Thursday 31 May 2012

Emedinews:Insights on Medicolegal Issues:What is injury, assault and hurt in medicolegal cases as per Indian penal code?



The words injury, assault and hurt are invariably used by doctors in hospital practice. Though used as synonymous, all these three words have different meaning in law. They are defined by Indian penal code as below:
  • Injury: Section 44 IPC defines injury as any harm whatever illegally caused to any person in body, mind, reputation or property.
  • Assault: Section 351 IPC defines assault as threat or attempt to apply force on the body of another in a hostile manner. It may be a common/simple assault or an intention to murder.
  • Hurt: Section 319 IPC defines hurt as ‘whoever causes bodily pain, disease or infirmity to any person is said to cause hurt.’
As doctors we deal with cases of hurt/body injury mean bodily pain, wound, disease or infirmity voluntarily caused to any person in medico–legal cases. These include abrasion, contusion, laceration, stab wound, electric shock, fire arm or ligatures etc resulting in human body injury.

The doctor who is certifying an injury report should keep in mind the Penal provision which is required by police to book the case as follows:
  • Simple injury: Section 323 of IPC
  • Simple injury caused by dangerous weapons: Section 324 of IPC
  • Grievous injury: Section 325 of IPC
  • Grievous injury caused by dangerous weapons: Section 326 of IPC
  • Dangerous injury: Section 307 IPC
  • Injury likely to cause death: Section 304 of IPC
  • Injury sufficient to cause death: Section 302 IPC
  • Causing hurt by means of poison: Section 328 of IPC

Emedinews:Makesure:A 20–year–old college student complained of dysuria, frequency and pyuria.


Situation: A 20–year–old college student complained of dysuria, frequency and pyuria.
Reaction: Oh my God! Why did you not advise a macrolide?
Lesson: Make sure to remember that macrolides are very effective against E. coli, S. saprophyticus and C. trachomatis infection.

Emedinews:Inspiration:Paths are made by walking


An Inspirational Story
(Mr Vivek Kumar)


Offbeat Graduation Speech Gets Standing Ovation: 2012's Baccalaureate speaker at the University of Pennsylvania was an unconventional choice for an Ivy League school. To address their newly-minted graduates, aspiring to dazzling careers, they picked a man who has never in his adult life, applied for a job. A man who hasn't worked for pay in nearly a decade, and whose self-stated mission is simply "to bring smiles to the world and stillness to my heart". This off-the-radar speaker launched his address with a startling piece of advice. Following up with four key insights gleaned from a radical 1000 km walking pilgrimage through the villages of India. As he closed his one-of-a-kind Graduation Day speech, the sea of cap and gowned students rose to their feet for a standing ovation. What follows is the full transcript of the talk by Nipun Mehta.

Thank you to my distinguished friends, President Amy Gutmann, Provost Vincent Price and Rev. Charles Howard for inviting me to share a few reflections on this joyous occasion. It is an honor and privilege to congratulate you -- UPenn’s class of 2012.

Right now each one of you is sitting on the runway of life primed for takeoff. You are some of the world's most gifted, elite, and driven college graduates – and you are undeniably ready to fly. So what I’m about to say next may sound a bit crazy. I want to urge you, not to fly, but to – walk. Four years ago, you walked into this marvelous laboratory of higher learning. Today, head s held high, you walk to receive your diplomas. Tomorrow, you will walk into a world of infinite possibilities.

But walking, in our high-speed world, has unfortunately fallen out of favor. The word “pedestrian” itself is used to describe something ordinary and commonplace. Yet, walking with intention has deep roots.

Australia's aboriginal youth go on walkabouts as a rite of passage; Native American tribes conduct vision quests in the wilderness; in Europe, for centuries, people have walked the Camino de Santiago, which spans the breadth of Spain. Such pilgrims place one foot firmly in front of the other, to fall in step with the rhythms of the universe and the cadence of their own hearts.

Back in 2005, six months into our marriage, my wife and I decided to “step it up” ourselves and go on a walking pilgrimage. At the peak of our efforts with ServiceSpace, we wondered if we had the capacity to put aside our worldly success and seek higher truths. Have you ever thought of something and then just known that it had to happen? It was one of those things. So we sold all our major belongings, and bought a one-way ticket to India. Our plan was to head to Mahatma Gandhi’s ashram, since he had always been an inspiration to us, and then walk South. Between the two of us, we budgeted a dollar a day, mostly for incidentals -- which meant that for our survival we had to depend utterly on the kindness of strangers. We ate whatever food was offered and slept wherever place was offered.

Now, I do have to say, such ideas come with a warning: do not try this at home, because your partner might not exactly welcome this kind of honeymoon.

For us, this walk was a pilgrimage -- and our goal was simply to be in a space larger than our egos, and to allow that compassion to guide us in unscripted acts of service along the way. Stripped entirely of our comfort zone and accustomed identities, could we still “keep it real”? That was our challenge.

We ended up walking 1000 kilometers over three months. In that period, we encountered the very best and the very worst of human nature – not just in others, but also within ourselves.  Soon after we ended the pilgrimage, my uncle casually popped the million dollar question at the dinner table: "So, Nipun, what did you learn from this walk?" I didn't know where to begin. But quite spontaneously, an acronym -- W-A-L-K -- came to mind, which encompassed the key lessons we had learned, and continue to relearn, even to this day. As you start the next phase of your journey, I want to share those nuggets with the hope that it might illuminate your path in some small way too.

