Devotional april

The Discerning Life

“Cast your burden on the LORD” (Ps. 55:22).

The worker has to have discernment like that of a farmer; that is, he must know how to watch, how to wait, and how to work with wonder. The farmer does not wait with folded arms but with intense activity; he keeps at it industriously until the harvest.
When someone comes to you a question which makes you feel at your wits’ end, never say, “I can’t make head or tail of it.” Of course you cannot. Always take the case that is too hard for you to God, and to no one else, and he will give you the right thing to say. When you are being taught by God to discern, you will deal with the case in the way that God has prompted you to and you will speak with discernment. When you are used of God it is not because you discern what is wrong, but because the Holy Spirit gives you discernment, and as you speak you realize in what an amazing way the words meet the case, and you say, “I wonder why I said that?” Don’t wonder anymore; it was the Spirit of God inspiring you. When we are used, we never know we are used, and the times we expect to be used, we are not. We have to keep our heads out of the rush of things in order that the Spirit of God may discern through us.
                               The discernment for the worker himself is this – I am God’s, therefore I am good for no one else; not good for nothing, but good for no other calling in life. “No one who puts his hand to the plow and looks back is fit for the kingdom of God” (Luke 9:62). If you have taken on you the vows of God, never be surprised at the misery and turmoil that come every time you turn aside. Other people may do a certain thing and prosper, but you cannot, and God will take care you do not. There is always one fact more known only to God.
                                   The one word to be written indelibly on each one of us is “I am God’s.” There is no responsibility in that kind of life; it is full of speechless childlike delight in God. Whenever a worker breaks down it is because he has taken responsibility upon himself which was never God’s will for him to take. Now think of your responsibility! There is no responsibility whatever, saving that of refusing to take the responsibility. The responsibility that would rest on you if you took it would crush you to the dust; but when you know God, you take no responsibility upon yourself; you are as free as a child, and the life is one of concentration on God. “Cast your burden on the LORD” (Ps. 55:22). The thing that interferes with our life with God is our abominable seriousness which chokes the freedom and simplicity which ought to mark the life. The freedom and simplicity spring from one point only, a heart at rest with God and at leisure from itself.
Oswald Chambers [Approved unto God)

Cme quiz april

INSTRUCTIONS

Please read the articles in ‘Current Medical Issues’ and answer the questions on this page. Only ONE answer is correct. You can then transfer your answers to the CME Credit Sheet (INLAND) included in your copy. Or you may also send in your answers to cme@cmcvellore.ac.in

CME CLINICAL CONTENT QUIZ CMI 13:2

  1. H1N1 influenza vaccination in children is recommended for

a. All children above age of 6 months
b. All children above age of 2 years
c. Only children with high-risk factors
d. Only children whose parents have fever

2. H1N1 influenza – In children with mild URI symptoms, no tachypnea and no risk-factors, the action to be taken is

a. Send home after explaining danger signs
b. Test for H1N1 influenza immediately
c. Treat with oseltamivir immediately
d. Admit in ICU and watch for worsening.

3. Status epilepticus is defined as continuous seizure activity for

a. 30 minutes or more
b. 15 minutes or more
c. 5 minutes or more
d. 28 seconds or more

4. In an acute ischemic stroke 6 hours old, with a BP of 190/110 mmhg, you need to

a. Bring down the BP slowly
b. Bring down the BP fast
c. Give sublingual nifedipine or any short acting antihypertensive as soon as possible.
d. Monitor BP frequently and treat only if it goes upto 220/120 mmHg.

5. Ischemic stroke- If you are referring elsewhere for thrombolytic therapy within the window period, do the following first:

a. CT brain to rule out hemorrhage

b. Give neuroprotective agents immediately

c. Give aspirin or clopidogrel loading dose

d. Nothing, just refer immediately

6. The most important preventive measure for stroke is

a. Control of blood glucose
b. Control of blood pressure
c. Control of dyslipidemia
d. Stop smoking

7. Delirium: All are true except

a. Decreased attention span and fluctuating consciousness are clinical hallmarks
b. Do not investigate for any ’cause’ – most are functional psychiatric problems
c. Low dose anti-psychotics are effective in management of symptoms
d. Reassurance, patient education are important aspects of treatment

8. Pre-eclampsia – In the treatment of hypertension in pregnancy which of these is true

a. Oral nifedipine is as effective as IV labetalol in acute BP management.
b. Phenobarbitone and Levetiracetam are the drugs of choice for seizure prophylaxis.
c. Diuretics are useful antihypertensives as they also reduce pedal oedema.
d. Mild hypertension should always be treated with medication.

9. Blocked airway is suspected when there is

a. Drop in saturation
b. If there is hypoxia on ABG
c. Deterioration in consciousness
d. Noisy breathing

10. Which of these is true in anti-retroviral prophylaxis for breast feeding infants

a. Efavirenz is the drug of choice.
b. Medications are of no use.
c. HAART is efficacious in preventing mother-baby transmission.
d. Nevirapine and zidovudine are contraindicated for prophylaxis.

Laughter April

Laughter – The Best Medicine

What Doctors Say, and What They’re Really Thinking

Well, well!…., what have we here…?
He has no idea and is hoping you’ll give him a clue.

Let’s see how it develops.
Maybe in a few days I can pick up something curable.

If it doesn’t clear up in a week, give me a call.
I don’t know what it is. Maybe it will go away by itself.

Well, we’re not feeling so well today, are we…?”
I’m stalling for time. I have no idea what you have.

There is a lot of that going around.”
This is the third one this week. I’d better read up about it.

 I’d like to run some more tests.”
I can’t figure out what’s wrong. Maybe the kid in the lab can solve this one.

