Tuesday, 12 December 2017

The Indian Medical Association announces bold steps aimed at restoring faith in doctors and the medical profession

The Indian Medical Association announces bold steps aimed at restoring faith in doctors and the medical profession
Proposes certain self-regulatory procedures for doctors and hospitals to adopt

New Delhi, 11 December 2017: The Indian Medical Association (IMA), the largest voluntary organization of Doctors of Modern Scientific Medicine today announced certain self-regulation procedures for hospitals and doctors. This comes in light of the recent incidents involving the lives of a pair of twins, and a 7-year-old girl. The doctor-patient trust in the country, which was already experiencing a downward spiral, has deteriorated further. Doctors, hospitals, the health industry, patients, media, and politicians all are unhappy. Doctors do not have the intent to be the cause for public unrest or loss of public trust. At the same time patients must understand that to err is human and one incident does not mean that there will be more such cases in future as well.

Trust is the foundation of a doctor and patient relationship. The medical profession is undergoing certain changes. While violence against doctors is on the rise and they are being held accountable, at times, for deeds not committed, it is also true that there is some introspection needed on the part of doctors and hospitals, failing which this trust may take a long time to reestablish. Today, the private sector looks after 80% of the patients that too with highest quality. In the absence of state subsidy private sector providing quality care  invariably will come at a cost which is still at fraction of a cost compared to that in advanced countries.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "We represent the collective consciousness of the largest medical association of modern doctors of the country, the IMA. A profession, which has been considered as second to none, & it will remain noble is today, being looked at with suspicion. However, the medical profession is the noblest profession. It is disheartening to see the erosion in trust and we want to make it more transparent. IMA is and will continue to work towards improving doctor-patient relationship. IMA is committed to practicing with humility and pledges to reform the existing system. We will also take the opportunity to say here that the doctor to patient ratio in India is skewed due to which doctors are under a lot of stress. Doctors are also human beings and not healing angels. Once treatment is administered, the recuperation of a patient depends upon physical and organic factors. It is unacceptable and absurd to victimize the medical practitioner if the patient does not respond to treatment.”

All doctors shall practice with compassion and follow IMA ALERT policy (Acknowledge, Listen in detail, Explain, Review and Thank you). The IMA has also announced formation of an IMA Medical Redressal Commission at the state level (in each state) to engage in social, financial, and quality audits of health care (Suo moto or on demand). The commission will have a public man, an IMA office bearer, one former state medical council representative, and two subject experts. The commission shall consider every grievance in a time bound manner. An appeal to the state commission will be heard by the "Head-quarters IMA Medical Redressal Commission" which will have the powers to take suo moto cases also. The headquarters shall also suggest reforms in healthcare on periodic basis.

Adding further, Dr Aggarwal, said, “What happened was most unfortunate. However, not all doctors are wrong, and the public must have faith in them. Such errors happen by accident and not intentionally. Having said this, it is also time for the medical profession to introspect and come out with self-regulation procedures. We are often blamed for prescribing costly drugs. From today onwards, all doctors in the country shall choose affordable drugs. We also appeal to the government to come out with an urgent ordinance for one drug-one company-one price policy. Doctors should actively participate in ensuring that no hospital sells any item priced higher than the MRP. No service charges should be added to procure drugs from outside. MRP shall not be dictated by the purchaser.”

