Emedinews:Insights on Medicolegal issues:Post-mortem suggests the majority of fatal stab wounds are on the chest

.• The doctor conducting the postmortem examination must keep in mind that the shape and size of the wound suggests the width and type of weapon whether it is single edged or otherwise, the depth of the wound will indicate the length of weapon, the directions and dimensions of the wound indicate the relative position of the assailant and the victim, and the position, direction and number of wound may indicate manner of production, i.e., suicide, accident or homicide.
• The medico-legal postmortem of 29 cases of death due to stab wound has been conducted by me in the year 2010 brought from south Delhi
• A stab wound is produced from penetration by long narrow instruments with blunt or pointed ends such as knife, dagger, nail, needle, spear, arrow, screw driver etc. into the depths of the body, penetrating the skin and the underlying tissues that is deeper than its length and width on skin.
• This is caused by driving the object into the body or from the body’s pressing or falling against the object and object penetrate due to body momentum.
• The wound is called punctured wounds when it enter a body cavity one way only however when the weapon enters the body on one side and comes out from the other side, it is called perforating wound.
• The wound of entry is larger and the wound of exit is smaller due to tapering of the blade in stab wound which is contrary to fire arm missile entry and exit wounds.
• The doctor must preserve for police if a broken fragment of weapon is found, it will identify the weapon or connect the accused person with the crime.
• Death due to sharp force violence is most common cause of homicide in India also in the many other parts of Europe, as well as in Africa and Asia. It also accounts for 30% of fatal and non-fatal family assaults in the USA

(Contributed by Dr Sudhir Gupta)

emedinews:Makesure:A patient with acute fever developed acute bleeding after aspirin was given.

Situation: A patient with acute fever developed acute bleeding after aspirin was given.
Reaction: Oh my God! Why was dengue not ruled out?
Lesson: Make sure that all patients with acute febrile illness are evaluated for dengue as low platelets count can precipitate bleeding in them, if aspirin is given to reduce fever.

Emedinews:Inspiration:devotion and obedience to your guru

Aruni of Panchala was a dedicated student of the ancient sage Dhoumya. In the days of yore, a student had to stay with the teacher and help in the teacher’s daily chores in order to receive the knowledge he sought. It was a day of cold winter. Aruni was carrying the firewood he had collected for the sage's household. As he was passing by a field, which belonged to the sage, he noticed a breach in the embankment that was holding water in his teacher's field. He realized that the water would seep away and the field’s crops would die with no water.

"What should I do? If I stop to build the embankment I will be delayed and there is no firewood at the hermitage to keep the place warm. I better rush to the hermitage with the firewood and then come back to take care of the breach." Meanwhile the sage and his disciples had assembled for the day's lesson. Aruni was missing.

Soon Aruni rushed in, dropped the firewood in the courtyard, and informed the teacher about the breach of the embankment. Then he quickly rushed out. Sage Dhoumya felt proud of his disciple, "It is hard to get such a responsible disciple."

Aruni ran all the way back to the troubled spot and tried to stop the leakage of water by putting some logs and mud. However, this did not stop the leak. The heavy pressure of water washed away the dam Aruni made. He felt helpless. It seemed impossible for him to stop the leakage without help. He thought for a while and then made a plan.

It was getting dark and the teacher became worried. He called his disciples and set out looking for Aruni. As he called out for Aruni, he heard a faint voice, "Here I am master!” The teacher and his disciples rushed to the spot and saw Aruni lying on the breach, in order to hold the water in the field. The disciples quickly pulled Aruni out from the freezing water. He was repeatedly muttering, "The water is flowing out, the crops will die."

"Don't worry Aruni! We will take care of the breach," said the disciples. "Never mind my son! You are more precious than the crop," said the teacher.

Aruni was covered in a blanket and brought home. Sage Dhoumya himself tended to Aruni. The sage then blessed his disciple with pride, "You shall, forever, be renowned for your unmatched devotion and obedience to your guru.

(Contributed by Dr Anil Jain)

Emedinews:Makesure: A patient with hiatus hernia developed severe symptoms after eating a ‘Paan’.

Situation: A patient with hiatus hernia developed severe symptoms after eating a ‘Paan’.
Reaction: Oh my God! Why was he given a peppermint?
Lesson: Make sure patients with reflex esophagus are not given any food which can relax GI sphincter.

Emedinews:Inspiration:Inspiring Tears

Unfortunately when people think of teenagers, good thoughts are not always the first to come to mind. I know I avoid going into my teenage daughter's high school at the end of their day because I don't want to be shoved and pushed in the hallways. I feel like I am running the gauntlet sometimes! I know they are just kids in a hurry to get out and blow off steam.

Fortunately I also get an opportunity to see teenagers at their best. Watching my daughter and her high school band's camaraderie is always a joy. For instance, when a fellow band member's music folder fell on the pavement everyone ran to help gather the music before it was scattered by the wind. They are a great group of kids.

But I witnessed an event yesterday that really warmed my heart.

My daughter had a band competition at a nearby high school. Her band was the last one to play and before they could play their last selection, the lights in the auditorium flickered and then went out.

The atmosphere in the large, dark space was pensive. The band, sensing this, started singing some of the familiar songs that they sing in the stands during football season. The audience started clapping and singing along. It was quite the experience, sitting in total darkness singing and clapping with dozens of people like it was an everyday occurrence.

I was so lucky to be able to experience this firsthand. My daughter is a senior and so this was one of her last concerts in high school. It was a moving inspirational experience I will never forget.

(Contributed by Ms Ritu Sinha)

Stay Tuned with Padma Shri Awardee Dr KK Aggarwal on 1st Navratri to Diwali a one-month long spiritual Yagna - Amavasya to Amavasya. 29 sept_1-2.mp3

Stay Tuned with Padma Shri Awardee Dr KK Aggarwal on 1st Navratri to Diwali a one-month long spiritual Yagna - Amavasya to Amavasya. 29 sept_1-2.mp3

Emedinews:Insights on Medicolegal issues:What is the Touch DNA TEST?

• Locard principle states that with contact between two items, there will always be an exchange. So, when a crime is committed, if the perpetrator deposits a sufficient number of skin cells on an item at the scene, and that item is collected as possible evidence
• Human being shed tens of thousands of skin cells each day, and these cells are transferred to every surface with which human skin comes into contact.
• Touch DNA samples are also processed exactly the same way as blood, semen, and saliva etc, Touch DNA analysis may be able to link the perpetrator to the crime scene, by collecting the skin cells and analyzing them.
• The key to obtaining successful Touch DNA results depends on recognizing items which may be suitable for Touch DNA analysis and using the sampling technique or collection method that will recover the highest number of skin cells.
• DNA test is done by using visible biological samples like blood saliva, semen etc. however touch DNA is usually not visible and since it is often deposited in smaller amounts than the DNA found in blood stains or other body fluids, it is more difficult to obtain DNA profiles from these samples. These means that low copy DNA profiling allows a very small amount of DNA to be analyzed, from as little as 10 to 30 cells.
• DNA in skin cells that are left at a crime scene may be sampled from a variety of items including gun grips, steering wheels, eating utensils, luggage handles, and clothing.
• Swabbing: The surface of the item is rubbed with a cotton swab to collect possible cells. This method is preferred for hard items such as glass or plastic.
• Cutting: May be used for soft items, such as clothing, in which fabric from areas of interest is cut to collect possible cells.
• In addition to the commonly used swabbing and cutting methods, the latest technologies have recently started using the “Scraping” and “Tape Lift” methods, in which the surface of soft items such as clothing are either scraped with a blade, or sampled with a small piece of tape, to collect possible cells.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure:A chronic smoker developed cancer of lung.

Situation: A chronic smoker developed cancer of lung.
Reaction: Oh my God! Why was he not screened for the cancer?
Lesson: Make sure all chronic smokers are given an option for lung cancer screening with low dose spiral CT.

Emedinews:Inspiration:Hanuman protecting the chariot of Arjun

When Arjuna gets disillusioned - in the battle field of Mahabharata, Krishna guides him and shows the right path to him - as is written in the Bhagwat Gita.

We get the lesson that whenever we get disillusioned in our personal lives, we can get back to our dharma and our scriptures where wisdom of ancient sages is described.