An 80 year old couple were having problems remembering things, so they decided to go to their doctor to get checked out to make sure nothing was wrong with them. When they arrived at the doctors, they explained to the doctor about the problems they were having with their memory.
After checking the couple out, the doctor told them that they were physically okay but might want to start writing things down and make notes to help them remember things.
The couple thanked the doctor and left.
Later that night while watching TV, the man got up from his chair and his wife asked, “Where are you going?” He replied, “To the kitchen.”
She asked, “Will you get me a bowl of ice cream?” He replied, “Sure.”
She then asked him, “Don’t you think you should write it down so you can remember it?”
He said, “No, I can remember that.”
She then said, “Well I would also like some strawberries on top. You had better write that down because I know you’ll forget that.”
He said, “I can remember that, you want a bowl of ice cream with strawberries.”
She replied, “Well I also would like whipped cream on top. Know you will forget that so you better write it down.” With irritation in his voice, he said, “I don’t need to write that down! I can remember that.” He then fumes into the kitchen.
After about 20 minutes he returned from the kitchen and handed her a plate of bacon and eggs. She stared at the plate for a moment and said angrily: ”   I TOLD you to write it down! You forgot my toast!”

Medical practice — At what cost?

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Medical practice — At what cost?
Dr. Arpit Jacob Mathew, Consultant General Surgeon, Christian Medical College, Ludhiana.

The young lady was brought to the small hospital in Jharkhand gasping for breath two hours after she had been bitten by a snake. She was quickly intubated and given the life-saving anti-snake venom antitoxin. For the next 2 days, the junior doctor manually ventilated her round the clock as she slowly recovered. Her hand, that had received the bite developed fasciitis and required a debridement. However after a week, she was ready to go home. The hospital bill, after heavy discounting, came to Rs. 1500, mainly for the medicines that needed to be replaced. After a day, the husband brought in the money to pay the bill. Out of interest, the doctor asked him how he found the money. He said he had taken a loan from the moneylender. And the interest – Rs.10 for every Rs.100, every month – making it an annual interest of 120%. The young doctor was horrified – that was a life sentence!

With the enthusiasm and altruism of youth, he offered to pay the money which could be returned to him if and when possible. But the farmer was resolute. He said it was actually a good bargain. He would never be able to repay the loan, but he would be able to work on the moneylender’s farm for the rest of his life and be sure of at least a meal a day. And when his young son was a little older, he too could work and this way, his family would be secure. For the sake of a medical bill he signed away his family into a lifetime of bonded labour.


Fig. 1. Hippocrates refusing a gift from Alexander the Great. Engraving by Anne-Louis Girodet

It is an oft-repeated story in the villages of our country, where decades of suppression have created a feudal system that would be unthinkable in a modern, educated society. A system that has bled the poor to feed the rich. A system that has sparked the rise of a violent movement that, according to our home minister, is the greatest threat to our national integrity. A system that is contributed to, in good measure by the desire for gain of those whose vocation it is to serve – our doctors. The astronomical amounts that buy undergraduate and post-graduate seats in the medical colleges of our country only rise every year. Our country is the world’s biggest bazaar for human organs. Many new initiatives in health care are quietly and confidently hijacked by doctors to work for their personal gain. In short, our health system has fine-tuned itself to greatly benefit one group of people – the doctors. Every patient who goes to a doctor, does so with mixed emotions. There is always the hope, that the doctor will find the cause of the problem and treat it. But there is also the fear, of the possibility of unnecessary tests, procedures and medicines that the doctor may order. It is no secret that for some doctors, every stroke of the pen is directly translated to some personal perk or benefit. The rich have no problem with this system. As with any form of corruption, it is the poor who suffer.

Health care for the poor in India has become a double edged sword. Not having it is a denial of one’s rights, but having it is detrimental to the well-being of the household – the ‘medical poverty trap’ and often health costs are driven steadily upwards by the constant search of health care professionals for higher profits and a better life, a situation that is easily exploited by health care companies and pharmaceuticals. The Hippocratic Oath often becomes a big hypocrisy.

In today’s world, there are two forces that drive the doctors. The more common one is the monetary drive, where decisions of health practice are driven by the higher salary, cut or perk. The more acceptable one is the drive for excellence, be it professional or academic. But there is a third drive – that is often forgotten. In our dedication to either monetary gain or professional advancement (or both), we often subdue the drive that should be given primary importance by anyone who has sworn the Hippocratic Oath – the drive of service. But service is often the last thing on most people’s mind at any point of medical education or practice. The number of doctors even from Christian Medical Colleges who serve in ‘areas of need’ are so few and far between. Our country desperately needs more healthcare professionals who will respond to the need and heed the cry of the many Indians who suffer under the yoke of poverty. Men and women of character, who have the courage of conviction to stand against the tide and make a difference like Dr. Tharien of Oddanchattram, Drs. Raj and Mabel Arole of Jamkhed, Drs. Abhay and Rani Bang of Gadchiroli, Dr. Binayak Sen and so many others. The issues are not always so simplistic, but we need to make a start somewhere. Individual decisions need to be made until, over time, we reach the ‘tipping point’ when the flow of health care service will turn from being doctor-centric to patient-centric. It sounds impossible, but that day will surely come. And it could start with you and me.

A young doctor stood at the bedside of a patient. This man had survived a major emergency operation in spite of a host of complications. He and his young daughter were extremely grateful to the doctor, but were pleading for a reduction in his bill. The young man took the plea to his boss, but was refused. The next day, the patient was gone, bill paid. Nine months later, the doctor saw his patient again. He had come for the birth of his daughter’s first child. The doctor was confused, remembering the beautiful young girl who had begged for a bill reduction. ‘But I thought she was unmarried,’ he said. ‘She is,’ replied the man, with a bowed head. ‘I sold her virginity to pay my bill.’

This is a true story


References:

1.Sanjay Kumar. ‘Healthcare is among the most corrupt services in India.’ BMJ 2003; 326 : 10 doi: 10.1136/bmj.326.7379.10/c (Published 4 January 2003

2. Peters , DH, Yazbeck , AS , Sharma, RR, Ramana, GNV, Pritchett, LH and Wagstaff, A (2002), ‘Better Health Systems for India ‘s Poor. Findings, Analysis and Options’, The World Bank

3. Krishna, A, ‘Falling into Poverty: Other Side of Poverty Reduction’, Economic and Political Weekly , February

4. Krishna, A, Kapila, M, Porwal, M, and Singh, V (2003b), ‘Falling into Poverty in a High-Growth State: Escaping Poverty and Becoming Poor in Gujarat Villages’,Economic and Political Weekly , December 6, pp 5171-5179

5. Krishna , A, Kapila, M, Pathak, S, Porwal, M, Singh, K, and Singh, V (2004), ‘Falling into Poverty in Villages of Andhra Pradesh: Why Poverty Avoidance Policies are Needed’, Economic and Political Weekly , July 17, pp 3249-3256

6. Whitehead , M, Dahlgren, G, and Evans T (2001), ‘Equity and Health Sector Reforms: Can Low-income Countries Escape the Medical Poverty Trap?’, The Lancet , Vol 358, September, 833-36

7. Malcolm Gladwell. ‘The Tipping Point’. Abacus, 2000.

Treatment of childhood diarrhoea and pneumonia

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Treatment of childhood diarrhoea and pneumonia in rural India is far from adequate
Source: The Know-Do Gap in Quality of Health Care for Childhood Diarrhea and Pneumonia in Rural India. Manoj Mohanan, PhD et. al., JAMA Pediatr.doi:10.1001/jamapediatrics.2014.3445Published online February 16, 2015.