The other points announced by IMA are as follows.
  • IMA recommends that all doctors should prescribe preferably NLEM drugs.
  • All doctors shall promote Janaushidhi Kendras.
  • We appeal to the government to classify all disposables under both NLEM and non-NLEM categories and cap the price of essential ones. Till then all medical establishments should sell the disposables at procurement prize after adding a predefined fixed margin.
  • Hospitals and doctors are often blamed of overcharging and over investigations. Billing should be transparent, and all special investigations should be well informed & explained.
  • Every doctor should ensure that it becomes mandatory on the part of the hospital administrator to give options at the time of admission to choose cost-effective treatment room and treatment (single room, sharing room, and general-ward) and explain the difference in total bill estimates.
  • All doctors should ensure that hospital estimates at the time of admission are near to actual.
  • The treating doctor must explain the chances of death and unexpected complications and resultant financial implication at the time of admission.
  • Once doctors take charge of a patient, the patient should not be neglected. They should look after the patient till discharge.
  • Emergency care is the responsibility of the state government and the government should subsidize the costs of all emergencies in private sector & create a mechanism for reimbursement.
  • Every medical prescription must include counseling on the cost of drugs and investigations.
  • IMA has zero tolerance to doctors indulging in female feticide.
  • IMA has zero tolerance to cuts and commissions. Medical establishment should revisit their referral fee system. Billing paid to doctors should be transparent and reflected in the bill.
  • No hospital can force their consultants to work on targets. Contractual agreements should be in such way in which of both parties that is consultant and the hospital is equally protected. All hospitals should consider not charging service charges from the consultants.
  • Choice of drugs and devices rests with the doctors based on the affordability of the patient and not on the profitability.
  • All hospitals must comply to the commitment towards EWS, BPL, and poor patients without any discrimination.
  • All patient complaints should be addressed in a timely manner through an internal redressal mechanism with a chairman from outside the hospital.
  • All medical establishments must ensure that their business ethics comply with the MCI ETHICS.
  • IMA LAMA policy is being developed as there are no clear guidelines at present.
  • Every dead body needs to be treated with respect and dignity.
  • All charitable hospitals should do their free work as assigned.
  • All needy patients must be routed through the social worker of the establishment and guided and directed to the appropriate place.
  • At least one more equally experienced but unrelated surgeon should be involved in the consent form during elective LSCS.
  • The patient has a right to get medical records within 72 hours of request. Acknowledge their request.
  • The patient has the right to go for a second opinion from an appropriately qualified medical doctor. The primary doctors have should not  get offended.
  • A hospital has no right to stop life-saving investigations or treatment for non-payment of bills if the patient is still admitted in the hospital. The government should make a mechanism for the reimbursement for the above for poor patients.
  • Ensure for us all are equal. BPL, APL, EWS, rich, or poor all should get the same attention and treatment.
  • IMA policy: With no National Guidelines on viability of fetus issue ,it is being looked upon by IMA, FOGSI, IAP and NNF.
  • We are not against any regulations and accountability, but we should all ask for a single window accountability at the state level. The state medical council should be proactive and take timely decisions. We should also ensure a single window registration.
  • We must ensure that our establishment has a transgender policy.
  • All government hospitals should be upgraded and have facilities like those in the private hospitals. All public, private or charitable hospitals should have quality accreditation.
  • No doctors should issue false certificates.
“All the above will & should be implemented with immediate effect”, said Dr Ravi Wankhedkar, National President Elect IMA, in his message.
The above have approval from most stakeholders. A copy of this is being sent to the Health Secretary, Govt of India and Health Minister, Govt of Delhi. Both President and Registrar, Delhi Medical Council, are requested to help in circulating this message to all doctors in Delhi.

We are thankful to the society for raising the issues and will request them to work with the medical fraternity to make IMAs project "Cure in India" a success. 

Straight from the Heart: Team IMA Initiatives with MCI

Straight from the Heart: Team IMA Initiatives with MCI  

Dr KK Aggarwal
National President IMA

1.       Finalized Indian Medical Services draft suggestions to the Govt. of India passed by CWC IMA and GBM of MCI.
2.       As per MCI Ethic Regulations 8.6, professional incompetence shall be judged by peer group as per guidelines prescribed by the MCI.  But these guidelines were never made. IMA and MCI finalized these guidelines, passed by CWC IMA and GBM of MCI.
3.       In its judgment in Jacob Mathew vs State of Punjab & Anr on 5 August, 2005, the Hon’ble Supreme Court of India directed Statutory Rules or Executive Instructions incorporating certain guidelines to be framed and issued by the Government of India and/or the State Governments in consultation with the MCI regarding prosecution of doctors for offences of which criminal rashness or criminal negligence is an ingredient. MOH wrote to MCI to make a task force to make recommendations involving IMA. IMA and MCI has framed these guidelines and passed by CWC IMA and GBM of MCI.
4.       In Parmanand Kataria vs Union of India clarification in MCI General Body Meeting, it was submitted that Evidence Act should also be so amended as to provide that the Doctor's diary maintained in regular course by him in respect of the accident cases would be accepted by the courts in evidence without insisting the doctors being present to prove the same or subject himself to cross-examination/harassment for long period of time.”  MCI-IMA task force has framed these guidelines, which have been passed by CWC IMA and GBM of MCI.
5.       With regard to NEET, IMA wrote to MCI to relax the norms for age and number of attempts and the same was done
6.       The extended list of disabilities now has been accepted by MCI for MBS admissions and 5% of the seats are now reserved for the same
7.       We wrote to MCI regarding non-payment of stipends to interns in many private colleges. MCI is looking into t.
8.       MCI changed the professor: student ratio.
9.       IMA Grievance Cell wrote to MCI about two cases to expedite their enquiry process
10.    IMA offered CPR training after tragic death of Smt. Premlata on 16th November, 2017 at MCI premises.
11.    May 10: Sub: imposing the condition of Good Standing Certificate for those who are Registered with registering authorities in other countries [Any Graduate or Post Graduate from our country whenever intends to register with registering authorities for practicing modern medicine in the concerned countries, he/she is required to furnish a Good Standing Certificate for their verification issued by the Medical Council of India. This is solely to ensure that the concerned registered medical practitioner has a good track record and there is nothing against him/her, especially with reference to ethical breech and/or violates. In the same breath and vein, it is necessary that a similar condition needs to be imposed for Indian doctors who are practicing in other countries after getting registered in that country and intends to come back to India. Imposition of similar conditions would be required for Indian students getting their MBBS or equivalent course outside India and coming back for registration in India; foreigners to India and asking for temporary license to practice and also for Indian doctors seeking multiple registrations in different states.  This would mean that before they are registered or re-registered with the registering authorities in India, they will have to furnish the similar Good Standing Certificate as a condition precedent. This will serve a similar purpose as the Good Standing Certificate issued by the MCI serves in respect of Indian Doctors seeking registration to the competent registering authority practicing modern medicine in foreign countries. Hence the suggestion.  We are sure that the required decision will be taken, in this regard for the enforcement by all concerned.
12.    June 20: IMA wrote about Female Genital Mutilation and hysterectomy of mentally unstable females to maintain the women's hygiene during menstruation and avoidance of pregnancy in sexual abuse. As per IMA, doing so is violation of women's fundamental rights. IMA requested to clarify the position of MCI as regards to these two practices so that we can put it as IMA policy.
13.    MCI restarted Dr B C Roy National Awards on persistent reminders by IMA.
14.    Response from MCI: “This has reference to your email dated 22nd January, 2017, wherein you have forwarded a representation pertaining to permissible filling up of non-medical teachers in pre and para clinical departments in medical colleges under the ambit of the Medical Council of India.  

