Unborn tomorrow & dead yesterday
Dr Kanwarjit Kochhar
I remember a winter evening way back in 1969 when I was posted at Civil Hospital, Fazilka. I was called to deliver a patient near the Pakistan border. We were not under any obligation to take this case and I was not being paid anything for this. But after hearing the history of the patient and about her suffering I decided to go. 

Manage your asthma
Dr Shakuntala Lavasa
TO be in control of one's body is a basic human desire. The key aim of asthma management is to teach patients how to respond appropriately to their changing symptoms under good control. Asthma symptoms which vary during the day, from day to day, and from place to place, may change with seasons activities, emotions, occupations, hobbies, food etc. 

Happiness
Dr Atima Gupta
WHEN my eyes get tired looking at slides under the microscope, and at samples, at the end of the day in my laboratory, I try to reflect beyond my chosen discipline — pathology. And what is pathology? It is the study of diseases or abnormalities, or more particularly, of changes in tissues or organs that are associated with disease. It is a deviation from the normal healthy state.

HEALTH BULLETIN
From God to man
Dr R. Vatsyayan, Ayurvedacharya
NO other herb has such a rich history of use in every single culture on this planet than garlic. The ancient civilisations of Rome, Greece, China and Egypt devised stellar stories about its origin. Ayurveda, the oldest medical system of the world, relates its own:

Q&A
Stones in the kidney

Unborn tomorrow & dead yesterday
Dr Kanwarjit Kochhar

I remember a winter evening way back in 1969 when I was posted at Civil Hospital, Fazilka. I was called to deliver a patient near the Pakistan border. We were not under any obligation to take this case and I was not being paid anything for this. But after hearing the history of the patient and about her suffering I decided to go. It was risky as this place was not quite safe being close to the border and it was getting dark. There was no alternative as the callers refused to bring the patient to the hospital.

Being the only qualified lady doctor in the city I took the risk. I was equipped with a delivery kit, a pair of forceps and a few medicines but, mind you, no oxygen or blood. I was in for a big shock when I reached the village. The patient was lying in a small hut not more than seven feet wide with a lantern as the only source of light. She was lying on a small bed which was full of sand. There was one dai sitting near her who told me that the baby was not coming out in spite of all her efforts. I listened to the baby's heart and the beat was there.

I requested the family again to shift the woman to the hospital but its members refused. I had to try and deliver the baby. I was very worried about my safety as well as that of the patient. I applied the forceps and the baby came out easily yelling away to glory. After that there was no problem. I was more than relieved and so were the people around. Though they had assured me that whatever the consequences, they would not mind, I was worried as I had never delivered anyone under such circumstances. I heaved a sigh of relief when I reached the hospital.

This happened three decades ago. I ask myself and my professional colleagues that if such a situation arises today, how many of us will go. I am sure the answer will be 100% no (including from me). The reasons are clear. First and foremost, there is personal security. Now no doctor likes to visit an unknown patient. Who knows in the garb of a patient who is taking you for a ransom? But in those days such incidents were rare. What would anyone get from a government doctor whose pay was just Rs 800 per month?

Secondly, if something drastic had happened to the patient, I might not have come back one piece. But somehow in our hearts we knew and we were made to understand that if we were putting in a sincere effort, no harm would come to us even if the patient died.

In the present scenario many of my colleagues will call me a fool to venture into such a thing but 30 years ago it was not such a foolish thing to do. We all know that a doctor's duty is to try and save a life. We should make a sincere effort with all the facilities available without worrying about the outcome. I am sure this approach was right at that time. Now the things are different. Then the doctor was looked upon as second God; now it is not so. Many patients feel the doctor is only making money and every doctor feels every other patient is a potential litigant. Every doctor wants that his patient should go satisfied and fully recovered as the goodwill bring in more "customers". So, knowingly, why will any doctor spoil a case? Does any one realise the condition of the doctor when anything goes wrong with his patient? His own blood pressure falls along with that of his patient's and he undergoes much mental strain. We, the doctors, are dealing with a very complicated machine — the human body — which can respond in the most unexpected manner under stress.

Among the professionals, who can say he is always right?

Does anyone blame a lawyer when he loses a case and his client is sentenced to death?

What happens to an architect when a newly constructed building or a bridge collapses, killing innocent people?

A drunken rich brat kills innocent people under his BMW. What happens when, because of mistaken identity, innocent people are killed by the police in New Delhi's Conn aught Place?

Then why such injustice to a doctor?