Background and methods:
Diarrhoea and pneumonia are the leading causes of death among children worldwide (24% of deaths in the age group 2-4) contributing to 2 million deaths in 2011. In India, the situation is especially precarious in rural settings where the level of knowledge and practices among health-care providers is far from adequate. Bihar has the highest infant mortality rate in India (55/1000 live births). One of the reasons proposed is what is termed as a “know-do gap” between knowledge of appropriate care and the actual care delivered among health care practitioners. This was brought to light in this observational cross-sectional study done using the Bihar Evaluation of Social Franchising and Telemedicine (BEST) project protocol.340 health care practitioners were evaluated concerning the diagnosis andtreatment of childhood diarrhoea and pneumonia in Bihar, India, from June throughSeptember, 2012.

The evaluation was done using ‘vignette interviews’ and ‘standardized patient’ (SP method) interviews. The standardized patient is a person who pretends to be the parent of a child (proxy) suffering from diarrhoea or pneumonia. The SP method isconsidered the criterion standard for practitioner performancemeasurement because it presents a well-definedincognito case (the health practitioner is not aware of the ‘case’) in a clinically accurate and consistent mannerto all practitioners. In the vignette method two interviewers act out a patient scenario with standardized questions and responses and the doctor’s responses are recorded.

For diarrhoea, correct treatmentwasdefined toincludeORSsalt with orwithout zinc supplements,with no prescription of unnecessaryor potentially harmful drugs according to the 2005WorldHealth Organization guidelines.The correct treatment for severe pneumonia wasdefined to include appropriate antibiotics, absence of potentiallyharmful drugs, and referral to a hospital.

RESULTS:
Of the 340 practitioners included in this study, 80% had noformal medical degrees in allopathy, Ayurveda, homeopathy,or Unani medicine.
Oral rehydration salts, the correct treatment for diarrhoea, arecommonly available, however only 3.5%of practitioners offered them in the diarrhoea vignette.WithSPs, no practitioner offered the correct treatment for diarrhoea.
Only 13.0%of practitioners offered the correct treatment for pneumonia in the SP group.
Although only 20.9%of practitioners prescribed treatments that were potentially harmful in the diarrhea vignettes, 71.9% offered them to SPs (P < .001). Unqualified practitioners were morelikely to prescribe potentially harmful treatments for diarrhea (adjusted odds ratio, 5.11 [95%CI, 1.24-21.13]).

Authors conclusions:
The level of knowledge is poor among health practitioners in rural India regarding recommended practice for management of diarrhoea and pneumonia in children. There exists a large gap between knowledge and actual practice in the management of childhood diarrhoea and pneumonia. Potentially harmful treatments were offered by those without a medical background.

EXPERT COMMENTS
Dr. Kirubah David, Assoc. Prof., Department of Family Medicine
Three quarters of child deaths in 2013 are due to communicable diseases, neonatal and nutritional causes. More than half a million of deaths were due to lower respiratory tract infections, malaria, diarrheal diseases and meningitis. (1) Most often it is the nurse, paramedics, generalist doctors, general practitioner in a local clinic or primary health center who first encounters the child with diarrhea or pneumonia. The opportunity to save and nurture life is at our hand and is done by simple steps in management. It does not need much of resources.
World Health Organization has outlined in simple steps how to identify children who are sick, provide immediate management and refer appropriately. We also need to continue the process of healing by teaching the mother how to manage at home. In our urban health center we have put down these steps as a copy in the desktop which we need to use to access the patient’s results. This is to help a new doctor to remember and practice uniformly. The following write-up aims to summarize these practice guidelines.

APPROACH TO THE CHILD WITH ACUTE DIARRHEA

Definition
Diarrhea is the passage of loose or watery stools at least three times in a 24 hour period. (2)

Clinical assessment

The assessment of child with diarrhea can be divided into four components to guide in management:

  • classification of the type of diarrhea (acute watery, dysentery, persistent)
  • assessment of dehydration (no dehydration, some dehydration, severe dehydration)
  • assessment of nutritional status ((moderate, severe malnutrition)
  • assessment of co-morbid conditions.(pneumonia, measles)

History

Ask the mother or caretaker about:

  • presence of blood in the stool
  • duration of diarrhea
  • number of watery stools per day
  • number of episodes of vomiting
  • presence of fever, cough, or other important problems (e.g. convulsions, recent measles)
  • pre-illness feeding practice
  • type and amount of fluids (including breastmilk) and food taken during the illness
  • drugs or other remedies taken
  • immunization history

Physical examination

  • Temperature, pulse, Capillary refill time, respiratory rate, weight, mid-arm circumference
  • Signs of dehydration and classify the severity of dehydration into no dehydration, some dehydration or severe dehydration to decide on management.
  • Restlessness or irritability
  • Lethargy /Unconsciousness
  • Sunken eyes
  • Skin turgor
  • Thirsty or drinks poorly
  • Blood in stool
  • Signs of severe malnutrition
    • Abdominal mass
    • Abdominal distension

Classification Signs or symptoms Estimated fluid loss
Severe dehydration Two or more of the following signs:

  • Lethargy/Unconsciousness
  • Sunken eyes
  • Unable to drink
  • Skin pinch goes back very slowly >2 seconds
More than 100ml/kg
Some dehydration Two or more of the following signs:

