Healthcare 2017- Ditch Robots And Bring Back The Doctors

Healthcare 2017- Ditch Robots And Bring Back The Doctors


After yet another fruitful year of practicing what I preach, I thought it’s time to put up a post on my pet peeve, again. The said peeve being, the practice of medicine is slowly being changed into a robotic occupation, where a doctor is given a set of instructions and told to follow them to a “t”. But unfortunately the human body doesn’t not cooperate with this by the book approach as every individual is unique by himself and every disease affects a person differently. Given a set temple and asked to follow the protocols given is the surest way to prolong disease till the patient is deceased. And that’s the reason why I always take evidence based medicine with a pinch of salt.

Evidence based medicine to give its due, works in a fairly efficient way, in a limited spectrum. But given its limitations it is inefficient at best and dangerous at its worst. And why, I will explain now. For those not familiar with evidence based medicine- it’s a set of treatment protocols (usually developed in western countries) which says after checking these protocols this is the best treatment for this disease and hence, everyone worldwide needs to follow these protocols whenever/wherever they see this same disease.

The problems with this approach are manifold. Let me just discuss the top two. Firstly most if not all of these protocols were developed for simple diseases and straightforward diagnostics/treatment procedures. If you have any complicated disease requiring multiple procedures, you just cannot follow any protocol template, you have to diagnose and treat case by case using all your years of experience and intuition and hope for the best. Which in turn defeats the very purpose of evidence based medicine. You need best evidence protocols for the most difficult cases because these are the ones which test you to the limits and are prone to end up with the death of the patient and the doctor being blamed for inadequate/insufficient treatment. Where others who have the luxury of time, weeks and months to study the symptoms will second guess the decisions you make in seconds by the patient’s bedside as the patient lies gasping for air and fighting death minute by minute. What’s the evidence say? Did you follow the treatment protocol? These questions are very easy to ask in hindsight but doesn’t help at the moment when most required.

The second major disadvantage with this protocol based approach for treatment is that the template developed most often uses a particular procedure using a particular piece of equipment which study in turn is sponsored by that particular equipment manufacturer. You can’t blame them – for most of these studies are really expensive and require large scale funding which governments never do and hence the researchers raise money from private players who naturally have a vested interest in promoting their products. So even if there is a better or more simpler or more low cost way available to treat that particular disease it will never be accepted as mainstream – because no one does research on it and no one publishes it and no one by which I mean no respectable medical board or journal accepts it- which results in the low cost or simpler alternative having the status only of quack medicine. While the costlier company sponsored study gets accepted in prestigious journals and then becomes the accepted standard of care worldwide merely because there is no other alternative to it. This grant of legitimacy to costly treatments in the absence of alternatives is the primary reason that doctors from developing countries hate evidence based medicine. It’s all very well to recommend protocols followed in Boston or the Massachusetts general hospital but not everyone is lucky to be practicing in Boston or Massachusetts. What about somebody practicing in Nigeria? Or Nellore? With no access to the level of diagnostic or treatment machinery as given in the protocol as per evidence based medicine? Is it fair to punish that doctor for treating that patient but not following the best established practice protocol? Whose fault is that and how can you apportion the blame?

This craze of getting more and more evidence based protocols also has the side effect of developing and insisting on more and more tests, more than 90% of which are unnecessary- like treadmill test, stress test, angiogram, CT slice- 64/128/216 machines – all of them being developed just to rule out any cardiac disease and your doctor has to prescribe these unnecessary tests every time you go for a simple muscle sprain or gastric distress and indigestion or any other condition which does not involve the heart. But because the best evidence based medicine protocol says you have to rule out heart disease in all cases, everyone gets to do a CT scan at the highest possible resolution beyond 64, beyond 128 beyond 216 slices- even if you are a healthy person with absolutely no evidence of any heart disease. But because the protocol formed in San Francisco or New York or London says so- you have to get that CT scan, every time you over eat samosas and have gas. If this wasn’t a waste of resources and such a tragedy it would be such an inside joke, but I can’t laugh at it now. And neither should the poor unfortunate patients who end up paying for all that waste of time.

