World COPD day Checkup camp today

Today is World COPD day. Jindal Clinics is organizing a medical camp on its premises. Patients are being offered free spirometry and breath carbon monoxide testing

Free Camps

Jindal Clinics is proud to announce its participation in two health camps. The first one was held by the Joshi foundation in Sec 15, Chandigarh and involved the checkup of over 2000 patients. The participants were honored by Mrs. Kiron Kher, member of parliament from Chandigarh  and the Home Secretary of Chandigarh, Mr. Anil Kumar.

The other camp was held in the town of Dhuri on 16-11-14, where over 125 patients were examined free of cost by Dr. Aditya Jindal.

What is bronchoscopy?

The lungs are host to many diseases, like tuberculosis, cancer, pneumonia, asthma, etc. In order to treat them properly, specialized diagnostic tests are required – bronchoscopy is one such test. It involves the insertion of a flexible endoscope or bronchoscope through either the mouth or the nose into the lungs and the respiratory system. The bronchoscope is connected to a camera and monitor to visualize the interior of the lungs. One can see various abnormalities like cancer growths, bleeding spots, foreign bodies, etc. Additionally, the bronchoscope is hollow – like a pipe – through which special instruments can be passed in order to take pieces (called biopsies) from abnormal areas seen inside. These pieces or biopsies are then studied under the microscope for proper and accurate diagnosis of various diseases.

Various types and sizes of bronchoscopes are available for all ages and diseases. One of the new type is called an Endo bronchial ultrasound bronchoscope or an EBUS scope. The EBUS scope has an ultrasound transducer built-in into the tip of the scope – which is the end that goes into the lungs. With the help of the ultrasound the internal structures can be accurately imaged and all biopsies taken directly under guidance of the ultrasound. This increases the safety, accuracy and yield of the procedure.

The diseases which usually need bronchoscopy for diagnosis include lung cancer, sarcoidosis, some types of tuberculosis, interstitial lung disease (lung shrinkage), etc. Another important use is the removal of foreign bodies especially in children.

Miracle drug for Ebola - ctd...

Miracle drug for Ebola - ctd...

In a follow up to the previous post ( see Miracle drug for Ebola) one of the American researchers has been declared cured of Ebola. It remains to be seen whether the cure was spontaneous or due to the administered drug.

Liberia to receive Zmapp drug to treat Ebola virus

In a new development, Liberia is likely to try out an experimental drug 'ZMAPP' for the current Ebola outbreak without the requisite human trials.  Read the previous post for more information.

Link for current post: Liberia to receive Zmapp drug to treat Ebola virus

Miracle drug for EBOLA

Two health care professionals suffering from EBOLA virus infection were miraculously saved by an experimental drug. Importantly, the drug, known as 'ZMapp' , had only been tested in animals till now! Talk about miracles.

You can read the whole story here:  http://edition.cnn.com/2014/08/04/health/experimental-ebola-serum/

"Lung dialysis"

Some things are beyond belief, though clearly plausible - as the following example illustrates.

     A male patient in the US suffering from cystic fibrosis underwent a double lung transplant followed by failure. He was posted for re-transplant but was told that his carbon dioxide levels were too high. However, his physician, who was a well read man and in contact with the bioengineering world decided to go in for something out of the ordinary. A sort of a mini ECMO machine had been developed a few years earlier, for removing carbon dioxide from the lung. Known as the Hemolung RAS, it functions by removing carbon dioxide from and adding oxygen to blood just like a dialysis machine. As it was not approved by the FDA, emergency approval was taken within 24 hrs and the patient put on the machine. Lo and behold, he improved, the carbon dioxide levels reduced to acceptable limits and he was taken up for retransplant!

Some salient points:

1. Cystic fibrosis is a sort of death sentence in general practice in India with only symptomatic treatment available
2. This patient underwent double lung transplant not once but twice
3. Emergency approval applied for and recieved within 24 hours!! (Seems like some sort of dream)
4. As the machine was not available in the US, the doctors incharge personally acquired it from across the border i.e. Canada
5. The patient remained for 20 days on the machine
6. The machine was not recommended for use by any professional society

Lessons:

1. Out of the box thinking is the key
2. Be uptodate in one's field
3. Persistence and perseverance are essential

The full article can be read here: http://medicalxpress.com/news/2014-07-patient-implanted-hemolung-lifesaving-lung.html

Thanks to Dr.Ajay Handa for updating me on this.