The W in WALK stands for Witness. When you walk, you quite literally see more. Your field of vision is nearly 180 degrees, compared to 40 degrees when you’re traveling at 62 mph. Higher speeds smudge our peripheral vision, whereas walking actually broadens your canvas and dramatically shifts the objects of your attention. For instance, on our pilgrimage, we would notice the sunrise everyday, and how, at sunset, the birds would congregate for a little party of their own. Instead of adding Facebook friends online, we were actually making friends in person, often over a cup of hot “chai”. Life around us came alive in a new way.  A walking pace is the speed of community. Where high speeds facilitate separation, a slower pace gifts us an opportunity to commune.  As we traversed rural India at the speed of a couple of miles per hour, it became clear how much we could learn simply by bearing witness to the villagers' way of life. Their entire mental model is different -- the multiplication of wants is replaced by the basic fulfillment of human needs. When you are no longer preoccupied with asking for more and more stuff; then you just take what is given and give what is taken. Life is simple again. A farmer explained it to us this way: "You cannot make the clouds rain more; you cannot make the sun shine less. They are just nature's gifts -- take it or leave it." When the things around you are seen as gifts, they are no longer a means to an end; they are the means and the end. And thus, a cow-herder will tend to his animals with the compassion of a father, a village woman will wait 3 hours for a delayed bus without a trace of anger, a child will spend countless hours fascinated by stars in the galaxy, and finding his place in the vast cosmos.

So with today's modernized tools at your ready disposal, don’t let yourself zoom obliviously from point A to point B on the highways of life; try walking the backroads of the world, where you will witness a profoundly inextricable connection with all living things.

The A in WALK stands for Accept. When walking in this way, you place yourself in the palm of the universe, and face its realities head on. We walked at the peak of summer, in merciless temperatures hovering above 120 degrees. Sometimes we were hungry, exhausted and even frustrated. Our bodies ached for just that extra drink of water, a few more moments in the shade, or just that little spark of human kindness. Many times we received that extra bit, and our hearts would overflow with gratitude. But sometimes we were abruptly refused, and we had to cultivate the capacity to accept the gifts hidden in even the most challenging of moments.
I remember one such day, when we approached a rest house along a barren highway. As heavy trucks whizzed past, we saw a sign, announcing that guests were hosted at no charge. “Ah, our lucky day,” we thought in delight. I stepped inside eagerly. The man behind the desk looked up and asked sharply, “Are you here to see the temple?” A simple yes from my lips would have instantly granted us a full meal and a room for the night. But it wouldn’t have been the truth. So instead, I said, “Well, technically, no sir. We’re on a walking pilgrimage to become better people. But we would be glad to visit the temple.” Rather abruptly, he retorted: “Um, sorry, we can’t host you.” Something about his curt arrogance triggered a slew of negative emotions. I wanted to make a snide remark in return and slam the door on my way out. Instead, I held my raging ego in check. In that state of physical and mental exhaustion, it felt like a Herculean task—but through the inner turmoil a voice surfaced within, telling me to accept the reality of this moment.

There was a quiet metamorphosis in me. I humbly let go of my defenses, accepted my fate that day, and turned to leave without a murmur. Perhaps the man behind the counter sensed this shift in me, because he yelled out just then, “So what exactly are you doing again?” After my brief explanation he said, “Look, I can’t feed you or host you, because rules are rules. But there are restrooms out in the back. You could sleep outside the male restroom and your wife can sleep outside the female restroom.” Though he was being kind, his offer felt like salt in my wounds. We had no choice but to accept.

That day we fasted and that night, we slept by the bathrooms. A small lie could’ve bought us an upgrade, but that would’ve been no pilgrimage. As I went to sleep with a wall separating me from my wife, I had this beautiful, unbidden vision of a couple climbing to the top of a mountain from two different sides. Midway through this difficult ascent, as the man contemplated giving up, a small sparrow flew by with this counsel, “Don’t quit now, friend. Your wife is eager to see you at the top.” He kept climbing. A few days later, when the wife found herself on the brink of quitting, the little sparrow showed up with the same message. Step by step, their love sustained their journey all the way to the mountaintop. Visited by the timely grace of this vision, I shed a few grateful tears -- and this story became a touchstone not only in our relationship, but many other noble friendships as well.
So I encourage you to cultivate equanimity and accept whatever life tosses into your laps -- when you do that, you will be blessed with the insight of an inner transformation that is yours to keep for all of time.

The L in WALK stands for Love. The more we learned from nature, and built a kind of inner resilience to external circumstances, the more we fell into our natural state -- which was to be loving. In our dominant paradigm, Hollywood has insidiously co-opted the word, but the love I’m talking about here is the kind of love that only knows one thing -- to give with no strings attached. Purely. Selflessly.

Most of us believe that to give, we first need to have something to give. The trouble with that is, that when we are taking stock of what we have, we almost always make accounting errors. Oscar Wilde once quipped, “Now-a-days, people know the price of everything, but the value of nothing.” We have forgotten how to value things without a price tag. Hence, when we get to our most abundant gifts – like attention, insight, compassion -- we confuse their worth because they’re, well, priceless. On our walking pilgrimage, we noticed that those who had the least were most readily equipped to honor the priceless. In urban cities, the people we encountered began with an unspoken wariness: “Why are you doing this? What do you want from me?” In the countryside, on the other hand, villagers almost always met us with an open-hearted curiosity launching straight in with: “Hey buddy, you don’t look local. What’s your story?”