So the best thing that you and I can hope for is that the government gets into the act and funds medical research in a big way so that individual researchers do not have to go begging bowl in hand to equipment companies who in turn dictate the treatments to be researched and published. And secondly the realization that data mining and rigid protocol’s don’t work for human beings. There is ample space in medicine for hard won experience and intuition based on it. Or otherwise we will continue to take angiograms for every patient who comes to the hospital with an acidity problem and advocate cardiac by-pass surgeries based on minuscule blockages seen in every minor blood vessel, whether they want to or not get a major heart surgery done. Why? Because the evidence says so, and you want to get the best possible treatment at international level don’t you?

I hope national governments realize the immense damage being caused to local healthcare managements by these artificially imposed from abroad protocols and either help in developing local protocols for local people or at least stop penalizing doctors for using years and years of experience to treat patients instead of following Boston rules. Support doctors not robots.


Going that Half an Inch Extra

Going that Half an Inch Extra

stone up hillDo you know what is hard? The hardest thing is just standing there, watching someone else do a sloppy job on what you think you can do better. Like for instance the other day i was in the OT and having wrapped up my surgery I happened to glance over at a table at the other end of the room where a colleague from the ent department was operating. The case in question was a patient with a naso-labial cyst- an infectious bag of pus in the no-man’s land between the nose and the mouth. If i had been the one to do the surgery I would have opted to do it under local anesthesia as i considered it a minor surgery but my colleague had decided to do it under general anesthesia which in my opinion was a bit of overkill.

Different cysts

 Anyhow, as I stood there and watched her explain the procedure to a couple of interns assisting the surgery, i heard her say that she was planning to start with a sub-labial incision from just below the lip. I couldn’t help but protest on hearing that and so i moved closer to the surgeon and murmured slowly in her ear “why not go a bit lower down and do a sub-gingival incision, that way we can prevent a visible scar” (def: an incision is the place where we cut into the tissue and finally suture – leaving a scar where the two ends join). She laughed aloud and turning to face me made a comment for the benefit of the watching students “who is going to bend down and look into the mouth to see if there is a scar or not?”

Naso-labial cysts – first look

A fair point and I accepted it, just that my training in plastic surgeries had conditioned me to try and hide all scars of any surgeries I did, whether visible or not. And then she made another comment, to the great amusement of the students “when something is right there why not take the easiest route? Why waste the extra time and energy?” Having been put in my place, I ignored the snub and all the sniggers behind me, as I pulled down my sterile mask and head cap and walked out of there to change out of my theatre dress into my normal formals and go back to my department.

During surgery- the cyst looks like this

Later on while i was sitting in the canteen sipping tea i reflected on that one comment about extra and waste. A few times in my life I have met people like that who would do just what is required but would not go a bit beyond what is strictly necessary and give an extra inch of effort. And as far as I have seen personally such people were never great successes in their lives or professions because they were easily satisfied with mediocrity and rarely made the effort to go beyond.

In one of my very first jobs as part of my rural postings i had a senior colleague who would three hours into the work day, click off his pen and stand up saying that he had worked enough for the salary he got and would leave me all alone to tackle the rest of the patients still waiting in a long line. And naturally as the conscientious/sincere (foolish?) type i was left alone to see the rest of the patients as dear colleague took a well deserved canteen break which lasted into the rest of the afternoon. On reflection, i always think that i had the best of the bargain for here I am so many years later still in the same profession while he no longer is practicing medicine, last i heard.

People like him intentionally set bars for their own successes by restricting themselves mentally. They have a strong conviction that extra work is just not worth the hassle and are easily satisfied with the work they do and the results they get. They tell themselves this is my best, this is all I can do without making any effort to see whether it’s really all they are capable of. You would have seen such people too- the ones who effortlessly make it into the top ten, the ones who with a little more hard work can easily make it into the top three but are satisfied with just what they achieve with the minimum effort necessary.

