Fever with headache

This being the dengue season all patients coming to the emergency with headache, fever or bodyache are sifted through with extra precaution. Going by numbers the incidence till now has been less than what it was in previous years but hasnt be low either.

Depending on the clinical presentation and symptoms dengue can be divided into thre types- the ‘usual’ or classical dengue or breakbone fever, Dengue hemorrhagic fever and Dengue shock syndrome. The illnes is caused by a virus and transmitted by a mosquito (Aedes) who usually bite during the day time. It has an incubation period of 3 to 10 days followed by sudden onset of gever and achills, intese headache, muscle and joint pain. Other symptoms include severe weakness, anorexia, altered taste sensation, colicky abdominal pain with abdominal tenderness. Fever is typically but not always followed by remisson and again fever (biphasic). In about 80% of cases there develops skin eruptions in remission or second fevrile phase which lasts for 1-2 days. Fever lasts for about 5 to 7 dys after which the recovery is complete with slow convalescence. The case fatality is quite low unlike the dengue hemorrhagic fever.

Thankfully patients have run of the mill fever and just ‘headache’ which respond to symptomatic treatment. Link to wikipedia on Dengue

A Complication

Last week a patient presented with one of the complications of operation for gall bladder stones in my emergency. Fifty five year old female was referred from a private hospital about 100km in the interior following development of jaundice. She was operated about a month and a half back for Cholecystitis with cholelithiasis by Laparoscopic cholecystectomy (small incision marks were present at the umbilicus and the other in right flank) and later converted to open – (the Kocher’s incision). The incision site was quite well healed and the patient herself looked cheerful enough other than a completely jaundiced look and her complains of itching all over body.

Now jaundice due to obstruction following gall bladder operation is one of the known and dreaded complication following cholecystectomy. This usually occurs when the common bile duct the tube carrying bile from liver to the gut is injured or clipped. The operation must have been difficult or the surgeon must have been aware of the possible complication as he opened up and had a look see. Serious complication following surgery for gall stones is relatively low but can be devastating for the patient and for the Surgeon involved. The percentage involved is more or less similar all over the world. Some people prefer immediate repair or management if the complication is found while operating but sometimes the injury may remain undetected or present later in the post operative period.

As for this patient; she was further stabilized and subsequently referred to “Mega Hospital” who routinely deal with such procedures. Bile duct injury can have major effect on quality of life and requires expert management subsequently. There is one thing to be said- As gall bladder operation is ‘bread and butter’ for a general surgeon so is its ‘complications’ for lawyers in medical malpractice.

Bile duct injury

addendum: There is an interesting post in Running a Hospital regarding factors leading to injuries in Laparoscopic cholecystectomy derived from Annals of Surgery with followup comments.

Dhoni and team win Twenty20 World Cup

The enthusiasm and expectation for the today’s final was palpable. The streets were uncharacteristically empty and by the time the finals started in Johanessburg in the evening traffic became very smooth. ( I know because i was on road while everyone else was glued to their television. I did catch the end though 😉 ). And what a great match it was!! After getting off to a great start the Indian innings wobbled midway but recovered to finish comfortably at 157 for 5 in 20 overs.
The Pakistani team was going great except for the fall of wickets at regular intervals. Their run rate dipped after the loss of fifth wicket and could not recover despite a valiant effort by Misbah. Surinder Sharma kept his cool to finish off the Pakistani batting lineup. I really admire todays bowling by Irfan Pathan. He deserved to be the man of the match. The final scorecard:

India 157/5 (20/20 ov)
Pakistan 152 (19.3/20 ov)
 		India won by 5 runs

Pakistan RR 7.79
Last 5 ovs 56/4 RR 11.20
Required RR 12.00
India RR 7.85

This team is doing great!!

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New CPR technique

Cardio Pulmonary Resuscitation

This months issue of American Journal of Emergency Medicine describes a new method of resuscitation by abdominal compressions only. As is quite well known CPR by itself is not very effective: succeeding in only a percentage of patients when instituted. The purpose of study was to determine the amount of coronary perfusion obtainable with OAC-CPR during VF compared with the coronary perfusion with the normally beating heart in the same animal. A second objective was to determine coronary perfusion during VF using standard chest-compression CPR and to compare it with the coronary perfusion for the normally beating heart in the same animal. A third objective was to compare the OAC-CPR ratios with the ratios obtained with standard chest-compression CPR. This latter comparison was designed to quantitate the superiority of OAC-CPR over standard chest-compression CPR.

