Emedinews:Insights on Medicolegal Issues:Contravention of PNDT Act may lead to Imprisonment up to 3 years

• The name of the registered medical practitioner who has been convicted by the court under sub–section (1), shall be reported by the Appropriate Authority to the respective State Medical Council for taking necessary action including the removal of his name from the register of the Council for a period of two years for the first offence and permanently for the subsequent offence.
• Any person who seeks the aid of a genetic counseling center or genetic laboratory or genetic clinic or of a medical geneticist, medical gynecologist or registered medical practitioner for conducting pre–natal diagnostic techniques on any pregnant woman (including the woman unless she was compelled to undergo such diagnostic technique) for purposes other than those specified in clause(2) of section 4, shall be punishable with imprisonment for a term which may extend to 3 years and with a fine which may extend up to ten thousand rupees and on any subsequent conviction with imprisonment which may extend to five years and with fine which may extend up to fifty thousand rupees.

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

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

Emedinews:Inspiration:Socrates philosophy

An Inspirational Story
(Mr Ranesh Kumar Sabharwal)

 
Keep this in mind the next time you are about to repeat a rumor or spread gossip.

In ancient Greece (469 - 399 BC), Socrates was widely lauded for his wisdom. One day an acquaintance ran up to him excitedly and said, "Socrates, do you know what I just heard about Diogenes?" "Wait a moment," Socrates replied, "Before you tell me I'd like you to pass a little test. It's called the Triple Filter Test."

"Triple filter?" asked the acquaintance.

"That's right," Socrates continued, "Before you talk to me about Diogenes let's take a moment to filter what you're going to say. The first filter is Truth. Have you made absolutely sure that what you are about to tell me is true?"

"No," the man said, "Actually I just heard about it."

"All right," said Socrates, "So you don't really know if it's true or not. Now let's try the second filter, the filter of Goodness. Is what you are about to tell me about Diogenes something good?"

"No, on the contrary..."

"So," Socrates continued, "You want to tell me something about Diogenes that may be bad, even though you're not certain it's true?"

The man shrugged, a little embarrassed. Socrates continued, "You may still pass the test though, because there is a third filter, the filter of Usefulness. Is what you want to tell me about Diogenes going to be useful to me?"

"No, not really."

"Well," concluded Socrates, "If what you want to tell me is neither True nor Good nor even Useful, why tell it to me or anyone at all?"

The man was bewildered and ashamed. This is an example of why Socrates was a great philosopher and held in such high esteem.

Emedinews:Insights on Medicolegal issues:What is the delusion of grandeur?

It is also termed as delusion of exaltation 

• This is a delusion of pleasant belief or feeling. The sufferer remains in a state of feeling of greatness, power and wealth. He may be extravagant in his thinking and action and may commit some crime in such a state of mind or may ruin his money or property.

• Erotomania is a type of delusion of grandeur, where the sufferer believes that a person of very high rank or social status loves him/her.

• The sufferer also believes that the imaginary person communicates his love in some manner or other, by posture or by communication in a secret or symbolic way.

• When a person suffering from delusion of grandeur, believes that he will be killed by another person for the huge property he possesses and if as remedial step he kills that person then he will have diminished responsibility for the commission of the act because though in this case there are elements of fear and apprehension about his own life and to safeguard his life he has killed the person, yet he is not fully absolved from the act he has committed because in such a case he could have tried lawful protective steps for his life i.e., he could have sought for the help of the police…

Emedinews:Makesure:A patient with acute chest pain died before reaching the hospital.

Situation: A patient with acute chest pain died before reaching the hospital.
Reaction: Oh my God! Why was water–soluble aspirin not given?
Lesson: Make sure that at the onset of acute heart attack and chest pain, water–soluble aspirin is chewed to reduce chances of sudden death.

Emedinews:Inspiration:The black dot

An Inspirational Story
(Ms Ritu Sinha)

A small town chamber of commerce invited a speaker to address its annual dinner. The community’s economy was bad, people were discouraged, and they wanted this motivational speaker to give them a boost.

During her presentation, the speaker took a large piece of white paper and made a small black dot in the centre of it with a marking pen. Then she held the paper up before the group and asked them what they saw.

One person quickly replied, “I see a black dot.”

“Okay, what else do you see?” Others joined in agreement: “A black dot.”

“Don’t you see anything besides the dot?” she asked. A resounding “No” came from the audience.

“What about the sheet of paper?” asked the speaker? “I am sure you have all seen it”, she said, “But you have chosen to overlook it.”

“In life, we also tend to overlook and take for granted many wonderful things that we have or happen around us and focus our attention and energy on small, dot like failures and disappointments. The so called ‘problems’ that we have are usually like the black dot on the paper. They are small and insignificant if we can widen our horizon and look at the whole picture.”

Are you one of the people who focus your attention and energy on dot-like problems?

Emedinews:Insights on Medicoleagl Issues:What is the vegetative state

What is the vegetative state?

