Monday 29 February 2016

Some Important Judgements in Cardiology

Some Important Judgements in Cardiology
Dr KK Aggarwal • “In view of the fact that entire basis of complaint was that only two stents have been implanted instead of three stents, as claimed by EHIRC, and since it was been established on record from the opinion given by AIIMS after reviewing the CD that three stents were implanted, ... this petition is to be allowed...” (Dr. T. S. Kler vs Govt. of NCT of Delhi & Anr. on 23 February, 2011, High Court of Delhi, W.P. (Crl.) 725 of 2007 with Crl. M.A. 6199 of 2007 % 23.02.2011) • “It has come on the record that the complainant was having blockage of multiple vessels due to diffuse atherosclerotic disease and dyslipidemia…It has also come on the record that the complainant had been taking treatment from different doctors and hospitals. Thus, the opposite parties cannot be blamed for any kind of medical negligence and deficiency in service. No case for interference in the impugned order in dismissing the complaint is made out.” (State Consumer Disputes Redressal Commission; R.R. Sharma Son of Late Sh. Bal vs Metro Heart Institute And Metro on 13 August, 2012) • “… a person with heart problem should have not been allowed to go in a private car and ambulance with all life saving equipments should have been provided by the doctor,…, just to show the bonafide and concern that the serious patient reaches the tertiary hospital, where his ailment could be managed.” (Sher Singh vs Grewal Hospital on 19 December, 2012: 2nd Bench: State Consumer Disputes Redressal Commission, Punjab; First Appeal No.541 of 2012). In similar conditions in "Smt. Indrani Bhattacharjee Vs Chief Medical Officer, Farakka Super Thermal Power Project & Ors.", 2007(2) CPC-370(NC), the commission had held the doctor liable. • “… The respondent has been paid at the admissible rate in AIIMS but claims the difference between what is paid and what is admissible rate at Escort. Looking to the facts and circumstances of this Case we hold that the respondent in SLP (C) No. 11968/97 is entitled to be paid the difference amount of what is paid and what is the rate admissible in Escorts then. The same should be paid within one month from today. We make it clear reimbursement to the respondents as approved by us be not treated as precedent but has been given on the facts and circumstances of these cases.” (Supreme Court of India; State of Punjab & Ors vs Ram Lubhaya Bagga Etc. on 26 February, 1998) • “… it is evident that this was a case of real and acute emergency. The Railway Board circular also provides that during acute emergency the Railway employee or his family member could be treated in private hospitals and the bills will be reimbursed by the railway department. Therefore, the Dy. Chief Medical Officer (TA), HQ, Western Railway, Mumbai, in his subjective satisfaction cannot mention a part of the Discharge Card and omit the relevant part which shows that the applicant was admitted with serious cardiac problem and required treatment in ICCU.” (Central Administrative Tribunal - Mumbai, Shri Bipinchandra N. Mistry vs Union Of India Through Its on 23 August, 2012) • “The ratio of the judgment of the Hon'ble Supreme Court in the case of State of Punjab and Ors. v. Ram Lubhaya Bagga (supra), as pointed out in the judgments of the Hon'ble High Court of Delhi in the cases of M.G. Mahindru v. Union of India and Anr. (supra) and J. C. Sindhwani v. Union of India and Anr. (supra), is not against full reimbursement of medical expenses incurred in a private hospital approved by the Government.” (Central Administrative Tribunal - Delhi: Shri Prakash Chand vs Union Of India (UOI) And Anr. on 23 January, 2007; Equivalent citations: 2007 (3) SLJ 312 CAT) • “When the patient is not aware of the disease or the symptoms of the same that would affect him, or the doctors are not aware of the symptoms of the disease and the insurance company does not do any medical check up before revising the policy, it cannot be said that there was suppression of material facts by the respondent.” (State Consumer Disputes Redressal Commission: United India Insurance Co. Ltd., vs Smt. Mili Dutta, Wife Of Shri Niharendu Dutta on 8 July, 2013) • “…the applicant having suffered heart attack was immediately rushed to the Apollo Hospital, New Delhi and was subjected to bypass heart surgery within two days of his... Merely because the applicant was not the member of the CGHS cannot deprive him of his entitlement for reimbursement of the medical expenses incurred by him. We therefore have no hesitation in concluding that the claim of the medical reimbursement of expenses incurred by the applicant is denied on untenable grounds and therefore, the O.A. deserves to be allowed and the respondents are required to be directed to entertain the claim of reimbursement of medical treatment expenses of the applicant and reimburse the same.”(Central Administrative Tribunal - Gwalior; Laxmi Chand vs Comptroller And Auditor General on 4 November, 2004; Equivalent citations: 2005 (2) SLJ 145) • “Thus, O.P.1 alone can be held guilty for deficiency in service in accepting the patient when senior doctors who alone were competent to handle the complications arising during or after the operation, as they were out of town and by not providing appropriate care or continuing with the treatment and presumably wrong diagnosis inspite of deteriorating condition. In our view, a lump sum compensation of Rs. 2.5 Lacs including cost of litigation will meet the ends of justice. Complaint is disposed of.” (State Consumer Disputes Redressal Commission, Moorti Sharma vs Indraprastha Medical on 8 January, 2007, C-372/1997, Delhi) • “… the Honble Supreme Court in its recent decision in Martin F.D. Souza Vs. Mohd. Ishfak reported in 2009 Indian Law SC 174 once again made clear that in proof of the allegation of medical negligence it has to be supported by expert evidence, else, the complaint is liable to be dismissed.” (State Consumer Disputes Redressal Commission, Kodali Venkateswara Rao vs Saumya Medicare International ... on 19 January, 2010: AP state).