  • Restlessness/Irritability
  • Sunken eyes
  • Drinks eagerly
  • Skin pinch goes back slowly
50-100ml/kg
No dehydration
Not enough signs to classify as some or severe dehydration Less than 50ml/kg


Management of diarrhoea in a primary health care setting
The objectives of treatment are to:

  • prevent dehydration, if there are no signs of dehydration
  • treat dehydration, when it is present based on estimated fluid deficit
  • prevent nutritional damage, by feeding during and after diarrhea
  • reduce the duration and severity of diarrhoea, and the occurrence of future episodes, by giving supplemental zinc

The treatment depends on the clinical diagnosis of fluid deficit. If you have diagnosed as ‘no dehydration’ in the child then:

  • Treat the child as an outpatient
  • Counsel mother on Oral Rehydration Salt(ORS) fluid 50 to 100ml after each loose stool in children up to 2 years and 100-200 ml per loose stool for children more than 2 years
  • Continue breast milk and other foods the child takes usually
  • Give zinc supplements 10mg/day for 10-14 days if the child is less than 6 months and 20mg/day if the child is more than 6 months
  • Try home based fluids like buttermilk with salt, water in which a cereal has been cooked(rice-water), tender coconut water etc.
  • Advise the mother to return if:
    • Child is drinking poorly or unable to drink or breast feed
    • Becomes more sick
    • Has fever or blood in stool
    • Persistent vomiting

If you have diagnosed as ‘some dehydration’ then:

  • Try oral ORS at 75 ml/kg over 4 hours in frequent small sips from a cup
  • If continuously vomiting ORS administer same amount 75 ml/kg as intravenous Ringer’s lactate solution for 4 hours
  • Reassess and decide to treat based on diagnosis of current fluid deficit
  • Continue breast feeds and other food that the child normally takes
  • Prescribe zinc

If the clinical diagnosis is ‘severe dehydration’ then:

  • Admit and start intravenous fluids immediately
  • Use Ringer’s lactate solution 100 ml/kg divided as shown:
Age First give 30ml/kg in: Then give 70 ml/kg in:
Less than 12 months 1 hour 5 hours
More than 12 months 30 minutes 21/2 hours
  • Reassess every 15-30 minutes. Constant clinical surveillance is mandatory. Peripheral oedema is the first sign of fluid overload. Stop rehydration until oedema disappears.
  • Repeat the bolus 30ml/kg dose if pulse remains feeble
  • Start ORS as soon as child can drink (5ml/kg/hour)
  • At the end of correction reassess and classify dehydration and treat accordingly
  • Continue breast feeds and other routine foods if child is tolerating
  • Prescribe oral zinc at 10 mg per day in children below 6 months and 20 mg per day in children more than six months for 10-14 days once dehydration is corrected
  • If there is no facility for IV correction, refer urgently to the nearest facility providing the mother enough ORS to give during the journey. If the health worker is confident in nasogastric feeding, the same quantity of fluid correction as ORS can be give via nasogastric tube.

There is NO ROLE for routine antibiotics. Antibiotics are indicated in clinically suspected cholera wherein you need to prescribe doxycycline 4 to 6 mg/day as single dose. In clinically suspected shigellabacillary dysentery (blood in stool), prescribe 15mg/kg of Ciprofloxacin twice a day for three days OR Cefixime 8-10mg/kg twice a day for five days.

More details are available in the WHO manual which is available as a downloadable document.(2)

Tips in prescribing ORS to ensure successful rehydration:

  • Teach a family member to prepare and give ORS
  • Give ORS to young children using a clean spoon or cup NOT a feeding bottle
  • You can use a dropper or syringe without a needle to put small amounts of solution in the mouth of babies
  • Vomiting of ORS can occur if given too quickly. If the child vomits, wait for 5-10 minute and then start giving ORS solution again but more slowly.

References

  1. Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet , Volume 385 , Issue 9963 , 117 – 171. 17th December 2014
  2. World Health Organization. The treatment of diarrhea: a manual for physicians and other senior health workers-4th revision. WHO 2005

Diagnosis and management of pneumonia in a primary health care setting

APPROACH TO A CHILD WITH COUGH

Respiratory infections can occur in any part of the respiratory tract such as nose, throat, larynx, trachea, bronchi or lungs. A child who presents with cough or difficulty in breathing may have infection of any part of the respiratory tract. Pneumonia is an infection of the lung and can be caused by bacteria or virus. The most common bacterial cause of pneumonia is Streptococcus pneumonia and Haemophilus influenza. The children with bacterial pneumonia may die from hypoxia or sepsis. In 2005, 369,000 Indian children below the age of 59 months died of pneumonia. (1)

The World Health Organization has written guidelines on approach to a sick child in a health center with minimum facilities. It is described as integrated case management process. (2) This process attempts to approach an ill child comprehensively preserving continuity of care. It relies on case detection using simple clinical signs and syndromic treatment. The treatments are listed based on action oriented processes rather than actual diagnosis. The principle behind this is when a child with any health problem is seen in a peripheral health center the goal of the health care worker is to arrive at a management decision which involves overall health improvement including nutrition and immunization status. It may not always have a label of clear cut diagnosis. It is based on a diagnosis but involves more of action. For example in a tertiary care center, if a patient presents with cough the onus is on arriving at a diagnosis of the disease after physical examination and investigations. In a peripheral health center, the onus is on action to make the health problem better. It may involve some uncertainty as the diagnosis is not always clear but the evidence based guidelines uses will alert the health worker for urgent referral or admission.

The Integrated Management of Childhood Illness (IMCI) process can be used by doctor, nurse or community health worker who see children in first/second level facility. When a child between 2 months and five years presents with cough the following general steps are undertaken:

  1. Greet the mother or caretaker and assess the child by asking and checking for general danger signs (if child is feeding, if child is vomiting, if child is lethargic or child has convulsions). Then ask for main symptoms.
  2. Examine the child, check respiratory rate by counting for one minute, examine for danger signs (chest in-drawing and stidor) and classify according to action required and decide on pre-referral treatment, referral, admission or outpatient treatment.
  3. Check nutrition and immunization status
  4. Provide practical treatment instructions to the mother on feeding, giving medicines at home, looking for danger signs and follow up.

