Doctor Killed Him??

“The Doctor Killed Him!”                               

Prof Maj S Bakhtiar Choudhary (Retd)

Just think once,

Are we attacking the pilot for delaying the flight?

Is aviation minister penalized for an air crash?

Are we assaulting Municipal offices for Air pollution?

Are we penalizing electricity board for cutting down the roadside trees?

These questions can go on….

Is doctor a Murderer?

The title seemed to pop out of the newspaper. Would have been better suited in a Robin Cook medical thriller, I thought wearily. In my 35 years of practice as a Medical Doctor, having served from the Armed Forces to private national hospital chains like Apollo, to regional consulting diagnostic centres like Elbit, Vijaya and Tenet, I have yet to come across a doctor who was in the medical profession to willingly take a life (Not to mention quacks, who don’t get appointed in respectable hospitals). Then why do these headlines scream ‘doctor is the murderer’ from the pages of social media every so often, as if it was the spoiler of a movie? Of course, the TRP ratings go up, just like the ‘likes’ to a post of a crime thriller. Why else would our media fan this fire?

Today media is repeatedly showing doctor is being beaten-up by patient’s attendants. Like how people learn things from movies, common man is learning that doctor can be made responsible for not saving life of a person. The result is assault on doctors on duty. Perhaps media is also not realizing their coverage could lead to more irresponsible and foolish behavior.

Doctor is trained to save people

Given the right facilities and the right faculties of mind (unless doctor has become crazy), no doctor would ever kill a patient simply because he is trained to do exactly the opposite-try and save the life! A doctor trains for almost a decade, with sometimes pitifully small remuneration (in the early years of the training), to physically and mentally exhausting working conditions, just because they believe that this is their purpose-to save lives and give patients best chance to live a healthy life. If they are unable to save a life, whose job is it to find out whether it was a mistake of the doctor or not? Not of the people who sometimes, in a fit of frenzy, go after the ‘life-saver’ themselves, as if blaming the death on the doctor and beating him with their own hands is going to bring back the dead. Revenge only leads to greater misery.

Why people behave foolishly?

Sometimes people behave foolishly! Especially the patient’s attendants! They believe beating the doctors is the ultimate solution. For even one second, they don’t think what a grave sin it is to punish the healer. For them, the healer is not God, just a human being. Taking the same argument further, if doctor is human then how can he save all the lives? There are some terminally ill patients who can be saved only by a miracle, not a human doctor. There are babies whose lives are yet so fragile, that saving all babies is impossible. There are such diseases which medical science is yet to understand fully. Statistics or data of any hospital, even the best hospitals in the developed nations in the world will reveal that all lives cannot be saved. Sometimes a mere blood clot can travel and get lodged in a place where it causes a stroke. This in spite of giving blood thinners. There are many such examples.

I welcome those attendants of patients to talk to me or any other doctor, who will patiently explain the no. of things that could go wrong in the human body. I wish doctors would pay more attention to patients’ attendants than they usually do. These attendants are also the sufferers, not just the patients. When a patient is lying on the hospital bed comatose or under influence of drugs, it is the care-givers waiting outside who are suffering the brunt of the situation. They need to be explained tactfully the seriousness of the patient.  It’s better not to give unrealistic hopes.

If the same doctor is busy, the doctor can delegate this task to another doctor. As per research, female doctors are better at this. Their motherly instinct takes over and they are known to give more time to patients and their care-givers than the male doctors. This known fact can be utilized by all doctors. Instead, sometimes doctors speak against their colleagues, which further damages the safety of the entire medical fraternity.

Doctors who handle emergencies and are on night duties are at high risk for attacks. It is better to prevent heated discussions with attendants by assigning a female doctor or an experienced female nurse to talk to them patiently. More than 2 attendants should not be entertained inside the hospital room. Entertaining unrelated people who accompany the patient can create trouble; hence should be discouraged. Some alleged incidents happen in private hospitals perhaps due to marketing strategy and management demands but not because of doctors. Unfortunately, the savior becomes the scape-goat.

