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Archive for the ‘cardiology-ethics’ Category

News : In any developed nation , 90 % of  total  health expenditure is  exhausted in prolonging  final few days of  human  life !

When cost of dying   . . .  exceeds cost of living   . . . this world will go nuts !

The current real world  experience  from India’s  five star  hospitals  indicate,  many elderly rich men and women  spend their  last few days  before being buried or burnt  .They spent an average of 15 lakh Rs per death . This amounts to the entire  “life time” cost of living   of  majority of Indians .

modern medicine art living and dying

Image courtesy from Flicker/ Rachel sian photostream

When   human organ donation is considered  a greatest philanthropic act, there is one more excellent alternative for those who can’t do it .If only every super rich translate  their cost of dying  into  cost of  others living !   many new lives  will bloom .

The exorbitant rise in  cost of  dying  in India ,  is a recent development and reflects the affluence , honor , pride and of course lots of prejudice lack of wisdom ! Instead of filling the  deep  pockets of greedy  corporates why not the rich add new  lives   ?  !

Final message

Let all elders  with irreversible conditions , who have finished their life , shall  die peacefully at home .Why don’t we ( Affluent  .  . . would  be cadavers !)  cross sponsor their dying cost to a  public  health , nutrition or medical fund .

After thought

Oh America ,  . . .  Am I right  ,?  Obama thought it and implementing it too !  I would believe , his health care policy is  a  small first step in this  direction  !

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One of my otherwise  well behaving  patient ,  suddenly asked me this question ,  before leaving my  clinic  after a 15 minute consult .

Doctor  . . . I am taking the clopidgrel and aspirin  for 5 years like a vitamin tablet  . . . is that all right  doctor ?

I just got curious, I checked  the prescription again . Yeh ,  he was right !

I have  been mechanically writing  Tablet Clopitab  A  since 2008 !

Clopidogrel abuse long term

For what ?

Some sort of CAD !   Was it for ACS ?   No , it was for chronic stable angina . No PCI,  . . . no DES !

Why the hell  he is taking dual anti-platelet  therapy for 5 years ?

Some  body  , some  where  , has  prescribed it . This man  is taking it  for years together with absolute sanctity.

I was amused  . . . it is also  my mistake . Why it never struck me  to scrutinize the prescription ?

I thanked him . I  removed clopidogrel  from the list , and asked him to continue tablet Ecosprin 150mg  for some time .

( And  now I  had a genuine doubt  ! Does he have CAD at all ! I browsed his file , I couldn’t  find a true documentation for CAD  as I feared  !)

I asked him to get back with an  exercise test ,  . . .  if it comes negative i  can even stop the aspirin as well  I  explained  him  ! (Now he got amused !)

Final message

Who wants Knowledge ?

It is  dumped every  where , free of cost  . . .  both in real and cyber world .Applying it requires more sense  .  and my patient  taught me that  !

Patients  not only  help us  earn  our  bread  and butter , they  do  enrich  our brain  as well ! Never get humiliated when a patient teaches  you a lesson in medicine !

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April-May  is  carnival time in India . . . cricket carnival.  In IPL  . . . Indian premier league , eight teams  will fight for the cup . IPL 2013  became a  smashing  hit  , until  last week  when  three players were arrested for  spot fixing in  an  over . And for the past 10 days the entire Indian  media has gone into  manic reaction over it !

Still ,  the  sport was wonderful , the skills shown were extraordinary , and what happened  was an aberration just like in  any other aspect of life  .  IPL is perfect mix of  sports , business , commerce and some sleaze .  Actually in a successful  business model  , one should actually be surprised  if  corrupt  practices  does not occur !

The game of cricket can never be killed by money !  The way  the issue was handled by  the media and the  reactions and public debates   for me  looks irrelevant . Is it justified ? 

We the people and media has  much much important things to do in India !

scandals in india

Fixing a Fix  . . .

