Oh Kolkata !

The increasing spate of violence against doctors in the country and elsewhere, epitomized by the horrifying incidents in Kolkata compels me to write the following.

Most attacks on doctors occur in the accident and emergency (A & E) services of a hospital or a clinic for following obvious reasons:

In the hospital wards, for patients suffering from subacute or chronic diseases or awaiting an elective procedure, there is enough time for the doctors to explain and for the patient and the relatives to understand, accept and ask questions. Decisions can be made jointly, and responsibility shared after discussion. An example in heart diseases is what is known as a “heart team” approach for decision making in a case with stable but complex coronary artery disease.

On the other hand, the ‘scene’ that happens in the A &E units is due to a combination of factors that the 3 ‘actors’ in the ‘drama’ suffer from, like lack of time, agitated mental states and seriousness/acuteness of illness or injury. 

Firstly, actor number one: The patient- mostly is one who has serious and acute illness or injury which has high mortality despite best treatment. This is what the relatives HAVE to understand and accept. For example, a patient in cardiogenic shock after a heart attack. Even the best of treatments like urgent opening of a blocked coronary artery by angioplasty and stent implantation leaves a mortality rate of 50 % (and not doing anything a mortality rate of almost 100%). Would you beat up a doctor who in the middle of night endeavors to save someone but is not successful for reasons beyond him?

Then the actor number 2: The agitated, ignorant, aggressive relative. Gone are the days when relatives were compliant and more accepting of the results of treatment. Now we have a combination of lack of understanding along with aggression and muscle- a particularly lethal combination.  Of course, some of it comes from the lack of time and expertise in communication skills of the doctor on duty-the 3rd actor in the drama.

Generally, the doctor on duty is from the lower or middle rung-not a senior person, is already harrowed with the continuous flow of serious patients and his or her inadequacies of facilities, time and communication skills. The requirement of urgent action leaves little time to explain the relatives the seriousness of the illness and possible outcomes with or without treatment. Even if a doctor is accused of being inefficient, having poor knowledge or judgment, he or she can never be accused of poor intent. His or her first and last effort is to treat in ways best known to him or her-which hardly deserves the ‘treatment’ he or she is meted out. Although Although God judges by intent, the world judges by results, unfortunately.

Since the A and E units are hardly the place to discuss these issues, the best way to prevent violence is probably by doing the following:

1.       Have training and workshops for A & E doctors in communication skills and behaviour changes-it is how you say that makes all the difference; also, by skits and role playing. Justifiably or not, people expect the same courtesy from doctors as they get now-a-days from other service people. May be the IMA and MCI can take a lead on this.

2.       Make violence against doctors a non bailable offence-and put up sign boards prominently to that effect outside all A and E departments and as news item in the media.

3.       Have at least 2 bouncers in every A & E department, (to be paid by a surcharge on every patient).

4.       Explore the feasibility, effectiveness and safety of use of crowd dispellers like tear gas guns etc.

5.       Put up sign boards such as “Your patient may have illness or injury that has a high chance of death despite treatment and certain chance of death without it. Please decide whether you want treatment or not”.

6.       Have a short consent form in relation to the above for the relatives to sign (in presence of a bouncer or security staff).

7.       Have meetings and seminars with the police force to initiate rapid response systems.

8.       Have public seminars and write ups on this topic-especially to political groups.

Finally, last night one of the TV channels was showing how patients are suffering due to the medicos' strike in Kolkata which only implies how much needed they are and how much difference they can make.

Would you hit a person you badly need?

 No wonder Socrates was compelled to say: “Why do you hate me, I have not helped you!”

Difference between heart attack and cardiac arrest. How does one explain it to police officers ?

Difference between heart attack and cardiac arrest.

How does one explain it to police officers ?

I am attending a lecture cum demonstration on cardiac resuscitation  organized for police personnel of Bandra area in Mumbai, India.

It is part of the I-care campaign by Holy Family hospital to teach cardiac resuscuitation to the general public as well as early use of an equipment (AED)  to give shock and revive a cardiac arrest victim.

As is usual, the talk also involved clarifying the difference between a heart attack and cardiac arrest.

Although the speaker did his best to explain the difference between a heart attack and cardiac arrest, seeing the confused faces of the people in audience, I intervened to tell them something in the language they would understand.

I said, “a heart attack is like arresting someone with handcuffs and taking him to jail”.

On the other hand a “cardiac arrest” is like shooting down a criminal to death - sudden and instantaneous.

When a person is handcuffed, he is alive but there is damage is to his reputation which increases as news spreads in time.

 Similarly, in a heart attack, although the heart continues to beat and the person is alive, there is increasing damage to a portion the heart muscle due to a blocked coronary artery.

