139 CMAAO CORONA FACTS and MYTH BUSTER Unusual CNS Manifestations

139 CMAAO CORONA FACTS and MYTH BUSTER Unusual CNS Manifestations

Dr K Aggarwal

President CMAAO

961:  Update on Covid-19

IMA-CMAAO Webinar on “Neurological complications in Covid-19 – Part 2”

27th June, 2020

4-5pm

Participants

Dr KK Aggarwal, President CMAAO

Dr RV Asokan, Hony Secretary General IMA

Dr Ramesh K Datta, Hony Finance Secretary IMA

Dr Sanchita Sharma

Faculty

Dr MV Padma Shrivastava

Prof & Head, Dept of Neurology

AIIMS, New Delhi

Key points from the discussion

• Covid-19 is very similar to SARS coronavirus of 2003 as it shares the same ACE2 receptor. The initial clinical manifestations are fever, cough, dyspnea and fatigue. The most important lab parameter is lymphopenia. In severe cases, viral pneumonia may lead to severe acute respiratory syndrome, which may be fatal.
• Diagnosis: rapid antigen test, Nucleic Acid Amplification Test (NAAT), which gives results in 2 hours and RT PCR test (nasopharyngeal swab), which gives results in 8-12 hours.
• ACE2 receptors are present in nervous system and skeletal muscles.
• Coronaviruses go beyond the respiratory tract and may invade the CNS resulting in neurological complications (CNS, PNS and skeletal muscle injury). Although the exact route by which the virus enters the nervous system is not known.
• A missed diagnosis of patient presenting with neurological manifestations increases the chances of spread of infection to HCWs.
• The Covid-19 virus may enter the CNS through the hematogenous or retrograde neuronal route (evident by the symptom of anosmia).
• Patients with severe disease have greater likelihood of developing neurological symptoms compared to patients who have mild or moderate disease.
• It has been shown that intranasal administration of SARS CoV and MERS CoV led to rapid invasion of the virus into the brain, the likely route being through the olfactory bulb via trans-synaptic route.
• Neurological damage that follows invasion of the Covid-19 virus in the CNS is partially responsible for the acute respiratory failure seen in these patients.
• Neurological complications seen include HCoV related meningitis, encephalitis, acute flaccid paralysis, early onset olfactory and gustatory dysfunction and changes in smell and taste perception. Anosmia, hyposmia and dysgeusia have been added in flu screen now.
• The first observational case series from Wuhan was published in April this year in JAMA Neurology, where around 40% of hospitalized patients had some neurological complaints. The CNS manifestations were dizziness, headache, impaired consciousness, stroke, ataxia and seizures were found in patients, while the peripheral nervous system manifestations included aguesia, anosmia, vision impairment, neuropathies, GBS. There were skeletal muscular injury manifestations.
• Red flags in lab parameters, which increase the chances of neurological complications, are lymphopenia, decreased platelet count and high BUN.
• Older Covid-19 patients with risk factors are more at risk of developing new onset cerebrovascular accident during hospitalization (did not present with stroke), which is an important negative prognostic factor. Most of strokes were ischemic stroke (Lancet).
• Older patients and those with diseases like HT, DM, CVD, and malignancy are more susceptible to Covid-19 and are also more likely to develop serious infection.
• Nervous system manifestations, which include acute ischemic stroke, intracerebral hemorrhage, encephalopathy, skeletal muscle injury, seizures are more common in patients with severe infections.
• Patients with severe infection had raised TLC, increased neutrophils, lymphopenia and high CRP; they also had high d-dimer levels (JAMA).
• Lymphopenia is indicative of immunosuppression in hospitalized patients; high d-dimer levels suggest a consumptive coagulopathy.
• Another paper published in last week of March has summarized the spectrum of neurological presentations in Covid-19 patients: Headache, malaise, fatigue, imbalance, anosmia/ageusia, cerebral hemorrhage, acute neuropathies, encephalitis, and seizures.
• Neurological presentations could be a manifestation of hypoxia, metabolic/respiratory acidosis, multiorgan dysfunction and sepsis, and certain medications.
• Inflammation could potentially be related to stroke occurrence (directly/indirectly) or could follow an acute stroke. Atherosclerosis is an inflammatory process; plaque destabilization and rupture may contribute to stroke.
• Covid-19 is also a prothrombotic state as high levels of d-dimer have been observed in these patients.
• Measures of protection for health professionals while managing neurological emergencies like stroke in the time of Covid-19 include PPE (level 2) for all team members, team member role designation, green corridor for stroke; CT scan machines need to be sanitized.
• Contact and droplet precautions: aerosol generating procedures such as oropharyngeal/nasal suctioning, bag valve mask ventilation, intubation, chest compression, NIPPV, nebulization and CPR are minimized; early extubation is not recommended; avoid CPAP, BiPAP and nasal high flow therapy due to the risk of aerosol formation.

