Wednesday, December 15, 1999

CPR & ECC: hearty revival
By Dr Suman Sharma Grover
While the history of resuscitation can be traced back to the Biblical times, expired air ventilation has been used throughout in an effort to revive the apparently dead. Tracheotomy was performed in the twelfth and thirteenth centuries in the treatment of drowned person. Paracelsus (in the late fourteenth century) is usually credited with the introduction of bellows to ventilate the lungs.

Their bloated childhood
By Dr Usha Kanwar
Obesity is no longer restricted only to the affluent nations. It has become a weighty problem worldwide. The percentage of obese persons is the highest in East Europe where it approximates more than 50 per cent among women whereas it is the lowest in Scandinavian countries. The percentage of obese Americans is roughly 35.

Let’s target men first-II
“Surveys show that only a minority of men — perhaps no more than one in three or one in four — has sexual relationships with someone other than their long-term partner. But that figure represents several hundred million men worldwide," says Martin Foreman, Director of the Panos AIDS Programme.

When no one went hungry
By Nancy Adajania

In my ancestral home in Gujarat, everybody was provided for. Even as hot water was poured into the morning dough, small balls of jowar were placed around the "thaal" for hungry ants. And in the blistering hot afternoons, water and food were given to the mentally ill, the orphans and old people from the village. At dusk, the cows nuzzled at the "chapatis" we held out to them, and after dinner, the bones were put aside for the dogs of the mohalla.

Before sleeping, my grandmother left a handful of grain in an otherwise empty granary jar, or a small piece of "chapati" in the steel box at night. I always thought that she was superstitious, repeating some ancient custom that has lost its meaning. Actually, she was practising the traditional act of giving: even non-living beings like vessels had to have their powers renewed with food; no mouth could go hungry. This act of giving was based on the principle of sharing, giving without expectation of return. A sense of wholeness was preserved in society by the act of sharing one's goods with others and constantly replenishing both, our physical and spiritual reserves. Here, there was no place for vulgar hoarding or investments made for future returns.

Sharing was institutionalised in traditional Indian society through the establishment of institutions of hospitality and learning. These institutions flourished all over India, from Kedarnath in the north to Thanjavur and Rameswaram in the south, as Jitendra Bajaj and Mandayam Doddamane Srinivas inform us in their book, Annam Bahu Kurvita. The chetrums, the charitable institutions of Thanjavur where people rested on their way to Rameswaram, were equipped with teachers and doctors. All the travellers, whether Brahmins or otherwise, were given boiled rice.

Today, these institutions have been replaced by the State, whose idea of giving is to perform spot-jobs in moments of crisis. What the State gives, through its ill-planned yojanas, can only be termed procedural giving. People live on subsistence wages, are underfed and thoroughly exploited; they just about survive at the margins of society. It is an ill-conceived charity that NGOs too indulge in. There are several voluntary organisations which function as disaster-management operators, confined to giving out the mandatory food and clothes to victims of some catastrophe or the other, and then moving on to worse-hit pastures.

On my field trips into the interiors of Maharashtra, it has been my experience that charity born out of ignorance leads to resentment, violence and anger in its recipients. It leads to despondency, a complete breakdown in the ability to think for oneself and finally, laziness and defeat.

The word charity comes from the Latin word caritas, concern. But charity today has come to mean nothing more than the system of doles, which will result in a generation that will never break this unequal contract of token generosity.

In the mid-18th century, British administrators made a detailed study of the traditional institutions of charity because they thought that large sums of money were being wasted on such useless activities. They felt that they could not extract revenue in areas where the act of giving was considered sacred. They systematically abolished these institutions which, for them, were a drain on the economy (that is, they cut into the profits that would otherwise accrue to the para-colonial British administration).

In the Report of the Indian Famine Commission, London, 1880, the commissioners worked out a neat transaction with the famine-affected people. First, put them on a 'dole'; then withdraw it, as soon as the people are fit to start work. This might seem like a logical solution, but the relief they recommended for the people was a hard day's work at specially organised labour camps in return for a subsistence wage 'sufficient for the purposes of maintenance but no more".