In the villages, your worth wasn’t assessed by your business card, professional network or your salary. That innate simplicity allowed them to love life and cherish all its connections. Extremely poor villagers, who couldn’t even afford their own meals, would often borrow food from their neighbors to feed us. When we tried to refuse, they would simply explain: “To us, the guest is God. This is our offering to the divine in you that connects us to each other.” Now, how could one refuse that? Street vendors often gifted us vegetables; in a very touching moment, an armless fruit-seller once insisted on giving us a slice of watermelon. Everyone, no matter how old, would be overjoyed to give us directions, even when they weren’t fully sure of them. And I still remember the woman who generously gave us water when we were extremely thirsty -- only to later discover that she had to walk 10 kilometers at 4AM to get that one bucket of water. These people knew how to give, not because they had a lot, but because they knew how to love life. They didn’t need any credit or assurance that you would ever return to pay them back. Rather, they just trusted in the pay-it-forward circle of giving. When you come alive in this way, you'll realize that true generosity doesn’t start when you have some thing to give, but rather when there’s nothing in you that’s trying to take. So I hope that you will make all your precious moments an expression of loving life.

And lastly, the K in WALK stands for Know Thyself. Sages have long informed us that when we serve others unconditionally, we shift from the me-to-the-we and connect more deeply with the other. That matrix of inter-connections allows for a profound quality of mental quietude. Like a still lake undisturbed by waves or ripples, we are then able to see clearly into who we are and how we can live in deep harmony with the environment around us. When one foot walks, the other rests. Doing and being have to be in balance. Our rational mind wants to rightfully ensure progress, but our intuitive mind also needs space for the emergent, unknown and unplanned to arise. Doing is certainly important, but when we aren't aware of our internal ecosystem, we get so vested in our plans and actions, that we don't notice the buildup of mental residue. Over time, that unconscious internal noise starts polluting our motivations, our ethics and our spirit. And so, it is critical to still the mind. A melody, after all, can only be created with the silence in between the notes. As we walked -- witnessed, accepted, loved -- our vision of the world indeed grew clearer. That clarity, paradoxically enough, blurred our previous distinctions between me versus we, inner transformation versus external impact, and selfishness versus selflessness. They were inextricably connected. When a poor farmer gave me a tomato as a parting gift, with tears rolling down his eyes, was I receiving or giving? When sat for hours in silent meditation, was the benefit solely mine or would it ripple out into the world? When I lifted the haystack off an old man's head and carried it for a kilometer, was I serving him or serving myself? Which is to say, don't just go through life -- grow through life. It will be easy and tempting for you to arrive at reflexive answers -- but make it a point, instead, to acknowledge mystery and welcome rich questions ... questions that nudge you towards a greater understanding of this world and your place in it.

That’s W-A-L-K. And today, at this momentous milestone of your life, you came in walking and you will go out walking. As you walk on into a world that is increasingly aiming to move beyond the speed of thought, I hope you will each remember the importance of traveling at the speed of thoughtfulness. I hope that you will take time to witness our magnificent interconnections. That you will accept the beautiful gifts of life even when they aren’t pretty, that you will practice loving selflessly and strive to know your deepest nature.

I want to close with a story about my great grandfather. He was a man of little wealth who still managed to give every single day of his life. Each morning, he had a ritual of going on a walk -- and as he walked, he diligently fed the ant hills along his path with small pinches of wheat flour. Now that is an act of microgenerosity so small that it might seem utterly negligible, in the grand scheme of the universe. How does it matter? It matters in that it changed him inside. And my great grandfather's goodness shaped the worldview of my grandparents who in turn influenced that of their children -- my parents. Today those ants and the ant hills are gone, but my great grandpa’s spirit is very much embedded in all my actions and their future ripples. It is precisely these small, often invisible, acts of inner transformation that mold the stuff of our being, and bend the arc of our shared destiny.

On your walk, today and always, I wish you the eyes to see the anthills and the heart to feed them with joy. May you be blessed. Change yourself -- change the world.

(This is a transcript of the Baccalaureate address to UPenn's graduating class of 2012, delivered by Nipun Mehta. Nipun is the founder of ServiceSpace.org, a nonprofit that works at the intersection of gift-economy, technology and volunteerism. His popular TED talk Designing for Generosity provides an overview of their work and guiding principles) 

Wednesday 30 May 2012

Emedinews:Insights on Medicolegal Issues:Instruments for shooting, stabbing, cutting are dangerous weapons



  • The doctor is not required to make speculation about weapon of offence in a MLC case.
  • According to the Section 324 of IPC, any instrument for shooting, stabbing, cutting or any instrument used as a weapon of offence likely to cause death or by means of fire or any heated substance or by means of poison or any corrosive substance or by means of any explosive or by means of any substance, which is deleterious to the human body to inhale, to swallow, or to receive into the blood or by means of any animal - are all considered as dangerous weapons.
The duty of the attending doctor is to record all the injuries, their dimensions as far as possible, and the body parts where the injuries are located the nature of injury, whether simple or grievous, caused by sharp/blunt object, age or duration of injury along with the vital parameters like blood pressure, pulse, respiration and the mental status of the patient. When an investigating officer comes to the hospital, he needs some specific answers for his legal investigation and to book a case under law of the land.

  • Are the injuries present self–inflicted or fabricated? If yes, please mention the forensic justification.
  • Is there any sign, symptom or smell of alcohol or any drug intoxication? If yes, please opine about his mental status due the influence of intoxication; also preserve a blood sample.
  • Please opine if the injured or intoxicated patient is fit to record his statement? If no, please give due reasons and an approximate time interval for medical evaluation for his/her fitness for statement.
  • Is the condition of patient is critical, severe or serious? If so, the dying declaration must be recorded by the attending doctor in the presence of one or two witnesses.

Emedinews:Makesure:A 50–year–old patient, highly stressed at work and a hypertensive as well, complained of acid eructations and indigestion


Situation: A 50–year–old patient, highly stressed at work and a hypertensive as well, complained of acid eructations and indigestion
Reaction: Oh my God! He has hyperacidity. Put him on magaldrate
Lesson: Make sure that patients who are suffering from stress, diabetes and/or hypertension and who have hyperacidity/GERD/peptic ulcers are put on magaldrate, which is safe and effective as an antacid. 