Only three persons ARJUNA, SANJAY AND HANUMAN heard the Gita DIRECTLY from Lord KRISHNA's mouth.

Sanjay was Dhritrashtra’s advisor and was narrating what was happening in the battlefield, and thus he got Gita gyaan.

Hanuman too was present there in the form of a small monkey, on the flag of Arjuna's chariot and received direct Gita gyan.

But why was Hanuman protecting the chariot of Arjun?

The incident that led to this was an earlier encounter between Hanuman and Arjuna, wherein Hanuman appeared as a small talkative monkey before Arjuna at Rameshwaram, where Rama had built the great bridge to cross over to Lanka to rescue Sita. After seeing the bridge Arjuna wondered aloud at Rama taking the help of monkeys rather than building a bridge of arrows. Hanuman heard him and challenged him to build such a bridge capable of bearing him alone.

Arjuna, unaware of the Hanuman’s true identity, accepted the challenge. Hanuman then proceeded to repeatedly destroy the bridges made by Arjuna, who at last vowed to take his own life if Hanuman could destroy his last arrow made creature.

Hanuman tried his best to destroy this last one but could not succeed. While he was toiling in his efforts he saw that the water under the bridge was fast becoming red. He immediately stopped his efforts and inspected what was happening under the bridge!!

To the surprise of Arjun and Hanuman, Lord Krishna was bearing the weight and thrusts of Hanuman on his shoulders to protect the bridge made from arrows. And the water was turning red as his shoulder was bleeding profusely.

Both Hanuman and Arjuna saluted Lord Krishna with folded hands.

Krishna hugged both of them and introduced both of them to each other and said that they both were equally dear to him but how could he let Arjuna take his life according to his vow.

Here lord Krishna took a promise from Hanuman that he would protect the chariot of Arjuna in the battle field of Mahabharata.

Thus Hanuman remained on the top of Arjuna’s chariot throughout the battle of Mahabharata.
(Contributed by Dr Anil Jain)

Emedinews:Insights on Medicolegal issues:The concept of 'required request' required in cadaver organ retrieval for transplantation

The concept of 'required request' requires to be introduced, wherein hospitals will be allowed to ask ICU patients, whether they would be willing to donate organs.
• It should be made mandatory for hospital ICUs to declare all brain deaths and register them with an online central organ registry for better coordination of cadaver organ donation, retrieval and transplantation.
• In India, certain amendments to the Human Organ Transplant Act 1994 are required to enhance cadaver organ retrieval and transplantation to bridge the huge demand-supply gap.
• The pool of donors, including increasing the supply of organs by widening the definition of 'near relatives' by allowing organ swaps among needy families, as well as, simplifying cadaver transplant procedures. Paired matching should be permitted i.e. if patient A's donor does not match A and likewise for patient B, then donor switch should be allowed, if it results in a match. Swaps or exchanges between families enable to fulfill the need of their family member in need of a transplant
• Hospitals equipped with ventilators and artificial life support system must make mandatory effort to coordinate with organ bank and retrieve organs and the reason of failure must be documented for further review.
• The World Medical Association (WMA) recommends that “The physician may, when the patient cannot reverse the final process of cessation of vital functions, apply such artificial means as are necessary to keep organs active for transplantation provided he acts in accordance with the laws of the country or by virtue of a formal consent given by the responsible person and provided the certification of death or the irreversibility of vital activity had been made by physicians unconnected with the transplantation and the patient receiving treatment.”
• These artificial means shall not be paid for by the donor or his relatives. Physicians treating the donor shall be totally independent of those treating the recipient and of the recipient himself.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure:A rape victim became pregnant.

Situation: A rape victim became pregnant.
Reaction: Oh my God! Why was an emergency contraceptive not given to her?
Lesson: Make sure that all victims of rape are given an emergency contraceptive.

Emedinews:Inspiration:Duty bound (Part two)

He tried to console his daughter, "It is futile Devayani to bring Kacha to life. The Asuras are determined to get rid of him. A wise soul, like you, should not grieve at a loved one's death. You are young and beautiful and you have your own life to live."

But Devayani was adamant. So strong was her love for Kacha. "Father” she said, “Kacha was your best student. I am in love with him. I cannot live without him."

Devayani stopped eating. Shukracharya could no longer bear to see his daughter in such agony. Again Shukracharya used his secret knowledge and called upon Kacha to come back to the world of the living. Kacha came back to life and spoke from inside the stomach of Shukracharya. "The Asuras killed me but I do not know how I happen to be inside your stomach?" echoed Kacha.

Shukracharya cursed himself for drinking the wine given by the Asuras. "Henceforth, wine shall be forbidden for those engaged in the pursuit of wisdom," declared Shukracharya in great frustration. Now Shukracharya had a real dilemma of his own. He could ask Kacha to come out but that would mean his own death.

When he told Devayani of his dilemma she was again adamant, "Father, I cannot live if either of you dies."

After long deliberation Shukracharya thought of a way out. He now knew the real purpose of Kacha's visit. He addressed Kacha, "I now see why you came and truly you have succeeded. There is only one way by which both of us can ensure Devayani's happiness. I will have to teach you the craft of Mritasanjivani.

With his new knowledge Kacha emerged from Shukracharya's dying body and then immediately brought his guru back to life. Shukracharya could not have been happier with his pupil's progress.

When the Asuras came to offer him wine, Shukracharya shouted, "You fools! Kacha now knows my secret. You helped him learn by your foolish deeds. But rest assured Kacha will continue to live with me because of his love for Devayani.

But Shukracharya was wrong. Kacha too faced the troubling dilemma. Waiting for the period of his studies to come to an end, Kacha kept silent. While his love for Devayani was deep, his sense of duty towards the devas was no less strong.

On the last the day of his studies, Kacha went to Shukracharya for his blessing. As a wise man and a dedicated teacher, Shukracharya concealed his grudge against Kacha but he was wondering how Kacha was going to bid farewell to Devayani.

Devayani waited for Kacha to propose marriage. But when Kacha broke the heartbreaking news that he was going to fulfill his obligations to his own people, her joy turned to tears. Devayani pleaded with Kacha to take her as his wife. But Kacha replied, "Peerless one! I was reborn in your father's stomach. I am therefore your brother. I can't marry you. I must return to heaven."

The broken-hearted Devayani cried out in her grief. She accused Kacha of using her to attain his goal. Distort she cursed Kacha, "You will never be able to use the craft of Mritasanjivani."

Kacha quietly listened and then spoke, "Devayani, it is wrong to curse me. I could have walked away without reviving your father. There is no doubt that my love was sincere and truthful. But, I also have a duty to perform towards my own people. Because of your unfairness to me, I am cursing you. No Rishi's son will ever marry you. I may still teach the craft of Mritasanjivani to others, even though I may not be able to use it myself." Saying this Kacha departed for the abode of Indra, king of the Devas. Shukracharya gently led Devayani away.

Emedinews:Insights on Medicolegal issues:Gratuitous medical services -rendering emergency medical care at scene of accident……

The legal and ethical duty which is imposed on the doctor to exercise due skill and care only arises where there is a doctor/patient relationship come in contractual existence as per Indian evidence Act.
• If a doctor is passing/crossing the scene of an road traffic accident/any medical emergency in which some person has been injured/sick and is in need of urgent medical/surgical attention/intervention to save the life or limb of the injured he/she would not be held to have been negligent, if suppose he does not render/provide medical assistance to the patient for violation of civil/criminal or consumer law , as no doctor / patient relationship has been established/came in force for medical care delivery and in consequences the doctor owes the patient no legal duty towards the injured person .
• If, however, the doctor goes to the medical assistance of a person who is injured in an accident revealing/pronouncing himself as doctor then a doctor /patient relationship is at once established in implied manner and the doctor become bound down ethically and has a duty to exercise reasonable/required standard skill and care in providing medical care at that length of situation regardless of whether or not his medical services are being given gratuitously.
• Many advance country states that when any physician gratuitously advises medical personnel at the scene of an emergency episode by direct voice contact, to render medical assistance based upon information received by voice or biotelemetry equipment, the actions ordered taken by the physician to sustain life or reduce disability shall not be considered liable when the actions are within the established medical procedures
• the American Medical Association, Alabama state trooper, medical aidman functioning as a part of the military assistance to safety and traffic program, chiropractor, or public education employee gratuitously and in good faith, renders first aid or emergency care at the scene of an accident, casualty, or disaster to a person injured therein, he or she shall not be liable for any civil damages as a result of his or her acts or omissions in rendering first aid or emergency care, nor shall he or she be liable for any civil damages as a result of any act or failure to act to provide or arrange for further medical treatment or care for the injured person.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A child with sore throat and the large lymph nodes developed fever.

