Wednesday,
March 17, 1999
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Medical
science and conscience Try to accept disease and
incurability Day-care surgery: some
realities Unmet needs of
adolescents |
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Medical
science and conscience A hospital is an institution which provides relief and comfort to thousands of sick and miserable people and emergency services at all hours.. Its purpose is not only the care of the sick but also the education of medical students and trainees. Working in hospitals has always been hard. Maintaining a balance between the necessary empathy and compassion to really care for our patients, and the emotional distance needed to protect ourselves from being overwhelmed by human suffering has been a continuous challenge. Overwhelming patient loads and dwindling resources multiply the burden and leave the caregivers exhausted. Angry, distressed and demoralised doctors cannot deliver optimal care. We must recognise these problems and invest in delivering the essential relief. The changes in surgical science and surgical care have occurred with such speed that the problems facing us have become unique. Research has led to new innovative therapies, advanced instrumentation and better understanding of the disease process. These advances have saved countless lives which previously would have been lost. The explosion of technological advancement needs incorporation into the current surgical practice so that it is translated into optimal patient care. One has to be appreciative of the potential of computer applications and virtual reality as educational tools. New optical technologies are expected to play a major role in the detection and treatment of cancers. What to talk of these advanced technologies, we are finding it difficult to maintain the existing machinery in a working condition. No one expects the boilers, autoclavers, diathermy machines, ventilators, etc, to keep functioning without regular maintenance. Stress on the machinery causes if to break down and wear out. Caring for patients is inherently stressful as the physician strives to accomplish the often unachievable goals of alleviating suffering and prolonging useful life. These stresses must be recognised by those who are in authority and are responsible for managing the affairs. The awareness of the known stressors will assist in the resolution of the problem. The cost of medical care has become a concern and there is no way to control it. Poor, unemployed and undernourished men, women and children continue to have limited access to medical care. Patients have started resenting the high cost and the increasingly impersonalised nature of medical treatment. The physicians who not focus on the utilisation of resources in the care of the individual patient waste money. we need to justify each test that we order. We have to think and rethink how it will be helpful or useful in making the diagnosis or performing the indicated intervention. What a heritage our profession has had-prestige, respect, morality, ethics, and a deep understanding of the human condition. Forces of change are threatening this heritage —the wonderful legacy we inherited from our professional fathers. A positive working environment is based on humanistic values. We should strive to create an environment that is friendly and positive with respect for one another. We need to keep our ethics and morals above reproach in a difficult environment. We need to be supportive of those who work with us. Health care professionals should encourage personal democracy in which all of us are willing to engage in a respectfully purposeful dialogue with one another. It is important that surgeons working in academic and community medical centres collectively work to the advantage of the colleagues in the particular environment. Otherwise there is the risk of our losing the respect of our colleagues, the faculty and the trainees. All of us need to be more careful about how we conduct ourselves outside our offices and hospitals. It is our duty to nurture the young so that they may proudly enter the appropriate arenas an stand the difficult ground. The heritage that we saw as young persons about the study of medicine is not apparent to today’s youth who see the unhappiness of our profession, and do not want this as their legacy or heritage. If the current trend persists and no remedial measures are taken, the future of our profession will be at stake. The decline is glaring and does not need to be described in so many words. Give people a chance to create and implement their ideas rather than creating obstacles in their functioning and progress. Make hospitals a place where everyone smiles — a lot! Ignite discussion and spark creativity. Remain an unassumingly humble person — a true team player. We should be deserving of the abundant affection of all our colleagues and students, and our teachers. What is needed is the making of a timely diagnosis. The development and appropriate treatment plan and its implementation and a critical assessment of the results are vital. The hope is that all of us will rise to the occasion, take stock of the problems facing us and adopt the necessary corrective steps so that we achieve greater heights in the 21st century. Let us not subject ourselves to unfortunate self delusions characteristic of our profession —and try to improve the system. Will the profession unify so that we gear ourselves to face the problems which we are going to face in the coming years? Dr Wig is a renowned surgeon and
administrator at the PGI. |
Try