All major heart hospitals in Delhi-NCR should take up the Mission Delhi project

On Thursday (25.4.19), the Indian Council of Medical Research (ICMR) has launched ‘Mission DELHI’, an emergency medical service, as part of which a motorbike-borne assistance unit can be quickly summoned for a person suffering heart attack or chest pain.

The pilot project has been launched in a radius of 3 kms around All India Institute of Medical Sciences (AIIMS), New Delhi and would be linked with Centralized Ambulance Trauma Services (CATS).

Under Mission DELHI (Delhi Emergency Life Heart-Attack Initiative), a pair of motorcycle-borne trained paramedic nurses would be the first responders for treating heart attack patients.

On getting a call, the pair would rush to the spot, gather basic information on the patient’s medical history, conduct a quick medical examination, take the ECG, and establish a virtual connect with the cardiologists at AIIMS and deliver expert medical advice and treatment.

While the emergency treatment is being provided, a CATS ambulance will arrive and take the patient for further treatment.

Even as the patient is on way to the hospital, doctors at AIIMS control center will evaluate the data received from the nurses to establish further course of treatment.

The attempt is to reach patients within 10 minutes. In this project, the clot buster will be given very soon even at home.

This project should not just be limited to ICMR and AIIMS.

Every major heart hospital in Delhi-NCR should take up this project and adopt area of 3 km around their hospital. All should be interlinked.

ICMR should provide them with the working model for implementation of the project for wider reach of this much-needed emergency medical assistance.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Budgetary allocation for health in the budget this year: The ups and downs

The total budget for health has been increased this year and is the highest in the last two financial years. With Rs 61,398 crore allocated for 2019-20, this is a 16% increase over the Rs 52,800 crore in the current financial year (2018-19).

As expected, the Ayushman Bharat scheme gets a major share of this.

Rs. 6,400 crore has been set aside for the Ayushman Bharat scheme for 2019-20. Of this, Rs. 250 crores are for setting up Ayushman Bharat Health and Wellness Centres under the National Urban Health Mission and Rs. 1350 crore are for the Health and Wellness Centres under the National Rural Health Mission. 

The allocation for National Health Mission for 2019-20 increased to Rs 31,745 crore.

Some national health programs have benefited.

·         The allocation for the National AIDS and STD Control Programme has been increased by Rs. 575 crore and it now stands at Rs. 2,500 crore vs Rs. 1,925 crore in the last budget. Is this justified? 

·         Allocation for the National Programme for Health Care for the Elderly increased from Rs. 80 crore to Rs. 105 crore. The same should have been more. 

Some national health programs had their budget cut back this year.

·         The National Mental Health Programme budget was reduced to Rs 40 crore this year as opposed to Rs 50 crore last year. What is the reason?

·         The budgetary allocation for the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke was reduced to Rs 175 crore from Rs 295 crore. This should have been doubled.

·         Allocation to the Tobacco Control Programme and Drug Deaddiction Programme was Rs. 65 crores, a decline by Rs. 2 crore.

·         The allocation of immunization or vaccination programme was cut 7% to Rs 6758.46 crore. This also should have been doubled with all vaccines given free to all.