Rhythmic abdominal compression-CPR works by forcing blood from the blood vessels around the abdominal organs, an area known to contain about 25 percent of the body’s total blood volume. This blood is then redirected to other sites, including the circulation around the heart.

The advantages listed for only abdominal compressions(OAC) includes-OAC-CPR eliminating the possibilities of rib fractures. It also provides substantially more coronary perfusion than standard chest-compression CPR. With OAC-CPR, Ao(aortic arch) pressure exceeds RA(Right Atrial) pressure during almost the entire compression-decompression cycle, thereby providing a high coronary perfusion. With standard chest-compression CPR, there is some retrograde coronary flow because RA pressure exceeds Ao pressure during a portion of the compression-decompression cycle. In this preliminary study, there was no evidence of damage to visceral organs found by the researchers. Read the whole article here Via Elsevier

A summary of the arcticle can also be found at Reuters health

Making a diagnosis

Automated programmes capable of diagnosis and suggesting further investigations or workup is just waiting in the wings. I suppose this is one of the initial events in that direction.

You want machines second-guessing you? by ZDNet‘s Dana Blankenhorn — But what if insurers start trusting the software over the physician, using it to question a doctor’s calls? What if doctors feel forced to follow Isabel’s recommendations, knowing this to be true? What if lawyers start using Isabel diagnoses to file malpractice claims?

Doctor’s Factory ?

http://www.jha.in/Pics/green.jpg
It is a fact that a large number of Indian medical graduates leave India for abroad. US is the prefered destination followed by UK and Australia. Do you think that they should be barred from going out? The present Health Minister does think so. After the recent fracas and then strike by residents in AIIMS this is what he had to say that the premier institute was slowly becoming a “doctors’ factory” for foreign countries and not for the needy Indians.

“Over 60 percent of the AIIMS passouts are going outside India. It’s becoming a doctors’ factory that is producing talent for foreign countries and not for the poor Indians,”

This debate is age old i suppose. And at the same time i think the quantum of medical graduates going out has gone done. what with difficult to get visa and poor working environment in those countries. what would be your opinion?
Rest of the stories continues here

Res Ipsa Loquitur

Doctor left a towel inside me, says 65-year-old. and from msn

Leaving behind instruments and gauze pieces after operation is certainly not a healthy practice. Besides being an extra burden for the patient; the doctrine of Res Ipsa loquitor applies with regard to negligence by the medical practitioner. Ordinarily acts of omission and comission need to be proved in court by expert evidence in court to determine negligence by a doctor but this need not be proved in case ” res ipsa loquitor” i.e “the thing or fact speaks for itself”. The reason for this post is this in todays news with regard to removal of ‘Sponge’ from a patient’s abdomen at a prominent institute.

A patient underwent open cholecystectomy (removal of gall bladder for stones) and complained of constant pain with purulent discharge. Investigations revealed a left over towel used for packing which was subsequently retrieved.

Now this is one of those cases when the surgeon will have to throw in his towel! The rule applies when (i). in the absence of negligence the injury would not have occured. (ii). the doctor had exclusive control over the injury producing agent. (iii). the patient was not guilty of contributory negligence.

Good news for me


Now this is a welcome news for me. Published in this months Hepatology

In an meta-analysis of 10 studies reviewed by Dr. Francesca Bravi from Milan’s Istituto di Ricerche Farmacologiche “Mario Negri” and colleagues included 2,260 cases of HCC. Collectively, the results showed a 41 percent reduction in the risk of liver cancer (or hepatocellular carcinoma, HCC) among coffee drinkers compared to those who never drank coffee.

Low to moderate coffee drinkers — defined in some studies as those who drank less than 3 cups per day and in others as less than 1 cup per day — had a 30 percent lower risk of HCC compared to coffee abstainers. High coffee consumption — defined in some studies as 3 cups or more each day and in others as 1 cup or more per day – had a 55 percent lower risk of HCC.

Earlier i had been wringing my heart while enjoying my cup. I will wait for the next news over my cuppa.