Sunday 30 June 2013

100 ways to improve patient doctor relationship

Happy Doctors Day



Dr K K Aggarwal

In India doctors has always been considered and given the status of God but with the inclusion of medical services under consumer protection act consumer relationship has started between a patient and a doctor.

In the US and UK the patient is considered God and in Japan a King. In India the patient is now considered as a boss. As the boss can fire his employee so can the patient in today’s consumer health industry.  The patient, therefore, should never be taken for a ride or for granted.

Patient should, therefore, be treated like a consumer and all the principles of consumer industry should apply to medical fraternity. Unfortunately, the medical professionals are not taught how to attend, treat and provide services.

Following are a gist of the principles which can help better patient doctor relationship.


1.     In a consumer industry, consumer is always given the top importance and in health industry, therefore, the patient should be given the top importance.

2.     Follow the principle. “Patient is always right”. He may or may not like arguments and can walk away if not satisfied.

3.    The famous marketing law also applies to patient-doctor relationship.  A satisfied patient (customer) will talk about you to 10 more people but an unsatisfied patient will talk to 100 people against you.

4.     Patients like customers can be equated to sheep.  They blindly follow each other.  Generally, all sheep follow a particular one & so does the patients.

5.      Patients like customers require very little to get satisfied.  In one of our survey 90% of patients were satisfied when waiting for their turn when the doctor came & said “that I will be with you in a minute”.

6.     As a part of medical training always do self role-play studies. Imagine yourself as a patient and imagine what wouldyou expect from a doctor.  Give the same to your patients.  Always put yourself in the patient’s shoe and then take actions.  This is what Bharat in Ramayana did with Ram’s shoes.

7.     Patient like a customer is the profit.  Rest everything is overhead. Without patients no establishment has any value. He is your asset.

8.     Believe in excellence:  Eliminate all those in the establishment who are not related to or are not going to help the patients. The purpose of medical practice should be to create more patients.  No patients no business. Carpets, chrome and chandeliers do not impress patients.  They want good service. In one of our survey sixty percent of the people put their faith in the capabilities of their doctor and not on their dress code.

9.     Patients do not want to be over charged: They don’t want to be over charged both in terms of money and time.

10.   Patients want your 100% all the time. They are not bothered whether you are tired, not slept the previous night or have been busy the whole day.  If you are attending they want your 100%.

11.   Do not loose old patients: Remember, getting a new patient may cost you six times more than to serve the existing one.  Always make sure that your existing patients are satisfied. The easiest way to get new patients is to look after your existing patients well.

12.  Always meet your patients personally, greet them shake hands with them and try to call them by name. The law is ”If I don’t go I don’t get”.

13.  Communicate continuously with your patients.  This can be through phone, email, letters, post cards, your personal newsletters and updating their knowledge with updates and warnings.

14.  In a medical establishment always insist that each of your healthcare providers visits the patient.

15.   Always talk to a patient in a language they can understand and never talk in front of them with a colleague in a language, which they cannot understand.

16.   Always look after your regular patients with special care. Give your patients the best service.  Always anticipate their problems and provide them early solutions.

17.   Patients like to have answers for their queries.  Always get the facts from them.  Analyze the facts and arrive at a decision. Never forget to listen, listen & listen to your patients.

18.  Remember, success in life as a journey and not a destination. Be consistent in your behavior and efforts in long run you will be the winner.  Always improve your CGR (character, goodwill and reputation).

19.   A good doctor always follows ABC in sequence.  Where A stands for Availability, B for Behavior and C for Competence.  Without availability competence has no value.

20.   While talking a decision remember, 3H.  Head, Heart & Hand.  Always think from your Head, then listen from the Heart (take a conscious decision), and then take an action (Hand). For example you are facing a problem. The head will give you 6 options but the heart will choose only one.

21.   In an establishment always fight for your patients.

22.  It is a good idea checking about the attitude of your health care providers on a regular basis from the patients.

23.  Prompt action: Always solve the small problems of your patient now. Never wait for the problems to become urgent.

24.  A dissatisfied patient is the best teacher.  Listen to him He or she may have a solution or a suggestion. Most people who complain are educated and have an answer to the question they are raising.

