Postmortem: 48 lakh fine for giving high oxygen to premature baby

Dr KK Aggarwal

Rajasthan state consumer forum on Friday imposed a fine of Rs 48 lakh on a private hospital situated at Kothputli town on the outskirts of Jaipur, for its negligence that led to an infant turning blind. 

Case

Nikita was admitted to Sanjivani Hospital situated at Kothputli on August 30, 2014, when she was told that the infant was underweight.

She was given 30% oxygen.

The infant developed ROP (retinopathy of prematurity)

Allegation: 30% oxygen was too much and caused ROP

Normal O2 should be 21%

Award: 45 lakh compensation

Discussion

Is it negligence, error of judgment or difference of opinion?

What is ROP?

·         ROP is a developmental vascular proliferative disorder that occurs in the retina of preterm infants with incomplete retinal vascularization.

·         It is an important cause of severe visual impairment in childhood.

·         ROP develops in 21% of patients and severe ROP in 5% in infants < 32 weeks gestation. No infant born at >28 weeks GA required surgical intervention.

·         The incidence of ROP in preterm infants (BW <1251 g) is 68%.

·         The incidence of ROP is 8%, 19% and 43% among infants born at ≥32 weeks, >27 to 31 weeks, and ≤27 weeks gestation, respectively

Risk factors

The most important risk factor for developing ROP is prematurity. However, more than 50 separate risk factors have been identified.

·         Low birth weight, low gestational age, assisted ventilation for longer than one week, surfactant therapy, high blood transfusion volume, cumulative illness severity, low caloric intake, hyperglycemia, and insulin therapy, have been independently associated with higher rates of ROP

·         Other possible risk factors include sepsis, fluctuations in blood gas measurements, intraventricular hemorrhage, bronchopulmonary dysplasia, systemic fungal infection, and early administration of erythropoietin for the treatment of anemia of prematurity.

·         Poor longitudinal weight gain

·         Elevated arterial oxygen tension is also thought to contribute. However, ROP is not the only consideration in determining the optimal target oxygen level in preterm infants. Excessive reduction of target oxygenation saturation has been associated with increased mortality.

·         Infection may worsen the course of ROP.

Breast milk feeding appears to play a protective role in preventing ROP.

Infants with trisomy 21 appear to be at a lower risk for ROP compared with other infants

The optimal SpO2 for preterm infants who receive supplemental oxygen therapy has not been fully established. Based on the available evidence, the most prudent target range for SpO2 in preterm infants is between 90 and 95%. This range minimizes both the low and high extreme oxygenation levels that have been associated with adverse outcomes and mortality.

Oxygen to a newborn is not decided by % of oxygen but by the SPO2 levels

·         Based on the available evidence the current recommendation is a target oxygen range from 90-95% resulting in minimizing extreme oxygenation levels for all preterm infants

·         This target range appears to be safe for preterm infants ≥28 weeks gestation.

·         In the most mature preterm infants (gestational age >34 weeks), the risk of ROP decreases and the upper limit can be increased to 97%.

·         There is also a paucity of data regarding oxygen target ranges as the preterm infant advances in age. However, by 2-3 weeks postnatal age, the risk of intermittent hypoxia increases, which may aggravate ROP by enhancing retinal proliferation. As a result, with advancing age one should typically raise target saturation to >95% if the infant still needs supplemental oxygen when the corrected PMA is >32 weeks.

·         Targeted SpO2 levels of infants with congenital heart disease, BPD, or pulmonary hypertension are individualized based upon the clinical status of the neonate due to the paucity of data regarding optimal oxygenation for these disorders. 

Opinion

At the most it can be difference of opinion. It does not appear to be negligence unless oxygen was given without measuring SPO2 levels.  

What can be done?

·         Challenge in the higher consumer forum

·         Defence: Give opinion of experts and published literature

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

Revisiting dengue: Look for rise in hematocrit and not just falling platelets

Whenever dengue strikes, platelet counts along with shortage of platelets become the high point of discussion and panic sets in. Because it is presumed that platelet transfusion is the main treatment option for dengue. This is not so.

Platelet transfusions are not needed unless the platelet counts are less than 10,000 or there is active bleeding and thickening of blood.