Complete absence of behavioral evidence for self or environmental awareness

• There is preserved capacity for spontaneous or stimulus–induced arousal, evidenced by sleep–wake cycles i.e. patients are awake, but have no awareness. This means that the patients appear awake. They have normal heart beat and breathing, and do not require advanced life support to preserve life and cannot produce a purposeful, co–coordinated, voluntary response in a sustained manner, although they may have primitive reflexive responses to light, sound, touch or pain.
• Patients cannot understand, communicate, speak, or have emotions and unaware of self and environment and have no interaction with voluntarily control passing of urine or stools. They sleep and awaken. As the centers in the brain controlling the heart and breathing are intact, there is no threat to life, and patients can survive for many years with expert nursing care.
• The following behaviors may be seen in the vegetative state:
• Sleep–wake cycles with eyes closed, then opened. Patient breathes on her own; Spontaneous blinking and roving eye movements; Produce sounds but no words; Visual pursuit following an object with her eyes; Grimacing to pain; changing facial expression; Yawning; chewing jaw movements; swallowing of own spit; no purposeful limb movements; arching of back; reflex withdrawal from painful stimuli; brief movements of head or eyes toward sound or movement without apparent localization or fixation; startled reaction on a loud sound.

Almost all of these features consistent with the diagnosis of permanent vegetative state were present during the medical examination of Aruna Shaunbag; behavior suggestive of a minimally conscious not vegetative state observed during the examination.

Emedinews:Makesure:A patient with dengue fever developed shock.

Situation: A patient with dengue fever developed shock.
Reaction: Oh my God! Why was the blood pressure 90/80 ignored?
Lesson: Make sure that a pulse pressure of less than 20 is not ignored, it is an impending sign that the patient is going into shock.

Emedinews:Inspiration:An honest man

An honest man

This is a story of a young man named Ping, who lived in a far away country and a King who was getting old and he needed to find a successor. So, the King devised a way to find his successor that would have courage and be honest. The King sent out a tiny seed to all the young men in the country.

Now, this seed was to be planted and nourished to the best of each young man's ability. Ping really wanted to be the new King. When he received his seed he went out and obtained a very beautiful pot, fertile soil and planted his seed. He watered it and nurtured it and watched it. BUT, nothing happened.

He moved his plant to another area with more sun, thinking it needed a different light. He watched it and watered it and nourished it and still, nothing happened. He went to his father and asked him what he could do. His father suggested putting it into another container and continues to nurture it. Still nothing! He was so disappointed and the time was drawing near, to go before the King and present his plant.

The day finally arrived to present his plant to the King and Ping was so embarrassed, because everyone there had beautiful plants. Some had beautiful flowers, some with beautiful green foliage and they all were so very beautiful. He was so embarrassed and disappointed that he sat in the back with his empty pot so he wouldn't be noticed.

The King started to look over all of the plants and he was not smiling. In fact he was frowning. He kept looking and all at once he saw Ping's empty pot and he called Ping up to the stand. And the King announced to all the men that Ping will be the next King. The King said Ping would be the next best King because of his honesty.

The King also expressed his disappointed and sad that there were so many dishonest men. The King continued to tell the men that he had boiled all of the seeds before he sent them out, and so none of the seeds would grow. You see, the King wanted someone with courage and someone that was honest to take over his Kingdom and he found it in Ping.

Emedinews:Insights on Medicolegal Issues:What was counteraffidavit of Dean, KEM Hospital in Aruna Shaunbag case?

What was counteraffidavit of Dean, KEM Hospital in Aruna Shaunbag case?

Aruna is clearly not in coma

• Aruna accepts the food in normal course and responds by facial expressions. She responds to commands intermittently by making sounds. She makes sounds when she has to pass stool and urine which the nursing staff identifies and attends to by leading her to the toilet.
• Thus, there was some variance between the allegations in the writ petition and the counter affidavit of KEM Hospital. Supreme Court, by order dated 24 January, 2011 appointed a team of three very distinguished doctors of Mumbai to examine Aruna thoroughly and submit a report about her physical and mental condition.
• The committee after thorough examination gave the opinion that she has evidence of intact auditory, visual, somatic and motor primary neural pathways. However no definitive evidence for awareness of auditory, visual, somatic and motor stimuli was observed during our examinations.
• On perusal of the report of the committee of three doctors the honorable SC noted that there are many technical terms which have been used therein which a non–medical man would find it difficult to understand. We, therefore, request the doctors to submit a supplementary report by the next date of hearing in which the meaning of these technical terms in the report is also explained.

Emedinews:Makesure:A patient’s blood pressure was not responding on Arkamin (clonidine).

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

Emedinews:Inspiration: The Triple-Filter Test

 
In ancient Greece, Socrates was reputed to hold knowledge in high esteem. One day an acquaintance met the great philosopher and said, "Do you know what I just heard about your friend?"

"Hold on a minute," Socrates replied. "Before you talk to me about my friend, it might be good idea to take a moment and filter what you’re going to say. That’s why I call it the triple filter test. The first filter is Truth. Have you made absolutely sure that what you are about to tell me is true?"

"Well, no," the man said, "actually I just heard about it and…"

"All right," said Socrates. "So you don’t really know if it’s true or not. Now, let’s try the second filter, the filter of Goodness. Is what you are about to tell me about my friend something good?"

"Umm, no, on the contrary…"

"So," Socrates continued, "you want to tell me something bad about my friend, but you’re not certain it’s true. You may still pass the test though, because there’s one filter left—the filter of Usefulness. Is what you want to tell me about my friend going to be useful to me?"

"No, not really."

"Well," concluded Socrates, "if what you want to tell me is neither true, nor good, nor even useful, why tell it to me at all?"

Emedinews:Insights on Medicolegal Issues:Sudden death due to cardiac origin–autopsy

Right coronary artery supplies blood to electrical area of heart

The most common cause of sudden cardiac death in adults over the age of forty was coronary artery atheroma seen in postmortem examination in about 100 cases randomly selected by me in AIIMS mortuary.