25.   Never have a meeting with dis-satisfied patients together.  It may be detrimental to your interest.

26.   Do not promise anything, which you cannot give.  Learn when to say “No”.

27.   Learn patience: When listening to patients try not to interpret them.  Be sympathetic to them.  Listen patiently, do not confront and always find a solution or give them alternative suggestions. While finding a solution, seek & discuss alternatives.

28.   Always help patients in analyzing a problem and solving it.

29.   Always compare yourself with yourself and not with other doctors. Remember GOD never made junks. Have confidence in yourself.

30.   Instead of making people change, change yourself.

31.   Do small things greatly. And do different things differently.

32.   Instead of firing your employee put fire in him and motivate him.

33.   Always build good thoughts.  Always be positive.  Remember, mistakes can always be better teachers. Treat every adversity as an opportunity to improve further.

34.  Stress is the body reaction to the interpretation of a situation. Change the situation, change your interpretation or prepare your body to withstand the stress.

35.   Stress is absence of ideas. Devote time to yourself and have a flow of ideas.

36.  The age of your patient is not number of years lived but 100-number of years lived. He has come to you for the future and not for what he ahs lived already. Always be positive in life.

37.   Always look at the positive aspects in life. Be happy that the glass is still half full and not worry that it has become half empty.

38.  You may be correct in your argument but the other may not be wrong from his or her perceptive. 6 or 9 depends from which direction you are looking at.

 39.   Do not get angry with errant patients.  Find out their end of story too.  Remember, the system may be wrong in your training.

40.  Never get angry with your employees. If a worker was as good as you he would not have been your worker.

41.  Eustress is positive stress. It’s required for life. Always accept challenges. Distress is negative stress. It’s harmful. Learn to manage it.

42.  Do not believe in KFP but in BFP. KFP is kee pharak penda hae (what difference it makes) and BFP is bada pharak penda ha (it makes a lot of difference). The “chalta hae” attitude is not good for any establishment.

43.   Remember, Parkinson’s Law. “the more people you have, less will be the output”. Do not believe in making committees or appointing new people under the existing ones. Have a horizontal chain with many people reporting to the same head.

44.  You are a role model to the society and your employees. Do not do any thing in public, which you asking them not to do. Do not smoke or drink in front of your patients.

45.   Always train your juniors. Learn to spend 6 hours in sharpening an axe and 1 hour in cutting it. So that next time you save 6 hours.

46.   Be a uniter and not a divider. Do not believe in the divide and rule politics. Remember you can only build house on rocks and not sands.

47.   What do you want to become? An ape or a monkey? Be an ape and not a monkey. Monkey represents wandering mind and ape the intellect.

48.   Washbasin vs. vacuum: The washbasin cleans the dirt while a vacuum sucks the dirt. The approach in life should be the washbasin one.

49.  Understand the word NURSE: you are basically nursing a patient. Nobility, Understanding, Responsibility, Simple and Efficiency. A nurse is a noble, understanding, responsible, simple and efficient health care provider.

50.  SERVICE, remember the word SERVE: Service, Excellent, Respect, Value and Enthusiasm. Provide excellent service full of value and respect in an atmosphere of enthusiasm.

51.   A matchstick has a head but no intelligence. Always think. Take a conscious decision. Do not just be a follower.

52.   When ever you are making a statement ask your self: is it the truth, is it necessary and is it kind. If any one of the answer is no do not speak.

53.  When ever you are going to take a action ask your self, Is it true, is it necessary, will it bring happiness to me and to others? If the answer is no to any one do not attempt.

54.   Always believe in non-violent communication. The principles are observation, feelings, need and request.

55.  When narrating or conversing always use “quote unquote”. Always give the actual observations and not your interpretations.

56.  Give your feelings and not the analysis. Instead of saying he hurt me say I got hurt.

57.  Put a board “thanks for not smoking ” instead of“ any smoking”.

58.  In your office write a sign board “ my answer is yes, now tell me your problem”

59.  Satisfy your needs and not what you want.

60.  You get what you deserve and not what you want. Be contended.

61.  Always request and not order. Even a safai karamchari has self-esteem.

62.  Creativity is diversity. The cycles involve intended intention, information gathering, information reshuffling, break (incubation period), insight, inspiration and implementation.

63.   Smile it costs nothing. Always greet with a smile. A smiling photo in the clinic always helps.

64.   Never criticize others in their absence:  have the courage to speak in their presence. Your criticism will reach them in no minutes.