Dengue causes low platelet count, but low platelet count by itself is never dangerous because patients with heart disease, diabetes are prescribed antiplatelets like aspirin, where they have a beneficial effect in preventing thrombotic complications. They are asked to report if they develop bleeding while on antiplatelets. Patients with idiopathic thrombocytopenic purpura (ITP) always have a low platelet count and they live a normal life on medication.

It’s not the platelet count alone with determines the prognosis of a patient of dengue.

More than the falling platelet count, it is the rapidity of fall in platelet count that is important. Even this does not alone is indicative of severity of illness.

Dengue not only causes low platelet count or destroys platelets, it also causes endothelial damage. Capillary leakage manifests as hemoconcentration and leads to increase in hematocrit and/or MCV and this is important. This is a medical emergency because a rising hematocrit means intravascular dehydration, which leads to multiorgan failure, hypotension and death.

Therefore, it is the rise in hematocrit along with rapid fall in platelets, which is the danger sign and is indicative of impending severe dengue.

Here is a simple Formula of 20 to identify high risk patients 

·         Rise in pulse by 20

·         Fall in upper blood pressure by more than 20

·         Rise in hematocrit by more than 20%

·         Rapid fall in platelets to less than 20,000

·         More than 20 hemorrhagic spots on the arm in one inch after tourniquet test

·         Difference between upper and lower BP is less than 20

Start fluid replacement at 20 ml/kg/hour immediately in such patients, and shift to nearest medical center for observation. 

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

Immediate Past National President IMA

Harm Reduction 2 : “Less harmful alternatives to tobacco”

Continuing our series on Harm reduction, we present the views of Jeannie Cameron, Founder and MD JCIC International, a UK-based strategic advocacy consultancy specializing in tobacco harm reduction. She also attended the seminar on “Harm Reduction” organized on 27th September at IIC, New Delhi.

When I spoke to her about tobacco harm reduction and e-cigarettes, this is what she had to say.

“There is a product called Swedish snus, which is like pasteurized smokeless tobacco product that you put in the mouth. Sweden has this product historically for 300 years. In Sweden, which is very good at its medical health and epidemiology, they have studied this for more than 50 years, and found zero or nil deaths from tobacco snus product.  Norway, next door in Scandinavia, also has started to use this product and also found zero deaths from it. When you compare that with a country like India which has significant use of oral and smokeless (tobacco) and you have huge deaths – 30-40% of tobacco related deaths are coming from that.

In Sweden, they were so wanting to ensure that they didn’t want to lose this product that when they joined the European Union (EU) in the 1970s, they have a special derogation in the law under the treaty to join EU to protect their use of this product. That’s how important it was for Sweden at the time. And the evidence everyone who is anywhere in the world, anyone would tell that it is less harmful than smoking.

I am not an expert on e-cigarettes so much because  when I did my legal dissertation at the time in 2007 on harm reduction and tobacco harm reduction, e-cigarettes were not even available. They were not really discovered then. So this information has come later.

The Royal College of Physicians and all the research that is coming in now – independent research, some research is coming from tobacco companies, but they put it out for independent scrutiny – it is all showing and the RCP saying that it is up to 95% less harmful than smoking.  

There are three products available now, which are less harmful than smoking.

One is Swedish snus, which is significant in Sweden. The other one is e-cigarettes; UK has now the fastest fall in smokers since they have been available because the UK allows them freely.

And, vaping is taking off all over the world as smokers find it’s a good replacement.

The third is the heated tobacco, which is launched in Japan only two years ago. It’s already something like 27% of Japanese smoking market. Japanese are known to be big smokers and they have switched over to using heated tobacco. Japan does not allow e-cigarettes, but they allow heated tobacco.

The way to think about is both these products are vaping because they are not producing smoke, whether it is a heated tobacco or whether it is an e-cigarette. They are producing vapor and vapor is not causing any harm to the lung like smoke is.

And as we know, it’s the nicotine they want … they smoke for nicotine, but they die from the smoke.

If we can provide people with something that is helpful to them in terms of their health, but still gives them the nicotine that they want, then that’s a much better thing. In India, that could make a huge difference.

All the time, there are new developments being made on nicotine, and nicotine is now being used to help cases of Parkinson’s, Alzheimer’s ... I think in the future there will be lot of emerging research, which will show that.  

