Emedinews:Insights on Medicolegal issues:Sudden and unexpected death presents a challenge in legal autopsy

• In cases of sudden death after pneumothorax, intravenous infusions, childbirth, operations, or sharp instrument injuries to the neck and thorax, it is important to check for air embolism to the heart.
• A postmortem chest radiograph should be taken and inspected for larger quantities of air in the heart and great vessels.
• Accuracy of observation, completeness of detail, and sound conclusions can be obtained only when the postmortem examination is done according to some definite and systematic plan so that regions and organs are successively examined without disturbing the relations and appearances yet to be investigated.
• Chest radiographs provide the most reliable method for determining the extent of pneumothoraces and whether or not a pneumothorax has resulted in mediastinal shift.
• Detection of a pneumothorax is easily done by holding the dissected skin and subcutaneous tissues of the chest to form a pocket adjacent to the ribcage in postmortem examination.
• The pocket is filled with water, and a scalpel is used to incise the thoracic cavity. The presence of air bubbles indicates a pneumothorax.
• In the cases of neonates and small infants during the autopsy, the thorax may be submerged in a bucket of water.
• The apparatuses described previously for detection of air emboli work equally well for detecting pneumothoraces
• The patients for whom death can be considered an expected outcome of a known illness and those for whom death is unexpected: This distinction is important because unexpected death due to unnatural causes, unintentional and intentional, usually falls within the purview of forensic pathology.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A patient on amlodipine developed severe gum hypertrophy.

Situation: A patient on amlodipine developed severe gum hypertrophy.
Reaction: Oh my God! Why was amlodipine not stopped?
Lesson: Make sure that all patients on amlodipine are watched for gum hypertrophy. Gingival hyperplasia is a known side effect of amlodipine.

Emedinews:Inspiration:Nothing Is More Important

I sat next to the bed of old man, a friend for over twenty years, and held his hand. Hal was dying. We both knew these next few days would be his last.

We spent time reminiscing about his long and fruitful career as a church pastor. We talked about old friends. We chatted about his family. And I listened as he offered sage wisdom and advice to a member of a "younger generation."

At a lull in the conversation, Hal seemed to carefully consider what he was about to say next. Then he squeezed my hand, gazed intently into my eyes and whispered, just loud enough for me to hear, "Nothing is more important than relationships."

I knew that this was somehow near the pinnacle of his life's learning’s. As he considered all of his experiences -- personal, professional, spiritual and family, this one ultimate observation surfaced above the rest: "Nothing is more important than relationships."

"Don't get overly caught up in your career," he seemed to be saying to me. "Likewise, don't use people in order to achieve your goals, and then throw them away. No project, no program, no task should be pursued at the expense of friends and family. Remember," I heard him saying, as clearly as if he were speaking the words, "that in the end, only your relationships will truly matter. Tend them well."

Writer Og Mandino puts it this way: "Beginning today," he said, "treat everyone you meet as if he or she were going to be dead by midnight. Extend to them all the care, kindness, and understanding you can muster, and do so with no thought of any reward. Your life will never be the same again."

At the end of a long life, my friend Hal would have agreed.

(Contributed by Ms Ritu Sinha)

Emedinews:Inspiration:No time to brag

Two geese were about to start southward on their annual migration, when they were entreated by a frog to take him with them. The geese expressed their willingness to do so if a means of conveyance could be devised.

The frog produced a long stalk of pond grass, got the geese each to grab an end with their beaks, while he clung to it by his mouth in the middle. In this way the three began their journey. Some farmers below noticed the strange sight. The men loudly expressed their admiration for the travel device and wondered who had been clever enough to discover it. Whereupon the vainglorious frog opened his mouth to say, "It was I," lost his grip, fell to the earth and was dashed to pieces.

Moral: When you have a good thing going, keep your mouth shut!

(Contributed by Ms Ritu Sinha)

Emedinews:Makesure:A patient on ACE inhibitor developed angioneurotic edema.

Situation: A patient on ACE inhibitor developed angioneurotic edema.
Reaction: Oh my God! Why was ACE inhibitor continued?
Lesson: Make sure that patients on ACE inhibitors are advised to watch for symptoms of urticaria and stop the drug immediately in case swelling of lip, face or tongue develops. (Br J Clin Pharmacol 1999;48(6):861–5)

Emedinews: Insights on Medicolegal issues - Traumatic events are extraordinary, not because they occur rarely, but rather because they overwhelm the ordinary human adaptations to life.

Traumatic events are extraordinary, not because they occur rarely, but rather because they overwhelm the ordinary human adaptations to life. Judith Herman, MD, Trauma and Recovery

Trauma triad of death is a term in medicine describing the combination of hypothermia, acidosis and coagulopathy of blood.

• In the cases of traumatic injuries if the cycle continues uninterrupted the three conditions share a complex relationship; each factor can compound the others, resulting in high mortality seen as sudden death in postmortem examination.
• This combination is commonly seen in patients who have sustained severe traumatic injuries and results in a significant rise in the mortality rate.
• Severe hemorrhage in trauma diminishes oxygen delivery, causing the patient's body temperature to drop - hypothermia. This in turn can halt the coagulation, which prevents blood from clotting resulting in coagulopathy.
• Due to the minimal level or absence of the blood-bound oxygen and nutrient, the body's cells burn glucose without oxygen for energy which in turn increases the blood's acidity such an increase in acidity can reduce the efficiency of the heart muscles, further reducing the oxygen delivery and hence triggering a deadly cycle.

Emedinews:Insights on Medicolegal issues:Forensic opinion in Close and contact wounds of fire arms missile

• When a firearm is discharged very close to or in contact with the skin surface, the gases produced by the explosion pass into the tissues along with the bullet and cause considerable laceration of the skin and subcutaneous tissues. Under these conditions the bullet entrance wound has a ragged appearance, especially over the skull where it may be stellate in appearance.
• At close range there is usually some blackening and tattooing of the skin around the bullet entrance wound, while the hair in the region of the wound may be singed, and there may be some skin burning and abrasion in relation to the hot gases. In contact wounds, the discharge passes into the tissues through the bullet entrance opening and powder deposits as well as blackening may be observed I the depths of the wound.
• When a firearm is discharged at a range of about 15 cm, the lacerating and burning effects of the gases are usually lost owing to the dispersion and cooling of the gases before they reach the skin. In these conditions the bullet entrance wound is circular in shape and is surrounded by a narrow zone of skin abrasion. Blackening of the skin is sometimes seen, while tattooing is invariably found at this range.
• Beyond a range of 15 cm, all traces of blackening usually disappear, while the bullet entrance is opening remains circular in shape.
• Powder grain deposits may still be present, and are usually seen up to ranges of about 40-60 cm, but the limit within which powder grain deposits can occur varies with different weapons and different cartridges.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: An 18-year-old girl complained of purulent nasal discharge, nasal congestion, pain in the cheek and upper teeth for last 10 days. CT scan showed maxillary sinusitis

Situation: An 18-year-old girl complained of purulent nasal discharge, nasal congestion, pain in the cheek and upper teeth for last 10 days. CT scan showed maxillary sinusitis.
Reaction: Remember to give macrolides.
Lesson: Make sure to remember that clarithromycin (macrolide) 500 mg twice-daily for 7 days is not only effective in maxillary sinusitis but also in other sinusitis.

Emedinews:Inspiration:A Bit of Wisdom

During a trying time in my life I have received much comfort from the comments and the input of readers and I would like to submit a bit of wisdom of my own. It results from my life experiences thus far.

Do not look in books for instructions on how to live your life. By doing so you will only end up following someone else's road. Look only inside yourself. You must trust your own voice, think with your own mind, follow your own heart, and believe in your own dreams. Only you know what you need or what is good for you. You can only survive and succeed when you are true to yourself and not to the opinions of others.

Do not look at life through the eyes of someone else; do not end up second-guessing your own thoughts and feelings in the false believe that others are automatically wiser than you are. Trust yourself, listen to your heart, chart your own course, be your own North Star and be what the Great Spirit intended you to be - one of a kind.

(Contributed by Ms Ritu Sinha)

Emedinews:Inspiration:Never Give Up

"You are never given a wish without also having been given the power to make it come true.” Richard Bach.

What you need is patience, perseverance, and a burning desire that constantly needs to be fueled. The quest for the realization of your dreams is like waging a momentous battle during which you might encounter severe setbacks. But success comes to those who turn adversities into opportunities, overcome their limitations and bounce back with renewed vigor.