65.  Do not believe in gossip. Tell a sentence and ask the person to pass it on till it comes back to you. And see how much it has been distorted. Gossip is something talked about a third person in his or her absence and not based on truth or without a reference.

66.   Dirty linen or a dirty fish. Take it out. Do not keep people who create nuisance in the organization.

67.   Do not believe new comers at first instance. Think before making a deal. Do not get attracted with new proposals. They may not get finalized.

68.   Do not make patient as friends. Always keep a distance.  When visiting their house do not sit with them and have a dinner on the dining table.

69.  Always have a female attendant when examining a female patient.

70.   Respect patient privacy. Do not talk about the illness to others without patients consent.

71.  Never resist second opinion.  The patient has the right for the same

72.  Never deny case records to the patient.  Every patient has a right to receive them legally within 72 hours.

73.   Never ignore an emergency.  You cannot refuse to see or attend an emergency. Weather you get your fees or not. It can have criminal implications.

74.  Never give telephonic or email consult: You are legally bound as if it was a regular consult.

75.  If prescribing a medicine on phone pronounce the alphabets. Remember two drugs may sound similar.

76.  Write legibly. Write drugs in bold letters so that there are no mistakes.

77.  Never write 4U insulin.  In one instance he received 40 units. Always write units and not U.

78.  Never write .25 mg always write as 0.25 mg. Other wise there are chances the patient may take 25 mg in the first instance.

79.  Never write a prescription “paracetamol 8-2-8” instead write “paracetamol 8am       2pm      8pm”. There are chances the person may take 8 tab in the morning, 2 in the afternoon and 8 at night.

80.  Give the option of generic named drugs from a standard company to the patient. They may be cheaper.

81.  When writing a prescription write the most important drugs on the top and not otherwise. This is how the patient is used to.

82.  Write clearly when you want the patient to take the medicines. Otherwise his assumption will be not to take empty stomach.

83.   Explain the patient about the charges.  They think hospital as a hotel not realizing that all charges vary according to the category chosen in a hospital.

84.  Never argue with you seniors in others presence. You may win arguments but loose relationships.

85.  Never criticize your colleagues in front of the patient. Even if they have made a mistake.

86.  Negligence is not error of judgment but inability to provide average degree of care.

87.  Remember the magnitude of care may vary but the standards of care should be the same.

88.  Do not call your colleague as a trainee, student or a junior. The patient may not understand that language.

89.   You have a right to refuse a patient provide it was not an emergency.

90.  You have a right to choose your fees.

91.   The business laws are: Profit, policy, happiness. Your policies should be such they not only ends in savings but also provides happiness to you, your patients and your employees.

92.  Even to your relations give consults in your chamber. You will have a better respect.

93.  Do not give walking consults in parties. Insist them to come to your chamber.

94.  Always update your knowledge. The patient is well read today.

95.  Never shy of saying, “ let me read about the subject”. Even judges do the same.

96.   Always ask the patient about other doctors he or she is seeing. There are chances he or she may be taking drugs from dentist, ortho or gynae doctor already for different ailments.

97.   Always ask for the old records.  No one will excuse you of missing drug reactions mentioned in the old records.

98.   Never hurt the religious sentiments of patients.  Respect all aspects of their emotions.

99.   Remember the Vedantic phrase:

Watch your thoughts, they become your words.

Watch your words, they become your action.

Watch your action, they become your habits.

Watch your habits, they become your character.

100.  Sow an action and reap a habit.

Sow a habit and reap a character.

Sow a character and reap a destiny.

Saturday 29 June 2013

FDA Warning for ondansetron and metoprolol



The US FDA has put a class of antiemetic drugs, including ondansetron on its latest quarterly list of products to monitor because of potential signals of an increased risk for serotonin syndrome.
The beta blocker metoprolol succinate also landed on the list because of reports that suggested therapeutic ineffectiveness.

Appearance on the watch list does not mean that the agency has concluded that the drug poses the health risk reported through FAERS. What it does mean is that the FDA will investigate whether there is a causal connection.

The antiemetics on the watch list belong to a subtype of serotonin blockers that bind to the 5-HT3 receptor. Serotonin syndrome is caused by excessive levels of the neurotransmitter. It can be fatal. Symptoms include confusion, agitation, dilated pupils, headache, rapid heart rate, and changes in blood pressure and temperature.


