Sued for wrong diagnosis and treatment

From malaysiakini

Housewife sues gov't for RM7.5m
Humayun Kabir | 14 May, 09 3:25pm
A 54-year-old housewife is suing the government a whopping RM7.5 million in damages for a wrong diagnosis on cancer, which lead to the unnecessary removal of her left breast.

Silvarany Thangavellu of Batu Gajah would seek RM5 million in general damages, and RM2.5 million in exemplary damages and damages for pain, suffering, embarrassment, trauma and interest and cost.

The case was mentioned in the High Court in Ipoh today.

Silvarany had filed the case on Feb 15, 2008 and is suing Dr L Vasu Pillai and director of the Ipoh General Hospital, the Health Ministry and the Malaysian government for medical negligence.

Her counsel, A Magesan of A Sivanesan & Co, said he would file the notice in court next week to prepare the case for hearing in court.

He said that his client was admitted into the Ipoh General Hospital for a stomach problem and her uterus was removed following the discovery of a fibroid growth.

On her subsequent medical visit on May 16, 2005, she was informed by Vasu that her pathology report showed she has cancer in her left breast.

It was surgically removed in an operation, performed by Vasu on Sept 7, 2005. She was discharged five days later.

A month after, she went for a follow-up medical check-up and was told by Dr Stephen Jacob, a doctor in the Ipoh General Hospital, that she was misdiagnosed for breast cancer and her left breast was wrongly removed.

Demonstrates the importance of ensuring samples are properly labeled and results are cross checked if they belong to the patient. The above report is likely to have omitted important details.

How can breast cancer be diagnosed if no biopsies were taken from the breast?? Why did the patient accept the diagnosis if the breast were not a concern? If indeed there was a mass and the pathology report indicated malignancy, are the attending doctors to be blamed for expeditiously removing the breast? If subsequent pathology of the breast tissue showed no malignancy, were the operating doctors at fault? If there is to be any finger pointing, perhaps it should be directed at the pathologist, should it not?

It will be interesting to know more details.

Interosseous Access in Adults

Recent problems with IV access in patients with dengue shock syndrome has brought to light interosseous(IO) access, even in adults. Unfortunately, unlike in pediatrics, the expertise of inserting IO lines among adult medical staff is lacking.

IO access was first researched among military personnel especially during combat situations, where IV access may be difficult. It has also been advocated during pre-hospital emergency care when iv access is difficult.

How much fluids can we run into the marrow cavity in adults? What are the complications of such a procedure? Are there better alternatives?

IO lines are not advocated more than 24 hours, during which time an IV access is preferable or a new site of IO is made. The risk of infection in prolonged IO access is a concern. Getting the needle into the marrow proper in adults can be difficult as the marrow has contracted in most long bones. Improperly placed IO lines can pose more problems. Insertion of IO lines can be very painful and sedation will be necessary. In the context of shock, sedation may not be ideal. On most occasions, the patients would have to be artificially ventilated first.

Alternatives are centrally placed lines or a venous cut-down. Unfortunately, these procedures require time to be inserted, a luxury not available in must resuscitations.

So should IO lines be advocated in our patients especially those with dengue?

Web citations

In this era of the internet, web citations are becoming increasingly common. However, one of the main problems is the fact that the documents can disappear from a previously searched URL in a flash. So when someone checks a web reference on your thesis, the page is no longer searchable.

Firstly, how do one write a web reference in a proper format. Perhaps this example is useful.

Plunkett, John. "Sorrell accuses Murdoch of panic buying", The Guardian, October 27, 2005, URL: http://media.guardian.co.uk/site/story/0,14173,1601858,00.html, Archived at http://www.webcitation.org/5Kt3PxfFl on December 4th, 2006.

AS you can see the URL is mentioned as opposed to a particular journal. This example also gives us an option of archiving our referenced documents on an online server, so as to avoid it from disappearing.

Some prefer to use the Digital Object identifier or DOI instead of a lengthy URL address. DOIs are more consistent and searchable as it is maintained by publishers and archives through registration agencies. Eg Pubmed uses PMID and it would make more sense to use the PMID as opposed to the URL which can change.

References
http://www.medscape.com/medline/abstract/19022207
Webcite

End of the road for Rimonabant?

From medscape,

Drug Maker Agrees to Suspend Rimonabant Marketing in Europe

from Heartwire — a professional news service of WebMD

Shelley Wood

October 23, 2008 (Zurich, Switzerland) — Rimonbant's rough ride may be nearly over: today, the European Medicines Agency (EMEA) announced that it has recommended suspension of the weight-loss drug, marketed as Acomplia in Europe [1]. According to an EMEA committee, the benefits of the drug "no longer outweigh its risks."