Situation: A child with sore throat and the large lymph nodes developed fever.
Reaction: Oh my God! Why were antibiotics not given in time?
Lesson: Make Sure that all children with sore throat and enlarged lymph nodes are given antibiotics as such sore throats are Streptococcal unless proved otherwise.

Emedinews:Inspiration: Duty bound (Part 1)

Long ago, the Devas and the Asuras fought all the time for the lordship of the three worlds. The Asuras were carefree and happy as long as Shukracharya, their preceptor, was with them. The valiant Devas, tired of the unequal struggle, went to Kach, the handsome son of Brihaspati, preceptor of the Devas and asked him to go to Shukracharya and learn the secret of Mritasanjibani.

The obedient and dutiful Kacha immediately set out to meet Shukracharya. He humbly presented himself before the great wise man, introduced himself as the son of Brihaspati, and asked to become his disciple.
Shukracharya was a true teacher. He immediately recognized Kacha’s brilliance as a student. Shukracharya did not differentiate between his students. He gave Kacha a warm welcome and accepted him as his pupil.
Shukracharya had a daughter, Devayani, whom he loved dearly. He introduced Kacha to his daughter saying, "Kacha has vowed to be my pupil till the period of his studies is over."

All learning in those days was handed down by word of mouth. The pupil lived with his guru's family as one of the household. In return for his education, the pupil served his guru with love and devotion. However, Shukracharya was very busy either at court or he was deep in meditation. So Kacha helped Devayani with her daily chores and watched after her.

Within a few days of his arrival, Kacha found himself spending all his leisure hours in the company of the lively Devayani. Devayani was slowly drawn towards Kacha and they fell in love. Shukracharya liked Kacha because he was an attentive disciple.

As the years passed, the Asuras became suspicious of Kacha. They wanted to get rid of him. One day as Kacha was attending Shukracharya’s cattle, the Asuras fell upon him and slew him. Then they cut him into pieces and fed his flesh to their dogs.

When Kacha did not come home at the normal hour, Devayani became alarmed. When the cattle came back without Kacha she ran in a panic to her father and told him that Kacha was missing. Shukracharya closed his eyes and to the great relief of Devayani, Kacha came back to life and appeared before her. When Devayani inquired about his disappearance, Kacha tried to explain in a puzzled voice, "I was killed by the Asuras but I do not know how I came back to life?" Shukracharya just smiled.

The love between Kacha and Devayani grew day by day. The Asuras were worried. They guessed right. Kacha was there to learn the secret of Mritasanjibani.

One day Devayani asked Kacha to get her a particular flower that only grows in the deep forest. Kacha went for it. The Asuras followed him and once again killed him. But this time they carried his body to a secluded spot, grounded up into a paste, and dissolved it in the water of the ocean.

Devayani waited and waited. When Kacha did not return she went again to her father. Shukracharya meditated and once again used the secret knowledge to revive Kacha. Devayani was overjoyed. The Asuras were now at their wits end. "How can we kill Kacha? Every time we kill him, his guru brings him to life!"

They went to one of the senior Asuras and asked him how to destroy Kacha for good. The senior Asura gave them an idea. The next day, when Kacha went out with the cattle, they again slew him. This time then burnt him in the jungle. Then they took the ashes home and mixed it in a wine which Shukracharya was very fond of. They took the drink to Shukracharya for a taste. Shukracharya loved it. He immediately drank it and blessed the Asuras.

When the cattle once again returned home without Kacha Devajani knew what had happened. "Will Kacha ever be mine?" she asked herself "The Asuras will never leave him alone!" She went to Shukracharya and wept. "Father, without Kacha I am as good as dead, please bring him back to life." Shukracharya waited for a while thinking. "It is no good to bring Kacha to life. The Asuras will only kill him again. "

(To be continued)

(Contributed by Dr Anil Kumar Jain)

Emedinews:Inspiration: Heaven and Hell

A holy man was having a conversation with the Lord one day and said, "Lord, I would like to know what Heaven and Hell are like."

The Lord led the holy man to two doors. He opened one of the doors and the holy man looked in.

In the middle of the room was a large round table. In the middle of the table was a large pot of stew which smelled delicious and made the holy man's mouth water.

But the people sitting around the table were thin and sickly. They appeared to be famished. They were holding spoons with very long handles that were strapped to their arms and each found it possible to reach into the pot of stew and take a spoonful, but because the handle was longer than their arms, they could not get the spoons back into their mouths. The holy man shuddered at the sight of their misery and suffering. The Lord said, 'You have seen Hell.'

They then went to the next room and opened the door. It was exactly the same as the first one. There was the large round table with the large pot of stew which made the holy man's mouth water. The people were equipped with the same long-handled spoons, but here the people were well nourished and plump, laughing and talking.

The holy man said, "I don’t understand."

"It is simple" said the Lord, "In this place the people have learned to feed one another."

(Contributed by Ms Ritu Sinha)

Emedinews:Makesure: A patient of gross ascites presents with complaints of difficulty in breathing on lying down.

Situation: A patient of gross ascites presents with complaints of difficulty in breathing on lying down.
Reaction: Oh my God! Why did you drain so much ascitic fluid.
Lesson: Make sure, to evaluate only moderately tap ascitic fluid as overenthusiastic tapping can be life–threatening.

Emedinews:Insights on Medicolegal issues:Medical care communication by doctor to patient must be documented

Doctor-patient/doctor-family communication is essential for patient/family satisfaction/approval with provided medical care

• Including patients in decision-making in health care always prevents malpractice allegations.
• Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. A medical record chronologically documents the care of the patient and is an important element contributing to high quality care.
• An open exchange of information must be encouraged. This is very important to reduce litigation. Details of interactions should be included in the medical record as they both relate to decisions about current care and can potentially help in future care decisions.
• Key components of this documentation include who participated in the meeting, how they are related to the patient, and the patient's competency if he/she participates in the discussion along with decisions that were made.
• Documentation of physician-patient discussions about patient wishes while the patient is still able to express them can help once the patient is no longer mentally competent.
• Along with medical facts such as physical exam and laboratory values, clinician decision-making and the reasons behind the decisions should be incorporated into the medical record.
• The medical record facilitates the ability of the physician and other health care professionals to evaluate and plan the patient’s immediate treatment, and to monitor his /her health care over time.

Emedinews:Insights on Medicolegal issues:Suicide by motor vehicle and fake vehicular Accidents to conceal crime

The one-vehicle car crash creates a special problem in the classification of death because the law states that suicidal intent must be proven. Reasons for this legal mandate relate to other legal issues, insurance claims, family concerns, and the stigma attached to suicide.
• Some vehicular accidents are suicidal in nature and most victims are drivers of the vehicle.
• Suspicion may arise from the circumstances preceding the accident, e.g. family quarrel, financial crisis, threats of suicide, history of depression, suicidal notes, etc.
• The characteristic of a suicidal death by a driver is a head-on collision with a road side object, pole or bridge support at a high rate of speed, without evidence of an effort to apply brakes or to evade striking the object.
• The accelerator pedal imprint is an additional evidence of the deliberate nature of the crash. Rarely, premeditated homicide may be disguised an accident. Suspicion should arise when the accident cannot be reconstructed.
• It is very rare a person may be killed by other means and the body placed in a vehicle is pushed off the road to make the scene look like an accident. In such a case careful examination of all the injuries is necessary. Sometimes a murder victim is burnt in a vehicle to conceal the crime. Sometimes putrefaction indicates the body to have been dead prior to the fire.
• The number of vehicular deaths recorded in the United States total 48,800, 46,620, 43,980, and 41,040 for 1989, 1990, 1991, and 1992, respectively. It is observed by analysts of fatal accidents that many of the deaths attributed to vehicle car accidents, especially single-vehicle car, may result from suicidal intent. However, the information necessary to conclude that the driver's intent was to terminate his/her life is generally unavailable.
(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A patient after sublingual nitrate developed fainting attack.

