HEALTH TRIBUNE Wednesday, March 14, 2001, Chandigarh, India

How not to treat the suffering old
Dr S.K. Jindal
famous Urdu couplet has an excellent satire on medicine which, in simple English, implies the continued increase in disease-severity in accordance with the continued administration of drugs. Although the expression is only a metaphorical reflection of the persistent mental agony of the poet, it clearly points to the state of incurability.

Quiet surgery on beating heart
YPASS surgery is the surgical treatment of coronary heart disease. In it, new pathways are created to restore blood supply beyond the blocked coronary arteries. The number of bypass operations done in our country is increasing rapidly. The reason for this are now clear.


  • There is no safe cigarette

  • Electrocution and hairdryer

Food fats-II



How not to treat the suffering old
Dr S.K. Jindal

A famous Urdu couplet has an excellent satire on medicine which, in simple English, implies the continued increase in disease-severity in accordance with the continued administration of drugs. Although the expression is only a metaphorical reflection of the persistent mental agony of the poet, it clearly points to the state of incurability. It is the perspective of iatrogenesis which limits the aggression and enthusiasm of doctors in treating patients with incurable illnesses. There is one clear goal in the art of medicine.

Nihil non nocere- First, do no harm.

"I will use treatment to help the sick according to my ability, but I will never use it to injure or wrong them".... so says the Hippocratic Oath.

There is no better example of the application of this principle than the practise of geriatric care for patients, especially at the fag end of life, for incurable illnesses. It is the palliation of symptoms which becomes more important than the prolongation of life.

Geriatric care at the end of life is an issue of delicate and balanced practice. While the principles of diagnosis and treatment of illnesses are broadly similar for the aged and the young, the practices and institutionalisation differ. In several ways, elderly patients, at extreme of age, may behave like children — their acceptance of drugs is difficult, tolerance poor and patience limited. They may throw tantrums and refuse all interventions. They may also get angry, agitated and annoyed with doctors and family members alike.

In spite of all these difficulties, they do need medical help, invasive tests, drugs and surgical operations. There is great difficulty in drawing a line between what to do and what not to do. Even more crucial is the act of deciding whether the medical approach should be aggressive or conservative.

In general terms, the aggressive approach is defined as hitting the disease with full force by all available means in modern medicine. The conservative approach implies the "wait and watch" policy, administering palliative treatment and largely allowing the disease to take its own course. The risks of the aggressive approach are obviously greater.

The issue of aggressive management vis-a-vis conservative management is generally relevant to incurable or partially curable illnesses and surgical or interventional treatments. For example, the treatment of an infection such as a pneumonic illness with antibiotic and oxygen therapy is highly desirable at any age. On the other hand, the institution of assisted respiration in a critical-care area for the same patient is not necessarily acceptable. The refusal of an aggressive approach in this situation is directly related to the known outcome of similar patients in the past. It is better to opt out of a situation where misery gets prolonged even if the death is delayed.

It is unfortunately true that complications of all procedures and the toxicity of drugs are significantly increased in old age. The elderly are also likely to suffer from disorders of multiple systems such as diabetes, high blood pressure, chronic heart and lung diseases, and gastrointestinal, neurological or joint and bone problems. It is not only the presence of a concomitant disease but also the treatment being taken for that disease which may interact or add to the effects and side-effects of drugs. Suffice it to say that an aged body is rather overburdened. It has to bear multiple problems with more inadequacies than a young and agile human being.

On the other hand, treatment cannot be denied on the mere pretext of age. Factually speaking, old age is only a relative term. There is no unanimity on one single figure - seventy, seventy-five, eighty or more. Therefore, the indications of tolerance to the treatments are also variable. A fit, ambulatory and healthy person of eighty can well tolerate therapeutic interventions while another individual may not do so at merely sixty-five years of age. Compulsorily, therefore, both medical and surgical treatment have to be individualised and tailored to the needs and the health status of the patient concerned.