While i am all for conservation of energy and letting person live life on their own terms, what i bar is people who are unwilling to make the extra effort but still expect success to come to them on a platter. And if it does not, these are the ones who whine loudest about the unfairness of life all the while taking it easy and just doing the minimum necessary to get by. While people with awareness of what it takes to achieve success never stint themselves when it comes to hard work. I remember a friend from college, a party dude, who on returning from a night out at the discotheque, say maybe around 1AM would still set the alarm to wake up at 5Am and study the day’s portions. That’s the kind of extra effort I am talking about.

But what I really deplore is people putting mental shackles on their own successes. They convince themselves that they can’t and go onto fulfill their own predictions. And not surprisingly end up as also-rans while people who go the extra mile never regret the choices they make or the sacrifices it takes. All those early mornings, all those late nights- all that hard work differentiates the person who is willing to go the extra inch for success from the person who is satisfied with what he can get without pain or sacrifice. And in the end it’s that extra inch which matters.

And so I believe and always will that it’s better to go down an inch below the visible margin despite the extra ten minutes it will take me to finish, if I can get a better than expected result. In the end what really matters is personal pride in a job well done and not merely others appreciation. What do you think?

Disclaimer : Images courtesy Google Images – copyright free.

Indian Guinea Pigs

We Indian Guinea Pigs say oink, oink.

Do we look like this to you ?

Have you ever seen an Indian guinea pig? No, it’s not a newly discovered species of guinea pig. You have known it all along – just take a look into the mirror and there it is staring back at you. Yep, you are IT. And before you start getting angry at me for calling you a guinea pig when you think of yourself as a human being- please take a look at this article from the respected medical journal Lancet. As per the article the respected medical journal is immensely worried that a new law which makes compensation compulsory in case of side effects when testing new drugs on humans for the first time- will drive drug companies away from spending their research dollars in India. I mean, if gods forbid the drug company has to test it on Americans or Europeans and something goes wrong with the new drug, what will happen? Won’t they have to pay millions of dollars as compensation? But Indians have a billion plus population and if a few hundreds of the surplus population dies in the noble search for new drugs to cure diseases well it’s all for the good of humanity isn’t it?

 Let me re-iterate again in this post- for those reading my blog for the first time that I am one of you- an on-again and off-again scientist myself and am not against research or development or progress in science. But as an Indian/Asian, the Hypocrisy of some of these Western scientists really sickens me. The HPV vaccine (Gardasil) which is being touted as the answer to all of America’s sexually transmitted diseases problems has an ugly history of being tested on illiterate tribal girls (pre-teens with no sexual contact history) who were informed that they were getting Vitamin injections for good health. A Standing Committee of Parliamentarians has severely indicted the western company who sponsored the research and its local Indian counterpart which did the actual research on behalf of the American company – for a few dollars more, a few tainted, dirty dollars more.

 And let’s not forget that it’s not only Big Pharma which exploits the illiterates and unfortunates as human guinea pigs- even the American Government is complicit in this exploitation. The National Institutes of Health which are federal institutes funded by American Taxpayers also outsource their clinical trials on patients to third world countries like India. Refer above article where the Lancet quotes the NIH of stopping 40 clinical trials in one month- July – isn’t it a whopping number for just one month? I am sure most American Tax payers are ignorant of where their tax dollars finally end up- in the hands of Biotech companies in Bangalore- for supporting unethical human research among the poor and illiterate. I am not blaming the common people of America, they are as much innocent of any of this as common Indians are- it’s the middlemen who are exploiting this situation of outsourcing clinical trials to third world countries- to make quick profits.

 The Indian biotech community has its hands steeped in the proverbial 30 pieces of silver. But that is no surprise to us Indians, is it? I mean, we have a long and fruitful history of foreign collaboration. That is how a few hundred Englishmen of the East India Company were able to rule and loot India for two centuries. And our Clinical trial companies would indeed lament even the smallest degree of governmental oversight as it would cut into their profit dollars and reduce their yearly bonuses, god forbid. Hence they are conducting a massive disinformation campaign against the new law on compensation for Drug Trials.

