Saturday, December 09, 2006

The cruelty of a profession

Everybody makes mistakes. Its part of life. And all mistakes have a cost. Some mistakes cost nothing like making a spelling mistake while blogging - you press a button and the mistake is gone. Others are more costly - like forgetting your wallet somewhere. And some mistakes may make you broke like making a tactical error in business. A mistake may be costly but not in terms of money like losing a child in a busy mall.

But the most unforgiving of mistakes are the ones we as medical professionals make. A mistake on the part of a medical man usually translates into direct damage to the patient. And yet thats all that they are ....mistakes ....which anyone can make.

As a doctor gains in experience, the less mistakes he makes. So when you look for an experienced doctor, its not because he'll do a better job but its because he's less likely to make a mistake.
Some of the common mistakes we as medical practitioners are guilty of are

  1. Wrong dosages of drugs - Unfortunately things can get ugly sometimes if a doc makes a mistake, especially if he is dealing with a child.
  2. A wrong diagnosis - To say that medicine is vast is an understatement. It is very possible for a doctor to miss a diagnoses no matter how well read or bright he is. And when diagnoses are missed, patients suffer.
  3. An improperly done surgery - This is a technical aspect. Just as a musician or a soccer player gets better with practice so does a surgeon. Most surgeries have a learning curve. Some learning curves are steep meaning one has to do that surgery many times before he can perfect it. So if he is going to be good only after 100 surgeries, what about the 99 he didn't do too well ? In those 99 he has made mistakes and many of those patients have suffered. Can anyone avoid that ? not really. There is no other way to make an experienced surgeon.
  4. A surgery done when none was needed - This happens when a surgeon is aggressive and inexperienced. In his early days, after a few successful surgeries a surgeon thinks he is invincible. He can cure anyone with his knife. He is God. Experience eventually humbles him. He realizes that many patients are better left alone. This is also kind of a learning curve. Sometimes a surgeon would do an unindicated surgery purely for monetary gains. That is vicious and cannot be forgiven.
  5. Fatigue mistakes - These are a huge number of mistakes a doctor is likely to make when he is tired. And believe me doctors get tired. If you knew the kind of hours a doctor puts in you would be shocked. And if he is a resident doctor I'd be shocked if he didn't make a mistake. What would happen if a truck driver fell asleep while driving? Now replace that driver with a doctor ....
  6. Forgetfulness - just a simple act of forgetting something can land a doctor into so much trouble. Forgetting to remove a tourniquet, forgetting a mop inside the wound .... all perfectly plausible mistakes which can be made by anyone and yet unforgivable results.
  7. Carelessness - a doctor omits to do a vital step as he was in a hurry to reach the party. Sounds so horrible. Rid him of his degree and put him behind bars. But aren't we all careless every now and then?
When a doctor does make a mistake are usual reaction is that of anger. How could someone give him a degree? He is so incompetent ! I will take him to court. Of course some mistakes are not forgiven by the courts so I won't stop you from going. But If you think about it with a cool head, you will realize that everything went wrong because of a mistake. A mistake that anyone could have made. No doctor is out there to harm you. It does a doctor no good to harm a patient. His reputation goes for a toss. Hell it doesn't even make economic sense to harm a patient. But still complications happen all the time......the reason - a simple mistake.

Monday, December 04, 2006

A scary phase in total knee arthroplasty

Total knee arthroplasty(TKA) has revolutionized the care of patients with knee pain. This is one surgery that has given excellent results and has proved to be a boon for the arthritic knee.

Even so, TKA has its problems -

  • By nature a prosthesis has a fixed life. One day it is going to fail. Just as a new car becomes old and starts breaking down, similarly a TKA prosthesis will give way in time. Much of the current research is concentrating on improving the life of the artificial joint.

  • The second problem is that of reproducing the normal knee movements. The normal knee is a complicated joint with sliding, gliding and rotation occurring between the two surfaces as the knee bends. It is difficult for an artificial joint to mimic these movements. Hence an artificial joint is unable to flex (bend) as much. Knee bending is important especially in India for cultural and social reasons. Driven by this patient demand, there is much pressure to make designs which allow more bending (high flexion).

There are many new advances being made in this field. Many of these are truly beneficial, others still to be proved and a few of them are quite useless. Lets review some of these.

  1. Unicondylar knee arthroplasty - Here only one compartment of the joint is replaced (usually the medial). The proposed advantages are that the minimal damage is done to the knee, the other 2 compartments are preserved, no ligaments are cut, surgery can be done in a minimally invasive way, revision to a total knee at a later date is easy. The good news is that the results of the unicondylar knee have come in and many centres are showing over 90% survival for 15 years. The bad news is that only a few patients qualify for this surgery (approx 7% of total patients needing surgery for knee arthritis). This surgery has disastrous results in improperly selected patients (beware of the over enthusiastic surgeon). Another thing the surgeon will not tell you is that a high tibial osteotomy, which is a simpler and cheaper procedure, works just as well. Further revision to a total knee has been cited by many authors to be difficult, disproving an earlier claim.

  2. Minimally invasive surgery (MIS) - There is a lot of interest and media hype about minimally invasive surgery. Unicondylar knees are usually done the MIS way. TKA is also being done with MIS with or without the help of computer navigation. MIS basically means to do the same surgery through a smaller incision with lesser trauma to tissues. Well this concept sounds very appealing, doesn't it ? MIS surgery does allow faster rehabilitation, but the results are the same at the end of 3 - 4 months. Further, because access is not as good as the routine incision, some surgeons have reported errors in making the bone cuts and therefore in the position of the final implants. MIS is not as big an advance as it is being promoted. The advantage gained is not worth it if it is at the cost of implant alignment. I feel a properly aligned routine TKA would work just as well.

  3. Computer assisted surgery (CAS) - Does computer navigation improve TKA results? The only thing that has been proved, is that it improves coronal alignment. Whether this translates into better longevity of the joint is still to be proved. CAS is as good as the operating surgeon. The surgeon needs to feed the computer information about the patients body parameters. He does this by placing probes at fixed points which transmit information to the computer via infra red rays (referencing). Using this information the computer creates a virtual model of the patient's knee. Over here lies the problem. There are a lot of errors in referencing. If wrong information is fed to the computer, wrong information is going to come out. Garbage in is garbage out. And yes, let me make it clear, the computer is not doing the surgery. To summarise, CAS is here to stay and will be indispensable in the future, but today it is of doubtful benefit in routine cases. However it is very useful in complicated cases, like those with deformities.

  4. High Flex Knee - This is one of the new knees that have come into the market. As the name suggests it promises a greater degree of bending of the knee by virtue of its design. But post operative knee flexion depends on many things such as the preop range of motion, the type of arthritis, the weight of the patient etc. Some patients will get flexion and some will not, no matter what implant. So all that this implant does is give those patients who were anyways destined to get good flexion, some more flexion. Even this is doubtful as many reports have come in that the results are the same, high flex or no high flex. Besides there is a real concern that this design may actually accelerate prosthesis damage by increasing stresses.

  5. The rotating platform Knee - This is another attempt to reproduce normal knee movements. By virtue of its design this knee allows some rotation that usually takes place in the normal knee. The proposed advantages are more knee bending and less prosthesis ware and a longer prosthesis life. Unfortunately most reports of long term follow up show no difference in either knee function or prosthesis life.