Product name: active ingredient (trade) or product class
Potential signal of a serious risk/new safety information
Additional information (as of May 1, 2013)
Metoprolol succinate  extended-release products
Lack of therapeutic effect, possibly related to product quality issues
FDA is continuing to evaluate this issue to determine the need for any regulatory action.
Serotonin-3 (5-HT3) receptor antagonist products: ondansetron, palonosetron
Serotonin syndrome
FDA is continuing to evaluate this issue to determine the need for any regulatory action.

What is etiquette-based medicine?

Our body consists of physique, mind, intellect, memory, ego and soul. We, therefore, have our physical profile, mental profile, ego profile and a soul profile.

Our soul profile makes us calm, compassionate, caring, smiling with full of empathy. Our ego profile (controlled) on the other hand makes us behave like a well dressed and self-disciplined gentleman.

Patients want us to live up to our soul profile and be compassionate with them and practice empathy and not sympathy. 

To practice conscious-based medicine, one needs to control one’s desires and detach oneself from the results of action and from attachment to the patient and the worldly atmosphere.

The job of medical associations and the councils should be to educate medical graduates to become compassionate physicians and if that is not possible, they should at least inculcate etiquettes and habits to make them learn good behavior. 

The new terminology for intellectual profile or skill based profile is now called etiquette based medicine which prioritizes behavior over feeling, stresses practice and mastery over character development and puts professionalism and patient satisfaction at the centre of the clinical counter and brings back some of the elements of the rituals that have always been important part of healing profession.

It is simpler to change behavior than attitude. Training of etiquette-based medicine complements with physicians becoming more humane. However, the aim should not be to make etiquette-based medicines a priority over compassionate based medicines. 

The first step in etiquette-based medicine is to learn good manners and good bedside skills. It includes patient-doctor communication and details of explanations at admission and discharge or declaring deaths. 

For example, when you are meeting a patient for the first time at the time of hospitalization, you may not be compassionate but at least you can follow the following:

·        Acknowledge the patient and ask permission to enter the room and wait for an answer.

·        Introduce yourself – shake hands and let the patient know your name.

·        Sit down near the patient and smile.

·        Explain in detail your role in the team.

·        Explain about the time, duration of everything of your plan.

·        And lastly, always thank him for giving you an opportunity to serve the patient.

Such a checklist is clear, efficient to teach, evaluate and is easy for anyone to practice. It does not address the way a doctor feels but at least it disciplines us how to behave.

Let our patients not start writing in the suggestion cards as under:

·        My doctor was not with me during consultation.

·        My doctor never smiles

·        I have no idea to whom I was talking to.

·        My doctor did not look in my eyes even once.

·        My doctor was all the time receiving phone calls on mobile

·        My doctor’s concentration was on the computer screen.


(With excerpts from Dr. M.W. Khan, MD, New MEJM 2008; 358, 1988-89, May 8)

Friday 28 June 2013

Clot dissolving therapy or angioplasty in early acute heart attacks

Outcomes are comparable between primary removal of clot in heart artery with stent angioplasty and clot-dissolving drugs in patients with ST-elevation heart attacks who present early. 

Results of STREAM study

·        Best is stent angioplasty if it can be done within 1 hour of presentation to the hospital.

·        Those who present within 3 hours of chest pain and stent angioplasty cannot be done in one hour there was no difference between the two treatments (stent angioplasty of clot dissolving drugs) in the primary composite end point of major adverse cardiovascular events at 30 days. 


Comments: In most non busy cardiac centers, stent angioplasty labs needs to be informed and angiographer called for doing the procedure. This takes time. In such cases, give clot-dissolving drugs.

Mold prevention strategies and possible health effects in the aftermath of floods

1.   Extensive water damage after major hurricanes and floods increases the likelihood of mold contamination in buildings.
2.   The recommendations assume that, in the aftermath of major hurricanes or floods, buildings wet for<48 hours will generally support visible and extensive mold growth and should be remediated, and excessive exposure to mold-contaminated materials can cause adverse health effects in susceptible persons regardless of the type of mold or the extent of contamination.
3.   For the majority of persons, undisturbed mold is not a substantial health hazard.
4.   Mold is a greater hazard for persons with conditions such as impaired host defenses or mold allergies.
5.   To prevent exposure that could result in adverse health effects from disturbed mold, persons should 1) avoid areas where mold contamination is obvious; 2) use environmental controls; 3) use personal protective equipment; and 4) keep hands, skin, and clothing clean and free from mold-contaminated dust.
6.   In the aftermath of extensive flooding, health-care providers should be watchful for unusual mold-related diseases.
Reference : Brandt M, Brown C, Burkhart J, Burton N, Cox-Ganser J, Damon S, Falk H, Fridkin S, Garbe P, McGeehin M, Morgan J, Page E, Rao C, Redd S, Sinks T, Trout D, Wallingford K, Warnock D, Weissman D: MMWR Recomm Rep. 2006;55(RR-8):1.