Sunday 28 February 2016

Health and the Union Budget 2016 – IMA’s suggestions

Health and the Union Budget 2016 – IMA’s suggestions

New Delhi, February 28, 2016: “Ensuring its citizens health and well-being is of uttermost importance for a government and we at the Indian Medical Association strongly believe that the time has come to increase the public expenditure on health from the current level of 1.2% GDP to at least 5%. The government must also ensure that a minimum of 55% of health budget is spent on primary, 35 percent on secondary and a maximum of 10 percent on tertiary care services as against the current levels of 49%, 22% and 28% respectively. Separate funds should be allocated for national disease control programs. Presently these programs cover only 15% of disease burden. Lifestyle diseases, re-emerging communicable diseases, health problems of the elderly, mental health, rare diseases, orphan drugs, etc. should receive adequate funds”, said Dr S S Agarwal, National President IMA & Padma Shri Awardee Dr K K Aggarwal, President HCFI and Honorary Secretary General IMA.

Other suggestions shared by IMA include

 Government should introduce a health cess (0.5%) as a component of the existing VAT system and the new Goods and the Services Tax (GST) that is proposed.
 There should be additional health cess for sweetened beverages/products, tobacco, alcohol and cars.
 Water, hygiene and sanitation are the corner stones for effective public health protection. Government should not only increase allocation to these areas, but also ensure that the money is spend properly and time-bound
 The present schemes such as JSBY, RSBY, JSY etc. should be converged so that we can evolve a comprehensive social security package
 Public and private sectors should not move as parallel systems, but should complement each other. Public private partnership in health should be promoted.
 The primary health centres where there is non-availability of doctors should be declared as difficult rural areas and special package of salary, incentive for higher education and allowances for house, vehicle, children’s education should be provided
 The population served by each PHC should be restricted to 30,000 and each PHC should have at least 3 Medical officers with MBBS qualification
 Central Government Fund should be allotted for periodic recruitment of health workers including doctors at PHC and CHC level
 Services of family doctor/single man private clinics should be optimally used on a retainer ship basis, at least in places where government doctors are not available at PHCs, until government is able to recruit and sustain regular doctors.
 Government should increase the allocation for health awareness programs.  A repository on health information should be created and disseminated using the social media.
 Non-communicable diseases and health needs of the elderly need urgent attention. Government should increase the allocation to these areas significantly. National programs for NCD and care of elderly should be introduced in all the districts within the next two years.
 Telemedicine should be given importance, with simultaneous investment in increasing the availability of trained and qualified human resources
 District hospitals should be converted to medical colleges on a need-basis in states with less number of medical colleges. This will avoid huge investment required to start stand-alone medical colleges.
 Keep aside, at least 2% of the health budget for health research. Build systems like online, time-bound clearance mechanisms for all health research proposals
 Use of Electronic Health Records (EHR) and enrolment of the entire population at the sub-center level should give a comprehensive picture of burden of disease, which should help to plan and allocate resources as per epidemiological need. Invest in a standard uniform EHR system for both public and private sector.
 Invest and promote health equipment manufacturing industry within the country. Health technology should be made a separate department under the Ministry of science and technology
 Medical grants commission should be instituted with adequate funding for research and collaboration between institutions and development and maintenance of uniform standards of medical education
 Lifesaving equipment should be exempted from all taxes
 Aided hospitals concept should be developed to support medium and small health institutions, which cater to 40% of health care needs of our population.
 The tax on health care like luxury tax for rooms and ICUs, VAT on drugs, service tax on procedures, import taxes on medical equipment’s should be withdrawn
 Electricity and water charges should be subsidized
 Various acts and regulations governing hospitals should be brought under single window and single registration should be made the norm. As on today, more than 72 such clearances are required

