|HEALTH TRIBUNE||Wednesday, March 1, 2000, Chandigarh, India|
light on breast cancer
There is a perpetual shortage of beds in hospitals, particularly in government hospitals, where the majority of the patients seek admission. Although new hospitals are being started and more beds are being added in the existing hospitals, there are long waiting lists in every government or charity centre. It is not uncommon to see a patient making multiple trips to a hospital to seek admission. He fails to do so, gets frustrated and ultimately gives up the idea of getting admitted only to land up in the hospital as an emergency case. He may start visiting the hospital again when the condition becomes worse as in cancer.
This is not a problem unique to India. It is being faced by almost all the developing countries. The developed countries have already faced it and come up with the idea of day-care surgery, also known as outpatient surgery or short-stay surgery.
Day-care surgery has been known for a long time. This means that the patients spend only a few hours in the hospital after the operation and are subsequently sent home. But the concept has been implemented on a larger scale over the past 10 years only.
Dr Sujit Pandit, Professor of Anesthesia from Ann Arbor, University of Michigan, delivered an informative lecture at the PGI recently and I would like to share the interesting points in it and the crux of the lively deliberations that it generated.
About a decade back, only 10 per cent of surgical operations were done as day-care procedures, but over the years it has become such a successful venture that almost 50 per cent of 37 million operations performed in the USA every year are now being carried out as day-care procedures. More and more major operations are being included in this programme.
The advantages or day-care surgery are many. Some of these are mentioned below:
(i) Prevention of cross infection to the patient from the hospital's atmosphere and other patients.
(ii) Sparing the much-needed hospital beds for seriously ill patients who require hospitalisation and close monitoring.
(iii) Sparing the doctors and the nurses the burden of monitoring very sick patients.
(iv) Cutting down the expenses. Health-care has become a very costly affair. In the USA an average hospital bed costs $600 per day and in India it may cost Rs 500 to Rs 5000 a day in a good nursing home. Even the PGI charges about Rs 1000 for a bed only. Other charges are inescapable.
(v) Psychologically, the patient and his relations feel happy to go back home and recover in their known environment.
(vi) The inconvenience to the patients and their relations are minimised.
But all said and done, the implementation of any new system requires planning, infrastructure and proper execution; success is achieved only if periodic evaluation is carried out, followed by the required restructuring and modification.
Here are some of the basic requirements for day-care surgery.
(i) The patient should be thoroughly examined in the outpatient department, not only about his present illness but also to evaluate his suitability for undergoing anesthesia and the operation.
(ii) All the relevant investigations must be carried out as outpatient tests.
(iii) Facilities must exist to receive the patient in the operation theatre complex at least three hours before the operation.
(iv) Pre-operative steps liked the change of clothes, the preparation of the part to be operated upon, the administration of premedication, the attestation of the consent form and other formalities have to be gone through before the operation.
(v) Facilities must exist to keep the patient in the post-operative ward till he comes out completely of anaesthesia and is able to travel to his residence.
(vi) The hospital facilities should be available round the clock so that the operated patient can be cared for promptly if he develops any problem.
(vii) Communication facilities are most necessary.
(viii) Arrangement should be made for a doctor or a nurse to visit the patient at home at night for evaluation and advice particularly for pain relief, the administration of antibiotics, etc.
(ix) It is desirable that the patient should stay within a radius of 20 to 25 km from the hospital.
(x) The patient should be given complete instructions at the time of discharge.
I am of the opinion that the most important factor is the establishment of mutual trust between the patient and the operating team.
The PGI has been
undertaking day-care surgery in a small way and it is
likely to get a big boost with the opening of the new OPD
complex where day-care surgery has been planned with six
operation theatres and various facilities. But we shall
have to move cautiously and progress slowly but steadily
to make this a successful venture. A multidisciplinary
approach and proper organisation are the key to success
in this field.
Prevention first step
Prevention is better than cure", is an old adage. There are several serious and troublesome diseases which are either preventable or at least modifiable but require changes in habits or life-style. Dietary modification and weight reduction, quitting smoking and alcohol, undertaking regular exercises and applying restrictions on specified activities are some examples of these changes.
They all require a significant effort on the part of an individual. On the other hand, many complex and even fatal problems can often be avoided by the adoption of very simple and small preventive steps without a major effort.
Unfortunately, rather than laying more stress on such safety steps, there has been a significant dilution of them in the recent times. This is so even amongst the educated people who, in spite of their greater belief and reliance on modernisation, bother little in the actual practice.
There is some kind of misconception amongst many of us that the scientific advancements have made many of the dicta, which were earlier prevalent, quite meaningless. A housewife, for example, shall tend to apply a medicated band-aid on a cut sustained by her young child rather than cleaning the site first.
Similarly, people often ignore to wash the hands and clean the site while giving injections with disposable syringes or needles. One tends to opt for the more sophisticated-looking procedures and devices without caring for the basic steps and instructions. This seems to be inherent in human nature.