It may be noted that in the context of unavailability of the medical teachers (possessing medical qualifications) in the pre and para clinical subjects, the regulation as provided for a permissible percentage of non-medical teachers in the subject of Biochemistry up to the extent of 50% and physiology, microbiology, pharmacology up to the extent of 30% with a rider that the same shall be filled up in case the teachers with medical qualifications are not available. This by no stretch means that the said percentage is earmarked for non-medical teachers. Ideally speaking medical college should have teachers possessing medical qualifications, but as there is paucity hence the provision in the regulation.”
15.    MCI raised the issue regarding ESIC: DACP guidelines, Govt of India, has not been implemented for promotion of Assistant professors to Associate Professors in ESIC Medical Colleges, though assured in the recruitment Advertisements.
16.    IMA opposed introduction of NMC.
17.    IMA opposed NEXT exam, which MCI supported.
18.    IMA opposed and wrote to MCI not to support post BDS bridge course to MBBS.
19.    IMA support amendments to IMC act and say no to NMC. IMA drafted a study group report to this aspect.
20.    IMA won the PCPNDT act case in Delhi High Court. Matter is in Supreme Court now.
21.    Both IMA and MCI were part of Inter-Ministerial Committee formed by Ministry of Health.
22.    IMA supported the UPRN circular issued by MCI.
23.    In NATCON 2017, MCI has been given a slot by IMA to introduce UPRN (Unique Permanent Registration Number).
24.    MCI: “…proposed change of the MODE OF EXECUTION of persons awarded capital punishment from HANDING TO LETHAL INJECTION as proposed by the Law Commission. “The Ethical Committee of Medical Council of India has deliberated on the subject of the mode of execution of death sentence as prepared by the Law Commission and has come to the unanimous view that in order to uphold the highest moral and ethical values of humanity, the Death Penalty (capital punishment) should be abolished altogether in our country.”

1. “The members of the Adhoc Committee appointed by the Hon’ble Supreme Court and of the Executive Committee of the Council considered the recommendation of the Ethical Committee with regard to law panel for execution by Lethal injection and decided that this matter does not come under the purview of the Council.” However, the Ethics Committee strongly feels that the matter should be reexamined by the Executive Committee afresh and the Ethics Committee decision be placed before the General Body………….”

25.    Three attempts for UG MBBS admission were shifted from retrospective to prospective. IMA was flooded with students calls after the Central Board of Secondary Education (CBSE) said that AIPMT attempts will be included in the proposed NEET exam (UG) starting this year. IMA immediately took up the cause. I spoke to MCI and also to Dr Ketan Desai, then President World Medical Association (WMA). Immediate action was taken. The Health Ministry has now clarified that "since any new regulation takes effect prospectively, NEET-2017 shall be counted as the first attempt for this purpose irrespective of the previous attempts in AIPMT/NEET, subject to the upper age limit. CBSE has been advised to make necessary corrections in the information bulletin and on their website cbseneet.nic.in, so that any application is not rejected on this ground. Data pertaining to applications already rejected will be erased so that rejected applications can be filed afresh" (Press Information Bureau, 3.2.17) …