• The most common finding at postmortem examination is chronic high–grade stenosis of minimum one segment of a major coronary artery, the arteries which supply the heart muscle with its blood supply.
• A significant number of cases also have an identifiable clot in a major coronary artery which causes transmural occlusion of that vessel.
• In 75 cases out of hundreds, the clots were seen in right coronary artery supplying the electrical area of heart.
• Death in these cases is thought to result from a period of transient or prolonged lack of blood supply in the muscle of the heart wall, which induces a ventricular arrhythmia/fibrillation and no changes in the myocardium are seen during postmortem examination.
• The absence of the histological signs of acute necrosis and a healed infarct are a common finding.
• Chronic high–grade stenosis causing previous episodes of ischemia and areas of focal fibrosis is seen histologically in the myocardium.
• Ventricular arrhythmias may arise from a myocardium which has been previously scarred by episodes of ischemia.

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

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

Emedinews:Inspiration:The wise farmer

An Inspirational Story
(Dr GM Singh)

Many years ago, in a poor Chinese village, there lived a farmer and his son. His only material possession, apart from the land and a small hut, was a horse he had inherited from his father. One day, the horse ran away, leaving the man with no animal with which to work the land.

His neighbors, who respected him for his honesty and diligence, went to his house to say how much they regretted his loss. He thanked them for their visit, but asked: “How do you know that what happened was a misfortune in my life?”

Someone muttered to a friend: “He obviously doesn’t want to face facts, but let him think what he likes, after all, it’s better than being sad about it.”

And the neighbors went away again, pretending to agree with what he had said.

A week later, the horse returned to its stable, but it was not alone; it brought with it a beautiful mare for company. The inhabitants of the village were thrilled when they heard the news, for only then did they understand the reply the man had given them, and they went back to the farmer’s house to congratulate him on his good fortune.

“Instead of one horse, you’ve got two. Congratulations!” they said. “Many thanks for your visit and for your solidarity,” replied the farmer. “But how do you know that what happened was a blessing in my life?”

The neighbors were rather put out and decided that the man must be going mad, and, as they left, they said: “Doesn’t the man realize that the horse is a gift from God?”

A month later, the farmer’s son decided to break the mare in. However, the animal bucked wildly and threw the boy off; the boy fell awkwardly and broke his leg.

The neighbors returned to the farmer’s house, bringing presents for the injured boy. The mayor of the village solemnly presented his condolences to the father, saying how sad they all were about what had occurred.

The man thanked them for their visit and for their kindness, but he asked: “How do you know that what happened was a misfortune in my life?”

These words left everyone dumbstruck, because they were all quite sure that the son’s accident was a real tragedy. As they left the farmer’s house, they said to each other: “Now he really has gone mad; his only son could be left permanently crippled, and he’s not sure whether the accident was a misfortune or not!”

A few months went by, and Japan declared war on China. The emperor’s emissaries scoured the country for healthy young men to be sent to the front.

When they reached the village, they recruited all the young men, except the farmer’s son, whose leg had not yet mended.

None of the young men came back alive. The son recovered, and the two horses produced foals that were all sold for a good price.

The farmer went to visit his neighbors to console and to help them, since they had always shown him such solidarity.

Whenever any of them complained, the farmer would say: “How do you know that what happened was a misfortune?”

If someone was overjoyed about something, he would ask: “How do you know that what happened was a blessing?”

And the people of the village came to understand that life has other meanings that go beyond mere appearance.

Emedinews:Insights on Medicolegal Issues:Medicolegal importance of age up to 15 to 21 years

• 15 years of age: Even if a wife, a girl of age below 15 years cannot give valid consent for sexual intercourse.
• 16 years of age: Any girl below 16 years of age cannot give valid consent for sexual intercourse. It will amount to rape even sexual intercourse done with consent.
• Age 18–21 years:
• In accordance with Indian Majority Act 1875, a person attains majority on completion of 18 years.
• In accordance with Child marriage Resistance Act, a female under 18 years and male under 21 years cannot contract marriage.
• In accordance with Section 366 B of IPC, importation of any girl from Jammu & Kashmir or a foreign country under the age of 21 years for illicit intercourse is a criminal offence.

Emedinews:Makesure:A 60–year–old male developed acute heart attack after consuming Viagra.

Situation: A 60–year–old male developed acute heart attack after consuming Viagra.
Reaction: Oh my God! Why was cardiac clearance not taken before?
Lesson: Make sure that all older patients get a cardiac clearance before they are given Viagra group of drugs.

Emedinews:Inspiration:All good things

He was in the first third grade class I taught at Saint Mary's School in Morris, Minn. All 34 of my students were dear to me, but Mark Eklund was one in a million. Very neat in appearance, but had that happy-to-be-alive attitude that made even his occasional mischievousness delightful.

Mark talked incessantly. I had to remind him again and again that talking without permission was not acceptable. What impressed me so much, though, was his sincere response every time I had to correct him for misbehaving. "Thank you for correcting me, Sister!" I didn't know what to make of it at first, but before long I became accustomed to hearing it many times a day.

One morning my patience was growing thin when Mark talked once too often, and then I made a novice-teacher's mistake. I looked at Mark and said, "If you say one more word, I am going to tape your mouth shut!" It wasn't ten seconds later when Chuck blurted out, "Mark is talking again." I hadn't asked any of the students to help me watch Mark, but since I had stated the punishment in front of the class, I had to act on it.