And the respected medical journal Lancet has now joined the chorus of fear mongers in threatening to move away clinical trials from India into countries with even lesser regulatory oversight- maybe in the Asia Pacific or maybe in Sub-Saharan Africa? Where a tame dictator or two will accept their drug dollars and look the other way? Anyhow, the people of India will not lament that the multinational drug companies are taking their research dollars away. Good riddance is what the average Indian will feel. And if a few Biotech companies in Bangalore have to slash their budgets- well it’s all for the best – let them do in-country research on some disease which will actually be of interest to the people of our country.

 And as for all those bleeding hearts who bleat about how this will retard the exploration of new cures for diseases, well let me speak as a common Indian citizen when I say that we Indians are glad to join the global mainstream at least in this- and wait for drugs which have already been tested somewhere and approved for use. Let us not be on the front line, the firing line of new drugs. This is one innovation we will gladly forgo and sit on the sidelines watching and applauding the brave heart pioneers. For when we look in the mirror we see only human beings – the same human beings like in America, in Europe and everywhere else in the world. So why do you see us as pigs?

For a “Purr-fect” Nude Look…..

For a “Purr-fect” Nude Look…..

“If you were me, would you go with the nude look?” she asked and I replied “oh honey, I go nude every single day”. Now if your overactive imagination is picturing me going about in a, well, in a state of undress, perish the thought. Cease, desist, and don’t think like that for a minute- for the nude we were talking about here refers to the face- a nude look sans any make-up for the face. Now if you are wondering what I have to do with makeup and such things, let me start the story from the beginning.

As part of a team of surgeons who do extreme make-over’s, I happened to treat an interesting patient recently. This particular patient was a 22 year old female and what’s more important, unmarried and looking to get married pretty soon. In quest of which marriage she had tried to look prettier by becoming thinner, even though she wasn’t very heavy looking to start with. But as they say, is there anything like being too thin or too wealthy?

This patient’s chosen method of rapid weight loss involved starvation, as she was hell bent on achieving a zero-size figure in time for her wedding. Unfortunately for her, she failed to realize that being thin does not necessarily translate into beautiful. There are lots of thin, ugly women walking around if you look, which is incredibly sexist and might bring me brickbats from the feminist brigades, but, hey it’s the truth, so sue me.

Anyway to get back to our patient this girl by binge dieting and extreme starvation became as thin as a stick and then having achieved her life’s goal assumed that she had become beautiful. Imagine then the shock to her system when she realized that despite the weight loss she was basically what she always was, albeit a thinner version with a constantly hungry look in her eyes. And then when she realized her folly she did what she should have done in the beginning -approached the professionals.

Let me digress here a bit and offer some general advice- losing weight and becoming thin if done the proper way with exercise retains the muscle tone but losing weight with starvation makes you lose all fat beneath the skin- which pads out and fills up the skin and consequently the skins sags and hangs – giving you an aged appearance – unless you get a skin tuck done by a cosmetic surgeon (if you don’t believe me – check out any liposuction patient after all the fat’s been sucked out- they look like the pug dog from the Hutch mobile advertisement- with loose rolls of skin hanging down). So, take my advice- walk, run or dance- but don’t starve.

And also, there is a general rule in plastic surgery that says “Soft tissue follows Hard Tissue” which translated from medical jargon means that the flesh follows the shape of the bone. So anything you do to the muscle and skin will not last long if it’s not in conformity with the bone beneath. If your jaw bones are long and protruding, however much you reshape your lip muscles, you will never have a pout till the bone beneath is also re-shaped and then the flesh above the bone will automatically adapt to the bone below and achieve the perfect shape we want.

So, after doing the very best we could to give her face an all-natural look- a few nips and tucks here and there, some bone grafts and some collagen/fibrin to bring the shape back to her face- we let her go home to heal. And she returned to us after the usual six weeks of healing to check up on her final results. As part of the hospital protocol- especially for extreme makeovers- and to guard against future litigation by disgruntled patients who are unable to bridge the gap between fantasy and the reality of their looks- the hospital has mandatory post- operative photographs for documentation (and as evidence for the legal team).