 Tax exemptions for medical start-ups.

Birth companions allowed during delivery in public health facilities: IMA welcomes move

Birth companions allowed during delivery in public health facilities: IMA welcomes move New Delhi, February 27, 2016: Birth companions are women who have experienced the process of labor and provide continuous one-to-one support to other women experiencing labor and childbirth. The presence of a female relative during labor is a low-cost intervention, which has proved to be beneficial to the women in labor. These women provide emotional support (continuous reassurance), information about labor progress and advice regarding coping techniques, comfort measures (comforting touch, massages, promoting adequate fluid intake and output) and advocacy (helping the woman articulate her wishes to the other). “IMA welcomes the innovative move by the Ministry of Health and Family Welfare aimed at reducing the maternal mortality ratio and infant mortality rate in the country. According to the recent announcement, birth companions will now be allowed during delivery in public health facilities. This step signifies India’s commitment under SDGs to further accelerate initiatives with specific focus on quality parameters of the interventions, “said Dr S S Agarwal, National President IMA & Padma Shri Awardee Dr K K Aggarwal, President HCFI and Honorary Secretary General IMA. Pre-requisites for a birth companion The birth companion has to be a female relative, preferably one who has undergone the process of labor. In facilities where privacy protocols are followed in the labor room, the husband of the pregnant woman can be allowed as a birth companion. She should not suffer from any communicable diseases. She should wear clean clothes. She should be willing to stay with the pregnant woman throughout the process of labor. She should not interfere in the work of hospital staff and the treatment procedures. She should not attend to other women in the labor room. The World Health Organization promotes labor companionship as a core element of care for improving maternal and infant health (WHO 2002). The regional plan of action for maternal and neonatal health care includes the monitoring of maternal and fetal well-being, and encourages the presence of a companion to provide support during labor and delivery as one of the interventions to improve neonatal health. A trained birth companion contributes to reduced tension and shortened labor, increased mother's feelings of control, decreased interventions and cesareans. It also enhances the partner's participation, improves outcome for the newborn, facilitates parent/infant bonding and decreases postpartum depression while increasing positive feelings about the birth experience. Robert Bradley in 1947 gave the woman's partner an active, major role (i.e., husband-coached childbirth) and emphasized an extremely natural approach, with few or no drugs and little medical intervention during labor and delivery. The Bradley Method emphasizes that birth is a natural process; mothers are encouraged to trust their body and focus on diet and exercise throughout pregnancy; and it teaches couples to manage labor through deep breathing and the support of a partner or labor coach

First Uterus Transplant in the United States​

First Uterus Transplant in the United States​ 
Dr K K Aggarwal

 
The first uterus transplant in the United States was carried out at the Cleveland Clinic.

Spanning nine hours, the operation was performed using a uterus from a deceased donor. It would take a year before the patient can try to become pregnant, allowing her time to heal and providing doctors room for adjustment in medications required to prevent rejection of the organ. Pregnancy would thereafter be possible only through in vitro fertilization. The patient’s eggs were removed surgically before the transplant, fertilized through her husband’s sperm and frozen.
The uterus transplant will be temporary, and it will be removed after the patient has had babies, so as to cease anti-rejection drugs.