I remember the scene as if it had occurred this morning. I walked to my desk, very deliberately opened by drawer and took out a roll of masking tape. Without saying a word, I proceeded to Mark's desk, tore off two pieces of tape and made a big X with them over his mouth. I then returned to the front of the room. As I glanced at Mark to see how he was doing, he winked at me. That did it!! I started laughing.

The class cheered as I walked back to Mark's desk, removed the tape, and shrugged my shoulders. His first words were, "Thank you for correcting me, Sister." At the end of the year, I was asked to teach junior-high math.

The years flew by, and before I knew it Mark was in my classroom again. He was more handsome than ever and just as polite. Since he had to listen carefully to my instruction in the "new math," he did not talk as much in ninth grade as he had in third. One Friday, things just didn't feel right. We had worked hard on a new concept all week and I sensed that the students were frowning, frustrated with themselves - and edgy with one another.

I had to stop this crankiness before it got out of hand. So I asked them to list the names of the other students in the room on two sheets of paper, leaving a space between each name. Then I told them to think of the nicest thing they could say about each of their classmates and write it down. It took the remainder of the class period to finish their assignment, and as the students left the room, each one handed me the papers. Charlie smiled. Mark said, "Thank you for teaching me, Sister. Have a good weekend." That Saturday, I wrote down the name of each student on a separate sheet of paper, and I listed what everyone else had said about that individual.

On Monday I gave each student his or her list. Before long, the entire class was smiling. "Really?" I heard whispered. "I never knew that meant anything to anyone!" "I didn't know others liked me so much." No one ever mentioned those papers in class again. I never knew if they discussed them after class or with their parents, but it didn't matter. The exercise had accomplished its purpose. The students were happy with themselves and one another again.

That group of students moved on. Several years later, after I returned from a vacation, my parents met me at the airport. As we were driving home, mother asked me the usual questions about the trip - the weather, my experiences in general. There was a lull in the conversation. Mother gave Dad a side-ways glance and simply says, "Dad?" My father cleared his throat as he usually did before something important.

"The Eklunds called last night," he began. "Really?" I said. "I haven't heard from them in years. I wonder how Mark is." Dad responded quietly. "Mark was killed in Vietnam," he said. "The funeral is tomorrow, and his parents would like it if you could attend."

To this day I can still point to the exact spot on I-494 where Dad told me about Mark. I had never seen a serviceman in a military coffin before. Mark looked so handsome, so mature. All I could think at that moment was, Mark I would give all the masking tape in the world if only you would talk to me. The church was packed with Mark's friends. Chuck's sister sang "The Battle Hymn of the Republic." Why did it have to rain on the day of the funeral? It was difficult enough at the graveside.

The pastor said the usual prayers, and the bugler played taps. One by one those who loved Mark took a last walk by the coffin and sprinkled it with holy water. I was the last one to bless the coffin. As I stood there, one of the soldiers who acted as pallbearer came up to me. "Were you Mark's math teacher?" he asked. I nodded as I continued to stare at the coffin. "Mark talked about you a lot," he said.

After the funeral, most of Mark's former classmates headed to Chuck's farmhouse for lunch. Mark's mother and father were there, obviously waiting for me. "We want to show you something," his father said, taking a wallet out of his pocket. "They found this on Mark when he was killed. We thought you might recognize it."

Opening the billfold, he carefully removed two worn pieces of notebook paper that had obviously been taped, folded and refolded many times. I knew without looking that the papers were the ones on which I had listed all the good things each of Mark's classmates had said about him.

"Thank you so much for doing that," Mark's mother said. "As you can see, Mark treasured it." Mark's classmates started to gather around us. Charlie smiled rather sheepishly and said, "I still have my list. It's in the top drawer of my desk at home." Chuck's wife said, "Chuck asked me to put his in our wedding album." "I have mine too," Marilyn said. "It's in my diary."

Then Vicki, another classmate, reached into her pocketbook, took out her wallet and showed her worn and frazzled list to the group. "I carry this with me at all times," Vicki said without batting an eyelash. "I think we all saved our lists." That's when I finally sat down and cried. I cried for Mark and for all his friends who would never see him again.

Emedinews:Insights on Medicolegal Issues:Suicide

Suicide

The World Health Organization estimates that suicide is the 13th leading cause of death worldwide. The method varies dramatically amongst countries.

• Over one million people commit suicide every year across the globe.
• Suicide is derived from a Latin word suicidium, from Sui caedere, "to kill oneself."
• Suicide is often committed out of despair, or attributed to some underlying mental disorder, which includes depression, bipolar disorder, schizophrenia, alcoholism and drug abuse.
• Financial difficulties, troubled interpersonal relationships and other undesirable situations play a significant role
• The leading methods in different regions include hanging, pesticide poisoning, and firearms.
• In India, 30% of suicides are from pesticides. The use of this method however varies markedly from 4% in Europe to more than 50% in the Pacific region.
• In the United States, 52% of suicides involve the use of firearms however asphyxiation and poisoning are fairly common as well. Together they comprised about 40% of US suicides.
• Other methods of suicide include blunt force trauma means jumping from a building or bridge, self, stepping in front of a train, or car collision, for example).
• Bloodletting means slitting one's wrist intentional drowning, self-immolation, electrocution, and intentional starvation are other suicide methods.
• A study found increased rates of suicide following the television news stories regarding suicide.

Emedinews:Makesure:A patient who had blood in the urine one month back was found to have large bladder cancer.