If you have fallen down, get up and brush the dust off your knees and move on. A temporary setback is not a defeat. For that matter, there's no such thing as defeat. Nothing is impossible in this world. If you have the will to win, you can achieve anything. And always remember that the whole world will help you when you want to achieve something.

Just imagine a young girl who learned dancing when she was three-years old and whose greatest passion remains dancing. She loses one of her legs in an accident. Read on this true incident that took place almost 20 years ago and find out whether she gives up dancing or fights back to realize what she believes in:

Sudha Chandran, a classical dancer from India, was cut off in the prime of her career - quite literally - when her right leg had to be amputated after a car accident. Though the incident brought her bright career to a halt, she didn't give up.

In the painful months that followed, she met a doctor who developed an artificial limb made from vulcanized rubber filled with sponge. So intense was her desire that she decided to go back to dancing after she had been fitted with an artificial leg. Sudha knew that she believed in herself and could fulfill her dream, She began her courageous journey back to the world of dancing - learning to balance, bend, stretch, walk, turn, twist, twirl and finally dance.

After every public recital, she would ask her Dad about her performance. "You still have a long way to go" was the answer she use to get in return.

In January 1984, Sudha made a historic comeback by giving a public recital in Bombay. She performed in such a marvelous manner that it moved everyone to tears while catapulting her to the number one position again. That evening when she asked the usual question her dad, he didn't say anything. He just touched her feet as a tribute to a great artiste.

Sudha's comeback was such heart-warming that a film producer was inspired to capture the incident into a celluloid box office hit, `Mayuri.' When someone asked Sudha how she had managed to dance again, she said quite simply, "YOU DON'T NEED FEET TO DANCE."

(Contributed by Ms Ritu Sinha)

Emedinews:Insights on Medicolegal issues:No Narco test without valid informed consent, rules Supreme Court of India

The most exhausting/frustrating and laborious part of a criminal investigation for agencies like CBI or FBI is extracting information from an uncooperative alleged accused and suspects by investigators in India as well as abroad. No individual should be forcibly subjected to any of these techniques/method of interrogation in question, whether in the context of investigation in any criminal cases or otherwise. The narcoanalysis test began to be used with the presumption that it provides a simply, nonviolent method of finding out the truth. In a world where until quite recently, torture was employed in criminal cases, perhaps narcoanalysis is a simple, civilized way of conducting criminal investigation

• The Supreme Court of India said that the so-called narcoanalysis, brain mapping and polygraph tests cannot be conducted on any person without their consent.
• The Apex Court further said the confession of guilt during the course of the tests cannot be treated as evidence in court.
• The results of narco test provided clues and did not have any evidentiary value. There is no scientific literature to prove truth serum works, human rights groups have held the tests to be mental torture.
• "The compulsory administration of any of these techniques is an unjustified intrusion into the mental privacy of an individual. It would also amount to 'cruel, inhuman or degrading treatment' with regard to the language of evolving international human rights norms," said a Bench comprising Chief Justice K G Balakrishnan and Justices R V Raveendran and J M Panchal.
• The police, instead of collecting real evidence, relied on these tests to spread rumors about the suspect, and selective leaks were made to the media that a particular suspect has made confession during the tests.”

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A patient on dialysis and on oral antacid developed aluminium toxicity.

Situation: A patient on dialysis and on oral antacid developed aluminium toxicity.
Reaction: Oh my God! You should have put him on Magaldrate preparations?
Lesson: Make sure to remember that Magaldrate preparations do not cause aluminium toxicity in patients undergoing dialysis.

Emedinews:Insights on Medicolegal issues:DOES & DON’T DOES IN CASE OF SEXUAL ASSAULT?

The offence of sexual assault is a brutal, dirtying, demoralizing assault on a woman, and if fully proven demands the most rigorous penalties allowed by law. Equally, the allegation of rape is easy to make, and the man accused falsely of the offence may shatter his life as well as the family he belong.

• The doctor should concentrate on what is the truth and on view of that what are the biological evidences available and can/required to be collected.

• The history of previous sexual intercourse of the female victim, Physical signs of injury to corroborate the history of incidence should be recorded after Medical examination with followingDOES & DON’T DOES

• Detailed and consistent history about time, place and circumstances of occurrence. The examination of scene of incidence, collection of various evidences, like, spot of blood, semen, bed sheet etc should be recorded.

• Doctor should neither act as detective nor as curtain for law

• Police should be informed only with the consent of the victim or her parents; otherwise, it will be a violation of professional secrecy. Sometimes, the victim may not give the correct history and alleged cause of injuries as due to rape.

• Doctors have no role of a detective. Even if the findings are suggestive of a sexual assault, he should not interrogate the victim to ascertain the veracity of the history.

• The version of the woman should be recorded verbatim and necessary treatment should be given if the victim is unconscious or unable to give a coherent version of the history, the police should be notified.

• Whatever be the case, all the details should be entered in the register, collect necessary samples and keep them in safe custody. Victim may change her/his mind and file a complaint before the police at a later date. Then the doctor has to disclose all the information to the Police.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A patient after receiving 40 units of insulin developed severe hypoglycemia

Situation: A patient after receiving 40 units of insulin developed severe hypoglycemia.
Reaction: Oh my God! The order was 4 units.
Lesson: Make sure that 4 unit is not written as 4.0 units as it may be incorrectly read as 40.

Emedinews:Inspiration:Never give up

Life is how you want it to be, open your eyes, and you will see
No matter what, you can have fun, and always remember, when it's done.
The memories of what has been, the mistakes, so you won't make them again
The good times, but the not-so-good times too, because these memories will see you through.
Never forget friends who've come and gone, Sing life's praises as a beautiful song
Loving and being loved are the greatest gifts, Close your heart, and these you'll miss
Life is how you want it to be, Open your eyes, and this you'll see...
Just one note: NEVER GIVE UP!

(Contributed by Ms Ritu Sinha)

Emedinews:Insights on Medicolegal issues:Precautions in Sampling of blood in forensic cases

• The site of injection should be cleaned by saline swab and not by spirit swab if the sample of blood is collected for alcohol estimation
• About 3-4 ml of blood is drawn as sample in chemically clean evacuated tubes of 5ml.
• set of water proof /not be vulnerable to freezing labels with identification codes to mark the tubes should be used
• EDTA should be used as anticoagulant. Tubes with liquid EDTA /fluoride reduce the risk of hemolytic leads to altered results
• 2ml of 5% aqueous solution of sodium citrate containing 0.2% w/v of formaldehyde or 0.5% w/v of formalin solution must be added to prevent decomposition which leads to altered results
• Plastic vacuum tubes/ Plastic vacuum gel tubes are preferred to glass tubes. . If vacuum tubes are not available or tubes are opened for freely flowing samples, stoppers which do not react with blood constituents should be available.
• special boxes for tube transfer and storage, earmarked refrigerator/ freezer must be available in hospital conducting medico legal cases
• About 3-4 ml of blood is taken in a sterile 5ml injection vial( properly sealed and labeled) containing about 2ml of 5% aqueous solution of sodium citrate containing 0.2% w/v of formaldehyde (or 0.5% w/v of formalin solution).
• Two approximately 1cm x 1cm size blood stains are formed on clean cotton cloth/gauze pieces and, after they are dry, they are transferred to a sterile 10ml injection vial it should be properly dried, before packing to avoid decomposition and then sealed & labeled.
• Bloodstains located on the body of an injured person are taken by rubbing with moistened clean cotton cloth pieces, it should be properly dried, before packing to avoid decomposition and then sealed & labeled.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A patient who had multiple blunt trauma on his abdomen is admitted for management.

Situation: A patient who had multiple blunt trauma on his abdomen is admitted for management.
Reaction: Oh my God! Why did you not do a peritoneal lavage?
Lesson: Make sure to perform a peritoneal lavage in patients of multiple blunt trauma to exclude peritoneal hemorrhage from ruptured abdominal organs as the peritoneal reaction is often mild and a thorough clinical examination is not possible.

Emedinews:Inspiration:Chasing meaningless goals

A farmer had a dog that used to sit by the roadside waiting for vehicles to come around. As soon as one came he would run down the road, barking and trying to overtake it. One day a neighbor asked the farmer "Do you think your dog is ever going to catch a car?"

The farmer replied, "That is not what bothers me. What bothers me is what he would do if he ever caught one." Many people in life behave like that dog who is pursuing meaningless goals.