But, I think, one of the big concerns also is the tax side and of the growers and economies which are dependent on tobacco should see it as potentially for future business opportunity in some respects because it is transitioning people. They don’t need to be afraid of it and in some parts of the world, where there are big growing places like Brazil or Indonesia and maybe a bit in India, they should see it as an opportunity.”

Mahatma Gandhi was hypertensive: What could have been the cause of his hypertension?

 Being of lean physique, it would appear that Mahatma Gandhi would be a fit person. The iconic image of the Mahatma leading the Dandi March, where he seems to be striding ahead of the others, certainly gives an impression of a person who is physically fit.

But the health records, released to commemorate his 150th birth anniversary indicate otherwise. Gandhi ji had hypertension and was reportedly on medication (sarpagandha or Rauwolfia serpentina).

We have his ECG tracing done at Calcutta  (now Kolkata) dated 28^th Oct., 1937. The record show that his heart rate was 72 per minute and was regular. On 26^th October, he had very early and slight fullness of neck veins, which were not present on 28^th Oct. His BP reading on 26^th Oct. was 194/130; on 28^th Oct. the BP was 150/98. He was prescribed adequate rest by the doctor “Adequate mental and emotional rest with 8 hours restful sleep in 24 hours are indicated” as the records show.

Let’s try to analyse his health status based on this information.

Mahatma Gandhi had hypertension and his ECG shows no left ventricular hypertrophy. There were only a few anti-hypertensive medications available then. Also, echocardiography was not available at that time.

Lifestyle factors, in particular obesity, are determinants of BP levels. Excess of body fat is a major factor predisposing to hypertension. Excess body fat, especially central obesity, is associated with metabolic syndrome and type 2 diabetes. This is ruled out.

Arteriosclerosis is ruled out as his diastolic BP was very high. In arteriosclerosis, the systolic BP is raised more than diastolic BP.

His BP on 26^th Oct. was 194/130; on 28^th Oct. it was 150/98. This is accelerated HT.

Gandhi ji lived by the principles of satya, ahimsa, sarvodaya and satyagraha. Yet he was hypertensive.

He had been advised adequate rest with adequate sleep by the doctor.

Could the stress of the country’s freedom struggle have been a factor in the genesis of his hypertension?

We can only speculate.

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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

Immediate Past National President IMA

Welcome to the Silver Jubilee celebrations of the Perfect Health Mela

This year, we are celebrating 25 years of the MTNL Perfect Health Mela, scheduled to be held from 23th October to 27th October 2018 at the Talkatora Indoor Stadium, New Delhi. The theme for the Mela this year is “Affordable Healthcare”.

This year, the Mela promises to be bigger, better and more exciting for everyone as we have introduced many new features such as the ‘Evening Conclaves’, ‘Mini Melas’ and ‘HCFI CSR Awards’.

The Evening Conclaves are thematic conclaves, which will bring together experts from various fields for panel discussion on relevant issues such as antimicrobial resistance, IVF, Indoor pollution. The panel discussions will be followed by entertainment programs like a comedy night, concert night, qawwali and others.

Mini Melas are melas within the main Mela with five different themes each day of the Mela such as Math Mela, Art Mela, female adolescent health.

The HCFI CSR Awards, under various categories, will honor the best CSR initiatives by organizations and individuals that have revolutionized the way healthcare and other social initiatives are delivered.

The Mela will also undertake campaigns on two issues – “Indoor air pollution” and “Make in India” - to raise awareness on the fact that indoor air pollution can affect health as much as outdoor pollution; and to realize the goal of affordable healthcare through the Make in India for Cure in India movement.

We often talk of pollution outside our homes. Indoor air pollution often goes unnoticed and can be a major health hazard even in urban areas. However, indoor air pollution is an equally urgent issue that needs attention because a major part of our life is spent indoors in homes, schools, colleges, offices etc.

Make in India is imperative for Cure in India and it must be promoted to ensure that no one lacks access to timely treatment. This covers medical devices as well. The aim is to achieve the overall goal of affordable health care for all by making all critical and lifesaving medical devices available and accessible at affordable prices.