Situation: A patient who had blood in the urine one month back was found to have large bladder cancer.
Reaction: Oh my God! Why was a cystoscopy not done at that time?
Lesson: Make sure that all painless bleeding in the urine are investigated for cancer at the first diagnosis.

Emedinews:Inspiration:The carpenter

An Inspirational Story
(Mr Paramjit Chadha)

Once upon a time, two brothers who lived on adjoining farms fell into conflict. It was the first serious rift in 40 years of farming side-by-side, sharing machinery and trading labour and goods as needed without a hitch. Then the long collaboration fell apart. It began with a small misunderstanding and it grew into a major difference and finally, it exploded into an exchange of bitter words followed by weeks of silence.

One morning there was a knock on John's door. He opened it to find a man with a carpenter's toolbox. "I 'm looking for a few days' work," he said. "Perhaps you would have a few small jobs here and there I could help with? Could I help you?"

"Yes," said the older brother. "I do have a job for you. Look across the creek at that farm. That's my neighbour. In fact, it's my younger brother! Last week there was a meadow between us. He recently took his bulldozer to the river levee and now there is a creek between us.  Well, he may have done this to spite me, but I'll do him one better. See that pile of lumber by the barn? I want you to build me a fence an 8-foot fence -- so I won't need to see his place or his face anymore."

The carpenter said, "I think I understand the situation. Show me the nails and the post-hole digger and I'll be able to do a job that pleases you."

The older brother had to go to town, so he helped the carpenter get the materials ready and then he was off for the day. The carpenter worked hard all that day -- measuring, sawing and nailing. About sunset when the farmer returned, the carpenter had just finished his job.

The farmer's eyes opened wide, his jaw dropped. There was no fence there at all.

It was a bridge .. A bridge that stretched from one side of the creek to the other! A fine piece of work, handrails and all! And the neighbour, his younger brother, was coming toward them, his hand outstretched..

"You are quite a fellow to build this bridge after all I've said and done.

The two brothers stood at each end of the bridge, and then they met in middle, taking each other's hand. They turned to see the carpenter hoist his toolbox onto his shoulder.

"No, wait! Stay a few days. I've a lot of other projects for you," said the older brother.

"I'd love to stay on," the carpenter said, "but I have many more bridges to build."

Remember this... 

God won't ask what kind of car you drove, but He'll ask how many people you helped get where they needed to go.

God won't ask the square footage of your house, but He'll ask how many people you welcomed into your home.

God won't ask about the clothes you had in your closet, but He'll ask how many you helped to clothe. 

God won't ask how many friends you had, but He'll ask how many people to whom you were a friend.

God won't ask in what neighbourhood you lived, but He'll ask how you treated your neighbours.

God won't ask about the colour of your skin, but He'll ask about the content of your character.

God won't ask why it took you so long to seek Salvation, but He'll  lovingly take you to your mansion in Heaven, and not to the gates of hell.

Emedinews:Insights on Medicolegal Issues:What is Dissociative identity disorder?

Dissociative identity occurs due to chronic mental trauma or stress. The affected person fails to integrate the various aspects of his personality. As a result, he has a different self–identity at different time, place and situation, which he again forgets in another place or time or situation where he presents with another identity. In the course of such shifting of personality, there are concurrent vague complaints of disease or trauma due to assault.

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

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

Emedinews:Inspiration:A Wise Donkey

One day a farmer's donkey fell down into a well. The animal cried piteously for hours as the farmer tried to figure out what to do. Finally he decided the animal was old, and the well needed to be covered up anyway; it just wasn't worth it to retrieve the donkey.

 He invited all his neighbors to come over and help him. They each grabbed a shovel and began to shovel dirt into the well. At first, the donkey realized what was happening and cried horribly. Then, to everyone's amazement, he quieted down. A few shovel loads later, the farmer looked down the well, and was astonished at what he saw.

As every shovel of dirt hit his back, the donkey did something amazing. He would shake it off and take a step up. As the farmer's neighbors continued to shovel dirt on top of the animal, he would shake it off and take a step up. Pretty soon, everyone was amazed, as the donkey stepped up over the edge of the well and trotted off!

 Life is going to shovel dirt on you, all kinds of dirt. The trick to getting out of a hole is to shake it off and take a step up. Each of our troubles is a stepping stone. We can get out of the deepest holes just by not stopping, never giving up!

 Shake it off and take a step up!

Emedinews:Insights on medicoleagl issues:Hotson v East Berkshire Health Authority case– (1987) 2 All ER 909

Hotson v East Berkshire Health Authority case– (1987) 2 All ER 909

This was a case of alleged medical negligence and compensation where the extent of the hip injuries to a 13 year–old boy was not diagnosed for five days. At the age of 20 years, there was deformity of the hip joint, restricted mobility and permanent disability. The judge found that even if the diagnosis had been made correctly, there was still a 75% risk of the plaintiff's disability developing, but that the medical staff’s breach of duty had turned that risk into inevitability, thereby denying the plaintiff a 25% chance of a good recovery.

Damages included an amount of £11,500 representing 25% of the full value of the damages awardable for the plaintiff's disability. On appeal to the Lords, the question was whether the cause of the injury was the fall or the negligence of the health authority in delaying treatment, since if the fall had caused the injury the negligence of the authority was irrelevant in regard to the plaintiff’s disability. Because the judge had held that on the balance of probabilities, even correct diagnosis and treatment would not have prevented the disability from occurring, it followed that the plaintiff had failed on the issue of causation. It was therefore irrelevant to consider the question of damages.