Doctors do no possess magical powers

First thing we must understand that Lord Krishna, Rama, Pope, Shankaracharya, NTR, Jayalalithaa and many have died and doctors or priests could not save them. Media should make people understand that doctors are human beings and do not possess magical powers. Instead people have learnt that doctor should save every life. Media should refrain from showing these incidents to increase their TRP rating. Those incidents should be handled independently without major publicity.

Disease patterns have changed over the years and accurate diagnosis is not always possible, Supreme Court has given guidelines that doctor cannot be penalised for not diagnosing accurately. Differential diagnosis and impressions on possible diagnosis are also valid. Pharma industry is not under the control of doctors. They cannot control the molecules which replace the older ones often. Media has the power and widespread coverage to explain this to the common man. Such an article should be printed along with the article reporting the beatings, not on another page, another day alone.

Political leaders should avoid following every case to make their importance in public. They don’t understand the anguish and careful attempts of a doctor and the pathos of an attendant. In case of alleged negligence, a case can be filed in a manner prescribed by law, in extreme situations.

Citizens should take care of their health with pro-active approach. Today majority of Indians are after money neglecting their bodies, I see many youth who visit me with severe disc disease due to sheer negligence and they expect the doctor to save them miraculously from surgery within no time. Doctors are humans. They have spent money and time to study for many years. More than 85% of doctors do not make enough money when compared to their counterparts; they have sacrificed so many nights in attending emergencies, they need peoples’ support and gentle understanding of their occupational needs.. 

 

“Vitamin ‘D’ Panacea of Life” Understanding the need of the day (Revelations of study of 9360 people)

“Vitamin ‘D’ Panacea of Life” Understanding the need of the day

(Revelations of study of 9360 people)

Prof Maj Dr S Bakhtiar Choudhary (Retd)

1.    Introduction

It has been estimated that 1 billion people worldwide have Vit D deficiency or insufficiency¹. India with its socio-cultural diversity, receiving reasonable sunlight throughout the year, it was believed that Indians would not suffer from Vitamin D deficiency. India’s geographical location extending 8.4° N latitude to 37.6° N latitude with tropical weather conditions should ideally provide ample exposure to sunlight. But Vit D deficiency is very common in India in all the age groups and both sexes across the country^2-4. Vitamin D regulates calcium absorption in conjunction with the parathyroid hormone and bone mineralization. Biochemical studies have implicated vitamin D deficiency in many chronic diseases including infectious diseases, autoimmune diseases, cardiovascular diseases, diabetes and cancer. Vitamin D insufficiency leads to reduced bone mass, which can be manifested as Osteoporosis and Osteomalacia in adults and rickets in children⁵.

Minimum of 30 ng/DL of Vit D required for absorption of Calcium Vit D is lower than 10 ng/DL, is likely to damage Vit D receptor (VDR’s) sites Doctors fail to treat Vit D deficiency on long term bases Avoiding staple food is likely to cause chronic Vit D deficiency Current Vit D recommendations are under estimates Vit D deficiency begins as early as 10 years of age or below

2.    Prevalence of Vitamin D

Vitamin D insufficiency is evident in half of adults in New Zealand ⁶, one-quarter of Australians ⁷, 14% of French ⁸, 36% of US young adults and 57% of US general medicine inpatients ⁹, and particularly in the elderly, including up to 90% in UK¹⁰ and 86% in Switzerland ¹¹.

   

 

Table-1. Prevalence of Vitamin ‘D’ in Indian general Population
Vitamins	Blood levels	People (Percent)
Vitamin ‘D’  ng/DL	Less than 3	3.7
	3-7.9	31.7
	8-15	43.5
	15.1-20.9	13
	21-30	5.7
	More than 30	2.4

          Vitamin D was thought to help only bones and prevent diseases like rickets. But today’s research has proved that vitamin D has much more role in preventing multi system disorders. For ex. diabetes, thyroid, pain, dementia, depression, PCOD, and many other diseases. Unfortunately, all tropical countries in southern globe like Africa, Arabian countries & India despite having sunshine throughout the year, have Vitamin D deficiency in most of the population. There are hardly 2.4 % of Indian population who have Vit D more than 30 ng/DL and rest are all either insufficient or deficient (Table -1).

3.    Adequate Exposure to Sunlight

Studies have proved that sunlight exposure for more than 30 mins at one time cannot increase absorption. Instead repeated bouts of exposure are needed.