Monday, 11 December 2017

Long-term use of statins can exacerbate the risk of developing Type 2 diabetes

Long-term use of statins can exacerbate the risk of developing Type 2 diabetes
Healthy diet and lifestyle changes can prevent complications

New Delhi, 10 December 2017:A recent study has indicated that those indulging in the long-term use of cholesterol-lowering drug, statin, are at 30% more at risk of developing Type-2 diabetes. It mentions that taking statin is associated with a 36% heightened risk of subsequently being diagnosed with Type-2 diabetes. Research also indicates that statins may impair the production of insulin, the hormone needed to lower the body’s levels of blood glucose.
Estimates place the number of people living with diabetes at 60 million in India, of which 95% have Type 2 diabetes. Type 2 diabetes is typically brought on by poor eating habits, too much weight and too little exercise. This condition, when poorly controlled, can increase the risk of cardiovascular disease, blindness, and even kidney failure.
Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, “In a person with Type 2 diabetes, the body does not utilize insulin properly and this condition is called as insulin resistance. The pancreas first makes extra insulin to make up for this. However, over time, it cannot make enough to keep the blood glucose at normal levels. While the exact trigger for this condition is not known, Type 2 diabetes could be a result of a combination of factors. Some may be genetically predisposed to the condition. People with a family history of obesity are also at an increased risk of developing insulin resistance and diabetes. Those who are obese have added pressure on their body’s ability to use insulin in controlling blood sugar levels. This can lead to Type 2 diabetes. The more fatty tissue a person has, the more resistant their cells become to insulin. Lifestyle factors also have a major role to play.”
The symptoms of Type 2 diabetes develop slowly, over a period of time. Some of them include increased thirst and hunger, frequent urination, weight loss, fatigue, blurred vision, slow healing of infections and wounds, and skin darkening in certain areas.
Adding further, Dr Aggarwal, said, “A healthy diet is, more expensive than an unhealthy one. The wide availability of cheap energy dense low-nutrient food is contributing to the global epidemic of type 2 diabetes. Foods which reduce the risk of type 2 diabetes such as vegetables, fresh fruit, whole grains and unsaturated fats need to be more affordable and more widely available.”
The following preventive measures can help prevent the onset of Type 2 diabetes in people.
·          Exercise more Exercise has various benefits including preventing weight gain, controlling blood sugar levels, and other conditions. A minimum of 30 minutes of physical activity every day is very beneficial.
·          Eat healthy A diet rich in whole grain, fruits, and vegetables is very good for the body. Fibrous food will ensure that you feel fuller for a longer period and prevent any cravings. Avoid processed and refined food as much as possible.
·          Limit your alcohol intake and quit smoking Too much alcohol leads to weight gain and can increase your blood pressure and triglyceride levels. Men should limit drinks to two per day and women to one per day. Smokers are twice as likely to develop diabetes as non-smokers and therefore, it is a good idea to quit this habit.

·          Understand your risk factors Doing so can help you in taking preventive measures at the earliest and avoid complications.

Straight from the Heart: IMA Grievances Cell

Straight from the Heart: IMA Grievances Cell

IMA HQs Mediation, Conciliation & Grievances Redressal Cell (IMA-MCGRC)

·            Total number of complaints Received- 162
·            Total number of complaints referred to State /Local Branches – 88
·            Total number of complaints resolved at IMA HQ - 55
·            Total Number of complaint Pending - 19

IMA Nagpur Mediation, Conciliation & Grievances Redressal Cell

  • Total complaints received so far: 235
  • Complaints disposed of: 233
  • Complaint pending for investigations: 2
  • Mutual agreement reached between complainant and doctor: 176 (74.4%)
  • Left cases where IMA is unaware about what happened to these cases: 41 (17.4%)
  • Cases of negligence referred to MMC/ State Ayush Medical council for action: 18 (8.2%) (unfortunately, except in three cases IMA did not receive any communication or feed-back from respective state medical/ ayush council)

Positive indications

  • Complaints lodged directly to police are now referred to IMA for technical advice.

  • Hon. Chief Minister of Maharashtra is from Nagpur and has a chief minister’s secretariat at Nagpur. Complaints received are forwarded to IMA Nagpur branch for investigation and technical advice.

  • Of late IMA is also receiving requests from Nagpur District Consumer Redressal Forum, to provide technical opinion on the complaint cases directly received by the forum.

  • During interaction, Dean, Government Medical College has informed that the medical board is constituted by the order of the government. And, therefore, officially representatives of grievance cell of IMA Nagpur branch cannot be invited during official meetings of medical board, whenever, a case of private practitioner comes before the medical board for hearing. However, he assured that, in such a case of private practitioner, he would invite informally, representatives of IMA to discuss with him ahead of the meeting whenever a case against private service provider comes up before the medical board for discussion.