Mats Brannstrom, Professor and Chairman, Department of Obstetrics and Gynecology, University of Gothenburg, Sweden and a world leader in uterus transplantation, forecast that this procedure would become popular in the future and expected that India would see its first baby from uterus transplantation by 2018, remarking that one in every 4,000 girls are born without a uterus across the globe.

Dr Brannstrom pioneered the first healthy baby delivered following uterus transplantation.

Saturday 27 February 2016

Birth companions allowed during delivery in public health facilities

Birth companions allowed during delivery in public health facilities 
Dr SS Agarwal, Dr KK Aggarwal

 
IMA has welcomed the innovative move by the Ministry of Health and Family Welfare aimed at reducing the maternal mortality ratio and infant mortality rate in the country.

Birth companions will now be allowed during delivery in public health facilities. This step signifies India’s commitment under SDGs to further accelerate initiatives with specific focus on quality parameters of the interventions. 
 
Birth companions are women who have experienced the process of labor and provide continuous one-to-one support to other women experiencing labor and child birth. The presence of a female relative during labor is a low-cost intervention, which has proved to be beneficial to the women in labor. These women provide emotional support (continuous reassurance), information about labor progress and advice regarding coping techniques, comfort measures (comforting touch, massages, promoting adequate fluid intake and output) and advocacy (helping the woman articulate her wishes to the other). 
 
Pre-requisites for a birth companion
The birth companion has to be a female relative, preferably one who has undergone the process of labor. 
  • In facilities where privacy protocols are followed in the labor room, the husband of the pregnant woman can be allowed as a birth companion. 
  • She should not suffer from any communicable diseases. 
  • She should wear clean clothes. 
  • She should be willing to stay with the pregnant woman throughout the process of labor. 
  • She should not interfere in the work of hospital staff and the treatment procedures. 
  • She should not attend to other women in the labor room. 
The World Health Organization promotes labor companionship as a core element of care for improving maternal and infant health (WHO 2002). The regional plan of action for maternal and neonatal health care includes the monitoring of maternal and fetal well-being, and encourages the presence of a companion to provide support during labor and delivery as one of the interventions to improve neonatal health. A trained birth companion contributes to reduced tension and shortened labor, increased mother's feelings of control, decreased interventions and cesareans. It also enhances the partner's participation, improves outcome for the newborn, facilitates parent/infant bonding and decreases postpartum depression while increasing positive feelings about the birth experience. 

Robert Bradley in 1947 gave the woman's partner an active, major role (i.e., husband-coached childbirth) and emphasized an extremely natural approach, with few or no drugs and little medical intervention during labor and delivery. The Bradley Method emphasizes that birth is a natural process; mothers are encouraged to trust their body and focus on diet and exercise throughout pregnancy; and it teaches couples to manage labor through deep breathing and the support of a partner or labor coach.

Draft IMA Antibiotics Policy

Draft IMA Antibiotics Policy

Dr KK Aggarwal


In a survey conducted by IMA, it was revealed that 50% of the healthcare providers felt that costlier medicines are stronger and better; 70% felt that newer drugs are better and stronger; 87% felt that minimum 2 antibiotics are required for fever; 80% co-related cough with necessity of antibiotics; 90% used Lerofloaxem  for Respiratory Tract infections and 50% were not aware with the terminology called Healthcare associated infections.  70% of them felt that it is cheaper to give an antibiotic than to investigate a patient in an overcrowded OPD.

Most practitioners were also afraid of legal and Consumer Protection Act implications.

Recently a case was filed against a Pediatrician under IPC 269 & 270 where he was charged criminally negligent as the neonate development hospital acquired septicemia

Central Government Act
Section 269 in The Indian Penal Code
269. Negligent act likely to spread infection of disease danger­ous to life.—Whoever unlawfully or negligently does any act which is, and which he knows or has reason to believe to be, likely to spread the infection of any disease dangerous to life, shall be punished with imprisonment of either description for a term which may extend to six months, or with fine, or with both.

Section 270 in The Indian Penal Code
270. Malignant act likely to spread infection of disease danger­ous to life.—Whoever malignantly does any act which is, and which he knows or has reason to believe to be, likely to spread the infection of any disease dangerous to life, shall be punished with imprisonment of either description for a term which may extend to two years, or with fine, or with both.”