Politicians fix voters by giving money !
CBI is fixed by Government  for money  !
Media  fixes  news  for money !
Students of the noble profession are desperate  to  fix examiners with  money !
Finance ministry’s  annual budget  is fixed by business tycoons !
Private medical colleges fix entrance exams after getting money !
Super powers fix  terrorists selectively  for money for self benefits !
Drug companies  fix doctors with  money !
Doctors  fix  labs  by  getting money !
Anxious parents try to  fix  marks of their children  for  money !
Government  fixes  tender  for money !
Some Judges fix  verdicts after getting money !
Live kidney donors are fixed  by criminal cartels for money !
Advocates  fix  false evidence   with  money !
Police fix innocents as criminals after getting money !
Thousands of marriages are fixed  with  money after  hiding  illicit  relations !
Huge  bank loans are fixed  based on  false affidavits and  promises !
TV reality shows are fixed with mad money !
Even pilgrims fix  Darshan  time by  paying huge money !
And finally  . . . One cricketer bowled   one of  the  balls . . .wide . . . .  in one of  the  over after getting money  !
The whole world erupted !
cricket scam India
Postamble
Can  there be  any justification for  justifying wrong  things in life ?
  If life is a fight between  good and evil  , I thought  it is absolutely absurd to justify  it  until recently  . . . but a  great epic of  India , Bhagawad Gita  which is considered as the  ultimate guideline for living ,differs (Or is it my perception !)
The summary of the epic goes something like this
  • Whatever happened has been good.
  • Whatever happens is good
  • Whatever will happen is also good.
Bhagavad Gita  has one more sermon  to  confuse  us ( me )  completely !
“Do your duty , do not expect any  returns and do not watch injustice silently  , protest  and fight  it with your full  potential” !
I welcome  the experts  of the Bhagawatham  to clarify me on this issue !

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News : It seems the pharma companies are worried   about  the new MCI  (Medical council of India ) guidelines  that restrict  sponsorship  for conferences and freebies to individual  doctors  . They think it is a  big set back  as it  may interfere with doctor’s  education and knowledge  !

ethics and pharma compnaies

They have proposed new amendments and  has asked  the health ministry to advice the MCI accordingly .(ie To help them bring back  the corrupt and bad practices  that  influence  doctors prescribing behavior  !)

It is true , for the  growth of medical science , we  require some sort of  a business model and  tax holidays for the companies for true  &  land  mark discoveries  . Currently the MCI allows to sponsor  medical  events or a conference  for an institution or organization .  But  what these companies want is  official permission to provide  incentives to individual doctors and influence them  ! .  More shockingly  they said  doctors knowledge will  suffer without these industrial support . It is an outright insult to all doctors who get educated  for over  decades* . In fact the heads of pharma companies require  few lessons from the medical fraternity  ,  how many drugs with  dubious scientific value  is playing havoc in  health of  the society !

Of course ,we can not blame the pharma companies  for  all . It is a collective evil.

Counter point

*This  is a  second  slap on the face of  medical profession  !  I am  sorry to say this ,  many of us ( Including  the blogger  ! )  are some way responsible for this state of affairs  . Shockingly ,  few of  our  colleagues are  proud  to  have illicit relationship with drug companies !  Younger generation   no longer consider  this as an offense  , since they are born and brought up with  capitation fee as their principal fodder. Commercial forces  has taken over  medical  profession . Many of the  colleges are owned by business barons and alcohol vendors  in India . It is a well known  fact , MBBS seats are now  sold for 50lakhs (like  3 bed room flats )  . Agents transact black money in secret basements of   medical colleges  once considered  as  temple  of  the  noble profession .

So what is  in-store  for the future ? . . .  Self regulation is best  regulation   . . .   Mahatma told us ! . It  may be  the most idealistic     solution   . . . but  currently   it appears   self  regulation is  as bad  as no regulation !

Link to the article

http://articles.timesofindia.indiatimes.com/2013-04-19/india/38673588_1_pharma-companies-pharma-industry-doctors

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Acute MI kills a few million people world-wide every year .It does not differentiate rich from poor. Logic would  tell us  , principles of management  should  not differentiate  the people  when  dealing with a myocardium in distress .

Unfortunately , we scientists do it with passion !

The problem is enormous  . . . the rich is suffering from too much* care and the poor is suffering from want of care !

The following flow chart  is a result of my observation from close quarters  about the management strategies in corporate as well as Govt hospitals .

The first chart exposes the problem .The second one tries  to address the issue

Please bear with me . . .  if the  stuff  sounds  too crazy !

* Too much care is also referred to as inappropriate care

Practical and ethical guidelines for stemi management corporate

And for the solution  . . . try this

Practical and ethical guidelines for stemi management

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The irony of modern medical care is  9/10 times  medical negligence is  defined in terms of  acts of omission  in  required  level of care . In reality  most medical negligence acts are related to knowingly overdoing a futile diagnostic or therapeutic modality.

This irony was never understood by the public, the professionals or  even the judiciary .This remains  the most dangerous issue  facing modern medicine !

Finally some light is appearing in the horizon . A Missouri  Cardiologist is suspended for overdoing things he knows best  . . . namely coronary stenting ! 

This may bring chills over many cardiologist’s spine .

cardiologist stents inappropriate use interventional

http://www.stltoday.com/news/local/metro/missouri-healing-arts-board-issues-first-emergency-suspension-of-doctor/article_205eaffd-1825-5d7d-a9de-a289c010fd65.html

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Critical  and intensive medical care is meant for supporting  an  individual organ (or multiple organs )  at times of extreme distress ,  till the  healing process  prevails over .Later , the patient  shall be shifted safely out of the unit .