To live a meaningful life, choose meaningful goals!

(Contributed by Ms Ritu Sinha)

Emedinews:Insights on Medicolegal issues:The sound wave is elicited when there is impact and injuries on skull

There are two types of impacts on skull and the sound wave elicited by the impact. The first at the site where the force is applied, the second where the advancing segments of the accelerated brain are brought suddenly to rest by the forces that resist its forward motion.

• Countercoup lesions of the brain were once thought to be caused by the brain moving within the skull in a straight line with the force of the blow striking against its opposite side, but from experiments on mechanics of head injuries it has been demonstrated that countercoup lesions are chiefly due to local distortions of the skull and the sudden rotation of the head as result of a blow, which arouse shear strains or slide produced by the pulling apart of the constituent particles of the brain .
• Shear strains occur due to pulling apart of the constituent particles of the brain. Shear strains occur in all parts of the brain, but they occur to a large extent at the base of the frontal lobe and the tip of the temporal lobe. This is because the skull gets a good grip on the brain in this region owing to the projecting ridge of the sphenoid bone. Hence, severe and extensive injuries occur in this region when a blow is struck on the occiput.
• On the other hand, countercoup injuries which are caused by rotation will not occur if the head is so well fixed that it cannot rotate at all when it receives a blow. Cerebral contusions and tears have been reported in autopsy as a result of trauma.
(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A patient with dengue developed acute lung injury after platelet transfusion.

Situation: A patient with dengue developed acute lung injury after platelet transfusion.
Reaction: Oh my God! Why were platelets transfused?
Lesson: Make sure that no platelets are transfused unless there is significant spontaneous bleeding.

Emedinews:Inspiration:The Swamis and the Mysterious Light

A long time ago, there were two swamis who lived in two neighboring caves. They spent most of their time in deep meditation, except the time they ate or were visited by devotees. The people who came to visit them revered the two swamis, and enjoyed listening to them and being in their proximity. They sought their company, since they always felt more peaceful and happy when near them, and also for a long time after they went away.

One cave was dark, as caves usually are, but in the other one there was sometimes a peculiar golden light illuminating the cave. It was not strong, but enough to be noticed and to mildly illuminate the cave. The phenomenon of the light bewildered the visitors, but they could not come to an agreement about the causes of the light. Both swamis were rather silent most of the time, and did not want to discuss the phenomenon of the light.

The company of the swamis aroused calmness and peace in the visitors. Their minds slowed their incessant chatter, and they experienced a pleasant inner peace and inner happiness. The visitors admired both swamis, but believed that the one living in the illuminated cave possessed supernatural powers and was more advanced. He certainly appeared to them as a mysterious person.

One day a great sage was passing by a near village, and being recognized by the villagers, one of them approached him and said: "Great master, we have a question to ask. There is a mystery which you might solve for us." "I will be glad to help you, if I can", answered the sage. "There are two swamis living here on the hill...", the villager started to recount. "Yes, I know", answered the sage, "and you inquire about the light in the cave." "Yes, great master, that is true. It is something that has been a riddle for us. Can you please tell us also, if the swami in the lighted cave is more advanced, and if he really possesses supernatural powers?"

"Pay attention to your inner self and not to outer phenomena. The outside world always changes, but inner self is constant. When in the presence of a teacher, listen to what he says and be aware of the influence of his words on you. Watch yourself, and see whether under his influence you become calmer and more peaceful, and your thoughts, at least for a while, slow down their mad race." "Yes most revered master", said one of the devotees, "but please enlightens us on the mysterious light."

The sage sat down, and started to explain: "Sometimes, when one works intensively on the spiritual path, and concentrates and meditates a lot, various phenomena may occur around him, such as lights, sounds or visions. This is not supernatural. The mind has a creative power, and when concentrated, can produce various phenomena even unintentionally." "It does not mean that one is more advanced than the other. Not all minds produce these things. Some do, and some don't."

"Some of the people who produce these lights may be aware of the light, and some may not. It depends on their psychic sensitivity. So it is also with the people who watch them. Not all see this light. In any case, it has nothing to do with whether one swami is more advanced or less advanced than the other one."

"Thank you great master, you have solved for us this great mystery", exclaimed the devotees of the swamis, who were standing by, deeply relieved and happy to understand the mystery that has been troubling them for a long time.

(Contributed by Ritu Sinha)

Emedinews:Makesure: A patient with pyogenic meningitis developed complications.

Situation: A patient with pyogenic meningitis developed complications.
Reaction: Oh my God! Why were antibiotics not given when the meningitis was suspected?
Lesson: Make sure that first dose of antibiotics is given at the time meningitis is suspected.

Emedinews:Insights on Medicolegal issues:The brain injury occurs mainly due to movements of the brain in relation to the skull

The falx cerebri and tentorium divide the cranial cavity into three communicating compartments and have a partly restraining effect on brain movements.

• Injuries like contusion and lacerations of the brain seen in vehicular accidents and falls from heights are caused by the application of violence to the head and may occur with or without external injury to the scalp and fracture of the skull.
• Injuries may be seen superficially anywhere on the surface of the brain, though the commonest site is the outer surface of the parietal and temporal lobes or deep within the brain substance, and are associated with hemorrhages limited in small areas or multiple hemorrhages diffused largely within the brain tissues. They are also associated with disturbances of cerebrospinal fluid circulation.
• These injuries, also known as coup lesions, are commonly found under the site of application of the blow, but are also sometimes found particularly during autopsy on the surface of the brain diagonally opposite the site of impact, and are called countercoup injuries.
• Coup injuries are most commonly found on the frontal lobes and near the tips of the temporal and frontal poles, rarely on the occipital poles. They are usually severe injuries.

(Contributed by Dr Sudhir Gupta)

Emedinews:Inspiration: My Little Miracle

I had just turned 19 when I was told I could not have children. I was devastated. Ever since I was a small child, I had prayed for a beautiful blonde haired, blue eyed baby girl. I used to pray to God that before He decided to come back for His children, He would allow me to have a baby girl. I was in a serious relationship at the time that I thought would last forever. He told me that he would love nothing more than to have a child to care for and love. I prayed that the doctors were wrong and that maybe if I prayed hard enough, God would prove them wrong.

Every night I would pray, "God, please let me be a mother. Let me have the honor of caring for one of your children." Just three months later, I found out I was pregnant. I had a very hard pregnancy. High blood pressure kept the doctors on alert. I found out I had Strep B, which could be fatal to the baby. I was scared. I didn't want to lose her. Every day I prayed that she would be OK. At only 33 weeks, she attempted to be born. "No," I prayed. "Not this early. Please. Just one more week at least. She needs to gain more weight." I was immediately hospitalized and put on total bed rest. I was given nothing to eat or drink for three days. On the fourth day, the doctors finally said I could eat and drink, that my body was doing what it was supposed to in preventing the birth.

Just a couple of days later, when I had reached 34 weeks, the doctors decided it was safe enough for me to have her. I was induced, and at 4:57 pm on September 18, 1998, I had the most beautiful blonde haired, blue-eyed baby girl. I named her Jessie-Mae Marie. She is now two-years-old and the best thing to ever happen to me. A real gift from God. No, her father and I are no longer together. He decided being a father was not for him. I am not sad about that. I am sad for him. He is missing out on her growing up and will probably always regret it.

So, if any of you are told there is no chance for you to have children, remember this. God still works miracles. He worked a big one in my life and I will always be grateful for that.

Emedinews:Insights on Medicolegal issues:What is the meaning of Death for the common people?

• The recent development in medical science/techniques has posed a number of improvements, whereas for so many years it was accepted that death has occurred if respiration and circulation have ceased for more than 10 minutes.
• Now it is possible for methods such as cooling the whole body to 15oC or 59oF or less to stop the heart and respiration for an hour or longer and restart them again at will. During this period, ECG and EEG show no electrical activity and body looks like a corpse.
• This leads to the view that it is not the cessation of the respiration or circulation but it is their failure to return that indicates death. Thus we are driven from a positive to negative approach. Therefore, the doctor while taking decision must satisfy himself that not only respiration and circulation has stopped, but their failure has persisted to such a period that under no circumstances it is possible for the person to come to life again.
• This is the form of death referred to in common people. Death is said to have occurred when a final expiration is followed by continuous immobility of the chest, loss of pulse and alteration of the features. These changes indicate that respiration and circulation have been stopped and the brain will stop functioning if it has not been so.
• Residual heart movement is not of practical importance as they are insufficient to maintain the circulation. Somatic death can be detected by ECG that will stop within minutes.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: An HIV patient died after sulfa prophylaxis

Situation: An HIV patient died after sulfa prophylaxis
Reaction: Oh my God! You should have known that he was sulfa sensitive.
Lesson: Make sure that patients with a history consistent with Stevens Johnson syndrome and toxic epidermal necrolysis or an exfoliative dermatitis due to a sulfonamide medication should strictly avoid the culprit drug and other agents in the same sulfonamide group. Re-exposure to the same agent may be fatal.

