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Archive for the ‘bio ethics’ Category

Today is one of the most auspicious days in Indian traditional festive time. Saraswathi pooja, a celebration of the Goddess of knowledge and education. I would like to share one of the all-time great quotes on learning from Thiruvalluvar a sage poet who lived in the southern Indian state of (mine), Tamil Nadu in 4th -5th century BC  2500 years ago.

 This Thirukural number 391 in the chapter of education goes on like this. (In the Tamil Language)

In English

Karka, Kasadara, Karpavai , Katrapin,

Nirka , Atharkku Thaga !

It says

Karka : Learn

Kasadara: Here comes the punch. Kasadara means pure.  He says simple learning is not at all-sufficient. One has to learn from good sources, learn deep that should be devoid of errors, contaminations, and falsehoods.

Karpavai  : Thus you learn all lessons in life meticulously.

Katrapin:  So, after this hard and enlightened learning, what we should do?  He answers next.

Nirka Atharkku Thaga: This means , don’t just stop with learning, follow it with action in a righteous way. Unless we do that he warns to conclude ( in another poem in the same chapter) there is no purpose of learning itself and we are again at risk of becoming illiterates.

So, what does this Thirukural teach the Nobel professionals who follow cutting edge medical research?

I think I need not elaborate . . . Acquiring knowledge and true learning has become two different processes.

It’s just a sample of one kural (Quote) among 1330 poetic quotes written in 133 chapters by this great philosopher of Tamil Nadu who shared the same timeline with Aristotle and Socrates of ancient Greece 5000 miles west of India. For those ,If you are interested in his monumental work on literature which can be referred to as the manual for effective living  (I wish to call it as “Standard operating protocol”  for human life)  please follow the link.

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This post was originally written in 2013.

A middle-aged man with STEMI  came to our CCU.  It is just another case of STEMI and asked my fellow to lyse.

Anterior STEM ecg

But it was not the case . He, told me, Sir, the patient had a syncope following chest pain and he has injured his face and Jaw. He was actively bleeding. When I saw this face, it was indeed  frightening.Strptokinase induced bleeding

What shall we do ? When a patient  with STEMI presents with bleeding facial Injury

  1. Rush for Immediate PCI (Which was  of course not possible in our place as it happened out of office hours! )
  2. Take that ultimate risk and thrombolysis
  3. Give only heparin ( Many times it is as good as  lysis )

We took a (bold ? ) decision to thrombolyse with streptokinase.(After  a CT scan which ruled out any Intracranial bleed like hematoma etc) Clopidogrel was also given.

absolute contrindication for thrombolysis facial trauma

Patient continued to bleed in the initial 3 hours and was oozing in the next 12 hours. Blood transfusion was contemplated, but it was not required. Dental surgeon opinion was sought, his teeth were pulled and a compressive bandage was applied.It arrested the bleeding.The ECG settled down.LV function was almost normal with minimal wall motion defect. He is posted for a coronary angiogram later.

Final message

 There may not be anything called “Absolute contraindication” everything appears relative

I presented this in the weekly clinical meet,  with a tag line of  How to save a patient, apparently by violating a standard guideline. Not surprisingly, It evoked laughter amusement from learned physicians. I wasn’t. Guidelines are meant to guide us agreed.They can not command us. They are not legally binding documents as well! Many lives can be saved if only we have the courage to overrule when it’s required.

Afterthought

Had this patient has bled to death during lysis what would have happened to the treating doctor? (or )If the patient has died due to MI, because of deferred thrombolysis, what would be the line of argument?

2020 update.

This case scenario is a non-issue as of today. With so much experience, we straight away do PCI . Just manage the oral bleeding if any.

 

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Poverty is a cruelest disease of mankind , the infective vector is not any deadly HINI or retro virus , but mostly the fellow humans themselves ! This is why WHO has included poverty in the ICD code (Z59.5 ) as a disease .

I used to wonder , as a member of Noble profession , should we fight against this disease or be happy to spend my entire life time cleaning the coronary arteries of affluent human-beings and earn few bucks !

Can growth of money eliminate poverty ? 

