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Archive for the ‘Two line sermons in cardiology’ Category

Shall I begin with a provocative quote (My own !)

Inability to think beyond  self , family, private life  reflects a backward and immature  state of human mind

How to eradicate this backwardness  we all suffer from !

I stumbled upon a book which made me wonder , whether  eradication of  backwardness is little to  do with education ! It lies much, much deeper in our cortical thinking influenced by  inheritance , evolution , culture and economy .

The stunning truth was exemplified  by  American political  scientist  Edward C. Banfield  .A must read for every one who have mind for society , community and the humanity !

In this book he introduced a new term to describe this self centered thinking as “Amoral familism”

“Banfield concluded that  human  plight was rooted in the distrust, envy and suspicion displayed by  them in  relations with each other. Fellow citizens would refuse to help one another, except where one’s own personal material gain was at stake. Many attempted to hinder their neighbors from attaining success, believing that others’ good fortune would inevitably harm their own interests”

Banfield theroy  and  “Moral Bankruptcy in Modern medical care

I am afraid  there is a  compelling link between Banfield’s observation in a remote Italian village  to the current  medical  community   mind set who care only for their patients who pay them and keep them happy !

If you  think  education will eradicate social backwardness ,Why ?  one of the most highly educated community that form the noble profession remain backward in their thinking !

How do you explain  innumerable instances of hospitals ,  doctors shutting doors for  lesser humans  even in dire emergencies ! ?

Why do many of them  join hands with powers that can be detrimental to the overall health of the society ?

The stunning irony is , they do it  unashamed (with pleasure  at times!)  in  violation of the oath they take when they join the Noble profession. Shall we call it  as ” Moral Bankruptcy in medical care ?

Read further

Moral Basis of a Backward Society 
 
Moral basis of a backward society banfield

Highlights of this book  (Text from Wikipedia)

The Moral Basis of a Backward Society is a book by Edward C. Banfield, a political scientist who visited Montegrano, Italy . He observed a self-interested, family centric society which sacrificed the public good for the sake of nepotism and the immediate family. Banfield as an American was witnessing what was to become infamous as the “mafia” or families that cared only for its own “members” at the expense of their fellow citizens. Banfield postulated that the backwardness of such a society could be explained ‘largely but not entirely’ by ‘the inability of the villagers to act together for their common good or, indeed, for any end transcending the immediate, material interest of the nuclear family’.

 

Link to this book in PDF

 

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nobel prize in medicine 2

Why not Nobel prize for clinical  science ?

 

nobel prize for medicine

Nobel prize was constituted  to reward people or organisation  who make a  huge impact on the welfare of man kind. It is given in various categories  for  outstanding contributions in Physics, Chemistry, Literature, Peace, Physiology or Medicine, and Economic Sciences

Unfortunately,  there is a strong bias towards  raw basic science when it is given in the filed of medicine.Do you know  ,there is no Nobel prize exclusive  for medical science ? It shares with human physiology the only field included for Nobel prize in medicine.

Evolution of human  history reveals it is not the stunning  scientific discoveries that impact the mankind . It is  largely dependent  on how we  use them . It is true and natural ,invention of  sub atomic particles , decoding  quantum mechanics  and  trans-cellular  signals always generate great interest  than others.

In medical science, time and again we have seen problems arise in  applying fruits of scientific  research into  practical  usage in the patient domain  in the bedside.

What is use of rewarding inventor of  nitric oxide with a  Nobel prize , when billion-dollar nitrate  industry is thriving on a non existing  life long indication of  stable angina .

It is  surprising  to note ,  Nobel  committee does  give credit to wisdom &  intellect  while awarding  prize in  peace,  literary  or  economic sciences. For some reason it lacks  such a vision when it comes to medical sciences !

We have seen Nobel prize being  awarded to organization that strive for peace and welfare of society and community like UN ,EU  etc.The world health organization is the premier power supposed to provide and  regulate the health in this planet.I do not recall any time WHO  was close to  considered for the  Noble prize in medicine  !

Nobel Ironies

Nobel committee rewards  economists who point out lacunae in vital world macro and micro economics  theories.

Dubious men(Heads of state )  are decorated with Noble peace prizes  for preventing a war in  one geographical area while doing exactly the  opposite elsewhere !