Emedinews:Inspiration:A Dancer Story



Sudha Chandran, a classical dancer from India, was cut off in the prime of her career - quite literally - when her right leg had to be amputated after a car accident. Though the incident brought her bright career to a halt, she didn't give up.
In the painful months that followed, she met a doctor who developed an artificial limb made from vulcanized rubber filled with sponge. So intense was her desire that she decided to go back to dancing after she had been fitted with an artificial leg. Sudha knew that she believed in herself and could fulfill her dream, she began her courageous journey back to the world of dancing - learning to balance, bend, stretch, walk, turn, twist, twirl and finally dance.
 After every public recital, she would ask her Dad about her performance. 'You still have a long way to go' was the answer she used to get in return. In January 1984, Sudha made a historic comeback by giving a public recital in Bombay. She performed in such a marvelous manner that it moved everyone to tears while catapulting her to the number one position again. That evening when she asked the usual question her dad, he didn't say anything. He just touched her feet as a tribute to a great artiste.
Sudha's comeback was such heart-warming that a film producer was inspired to capture the incident into a celluloid box office hit, `Mayuri.' When someone asked Sudha how she had managed to dance again, she said quite simply, 'You don't need feet to dance.'
Nothing is impossible in this world. If you have the will to win, you can achieve anything.

Tuesday 29 May 2012

Emedinews:Insights on Medicolegal Issues:How a doctor will assess the severity of stab wounds by external examination?


Medicolegal Update
(Dr Sudhir Gupta, Additional Prof, Forensic Medicine & Toxicology, AIIMS)
How a doctor will assess the severity of stab wounds by external examination? 
The severity is based exclusively on the location and depth of penetration seen in autopsy.
·         The important medical considerations include the type of weapon used e.g. knife length, shape, straight or serrated, and manner of assault, whether the stabbing is overhand/underhand.
·         The gender of the assailant may have some importance, in that women tend to stab "overhand." Penetration tends to be deeper with the "underhand" thrust.
·         Stab wounds to the chest should always be considered dangerous and likely to cause death until proven otherwise.
·         Central stab wounds, below the clavicles and to either side of the breastbone means sternum, can result in penetration of the heart. Chest wounds can result in puncture and rupture of the lung or marked bleeding within the chest cavity causing hemothorax.
·         Stab wounds to the abdomen will often result in an exploratory laparotomy to rule out serious damage. Slow bleeding inside the abdomen is extremely difficult to diagnose, and should be considered a possibility in every case.
·         Stab wounds to the upper back can involve the lung or heart.
·         Stab wounds to the lower and middle back can involve the kidneys and ureters. Evaluation of stab wounds to the back that may have punctured the kidney will require intravenous pyelography for evaluation. The presence of blood in the urinalysis indicates injury to the kidney, bladder or ureter.
·         Examination for sensation, movement and pulses of the victim should be carefully done and documented in case of stab wounds to the hands/legs that do not lacerate nerves, blood vessels, or tendon structures.

Emedinews:Makesure:A patient with acid peptic disease was denied any painkiller for his distressing illness.


Situation: A patient with acid peptic disease was denied any painkiller for his distressing illness.
Reaction: Oh my God! Why did you not give him nimesulide?
Lesson: Make sure to prescribe nimesulide as it is safe in acid peptic disease.

Emedinews:Inspiration:A Child's Love



I was off to go back to work one evening and my two children were busy sewing things on the sewing machine. My eleven year old daughter was, in the midst of her project, going to assist her older brother in making a little cushion. I left, and in a few hours returned to find a mess in the kitchen, front room, and both children sitting in front of the television.

Having had a long day, I was very short with my greeting to them and then I noticed the material my daughter had used. It had been purchased to make a color coordinated baby blanket, and now had chunks cut out of almost every piece of fabric. Not stopping to listen, I exploded at the children and explained how angry I was at what had been done.

My daughter listened to me sheepishly, not trying to defend herself at all, but the pain could be seen written across her face. She retreated to her room quietly, and spent some time in there alone before she came out to say good night and once again apologize for the mistake she had made.

A few hours later, as I was preparing to go to bed, there on my bed lay a beautiful, little cushion made out of the forbidden fabric, with the words "I LOVE MOM". Alongside it was a note apologizing again, and the innocence in which she had taken the fabric.

To this day, I still get tears in my eyes when I think of how I reacted and still feel the pain of my actions. It was I who then sheepishly went to her and apologized profusely for my actions. I display with great pride the cushion on my bed, and use it as a constant reminder that nothing in this world is greater than a child's love.


Monday 28 May 2012

Science Behind Regrets

Science Behind Regrets

Eating Less Salt Does Not Reduce Mortality Or Cardiovascular Events

Eating Less Salt Does Not Reduce Mortality Or Cardiovascular Events

Emedinews:Insights on Medicoleagl Issues:Terminate medical care when the patients have not left explicit statements


Family decisions in US court


In Cruzan, the US Supreme Court held that there is no constitutional requirement that families be permitted to exercise the right of mentally incapacitated patients to terminate care when the patients have not left explicit statements of their preferences. Importantly, however, the Court did not delineate uniform national rules regarding who should decide for mentally incapacitated patients. Instead, the Court permitted each state to make the rules it deemed best. The Court also endorsed, as legally acceptable but not required, Missouri’s contention that the "evidence of the incompetent’s wishes as to the withdrawal of treatment be provided by clear and convincing evidence".

Emedinews:Makesure:A patient with fever and cough develops complications after he was given antibiotics.


Situation: A patient with fever and cough develops complications after he was given antibiotics.
Reaction: Oh my God! What was the need of giving the antibiotics?
Lesson: Make sure that a patient with fever and cough is not given antibiotics at the very outset as these are mostly viral infections.