Fair complexion people are likely to make more vitamin D in a shorter duration of exposure to sun, than their darker counterparts of same age. Darker complexion people have thicker skin and do not absorb adequate Ultra Violet B rays (UVB) to make sufficient vitamin D in the skin, in a short span of time.

For many years people feared skin cancers on exposure to sunlight & thus avoided roaming in the sun or applied sunscreen lotions and other protective measures. This has led to vitamin D deficiency all over the world.

The elderly people are likely to make less vitamin D through the skin, as absorption is poor. People who are on anti-cholesterol tablets for prolonged periods are likely to reduce 7-dehydro cholesterol, a type of cholesterol which is responsible for making vitamin D under the skin with the help of UVB rays when exposed to sun. Hence, they are likely to be deficient, which is a large chunk of elderly population.

4.  Direct and Uninterrupted Exposure- We get 80 % of vitamin D from sunlight in the presence of uninterrupted ultra violet B rays in the sunlight spectrum. These rays are very sensitive and cannot penetrate 1mm glass hence they are unlikely to penetrate normal clothing and make the vitamin in the skin. Atmospheric pollution, dust, suspended particles, & chemical gases may seriously interfere with UVB reaching the humans sitting in closed compartment of offices, vehicles like cars and buses.

5.    Changing food habits & vulnerability to social media

Vit. D is a fat-soluble vitamin, and it is available in fatty food substances. However, today the trend is to reduce the body weight in order to look attractive and feel good about the body image. When trying to do so, first thing people restrict is fatty food and non-veg. In a person who is already deficient in vitamin D, E, A & K, body tries to store fat, thinking more vitamins will be available through fat. So, during this process it becomes hard to lose weight, as body is trying to hold on to whatever fat is there, thinking these fat-soluble vitamins are available in the body’s fat. Hence, most people who are trying to reduce weight find it hard to lose weight, as they are going against the body’s needs.

6.    Their efforts are counter-productive.

People are vulnerable to the information available through social media, and without consulting the experts, they are making changes in their native staple food habits. For ex. people in twin cities used to consume more of regional foods such as rice, locally available fruits, and nuts, like groundnut, sesame (till), coconut and cashew nut, since these are our regional nuts. Now there is an increased awareness of health which has led people to do ‘dieting’, & indoor exercise programs. But four decades ago, diabetes was prevalent in only 13% people in Hyderabad, now it has jumped to 27%, which is contrary to our efforts to obtain better health. Change in food habits that has happened due to various reasons like body image issues, social media etc. is not leading to better health.

Changing food habits from staple to modern leads to intolerance in the gut, gradual villous damage  in the intestine and leads to serious chronic diseases, such as irritable bowel syndrome, ulcerative colitis, constipation, gas etc., and these changes further cause serious micro-nutrient deficiencies. Today we see large no of people suffering from these intestinal disorders, and doctors find it hard to treat them.

People who consume alcohol are likely to disturb their micro-nutrient absorption along with vitamin D.

7.  Vitamin D Rich Foods Non vegetarian sources like fatty fish (big and fat fish, not small fish), whole egg, and mutton are the best sources. Whole milk, butter, cheese, mushrooms, lentils like lobia (black eyed white grams), okra are reasonably rich in vitamin D for vegetarians but must be eaten on regular basis.

Food Intolerance- Persons having intolerance to milk and milk products such as lactose and most of Southern and coastal Indian population who are largely sensitive to gluten in wheat and corn and other cereals, are likely to be seriously deficient hence they need very frequent estimation of the vitamin D and suitable supplementation.

8.    Diseases Affect Vitamin D Absorption

Healthy diet provides 20% of vitamin D requirements of the day. Vitamin D3 comes directly from the skin (with exposure to sunlight), while D2 is from the dietary sources. Both are converted into active form of D called calcitriol, by the liver and kidney. People with liver and kidney disease are most likely to become deficient and need serious supplementation program by a physician.