There are people for and against both these practices amongst doctors, patients, family members, lawyers and other groups. The de facto treatment is always decided by the physicians concerned in consultation with patients and family members. Unfortunately, most of the time, the wider perspectives of "going all the way" are not known or not anticipated. Frequently, one ends up in prolonging death than living longer. It may be worthwhile here to quote Ashley Montagu, the British anthropologist:

"The goal of life is to die young, as late as possible".

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



Quiet surgery on beating heart

BYPASS surgery is the surgical treatment of coronary heart disease. In it, new pathways are created to restore blood supply beyond the blocked coronary arteries. The number of bypass operations done in our country is increasing rapidly. The reason for this are now clear.

  • The disease is becoming more common in society.
  • More and more people are becoming aware of the disease and its treatment.
  • Diagnostic procedures are easily available.

The alarming thing is that in the last decade more people from the young age group (35-45 years) have been getting this disease.

The traditional coronary artery bypass grafting (CABG) is done with the use of the heart-lung machine, using the technique of cardiopulmonary bypass. It needs the use of costly and disposable items and large quantities of drugs. Cardiopulmonary bypass produces many ill effects, specially on the kidney, the lung and the liver. It is specially harmful for patients with persisting kidney and lung ailments. It also created a lot of problems of patients with poor heart function.

Most surgical disciplines are making their procedures less invasive. Many abdominal operations are now being done by laparoscopic techniques. Cardiac surgery is one of the disciplines where the technique is highly invasive.

Many changes have been seen recently in cardiac surgery. Perhaps one of the most innovative is the off-the-pump artery bypass surgery (OPCAB) for myocardial revascularisation.

With the attention of cardiac surgeons and the support of the biomedical industry, cardiac surgery is gradually being made less and less invasive. OPCAB is a form of such surgery. Here cardiopulmonary bypass is avoided and the heart is not stopped. The heart continues to beat while the surgery proceeds. The operative area is made almost motionless with the use of mechanical stabilisers. One of the commonest one in use is made by Medtronics. It is called the Octopus. The latest version is called Octopus III. It is a simple but cleverly engineered device.

In OPCAB, the breast bone is divided in the midline. The graft to be used is harvested. The heart is exposed. The target area is brought into view with the use of special sutures, and table-positioning. Once the heart is positioned in the desired fashion and the blood pressure and heart rate become stable, the stabiliser is applied. It achieves almost a motionless field in that localised area. The rest of the heart continues to beat, maintaining the circulation.

This technique of bypass surgery is cheaper than the traditional one and there are fewer chances of complications to the kidneys, the lungs, the liver or the brain. The heart too tolerates the procedure much better. Less of drugs and life-supporting measures is needed after the surgery. The patient's hospital stay time is greatly reduced; the majority of them can go home in five to six days as compared to 10 or 12 days for the patients undergoing the traditional operation. This technique is specially helpful to patients with significant kidney, lung, liver or brain disease.

This writer saw the entire new procedure recently at the BBC Heart Care (Pruthi) Hospital, Jalandhar, where almost all bypass surgeries are now being done using the new technique (OPCAB). The success rate is claimed to be 99 per cent. It is a centre of scientific excellence, compassion and personalised care. It needs no recommendation or advertisement. — K.P.S.

Next week “Viagra’s Indian avatars: helpers and potential killers”
by Dr Rajeev Gupta




There is no safe cigarette

Pictures of diseased lungs and rotten teeth appearing on cigarette packages sold in the country may remind the smokers of the effects of their habit. This will be a much greater deterrent to smoking than the deliberately minutely written message. Photo-based warnings are more effective. — J.D.W.

Electrocution and hairdryer

About 22,500 hairdryers with faulty wiring and loose electrical connections are being recalled by Pebco Inc, the Consumer Product Commission (CPSC) said on Tuesday. The hairdryers lack ground fault circuit interrupters that are used to stop the flow of electrical current in water.

“The hairdryers pose an electrocution and fire hazard to consumers,’’ according to a CPSC statement.