MCI Ethics Regulations 2.4 talks about that a patient should not be neglected. Also MCI Regulation 3.1.2 warns not to do investigations in a routine manner.  On the contrary,  2002 Judgement of Supreme Court by Justice M. Kartzoo said that one should not  rely only on clinical history but also go for investigations when indicated.


“MCI Ethics Regulations
2.4 The Patient must not be neglectedA physician is free to choose whom he will serve. He should, however, respond to any request for his assistance in an emergency. Once having undertaken a case, the physician should not neglect the patient, nor should he withdraw from the case without giving adequate notice to the patient and his family. Provisionally or fully registered medical practitioner shall not willfully commit an act of negligence that may deprive his patient or patients from necessary medical care.

1.1.2        Consulting pathologists /radiologists or asking for any other diagnostic Lab investigation should be done judiciously and not in a routine manner.”



We have not come across on any legal case against a doctor for using Antibiotics. In most of the cases, cases for filed for not using antibiotics. 
Medical profession is often blamed of over prescribing, writing newer drugs when older drugs are equally affected. British Media, especially BMJ & Lancet, has been writing that development of bacterial resistance in India is because of corruption and over use of antibiotics. 

Most doctors in India work in adverse situations which is the major factor for development of drug resistance.

Drug General Controller of India does not inform the introduction of newer drugs or banning of a drug to each & every doctor on a regular basis.  Just putting the information in a newspaper or on the website is not the answer, as 50% of the doctors even today are not digital friendly.

As per MCI 1.2.3 Regulation, medical graduates needs to update their knowledge on a regular basis but the Council has not made it mandatory for the medical colleges to hold annual review programme on an yearly basis.  Most of the medical updates are pharma sponsored and the information, a practitioner gets, is often biased.

Price variations are allowed in the country. In a recent IMA Survey, it was found that the drug Meropanam (with equivalent salt)  can be available at Rs. 500/- as well as at Rs.2,800/-.

Multiple brands in the country will invariably allow practices to lure doctors.

The list of drug prices is also not available on a centralized Govt. website.

A General practitioner has no access to anti biogram or recommendations from Infection Control committee. Even NABH does not enlist that information.  

Even the Govt. Policy of intermittent regimen for treatment for TB and now shifting to daily  regimen has created more confusion than right answer.

Govt. has opened Jan Aushadhi Kendras but most of the essential drugs are not available there.

Most of the doctors fear prescribing Pencilin and Septron though pencilin still has no resistance to any antibiotics.

No regulation against quacks, AYUSH doctors, chemists and Nurses to prescribe allopathic antibiotics also ends up in over and irrational prescriptions.

UN-checked use of antibiotics in animals  husbandry & agriculture use adds to the existing problems.


IMA Contribution:

·         IMA is compiling 10 Points which every doctor must know about antibiotics ·         IMA is appointing an Independent Infection Control Committee at National/State and Branch level. ·         IMA is conceptualizing Trade Tendering for vaccines so that they are available at a cheaper cost to the patients. ·         IMA is compiling a book on “ when not to use antibiotics”.

Friday 26 February 2016

IMA Welcomes Bio Toilets in the Trains

IMA Welcomes Bio Toilets in the Trains
Dr SS Agarwal, Dr KK Aggarwal

 
All trains in India should have eco-friendly bio-toilets. They are based on bio-digester concept of the Defence Research and Development Organisation (DRDO). 

Bio-toilets would ensure that there was no bad smell in toilets and no infestation of cockroaches and flies, besides eliminating the ordeal of removing human waste, which was acidic in nature and causing corrosion in coaches as well as the track.

Under the bio-toilet concept of the DRDO, the bio-digester tank in every toilet is filled with inoculums containing four types of bacteria. The water trap system in the toilet prevents air from getting into the tank, the human waste is processed by anaerobic bacteria in seven chambers in the tank and the methane gas is allowed to escape into the air.
Indian Railways will provide 17,000 bio-toilets in trains and additional toilets at 475 stations before the closure of this financial year.

Some facts
  • 60% of Indian population defecates in the open
  • Annually 2.4 million Indian children die of diarrhea, caused by open defecation
  • GOI spends INR 12 billion on rectifying ailments resulting from improper sanitation
  • 78% girls in rural India drop out of school owing to inadequate sanitation facilities
  • Indian Railways spends INR 350 Crore annually on rectifying rail corrosion
  • Only 31% of our country's population has access to proper sanitation facilities
  • Only 11% of the Indian rural families dispose child excretion safely
  • 80% of children's solid excretion is left in the open or thrown into the garbage
  • Over 75% of our country's population has access to Mobile Phones but basic Sanitation is a remote dream!
  • Untreated human waste leads to Viral Gastroenteritis, Typhoid, Cholera, Jaundice, Diarrhea, Viral Hepatitis, Malaria and Chikungunya.

Thursday 25 February 2016

IMA’s stand on Life-Saving Machines, Devices, and Equipment

IMA’s stand on Life-Saving Machines, Devices, and Equipment

 New Delhi, February 25, 2016: Life-saving machines and devices such as pacemakers, CPAP, BiPAP, orthopedic implants, intra cardiac valve replacements, vascular stents, relevant laboratory diagnostic tests, X-ray and such similar implants and machines are often prescribed by registered medical practitioners to their patients.

“The Indian Medical Association (IMA) believes that all such life-saving equipment’s are and should be fully covered in insurance policies/Mediclaim/PSU reimbursement etc. Accordingly, IMA has sent out a notice to all its 2.5 lakh members advising them to educate their patients, who have been prescribed any such life-saving equipment as well as helping them get their treatment reimbursed”,
said Dr SS Agarwal – National President IMA and Padma Shri Awardee Dr KK Aggarwal – Honorary Secretary General IMA and President HCFI

The IMA policy is validated by the following judgments:
1. In case titled as “The New India Assurance Co. Ltd. & Anr. Versus Mrs. Sonali Sareen & Anr”, during the course of treatment in Sir Ganga Ram Hospital, the patient was recommended to purchase the CPAP/BiPAP machine.  Since the purchase of the machine was recommended by the treating doctor, the complainant purchased the same for a sum of Rs. 70,000/- and thereafter lodged the claim under the cashless insurance policy.  The Ld. District Forum had held that purchase of machine was the part of the treatment and without this machine the patient could not have been treated. Thus, denial of the payment of this price of the machine is tantamount to deficiency of service on the part of the insurance company. The said order and judgement passed by Ld. District Forum had been duly accepted by the Hon’ble State Consumer Disputes Redressal Commission vide order dated 09.12.2014.

2. Further, in the matter titled as “New India Assurance Co. Ltd. versus Ganashyamadas A. Thakur,” vide order and judgment dated 07.02.2014, Hon’ble National Consumer Disputes Redressal Commission had held that:


“The fact that Respondent/Complainant wife had taken treatment as an in-patient at M/s Bhagwan Mahaveer Jain Hospital for Severe Obstructive Sleep Apnea is not in dispute. It is further an admitted fact that on discharge she was advised CPAP usage at night as a continuing part of the treatment to regulate her breathing and ensure that there was adequate inflow of oxygen since the CPAP had to be used along with 1-2 litre oxygen/minute. Keeping in view this important fact, we find force in the conclusion reached by the Fora below that like the pacemaker, which is used to control abnormal heart rhythms, the CPAP device though not an implant is a continuous positive airway pressure to keep the airways open and thus like the pacemaker is not only an integral part of treatment but necessary for patient survival. No doubt Clause 2.4 of the policy does not mention CPAP but it is obviously not a comprehensive list because it talks of various devices like pacemaker. As stated above, since the CPAP device like the pacemaker is important for the patient treatment and survival, it may not be reasonable to exclude it. Apart from this, in the exclusion clause, on which the Petitioner/OP had relied before the Fora below, it is stated that the Insurance Company will not be liable to make any payment in respect of the equipments, such as braces, non-durable implants, eyeglasses, contact lenses etc. These may be important but are not life-saving equipments unlike the CPAP. So far as the hospitalization of Respondent/Complainant daughter is concerned, we also agree with the conclusion reached by the Fora below and directing the Petitioner/OP for reimbursement of the same.”

