Emedinews:Insights on Medicolegal issues: Postmortem examination in a case of pneumothorax

Postmortem examination in a case of pneumothorax

• In cases of sudden death after pneumothorax, pneumoperitoneum, 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 post-mortem examination is made 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.

Emedinews:Makesure:A patient was denied rheumatic prophylaxis as IM penicillin was under short supply.

Situation: A patient was denied rheumatic prophylaxis as IM penicillin was under short supply.
Reaction: Oh my God! Why was he not given oral penicillin.
Lesson: Make sure that all such cases are not denied oral penicillin V.

Emedinews:Inspiration:Asked From God

I asked God to take away my pain, God said, No. It is not for me to take away, but for you to give it up.

I asked God to make my handicapped child whole. God said, No. His spirit is whole, his body is only temporary.

I asked God to grant me patience. God said, No. Patience is a byproduct of tribulations; it isn't granted, it is learned.

I asked God to give me happiness. God said, No. I give you blessings. Happiness is up to you.

I asked God to spare me pain. God said, No. Suffering draws you apart from worldly cares and brings you closer to me.

I asked God to make my spirit grow. God said, No. You must grow on your own, but I will prune you to make you fruitful.

I asked God for all things that I might enjoy life. God said, No. I will give you life, so that you may enjoy all things.

I ask God to help me LOVE others, as much as He loves me. God said...Ahhhh, finally you have the idea.

This day is yours don't throw it away.

May God Bless You. To the world you might be one person, but to one person you just might be the world.

Emedinews: Insights on Medicolegal Issues:Immunization death and sampling for toxicological screening

The doctor conducting the autopsy is duty bound to take samples, which should be sent to forensic laboratory for toxicological/chemical examination.

• The site of injection and the tissues lying below up to 2-3 cms (button size) with dermis and epidermis of the sight of injection 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 should be preserved for for toxicological/chemical examination i.e. liver (80-100gm), brain (100 gm) 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 length 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 the visceral specimens should be collected in separate containers or a wide- mouthed bottle as prescribed; saturated saline should be added as preservative. The quantity of the saline should be sufficient to cover all the pieces of specimen viscera in the 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.

Emedinews:Makesure:An asthmatic with respiratory rate of 37 developed respiratory arrest.

Situation: An asthmatic with respiratory rate of 37 developed respiratory arrest.
Reaction: Oh my God! Why was the patient not put on the ventilator in time?
Lesson: Make sure to remember that a respiratory rate of >35 is a warning signal to start ventilation therapy.

Emedinews:Inspiration:The secret of happiness

A certain shopkeeper sent his son to learn about the secret of happiness from the wisest man in the world. The lad wandered through the desert for 40 days, and finally came upon a beautiful castle, high atop a mountain. It was there that the wise man lived.

Rather than finding a saintly man, though, our hero, on entering the main room of the castle, saw a hive of activity: tradesmen came and went, people were conversing in the corners, a small orchestra was playing soft music, and there was a table covered with platters of the most delicious food in that part of the world. The wise man conversed with everyone, and the boy had to wait for two hours before it was his turn to be given the man’s attention.

The wise man listened attentively to the boy’s explanation of why he had come, but told him that he didn’t have time just then to explain the secret of happiness. He suggested that the boy look around the palace and return in two hours. "Meanwhile, I want to ask you to do something", said the wise man, handing the boy a teaspoon that held two drops of oil. "As you wander around, carry this spoon with you without allowing the oil to spill".

The boy began climbing and descending the many stairways of the palace, keeping his eyes fixed on the spoon. After two hours, he returned to the room where the wise man was. "Well", asked the wise man, "Did you see the Persian tapestries that are hanging in my dining hall? Did you see the garden that it took the master gardener ten years to create? Did you notice the beautiful parchments in my library?" The boy was embarrassed, and confessed that he had observed nothing. His only concern had been not to spill the oil that the wise man had entrusted to him. "Then go back and observe the marvels of my world", said the wise man. "You cannot trust a man if you don't know his house". Relieved, the boy picked up the spoon and returned to his exploration of the palace, this time observing all of the works of art on the ceilings and the walls. He saw the gardens, the mountains all around him, the beauty of the flowers, and the taste with which everything had been selected. Upon returning to the wise man, he related in detail everything he had seen. "But where are the drops of oil I entrusted to you?" asked the wise man. Looking down at the spoon he held, the boy saw that the oil was gone.

"Well, there is only one piece of advice I can give you", said the wisest of wise men. "The secret of happiness is to see all the marvels of the world and never to forget the drops of oil on the spoon".

Emedinews:Insights on Medicolegal issues:Can a doctor disclose the medical condition of the patient?

 The conclusive summary of the Principle of "duty of care", as applicable to persons in medical profession, includes the duty to maintain confidentiality.

·         From ancient age in India the medical ethics has viewed the duty of confidentiality as a relatively non-negotiable tenet of medical practice.

·         The Hippocratic Oath express about patient confidentiality as Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.

·         Patient Confidentiality is mandated in America by  laws  known as Health Insurance Portability and Accountability Act (HIPAA) of 1996, specifically the Privacy Rule, and various state laws, some more rigorous than HIPAA. However, numerous exceptions to the rules have been carved out over the years in view of medico-legal cases.

·         Many American states require physicians to report gunshot wounds to the police and impaired drivers to the Department of Motor Vehicles.

·         Confidentiality is also challenged in cases involving the diagnosis of a sexually transmitted disease in a patient who refuses to reveal the diagnosis to a spouse, and in the termination of a pregnancy in an underage patient, without the knowledge of the patient's parents.

