Can accidental drowning occur medically?

Dr KK Aggarwal

Recipient of Padma Shri

Actor Sridevi died of accidental drowning in her hotel bath tub after losing consciousness, according to the forensic report by the Dubai govt. on Monday. However, the report, which carries the stamp of the "Ministry of Health UAE" and the director of preventive medicine, Dubai, Dr Sami Wadie, does not state the cause of unconsciousness.

Can accidental drowning occur medically? Yes. Medical conditions can cause accidental drowning. Seizure disorders, which can be first-onset episode, can cause accidental drowning. Alcohol and/or use of illicit drugs increases risk of accidental drowning as it may affect balance, coordination and judgment. Stroke, syncopal attack (heart attack) or undetected primary cardiac arrhythmia are other factors that can cause accidental drowning. A gasping patient with ventricular arrhythmia will end up with drowning.

If there are no signs of struggle, then ‘accidental drowning’ can be a medical opinion. It is up to the police to accept this opinion or find it as a case of ‘homicidal drowning’ and investigate any foul play.

Some salient facts on accidental drowning

Drowning is the third most common cause of accidental death. A victim of drowning can be revived by cardiopulmonary resuscitation (CPR) with rescue breathing. Prolonged resuscitation, up to many hours, has been known to revive patients with hypothermia and cardiac arrest.

Antemortem drowning can be identified by the presence of fine, white, leathery, copious froth or foam tinged with blood at the mouth and nostrils (Froth is of lasting nature and large in quantity), cadaveric spasms in hands, diatoms in tissues from brain, liver and bone marrow of long bones, presence of water in stomach and intestines, voluminous water logged lungs along with fine froth in lungs and air passages.

A bathtub drowning is a major cause of death in a bathtub. The bathtub is the most common site of seizure-induced drowning; hence, patients with epilepsy should be advised to take showers instead of baths. Heart attack leading to syncope and subsequent falling in the tub can cause drowning. Besides the causes discussed above, mutations in the cardiac ryanodine receptor (RyR)-2 gene, which is associated with familial polymorphic VT in the absence of structural heart disease or QT prolongation, have been identified in some individuals with unexplained drowning. Concomitant trauma, paralysis, heart attack or hypothermia, which can lead to rapid exhaustion or cardiac arrhythmias are other factors for accidental drowning. Duration of submersion >5 minutes is the most critical factor.

Several studies have reported incidents of bath tub drowning with varying medical histories as follows:

·         A total of 268 victims were found unconscious or dead during tub bathing. After postmortem examination, the manner of death was judged as natural cause in 191 (71.2%) and accidental drowning in 63 (23.5%) cases. Drowning water inhalation, which was confirmed in 72% of victims, was absent in the others. Whereas, inhalational findings were more frequent in victims with other backgrounds such as alcohol intake, mobility disturbance, and history of epilepsy (Am J Forensic Med Pathol. 2013 Jun;34(2):164-8).

·         In a series of 14 cases of suicide by drowning in the bath in the Bristol area, England between 1974 and 1996, six cases had evidence of concomitant alcohol or substance use. Seven cases had a past psychiatric history and a history of previous deliberate self-harm. Most drowned at home, face down, fully clothed (Med Sci Law. 1999 Oct;39(4):349-53).

·         A retrospective review of 92 deaths in the bathtub in Maryland found 71.7% incidence of bathtub drowning; 28.3% were the absence of bathtub drowning. Three leading contributory causes of death were cardiovascular disease, drug/alcohol-related death, and seizure disorder in both groups More than triple overlapped drowning-related signs (history of recovery from the water, foam in the air way, watery fluid in the sphenoid sinuses, hyperinflated lungs and watery fluid in the stomach contents) could be beneficial for the diagnosis of a bathtub drowning. (Forensic Sci Int. 2015 Aug;253:64-70).

·         In a retrospective analysis of 245 bathtub death cases between 1971 and 1988 carried out in the Institute of Legal Medicine in Hamburg, 66 cases proved to be natural deaths, 76 were classified as suicides, 39 as accidents and 13 as homicides, while 51 fatalities remained unclear with respect to one of these groups. About 50% of the victims were alcoholized.  (Arch Kriminol. 1991 Jul-Aug;188(1-2):35-46).

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Sridevi’s untimely death brings to forefront sudden cardiac death in women

Dr KK Aggarwal

Recipient of Padma Shri

    

The tragic and very untimely death of actor Sridevi, a Padma Shri Awardee, brings to forefront the topic of sudden cardiac death (SCD) in women. The passing away of a talented actor reiterates the need to identify women at risk and to manage these risk factors for better outcomes.