India continues to have the highest burden of both TB and MDR TB patients and accounts for about a quarter of the global TB burden.

A suitable budget should be allocated to eradicate TB from the country. The treatment to all should be made free of cost and be available only through the government.

(Source: NDTV, Economic Times, India Today)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

All deaths should be audited to find preventable causes: Virtual autopsy may provide the answer

The All India Institute of Medical Sciences (AIIMS), New Delhi and ICMR are collaborating on a project to conduct virtual autopsies, as reported in TOI, Jan 20, 2019. The head of the Forensics Department at AIIMS said that they have already set up a digital X-ray machine to conduct autopsy of the deceased with bone injuries or fractures caused after an accident. He further said that in virtual autopsy, the deceased’s records are available in digital format and thus it permits additional analysis by other forensic pathologists on the same body; second or third opinion even after years if some allegations crop up in the future.

The word “autopsy” is Greek in origin. It is derived from “autos” (self) and “opsomei” (I will see), which means “to see with one’s own eyes”.

Virtual autopsy has also been called “virtopsy” by Thali et al (Leg Med (Tokyo). 2007 Mar;9(2):100-4); it originates from the Latin word “virtus”, which means “useful, efficient and good”. They deleted “autos” to eliminate its subjectivity and combined the two terms virtual and autopsy thereby coining the term “virtopsy”.

Virtual autopsy, therefore, is an alternative to traditional autopsy.

It has been called touch-free autopsy (J Forensic Dent Sci. 2017;9(1):42) as it employs imaging methods that are routinely used in day to day practice such as CT (whole body or limited) and magnetic resonance imaging (MRI). CT guided postmortem biopsies can be added for histopathological and genetic correlations. Hence, it can identify details that may have been missed on conventional autopsy.

CT scan is a superior tool to conventional autopsy in identifying entry and exit pattern of wounds (fracture patterns), pathological gas collections and gross tissue injury. Postmortem MRI is highly sensitive, specific, and mainly used for assessing soft tissue injuries, neurological/non-neurological trauma, contusions, and hematomas (J Forensic Dent Sci. 2013;5(2):146-8). A comprehensive analysis of both surface and deep tissue findings may require fusion of CT, MRI and 3D surface data.

All deaths should be self-audited to look for preventable causes. Virtual autopsy can be done in no time; it leaves no scar being non-invasive and can be the answer in finding the cause in unexplained deaths. This is necessary to prevent similar future episodes in the community. It is also the answer for most medicolegal disputes.

Virtual autopsy is an established practice in many western countries such as Switzerland.

The IMA had issued a Virtual Autopsy Draft Statement, when I was the National President, IMA as follows: “IMA is for establishing virtual autopsies at clinical level for non-medicolegal cases (whole body CT, whole body MRI, postmortem angio, molecular autopsy).”

Since the Govt. has started thinking along the lines of virtual autopsy, in every death, the family should be given an option for virtual biopsy with/without mini FNAC/tissue biopsy.  And informed refusal must be noted.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

This is good news: PCR teams to be first doctors on spot in Delhi

PCR vans are usually the first to respond to a road emergency, and now the police control room personnel are set to turn paramedics to manage accident trauma, reported the TOI (Jan.17, 2019). The Delhi PCR vans will now carry cervical collars and fracture braces, among other medical accessories, to provide proper care within the crucial first five minutes of an accident. The van will now also carry ice packs and eye shades to ensure that the victim is in comfort and the pain from the injuries is managed before they are shifted. Additional training will also help the police personnel to judge and deal with the medical condition of the victims.

Doctors from AIIMS and NGOs, who already teach the cops how to provide cardio-pulmonary resuscitations and undertake basic procedures, will instruct them in life-saving measures.

This is good news indeed.

Any delay in treatment in acute emergencies can mean a difference of life and death for the victim. Most acute emergencies will require emergent evaluation and treatment without any delay. The large majority of deaths occurs either at the scene or within the first four hours after the patient reaches a trauma center.

The concept of “golden hour” emphasizes the need for rapid intervention during the first hour of care following major trauma. Prompt medical treatment during the golden hour has the highest likelihood of preventing death.