We should not forget that a doctor is dealing with sick people who come to him following their own free will especially in elective cases and they have plenty of time to choose and decide on their doctor after consulting others. Why has he to face the wrath of the same people if something adverse happens? In many cases the doctor is manhandled. His clinic and house are stoned and he is handcuffed. In emergencies things are worse if a doctor says he is not equipped for the particular cases and advises the relatives to shift the patient to an institute (after assessing the condition) and, God forbid, the patient dies on the way. On the other hand, if he feels the patient might not reach the hospital and he wants to give the last chance, he faces the same criticism. All is in spite of the fact that everything is explained to the people around and consent is obtained! The doctor is to be blamed both ways.

Why? is he a criminal? Did he intentionally spoil the case or kill his patient? Why does the media splash the news with mirch masala without verifying it from the doctor concerned? Does anyone think what would happen to his future practice, the practice for which he struggled for so many years?

I don't say negligence or complication does not occur but that does not mean the doctor should be treated like a murderer. There should be a proper inquiry by a senior medical faculty and strict action should be taken against the erring doctor. Even consumer courts should consult a board of doctors before admitting a case. But in the case of a complication a warning should be enough. It is difficult to anticipate a complication sometimes. A patient can have a complication from a simple tablet or an injection or a day-to-day procedure. It is true that the doctors, at whichever level they are working, should be well equipped for various eventualities. But will it be practically possible to:

• have blood ready for each and every delivery and abortion or a simple surgery?;

• get all the detailed investigations done for every fever case and keep the patient in a hospital, increasing his financial problems?;

• send all head injury cases (even minor ones) for CT Scan and MRI and admission to the already overflowing institutes?;

• refuse to touch or give first aid to a very sick patient for the fear that if he dies in your clinic, you will be in trouble?

The doctor- patient relationship is one of trust and faith. The doctor expects his patient to follow the prescription faithfully and report to him in the case of any problem during the course of the treatment rather than leave it half way and consult another doctor. The patient also expects from his doctor a patient hearing of his problems and an honest opinion keeping in view the facilities available to him including the financial status. If both parties are honest with each other, there is no reason why there should be any grudge. The sacred bond established by suffering should be nurtured with respect. Tomorrow should hark back to yesterdays.

Dr Kanwarjit Kochhar is a well-known gynaecologist based at Deep Nursing Home, Chandigarh. (Ph: 705773 and 702325)

Manage your asthma
Dr Shakuntala Lavasa

TO be in control of one's body is a basic human desire. The key aim of asthma management is to teach patients how to respond appropriately to their changing symptoms under good control. Asthma symptoms which vary during the day, from day to day, and from place to place, may change with seasons activities, emotions, occupations, hobbies, food etc. The treatment has to be adjusted accordingly. The aim of the treatment is to stop asthma from interfering with the enjoyment of life.

Avoid the known triggers of symptoms: An obvious target for intervention is allergen reduction. For this it is pertinent to have allergy tests so that the offending agents in food or contact can be avoided. If allergens are unavoidable (inhalant allergens), immunotherapy is the answer. Allergen-specific immunotherapy reduces asthma symptoms and medication requirements. A recent WHO position paper, which has been endorsed by eight other international bodies has concluded that allergen immunotherapy is an effective treatment for patients with allergic asthma. Immunotherapy reduces asthma symptoms and asthma medications. While the inhaled corticosteroid therapy remains the mainstay of the treatment, any reduction in this type of treatment while maintaining good asthma control, is welcome.

Learn what are the things that can make asthma worse. But if you can't avoid them (visiting your boss with his dogs); increase your treatment before the visit. The one trigger that you should not avoid is exercise. Take the treatment meant to be taken before exercise but do not avoid this positive trigger. There are parents who want to get PT and games excused on medical grounds fearing that the dust of the play ground and physical activity may induce asthma attacks. Do you know that Steveovet (athletics), Karen Pickering (swimming) and Paulscoles (football) reached the very top in their career with appropriate asthma treatment? In the 1984 Olympics of the 11% players experienced asthma symptoms and almost 2/3rd went on to win the gold.

Learn to recognise the change in asthma. Learn how to recognise that your asthma is getting worse. Cough, chest tightness, shortness of breath, not being able to complete sentences and a drop in the value on the peak flowmeter are the indicators of the worsening. Peak flowmeter is a simple, inexpensive but invaluable tool for self-monitoring. Learn from your doctor how to use it.

Learn about brown and blue inhalers. Brown inhalers are preventers which contain a tiny dose of steroid. These do not make any noticeable difference when you take them, but get the inflammation of the respiratory pipe under control. (This is the cause of asthma.) They have to be used regularly. Don't worry about the idea of using a steroid. The blue inhalers relax the breathing pipe. They start working at once and the effect lasts a few hours. These are meant for emergencies. If you find that you need to use the blue inhalers everyday for more than a week, it is necessary to start using the brown preventer inhaler daily so that the disease remains under control and the blue rescue inhaler is not needed.

Learn how to use the inhalers properly: Get the technique checked. Using inhalers properly is not always easy. Even if you know how to use them, it is nevertheless easy to do so wrongly when hurrying to work in the morning. Take time to do it properly or you will waste the medicine and the effort. You will have the wrong notion of the failure of the treatment. Check from time to time that you are doing it in the right way.

Learn how to change the doses of the inhalers if your symptoms change. If you wheeze in spite of the brown (preventer) inhaler, you need the blue inhaler. A couple of puffs will give relief but it is perfectly safe to use more, if need be. In sudden bad attacks, you can use up to 10 to 12 puffs from the blue inhaler. If you have to do it, do get in touch with your doctor. 100 much of blue inhaler may make your hands shake and may make you feel a bit dizzy. Just stop, and the signs will wear off in 10 minutes. If the effect of the blue inhaler lasts for less than four hours, you should see your doctor.

If your asthma gets worse, you need to increase temporarily the dose of the brown inhaler. It can safely be doubled or trebled for up to two weeks — a maximum of 2000 mcg for adult per day. Do consult the doctor. Do not make any permanent change yourself.

Learn how to tell the difference between panic and asthma. A panic attacks can feel like asthma attacks and you can have an asthma attack and a panic attack at the same time. In panics you breath faster and these cause the tingling of lips and fingers, dizziness and the feeling of breathlessness. Try, calm down and breathe slowly. In an emergency treat both as the use of inhalers will not do any harm even if you don't need them. But in the long run, try to sort out what is what so that you do not take unnecessary asthma treatment. The use of peak flowmeter can help here.

Know when to consult your doctor. If in doubt, do so surely.

Is self-management working? The three key domains — sleep disturbances, daytime symptoms and interference with normal activities in order to judge the quality of life — have to be assessed. We need to see whether these results are being achieved with the appropriate use of treatments, watching both for inadequate use and excessive use of medicines. And the key question for the doctor is "Is there anything I can do to make you feel more in control of your asthma?"

Dr S. Lavasa is a well-known paediatrician, allergy specialist and public educator. She can be contacted on telephones 782766 (Chandigarh) and 562239 and 563447 (Panchkula). Email: slavasa@yahoo.com

Happiness
Dr Atima Gupta

WHEN my eyes get tired looking at slides under the microscope, and at samples, at the end of the day in my laboratory, I try to reflect beyond my chosen discipline — pathology. And what is pathology? It is the study of diseases or abnormalities, or more particularly, of changes in tissues or organs that are associated with disease. It is a deviation from the normal healthy state. The other day my thought process stopped at a none-pathological state — at happiness. Here is how I remember the thoughts occurring:

In this era of unsatiable materialism, people yearn for happiness. They think somewhere someday is doing something special to achieve ‘‘happiness’’. If we cannot achieve happiness, can we learn to derive happiness from the prevailing situation? Yes. We can, because happiness is an attitude; it is not a condition. It lies in the present, not in the future. Let us not ruin our brief present moments of happiness in search of bigger and distant instances which may never occur. Remember, drops contribute to the making of an ocean. Happiness is like a balloon which, if not caught at the right time, gets beyond our reach. Though we cannot force happiness to happen, we can very well acknowledge its presence.

When we are bogged down with problems, we should listen to children shouting and laughing without inhibition. So, appreciate the setting of the sun, the chirping of birds or the falling of rain drops over delicate leaves. Happiness doesn’t depend upon who we are or what we have. It depends upon what we think.

The Ludhiana-based pathologist runs the Gupta Medical Lab in Tagore Nagar (phones 472822 and 472899).

HEALTH BULLETIN
From God to man
Dr R. Vatsyayan, Ayurvedacharya

NO other herb has such a rich history of use in every single culture on this planet than garlic. The ancient civilisations of Rome, Greece, China and Egypt devised stellar stories about its origin. Ayurveda, the oldest medical system of the world, relates its own: garlic grew as an offshoot of drops of amrita which fell on the earth during the epic battle between gods and demons. Surrounded by an aura of magical and medicinal mysteries, the charm of garlic has remained undiminished over the centuries of its use.