·         In India a law like HIPAA is required or should be incorporated in code of medical ethics by MCI

((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:Another way to win

Kay Poe and Esther Kim have been best friends since they were seven years old. Among other things they have in common, the two young ladies from Houston both compete at the highest levels in taekwondo. How good are they? Esther and Kay advanced to the finals in the Women's Olympic Flyweight division at the 2000 U.S. Olympic Team Trials on May 20 in Colorado Springs.

"I don't think of her as just a friend. I think of her more as a sister," Kay says. "We've grown up together, and we always push each other and help each other out the best we can training wise." What a story was unfolding! Reporters and photographers were poised to record the outcome of so intense a competition between two girls who have been close for so long. But a sports story would soon be overshadowed by a far more important friendship story.

Kay had dislocated her left kneecap in her semi-final match of the round robin tournament. Though ranked number one in the world at her sport, it was questionable that she could compete against her best friend. She could barely stand, so it was a foregone conclusion that Esther would win, travel to the 2000 Olympic Games in Sydney, and represent the United States in the international competition these two had trained and worked toward for so long.

On the day of the match, Esther Kim shocked the crowd by forfeiting rather than defeat her friend in an unfair competition. In allowing the better taekwondo fighter to represent the United States in Sydney, she won a personal battle over ego and selfishness. Amidst frequent stories of cheating and taking unfair advantage in order to win at any price, Esther showed how to win by losing.

"Even though I didn't have the gold medal around me," said Esther, "for the first time in my life, I felt like a real champion." Her generosity of spirit was honored with the Citizenship through Sports Award and with an all-expenses-paid trip to the 2000 Olympic Games from the International Olympic Committee.

In the Bible, Paul wrote about giving up certain "rights" for the sake of people he loved (see 1 Corinthians 9:1-15). Parents do it all the time for their children. And occasionally friends make magnanimous gestures like Esther's.

The next time you are inclined to bemoan the selfishness of the masses, recall this story of a 20-year-old athlete's largesse. The next time you have the chance to show magnanimity, let it inspire you to rise to the level of her example.

(Ms Ritu Sinha)

Emedinews:Insights on Medicolegal issues:Immunization death and legal autopsy

• It is recommended that an autopsy in a death suspected to be due to an adverse event following immunization (AEFI) be performed as soon as possible (within 72 hours) to avoid tissue damage, development of post mortem artifacts and autolysis of the adrenal glands, which can alter diagnosis.
• The detailed patient’s history is included in the autopsy form that it is submitted to the team (autopsy surgeon/ pathologist/ forensic specialist) conducting autopsy.  The additional specific information to the autopsy team will help them look for any underlying disease/pathologies in the deceased, which may be cause of death or contributed in the cause of death.
• Samples for both histopathological and toxicological examination should be sent to approved and accredited government reference labs through investigating police agencies. The samples should be collected and transported to forensic labs as early as possible to avoid loss of biological samples due to decomposition.
• All samples  should  be labeled with the name, number and autopsy report/ form number along with the necessary documents requesting the examination and investigation, and  the conclusions from the autopsy, which  should  list   the   cause   of   death, utilizing International Classification of Disease (ICD 10) and, if possible, the causative agents/drugs.
• Samples for histopathology to be sent to a pathologist to detect underlying disease/pathologies in the deceased that may have caused or contributed to death. The samples should be representative of the suspicious area of disease/pathology; however, in general liver (80-100gm), brain (100 gm) with meninges, fragments from both adrenal glands, half of transverse section of kidneys, half of spleen and  whole heart should be sent.
• All the visceral specimens should be collected in separate containers or a wide- mouthed bottle as prescribed; 10 % formalin should be added as preservatives. The quantity of the formalin 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 pathological examination. 

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:A small candle and the man

I'm really interested in story about a small candle carried by a man who was climbing the stairs of a lighthouse.

In their way up to the top, the candle asked the man, "Where are we going?" "We're going to the top of this lighthouse and give signals to the big ships on the ocean," the man answered.

"What? How could it be possible for me with my small light to give signals to those big ships?" "They will never be able to see my light", replied the candle weakly. "That's your part. If your light is small, let it be. All you have to do is keep burning and leave the rest to me", said the man.

A little later, they arrived at the top of the lighthouse where there was a big lamp with a loop behind it. Then the man lit the lamp with the light of the candle and instantly, the place shone so brightly that the ships on the ocean could see its light.

With our being and our limitations, we're hardly able to do any meaningful things. Yet, one thing you should bear in mind is that your life is like a small candle in God's powerful hand. All your abilities and expertise will remain as a small light if you don't put your life in God's hand. On the contrary, even if your light is so small or dim, if you entrust all your life to God, he is able to make your small light into a big one that brings blessings to many people.

Even it wasn't impossible for Joshua, who was Moses' servant, to feel slightly fear when God ordered him to lead the Israelis invading the Canaan. God comforted and strengthened Joshua that He would never leave him. God even promised him victory over victory. All God asked from him was, "Be strong and very courageous. Be careful to obey all the law my servant Moses gave you; do not turn from it to the right or to the left, that you may be successful wherever you go." (Joshua 1:7)

Do not look at your inability, limitations, and weaknesses. God entrust you with something, whether it is a work or a ministry. Have faith that you are in His mighty hand that He will use you according to His will. When we put all our trust in Him, we will see how He uses our lives, including our limitations, to be blessings to others.