This situation should not come as a surprise to the recipients of the EGS (Employment Guarantee Scheme), especially in Maharashtra. The EGS is meant to support people during critical situations like drought or crop failure. But in Maharashtra, the EGS is employed for road construction, electrification and afforestation, thus limiting the employment opportunities of people who could have done the same work for higher market wages. Or take the ICDS, the Integrated Child Development Scheme, which provides khichri to undernourished children, but does not feel it necessary to construct creches so that the children of working mothers are not neglected.

An intelligent charity born of vision and compassion for its recipients is the only way out; nothing can be achieved by extending the leprous hand of condescension.

Courtesy : Humanscape

CPR & ECC: hearty revival
By Dr Suman Sharma Grover

While the history of resuscitation can be traced back to the Biblical times, expired air ventilation has been used throughout in an effort to revive the apparently dead. Tracheotomy was performed in the twelfth and thirteenth centuries in the treatment of drowned person. Paracelsus (in the late fourteenth century) is usually credited with the introduction of bellows to ventilate the lungs.

The modern history of resuscitation began in the middle of the eighteenth century. This was a period when a wave of humanitarianism spread through Europe. A society for the Recovery of Drowned Persons was founded in Amsterdam in 1767. In the past two decades, positive pressure ventilation applied to the mouth has been used for resuscitation.

The interaction closed chest compression with mouth-to-mouth ventilation was developed as basic cardiopulmonary resuscitation (CPR) which offered greater hope by substantially reducing sudden deaths that occurred each day before the patients reached the hospital. Effective CPR is based on the artificial delivery of oxygenated blood to systemic circulatory beds at rates sufficient to preserve vital organ functions and at the same time provide physiological substrate for the return of spontaneous circulation.

In 1966, CPR training was recommended in USA for medical, allied health and other professional personnel by the external chest compression technique. In 1973 the CPR training programme was extended to the general public. This training — basic life support (BLS) and advanced cardiac life support (ACLS) — is provided by highly trained personnel for all life-support units and hospitals on an integrated stratified communitywise basis. Unfortunately in India, we do not have any such organised programmes and even our young graduates, who come out of medical colleges, fail to perform cardiopulmonary resuscitation in case of an emergency.

Heart attack (myocardial infarction) is the most sudden cause of death and is a prominent medical emergency. In addition, many victims of drowning, electrocution, suffocation and drug intoxication can be saved by the prompt initiation of CPR and the early use of ACLS. Strokes are another problem of a high magnitude and need early diagnosis and treatment. This is possible by prompt action to provide rapid entry into the emergency medical services (EMS). The early application of ACLS techniques in the neonatal period not only saves lives but also, by avoiding brain damage, prevents a lifetime of suffering and economic drain from occurring. Trauma is the major cause of death and debility in the paediatric and young adult population (age 1-44 years). The emphasis on trauma prevention in the paediatric programmes promises to educate a large segment of the lay public in injury-prevention.

The greatest risk of death from a heart attack occurs within two hours after the onset of the symptoms. The success of thrombolytic agents in decreasing the morbidity and mortality of acute myocardial infarction (MI) has increased the urgency for early care. The efficacy of thrombolytic therapy in altering the course of acute MI decreases rapidly with time.

Beyond six hours after MI, the value of thrombolytic therapy is limited.

The public, especially persons at high risk and their families and friends, must recognise the usual signs of a heart attack and the need for prompt attention.

They must be taught how to gain rapid access to the EMS system. The optimal way to facilitate EMS response is through the use of the emergency telephone of a hospital that provides 24-hour life-support capability. The victim should be accompanied by someone, whenever possible, to drive and assist if necessary.

The purpose of BLS programmes is strictly educational. These are designed for imparting training in CPR and for the use of the acquired skills. Targeting courses to relatives and close friends of the persons at high risk must be continued. Students bring a number of concerns to these courses, and these must be addressed. These include the fear of imperfect performance, the fear of responsibility, anxiety and guilt — and the fear of infection. In addition, students are frequently reluctant to perform CPR even after they are trained. Programmes must, therefore, incorporate information about the willingness to perform CPR and students must be encouraged to develop an individualised action plan in the event of emergency.

Retention is another key issue in BLS education. To improve retention, the multiple performance steps should be simplified and key factors that determine successful performance and outcome highlighted. Flexible approaches to education such as public service announcements and the use of videotapes should be encouraged. Timely feedback on knowledge and skill acquisition will allow the learner to evaluate his or her performance and correct deficiencies or review the students manual.