Situation: A patient after sublingual nitrate developed fainting attack.
Reaction: Oh my God! Why was the systolic murmur missed on auscultation?
Lesson: Make sure that patient with left ventricular outflow tract (LVOT) obstruction are not given sublingual nitrates.

Emedinews:Inspiration: life how many colors you have

Ferdu was a retired person. He retired from railways. He was a peon in railways. After retirement he opened a 'khokha' just opposite and a road across to my house. He used to sell pan,cigarettes and bidi there.

Ferdu told me that he was a lonely person. When he retired he had none of his relatives alive. So he used to come to the shop early in the morning and leave late in the evening. Nobody knew where he was residing.

He was very lean and thin, of about five feet in height and had a very dark complexion. His skin of face was full of wrinkles. There was not a single positive point in his personality. He was a very short tempered person and had no friends and only a few customers. He was a patient of asthma and a chain smoker of bidis. I always visited him at his shop and provided him some medicines for his asthma. In return he always paid me a very weak but wicked smile.

Some of the naughty boys of the colony almost daily used to come to his shop and used to say him 'FUDDU'. And this altered name always irritated Ferdu and he always started shouting and abusing the boys. But as usual boys did not stop teasing him until Ferdu started throwing stones over them. Seeing his reaction, the boys laughed and clapped and enjoyed. The boys used to reappear again after a short time and again the whole episode was repeated. I saw this thing to happen again and again for so many years.

One day I heard that Ferdu was dead at that very shop. I went to the shop and certified that Ferdu was dead. I requested the crowd for the preparation of his funerals. But nobody gave ear to my request.

After a short period of time those naughty boys gathered at the scene. They all were sad and weeping a lot. They sat around the body of Ferdu and mourned his death. After some time they realized that Ferdu had no relatives and no other person was ready to arrange the funerals. So they took this responsibility. They inquired about the religion of Ferdu. But no one amongst the crowd knew the religion of Ferdu. The boys were Hindu so they decided to do the funerals as per Hindu religion. They contributed their Pocket money for this. Some persons also donated the money. Boys did all the arrangements for funerals. They did this as his sons could do.

I was amazed to see this mysterious relation. This relation developed out of hatred of Ferdu with the boys and a play of teasing and applauding of boys with Ferdu. 'O' life how many colors you have?

(Contributed by Dr Anil Kumar Jain)

Emedinews:Insights on Medicolegal issues:Very old, very young or in patients in poor health harmed more by poison

• The effect of exposure depends partly on how long the contact lasts and how much poison gets into the body, and partly on how much poison the body can get rid of during this time. Exposure may happen only once or many times.
• Acute exposure is a single contact that lasts for seconds, minutes or hours, or several exposures over about a day or less.
• Chronic exposure is contact that lasts for many days, months or years. It may be continuous or broken by periods when there is no contact. Exposure that happens only at work, for example, is not continuous. Chronic exposure to small amounts of poison may not cause any signs or symptoms of poisoning at first.
• It may be many days or months before there is enough chemical inside the body to cause poisoning. For example, a person may use pesticide every day.
• Each day the person is exposed to only a small amount of pesticide, but the amount of pesticide in the body gradually builds up, until eventually, after many days, it adds up to a poisonous dose. Only then does the person begin to feel unwell.
• WHO states that a poison is any substance that causes harm if it gets into the body. Harm can be mild for example, headache or nausea or severe for example, fits or very high fever, and severely poisoned people may die.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A patient with chest pain with normal ECG died half an hour later.

Situation: A patient with chest pain with normal ECG died half an hour later.
Reaction: Oh my God! Why was acute MI not suspected?
Lesson: Make sure all patients of chest pain are observed for 12 hours. ECG can be normal in acute heart attack for up to six hours.

Emedinews Inspiration

An old man was visiting a city for the first time in his life. He had grown up in a remote mountain village, worked hard raising his children, and was then enjoying his first visit to his children's modern homes.

While being shown around the city, the old man heard a sound that stung his ears. He had never heard such an awful noise in his quiet mountain village. Following the grating sound back to its source, he came to a room in the back of a house where a small boy was practicing on a violin.

'SCREECH! SCREECH!' came the discordant notes form the groaning violin. When he was told that it was called a 'violin', he decided he never wanted to hear such a horrible thing again.

The next day, in a different part of the city, the old man heard a beautiful sound, which seemed to caress his aged ears. He had never heard such an enchanting melody in his mountain valley. Following the delightful sound back to its source, he came to a room in the front of a house where an old lady, a maestro, was performing a sonata on a violin. At once, the old man realized his mistake. The terrible sound that he had heard the previous day was not the fault of the violin, or even the boy. It was just that the young man had yet to learn his instrument well.

With a wisdom reserved for the simple folk, the old man thought it was the same with religion. When we come across a religious enthusiast causing such strife with his beliefs, it is incorrect to blame the religion. It is just that the novice has yet to learn his religion well. When we come across a saint, a maestro of her religion, it is such a sweet encounter that it inspires us for many years, whatever their beliefs.

But that was not the end of the story.....

The third day, in a different part of the city, the old man heard another sound that surpassed in its beauty and purity even that of the maestro on her violin. What do you think that sound was?

It was a sound more beautiful than the cascade of the mountain stream in spring, than the autumn wind through the forest groves, or than the mountain birds singing after a heavy rain. It was even more beautiful than the silence in the mountain hollows on a still winter's night. What was that sound that moved the old man's heart more powerfully than anything before?

It was a large orchestra playing a symphony.

The reason that it was, for the old man, the most beautiful sound in the world was, firstly, that every member of that orchestra was a maestro of their own instrument; and secondly, that they had further learned how to play together in harmony.

(Contributed by Ms Ritu Sinha)

'May it be the same with religion,' the old man thought. 'Let each one of us learn through the lessons of life the soft heart of our beliefs. Let us each be a maestro of the love within our religion. Then, having learned our religion well, let us go further and learn how to play, like members of an orchestra, with other religions in harmony together!' That would be the most beautiful sound!

Emedinews:Insights on Medicolegal issues:What is disinterment in Forensics?

To dig up something buried, especially a corpse is called disinterment

• Many early groups buried the corpse in the ground and exhumed it at a later date for religious rituals, a practice still undertaken by some traditional societies.
• In fourteenth-century France, it became common procedure to dig up the more or less dried-out bones in the older graves in order to make room for new ones.
• The high death rate from the European plagues coupled with a desire to be buried in already-full church cemeteries led to old bones being exhumed so that new bodies could be placed in the graves. In times past, on rare occasions prior to embalming, the body was removed from the ground. This happened when burial professionals or the authorities suspected that the person might have been buried alive.
• The French philosopher and death expert Philippe discussed necrophiliacs who disinterred dead bodies for sexual purposes and scientists who dug up corpses to conduct scientific experiments.
• It is common knowledge that for centuries until cadavers were legally provided medical schools exhumed dead bodies for teaching purposes. One of the reasons the use of the wake was enacted in many societies was to deter those who might steal corpses.
• To test methods for preventing or slowing down the process of postmortem decay. U. Mobus and colleagues describe an usual case of exhumation, in which a young person "exhumed" a child's body involved in a road accident because he wanted to test methods for preventing or slowing down the process of postmortem decay.

(Ref: Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Volume 2, Number 2, July-December 2001)

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A patient of asthma worsened on aspirin.

Situation: A patient of asthma worsened on aspirin.
Reaction: Oh my God! Why was history of allergy not taken?
Lesson: Make Sure that patients with asthma are not given aspirin without asking a history of allergy.

Emedinews Inspiration: Honesty

Morality may consist solely in the courage of making a choice. Wickedness is always easier than virtue, for it takes a short cut to everything. But over time you learn, you can't make wrong work.

There are always two choices, two paths to take. One is easy. And your only reward is that it's easy. You cannot do wrong without suffering wrong.

Work joyfully and peacefully, knowing that right thoughts and right efforts will inevitably bring about right results.

You can never lose anything that really belongs to you, and you can't keep that which belongs to someone else.

You always experience the consequences of your own acts. If your acts are right, you'll get good consequences; if not, you'll suffer for it.

Sooner or later everyone sits down to a banquet of consequences.