Emedinews:Insights on Medicolegal issues: The Therapeutic privilege of a doctor

• When two or more persons agree upon the same thing in the same sense, it is a valid consent as per the definition of the consent given in Section 13 of the Indian Contract Act. The Doctor who performs an intervention without the patient’s consent commits an offence for which he is liable as per law. Consent may be express or implied.
• Express consent in an oral or written authority by the patient to render the proposed medical/surgical treatment. Consent may be implied to conduct medical examination from the conduct of the patient who voluntarily submits to treatment under circumstances which would indicate awareness of the planned treatment impliedly authorizes the treatment, even without express consent.
• The patient has a legitimate right to determine what medical/surgical, diagnostic or therapeutic intervention has to be done on his/her own body and the doctor has to obtain a valid consent after giving full information of medical procedure to be done to the patient.
• A patient who presents himself or herself at the doctor’s clinic/hospital after appointment/purchasing OPD Card/paying doctors fee for consultation/routine medical procedure/examination by way of palpation/auscultation implies his/ her consent to treatment by the doctor/hospital.
• It is now recognized that the patient has the right to full information in patient as consumer terms, concerning his diagnosis, treatment and prognosis. He/she should also be informed about the alternative treatments/methods and its possible complications. Informed means the consent of a patient to the performance of the health care services provided by a registered medical practitioner, that prior to the consent having been given, the doctor/team of/hospital authority has informed the patient of the nature of the purposed procedure or treatment of those risks and alternative treatment or diagnosis that a reasonable patient would consider material to the decision whether or not to undergo treatment or diagnosis.
• In standard ethical/prudent practice of medicine, the doctor has a duty to disclose the information/complete information. There are  two exceptions: No disclosure is required, if the patient indicates a preference not to be informed or if the physician or surgeon believes in the exercise of sound medical judgment, that the patient’s personality is so anxiety-prone or disturbed that the information would not be processed rationally or that it would probably cause significant psychological harm or is not in the interest of his/her mental and physical health or it will cause adverse effect on good prognosis of health of the patient.
• This exception to the legal duty of full disclosure to patient as informed consent in medical care delivery is called the ‘therapeutic privilege’ of a doctor. The consultation/share the information with legal heirs another physician familiar with the patient/family doctor, with a close relative or friend of patient, or all is advisable for a treating doctor in good faith and must be documented as an extended informed consent under heading of therapeutic privilege

Emedinews: Inspiration:Our Truth with Your Eyes

Begin the do's and lay down the tries. Wake up to realize, or sleep with memorized lies of how you lived truly alive.
Please wake!
Just wake and see..... With a keen eye trained to see beyond the horizon of what you are truly meant to be. No more dreams of an unrelenting battle within. When you rise, the truth and knowledge will begin.
Subtle yet absolute, those changes will infuse with the darkness that held on to you. Your reality will drift, leaving a knowledge and lesson from a teacher unknown
The answer is here! It's the spin-tingling truth. Lay down the tries and begin the do's.

Emedinews:Makesure: A patient with prosthetic heart valves (bioprosthetic) developed infective endocarditis.

Situation: A patient with prosthetic heart valves (bioprosthetic) developed infective endocarditis.
Reaction: Oh my God! Why was he not given infective endocarditis prophylaxis?
Lesson: Make sure that all patients with prosthetic heart valves (bioprosthetic or homograft) are given infective endocarditis prophylaxis. 

Emedinews:Makesure: A 4–year–old girl with rickets is unresponsive to high doses of vitamin D.

Situation: A 4–year–old girl with rickets is unresponsive to high doses of vitamin D.
Reaction: Oh my God! Why didn’t you advise alfacalcidol?
Lesson: Make sure to advise alfacalcidol in patients unresponsive to calcium/vitamin D therapy. Alfacalcidol, in numerous studies, has been found to be effective in refractory cases of rickets. 

Emedinews:Inspiration:The seven C's of Success by Brian Tracy

Clarity: Eighty percent of success comes from being clear on who you are, what you believe in and what you want.

Competence: You can't climb to the next rung on the ladder until you are excellent at what you do now.

Constraints: Eighty percent of all obstacles to success come from within. Find out what is constraining in you or your company and deal with it.

Concentration: The ability to focus on one thing single-mindedly and see it through until it's done takes more character than anything else.

Creativity: Flood your life with ideas from many sources. Creativity needs to be exercised like a muscle; if you don't use it you'll lose it.

Courage: Most in demand and least in supply, courage is the willingness to do the things you know are right.

Continuous learning: Read, at the very least, one book a week on business to keep you miles ahead of the competition. And just as you eat and bathe, organize your time so you spend 30 minutes a day exploring email, sending messages, going through websites, because like exercise, it's the only way you can keep on top of technology. If you get away from it, you'll lose your edge...

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 from children

My daughter mentioned something today that made me think and want to share it with you.

I just learned from my daughter, Gabrielle. She asked me what I thought about the average fourth grader. I asked her why. She said in school she was doing a project on the average fourth graders and didn't feel totally comfortable with it. Simply, when she looked around her classroom she clearly saw that each of her classmates were different/unique and none fit perfectly into this average 'label'.

A 9-year-old quickly was intelligent enough to rip apart 'the label' so it wouldn't blind her to the facts of the individuality and uniqueness of her fellow classmates/human beings.

I've always said, "If you put toddlers/children representing many skin colors and cultures in a playground, they'd play." It seems to me there are some things adults can learn from children.

Emedinews:Makesure:The patient missed her last dose of hepatitis B vaccine as she was out of station at 6th month.

Situation: The patient missed her last dose of hepatitis B vaccine as she was out of station at 6th month.
Reaction: Oh my God! Why was the vaccine not given between 4–6 months.
Lesson: Make sure that all patients are given the complete vaccine regimen. The correct regimen is 0, 1–2 months and 4–months.