Whatever be the modern technology , the single most important factor that  determines the success of ICU outcome  lies within the  patient body ( One estimate says  patient factor constitutes almost  85-90% -Dukes medical center )

Ironically , the modern gadgets, drugs , devices  threatens  . . .  rather  fights . . . with this  inherent  patient fighting  mechanism . We will  never-ever know how many cellular switches are turned on by our biological high  command ,  that compensates  and tries to restore  body  homeostasis.

critical care unit icu ccu.jpg evidecne based medicine modern medicine

Here is a  personal experience with a patient management scenario in an ICU  . The  patient is none other than my father !

He  is a 82 year old man who has  developed a acute febrile illness which rapidly degenerated into  acute respiratory failure  and  X ray  showing  infective bilateral pneumonia  and  probable ARDS  .He was on ventilator for 4 days  and subsequently weaned  off but still  heavily dependent on oxygen . His lung is wet with crackles and wheeze intermittently . His cardiac function was excellent . In one of the episodes of hypoxia he  developed  , mild shooting of blood pressure and minimal ST changes .  Alarmed  by this he was started on  beta blocker , for the first time  . It  was titrated up to maximum doses for a suspected ischemic  episode .

It is  well-known , ECG changes are extremely common in hypoxia , tachycardiac  stressed individuals .

Sympathetic  blockade  is important , only  if ,  it is an inappropriate surge  . When the body fights a disease it is the only major biological weapon available to him .How is it justified to block it ?

When this was discussed with the  team they said they have no power to deviate from  protocol and there is one article , that says  BBs are  beneficial even in COPD !

The patient  continues to be in ICU dependent on oxygen with extreme  ICU fatigue  definitely worsened by the heavy dose of adrenergic blockers which is in my opinion delaying recovery !

Different   organ specialist are prescribing  drugs  according to their level of understanding  (evidence is always available for them  . . . some where )  and radiology fellows  keep taking  snaps of  distressed  organs  in various angles  in HD quality images . Meanwhile , CT scan  seems to have revealed a chronic  interstitial  process   . . . how to diagnose a chronic lung condition  in a man who is  yet to recover from major acute inflammatory lung Injury ! I do not know ? And the current development is they are considering disseminated tuberculosis !

You may a big physician , the patient  may be a very close family member  , modern health care  system makes you watch  helplessly once you hand over  patient to a   complex care  unit .

We hope for the  best .

Final message

               Medical practice  . . . however intensive the care may be  . . .   the bottom line is  . . . it  should be based on  common sense . Modern medicine  tends  to make  this faculty of our brain  blunted .

The  specialty of Intensivist   is largely  misunderstood  . It goes more with  satisfying scientific egos  and public  perceptions  rather than true patient needs .

We need not react to every changing parameter that emanates  from the modern machines  that  keep sending out live  data from a seriously ill patient ,  on a moment  to moment  basis ! (We simply do  not need that ! If only a pilot  reacts with  jitters to every air pocket turbulence ,  he will  not reach the destination safely  ! )

From a cardiologist perspective ,  the humble  request  to all Intensivists   and critical  care physicians   is ,   avoid being  in  “fire fighting mode”   for all  those subtle ECG changes  that occur  in ICUs ,  especially with multi- system disorder (Caution : Acute coronary syndrome in CCU / post PCI  set up   is different story altogether where even a minor ST shift can be significant ! )

Heaven’s  sake  let us  rely more  in  our  brain rather than  the machines and devices !

Above story is not even a tip of an Iceberg . I come across it  every day  in  many ICUs  I visit  . The  most saddening aspect  is ,  we can not point out these mistakes  to our fellow professionals ,  as it  amounts to   hurting academic egos .They are more important  than patient care at any given point of time !

Counter point

For any system to work  , it  needs  a  strict set of guidelines ,  other wise the system of care will fail. This is a  fundamental basis on which modem medical  care works . The only issue is ,  we  should keep checking for any inadequacies in the evidence base and try to correct it. So do not blame the  EBM . It has come to stay .That is the future ! You are very pessimistic towards  modern science !

Rapid response to counter point

But the real issue is  . . . by the time next evidence base finds a major flaw  in the existing system of care ,  damages are already done . So with your clinical acumen  every learned physician is free to create  his own real world  experience .(That is also called Level 3 evidence now ) ** Protocols are not  sacred sermons . It  may  be (rather must be !)   violated if there is a need for the benefit of patient .