To conclude there are many attractive & new things happening in knee arthroplasty. A lot of people out there are trying to sell you something new claiming it to be better. But new is not always better. The routine TKA is still the gold standard and it has been proved time and over. This is a very scary phase in TKA surgery and I warn the patient/consumer to do their homework thoroughly before deciding to go ahead with a new and fashionable surgery.

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Friday, December 01, 2006

World AIDS Day........Mumbai Doctors Walkathon

Ranbaxy organised a Mumbai doctors walkathon on 1st december '06. The walkathon took off from Nariman point at 7:30 am. The doctors turned up in a huge number. Here are some pics of the event.

Bakhtiyar & Tanaz were there.....

So was A.N. Roy.......

The walkathon kicks off !

The docs on the road. Wonder why it was not a marathon ? Are mumbai docs in no shape to run ?? Anyways it was good effort for AIDS awareness. Great going Mumbai docs !

Thursday, November 30, 2006

osteoporosis ..... beyond calcium.

The North American menopause society has published new guidelines for the management of post menopausal osteoporosis.

There is much more to management of osteoporosis than calcium and vitamin D. Osteoporosis is a major health problem and some working knowledge about it is essential.

Do you need to get tested for osteoporosis ? I have answered that question in my previous post.

First lets enumerate the non pharmacological methods

  • A balanced diet with adequate calcium and vit D intake.
  • Adequate exercise.
  • Smoking cessation.
  • Avoidance of excessive alcohol intake.
  • Fall prevention.
Drug treatment of osteoporosis is recommended for all postmenopausal women
  • who have had an osteoporotic vertebral fracture.
  • who have bone mineral density values consistent with osteoporosis (ie, T-score worse than or equal to -2.5).
  • who have a T-score from -2.0 to -2.5 plus at least one of the following risk factors for fracture: thinness, history of fragility fracture (other than skull, facial bone, ankle, finger, and toe) since menopause, and history of hip fracture in a parent.
The first line drugs for treating post menopausal osteoporosis are the bisphosphonates. These drugs act by decreasing osteoclast activity. Osteoclasts are the cells that absorb or remove bone. Thus these drugs decrease bone turnover and help maintain bone mass.

The effectiveness of these drugs to reduce fracture rates have been well documented.
They have been shown to increase BMD by 6%-8% at the spine and by 3%-6% at the hip over a three-year period. Both vertebral and nonvertebral fractures were reduced by approximately 50% over this period of treatment. The bisphosphonates commonly used are alendronate, etidronate and residronate.

The most important precaution is to take the drug on an empty stomach. This is because food interferes with its absorption. One should not eat anything for half an hour after taking the drug.

The second important precaution is to take the drug with a glass full of water. The drug is known to cause esophageal irritation so a glass of water is necessary to wash down the drug.

A good advantage is that many of these drugs can be taken only once or twice a week. Alendronate for instance can be taken once a week as a single tablet of 70mg.

One serious complication that has been reported is that of jaw necrosis. There was approximately a 7% incidence in cancer patients treated with bisphosphonates for 3 to 4 years. However the incidence in patients treated with osteoporosis is very low.

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Wednesday, November 29, 2006

Street Children

India is making huge economic progress, but my country still has a long way to go ......
The issue that pains me most is the state of homeless children. SKCV - India ( Street Kids Community Villages) is doing its bit.

Mark Helyar writes ...."SKCV (Street Kids’ Community Villages) is a project for homeless young people in Vijayawada, Southern India. Founded in 1984 by Manihara, a family friend, it is home to over 150 boys, girls and young adults who would otherwise be living rough on the streets.

There are about 19,000 street and working kids in Vijayawada and over 100 million throughout India. Invariably they are children who have run away from broken homes, abuse and family conflict. Some are abandoned or forcibly thrown out whilst other are attracted to city life by the glamor and appeal of mass media, magazines and movies."

Some hard facts by SKCV are
  • There are more than 100 million street and working children in India.
  • They are eking out a grim existence in India's towns and cities.
  • Children as young as six have to resort to car washing, begging, carrying luggage, fetching tea or working in small industries to support themselves ... and sometimes their families.
  • More than 20% of India’s Gross National Product is produced by children.
  • Girls as young as eight are forced into prostitution in order to survive.

the typical life of a homeless in India is

  • He is around 12 years old from a large family in a disadvantaged, rural area. None of the adults in his family has a job and he is the butt of constant abuse and neglect that finally drives him away from home.
  • He drops out of school and works in small cafes or picks rags for sale or begs to support himself, earning a meager 10 to 75 pence a day. With nowhere safe to keep his earnings, they are often stolen along with the few possessions he may own. Yet in spite of the harsh, often brutal conditions on the street, he finds them preferable to life in an institution.
  • Because he has no regular medical attention or nutritious food, he is constantly sick and weak. He sees his family rarely, but would love to return home it life were different for him there.
  • He is the victim of abuse on the streets, both from the general public who scorn him and the police. In his despair, he turns to drugs or glue sniffing and his health deteriorates rapidly. He is at risk from HIV and Aids, yet does not fully understand the dangers.
  • He harbors a deep mistrust of adults and craves love, security and happiness.
SKCV is doing some really good work. I recommend them for your donations.

Monday, November 27, 2006

Feedback on 'Physical fitness is free...for smart people'

This is some of the feedback I got on - Physical fitness is free...for smart people.

Mark Says

Exercise isn't totally free.

If you're going to run, you have to buy a good pair of running shoes, and if you want to take up cycling, I recommend you buy a good bike.

Don't skimp on those items. If you do, you'll regret it in the end, and won't get the benefit you expect.

But you're right about one thing, all it takes is time, and no matter what you may choose to believe, there is plenty of time available. But even more importantly, you have to stay motivated, and setting a goal will help with that.

During my 25 years as a competitive cyclist (at the local level), I have found there is nothing easier to accomplish, then to invent an excuse not to train. It may seem difficult to overcome at times, but I know from experience, that I'll regret it even more afterwards, if I give in to the temptation.

Vreni Gurd says

Resistance training outside a gym

Cardiovascular exercise is easy to do outside a gym setting and is far more pleasurable. Resistance training is a bit tougher because it takes some know-how and imagination, but there is a lot one can do with very little. Body-weight exercises like squats, lunges, push-ups, pull-ups work well, and if a small investment is made into a Swiss Ball (about $50) a whole world of resistance and stretch exercises become possible. Tubing is also very inexpensive and is a good way to add resistance exercise to a workout.

To progress, do more repetitions, do the exercise more slowly and with impeccable control, or make the exercise less stable. This won't give you a bodybuilder's physique, but it will tone you up, and get you in decent shape. And if the resistance routine is set up well, it can be a great cardiovascular workout too! To get the know-how (the power is in the details!), there are good books on the subject, but it may actually be worth hiring a personal trainer or conditioning specialist for an hour to ensure that the exercises are done correctly. Small investment compared to a gym membership.

But Orthindia and Marc are right. The commitment is about time, not money! And it sure is easy to find an excuse not to exercise!