Emedinews :Inspiration:8 Lies of my Mother

This story begins when I was a child: I was born poor. Often we hadn't enough to eat. Whenever we had some food, Mother often gave me her portion of rice. While she was transferring her rice into my bowl, she would say "Eat this rice, son! I'm not hungry."

This was Mother's First Lie.

As I grew, Mother gave up her spare time to fish in a river near our house; she hoped that from the fish she caught, she could give me a little bit more nutritious food for my growth. Once she had caught just two fish, she would make fish soup. While I was eating the soup, mother would sit beside me and eat the what was still left on the bone of the fish I had eaten, My heart was touched when I saw it. Once I gave the other fish to her on my chopstick but she immediately refused it and said, "Eat this fish, son! I don't really like fish."

This was Mother's Second Lie.

Then, in order to fund my education, Mother went to a Match Factory to bring home some used matchboxes, which she filled with fresh matchsticks. This helped her get some money to cover our needs. One wintry night I awoke to find Mother filling the matchboxes by candlelight. So I said, "Mother, go to sleep; it's late: you can continue working tomorrow morning." Mother smiled and said "Go to sleep, son! I'm not tired."

This was Mother's Third Lie.

When I had to sit my Final Examination, Mother accompanied me. After dawn, Mother waited for me for hours in the heat of the sun. When the bell rang, I ran to meet her.. Mother embraced me and poured me a glass of tea that she had prepared in a thermos. The tea was not as strong as my Mother's love, Seeing Mother covered with perspiration, I at once gave her my glass and asked her to drink too. Mother said "Drink, son! I'm not thirsty!".

This was Mother's Fourth Lie.

After Father's death, Mother had to play the role of a single parent. She held on to her former job; she had to fund our needs alone. Our family's life was more complicated. We suffered from starvation. Seeing our family's condition worsening, my kind Uncle who lived near my house came to help us solve our problems big and small. Our other neighbors saw that we were poverty stricken so they often advised my mother to marry again. But Mother refused to remarry saying "I don't need love."

This was Mother's Fifth Lie.

After I had finished my studies and gotten a job, it was time for my old Mother to retire but she carried on going to the market every morning just to sell a few vegetables. I kept sending her money but she was steadfast and even sent the money back to me. She said, "I have enough money."

That was Mother's Sixth Lie.

I continued my part-time studies for my Master's Degree. Funded by the American Corporation for which I worked, I succeeded in my studies. With a big jump in my salary, I decided to bring Mother to enjoy life in America but Mother didn't want to bother her son; she said to me "I'm not used to high living."

That was Mother's Seventh Lie.

In her dotage, Mother was attacked by cancer and had to be hospitalized. Now living far across the ocean, I went home to visit Mother who was bedridden after an operation. Mother tried to smile but I was heartbroken because she was so thin and feeble but Mother said, "Don't cry, son! I'm not in pain."

That was Mother's Eighth Lie.

 Telling me this, her eighth lie, she died. YES, MOTHER WAS AN ANGEL!

M - O - T - H - E - R

"M" is for the Million things she gave me
"O" means Only that she's growing old
"T" is for the Tears she shed to save me
"H" is for her Heart of gold
"E" is for her Eyes with love-light shining in them
"R" means Right, and right she'll always be

Put them all together, they spell "MOTHER" a word that means the world to me.

For those of you who are lucky to be still blessed with your Mom's presence on Earth, this story is beautiful. For those who aren't so blessed, this is even more beautiful.

(Contributed by Dr GM Singh)

Emedinews:Insights on Medicolegal issues: Estimation of bone age

• The lower end of radius bone fuses at the age of 16-17 years in male; in the case of female it fuses at the age of 17-18 years.
• The lower end of ulna fuses at the age of 18 years in case of male and in case of female it fuses at the age of 17 years.
• If the fusion of radius and ulna is seen in both, the attainment of age of 18 years cannot be ruled out.
• To be radiologically more specific and precise as recommended for forensic opinion, an X-ray of hip bone for crest of ilium and ischial tuberosity should be done since their fusion in male or female occurs between 18-20 years.
• The radiological examination for appearance and fusion of ossification centre of left hand if the person is right-handed and vice-versa should be advised/ considered more safely by doctor since it gives more reliable radiological picture due to less wear and tear.

Emedinews:Makesure:A patient’s blood pressure was not responding to Arkamin.

Situation: A patient’s blood pressure was not responding to Arkamin.
Reaction: Oh my God! Why was the patient given Artamin?
Lesson: Make sure that prescription is written with the drug name spelled clearly.

Emedinews:Inspiration: A Strong Woman vs Woman of Strength

A strong woman works out every day to keep her body in shape... but a woman of strength kneels in prayer to keep her soul in shape...

A strong woman isn't afraid of anything... but a woman of strength shows courage in the midst of her fear...

A strong woman won't let anyone get the best of her... but a woman of strength gives the best of her to everyone...

A strong woman makes mistakes and avoids the same in the future... a woman of strength realizes life's mistakes can also be God's blessings and capitalizes on them...

A strong woman walks sure footedly... but a woman of strength knows God will catch her when she falls...

A strong woman wears the look of confidence on her face... but a woman of strength wears grace...

A strong woman has faith that she is strong enough for the journey... but a woman of strength has faith that it is in the journey that she will become strong...