In any hospital which does cosmetic surgeries, there are specialists appointed for the purpose of getting patient photographs- photographers and make-up specialists. One of the tricks the photographer employs is to undershoot the pre-operative photos to highlight the post surgical effect- which is unnecessary in my opinion. And vice versa they go all out – overboard sometimes- in getting the post surgical photos- with heavy make-up and lighting effects- which is where the creative difference arose as I mentioned in my first para above.

As an end user and as someone from the team responsible for the actual result- I like to be involved in these photo shoots despite murmurings that I am a know-it-all poking my nose everywhere. I discount the murmurs as I feel that it’s only my insatiable curiosity to learn something new which drives me to hang about the patient photo shoots. Anyway, I always feel that the stark look which the photographers shoot for the pre- surgical pictures are way better than the heavily made up faces they shoot for the post-surgical photos. And hence I decided to get hands-on this time.

As I had been the one from the team who had coordinated the entire makeover for this particular patient and she trusted my judgment, I had to put my foot down for the look I wanted for this patient- a nude look. Now a nude look for those who don’t know much about make-up (which is me -before wikipedia) is a minimal make-up look- as far as possible approaching the natural face. Which is the very point of doing a cosmetic surgery- to make someone look beautiful even in the morning when they wake up sleepy faced.

The make-up team had an ingrained habit of applying make-up liberally but I convinced the patient that a nude look would show her the real results achieved and I sat down with the make-up team and was constantly giving them advice to restrict the amount they usually dab- something which almost drove them nuts, I think.

And the conversation during the photo-shoot went something like this:

Please put just a hint of concealer around the shadow areas of the nose and eyes. Now use that foundation sparingly and blend it in please. Yes, use that marble tone- that would suit this skin tone better. No, no blush please, please don’t, not over the cheek bones- we have accentuated it naturally with bone grafts- we don’t want to highlight it further. Ok, just a little hint of powder. Do you really want to make it soo glossy? Or do you think we can pat it down for a matte finish? What does the photographer feels- shall we ask him? Oh, ok, you would adjust the effect with the lights then?

Now for my signature look- add on the lipstick….MAC raspberry? No I prefer the Estee Lauder one- Coralline Red- here, this is the shade I was telling you about- apply it to her lips and see how the peachy shade makes the lips more inviting and perfectly complements the nude look of the face rather than the bright red raspberry you advice. Yeah, it’s not my province, I know, but hey, who better to admire a lipsticks effects than a man? We look at it from the consumer point of view, so trust me go with the coralline red- it will make your lips all peachy and delectable. What, you want me to apply it and show you the effect? Oh, just kidding me, were you?

OK time to pose- be natural, don’t use all those patented poses like the photographer showed you pictures of- be free to give us your own poses- we can always delete later on if we don’t like it. So mr.photographer, are we ready with the soft focus lights? And after you finish shooting the regular ones, I want a few grayscales for my own patient records- no I prefer grayscale without any hint of touch up- for my surgical notes. OK. Thank you all. Nice shoot. And I expect to see you again- next month- for your final check up. Bye.

082013_1457_ForaPurrfec5.jpgAnd you walk away with the sense of a job well done having captured the prefect image you wanted, but then you are in for a surprise -for whatever effects you tried to achieve on the floor of the studio- the photographer who does the final post-processing uses his photoshop software to give the pictures a uniform bland look like all those models with plastic faces you see on magazines- any sign of individuality in your shot composing is all lost by the time the picture is printed out and you grin and bear it and just add it the patient records and close the file.

Disclaimer : I am not recommending the nude look for everyone- every look should be decided by the individual’s skin tone and more importantly- by the occasion. I am also not recommending you go for a matt finish over a glossy finish or you apply highlights over the cheeks. I am also not recommending you try out coralline red lipstick. I am especially not endorsing any of the products named above. To each their own.