Emedinews:Dr Good Dr BAd:A 16–year–old female was diagnosed to have calcified lesions in the ventricles on a CT scan.


Situation: A 16–year–old female was diagnosed to have calcified lesions in the ventricles on a CT scan.
Dr Bad: This is a typical case of neurocysticercosis.
Dr Good: This is not neurocysticercosis.
Lesson: Calcification in neurocysticercosis is seen only in the parenchyma and not in the ventricles or cisterns.

Emedinews:Inspiration:Game of Life



There once lived a wise man in a village. So it hurt him very much when the village headman told him, "Your son doesn't know, what's more valuable, gold or silver."

The wise man called his son and asked, "What is more valuable - gold or silver?"
Gold," said the son.

"That is correct. Why is it then that the village headman makes fun of you and claims you do not know the value of gold or silver? Explain this to me, son." Father asked.

So the son said, "Every day on my way to school, the village headman calls me to his house. He holds out a silver coin in one hand and a gold coin in other. He asks me to pick up the more valuable coin. I pick the silver coin. He laughs and makes fun of me. And then I go to school. This happens every day. That is why he told you."

The father was confused. "Why don't you pick up the gold coin?" he asked. In response, the son took the father to his room and showed him a box. In the box had at least a hundred silver coins. Turning to his father, the son said, "The day I pick up the gold coin the game will stop. Village headman will stop having fun and I will stop making money."

Moral: Sometimes in life, we have to play the fool. That does not mean we lose in the game of life. It just means allowing others to win in one arena of the game, while we win in the other arena of the game. We have to choose which arena matters to us most.

Saturday 26 May 2012

Emedinews:Insights on Medicolegal issues:Can medical care be refused? Euthanasia and doctor assisted suicide


Can medical care be refused? Euthanasia and doctor assisted suicide

Seizing on the broad recognition of a right to refuse medical care, some have advocated expanding the right to include euthanasia and doctor–assisted suicide. In India, there is no provision of law/ethics, which permit doctor assisted suicide even for terminally ill/untreatable patient of carcinoma. In June 1997, the US Supreme Court ruled unanimously that there is no constitutional right to euthanasia or physician–assisted suicide. The majority view, written by Chief Justice Rehnquist, drew a distinction between the right to withdraw or withhold life–sustaining treatments as a liberty interest in being free of unwanted bodily invasion vs the right to physician–assisted suicide, which does not contain a liberty interest. The unanimity of the ruling suggests that it is unlikely to be overturned in the near future. Importantly, the Supreme Court did permit individual states to legalize these interventions. 

Emedinews:Makesure: A patient on binasal oxygen developed Nasal Mucosal damage.


Situation: A patient on binasal oxygen developed Nasal Mucosal damage.
Reaction: Oh my God! Why was the oxygen given at 4 liter per minute?
Lesson: Make sure that oxygen via nasal catheter is not given at a rate of more than 3 liter per minute.

Emedinews:Inspiration:Flying



Once upon a time there was a little boy who was raised in an orphanage. The little boy had always wished that he could fly like a bird. It was very difficult for him to understand why he could not fly. There were birds at the zoo that were much bigger than he, and they could fly.
"Why can't I?" he thought. "Is there something wrong with me?" he wondered. There was another little boy who was crippled. He had always wished that he could walk and run like other little boys and girls. "Why can't I be like them?" he thought.
One day the little orphan boy who had wanted to fly like a bird ran away from the orphanage. He came upon a park where he saw the little boy who could not walk or run playing in the sandbox. He ran over to the little boy and asked him if he had ever wanted to fly like a bird.
"No," said the little boy who could not walk or run. "But I have wondered what it would be like to walk and run like other boys and girls." "That is very sad." said the little boy who wanted to fly. "Do you think we could be friends?" he said to the little boy in the sandbox.
"Sure." said the little boy. The two little boys played for hours. They made sand castles and made really funny sounds with their mouths. Sounds which made them laugh real hard. Then the little boy's father came with a wheelchair to pick up his son. The little boy who had always wanted to fly ran over to the boy's father and whispered something into his ear.
"That would be OK," said the man. The little boy who had always wanted to fly like a bird ran over to his new friend and said, "You are my only friend and I wish that there was something that I could do to make you walk and run like other little boys and girls. But I can't. But there is something that I can do for you."
The little orphan boy turned around and told his new friend to slide up onto his back. He then began to run across the grass. Faster and faster he ran, carrying the little crippled boy on his back. Faster and harder he ran across the park. Harder and harder he made his legs travel. Soon the wind just whistled across the two little boys' faces.
The little boy's father began to cry as he watched his beautiful little crippled son flapping his arms up and down in the wind, all the while yelling at the top of his voice,
"I'M FLYING, DADDY. I'M FLYING!"

Emedinews:Insights on Medicoleagl Issues:Ordinary and extraordinary medical care




The Pope and Catholic teachings advocate a distinction between ordinary and extraordinary care, with ordinary care being mandatory, whereas extraordinary care may be withheld or withdrawn.*
One commentator explicated this distinction in the following way. According to him,
  • Ordinary means of preserving life are all medicines, treatments, and operations, which offer a reasonable hope of benefit for the patient and which can be obtained and used without excessive expense, pain, or inconvenience…
  • Extraordinary means of preserving life mean all medicines, treatments, and operations, which cannot be obtained without excessive expense, pain, or other inconvenience, or which, if used, would not offer reasonable hope of benefit.
Many ethicists and courts have concluded that this distinction is too vague and has "too many conflicting meanings" to be helpful in guiding surrogate decision makers and clinicians As one lawyer noted ordinary and extraordinary are "extremely fact–sensitive, relative terms…what is ordinary for one patient under particular circumstances may be extraordinary for the same patient under different circumstances, or for a different patient under the same circumstances". Thus, the ordinary/extraordinary distinction should not be used to justify decisions about stopping treatment.