The need for immediately available BLS and rapidly available defibrillation and ACLS places an obligation on those responsible for facilities with a large captive population. The managers of factories, schools, office buildings, apartments, stadiums, large fairs and the like should be encouraged to train security and other personnel in the techniques of CPR and the use of the automated external defibrillators. BLS training, ACLS capability and early ACLS can be relatively inexpensive. The investigation of EMS capabilities in the immediate area of the facility may provide an acceptable solution without additional expenses.

Guidelines for CPR and emergency cardiac care (ECC): The imperative for accessing EMS promptly is telephoning EMS whenever possible as a first step in the BLS protocol when witnessing a collapse or coming across an unresponsive victim. However, in the paediatric age group, one minute of CPR is still recommended after the initial assessment and before breaking to call EMS. Obviously shouts for help should occur immediately after the initial assessment. The time taken during the ventilation for filling of the lungs is 1.5 to two seconds per breath to further decrease the likelihood of gastric insufflation. In infants and children, where small tidal volumes are required, the ventilatory rates are faster — one to 1.5 seconds per breath. Ventilation is accomplished by the mouth-to-mouth technique after clearing the victim's mouth with a piece of cloth if there are secretions or vomits. The head tilt, chin lift method is recommended for initial airway control.

The unresponsive victim with spontaneous respiration should be placed in the "recovery position" if no cervical trauma is suspected. The placement in the recovery position consists of rolling the victim on to his or her side to help protect the airway.

Instructors in BLS need to be familiar with and able to teach mouth-to-barrier-device ventilation. The oesophageal obturator airway, the oesophageal gastric tube airway, the combination of oesophageal tracheal tube and the pharyngotracheal lumen airway are also used. When the victim is pulseless, chest compression is begun by locating the proper hand position — 15 external chest compressions at the rate of 80-100 per minute with two slow rescue breaths.

ACLS includes the knowledge and skills necessary to provide the appropriate early treatment for cardiopulmonary arrest. Therefore, the rescue personnel should know the indications for and the techniques of using adjunctive equipment and drugs. Such equipment should be tested periodically according to the prescribed regulations and adequate records of such tests should be maintained. These techniques include electrocardiographic (ECG) monitoring, arrhythmia's recognition and the establishment and maintenance of intravenous (IV) access.

Public service announcement by CPR training organisations should promulgate a single message to activate the EMS system first. The early activation of the EMS system is a vital part of the guidelines. In addition, the assessment and early performance of bystanders in providing CPR are critical and lay persons should be encouraged to learn BLS.

The writer is a consultant anaesthesiologist based in Chandigarh.

Their bloated childhood
By Dr Usha Kanwar

Obesity is no longer restricted only to the affluent nations. It has become a weighty problem worldwide. The percentage of obese persons is the highest in East Europe where it approximates more than 50 per cent among women whereas it is the lowest in Scandinavian countries. The percentage of obese Americans is roughly 35. Even in poorer nations such as China, India and parts of South America, people are getting fatter faster than before. According to a report in Lancet, obesity is a "potential medical calamity", which predisposes one to many serious human ailments including cardiovascular diseases, diabetes and stroke, to name just a few.

The scene in India has become murky.

According to a study done by the Nutrition Foundation of India, Delhi, more than half of the urban females and one third of the urban males in this country are obese. These figures get even more scaring when we consider the fact that Indians are genetically predisposed to accumulating fat in the tummy region, resulting in abdominal obesity which is far more sinister than general obesity.

This is a major cause of concern because abdominal obesity exists even among those who do not look obese or are so, if we adhere strictly to well-established anthropometric parameters and other physiological determinants.

According to an article published in Paediatricts, obesity is one of the most serious health problems facing today's youth.

The obesity scene in our country is getting worse as has been pointed out in the editorial in the recent issue of the Journal of the Indian Academy of Paediatrics which forewarns that childhood obesity here is expected to reach epidemic proportions among the Indian affluent.

