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Monthly Archives: September 2008

Two days ago a patient was brought into the hospital with a heart attack. Though he had raised the alarm that he had severe chest pain, and though his immediate family had recognized that this could be a heart attack, he took full two-and-a-half hours to reach our hospital emergency room, the nearest one, in the middle of the night when there was practically no traffic!

 

This is how:

 

First there was the transport issue: the family didn’t own a car. So they had to wake their neighbor and explain to him about the crisis and then it took some minutes for the neighbor to dress and take the car out of his house premises.

 

Then, the patient was driven to the house of a doctor within the same locality. The good doc was awoken, listened to the patient’s story, mercifully conducted a cursory examination in the car itself, without wasting much time. He also felt that this looked like a heart attack, and since he did not have the facility to perform an ECG test in his house, he suggested that the patient be taken to a nearby nursing home.

 

The nursing home was a short drive, the patient had to be put on a stretcher, carried into the casualty area, and an ECG was obtained. There was a junior doctor on duty who confirmed the family’s suspicion that this was indeed a heart attack. But since there was no ICU facility in the nursing home, the family was advised to shift the patient to a bigger hospital. This meant that the whole drama of lifting the stretcher, putting the patient into the car and driving around had to restart.

 

Mercifully someone had the forethought of calling up a friend and then after consensus they drove to the nearby tertiary care hospital, where we could attend to him. Though valuable time was lost patient survived with some damage to the heart muscle.

 

Things could have been worse: he could have had a cardiac arrest while being driven around or even inside the nursing home and might never have reached the tertiary care hospital at all! How could this have been bettered?

 

You know, if you walk into a hotel lobby or a high rise corporate office, you have detailed building evacuation plan in case of fire or some such disaster. Why can’t we have such disaster management plans for our homes? I’m suggesting one for cardiac emergencies. Make this plan today when all is well at home.

 

First, identify a hospital which has the facility of ECG and has an ICU to treat heart attack patients, which is the fastest to reach. Remember, fastest need not be the physically closest one. In many metros in India, during peak hour traffic some places are hard to reach in a hurry. In fact, you can identify different hospitals for day and night time when the traffic conditions are likely to be different.

 

Get the emergency contact numbers for hospital you are going to reach and write it down someplace handy: it can be a wall calendar in the kitchen (common middle class family practice in south India), or on a sticker on the undersurface of your telephone.

 

Next, pre-determine the mode of transport in case of emergencies. If a car and a designated driver are at home, then that is your transport mode. Call the hospital emergency that you are coming and the designated driver will drive.

 

If a car is unavailable, or if the designated driver is not at home or himself/herself is the casualty, then the best bet is to get an ambulance. The ambulance can be from the same hospital or from another nearby source. Get the emergency contact numbers of one or more ambulance services and write it down along with the hospital emergency numbers.

 

Keep aspirin tablets handy: 325 milligram tablets should be fine. In case someone has chest pain & you suspect it is heart related one tablet of aspirin should be chewed, not swallowed. Many of us are advised by friends or family that sorbitrate tablets should be given to patients for heart pain. Unless, advised by a doctor, this can actually cause blood pressure to drop and be dangerous.

 

The most important thing to do in a suspected heart attack to get good secondary care treatment as early as possible. Plan ahead and do not waste time in getting to the right place. The instructions to family members as to what to do in a crisis situation should be explicit and should be followed as a reflex even in the middle of the night.

 

Even organisations can have similar medical disaster management plans drawn up for their shop floors and facilities so when men (or women) at work are affected, things move fast.

 

That should save some lives!

 

 

 

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In May, I started this blog when I was facing a dilemma: I wanted to bounce ideas off you as to whether I should send an old man for surgery or not (link). Now I am writing in to tell you that I did send him up for surgery and my worst fears came true.

 

No, my worst fear was not that the patient died during surgery. It was that the family holds me, atleast indirectly responsible for the sad outcome.

 

In May I wrote, ‘The family looks up to me to take a decision. “We trust you. Do whatever is best for him. But please make sure that he’s alright”. The last line is a killer!’

 

After the patient died, the family came back and met me. Sons came in first. It was not very difficult to say that I was sorry for the family’s loss of a parent and that we had done everything we could, and that some times it helps to be fatalistic. We went through the fact that both I and my surgeon had explained that the surgery carried a reasonably important risk of dying for the patient. The sons had actually signed the high risk consent after appropriate counseling. Perhaps they understood that we had not intended that the patient should die! They left thanking my fidgety self for taking care of their father during his illness and last moments.

 

Then the inconsolable daughter walked in. She did not and does not even now understand that 10% risk of dying during surgery meant that out of 10 such patients one will actually die. “I thought it’s just a 10% risk, but if you had told me that he is going to die during surgery, I would have convinced him against it”

 

Huh?

 

At a point of time I had to be a bit impatient. When we explained 10% risk of dying, we didn’t mean that 10% of his body will die and the rest will go home fine! We actually meant that there is a real possibility of dying…she told me that the family had trusted me because of the way I had taken care of her father for nearly two years. But the misgiving with which she finally walked away was that had I not advised him to go for surgery, he would have lived for some more time. Given the fact that he was quite sick the last few days, I was not sure of how long he would have lived but then how could I argue on that?

 

My point is not that it was after a truly sincere debate that I had resorted to surgical advice. I can’t tell the family that it was such an important dilemma that it turned me into a blogger!

 

My point is: Doctors are going to take hard decisions. Some of their patients are going to die. It never matters how much science or philosophy goes behind those decisions: if your decision was followed by death or disability, you will be held responsible for it!