SCD is an unexpected death that occurs due to a cardiovascular cause. While those with heart disease are at a greater risk of sudden cardiac arrest leading to sudden cardiac death, it is the asymptomatic person, who appears healthy and has no known heart disease, who is most at risk of sudden cardiac arrest. SCD can be the first manifestation of coronary artery disease (CAD). Lifestyle factors that influence CAD risk might also have an impact on the risk for SCD. Hence, adherence to a low-risk lifestyle is associated with a low risk of SCD (JAMA. 2011 Jul 6;306(1):62-9).

According to a 38-year follow-up from the Framingham Heart study, which examined the incidence of sudden cardiac death in women in comparison to men, women are at lower risk for SCD than men. In women with underlying coronary heart disease (CHD), the risk of SCD is 50% less than in men with CHD. But, in the absence of prior overt CHD, the incidence of SCD is higher in women compared to men; 63% vs 44%, respectively. Among patients with heart failure, the absolute risk in women is only one-third that of men.

Phobic anxiety is associated with an increased risk of SCD in women. Some, but not all, of this risk can be ascribed to CHD risk factors associated with phobic anxiety such as diabetes, hypertension and high serum cholesterol.

Sudden cardiac arrest may not be as sudden as is usually thought. About 50% of victims of sudden cardiac arrest have some tell-tale warning signs that their heart is in danger of stopping in the month preceding their attack, which include any combination of chest pain and pressure, shortness of breath, heart palpitations, and flu-like sensations (such as nausea, back pain and/or abdominal pain). While less than 20% of those who experience symptoms actually reach out for potentially lifesaving emergency medical assistance.

Cardiac arrest is not the same as a heart attack. A cardiac arrest occurs when electrical activity of the heart is disturbed and the heart stops working, while a heart attack is the result of arterial blockage that cuts off blood flow to the heart. Heart attacks can increase the risk of cardiac arrest; however, heart attacks do not lead to sudden cardiac arrest but when sudden cardiac arrest occurs, heart attack is the most common cause.

Sudden cardiac arrest (SCA) and sudden cardiac death (SCD) are same. If an intervention such as CPR or defibrillation, cardioversion restores circulation, it is called sudden cardiac arrest. But if the patient dies, it is referred to as SCD.

Ventricular tachycardia (VT)/ventricular fibrillation (VF) account for most such episodes, while bradycardia or asystole (no heart beat) make up the remaining.

CPR is a life-saving procedure in the event of a sudden cardiac arrest. 

Screening for heart disease

A heart attack in women presents differently compared to men. Women are less likely than men to have typical features of a heart attack. Women have more chances to present with angina than heart attack but when they present with heart attack it is more fatal. Many cases of heart attack in women go unrecognized, particularly at younger ages or in patients with diabetes.

lSix minutes walk test: You do not have significant blockages, if you can walk more than 500 m in six minutes or if you can walk 2 km or climb two flight of stairs.

lNever ignore unexplained weakness, tiredness, first onset chest burning or first onset breathlessness after the age of 40.

lIf any member of your family has had heart disease before the age of 55 years (male) or before 65 years of age (female), this is a strong positive family history.

lIf the SCD of Sridevi is found to be associated with heart blockages, this would be a strong family history for her family for future generations.

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Sridevi passes away: What factors contributed to her tragic death?

 Dr KK Aggarwal

Recipient of Padma Shri

Actress Sridevi passed away at the age of 54 years due to sudden cardiac arrest on Saturday. While her family (actor Sanjay Kapoor) has said that she had no history of heart disease, a Facebook post and Whatspp message is being circulated that blames her untimely death on plastic surgeries and other cosmetic procedures she may have undergone in an effort to ward off signs of aging and look young.

The post, whose authenticity cannot be verified says “Society demanded that she stay slimmer/look younger than a40-year-old and hence, the continuous surgeries. When I met her about 5 years ago, she was beautiful but a sad version of that self that we loved so much in a movie like Chandni. What a lot of pressure to keep her weight down, to make sure that her face had no wrinkle lines....continuous clinic visits in Southern California” (Read more at: https://www.oneindia.com/india/plastic-surgeries-desire-look-young-could-have-led-sridevi-s-death-claims-viral-post/articlecontent-pf31730-2648473.html)

Repeated plastic surgeries per se cannot cause sudden cardiac arrest, however, the associated stress can lead to such an adverse event. The stress of surgery and the recuperation process may result in some degree of depression. A person who is already insecure about their appearance may become severely depressed if the result of the surgery is not what he/she expected to be.