According to Dr N.K. Arora, an Indian epidemiologist, while "we have 53 per cent children who suffer from undernutrition, there is an emerging class which is suffering from a different kind of malnutrition" involving not only increased food intake but also the sedentary lifestyle of children from affluent homes. "Such children are spending more time on physically passive activities like TV-viewing, computer games and talking on the phones", says Dr Shetty, Professor of Human Nutrition at the London School of Hygiene and Tropical Medicine.

Further, "these affluent children" are being sent to school in cars and discouraged from playing on streets for fear of accidents. Such passive behavioural patterns are compounded by the consumption of high-fat or high-sugar foods.

A survey of more than 4000 children aged 8 to 16 years has revealed that those who watch TV for four hours or more daily are significantly fatter than those who watch it for two hours or less (Health and Nutrition, May 1999). These observations stand corroborated by US nutrition experts who too have concluded that "watching too much TV is one of the main reasons why so many children in the USA are overweight".

Dr Wilhelm Dietz, a nutrition scientist at the National Centre for the Prevention of Chronic Diseases in Atlanta, said sometime ago that the tests carried out at several schools in Massachusettes and at a clinic in Pittsburg, Pennsylvania, showed clearly that children soon shed their excess weight when they ceased spending much time in front of TV sets. These tests involved studying the eating and TV-watching habits of 1,295 school children in the sixth and seventh grades.

The experimental study revealed that overweight children, who reduced the time they spent watching TV by 20 hours per week, lost up to 20 per cent of their body weight in four months, and were able to maintain their slimness. By comparison, another group of TV addicted children who simply did more physical exercise during the same period lost only 13 per cent of their weight and after a degree of initial success quickly put it back again. According to Dr Dietz, the parents tended to underestimate the amount of time their children spent motionless in front of TV sets.

Paediatricians recommend that children should not be allowed to watch TV for more than one or two hours every day. The more they watch TV, the more lethargic and obese they become.

Dietz recommends that parents of the TV-addicts need to adopt a tactful "bonus strategy" to encourage their children to acquire better habits by providing them with appropriate alternatives so that they are willingly taken away from their sets. One should never provide TV sets in the children's bedrooms even if doing so is affordable.

Obesity is bad but childhood obesity could be worse not merely because it makes one prone to fatness later in life. Plague-clogged arteries (atherosclerosis) have been reported in obese kids as young as six years. Better "nip this evil in the bud", the doctors recommend. Over-feeding by over-enthusiastic parents in infancy and early childhood to make their children look plumpy and chubby leads to an increase in the number of adipocytes (the fat cells) in them which store the excess body fat and also serve as repositories for it later in life.

The formulation of preventive strategies for obese children should start from infancy because excessive weight even at birth is considered to be the forerunner of obesity in later life. Adipocytes, when confronted with excess fat, gradually suck it, increase in volume and finally swell like balloons to accommodate as much of it as possible. If excessive fat intake is allowed to persist, there occurs a matching increase in the number of adipocytes to facilitate additional fat storage paving the way for obesity. However, before adolescence sets in, the adipocytes stop dividing but those already formed stay permanently and are prone to "ballooning up", whenever excessive fat is available. This is how childhood obesity predisposes one to obesity later in life which is a proven risk factor for many serious human diseases. It also serves as a signal for premature ageing as well to early death. Why let it happen any way?

Let’s target men first-II

“Surveys show that only a minority of men — perhaps no more than one in three or one in four — has sexual relationships with someone other than their long-term partner. But that figure represents several hundred million men worldwide," says Martin Foreman, Director of the Panos AIDS Programme.

Although men drive the epidemic, women are more vulnerable to HIV. This is because men often deny women the opportunity to protect themselves and because women are physiologically more susceptible to the virus than men.

A woman is at least twice as likely to contract HIV from a male partner with the virus than the other way around, and the risk for both sexes rises if either has another sexually transmitted infection. Because they are often internal, women tend to be less aware than men of such infections, which further heightens their susceptibility.

When these factors are taken together it means that even though more men than women currently contract HIV worldwide, the rate at which women are infected is rising faster than that of men.

The report says that recognition of their vulnerability has led to women being the target of many HIV/AIDS prevention programmes, particularly through family planning programmes and ante-natal clinics. "Such programmes have played a major role in raising awareness of the disease but in themselves they are insufficient: women cannot protect themselves unless men also do so", it says. — TWMF & Panos

(To be concluded)