Emedinews:Inspiration:Most Popular Vs the Right Decision

A group of children were playing near two railway tracks, one still in use while the other disused. Only one child played on the disused track, the rest on the operational track. The train is coming, and you are just beside the track interchange. You can make the train change its course to the disused track and save most of the kids. However, that would also mean the lone child playing by the disused track would be sacrificed. Or would you rather let the train go its way?

Let's take a pause to think what kind of decision we could make........Most people might choose to divert the course of the train, and sacrifice only one child. You might think the same way, I guess. Exactly, I thought the same way initially because to save most of the children at the expense of only one child was rational decision most people would make, morally and emotionally. But, have you ever thought that the child choosing to play on the disused track had in fact made the right decision to play at a safe place?

Nevertheless, he had to be sacrificed because of his ignorant friends who chose to play where the danger was. This kind of dilemma happens around us everyday. In the office, community, in politics and especially in a democratic society, the minority is often sacrificed for the interest of the majority, no matter how foolish or ignorant the majority are, and how farsighted and knowledgeable the minority are. The child who chose not to play with the rest on the operational track was sidelined. And in the case he was sacrificed, no one would shed a tear for him. The great critic Leo Velski Julian who told the story said he would not try to change the course of the train because he believed that the kids playing on the operational track should have known very well that track was still in use, and that they should have run away if they heard the train's sirens.

If the train was diverted, that lone child would definitely die because he never thought the train could come over to that track! Moreover, that track was not in use probably because it was not safe. If the train was diverted to the track, we could put the lives of all passengers on board at stake! And in your attempt to save a few kids by sacrificing one child, you might end up sacrificing hundreds of people to save these few kids.

While we are all aware that life is full of tough decisions that need to be made, we may not realize that hasty decisions may not always be the right one. “Remember that what's right isn't always popular... and what's popular isn't always right." Everybody makes mistakes; that's why they put erasers on pencils.

(Contributed by Ms Ritu Sinha)

Emedinews:Insights on Medicolegal issues:How will a doctor diagnose a fabricated bruise?

Some irritant substances like juice of marking nut, used by washer men for marking the clothes is generally used to create false bruise. Juice of marking nut when applied to the skin produces injuries, which look like a bruise.

• Fabricated bruise is self-made or false injury produced by a man or woman itself or by the help of some person with malign intention to make false allegation of being injured by someone for framing someone in false criminal offences.

• These false contusions are produced with a malign intention to support a false allegation or charge of criminal infliction of injury and are seen in many occasions in medical practice. These juices are also used to produce false bruises in female private parts, arms pits to make a false allegation of rape.

• These injuries are very superficial and on close examination are found to be granulated. They are always present on accessible parts of the body; but, in same cases, false bruise may be created on non-accessible part of the body, mostly with the help of somebody.

• The false bruise is usually very small in size, may be multiple in numbers with absence of continuity in each other and can be differentiated on examination.

• The color photographs of injuries should be taken as a part of medico legal report.

• If the examining doctor is in a dilemma about false bruise, he must refer the case to a forensic doctor for further medicolegal opinion

(Contributed by Dr Sudhir Gupta)

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 the patient thoroughly and only moderately tap the ascitic fluid since overenthusiastic tapping can be life threatening.

Emedinews:Inspiration:Monetary Reminder

Imagine there is a bank, which credits your account each morning with £86,400, carries over no balance from day to day, allow you to keep no cash balance, and every evening cancels whatever part of the amount you had failed to use during the day. What would you do? Draw out every penny, of course!

Well, everyone has such a bank. Its name is Time.

Every morning, it credits you with 86,400 seconds. Every night it writes off, as lost, whatever of this you have failed to invest to good purpose. It carries over no balance. It allows no overdraft. Each day it opens a new account for you. Each night it burns the records of the day. If you fail to use the day's deposits, the loss is yours.

There is no going back. There is no drawing against the "tomorrow."

Therefore, there is never not enough time or too much time. Time management is decided by us alone and nobody else. It is never the case of us not having enough time to do things, but the case of whether we want to do it.

Emedinews:Insights on Medicolegal issues:Right coronary artery is called artery of sudden death since it supplies the electrical area of heart

The most common cause of sudden cardiac death in adults over the age of 40 seen in postmortem examination in approximately 100 cases randomly selected by me in the mortuary at AIIMS has been coronary artery atheroma.

• The most common finding at postmortem examination is chronic high-grade stenosis of minimum one segment of a major coronary artery, the arteries which supply the heart muscle with its blood supply.

• A significant number of cases also have an identifiable clot in a major coronary artery which causes transmural occlusion of that vessel.

• In many cases out of hundreds, the clots were found in the right coronary artery supplying the electrical area of heart.

• Death in these cases is thought to result from a period of transient or prolonged lack of blood supply in the muscle of the heart wall which induces a ventricular arrhythmia/fibrillation and no changes in the myocardium is seen during postmortem examination.

• The absence of the histological signs of acute necrosis and a healed infarct are common findings.

• Chronic high-grade stenosis causing previous episodes of ischemia and areas of focal fibrosis is seen histologically in the myocardium.

• Ventricular arrhythmias may arise from a myocardium, which has been previously scarred by episodes of ischemia.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A patient with diabetes shows deteriorating kidney function.

Situation: A patient with diabetes shows deteriorating kidney function.
Reaction: Oh my God! His HbA1c is very high?
Lesson: Make sure that strict glycemic control is maintained in patients with type 2 diabetes in order to delay vascular complications.

Emedinews:Inspiration:Making change

Many of us do not like what we see around us but the last thing we ever do is to change it. I think that is the beginning of failure and that is why what we hate still remains around us. If you do not want the things you see around you, don't just watch and hope it will change. There must be a work plan that will determine what you are going to do to change it.

We have such an amazing power of creativity inside us to change the way things work around us. Only lazy people go about and say that is the way things have been working and that is the way they are going to continually work.

I have come to discover that things around us are dependent on our actions and inactions. What I mean is that the circumstances that we like depend solely on the things we do and the things we do not do.
Do you want you country to change? Start by changing the small things around you.

Before you think too far about any small thing to change, let me help you by saying that your habit should be the first thing to change. Change what you think about and change what you talk about. Change the things that get your attention before you plan to change a nation.

Can you remember how difficult it was for you to break a habit that you desired to break some years back? Do you remember that habit of yours that you are still struggling to break? If so, then you must accept that things are not just going to change by the stroke of a magic thought.

If it is not so easy to change yourself when you want to, it is not going to be so easy to change the people around you. Many people do not find it easy to change themselves yet they want to change a nation.
I think the best way I have changed people around me is that I changed myself.
People are watching you. Some of them do not expect you to change so your change is going to be like a miracle to them. When you change, they will change. Just change yourself and see how many people will tell you later that you were the one who changed them.

That is one simple way young people can change their nations. Go ahead now. Do it!

(Contributed by Ms Ritu Sinha)

Emedinews:Makesure: A patient intolerant to penicillin was denied rheumatic prophylaxis

Situation: A patient intolerant to penicillin was denied rheumatic prophylaxis.
Reaction: Oh my God! Why was he not put on sulfa?
Lesson: Make sure that patients who cannot tolerate penicillin are put on sulfadiazine or sulfisoxazole. This antibiotic class is effective for preventing group A streptococcal (GAS) infection although it cannot be used to achieve eradication.

Emedinews:Inspiration:Love, Wealth and Success?

A woman came out of her house and saw three old men with long white beards sitting in her front yard. She did not recognize them. She said "I don't think I know you, but you must be hungry. Please come in and have something to eat."

"Is the man of the house home?” they asked. "No", she said. "He's out." "Then we cannot come in", they replied.

In the evening when her husband came home, she told him what had happened. "Go tell them I am home and invite them in!" The woman went out and invited the men in.