I do not intend to suggest that the modern methods are in any way inferior. Factually speaking, there is no competition between the old and the new and the two are mutually additive and inclusive. It is either the problem of our interpretation or some kind of antagonism created by commercial hysteria. It is not uncommon to see advertisements advocating "new health products" ridiculing the fundamentals of preventive care. From the pure scientific point of view, the sequence of steps to be undertaken is generally chronological, beginning with the already existing and ending up with the most recent knowledge.
It is wiser, for example, for the housewife to apply a band-aid after cleaning the site with soap and water and wiping out the blood or the debris from the cut-site. Similarly, the medical and paramedical personnel giving injections need to wash and dry their hands and arms thoroughly and observe other steps of sterilisation even while using disposable articles.
The scope of preventive steps is endless. It extends from frequently reported safety tips told by parents to those taught by teachers and other experts. They are also available in abundance in the grandma's stories and the "Doctor's Health-book". But man is care-free in nature, casual in action and blissfully ignorant of results.
We all believe that prevention is something which concerns others. This, unfortunately, is true only as long as we are not affected ourselves. But once one is affected, it is generally too late when "prevention" either does not matter or matters very little.
Prevention is a broad term encompassing minor safety steps from those undertaken in the house, on the road and at work to major changes in habits and life-style.
Strategies in health-care are not limited to mere prevention of medico-surgical diseases; these also extend to the prevention of all kinds of onslaughts on health, including those by accidents, fires, violence and other natural or unnatural hazards.
The basic premise in prevention is to understand that everyone has to face the risks to health. One must never exclude oneself from the list of those who can be affected be it the risk of an accident while driving or that of the development of lung cancer while smoking.
Extending the scope of prevention on the road is something which cannot be avoided. A psychoanalyst might, perhaps, interpret our driving on the roads as indicative of the presence of suicidal tendencies. We observe traffic rules more to avoid police harassment or fines than to keep ourselves intact. Many of us keep helmets close to us rather than on our heads while driving scooters or motor-bikes. How tragic is the result of an accident or a fall is only to be seen in the emergency, neurosurgical and orthopaedic wards of hospitals where streams of accident victims keep pouring in. Lives of many of those who survive are never the same again.
I am not a safety expert but I do know that a head which hits the road or another vehicle is always the loser. Why should one like to end up as a loser? In fact, it is rather fashionable for a scooterist and a "biker" (even a girl) to wear a helmet while driving; it is considered "cool" in the West. Ideally, even the cyclists need protection for their heads.
Simple precautions can significantly reduce the spread of innumerable infections. The need to avoid eating uncooked, uncovered and cut vegetables, fruits and other raw eatables, drinking water from unsafe places and consuming unhygienically prepared "chaat" and "chutney" is stressed by all health educationists.
A highly motivated and safety-conscious gentleman from Chandigarh once explained to me how micro-organisms could be transmitted while currency notes were counted by different people with finger-tips moistened with saliva. Lavatory seats, flush chains and even doors of public toilets used by different people constitute important sources of disease transmission.
The transmission of diseases such as hepatitis, and HIV infection, through contaminated blood and infected syringes is a well-stressed risk. Similar stress is importantly placed on avoiding promiscuity and the use of condoms and sheaths to prevent sexually transmitted diseases, including AIDS. The awareness of the risk and the use of proper precautions are important.
The extremes of weather conditions may induce all kinds of medical problems. While adequate clothing or warming is required in the cold weather, it is the avoidance of direct exposure to sunlight during the hot and humid season which helps. The drinking of plenty of liquids and the consumption of fresh fruits, especially bananas and oranges, can prevent the loss of potassium in the hot weather. This is particularly necessary in the cases of the children, the sick, the aged and those individuals who have to exert themselves for one or the other season.
The list, by no means, is exhaustive or comprehensive. What is important is the development of an attitude of safety and the following of standard recommendations religiously. This holds true all through our daily lives in the house, at a picnic, while driving on the road, while swimming in a pool, while climbing a hill or when working in a factory. Problems generally occur only when one ignores the recommended steps. It always helps to remind oneself that each recommendation has not only a story but also a tremendous amount of fiscal and experimental investment behind it. We are here only to enjoy the profits of those investments free of charge!
More light on breast cancer
Breast cancer is the second most common form of cancer affecting women in India. There has been a steady rise in its incidence. It is affecting Indian women at a much younger age as compared to those in the West. Obviously, the disease here is seen at an advanced stage.
The management of breast cancer is controversial. The confusion is multiplied as there is no recommended standard management protocol for the disease in India. To eliminate this lacunae, Prof S.M. Bose of the PGI, who has written the article on day-care surgery, has brought out a book, "Consensus on Breast Cancer" which covers all aspects of the disease, right from classification to follow-up.
The contributors to the book are eminent medical persons interested in the subject.
The volume was released during the inaugural function of the International Breast Cancer Conference held at Nagpur recently.
