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Archive for May, 2012

When “Quality of life” fights with “Quantity of life” doctors get confused !

Posted in bio ethics, Cardiology - Clinical, tagged , , , , , on May 19, 2012| Leave a Comment »

A  72 year old man in  terminal heart failure with  three previous admissions in  last one year  comes with severe breathlessness . He was  exhausted with  rigorous  drug regimens  for refractory heart failure in the past few months. Since he  was always feeling better after an infusion of Dobutamine he demanded it . Doctors were very clear  , ” Repeated  Dobutamine infusion will  hasten  the LV dysfunction and longevity is  will shorten”

The family began to think . While they  wished  for him to   live longer , the sick man  insisted  on  early  relief from his  symptoms .

How often in medicine ,   there is a trade off  between  symptoms and survival ?

It is a more common situation than we believe , especially in many  chronic  disorders like terminal organ failure and malignancies. .  So we need a simple scale to  asses the quality of life and survival  outcome for our patient. The following table  could help us . I  learnt this from   the great teacher Valentine Fuster’s  lecture  which  I attended in New Delhi recently !

Final message

Let us  attempt to  make a patient’s  life ” feel  good “ ,  if  he is going to live shorter .  Let us avoid  prolonging  a  life ,  if the treatment is making him feel  bad  , when the  life  expected  is  short !

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How to diagnose complete heart block without ECG ?

Posted in Cardiology - Clinical, cardiology -ECG, Cardiology-Arrhythmias, tagged , , , on May 18, 2012| Leave a Comment »

You are asked to see a patient with a pulse rate of 45 /mt .  Is it sinus bradycardia  or  complete heart block  ? 

Only one condition , . . .  you must conclude in the bed side !

  • Heart rate  may give a clue ( HR of  30-40 is common in CHB . Less common in sinus bradycardia.)
  • Pulse volume is large in both (More so in CHB )
  • JVP  shows occasional cannon waves hitting the neck  in CHB. Cannon wave can never occur in sinus rhythm
  • S 1 intensity may vary in CHB (As  Marching through  of  P waves  occur in CHB  ,  when it falls close to QRS  , it results in a  short PR interval  and a  loud S1   . Since marching through is a intermittent phenomenon S 1 intensity also varies.)
  • A short systolic murmur may be  heard intermittently due to   trivial MR/TR in CHB  ( Competitive AV valve movement )
  • A  simple bed side test  . Ask the patient  to exert for a minute -Sinus bradycardia raises  the HR with a fair regularity  to 80-90/mt  or so. CHB doesn’t  (Note :  CHB with  junctional rhythm can  sometimes increase the HR  significantly )
  • Finally response to Atropine   is prompt with sinus bradycardia.

Final message

Bed side skills in recognising cardiac arrhythmias are still relevant even in the current  era of carto and 3d electro anatomic mapping .

After all ,  the 19th century clinical wizard Wenke back recognised the second degree  AV  block at the bed side  well before  the ECG machine  was invented. He meticulously observed progressive prolongation of a-c interval and subsequent drop of c wave in the jugular  vein !

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Mysteries in Medical Philosophy !

Posted in bio ethics, Quotes, Venkat quotes, tagged , , , on May 18, 2012| Leave a Comment »

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A shocker of a discovery : HDL cholesterol could after all be a “Good -Old ” Bad cholesterol

Posted in cardiac drugs, cardiology -Therapeutics, Clinical cardiology, dyslipidemia, tagged , , , , , , , , on May 18, 2012| Leave a Comment »

International Astronomical Union  in the year 2006  removed Pluto from the solar system for a simple reason ,  the so-called Pluto never revolved around  Sun , hence it ceased to be a planet of the solar system , it was more of an asteroid !

So, an astronomical fact engraved in our brains for so long  became a fairy tale. It is very hard  to erase  a  myth however solid the new evidence are against it.

The concept of HDL as good cholesterol has been etched deep in physician as well as our  patients.

Now comes the shocker from Lancet

How are we so sure ,  about these  Invisible spheres of  lipids that  move  around  our “Bio-system” in a presumed fashion .  .  .  even huge visible planets  fool us easily !

The Link to lancet study

It is  a wonderfully done study where  thousands of patients  who exhibited  genetically high HDL levels , never showed any advantage in terms of CAD prevention.  A stunning blow to a belief.

Incidentally ,  few years back  the failure of  drug Torcetrapib proved the same point  .  (The drug which elevates  HDL  proved useless in preventing CAD  ) but the  medical world failed to interpret it properly.

I am sure, still sections of physician  community would continue to believe HDL is great molecule for CAD protection !

Science is  often what we presume . . . but the fact usually turns out to be some thing  else !  but the journey towards truth  must continue !

                      When  a  million tonne  Pluto  suddenly disappear from Solar system . . . it is not a  big deal for  a  “miniscule medical myth”   to get shattered !

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When Robots help doctors during a surgery it charges 100,000 $ more !

Posted in bio ethics, cardiology -Therapeutics, medical quotes, Quotes, Technology, Venkat quotes, tagged , , , , on May 16, 2012| Leave a Comment »

An  article , I stumbled upon recently  discusses why American health care is  in deep trouble. There is a huge variation in the health care costs across the country. The article goes on to reveal  ,   a  simple  Appendicectomy can  cost  anywhere between 7500   to 1,70000 $  in different hospitals in USA.  (In India it costs  1000 $  in  any  star hospital !)

The fundamental flaw is   treatment  being the same ,   it is delivered in such a  fashion ,  the cost incurred is  kept ridiculously high.

It is akin to comparing  a 10 dollar  lunch to a 1000 dollar feast , both  ultimately  fulfills a  purpose ,   relive the hunger effectively

while , the later can  damage the country’s economy  in a variety of ways !

https://www.massdevice.com/blogs/massdevice/anatomy-walletectomy

Car makers automate the industry with Robots to   reduce  the  human labor and  cost of a vehicle ,  while medical industry does the opposite   . . .  privileged few get their appendix removed with a help of metal hand  !

Final message

Modern medicine must  aim to improve the quality  of  care  with a   positive impact  at a reasonable cost . In the name of cutting edge technologies ,  it  should not raise  the medical bill in a meaningless  fashion .This is meager exploitation of  human suffering.

It is  hilarious to note  certain medical  Robots* are primarily  made to assist  surgeon  for which  no assistance is required at all !  (I heard a story about a  Robot  which responds  to voice command   and pass on a   knife  for cutting and a gauze for wiping ! What a great medical discovery !)

Disclaimer

*  Of course  Robots (Cyber knifes )   may have a role  in some rare surgeries which require high precision  cutting  especially in  Neuro  ,  Vascular ,  oncological  surgeries.

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