  • IMA Nagpur had discussed this issue with Secretary Medical Education during his visit to Nagpur. He has promised to induct IMA representative with representative of a concerned specialist’s organization, as special invitee for meeting of medical board when a case against a private service provider comes for hearing before the medical board. IMA has already submitted a proposal to Secretary Medical Education in this regard, and hopefully waiting to receive favorable orders in this regard.

Sunday, 10 December 2017

Straight from the Heart: CC Reporting

Straight from the Heart: CC Reporting
We have tried to compile the important meetings held during the year. Following is a list of meetings with government including stakeholders as well as international meetings that IMA participated in. All states branches can attempt to compile a similar list of meetings that your state participated in.

Meetings with government/stakeholder’s/ officials

  • Inter-ministerial meetings
  • Monthly meeting of IMA with MoH
  • Shri JP Nadda on 20th January 2017
  • Shri CK Mishra on 3rd March 2017
  • Member of Parliament Doctors meeting on 17th May 2017
  • Addl. Secretary (Health) Shri Sanjeeva Kumar with IMA 19th May 2017
  • Shri Satyender Jain, Health Minster, Delhi Govt.
  • Shri JP Nadda on 6th June 2017
  • Dr Jagdish Prasad on 6th June 2017
  • Shri CK Mishra on 6th June 2017
  • Shri Jitendra Singh on 6th June 2017
  • Shri JP Nadda on 23rd June 2017
  • Dr CP Thakur, Dr Mahesh Sharma, Dr Sanjay Jaiswal and Dr Vikas Mahatme on 24th May 2017
  • FOMA meeting on 6th April 2017 at Hotel Lalit, New Delhi
  • 23rd May meeting with FOMA stakeholders regarding plan organization of Dilli Chalo Movement on 6th June 2017
  • IMA Meeting with WHO Officials on 17th June 2017
  • Meeting with President-Elect Govt. of India on 21st July 2017
  • Meeting with Dr Sanjeeva Kumar, Addl. Secretary, MoHFW on 16th August, 2017
  • Meeting Shri GP Samanta, Under Secy, GOI  to discuss the issues raised by IMA during the meeting with Hon’ble HFM on 19th September 2017 at 3.00 pm under the chairmanship of Addl. Secy. (Health) in Nirman Bhawan, New Delhi
  • Meeting with Shri Sunil Kumar Gupta, Under Secy., GOI, MoHFW, Meeting to discuss the issue raised by IMA on 27th September 2017 , Nirman Bhawan, ND
  • Meeting with Dr Anil Kumar, Addl. DDG (AK) reg. Meeting of sub-committee to finalize the draft notification in respect of medical diagnostic laboratories including signatory authority/Technical head of medical diagnostic laboratory on 1st November, 2017 under the chairmanship of Dr B D Athani, Spl. DGHS Nirman Bhawan, ND
  • Shri GC Dobhal, Deputy Secretary, Petition Committee reg. Meeting of the Parliamentary Committee on petitions, Lok Sabha, w. r. t. Medical Reforms in the country on 20.11.2017 Parliament House Annexe, New Delhi

Other meetings

  • NABH Board Sub-Committee Meeting on 13th January 2017, New Delhi
  • 2nd Meeting of National Core Group on Elimination of Mother to Child Transmission (EMTC) on 6th February 2017
  • Stakeholder Consultation meeting for preparation of Concept Note (2018-20) for Global Fund Grant reg. on 13th February 2017 at New Delhi.
  • NABH Board Sub-Committee Meeting on 17th February 2017, New Delhi
  • 26th Board Meeting of NABH on 24th March, 2017, New Delhi
  • 2nd Meeting of National Medical Wellness Tourism on 28th March 2017 at New Delhi
  • Meeting of Working Group Environment Health on 30th March 2017 at Indira Paryavaran Bhawan, New Delhi
  • Meeting of World Malaria Day on 25th April 2017 at New Delhi
  • Meeting regarding setting up of Facilitation Counters for visitors arriving on e-Medical Visa at International Airport on 25th April 2017 at New Delhi.
  • Meeting Of Governing Body-NBE on 28th April, 2017 New Delhi
  • Meeting of Signal Review Panel Meeting at CDSCO (PvPI) on 16th May 2017
  • Meeting of Expert Group to review self assessment report for patient safety for India & capacity development on patient safety on 30th May 2017 at New Delhi.
  • Meeting of the Expert Committee constituted to draft comprehensive FAQs related to the PC & PNDT Act, 1994 reg. on 30th May 2017 at Nirman Bhawan, New Delhi.
  • National Workshop on “Parivar Niyojan-Sashakt Samaj, Rashtra Ka Vikas on 11th  July 2017 at Vigyan Bhawan, New Delhi
  • Launch of National Strategic Plan (2017-22) by Hon’ble HFM on 12th July 2017 at 5.30 PM at Sovereign Hall, Le Meridien, New Delhi
  • Stakeholders Consultation for MTAB-Reg. on 27th July 2017 at New Delhi
  • National Board of Examination governing council meeting on 7th September, 2017, New Delhi
  • NBQP QCI 12th Nation Quality Conclave on 21-22 September, 2017
  • Inauguration of Pharmacovigilance Programme of India as a WHO collaborating centre on 30th October 2017
  • NABH Board Meeting on 3rd November, 2017
  • NBE Board Meeting on 9th November, New Delhi
  • National Steering Committee PCPNDT Act on 3rd November, 2017