Garlic's Sanskrit name rasona literally means lacking one taste; it contains all the six tastes except sour. Ayurveda has described it as hot in potency and pungent in post-digestive effect. It is unctuous, sharp and heavy. It pacifies kapha and vata but aggravates pitta. Modern analyses of garlic show that it contains water, protein, carbohydrates and other substances like calcium, phosphorus, iron and vitamin B complex, besides traces of iodine. It also contains volatile oils and sulphur compounds of which some are responsible for its sharp odour.

Though in recent times garlic has acquired a reputation as an effective immunostimulant, anti-viral, anti-cholesterol, cardio-vascular tonic (and also as a tumour inhibiting medicine), ancient ayurvedic texts have eulogised it for its extraordinary healing properties and called it maha aushadhi (great medicine).

Garlic has been described as a stimulant, carminative, digestive, metabolic corrector and killer of intestinal worms. It also has laxative, diuretic, expectorant, anti-inflammatory, aphrodisiac and rejuvenative properties. Given in low doses, it helps in hypertension, raises the body's immunity, fights viral and bacterial afflictions, keeps cholesterol and tryglycerides level under control and acts as an anti-oxidant substance.

As a home remedy, it is used both externally and internally to combat many diseases. A few cloves of garlic are added to hot oil used for body massage and oleation. Frying five to six cloves of garlic in desi ghee and taking it before lunch provides an adjuvant effect for controlling the flare-up phase of rheumatoid arthritis. The medicated milk of garlic (kshirapaka) works well in many vata diseases like sciatica, lumbago and paralysis whereas the consumption of garlic in one's daily diet reduces body toxins besides controlling the lipid profile.

However, one fails to understand why such a useful herb didn't get religious sanction despite its "divine" origin and is rather feared as being tamasika Ayurvedic texts describe a method to lessen its strong ordour. Put a few peeled off cloves of garlic in buttermilk or diluted curd overnight. If used next day, the garlic will lose much of its sharpness and offensive odour. Those who want to use raw garlic, and also to whom its suitability is in doubt, can try this method. Cooking it in ghee too reduces its pungency.

There are many ayurvedic classic medicines containing garlic — Rason Vati, Lashunadya ghrit and Rason Ghrit. Kashyap Samhita, while describing the famous Rason Kalpa, is more explicit in telling that garlic should be used sparingly by persons of pitta prakriti. In kapha and vata diseases it should be used with honey and ghee respectively. The maximum dose of raw garlic cloves is up to six pieces and to counter its unsavoury effect the powder of coriander seeds should be used.

Dr Vatsyayan is an ayurvedic consultant. He is based at Sanjivani Ayurvedic Centre, Ludhiana. Phones 423500 and 431500 (E mail - sanjivni@satyam.net.in)

Q&A
Stones in the kidney

Q I had a stone in my left kidney. Can I develop stones in other parts of the urinary system?

A Yes. A patient of kidney stones may develop stones in other parts of the urinary system, as a new stone or a small particle may break away from the kidney stone and get lodged in the ureter (the tube linking the kidney to the urinary bladder) or in the urinary bladder.

Q Can kidney stones recur?

A Yes. Kidney stones are known to recur either in the same kidney or elsewhere in the urinary tract. A urinary tract infection or an obstruction, and systemic diseases, are known to be responsible for this.

Q What is the probability in a kidney-stone patient of the formation of a stone again?

A A stone former is likely to form stone again if no precautions are taken. About 50% will re-form within 10 years and about 100% will do so within 25 years.

Q What are the dietary precautions a person should take so that new stones are not formed again?

A 1 A patient of kidney stones should take plenty of fluids by mouth so that the urine output remains above 2 per day. It is also necessary that the water intake is equally distributed over the 24-hour period so that a patient of kidney stones passes at least 300 ml of urine per three hours.

2 The stone that has been taken out should be analysed so as to find out its constituents. The common constituents are oxalate, calcium, phosphates and uric acid.

3 The urine and the blood of the patient should be tested for a number of parameters. Depending upon the results of these tests, and also the stone analysis, the patient is advised dietary modification, restriction of salt and/or drug therapy.

Q What are the diseases that can give rise to kidney stones?

A There are a number of systemic diseases which can result in the formation of kidney stones. These include hyperparathyroidism, familial hypercalciuria and renal tubular acidosis.

Q Is stone-formation related to the environment?

A Such persons as work in a humid atmosphere and take less fluids than necessary are more prone to developing stones in the kidney as the minerals are likely to get precipitated.