We may think so  . . .  but it doesn’t most times .Of course ,  affluence bring more jobs to the poor , logically it should alleviate poverty. But , we  know the reality. Its not that easy concept to understand . However we have robust evidence for the opposite ie affluence can aggregate poverty .

If poverty is a disease &  if  mindless  affluence is an Indirect cause for it  , then affluence also becomes a potential disease , Is in’t ? Will WHO include it in ICD listing ?

May I propose Z59.5A to be called  Uncontrolled &  manic desire for affluence ?  Since it is  made at the cost of  fellow humans , it should be clubbed along with poverty as a worrisome disease. Once its included in the ICD manual , I guess it will be unethical to ignore this disease. 

We all aim for growth in life .Nothing wrong in that .There are many facets of life that requires growth. Unfortunately , for most  homo-sapiens ,  growth is synonymous with multiplication of money . . . nothing else seems to matter ! Money when it grows unregulated ,  begins to control you and hijack your  body and mind .

One more issue to  comprehend is , rapid growth of money is possible only at the cost of something (or someone) else – Akin to cancer cachexia ,it depletes the body (Earth ) of it’s resources ( Nature abuse ,  extreme poverty , inequality ,  Third world exploitation , wars, etc ) For the  medical professionals  it is all the more important that growth shouldn’t mean money , as it has a direct and conflicting  impact on some one else’s life  !

mitosis of money 003

Just Imagine ,  if the all the car companies combine together , aim for a  dramatic growth from the current  4 %  to 25 % by 2030  and manage to  achieve it by any means ! . . . This planet will sink in the combined weight of automobile Junk !

It is obvious , uncontrolled growth in any form requires vigorous regulation and  Intervention and will eventually require a radical surgery if the growth goes unabated  !  

Counter point

It is foolish to link growing money and wealth  equivalent to cancer. Unlike cancer cells , money multiplied can be put into use for those in need .It is the principle of charity .But the reality is , human beings who are rabidly after money rarely have this mind set.In contrary the haven’ts have it in plenty. In my opinion, excess money has a dubious  capacity  to  contaminate  human values  ! (Why should some rich and elite opposes affordable health care  to poor ?)

Let us amass wealth and help others . Microsoft  is able to do it. Apple may do it later. What is the need for big companies social responsibility and philanthropy ? If the business worlds  motive and end product  promotes equality and goodness , sans exploitation , the question of charity at a later date never  arises.

Final message

If extreme poverty is a disease ,  forces that Initiates or sustains  poverty cycle can not be a bliss. In this context , the  manic affluence (& the urge for it)  should be included as a communicable disease since it seems to be most contagious as well.

In health care delivery “affluent and modern care” may also connote a sinister meaning. Poor people might think they are deprived of good care because they cant afford it. But ,truth hides deep. True sustainable caring is little to do with affordability+ , since most of the modern health care expenditure is jacked up with junk.

I know in my country people sell their life time assets for what they think as  crucial health care .(Of course universal health care insurance is just beginning to come in. Here again insurance based health care has inflated the actual costs and threatening to impose inappropriate therapies .

As a medical professional we should aim for the cheapest  and best form* of treatment to our patients . Artificially inflating the cost of therapy by worthless drugs, devices, procedures and disseminating them invariably leads to pathological  growth of science.

*If any one thinks “cheap and quality” doesn’t go together in medical care it is ignorance ! Most problems has simple and effective solution.

Post-amble 

 I object this statement -Modern health is nothing to do with affordability.

We need to go to the basics then .What is true health ? Forget about transplants, Organ Assists, Five star critical care .They seem to work in a minority , but drain the world economy. Its Impact on global health is at best minuscule. One Important analysis say 90% health care cost is wasted in prolonging the last 30 days of life of homo-sapiens.(Will get the reference for it )

Please note 

Diseases that occur to  affluent population  is entirely different topic . Can be found elsewhereDisease of affluence

 

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Bedside wisdom

We have been  using unfractioned Heparin for long , and its  is better than any other anticoagulants  in ACS . . . 

Our observation shows that Streptokinase has distinct advanatge over Tenektepelase as it works longer duration  . . .

My experience  says Diuretic and beta blockers  are still good as first line therapy for Hypertension  . . .

Mind you , there are infinite  number of such wisdom in every sub specialty of medical field.