to accept disease and incurability SEEKING cure from an illness is a goal cherished by both the patient and the physician. It seems cruel to suggest for a doctor that a particular disease or an ailment is incurable and that at best palliation, and at worst perhaps nothing can be offered. This in spite of so many technological wonders! People find it hard to digest and feel that it is ridiculous to believe that a problem can be insurmountable. One keeps on pondering that a solution must exist—perhaps in a bigger hospital, or abroad— in the dreamland called America. It is left to the lesser gods, such as physicians to explain that the treatment-options are almost similar all over the world. The availability and facilities, however, vary tremendously. This brings us back to the same basic question whether the treatment/option for a particular illness is likely to be curative, palliative or just a placebo. I cannot deny that the availability determines the nature of the treatment to a great extent. What can be cured at a particular centre may only be palliated at another. The most glaring example is that of transplantation of an organ. A damaged kidney may be replaced at a centre where this is routinely done; at other places, it is managed conservatively with drugs. The same holds true for many other surgical and medical treatments and interventions. But advertisements on the availability of treatments are so rampant and the movement of people so frequent that the barriers are only temporary obstacles. Finally, it is the nature of the illness which is the most important factor. Needless to say that the costs, expertise and socio-economic and psychological factors would greatly influence the treatment-seeking behaviour as well as the disease-management score. Palliation remains an important form of treatment for incurable as well as potentially curable diseases. Palliation essentially means relief from distressing complaints. Intractable pains, itching, loss of appetite insomnia, breathlessness and weakness are some of the common symptoms. Several other problems, which may cause almost unending grief, may occur due to the involvement of general or specific body-systems. Unfortunately, palliation is not necessarily feasible all the time. Consider the example of a conscious patient, out of breath from an end-stage lung disease, who is severely restless. You cannot administer sedatives for the fear of stopping respiration. One can offer nothing but only a false assurance. Advanced cancers and organ-failures are typical examples where the issue of palliative vis-a-vis more heroic forms of treatment continues to haunt. More often than not, it is only palliation which can be offered. Although the replacement of an internal, non-functional organ is certainly more close to curative treatment, for the present, it is obviously limited in scope for widespread application. Similarly, very little can be done for many degenerative and genetic diseases. The list of such diseases is almost endless neuromuscular paralyses and degenerations, cardiomyopathies, emphysema, honeycombed lungs, cirrhosis and so on. Even for common problems such as diabetes mellitus, hypertension and asthma, there are no permanent cures, although one can live normally with their presence. The idea of continued medication, with or without other restrictions throughout life, is certainly not the ideal or the most desirable alternative. One finds it very difficult to accept a change in habits and the life-style even for the continuously bothering, although simple problems such as dyspepsia, obesity, smoker’s cough and arthritis which at least are theoretically treatable. Unfortunately, the persistence of a disease and/or its incurability is a fact which is not acceptable. There is nothing wrong in being hopeful, and for that matter aggressive, in seeking treatment. This is a very healthy sign and reflects positive thinking. But there is always a point when acceptance helps in managing a problem more efficiently. I have often felt that we drag a bit long. This may not only delay, but also affect the quality of treatment. Disease-acceptance helps one to adopt more realistic management and avoid the wastage of time and resources in search of an elusive cure. One is also saved from falling in the hands of fraudulent practitioners and charlatans claiming magical cures. The trauma of a failure for a radical cure gets worse with each new effort. This is altogether preventable. It is not my intention even for a moment to reflect pessimism for the inevitability and advocate non-treatment. I shall go the whole hog in identifying treatable problems. In fact, I feel miserable whenever I find someone living with a treatable disease, albeit miserably. Acceptance here is restricted to coping with a problem which is there to last. It is a state of mind which needs to be tuned to the facts of life. Acceptance implies living with a problem rather than abandoning hope. One has to develop alternative routes to live! Wise-counselling, reassurance and other socio-psychological supports are generally required to strengthen the alternatives. Often we remain obsessed with the problem,and the loss. Accepting a problem, on the other hand, is just like dealing with a physical handicap. When one loses a limb, one has to invest one’s energy to minimise the disability and derive the maximum output from the functional limbs. Nothing is served by weeping over the loss. Acceptance is the only way. The sooner it is done, the better it is. Dr Surinder K. Jindal is a
renowned specialist in pulmonary medicine. He heads the
Department of Medicine at the PGI, Chandigarh. |
Day-care
surgery: some realities OVER the last two decades, out-patient surgery also known as day-care surgery or ambulatory surgery has grown at an exponential rate. Today almost 60 per cent of all elective surgery in the USA is performed in the out-patient setting. Though the figure at 25 per cent is quite small in India, it has increased considerably during the past 10 years. This rapid growth in day-care surgery is due to the development of new and short-acting anaesthetic drugs which, in turn, have changed the role of the anaethesiologist. While the surgical procedures are much the same whether performed in the in-patient or out-patient setting, anaesthesia and post-operative nursing care are now significantly different. Here, the anaesthesiologist is responsible for screening, evaluating, informing and preparing the patient-both physically and psychologically-for surgery because he is to be discharged within a few hours of the operation. This calls for specialised skills in out-patient anaesthesia to meet the specific needs of such patients. Out-patient surgery is becoming more and more popular because anaesthesia and surgical procedures are most cost-effective in the out-patient surgical facilities than in the in-patient setting without sacrificing quality. What minimises the cost is the avoidance of unnecessary pre-operative screening, decreasing room