The Mela will showcase its usual activities across categories such as free health check-ups, entertainment programs, lifestyle exhibitions, lectures, workshops, CPR training, inter-school competitions (Harmony and EcoFest), a unique competition for specially-abled children (Anmol),  inter-college competitions (National Youth Fest) among others.

Entry to the Mela is free for all.

Join us as we celebrate the silver jubilee celebrations of the Perfect Health Mela.

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

Immediate Past National President IMA

Follow the four principles of Gandhian philosophy

The 150th birth anniversary of Mahatma Gandhi starts today and gives us an opportunity to recall the four fundamental principles that Mahatma Gandhi taught: Truth (satya), non-violence (ahimsa), welfare of all (sarvodaya) and peaceful protest (satyagraha). These principles can hold people together and hence form the backbone of dharma, which means “to hold together”.

Satya means oneness in your thoughts, speech and actions. Gandhi believed that “there is no religion higher than truth”. The Yoga-shastras as well as the Yoga Sutras of Patanjali propagate truthfulness as one of the main components for living a disciplined life.

Gandhi preached the concept of “experimenting with truth”, a phrase that also formed the subtitle to his autobiography. He taught how to learn through trial and error, often admitting to mistakes and changing one’s behavior accordingly. Non observance of truthfulness is the root cause of any corruption in the society.

Ahimsa teaches us the path of non violence. It should be practiced not only in actions but also in thoughts and speech. Ahimsa also forms the basis of Jainism and Hinduism as a religion.

The third principle is sarvodaya or welfare for all. The basic fundamental teaching of the Vedic science is also based on sarvodaya. It talks about “bahujan hitay-bahujan sukhay” - “the good of the masses, the benefit of the masses”. Gandhi found in it a composite concept of social welfare and economic justice. Any action, which is aimed and seems to be aimed at the welfare of the people will be accepted by all.

Satyagraha is protest based on satya (path of truthfulness) and non violence and includes peaceful demonstrations, prolonged fasts etc. i.e. a non violence-based civil resistance. It is based on the law of persistence. Satyagraha is formed by two Sanskrit words satya (truth) and agraha (holding firmly to or firmness). Gandhi said “Satyagraha is a weapon of the strong; it admits of no violence under any circumstance whatsoever; and it ever insists upon truth”. He said that if you are firm in the truth in the long run you are going to win.

These are basic principles that doctors should also follow as doctors not only need to be scientifically and legally correct, they also should be morally and ethically correct. Non-maleficence (do no harm) and beneficence (do good) are the pillars of medical ethics

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

Immediate Past National President IMA

Aim at achieving a parasympathetic state of mind

Every adversity is an opportunity to learn and therefore giving up is not the answer. 

A new research from the University of Portsmouth in the UK has found that people can die simply because they've given up, life has even beaten them, and they feel defeat is inescapable to them. The study is the first to describe the clinical markers for 'give-up-itis', a term used to describe what is known medically as psychogenic death. It usually follows a trauma from which a person thinks there is no escape, making death seem like the only rational outcome.

Although not akin to depression, the act of giving up on life and dying usually within days is a very real condition often linked to severe trauma. There are five stages leading to progressive psychological decline. Research indicates that give-up-itis could stem from a change in a frontal-subcortical circuit of the brain governing how a person maintains goal-directed behaviour.

The five stages of ‘give-up-itis’ are social withdrawal, apathy, aboulia (severe lack of motivation psychic akinesia (profound apathy) and psychogenic death.

Giving up is not the answer. Youngsters today are prone to get dejected by the smallest of sufferings. It is important to be self-motivated.

According to Hinduism, the very fact we are born means that in our last life, we did not get liberation or Moksha. It also means that some sufferings in our last birth remained. Therefore, the purpose of this birth is to face those sufferings. When the purpose of our life is to face sufferings, why suffer from them? They should be considered as ‘sukh’ and not ‘dukh’. As per Vedic literature, every adversity is an opportunity to learn or to do something different.”

The four notable principles of Buddhism also talk about the same. The first is that suffering exists, second that there is a reason for every suffering and third that it is possible to neutralize the suffering by understanding the 8 paths of cessation of suffering.

