After the accidents
By Dr J.D. Wig
INJURY continues to be the leading cause of morbidity and mortality. Motor-vehicle-related incidents (including pedestrian-caused and bicyclist-caused accidents) are the most common aetiology. India has the highest accident rate in the world — 140.3/10,000 vehicles.

Hope & health in trivia
By Dr Surinder K. Jindal
What Mirza Ghalib would seek in a glass of wine or Wordsworth in daffodils was found by Roger Bone in the taste of lemonade on a summer afternoon when he was detected to be suffering from renal cancer in 1994. About a year later, his cancer spread to the bones and lungs, and he died soon afterwards while relishing another taste of lemonade. He had then commented that over time, "seemingly trivial things to become more important".

Surgery to save heart & brain
MRS Bimla Devi of Hebowal Kalan, Ludhiana, is a person with a strong will. She was diagnosed as having a continuing heart attack (evolving myocardial infarction) in spite of being under the maximum possible treatment in Ludhiana. She had already had angioplasty (ballooning) with stent. She was in danger of sustaining a fatal heart attack.

• Value of what you eat

Banish the fear
No aid to AIDS in 2001: specialist

Bull cloned for disease resistance
COLLEGE STATION, Texas — Researchers at Texas A&M University showed off a black baby bull that they said was the first ever cloned to capture the original animal’s unusual ability to resist disease.

Fragile bones
Osteoporosis is characterised by low-bone mass as well as the deterioration of bone tissue at the microarchitectural level. This causes the fragility of the bones which consequently increases the fracture risk.

After the accidents
By Dr J.D. Wig

INJURY continues to be the leading cause of morbidity and mortality. Motor-vehicle-related incidents (including pedestrian-caused and bicyclist-caused accidents) are the most common aetiology. India has the highest accident rate in the world — 140.3/10,000 vehicles. In the USA it is only 2/10,000 vehicles. The accident death rate in the world is decreasing, even though the number and speed of vehicles has increased. In our country the number of road accident fatalities is rising disproportionately. Newspapers regularly report daily accidents that kill people.

Auto accidents present a real public health problem and the prince and the pauper are equally affected. This is an economic problem, a social problem and a traffic problem. However, there is no effect on the public mind.

Trauma care has made great strides worldwide in recent years, especially in more affluent countries, where new methodology has brought the seemingly impossible within reach. The surgeons facing trauma must be prepared for the inevitable complications of delay in reaching hospitals, poor initial management and often a poorer state of health or nutrition.

Let us have a look at the measures that can significantly lessen the death toll. Legislation, appropriate and prompt, will go far towards minimizing the risks. The introduction of random breath tests has produced a significant lowering of the fatality rate on the roads in developed countries. In our country, a large number of road traffic victims are found to have high blood alcohol levels. We see frequently vehicles with bald tyres, wobbly wheels, windscreens obscured by cracked glass or decorations, absent rear-view mirrors and faulty brakes.

Intense and informed lobbying and a prolonged and intense campaign by interested persons—both doctors and non-medical persons — to inform the public and cause pressure on the legislators and all those engaged in looking after the nation's health to pass the necessary legislation will go a long way in bringing a handsome dividend.

All liquor vends on the major roads and highways need to be shifted and then closed if we have to make any headway in this regard.

Commitment to improving the nation's health is necessary. The distances are great in India and ambulances are hard to find. Communication too is difficult. The roads are in poor shape. These make the transfer of an injured patient unbearably painful and dangerous.

What can be done to reduce the incidence of injury to the vulnerable road users? All Indians need to be asked to help in the reduction of needless suffering caused by trauma. There is an urgent need to stimulate a debate. Although we are doing something in this regard, our efforts are inadequate. The Vehicle Licensing Authority should consider the devastating effect an undeserved driving licence can have upon the community. Traffic rules need to be strictly followed and ruthlessly implemented. Parents too should help by teaching their children not to drive till they obtain a licence in a fair manner.