More than meets the eye

More than meets the eye

'There is more to this than meets the eye.' I used to think that this was just a turn of phrase; however, after joining a medical career it became a living truth for me. A recent example will suffice.

A 54 year old lady, presented to me last week, with a history of long standing asthma for the last 18 years. It was poorly controlled and managed, with her requiring frequent nebulization therapy and repeated short courses of oral steroids. She appeared to be chronically malnourished and indeed, on examination, her BMI was 17 kg/sq m. One often forgets, in this modern era of inhaled bronchodilators, what asthma can do to a person. She was a small reminder that we are only one step above the previous generation in the treatment of this disease. Although much research is going on, except for the reliable beta agonists and corticosteroids, the other medicines available are insufficient to control asthma on their own.

Coming back to the case; after taking the history and examining her - to repeat myself again - I thought "There is more to this than meets the eye" and ordered further workup. Lo and behold, she came a week later with an X-ray full of alveolar and interstitial opacities. Our patient was accompanied by her brother, who was an X-ray technician. Now, there is a tendency in our part of the world to attribute almost all X-ray abnormalities to tuberculosis, and more so in medical and para-medical staff. Even worse, this gentleman was a veteran radiographer, with over 15 years experience. I had a hard time convincing him of further workup; throughout  the consultation he kept looking at me out of the corner of his eye!

Anyway, they came after a few days with an HRCT of the chest and serological investigations. I was pleased to see that my hunch was right and she was finally diagnosed to have ABPA or Allergic broncho-pulmonary aspergillosis, which is much prevalent in this area. Her brother was all smiles!!

The 'TB' X-ray

Typical mucus plugging

Extensive bronchiectasis and centrilobular nodules

ABPA or allergic bronchopulmonary mycosis (ABPM) is an allergic reaction to colonization of the airways by fungal elements, most commonly Aspergillus species ( hence, commonly ABPA rather than ABPM!) It affects a substantial portion of asthmatics, especially those suffering from severe or difficult to control asthma. The diagnostic criteria are still evolving; also there is no clarity on whom to screen for the disease. The pointers in this case were:

1. Difficult to control disease
2. Severe disease
3. X-ray abnormalities 

However, the clinching point was the phrase - 'There is more to this than meets the eye!'

End of Life Care: The Hindu Viewpoint

The traditional Hindus believe in the continuity of life after death.  There is a great degree of sanctity attached to the pre-death worship, performance of last rites and to the rituals both before and after the death.  It is strongly believed that the type and mode of death is an important determinant of the peace for the immortal soul ever thereafter.  An easy and peaceful death is crucial to attain ‘nirvana’ or ‘mukti’ i.e. liberation from the sufferings and miseries of the life and the death cycle.

The terminal care therefore essentially focuses to achieve the ‘best possible’ quality of life without interfering with the attempt to prolong the life.  There is supreme importance of ‘care beyond cure’ and to ‘dying with dignity’.  Factually, the Hindu concept of life is centred around respiration and the length of life is measured by the ‘limited’ number of breaths which are fixed.  Many a life-prolonging treatments especially the artificial continuation of breathing with the help of ventilators are therefore in direct conflict with the traditional viewpoint.  This, I believe is applicable only for artificial continuation of life in an otherwise death (e.g. the brain-dead) individual than for assisted respiratory support as a mode for treatment.

Palliative treatment in Hinduism is quite in conformity with the existing concept of terminal care which involves the ‘care beyond cure’ philosophy.  One aims to prevent, relieve or soothe the symptoms of disease without affecting a cure.  The pre-terminal (and terminal) are designed to offer symptomatic relief from the pain and suffering of approaching death.  It is not a substitute or an alternative to curative treatment, but only an acceptance of the inevitability and of the limitations of life-prolonging treatments.

Rituals and Rites

                Both the individual and the family are generally concerned with the last wish acts, and rituals near the death.  Death in the bed is analogous to death of the sick which must be avoided.  A dying individual is preferably moved to the floor – not for cardiac massage but to lie in the lays of mother-earth.  Verses from the holy books such as the Gita or the Vedas should be sung and the water from the sacred rivers, especially the Ganges should be made available.  The dying does like to bless the children as much as hey like to be blessed.  There is no better death for a Hindu senior than to die with everyone of the progeny around.