Ten points which an interventional cardiologist must explain to referring physician

Ten points which an interventional cardiologist must explain to referring physician

Dr K K Aggarwal


1.     That ECG can be normal in acute MI
2.     That acute onset LBBB often has underlying acute CAD
3.     That among patients treated with fibrinolytic drugs for STEMI there are two types of failed therapy: primary failure and threatened reocclusion.  Immediate percutaneous coronary intervention is the treatment of choice for both forms. It is called rescue or salvage PCI when performed after primary failure.
4.     That coronary artery reperfusion with either PCI or fibrinolytic therapy improves clinical outcomes in nearly all groups of patients with an acute STEMI who present within 12 hours of symptom onset.
5.     That for STEMI patients who present within 12 hours of symptom onset, do primary PCI rather than fibrinolysis if PCI can be delivered within 120 minutes of first medical contact by skilled practitioners
6.     That primary PCI should be performed within 90 minutes for patients who arrive at or who are transported by an emergency medical service to a PCI-capable hospital. Patients who arrive at or who are transported to a non-PCI-capable hospital should be transported urgently to a PCI-capable hospital if they can receive primary PCI within 120 minutes of first medical contact. 
7.     That for patients who cannot receive timely primary PCI, fibrinolytic therapy should be given. Fibrinolytic therapy should be administered within 30 minutes of first medical contact, and sooner if possible.
8.     That for patients who present after 12 hours (and up to 24 hours) of symptom onset who have evidence of ongoing ischemia, do PCI as opposed to no reperfusion therapy
9.     That for patients with severe heart failure, hemodynamic, or electrical instability, do primary PCI as opposed to no reperfusion therapy
10.  That for patients who appear to have a large area of myocardium at risk or hemodynamic instability and for whom PCI is not available, give fibrinolytic therapy as opposed to no reperfusion therapy

Door to balloon time should be reduced

Door to balloon time should be reduced

Dr K K Aggarwal

Primary percutaneous coronary intervention (PPCI) with stenting, if performed in a timely manner, is associated with better outcomes than fibrinolysis. Also the time from symptom onset to PCI has not been shown to be an important determinant of outcome. The benefit from PPCI is less dependent upon the time from symptom onset than is fibrinolysis.
However the time from hospital arrival to PCI (door-to-balloon time) is an important determinant of benefit, with the best outcomes occurring when the time to PCI is 90 minutes or less.
Increasing system delay is associated with worse outcomes.

Patients who are transferred to a PCI center have better outcomes than those treated with fibrinolysis at the presenting hospital. Most of the benefit is due to a lower rate of reinfarction after PCI, which is unrelated to the time required for transfer.

Ambulance protocols that bypass non-PPCI-capable hospitals and thereby shorten system delays to PPCI are associated with improved outcomes in ST elevation myocardial infarction.

Hospitals also should adapt strategies to reduce door-to-balloon times and thereby improve outcomes in STEMI patients treated with PPCI.

PPCI should not be performed in hospitals without on-site cardiac surgery unless they meet specific criteria, including having a proven plan for rapid transport to a cardiac surgery operating room in a nearby hospital and having appropriate hemodynamic support capability for transfer.
Primary PCI should be performed within 90 minutes for patients who arrive at or who are transported by an emergency medical service to a PCI-capable hospital. Patients who arrive at or who are transported to a non-PCI-capable hospital should be transported urgently to a PCI-capable hospital if they can receive primary PCI within 120 minutes of first medical contact. 

For patients who cannot receive timely primary PCI, fibrinolytic therapy should be given. Fibrinolytic therapy should be administered within 30 minutes of first medical contact, and sooner if possible.

Each 30 mins delay leaves to 7.5% increase in mortality 
Remember  3 D
1.     Door to balloon time
2.     Early and correct diagnosis
3.     Dedicated acute MI set up in the hospitals  

MCI code of ethics: 2.4 The Patient must not be neglected: A physician is free to choose whom he will serve. He should, however, respond to any request for his assistance in an emergency. Once having undertaken a case, the physician should not neglect the patient, nor should he withdraw from the case without giving adequate notice to the patient and his family. Provisionally or fully registered medical practitioner shall not wilfully commit an act of negligence that may deprive his patient or patients from necessary medical care.