Thursday 27 June 2013

Health risks from dead bodies are negligible

The health risks of dead bodies are dangers related to the improper preparation and disposal of cadavers.

As per WHO In situations where there are large numbers of deaths following a disaster dead or decayed human bodies do not generally create a serious health hazard, unless they are polluting sources of drinking-water with faecal matter, or are infected with communicable diseases.  In most smaller or less acute emergency situations therefore, families may carry out all the necessary activities following a death, where this is customary practice
While normal circumstances allow cadavers to be quickly embalmed, cremated, or buried, natural and man-made disasters can quickly overwhelm and/or interrupt the established protocols for dealing with the dead resulting in decomposition and putrefaction of cadavers.
The public concern has been health, logistical, and psychological issues.
In panic people either bury the dead quickly or apply disinfectant to bodies for the specific purpose of preventing disease.  Both have no scientific basis.
In a disaster the following may happen
a.       The body gets buried naturally with no ill consequence
b.      The body gets flown in water with no consequences
c.       The body gets decomposed and produces foul smell. Need simple customs and ritual filled cremation.
d.      Vultures start eating the body as natural air burial again of no health consequence.
Health Risks are minimal
1.  Microorganisms involved in the decay process (putrefaction) are not pathogenic.
2.  The health risks from dead bodies in such cases are minimal. Unless the person was suffering from a  disease the fear of spread of disease by bodies killed by trauma is not justified.
3.  No scientific evidence exists that bodies of disaster victims increase the risk of epidemics AND cadavers posed less risk of contagion than living people.
4.  The priority should be going into establishment of water supply, sanitation, shelter, warmth and hygienic food for the survivors, not digging mass graves.
5.  Spraying is a waste of disinfectant and manpower.
6.  Indiscriminate burial of corpses can demoralize survivors.
7.  Lack of death certificates can cause future practical problems to survivors.
8.  Religious and cultural practices should not be bypassed.
9.  Survivors present a much more important reservoir for disease [than cadavers]. Real risk is contamination of water supplies by unburied bodies, burial sites, or temporary storage sites may result in the spread of gastroenteritis from normal intestinal contents.
10.        Only corpses who died from certain contagious diseases do, indeed, spread disease, such as the case with smallpox and the 1918 flu.
11.        There is little evidence of microbiological contamination of groundwater from burial.
12.        Where dead bodies have contaminated water supplies, gastroenteritis has been the most notable problem, although communities will rarely use a water supply where they know it to be contaminated by dead bodies.
13.        To those in close contact with the dead, such as rescue workers, there is a health risk from chronic infectious diseases which those killed may have been suffering from and which spread by direct contact, including hepatitis B and hepatitis C, HIV, enteric intestinal pathogens, tuberculosis, cholera and others.
14.        The substances cadaverine and putrescine are produced during the decomposition of animal (including human) bodies, and both give off a foul odor. They are toxic only if massive doses are ingested (2 g per kg of body weight of pure putrescine in rats, a larger dose for cadaverine), causing adverse effects.
15.        Maggots in decomposed bodies also do not carry immediate health risk.

Do’s and Don’ts in flood disaster


1.      Do not drink dirty water. Boil it or put chlorine or iodine into it before consuming.

2.      Sprinkle medicine in dirty water.

3.      Destroy all food contaminated by flood water.

4.      Beware of insects and poisonous snakes which may have entered the house along with the flood.

5.      Make sure that your electricity is not leaking or you may get electrocuted.

6.      Follow the principle of boil it, cook it, peel it, heat it or forget it.

7.      Check the sewage system so that it does not get mixed with drinking water.

8.      If there is a breakage in the drainage system, stop using latrine and do not use water.

9.      Switch off the main electricity to prevent electricity leakage.

10.     Make sure all the plugs in the house are 3-pin plugs and earthing is proper

11.    Check any leakage of gas.

12.     Your mobiles may not work but landline phones may still be working for some time.

13.     Act and don’t react.

14.     Panic situation can harm.

15.     Try to communicate with people for help and always follow the weather forecast, if available.


(with inputs from Indian Medical Association)

Wednesday 26 June 2013

Post flood illnesses



1. Post flood impact:  The 2010 Pakistan flood affected 20 million people. The impact of the event and recovery was measured at 6 months in a cross-sectional cluster survey of 1769 households conducted six months post-flood in 29 most-affected districts. [1]

·         Households were headed by males, large and poor. 