However , the typical response from any  modern scientific intellect would be . . .

Stop it . . . Its old  stuff folk  , What does the current data say ?

medical-data-ethics-futility

Common uttering  in scientific forums,

Is there data backing up your  treatment modality ?

Is there sufficient data ?

Come’on , grow up , don’t talk about experience in a scientific forum . . . come out with data man !

No one seem to care the quality of the data . Every one bothers  about the quality of the Author and Journal instead  .  if its X Y Z its ok If its A B C no its not acceptable data.

Probably , Data is most misused word in medical science.

In scientific world,  “unpublished sense” goes straightway to  dustbin ,while we have so many avenues for the  published nonsense to  be celebrated (Still, bulk of guidelines in cardiology is backed up by Level C evidence which means experience  of experts !)

By the way what do we mean by data ?

Its organised collection of genuine scientific information , that’s post processed ,  follow it up with sound inference and faithful questioning and debate that should ultimately end up as  “clinical  application” in patient domain for consumption.(No prizes for guessing , whats happening in real world !)

OMG, give us back that elusive Common sense . . . which  I  think we  lost some time  at the turn of this millennium  !

Wrong or useless data : Who will recall ?

Once applied to patient , these data is  to be scrutinized and monitored . If we find a study conclusion  and reality does not match , we  need to stall the data from adversely  exploding .Every stake holder should have the power to do it. There have been instances a treatment modality got banished in one country is legally permitted in other country knowing fully well the futility.

Final message 

Modern scientific Data* is not God sent. Its  created , synthesised and disseminated in various mind factories. All you require is , backing up with some pioneering journal publication with huge impact factor.It’s not really blasphemy to question things which doesn’t make sense .Unfortunately , wrong data can be tackled only with further data .(There is no other means I guess !)

When does “good common sense”  become hard data and evidence ?

Its the act of publication , so  please guys whenever you  find some contamination  in so-called scientific data  please post here.  To begin with I am registering a new Journal  “Commonsense journal in cardiology”

*Please note, data is not a bad word as this write-up  seem to suggest.Naturally occurring , epidemiological and  observational data about diseases are the foundations for medical science .The issue become murky when few motivated humans play brutal  games at the sensitive  interface between science and truth.

It should be acknowledged , there is a distinct risk  of  this fight against falsehood end up in blocking  true progress  of science . Still , Homo sapiens  are (believed to be !)  intelligent enough to differentiate good from bad , that’s the reason God gave us the sixth sense !

Link to Lown Institute (Started by Cardiologist and Nobel peace prize  Laurate Dr Lown who strives hard to pursue this goal)

Further reading :  Scientific Reversals in cardiology 

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medical ethics stastistics www.drsvenkatesan.com

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We all know to err is human , but most of us probably won’t agree medical mistakes , (bulk of which happen in the name of practicing state of the art of science ! ) could be the dominant theme in modern medical care !

BMJ exposes this  well known secret with the help of most authentic data from an apex scientific body CDC , Atlanta .

Reference

http://www.bmj.com/content/353/bmj.i2139#

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Men are from Mars , and  Women are from Venus  ” . . . Do you agree ?

Many probably witness the much talked  differential behavior among the gender  every day. Its argued , men take more risk in life ( often  senseless !) , some go to the extreme to  suggest  Men are Idiots and decorate them with a  provocative title  MIT (Men Idiot Theory ) (Mcpherson 2011).Risk taking is important in life, but at  what cost ? Does women (Who  are caring by nature )  help themselves  and the society by less risk taking behavior ?

I stumbled upon this rare piece of writing from BMJ which  would demand  in depth analysis  into this gender phenomenon based on  evolutionary biology and genetics.

This article concludes, Yes, men  . . . indeed  tend to take some foolish risks in various life situations that result in potential harm.

Gender difference in medical outcome men are from mars women venus male idiotic theory darwin theory

What is the influence of MIT on medical profession and patient outcome ?

Now , Iam compelled to ask  a hypothetical question .Does women medical professionals take  less aggressive stance and low risk taking behavior  and in the process result in less mortality and morbidity to our patients  ?

I would think the answer to that question  would be in affirmative .I wish  BMJ or anyone  should design a study on this issue.

