Emedinews:Insights on medicolegal issues: Medical testimony of doctor in the Court of law

The doctor should acquire the habit of making a careful note of all the facts observed by him. Vagueness and theory have no place in legal medicine. He should examine the facts which come to his knowledge in his special capacity, draw his conclusions logically and correctly after a detailed consideration of the pros and cons of the case, and indicate to the Court that interpretation, along with the grounds on which it is based. Presumption is not proof, and conjecture is not evidence. The Court has no special medical knowledge. It relies on medical witness for an opinion and expects him to assist it with his special knowledge and experience in perusal of truth.

Emedinews:Makesure:A foreigner with 2 loose motions developed sepsis.

Situation: A foreigner with 2 loose motions developed sepsis.
Reaction: Oh my God! Why was antibiotic not started early?
Lesson: Make sure that all cases of travelers' diarrhea (in foreigners) are treated with antibiotics.

Emedinews:Inspiration:Follow your dream

An Inspirational Story
(Ms Ritu Sinha)

Once upon a time, there was a large mountainside, where an eagle's nest rested. The eagle's nest contained four large eagle eggs. One day an earthquake rocked the mountain causing one of the eggs to roll down the mountain, to a chicken farm, located in the valley below.

The chickens knew that they must protect and care for the eagle's egg, so an old hen volunteered to nurture and raise the large egg. One day, the egg hatched and a beautiful eagle was born. Sadly, however, the eagle was raised to be a chicken. Soon, the eagle believed he was nothing more than a chicken.

The eagle loved his home and family, but his spirit cried out for more. While playing a game on the farm one day, the eagle looked to the skies above and noticed a group of mighty eagles soaring in the skies. "Oh," the eagle cried, "I wish I could soar like those birds." The chickens roared with laughter, "You cannot soar with those birds. You are a chicken and chickens do not soar."

The eagle continued staring, at his real family up above, dreaming that he could be with them. Each time the eagle would let his dreams be known, he was told it couldn't be done. That is what the eagle learned to believe. The eagle, after time, stopped dreaming and continued to live his life like a chicken. Finally, after a long life as a chicken, the eagle passed away.

The moral of the story: You become what you believe you are. So if you ever dream to become an eagle follow your dreams, not the words of a chicken.

When can pregnancies be terminated by Registered Medical Practitioners?

A Registered Medical Practitioner shall not be guilty of any offence under that code or under any other law for the time being in force, if any pregnancy is terminated by him in accordance with MTP Act

• where the length of the pregnancy does not exceed twelve weeks,
• where the length of the pregnancy exceeds twelve weeks but does not exceed twenty weeks, if not less than two medical practitioners are of the opinion, formed by doctor in good faith that – the continuance of pregnancy would involve a risk to the life of the pregnant woman or of grave injury to her physical or mental health, or there is a substantial risk that the child, if born, would suffer from such physical and mental abnormalities as to be seriously handicapped.
• Where any pregnancy is alleged by the pregnant woman to have been caused by rape, the anguish caused by such pregnancy shall be presumed to constitute a grave injury to the mental health of the pregnant woman.
• Where any pregnancy results as a result of failure of any device or method used by any woman or her husband for the purpose of limiting the number of children, the anguish caused by such pregnancy shall be presumed to constitute a grave injury to the mental health of the pregnant woman.
• In determining whether the continuance of a pregnancy would involve such risk of injury to the health as is mentioned in sub–section (2), account may be taken of the pregnant women’s actual or reasonably foreseeable environment.
• No pregnancy of a woman, who has not attained the age of 18 years, or, who, having attained the age of 18 years is a mentally ill person (substituted for "lunatic" by Amendment Act, 2002), shall be terminated except with the consent in writing of her guardian.

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.

I want to be possible

An Inspirational Story
(Ms Ritu Sinha)

I want to be possible

The teacher asked her class what each wanted to become when they grew up. A chorus of responses came from all over the room.

“A football player,” “A doctor,” “An astronaut,” “The president,” “A fireman,” “A teacher,” “A race car driver”, and so on.

Everyone that is, except Tommy.

The teacher noticed he was sitting there quiet and still. So she said to him, "Tommy, what do you want to be when you grow up?"

“Possible,” Tommy replied.

“Possible?” asked the teacher.

“Yes,” Tommy said. “My mom is always telling me I'm impossible. So when I get to be big, I want to be possible.”

Emedinews:Insights on Medicolegal Issues:What are incised–looking and incised wounds?

The wounds produced by a blunt weapon or by a fall on the hard surface/object, on tense structures/skin covering the bones, such as the scalp, eyebrow, iliac crest, shin, perineum, knee or elbow when the limb is flexed look like incised wounds; however, they are lacerated wounds, also called split lacerations, caused by blunt force and create confusion in the mind of police official about sharp weapon. Under magnifying lens, the edges of such wounds are found to be irregular with bruising. Such wounds are also produced by broken glass pieces, broken crockery, which have the characteristics of incised wounds but the edges appear parallel with one end of the wound.