History

  • Ask for general danger signs( feeding, vomiting, lethargy, convulsions), duration of cough, wheeze
  • Ask general feeding habits (breast feeding, weaning etc.)
  • Ask immunization status
  • Ask for any other associated illness like fever, diarrhea or skin rash

Physical examination

  • Check child’s temperature, weight, capillary refill time, heart rate and respiratory rate
  • Classify fast breathing based on respiratory rate counted for one whole minute when the child is quiet:
Age of child Fast breathing if respiratory rate is:
Less than two months 60 or more per minute
Two months to 12 months 50 or more per minute
12 months to five years 40 or more per minute
  • Check for chest in-drawing : The child’s shirt or dress has to be lifted up to look for this sign. Look at the lower chest wall at the ribs. The child has chest in-drawing if the chest wall moves IN when the child is breathing IN. In normal breathing the chest wall moves out when the child is breathing in. This sign is a danger sign and indicates respiratory distress.
  • Check for stridor: This is a harsh sign that is heard when the child is breathing in and there is oedema of larynx, trachea or epiglottis.
  • Auscultate for wheeze or added sounds

Treatment
When the diagnosis is made as severe pneumonia, the antibiotic recommended by WHO is parenteral ampicillin and gentamicin. (3)

  • Ampicillin 50mg/kg/dose or benzyl penicillin 50,000 units per kg IV/IM/dose every six hours for five days
  • Gentamicin 7.5 mg/kg per day for five days
  • Maintain hydration with parenteral fluids if not taking anything orally
  • If there is worsening of symptoms the second line antibiotic recommended by WHO is injection ceftriaxone 80mg/kg per day in single or two divided doses for a total of 10 days OR injection cloxacillin 50mg/kg every six hours IV/IM and injection gentamicin 7.5mg/kg per day for 10 days. At this point a decision to get a chest x-ray needs to be done to check for complications of pneumonia. (4)

On making a diagnosis of pneumonia the recommended antibiotic is oral amoxicillin 80mg/kg/day in two or three divided doses for five days.No antibiotics are indicated for cough or cold.

The general supportive measures are normal saline nasal drops, steam inhalation, warm drinks and paracetamol (10-15mg/kg) for fever.The mother needs to be educated on danger signs.

Fig. 1: Recommendations based on the Integrated Management of Childhood illness (ICMI) guidelines of the World Health Organisation (WHO) for children aged 2 months to 5 years.


References

  1. Million Death Study Collaborators, Bassani DG, Kumar R, Awasthi S, Morris SK, Paul VK, Shet A, Ram U, Gaffey MF, Black RE, Jha P.Causes of neonatal and child mortality in India: a nationally representative mortality survey. Lancet. 2010 Nov 27;376(9755):1853-60. doi: 10.1016/S0140-6736(10)61461-4. Epub 2010 Nov 12.
  2. World Health Organization. Department of child and adolescent health and development. Handbook Integrated management of childhood illness. 2005
  3. World Health Organization. Revised WHO classification and treatment of childhood pneumonia at health facilities evidence summaries. 2014
  4. Brett D. Nelson Essential Clinical Global Health. John Wiley and sons Ltd. 2015


Cutting edge – April

PDF Version

A LOOK INTO THE FUTURE

The rate of change in our knowledge and use of technology in the medical field over the last 100 years has been mind-boggling. A hundred years ago, x-ray and ECG were ‘proof-of-concept’ inventions and a medical textbook considered the ‘sciagragh’ (x-ray) to be nothing more than a side-show trick and of no practical use. In fifty years, the possibility of cochlear implantation entered mainstream medical consciousness thanks to William House. Another fifty years down the line, transplantation of organs has become a routine procedure and significant advances have been made in our understanding of brain function, stem cell therapy, nanomedicine and individualised, targeted therapy for malignancies and other disorders. Not all of these however, have found acceptance in mainstream medical practice and many are still just ‘technologies’ waiting to be either accepted or discarded. Neuroprosthetics and bio-printing are some of the cutting edge technologies available today- they are still at a ‘proof-of-concept’ stage, that is, they have the potential to make an impact. Whether they will, only time will tell.

Neuroprosthetics

Football World Cup 2014 – The world watched as Juliano Pinto, a paraplegic patient kicked off the sporting extravaganza in Brazil by using a mind-controlled exoskeleton to stand and kick a football. Earlier in 2005, Cathy Hutchinson, a quadriplegic, reached out for, retrieved and drank a glass of water using a mind-controlled prosthetic robotic arm.1 Both of these prostheses were very limited in their range of movement and practical usefulness but demonstrated a proof of concept that an interface between the body’s neural system and a machine was possible.

Brain-machine interface (BMI) technology is not something new. Cochlear implants for hearing loss and Deep Brain Stimulation (DBS) for degenerative conditions like Parkinson’s disease are some examples of BMI technology that have been used for several years. Robotic prosthetic arms and legs for people who have lost the use of their limbs is still a work in progress. The exoskeleton that was used to kick the football developed by Professor Miguel Nicolelis and his team in North Carolina used scalp electrodes to pick up electrical signals from the wearer’s brain and processed these through a computer backpack. It was very limited in its function and range of movement – Juliano just about managed to stand and take a few steps. The challenge lies in decoding the neural signals picked up by the participant’s neural interface implant. These signals have to be then converted to digital commands that the robotic device can follow in order to execute the exact intended movement. The more complex the movement, the more difficult the decoding task. For sustained movement and functionality, electrodes will have to be placed in the motor cortex to give clear and strong commands to the robotic arms. This is a very invasive technique raising more questions than can be answered reasonably right now.