(Contributed by Ms Ritu Sinha)

Emedinews:Insights on Medicolegal issues:No two people except identical twins have the same DNA structure

• Human being has a unique signature that lives within every cell of our body. This signature is commonly known as DNA, testing is done by taking DNA extracts from biological sample putting them into a gel matrix and then using probes to help extract certain markers.
• We get our DNA from our biological mother and biological father. Each of them contributes 50% of our chromosomes that will make up our DNA, which will stay with us for our entire lives without change. This is the very reason that makes DNA such a great choice for uniquely identifying a person.
• Questions may arise as to how accurate DNA tests are. After all, in the past blood tests cannot have been as accurate as we might have hoped. They often left a bit of uncertainty or could not be conclusive in many areas. But thanks to the uniqueness of DNA almost all of these doubts can now be taken away.
• Testing can be done on DNA to help determine parentage, ancestry, presence of genetically-based diseases and to help identify someone who may have been present at a crime scene.
• Most DNA tests are run at least twice, both independent of each other. This not only builds upon the credibility of the test but also helps ensure that no wrong data or incorrect marker analysis was performed on the first test. If any discrepancies are detected between the two tests then a new sample is used and the entire test is performed again to understand where the discrepancy may lay.
• Modern testing procedures and rules for DNA analysis mean that with rare exception DNA testing results can be guaranteed to be more than 90% accurate for most paternity, forensic and genetically-based disease analysis.
• However human error can come into play. A lab may mistakenly switch samples or key in data incorrectly. All of these factors are possible, but are very rare in occurrence. If there is ever any doubt as to the authenticity or correctness of a test it can simply be performed again to confirm accuracy.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: An elderly died of pneumonia.

Situation: An elderly died of pneumonia.
Reaction: Oh my God! Why was pneumonia not suspected?
Lesson: Make sure in all elderly, pneumonia is excluded even if the symptoms are atypical in nature.

Emedinews Inspiration: Her struggle.....Part three

After all of my social and official duties towards Sultan were over, I went to the 'ICTC'. I conveyed to the doctor the fate of Sultan. I asked her that as I was pregnant and HIV-positive, were there any legal bindings on me to give birth to my baby or not. She told me that confidentiality was the primary object of 'ICTC' . She had told me about the HIV status of Sultan only after he had consented to it. There were no legal bindings even over him to tell his wife about his HIV status. At least we the health providers keep it confidential. She told me that it was up to me to go for a baby or not. Till date HIV-positives have full right to go for a baby or not . She told me HIV-positive mothers could transmit HIV infection to their babies during pregnancy, during labor or delivery and via breast milk. There are medicines which can reduce this risk. But even after proper prophylaxis, there were chances of mother to child transmission (MTCT). If you opt for a baby to be delivered you have to take extra calories in your diet throughout your pregnancy. During childbirth also, it was not mandatory that HIV-positive mothers should disclose their status to the doctor but such disclosures might save the life of mother and child or might be good to stop MTCT. If HIV mothers gave birth to a child there are up to 20 % chances of MTCT and up to 20 %. A HIV-negative baby born to HIV-positive mother might get it through breastfeeding. Drugs given to the mother during pregnancy and to the baby just after birth can reduce this up to almost 2 % chances. If HIV-positive mother does not opt for breastfeeding, she has to opt for AFASS criteria for feeding the baby. The AFASS criteria was to protect child from getting opportunistic infections as these infections might kill more newborn babies than the number of babies getting HIV infections through breast milk. If HIV-positive mothers opt for breast feeding it has to be total breastfeeding, no milk substitute are allowed for six months then abrupt stopping of breastfeeding is recommended. The HIV-positive mothers during pregnancy and HIV-positive new born should receive the same vaccines as if they were HIV negative.

I thanked the doctor for the information given and visited my mother’s home. She still did not know about my HIV status or my pregnancy. She formally condoled Sultan’s death and insisted that I should remarry now. Then I told her that I was HIV-positive and pregnant too. She was shocked and started weeping. I was the main cause of her sorrows. I never gave ears to her advice. I could not stay there very long. I returned home.

Then was the time when I had to take firm decisions. But every decision of me regarding my life had been a catastrophe for me. Sultan and each person known to me opposed my decision to be pregnant. But I went for pregnancy. HIV virus showed me no courtesy. It infected me and was in my blood for ever. Should I go for abortion? But why? I could adopt a child when I was HIV-negative. I insisted on having Sultan’s child regardless of me acquiring the infection. What was the difference in the situation now? What I wanted was inside me. But this virus would not spare my baby. How would my baby after birth withstand the disease and the stigmas associated with it? Then once again I collected all my courage and made a final decision that I would struggle against this cruel virus. I would give birth to my child .The last remains of Sultan had every right to flourish. I would take every necessary medicine available on the earth. My baby would see the world. Let me prove that this virus could not be bigger than human efforts. I would give birth to my baby and would also breast feed him. And only this child would tell the world that the love story of his parents was not an inch lesser than the story of Laila-Majnu.

I took every precaution and medication during the pregnancy which the doctors advised me. I had disclosed my status to the Obstetrician. Maa visited often but she was not happy with me at all. My diet was increased. I was getting 600 extra calories per day.

I gave birth to a son. Doctor gave my son a prophylactic dose of syrup Nevirapine. I fed him colostrum. I was anxious to know the HIV status of my son. But the doctor told me that it was not possible as baby had mother's antibodies against HIV. Doctors had also counseled me about the health of my breasts and oral hygiene of baby's oral cavity. They also counseled me about AFASS criteria if I did not feed my baby.

The baby grew. He was healthier than the other babies of his age. After six months I stopped breastfeeding abruptly as advised by doctors.

At the age of about one year, my son underwent HIV test. He was HIV-negative. That day I could not prevent my tears to flow out of my eyes . After all I had defeated that dreaded virus. This was a victory of human efforts over HIV.

Today my son is five years old and I am not taking antiretroviral treatment as my CD4 count is over five hundred. Doctors of ICTC say that I can live upto 15more years and I have taken another oath that if I will be alive up to the marriage of my son I will marry him with an HIV-positive girl. Of course, only if she got it accidentally, as Sultan got it. Till than I have to remain alive whatsoever may be the circumstances. I will struggle to see that happen. Thus her struggle starts........

(Contributed by Dr Anil Kumar Jain)

Emedinews Inspiration: Her Struggle…Part 2

That was the first night after our married life when we slept in separate rooms. All the night I could not sleep as only one thing, my fate if Sultan was HIV-positive, was churning my brain. I was also sure that Sultan too remained restless all that night. Next day when we reached to the ICTC, I was asked to sit outside while Sultan went inside the doctor’s chamber. When I went inside, one glimpse of his face was enough to tell me that his test for HIV was positive. Suddenly I felt that I was about to faint. But I had to face that cruel disclosure so I sat near Sultan silently. The Doctor told me that AIDS had treatment and the quality of life and survival could be improved with treatment. Doctor advised me too to give a blood sample. After my signing of an 'Informed Consent'. Doctor told me if I was HIV negative in the first test then my next test would be done after three months. We both did as doctor advised to do.

After reaching home I blamed Sultan that he knew about his disease even before our marriage but he politely refused it. We quarreled on this issue for some time. And reached office separately, a rare incident after marriage. I could not work properly that day. Suddenly my happy married life had turned into a hell and at least I was feeling the wrath of it. No argument of Sultan could convince me that he was innocent and infection entered his body through blood transfusion.

Next day I was declared negative to the test. It was a surprise. How it was possible? We regularly had sexual contact without the protection of Nirodh. I asked the doctor about this. She told me that it was Possible, as the chances of HIV transmission through sexual contact was only one percent. It meant that if an HIV-positive person would make contact with one hundred persons the chances are that HE or SHE will transmit it to one person. The doctor told me that there are 95 percent chances of HIV transmission through infected blood transfusion. Doctor counseled us (post test counseling). She said that I could safely live with Sultan. We could use same utensils, share same bed and same toilets. We can hug each other, kiss each other.....but practice safe sex. Doctor advised Sultan for CD4 count to be performed for the treatment of the disease. She advised him to take more nutritious food, exercise regularly. She advised Sultan to visit ICTC at least every month. Then the doctor requested Sultan to wait outside and told me that now it was my responsibility to keep Sultan cheerful and out of 'intrinsic' stigma (stigma which arises from inside and it is like inferiority complex) as he feels guilty complex. I asked her how could we have a baby when we have to use some protection now. She said IVF [in vitro fertilization] could solve our problem or we could adopt a baby.