Carrying the analogy further, just as the damage to a person’s reputation can be salvaged, the earlier he is released with as minimum fan- fare as possible, the damage after a heart attack can be minimized, the earlier we intervene with medicines and angioplasty (to remove the blockage in coronary artery).

On the other hand, a cardiac arrest is instantaneous stopping of heart pumping so that blood supply to brain stops. This is akin to a criminal being shot down to instantaneous death.

Is there a relation between a heart attack and cardiac arrest ?

Some  heart attacks (20 to 30%),  but not all, may lead to sudden cardiac arrest.

Conversely, most cardiac arrests are due to coronary blockages or heart attacks. In young individuals there are other causes such as in born defects of electrical system or muscles of the heart.

So, is the treatment different for both ?

A heart attack victim with chest pain or breathlessness, but alive, is best served by taking him to a hospital as fast as one can (nearest is best). Opening the blocked artery as fast as possible is the aim. Minutes count.

On the other hand, a cardiac arrest victim must be treated then and there. Once you recognize someone has collapsed and is not responding and not breathing, the first thing to do is to call for help (a cardiac ambulance or a defibrillator or an AED-automated external defibrillator). Having done that, and till this help arrives, one starts proper and effective chest compressions (100/minute), 2 inches deep at the lower part of the breast bone (sternum). Minimizing damage to the brain and reviving the heart is the aim. Seconds count.

Experience in cities like Seattle has shown a survival rate of 40 to 50 % when CPR is initiated by bystanders.

Did the explanation go well with the police officers?

The smiling faces said it all.

The Cholesterol Confusion

The Cholesterol Confusion

Half- truths are injurious to your health!

If someone told you “smoking is beneficial for health”, at the most it may amuse you, but you would easily discard it as false. No half- truth about it.

However, when in the garb of a truthful statement, misleading falsehood is propagated, that too in what  now-a-days is turning out to be the fastest mode of communication-the social media-it has the propensity to cause harm of great magnitude.

Such a message has been in circulation recently, captioned:

 “Cholesterol is finally officially removed from Naughty List”.

Yes, the 300gm per day limit on dietary cholesterol is relaxed. But this is nothing new or extra-ordinary, because dietary cholesterol- that is raw cholesterol in diet like egg yolk, has low propensity to raise blood cholesterol in the quantity consumed (each egg yolk has 186 mg of cholesterol). However, what raises blood cholesterol most is saturated fats and trans fats.

The danger from the circulating message is the lumping together of foods containing ONLY cholesterol, like eggs and seafood, including shrimp and lobster with foods containing BOTH cholesterol and saturated fats & trans fats,  like dairy products, meat, and some processed foods.

Both are not the same. The 2015-2020 US guidelines have NOT recommended butter, full-fat dairy products, and meat as safe, as wrongly mentioned in the circulating message.

The US guidelines can be seen from: http://health.gov/news/dietary-guidelines-digital-press-kit/2016/01/top-10-things-you-need-to-know/

The relevant sections reproduced verbatim, say the following:

5.       Healthy eating patterns limit added sugars. Less than 10% of your daily calories should come from added sugars. ChooseMyPlate.gov provides more information about added sugars, which are sugars and syrups that are added to foods or beverages when they are processed or prepared. This does not include naturally occurring sugars such as those consumed as part of milk and fruits.

6.       Healthy eating patterns limit saturated and trans fats. Less than 10% of your daily calories should come from saturated fats. Foods that are high in saturated fat include butter, whole milk, meats that are not labeled as lean, and tropical oils such as coconut and palm oil. Saturated fats should be replaced with unsaturated fats, such as canola or olive oil

So please do not mix up foods containing cholesterol ONLY,  with foods containing BOTH cholesterol and saturated fats & trans fats.

While the former can be had in moderate amounts, the recommendation for saturated fats is not more than 10% of total calories, and trans fats - as low as possible. And yes, sugar should be restricted.

The second half- truth reads :  “Cholesterol doesn't cause heart disease”.

Yes, cholesterol in the blood is important for many body functions. Yes, the majority of the cholesterol  is produced by your liver. Yes, many (not majority of) people who have heart attacks have normal cholesterol levels. And yes, cholesterol doesn’t CAUSE heart disease the way the TB germ produces TB or the polio virus causes polio.  

In fact, we still don’t what is THE cause of heart disease. But we do know the following :

1.       That atherosclerosis is a disease of multiple causality. That there are various factors (we call ‘risk factors’) which singly or in combination increase your chances of having atherosclerotic coronary artery disease (CAD).

2.       That cholesterol is one of the most important of these risk factors and studies on millions of people world wide show that CAD is a continuous function of cholesterol levels even within the range we once considered "normal."

3.       Other risk factors are high blood pressure, diabetes, smoking  abdominal obesity, diet, physical inactivity, ageing, male gender (at least in the young), occurrence of coronary disease in family members etc.

4.       Different set of risk factors operate in different people. In some patients, high cholesterol alone may indeed be the dominant cause; for example people with genetically very high cholesterol levels; in others, hypertension is the dominant cause, for example in the Japanese; in still others, cigarette smoking may be the dominant cause.  But in most people multiple factors act synergistically to cause CAD.

5.       That more than a century of laboratory and human findings show that some abnormality in lipids (fats circulating in the blood like LDL and HDL cholesterol, triglycerides etc) is highly associated with atherogenesis. Although LDL cholesterol (LDLC) level is the commonest and most easily measured abnormality linked to atherosclerosis, in many patients LDLC may be normal and other abnormalities in the blood may be the reason for the disease -such as low HDL cholesterol, high  triglycerides, high Non HDLC,  LDL particle number or size, HDLC particle number or size, apoB concentration, , Lp(a), hsCRP, homocystein  etc.. That is why, although LDLC is our primary target, we also look at complete lipid profile and other chemicals in blood.

6.       That whatever the cause, the final pathway for atherosclerosis is inflammation of the inner lining of arteries (making it sticky) due to above mentioned factors and entry of cholesterol containing lipoproteins into this lining creating atherosclerosis.

7.       And finally, that  whatever the cause, studies on millions of patients worldwide since decades have shown that reducing blood cholesterol-whether by diet and exercise or by drugs or by both- causes a substantial reduction in heart disease occurrence. Diet, exercise , healthy life style and drugs like statins, not only reduce cholesterol levels in the blood but also cause the fatty deposits in arteries to stabilize and even regress, which can REVERSE CORONARY DISEASE, as seen in many studies and our own experience in clinical practice.

So the cholesterol story is not a ‘scam’, but the unfolding of one of the most important discoveries of the last century.

American Plate or Indian Thali ?!

American Plate or Indian Thali ?!

MyPlate is the current nutrition guide published by the United States Department of Agriculture, which shows a plate divided into 4 parts for easier understanding and intake of food portions. It replaces the old food pyramid diagrams as a guide to food intake.

As seen in the plate, half the plate should be filled with fruits and vegetables. A quarter each with lean proteins, whole grains and a cup with low-fat dairy.

MyPlate is divided into sections of approximately 30 percent grains, 40 percent vegetables, 10 percent fruits and 20 percent protein, accompanied by a smaller circle representing dairy, such as a glass of milk or a yogurt cup.

2015-2020 Dietary Guidelines for Americans accordingly advises the following healthy eating pattern which includes:

o    A variety of vegetables: dark green, red and orange, legumes (beans and peas), starchy and other vegetables

o    Fruits, especially whole fruit

o    Grains, at least half of which are whole grain

o    Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages

o    A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), soy products, and nuts and seeds

o    Oils, including those from plants: canola, corn, olive, peanut, safflower, soybean, and sunflower. Oils also are naturally present in nuts, seeds, seafood, olives, and avocados.

2.     Healthy eating patterns limit added sugars. Less than 10% of your daily calories should come from added sugars. ChooseMyPlate.gov provides more information about added sugars, which are sugars and syrups that are added to foods or beverages when they are processed or prepared. This does not include naturally occurring sugars such as those consumed as part of milk and fruits.

3.     Healthy eating patterns limit saturated and trans fats. Less than 10% of your daily calories should come from saturated fats. Foods that are high in saturated fat include butter, whole milk, meats that are not labeled as lean, and tropical oils such as coconut and palm oil. Saturated fats should be replaced with unsaturated fats, such as canola or olive oil

4.     Healthy eating patterns limit sodium. Adults and children ages 14 years and over should limit sodium to less than 2,300 mg per day, and children younger than 14 years should consume even less. Use the Nutrition Facts label to check for sodium, especially in processed foods like pizza, pasta dishes, sauces, and soups.

How interesting that MyPlate closely resembles the Indian Thali ! Just fill half the thali with veg salad & fruits, quarter with dal & pulses and a quarter with our whole grain wheat & millet roti’s & unpolished rice with a cup of low fat curds or buttermilk (“chhaas”), and you have a healthy thali meal !

Kill two birds with one stone :

Kill two birds with one stone :

The two intimidating ‘birds’ are cancer and coronary heart disease.

The ‘stone’ in our hand is a healthy life style and healthy levels of blood pressure, cholesterol and sugar.

We all know that a healthy life style and optimum blood pressure, cholesterol and sugar levels are associated with a low likelihood of coronary heart disease.