Emedinews:Makesure:A patient with suspected MI died after receiving sublingual nitrate.

Situation: A patient with suspected MI died after receiving sublingual nitrate.
Reaction: Oh my God! Why was a history of intake of Viagra drug not taken?
Lesson: Make sure to take a history of Viagra drug intake before giving nitrates, because co–administration of the two drugs can cause a fatal fall in blood pressure.

Emedinews:Inspiration:The situation

An Inspirational Story
(Mr Vivek)

The situation

In Washington, DC, at a Metro Station, on a cold January morning in 2007, this man with a violin played six Bach pieces for about 45 minutes. During that time, approximately 2,000 people went through the station, most of them on their way to work. After about 3 minutes, a middle-aged man noticed that there was a musician playing. He slowed his pace and stopped for a few seconds, and then he hurried on to meet his schedule.

About 4 minutes later:

The violinist received his first dollar. A woman threw money in the hat and, without stopping, continued to walk.

At 6 minutes:

A young man leaned against the wall to listen to him, then looked at his watch and started to walk again.

At 10 minutes:

A 3-year old boy stopped, but his mother tugged him along hurriedly. The kid stopped to look at the violinist again, but the mother pushed hard and the child continued to walk, turning his head the whole time. This action was repeated by several other children, but every parent - without exception - forced their children to move on quickly.

At 45 minutes:

The musician played continuously. Only 6 people stopped and listened for a short while. About 20 gave money but continued to walk at their normal pace. The man collected a total of $32.

After 1 hour:

He finished playing and silence took over. No one noticed and no one applauded. There was no recognition at all.

No one knew this, but the violinist was Joshua Bell, one of the greatest musicians in the world. He played one of the most intricate pieces ever written, with a violin worth $3.5 million dollars. Two days before, Joshua Bell sold-out a theater in Boston where the seats averaged $100 each to sit and listen to him play the same music.

This is a true story. Joshua Bell, playing incognito in the D.C. Metro Station, was organized by the Washington Post as part of a social experiment about perception, taste and people's priorities.

This experiment raised several questions:

In a common-place environment, at an inappropriate hour, do we perceive beauty?

If so, do we stop to appreciate it?

Do we recognize talent in an unexpected context?

One possible conclusion reached from this experiment could be this:

If we do not have a moment to stop and listen to one of the best musicians in the world, playing some of the finest music ever written, with one of the most beautiful instruments ever made.

How many other things are we missing as we rush through life?

Enjoy life NOW. It has an expiration date!!!!! 

Delusion of persecution

Medicolegal Update

 (Dr Sudhir Gupta, Additional Prof, Forensic Medicine & Toxicology, AIIMS)

Delusion of persecution

• Delusion of persecution is an unpleasant delusion.
• The person is suspicious and apprehensive and leads a life of distress and pain. The sufferer believes that something bad is going to happen to him. He/she fears that he may be killed by somebody or his property may be robbed.
• Such a person may feel himself so helpless that he may even commit suicide or may kill his own family members to "save" them from some imaginary danger. He may even kill some innocent person thinking him to be his enemy who is "out to destroy him, his family and his property."
• In an insane person, delusion of grandeur may change to delusions of persecution. A man who wrongly believes that he possesses huge property, may at a time start to think wrongly that another person is out to kill him to inherit his property.

Emedinews:Makesure: A patient with suspected pneumonia and normal x–ray died 12 hours after admission.

Situation: A patient with suspected pneumonia and normal x–ray died 12 hours after admission.
Reaction: Oh my God! Why were antibiotics not started?
Lesson: Make sure that all patients with suspected pneumonia are given antibiotic at the first suspicion as x–ray can be normal in the first 24 hours.

A simple gesture

An Inspirational Story
(Ms Ritu Sinha)

A little boy selling magazines for school walked up to a house that people rarely visited. The house was very old and run down and the owner hardly ever came out. When he did come out he would not say hello to neighbors or passersby but simply just glare at them.

The boy knocked on the door and waited, sweating from fear of the old man. The boy's parents told him to stay away from the house, a lot of the other neighborhood children were told the same from their parents.

As he was ready to walk away, the door slowly opened. “What do you want?" the old man said. The little boy was very afraid but he had a quota to meet for school with selling the magazines.

"Uh, sir, I uh am selling these magazines and uh I was wondering if you would like to buy one." The old man just stared at the boy. The boy could see inside the old man's house and saw that he had dog figurines on the fireplace mantle. "Do you collect dogs?" the little boy asked. "Yes, I have many collectibles in my house, they are my family here, and they are all I have." The boy then felt sorry for the man, as it seemed that he was a very lonely soul. "Well, I do have a magazine here for collectors, it is perfect for you, I also have one about dogs since you like dogs so much." The old man was ready to close the door on the boy and said, "No boy, I don't need any magazines of any kind, now goodbye."

The little boy was sad that he was not going to make his quota with the sale. He was also sad for the old man being so alone in the big house that he owned. The boy went home and then had an idea. He had a little dog figure that he got some years ago from an aunt. The figurine did not mean nearly as much to him since he had a real live dog and a large family. The boy headed back down to the old man's house with the figurine. He knocked on the door again and this time the old man came right to the door. "Boy, I thought I told you no magazines."