"We do not go into a House together," they replied. "Why is that?" she wanted to know. One of the old men explained: "His name is Wealth," he said pointing to one of his friends, and said pointing to another one, "He is Success, and I am Love." Then he added, "Now go in and discuss with your husband which one of us you want in your home."

The woman went in and told her husband what was said. Her husband was overjoyed. "How nice!!", he said. "Since that is the case, let us invite Wealth. Let him come and fill our home with wealth!" His wife disagreed. "My dear, why don't we invite Success?" Their daughter-in-law was listening from the other corner of the house. She jumped in with her own suggestion: "Would it not be better to invite Love? Our home will then be filled with love!" "Let us agree to our daughter-in-law's advice," said the husband to his wife. "Go out and invite Love to be our guest."

The woman went out and asked the 3 old men, "Which one of you is Love? Please come in and be our guest." Love got up and started walking toward the house. The other two also got up and followed him.

Surprised, the lady asked Wealth and Success: "I only invited Love, Why are you coming in?" The old men replied together: "If you had invited Wealth or Success. The other two of us would've stayed out, but since you invited Love. Wherever He goes, we go with him.

Wherever there is Love, there is also Wealth and Success!!!!!!"

(Contributed by Ms Ritu Sinha)

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

The mission of medical doctor is to safeguard the health of the people. The Declaration of Geneva of the World Medical Association (WMA) binds the doctor with the words, "The health of my patient will be my first consideration." In the treatment of the sick person, the doctor must be free to use a new diagnostic and therapeutic measure, if in his/her judgment it offers hope of saving life, re–establishing health or alleviating suffering.
• The potential benefits, hazards and discomfort of a new method should be weighed against the advantages of the best current diagnostic and therapeutic methods.
• In any medical study, every patient including those of a control group, if any, should be assured of the best proven diagnostic and therapeutic method.
• The refusal of the patient to participate in a study must never interfere with the doctor–patient relationship.
• If the doctor considers it essential not to obtain informed consent, the specific reasons for this proposal should be stated in the experimental protocol for transmission to the independent committee.
• The doctor can combine medical research with professional care, the objective being the acquisition of new medical knowledge, only to the extent that medical research is justified by its potential diagnostic or therapeutic value for the patient.
(Ref: 18th World Medical Assembly, Helsinki, Finland, 1964 and revised by the 29th World Medical Assembly, Tokyo, Japan, 1975).

(Contributed by Dr Sudhir Gupta)

Emedinews:Insights on Medicolegal issues:If a doctor reaches the standard of a responsible body of medical opinion, he is not negligent

• Mr Bolam was a voluntary patient at a mental health institution run by the Friern Hospital Management Committee in United Kingdom. He agreed to undergo electroconvulsive therapy. He was not given any relaxant drugs, and his body was not restrained during the procedure.
• He flailed about violently before the procedure was stopped, and he suffered some nasty injuries, including fractures of the hip bone. He sued the Committee for compensation. He argued they were negligent for not issuing relaxants/not restraining him/ not warning him about the risks involved.
• The Judge noted that medical opinion was opposed to the use of relaxant drugs, and that manual restraints could sometimes increase the risk of fracture and it was the common practice of the profession to not warn patients of the risk of treatment when it is small unless they are asked.
• In this case, the jury delivered a verdict in favor of the defendant hospital. Given the general medical opinions about what was acceptable electro-shock practice, they had not been negligent in the way they carried out the treatment.
• That passage is quoted very frequently, and has served as the basic rule for professional negligence over the last fifty years.

(Contributed by Dr Sudhir Gupta)

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 only moderately tap ascitic fluid as overenthusiastic tapping can be life–threatening.

Emedinews:Inspiration:The Glasses

Mother's father worked as a carpenter. On this particular day, he was building some crates for  the clothes his church was sending to some orphanage in China. On his way home, he reached into his shirt pocket to find his glasses, but they were gone. When he mentally replayed his earlier actions, he realized what happened; the glasses had slipped out of his pocket unnoticed and fallen into one of the crates, which he had nailed shut. His brand new glasses were heading for China! The Great Depression was at its height and Grandpa had six children. He had spent $20 for those glasses that very morning. He was upset by the thought of having to buy another pair. "It's not fair," he told God as he drove home in frustration. "I've been very faithful in giving of my time and money to your work, and now this."

Several months later, the director of the orphanage was on furlough in the United States. He wanted to visit all the churches that supported him in China, so he came to speak one Sunday at my grandfather's small church in Chicago. The missionary began by thanking the people for their faithfulness in supporting the orphanage. "But most of all," he said, "I must thank you for the glasses you sent last year. You see, the Communists had just swept through the orphanage, destroying everything, including my glasses. I was desperate. Even if I had the money, there was simply no way of replacing those glasses. Along with not being able to see well, I experienced headaches every day, so my coworkers and I were much in prayer about this. Then your crates arrived. When my staff removed the covers, they found a pair of glasses lying on top.

The missionary paused long enough to let his words sink in. Then, still gripped with the wonder of it all, he continued: "Folks, when I tried on the glasses, it was as though they had been custom-made just

for me! I want to thank you for being a part of that."

The people listened, happy for the miraculous glasses. But the missionary surely must have confused their

church with another, they thought. There were no glasses on their list of items to be sent overseas.But sitting quietly in the back, with tears streaming down his face, an ordinary carpenter realized the Master Carpenter had used him in an extraordinary way.

(Contributed by Ms Ritu Sinha)

Emedinews:Insights on Medicolegal issues:Most important advances in the arena of medical practice have been the use of technologies.

• Medical professionals today rely on a number of different types of equipment every day, from heart defibrillators to IV pumps to CT scans to automated breathing apparatuses. When any of these devices fail, the results can be disastrous, resulting in the injury or death of a patient.

• When the medical devices fail, as all machines generally have a tendency to do, the risks have major consequences and are dangerous for human health.

• Medical equipment failure can result from both manufacturing defects or human error i.e. it was used incorrectly by the medical staffer involved and the concept of product liability develops.

• Medical professionals should keep a constant eye on the equipment/s to ensure that it is working properly and be adequately trained to use the device safely.

• A register of maintenance of medical equipment must be maintained with signature of all stake holders for record. Failure to do so is a form of negligence that places the hospital and its staff at liability.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A 20–year–old college student complained of dysuria, frequency and pyuria.

Situation: A 20–year–old college student complained of dysuria, frequency and pyuria.
Reaction: Oh my God! Why did you not advise macrolide?
Lesson: Make sure to remember that macrolide are very effective against E. coli, S. saprophyticus and C. trachomatis infection.

Emedinews:Inspiration:Look Fear in the Face

Look fear in the face. Be brave and bold. Don't be scared of the unknown. Accept your own wrongdoings as an opportunity to search deep within your soul. This way, you cannot blame others for your problems.

Be strong my child, admit defeat and always stand tall with dignity and pride. Allow your tribulations to become your guide for new found wisdom. Don't look back with regret; move forward with positive thoughts about the good and bad.

Be slow to speak and listen openly to what others have to say with respect. Remember you have a choice to make. Live negatively or positively; the choice is only dependent upon you.

You are sent to this world for a reason; a gift to others and remember always you have a special purpose so never give up but move straight ahead with love, peace, forgiveness, and strength!

(Contributed by Ms Ritu Sinha)

Emedinews:Insights on Medicolegal issues:Clinical and forensic autopsies is overlapping to each other

• Whether clinical/pathological or forensic, autopsy is nothing but medical study of a dead body and is carried out for enhancing clinical findings and its correlation with patient clinical manifestation during the treatment or understanding some unrevealed aspect of disease/diagnose the disease which has caused the mortality when ante-mortem efforts have failed or the autopsy/disease process in situ, thus enriching medical knowledge findings may be simultaneously used for medico-legal purpose
• Postmortem examination of a dead body is carried out to gain insight of anatomy and pathology of corpse and close examination of the injuries, marks of weapon or disease process and it’s significant for forensic application of medical knowledge.
• The procedure of both types of autopsies is same. Autopsy conducted by a forensic expert in cases of sudden/unexpected/unexplained death is nothing but a purely clinical autopsy.
• The opinion expressed on the basis of a clinical autopsy is examined or cross examined in departmental/institutional peer review as the findings and opinion after a forensic autopsy has to withstand the acid test of cross examination by the defense lawyer/prosecutor and judges on circumstantial evidences available before honorable court.
• Both clinical and forensic autopsies have a complimentary role towards each other.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A patient died after receiving penicillin injection.