Disclaimer

* This is not an  attempt to disgrace the concept  of intensive  medical care . Please remember ,  finding fault  could be same as finding facts .(At least in   medical care )

 

Update ( February 24th, 2013  Sunday , 12.05  AM )

After 25 days of  intensive and aggressive  medical care   we lost one of the great lives

of modern times  which will be celebrated by his  sons and daughters forever !

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* Obfuscation:  hiding of intended meaning in communication, making communication confusing, wilfully ambiguous, and harder to interpret

This world can not be a perfect place and  it is foolish to expect the same !   What is published in medical literature is at best , an abstract thinking  of an unfinished agenda . Still public think  science is   . . . what doctors say ! They feel doctors can not simply watch a person  dying. They want us  act like  God. This is  how medical men became Demi-Gods  by default.

Here was a big opportunity . Who exploited it ? Obviously the greedy corporates  who embarked  on a dirty journey to en- cash this trust  and fill their coffers .This is the foundation  on which the  basics of medical market economy rides !

It is an un-pardonable on-going deceit among  modern human civilization . It has  spoiled  the trust between the patient and doctor and  probably  irreversibly  contaminated  in recent decades !

There are very few positives  though,  with occasional noble medical  souls (Like  BMJ,Lancet )   trying to keep the sinking ship afloat !

This sounding board article (Now we rarely  get to see )  from NEJM way back  in 1975  exposes a  shocking revelation  politely . Now, 40 years after ,  the importance of such article has grown  many fold . We are witnessing  every day ,  medical scientist break  stories ( Yes  . . . it is story )  in general media  with  absolute academic cowardice !

We expect more such  face bashing articles from NEJM . It would definitely  make   immense  good  for  our profession  which needs it  desperately !

Reference

I’m linking the original NEJM article ; Hope it does not violate copy right !

http://www.bumc.bu.edu/facdev-medicine/files/2011/03/Crichton_M_nejm1975_293_1257_medical-obfuscation_structure-function.pdf

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Here is  the two versions  of  a  discussion  by a  cardiologist  to his  patient , on the day of his discharge  from a  state of the art trans national  heart health  service in southern  India.

An alluring cardiologist .

  • I have implanted  the  world’s  best drug eluting stent to your block .
  • The block has  vanished without a trace  .
  • You will be free from pain  here after .
  • You can enjoy a new lease of life .
  • You can go for holidays , you can cherish  ,   you can do whatever you want  .
  • Forget about complications  it is negligible .
  • But please take all the drugs regularly .

A Bitter cardiologist

  • This stent is a temporary solution to your problem .
  • Do not think you are cured of your illness .
  • Atherosclerosis can never been cured completely.
  • You have to be careful .
  • Avoid very strenuous activity .
  • It can re occlude at any time even if you skip  the tablets for  few days .
  • After all, it takes only  6 minutes to form a blood clot  .
  • You may  require CABG in  future  as most stents  get blocked  by  5 -10 years .
  • Further , the drug you are taking may develop resistance and you may  recur the same old problem .

Final message

So , the  art of  medicine  is to hide some of  the  unpleasant outcomes from the patient and project only positive aspects to our patients *

* This is often a controversial  issue . Scientifically advanced health care system  do not agree with this . But  I would believe , that is one of the major reasons   they are suffering from huge health care crisis !

I do not agree with  the concept  of empowering  patients with  bitter truths   . This  need not be  vigorously  practiced.   Disclosure of all potential complication  to our patients  , by itself a trigger  such  events  by meager anxiety .

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The principles of pre-discharge EST  

This concept came about 20 years ago (1980s) to risk stratify patients following  ACS to triage early coronary angiogram and revascualrisation. Generally patients are discharged by 5-7 days after an MI  (May be  3-5 days in some hospitals)  . Doing an exercise stress test  early within  2 weeks has not been very popular with many cardiologist even though it was recommended by many guidelines.The type of stress recommended  here  , is heart rate limited sub maximal 70% of  THR (Usually around  140 /mt )  is performed . This is due fear of precipitation another ACS.

Still,  there are definite  advantages for  pre-discharge EST .It help us  identify  high risk  subsets of  STEMI and reduce the  intermediate term mortality .More importantly it  gives  us an opportunity  to  exclude  inappropriate  revascualriations  even without an angiogram . (The well known coronary dogma  ie  if a post STEMI patient performs > 10  METS ,  his  heart carries little  risk  for  future events  still holds good  !)

With the advent of liberal usage of CAG and improved techniques of revascularistion ,  most  patients  directly undergo pre-discharge CAG rather than EST !

Further reading

Does any cardiologist have guts to do a pre- discharge EST after  a successful primary PCI ?

Read a related article in this blog .

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