Its manufacturer, Sanofi-Aventis, has responded, agreeing to what it is calling a "temporary suspension" of the drug [2]. cont here

Related article on Medicine Malaysia,

Monday, September 10, 2007
Rimonabant : Weight Loss wonder?

Rimonabant is a CB1 cannabinoid receptor antagonist, some say the next generation anti obesity drug. Observations that heroin causes an increase in appetite led to the discovery of the role that the endocannabinoid system played appetite control and subsequent weight problems.

It first came into prominence in 2004 and recent trials have churned out data proving long term safety and superior efficacy in terms of weight loss, improved cholesterol profile, reduced abdominal circumference and even benefits for Type II diabetics.

Patients in the RIO-Europe trial who were on 20 mg of Rimonabant achieved 15-20 pounds weight loss, 7.5 cm waist reduction, 30% increase in HDL and 9% reduction in triglycerides. RIO-North America displayed similar results.

Indeed a promising addition to the armamentarium in our fight against the flab.

A case of too good to be true?

Microbial flora on restaurant beverage lemon slices.

The next time you order a drink, you may get more than you bargained for.

Conclusion

Although lemons have known antimicrobial properties, the results of our study indicate that a wide variety of microorganisms may survive on the flesh and the rind of a sliced lemon. Restaurant patrons should be aware that lemon slices added to beverages may include potentially pathogenic microbes. Further investigations could determine the source of these microorganisms, establish the actual threat (if any) posed by their presence on the rim of a beverage, and develop possible means for preventing the contamination of the lemons. It could also be worthwhile to study contamination on other beverage garnishes, such as olives, limes, celery, and cherries, and to investigate whether alcoholic beverages have an effect not seen with water and soda.

Reference
Loving, Anne LaGrange; Perz, John. "Microbial flora on restaurant beverage lemon slices" The Free Library 01 December 2007.

Litigation : A trend?

Housewife sues hospital, govt for RM5mil
By EMBUN MAJID

ALOR STAR: A housewife is suing the Government and the Sultan Abdul Halim Hospital for more than RM5mil in damages for alleged negligence that resulted in her suffering chronic kidney failure.

K. Hemalatha, 31, from Taman Sutera, Sungai Petani filed a suit at the Alor Star High Court Registrar Office on Monday.

In the suit, Hemalatha has named the Sultan Abdul Halim Hospital director and the Malaysian Government as the first and second defendants respectively.

She is seeking RM55,557.30 in special compensation, RM5mil in general damages and exemplary compensations, and other relief and cost deemed fit by the court.

In the suit, Hemalatha claimed that she suffered from chronic kidney failure due to the negligence committed by doctors who attended to her when she delivered her fourth child via the Caesarean section on July 11, 2007.

She claimed that the doctors had failed to conduct the necessary tests and diagnose her condition before the surgery.

She also claimed that the doctors had failed to make abdominal and renal evaluation to identify the correct stage of her renal failure before the surgery was performed.

Hemalatha further claimed that her stomach became bloated and she had difficulty in breathing the following day (July 12) after the Caesarean section was done.

She was told by a doctor who examined her that she had internal bleeding.

Hemalatha claimed that she was operated on for the second time on the same day and an ultrasound performed on her later showed that both her kidneys had shrunk.

She claimed that she then underwent an ultrasound at a hospital in Penang on Aug 28, 2007 and was told that both her kidneys have failed to function and she has to undergo dialysis treatment for the rest of her life. She is now under medication.

Much information has been left out in this article and it would be unwise to comment on the rationale for this suit.

However, I find that the press should not highlight litigations when it has yet to be brought forward to the courts. This move deflates confidence in the healthcare system and does little justice to those who have been working hard to maintain a good quality of healthcare. It passes unfair judgements to those involved.

My recommendation to the press is that they should thoroughly research the facts before putting it on paper. Many litigations are done without proper grounds. Highlighting each and every one of them will certainly tarnish the image of healthcare in Malaysia. They should have an independant panel of doctors to decide the factual basis of such allegations.

As of now, the only reason for such a press report is to sensationalise a topic that often times tickles the sensitivities of many, making them a good read.

Medical Rituals

Malaysia, once again, famous for all the wrong reasons. However, it is an important part of humanity and has been in existence in all shapes and forms for centuries. There are no rules here, anything goes. It is like creating games for children where the only limitation is one's imagination. So the question is, why do reasonably educated individuals fall for such a scam?