Reference

1.Harris CR, Jenkins M, Glaser D. Gender differences in risk assessment: why do women take fewer risks than men? Judgm Decis Mak2006;1(1): p. 48-63.

2.Eckel CC, Grossman PJ. Men, women and risk aversion: experimental evidence. In: Plott CR, Smith VL, eds. Handbook of experimental economics results. Vol 1. North-Holland, 2008:1061-73.

3.McPherson J. Women are from Venus, men are idiots. Andrews McMeel, 2011

4.Northcutt W. The Darwin Awards: The official Darwin Awards: 180 bizarre true stories of how dumb humans have met their maker. Orion, 2004.

 

 

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These two quotes  on practice of medicine are close to my heart , one from Voltaire , a non medical man (a French poet )  and  the other from ,one of the greatest medical professional of our times, William  Osler .

gretest medical quotes william osler voltaire

It is amazing ,how the thinking pattern of a  philosopher  and a true scientific professional living  centuries apart are almost in sync with a great medical reality !

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I was recently asked to suggest a topic for debate on STEMI in  a major Indian cardiology conference. I wished , this is what we  should be mulling  over, with a set of  virtual  guest lectures and special invitees from heaven ! Plenary  session : State of the Art  STEMI care             Time :  11.AMSpeaker : Dr Hippocrates Topic : Aren’t  we erring   on either side of the  Noble profession ? Moderator:  Dr. William Osler Chairperson :  Dr .Harvey Cushings, Dr,Sir Thomas Lewis ,Dr Paul Wood , Excerpts : “While , vast number of  our country-men’s  culprit artery doesn’t even get that  mandatory  Aspirin on time . . . an urban rich  man’s  distal non-culprit artery  is decorated with a fancy  bio-vascular scaffold making  that innocuous lesion vulnerable in the process as well !  Aren’t  we erring   on either side  in the  Noble profession ?

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A cardiologist  is  a physician who has  trained himself  in a special  way  to deal with any problem of heart.Ironically , it exists only on paper.The field has developed so vast  no one can master everything .There is no such  “Pan or global cardiology expert” .In fact it would be shortly become unethical to try to become one !

Pediatric cardiology  has developed into such a big field , doing a echo in newborn or  infant has become a comprehensive job and  requires  special talent .This unique  and excellent study from Narayana Institute , Bangalore published in the  prestigious Annals of pediatric cardiology   throws up interesting realities about the quality of echo report done by adult cardiologists in children .The error rate  appears  huge and stands at  prohibitive 38%. While many errors were minor , major  were also not insignificant (23%)

pediatric echocardiography by adults cardiologist

With bulk of the pediatric echo  involves  in the critical decision making  process of device closures and interventions the  data required  becomes vital .The commonest cause for  error is probably not due lack of  knowledge and but to due to lack of commitment and  continuous  exposure in doing echocardiograms in  those age group.

While this paper  decently skirts the issue of quality of pediatric echo done in medium sized hospitals without pediatric cardiology service ,I can say the error rates or inadequate reportage could be significant  in such hospitals  with apparently good ranking .

Final.message

Of course ,we have many  adult cardiologist who do  excellent  pediatric work , It looks like , as a general rule  performing pediatric echocardiograms  by non -institutionalized  adult cardiologist  may not be appropriate ! It may be wise for them to avoid doing echocardiogram in small infants with  truly complex disorders (even perceived  complex) till they gain the required expertise and confidence.

I recall an  adverse  issue happened years ago ,  when I had  missed an associated    PAPVC  in ASD that made my surgeon anxious on table .In a country like ours there is no one to audit our work , “our conscience remains the only option” to deliver the best for our patients  especially so, when they are tiny lives in distress.

After thought

Who am I to suggest  who should do echocardiogram ? , after all every cardiologist is licensed  to do that . One simple  suggestion  would be , if  not confident  they can at least mention in their report it is only  preliminary evaluation and need to be followed up with  an expert . I do that whenever its required  and gives me peace of mind as well !

More controversies* to come

Can adult cardiologist do pediatric intervention ?

* Controversy : One of the meaning for this word  is  “It is a thought  process  set into motion , that aids digging up hidden truths ”

Reference

 

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