Emedinews:Insights on Medicolegal issues:Medical Testimony of Doctor in the Court of Law

Do not misrepresent documents/medical literature in the Court of Law

When evidence is read into the record of a trial, only that portion of the document which validates the information being discussed needs to be read aloud. One paragraph or even one part of a paragraph may be all that is necessary to substantiate the point you are making. Documents must be presented in the words of the author. When you paraphrase evidence, you argue in a circle. Reading the remainder of the document, even if it establishes a context for the evidence, is unnecessary and time-consuming. When a document is cut in a manner which lends the quoted passage a meaning other than what would be derived from a more complete reading, you are misrepresenting the document. This does not mean, however, that you are responsible for drawing the same conclusions from information as the author of the document.

Drawing a contrary conclusion from passages accurately interpreted does not constitute misrepresentation. The fact that the author of the document reached a different conclusion from the information argues perhaps persuasively against your conclusion. However, you have not misused the evidence.

Emedinews:Makesure:A neonate in an ICU being administered IV calcium exhibits signs of inflammation and necrosis at injection site

Situation: A neonate in an ICU being administered IV calcium exhibits signs of inflammation and necrosis at injection site.
Reaction: Oh my God! Why didn’t you observe the IV site carefully.
Make Sure that all hypocalcemic neonates are put on a cardiac monitor while receiving calcium infusions and the IV site is closely observed, because extravasation of calcium can produce severe interstitial necrosis. 

Emedinews:Inspiration: Yellow Paper Clips

Georgia, a friend of my wife, was recently divorced and trying to raise her two sons when the Gulf War broke out. She heard about soldiers in the service who had no family and needed pen pals. Letters addressed to "Any Soldier" were distributed by commanding officers who noticed any soldiers getting little or no mail. Georgia wrote to 25 such soldiers almost daily, most of them men.

Keeping up with 25 pen pals on a daily basis almost consumed Georgia's time and talents. She sent poems, little stories, and words of hope and encouragement. When there were time constraints, she would write one letter and copy it for everyone. Greetings were sent whenever she knew about a special event, like a birthday.

One day, Georgia received a letter from a soldier that was depressed and discouraged. She pondered as to how she could help lift his spirits. It was then that she noticed that at work there were paper clips of various colors. Georgia took one of the yellow paper clips and photo copied it in the palm of her hand. She sent this picture with the paper clip with the following message: "This yellow paper clip that you see in my hand represents a hug that I am sending to you. You can carry this paper clip in a pocket or anywhere, and whenever you feel down, you can just touch and hold it and know that somebody cares about you, and would give you a hug if she were there." Georgia sent a copy of this picture along with a paper clip and the message to each of her other correspondents.

After the war ended, Georgia received one of the pictures of her hand holding the yellow paper clip, and on the back were over 150 signatures of people that had been given her "hug".

During the years, Georgia named other paper clips. Pink came to mean a kiss, green was for good luck, and so on.

Years later, Georgia was giving a class as part of a seminar for positive thinking. She shared with the members of the class her paper clip symbolism, and made a bracelet of multi-colored paper clips for each of them. One of the women exclaimed "So you're the one!" The class member told Georgia that she was visiting her brother and needed something to hold papers together. She had noticed a yellow paper clip on the refrigerator held there with a magnet. She borrowed the paper clip for her papers. When the brother saw it, he grabbed it and scolded her, and told her never to touch the yellow paper clip again. Now she knew why.

No one will never know how far her message has spread, nor how many lives have been touched by a simple yellow paper clip.

Emedinews:Insights on Medicolegal issues:Witness –doctor “selling his testimony

In United States today the liveliest intra-professional and inter-professional discussion resolved about the witness –doctor “selling his testimony “as a witness for either party on payment.  The modern court has warned of this danger, said put the role of medical witness in its true perspective. Doctor as expert/forensic witness is a part of trial apparatus of court in finding the whole medical truth and facts and every possible step should be taken to channel his contribution in a direction that will serve to achieve truth and justice in the court of law if such medical witness will be paid from one party then how he/she will be towards the whole truth of medical perusal. One such step suggested by the American court is to make/treat the expert medical witness reports as non-partisan, objective and scientific as are the notable activities of his profession.  

Emedinews:Makesure:A patient with acid peptic disease was denied any painkiller for his distressing illness.

Situation: A patient with acid peptic disease was denied any painkiller for his distressing illness.
Reaction: Oh, my God! Why did you not give him nimesulide?
Lasson: Make sure to prescribe nimesulide as it is safe in acid peptic disease.

Emedinews: Inspiration:Working Towards What You Already Have

The American investment banker was at the pier of a small coastal Mexican village when a small boat with just one fisherman docked. Inside the small boat were several large yellow fin tuna. The American complimented the Mexican on the quality of his fish and asked how long it took to catch them. The Mexican replied, "Only a little while."

The American then asked, "Why didn't you stay out longer and catch more fish?" The Mexican said, "With this I have more than enough to support my family's needs." The American then asked, "But what do you do with the rest of your time?"

The Mexican fisherman said, "I sleep late, fish a little, play with my children, take siesta with my wife, Maria, stroll into the village each evening where I sip wine and play guitar with my amigos, I have a full and busy life."

The American scoffed, "I am a Harvard MBA and could help you. You should spend more time fishing; and with the proceeds, buy a bigger boat: With the proceeds from the bigger boat you could buy several boats. Eventually you would have a fleet of fishing boats. Instead of selling your catch to a middleman you would sell directly to the processor; eventually open your own cannery. You would control the product, processing and distribution. You would need to leave this small coastal fishing village and move to Mexico City, then Los Angeles and eventually New York where you will run your ever- expanding enterprise."