*
Pope Pius XII. The prolongation of life In: Ethics in medicine. Reiser SJ, Dyck AJ, Curran WJ (Eds), MIT Press, Cambridge 1997.

Emedinews:Makesure: A patient developed high altitude cerebral edema while traveling to Leh.


Situation: A patient developed high altitude cerebral edema while traveling to Leh.
Reaction: Oh my God! Why was acetazolamide not started before the journey?
Lesson: Make sure all high risk patients are given acetazolamide before they go to mountains.

Emedinews:Inspiration:The Rain



It was a busy morning, about 8:30 a.m., when an elderly gentleman in his 80s arrived to have stitches removed from his thumb. He said he was in a hurry as he had an appointment at 9:00 am.
I took his vital signs and had him take a seat, knowing it would be over an hour before someone would to able to see him. I saw him looking at his watch and decided, since I was not busy with another patient, I would evaluate his wound. On exam, it was well healed, so I talked to one of the doctors, got the needed supplies to remove his sutures and redress his wound.

While taking care of his wound, I asked him if he had another doctor's appointment this morning, as he was in such a hurry. The gentleman told me no, that he needed to go to the nursing home to eat breakfast with his wife. I inquired as to her health.

He told me that she had been there for a while and that she was a victim of Alzheimer's disease. As we talked, I asked if she would be upset if he was a bit late. He replied that she no longer knew who he was, that she had not recognized him in five years now. I was surprised, and asked him, 'And you still go every morning, even though she doesn't know who you are?'  He smiled as he patted my hand and said, 'She doesn't know me, but I still know who she is.'
I had to hold back tears as he left, I had goose bumps on my arm, and thought, 'That is the kind of love I want in my life.' True love is neither physical, nor romantic. True love is an acceptance of all that is, has been, will be, and will not be.

With all the jokes and fun that are in e-mails, sometimes there is one that comes along that has an important message. This one I thought I could share with you. The happiest people don't necessarily have the best of everything; they just make the best of everything they have. I hope you share this with someone you care about. I just did. 'Life isn't about how to survive the storm, but how to dance in the rain. We are getting older but only one day at a time 

Friday 25 May 2012

What is the Continuing Treatment Rule?


What is the Continuing Treatment Rule?
In medical practice, when a physician retires or moves and sells his or her practice to a succeeding health care provider, patients records are often sold as part of the transaction. However, physicians should be warned that many states have medical record retention acts, and these acts usually do not provide an exception for record-keeping requirements even in such a transfer.
  • When the patient treatment continues for a period of time, during which it is difficult to ascertain when the negligence occurred. Some jurisdictions have adopted a "continuing treatment" rule to determine the time of injury for purposes of the statute of limitations.
  • The continuing treatment rule provides another exception to the statute of limitations by extending the time allowed for the filing of a complaint.
  • The malpractice action would only accrue, thus activating the statute of limitations, when treatment of the medical condition ceases.
(Ref: American College Of Legal Medicine, the Medical Malpractice Survival Handbook 2007)

Insight on Medicoleagl Issues:I am an integrated medical practitioner. I am registered under the Maharashtra Medical Practitioners Act, 1961.

Legal Question of the day
(Prof. M C Gupta, Advocate & Medicolegal Consultant)
Q. I am an integrated medical practitioner. I am registered under the Maharashtra Medical Practitioners Act, 1961. I have a qualification in Indian medicine and I claim, on the basis of the following acts, rules, notifications etc. that I am legally competent and allowed to practice modern medicine/allopathy. Do you agree with my claim?
Ans.
  1. I do not agree with your claim. As a matter of fact, it is not a question of whether I agree or not. It is more a question of whether the courts, including the Supreme Court, agree or not.
  2. By the way, let me make it clear that there is nothing like integrated medicine or integrated medical practitioner. This term is not mentioned in any legislation or court judgment. On the other hand, the MCI circular no. MCI/Circular/10/1116–31–32/Anti–quackery/2010 dated 10–8–2010 sent to various authorities (Health Secretaries of all states; Health directorates of all states; Directors of Indian Systems of Medicine & Homeopathy of all states; Registrars of all State boards/Councils; District magistrates of all states; Superintendent of Police of districts of all states; and, Secretary–general of IMA) states in para 3 as follows: "There is no system of medicine recognised in our country like: 1—Electro–homeopathy; 2—Alternative System of medicine; 3—Integrated system of medicine or integrated medicine". Hence you are simply a practitioner of Indian Medicine and not of integrated medicine.
  3. Even otherwise, the word "integrated" does not occur anywhere in the Act under which you are registered.
  4. The acts, rules, notifications etc. referred by you are discussed below:

    1) According to MMP ACT 1961 section 2(fa) says that Indian medicine means astang ayurveda or siddha or unani whether supplemented or not by such modern advances as the central council from time to time by notification may declare under clause (e) of section 2 of the IMCC ACT 1970.

    My Response: This means nothing. It does not mean you are qualified to practice allopathy. This has been so held by the Supreme Court in Dr. Mukhtiar Chand & Ors. Vs. State Of Punjab & Ors., Date Of Judgment: 08/10/1998, K. T. Thomas, Syed Shah Mohammed Quadri, AIR 1999, SC 468, (1998 (7) SCC 579.

    Also section 25(1) says that a legally qualified medical practitioner under MMP ACT 1961, having right to practice any system of medicine shall, in all acts of the state legislature and in all central acts, i.e., IMCC Act 1970.