Helmets: It is time to use them. The evidence that they reduce head injury is too strong to be ignored. Further delays in promoting the use of helmets may increase the number of lives ruined by the devastating consequences of preventable brain injury. Helmet-wearing should be made compulsory. Religious views are sometimes seen as a barrier to the wearing of helmets. We should consider this as a matter which is for individuals to decide. People are dying and we are indifferent.

Better roads, safer vehicles and traffic rule-enforcement are simple measures and 40 per cent of the fatalities can be prevented. What should be done for 60 per cent of the fatalities? The solutions include political priorities, adequate organisation and the exchange of know-how.

Prehospital trauma: A large number of non-brain traumatic deaths is said to be potentially reversible. A significant part of the critical period is often spent in a prehospital environment. Little attention is being paid to prehospital trauma care. All over the world, advanced trauma life support courses were introduced in response to the large number of potentially preventable trauma deaths, aiming particularly at improving care during the critical first hour.

The appropriate training of emergency service personnel and the proper equipping of their vehicles are key components of effective prehospital care. Our policy-makers need to look into the development of pre-hospital care. We need to run special courses for members involved in the care of these injured patients. We need to teach them skills relevant to trauma, namely airway management, oxygen therapy, fluid resuscitation, spinal immobilisation, monitoring, extrication and maintenance of normal body temperature.

How many ambulances, ambulance teams and ambulance personnel do we have to cover our massive population? How many of our citizens are being transported to hospitals by ambulances? What are the education and skill levels of the emergency medical personnel? We need to have emergency ambulance services especially in accident-prone areas carrying basic resuscitation equipment. The "treat in the street" concept is the most important prognostic factor. The ambulance men must provide basic care such as keeping the victims warm and performing splintage. They should control the bleeding. We need to train personnel to provide manual airway maintenance, cardiac massage and venipuncture for fluid resuscitation.

The rapid evacuation and transport of injured persons to a hospital is not possible in our country. Helicopter transportation is a standard patient transportation modality abroad. We need to have a dedicated ambulance service on the national highways so that a well-equipped vehicle reaches the site of the accident within 10 minutes of receiving information. Communication is an important aspect which needs to be looked into to cut delays.

Prehospital trauma care is an area which needs to be developed quickly. We need to train personnel for on-the-site care. Medical control is essential for effective prehospital care and medical involvement encompasses the planning of services, and the education and training of personnel. On-the-scene supervision should be a part of that role at times, providing direct supervision of the care of an individual patient.

Together with efforts at accident prevention, plenty of work needs to be done in this area in order to achieve "The Health of the Nation target" of reducing the death rate in accidents. Every hospital associated with a medical college should have an emergency and critical care medical centre. It should rapidly develop a management system for severely traumatised patients. Prehospital trauma needs to be discussed and the chosen personnel should be trained for these. We need to catch up with the global standards for the care of trauma victims in the twenty-first century. Until we achieve this, education (the prevention of injury), enforcement (traffic rules, alcohol-testing, vehicle-safety) and training (of personnel) should be high priorities. Community involvement is a must. Political parties need to project their national health policies. In this New Year, let us have a time-limit in Chandigarh in this regard. We should upgrade ambulances and emphasise public education programmes. We should also aim at an eight-minute response to 90% of the calls.

Dr Wig, the eminent surgeon and author, based at the PGI, has written this article in response to queries arising from two of his articles on trauma-management.


 

Hope & health in trivia
By Dr Surinder K. Jindal

What Mirza Ghalib would seek in a glass of wine or Wordsworth in daffodils was found by Roger Bone in the taste of lemonade on a summer afternoon when he was detected to be suffering from renal cancer in 1994. About a year later, his cancer spread to the bones and lungs, and he died soon afterwards while relishing another taste of lemonade. He had then commented that over time, "seemingly trivial things to become more important".

Roger Bone was an American physician who pioneered intensive care for critically ill patients. Throughout his life, he provided artificial respiratory support to thousands of patients. He is a name to remember for all intensivists. But for more than his contribution to the field of critical care he will be remembered for his fight with death and friendship with life. Life had been good to him, he surmised. But he had been good to life — even after his death!

One can read plenty in what Dr Bone had written and practised. He talked of the need to possess good health and enjoy the gifts granted by God. The smell of roses, the chirping of birds, the blowing of winds and the sweetness of lemonade are all precious and enjoyable things.

We are often burdened with unnecessary and unimportant stresses and worries about what we have not got. We overlook or ignore the free gifts of nature, of which good health is the most precious blessing. A healthy human being is a very rich person endowed with immense potential and wealth. Material wealth is peanuts in the absence of good physical and mental health.

But can we ensure or insure good health all the time? Obviously not. Health does deteriorate with time. Moreover, death is inevitable. Every time, we need to learn from the famous episode of the enchanted pool in the great epic, Mahabharata. To the question posed by Yaksha as to what was the strangest thing in the world, the exiled but unfazed Yudhishthira had replied: We see everyone in this world dying and yet we keep on believing that we shall live forever... Happily thereafter, Yaksha granted life to four of Yudhishthira's, brothers who had earlier fallen to death without heeding Yaksha's warnings.

Dr Bone also reminded us of the American writer Thornton Wilder who dramatised the fact that life could end quickly and without warning..... "At one moment you get married and before you know it, that white-haired lady by your side is 70 and has eaten 50,000 meals with you".

But see the enormity of enjoyment of having 50,000 delicious meals together with your wife. Forget the poets, philosophers or preachers. For simple human beings, the mere satisfaction of having a good meal is enough of a reason to carry on unabated.

Some time ago, I came across a short story about a man who, after pleasing Yama, had asked that he should be warned of death before His visit to him. Many years later, Yama arrived at his door.

The man was stunned to find the unexpected guest and reminded Yama about the promise He had made to which the Death-God replied: "You ignorant man! I had given you plenty of warnings in the past. Your hair were greyed; your eyes cataracted; your joints degenerated; and your arteries narrowed and so on. Every time, you won by avoiding the warning signals — dyeing your hair, getting your cataract removed, replacing your joints, getting your arteries mended and so on. I was left with no option. I could not accept defeat from a mortal being like you. I had to finally come.”

Marvellously, man has purchased health and delayed death to a significant degree. He has achieved a kind of technological invincibility in the drama of life. Lost somewhere in this complex conglomeration, however, is peace of mind. Peace somehow has no direct friendship with technological superiority, money, power, achievement, intelligence, or even worship. It is an enigma which bothers almost every individual.

One often wonders as to what or who is the greatest enemy of our peace. Is it poverty? Is it ill health? Jealously? Competition? Depression? Helplessness? Failure? None of us knows the exact answer. But the solution, perhaps, is better appreciated. Seek pleasure in the trivia of life. How relieving it is to find a place to park your car in a jammed parking place or to find a seat in a crowded bus! Equally enjoyable is a thankful smile of a client, or the sense of gratitude shown by a patient. The blossoming of flowers, a pensive morning walk, the sight of magnificent hills, a flight of pigeons in the expanse of the sky or the taste of lemonade: all can provide immense pleasure only if we are ready to perceive. Factually speaking, the seemingly trivial things do not become more important over time; they remain important all the time.

Professor Jindal heads the Department of Pulmonary Medicine at the PGI, Chandigarh.


 

Surgery to save heart & brain

MRS Bimla Devi of Hebowal Kalan, Ludhiana, is a person with a strong will. She was diagnosed as having a continuing heart attack (evolving myocardial infarction) in spite of being under the maximum possible treatment in Ludhiana. She had already had angioplasty (ballooning) with stent. She was in danger of sustaining a fatal heart attack. She also had a major blockage in one of the arteries of her brain from which there was the risk of developing a stroke in the brain which could lead to hemiplegia (paralysis) or coma.

She was referred to Dr Harinder Singh Bedi, Chairman, Department of Cardiac Surgery, the Tagore Heart Care, Jalandhar. Dr Bedi realised that the only way to avoid a major brain and heart attack was to go in for combined surgery to repair the arteries of the heart and the brain.

This surgery is called "Combined carotid endarterectomy and coronary artery bypass grafting" (Combined CEA+CABG).

The patient underwent this major surgery and had rapid recovery.