The Mexican fisherman asked, "But, how long will this all take?" To which the American replied, "15 to 20 years." "But what then?" asked the Mexican. The American laughed and said that's the best part. "When the time is right you would announce an IPO and sell your company stock to the public and become very rich, you would make millions." "Millions? Then what?"

The American said, "Then you would retire. Move to a small coastal fishing village where you would sleep late, fish a little, play with your kids, take siesta with your wife, stroll to the village in the evenings where you could sip wine and play your guitar with your amigos."

Emedinews:Insights on Medicolegal issues: The Cross-Examination debate in medical cases

The Cross-Examination debate in medical cases

A system of the cross examination trial/debate format in medical care/cases in western countries is developed by medical forums & forensic association to self-regulate the quality/standard of medical care delivery system and defend the cases of medical negligence with decorum as a lesson for further improvement in quality medical care and reduced medical error. The cases of medical negligence against the doctor causes an unrest to the medical professional and has no guidance is available in our country to defend the same by medical association/council.

The Cross-Examination debate in medical cases/negligence uses a team oriented, switch-sides format.  Debates are held between two person teams of doctors. The affirmative team is assigned the role of supporting the proposition, and the negative team is assigned the role of opposing the proposition.  During the course of a tournament, you will be assigned to argue the affirmative side in about half of your tournament debates, and the negative side in the remaining debates. The cross-examination format involves eight speeches and four cross-examination sessions. The first four speeches are designated as constructive speeches. These are longer speeches, and are open to new lines of argument at any point in time. The final four speeches are designated as rebuttal speeches. These shorter speeches are reserved for summaries, which mean they are not open to new lines of argument.  Interspersed between the constructive speeches are short cross-examination sessions, in which the debater who has just finished speaking is questioned by an opponent.  During the course of the medical debate, each debater will deliver a constructive speech, a rebuttal speech, be cross-examined by an opponent, and cross-examine an opponent. The order of speech is arranged to give the affirmative the open and closing speeches in the debate.  Cross-examination debate tournaments are sanctioned by rival professional associations, the Cross Examination medical Debate Association (CEDA) and the National Debate Tournament Committee of the American Forensic Association working well in self-regulation of medical education and standard of therapeutic & diagnostic updated medical care delivery system in the larger and better interest of the patient care and decrease medical litigations in a fair/ethical ways. 

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:Words to Live By...

Accept that some days you're the pigeon, and some days you're the statue. Always keep your words soft and sweet, just in case you have to eat them. Always read stuff that will make you look good if you die in the middle of it. Drive carefully. It's not only cars that can be recalled by their maker. Eat a live toad in the morning and nothing worse will happen to you for the rest of the day. If you can't be kind, at least have the decency to be vague. If you lend someone $20, and never see that person again, it was probably worth it. It may be that your sole purpose in life is simply to serve as a warning to others. Never buy a car you can't push.

Never put both feet in your mouth at the same time, because then you don't have a leg to stand on. Nobody cares if you can't dance well. Just get up and dance. The early worm gets eaten by the bird, so sleep late. When everything's coming your way, you're in the wrong lane. Birthdays are good for you; the more you have, the longer you live. Ever notice that the people who are late are often much jollier than the people who have to wait for them? If ignorance is bliss, why aren't more people happy? You may be only one person in the world, but you may also be the world to one person. Some mistakes are too much fun to only make once. Don't cry because it's over; smile because it happened. We could learn a lot from crayons: Some are sharp, some are pretty, some are dull, some have weird names, and all are different colors but they all have to learn to live in the same box.

A truly happy person is one who can enjoy the scenery on a detour. Happiness comes through doors you didn't even know you left open. Have an awesome day, and know that someone has thought about you today....

Emedinews:Insights on Medicolegal issues: Doctor in the Court room

Physician in the courtroom is the traditional contribution of medicine to justice Truth is perused by law and medicine and it is not captured in the court of law. Medical literature/books/journal/case law in the form of medical evidence if produced by medical practioner must be available for visual inspection in the court of law. Even though you have ready evidence into the record of the trial/debate, your opponents and the critic have a right to examine the evidence more closely.  An opponent may ask to inspect your evidence at the conclusion of your argument/speech, and your critic may ask to inspect select pieces of evidence at the conclusion of the argument/debate. Both requests are quite common.  You should give them the evidence they request, and be able to tell them exactly what you read from the document. Although quoted evidence is vital to cross-examination trial/debate, it is not difficult to grasp the basic principles of collecting and using evidence. What medical evidence is, and how it is used, will quickly become evident as you listen to a few cross-examination trial and its legal debates in the court of law. 

Emedinews:Makesure:A 36–year–old truck driver had severe allergic rhinitis and came for treatment.

Situation: A 36–year–old truck driver had severe allergic rhinitis and came for treatment.
Reaction: Oh my God, why was he not prescribed azelastine nasal spray?
Lasson: Make sure to avoid oral antihistamines in persons who perform tasks like driving as they may cause sedation and drowsiness; instead prescribe azelastine nasal spray which is effective and non–sedating.

Emedinews:Inspiration:When You Thought I wasn't Looking

A message every adult should read, because children are watching you and doing as you do, not as you say.

When you thought I wasn't looking, I saw you hang my first painting on the refrigerator, and I immediately wanted to paint another one.

When you thought I wasn't looking saw you feed a stray cat, and I learned that it was good to be kind to animals.

When you thought I wasn't looking, saw you make my favorite cake for me and I learned that the little things can be the special things in life.

When you thought I wasn't looking I heard you say a prayer, and I knew there is a God I could always talk to and I learned to trust in God.