·         The flood destroyed 54.8% of homes and caused 86.8% households to move, with 46.9% living in an IDP camp. 

·         Lack of electricity increased from 18.8% to 32.9% 

·         Lack of toilet facilities increased from 29.0% to 40.4%

·         Access to protected water remained unchanged (96.8%)

·         88.0% reported loss of income

·         Immediate deaths and injuries were uncommon but 77.0% reported flood-related illnesses.

2. Post-flood infectious diseases: Following a flood, there exists the potential for transmission of water-borne diseases and for increased levels of endemic illnesses such as vector-borne diseases. The Japan Disaster Relief (JDR) Medical Team was sent to Mozambique where a flood disaster occurred during January to March 2000. The team operated in the Hokwe area of the State of Gaza, in the mid-south of Mozambique where damage was the greatest. A total of 2,611 patients received medical care during the nine days. Infectious diseases were detected in 85% of all of patients, predominantly malaria, respiratory infectious diseases, and diarrhea. There was no outbreak of cholera or dysentery. The incidence of malaria increased by 4 to 5 times over non-disaster periods, and the quality of drinking water deteriorated after the event. Also, there was a heightening of risk factors for infectious diseases such as an increase in population, deterioration of physical strength due to the shortage of food and the temporary living conditions for safety purposes, and turbid degeneration of drinking water. [2]

3. Post-traumatic stress disorder:  A traumatic experience outside the scope of the usual human experience (flood) results in a certain number of people in a traumatic disorder. The disorder is observed in 30-80% of the survivors of catastrophic events and the prevalence in the course of life is 9.2%. The symptoms include reliving the experience of the traumatic event, avoidance of stimuli related to the trauma, generally dulled reactions and a lack of alertness. PTSD etiology comprises the following: stressor (strength, duration and circumstances of occurrence), personality (age, personality traits, previous experience, genetic predisposition and available social support) and organic factors (effects of autonomic nervous system and neurobiological changes in the brain). [3]

4. The Dhaka experience:  Bangladesh experienced one of the worst floods in recorded history in 1998. The city's roads were completely under water, and most areas were water-logged with drainage and sewage systems blocked. Rising water levels compelled many slum dwellers to move to temporary shelters and relief camps. Women and children were the worst affected. The lack of sanitation facilities and privacy forced women and children to defecate in their own homes. There was an acute scarcity of safe drinking-water, and food prices rose dramatically. Diarrhea, fever and colds were the most common illnesses affecting the poor. The floods left many of them unemployed, and in some families, the result was increased tension and incidents of domestic violence. In some areas, members felt pressured to repay micro-credit loans. Most NGOs, however, suspended loan repayments. 

5:  Effect of global warming: Severe flooding may become more frequent due to global warming. A historical cohort study following severe river flooding on 12 October 2000 in the town of Lewes in Southern England showed that having been flooded was associated with earache, and a significant increase in risk of gastroenteritis with depth of flooding. Adults had a 4-times higher risk of psychological distress. Flooding remained highly significantly associated with psychological distress after adjustment for physical illnesses. [5]

6.  Mold prevention strategies and possible health effects:  Extensive water damage after major hurricanes and floods increases the likelihood of mold contamination in buildings. The recommendations assume that, in the aftermath of major hurricanes or floods, buildings wet for <48 hours will generally support visible and extensive mold growth and should be remediated, and excessive exposure to mold-contaminated materials can cause adverse health effects in susceptible persons regardless of the type of mold or the extent of contamination.      

For the majority of persons, undisturbed mold is not a substantial health hazard. Mold is a greater hazard for persons with conditions such as impaired host defenses or mold allergies.

 To prevent exposure that could result in adverse health effects from disturbed mold, persons should:
·         Avoid areas where mold contamination is obvious;
·         Use environmental controls
·         Use personal protective equipment and
·         Keep hands, skin, and clothing clean and free from mold-contaminated dust.