International Meetings

  • Annual Scientific Meeting of Chinese Medical Association held on 14-15 January, 2016 at Nanjing (China)
  • International Summit on Air Pollution - Health Advisories held at New Delhi on March 10, 2017
  • Cyprus to attend and participate in the UNESCO Chair in Bioethics – 12th World Conference on Bioethics, Medical Ethics & Health Law to be held from March 19-24, 2017 at St. Raphael Hotel Resort & Congress Center, Limassoi, Cyprus.
  • 206th World Medical Association (WMA) Council Meeting to be held from April 15th to 22nd April, 2017 at the Avani Victoria Falls Resort in Livingstone, Zambia
  • Annual Meeting of Swedish Medical Association in Stockholm from 29th May to 31st May 2017 at Hotel Scandic Continental Vasagatan 22, Stockholm, Sweden.
  • The Annual Meeting of the American Medical Association on June 10-14, 2017 at Hyatt Regency Hotel, Chicago, Illinois, USA.
  • BMA Annual Representative Meeting on Sunday 25 June- Thursday 29 June 2017 at the Bournemouth International Centre, Exeter Road, Bournemouth BH2 5BH,
  • 32nd CMAAO General Assembly in September 13-15, 2017
  • WMA General Assembly on October 11-14, 2017 at Renaissance Downtown Hotel, Chicago
  • WMA European Region Meeting on End-of-Life Questions on November 16-17, 2017 at Vatican

Increased exposure to perchlorate in pregnant women can hamper fetal brain development

Increased exposure to perchlorate in pregnant women can hamper fetal brain development
Imperative to reduce exposure and increase consumption of iodine rich food
New Delhi, 09 December 2017: As per a recent study, expecting mothers, who are exposed to elevated levels of a common environmental pollutant, perchlorate, had lower levels of a thyroid hormone crucial for normal fetal brain development. It is important to minimize exposure to this chemical in pregnant women to prevent potential neurodevelopmental abnormalities in children. Perchlorate is a common environmental pollutant found in water, milk, some foods and everyday chemicals, including fertilizers and air bags.
Perchlorate is known to reduce absorption of iodine from the blood into the thyroid, where iodine is needed to make the thyroid hormone, T4. Since T4 is essential for normal fetal brain development, this suggests that perchlorate exposure could decrease maternal thyroid hormone levels, which may lead to brain development defects in babies.
Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "Manufactured perchlorate is used as an industrial chemical and can be found in rocket propellant, explosives, fireworks and road flares. Natural perchlorate is found in some drinking water and some foods. In addition, trace amounts of perchlorate may be used as a component in some food packaging. During the 1st trimester, a developing fetus is completely dependent on its mother for thyroid hormone. During the 2nd and 3rd trimesters, the fetus receives approximately 30% of its thyroid hormone from the mother. Any deficiency has an adverse effect on the fetus.Drinking water with 5 ppb perchlorate can reduce maternal thyroid to a level that causes abnormal fetal brain development.”
Newborns must produce thyroid hormone on their own because breast milk provides almost none. Infants also use up their thyroid hormone quickly and have very little in reserve. These factors make infants especially vulnerable to disruptions.

Adding further, Dr Aggarwal, said, “Iodine is a building block of thyroid hormone. Low iodine levels, and/or the gland's inability to absorb iodine can prevent the thyroid from producing enough thyroid hormone, resulting in an underactive thyroid, or hypothyroidism. Babies of mothers who have hypothyroidism are at increased risk of cognitive and developmental problems, or, in more severe cases, cretinism and birth defects.”

The following are some good sources of iodine.