Job dissatisfaction and relational disharmony can be factors in a sudden adverse cardiac event. She ruled the Hindi film industry as the no. one female star in the 80s. She was also an acclaimed actress in the South film industry. Her elder daughter was to make her debut in Hindi films. So, she had something to look forward to.

It is being said that she was on a weight loss diet. A ketogenic diet is a diet which has low carbs, high fats and adequate proteins (1 gm/kg body weight). It is a type of starvation diet (starvation of carbohydrates), which puts the body into a metabolic state called ketosis, wherein the body derives energy from ketone bodies unlike a normal, higher carbohydrate diet, where glucose is the source of energy. And, the extra glucose is converted into fat, which is then stored. A ketogenic diet therefore burns fat rather than carbohydrates, resulting in weight loss.

Cardiac arrest in the setting of diet pill consumption has been reported. The American Journal of Emergency Medicine has published a case describing ventricular tachycardia/fibrillation arrest in an otherwise healthy 48-year-old woman who was taking no medications other than phentermine, a common appetite suppressant. It has been suggested that phentermine, which is a chemical analog of the potent amphetamine class of noradrenergic stimulants, may promote potentially fatal cardiac outcomes (Am J Emerg Med. 2008 Jul;26(6):732.e1-3). Vigorous physical activity also may be a potential trigger of sudden cardiac arrest in some patients (Int J Cardiol. 2009 Jan 24;131(3):345-9).

These factors may not have contributed to her death, as was being circulated on social media earlier.

However, yesterday, quoting the Dubai government's media office feed on Twitter, the PTI reported that “Following the completion of post mortem analysis, Dubai police headquarters stated that the death occurred due to drowning in her hotel apartment's bath tub following loss of consciousness.” The Dubai-based Gulf News said in a report that the actor was under the influence of alcohol. She fell into the bathtub and drowned. It also attached a copy of the UAE government's forensic report on its Twitter handle. The report, citing accidental drowning as the cause of death, has a stamp of the "Ministry of Health UAE" and the director of preventive medicine, Dubai, Dr Sami Wadie.

A normal person would not drown in a bath tub unless he/she is unconscious or is under the influence of alcohol, which was found only in traces.

Perhaps she had a cardiac arrest and she fell down in the bath tub or she became unconscious and fell down in the bath tub, leading to her accidental drowning.

The delay in handing over of the body and the forensic report is not because any foul play is suspected. The normal procedure in UAE takes about 4-5 days. This is usual. 

Voluntary work is incomplete without meaningful engagement and mindful participation

Dr KK Aggarwal

Recipient of Padma Shri

The English dictionary gives the meaning of the word ‘voluntary’ as something “done or undertaken of one's own free will” or something “done willingly and without constraint or expectation of reward”.

A voluntary act forms the foundation of social welfare. Whenever we talk of voluntary work, National Cadet Corps (NCC), National Service Scheme (NSS), Rotarians, Lions are some of the names that immediately come to mind.

The practice of charity or assistance is enshrined in our Indian ethos. In Vedic language, someone who gives is said to be like a devta. But this giving has to be unconditional and loving. The Bhagavad Gita also teaches us selfless giving without motive...“an action that is ordained, done by one undesirous of fruit, devoid of attachment, without love or hate, that is called pure” (Gita XVIII, verse 23).

A volunteer is a giver. Giving is not by force or coerced. A voluntary work is not done at the level of mind or physical body, but is at the level of the soul.

Every voluntary work has two characteristics. The first is meaningful engagement and the other is mindful participation.

Not doing something just for the sake of doing it is called meaningful engagement. Every action should count and not be ‘mere tokenism’. Only then it will make an impact in the life of the person who you are trying to help. Never volunteer only because someone in the family or a friend or a colleague is doing so.

Get involved. Open your eyes of the physical, mind and soul and then decide on the type of volunteer work you should do.

The principles of “Suno Samjho Jaano Karo” come into play here. These principles are the essence of Vedic science. They have also been clearly defined in Bhagavad Gita by Lord Krishna. Hearing is at the level of physical body and mind, listening is at the level of intellect and wisdom is at the level of soul. One should hear, listen, understand and convert it into wisdom. Hearing means that you hear anything but listening means using your intellect to learn its meaning. Understanding means you should understand its value in your context and wisdom means you should practice it, again and again, to learn intricacies of its implications and the knowledge gets switched to your consciousness forever.