Situation: A patient died after receiving penicillin injection.
Reaction: Oh my God! Why was anaphylaxis not suspected?
Lesson: Make sure that each time a patient is given penicillin injection, anti anaphylaxis measures are available.

Emedinews: Inspiration: Little Brown Boy

Danielle was only four when she burst through the front door, having just gotten off the school bus, after preschool. Charging through the living room, she spotted me in the dining room and launched into a speech while she headed toward me. While it was comical to see such a little person behave so dramatically, her outrage seemed real enough that she had my full attention.” They are MEAN to him!" she raged, her little fist hammering the table top for emphasis. “Who is mean to who?" I interrupted. “Those kids on the bus! They are MEAN to the little brown boy!" She looked up at me, hands on her hips, her eyes wide, incredulous. I knew she expected me to right this injustice immediately. It was the first one she had discovered in her very new Out in the World on Her Own adventures. “They make fun of him and make fun of him and make fun of him." Her golden head nodded emphatically with each repetition. "They laugh at him. They copy the way he talks. They hurt his feelings!" I watched her while I listened. This was something very different for her, this little girl I knew so well. I had never seen her just this way before. I even saw flashes of anger in her green eyes.

"The way he talks...?" I prompted, as if she needed prompting. I sat down at the table and set her on my lap. “He doesn't talk perfect, but that's just because he's a little kid!" this four-year-old elderly person informed me loudly, inches from my face. She looked directly into my eyes, needing answers. "WHY are they so MEAN?"

My husband and I had been a little apprehensive about sending her to and from preschool ("Head start") on a bus with many of the kids so much older and bigger and tougher than she was. This was our baby of the family, our sheltered miniature princess, and it was not easy to back off and let her face the world without us for a few hours a day ... Alas, even princesses grow up. “Do you think they might be doing that just because he's new?" I asked her. She thought for a minute. "No. When I was new, they didn't make fun of me."

I took a deep breath. "Do you think maybe they tease him because his skin is black?" She thought for a minute, clearly puzzled. Then she wrinkled her nose and said, "You mean brown?" I nodded and she went on: "Because he's BROWN? You don't make fun of someone just because of that!"

I told her I hoped she was right. She was learning lessons none of us should need to learn. Man's inhumanity to man ... Kid's inhumanity to kids ... Whatever the reason, people can be so cruel.(Since we were looking into that subject, and since Danielle has a Downs' syndrome sister who rode on the same bus, I asked quietly, "Does anyone on the bus make fun of Shannon, Danielle?"

I'll never forget the look she gave me. My question threw her totally off guard. Her brow furrowed, her nose wrinkled again and she asked, "Why in the world would they make fun of Shannon?" The very idea was ludicrous. Her mother could be so silly sometimes...Relief was great...

But just in case, there really was a flash of racial prejudice or any other mean-streak residing in the preschool bus in our little rural neighborhood, it was necessary to take a bit of action. First, I telephoned the principal and informed him that my preschooler had come home upset because of the way a little boy was treated on the bus. I told him what she had told me, and he asked me to thank her for him, for alerting us to a possible problem, something that needed his attention. He assured me he would look into it and he appreciated Danielle's and my concern. She was happy. We had done something. Then, for good measure, she and I sang a song together: a song we both knew very well.

"Jesus loves the little children All the children of the world. Red and yellow Black ('AND BROWN', I threw in) and white, All are precious in His sight. Jesus loves the little children of the world. “I don't know how the principal chose to handle the problem: I don't know what he said to the kids. But rest assured Danielle kept me posted on Life on the School Bus, and there was not even one more negative incident involving the little brown boy.

A princess had seen to that.

Emedinews:Insights on Medicolegal issues:Obscure autopsy is important in cases where no significant finding are discovered in autopsy

Negative autopsy is very useful in cases where there is no adequate history of death. When in a postmortem examination, if despite all efforts i.e. macroscopic or gross, microscopic chemical and toxicological result could not give conclusive information regarding cause, manner or other required medicolegal aspect of death, then obscure or negative autopsy may provide logical conclusion.
• Death from fear/fright or shock/cases of post fracture air embolism
• Death due to lesion in neck as diphtheria, laryngeal bronchitis/swelling of glottis or chocking on food
• Cases like brown atrophy of heart associated with starvation, asthma or cancer
• Sickle cell disease/Lesion of adrenal gland/hemorrhage or destruction by tumor
• I have found negative autopsy to be very informative in death due to distal coronary artery occlusion or coronary arteries spasm

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A patient was brought to the ICU in cardiogenic shock.

Situation: A patient was brought to the ICU in cardiogenic shock.
Reaction: Oh my God! Why didn’t you take him for emergency angiography and subsequent PTCA.
Lesson: Make Sure to perform an emergency diagnostic angiography and mechanical revascularization with PTCA in patients of cardiogenic shock. Results of NRMI–2, an ongoing trial suggest that this intervention is much better than thrombolytic therapy in such patients.

Emedinews:Inspiration:Learning to Get Back Up

Bringing a giraffe into the world is a tall order. A baby giraffe falls 10 feet from its mother's womb and usually lands on its back. Within seconds it rolls over and tucks its legs under its body. From this position it considers the world for the first time and shakes off the last vestiges of the birthing fluid from its eyes and ears. Then the mother giraffe rudely introduces its offspring to the reality of life.

In his book, A View from the Zoo, Gary Richmond describes how a newborn giraffe learns its first lesson. The mother giraffe lowers her head long enough to take a quick look. Then she positions herself directly over her calf. She waits for about a minute, and then she does the most unreasonable thing. She swings her long, pendulous leg outward and kicks her baby, so that it is sent sprawling head over heels.

When it doesn't get up, the violent process is repeated over and over again. The struggle to rise is momentous. As the baby calf grows tired, the mother kicks it again to stimulate its efforts. Finally, the calf stands for the first time on its wobbly legs.

Then the mother giraffe does the most remarkable thing. She kicks it off its feet again. Why? She wants it to remember how it got up. In the wild, baby giraffes must be able to get up as quickly as possible to stay with the herd, where there is safety. Lions, hyenas, leopards, and wild hunting dogs all enjoy young giraffes, and they'd get it too, if the mother didn't teach her calf to get up quickly and get with it. The late Irving Stone understood this. He spent a lifetime studying greatness, writing novelized biographies of such men as Michelangelo, Vincent van Gogh, Sigmund Freud, and Charles Darwin. Stone was once asked if he had found a thread that runs through the lives of all these exceptional people. He said, "I write about people who sometime in their life have a vision or dream of something that should be accomplished and they go to work.

"They are beaten over the head, knocked down, vilified, and for years they get nowhere. But every time they're knocked down they stand up. You cannot destroy these people. And at the end of their lives they've accomplished some modest part of what they set out to do."

(Contributed by Ms Ritu Sinha)

Emedinews:Insights on Medicolegal issues:Immunization death Ideal containers/preservative for viscera postmortem examination

 For preservation of viscera, clean, wide-mouthed glass bottles fitted with glass stoppers of one liter capacity should be used. Rubber inserts should preferably not be used under caps.

·         20-30 ml of blood taken from femoral artery or vein by per skin puncture should be collected in 60ml screw-capped bottles or in plastic capped tubes/10 mg of sodium or potassium fluoride per ml of blood should be added in blood for preserving blood.

·         20-30 ml of urine is obtained from direct puncture of the bladder during the postmortem examination  with a syringe and needle and should be collected in 60 ml screw-capped bottles or in plastic capped tubes and preservative 20-30 mg of thymol blue or boric acid or acetic acid should be added as preservative.

·         Saturated sodium chloride solution (common salt.) for all the visceral samples for chemical/toxicological examination.

·         If there is an associated history of death due to acid intoxication, then all the samples should be preserved in rectified spirit. 

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A 14 year–old girl suffering from dysmenorrhea wanted an analgesic for her pain.

Situation: A 14 year–old girl suffering from dysmenorrhea wanted an analgesic for her pain.
Reaction: Oh My God! Why was aspirin given!
Lesson: Make sure to remember that aspirin is contraindicated in children.

Emedinews:Inspiration:Let the Light Shine

Bill was driving home one evening, on a two-lane country road. Work, in this small Midwestern community, was almost as slow as his beat-up Pontiac, but he never quit looking. Ever since the factory closed, he'd been unemployed, and with winter raging on, the chill had finally hit home.