I spend hours in a gym everyday helping others improve their health through exercise and find it tough to motivate myself to stay after the work-day is over to train myself. So, like Marc suggested, I've set a goal. Next October, I'm hiking the Grand Canyon, so I better be able to handle a 50lb pack on my back for 6-8 hours a day hiking both down and up a fairly steep slope. Much of my training for this trip will be outside in the BC mountains, which will be far more pleasurable than being stuck in a gym! I can't wait!

Vreni Gurd

Health and Vitality Coach

Saturday, November 25, 2006

Why should I quit smoking ?

If you are not convinced about quiting smoking, read on
  1. It increases the risk of lung cancer. The risk of dying from lung cancer is 22times higher in men and 12 times higher in women.
  2. It increases the risk of cancers of the lip, oral cavity, larynx, pharynx, esophagus, pancreas, urinary bladder, cervix and kidney.
  3. It increases the risk of developing coronary heart disease by 2 to 4 times.
  4. It doubles the risk of getting a stroke.
  5. It accelerates atherosclerosis. The risk of developing peripheral vascular disease is increased by 10 times.
  6. It increases the risk of chronic obstructive lung disease. The risk of dying is increased by ten times.
  7. It increases the risk of infertility in women.
  8. In pregnancy, it increases the risk of low birth weight, preterm delivery, still birth, placenta praevia, placental abruption, childhood meningitis and sudden infant death syndrome (SIDS).
  9. It increases the risk of osteoporosis and of subsequently suffering a hip fracture.
  10. It is a strong asthma trigger.
  11. Smokers who fracture may take longer to heal than nonsmokers and may experience more complications during the healing process.
  12. It increases the risk of cataract.
  13. It is a risk factor for age related macular degeneration (in the eyes).
  14. It accelerates diabetic retinopathy.
  15. It damages the optic nerve (tobacco-alcohol amblyopia).
  16. In patients with HIV, smoking makes it more difficult to fight of serious infections, worsens liver problems and worsens HIV medicine complications.
  17. Smokers have lower sperm counts. The sperms have poor motility and show abnormalities in shape and function.
  18. It increases the risk of exercise related injuries.
  19. It has a detrimental effect on athletic performance.
  20. It is associated with low back pain and rheumatoid arthritis.
  21. Smokers have disturbed sleep patterns.
  22. It is a risk factor for emphysema & chronic bronchitis.
  23. It reduces alertness and reflex speed.
  24. Asbestos workers who smoke have 90 times the risk of dying compared to non smokers and non asbestos workers.
  25. It is a risk factor for gastro-esophageal reflux disease (GERD).
  26. Smokers are more likely to develop a peptic ulcer. An ulcer in a smoker will take longer to heal or may not heal at all.
  27. It damages the liver.
  28. It increases the risk of developing Crohn's disease.
  29. It increases the risk of developing gall stones especially in women.
  30. It accelerates the normal aging process of the skin and contributes to wrinkles.
  31. Smokers are more than twice as likely as nonsmokers to develop dementia of any kind and Alzheimer's disease.
  32. It lessens life expectancy by an average of 15 years.
  33. Women who smoke have an increased risk for death from ruptured abdominal aortic aneurysm.
  34. Women smokers have an early menopause and experience more menopausal symptoms.
  35. It increases the risk of depression.
  36. Smokers are more likely to develop priodontitis or gum disease and yellow teeth.
  37. Smoking is a risk factor for acute myeloid leukemia.
  38. Complication rates after surgery are higher in smokers.
  39. It increases your chances of being hospitalized by up to 60%.
  40. Smoking causes bad breath.

Maharashtra Medical Council Notice



[Under Section 23 (a)]

No. MMC / REN / 2006 / 422: - Notice is hereby given to all Registered Medical Practitioners / Graduates, whose names are borne in the Medical register as on 31-12-2004 maintained under the Maharashtra Medical Council Act, 1965 (other that those, who are registered provisionally) that they have to submit an application in the accompanying prescribed form to the undersigned, for the continuance of their names on the register (i.e. renewal of registration ) as provided in Section 23 (a) of the Maharashtra Medical Council Act,1965 and Amendment Act, 2003.

The application form should be accompanied with......

Read the full notice here.

Petition by Dr. Adhiraj Joglekar

India ranks 127 amongst 177 countries with regards to the Human Development Index. India spends just over 1% of it's total GDP on Health. This is equal to Rupees 160 (just over 3 Euro's) per head per anum. India's low health spending means India ranks an abysmal 171 out of 175 according to 2004 UNDP report.

Union health secretary J V R Prasad Rao explains what this skewed funding pattern means for India’s people: “With the funding so low, we can either fund doctors or get medicines or provide support services. We cannot take care of all this.”

80% of the population lives in rural areas, but 80% of health provision is urban. Over 85% of health provision is through private enterprise.

To make matters worse - immoral and unethical practices are a norm within the health sector. Unfortunately for a private medical practioner, earning a decent living (comparable to otherprofessionals from IT / MBA sector) is impossible without being a part of such corruption. The latter includes giving kick-backs to referring colleagues. Often this leads to quick & dirty ways of earning money i.e. 'sham' or 'unwanted' procedures. The other option is to consider working in public hospitals where you could get paid just as much as in a call-centre. In contrast salaries of those working in BPOs / software industry are 2-3 times higher.

The Medical Council of India currently functions only as a registration body. Once registered the MCI has no idea about the whereabouts of a doctor. Further it has no teeth and is unable to curb curruption and unethical practices including those carried out by quacks.
We, the undersigned, agree and request the Health Minister of India to implement the following:

1) The Indian Health Expenditure should increase several fold in the coming years. Mr Chidambaram raised it by 22% in 2006, but we.....

To read more and sign, see the petition

Friday, November 24, 2006

Physical fitness is free...for smart people

At some point all of us have had the temptation to join a gym. A friend tells you about a cool gym he has joined or you read an add in the papers. The gym has impressive stuff like sophisticated machines, training programs, weight loss guarantees, etc. You have not been exercising of late, so the idea of getting into shape appeals to you.

So you decide and go and get yourself enrolled. They offer you a program for a year, convincing you that it is the best deal and will save you a lot of money. You think to yourself - 'If I enroll for a year, it will be an incentive to keep going because I've paid so much money! Besides this is such a good bargain!' The deal is struck and your money is gone.

And you start going to the gym. Initially the enthusiasm is high. You are enjoying yourself and you don't skip a day. A month goes by. The daily routine is getting tougher, the exercise sessions longer and boring. The pinch you felt in your pocket is becoming a distant memory. You skip a day. You start getting distracted, and now you are going alternate days.
2 months pass by, you haven't been to the gym in a week. You make yourself go the next day.
A year has passed by. You have forgotten about the gym. So many people get themselves into this situation everyday, month and year.

Yes there are people who go the whole year and for many years after that. I congratulate them on their commitment. This post is not for them. It is also not for those committed to body building. This is for people like me - the lazy who dream that someday they will get into shape. And believe me, we are in the majority.
My message is simple. Don't waste your hard earned money on a gym. Hey! wait a minute. I'm not telling you not to exercise. Hear me out.