Mindfulness participation means involving yourself completely into the activity that you are volunteering for. This may be called yogic doing or meditation through work.

So, when you do voluntary work

·         Own that work

·         Belong to that work

·         Involve every stakeholder (inclusiveness)

Volunteering is not just giving, it is also learning. You learn when you share, you learn from the experiences of others.

Volunteer work is also a corollary of copy ‘left’, which means relinquishing or giving up your copyright on an idea, which you do not want to work on or implement. This allows people to share common ideas of community interest.

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Safety Tips from a senior police officer

Dr KK Aggarwal

Recipient of Padma Shri

I happened to interact with a SHO who came to me for checkup. I gave him preventive health tips and asked him to reciprocate with some tips that we could take to prevent thefts and most importantly be safe.

Here are some safety tips from a senior police officer as part of the Delhi Police Week celebrations held on the occasion of its Raising Day on February 16, 2018.

·         Never throw empty boxes, empty shopping bags etc. in your garbage. The rag pickers would identify that you have done a lot of shopping that day.

·         Jewelry is hard cash. You do not show your hard cash on the roads. Wear jewelry only in functions and not on the roads.

·         Most rag pickers in Delhi are from Bangladesh and are an organized group.

·         Most people in Delhi are educated and intelligent. Think twice before you say: "bechara"

·         Do not travel or drive alone on the roads between 10pm and 6am. 

·         Never stop your car in areas with no habitation or light in the night.

·         Always check the back seat before getting into the car.

·         Vishwasghaat Wahin Hota hai, Jahan Vishwas hota hai.

·         Never indulge in road rage; say sorry and try to defuse the situation.

·         People walking aimlessly in any colony should be regarded with suspicion; they may be on a “recce” identifying places for future crimes.

·         Never keep cash or jewelry in your house.

·         Never take out a single Rs 2000/- note from your pocket, from a bundle of notes. It tells people that you have a habit of carrying cash.

·         Never give someone ready cash on spot at home; always say I will get it from bank and give you next day or so.

·         Always keep one room in the house out of reach of the maid servants.

·         Always keep your door locked even if you are at home.

·         Always know your neighbors.

·         If you are not going to be in town, always inform a trusted neighbor.

·         Do not let a stranger in your home on the pretext of making a phone call.

·         Never keep any expensive items in the car visible to people.

·         Never keep your bags open in public places, especially in temples, cremation places, prayer meetings etc.

·         Thieves may look like normal people, well dressed and speaking fluent English

·         Gold and cash once stolen will get distributed or melted within no time.

·         Do not become friends with unknown people, even if they behave very friendly.

·         Do not accept any prasad from any stranger.

·         Never accept lift from strangers. Never get into a car with a stranger for any reason.

·         Tell your children never to admit to being home alone on the phone or to someone at the door.

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Dr BK Goyal, a doyen of cardiology passes away

Dr KK Aggarwal

Recipient of Padma Shri

Dr BK Goyal, eminent cardiologist of the country passed away on Tuesday following a cardiac arrest at the age of 82 years.

He has been a pioneer in cardiology and his career spanning more than five decades has been richly strewn with numerous awards and laurels, both national and international.

He had a long association with Bombay Hospital as its Honorary Dean and was Chief Cardiologist at the Bombay Hospital Institute of Medical Sciences. He was also the Director-Professor of Cardiology of JJ Group of Hospitals, Grant Medical College and Haffkine Institute, Mumbai. He was appointed Professor Emeritus of Cardiology at the Grant Medical College for life by the Govt. of Maharashtra.

Dr BK Goyal was the only foreign cardiologist (outside the US) chosen as an Honorary Consultant Cardiologist with the world-renowned Texas Heart Institute in Houston.

He was the Sheriff of Mumbai in 1980.

Dr BK Goyal had the rare distinction of being honored with all the three Padma awards, one of the highest civilian awards of the country: the Padma Shri (distinguished service) in 1984, Padma Bhushan (distinguished service of higher order) in 1989 and Padma Vibhushan (for exceptional and distinguished service) in 2005.

His name was in circulation for the post of the Vice President of India in 2007 and also the President of India in 2012.

What an honor it would have been for the medical fraternity if he had indeed become the Head of the State.

He was a father figure for many budding cardiologists and his passing away has left a huge void not only in cardiology, but also in the medical profession as a whole.

Such a distinguished career is deserving of the nation’s highest recognition.

We pay homage to this great man. Our thoughts and prayers are with his family.

May his soul rest in peace…

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA