Sudden death is a doctor's nightmare
Dr S.K. Jindal
SANT SINGH was hit on the road by a speeding truck. He was brought on a tractor-trolley to a nearby health centre after about two hours. The centre was totally ill-equipped either to arrange and transfuse blood or to ligate any bleeding vessel. He was finally referred to the city hospital where he died of shock while being operated upon.

SPECIAL ARTICLE
Suicide: the road untravelled
Dr Rajeev Gupta
THOUSANDS of people commit suicide every day in our country. Some among them had earlier talked about their desire to end their lives. Others were afraid of sharing their feelings with their family members and friends. Very precious lives, some in the most productive age groups, are lost for ever, leaving permanent scars on the minds of their families and a trail of unlimited pain, suffering and mental torture.

HEALTH BULLETIN
The psychotropic drug of Ayurveda
Jatamansi
WHILE classifying the diseases according to adhishthana (place of origin), sages of Ayurveda have broadly put them in two types: sharirik (physical) and manasik (mental). 

• Ten ways to help you reduce stress and live well

• Questions & Answers

Sudden death is a doctor's nightmare
Dr S.K. Jindal

SANT SINGH was hit on the road by a speeding truck. He was brought on a tractor-trolley to a nearby health centre after about two hours. The centre was totally ill-equipped either to arrange and transfuse blood or to ligate any bleeding vessel. He was finally referred to the city hospital where he died of shock while being operated upon. The crowd of aggrieved friends and relatives was furious and smashed the hospital. The doctor was booked by the police for gross negligence and inadequacy of services.

Ram Devi, a young and apparently healthy lady, developed acute anaphylactic reaction following the administration of an injectable drug. The doctor who gave the injection was hit even before resuscitation could be tried.

Similarly, the relatives of Balbir Kaur had ransacked the nursing home where she died of seizures after admission for toxaemia of pregnancy.

I have not created the above scenes out of an action movie but from the true facts of the day-to-day practice. The names are fictitious but the stories are true and representative. Violent reactions to such medical incidents or accidents are increasing. Often spontaneous, these are sometimes motivated. Undoubtedly, the trend is dangerous. It not only shows wholesale unreasonable thoughtlessness but also the mind-boggling killing of a faith that existed between the people and the healers for ages. The mutual trust has been eroded.

There is no greater nightmare for a doctor than facing the sudden death of a patient in a medical accident which happens rather unexpectedly. The doctor is accused of negligence and occasionally even of complicity. Death is almost directly attributed to the actions and/or non-actions of the man on the spot who, in all probability, would have acted in the greatest interest of the patient, according to his or her own capability, expertise, conditions and facilities available on the spot. The doctor, after all, is not a party interested in the death. He just happens to handle a particular patient brought for some particular problem.

The sudden loss of a near and dear one is very painful. It is frequently expressed in anger and occasionally in violence. Such a reaction is well known and very short to last. But what is really dangerous is the general involvement of almost everyone around in a hysterical frenzy against the person who has done his or her "best". It is questionable whether all that was done was the best or the optimum.

I can agree that the actions could be inadequate or perhaps wrong. But every thoughtful person will admit that there is hardly any scope for an intentional wrongdoing. It is incidental that a particular doctor gets involved in a particular patient without any enmity or motive against the patient. Therefore, an intentional mismanagement is unlikely. In any case, intentional harm to a person (or a patient) is an act which does fall not in the realm of medical practice (or malpractice). If a doctor has got any personal involvement of such nature with a particular person who may happen to be his patient, it is a matter entirely between the person concerned and the law. The profession has nothing to do with such an action.

What agitates a concerned relative of the victim is the sudden happening of an unexpected misery and the failure to have it reverted. The doctor is perceived as a person who could retrieve the loss. If this does not happen, he is perceived as a devil and becomes the subject of people's ire.

Unfortunately, in most such cases, the situation is irretrievable or unmanageable because of innumerable factors. Sant Singh had gone into an irreversible shock long before he was brought to the city hospital. Ram Devi's reaction was unexpected and could happen anywhere in the world. Balbir Kaur's toxaemia could be attributed to her own and her family's ignorance or negligence to take care of antenatal problems. There would be additional contributory causes and alternative explanations. In such cases, however, the doctor who gets punished is the least guilty of all.

It is theoretically true that a lot more can be done to save people who fall victim to medical accidents. This requires an overall restructuring of socio-administrative systems in addition to medical management. In ideal and modern medical set-ups, of which we talk and which we expect to happen, Sant Singh should have been evacuated or airlifted in the first hour to a larger trauma centre and possibly transfused on his way and Balbir Kaur should have been following good antenatal care and managing contributory problems.

As I said earlier, Ram Devi's accident could have happened anywhere, but better management might have been possible.

Undoubtedly, one expects excellent medical management of medical accidents. But one needs to be realistic and accept the consequences and complications. Medical accidents must be prevented as far as possible. Most medical accidents, however, are not attributable to the doctor but to the disease and the existing infrastructure to handle the problem. To punish the person who tries to take the patient out of that problem is like punishing the innocent if you cannot get hold of the guilty.

An old story tells of a king who ordered the hanging of the person who entered the gates of a city early in the morning to substitute for a murderer who was too heavy to be hanged.

Dr Jindal is the Professor and Head of the Department of Pulmonary Medicine at the PGI, Chandigarh

SPECIAL ARTICLE
Suicide: the road untravelled
Dr Rajeev Gupta

THOUSANDS of people commit suicide every day in our country. Some among them had earlier talked about their desire to end their lives. Others were afraid of sharing their feelings with their family members and friends. Very precious lives, some in the most productive age groups, are lost for ever, leaving permanent scars on the minds of their families and a trail of unlimited pain, suffering and mental torture. Experience has shown that each one of them was on the edge and for the majority, being ambivalent towards dying, a little timely support made available in time could have made a vital difference between life and death.

Hardly does any day pass when one does not find reports about suicide or attempted suicide in any national, regional or local newspaper. The problem of suicide continues to haunt sociologists, psychologists, psychiatrists, educationists, social workers and other medical professionals throughout the world. In the USA, suicide among the adolescents is the third leading cause of death exceeded only by accidents and homicide. A WHO report pinpoints suicide as one of the first eight causes of death in advanced countries.

There was possibly no period of history where suicide was not known. Even in primitive societies and in ancient times suicide was recorded. In an article "Suicide in West Bengal — century Apart", Dr D.N. Nandi, a past President of the Indian Psychiatric Society, writes: "Neither the triumph of scientific medicine, nor the rise in the standard of living has prevented the loss of life through suicide". On the contrary, evidence suggests that there is an increase in the reporting of suicidal rates in many countries.

In our own country the suicide rate has gone up in many states. The data obtained from the statistics of the Union Home Ministry reveals a steady increase in the number of suicides in our country.

Scientists have tried to identify the factors leading to suicidal behaviour. Studies of suicide attempts in various parts of India have shown that about 50 to 70 per cent individuals who have made suicidal attempts suffered from a wide variety of psychological problems like depression, schizophrenia, drug addiction, alcohol dependence, personality disorders and hysterical behaviour.

In some studies 30 to 50 per cent of those who had made suicide attempt were already under psychiatric treatment. The suicide risk in primary mood disorder is 25 times greater than the risk in the general population and about 10 to 15 per cent of the patients with depression die by suicide. Depression has a tendency to colour every event with negativity. So, a patient of depression feels that his future is completely bleak. (To be continued)

Dr Gupta is an eminent psychiatrist based in Ludhiana

HEALTH BULLETIN
The psychotropic drug of Ayurveda

Jatamansi

WHILE classifying the diseases according to adhishthana (place of origin), sages of Ayurveda have broadly put them in two types: sharirik (physical) and manasik (mental). Apart from the medicines which act on different systems of the human body, there are various herbs which have been described in the texts as sangyasthapaka and manasdoshhar a (psychotropic). Jatamansi is the foremost of these herbs.

Found at high altitudes in the Himalayas and also known as sulomasa, bhutjata and tapaswini in Sanskrit, Jatamansi truly resembles the uncombed hair of an ascetic. It has been described as a combination of three tastes — bitter, astringent and sweet. Jatamansi is light, unctuous, sharp and cold in effect and it alleviates all the three doshas, specially kapha and pitta. Its chemical composition consists of a volatile oil and two alkaloids besides an acid which is known as jatamansic acid.

Jatamansi is famous for its soothing and sedative action on the central nervous system. With an Ayurvedic perspective, pranavata is an important depiction of vata dosha which is responsible for all mental functioning and giving tone and tenor to emotions whether negative or positive.

Jatamansi is the most effective herb for putting an end to its imbalance. It is also an anti-convulsant, a memory booster and a brain tonic. In addition, Jatamansi has carminative, anti-spasmodic, diuretic and emmenogogue (that which promotes the menstrual discharge) properties.