Physical fitness is not an investment of money. It is an investment of time. No gym, however cool, is going to get you into shape if you are not there! So the real question is not 'Can I afford this gym?' but 'Can I take out the time to exercise?' Just paying lots of money is no incentive to keep you going. You have to be committed to taking out the time. So many people try to buy health with their cash and fail. The benefits of investing cash are obvious to them, yet they fail to invest time for health. Go to a gym, heck go to an expensive one if you can afford it, but understand that you will have to invest time. That really, is the bottom line.

If you can take out the time, physical fitness is free, literally. Simply because there are so many ways to exercise. Go jogging on the road. Go bicycling. Go swimming. Do aerobics at home in front of your T.V. All these will get you in shape. Yes an equipped gym with a good training program may work better, but only marginally. A gym is just an option not a prerequisite. The prerequisite is time. I spend Rs. 2 and 45 minutes everyday to jog in a beautiful jogging park.

So don't sign up to an expensive gym, end up not going and waste your money. Instead realize that it is time you have to invest, invest it in exercise, get fit and save your money!

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Thursday, November 23, 2006

what is wrong with team India?

All out for less than 1oo runs against South Africa? India lose by a whooping 157 runs !!! Whats wrong with the team ? They lost to West Indies and Australia, failing to qualify for the semi finals of the just concluded ICICI tournament.

What happened to all the new talent & enthusiasm ? A few months back team India looked very promising but now they are back to their usual incompetent selves.

Boo Boo, team India !!!!!

Wednesday, November 22, 2006

Prosthetic disc replacement it for you ?

There is a lot of talk nowadays about prosthetic disc replacement (PDR) for low back pain. Should all patients with back pain get their discs replaced ? Is it the new ultimate therapy for back pain ?

PDR is another wonderful advance in the treatment of low back pain. Here the patient's diseased disc is replaced by a prosthetic one, much like a total knee replacement. Chronic low back pain is a big and difficult problem, frustrating for both, the doctor and the patient. In this depressing scenario, the results of PDR look promising. Unfortunately only a few patients would qualify for disc replacement. This is because there are multiple causes for low back pain. Pain could arise from the discs, the facet joints, the ligamentum flavum, etc. Obviously a disc replacement is useless for pain arising from facet arthropathy.

What, then are the indications for disc replacement ?
Disc replacement is advocated in ...
  1. Patients with severe & disabling pain with degenerative disc disease who have failed at least 6 months of non operative treatment. (anti-inflammatory and analgesic medication, physiotherapy, injections, acupuncture, bed-rest, back school training) with
  2. Objective evidence of disc disease in the form of x rays and MRI with
  3. A positive provocative discography as confirmation (preferable)
  4. In patients between 18 to 60 years of age.
Disc replacement is not for ...
  1. Patients with facet arthropathy.
  2. Patients with osteoporosis.
  3. Patients with spinal deformities and instabilities (spondylolisthesis, post op instability)
  4. Patients with morbid obesity.
  5. Patients with disc bulges that significantly compress the spinal cord & nerve roots causing leg pain and weakness.
  6. Patients with infection.
  7. Patients with failed back syndrome and epidural fibrosis.
As is obvious, PDR is useful for a limited population of patients. In fact only 5% of of patients qualifying for lumbar spine surgery meet the criteria for disc replacement.

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Tuesday, November 21, 2006

Suffering from Rheumatoid Arthritis ? .....are you getting a raw deal ?

The sad news is that rheumatologists are still treating RA sub optimally. If this is the scenario with rheumatologists (experts), imagine what orthopaedic surgeons and G.P.'s must be doing ?
Rheumatoid arthritis is a chronic debilitating condition that causes an inflammation of multiple joints. It is an autoimmune disorder, i.e. the body's immune system attacks the joints.

Today RA can be treated effectively and successfully. By current standards patients should have high expectation from treatments and most patients should be doing well. But, in India this is far from true. Literature reveals shocking information. The so called experts are just not delivering the goods.

So, is your rheumatologist doing the right things ? lets find out ...
I've listed ten things any decent rheumatologist should be implementing in his practice.
  1. DAS28 - the disease activity score using 28 joint counts. This score is used to objectively monitor disease activity. It has been extensively validated. At each clinical assessment the doctor fills out a DAS28 form. A DAS28 less than 3.2 means low disease activity, and a score of less than 2.6 means that the patient is in remission. Remission is the goal of treatment. At each visit a scoring is done and if it is high, a positive measure is taken in the form of adding/changing a drug or increasing dosages. With objective assessments remission is achieved faster.
  2. VAS - visual analogue scale. This is part of the DAS28 scoring system. It is used to more accurately measure pain. Attributing adjectives like mild, moderate or severe to a patients pain is not good enough. The patient marks a point on a 100mm line, depending on the severity of his pain. 0 - no pain, 100 - very severe pain. The measurement in millimetres from 0 is the VAS score.
  3. HAQ - health assessment questionnaire. It is another useful way to assess disease activity.
  4. TICORA - tight control of RA improves outcomes. Tight control means a visit to the rheumatologist every month. A DAS28 score is taken at every visit. All with scores greater than 2.4 should have an escalation of drug therapy.
  5. DMARDS - disease modifying anti rheumatoid drugs. Anti inflammatory drugs alone are not effective in RA. DMARD's are drugs that have been found to revert the disease process and induce remissions. Problems include slow onset of action and significant side effects. Methotrexate is the commonest DMARD used. DMARD's are usually used in combinations.
  6. Intra articular steroid shots - This is a very effective treatment modality. It is used as an adjunct to DMARD's to improve DAS28 scores.
  7. Leflunamide - trade name ARAVA. It is a newer addition in the DMARD list. It is a promising new drug.
  8. Biological agents - These drugs are the new happening thing in RA. RA is an auto immune disorder. The immune system causes an inflammation of the joint with the help of pro inflammatory molecules. The biological agents inhibit these pro inflammatory molecules, thus decreasing inflammation in RA. Eternacept and infliximab are the 2 agents available in India. The results of these drugs are very promising. On the downside they are very expensive. As they inhibit the immune system, some serious infections have occurred in patients taking these drugs. But with due care the risk is low.
  9. Exercise - As an adjunct to medicines, the importance of exercise cannot be ignored. Exercises improve outcomes, restore function and add a feel good factor.
  10. Surgery - Last but not the least is surgery. Timely surgery in RA, can help maintain function and relieve pain.
So if your suffering from RA, you can do something about it. If your rheumatologist has no clue about DAS 28, ditch him. But before you go, do the poor guy a favour and teach it to him.

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Sunday, November 19, 2006

Cut Practisitis - an epidemic among indian docs

This epidemic is spreading fast, gripping hundreds of new docs everyday. In this disorder, a simple thank you does not suffice. There is a need to show gratitude with an envelope filled with cash.

A specialist affected with this ailment, will give/receive a cut from the following people -
  1. The GP's cut - First he will go hunting around for every general practitioner he can find. He will beg them to send him patients. When the GP does send him one, He will pay him a cut of up to 40% of his fees. If he falters, no more patients for him.