I asked the doctor how was the infected blood transfused to Sultan. She told that five years back there were no provisions for screening blood for HIV. Later it became necessary. Moreover if donor of blood or body tissues or organs has a recent infection of HIV he or she might be in window period i.e. His or Her blood would test negative for HIV but HE or SHE still might transmit HIV infection to the recipient of blood. .

After reaching home that day I was a little relaxed as I did not have the infection. But another big question was for our future life and Sultan’s life. But, first I had to investigate whether Sultan was telling a truth that he was transfused blood five years back. Only then it was to be decided that we were going to live under same roof.

Next day I took a leave from my office and reached the hospital where Sultan told me that he was transfused blood. After one hour of study of their old records one of the hospital people told me that Sultan was right. He actually was transfused blood as he was bleeding profusely from his nostrils. His nasal bone was fractured . From there I reached to my mother's home. I told her each and every thing in detail . She immediately advised me for a divorce. She blamed Sultan that he knew about his disease before marriage and on this basis I could get divorce. But I was mentally not in a position to take a decision.

I returned home and started thinking with a very cool brain. I could live with Sultan but How it was possible to make sexual contact with a person which was having HIV infection even when we were using condom? How long he was going to live? Should we adopt a baby? In IVF technique doctors will use the sperms of a person other than Sultan? Maa was advising about divorce? But how could I do that when to marry Sultan was my decision? Nobody forced me to marry Sultan. And if I had been HIV-positive and Sultan was HIV-negative then would Sultan be correct in divorcing me? How could I leave Sultan now when he needed me most? But I was still HIV negative and young and could marry again easily. Sultan returned from office. I told him that I went to the hospital and he was telling a truth. Sultan sat near me and hugged me and said that he was going to a lawyer next day and was asking him to prepare papers of divorce . Then I told him about the same advice of my Maa. Sultan advised me to think over it peacefully and to take appropriate time for it.

I thought it peacefully several days and reached on the decision that I was not going for divorce to Sultan. More over we would have our own baby, No IVF no adoption. In the process if I got the HIV infection it hardly matters to me. When I and Sultan decided to marry we took an oath that we would remain inseparable there after whatever might be the circumstances. This tiny virus should not dent our promises made to each other.

Next day we went to the ICTC center . CD4 count was 410/cubic cc and there was no need to start 'antiretroviral' treatment immediately. I told the doctor that we planned to have a baby of our own , and no IVF no adoption. What are the chances of baby being HIV-negative or positive. She told us that if we took every precaution even there are about 2 percent chances of the baby acquiring the infection. Though Sultan opposed it, he agreed to have sexual relations without condom till I became pregnant. We had unprotected sex up to three months when my next test for HIV was scheduled . I went to the ICTC center for HIV test. My blood sample was taken after 'Informed Consent'. On the way to home I also gave a urine sample for pregnancy test as I missed my period.

Next day I went alone to collect my both test reports as Sultan had to go to a nearby city for official work. Both my reports were positive, I was pregnant as well as HIV-positive. It was shocking to me. But the decision had been mine. I had to live with this infection lifelong. But what about the baby? Let Sultan come. I waited eagerly for Sultan. But he did not come. The news of his death came. His car met with an accident when he was returning home. He died on the spot.

To be continued...........

(Contributed by Dr.Anil Kumar Jain) 

Emedinews:Makesure: A 40–year–old hypertensive complains of head reeling in spite of being on antihypertensive.

Situation: A 40–year–old hypertensive complains of head reeling in spite of being on antihypertensive.
Reaction: Oh my God! Her blood pressure is still high. Why didn’t you advise lifestyle modification?
Lesson: Make sure to first advise lifestyle modifications like exercise, low salt diet, high fiber diet, decreasing stress etc. before advising antihypertensive medication, in essential hypertensives.

Emedinews:Insights on Medicolegal issues:Hair and fiber in forensic cases

• Hair and fiber are commonly used in investigation in cases of assaults, sexual offences, bestiality- found on human body or at the scene of crime.
• Hair comprises mainly two parts: shaft is the part above the skin, and root lies below the skin. The root has a bulb as a base, embedded in hair follicle. The cuticular scales cover the shaft. The shaft has two layers: outer one is called cortex, and the inner one medulla.
• Pigment of hair is present in the cortex. The cuticular scales present around the cortex are non-nucleated cells originating from follicle, and are keratinized.
• The medulla consists of cylinder-like cells produced by matrix cells. The ratio of medullar diameter to that of the shaft is known as medullar index.
• The medullary column is present in the center of the cortex. The pigment granules present in the cortex consist of melanin. It is made up of several units of monomer, consisting of indole and quinone. It contains amino acids like dihydroxy phenylalanine and tyrosine.
• The medullar cells contain large amount of glycogen.
• Macroscopic and microscopic examination of hair is done in the forensic laboratory, to distinguish it from fiber and to ascertain whether the hair is of a human hair or an animal and to fix the individual identity

(Contributed by Dr Sudhir Gtupta)

Emedinews:Insights on Medicolegal issues:What is hanging and Hangman's fracture?

The location of the knot of the hanging rope is a major factor in determining the mechanics of cervical spine injury, with a submental knot or Hangman's knot under the chin being the only location capable of producing the sudden, straightforward hyperextension injury that causes the classic "Hangman's fracture”. The cause of death in hanging depends on the conditions related to the event. When the body is released from a relatively high position, the major cause of death is severe trauma to the upper cervical spine. However, the injuries produced are highly variable. A hanging may induce one or more of the following medical conditions leading to death:

• Closure of the airways/closure of carotid arteries causing cerebral ischemia/closure of the jugular vein causing apoplexy are the main causes of death in hanging along with the induction of carotid reflexes, which reduces heartbeat and may result in cardiac arrest.
• Breaking of the neck/cervical fracture causes traumatic spinal cord injury or decapitation. Judicial hanging fractures the cervical spine. However, in some cases, the classic hangman fracture (bilateral fractures of the pars interarticularis of the C2 vertebra) is seen.
• Death from a "hangman's fracture" occurs mainly when the applied force is severe enough to also cause a severe subluxation of the C2 and C3 vertebra that crushes the spinal cord.
• When cerebral circulation is compromised by any mechanism, arterial or venous, death occurs in 4 to 5 minutes from cerebral hypoxia, although the heart may continue to beat for some period after the brain can no longer be resuscitated.
• The time of death in such cases is a matter of convention. In judicial hangings, death is pronounced at cardiac arrest, which may occur at times from several minutes up to 15 minutes or longer after hanging.

Emedinews:Makesure: An elderly patient with unstable angina presented with URTI and was found to be positive for C. pneumoniae infection.

Situation: An elderly patient with unstable angina presented with URTI and was found to be positive for C. pneumoniae infection.
Reaction: Remember to start macrolides immediately.
Lesson: Make sure to remember that erythromycin 2 g/day for 10-14 days reverses the increased risk of atherosclerosis. Sero-epidemiological studies have shown a strong association between C. pneumoniae infection and atherosclerosis in patients with cardiovascular disease.

Emedinews Inspiration: Her struggle.....Part One

Today I remember when for the first time I told my mother that Sultan was my colleague, was earning more than me, was tall and of charming personality but was of different religion, my mother's first reaction was of great surprise and she advised me never to meet him again and not to disclose it to my father. But it was the question of my life and Sultan and I were of the view that religion was a very personal thing and religious beliefs could remain intact even after marriage.

My mother told my father same day. He also advised me about the pros and cons of this inter religious marriage and tried his best to convince me otherwise. Sultan and I ultimately had a court-marriage with an understanding that we would remain inseparable in future even under the oddest circumstances. Sultan had no close relative and my parent and relatives were not present on the occasion.

As we had planned, we avoided pregnancy using condom and safe period upto two years of our marriage. These two years were the best years in my life. Our different religions could not dent our family affairs. My parent and other relatives never visited our home. My mother used to ring me occasionally, I visited my parent's home several times but my parent never welcomed me and Sultan. But I was happy with Sultan and never expected more from my parent and other relatives. We were thankful to God that he gave us a beautiful life. Every thing was OK in my life.