  • Most dairy products are iodine enriched. Two varieties of cheese that are rich in this mineral include Cheddar and Mozzarella.
  • Iodine is found in seafood. One of the richest sources is a seaweed called kelp.
  • Eggyolk is one of the safest and simplest sources of iodine.
  • Milk Studies indicate that every 250ml of milk has about 150 micrograms of iodine.
  • A single cup of yoghurt can meet half of the daily iodine requirement giving close to 70 micrograms of iodine. It is also good for the stomach and rich in calcium and protein.
  • Apart from the above food items, some others that are good sources of iodine include fruits like bananas, strawberries; vegetables such as green leafy vegetables, onions, and sweet potatoes; and grains, nuts and legumes like peanuts, barley, etc. 

Saturday, 9 December 2017

To Err is Human: Post Mortem of the recent Max controversy

To Err is Human: Post Mortem of the recent Max controversy
Dr KK Aggarwal
National President IMA

“A premature (22 weeks) newborn was allegedly declared dead. While being taken for the funeral, the newborn was discovered to be alive, put on life support system, and died after 5 days. His twin was stillborn.”

This was a ‘medical error’ caused due to wrong diagnosis and declaring a newborn dead in the presence of hypothermia. This amounts to professional incompetency and it is for the MCI or State Medical Council to take necessary action against the concerned doctors.

Clinical death vs permanent death is a concept that started after the introduction of CPR in the country. A similar mistake occurred in Safdarjung hospital in June 2017, that of terming clinical death as brain death. In clinical death, the person may have no signs of life, but the brain remains alive for 10 minutes in routine deaths and for few hours in hypothermia. CPR during this period can revive the heart.

There is always opportunity in adversity and the same is true for this incident as well. Measuring rectal temperature in newborn is not currently the practice. However, in view of this incident, measuring rectal temperature should now become part of the protocol adopted before declaring a newborn dead. This will ensure that no patient is declared dead under conditions of hypothermia.

 Mistakes or errors are a part of clinical practice. They should be accepted as there is always a lesson in them. However, with knowledge, we can learn more about how to avoid them.
 This was, however, not a case of criminal negligence.

 For this incidence to be called criminal negligence and to apply Section 308, there should have been an intention to declare an living baby dead or the knowledge that the baby was alive. According to me, the doctor on duty was unaware that the baby was alive.

 Even today, not everyone knows that in hypothermia, the brain can remain alive for few hours.
 I personally feel such mistakes will continue to happen until widespread dissemination of this knowledge is undertaken.

 Are medical errors common?
 The Institute of Medicine released their landmark report To Err Is Human in 1999 according to which 98,000 people die in US hospitals every year from preventable medical errors.
 In 2013, there were about 400,000 deaths from preventable medical errors. Today, 1.7 million Americans are victims of preventable medical errors, which lead to as many as 440,000 deaths annually. In India, the number is likely to be higher.

Was this mistake avoidable?
I feel mistakes occurred at every level. The first one was by the first junior doctor, second by nurse, third by the senior nurse, and lastly by the consultant. If the child was alive, at least one of them could have noticed.

It’s clear that the child had no heart beat and hence the error in judgment.
Also, the very fact that all concerned missed the diagnosis of alive brain indicates the level of ignorance and absence of established protocols in the medical society.

IMA has since issued an advisory to make sure that all practitioners are aware of this fact. It is also creating guidelines regarding declaring death in hypothermia cases.
Doctors and nurses also make mistakes as a part of their learning curve. Only bad doctors sexually molesting patients, stealing drugs, or making a wrong diagnosis with no insight need to be punished.

Definition of abortion
As per the Medical Termination of Pregnancy Act, termination of a pregnancy at 20 weeks is an abortion and delivery after 20 weeks and before 37 weeks is a premature delivery.

What is prematurity?
Prematurity is defined as a birth that occurs before the completion of 37 weeks (less than 259 days) of gestation. It is associated with approximately one-third of all infant deaths and accounts for about 45% of children with cerebral palsy, 35% of children with vision impairment, and 25% of children with cognitive or hearing impairment.
The risk of complications increases with increasing immaturity. Thus, infants who are extremely preterm (EPT), born at or before 25 weeks of gestation, have the highest mortality rate (approximately 50%) and if they survive, they are at the greatest risk for severe impairment.

What is fetal viability?
A fetus delivered after 28 weeks or one with a weight > 900 gram is a viable fetus; no consent is required for active resuscitation (surfactant and ventilator if required)

What about 20-28 weeks?
Today 20-28 weeks means extreme prematurity. The fetus must be put on warmer and symptomatic therapy. It is a norm to not put the fetus on ventilator. However, if the parents insist on placing the 22-week-old baby on ventilator, the doctors can find it extremely hard to refuse. The process should then be carried out only after informed consent. In cases the patient cannot afford, he or she must be transferred by the private hospital under supervision to a government hospital with nursery facility.

Classification of prematurity

Preterm infants can be classified according to gestational age (GA) as follows.