  2. The Pharmacist's cut - He will convince the patient to buy medicines from a particular pharmacy. He will praise that pharmacy so much, the poor patient will think that all other drug stores are selling water and sugar tablets in the name of medicine. In return he will get a fat cut.
  3. The Radiologists cut - 'can I get this sonography done at another place ?' just try and ask him that question. He will look at you as though you have just murdered someone. Of course the real reason is a fat cut.
  4. The Pathologist's cut - Don't get the investigations, he has asked for, done at another lab (other than the one specified by him). In all probability he will throw the reports out of the window and ask you to get them repeated. Any guesses why ?

  5. The Peon's cut - As soon as he enters the hospital, he will start shelling out cash to the peon, watchman, lift man, ward boy & anybody else he can find. Why ? so that when the right patient walks in, he is immediately sent to him.
These are just a few basic cuts. There are many more, with newer ones coming up all the time.
Ironically, this is a much sought after disorder. Everyone wants it. This is because it offers protection from another disorder, a disorder called poverty !

Friday, November 17, 2006

Casino Royale

I know, I know ......this blog is for orthopaedic help. But I love the movies, so I'm going to be a little flexible here.

Casino Royale starts of on a dull note, but then the movie gets interesting. The story line is pretty typical, Bond style. Yet it is fast enough so you are not bored. The action scenes are edge of the seat, especially the one in the beginning.
And, I must give credit to Daniel Craig. What an awesome body! He is a very convincing Bond. He has a kind of innocence which is appealing.

Eva Green looks stunning.

All in all, a good movie. Nothing brilliant or earth shattering, but definitely worth a dekho !

Wednesday, November 15, 2006

Bone mineral density

Early diagnosis and treatment of osteoporosis can reduce fracture risk. RadiologyInfo has an excellent page on bone densitometry and DEXA scans for osteoporosis. A dexa scan is currently the gold standard for measuring bone mineral density (BMD). There is growing interest in quantitative ultrasound as an alternative, but it still needs to go a long way to prove itself. Other less widely used techniques are peripheral quantitative computed tomography, quantitative magnetic resonance (QMR) and magnetic resonance microscopy.

The WHO recommendations for who to test for BMD are
for women -
    1. In postmenopausal women if there is x ray evidence of demineralisation, evidence of vertebral fracture/deformity or if steroid therapy for more than 3 months is contemplated.
    2. In all postmenopausal women above 65 years of age.
    3. In postmenopausal women below 65 years of age if they have risk factors like maternal history of fragility fractures, low body weight or medical conditions associated with bone loss like premature menopause, hyperparathyroidism, hyperthyroidism, chronic renal failure, chronic liver disease, malabsorption or use of anti convulsants.
    4. In premenopausal women who have medical conditions associated with bone loss listed above.
    5. In healthy premenopausal women, BMD testing is not indicated.

for men -

  1. BMD testing is definitely indicated in the presence of vertebral deformity, fragility fracture, hypogonadism or chronic steroid therapy.
  2. BMD is less definitely indicated in case of alcohol abuse, low weight, x ray evidence of demineralisation or medical conditions associated with bone loss listed above.
  3. BMD testing is not recommended for healthy men with no risk factors.

BMD testing is not for everyone. Consider getting it done only if you fall in one of the above categories. Potential harms of DEXA are radiation and cost. Bone mineral density should be measured only to assist in making a clinical management choice.

Besides DEXA quality matters. BMD measurement is not a simple procedure & errors can lead to therapeutic decisions that can harm patients.

BMD measurements have today become essential for fracture prevention and osteoporosis treatment, but due care is needed in utilising this asset.

Tuesday, November 14, 2006

computer assisted surgery in orthopaedics ?

Computer navigation or computer assisted surgery (CAS) is the major new thing in orthopaedics.

What is computer navigation or CAS ?

As the name suggests, the surgeon uses the computer to help him in surgery. This is done with the help of sensors which are placed at specific points on the part to be operated. For eg. the knee. These sensors send information via infra red rays to the computer. With this information the computer reconstructs a visual of the patients anatomic part. On the visual, the computer guides the surgeon on how much to cut the bone? at what angle? where to place the implant? etc.

What are the advantages of computer navigation ?

With CAS, the accuracy of the surgery increases. For example, in a total knee replacement, the accuracy of the placements of the components is better with CAS.
CAS also enables the surgeon to perform the same surgery through a smaller incision (minimally invasive surgery)

Are there any disadvantages ?

Though accuracy is better with CAS, whether this translates into better functional results or improves long term survival of the joint (in cases of joint replacement) is still to be proved.
Besides the technique requires expensive instrumentation and has a learning curve. CAS usually increases surgery time.

I cannot afford computer navigation, is my surgery doomed ?

CAS is still in its infancy. An experienced surgeon will achieve acceptable accuracy with conventional instrumentation. CAS today is an option not a necessity.

When is CAS most useful ?

It is especially useful in cases of bony deformities, retained hardware or when convential instrumentation cannot be used to gain proper alignment.

CAS is useful in which orthopaedic surgeries ?

It is most useful and currently used in total or unicondylar knee arthroplasty & hip arthroplasty. Surgeons have started using it to guide placement of pedicular screws in spine surgery. It is becoming popular in fracture care

If you have any further questions on CAS, send them to me at

Monday, November 13, 2006

Exercising for back pain

Chronic low back pain is common. However, finding an effective treatment is not. Doctors today are still in search of the elusive lumbar spine pain generator

Not wanting to complicate matters further, the real question I wanted to ask was - Is exercising useful for back pain?
Literature reveals the Cochrane review
A summary of their review says
"Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain, particularly in populations visiting a healthcare provider. In adults with subacute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes, though evidence for other types of exercise is unclear. For patients with acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments."
So there is evidence that exercise for low back pain works ! but which exercises ?

Here is a list of a few of them

First the basics
    1. Avoid exercising if you have acute back pain, consult your doctor first
    2. Don't expect miracles. Exercise is helpful, not curative
    3. Always do a few warm up stretches first
    4. Start with sets of 5 repititions, 4 times a week and work upto 10 repititions

here goes.....

  1. Pelvic Tilt - Lie on your back with knees bent. Put your hands on the abdomen. Then pull your abdomen towards the floor. Use your stomach muscles. Hold for ten seconds. Repeat.
  2. Back Lift - Lie on your stomach with your arms overhead. Lift your head and shoulders, without looking up. Hold for ten seconds. Repeat.
  3. Abdominal Curl - Lie on your back with your knees bent. Curl up to raise your head and shoulders. Hold for ten seconds. Repeat.
  4. Wall slides - Stand with your back against the wall with your knees bent at 90 degrees. The knees should be slightly apart. Hold for ten seconds. Repeat.
  5. Leg raises - Lie on your stomach. Raise the leg from the floor. Hold for ten seconds. Repeat. Then lie on your back. Again raise the the leg as much as you can. Hold for ten seconds. Repeat.
  6. Knee to chest stretch - Lie on your back with both knees bent. Hold one thigh and bring knee upto chest. Hold for 10 seconds. Repeat.
  7. Hamstring Stretch - Lie on your back with knees bent. Hold one thigh behind knee. Now straighten the knee as much as you can. Hold for 10 seconds. Repeat.
  8. Heel raises - Stand on both feet. Raise heels. Hold for ten seconds. Repeat.
  9. Hip flexor stretch - Lie on your back near edge of bed, holding knees to chest. Slowly lower one leg down, keeping knee bent, until a stretch is feltacross top of the hip/thigh. Hold for ten seconds. Repeat.
  10. Aerobic exercise - Low impact aerobic exercise is an essential component of any back training program.