 

My posts are never likely to be daily, but I am constantly on the look out for a good thing to write about. Except during the past one week.

The virus (I presume, I got better without antibacterials!) that got me this time was particularly nasty. I texted to a friend that I f**ked me so badly each time the fever spiked, that I was convinced that what I had was ‘gay fever’ and going by the way by spine ached during these days of being ill, I thought the virus caused ‘broke back fever’

Jokes apart I’m back at work. Mind is a bit rusty, but shall come back with a post shortly

Thanks anonymous reader, for coming this way & especially for passing this way again

People who develop blocks in the coronary arteries are often advised to undergo bypass surgery. During last quarter of 20th century coronary angioplasty saw dramatic improvements leading to a sea change in the kind treatment offered to patients with coronary artery disease (CAD). In the west, there has been a sharp decline in the number of coronary artery bypass grafting (CABG) surgeries and a phenomenal increase in the number of angioplasties.

 

Is that because angioplasty is better than surgery?

 

More importantly, is this situation applicable to India?

 

There are patients of CAD where CABG is the only solution. Angioplasty will simply not do. Similarly, there are patients where angioplasty and not surgery is the appropriate treatment. For the sake of this discussion, we leave out these unambiguous cases. The argument as to whether surgery or stenting is superior is relevant in cases where both treatments are equally feasible and a choice requires to be made.

 

The recently published Stenting versus Internal Mammary (SIMA) trial (conducted at multiple hospitals in Europe, Chief Investigator Dr Jean-Jacques Goy, MD, University Hospital, Lausanne, Switzerland) should serve as an ideal backdrop to this comparison between surgery and stenting.

 

Coronary block occurring at the beginning (proximal part) of the major blood vessel called Left anterior descending (LAD) artery of the heart are often fatal. This proximal LAD block is so feared that the artery is euphemistically known as the ‘widow maker’. Traditionally CABG surgery has been the main treatment of blocks in this location. There has been no direct comparison of long term results of surgery and stenting for treating blocks of this kind.

 

This new study has shown that patients who undergo stenting for proximal LAD blocks fare as well as those who undergo surgery, as far as protection against heart attacks and loss of life. The study also showed that in some patients whose blocks were treated by stenting, the blocks recurred. Such patients then required to undergo repeat angioplasty or CABG surgery.

 

In essence this means that:

 

1.         Patients with critical blocks in the widow-maker artery now have two options: Bypass surgery or stenting. Either way the risk of such a patient getting a heart attack or actually dying are quite low

 

2.         Stenting offers a convenience unbeatable by surgery. Patient is up and about in two or three days.

 

3.         In nearly 80% of patients, there is no recurrence of the block and patient will not need another procedure in his/her entire life for this block.

 

 

This study was begun over a decade ago and in those days the heart specialists used ‘Bare Metal’ stents (BMS). These BMS carried a risk of recurrence of the block in nearly 20% patients who were treated. On the other hand, bypass surgery is far superior in the long term if the internal mammary artery (IMA, the artery behind the breast bone) was used for grafting. Over 95% of patients with IMA graft to the LAD were free from problems even after 15 years of surgery! Because of this difference in risk of recurrence, surgery was always considered superior to stenting.

 

Cut to 2002: Johnson & Johnson released a new stent, CYPHER, known as Drug Eluting Stent (DES) essentially a BMS which was coated by a special medicine, which was intended to prevent the recurrence of the blocks treated. After several million of these DES having been implanted, we know that there is no recurrence in 90 – 95% of patients: as good as surgery with IMA graft. Soon after other DES have appeared in the market and look to be as good as CYPHER if not better.

 

Through SIMA study we know that stenting is safe even with BMS. Cardiologists are certain that with the use of DES even the recurrence rates are comparable to surgery, so stenting seems to be an effective alternative to surgery.

 

Caveats for the Indian patients:

 

1.         Several cardiac surgery centres in India especially in the tier 2 cities lack the expertise to offer IMA graft for the widow maker artery in bypass surgeries. Veins from the leg are used instead. Venous grafts are not as durable as IMA grafts and in fact nearly 20% of them occlude in the first 5 to 6 years. While venous grafts are acceptable in grafting of other arteries, in most cases IMA grafts must be preferred for the LAD. So before a patient decides on surgery it should be confirmed whether an IMA graft will be used.

 

2.         Many makes of DES are available in India manufactured in India, Europe, China and so on. Though none of these stents have been specifically compared in tests against bypass surgery, only few can claim really low recurrence rates. In other words all DES are not equal. So a patient offered stenting with a DES should not automatically assume that he will have a surgery-equivalent procedure unless he knows what DES is being used

 

3.         In the west, the leaning towards stenting is because stenting is cheaper than bypass surgery. Insurance companies prefer to go along cardiologists who advise stenting. Hospitals are happy because number of hospital days are less and so patient turnover can be more.

 

4.         In India, however, CABG is far cheaper than stenting with DES. So the western preference of stenting over surgery need not be automatically applied to India.

 

So what seems to be the right thing for the Indian patients with block in the widow maker artery?

 

1.         Stenting with a standard DES is as good as CABG with IMA grafting

 

2.         In case the stents fail, a second procedure would most likely be required.

 

3.         So, if you are short on cash (selling off a couple of cows or an acre of land to raise the money), perhaps surgery is a better choice because it is likely to be a once-in-a-lifetime procedure.

 

4.         If you have loads of cash and prefer to avoid surgery, stenting with a standard DES is fine: because there is a 95% chance that you actually get away!

 

5.         All this applies to the average patient: there are special circumstances in which these rules do not apply and the treating doctor is the best person to take the decision