“Platinum 10 minutes” refers to first ten minutes after trauma and refers to the importance of starting first aid within 10 minutes to reduce the chances of death.

Heart Care Foundation of India (HCFI) is actively engaged in training people from all walks of life, including school children, in the life-saving technique of hands-only CPR (CPR 10).

There is substantial evidence to suggest that CPR is effective in the first 10 minutes of cardiac arrest. After 10 minutes of death, there is practically no chance of recovery unless patient is in hypothermia. So, we created a formula of 10 which is “within 10 minutes of death (earlier the better), at least for the next 10 minutes (longer the better, up to 25 minutes), compress the centre of the chest of the victim with a speed of 10×10 i.e. 100 per minute”.

This way the public can remember the technique of CPR after sudden cardiac death. It is easy to learn and easy to do and one does not need to be a doctor or be certified in this technique to do CPR.

Numerologically also, the CPR equates to number 10. In English alphabets, ‘C’ comes at number ‘3’, ‘P’ comes at number ‘16’ and ‘R’ comes at number ‘18’. If we add the three i.e. C=3, P=16, R=18 (3 + 16 + 18 = 37) and, if we further add the two digits in ‘3 + 7’, the total we get is ‘10’. So, numerologically also, ‘CPR 10’ should be an effective way to remember.

HCFI had also provided training on CPR for 100% PCR vans (over 8000) in Delhi in 2014 along with the Indian Medical Association (IMA) and Delhi Red Cross Society. 

The PCR vans should also be equipped with Automated External Defibrillator (AED) machine and personnel should be trained in the use of the AED. Defibrillation within 3 to 5 min of collapse can result in survival rates as high as 50-70%.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Apology works

AIIMS New Delhi, a premier institute of the country, has tendered an apology to a patient who underwent a wrong procedure.

The written apology was sent to the 30-year-old patient, a resident of Bihar, and her husband was contacted with an offer for additional treatment. Allegedly, an arteriovenous fistula was made in the patient who did not have any kidney-related illness and instead was seeking treatment for pain in abdomen. AV fistula is created surgically in chronic kidney disease patients undergoing dialysis. Documents were allegedly tampered with to cover up the medical negligence.

Primum non nocere i.e. “first (above all) do no harm” is the cardinal principle that guides the ethics of practice of medicine. From it is derived the principle of non maleficence (do no harm) and its natural corollary, the principle of beneficence (do good).

Doctors never harm a patient intentionally. But sometimes, errors do happen even with all precautions.

In the event of any unanticipated adverse incident or outcome that may cause harm to the patient, patients now want answers. They can no longer be pacified with medical jargon; instead, they want to know the facts of the matter and the circumstances leading to it. They also want to know if a medical error could have caused the adverse outcome and want doctors and establishments to apologize to them, if the error was ‘avoidable’.

Non disclosure or ‘hushing up’ of errors increases feelings of anger and blame in the patients and creates distrust between the doctor and patient. And the aftermath is well-familiar to us all – negligence lawsuits against doctors and hospitals or angry relatives and friends ransacking the hospital or assaulting the doctor and other staff.

Apologize to the patient in such situations…an apology works.

While an apology does not undo the damage caused, it can alleviate the resulting feelings of anger and distrust. An apology can be either with admission of guilt or without admission of guilt.

But doctors find it difficult to admit to a mistake. Doctors are apprehensive - quite rightly so, given the absence of apology laws in the country - that apologizing for a mistake can be considered an ‘admission of guilt’ and used as evidence in courts of law.

Some states in the US have apology laws that protect an apology from being admissible as evidence in courts of law in medical negligence cases

While saying sorry for any wrong done is an immediate instinct of human nature, on the other hand, the fear of ensuing litigation prevents doctors from admitting to their mistakes. It is a classic ‘Catch-22’ situation because the outcome may anyway be a medical malpractice claim now or at a later date, when the mistake may be discovered.