A neatly incised laceration is an incised wound. An incised wound, cut, slash, and slice is a clean cut through the skin that may or may not involve underlying tissues and structures and is caused by a sharp–edged instrument, such as knife, razor, blade, scalpel, sword, which is longer than the depth of wound.

Significance for doctors and police officials

• Provides clue about the weapon used and the direction of the force.
• Duration of injury can be determined.
• Location of the wound may suggest mode of production i.e. suicide, accident, homicides, fabricated or otherwise

Emedinews:Makesure:A patient with Chikungunya had persistent joint pains.

Situation: A patient with Chikungunya had persistent joint pains.
Reaction: Oh my God! Why was a trial of hydroxychloroquine not given?
Lesson: Make sure that all patients of Chikungunya fever with persistent joint pains are given a trial of hydroxychloroquine.

An Inspirational Story

An Inspirational Story
(Dr GM Singh)

One of my fondest memories as a child is going by the river and sitting idly on the bank. There I would enjoy the peace and quiet, watch the water rush downstream, and listen to the chirps of birds and the rustling of leaves in the trees. I would also watch the bamboo trees bend under pressure from the wind and watch them return gracefully to their upright or original position after the wind had died down.

When I think about the bamboo tree's ability to bounce back or return to its original position, the word resilience comes to mind. When used in reference to a person this word means the ability to readily recover from shock, depression or any other situation that stretches the limits of a person's emotions. Have you ever felt like you are about to snap? Have you ever felt like you are at your breaking point? Thankfully, you have survived the experience to live to talk about it.

During the experience you probably felt a mix of emotions that threatened your health. You felt emotionally drained, mentally exhausted and you most likely endured unpleasant physical symptoms.

Life is a mixture of good times and bad times, happy moments and unhappy moments. The next time you are experiencing one of those bad times or unhappy moments that take you close to your breaking point, bend but don't break. Try your best not to let the situation get the best of you.

A measure of hope will take you through the unpleasant ordeal. With hope for a better tomorrow or a better situation, things may not be as bad as they seem to be. The unpleasant ordeal may be easier to deal with if the end result is worth having.

If the going gets tough and you are at your breaking point, show resilience. Like the bamboo tree, bend, but don't break!

World Medical Association (WMA) guidelines for medical doctors in biomedical research involving human subjects

• Doctors should abstain from engaging in research projects involving human subjects unless they are satisfied that the hazards involved are believed to be predictable. Doctors should cease any investigation if the hazards are found to outweigh the potential benefits.
• In publication of the results of his or research, the doctor is obliged to preserve the accuracy of the results. Reports of experimentation not in accordance with the principles laid down in this Declaration should not be accepted for publication.
• In any research on human beings, each potential subject must be adequately informed of the aims, methods, anticipated benefits and potential hazards of the study and the discomfort, it may entail. He or she should be informed that he or she is at liberty to abstain from participation in the study and that he or she is free to withdraw his or her consent to participation at any time. The doctor should then obtain the subject’s freely given informed consent, preferably in writing.
• When obtaining informed consent for the research project the doctor should be particularly cautious if the subject is in a dependent relationship to him or her or may consent under duress. In that case the informed consent should be obtained by a doctor who is not engaged in the investigation and who is completely independent of this official relationship.
• In case of legal incompetence, informed consent should be obtained from the legal guardian in accordance with national legislation. Where physical or mental incapacity makes it impossible to obtain informed consent, or when the subject is a minor, permission from the responsible relative replaces that of the subject in accordance with national legislation.
• The research protocol should always contain a statement of the ethical consideration involved and should indicate that the principles enunciated in the present Declaration are complied with.

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

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:Inspiration:Three yellow roses

An Inspirational Story
(Ms Ritu Sinha)

Three yellow roses

I walked into the grocery store not particularly interested in buying groceries.
I wasn’t hungry. The pain of losing my husband of 37 years was still too raw. And this grocery store held so many sweet memories.

Rudy often came with me and almost every time he’d pretend to go off and look for something special. I knew what he was up to. I’d always spot him walking down the aisle with the three yellow roses in his hands. Rudy knew I loved yellow roses.

With a heart filled with grief, I only wanted to buy my few items and leave, but even grocery shopping was different since Rudy had passed on. Shopping for one took time, a little more thought than it had for two.

Standing by the meat, I searched for the perfect small steak and remembered how Rudy had loved his steak. Suddenly a woman came beside me. She was blond, slim and lovely in a soft green pantsuit. I watched as she picked up a large pack of
T-bones, dropped them in her basket, hesitated, and then put them back. She turned to go and once again reached for the pack of steaks.