The problem began when Sultan started losing weight and developing early fatigue. One of our family friends was a qualified Doctor and he prescribed some medicines to Sultan but he continued to lose weight. One day he visited our home and advised us both to visit a nearby ICTC (Integrated Counselling and Test Center for HIV and AIDS). When we visited the Center, we told the counselor about Sultan’s problem. He sent us to the doctor’s chamber. The doctor enquired in detail about Sultan's problem and asked him about:

His extra marital or pre-marital sexual relations.

History of any blood transfusion in previous five years

Any habit of taking intravenous drugs and sharing needles while doing so.

Sultan said that once in a road accident his nasal bone had been fractured and he had been bleeding profusely. He was taken to a nearby hospital and was asked for one unit of blood transfusion. As he did not have a close relative to give him blood, he had to purchase it from a professional blood donor. This was about five years back. Sultan told the Doctor that he had no pre-marital or extra marital relation. He was advised to undergo HIV test and was also counseled about post test scenario. After an informed consent for the test, blood sample was taken. We were asked to come next day to collect the report.

Rest of the day was a very long day to me. Did Sultan have HIV infection? Did he have extramarital relations? Was my decision to marry him correct? If he turned out to be HIV-positive, should I convey it to my parents and should I continue my sexual relations with him? I was restless. By night, I was sure that he had already transmitted that infection to me. The other part of my brain was arguing that I should wait the result to come. I should not be so cruel even to think against Sultan. After all he was my Love. He was my choice. We vowed to remain inseparable in every circumstance whatsoever they might be. Was it true that he had been transfused blood? But he had no marks of injuries! He had never mentioned the incident to me. What would my future be, if he turned out to be HIV-positive. Had I also had become HIV-positive?

But we had married against the wishes of our parents and society. What of the promises and vows we had taken together? Could a virus of size 120 nm make us separate? Was this virus stronger than the society? What should I do?

(To be continued.............)

(Contributed by Dr.Anil Kumar Jain)

Emedinews:Insights on Medicolegal issues:Smothering death- Forensic autopsy

Deviation of the nose, bruising of the upper lip, and suspected intra-oral and facial bruising are diagnostic autopsy findings in death due to smothering
• Smothering is defined as an obstruction of the air passages above the level of the epiglottis, including the nose, mouth, and pharynx.
• This is in contrast to choking, which is considered to be due to an obstruction of the air passages below the epiglottis.
• The manner of death in smothering can be homicidal, suicidal, or an accident.
• Accidental smothering is considered to be a rare event among middle-aged adults, yet many cases still occur.
• Homicidal smothering is the deliberate occlusion of the external airways, usually using the hands, pillows, or bedding.
• Victims are often those who are unable to resist, such as the young or the old or highly intoxicated. The limited resistance offered by these individuals may result in a comparative lack of injury.
• Murder is comparatively rare however in some cases the assailant has tried to cover his or her tracks by setting fire to the location at which the deceased is finally found. This could be a house, an office, a workshop, anywhere.
• The autopsy surgeon must look for the telltale signs: the bloodshot eyes, the high levels of carbon dioxide in the blood and bruising around the nose and mouth and may even collect trace evidence such as hairs and fibers from around the nose and mouth of the deceased.
• Histological sampling of suspected injuries can be rewarding, even in the presence of severe post-mortem deterioration due to decomposition.
• The upper lip and lower lip should be excised and processed for histology, sections may show remarkably good tissue preservation and extensive recent bruising,

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A patient’s blood pressure was not responding on Armament.

Situation: A patient’s blood pressure was not responding on Armament.
Reaction: Oh my God! Why was the patient given Artamin?
Lesson: Make sure that prescription is clearly written.

Emedinews Inspiration: Harmful addictions

This morning I received a call from a young lady named Jenny. She was the daughter of an old friend, Morgan, whom I had cut off ties with a few years ago because of her addictions relating to alcohol and prescription drugs. The moment I saw the name appear on the caller ID I knew it was not good news -nor was it a "Care-Call" to just check in on me as I had had no contact with any of Morgan's family members for a number of years as well.

My first instinct, when I read the name announcing itself on my phone line, was that Jenny was calling me to inform me of her grandmother's passing as Barbara is now in her mid 70s and has had numerous medical complications. However, by the time Jenny was finishing the final words of her very first sentence, I knew the call was relating to her mother Morgan instead! Jenny informed me that her mother had been found dead in her home just two days earlier and that the family would be flying in to hold the services in the city Morgan passed on in.

I live just a few miles away and I was touched that I even got a call! I am a rather private person where my emotions are concerned and I am using this unfortunate and tragic opportunity to simply let my mind wrap around the fact that the final chapter in the book of such an amazing and absolutely brilliant woman's life has come to a bitter end. Morgan was soft spoken, charismatic and most of all she was a warm and gentle soul. Whenever I met with her outside of her inebriated or drug-influenced state, she spoke of such delightful topics as the value of learning, how to connect to someone else's situation free of judgment, and to simply observe and remove oneself from discrimination and disdain. She carried a type of wisdom with her that was always a contradiction to the flip-switch we encountered when she would partake in her drinking and substance abuse. She reminded me of those old black and white comedies where in which a gentleman would dress in perfect uniform on one side -allowing viewers to see the very essence of who he was as a proper gentleman while the other half of his appearance mocked its self by transforming him into a woman.

Then the actor would begin to turn from side to side in order to properly assign each character -the feminine and the masculine… allowing them to express and explain their own take on whatever imaginary text or content they were negotiating themselves around. That was Morgan.

She was so profoundly profound on one side of her spirit and yet so frighteningly frightened on the other. I cannot even begin to imagine living within the confines of such a bitter dispute. I see how such an existence could and would drive any human being to the literal brink of insanity. In that place of acceptance, I can begin to unveil the fine line between her battle to defeat her demons and the one those very same monsters waged back in their own determination to prevail as well.

As unfair and unnecessary as all of the tragedy was - it hopefully has instilled in those of us left remaining in this disarranged and obscure moment to recognize the importance each and every one of us must embrace regarding our own value and worth. If I had to say anything about her death it would be that at least now -for Morgan the battle is over. The war has come to an end and she is no longer suffering. The lesson I will carry away with me from all of this is:

Addiction holds its vessels hostage because of the shame and guilt they do not let go of. If an addict could hold his or her head up high and see their true importance -they could then never betray themselves again by contaminating their bodies and minds with its influence. Someone plagued by addiction is really only running from themselves and I, for one, am glad the marathon of madness that Morgan ran for far too long is now over.

I would like to imagine that when she crossed the finish line God himself was there -arms open wide, smiling and embracing her as she deserved nothing less. Her kind of struggle should teach us all about the frailty of being a human being and about the courage it took for her to be here so long while in the strong-hold of a never ending complexity -wrenched in pain and fear.

There are many of us left who have had to remove ourselves -for one reason or another from the demands another's addictions often placed on us. To the people who are feeling weighed down and burdened by their own decision to walk away I say only this, "We were never showing a lack of love in doing so against that person - we were showing love for ourselves, our children or other loved ones instead." I, for one, forgive myself for discontinuing contact with Morgan on the physical plane because on the spiritual one I never gave up on her and I continued to pray for her -to wish her well - to give room to remembering her qualities instead of her deficits. After all in the end all the love, support and understanding can never save someone from themselves.

Today, however, is a new day and from this moment on we can carry peace and compassion with us …or we can welcome the same conflict as an addict and then we all lose. I, for one, cannot make that choice. Life, in the end, is really ours to command. Pain can only take over our lives if we so allow it. Morgan -and the millions of others who have died because of their addictions are proof of that unfortunate truth. As I draw this to a close -I am left with one thought -a song so faint playing in the background once lost in the archives of my mind -Sara McLachlan’s Song…In the Arms of the Angels.

Morgan "May you find some comfort there!"

(Contributed by Ms Ritu Sinha)

Emedinews:Makesure: A patient on 10 units of insulin developed hypoglycemia with 11 units of insulin

Situation: A patient on 10 units of insulin developed hypoglycemia with 11 units of insulin
Reaction: Oh my God! Why was additional insulin given?
Lesson: Make sure that insulin dose is calculated correctly. The formula is 1500/total daily dose. The value will be the amount of sugar fluctuation with one unit of insulin.