Remember that in every ‘dukh’ you think of ‘sukh’ and in every ‘sukh’ you think of a ‘dukh’. Positive thinking produces nearly a 30% drop in perception of pain. Next time you have a problem, think differently and learn to enjoy them. One should learn to disassociate from, both, external pain as well as pleasure, and only then can one acquire true internal happiness.”

Just as photon is the smallest unit of light and quantum is the smallest unit of energy, Qualia is the smallest unit of thought. Quantum teleportation is the transportation of quantum information via the phenomenon of entanglement. At the level of quantum, consciousness is the extreme parasympathetic state of mind or Samadhi. Those engaging in activities such as music and dance are able to achieve a parasympathetic state of mind.

The 25th Perfect Health Mela 2018 will explore some of these concepts during the cultural conclaves and programmes.

Celebrating its silver jubilee this year, the Mela will be held from 23rd to 27th October at the Talkatora Indoor Stadium, New Delhi.

The Board of Governors taking over was inevitable

The Niti Aayog had always wanted to change the structure of MCI for long. However, it was getting postponed either by pressure from the medical community including IMA or by the opposition political parties.

The NMC Bill had been put before the Parliament twice but had not been passed. It may not get passed in the winter session too. After that it will be National election time.

The bureaucracy is very adamant in making this change. The term of the MCI was getting over on 5th November. If the govt. had started the MCI re-election period, this would mean being elected for five years.

The Supreme Court had already consented to an overarching control of a 5-member committee.

So, the best way for the government was to not continue with the MCI beyond 5th November and run it with a 5-7 member Board of Governors as the Congress had done in the past with the same members who had been running it for the last one year with additional two members.

Most of these members nominated to the Board of Governors have proven integrity. Dr Sanjay Shrivastava, who has been appointed the Secretary General has a wide experience of the MCI.

The whole procedure has been advanced by one month with an idea that by the time the next parliament sits, they will have had enough time to adjust. The government is hoping to get the NMC Bill passed in November. If not, continue with the Board of Governors for the next one year.

Till the NMC comes, the present infrastructure and staff of MCI continues.

MCI Take-over: Malafide and Scheming (Team IMA 2018)

In an emergency session in Mumbai, the IMA Action Committee condemned the supersession of the Medical Council of India (MCI).

This action of the Government, at a juncture when the election to MCI has been announced, is unwarranted and malafide. The composition of the Board of Governors (BOG) itself is unacceptable. Directors of major National institutions would scarcely find time to administer more than 450 medical colleges and their UG and PG courses. Moreover, there is no representation to women and Registered Medical Practitioners.         

                                     

The Indian Medical Association (IMA) is convinced that supersession of MCI is only a smoke screen and ploy to prepare the ground for NMC and sabotage the democratic process of MCI. Why the Government was in a hurry to scuttle a democratic process needs an answer.     

                                        

 IMA’s concerns remain. Bringing MCI directly under the government control seems to be the plan to implementation of Bridge Courses, crosspathy and registration of non medical persons.

IMA demands that the BOG should refrain from taking any major policy decisions or amendments changing the character of the IMC Act.

IMA also demands that the election process in progress in MCI should be allowed to continue.   

    

IMA will continue its resistance to NMC Bill. Any intentions of the NMC Bill implemented through the appointed BOG will be fought with determination. 

• This is the fourth time that BOG is being appointed. All the previous attempts were an abject failure. 
• The eminent clinicians appointed have little exposure to the day-to-day administration of MCI. 
• The Government has not cited any reason for superseding MCI.                     
• MCI Election process is on.  It was inappropriate for the Government to supersede at this stage. This betrays a malafide intention. 
• BOG should conform to the basic tenets of IMC Act and refrain from tinkering with its fundamental structure. 
• Crosspathy, registration of non medical persons, bridge courses and mixing of syllabi are core concerns. The fidelity, identity and the privileges of the profession will be defended at any cost.       
• 184 private medical colleges are awaiting recognition due to strict norms of the outgoing MCI team.  IMA, media and the people should keep vigil in this regard.
• IMA foresees a highly difficult period ahead when checks and balances have been removed.
• A generation of substandard doctors will be the legacy of this action.
• IMA will keep its tryst with destiny and redeem the profession from dark forces. Every single challenge thrown at the profession will be repulsed with single minded. 

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

Immediate Past National President IMA