When you thought I wasn't looking, I saw you make a meal and take it to a friend who was sick, and I learned that we all have to help take care of each other.

When you thought I wasn't looking, I saw you give of your time and money to help people who had nothing and I learned that those who have something should give to those who don't.

When you thought I wasn't looking, I saw you take care of our house and everyone in it and I learned we have to take care of what we are given.

When you thought I wasn't looking, I saw how you handled your responsibilities, even when you didn't feel good and I learned that I would have to be responsible when I grow up.

When you thought I wasn't looking, I saw tears come from your eyes and I learned that sometimes things hurt, but it's all right to cry.

When you thought I wasn't looking, I saw that you cared and I wanted to be everything that I could be.

When you thought I wasn't looking, learned most of life's lessons that I need to know to be a good and productive person when I grow up.

When you thought I wasn't looking, I looked at you and wanted to say, "Thanks for all the things I saw when you thought I wasn't looking."

LITTLE EYES SEE A LOT: Each of us, parent or friend, influence the life of a child. How will you touch the life of someone today?

Emedinews:Insights on Mediolegal issues:Autopsy findings in hanging

• The mark on the neck in hanging oblique/incomplete placed high up with pattern abrasions.
• The circumstances will usually indicate the fact of hanging, but sometimes the rope will break or become detached, and the deceased will be found lying with a ligature around his neck.
• The victim may sit or slump on a chair, bed or floor with the rope attached to a point only slightly above neck level. Very confusing for public perception
• Postmortem hypostasis will occur in the legs and hands if the body has been in the vertical position for at least a few hours. When the body is cut down and laid horizontal for a considerable time, some or all of this may flow back into the usual pattern.
• Petechial hemorrhages are the exception rather than the rule; most series have reported them in about 25 % of cases.
• There are no injuries on the hands and other part of the body of victim in the form resistance
• Dribbling of saliva is considered to be a sign of antemortem hanging but it is not necessarily seen in all the cases of hanging since the secretion of saliva in hanging is dependent upon, the stimulation of salivary glands by ligature material during the course of hanging.
• In a case of partial hanging when only partial body weight is working as constricting force on neck, the  ligature mark is faint. Hence, in this case or any other case of hanging particularly partial hanging where the salivary glands are not pressurized by the constricting force of ligature, no dribbling of saliva is seen and the same in this case cannot be ruled out.
• The neck of the deceased will not be stretched and elongated in this case since as it is a case of partial hanging and complete body weight is not working as stretching force.
• The eyes may remain open in a case of antemortem hanging.
• As per literature suicide notes are left only in about 25 % cases.

Emedinews:Makesure:A-28-year old male presents with increased frequency

Situation: A-28-year old male presents with increased frequency and occasional blood in urine. Examination of urine shows sterile pyuria.
Reaction: Oh my God! Why didn’t you check for TB?
Lesson: Make Sure to rule out TB in patients with frequency, dysuria, hematuria. Sterile pyuria is the first clue to diagnosis.

Emedinews:Insights on medicolegal issues:Forensic opinion in case of fatal hanging

• Hanging was formerly thought to be a pure asphyxia as a result of ‘cutting off the air’ by occlusion of the airway during the fatal pressure on the neck.
• It has been recognized by many forensic authors that the rapidity of death in many cases made it impossible for hypoxia to be the sole or even major cause. Many victims died almost immediately and exhibited none of the so-called ‘classic’ signs of asphyxia.
• Hanging means self-suspension; the body weight is constricting force/partial/complete, which constricts the laryngeal/tracheal lumen, root of tongue/venous congestion/reflex vagal inhibition/cerebral ischemia/fracture and dislocation of cervical vertebra as in case of typical/judicial hanging.
• The doctor who is conducting the postmortem examination, on the basis of position and type of knot/material/partial/complete hanging/length of duration of hanging/slipping of ligature/partial hanging, has to opine with clarity on the following

• Whether the death is due to strangulation by ligature and subsequent postmortem hanging? This is a point of contention and requires clarity.
• What is the medicolegal inference of injury in neck as described ligature mark? Whether it is a case of antemortem homicidal hanging by use of force or poisoning?
• Whether it is a case of death due to asphyxia as a result of antemortem hanging or not? If yes then whether it is a case of suicidal hanging?
• What is the forensic importance/explanation of any other injury on body…..poisoning? 

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:Inspiration:God is never wrong

A king who did not believe in the goodness of God, had a slave who, in all circumstances, said: My king, do not be discouraged, because everything God does is perfect, no mistakes!

One day they went hunting and along the way a wild animal attacked the king. His slave managed to kill the animal, but could not prevent his majesty losing a finger.

Furious and without showing his gratitude for being saved, the nobleman said "Is God good? If He was good, I would not have been attacked and lost my finger."

The slave replied: "My king, despite all these things, I can only tell you that God is good, and he knows "why" of all these things. What God does is perfect. He is never wrong!" Outraged by the response, the king ordered the arrest of his slave. Later, he left for another hunt and was captured by savages who made human sacrifices.

In the altar, ready to sacrifice the nobleman, the savages found that the victim had not one of his fingers, so he was released. According to them, it was not so complete to be offered to the gods. Upon his return to the palace, he authorized the release of his slave that he received very affectionately.

"My dear, God was really good to me! I was almost killed by the wild men, but for lack of a single finger, I was let go! But I have a question: if God is so good, why did he allow me to put you in jail?"

"My King, if I had gone with you in this hunt, I would have been sacrificed for you, because I have no missing finger, therefore, remember, everything God does is perfect. He is never wrong."