She saw me watching her and she smiled. “My husband loves T-bones, but honestly, at these prices, I don’t know.” I swallowed the emotion down my throat and met her pale blue eyes. “My husband passed away eight days ago,” I told her. Glancing at the package in her hands, I fought to control the tremble in my voice. “Buy him the steaks. And cherish every moment you have together.” She shook her head and I saw the emotion in her eyes as she placed the package in her basket and wheeled away.

I turned and pushed my cart across the length of the store to the dairy products. There I stood; trying to decide which size milk I should buy. A quart, I finally decided and moved on to the ice cream section near the front of the store. If nothing else, I could always fix myself an ice cream cone. I placed the ice cream in my cart and looked down the aisle toward the front.

I saw first the green suit, and then recognized the pretty lady coming towards me. In her arms she carried a package. On her face was the brightest smile I had ever seen. I would swear a soft halo encircled her blonde hair as she kept walking towards me, her eyes holding mine. As she came closer, I saw what she held and tears began misting in my eyes.

“These are for you” she said and placed three beautiful long stemmed yellow roses in my arms. “When you go through the line, they’ll know these are paid for.” She leaned over and placed a gentle kiss on my cheek, then smiled again.

I wanted to tell her what she’d done, what the roses meant, but still unable to speak, I watched as she walked away, tears clouding my vision. I looked down at the beautiful roses nestled in the green tissue wrapping and found it almost unreal. How did she know? Suddenly the answer seemed so clear. I wasn’t alone.

“Oh, Rudy, you haven’t forgotten me, have you?” I whispered, with tears in my eyes. He was still with me, and she was his angel.

What is Forensic Thanatology?

Thanatology is the branch of science that deals with death in all its aspects. Shapiro, a well–known thanatologist defined death as the irreversible loss of the properties of living matter. However, it is difficult to appreciate his claim that this definition satisfies the practical requirements for death certification.

• Black’s law dictionary (Black 1951) in United States defines death as "The Cessation of life, the ceasing to exit", defined by physicians as total stoppage of circulation and cessation of vital functions, thereupon such as respiration and pulsation
• Section 46 IPC states that death denotes the death of a human being unless the contrary appears from the context.
• Section 2 (b) of the Registration of Births and Deaths Act defines death as Permanent disappearance of all evidence of life at any time after live birth gas taken place.

(Ref: Dr. PC Dikshit, Head (MAMC) MD LLB, Concise Textbook of Forensic Medicine & Toxicology, Peepee Publishers)

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

Situation: A patient with 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:Will you be a memorable mother?

An Inspirational Story
(Ms Ritu Sinha)

Will you be a mother who's remembered fondly by your children when they're grown? Will you be a mother who affects their lives in ways they'll recall with love and laughter?

A family can be close and create fond memories by sharing and doing things together. However, it's often to the mother that the task falls of initiating family activities and pleasures her children will engage in with their children in future years.

Do you recall incidents and traditions from your childhood you want to share with your children and create a feeling of family continuity?

I realize now that Mother often must have had work to do. But she took time from her busy day as a farmwife for walks and picnics with us four children, doughnut making feasts, story sessions at bedtime, swimming in the brook in summer, and listening to us and talking with us when we had problems or secrets to share.

Looking back, I never remember her remarking, "No, I'm too busy," although she must have said it many times. The memorable times we shared together far overshadowed the times she had to refuse.

My daughter and I engaged in some of these activities as I shared with her my childhood experiences. It helps to bring continuity to the generations as a child realizes he/she's sharing in a long line of family traditions.

Just possibly the enjoyment of these childhood activities and family highlights will be remembered by their children when they have families of their own. I've heard my daughter say to her son and daughter, "When I was little, I used to do this...just like Nanny and Great Grandma did."

As I look around the happy faces at my husband's family reunions, I realize that it was mainly because of my mother-in-law's efforts that the family now has many memories to bind them together.

Families need a sense of belonging, a sense of doing things together that makes them part of a long line of families. In these days, when the family unit is battered on all sides, it's often the mother who can do so much to make for her family a haven at home, a place of happiness and security, a place which will stir fond memories as the children recall the incidents that formed their lives because of their memorable mother.

Emedinews:Insights on Medicolegal Issues:What are the shock waves in bullet injury

When bullets produce tracks in dense tissues, such as muscle, liver, spleen and blood, the tissues are compressed ahead of the track by a compression wave, in the form of a shock wave of spherical form. Tissue damage can also be produced at a considerable distance away from the original bullet track. Thus, the urinary bladder, stomach and colon may be ruptured in high velocity wounds situated at a remote distance from the abdominal cavity itself. The site of the permanent local track is marked by tissues which have been totally destroyed, and this is similar to low–velocity bullets. Surrounding this is a layer of necrotic debris caused by the temporary cavitation effect and secondary missiles, highly contaminated by micro–organisms. A variable thickness layer of live tissue surrounds the zone of necrosis, consisting of an inner portion which will prove to be non–viable as a result of the injuries sustained, and an outer portion that will remain viable provided that optimum conditions are provided for healing. Around this zone is the normal tissue.

A diabetic patient with BP of 130/90 developed acute heart pain.

Situation: A diabetic patient with BP of 130/90 developed acute heart pain.
Reaction: Oh my God! Why was his BP not kept below 120/80.
Lesson: Make sure that all patients with diabetes should have a goal BP of less than 120/80.

Emedinews:Inspiration: A bouquet for mother

An Inspirational Story
(Ms Ritu Sinha)

A man stopped at a flower shop to order some flowers to be wired to his mother who lived two hundred miles away.

As he got out of his car he noticed a young girl sitting on the curb sobbing.

He asked her what was wrong and she replied, “I wanted to buy a red rose for my mother. But I only have seventy-five cents, and a rose costs two dollars.”

The man smiled and said, “Come on in with me. I’ll buy you a rose.”

He bought the little girl her rose and ordered his own mother’s flowers.

As they were leaving he offered the girl a ride home. She said, “Yes, please! You can take me to my mother.”

She directed him to a cemetery, where she placed the rose on a freshly dug grave.

The man returned to the flower shop, canceled the wire order, picked up a bouquet and drove the two hundred miles to his mother’s house.

Emedinews:Insights on Medicolegal Issues:Lacerated wound

The direction of the shelving of margins of a lacerated wound indicates the direction of the blow applied to cause the wound as seen in MLC cases.

·         Lacerations are tears or splits of skin, mucous membranes, muscle or internal organs produced by application of blunt force to a broad area of the body, which crushes or stretches the tissues beyond the limits of their elasticity.

·         Crush injury from a direct blow may produce an irregular or stellate laceration with a variable degree of devitalized tissue, abrasion and visible contamination.

·         Do not close a laceration if there is visible contamination, debris, non-viable tissue or signs of infection. Wounds may involve vascular areas of the face and scalp where the risk of infection is low or extremities where infection becomes a greater risk, along with the possibility of tendon and nerve damage. The elderly and patients on chronic steroid therapy may present with "wet tissue paper" skin tears following relatively minor trauma.

·         When produced by a blunt weapon, such as club, crowbar, stone, brick etc., a lacerated wound is usually accompanied by a considerable amount of bruising of the surrounding and underlying tissues, and has inverted and irregular edges. The direction of the shelving of margins of a lacerated wound indicates the direction of the blow applied to cause the wound.

·         When a heavy weight such as the wheel of a heavy cart or a truck passes over an extremity, by its shearing and grinding force, it tears the skin from the underlying tissue and crushes the muscles and soft part lying beneath it realizing considerable blood and fat in them.

·         Crush injury syndrome or fat emboli may follow a lacerated wound. The tear, avulsion, split are types of laceration.

A patient with renal failure came to a doctor.

Situation: A patient with renal failure came to a doctor.
Reaction: Oh, my God! Why was he given painkillers?
Lesson: Make sure to remember that most painkillers (barring nimesulide) are not kidney–friendly drugs.

Emedinews:Inspiration:When God created mothers

An Inspirational Story
(Dr GM Singh)

When the Good Lord was creating mothers, He was into His sixth day of “overtime” when the angel appeared and said. “You’re doing a lot of fiddling around on this one.”
And God said, “Have you read the specs on this order?” She has to be completely washable, but not plastic. Have 180 moveable parts…all replaceable. Run on black coffee and leftovers. Have a lap that disappears when she stands up. A kiss that can cure anything from a broken leg to a disappointed love affair. And six pairs of hands.”
The angel shook her head slowly and said. “Six pairs of hands…. no way.”  “It’s not the hands that are causing me problems,” God remarked, “It’s the three pairs of eyes that mothers have to have.”
“That’s on the standard model?” asked the angel. God nodded.  “One pair that sees through closed doors when she asks, ‘What are you kids doing in there?’ when she already knows. Another here in the back of her head that sees what she shouldn’t but what she has to know, and of course the ones here in front that can look at a child when he goofs up and say. ‘I understand and I love you’ without so much as uttering a word.”
“God,” said the angel touching his sleeve gently, “Get some rest tomorrow….”
“I can’t,” said God, “I’m so close to creating something so close to myself. Already I have one who heals herself when she is sick…can feed a family of six on one pound of hamburger…and can get a nine-year-old to stand under a shower.”
The angel circled the model of a mother very slowly. “It’s too soft,” she sighed.
“But tough!” said God excitedly. “You can imagine what this mother can do or endure.”
“Can it think?”
“Not only can it think, but it can reason and compromise,” said the Creator.
Finally, the angel bent over and ran her finger across the cheek.
“There’s a leak,” she pronounced. “I told You that You were trying to put too much into this model.”
“It’s not a leak,” said the Lord, “It’s a tear.”
“What’s it for?”
“It’s for joy, sadness, disappointment, pain, loneliness, and pride.”
“You are a genius, “said the angel.
Somberly, God said, “I didn’t put it there.”

Padma Shri Awardee Dr KK Aggarwal on Patients with acidity should avoid ...

Padma Shri Awardee Dr KK Aggarwal on Patients with acidity should avoid ...

Difference between antemortem and postmortem bruises

·      Some people bruise easily, whereas others may have tougher skin tissue. Apply a cold compress to the bruise for at least 10 minutes to reduce swelling or the amount of bruising after an injury,

·         In some cases of brought dead or dead in arrival the doctor attending the case in emergency may be confused or is not be able to differentiate between antemortem bruise and postmortem artifact and the postmortem bruise is entered in MLC as injuries. I have seen such cases in AIIMS during autopsy.

·         Close examination by doctor in emergency may help to differentiate because in antemortem bruises there is swelling and damage to epithelium, coagulation and infiltration of the tissues blood and color changes. These signs are always absent in postmortem bruises.

·         It is seen that contusions and abrasions produced immediately after death show a very low degree of changes.  

·         Appreciable bruising does not occur after 2-3 minutes of death due to arrest of heart and blood circulation, but by using great violence small bruises can be produced up to 3 hours after death where the tissue can be forcibly compressed against the bone or if the body is dropped on the ground from a height or from transport trolleys or running vehicle. 

·         Some of the evidences of bleeding are seen without history of trauma due to tearing of small veins in the skin when the body is lifted from the scene of death and transportation handling and the same is called postmortem artifact.

A dengue patient with BP 100/90 developed shock.

Situation: A dengue patient with BP 100/90 developed shock.
Reaction: Oh my God! Why was rapid fluid challenge not given?
Lesson: Make sure that pulse pressure (upper minus lower blood pressure) is maintained above 40 in all patients with dengue.

Emedinews:Inspiration:Why women cry

An Inspirational Story
(Dr GM Singh)

One day, a young boy asked his Mom. "Why are you crying?" "Because I'm a woman" she told him.
"I don't understand," he said. His Mom just hugged him and said, "And you never will, but that's okay."

Later the little boy asked his father, "Why does Mom seem to cry for no reason?" "All women cry for no reason" was all his dad could say.

The little boy grew up and became a man, still wondering why women cry. Finally, he put in a call to God.

When God got back to him, he asked, "God, why do women cry so easily?" God answered, "When I made woman, I decided she had to be special. I made her shoulders strong enough to carry the weight of the world, yet her arms gentle enough to give comfort. I gave her the inner strength to endure childbirth and the rejection that many times will come, even from her own children. I gave her a hardness that allows her to keep going and take care of her family and friends, even when everyone else gives up, through sickness and fatigue, without complaining. I gave her the sensitivity to love her children under any and all circumstances, even when her child has hurt her badly. She has the
very special power to make a child's boo-boo feel better and to quell a teenager's anxieties and fears.
I gave her strength to care for her husband, despite faults, and I fashioned her from his rib to protect his heart. I gave her wisdom to know that a good husband never hurts his wife but sometimes tests her strengths and her resolve to stand beside him unfalteringly.

For all of this hard work, I also gave her a tear to shed. It is her's to use whenever needed and is her only weakness." "When you see her cry, tell her how much you love her and all she does for everyone. And even though she may still cry, you will have made her heart feel good." "She is special!"

Morphine

The name Morphine originates from the Morpheus, the Greek God of dreams

·         Morphine is an alkaloid of opium a white, shining crystals, having a bitter taste and alkaline reaction.

·         It is very sparingly soluble in cold water, but is soluble in boiling water.

·         Morphine hydrochloride and morphine sulfate are medicinal preparations and morphine acetate is a non-official preparation, the dose of each being 8 to 20 mg. These salts are bitter in taste, neutral in reaction and are five to eight times more powerful than opium.

·         Morphine has a depressant action on the cortex, the respiratory and cough centers in the medulla are depressed but the vagus and vomiting centers are stimulated.

·         The spinal cord is also stimulated. Its most outstanding effect is relief of pain, partly due to depression of the cerebral area of pain perception and partly due to its euphoric effect. 

A patient with rheumatoid arthritis developed deformity.

Situation: A patient with rheumatoid arthritis developed deformity.
Reaction: Oh my God! Why was treatment not started early?
Lesson: Make sure all patients with Rheumatoid Arthritis are started with specific treatments within 3 months of diagnosis.

Things Change

An Inspirational Story
(Ms Ritu Sinha)

Things Change

Alex W Miller

For most people, graduation is an exciting day - the culmination of years of hard work. My graduation day... was not.

I remember that weekend two years ago. Family and friends had flown in from across the country to watch our class walk across that stage. But like everyone else in my graduating class, I had watched the economy turn from bad to worse my senior year. We graduates had degrees, but very limited prospects. Numerous applications had not panned out and I knew that the next day, when my lease ended, I would no longer have a place to call home.

The weeks ahead weren't easy. I gathered up everything I couldn't carry and put it into storage. Then, because I knew my small university town couldn't offer me any opportunities, I packed up my car and drove to Southern California to find work. But what I thought would take a week dragged into two, and then four, and 100 job applications later, I found myself in the exact same spot as I was before. And the due date to begin paying back my student loans was creeping ever closer.

You know that feeling when you wake up and you are just consumed with dread? Dread about something you can't control - that sense of impending failure that lingers over you as you hope that everything that happened to you thus far was just a bad dream? That feeling became a constant in my life. Days felt like weeks, weeks like months, and those many months felt like an unending eternity of destitution. And the most frustrating part was no matter how much I tried, I just couldn't seem to make any progress.

So what did I do to maintain my sanity? I wrote. Something about putting words on a page made everything seem a little clearer - a little brighter. Something about writing gave me hope. And if you want something badly enough... sometimes a little hope is all you need!

I channeled my frustration into a children's book. ‘Beyond the River’ was the story of an unlikely hero featuring a little fish who simply refused to give up on his dream.

And then one day, without any sort of writing degree or contacts in the writing world - just a lot of hard work and perseverance - I was offered a publishing contract for my first book! After that, things slowly began to fall into place. I was offered a second book deal. Then, a few months later, I got an interview with The Walt Disney Company and was hired shortly after.

The moral of this story is... Don't give up. Even if things look bleak now, don't give up. Two years ago I was huddled in my car drinking cold soup right out of the can. Things change.

If you work hard, give it time, and don't give up, things will always get better. Oftentimes our dreams lie in wait just a little further upstream... all we need is the courage to push beyond the river

Emedinews:Insights on Medicolegal Issues:Embalming certificate of deceased is required by law in air/rail transportation

Embalming is the process of chemically treating a dead body developed by the ancient Egyptians of preserving a person's body after death or delay the decomposition of the body, restore it to an acceptable physical appearance and reduce the presence and growth of bacteria to prevent foul smell as well as perfume or add fragrance to corpse.

·         One of the most famous embalmed corpses today is Russian communist leader Vladimir Lenin, whose embalmed corpse is on display at the Red Square mausoleum in Moscow, the corpse is very well-preserved, and should last for at least another hundred years.

·         The process of embalming has a very long history, dating back to the Egyptian process of mummification. Though their techniques were quite different from those used today, the effect was the same — to preserve an individual's body after death. In case of the ancient Egyptians, they believed that the spirit would return to the body after death, so it must remain in good condition. To preserve the corpses, they covered bodies in a drying chemical called natron, and then wrapped them in linen sheets.

·         Today, embalming is done by injecting chemicals directly into the bloodstream to preserve the corpse's appearance. The most commonly used chemicals for embalming are formaldehyde and ethanol. A combination of these two chemicals is sufficient to preserve the body for a short time means up to a week

·         To keep the corpse in good condition for a longer period i.e. up to a month, you would use a solution made up almost entirely of formaldehyde.

·         There are several steps involved in modern embalming. First, the embalming fluid is injected directly into the deceased’s blood vessels, and pushed through the body with a mechanical pump. Next, the internal organs are hollowed of their contents and filled with embalming fluid. The chemicals are then injected beneath the skin wherever necessary, followed by a final surface embalming on injured areas of the body. 

Legal Question of the day:What is to be done when there is a conflict between a state law and a central law

Legal Question of the day

(Prof. M C Gupta, Advocate & Medicolegal Consultant)

Q. What is to be done when there is a conflict between a state law and a central law?

Ans.

1. As a general principle of law, a central law takes precedence over a state law. A state law cannot over-ride a state law.

2. However, if no body challenges a wrong state law, it may continue to be used. A common example is the wrong state law requirement that every physician working in the state must get registered with the SMC even though his name may be already on the state register. This is in violation of the IMC Act, 1956. But doctors (who claim themselves to be genius, law abiding intellectuals next to god in the nobility of their profession), are happy accepting the wrong state law. They are not bothered about challenging it. Nor is there association, the IMA, so interested!

That is how the illegality prevails.

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:Tat Tvam Asi:Leukocyte-reduction filters

Tat Tvam Asi……..and the Life Continues…..

(Dr N K Bhatia, Medical Director, Mission Jan Jagriti Blood Bank)

Special “third-generation” blood filters can reduce the number of leukocytes in red cell or platelet components of less than 5x10, a level that reduces the risk of HLA alloimmunization and transmission of cytomegalovirus (CMV) as well as the incidence of febrile transfusion reactions. These filters contain multiple layers of synthetic non-woven fibers that selectively retain leukocytes but allow red cells and platelets to pass. Selectivity is based on cell size, surface tension characteristics, the difference in surface charge density among blood cells, and possibly, cell to cell interactions and cell activation/adhesion properties.

Because filters for red cells and filters for platelets do not use the same technology for leukocyte removal and may have strict priming and flow rate requirements, they must be used only with their intended component and only according to the manufacturer’s directions. The use of these filters at the bedside is more complex than the use of standard infusion sets. The filters are expensive and will be ineffective if improperly primed or used. Those designed only for gravity-drip infusion should not be used with infusion pumps or applied pressure.

A quality control program that measure the effectiveness of leukocyte reduction helps monitor the filter or system in place, and is especially important with bedside filtration. Routine methods of automated blood cell counting are not sensitive enough to enumerate the small numbers of leukocyte in leukocyte reduced components; the use of high volume manual counting chambers or flow cytometric procedures is preferred.

Who should not have endometrial ablation?

Infertility Update

(Dr Kaberi Banerjee, IVF Expert, New Delhi)

Women who are pregnant, who would like to have children in the future, or have gone through menopause should not have this procedure. If you have an intrauterine contraceptive device, you must have it removed before endometrial ablation. Non-cancerous or pre-cancerous growths cannot be treated with endometrial ablation.

Emedinews:Inspiration: Face difficulties positively

An Inspirational Story
(Ms Ritu Sinha)

This parable is told of a farmer who owned an old mule. The mule fell into the farmer’s well. The farmer heard the mule praying or whatever mules do when they fall into wells. After carefully assessing the situation, the farmer sympathized with the mule, but decided that neither the mule nor the well was worth the trouble of saving. Instead, he called his neighbors together, told them what had happened, and enlisted them to help haul dirt to bury the old mule in the well and put him out of his misery.

Initially the old mule was hysterical! But as the farmer and his neighbors continued shoveling and the dirt hit his back, a thought struck him. It suddenly dawned on him that every time a shovel load of dirt landed on his back, HE WOULD SHAKE IT OFF AND STEP UP!

This he did, blow after blow. “Shake it off and step up…shake it off and step up…shake it off and step up!” He repeated to encourage himself. No matter how painful the blows, or how distressing the situation seemed, the old mule fought panic and just kept right on SHAKING IT OFF AND STEPPING UP!

It wasn’t long before the old mule, battered and exhausted, stepped triumphantly over the wall of that well! What seemed like it would bury him actually helped him . . . all because of the manner in which he handled his adversity.

That’s life! If we face our problems and respond to them positively, and refuse to give in to panic, bitterness, or self-pity.

Insoghts on Medicolegal Issues:What is concussion of the brain?

Concussion of the brain is a rotational injury caused by sudden acceleration.

·         As seen in autopsy it occurs when the head is free to move with sufficient velocity, but not when it is fixed. It is more commonly known as ‘stunning ‘, and may be produced by direct violence on the vertex, by indirect violence as a result of a violent fall upon the feet from height, or by an unexpected fall on the ground, when pushed forcibly in any traffic accident or an injury received in industry.

·         The impact on hollow structures of skull is propagated by radiating waves of motion along with the site of impact and coverage as they approach the opposite pole giving rise at the point of collision to a contralateral or countercoup injury.

·         The contusion and laceration of brain occurs due to the traction as the brain is torn away from its covering by the force of its own momentum. Application of a blow to the movable head is followed by a positive pressure in the area of brain underlying the zone of impact and by a negative pressure over the contralateral brain surface where the brain pulls away from the skull.

·         The injuries of the brain heal by forming adhesions and may later cause secondary epilepsy.

Emedinews:Makesure:A diabetic patient died of flu pneumonia.

Situation: A diabetic patient died of flu pneumonia.

Reaction: Oh my God! Why was flu vaccine not given?
Lesson: Make sure that all diabetics are given flu vaccine every year. 

A heart warming story

An Inspirational Story
(Ms Ritu Sinha)

There is a story many years ago of an elementary teacher. Her name was Mrs. Thompson. And as she stood in front of her 5th grade class on the very first day of school, she told the children a lie. Like most teachers, she looked at her students and said that she loved them all the same. But that was impossible, because there in the front row, slumped in his seat, was a little boy named Teddy Stoddard.

Mrs. Thompson had watched Teddy the year before and noticed that he didn't play well with the other children, that his clothes were messy and that he constantly needed a bath. And Teddy could be unpleasant. It got to the point where Mrs. Thompson would actually take delight in marking his papers with a broad red pen, making bold X's and then putting a big "F" at the top of his papers. At the school where Mrs. Thompson taught, she was required to review each child's past records and she put Teddy's off until last. However, when she reviewed his file, she was in for a surprise.