Seeing the good result, another patient, with a similar problem, Mrs Sumitter Kaur of Talwandi Daddian (Tanda), was motivated by Mrs Bimla Devi who was still in the hospital. Sumitter Kaur had a more severe form of the disease but she also did very well.

Atherosclerosis or deposition of fats in the arteries of the body is a generalised process. The arteries of the heart and the brain get affected together. Combined CEA+CABG is the only option for such patients and is one of the most difficult surgeries being performed in very few centres. In North India, Dr Bedi is the only person performing such procedures successfully. He learnt the

technique from Dr Mark Shanahan, Dr V. Chang and Prof Reg Lord of the St Vincent's Hospital, Sydney, Australia. Twenty-five patients have already had successful operations performed by him. They have been presented before and endorsed by international specialists in Canada, the USA and Germany.




 

Value of what you eat

Each portion is 100 gm or 100 ml, unless otherwise stated.

Banish the fear
No aid to AIDS in 2001: specialist

Q. How grave do you think the situation of AIDS is?

A. AIDS is indeed a threat to humanity all round the globe. India, in particular is almost at war with this deadly disease. There are, at present, 10 million cases of HIV infection in India alone. The government, however does not accept more than 2-3 million HIV cases as against the actual number.

The situation becomes not only grave by the virtue of AIDS being incurable, but by the very fact that not much has been done about it as yet. Precisely all the developing nations have yet not given AIDS REGRESSION its due. The Indian authorities prefer to keep mum rather than do something substantial to check the incidence of AIDS.

Q. In India, how is the AIDS problem difficult to counter?

A. Well, people here are driven by their culture and respective religion. Their tradition for example, does not allow the children to be given sex-education, while in the school. Similar is the case with women, who are not allowed enough space by this conservative society. Simple awareness or a modern concept takes years together to get acknowledged. Such reservations have obstacled preliminary AIDS information from the people's reach. Simple caution such as practicing safe-sex is a hushed up topic rather than being a sermon, especially for the teenagers. Moreover, the instability in the government adds to all these complexities that undoubtedly make India more threatened by AIDS than any other nation.

Q. AIDS was never the baby of India. Then how come, as compared to other countries, we present a more pathetic state?

A. Agreed, AIDS did not originate from India. But this fact cannot overshadow the profound status of this HIV infection in the present Indian scenario. A study reveals that by the next decade, India will house nearly 50 million AIDS patients. In my country Canada, AIDS patients do exist. But there, the disease as well as the infected numbers are both checked and regressed each day by different endeavours of the government. Little or almost no such regression is being observed in India. Here.

AIDS is a taboo that restrains people from even approaching the doctor. This aggravates the situation further and makes it difficult for both the doctor and the patient's family to handle.

Expensive medications, further handicaps the health authorities from providing basic treatment to the AIDS patients and elementary safety measures to the doctors dealing with such patients. Lack of amenities and the right approach worsens the situation.

Q. What kind of mandatory safety measures does the doctor require while treating an AIDS patient?

A. Since the mixing of the internal body secretion of the infected with the normal person propagates AIDS, precautionary measures play a very vital role in its regression. For such basic safety measures, availability of medicines, good gloves, gowns, and operation theatre surgical kits need be provided in the hospital.

Without these minimal requirements, doctors would hesitate in treating patients for AIDS. Perhaps many of them may even drop the idea of specialising in AIDS' treatment. Competent medication facility should be made necessary for all the medico-professionals unconditionally.

Q. What kinds of medicines are available for AIDS infection?

A. AIDS has no known empirical cure as yet, but the newer drugs can control the infectious process to a great extent. The first drug used was AZT. Subsequent drugs, which have come out into the market for treating AIDS are indinavir, 3tc, d4T and others. Generally a cocktail of two or three drugs is used.

Q. How far are these medicines successful in countering the AIDS' dread?

A. Medicines alone cannot counter any disease without the positive zeal of the patient. Similar is the case with AIDS patient. The life expectancy surprisingly is beyond the numbered years in Canada and the USA where the patients are provided with the best available medicines and proper counselling. In India, perhaps the situation is entirely different, where the patients do not survive for more than 8-10 years after being diagnosed with AIDS.