Saying “I/We have made a mistake” and acknowledging that mistake with an apology takes lot of courage. But it goes a long way in restoring trust between the doctor and the patient and may defuse a situation that is just ready to explode.

Opinion 8.121 of the American Medical Association (AMA) Code of Medical Ethics says “Physicians must offer professional and compassionate concern toward patients who have been harmed, regardless of whether the harm was caused by a health care error. An expression of concern need not be an admission of responsibility. When patient harm has been caused by an error, physicians should offer a general explanation regarding the nature of the error and the measures being taken to prevent similar occurrences in the future. Such communication is fundamental to the trust that underlies the patient-physician relationship, and may help reduce the risk of liability.”

The Joint Commission standard also says, “Patients and, when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes” (RI. 1.2.2).

Related links

·           Medical Errors: “I am sorry” http://drkkaggarwal.blogspot.in/2017/09/medical-errors-i-am-sorry.html

·           The spiritual prescription: "I am sorry" http://issue.emedinews.in/archive/13_6_14.html

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

Depression among doctors is a growing problem: Genesis of depression

Dr KK Aggarwal

Mail Today recently featured a cover story of how mounting stress level due to work pressure is taking a toll on the mental health of doctors at All India Institute of Medical Sciences (AIIMS), Delhi. Some of them are admitted in the psychiatric ward of the institute and are undergoing treatment, the story further said.

Depression among doctors is a growing problem and it is now increasingly being reported. According to a study published in JAMA (JAMA. 2015;314(22):2373-2383), between 20.9% and 43.2% of trainees screened positive for depression or depressive symptoms during residency.

As per quantum physics matter can be sequentially broken into atoms and then to subatomic particles (protons, electrons and neutrons), photons, quantum and wave. A photon is both a wave and a particle at the same time (wave particle duality). The human body is also a particle and a wave at the same time. In terms of science, this duality exists as a balance between sympathetic and parasympathetic states.

According to the Vedas, thoughts arise from our consciousness. Thoughts lead to action. Every action leads to a memory, which in turn leads to a desire. A cycle of action, memory and desire is subsequently set into motion. Fulfilled desires result in actions to realize that desire again or fulfil a new desire. Repeated fulfilment of desires leads to habits, addictions and behavior. Unfulfilled desires lead to anger, which can be expressive anger or suppressive anger.

Expressive anger (anger-out), or uncontrolled outbursts of anger, becomes evident as aggressive behavior and/or violence. Suppressive anger (anger-in), can be acute or chronic. Acute suppressed anger can manifest as acute heart attack, acute asthmatic or anxiety attack. While, chronic suppressed anger may lead to depression in due course of time.

Non fulfilment of desires, expectations and aspiration over a period of time therefore is the main cause of depression.

The desires are need-based. Human behaviour is governed by needs, which can be at the level of physical body, mind, intellect, ego or the soul. These needs result in desires, expectations and aspirations.

These can be in the form of respect, recognition and prestige, once the basic physical needs of food, clothing etc. are satisfied.

The feeling of discontent may also be a result of humiliation from seniors/faculty, exam pattern, hurt ego (by patients and/or their families), the daily trauma of dealing with sickness/death, long gruelling shifts, sleep deprivation, social isolation topped with the perennial sword of litigation.

As a way to deal with this stress, some are pushed to self-destructive habits and addictions (alcohol and substance abuse) and some may even resort to the ultimate step of taking one’s own life.

Become a doctor demands lot of self-sacrifice. The extreme stress tests one’s fortitude and perseverance every day.

Overworked and exhausted doctors are bound to mistakes as happened in the case of Dr Bawa-Garba, NHS in UK. She was convicted of manslaughter by gross negligence following the death of a 6-year-old boy with Down syndrome. Her name was erased from the medical register following an appeal from the GMC. Missing the diagnosis of sepsis and thus delaying initiating antibiotic treatment was one among several charges of negligence levelled against her. The charge of manslaughter against their colleague will also adversely affect the morale of other doctors.

Depression therefore is an outcome of the chronic suppression of emotions or need-based desires or their non-fulfilment, particularly for those who have high expectations or high aspirations.