P.S. I would have loved to show you the pictures of the patient we shot as examples for what I am talking about -but medical ethics and doctor patient confidentiality forbids me from using them on social media. Only the hospital has the right to use those photos as part of their promotional campaigns and advertisements.

Shoot First, Ask Later Policy – Of Giving Antibiotics

Shoot First, Ask Later Policy – Of Giving Antibiotics

(Disclaimer : I have tried to avoid medical jargon and simplify this as much as possible for everyone to read and understand- some of my fellow medicos might call it oversimplification- but I want people to understand the issues and form their own opinions. As always I would love to answer your comments and questions related to this post)

 This morning I saw a patient in her early twenties who had undergone a open heart surgery for valve replacement in the heart a couple of years ago and the patient shared the story of how she had suffered from frequent knee pains in her younger years and how it developed into a heart disease without being diagnosed. Joint pains followed by valvular disease of the heart is known as rheumatic heart disease- a misleading name – since it is caused by a bacterial infection from a bacteria called Streptococcus (Strep Pyogenes)- the same one responsible for sore throat disease- cough and cold and sniffling nose, anyone?.

Streptococcal sore throat is often mistakenly diagnosed as a common cold -which is caused by a virus and is self limiting and is automatically cured after a week or so. But if the strep infection is not diagnosed and treated by giving antibiotics at the initial stage itself then the heart and its valves are damaged resulting in uneven pumping of blood by the heart and hence by the time the disease is finally confirmed the only treatment left is open heart surgery for replacement of the diseased heart valve by a new artificial valve. And to think that it could have been easily prevented – if someone had diagnosed it early and prescribed the correct antibiotics to kill those bacteria in the throat itself. Makes you wonder doesn’t it?

Which brings to mind an interesting online conversation I had a few days ago based on one of my recent blog posts- with a couple of fellow medicos (Sai Sriram and Sulaiman)- on antibiotic abuse. I want to share the same here on the blog as there were several interesting points made which would be of use to everyone. And I hope, would also offer you an insight on the thought processes of doctors and how and why certain prescriptions contain antibiotics and others don’t.

Every single doctor when he/she undergoes the basic course and during residency training is taught about the inviolability of evidence based medicine- that is treating diseases based on best practices developed by research and published in journals. There are clearly defined protocols for each and every disease treatment- developed internationally and standardized for treatment all over the globe and doctors are expected to follow it in all countries and circumstances. But practical realities differ from country to country and play a major role in actual prescription writing.

For example, a doctor practicing in a country like the United states of America with a robust and well developed emergency medicine facilities can often adopt a wait and watch approach when it comes to certain diseases like infections -to see if it really develops into a major disease (life threatening) or if the persons normal immune system can deal with the infection on its own without need of taking any medicines. But in a country like India where emergency facilities are more often swamped by accident cases, suicide patients etc and there are very few infection specialists and many more general practitioners -the treatment of infections is radically different on the ground. Here doctors prefer the prevention is the best cure formula rather than patience is a virtue formula practiced abroad. Let me explain my point with examples.

When a patient, let’s say a child is brought to the doctor with a sore throat, cold and fever -it is clinically difficult to differentiate whether the sore throat is caused by a virus or by a bacteria and investigation like culture method to diagnose the organism responsible takes a few days at least to come out with the results. In such cases some doctors prescribe antibiotics immediately -just to cover the bases but other doctors don’t- for they reason that if it’s a viral infection, it is soon going to go away on its own, so why should we give something of no use -for antibiotics don’t work on viruses.

And there are so many evidence based medicine guidelines which scream that easy availability of antibiotics- pill popping even when unnecessary -is causing widespread antibiotic resistance and require stronger and stronger antibiotics in future for even simple infections. So following international guidelines and out of best intentions – the doctors don’t prescribe any antibiotics and nine times out of ten the infection is viral and heals quietly. But rarely, in the rarest of rare cases-the infection spreads throughout the body and attacks the heart and other important organs. And that’s when the doctors start second guessing themselves about whether they should have given antibiotics – just to play safe. And believe me it is as traumatic for the doctor who could have done something but didn’t do it -as it is for patients themselves.