Neuroprosthetic arms and legs for amputees, that use Targeted muscle reinnervation (TMR) shows some more promise. Here, severed nerves are transferred to other target muscles and the electrical signals generated when the muscle contracts can be used to control a prosthetic arm or leg. Research is on to develop ways in which the person can not only touch and grasp but also feel what he or she is touching, thus making the process much more life-like and meaningful.2


Retinal Implants

Loss of vision can be devastating especially if it is because of damage to the retina or the neural visual pathway. There appears to be some hope for treatment in these situations in the form of implants. Stimulation of the primary visual cortex is a possibility but there are significant issues with compatibility, surgical complications, sustained power supply and heat dissipation that need to be addressed before this can be clinically applied. Stimulation of the retina however, has seen the light of day and two systems have found clinical application. The US FDA approved the Argus II Retinal Prosthesis System developed by Second Sight in 2013 for the treatment of those blinded by advanced retinitis pigmentosa.3 The Argus II includes a small video camera, a transmitter mounted on a pair of eyeglasses, a video processing unit and a 60-electrode implanted retinal prosthesis (microchip). The 3×3 mm microchip (0.1-millimeter thick) containing about 1,500 light-sensitive photodiodes, amplifiers and electrodes is surgically inserted beneath the fovea in the retina’s macula region. The chip receives visual signals from the camera which then stimulates intact nerve cells in the retina. The nerve impulses from these cells are then led via the optic nerve to the visual cortex where they create impressions of sight. This does not restore full vision but does improve the patient’s ability to perceive images and movement. The best result achieved by the device in clinical trials was a visual acuity of 20/1260.4 Alpha IMS is another sub-retinal implant that works without the need for an external video camera and which stimulates the bipolar cells of the retina. Twelve month follow-up showed that 86% if patients could perceive light, 59% detected the source of light and almost 50% reported meaningful visual experiences.

3D Printing

Three-dimensional (3D) printing has been used to design and generate objects of practical value for quite some time. The use of this technology to ‘print’ and grow organs is now beginning to reshape medical practice. In 3-D bioprinting, layer by layer precise positioning of cells and other biological material is done and these cells are then used to populate a scaffold using a machine, to generate a biological structure. Multi-layered skin, bone, vascular grafts, tracheal splints and heart tissue are some of the tissues that have been printed and transplanted.5 Even organs like the urinary bladder and kidney have been built with limited success. These have great potential in that rejection risk is reduced because the tissue can be made from the patient’s own cells. The implications of bioprinted tissue for healthcare is however complex and filled with challenges. Theoretically, it is possible to ‘print’ or ‘grow’ any organ but practical issues remain. Human organs are much more complex than just a set of cells connected together. These organs also need a proper circulatory system for blood supply to sustain them and mechanisms for repair. Ethical issues abound and along with the practical issues of complexity and application, bioprinted organs are still a long way away from resolving the long waiting list for organs for transplantation. 3-D printing in the meanwhile has found application in research, drug discovery and toxicology. This technology has found use in the creation of accurate models based on a patient’s unique anatomy to be used by surgeons for planning a complex surgery and to make individualized prostheses for implantation.

The quest for alleviating suffering and making life a little more liveable for those suffering from loss of limbs or organ failure will continue to fuel innovation and the search for new solutions. Neuroprosthetics and bioprinting are just two among many budding technologies (like stem cell therapy, nanomedicine, regenerative medicine) that are exciting and show promise for future practical application. Not everything that shows promise however ends up being practical, safe or useful in the long run. Some grow and prosper while others are left by the wayside. Which of these inventions and medical technologies will stay – that is something that only time will tell.

References:

1. Hochberg LR, Bacher D, Jarosiewicz B, et al. Reach and grasp by people with tetraplegia using a neurally controlled robotic arm. Nature. 2012;485(7398):372-375. doi:10.1038/nature11076.
2.Roberta Kwok . Neuroprosthetics: Once more, with feeling.. Nature 497, 176–178 (09 May 2013).
3. Larry Greenemeier . FDA Approves First Retinal Implant.. Nature doi:10.1038/nature.2013.12439
4. Fernandes, R.A.; Diniz, B.; Ribeiro, R.; Humayun, M. (25 June 2012). “Artificial vision through neuronal stimulation”. Neuroscience Letters 519 (2): 122–8.
5. 3-D bioprinting of tissues and organs. Sean V. Murphy, Anthony Atala. Nature biotechnology, 32(8), Aug 2014:773-785.
6. Images from Neuroprosthetics: Once more, with feeling.. Nature 497, 176–178 (09 May 2013) – used with permission.

Airway management

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BASIC AIRWAY MANAGEMENT

Dr. Madhurita Singh, Associate professor, Department of Critical Care, CMC Vellore

Introduction

In the initial assessment and management of any critically ill patient the ABC’s (Airway, Breathing and Circulation) are the first priority. Hypoxia will begin to cause irreversible brain injury within approximately 5 minutes and so airway management must precede any other treatment.

The ability to establish and maintain an open airway in a patient, and the ability to ensure adequate ventilation and oxygenation of the patient, are therefore essential skills for physicians. For the purposes of this module “basic airway management” will refer to those basic interventions that maintain an open airway and assist ventilation but do not include endotracheal intubation.

Recognizing inadequate airway and ventilation

The first thing that doctors need to recognize is when the patient is not ventilating his/her lungs adequately.

Adequate ventilation involves two factors

  1. Adequate intake as well as adequate exhalation of air – This indicates that there is enough tidal volume going into the patient as well as coming out.
  2. Adequate respiratory rate.

The combination of these provides adequate oxygen for gas exchange as well as allows removal of carbon dioxide. Any problem with these two processes will cause inadequate oxygenation and ventilation.

So what are the reasons of inadequate ventilation? The most common reasons are airway obstruction or inadequate respiratory effort or a combination of the two.

Airway obstruction:

Airway obstruction results in hypoventilation, increased work of breathing and impaired gas exchange in the lungs. If this is not recognized in time and treated adequately, it can result in development of hypercarbia and ultimately hypoxaemia. Provision of supplemental oxygen (using a mask or nasal canula) when there is an airway obstruction will not resolve the problem of hypercapnia associated with hypoventilation and impaired alveolar ventilation.

Obstruction may be partial or complete, depending on the mechanism or cause. Complete airway obstruction will rapidly cause hypoxia and cardiac arrest, whereas partial obstruction may be more insidious in onset.

Recognizing airway obstruction

Some of the important signs of airway obstruction are:

  1. Noisy breathing: This is the hallmark of a compromise in upper airway. It is indicative of partial obstruction that can lead on to total obstruction. Noisy breathing may be in the form of snoring, gurgling (blood, vomit or secretions) or stridor.
  2. Use of accessory muscles of respiration, agitation
  3. Expiratory wheeze (indicative of lower respiratory tract obstruction)

Recognition of airway compromise, as seen from the above description is primarily based on observation and listening to the patient. A decrease in saturation is a late indication of ventilation and oxygenation. If one waits till the saturation decreases below 90%, significant damage due to hypoxia would have already occurred. Dependence on the reading from a saturation probe should never substitute for looking and listening to the breathing of a patient.