These exercises are a good starting point. A swiss ball could also be used.

For the more enthusiastic, I would recommend the core spinal fitness systems from MedX

Sunday, November 12, 2006

Chikungunya Fever

I was surfing the net for info on Chikungunya fever. I came across a review on Harshad's Site. I think he has written an excellent review and it is a must see for anyone wanting to know more about the disease.
Some excerpts from the review are

"The name has been derived from a Makonde word meaning that which bends up reference to some victims' inability to walk up right........
The history of Chikungunya outbreak in India dates back to 1824 whereas the virus was first isolated in 1963 from Kolkata. 4 The viral activity in humans have been observed till 1971......The present outbreak in India started during December 2005 where the country has so far experienced more than 11,00,000 (11 lakh) of Chikungunya infected cases which still continues. 6 The cases were first reported from Andhra Pradesh, one of the worst affected states. Subsequently reports were poured in from several districts of Karnataka, Kerala, Maharashtra , Orissa, Madhya Pradesh, and Tamil Nadu. Even Andaman experienced the first Chikungunya epidemic during June 2006. Presently the outbreak is underway in western parts of India specially Gujarat and Rajasthan. "

Essentialdrugs has a good article about the possible use of chloroquin in the treatment of arthralgia associated with Chikungunya.
Lastly a word about Chikungunya prevention. Its simple - 'avoid mosquito bites'. This is not something new for us Indians. Still I'd like to say again

  • Eliminate stagnant water to avoid breeding of mosquitoes - avoid clogging of water pipes, cover all water tanks, get rid of outdoor containers retaining water like food cans and renew water in flower vases.
  • Use insect repellants
  • Use mosquito nets
  • Wear long sleeve clothes of a light shade
  • Apply 20 - 50 % DEET (N, N-diethyl-meta-toluamide)
  • Apply 0.5% Permethrin spray on clothes
  • If there are large collections of stagnant water in your neighborhood, inform the authorities (hopefully they will spray the area)

Thursday, November 09, 2006

40 benefits of aerobic exercise

Everybody knows that aerobic exercise is beneficial. Lots of sites list the benefits. I wanted to make a comprehensive list. I've tried to include as many as I could find. I've tried to avoid repititions.

So here goes

  1. Exercise increases the concentration of High density cholesterol (HDL) or good cholesterol
  2. It decreases the concentration of Low density cholesterol (LDL) or bad cholesterol
  3. It lowers high blood pressure
  4. It prevents the development of high blood pressure if you are at a risk
  5. It prevents osteoporosis
  6. It strengthens muscles
  7. It helps you loose weight and prevents obesity
  8. It helps lower blood sugar and insulin requirement if you are diabetic
  9. It reduces depression
  10. It helps deal with pain and stress
  11. It helps reduce the risk of cancers of the colon, uterus, prostate & breast
  12. It reduces insomnia
  13. It reduces the risk of heart disease
  14. It reduces the risk of premature death
  15. It enhances work and sport performance.
  16. It keeps joints, tendons and ligaments flexible
  17. It reduces some of the effects of ageing
  18. It reduces the risk of developing type 2 diabetes.
  19. It decreases the symptoms of arthritis
  20. It decreases the number of sick days
  21. It increases concentration levels
  22. It increases your self esteem and confidence
  23. It improves the functioning of the immune system
  24. It improves skin tone
  25. It decreases the risk of stroke
  26. It decreases the incidence of falls in the elderly.
  27. It increases your aerobic capacity
  28. It decreases a woman's risk of developing endometriosis.
  29. It decreases back pain ans improve back stiffness
  30. It protects against some brain disorders like Parkinson's, Alzheimer's, dementia
  31. It decreases craving in those trying to quit smoking
  32. It helps to manage anger
  33. It improves digestion
  34. It improves body shape
  35. It decreases menstrual cramps
  36. It improves sexual performance
  37. It provides socialisation opportunities
  38. It improves cognitive function
  39. It provides physical and psychological benefits in pregnancy
  40. It decreases the risk of peripheral vascular disease

Wednesday, November 08, 2006

Should I take a second opinion ?

Why should I take a second opinion? after all isn't there a definitive treatment for a disease? If two doctors have different opinions does that mean that one of them is wrong? If he is wrong should I report him?

The problem is that medicine is not an exact science. Two doctors may have completely different opinions and still they may both be correct !

Many factors influence a doctors decision

  • His education and training. There are bound to some differences in the training of the thousands of medical colleges. Add to this the huge amount of new stuff coming in everyday. Obviously the more well read and up to date a doctor is, the better his decision is going to be.
  • His experience. Experience adds to knowledge like color to a painting. Change the colors and the picture is different. A particular treatment will fall into disfavour with a doctor because of a bad experience he has had.
  • His teacher. A doctor is likely to treat a patient like his teacher would have. This is because he is familiar with the treatment methods and has seen them work.
  • His personality. An aggressive personality is more likely to offer surgery than a more fearful one. Of course many surgeons would not agree with me on this one.
  • The degree of specialisation. A specialist tackles a particular disorder much much more than the non specialist. So A specialist is more likely to have better judgement.

So it is easy for doctors to have different opinions. In today's practice it is essential to take a second opinion. This ensures you get the best that medicine has to offer. A second doctor supporting the opinion of your own, increases your confidence.

The problem arises when opinions differ, then what do you do? in that case

  • You can take a third opinion, but make sure it is from a really good specialist in the field and then do as he says or
  • You can do a little studying of your own. Find out the advantages and disadvantages of a particular treatment method, see what is important to you and make your decision.

Tuesday, November 07, 2006

Intra articular steroid shots work for OA knee

Many patients suffer from painful knees. The common cause is osteoarthritis. Most patients can be managed by medicines and exercise. Some will need surgery.
However a significant number are in between. What I mean is that medicines don't help and their knees are still not bad enough for surgery.

Should these patients be considered for intra articular steroids? Traditional teaching says that they do not work for OA. Further they are likely to accelerate the joint deterioration.

Marshall Godwin ET AL., have done a study of literature to answer this question. Does traditional teaching hold any water?

They found that steroid shots have been proved to be useful, giving a statistically significant reduction in pain one week after injection. The beneficial effects could last for up to 4 weeks, but is unlikely to continue beyond that. Furthermore, there were no reported adverse consequences. Evidence for accelerated joint deterioration is weak. Radio graphic examination did not show worsening.

The conclusion - A steroid shot is an important tool in the treatment of osteoarthritis, and patients with painful knees should not be denied their benefits.

Monday, November 06, 2006

the myth of the lumbar corset

If you have suffered from chronic low back pain, the idea of a lumbar belt must have seemed appealing. The fact is many people use one and even get habituated to it.
The myth is if you have back pain, use a belt, it will help.
This unfortunately is far from true.

If worn for the wrong reasons, a belt can cause muscle atrophy. This further weakens your back and aggravates the pain. So you wear the belt more often. A self propagating cycle starts which ends in habituation to belt wear.