"No, sir I know that, I wanted to bring you a gift." The boy handed him the figurine and the old man's face lit up. "It is a Golden Retriever, I have one at home, and this one is for you." The old man was simply stunned; no one had ever given him such a gift and shown him so much kindness. "Boy, you have a big heart, why are you doing this?" The boy smiled at the man and said, "Because you like dogs." From that day on the old man started coming out of the house and acknowledging people. He and the boy became friends; the boy even brought his dog to see the man weekly.

This simple gesture changed both of their lives forever.

Surgical error deaths

Medicolegal Update

 (Dr Sudhir Gupta, Additional Prof, Forensic Medicine & Toxicology, AIIMS)

Surgical error deaths

A UK survey has suggested that the damage to underlying structures is the commonest complication for which patients successfully sue surgeons.

• The survey found that damage to veins, nerves, and other underlying structures accounted for nearly one third of 115 successful claims, with infection accounting for another 12%.
• Patients also sued successfully after they were burnt by diathermy, after spirit–based skin preparations ignited, and after adverse reactions to iodine.
• Retained items and failed or delayed diagnosis accounted for 8% and 7% respectively of successful medical negligence claims.
• The retained items—which included a pair of forceps and a surgical pack after a hemorrhoid surgery occurred despite formal written procedures for swab and needle counts in operating theatres.
• The top award was for £550000 ($880000) and was allocated to relatives of a patient with a history of deep vein thrombosis and pulmonary embolism who died of an embolism four weeks after elective surgery for varicose veins. The patient had received no anticoagulant treatment until two weeks after surgery.

Emedinews:Makesure:An HIV patient died after sulfa prophylaxis.

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

Emedinews:Inspiration:A pillow and a blanket

An Inspirational Story
(Ms Ritu Sinha)

A long time ago, a young, wealthy girl was getting ready for bed. She was saying her prayers when she heard a muffled crying coming through her window. A little frightened, she went over to the window and leaned out. Another girl, who seemed to be about her age and homeless, was standing in the alley by the rich girl’s house.

Her heart went out to the homeless girl, for it was the dead of winter, and the girl had no blanket, only old newspapers someone had thrown out. The rich girl was suddenly struck with a brilliant idea. She called to the other girl and said, "You there, come to my front door, please." The homeless girl was so startled she could only manage to nod.

As quick as her legs could take her, the young girl ran down the hall to her mother’s closet, and picked out an old quilt and a beat up pillow. She had to walk slower down to the front door as to not trip over the quilt which was hanging down, but she made it eventually. Dropping both the articles, she opened the door.

Standing there was the homeless girl, looking quite scared. The rich girl smiled warmly and handed both articles to the other girl. Her smile grew wider as she watched the true amazement and happiness alight upon the other girl's face. She went to bed incredibly satisfied. In mid-morning the next day a knock came to the door. The rich girl flew to the door hoping that it was the other little girl there. She opened the large door and looked outside. It was the other little girl.

Her face looked happy, and she smiled. "I suppose you want these back." The rich little girl opened her mouth to say that she could keep them when another idea popped into her head. "No, I want them back."

The homeless girl's face fell. This was obviously not the answer she had hoped for. She reluctantly laid down the beat up things, and turned to leave when the rich girl yelled, "Wait! Stay right there." She turned in time to see the rich girl running up the stairs and down a long corridor. Deciding whatever the rich little girl was doing wasn't worth waiting for she started to turn around and walk away. As her foot hit the first step, she felt someone tap her on the shoulder, turning she saw the rich little girl, thrusting a new blanket and pillow at her.

"Have these." she said quietly. These were her own personal belonging made of silk and down feathers. As the two grew older they didn't see each other much, but they were never far from each other's minds. One day, the Rich girl, who was now a Rich woman, got a telephone call from someone, a lawyer, saying that she was requested to see him. When she arrived at the office, he told her what had happened.

Forty years ago, when she was nine years old, she had helped a little girl in need. That grew into a middle-class woman with a husband and two children. She had recently died and left something for her in her will. "Though," the lawyer said, "it's the most peculiar thing. She left you a pillow and a blanket."

Emedinews:Insights on Medicolegal Issues:What is delirium?

• In delirium, the consciousness of the person is disturbed with impaired orientation, blunted critical faculties and irrelevant or incoherent thought content.
• A person may go into the state of delirium in many conditions, such as due to mental unsoundness, acute conditions like high fever, acute poisoning cases, as in dhatura poisoning and head injury
• Delirium tremens is a condition of delirious state, which occurs in chronic alcoholics due to sudden increase of the dose of alcohol or sudden withdrawal or some diseases and head injury etc. There is incoherency, coarse or violent tremor, hallucination, disorientation etc.
• During such a mental state the person may commit some unlawful, destructive act for which he is not legally responsible, because delirium is considered as a state of definite mental abnormality.

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

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

Emedinews:Inspiration:A new pair of shoes

An Inspirational Story
(Dr GM Singh)

When I got sober my sponsor told me that I had to be willing to change everything about my life -- everything. So, I wore blue jeans and switched to slacks. I wore western shirts and switched to T-shirts. But the one thing I just couldn't give up was my cowboy boots.

I went to my sponsor and said, "Surely I won't get drunk over a silly pair of cowboy boots. I'm willing to change a lot of things, and if needed I could even give up those boots, but it seems so silly."

My sponsor said, "I don't know how silly it is, or if you'll get drunk over those cowboy boots, but I can tell that you are not 'entirely' willing, though."