turnover times, decreased post-anaesthesia unit stays and reduced unanticipated admission and staffing needs. The term cost-effective-quality-care is frequently mentioned by government as well as private hospitals and nursing homes. One often comes across advertisements of package offers for a particular surgery in newspapers. But it must be remembered that costs cannot be lowered indefinitely without consequently reducing the quality of patient-care. In order to be acceptable, responsible quality must go hand-in-hand with adequate safety, while also reducing costs. Society or the public has to change its expectations regarding the standard of health-care in general. The patient has to decide the amount and quality of health-care he or she can afford. The main clinical advantage of performing an operation on an out-patient basis relates to the reduced demand for post-operative medications and faster recuperation when compared to traditional hospitalisation and bed-rest. From the patient’s point of view, out-patient surgery is less disruptive to personal and family life. In addition, the freed hospital beds can be used by more needy patients. Proper patient-selection is mandatory for successful day-care surgery. Most patients accepted for day-care surgery conform to the American Society of Anaesthesiologists Physical Status I or II. This means that they are free from any systemic illness which can alter the outcome after anaesthesia or surgery. Similarly, surgical procedures suitable for out-patient surgery generally are accompanied by minimal post-operative impairment in the form of blood loss, pain or even nausea and vomiting. Generally, the patient should be able to take care of himself or herself post-operatively. The duration of the surgical procedure per se is not important as long as the post-operative physiological impairment is at an acceptable level. However, longer procedures are usually associated with longer intermediate recovery and a high incidence of nausea and vomiting. These patients are ideally suited for an overnight admission to the hospital. Patients at the extreme of age that is, less than six months and more than 70 years are not suitable for day-care surgery because the recovery of the motor skills and cognitive skills is slower in such patients after general anaesthesia or sedation. By contrast, infants appear to be at increased risk of developing post-operative respiratory complications. Patients presenting themselves for day-care surgery need both pre-operative assessment and pre-operative preparation. The pre-operative assessment is used to obtain relevant information regarding the patients’ medical history, physical condition and laboratory investigations. The pre-operative preparation can be used to facilitate efficient, safe and comfortable transit through the entire process of the surgical procedure. The pre-operative respiratory preparation includes the administration of anxiolytic, sedative, analgesic and antiemetic drugs and written and verbal instructions to the patient. A good pre-operative preparation optimises pre-operative efficiency and ensures an excellent post operative outcome. The pre-operative visit by the patient to the medical centre should be used by the nursing staff to familiarise the patient and the family with the place. The practice of leaving the patient unprepared prior to the day of surgery can result in unnecessary delays, last-minute cancellations and inadequate patient management. A patient is generally concerned about post-operative pain, nausea and about not being asleep during the operation. Out-patients also dislike a lengthy wait prior to surgery. In unprepared patients, a significant amount of anxiety is present at least six days before the operation, Often day-care patients are inadequately sedated because of fear of prolonged recovery. But increased anxiety can lead to an increase in stress hormones and thus also an increase in the anaesthetic requirements, which prolong the recovery time. Besides drugs, these patients should, therefore, be informed about perioperative events to reduce uncertainty. They would then have a better control over the situation due to more clearly defined expectations which, in turn, would help in reducing psychological stress reactions. Thus in a modern day-care centre both psychological and pharmacological means should be used to decreased post-operative morbidity. Proper pre-operative preparation should include written and verbal instructions regarding the arrival time, place, fasting, information concerning the post-operative, course, limitations in driving abilities and the need for a responsible adult to escort and accompany the patient during the post-operative period. Clinical experience suggests that patients should be provided with as much information as they express the need for, but should not be flooded with uninvited details. Children are different from adults in many ways. They may be more emotionally traumatised regarding anaesthesia and the surgical procedure than adults. Even brief, unprepared hospitalisation may interfere with the development of the child and cause regression. As with adults, an unfamiliar setting, threatening medical equipment, hospital sounds and smells and potentially painful procedures, combined with a lack of control, are identifiable stresses in children. Nevertheless, in a child-depending upon his or her nonpharmacological approach to preoperative preparation may involve the use of play-oriented pre-operative teaching, books, pamphlets and video programmes. Parents may also benefit from video preparation so . Minimising the child-parent separation time is desirable in order to reduce anxiety. This separation may be more traumatic than the illness itself. At three years of age, separation anxiety begins to subside and parents should support the induction of anaesthesia. The patient and parents should be united as soon as possible in the recovery room. For children, who must be separated from their parents, it helps if they are told when they would be able to meet them again. It may be beneficial for the separated child to have a familiar object as a symbol that parents will be there after the procedure. Adolescents or older children benefit from verbal information and cognitive preparation. The patient should