In India most practitioners prefer not to take this risk and by routinely prescribing antibiotics make sure that the rare case does not happen to their patients- antibiotic over use protocols be damned. Most doctors are either not trained to communicate all the reasons for not giving antibiotics or they just don’t have the time to confront an anxious parent of a sick child and try to convince them to wait and watch before taking any concrete step to cure the child -masterly inactivity technique of treatment (with apologies to Warren Hastings).

Besides more often we see that the most popular doctors are the “take immediate action” types and the average patient prefers a doctor who prescribes antibiotics rather than just give advice. And we cannot find fault with them for it’s easier to trust a doctor who give medicines than the doctor who shows you reams of statistics and dozens of scientific evidence about antibiotic abuse but does nothing else. Every patient prefers to go home with some medicine or the other- even if it’s just for mental satisfaction.

And don’t mistake me, not for a moment am I suggesting that we give drugs based on the whims and fancies of the patients. No we don’t and we shouldn’t. We should as far as possible follow the best practices of evidence based medicine and give only the treatment actually required. But we should also remember that we are treating people and not just diseases. And it’s up to us to reconcile the dilemmas involved by listening to our patients- spoken and unspoken complaints.

Medical diagnosis is not often cut and dried- it involves a degree of subjectivity and guess-work. No doctor intentionally plans to give unwanted drugs (at least most don’t-exceptions are always there) to any patient. The simplest and most obvious reason for giving antibiotics is they assume they are treating a bacterial infection and not a viral infection. If it’s a bacterial infection the patient gets well immediately. And even if it is a viral infection the patient is going to get well anyway. And so unless we are absolutely sure that the benefits of giving prophylactic antibiotics is outweighed by the risks involved I vote that we continue to prescribe antibiotics where necessary.

So to get back to my original premise of the title – should we shoot antibiotics first and then decide later? Or should we not? In my view- there are no clear cut solutions for this problem- it is complicated, confusing and most of the time it requires a bit of compromise to suit the particular patients condition. Horses for courses is the only solution I would recommend. Rather than follow a guideline based medicine I would suggest an individualized medicine paradigm where patients are at the center of everything and not rule books framed in a distant laboratory.

So I rest my case by saying that -“If the shoe fits wear it. If not- don’t cut off the foot trying to cram it into the shoe.”

P.S. The introduction of the American model of Defensive medicine where doctors have to keep justifying every single clinical decision of theirs to insurance companies which are the paymasters is ill-suited to Indian conditions. What we are seeing now is just the crest of the wave- the tsunami will soon be here.

Post-Operative Differences and Wound Healing Dilemma’s

Post-Operative Differences and Wound Healing Dilemma’s

Continuing from where I left off in my last post, my mom’s had her surgery and she is in recovery. But I have a couple of issues with the choice of treatment for the post-operative period prescribed by her surgeon and hence I thought I would discuss my dilemmas in this post, with you. The first shock was when the nurses did an allergy test for penicillin allergy and I was flabbergasted (no other word to describe my reaction) on seeing the injection made with the test dose in the forearm to see if there is any reaction. I almost asked the nurse right out “Excuse me, in which century am I? Did I somehow slip back a hundred years or so in a time machine?”

For, as every child knows, penicillin was invented in the last century – even before the Second World War – by a guy called Alexander Fleming and it cured a lot of infections back then but it has been largely superseded by newer and better antibiotics over the years. Currently, we (any doctor who qualified after the millennium) prescribe antibiotic-cocktails based on genomic typing of the bacteria which does a targeted delivery of the lethal dose right into the bacteria’s guts and hi-tech stuff like that. And here was a doctor who wanted to prescribe old school penicillin with its history of allergies and all. As everyone knows – any antibiotic or for that matter any medicine has the potential for being allergic to any individual ( we don’t know why but guess it’s genetic) but the safety margin is pretty high with the newer combinations which not only work better but are also far safer even when given in high doses.