                After-death handling of the body is both sacred and ceremonial.  It must be properly cleaned and bathed.  Nice and preferably new clothes, sometimes including the jewellary are worn before consigning the body to the flames.

Bereavement

                Generally speaking, the degree of emotional attachment and inter-dependence is high in Hindu families.  A sudden, or even a slow exit of a member of the family is mourned and remembered for long.  The period required for resolution of grief is longer. It is possibly for this very reason that a number of sacred acts are undertaken afterwards.  For example, the body remains and ashes are collected on the 3^rd day or so and immersed in a sacred river.  Several other functions are undertaken in the next two weeks and on fixed intervals in the following year. 

References

1. Banerji SC.  Indian Society in the Mahabharata.  Varanasi: Bharata Manisha, 1976.
2. Basham AL.  Aspects of Ancient Indian Culture.  New York: Asia Publishing House, 1970.
3. Crawford SC (eds).  Hindu Bioethics for the twenty – first century.  State University of New York Press, New York 2003.
4. Humphry D (eds).  The Practicalities of Self-Deliverance and Assisted Suicide for the Dying.  Time Books International, New Delhi 1991.
5. Crawford SC (eds).  Dilemmas of Life and Death.  State University of New York Press, Albany 1995.

_____________________________________________

Dr Surinder K. Jindal, MD, FCCP, FAMS, FNCCP

(Ex-Professor & Head, Department of Pulmonary Medicine

Postgrad Instt of Med Edu & Res, Chandigarh, India)

Medical Director, Jindal Clinics, SCO 21, Dakshin Marg, Sector 20 D,

Near Guru Ravi Das Bhawan, Chandigarh, India 160020.

Email: dr.skjindal@gmail.com

Website: jindalchest.com

Ph.  Clincis: +91 172 4911000,  Res.  +91 172 2712030/ 31

Withdrawal of Life Supports?

Life Prolonging Treatment : The Right to Refuse?

(Legal and Ethical considerations)

            In medical parlance, a life prolonging treatment refers to all treatments which have the potential to postpone the death of patients suffering from incurable and terminal illnesses.  These conditions may include advanced cancers, failures of organs such as the lungs, heart, kidneys, liver or others and progressive, end stage neurological illnesses.  Advancements in modern technology have made it possible to sustain lives of such patients for several days, weeks or sometimes years with treatments involving cardiopulmonary resuscitation, artificial respiration, cancer chemotherapy, dialysis, artificial nutrition, hydration and other multiple drugs. 

The subject has raised a whole lot of new questions and dilemmas in not only the medical and legal  circles but among the general public all over the world.  Media has often extensively covered and discussed such examples.  Legal and medical literature is replete with opinions and judgments on such questions and cases involving legal interventions.  Most such examples have emanated from the West, although there have been a few instances in India.  With a rapid expansion of techno-medical scenario promising almost moon to every individual, the demands of people to live long have also increased. But the costs are tremendous and there are wider gaps in availability of resources, expertise and manpower, infrastructure, awareness and knowledge in providing life prolonged treatment.  This has posed a huge burden on the shoulders of medical practitioners, health professionals and policy makers. 

Even more basic than all other considerations is the core issue of medical judgement and its legal sanctity to provide life prolonging treatment.  It is a curious turn of events that medical practitioners tend to look to law for each of their action.  No citizen, much more so a medical doctor can afford to ignore law.  But medical judgements cannot always be surrogated to legal justifications especially since the law is other silent or ambiguous on most of the issues related to prolongation of life.

I give below two real case examples for you all to consider:

      

            

                The legal considerations as well as the medical opinions guiding the judgements and actions of doctors are yet in an evolving phase in this country on the issue under discussion.  It is therefore, worthwhile to look into examples available elsewhere.  Most of the Western medical associations have come up with more clear guidelines to help doctors to decide action.  The British Medical Association has laid quite comprehensive recommendations on several issues with respect to decision making on ‘withholding’ or ‘withdrawing’ life prolonging treatment.  Needless to say that the guidelines can only act as an aid in the process of decision-making rather than form a protocol of action.  A doctor is essentially guided in his action by the primary goal of medicine i.e. to benefit the patient by restoring or maintaining the patient’s health.