In the aftermath of extensive flooding, health-care providers should be watchful for unusual mold-related diseases. [6]

References

1.       Kirsch TD, Wadhwani C, Sauer L, et al. Impact of the 2010 Pakistan Floods on Rural and Urban Populations at Six Months. PLoS Curr 2012 Aug 22;4:e4fdfb212d2432.
2.       Kondo H, Seo N, Yasuda T, et al. Post-flood--infectious diseases in Mozambique. Prehosp Disaster Med 2002 Jul-Sep;17(3):126-33.
3.       Mandić N. Post-traumatic stress disorder. Lijec Vjesn 1995 Jan-Feb;117(1-2):47-53.
4.       Rashid SF. The urban poor in Dhaka City: their struggles and coping strategies during the floods of 1998. Disasters 2000 Sep;24(3):240-53.
5.       Reacher M, McKenzie K, Lane C, et al; Lewes Flood Action Recovery Team Health impacts of flooding in Lewes. A comparison of reported gastrointestinal and other illness and mental health in flooded and non-flooded households. Commun Dis Public Health 2004 Mar;7(1):39-46.

6.       Brandt M, Brown C, Burkhart J, et al. Mold prevention strategies and possible health effects in the aftermath of hurricanes and major floods. MMWR Recomm Rep 2006;55(RR-8):1-27.

Tuesday 25 June 2013

Disaster Management at Uttarakhand


 The present Uttarakhand flood has again shown the failure of national disaster plan in the country. Tens of thousands of people have disappeared from the area. At the moment, people are only counting loss of tourists, the local inhabitants; nobody knows how many of them have died.
 In the last two weeks, I have been approached by several members of NGOs and agencies to donate fund, food and clothes. This happens every time there is a catastrophe. This again indicates Government system failure.
 At such a scale, individuals or unorganized sectors cannot help. Disaster management is always a hierarchy-based crisis management with a leader at the apex. For any catastrophe such as this, the leader invariably should be the government, who should direct everybody in the country to pool resources and ensure that they reach the needy people.
 Yesterday, a couple of media people asked me why we were not sending a team of medical doctors to Uttarakhand. My answer was very simple. Most of us have already offered and are still offering their services to the government, it is the duty of the government to take help from private sector and assign them work in areas where it is needed the most. Otherwise what will happen is that 90% of the benefits would be given to the people who need it the least because they are at the periphery of the disaster.
 The people who are in real need are all either in the centre of the disaster or placed faraway where the help will never reach by non-governmental efforts.
 People on the periphery may end up taking the same help again and again from different NGOs and may get food, clothes, some of which they would never be able to consume.
 Suggestions
· DGHS should hold a meeting of presidents of all medical associations in the country and work out a strategy.
· Identify an area in Uttarakhand, which is safe and future disaster (flood) free, where base health camps can be created and medical help can be flown there.
· The job of government should be to lift patients to the base camps, where a coordinated team of medical services can look after the victims.

Monday 24 June 2013

New European High Blood Pressure Guidelines

  1. The European Society of Hypertension and the European Society of Cardiology has come out with new guidelines for the management of high blood pressure.

  1. The new recommendation is that all blood pressure patients should be treated to keep the upper blood pressure lowers 140 mm Hg.

  1. In patients with diabetes the lower blood pressure should be kept lower than 85 mm Hg

  1. In patients younger than 80 years, the upper blood pressure can be kept 140-150 mm Hg

  1. Blood pressure more than 140/90 increases the risk of cardiovascular disease.

  1. The salt recommendation is 5 to 6 gram per day. 

  1. Reduce salt to 5 gram per day can reduce upper blood pressure by up to 2 mm Hg in normal persons and 4 to 5 mm Hg with patients with high blood pressure.

  1. Loosing 5 kg. of weight can reduce upper blood pressure by 4 mm Hg.

  1. Regular aerobic exercise training in high blood pressure patients can reduce upper blood pressure by 7 mm Hg.

  1. Drug therapy should be started typically within a few weeks if diet and exercise should be started as first line without indicated.

  1. The main aim of treatment is to lower blood pressure rather than how it is lowered.

  1. ACE inhibitors and AR blockers should not be combined.

  1. Those people whose blood pressure is not getting controlled renal denervation surgery should be considered.