Now, studies show that even the probability of cancer is affected by these measures.

The 4 life style measures  are diet, physical exercise, avoidance of smoking and obesity.

The optimum levels of total cholesterol to have with a healthy lifestyle are  <200 80="" a="" additionally="" and="" are="" blood="" control="" course="" diastolic="" different="" dl.="" dl="" drugs="" f="" fasting="" glucose="" have="" hg="" if="" life="" measures="" mg="" mm="" mmhg="" nbsp="" not="" o:p="" of="" pressure="" resorted="" serum="" set="" slightly="" systolic="" targets="" these="" to="" under="" with="">

Greater the adherence to all these metrics, greater the benefit, so that if all the parameters are taken care of, cancer chances reduce by 50%, recent studies show.

Interestingly also, the two drugs known to prevent heart disease- aspirin and statins- are also now found to have some benefits in cancer prevention.

In Asian population, studies have found additional benefit with  a normal waist to hip ratio ( ≤ 0.9) and increased fruits and vegetables in diet.

Thus, having a healthy lifestyle and ideal readings with judicious use of medications can not only prevent heart disease. They can do a profitable  “side business” too !

Why not kill two birds with one stone ?

Is walking in the house, exercise ?

Is walking in the house, exercise ?

Recently, while on a holiday, I went to the hotel pool to swim.  After some time I found that I was not getting tired even after 45 minutes of non- stop swimming, which would happen  at 30 minutes in my club pool. I was wondering what was the reason, since the time and distance covered was the same- in fact more.
Then it struck me that compared to my club swimming pool the hotel pool was smaller in length,  so my stopping and turning at the ends was more frequent than what happens in the club pool which is longer.

Every time you reach the end of the pool and turn, you break speed and slow down. This allows a little rest and one can swim for longer time.

The same happens when you walk in the house. However big it may be, you slow down at the walls while turning and hence you are not walking at constant speed like on the beach or a walking track. Thus, although you may walk for the same time, it doesn’t give you the same cardio vascular training or fitness or conditioning as walking with constant speed.

Although something is better than nothing, walking in the house does not give you the same cardio benefits as walking out on the road, park, beach or a treadmill.
So unless there is a compelling medical reason, one should not substitute walking in the house for outdoor or treadmill walking.  Thirty minutes five times a week or 50 minutes thrice a week, round the year, is the minimum “dose”  of any aerobic activity like brisk walking, running, swimming, skipping, dancing cycling etc. to confer cardio vascular benefit.

Walking slowly after dinner in the house or outside is a different matter and not for cardiovascular fitness. People with known heart disease should this post dinner walking only after medical advice from their doctors.

Yet another exercise magic !

How an Active patient and an Astute physician “Abort” a heart attack !

Mr Parker is a 75 year old diabetic. He is always on the go. Wherever possible, whenever possible he avoids a vehicle or an elevator but walks and climbs besides doing his regular half hour walk every morning.

But one evening his long standing diabetes played spoil sport.  He started getting chest pain and hence went to his family physician. The doctor took his ECG, diagnosed a heart attack (technically termed ST elevation myocardial infarction) and packed him off to Nanavati hospital. (Fig 1 from attachment)

But before sending him, he did a wise thing. He gave him a soluble aspirin to chew and 4 tablets of  clopidogrel (another blood thinner like aspirin) to swallow.

By the time Mr Parker reached the hospital, his pain had subsided completely and the ECG reverted to normal (in medical terms- the elevated ST segments regressed to baseline). (Fig 2 from attachment)

This was because of the dissolution of the clot or thrombus which was occluding a coronary artery.  Usually it requires the intravenous injection of a clot buster (fibrinolytic drug) or emergency balloon angioplasty to dissolve or remove the clot and open the artery. In Mr Parker’s case it happened without any of these these remedies. It is very likely it came about due to the physical activity habit of the patient as well as the timely diagnosis with an ECG and administration of the blood thinners in correct dosage by the family doctor.

An angiogram that I did the next day confirmed our premise, and Mr Parker was referred for bypass surgery due to presence of multiple serious blocks in other arteries too.

Regular, moderate intensity  physical activity is known to stimulate body’s own “fibrinolytic” system- that is, the body’s ability to spontaneously dissolve unwanted clots.

.

Although due to diabetes, Mr Parker had fat deposits and a threatened heart attack due to clot formation, the latter “melted”  due to a combination of his own vigorous fibrinolytic potential because of regular exercise and the blood thinners promptly given by the doctor after a quick diagnosis of ST elevation MI. Hence he did not suffer from much damage to his heart muscle. The bomb was diffused before it could explode !