Wednesday 24 February 2016

Health and the Union Budget: IMA’s Viewpoint

Health and the Union Budget: IMA’s Viewpoint

New Delhi, February 24, 2016: India continues to have a high burden of diseases despite the various health program and policies, which have not been able to achieve the desired goals and objectives.

A High-level expert group (HLEG) on Universal Health Coverage (UHC) constituted by Planning Commission of India submitted its report in Nov 2011 for India by 2022. The recommendations for the provision of UHC pertain to the critical areas such as health financing, health infrastructure, health services norms, skilled human resources, access to medicines and vaccines, management and institutional reforms, and community participation. Planning commission has estimated that 3.30 lakh crores has to be spent in 12th FY period (2012-2017) to achieve the goal of UHC by 2022. We are already into fourth year of the 12th FYP and yet only a meager proportion of this amount has been budgeted so far on an annual basis.
                                                         
Public spending on health - It is believed that an important factor contributing to India’s poor health status is its low level of public spending on health, which is one of the lowest in the world. In 2007, according to WHO’s World Health Statistics, India ranked 164 in the sample of 191 countries in per capita terms. This level of per capita public expenditure on health was less than 30% that of China (WHO, 2010). Also, public spending on health as a percent of GDP in India has stagnated in the past two decades, from 1990–91 to 2009–10, varying from 0.9-1.2% of GDP.

“If we look at the world health delivery models, most of the developed countries are health care providers, e.g. UK and most of the European countries, Australia etc. Some countries like United States are health care facilitators. India is neither a health care provider nor a facilitator. This is obvious from the budget allocations over the years, which have stagnated around 1%. India should have set apart at least 5% of the GDP for health care. India is neither a health care facilitator since the private sector which provides 70% of the health care is not, in anyway, supported by the Government. On the other hand, the government is bringing more and more regulations which affects financial viability of the private health care institutions and denial of health care through the private sector. 80% of health expenditure of our population is out-of-pocket”, Dr SS Agarwal, National President IMA & Padma Shri Awardee Dr KK Aggarwal, President HCFI and Honorary Secretary General IMA said.

A few of IMA’s suggestions for the Union budget:


  • To increase the public expenditure on health from the current level of 1.2% GDP to at least 5% by the end of the 12th.
  • To ensure that a minimum of 55% of health budget is spend on primary, 35% on secondary and a maximum of 10% on tertiary care services as against the current levels of 49%, 22% and 28% respectively
  • Separate funds should be allocated for national disease control programs. Presently these programs cover only 15% of disease burden. Lifestyle diseases, re-emerging communicable diseases, health problems of the elderly, mental health, rare diseases, orphan drugs, etc. should receive adequate funds.
  • There are 6000 rare diseases identified in India with 6 million people suffering from it. Recently, in a Judgment, the Supreme Court observed that all doctors should be aware about rare diseases. Two more Delhi High court Judgments by Justice Manmohan Singh have clearly defined that under Articles 14 and 21 of the Constitution, every person suffering from rare disease has the right to receive medical treatment free of cost from the State Govt.
  • Special funds should be allotted for research and surveillance of epidemics like virology centers, research studies on possible newer epidemics like Ebola.
  • There should be a separate budget to train 100% of general public in CPR. With this, more than 20 lakh deaths can be avoided even in the absence of medical professionals.
  • Any outbreak is a national calamity for which a separate budget should be earmarked and should be supported by the national government. During the outbreak, the Govt. should provide charges for hospitalization, investigations and drugs to the effective person in the Govt. sector and reimburse at CGHS rates in the private sector. Also each death in the outbreak should be suitable compensated.
  • Separate budget to treat all emergencies and the cost to be reimbursed at CGHS rates to any one providing the service.
  • Funding of research centers should be increased and ensured, particularly health issues related to pilgrimages, mass gatherings, religious festivals and natural disasters and health impact of industrialization.
  • Funding of special health issues among the tribal, coastal population, industrial townships should be separately earmarked.
  • Food safety needs to be addressed with special fund for research and surveillance • Vaccine development and introduction to national vaccination schedule of new vaccines should be supported.