The web of the back says that belts may be used for

  1. Patients with back pain when performing heavy work such as weightlifting. This is obvious to understand.
  2. When acute back pain limits activity significantly. Here the belt is used to allow the patient to walk. Because walking around is a better idea than being bed ridden, a belt in such a scenario is useful.
  3. For older patients, again only to allow them to return to normal daily activities.
  4. For adolescents or children with scoliosis.

Most patients do not fall into any of the above categories.

The bottom line is use a belt if your incapacitated by pain, only if it allows you to move around and get rid of it as soon as you can.

Sunday, November 05, 2006

10 things you should know before putting your leg in a plaster cast

Most of us have seen a plaster, many have been in one. To avoid a ugly complication, follow these simple 10 tips.

  1. Do not wet the plaster cast, it will break.
  2. Keep the limb elevated. If your sitting on your couch do not let your limb hang downwards but elevate it on a stool. This helps decrease the swelling.
  3. If your cast breaks, becomes loose or soft in places, go back to the doc. A broken cast fails to immobilise the limb - your fracture may not heal properly.
  4. Do not cut part of the cast or try and remove the cast on your own. You may not succeed or may cause injury.
  5. Ask your doctor about prophylaxis against thrombo-embolism. If you have the risk factors, you'll need it.
  6. The skin below the cast may develop a sore, especially at pressure points. A bad odor & excessive pain should alert you.
  7. In case of a lower limb cast, ask your doctor how much weight you can bear on the limb. It could range from nil to full.
  8. For heavens sake, do not put anything into the cast (like a hairpin to scratch the skin)
  9. This one is the latest - if your child is getting a cast removed, use ear plugs. The noise from the plaster cutting saw causes excessive anxiety in the child
  10. Run to your doc if you get any of the following symptoms
  • excessive swelling
  • excessive pain
  • a feeling of tightness
  • bluish discoloration of skin
  • tingling in your toes or fingers

Your doctor will immediately loosen or remove the cast. If prompt action is not taken, a compartment syndrome may develop. It basically means there is too much pressure which causes a decrease in the blood supply of the limb & may lead to gangrene.(you definitely don't want that to happen.)

Saturday, November 04, 2006

how to save money in a hospital ?

Have you recently been to a hospital ? do you remember seeing the bill ? then you must remember feeling cheated ? the frustration of not understanding the medical mumbo jumbo ?

The bad news is hospitals nowadays do overcharge through medical & hospital bill errors. The bills are so difficult to understand ....... the result - you end up being cheated, sometimes of a lot of money.

The good news is help is available. I compiled a list of links to a few excellent pages, full of good, solid advice on how to save your hard earned money.

How to detect medical & hospital billing errors? see

For some more tips on saving on medical bills ....

You still having trouble, there are people who will check your bill for you.... are a must.

For insurance tips

The 10 ways to avoid outrageous hospital overcharges
& the 8 most common hospital billing errors are a must.
If you are still not convinced you need to see
10 Things Your Hospital Won't Tell You
even the B.B.C. is talking about the The hidden costs of hospitals

Friday, November 03, 2006

10 things you should always ask your doctor before surgery

  1. Is there another option?
    Listen to the option. Even if it has a low chance of success I might want to give it a chance.
  2. What if my surgery fails?
    Even though he has assured me a thousand times that the chances of failure are miniscule, I’ll still ask him the question. After all you don’t want any rude surprises at the end. As an example ….. lets consider I have knee pain while walking & I am advised knee replacement. Some of the complications of the surgery may make it difficult for me to walk at all !
  3. What are the results of the surgery?
    The surgeon is likely to say that the results are good. But for how many years?
    What I mean is that some procedures are relatively new. The results of only a few years are available. Often as more long term studies come in, more failures become apparent and many times the procedure is abandoned. So it is wise to stick with a procedure that has stood the test of time.
  4. Who is going to assist you?
    A smart surgeon always takes the help of a well qualified assistant. Here 2 brains are definitely better than one.
  5. Tell me about the operation theatre (OT)?
    Like in my earlier post, I will again emphasize the importance of the OT. OT’s reserved for a particular surgery/branch are better than OT’s in which all types of surgeries are done. Laminar airflow is a definite plus point.
  6. What is the post op protocol?
    Ask in detail, like the no. of days in the hospital? No. of dressings? Physiotherapy protocol? When will I be able to walk? When will I be able to get back to work? Again no surprises.
  7. What anesthesia will I be given?
    I want to know if he’s (anesthetist) going to put a tube down my throat or poke a large needle down my spine? I’d also like to meet the anesthetist before hand & not just before surgery.
  8. Is my surgery major or minor?
    While these are very vague terms, indirect questions like … How many blood transfusions will I need? Will I need an I.C.U. post op.? will help to give me some idea.
  9. How much pain will I have to endure?
    Patients always underestimate the amount of pain they are going to get. Ask about what analgesics will be used & find out if there are better options.
  10. How many of these surgeries have you done or how many do you do, everyday?
    Of course, the more the better.

Thursday, November 02, 2006

damage to nerves and vessels ......

Continuing my complication list, I want to bring your attention to neurovascular damage.

In every surgery, there is a risk that the surgeon may damage an important vessel or nerve. This is more likely in certain surgeries. For eg. In surgeries of the hip joint, the sciatic nerve may be damaged. The risk is much more if multiple surgeries are done.

What happens when a nerve is damaged ?

If the nerve is a major one, like the sciatic nerve then it could result in varying degrees of paralysis of the lower limb. Some injuries (neuropraxia are milder than others(neurotemesis). Recovery depends on the degree of damage Management of nerve injuries is often an uphill task

What about a vessel ?

When a major vessel is damaged, all hell could break loose. Usually the services of a vascular surgeon are immediately utilised for damage control. See If I am lucky, everything will turn out alright. Worst case scenario is an amputation (don't worry - this is extremely rare !) In addition to limb ischaemia, you could end up loosing a lot of blood.

What can I do to prevent these complications ?

The most important thing I can do is to choose my surgeon very carefully. Obviously the surgeon should be well qualified, highly accomplished, etc etc.
Other than this I will want to know the no. of such surgeries performed by him. A surgeon performing a particular surgery day in & day out will have far less complications than the surgeon who performs the same surgery occassionally.

I guess having a super duper specialist helps !

I,ll be back with more

Wednesday, November 01, 2006

orthopaedic surgical complications

Don’t worry Mr. Y, this procedure is safe.

What anybody, about to undergo an orthopaedic procedure, must know about surgical complications.

I have been suffering for months. The pain is becoming unbearable. Every possible option of treatment is exhausted. My doctor offers me surgery.
I finally see a ray of hope. Freedom from this misery, is it possible?
‘this procedure has a very high success rate Mr. Y’ …….I am convinced and why shouldn’t I be ? Modern orthopaedic surgery has become a boon for many. That is a fact. If surgery is indicated (meaning there is enough scientific proof that the surgery will benefit the particular condition), I would strongly recommend it. Today surgery to a great extent is safe.
‘This procedure has a low complication rate’ though this statement is true, I think everybody has a right to know what could wrong in a surgery. But why should I bother, I trust my doctor. Besides the benefit from the surgery far outweighs the risk, right?
Right. But what I need to realize is that
  • Surgery may not be the best option
  • Unindicated surgeries usually fail
  • Doctors with more experience (those who do the particular surgery in large numbers) have a lower complication rate.
  • Factors other than the operating surgeon can affect complication rates.
  • Anaesthesia complications are very rare but can occur.