                One of the most contentious subject is related to the decision of patients to refuse a life prolonging treatment.  The law generally gives the right to an individual to decide and choose an option.  One is however faced with two different scenarios i.e. in case of a dying patient who may have the capacity to make and communicate decision vis a vis a patient who does not have this capacity (for example because of altered or impaired consciousness).  In other words, a patient may be either competent or may have lost the competence to decide.  Our discussion here refers to only the adults since babies, children and several other groups may not legally possess this competence at all.

                Legally speaking, an adult has the full competence to make decisions unless there are doubts on grounds of mental incapability or misconception of reality.  In a famous trial in U.K. (reg. MB (Medical Treatment), in 1997), the Court has rejected the decision of a patient since he believed that his blood was poisoned because it was red.  The mere observation that individual’s decision appears irrational or unjustified to others cannot be taken as evidence of lack of mental capacity.  But doubts may arise if the decision is contrary to the previously expressed wishes. 

                The right to refuse treatment is firmly established in British Law.  This had been reasserted in other cases including St. George’s Health Care, National Health Service Trust vs S (etc.).  Interestingly, the right of refusal was upheld even in a psychotic patient who held erroneous views on several matters but was considered as correct with respect to refuse amputation of his gangrenous foot.  In the United States too, the Supreme Court in the Cruzan case as well as several other cases had cleared expressed the principle that an individual has the constitutional right to refuse treatment even if this may result in his/her death.  This right has been reiterated in several other judgements even where the patients did not have life threatening illnesses.

                Another important issue which has emerged in terminal care is the concept of ‘advanced directives’.  Several sick patient like to leave written (or even verbal) directives expressing their wishes and desires regarding resuscitation and terminal care.  A ‘Do Not Resuscitate (DNR)’ directive by a terminally ill patient is not an uncommon practice in Western medicine. 

                Most ‘advanced directives’ have got legal sanctions and several judgements of the courts are available on the issue.  In U.S.A., the courts and legislatures have recognized this  legal tool of “advance care planning”.  Following the patient self-determination Act (1990), the hospitals are required to inform patients of their right to refuse medical treatment and to make advance directives.  These directives can be considered at par with the expressed desires of people for example the will regarding inheritance of their properties, wishes to donate eyes and body organs after death, or the method of their funerals and last rites. 

The real dilemma is for the doctor looking after a patient who has left a DNR or ‘refusal to get treatment’ order.  The competence of such an advance directive is always challengeable.  On the other hand, providing treatment against the expressed wishes of a patient may also land the doctor in trouble.  The Medical Associations would therefore, recommend that wherever genuine doubts exist about the validity of an advance refusal, the doctor should act in favour of giving at least emergency treatment and buy more time to decide in consultation with the family and the colleagues.

                Undoubtedly, the debate on the issue and the dilemma faced by the caring doctors are bound to continue.  No final protocol can be made for the doctors to act.  They need to follow the existing cultural and medical practices of the land.  Nonetheless, more individuals are likely to assert their rights in refusing life prolonging treatments.  The core philosophy in terminal care remains – Exit with Dignity.

Resource References

1. British Medical Association.  Withholding and withdrawing life-prolonging medical treatment. London, BMJ Books 1999.
2. Emanuel LL, von Gunten CF, Ferris FD.  The Education for Physicians on End-of-Life Care Curriculum, EPEC Project.  The Robert Wood Johnson Foundation, 1999.
3. British Medical Association and the Law Society.  Assessment of Mental Capacity: Guidance for Doctors and Lawyers. London: BMA, 1995.
4. Cassel CK, Foley KM.  Principles for care of patients at the end of life: an emerging consensus among the specialities of medicine. New York Milbank Memorial Fund, 1999.
5. Meisel A.  The right to die, 2^nd ed. New York: John Wiley and Sons, 1995.

_____________________________________________

Dr Surinder K. Jindal, MD, FCCP, FAMS, FNCCP

(Ex-Professor & Head, Department of Pulmonary Medicine

Postgrad Instt of Med Edu & Res, Chandigarh, India)

Medical Director, Jindal Clinics, SCO 21, Dakshin Marg, Sector 20 D,

Near Guru Ravi Das Bhawan, Chandigarh, India 160020.

Email: dr.skjindal@gmail.com

Website: jindalchest.com

Ph.  Clincis: +91 172 4911000,  Res.  +91 172 2712030/ 31