It was a lonely road. Not very many people had a reason to be on it, unless they were leaving. Most of his friends had already left. They had families to feed and dreams to fulfill, but he stayed on. After all, this was where he buried his mother and father. He was born here and knew the country. He could go down this road blind, and tell you what was on each side, and with his headlights not working, that came in handy.

It was starting to get dark and light snow flurries were coming down. He'd better get a move on. You know, he almost didn't see the old lady, stranded on the side of the road. But even in the dim light of day, he could see she needed help.

So he pulled up in front of her Mercedes and got out. His Pontiac was still sputtering when he approached her. Even with the smile on his face, she was worried. No one had stopped to help for the last hour or so. Was he going to hurt her? He didn't look safe, he looked poor and hungry. He could see that she was frightened, standing out there in the cold. He knew how she felt. It was that chill that only fear can put in you. He said, "I'm here to help you ma'am. Why don't you wait in the car where it's warm? By the way, my name is Bill." Well, all she had was a flat tire, but for an old lady, that was bad enough. Bill crawled under the car looking for a place to put the jack, skinning his knuckles a time or two. Soon he was able to change the tire, but he had to get dirty and his hands hurt. As he was tightening up the lug nuts, she rolled down her window and began to talk to him. She told him that she was from St. Louis and was only just passing through. She couldn't thank him enough for coming to her aid.

Bill just smiled as he closed her trunk. She asked him how much she owed him. Any amount would have been all right with her. She had already imagined all the awful things that could have happened had he not stopped. Bill never thought twice about the money. This was not a job to him. This was helping someone in need, and God knows there were plenty who had given him a hand in the past. He had lived his whole life that way, and it never occurred to him to act any other way. He told her that if she really wanted to pay him back, the next time she someone who needed help, she could give that person the assistance that they needed, and Bill added "...and think of me".

He waited until she started her car and drove off. It had been a cold and depressing day, but he felt good as he headed for home, disappearing into the twilight. A few miles down the road the lady saw a small cafe. She went in to grab a bite to eat, and take the chill off before she made the last leg of her trip home. It was a dingy looking restaurant. Outside were two old gas pumps. The whole scene was unfamiliar to her.

The cash register was like the telephone of an out of work actor-it didn't ring much. Her waitress came over and brought a clean towel to wipe her wet hair. She had a sweet smile, one that even being on her feet for the whole day couldn't erase. The lady noticed that the waitress was nearly eight months pregnant, but she never let the strain and aches change her attitude. The old lady wondered how someone who had so little could be so giving to a stranger. Then she remembered Bill. After the lady finished her meal and the waitress went to get her change from a hundred dollar bill, the lady slipped right out the door. She was gone by the time the waitress came back. She wondered where the lady could be, and then she noticed something written on a napkin.

There were tears in her eyes, when she read what the lady wrote. It said, "You don't owe me a thing, I've been there too. Someone once helped me out, the way I'm helping you. If you really want to pay me back, here's what you do... “Don’t let the chain of love end with you."

Well, there were tables to clear, sugar bowls to fill, and people to serve, but the waitress made it through another day. That night when she got home from work and climbed into bed, she was thinking about the money and what the lady had written. How could she have known how much she and her husband needed it? With the baby due next month, it was going to be hard. She knew how worried her husband was, and as he lay sleeping next to her, she gave him a soft kiss and whispered in a soft, and low voice, "Everything's going to be all right; I love you Bill."

Emedinews:Insights on Medicolegal issues:Autopsy in deaths due to adverse events following immunization

• The doctor conducting the autopsy is duty bound to take samples for toxicological screening and should send them to forensic laboratory for toxicological/chemical examination
• The site of injection and the underlying tissue up to 2-3 cms (button size) with dermis and epidermis should be excised out. It should be preserved in a glass jar which should be filled two-thirds with saturated saline water. The specimens should be sealed, signed, labeled by the doctor/autopsy surgeon and should be handed over to police /investigating officer for further toxicological/chemical examination.
• The viscera for toxicological/chemical examination/ the following viscera specimen/biological samples should be collected for toxicological/chemical examination; 80 to 100 gms of liver, 80 to 100 gms of brain with meninges, whole of the stomach with gastric contents. If there are no gastric contents, a section of stomach should be sent. The upper part of small intestine about 30cm long with its contents Fragments from both adrenal glands, half of transverse section of kidneys, half of spleen. Blood 100 ml ideal / minimum 10 ml and urine 100 ml/ minimum 10 ml.
• All visceral specimens should be collected in separate containers - a wide mouthed bottle as prescribed - and saturated saline should be added as preservatives. The quantity of the saline should be sufficient to cover all the pieces of specimen viscera in bottle.
• The specimens should be sealed, signed, labeled by the doctor/autopsy surgeon and should be handed over to police /investigating officer for further chemical examination in a forensic lab.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A patient died after receiving penicillin injection

Situation: A patient died after receiving penicillin injection
Reaction: Oh my God! Why was anaphylaxis not suspected?
Lesson: Make sure that each time a patient is given penicillin injection, anti anaphylaxis measures are available.

Emedinews:inspiration:Learning patience with God

My mother was dying of leukemia. My two older sisters, father and I had shared the last three weeks in the hospital room with her. In two years, she had gone from a strong matriarch to a helpless invalid.

For the last three days, she had been in a semi-conscious state of moaning and lifelessness. She could no longer speak through her dry, swollen lips. Her eyes had the blank void of a moonless midnight. On the night of the third day, I knew what I must do. I must cease being the selfish, clinging son. I sped purposefully to the chapel. There I gave God permission to take my mother. I could no longer stand to see her suffer, so I prayed for the permanent healing that only death can bring.

I returned to the room with a peaceful heart for I knew by the next morning my mother would also be at peace. I had the best night's sleep in weeks. The next morning, as the sun broke through the window, I awoke. My first thoughts were, "It's over". But then a noise, a stirring directed my attention from the window to the bed. A small movement made me realize that my mother was still alive. It was all I could do to keep from screaming aloud, "God, how can you do this to me? I became a selfless son, and gave you permission to end this, and you still kept her in her misery." But before I could have exclaimed this, I was shocked to see that there was more than just a movement.

My mother rolled onto her side, and looked into the glare of the newly risen sun. Then, as the sun made sparkling starbursts in her eyes, she licked her parched lips, and said "Gee, it's going to be a beautiful day today". Needless to say this got our attention quickly. Being the youngest, and fastest, I was first to her bedside. "Mom, it's me, Jerry, do you recognize me"? "Of course I do Jerry", she replied.

We all took our turns talking to her. Other relatives came and were able to talk to her, as she answered not in her old voice, but rather in the voice of a child. The doctor's explanation was that the brain stem was being destroyed, accounting for the sudden change. It was a joyous day of laughing, and celebrating life with our family. That night we all went to sleep peacefully.

The next morning, we were awakened to the stirring of angel's wings, and my mother was finally healed of her suffering. She had awakened to the Risen Son.

The next few days were hectic with funeral plans. It was only after the funeral that I stopped to think of what had happened. If God had answered my prayer, in my time, in my way, my final memories of my mother would have been that of a helpless invalid, with void eyes, lying motionless in a deathbed. Instead, God answered my prayer in his time, in his omniscient way.

Now, my memories of my mother are of a day of laughing and rejoicing. Since that time I have had many rocky roads. Financial failure. A divorce. The loss of my father. But throughout it all, regardless of how stormy the night might be, I know that through God's love, and perfect timing, I can awaken the next morning to a newly risen sun, or to the Risen Son, and say "Gee, it's going to be a beautiful day today."

(Contributed by Ms Ritu Sinha)

Emedinews:Insights on Medicolegal issues:Doctor should always document the resuscitative/surgical injuries in case of death of a medico-legal case

Doctor should always document the resuscitative/surgical injuries in case of death of a medico-legal case
The site of rib fractures after heavy blunt thoracic injuries was preferably found in the dorsal region
Doctors must have a complete understanding and clarity about the methods, indications and duration of resuscitation used in a particular case and whether all these have been documented in the clinical sheets or not. Resuscitative attempts may lead to skeletal, cardiac and abdominal viscera injuries. The investigating police officer should make a note on the basis of statements taken from the relative and doctors who attended the deceased and the same should be enclosed in inquest paper before handing them over to the autopsy surgeons.