Vulnerability and desperation. When the 'sane' world offers little explanation to a problem, alternative views become a suitable substitute. From health to financial matters, the solutions from alternative sources are sometimes infinite. It's amazing that people will believe almost anything, no matter how ridiculous it may seem. From bizzare rituals to downright ludicrous concoctions, a cure is somehow always around the corner.

The placebo effect do assist alternative solutions to florish. Sure, there will be someone who will feel better and swear by its effectiveness. Clinical trials are almost never performed but those flocking to them could almost result in a stampede.

I remember how at one time a family sweared that a 'doctor' did perform a special surgical techniques that could remove water from the body for congestive cardiac failure, which was sutureless. He came with surgical plasters on his body. The family claimed to have seen blood oozing out and the 'surgeon' plucking things from the body. On removal of the plaster, only a superficial scratch that masqueraded as a surgical scar. It took some convincing talk before the family admitted that it was just a scam. They paid a few thousand ringgit for that.

Now that the Ministry of Health is allowing traditional medical practices to be set up in a hospital, i wonder if this will lend legitimacy to dubious claims or drugs. What regulations are in place and is evidence-based care important for this branch? Or are we perfecting the art of shooting ourselves in the foot!

Ministry of Health short on funds

I find this report recently in a local daily as perplexing. Slashing the budget of healthcare pushing the Minister of Health into a begging mode is ridiculous. When a hospital does not have a proper and well equipped emergency room, there should be an urgent need to rectify the situation.

Instead, there is a budget cut. Such development funds are vital to ensure that Malaysia stays at a satisfactory level of healthcare provision. As the current situation stands, there is already a lack of monetary backing in research and development, a field so vital if we are to become a developed nation in the near future. Sadly, the infrastructure itself is lagging behind in acceptable standards and certainly not to mention the human capital.

The public expects a high standard of healthcare but the mismatch in funding is glaringly evident. I suggest a budget cut in military spending which remains a huge priority, be made. Acquiring submarines in this neck of the woods is foolish as it is geographically inappropriate and certainly adds little to the line of defence.

Healthcare budgets worldwide is forever expanding. A more prudent spending and planning is essential, a well known fact even to any non-economists.

Overtransfusion?

Following a report in The Star about "Blood supply low in hospitals"

One of the said culprits was the increase in dengue cases leading to the need for transfusion. This raises questions as to whether we are transfusing patients necessarily.

Those of us who have treated dengue will know that on most occasions there is little need to transfuse. One of the main pathophysiology of dengue shock syndrome is the fact the plasma leaks out of the capillaries leading to hypovolemia and thus a drop in blood pressure. The treatment would be to replenish this fluid with intravenous fluids.

Even the drop in platelets rarely require transfusion unless there is evidence of excessive bleeding due to thrombocytopenia.

So are we overtransfusing our patients with dengue and putting them at risk of transfusion related complications?

Rimonabant : Weight Loss wonder?

Rimonabant is a CB1 cannabinoid receptor antagonist, some say the next generation anti obesity drug. Observations that heroin causes an increase in appetite led to the discovery of the role that the endocannabinoid system played appetite control and subsequent weight problems.

It first came into prominence in 2004 and recent trials have churned out data proving long term safety and superior efficacy in terms of weight loss, improved cholesterol profile, reduced abdominal circumference and even benefits for Type II diabetics.

Patients in the RIO-Europe trial who were on 20 mg of Rimonabant achieved 15-20 pounds weight loss, 7.5 cm waist reduction, 30% increase in HDL and 9% reduction in triglycerides. RIO-North America displayed similar results.

Indeed a promising addition to the armamentarium in our fight against the flab.

Rimonabant (wikipedia)

More to communication skills

From Medscape,

Physicians With Poor Communication Skills Linked With More Patient Complaints NeW YORK (Reuters Health) Sept 06 - Physicians who have low scores on assessments of patient-physician communications early in their career are more likely than their peers with higher scores to be reported to medical regulatory authorities, according to a longitudinal study in Canada reported in the Journal of the American Medical Association for September 5th. continuing story

Often times, the medical fraternity stresses on a good doctor-patient relationship as an ideal quality. Indeed it is. However, I feel that it is equally important to have a good doctor-doctor communication as well. This less often talked about subject is lacking in many doctors today.

Communicating effectively among doctors is an attribute that defines competence. A short tempered and condescending doctor paints a picture of instability and a lack of self confidence. Our daily practice unfortunately exposes many encounters that often lack civility. Does a grandiose position or degree grants a doctor the right to ridicule another?

Perhaps doctors need more training when it comes to communicating among themselves. Only when this is in order that a good doctor-patient relationship can blossom.