    So why should I be more aware? …because I can make a more informed decision regarding surgery. If I know what is likely to go wrong, I can take steps to minimize those complications. I can ask the right type of questions. If malpractice is involved, it will be obvious to me.

    The purpose of this article is not to discourage someone from undergoing surgery, but to extract maximum benefit with least risk by the process of awareness.

    In this article I will discuss only general complications which are common to most orthopaedic procedures. My list is not comprehensive. My emphasis will be on those complications that are readily preventable and more common. I will attempt to put the information in understandable English (rather than use medical mumbo jumbo) This is my first attempt. I will appreciate any constructive criticism.

    The first complication on my list is the most frightening. It is infection. Most common misconceptions are

If I contract infection its probably bad luck.
Even though infection is common in certain people (like those suffering from diabetes), it is difficult to say who will get an infection. Therefore medical men discuss infection in the form of a rate, for eg. ‘The infection rate for this procedure is around 1%, Mr. Faltoo’ meaning 1 in every 100 patients will get infected. The unfortunate thing is, that 1 could be me. So I want to know whether an infection rate be reduced? The good news is yes. There are many ways like

1. The operation theatre. Patients seldom realize that the quality of the operation theatre has a major impact on infection rates. Firstly a good operation theatre is hidden behind many layers of isolation. In simple words this means that to reach inside a good theatre I will have to pass through many doors. Behind every door I will see fewer people and the ones inside will be in a surgical uniform. If I reach my operation theatre by passing through one or two doors then the alarm bells should start ringing. Secondly there are two kinds of surgical patients. The first are the clean cases. These guys have no pre existing infection. And the second are the infected cases with pre existing infection. For eg. A patient posted for an abscess drainage is an infected case. Usually the theatre for the infected guys should be very, very far away from the ‘clean theatre’. If both the types of surgeries are being done in the same complex, I want to run away.
Also some surgeries disrupt natural bacterial habitats For eg. Surgery on the colon or the genital tract. These surgeries have more bacterial contamination than most orthopaedic procedures. So if the theatre for my orthopaedic surgery is also being used for general surgical or gynaecological procedures, I again want to run. The third point is of newer advances. This is especially true for joint replacement surgery. These advances are laminar air flow & body exhaust suits. Laminar air flow is a system which reduces the no. of bacteria in the OT air by rapid air exchanges. It has made a huge impact on reducing infection rates. The operating team is a big source of bacteria. Body exhaust suits aim to reduce contamination from this source. I will always ask my surgeon about the OT quality. If his response is specific and he gives me a detailed account of the effort that has gone into constructing the OT & the list of anti infection measures taken, then I am satisfied. If his response is vague then I want to run. Last but not the least is the operating team discipline towards asepsis in the OT. A strong commitment to maintain OT sterility goes a long way in preventing infection. And in the case of infection prevention truly is the best treatment.

2. Antibiotic prophylaxis this means using an antibiotic as a preventive measure. Most surgeons will give 2 to 3 antibiotic shots perioperatively ie before the surgery and for a period of time after surgery. The protocol differs. Every surgeon uses one that he is comfortable with and that works in his set up. The important thing to remember is point no 1 is far more important than point no. 2. A antibiotic cannot be used to compensate for sub optimal OT conditions. If my surgeon says ‘ don’t worry about the OT Mr. Y, we’ll give you a powerful antibiotic’ I’ll be gone.

3. Have a bath this is such an important advice, but most surgeons will forget to tell the patient. My own skin is the most common source of bacteria which cause infection. Therefore if I have a good clean bath and especially clean the site of proposed surgery, my infection rate is going to drop.

4. Do I already harbor an infection ? if I am already suffering from an infection like a urinary tract infection, then my chances of infection after surgery rise. So I need tell my doctor about any pre existing infection. I’ll expect him to delay surgery till my infection is under control.

Infection is cured by dressing and antibiotics.
Though dressing an antibiotics are successful in curing a percentage of post operative infections, most need a second sometimes multiple surgical procedures. This amounts to a longer hospital stay & a lot of more expenses. Add to that pain and anxiety and I realize that I am very afraid of infection. I definitely want to stay far, far away from it.

I am healthy so I’ll not get infection
From the above discussion it is obvious that this statement holds no water.

I got infection because I ate rice
This is a very popular belief in Indian patients. Infection has got nothing to do with what you eat

To summarize I would like to once again stress that surgical infection is best prevented and OT quality and discipline go a long way in doing just that.

…to be continued. I will be happy to answer any queries.

Tuesday, October 24, 2006

My Journey

I came into this world in the year 1977. My mom said the doctor used a forceps to grab my head and pull it out ..... imagine that!! He squashed my delicate cranium like a lemon !! ... a head injury on my first journey. That was the start of my brain damage.
when I was 3 I fell from the top of the stairs..... the result - Head injury 2 & some more brain damage.
I attribute the course my life took up to now and the future to this early brain damage.
.....I started getting very good grades in school ! .... I started becoming very competitive (definitely would not recommend that to anyone) ..... I would be sad when I had to miss school (O my God !)
people told me 'become a doctor son', 'you'll make a lot of money', 'people will respect you', 'you'll be paid just to write a prescription'
It was my very impressionable mind at that young age coupled with the brain damage that made me decide to become a doctor. Maybe it was in the genes. You see half of my mothers cousins were doctors, so I can’t rule that out.
I had a tough time getting into med school…. But I managed …why? Obviously for all those rewards at the end.
So I struggled, I studied, I had sleepless nights. To say that I worked hard was an understatement ….but those promised fruits kept me going.
Then graduation day came, but it came alone. When I asked for my due rewards, I was rudely told that ‘a MBBS alone has no value in today’s world son, you have to specialize!’
Oops! It took me a while but I started to accept the reality of the situation. Ok boss, specialize karega (I will specialize)
I was impressed with orthopaedics, it seemed at the time to require more hands than brains. I mean how difficult could nuts & bolts get, right? Besides the branch added a kind of mechanical flavor to medicine and I liked that.
I guess a lot of people shared my views cos it was the toughest branch to get. So take another branch ….no ! Excited by the challenge my damaged brain took over, & I went for it.
Orthopaedics I got but after a long 2 year wait.
Starting my residency, I realized I was only partially correct. Mechanical it was, but easy it wasn’t. For the first time in my medical career, I had difficulty even understanding the subject. As we often say in India…. Sab kuch sir ke upar se gaya ! (everything went over my head)
So again I struggled, I studied, I had sleepless nights…..but this time it was twice as tough. graduation day came, but guess what, it came alone! Kya hua bhaiya? (what happened?)
I was rudely told ‘Orthopaedics has become a general branch now son, you have to specialize’ I could not believe it. So now I am back to square one. In a state of shock. I am waiting for my damaged brain to take over & get accepted at a fellowship program ….thats what they call specialization now! But I am not putting too much hope into it as I am sure I will get another rude answer at the end of it. So here I am waiting for that elusive thing known as success!