Dr Bose, the eminent
cancer surgeon, received the prestigious Dr B.C. Roy
National Award for Eminent Medical Teacher last year. His
popular book titled "Cancer", published by the
Government of India and written for the health education
of the people, has been translated into many languages.
The specialist has also been elected a Fellow of the
National Academy of Medical Sciences.
Your primary medical vocabulary
Acute disease: A disease with severe symptoms of rapid onset and short duration.
Anaemia: A condition of blood with reduction of red blood cells or haemoglobin or both.
Anastomatic channel: A channel connecting two arteries or veins.
Angina (angina pectoris): A heart pain of short duration, often less than 20 minutes; the usual location is the front of the chest.
Angiography: X-ray of the arteries after the injection of a substance that is opaque to X-rays; frequently performed on the coronary arteries.
Angioplasty: Plastic surgery on an artery, usually the coronary artery.
Aorta: The largest artery of the body into which the heart pumps blood for distribution into the whole body through its branches.
Artery: A tube-like structure that carries blood from the heart to the tissues.
Artery, coronary: An artery supplying blood to the heart.
Asthma: Difficulty in breathing caused by a spasm of the air tubes of the lungs due to allergy.
Asthma, cardiac: An entirely different condition of difficulty in breathing due to dysfunction of the left ventricle of the heart.
Atheroma: A plaque of fatty deposit on the wall of an artery.
Atrium: A chamber of the heart that receives blood from the body (right) or from the lungs (left).
Blood vessel: Artery or vein.
C.A.D: Coronary artery disease.
Capillary: The thinnest blood vessel; capillaries form the network in tissues from which the exchange of oxygen, carbon dioxide, water, salts and nutrients between the blood and tissues takes place.
Carbohydrates: Nutrients that are converted by the body into sugar (glucose) to produce energy; abundant in vegetarian food.
Cardiac: Pertaining to the heart.
Cardiac arrest: Sudden stoppage of the heart's action.
Cardiovascular: Pertaining to the heart and blood vessels.
Cholesterol: A fatty substance present in animal fats, body tissues and blood.
Chronic disease: A disease of long duration, of gradual onset and slow progression; not acute.
Coma: Unrousable unconscious state.
Coronary artery: An artery supplying blood to the heart.
Coronary bypass operation: A shunt established surgically that permits blood to travel from the aorta to a coronary artery bypassing the obstruction in the latter; also called coronary artery bypass graft or CABG.
Diuretic: A drug that increases the volume of urine.
Extra systole: Premature heart beat.
Foetus: Unborn child.
Gangrene: Death and decay of a part of the body due to the cessation of its blood supply.
Genetic: Pertaining to genes that carry inheritance.
Hypertension: High blood pressure, usually accompanied by some metabolic abnormalities.
I.H.D: Ischaemic heart disease.
Infarct: An area of dead tissue following the cessation of its blood supply.
Insulin: A hormone secreted by the pancreas; it metabolises sugar.
Intrauterine life: Life within the womb.
Ischaemia: Inadequate flow of blood to a part caused by obstruction to its blood supply.
Ischaemic heart disease (I.H.D): Coronary artery disease or (C.A.D) or coronary heart disease (C.H.D). Narrowing and obstruction of the coronary artery due to fatty deposits, sufficient to prevent adequate blood supply to the heart, causing angina or heart attacks.
Lesion: An area of diseased tissue.
Lumen: Bore of an artery or vein.
Metabolise: Break-down of food material by the body for energy production.
Metabolism: The sum total of all chemical changes that take place within the body for the maintenance of life, like energy production and body-building activity.
Myocardial infarction: An acute heart attack; death of a part of the heart muscle following the cessation of its blood supply.
Necrosis: An area of dead tissue surrounded by a healthy area.
Nicotine: One of the toxic alkaloids found in tobacco.
Physiological: Concerning the functions of the body.
Proteins: Body-building substances in food; they are essential constituents of the body; e.g. animal muscles are all protein.
Side-effects: Unwanted, usually harmful, effects produced by a drug.
Stroke: Sudden loss of consciousness followed by paralysis, caused by bleeding in the brain or the clotting of blood in one of its arteries.
Thrombosis: The formation of blood clot within an artery or vein.
Tissue: A collection of similar cells, which act together in the performance of a particular function, e.g nerve and muscle.
Treadmill: A platform moving at variable speeds and at variable inclines on which the patient makes a stationary run; used for evaluating the fitness of the heart by steadily increasing the level of exercise with simultaneous ECG to observe the changes produced by exercise.
Vein: A tube-like structure that carries blood from the tissues to the heart.
Ventricles: Two pumping chambers of the heart, the left and the right; the left one pumps blood into the aorta for distribution to the body and the right pumps blood into the lungs for oxygenation.
Last month surgeons
pushed back the frontiers of medicine. In a secret
operation, they gave a disabled patient new hands taken
from a dead body. Will leg, face and body transplants be
next? A brief news item on this subject was published in
Health Tribune last week. Please see the details next