Teddy's first grade teacher wrote, "Teddy is a bright child with a ready laugh. He does his work neatly and has good manners...he is a joy to be around."

His second grade teacher wrote, "Teddy is an excellent student, well liked by his classmates, but he is troubled because his mother has a terminal illness and life at home must be a struggle."

His third grade teacher wrote, "His mother's death has been hard on him. He tries to do his best but his father doesn't show much interest and his home life will soon affect him if some steps aren't taken."

Teddy's fourth grade teacher wrote, "Teddy is withdrawn and doesn't show much interest in school. He doesn't have many friends and sometimes sleeps in class."

By now, Mrs. Thompson realized the problem and she was ashamed of herself. She felt even worse when her students brought her Christmas presents, wrapped in beautiful ribbons and bright paper, except for Teddy's. His present, which was clumsily wrapped in the heavy, brown paper that he got from a grocery bag.

Mrs. Thompson took pains to open it in the middle of the other presents. Some of the children started to laugh when she found a rhinestone bracelet with some of the stones missing, and a bottle that was one quarter full of perfume. But she stifled the children's laughter when she exclaimed how pretty the bracelet was, putting it on, and dabbing some of the perfume on her wrist. Teddy Stoddard stayed after school that day just long enough to say, "Mrs. Thompson, today you smelled just like my Mom used to."

After the children left she cried for at least an hour. On that very day, she quit teaching reading, and writing and arithmetic. Instead, she began to teach children.

Mrs. Thompson paid particular attention to Teddy. As she worked with him, his mind seemed to come alive. The more she encouraged him, the faster he responded. By the end of the year, Teddy had become one of the smartest children in the class and, despite her lie that she would love all the children the same, Teddy became her "teacher's pet." A year later, she found a note under her door, from Teddy, telling her that she was still the best teacher he ever had in his whole life.

Six years went by before she got another note from Teddy. He then wrote that he had finished high school, third in his class, and she was still the best teacher he ever had in his whole life. Four years after that, she got another letter, saying that while things had been tough at times, he'd stayed in school, had stuck with it, and would soon graduate from college with the highest of honors. He assured Mrs. Thompson that she was still the best and favorite teacher he ever had in his whole life. Then four more years passed and yet another letter came. This time he explained that after he got his bachelor's degree, he decided to go a little further. The letter explained that she was still the best and favorite teacher he ever had. But now his name was a little longer-the letter was signed, Theodore F. Stoddard, MD.

The story doesn't end there. You see, there was yet another letter that spring. Teddy said he'd met this girl and was going to be married. He explained that his father had died a couple of years ago and he was wondering if Mrs. Thompson might agree to sit in the place at the wedding that was usually reserved for the mother of the groom. Of course, Mrs. Thompson did. And guess what? She wore that bracelet, the one with several rhinestones missing. And she made sure she was wearing the perfume that Teddy remembered his mother wearing on their last Christmas together.

They hugged each, and Dr. Stoddard whispered in Mrs. Thompson's ear, "Thank you Mrs. Thompson for believing in me. Thank you so much for making me feel important and showing me that I could make a difference."

Mrs. Thompson, with tears in her eyes, whispered back. She said, "Teddy, you have it all wrong. You were the one who taught me that I could make a difference. I didn't know how to teach until I met you."

Countercoup injury of brain

·         Two types of impact occur 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.

·         Counter coup 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, experiments on mechanics of head injuries have demonstrated these 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 and pull apart the constituent particles of the brain. These are produced in all parts of the brain, but to a large extent at the base of the frontal lobe and the tip of the temporal lobe, as the skull gets a good grip on the brain in this region due to the projecting ridge of the sphenoid bone. Hence, severe and extensive injuries occur in this region with a blow 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.

(Ref: Modi’s Medical Jurisprudence, 25^th Edition)

An 18–year– old girl complained of purulent nasal discharge

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

Lesson in Life

An Inspirational Story
(Dr GM Singh)

Mr. Turtle was walking down the road when he spotted an eagle at the top of a very tall tree. He shouted, "Good Morning, Mr. Crow."

Mr. Crow shouted back down, "Good Morning Mr. Turtle." Mr. Turtle shouted up, "Whatcha doin' today?" and the answer shouted back down was, "Absolutely nothin' Mr. Turtle - Absolutely nothin' and loving it."

Well, that sounded pretty good to Mr. Turtle, so he shouted back up, "Do you think I could do that too?" Mr. Crow shouted back down, "I don't see why not!" So, Mr. Turtle lay down on the side of the road and began doing absolutely nothing.

In 30 minutes a fox came along and ate him.

The moral of the story is: You can get away with doing absolutely nothing, but only if you are really high up.