The injuries produced in human body when attempting for resuscitation pose difficulty in interpretation of injuries noted at post mortem examination or in inquest paper by the investigating law enforcement agency. Before proceeding to make an interpretation, the doctor conducting the autopsy should know if there has been an attempt for resuscitation and who did it and for how long.

• The method generally used for life saving attempts by non-medical persons who are with the critical patient is mouth-to-mouth respiration and manual chest massage which may causes contusions.
• Bag and mask intubations, endotracheal tube, obdurate airway are used for respiratory ventilation.
• The mechanical methods like thumper, active compression-decompression device and defibrillators are used in resuscitation. The closed chest cardiac massage along or with interspersed abdominal compression is also used for resuscitation.
• Injections, closed-chest cardiac massage and other resuscitation procedures to the patients may result in the fracture of a chest vertebra, serial fractures of ribs resulting in an unstable thorax, bilateral hemothorax, tension pneumothorax, rupture of kidney and spleen.
• The site of rib fractures after heavy blunt thoracic injuries was preferably found in the dorsal region.
• The injuries which are received/inflicted on body prior to death are called mortem injuries and may or may not be a contributing factor in causing the death or they may have occurred due to much other reason like resuscitation/transport of sick /ill person for medical care called artifact

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure:A 20–year–old college student complained of dysuria, frequency and pyuria.

Situation: A 20–year–old college student complained of dysuria, frequency and pyuria.
Reaction: Oh my God! Why did you not advise macrolide?
Lesson: Make sure to remember that macrolide are very effective against E. coli, S. saprophyticus and C. trachomatis infection.

Life and Love's unending journey

Love should always remain hopeful and positive in the difficult journey that follows along lives "bumpy detours and highways". Love should never lead dreamers astray, left to stumble and stammer along the "narrow muddy paths" of unfulfilled love, nor leave them alone to pass the dark and shadowy graveyards on the "lonely boulevards" of broken hearts, strewn with unkept promises and shattered dreams of "what was to be".

Love should always be alert and avoid the uncompromising gray sidewalk of the "two way street" of opposite direction and conflict and seek the sunny "one way street" of like attraction, goals, aims, purposes and desires.

So always drive on the "high road" on life's golden carpet down the "yellow brick road" to love and life's grand "promenades" and elegant "thoroughfares," leaving together to follow and smell the sweet scents and fragrances that waif and rise to greet and linger in the air.

(Contributed by Ms Ritu Sinha)

Emedinews:Insights on Medicolegal issues:What are the WMA guidelines for medical doctors in biomedical research involving human subjects?

Medical progress is based on research which ultimately must rest in part on experimentation involving human subjects. The purpose of biomedical research involving human subjects must be to improve diagnostic, therapeutic and prophylactic procedures and the understanding of the etiology and pathogenesis of disease.

• Any act or advice which could weaken physical or mental resistance/health of a human being may be used only in his interest.” In the field of biomedical research a fundamental distinction must be recognized between medical research in which the aim is essentially diagnostic or therapeutic for a patient, and medical research, the essential object of which is purely scientific and without direct diagnostic or therapeutic value to the person subjected to the research. The World Medical Association has prepared the following recommendations as a guide to every doctor in biomedical research involving human subjects. It must be stressed that the standards as drafted are only a guide to physicians all over the world. Doctors are not relieved from criminal, civil and ethical responsibilities under the laws of land applicable to them.

• Biomedical research involving human subjects must conform to accepted scientific principles and should be based on adequately performed laboratory and animal experimentation and on a thorough knowledge of the scientific literature.
• The designs and performance of each experimental procedure involving human subjects should be clearly formulated in an experimental protocol which should be transmitted to a specially appointed independent committee for consideration, comment and guidance.
• Biomedical research involving human subjects should be conducted only by scientifically qualified persons and under the supervision of a clinically competent medical person. The responsibility for the human subject must always rest with a medically qualified person and never rest on the subject of the research, even though the subject has given his or her consent.
• Biomedical research involving human subjects cannot legitimately be carried out unless the importance of the objectives is in proportion to the inherent risk to the subject.
• Every biomedical research project involving human subjects should be preceded by careful assessment of predictable risks in comparison with foreseeable benefits to the subject or to others. Concern for the interests of the subject must always prevail over the interest of science and society.

(Reference 18th World Medical Assembly, Helsinki, Finland, 1964 and revised by the 29th World Medical Assembly, Tokyo, Japan, 1975).

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: An asthmatic patient became worse after receiving a painkiller

Situation: An asthmatic patient became worse after receiving a painkiller.
Reaction: Oh my God! Why was he not put on a leukotriene receptor antagonist?
Lesson: Make sure that a patient with asthma is not given aspirin or he is put on a leukotriene receptor antagonist (zafirlukast or montelukast).

Emedinews:Inspiration:Living and Giving

Whatever you give away today, or think or say or do will multiply about 10-fold and then return to you. It may not come immediately, nor from the obvious source but the law applies unfailingly, through some invisible force.

Whatever you feel about another, be it love or hate or passion will surely bounce right back to you in some clear (or secret) fashion If you speak about some person, a word of praise or two, soon, tens of other people will speak kind words of you.

Our thoughts are broadcasts of the soul, not secrets of the brain. Kind ones bring us happiness; petty ones, untold pain. Giving works as surely as reflections in a mirror. If hate you send, hate you'll get back, but loving brings love nearer.

Remember, as you start this day and duty crowds your mind, that kindness comes so quickly back to those who first are kind. Let that thought and this one direct us through each day.

The only things we ever keep are the things we give away.

(Contributed by Ms Ritu Sinha)

Emedinews:Insights on Medicolegal issues:The Accreditation of DNA lab must be proven for legal use

The Nobel Prize winning inventor of PCR, Kary Mullis, said that he does not think that genotyping should be used for Forensics, except as one piece of the puzzle.

• The reliability and acceptability of DNA test results rest on the accuracy of DNA samples that have been collected for analysis. Poor collection procedures, improper storage of samples and mishandling of samples/false results are the leading causes for errors in DNA testing.
• The credential of scientist/accreditation of laboratory must be carefully scrutinized before the legal use of DNA report by law enforcement agency in the interest of truth and justice
• The science of human genetics is still not complete, well-elaborated and the scientist across the globe does not know beyond doubt and probability as to how frequent is natural chimerism?
• Forensic science does not exactly know how common are false-negatives.
• The main deliberated reason as found in DNA testing is that samples get rejected from the lab because the swab is contaminated in such fashion that makes it impossible to get usable DNA samples from it.
• Sample contamination may occur even if the sample swab is dropped on the floor or counter, or used accidentally by people who are not trained or even semi trained people who do not know the intricacies of DNA science or there is lack of proper competent supervision. Such samples needs to be disposed of and a fresh swab should be used.
• The swab collection method is another important part for proper tracking and identification of the sample. This is not a failure of the swab, but of the people that are handling the swab. It must be correctly identified and tracked through the system to make sure that it is not confused with other samples that may be in the lab. All swabs come with a bar-coded container that they are placed in. It is also advised to insert a tiny RFID chip in the swab itself to further help track and identify the swab.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure:During evening round in a Nephrology ward, a doctor came across a patient complaining of headache.

Situation: During evening round in a Nephrology ward, a doctor came across a patient complaining of headache.
Reaction: Give him a tablet of Nimesulide.
Lesson: Make sure to remember that nimesulide, a selective COX–2 antagonist has minimal potential for renal toxicity.

Emedinews:inspiration:Knowing Yourself

Control, fear, doubt and anger; these are the real deadly killers of the human race. We hurt ourselves by feeling these emotions and we hurt others by directing these emotions at them.

But what if we could direct unconditional love to whomever we meet? What then? Could we help the world be a better place? Maybe, maybe not but we'd certainly help ourselves. Why do we let other people hurt us? Because we put expectations on them, expectations that we ourselves have failed to live up to with others.

If you love someone you feel it and that feeling is yours. Look at children. We still love our children when they disappoint us why not our workmates, teachers, friends and most of all partners? It's because we put conditions on what we give out.

Who hasn't bought a present or done a job around the house expecting something in return - why? If you want to help someone or give something you choose to do it because you want to, not for "Brownie Points". No other reason than just because you want to - that is showing love.

You can help an old lady with her groceries and it feels good so why not with everything else

When you learn that giving love without expectation is the purest of all faith, then and only then, will you be on the road to really knowing yourself.

(Contributed by Ms Ritu Sinha)