and when they need it.

·         Patient-centeredness and equity: All people, regardless of disease or condition; age, gender, race or ethnic background; sexual orientation; geographic location; socio-cultural background, economic or legal status, must have fair and impartial access to quality healthcare.

·         Choice and empowerment: All patients have the right to know about the healthcare services that are available. Patients must be able to be meaningfully involved in healthcare decision-making in a variety of ways at the local, national, regional and global level.

·         Quality: It is not enough for all patients to have access to healthcare. Provision needs to be safe, of the highest attainable standard and include a commitment to learning and improvement. Patients need to define what constitutes quality in healthcare.

·         Partnership and collaboration: Patients have a moral and ethical right to play a meaningful role at all levels; in health and in other areas that can have an impact on health and wellbeing.

·         Sustainability and the value of healthcare: All stakeholders need to recognize the value of healthcare when considering investing in universal health coverage.

·         Accountability and transparency: Accountability and transparency are vital to delivering safe, effective and affordable healthcare. All stakeholders need to be held accountable on commitments they have made to implement universal health coverage, and be accountable to the patients that they serve.

IMA initiative: Key messages

·         Leave no-one behind.

·         UHC is only truly patient-centered when health services are universally accessible, affordable, and of high quality.

·         IMA members to take responsibility for implementing robust national frameworks and appropriate measures to achieve patient-centered UHC.

·         Healthcare stakeholders to be held accountable for their commitments to achieve UHC.

·         Collaborative decision-making, based on genuine patient involvement, is key to ensuring that no-one is left behind.

As a board member of PSM (Partnership for Safe Medicine), both myself and IMA are committed to the patients.  

I will be taking over as the National President IMA on 28^th December and have included the important issues of ‘Patient Safety’ and ‘Patients’ Rights’ in my agenda. 

IMA will be closely working with Bejon as an advisor and PSM to take this forward. 

I am sorry I will not be able to join you all in Varanasi due to viral fever. But, I wish the event all success. 

(Speech at Varanasi, on the occasion of Patient Solidarity Day, Organized by PSM India)