9.    Socio cultural habits

Habits among Gujaratis, Marwadis and Muslims, such as burkha, purdah (veil) where women are covered mostly from head to toe are at high risk of not getting adequate exposure to sunlight. In recent times, people have changed their habit of dressing. For ex. South Indian women wearing North Indian clothing such as salwar kameez, churidar kurta may lead to deficiency because of less exposure to body parts. Sari, our traditional India dress for women leaves more than 30% body exposed, which is beneficial for absorption. Similarly, men no longer wear dhoti which has more body exposed than the pant and shirt of today.

10.      Sports persons and Vit D Deficiency (Table-2)

Table -2. Vit D Deficiency status Indian Sports Persons
Table Tennis               Badminton  Shooting             Tennis           Cricket          Athletics	60  % 46  % 41 % 26  % 23  % 17  %

It is unusual to note that many sports persons are found to be severely deficient in Vit D. This may be because of changes in dressing, changes in eating habits and due to sub-clinical mal-absorption. Food intolerance among sports person need to be evaluated as they contribute for poor absorption of Micro-nutrients. Players like cricketers are also found to be deficient because of their dressing - full pants, full sleeves, helmet, gloves, despite playing outdoors. Players should wear shorts and t-shirts for few hours before wearing full uniform.

Sunlight should touch the skin for longer time. Especially in cities, badminton, table tennis & chess players often have vitamin D deficiency, hence they should have outdoor fitness program in sun, 3-4 days a week. Vit D deficiency is very common among many players and this increases their risk for injuries due to abnormal joint stiffness.

11.                     Rural population have slightly lesser deficiency. This may be due to better availability of UVB rays due to less pollution, and better exposure due to clothing such as shorts and t-shirts instead of full pants and shirts.

12.               Women and young girls with severe vitamin D deficiency have higher risk for schizophrenia, asthma, type 1 diabetes, and rickets in childhood.

During pregnancy, vitamin D deficiency can lead to diminished lactation, risk for gestational diabetes, pre-eclampsia, spontaneous pre-term birth, higher risk for c-section, lower birth weight, lower infant size, lesser bone density and health, reduced IVF success and repeated bacterial vaginal infection. 

During adulthood, women without pregnancy are at risk for hypertension, obesity, type 2 diabetes, abdominal cancer, multiple sclerosis etc. In senior women, cognitive impairment, myopathy, osteoporosis, Osteomalacia, frequent falls and fractures can occur. It is found that dietary intake of vitamin D during pregnancy is 80% below recommendation. It is also found, good vitamin D supplementation during pregnancy helps in regulating placental hormones and improves labor.

During lactation, it improves breast milk and increases circulating calcitriol concentration in nursing infants. It also prevents infantile rickets.

13.              Managing Vitamin by testing

Vitamin D is tested by a simple blood test costing Rs 600-2500 in different labs. Although recommendations say 30 ng/dl of vitamin D is sufficient but for good health, body needs 60 and above ng/dl for both sexes. Current recommendations underestimate the body’s requirements. Healthy rural youth were found to have vitamin D 60-70 ng/dl without any supplementation (eat well, exposure to sunlight). For pain relief, for better joint mobility and good proactive health management, one needs to maintain 60-70 ng/dl throughout the year and throughout life, which may be impossible. This is because 6 months to a year, exposure is compromised due to rainy season, winter season, summer heat and fear of going out in the sun. Modern youth are more inclined to exercising in gym, and modern jobs involve long hours of work. Commutation in cities takes away their valuable time, and exposure is neglected. One needs exposure to sunlight at least 3 days in a week, 20-30 mins, once or twice a day, with a direct contact to 30% of the body.

14.                     Extremely Low Levels of Vitamin D

People with vitamin D less than 10 ng/dl in their blood are at the highest risk for pain disorders, thyroid dysfunction, diabetes and people with less than 5 ng/dl may be at risk for cancer. People get relief from most pain disorders when their levels are more than 50 ng/dl. Calcium is absorbed when vitamin D is more than 30 ng/dl.