Emedinews:Insights on Medicolegal issues:Ante mortem and postmortem injury

One major difference between an ante mortem and a postmortem injury is the presence of signs of bleeding

• The injury received in the body prior or before death is called antemortem injury. These injuries may be a contributing factor in the death or even its cause. But, they may also have occurred many days/months or years ago.
• During an autopsy, the autopsy surgeon assesses the age of antemortem injuries, as well as distinguishing them from postmortem injuries—that is, injuries occurring after death. Postmortem injury can come from various sources such as deliberate mutilation of a body by a murderer following a homicide, predation by wild animals, or careless handling in the mortuary. Postmortem injuries can cause confusion over the manner and cause of death.
• One major difference between an antemortem and a postmortem injury is the presence of signs of bleeding. While the person is still alive, the blood is circulating and any injuries such as cuts or stabs will bleed. After death, the body usually does not bleed. However, there are exceptions. For instance, when a person drowns, their body usually floats face down and these results in the head becoming congested with blood.
• If the cadaver receives a head injury by colliding with blunt object/force, then there could be some evidence of bleeding. Scalp wounds sustained after death may also leak some blood. It can be especially difficult to distinguish between injuries inflicted in the very last few minutes of life and those caused postmortem. If the person collapses, there may be areas of laceration to the head and scalp which may be very hard to interpret.
• After death, the blood stays liquid in the vessels and no longer clots. Careless handling of a cadaver may produce some postmortem bruising which may need to be distinguished from antemortem bruising. Blood also tends to pool under gravity after death, causing a bruised appearance in the lower limbs, arms, hands, and feet known as lividity or discoloration. Some of the smaller vessels may even hemorrhage under the pressure of this pooled blood. These bruises could be confused with ante-mortem bruising.
• Recent research has focused on improved techniques for distinguishing between an antemortem and a postmortem injury by analyzing damaged tissue. Antemortem injuries show signs of inflammation, while postmortem injuries do not. Some research suggests that tissue from ante mortem injuries contains a chemical involved in inflammation leukotriene B4 (LTB4). Postmortem injuries were found to have no LTB4. This could help the doctor for assessment of the injuries more accurately.

(Contributed by Dr Sudhir Gupta)

Emedinews Inspiration: Never underestimate the power of your actions

One day, when I was a freshman in high school, I saw a kid from my class was walking home from school. His name was Kyle. It looked like he was carrying all of his books. I thought to myself, "Why would anyone bring home all his books on a Friday? He must really be a nerd." I had quite a weekend planned (parties and a football game with my friend’s tomorrow afternoon), so I shrugged my shoulders and went on. As I was walking, I saw a bunch of kids running toward him. They ran at him, knocking all his books out of his arms and tripping him so he landed in the dirt. His glasses went flying, and I saw them land in the grass about ten feet from him. He looked up and I saw this terrible sadness in his eyes.

My heart went out to him. So, I jogged over to him and as he crawled around looking for his glasses, and I saw a tear in his eye. As I handed him his glasses, I said, "Those guys are jerks. They really should get lives." He looked at me and said, "Hey thanks!" There was a big smile on his face. It was one of those smiles that showed real gratitude. I helped him pick up his books, and asked him where he lived. As it turned out, he lived near me, so I asked him why I had never seen him before. He said he had gone to private school before now. I would have never hung out with a private school kid before. We talked all the way home, and I carried his books. He turned out to be a pretty cool kid. I asked him if he wanted to play football on Saturday with me and my friends. He said yes. We hung all weekend and the more I got to know Kyle, the more I liked him, and my friends thought the same of him. Monday morning came, and there was Kyle with the huge stack of books again. He just laughed and handed me half the books.

Over the next four years, Kyle and I became best friends. When we were seniors, we began to think about college. Kyle decided on Georgetown, and I was going to Duke. I knew that we would always be friends, that the miles would never be a problem. He was going to be a doctor, and I was going for business on a football scholarship.

Kyle was valedictorian of our class. I teased him all the time about being a nerd. He had to prepare a speech for graduation. I was so glad it wasn't me having to get up there and speak. Graduation day, I saw Kyle. He looked great. He was one of those guys that really found himself during high school.

He filled out and actually looked good in glasses. He had more dates than I had and all the girls loved him. Boy, sometimes I was jealous. Today was one of those days. I could see that he was nervous about his speech. So, I smacked him on the back and said, "Hey, big guy, you'll be great!" He looked at me with one of those looks (the really grateful one) and smiled. "Thanks," he said. As he started his speech, he cleared his throat, and began.

"Graduation is a time to thank those who helped you make it rough those tough years. Your parents, your teachers, your siblings, maybe a coach...but mostly your friends. I am here to tell all of you that being a friend to someone is the best gift you can give them. I am going to tell you a story."

I just looked at my friend with disbelief as he told the story of the first day we met. He had planned to kill himself over the weekend. He talked of how he had cleaned out his locker so his Mom wouldn't have to do it later "Thankfully, I was saved. My friend saved me from doing the unspeakable." I heard the gasp go through the crowd as this handsome, popular boy told us all about his weakest moment. I saw his mom and dad looking at me and smiling that same grateful smile. Not until that moment did I realize it's depth.

Never underestimate the power of your actions. With one small gesture you can change a person's life. For better or for worse. God puts us all in each other's lives to impact one another in some way. Look for God in others.
(Contributed by Ms Ritu Sinha)

Emedinews:Insights on Medicolegal issues:Death from respiratory failure in surgery

Hypoxia.

·         Text mentions that the cardiac arrest is mainly neurogenic and any irritation of the respiratory tract, such as laryngoscope or intubations may cause a lightly anesthetized patient to have a cardiac arrest.

·         Hypoxia is a potent precipitating factor in cardiac arrest, either from faults in the apparatus or more commonly due to inexperienced anesthetist, especially in handling the equipments with which he is not familiar. An overdose of the anesthetic agent depresses the respiratory centre and begins a descending spell of hypoxia.

·         Airway obstruction is another danger which may be blood, teeth, and dentures inside the tract or faults in the connecting tube, laryngeal spasm, swabs and an abnormal posture of neck.

·         Regurgitation of gastric contents is a real danger and I have seen this in many cases.

·         From the autopsy surgeon’s point of view, the finding of gastric contents in the airways must be backed up some clinical evidence of its ante-mortem origins before making any conclusion because many bodies has some gastric contents in some part of the air passage at the time of autopsy, mostly as a result of postmortem transfer that is a consequence of the dying process and not a cause of death.

·         Some physical faults in the anesthetic equipment such as faults in the connecting tube which may be internal delamination not seen from outside, may cause death.

·         Flowmeter errors occur, but confusion of bottled or pipe gas supplies or the connection of an empty cylinder are more common.

·         Any electric appliance is potentially dangerous and defective cauteries, defibrillators and diathermy equipments have all caused death.

·         Explosion from inflammable gases and vapors during intervention have also caused death

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A patient with LBBB in ECG developed acute pulmonary edema.

Situation: A patient with LBBB in ECG developed acute pulmonary edema.
Reaction: Oh my God! Why was underlying low cardiac functions not suspected?
Lesson: Make sure all patients with LBB undergo echo to rule out ejection fraction. This may not be true for RBBB.

Emedinews Inspiration:Happiness

The King asked an old wise monk to write down something that could encourage the prosperity of his family for years to come. It would be something that the family could cherish for generations. On a large piece of paper, the old monk wrote. "Your majesty dies, the queen dies, and the prince dies, the prince’s son dies."

The King man became angry when he saw the monk’s work. "I asked you to write something down that could bring happiness and prosperity to my family," the King yelled. “Why do you give me something depressing like this?"

"If your son should die before you," the monk answered, "this would bring unbearable grief to your family.

If your grandson should die before your son, this also would bring great sorrow. If your family, generation after generation, disappears in the order I have described, it will be the natural course of life. This is true happiness and prosperity."

(Contributed by Ms Ritu Sinha)

Emedinews: Dr Good Dr Bad: A patient with pain in abdomen was found to have TLC > 20000.

Situation: A patient with pain in abdomen was found to have TLC > 20000.
Dr Good: Rule out liver abscess
Dr Bad: Get TLC repeated
Lesson: Liver abscess typically has TLC > 15000.