understand the reason for the procedure, and also agree with the general procedure and the expected outcome. This age group needs a mechanism which answers its questions at any time. Persons become more inquisitive after the preparation process. Parents also need emotional support when their child undergoes surgery. All children need to know that they will wake up after the procedure and that the anaesthesiologist will be there all the time to ensure that they do not wake up during the procedure. Once the surgery is over, it is the hour to assess the recovery of the cognitive and psychomotor functions to determine the appropriate time of discharge of the patient. The recovery room nurse, the anaesthesiologist, the surgeon, the patient and the escort play an important role in determining when the home-ready stage has been achieved. The majority of parents are in the home-ready stage within two hours after admission to the recovery room. Pain control and vomiting are two important factors which determine the patient’s discharge from the out-patient facility. Prior to discharge, the patient’s dressing should be checked and verbal and written instructions regarding post-operative care given. Most anaesthesia-related side-effects such as pain, nausea, vomiting, dizziness, headache and myalgias resolve within 24 hours. However, if these symptoms persist, the patient should be encouraged to contact the facility regarding appropriate follow-up care. The patient must leave in the company of a responsible adult and be aware of the recommendations regarding appropriate activities after discharge. Out-of-town patients should spend their first post-operative night within a reasonable distance from the medical centre. Patients and their relatives must be explained that they may need hospitalisation in case of an untoward incident and post-operative follow-up is essential. The writer is a well-known
specialist in anaesthesiology and related disciplines.
She is based in Chandigarh.
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Unmet
needs of adolescents THE period of adolescence (between the age of 10 and 19 years) marks the transition from childhood to adulthood. Although no longer a child, the young person is not yet considered a grown-up adult. During this time there is progression from the appearance of secondary sex characteristics to sexual and reproductive maturity and development of the adult mental process and adult identity. These adolescents number more than one billion and comprise nearly one fifth of the world’s population. They are growing in number and are expected to be more than 1.2 billion in the year 2010. Virtually, all of this growth is occurring in developing countries. Having survived infancy and childhood diseases as a group, they are among the healthiest members of society. As they mature and become physically active, more young people face serious health risks related to sexual activity. The risks include sexually transmitted diseases with long-term morbidity and infection with HIV and AIDS. Up to six million people infected with HIV are younger than 25 years. Worldwide, children and adolescents suffer the physical and emotional trauma of sexual assault and rape. Teenage pregnancy and child-bearing are associated with two to four times higher mortality or morbidity. Every year, 15 million women under 20 give birth accounting for up to one fifth of all births. Some of these are out side of wedlock and others are because of early marriage. The estimates of abortion among women under 20 in developing countries range from 1.1 million to 4.4 million per year. Many of these are rendered unsafe specially when pregnancy occurs out side of wedlock leading to mortality and life-long morbidity, including infertility. As these children enter puberty, their physical interests increase. In previous generations, it was limited to marriage but now with the changing attitudes and norms of society, and the influence of the mass media, including TV and pop industry, where permissiveness is glamourised, promiscuity among unmarried youth is increasing and casual physical activity is more common. A few studies on the sexual behaviour of youth from Chandigarh, Delhi, Bombay and Gujarat have shown that 6-25 per cent of adolescents between the age of 16-19 years are “active” or have “expeience”. A study from Delhi revealed that 50 per cent of the students had a permissive attitude towards premarital sex. These adolescents face the risks with too little factual information, too little guidance about their responsibilities and too little access to health-care. Young adults in many countries are being helped by various educational programmes, including sex education under the broad heading of “family life education” which focuses on young people’s planing of their productive life and includes discussion on reproductive physiology, sexuality and contraception. In many countries, including India, these programmes are slowed by controversy or the fear that discussion will arouse curiosity, reduce reticence and increase physical activity. Many parents find it difficult to talk to their children and adolescents on any matter related to the body organs, leave aside various physical activities. Many teachers do not feel comfortable while teaching reproductive biology specially in a co-educational school. While we keep debating the need of educating our adolescents about sex and sexual responsibilities, young people all over the world say they learned too little and too late about these matters and whatever they learned, they learned from friends, peer groups, TV programmes etc. Much of the information is often unscientific. The issue of meeting the diverse needs of young adults challenges parents, communities, health-care providers and educators. We, in the Department of Obstetrics and Gynaecology at Government Medical College Hospital, Sector-32, Chandigarh, have addressed the problems of adolescents related to sexual maturity at the North Zone Obstetrics and Gynaecology Conference held on January 24, 1999. Eminent speakers from the North Zone of India took part in it. Dr Sarla Malhotra is the Professor
and Head of the Department of Obstetrics and Gynaecology
at Government Medical College, Chandigarh.
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