Pithy Loquacity

Category: Medicine

  • In case you were unaware!

    If romantic fiction is any guide, any doctor looking for love would be advised to be an emergency room surgeon or deliver babies rather than practise colon resection or remove in-grown toenails.

    So says Irish Psychiatrist Brendan Kelly, who has probed at length into the burgeoning literary field of medical romance.

    In an offbeat letter published in Saturday’s Lancet, Kelly describes the typical plot structure and characterization ( the Lancet-reg required)

    As for the storyline, novelists skirted such hazards as malpractice suits for removing the wrong kidney or infection by a hospital superbug.(too hum drum?)

    Instead, they stuck to a tried-and-trusted formula of the doctor as a saviour in a white coat.

    How does he do it? Is he reading these books while patients pour out their woes?

  • Painkiller is number one drug in India

    According to the latest ORG survey Diclofenac painkiller brand Voveran is the most used drug in India displacing cough medications which till now were the topmost brand. This has already been the trend in other markets. One not so surprising drug in the topmost brand is Liv 52 an ayurvedic preparation from Himalaya. As reported in the Times of India.

    Last year, cough syrup Phensydyl marketed by Nicholas Piramal, was the top brand, followed by another cough syrup Corex. The second largest brand for the January-July period is Corex (Pfizer), followed by ayurvedic liver tonic Liv-52 (Himalaya), anti-diabetic Human Mixtard (Abbott) and lastly, Phensydyl.

    Industry experts attribute the spurt in sales of Voveran due to rise in viral fever this year. Doctors often prescribe pain medications to address bodyache, a common phenomenon of viral infections.

    Last year, growth in therapeutic segments such as anti-infectives was robust on the backdrop of episodes like chikungunya, scares of bird flu and dengue, while this year cases of viral infections have been more rampant.

    I think this trend will continue. As for the use of ayurvedic preparations like candy by allopathic practitioners the less said the better..

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  • In queue

    In a very busy emergency we were attending to a RTA (road traffic accident) victim having serious head injuries and other multiple injuries in terminal condition; totally ignoring a drunk having minor injuries who was waiting for his turn for a while. After hanging around observing his comment was- ” If he had been wearing his helmet he would be waiting for his turn after me.”

    GCS-15/15

  • Chief O Complaint

    Actual conversation (translated from Hindi) with a patient having Gastritis.

    Me: So what brings you here.
    He: I came by bus.
    Me: No, No. Whats your complaint?
    He: My wife; she sent me.
    Now the situation was begging for a leading question so-
    Me: You are having abdominal pain?
    He: Oooh yes. and then the rest followed..

  • Gone to the dogs

    Wonder what it was with dogs last week. Attended no less than seven or eight cases of dog bite in a single day. all shape and categories. Most didn’t require much other than cleaning of wounds and advise regarding vaccination and antibiotics. The situation of rabies being what it is in our country I always advise both active and passive immunization in cases of severe injuries.

    Jayakumar R
    Department of Animal Biotechnology, Madras Veterinary College, Tamil Nadu Veterinary and Animal Sciences University, Chennai-600 007.
    A pilot survey of the dog population and rabies vaccination in India.
    Biomedicine. 1997; 17(1): 25-7
    ABSTRACT: A pilot survey of the dog population and the status of rabies vaccination was conducted by using a questionnaire prescribed by the World Health Organization in a suburban area to determine the size and structure of the dog population and its level of rabies vaccination. There was a ratio of 1:19.23 dog to human and the mean number of dogs per household was 1:11. The level of rabies vaccination was 39,1 percent. With the rabies incidence in India still unacceptably high this level of vaccination is clearly inadequate and measures designed to increase the rate of vaccination are emphasized.
    KEYWORDS:
    Dog Diseases/PC; Rabies/VE; Vaccination/VE; Rabies/PC; Population Dynamics; Animal; Dogs; Data Collection
    References: 14
    Record Identifier: NI004243

    One seven year old bitten by the village dog was in really bad shape with large laceration over scalp and part of skin torn away. The wound was repaired primarily after debridement and a little bit of mobilization. I reexamined the wound today and it has healed quite well. Great!

    I have seen a few cases of rabies and I can tell you it is mind numbing and disturbing. The future remains grim.

  • Attending a summon

    This week I attended a court for summon as a witness. I had treated a person who was assaulted by his neighbour for some petty reason about 4 years back. No great damage – a few laceration and abrasions which I had stitched and dressed and subsequently discharging him the same day. Armed with the copy of summon I presented myself to the court clerk. The case came up just after the lunch recess and I didn’t have to wait much.The hearing was all very pleasant and expeditious. I had previously given an opinion regarding the injuries sustained in writing, which was already submitted. I confirmed it to be my opinion under oath. Minimal amount of cross questions by either lawyer and I was on my way back in less than an hour.

    On an average in a week I have to deal with 22 to 25 such cases; and it has been so since last so many years. I have already attended a few of these summons previously but the frequency has increased recently. Besides these cases there are about 7-8 cases in a week of stab injuries, hemothorax / pneumothorax following assault or firearm injuries which are ‘Serious’; I wonder where all these will lead to? Will I be spending a major portion of time in Court houses; I wonder.

  • Dengue for surgeons

    Despite what is in the textbooks Dengue patients do not always develop rashes till the platelet levels have fallen waay down and even then hemorrhage may be sudden. Today i saw a patient in emergency who was complaining of pain in right upper abdomen and had fever for last 2 days. I had a suspicion of liver abscess and to confirm i got a ultrasound examination done. The radiologist found inflammation of gallbladder without any stones suggestive of dengue and it was confirmed as such. Quite a number of patients present with upper abdominal pain with fever and it has happened quite a few times that on clinical examination i have suspicion of Acute cholecystitis which on ultrasound examination is suggestive of dengue and later confirmed as such. Discussion of dengue from surgical point of view can be seen here .

  • 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.

  • 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