Causes of airway obstruction: (1)

  1. Obtundation of consciousness: In a patient with a low level of consciousness, the cause of the obstruction will often be the result of the tongue falling back into the posterior pharynx due to loss of tone in the submandibular muscles.
  2. Intraluminal contents: Pooled secretions, blood, vomitus and foreign bodies (Eg. Broken tooth in trauma)
  3. External compression: Haematoma, tumour, goitre
  4. Direct trauma: Blunt trauma to maxilla, larynx, mandible, burns, smoke inhalation
  5. Artificial airways Blockage or displacement of tracheostomy, displacement of tracheal stent
  6. Excessive granulation tissue Prolonged mechanical ventilation, tracheal stenosis, supraglottic stenosis
  7. Neurocognitive and Increased risk of aspiration, e.g. Parkinson’s disease, post-stroke,
  8. neuromuscular disorders : myasthenia gravis

Management of obstructed airway:

Once obstruction of the airway is detected, immediate measures have to be taken to discover the cause and to maintain the airway. Delay can lead to dangerous hypoxemia and cardiac arrest.

Opening up and maintaining an obstructed airway may require one or more of the following measures:

  1. Physical manoeuvres – like head tilt-chin lift or jaw thrust
  2. Suctioning – to remove debris and foreign bodies
  3. Positioning
  4. Airway adjuncts
  5. Endotracheal intubation

If the patient is making respiratory effort but is not adequately ventilating his/her chest because of airway obstruction the doctor must determine the cause and take immediate measures to alleviate the obstruction.

In an unconscious patient, the cause of the obstruction will often be the result of the tongue falling back into the posterior pharynx due to loss of tone in the submandibular muscles. This problem can be quickly corrected using a simple maneuver such as a head tilt-chin lift or jaw thrust and this may be all that is needed to open the airway and allow adequate chest ventilation. If the physician encounters noisy or “gurgling” respirations at this point, the upper airway should be suctioned for vomitus and excess secretions.

In patients with a low level of consciousness (Eg. Head injury), the airway may be maintained by proper positioning (semi-prone position) to prevent the tongue from falling back and obstructing the airway in the supine position.

Endotracheal intubation is the definitive intervention in the management of an obstructed airway as it not only provides passage for air, but also protects the trachea from further obstruction due to pooling of secretions etc. Endotracheal intubation will be discussed in the next module.

Some of the simple interventions to maintain airway in a critically ill patient are described below.

Simple airway manoeuvres

Fig.1: Chin-lift and jaw thrust manoeuvres


Head Tilt-Chin-Lift:

This manoeuvre should only be used if the physician is confident there is no risk of injury to the cervical spine. Standing on the patient’s right hand side, the doctor’s left hand is used to apply pressure to the forehead to extend the neck. The volar surfaces of the tips of the index and middle finger are used to elevate the mandible, which will lift the tongue from the posterior pharynx. (Fig.1)

Jaw-Thrust:

Where there is risk of cervical spine injury, such as a patient who is unconscious as a result of a head injury, the airway should be opened using a manoeuvre that does not require neck movement. The jaw thrust is performed by having the physician stand at the head of the patient looking down at the patient. The middle finger of the right hand is placed at the angle of the patient’s jaw on the right. The middle finger of the left hand is similarly placed at the angle of the jaw on the left. An upward pressure is applied to elevate the mandible, which will lift the tongue from the posterior pharynx. (Fig.1)

Positioning

In patients with a poor level of consciousness due to any cause, airway obstruction is usually because the tongue falls back in the supine position and partly obstructs the upper airway. If endotracheal intubation is not being considered, (Eg. mild to moderate head injury), the airway in these patients can be maintained by semi-prone positioning. The patient lies on the side with the chest supported by pillows and head facing down. Instability of the cervical spine will have to be ruled out before positioning.

Airway adjuncts

Once the airway is open, an oropharyngeal or nasopharyngeal airway may need to be inserted to make it easier to maintain an open airway. Both of these devices prevent the tongue from occluding the airway and thereby provide an open conduit for air to pass. It is important to note that these two airway devices, unlike a cuffed endotracheal tube, will not protect the trachea from aspiration of secretions or stomach contents. If a patient is unable to protect their own airway, they should have an endotracheal tube inserted as soon as possible by someone who is training and expertise in that skill.


Oropharyngeal airway

Fig.2: Oropharyngeal airway – Assessing size (2)


The oropharyngeal airway is essentially a curved hollow tube that is used to create an open conduit through the mouth and posterior pharynx. A rough guide for choosing the correct size is to hold the airway beside the patient’s mandible, orienting it with the flange at the patient’s mouth and the tip at the angle of jaw. The tip should just reach the angle of the jaw. While inserting the airway you want to avoid pushing the tongue into the posterior pharynx. This can be accomplished by starting with the curve of the airway inverted, and then rotate the airway as the tip reaches the posterior pharynx. Alternatively a tongue depressor can be used to move the tongue out of the way as the airway is passed. Whichever technique is chosen the physician must be certain that the airway is indeed in the right position. If there are problems ventilating the patient after insertion of the airway then it should be removed and reinserted.

Nasopharyngeal airway


The nasopharyngeal airway is a soft rubber or plastic hollow tube that is passed through the nose into the posterior pharynx. To measure the length of the airway, measure the distance from the tip of the nose to the tip of the tragus. The diameter of the airway should also be measured and it should be little less that the diameter of the patient nares. The nasopharyngeal airway is generally better tolerated than the oropharyngeal airway in a semiconscious patient. The nasal airway is well lubricated with lignocaine jelly and inserted with the bevel toward the septum.

Fig.3: Assessing size of nasopharyngeal tube (3)


Fig. 4: Insertion of nasopharyngeal airway


While a nasopharyngeal airway may be left in place, an oropharyngeal airway should only be used as a temporary measure to keep the airway open before definitive management like endotracheal intubation. This is because the oropharyngeal airway does not protect the trachea and also prevents the patient from swallowing and if left in place for long periods (especially in a patient who is able to swallow), it only quickens the process of pooling of secretions and aspiration.

Bag-mask ventilation

Fig. 5: Bag-mask ventilation (two-person technique) (5)


A patient who is not able to breathe adequately on their own will require support of their breathing through artificial means. In order to push oxygen rich air into the patient’s chest, some form of positive pressure ventilatory assistance is required. The technique of bag-mask ventilation is difficult even in the best of hands and will require considerable practice before it can be done effectively on a patient. However, if mastered, this can be lifesaving in an emergency.
The first step in bag-mask ventilation is to select a mask that will cover the mouth and nose of the patient and create a tight seal. The mask is then attached to the bag device, which should be attached to high flow oxygen (15L/min.) such that the reservoir of the bag is fully inflated.

Generally, physicians will hold the bag device with their right hand and secure the mask to the patient’s face with their left hand. While securing the mask to the patient’s face you want to create a tight seal in addition to elevating the mandible to maintain an open airway. This is done by hooking the fifth finger at the angle of the jaw, holding the mandibular body with the third and fourth fingers and holding the mask between the index finger and thumb. The correct technique is to lift the mandible up with the third, fourth and fifth fingers while holding the mask tight against the patient’s face with the thumb and index finger.

If there is obstruction to air flow or the chest does not rise, recheck to make sure that there is a tight seal to the face, that the mandible is being elevated to open the airway and, if an artificial airway is being used, that it is in place. Readjust the mask and try again.

Two-person technique

The biggest challenge in bag-mask ventilation is maintaining an open airway and a tight seal using one hand. If a second person is available, it is recommended that one person manages the mask and the airway, while the second person squeezes the bag to ventilate the chest. The person responsible for the mask stands at the head of the bed and places his thumbs on the top surface of the mask. The remaining fingers are then used to grip the mandible on either side. The mask is squeezed between the thumbs and the fingers to create a seal and at the same time the mandible is elevated to open the airway. This technique is considerably easier, but again, the doctor must be constantly checking that air is flowing easily into the patient and that the chest is rising and falling. The rate of ventilation should be about 12 – 15 breaths per minute. In a cardiac arrest, the rate of respirations is 1 breath every 6-8 seconds. In a respiratory arrest, the rate of respirations is 1 breath every 5-6 seconds.

Fig. 6: Holding mask in two-person technique (6)


Equipment tray

Gloves

The rescuer should at all times avoid direct contact with the blood and other body fluids of the patient. If available, gloves should be worn during all airway management procedures.

Suction

In most resuscitation situations, the patient will either vomit, or at the very least, have an excess of secretion in their oropharynx. If available, a suction catheter should be included as part of your basic airway equipment.

Lubricant

If a nasopharyngeal airway is used, it will require lubrication of its outer surface prior to insertion. Xylocaine Jelly is used because it is a good lubricant and it reduces irritation through its local anaesthetic effect.

Nasopharyngeal Airway

The nasopharyngeal airway is made of soft, pliable plastic, and is inserted through the nares and into the nasopharynx, thus providing a patent airway to facilitate chest ventilation. It has the advantage of being better tolerated in the conscious or semi-conscious patient than the oropharyngeal airway. It is also easier to insert in a patient who has his/her teeth clenched. It is important to note that the NP airway does not protect the airway from aspiration of vomitus.

Oropharyngeal Airway

The oropharyngeal airway is a rigid plastic device, which is inserted through the mouth into the oropharynx. This provides a patent airway to facilitate chest ventilation. It is important to note that the oropharyngeal airway does not protect the airway from aspiration of vomitus.

Bag-Valve Ventilator

The bag-valve ventilator is a device designed to ventilate the chest. By attaching an oxygen supply, it can be used to ventilate the chest with a high concentration of oxygen. The bag-valve ventilator can be used with a mask, as in basic airway management, or it can be attached to an endotracheal tube as part of advanced airway management.

Mask

Masks are used to provide a tight seal between the patient’s face and the bag-valve ventilator. Masks come in various sizes. The correct size of the mask for a particular patient should provide a tight seal around the nose and mouth. The pointed end of the mask creates a seal over the bridge of the patient’s nose, while the round end creates a seal between the lower lip and chin.

Steps toward assessing the airway (Basic Life Support protocol):

Step 1: Assess responsiveness

Use the “shake and shout” technique to assess responsiveness. At the same time scan the chest for breathing. If the patient is unresponsive and not breathing, proceed to the next step. If the patient is breathing proceed to step 4

Step 2: Call for help

In all resuscitation situations, the first one on the scene will require assistance and hence the importance of this step. At this point you must ask for a monitor with facility for SpO2, non-invasive blood pressure and ECG monitoring, a defibrillator and personnel to come and assist with resuscitation.

Step 3: Check pulse

If there is no pulse, start chest compressions immediately and follow the basic life support protocol. If pulse is present and the patient is not breathing proceed to the next step.

Step 4: Open the airway

Noisy breathing is indicative of an obstructed airway. In an unconscious patient, the most common cause of airway obstruction is the tongue. To relieve the obstruction and open the airway, a simple manoeuvre such as the Head-Tilt/Chin-Lift manoeuvre can be performed. Alternatively, a Jaw Thrust manoeuvre can be used if there is concern that a C-spine injury may be present.

Step 5: Ventilate chest

In the absence of spontaneous respiration, the rescuer should immediately ventilate the chest and watch for adequate chest rise. If adequate chest rise is not seen, insert an oral airway and try ventilation again. If chest rise is still not seen, do a two-handed mask holding and ask another person to squeeze the bag. Remember, adequate chest ventilation is the single most important determinant of patient outcome in an apneic patient. Continue ventilating till help arrives and definitive care with endotracheal intubation can be performed. If you are the only one at the scene, ask a nurse to gather the equipment for endotracheal intubation and perform it, all the while continuing mask ventilation.

Sources:

  1. Managing airway obstruction. British Journal of Hospital Medicine, October 2012, Vol 73, No 10
  2. Essentials of Critical Care – 8th Ed. Division of critical care, CMC Vellore.
  3. Image from http://emedicine.medscape.com/article/80184-overview#a15