In this modern  millennium  where scientific pursuits are contaminated and  many of the  research questions are misdirected or irrelevant , Nobel committee needs a through rejig in the manner in which  medical  Nobel prize is  being awarded. We know ,Noble’s death wish was to award the brightest mind with highest scientific  breakthroughs in those world . . . but

I guess Alfred Nobel if alive would have changed his rules .He wouldn’t  have imagined modern science would systematically devalue common sense and reinventing it would also deserve an award equivalent to Nobel !

Some of the medical  discoveries that deserve noble medical prize

  • States which excel in   school health nutrition and  other basic health programs  for the downtrodden
  • Doctors who promote bed side clinical skills
  • Tobacco eradication networks
  • Organisations like medicine san-frontiers which strives for basic life saving medication for all
  • Journal houses that specialise  on Medical ethics and clinical sciences
  • Medical professionals and institutions provide value education
  • Medical economists who expose the wasted financial resources that  widen the gap between sick and rich

How about    Nobel prize in cardiology  for preventive cardiologist  who successfully terminates a million statin prescription and restoring natural exercise directed lipid regulation in them  ?

How about  Noble prize for a noble  physician sitting in corporate hospital infested with all commercial ingredients who could resist and argue successfully  against   inappropriate tonsillectomies  and appendectomies ?

I am sure , such a man will be a  laughing stock  for most of us !

An appeal to Nobel committee

It is a wish , Noble prize  in medicine is to be included for people who do yeomen services in preventive and  clinical care and professional who carry forward the legacy of  caring for the sick with  clinical application of available scientific wisdom !

In this scientifically obsessed world , It will be a new beginning in the  way future medical research will be directed and nurtured ! Only then the true power of Noble prize in medicine will be  realised !

Reference

Link to Wikipedia Nobel prize in Medicine

 

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medical morality

Tree of life : When professional morality suffers a mortality . . . human health becomes a causality !

Greatest threat to the future of  human health is  . . .

  • Not from  exotic  infectious agents , bird flu  or  mosquito  fevers
  • Not from  epidemic of cardio vascular disease
  • Not from  thousands of  published  diseases in ICD code
  • Not from  aging population and failing  vital  organs
  • Not from  lack of availability of life saving  drugs and devices
  • Not from  lack of  hospital beds.
  • Not from  good sanitation
  • Not from  hunger and poverty
  • Not from  lack of para medical workers
  • Not from  lack of health awareness and education

But from  . . .

  • The way  health care is administered in this planet .
  • The way  noble professionals are created .
  • The way  trivial health  issues prevail over  major  health crises  that  wallop the health budgets.
  • The way by which  medical morality is systematically destroyed
  • The way   “concept of  health” is  sold  as a  buyable  commodity by insurance companies.
  • The way  medical journals churns out  junk articles in the name of research.
  • The way corporates indulge in  delirious pursuit  to  increase  bed occupancy rate of their  patient  ware houses (Also called Hospitals)
  • The  way greedy drug companies aim to increase the per capita drug consumption of  ill informed  homo-sapiens  by discovering  pseudo  drugs for pseudo  illness
  • The way   health insurance policies are misused
  • The way  rich spend billions for reconstructive  cosmetic  surgery while the poor die for want of basic medicines !

 

Link to a wonderful  article  on moral education for our kids in medical school !

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Interventional cardiologist extraordinary  cath lab tips invasive great

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modern medicine ethics hippocrates

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Time is muscle. This quote  became  sort of ” cardiology sermon”  in the last  few decades .Cardiologist think  they stand  on a 100 meters sprint track once a patient with STEMI arrives .This is indeed true ,  if we  agree  time is  muscle and  our urge is to reduce the door to balloon time .Please  remember ,  this rush matters  much ,  only if the patient comes through very early  when the muscle is really getting damaged . (No issues  . . . even if the fire engine comes in  slow motion if the  house is burnt fully !)

Time is muscle agreed  . . .  but  muscles are  kept alive by  factors other than time  !  So muscles can  defy time if God  is willing !

Time is one of the important components of management of STEMI.  Other things matter too !  Age , baseline co-morbidity ,  underlying extent of CAD, collateral support of IRA territory , and finally  individual variation in hypoxic damage in myocyte is (Rarely  been studied in detail.)