Since ancient times, Ayurvedic physicians are using Jatamansi in a number of diseases like unmad (insanity), apasmar (epilepsy) and yoshapsmar (hysteria). Due to its sedative action it is very effective in chronic anxiety, depression, insomnia, migraine and tension headaches. In the menopausal syndrome it is used in combination with other nervine tonics.

Jatamansi is also effectively used as an aromatic and cosmetic herbal drug to promote and protect skin health. Here are some of its common uses .

n In chronic anxiety and depression, mix one gram of the Jatamansi powder, 250 mg each of akik, jaharmohra and praval pishtis and 60 mg of mukta pishti. Regularly taking it twice a day controls hyper excitement and anxiety. This formulation is effective not only in restlessness and palpitation but also in mild hypertension.

n To counter stressful conditions, take 2 grams of ashwagandha powder along with half a gram each of the powders of jatamansi and brahmi. Taking it twice a day, preferably with milk, is a good recipe for treating depression, insomnia, nervous exhaustion and psychological upheavals of the menopausal phase.

n Patients of migraine and tension headache can try powders of jatamansi and pipplamoola, one gram each, added with half a gram of godanti bhasma twice a day for a couple of weeks.

Various classic Ayurvedic medicines such as mansyadi qwath and rakshoghna ghrit contain jatamansi as the main ingredient. The short-term therapeutic use of Jatamansi is generally safe but its prolonged use may need observation by a physician.

Dr R. Vatsyayan is an Ayurvedic consultant. He is based at the Sanjivani Ayurvedic Centre, Ludhiana. (Phones: 423500 and 431500; e-mail sanjivni@satyam.net.in)

Ten ways to help you reduce stress and live well

1. Talk it out. When something worries you, don’t keep it to yourself.

2. Escape for a while. When things go wrong, it helps to escape from the painful problems for a while.

3. Laugh! Read one of your favourite jokes or simply laugh aloud.

4. Visualise yourself relaxing at your favourite vacation spot or completing some big and difficult task with ease.

5. Take a quick "mental break" by visualising a favourite place in your mind — whether it be the ocean, the mountains, or your own backyard. Concentrate on "seeing", "smelling" and "hearing" the things you imagine.

6. Massage: Close your eyes and use your fingertips to vigorously massage your forehead and the back of your neck. Rub in circles, and rub hard.

7. Get out of the rut: Making up new ways to do old things can be a great reliever of both stress and boredom. Try taking different routes when driving to work, or change the way you do ordinary tasks such as putting on makeup, fixing your hair or getting dressed.

8. Develop hobbies: What’s fun for you can be good for you. Whatever your interests are, indulge in them. Feeling competent and in control is relaxing.

9. Do something for others. If you feel you are worrying about yourself all the time, try doing something for somebody else.

10. Above all, forget the "superman" or "superwoman" image. No one can be perfect in everything.

(This interesting piece has come with Ipca 3c).

Questions & Answers

A Cancer is the abnormal growth of a cell or a group of cells. Normally, the cells divide in a systematic manner but when cancer sets in, the cells start multiplying in a haphazard manner. The resultant cells are also abnormal.

A No. Cancer is not infectious and it cannot be transmitted from one person to another.

A It is estimated that at present in India, there are about 20 lakh cancer patients. About 10 lakh new patients are diagnosed every year. One out of eight persons is likely to develop cancer during his lifetime.

A As per the present state of knowledge, there is no direct evidence to suggest that the consumption of alcohol gives rise to cancer although it is detrimental to health in many ways. There is some indirect evidence. Alcohol is known to produce cirrhosis of the liver and patients of liver cirrhoris are comparatively more prone to liver cancer.

A No. It is neither practical nor advisable. If a mole is situated in a place which causes constant irritation, for example a mole situated on the cheek in the area of shaving, it should be removed. Similarly a mole or a wart which starts increasing in size, changes its colour or starts bleeding, should be removed and a biopsy should be carried out to rule out the presence of cancer.

A Yes. Multiple cancers at the same time or another cancer developing subsequently are well known. It should be understood that cancer or its treatment does not provide any immunity from the development of another cancer in some other part of the body.

A Yes. A number of non-cancerous diseases are known to change into cancerous ones over a period of time. Some of the common ones are ulcerative colitis, polyps in the large intenstine and chronic ulceration in the mouth, skin, stomach, genetalia etc.

Dr Bose is a famous cancer surgeon. He is based at the PGI, Chandigarh.