15.                     Frequent Testing and Prolonged Supplementation

Most of us do not have 100% regulated digestion throughout the month. Minor disturbance in digestion can seriously impair absorption of these nutrients. That means frequent checking and supplementation. Vitamin D test should be done twice a year, before monsoon in June and at the end of winter, in Feb or Mar. Oral supplementation is better than injectable, to encourage absorption in gut. Vitamin D receptor sites become seriously damaged once person becomes deficient, and may take months to years before becoming active again. That’s why one needs prolonged supplementation. If deficiency is noted in children as young as 7-8 years, they are likely to become seriously deficient as adults as receptors get damaged, without any symptoms. Children need to be tested at least once every year.

16.  Vitamin D Toxicity people often have fear that excess vitamin D supplementation will lead to toxicity but fortunately this is not likely. Only 4000 IU or more of vitamin D every day for couple of months may lead to toxicity.

  

     17.  Self-medication It is not advised to take commercial diet supplements off the shelf without doctor’s advice. Because they may not have adequate vitamin D formulations. Most people need 1000 IU of D3 tabs daily and pregnant women, lactating women, sports persons, and elderly and people who are diagnosed as deficient need higher supplementation under supervision. It is important to note that calcium tablets do not have adequate Vit D. Before you take any pharmaceutical supplements off the shelf, it is important to get advice from a doctor.

     18. Management Advice

          Time management is essential and should begin with childhood so that they develop habit of getting exposed to sun and eating right. But one should protect eyes from the UV rays by wearing UV protective sun glasses. People who are sensitive to UV rays can safely expose to sunlight for up to 10 mins before applying protective cream. Changes should be made in clothing, for ex. half shirts and shorts as school uniforms. Children should be taken for frequent outdoor recreational activities like trips to the zoos rather than be allowed to spend time on phone and TV. Sudden pain, stiffness in joints, tiredness, feeling of bone pain, sudden increase in weight, disturbance in menstrual cycle are most likely due to person being vitamin D deficient.

Note: These predictions are based on my study of more than 9360 people of all ages and both genders. Final publication will be made available soon.

Contact: Pl contact Prof Maj S Bakhtiar Choudhary, Hyderabad Spine Clinics

E-mail: sbakhtiar@hotmail.com, www.drbakhtiar.com

Tel: 8008123940

References

1.      Hollick MF. Vitamin D deficiency. N Engl J Med 2007;357:266-281.

2.      Harinarayan CV, Joshi SR. Vitamin D status in India-Its implications

and Remedial Measures. J Assoc Physicians India 2009;57:40-48.

3.      Marwaha RK, Sripathy G. Vitamin D and Bone mineral density of healthy school children in northern India. Indian J Med Res 2008;127:239-244.

4.      Harinarayan CV. Prevalence of vitamin D insufficiency in postmenopausal South Indian women. Osteoporos Int 2005;16:397- 402

5.      M.F. Holick, Photobiology of Vitamin D, in: D. Feldman, J.W. Pike, F.H. Glorieux (Eds.), Vitamin D, second ed., vol. 1, Elsevier Academic Press, 2005, pp. 37–46.

6.      C.M. Skeaff, J.E.P. Rockell, T.J. Green, Serum 25OHD Concentrations of New Zealanders Aged 15 Years and Older, UV Radiation and its effects – an update 2006, Royal Soc. New Zealand, 2006.

7.      J.J. McGrath, M.G. Kimlin, S. Saha, D.W. Eyles, A.V. Parisi, Vitamin D insufficiency in south-east Queensland (letter), Med. J.Aust. 174 (2001) 150.

8.      M.C. Chapuy, P. Preziosi, M. Maamer, S. Arnaud, P. Galan, S. Hercberg, P.J. Meunier, Prevalence of vitamin D insufficiency in an adult normal population, Osteoporos. Int. 7 (1997) 439–443.

9.      M.F. Holick, High prevalence of vitamin D inadequacy and implications for health, Mayo Clin. Proc. 81 (2006) 353–373

10. D. Corless, M. Beer, B.J. Boucher, S.P. Gupta, Vitamin-D status in long-stay geriatric patients, Lancet 1 (1975).

11. R. Theiler, H.B. Stahelin, A. Tyndall, K. Binder, G. Somorjai, H.A. Bischoff, Calcidiol, calcitriol and parathyroid hormone serum concentrations in institutionalized and ambulatory elderly in Switzerland, Int. J. Vitam. Nutr. Res. 69 (1999) 96–105.