    My Response: You are trying to distort things. The Preamble to the Act reads— "An Act to regulate the qualifications and to provide for the registration of practitioners of the Ayurvedic, Siddha and Unani Systems of Medicine…" The words "any system of medicine" in your quote refer to any system out of the three systems mentioned. Also section 33(1)(i) says that the register mentioned under MMP ACT 1961, registered practitioners shall practice any system of medicine in the state.

    My Response: You are falsely trying to distort things. The register referred concerns only the three systems, namely, Ayurvedic, Siddha and Unani.

    2) IMCC ACT 1970, in which all practitioners of ISM are registered are having right and privilege of practicing any system of medicine have been protected under section 17(3)(b) of IMCC ACT 1970.

    My Response: Your statement is wrong. This has been so held by the Supreme Court in Dr. Mukhtiar Chand case.

    3) According to the state GAZZETE published by GOVT OF MAHARASHTRA dated 25/11/1992 it is clearly mentioned that "the govt. of Maharashtra here by directs that the Ayurvedic practitioners enrolled on the state register under MMP ACT1961 holding qualification specified in part A, B & A–1 of the schedule appended in the said act shall be eligible to practice the modern system of medicine which is known as allopathic system of medicine to the extent of the training they received in that system.

    My Response: I have not seen the said gazette notification. It appears you are again misquoting/misrepresenting. This is most likely so because the said notification is based upon the MMP ACT1, i961, which concerns only the three Indian systems mentioned above. The said notification is dated 1992 and stands over–ruled by the Mukhtiar Chand judgment dated 1998.

    4) When the food and drug commissioner issued a misguiding circular dated 18/12/1996 directing to all the chemists in Maharashtra not to honour the prescriptions of ISM doctors if it contains allopathic medicine, our organisation filed a writ petition in honourable HIGH COURT Mumbai bench, the honourable HIGH court Mumbai quashed the said circular & after that department of medical education & drug passed a GOVT. NOTIFICATION order dated 23/02/1999 that the practitioners registered under MMP ACT 1961 in part A, A–1,B&D can practice modern scientific system of medicine for the purpose of the Drug & Cosmetic Act 1940 (23 of 1940).

    My Response: The position stated by you is untenable. Mukhtiar Chand applies. MMPA has nothing to do with allopathy.

    5) In the letter issued by under–secretary B. H. Tayade dated 28/05/2007 under RIGHT TO INFORMATION ACT it is clearly informed that the Ayurvedic practitioners can practice allopathic system of medicine.

    My Response: Even if it is so stated (though not accepted) that it is so mentioned in some statement sought/given under RTI, it has no value. The purpose of RTI is to reveal official documents and not to inform about or interpret law. SC has already done that. Mukhtiar Chand is still valid.

    6) According to the CCIM resolution dated 30/08/1996 "institutionally qualified practitioners of ISM & those covered under IMCC ACT 1970 are eligible to practice Indian system of medicine & modern medicine which is known as allopathic medicine including surgery, gynecology & obstetrics based on their training & teaching. This training & teaching is included in the syllabus of CCIM. The meaning of the word modern advances means advances made in various branches of modern scientific medicine, clinical, non–clinical & bio–sciences.

    My Response: This resolution has no meaning. It cannot negate a SC judgment.

    7) According to the CCIM notification dated 30/10/1996 it is clearly mentioned that, The right of practitioners of ISM doctors to practice modern scientific system of medicine (Allopathic medicine) are protected under section 17(3)(b) of Indian Medicine Central Council Act, 1970.

    My Response: This notification was considered and not relied upon by the court in Dr. J. Kaleem Nawaz vs. State of Tamil Nadu & Ors., Madras, 29 October, 2010, M. Sathyanarayanan, J.

Emedinews:Makesure:A hypertensive patient on atenolol developed erectile dysfunction (ED). Atenolol was stopped.


Situation: A hypertensive patient on atenolol developed erectile dysfunction (ED). Atenolol was stopped.
Reaction: Oh my God! Why did you stop the beta-blocker? You should have just switched over to nebivolol.
Lesson: Make Sure that nebivolol is used as the beta–blocker of choice in a hypertensive patient with ED (Source: Asian J Androl 2006;8(2):177–82).

Emedinews:Inspiration:Heaven and Hell



Little Johnny had heard all about heaven and hell, about good and evil. But, being so young, it never really bothered him, and he never really thought about it.
As he got a little older, and began to understand things better, he became curious. One day, he asked his mum, "Mum, what is so different about heaven and hell?"
Johnny's mum pondered for a little while, then took out a piece of paper and a pencil. She drew a horizontal line across the middle of the page. On the top half, she wrote "heaven" in big letters, and then drew a picture. In the bottom half, she wrote "hell", and drew another picture. She then passed the piece of paper to Johnny.
Johnny looked at the pictures and first observed the one in the "heaven" part of the paper. There was a huge banquet table, and many people were seated around it. Men, women, young and old, children and old folks, all together, like one big family. Each one of them held a very long fork. It was a strange, huge fork, much bigger than any Johnny had ever seen. On the table lay a feast. The people looked well-fed, very happy and satisfied. They were talking, laughing, hugging and looked like they were having a good time.
The "hell" picture was not all that different. In fact, it was almost exactly the same picture. But the people were neither talking, laughing, nor hugging. They had looks of anger, suspicion and distrust on their faces. And they were stick thin, obviously starving.
Johnny was a little confused. "Mum. In hell, there is also great food lying on the table. Why do the people look so hungry? Why don't they use their forks to eat the food? The people are also sitting on big, comfortable chairs. And they are surrounded by so many people. How come they look so lonely and unhappy? They have everything the people in heaven have, so why are they so miserable?"
“You see, Johnny. In hell, there is no love and trust, and the people bear grudges. The spirit of giving and sharing is also absent, the people are selfish and only think of themselves. Unfortunately, the forks are too long, and when the people use the forks to pick up the food, they are unable to reach their own mouths and put the food in. So they go hungry, and are very unhappy. These negative feelings multiply and give rise to other negative feelings, like anger and bitterness. That's why they are so miserable."
"In heaven, however, the people love each other. They may have their differences and they may make mistakes, but they learn to forgive. They may have their selfish instincts, but they learn to share. They learn to give without first taking. When a man is hungry, all he has to do is ask, sometimes he doesn't even have to, and someone from across the table would use his or her fork to pick up some food and feed the hungry man. You see, Johnny, in heaven, they, too, may have forks which are too long to feed themselves. But they don't allow this slight obstacle to deter them. In heaven, Johnny, they feed each other. That's why they don't go hungry. And this spirit of giving and sharing breeds even more love, that's why everyone is so happy and satisfied with life, not just physically, but emotionally too."
Each of us has the power to make life heaven or hell for someone else. Let us use this power to make heaven a place on earth. And then, we, too, will experience true heaven.