Although no such reports have been received to CPSC or Pebco, the recall was issued as a preventive measure.

Subject to recall are the Black Jet 1200 and the Black Jet 1700, black with gold lettering, and the Pebco 1500 model that is white with purple lettering. Model names are located on the air intake grill. The hairdryers can also be identified by a label on the handle that states “DO NOT USE/IMMERSE IN WATER.’’

The hairdryers were sold for between $25 and $30 by beauty salons and hair care stores throughout the country from March, 1999, through December. Reuter


Food fats-II

Dr Sharda Ranjan
answers readers' questions

Q What are essential fatty acids?

A The human biochemical machinery can make fatty acids from components derived from carbohydrates or proteins in the diet, with one exception. The biochemical machinery lacks the enzymes called desaturases, necessary to put double bonds in position omega 1 to omega 9. Beyond omega 9, the human biochemical machinery has no difficulty in putting in double bonds. Since omega 6 and omega 3 polyunsaturated fatty acids are required for prostaglandin synthesis and in some cell membranes, they are called essential fatty acids. They have to come in food as such. They can't be synthesised in the body.

Q Does it make any difference if the essential fatty acid in the diet is Omega 6 or Omega 3 fatty acid?

A It does. Although the body will use and incorporate into itself which ever essential fatty acid, Omega 3 or Omega 6, is available; there occurs some change in the body chemistry with a change in the ratio of these two essential fatty acids. It seems that the optimal ratio of Omega 6 to Omega 3 is 5:1.

If Omega 6 is greatly in excess the blood platelets become sticky and the blood becomes somewhat hyper-coagulable.

If Omega 3 is greatly in excess, a bleeding tendency occurs.

Q We need only 1 gm of these polyunsaturates per day but the Indian city-dweller consumes from 50 to 100 gm of polyunsaturates a day in the form of vegetable oils (corn, sunflower, groundnut, cottonseed, soyabean etc.) for cooking. Is it safe?

A Probably not. The situation may be like Vitamin A and Vitamin D — essential in small amounts — dangerous in large. The safety of consuming large amounts of polyunsaturates over extended period of time has not yet been established. Moreover, with the exception of soyabean and mustard oils, all cooking oils of India lack Omega 3 polyunsaturates. Indians are, in fact, overconsuming Omega 6 polyunsaturated fatty acids. The distortion of Omega 6 to Omega 3 ratio is known to cause sticky platelets and hypercoagulable blood. Recently, it has been shown that hyperalimentation with Omega 6 polyunsaturated fatty acids (without Omega-3) causes increased oxidative stress and poor immune response.

Q Could the present coronary epidemic in India be due to mass poisoning with Omega 6 polyunsaturated acids?

A It could be. However, we should wait for complete scientific evidence before making this statement. While we are looking for evidence, we should also look for the effect of pesticides, fertilisers, food preservatives and atmospheric pollutants on the coagulation-fibrinolytic system and vascular endothelial health. The graph of the use of these substances, the graph of consumption of Omega 6 rich oils and the graph of incidence of coronary heart disease look very much alike.

Q This is very disturbing!

Can you give us a simple recommendation regarding fat in our diets?

A I can try.

Eat as little fat as you can.

Fats in the diet are either visible or invisible.

Visible fats are the cooking media about which I have been talking.

Restrict the consumption of cooking media to three teaspoons a day.

Regarding invisible fats although all vegetable seeds, all dairy products and all flesh products are rich in invisible fat, the following are the three richest sources in India:

(1) whole-cream milk and its products;

(2) eggs;

(3) pork and its products.

The consumption of these three groups should be greatly reduced. The slogan, therefore, is.

"Very little of the three invisible

Three little spoons of the visible"

Q The last question, please. Three little spoons of which visible fat?

A One little spoon of cow's butter a day.

One little spoon of mustard oil a day.

One little spoon of soyabean oil a day.

With current knowledge, this is the most sensible plan.