Door  to balloon time for a patient  who lands up within  1 hour window need  to be  much  different from a patient who comes at 10 th hour .The issue is important  because  we use a procedure which requires delicate decision-making ,(IRA-Non IRA issues etc)  the results can be  sub optimal ,  and even be hazardous in low risk STEMI . So , door to balloon time  may be a less  important  component of  time window in a patient who comes after 6 hours .This is the reason  overall outcomes are not changing in a large cohort  of rapidly performed PCI.

The presumed  absolute  relationship  between  “Time  and  muscle”  concept is  always been a suspect . This  is proven by a flawless study from  NEJM .

nejm stemi most important article

http://www.nejm.org/doi/full/10.1056/NEJMoa1208200

This study should infuse more sense to  us ,  time and again, we are  hijacked and sedated by high dose of  pseudo scientific concoction .In fact ,  indiscriminate rapid PCI may not be in  the good interest of  all  patients with STEMI ,  if it is not properly done  .Without realising this fact many developing countries are indulging in extravagance of  costly STEMI programs wasting  the exchequer.

This landmark NEJM  paper convincingly underscores a fact  that  achieving  rapid door to balloon time  is not  going to be the game changer in  conquering  the Global   STEMI  championship  . We have to take the coronary care into the streets  or to their homes as well .This is where the pre-hospital thrombolysis will  emerge in a big way in the future .

A slow and steady thrombolysis beats a fast and furious primary PCI on any given day in all uncomplicated STEMI .This we have proven for over three decades in  one of the India’s largest coronary care unit .( Where is the data man ?  Genuine experience is data . Why  we require , the act of publication to convert an experience into evidence . Often times ,  I  would feel , data is the most unscientific word in medicine . Many Truths  lack evidence , false hoods come with plenty !  For all those  scientific  homo sapiens  , please recall  70 % of ACC/AHA class 1 recommendations are backed by level C evidence ie simple opinion from  perceived experts! )

Final message

A fast and furious primary PCI may not be  the answer in all STEMI population

Thrombolysis  can be  done  with near  zero time delay , it does not require special expertise where an ambulance driver can reperfuse   a myocardium without much fuss and glamor ! He does not have to  split his hair to identify which is the IRA in a complex multivessel STEMI as well ! The streptokinase and TPA will home in  to the target site  smoothly and swiftly .

If indeed ,  time is the major factor in STEMI , we have many other ways to tame  the time . If muscle is more important than time ,  pPCI is  rarely  the answer !

Some India specific  thoughts

Is it not a shame  , we talk about primary PCI  for all  our patients  who do not even get timely Aspirin* after a STEMI! .It is something akin to what we witness every day ,  as our country folks  wield touch screen  Androids  . . . conversing  in open air toilets !

* While the importance of  Aspirin is undermined , It is different story altogether , these patients  get sorbitarate promptly whenever they get chest pain  (mis-placed and  dangerous priority ! )  prescribed by the  roaring  GPs ,  who suffer from discontinuous medical education ,  propelled  by the deeply penetrated 1000 crore oral Nitrate market .

And STEMI workshops are conducted by self-proclaimed experts  every few months in posh  7 star hotels all over India .

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The doctrine  of  modern medicine  goes  something like this   . . .

For most medical problems ,  there  would be a solution. Keep  trying . . . till you get it !

*But , just make sure that problem on hand deserves a solution in the first place !

Modern medicine continues to  remind us  every day , the much hyped solutions  often end up in new problems and  many  times worse than the original problem !

Oh ! what a  great a quote ! When I  was boasting   myself  . . .  My wife reminded  me ,  this is just  plagiarized version of  a  2000 year old Hippocratic thought !

Primum non nocere  . . . first do no harm !

But , Hippocrates’  life  was  not  contaminated  with  drug eluting stents, I pads, and  BMWs

If   Hippocrates  arrives  in   cath lab  today  by BMW which sucks  50000 Rs EMI  ,Everolimus coated  coronary  jewellery   will  definitely  tempt him !

You  can’t  simply   compare lives separated by 2000 years

. . . I told my wife !

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