“Okay, okay," I said. "I'll prove it to you. I'll give up the boots for 30 days just to demonstrate my willingness to God."

So, I bought a pair of tennis shoes, and after 30 days of not wearing my cowboy boots, wearing tennis shoes instead, the strangest thing happened -- my feet stopped hurting.

That's how it was getting sober and giving up the high life. I never stopped to think that the boots were causing my feet to hurt, or the booze was causing my life to hurt. I got willing to give up the stuff, one day at a time, for 30 days, then 60 days, then 90 days ... and my life stopped hurting.

And every day I do something different, some change in some small way. Maybe I just put my socks on different, or drive to work a new way.

Every day, I try to do little things in a big way so that when big things happen I can handle them in a little way.

Emedinews:Insights on Medicolegal Issues:UK Clinical negligence law –Bolam – v – Friern Hospital Management Committee 1957

Sir Liam Donaldson said patients deserve to receive quality healthcare

• UK Clinical negligence law defines negligence as any act or omission which falls short of a standard to be expected of "the reasonable man."
• It is necessary to show that whatever the Doctor did or did not do fell below the standard of a reasonably competent Doctor in that field of medicine.
• In the leading case of "Bolam – v – Friern Hospital Management Committee 1957," it was stated that a doctor must act in accordance with a practice which is accepted as proper by a responsible body of men
• There are several acceptable ways of doing something and this may mean that there is no negligence if an alternative method is chosen.
• The fact that another person would not have done things in the same way does not automatically mean that there was clinical negligence.
• The Doctor will be able to defend the compensation claim successfully, if it can show that a responsible body of reputable Doctors in the relevant field would have acted in a similar manner.
• This means that a judge will hear evidence from experts and decide whether the actions taken were appropriate.

EMedinews:Makesure:A female patient C/O lower abdominal pain, fever and had uterine tenderness on bimanual palpation

Situation: A female patient C/O lower abdominal pain, fever and had uterine tenderness on bimanual palpation.
Reaction: You should do cervical swabs and consider starting antibiotics.
Lesson: Make Sure to remember that a woman with such symptoms may have endometritis, which requires prompt diagnosis and may respond to doxycycline and metronidazole.

Emedinews:Inspiration:The art of giving

An Inspirational Story
(Dr GM Singh)

Rivers do not drink their own water, nor do tree eat their own fruit, nor do rain clouds eat the grains reared by them. The wealth of the noble is used solely for the benefit of others! Even after accepting that giving is good and that one must learn to give, several questions need to be answered.

1. The first question is: When should one give?

We all know the famous incident from Mahabharat: Yudhishthir asks a beggar seeking alms to come the next day. On this, Bhim rejoices that Yudhishthir his brother, has conquered death! For he is sure that he will be around the next day to give. Yudhishthir gets the message.

One does not know really whether one will be there tomorrow to give!

The time to give therefore is now.

2. The next question is: 'How much to give?'

One recalls the famous incident from history: Rana Pratap was reeling after defeat from the Mughals. He had lost his army, he had lost his wealth, and most important, he had lost hope, his will to fight. At that time, in his darkest hour, his erstwhile minister, Bhamashah, came seeking him and placed his entire fortune at the disposal of Rana Pratap. With this, Rana Pratap raised an army and lived to fight another day.

Give as much as one can!

3. The next question is: 'What to give?'

It is not only money that can be given away. It could be a flower or even a smile.

It is not how much one gives but how one gives that really matters. When you give a smile to a stranger that may be the only good thing received by him in days and weeks!

"You can give anything but you must give with all your heart!"

4. One also needs answer to this question whom to give?

Many times we avoid giving by finding fault with the person who is seeking. However, being judgmental and rejecting a person on the presumption that he may not be the most deserving is not justified.

"Give without being judgmental!"

5. Next we have to answer: 'How to give?'

Coming to the manner of giving, one has to ensure that the receiver does not feel humiliated, nor the giver feels proud by giving.

In giving, follow the advice 'Let not your left hand know what your right hand gives? Charity without publicity and fanfare is the highest form of charity.'

'Give quietly!'

While giving, let not the recipient feel small or humiliated. After all, what we give never really belonged to us. We come to this world with nothing and will go with nothing. The thing gifted was only with us for a temporary period. Why then take pride in giving away something which really did not belong to us?

Give with grace and with a feeling of gratitude.

6. "What should one feel after giving?"

We all know the story of Eklavya. When Dronacharya asked him for his right thumb as "Guru Dakshina, he unhesitatingly cut off the thumb and gave it to Dronacharya. 

There is a little known sequel to this story.

Eklavya was asked whether he ever regretted the act of giving away his thumb. He replied, and the reply has to be believed to be true, as it was asked to him when he was dying.

His reply was "Yes! I regretted this only once in my life. It was when Pandavas were coming in to kill Dronacharya who was broken hearted on the false news of death of his son, Ashwathama, and had stopped fighting. It was then that I regretted the loss of my thumb. If the thumb was there, no one could have dared hurt my Guru?

The message to us is clear. Give and never regret giving! 

7. And the last question is: 'How much should we provide for our heirs?'

Ask yourself 'are we taking away from them the gift of work? - A source of happiness? The answer is given by Warren Buffett: 

"Leave your kids enough to do anything, but not enough to do nothing!"

I would conclude by saying: Let us learn the Art of Giving, and quoting Saint Kabir: "When the wealth in the house increases, when water fills a boat, throw them out with both hands!"

This is the wise thing to do!