·        Late preterm birth: GA between 34 and 37 weeks
·        Very preterm birth: GA less than 32 weeks
·        Extremely preterm birth: GA at or below 28 weeks

Preterm infants are also classified by birth weight.

·        Low birth weight (LBW): Less than 2500 g
·        Very low birth weight (VLBW): Less than 1500 g
·        Extremely low birth weight (ELBW): Less than 1000 g

When to declare death?
No death to be declared in presence of hypothermia.

What is hypothermia?
A core body temperature of 90-95°F (32 to 35°C) is mild hypothermia, 82 to 90°F (28 to 32°C) is moderate hypothermia, and below 82°F (28°C) is severe hypothermia.
In about 14% of premature babies, core body temperature below 35°C is common.

Can a fetus appear dead when it is not?
In severe hypothermia, cold slows or stops the metabolic machinery underlying body function. The metabolism slows by approximately 6% for each 1°C (1.8°F) decrease in body temperature, such that at 28°C (82°F), the basal metabolic rate is approximately half of normal. At this temperature, all body systems begin to fail including circulation, ventilation, and the central nervous system. Patients often lose consciousness and vital signs may be absent. Muscle rigidity without shivering can be mistaken for rigor mortis. The absence of shivering and presence of stupor, skin flushing, muscle rigidity, hypoventilation, and circulatory failure means very cold patients often appear dead rather than hypothermic. This may partly explain why many severely cold patients are pronounced dead without consideration of hypothermia.
However, in this stage of severe hypothermia (core temperature <28°C or 82°F), a suspended metabolism may protect against hypoxia. There have been cases of patients surviving anoxia for 12 to 18 minutes at 28°C (82°F) and up to 60 minutes or more at 20°C (68°F). Intact recovery has been reported after submersion for up to 66 minutes, after hours of arrest without cardiopulmonary resuscitation (CPR), after CPR for as long as six and a half hours, and with total resuscitation times up to nine hours.

Thus, recognition of hypothermia in such patients may sometimes permit successful recovery despite prolonged arrest. Only with such recognition can the patient benefit from rapid, effective rewarming, and vigorous support.

How a doctor from Oxford, ‘Dr Amit Gupta’, would have managed a 22-week-old baby?
A 22-week preterm birth is not viable for life
Firstly, as a neonatologist, I would not expect to be called in to attend the delivery of babies that are preterm.

To put it in context, when a mother carries her baby for 9 months, it is a 40-week gestation period. Survival at 22 weeks gestation is only about 3% in the UK and 5% in the US.
These babies, weighing anywhere between 250 grams and 500 grams, are extremely fragile and have such severely immature organ systems that current technology struggles to transition them to full maturity. It is accepted practice to not offer resuscitation at 22 weeks. This may change in the future, but for now, the prognosis is grim for babies born at 22 weeks.
I would talk to parents and explain.

Before delivery, however, our obstetric staff would counsel the parents on the abysmal outcome of babies born so prematurely. Many would not even survive the process of labor. However, if they did, parents would be offered support and may choose to hold the babies, to stay with them, and take their time to say their prayers and goodbyes.  

For a baby born alive, the parents would be explained that the babies might continue to show signs of life for several minutes or even hours.

Though it may sound shocking, we do come across cases where the heart rate is so faint after birth, the breathing so shallow and intermittent, that the doctor attending the delivery presumed that the baby is dead.

So, while it is crucial that the healthcare professional is 100% sure before death is pronounced, there have been cases where death has been falsely presumed.

Should babies be handed over in a plastic bag?
No. This reflects a poor attitude towards human dignity and the lack of empathy towards the enormous tragedy befalling the parents. Even if parents consider the death of a baby at 22 weeks as a miscarriage and choose to not carry out final rites, the body should be handed over respectfully. However, in this case, the plastic bag probably provided the warmth needed to revive the baby.

What is the answer?
The answer to such situations is: Fix the 'culture'.
·        Communicate, communicate, and communicate
·        Compassion should be demonstrated in practice as much as in feeling. Health care is compassion and everything else stems from it. A compassionate attitude of staff in clinical medicine is more important than all the brilliant CVs, flashing monitors, and state-of-the-art equipment put together. The poor/inconsiderate/uncompassionate communication is at the core of why patients sue. A programme, which embeds a culture of transparency, openness and compassionate communication, makes both moral and financial sense.

·        Call relatives, meet them if they are willing, and then listen to them. When you think you have listened enough, listen some more (and switch your mobile phone off when you do!). Apologize for the pain they have undergone. Don't indulge in non-apology. An apology is not an admission of guilt, but an acknowledgment of the pain they have been through. And tell them what you would do so that other parents don't go through this experience.