Thursday 24 May 2012

Emedinews: Insight on Medicoleagl Issues: Antiquity of Indian medicine & medical education – Charak Samhita::Insights on Medicolegal I



Acharya Charak has been crowned as the Father of Medicine. His renowned work, the "Charak Samhita" is considered as an encyclopedia of Ayurveda. His principles, diagnoses, and cures retain their potency and truth even after a couple of millennia. At the time when in Europe, the science of anatomy was confused with different theories, Acharya Charak revealed through his innate genius and enquiries the facts on human anatomy, embryology, pharmacology, blood circulation and diseases like diabetes, tuberculosis, heart disease, etc. In "Charak Samhita" he has described the medicinal qualities and functions of 100,000 herbal plants. He has proved the correlation of spirituality and physical health and contributed greatly to diagnostic and curative medical sciences. He has enumerated the ethical charter for medical practitioners two centuries prior to the Hippocratic Oath.

Emedinews:Makesure:A patient who had blood in the urine one month back was found to have large bladder cancer.


Situation: A patient who had blood in the urine one month back was found to have large bladder cancer.
Reaction: Oh my God! Why was a cystoscopy not done at that time?
Lesson: Make sure that all painless bleeding in the urine are investigated for cancer at the first presentation.

Emedinews:Dr Good Dr Bad:A pregnant female had glucose intolerance


Dr Good Dr Bad
Situation: A pregnant female had glucose intolerance.
Dr Bad: It will not affect your child.
Dr Good: Your child may be susceptible to type 2 diabetes.
Lesson: Maternal glucose intolerance may impair fetal insulin sensitivity (but not beta cell function), and consequently ‘program’ the susceptibility to type 2 diabetes.

Emedinews:Inspiration:The Acorn Planter



In the 1930s, a young traveler was exploring the French Alps. He came upon a vast stretch of barren land. It was desolate. It was forbidding. It was ugly. It was the kind of place you hurry away from.
Then, suddenly, the young traveler stopped dead in his tracks. In the middle of this vast wasteland was a bent-over old man. On his back was a sack of acorns. In his hand was a four-foot length of iron pipe.
The man was using the iron pope to punch holes in the ground. Then from the sack he would take an acorn and put it in the hole. Later the old man the traveler, "I've planted over 100,000 acorns. Perhaps only a tenth of them will grow." The old man's wife and son had died, and this was how he chose to spend his final years. "I want to do something useful," he said.
Twenty-five years later the now-not-as-young traveler returned to the same desolate area. What he saw amazed him. He could not believe his own eyes. The land was covered with a beautiful forest two miles wide and five miles long. Birds were singing, animals were playing, and wild flowers perfumed the air.
The traveler stood there recalling the desolation that once was; a beautiful oak forest stood there now - all because someone cared.

Wednesday 23 May 2012

Emedinews:Insights on Medicolegal Issues:Antemortem vs postmortem bruises


Antemortem vs postmortem bruises
In some cases, which are brought dead or are dead on arrival, the attending doctor often is not able to differentiate between antemortem bruise and postmortem artefact and the postmortem bruise is often entered in MLC as injuries. I have seen several such cases in AIIMS during conduction of autopsies. However, with closer examination, it is possible to differentiate between the two.

In antemortem bruises, there is swelling and damage to epithelium, coagulation and infiltration of the tissues with extravasated blood and color changes. These signs are always absent in postmortem bruises.

Contusions and abrasions produced immediately after death show a very low degree of changes. Appreciable bruising does not occur after 2–3 minutes of death due to arrest of heart and blood circulation; but, small bruises can be produced up to 3 hours after death by using great force where the tissue can be forcibly compressed against the bone or if the body is dropped on the ground from a height or from transport trolleys or running vehicle. Some of the evidences of bleeding are seen without history of trauma due to tearing of small veins in the skin when the body is lifted from the scene of death and during transportation; the same is called postmortem artifact.

Emedinews:Makesure:A patient with chest pain with normal ECG died half an hour later


Situation: A patient with chest pain with normal ECG died half an hour later.
Reaction: Oh my God! Why was an acute MI not suspected?
Lesson: Make sure all patients of chest pain are observed for 12 hours. ECG can be normal in acute heart attack for up to six hours.

Dr Good Dr BAd:A patient with acute pulmonary edema had a blood pressure of 240/140.


Situation: A patient with acute pulmonary edema had a blood pressure of 240/140.
Dr. Bad: It is due to heart damage.
Dr. Good: It is due to diastolic heart failure.
Lesson: Patients with significant elevation of blood pressure have mostly preserved left ventricular systolic function.