Often we complain about life, and negative things that happen to us, forgetting that nothing is random and that everything has a purpose.

Every morning, offer your day to God, don't be in a rush.

Ask God to inspire your thoughts, guide your actions, and ease your feelings. And do not be afraid. God is never wrong!

You know why this message is for you? I do not know, but God knows, because he never makes mistakes.......

The path of God and his word is perfect, without impurities. He is the way of all those who trust in Him.

What you do with this message is up to you. May God put in your heart the desire to send it to someone. God knows why He choose you to receive this message. Please bless someone with it.

God is never wrong

Emedinews:Insights on Medicolegal issues:Hanging is almost always suicidal

• Apart from the now rare ‘lynching’, hanging is almost always suicidal or accidental, the former being by far the most common.

• Hanging has many features in common with ligature strangulation. Death is, however, more often caused by reflex cardiac arrest from pressure on the carotid structures.

• Many more victims of hanging are found to have pale faces, rather than the congested, hemorrhagic appearance of the slower asphyxial type of death.

• The rapid onset of heart stoppage may antedate any evidence of congestive or ‘asphyxia’ signs, causing death immediately or within seconds, or at any time thereafter.

• Overstimulation of nerve endings in the carotid sinus or adjacent arterial sheath may be brought about by direct pressure from fingers or from a ligature during strangulation or hanging-or from a blow directed at the side of the neck.

• Severe pain, such as a blow on the larynx or genitals, may also trigger a ‘vagal response’. absence of congestion, cyanosis and petechial, the pale faces indicating that cardiac arrest had taken place before the congestive signs had time to appear. Electrostimulation has an excellent chance of revival.

  

Reference…………………..James and Silocks (1992), In a 15-year survey of hanging in Cardiff, found congestive-petechial features in 27 percent, being related to the completeness of suspensions

Emedinews:Makesure: A rape victim developed HIV infection.

Situation: A rape victim developed HIV infection.
Reaction: Oh my God! Why was she not given post exposure ART prophylaxis?
Lesson: Make sure all rape victims are counseled for HIV post exposure ART prophylaxis.

Emedinews: Inspiration :Mr. Doctor “Why are You Irresponsible?”

"The doctor was called one evening for an urgent surgery. He answered the call, changed his clothes, reached hospital in minutes and went directly to the surgery block. He found the boy's father waiting, in the hall for the doctor.  On seeing him, the dad yelled: "Why did U take all this time to come?

Don't you know that my son's life is in danger? Don't you have any sense  of responsibility?" The doctor smiled and said: "I am sorry, I wasn't in the hospital and I came as fast as I could after  receiving the call...... And now, I wish you'd calm down so that I can do my work"

 "Calm down?! What if your son was in this room right now, would you calm  down? If your own son dies now what will you do?" said the father angrily

The doctor smiled again and replied: "I will say what "Job" said in the Holy Bible: "From dust we came and to
dust we return, blessed be the name of God". Doctors cannot prolong lives. Go and intercede for your son, we will do our best by God's grace" "Giving advises when we're not concerned is so easy" Murmured the father.

The surgery took some hours after which the doctor went out happy, "Thank goodness!, your son is saved!" And without waiting for the father's reply he carried on his way running. "If you have any question, ask the nurse!!"

"Why is he so arrogant? He couldn't wait some minutes so that I ask about my son's state," commented the father when seeing the nurse minutes after the doctor left. The nurse answered, tears coming down her face:

"His son died yesterday in a road accident, he was in the burial when we called him for your son's surgery. And now that he saved your son's life, he left running to finish his son's burial.

 Never judge anyone..... because U never know how their life is and what they're going through.

Emedinews:Makesure: A patient of pulmonary Koch’s taking ATT complained of numbness in fingers and toes

Situation: A patient of pulmonary Koch’s taking ATT complained of numbness in fingers and toes.
Reaction: Oh my God! I forgot to prescribe vitamin B complex.
Lesson: Make sure that in patients talking ATT (including INH) B-complex vitamins (especially vitamin B6) are prescribed to prevent neuropathy. Addition of antioxidants and multivitamins also boost the immune system.

Emedinews:Inspiration:What goes around comes around

His name was Fleming, and he was a poor Scottish farmer. One day, while trying to make a living for his family, he heard a cry for help coming from a nearby bog.

He dropped his tools and ran to the bog. There, mired to his waist in black muck, was a terrified boy, screaming and struggling to free himself. Farmer Fleming saved the lad from what could have been a slow and terrifying death. The next day, a fancy carriage pulled up to the Scotsman's sparse surroundings. An elegantly dressed nobleman stepped out and introduced himself as the father of the boy Farmer Fleming had saved.

"I want to repay you," said the nobleman. "You saved my son's life." "No, I can't accept payment for what I did," the Scottish farmer replied, waving off the offer.

At that moment, the farmer's own son came to the door of the family hovel. "Is that your son?" the nobleman asked. "Yes," the farmer replied proudly. "I'll make you a deal. Let me take him and give him a good education. If the lad is anything like his father, he'll grow to a man you can be proud of.

"And that he did. In time, Farmer Fleming's son graduated from St. Mary's Hospital Medical School in London, and went on to become known throughout the world as the noted Sir Alexander Fleming, the discoverer of Penicillin. Years afterward, the nobleman's son was stricken with pneumonia. What saved him? Penicillin. The name of the nobleman? Lord Randolph Churchill. His son's name? Sir Winston Churchill.

Someone once said: What goes around comes around. Work like you don't need the money. Love like you've never been hurt. Dance like nobody's watching.