Q. Are there any adverse effects of the available AIDS medicines?

A. Granulocytopaenia, anaemia, neuroloxicity and hepatoxicity are some of the commonly encountered adverse effects, but the newer drugs have a better patient compliance.

Q. Since a notable percentage of HIV positive patients are haemophiliacs and anti-retroviral drugs can give rise to thrombocytopaenia, can you recommend some drugs for them?

A. Yes, 3TC and d4T are amongst the few drugs that can be given to haemophiliacs infected with HIV.

Q. Is Gene therapy of value in AIDS and if so what are the prospects?

A. The only major research done is on nucloside inhibitors of reverse transcriptase and inhibitors of protiases. These show promising results, but nothing concrete can be expected for a long time. Even the chances of a vaccine against AIDS look very remote.

Q. Since there is a lot of expense involved in medication, what do you think can be the best proposal for India to counter AIDS?

A. Yes, the medication is far too expensive for all individuals to bear it over a period of years. In the Western countries, this burden is not felt since the government caters to all the medical expenses of its citizens. But in India, the situation is entirely different. The majority of the AIDS patients fall below the poverty line, which makes it impossible for them to bear the expenses. In such a country, prevention and awareness about AIDS needs to be stressed upon over and over again. The government ought to join hands with various NGOs to combat the dread of AIDS.

Q. How do you propose an effective awareness process?

A. Awareness should start primarily with the children since they become the mouthpiece and the essential motivators of society. Sex education needs to be a part of their school curriculum right from the age of twelve.

Emphasis, then should be laid on promoting safe sex among individuals by using condoms.

I personally feel that the best one can do to keep AIDS at bay is by being faithful to his/her partner.

Further stress should be laid on using disposable syringes. Haemophylic patients ought to rely upon confirmed sources of blood since its transfusion is one among the major reasons for AIDS' spread.

All these very important points should be emphasised by the media, government and various NGOs at all levels. Only an extensive endeavour can make the 100 million Indians aware about the dread of this disease.

Q. What about checking AIDS infection from the expectant mother to the unborn child?

A. Transfer of this infection has not been acknowledge through the placenta, from the mother to the child.

The virus is only explained to infect the child during pregnancy, while birthing (due to some aberration caused during delivery) or through breast-feeding. Thus, there are only one-third chances of the foetus being infected with AIDS from his mother. The baby, if infected either gives up life within the womb or dies before its fourth or fifth birthday

— Perfect Health Newsworks


 

Bull cloned for disease resistance

COLLEGE STATION, Texas — Researchers at Texas A&M University showed off a black baby bull that they said was the first ever cloned to capture the original animal’s unusual ability to resist disease.

The month-old calf named 86 Squared, offered the promise of providing the world with disease-free cattle, the scientists said.

“The impact of cloning disease-resistant cattle is potentially monumental. This research will benefit ranchers in many countries who cannot afford to vaccinate or test their herds,’’ said geneticist Joe Templeton.

The three-foot-tall calf was produced from genetic material taken 15 years ago from a six-year-old bull named 86, who had been found to be naturally resistant to three infectious diseases -brucellosis, tuberculosis and salmonellosis.

Scientists will begin testing the cells of ’86 Squared’ next month to determine whether he also has the disease resistance, but researcher Mark Westhusin said he has all genetic markings of 86.

“We’re pretty confident he’s also resistant,’’ he said at a news conference on the Texas A&M campus 128 km northwest of Houston. — Reuters


 

Fragile bones

Osteoporosis is characterised by low-bone mass as well as the deterioration of bone tissue at the microarchitectural level. This causes the fragility of the bones which consequently increases the fracture risk.

Osteoporosis not only impairs the quality of life for many older people but also becomes a matter of life and death in a few cases. In the West, osteoporosis has been labelled as the "silent epidemic" because the people suffering from it are unaware of their disease until they have painful disabling effect or potentially fatal fractures like the collapse of the bones in their back (vertebral fractures).