And so I ended up having this big dilemma- should I step in and suggest a better (in my view) or newer antibiotic to my mom? And will it be considered an impertinence – by interfering in the work of another surgeon? Or should I silently wait till we got home and then discarding the penicillin shift my mom over to my choice of drugs? After agonizing over the decision like Hamlet, the prince of Denmark, I finally decided to let it go- that maybe giving penicillin was not such a bad trick after all, for just like us the bacteria’s would not have seen it for an hundred years or so and hence the suckers wont realize what hit them when they get the penicillin- in rugby parlance- it’s called a hail mary pass or in our local chennai auto driver style- put indicator on left and turn vehicle to right and let’s see if the suckers can be caught unaware.

Besides all these antibiotics are given just for a day or two or three- the immediate post-operative period and only to prevent any infection- as a precaution to make sure that the bacteria don’t take advantage of the patients weakened body after the surgery. So any antibiotic including penicillin should be fine in that limited preventive role. With that thought in mind I decided to let my mom follow her doctor’s post-operative treatment plans and not interfere in it. Decision made- mind at peace.

My next dilemma arose when I realized that my mom’s doctor was not going to prescribe to her any supplements or nutrients for wound healing, as I personally prefer to do for my patients. I gather that the doctor has a personal preference of letting the wound heal naturally, waiting patiently for as long as it takes. But we of the modern generation prefer to give our post-surgery patients -vitamins like b-complex and vitamin c and other minerals like selenium and calcium which are needed by the body for wound healing. The old standby of giving sathukudi juice (sweet lime juice)/horlicks for wound healing is now only seen in films and television advertisements- not in real life.

There are even newer treatments being studied now – like platelet rich plasma and nano-drug spherules for wound healing, which promise faster wound healing by better nutrients delivery at the exact wound sites. These work on the simple premise that instead of wasting the nutrients in the entire blood stream it’s better to deliver it where actually needed- at the wound site where it will help in healing faster.

As of now when we let natural wound healing take place, the cells in the superficial layer migrate over the gaping wound and close it in a matter of 5-7 days and that’s when the sutures- the threads which hold the two cut edges closely together are removed, because once the cells from the two sides join up in the middle to form a bridge over the wound there is no more need to artificially pull them close and hold them together tightly.

But the bridge analogy still applies to the wound, for what might look completely healed to us (after one week) when we remove the bandages is actually only 20% healed -for the bridge is spanning over a wide abyss- and there is nothing underneath to support. The wound has just a small covering of cells closing it externally and underneath it there is still a big open wound and it takes anywhere from 21 days to 6 weeks for the entire wound to fill up with cells and heal completely and get its original strength back. It’s in order to assist this gap-fill and make it happen sooner -that the newer treatment modalities are trying.

The most popular wound healing research being conducted now is in the Platelet rich plasma technique. Our platelets – the 3rd type of cell in our blood other than the Red blood cells and White blood cells everyone knows about- are mainly responsible for wound healing and blood clotting. As such they contain lots of essential stuff for wound healing and hence a technique called platelet rich plasma is now being tried out in several labs which involves taking out our own blood out of our bodies and then filtering it to get the platelet cells alone and finally injecting them back into the wound area directly instead of waiting for them to travel through the entire body and reach the wound- which might take time. This treatment is still in the experimental stage as not many patients can stand the thought of their blood being taken out, filtered of its cells and injected back again into their bodies.

So to come back to my mom, I have decided to add a vitamin b/c tablet to help the wound healing process along. Of course without asking her doctors permission to do so -which is wrong, I know, I know. But hey, it’s in a good cause right? And I believe every little bit matters when the intention is right. What do you think?

P.s. as my mom is getting discharged tomorrow from the hospital- my hospital series of posts is now at an end. Or maybe not – for I have one final post in mind about how corporate hospitals fleece unwary patients who don’t know any better. But writing it down…..won’t it be like biting the hand which feeds? Time to start my Hamlet Act again.