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Dr. Ranga Bashyam, Dr. M.S. Valiathan,
Dr. N.H. Antia, Dr. R.D. Prabhu and colleagues who have organized
this spectacular IInd A.R.S.I. conference at SHIMOGA, my dear friends,
colleagues Ladies and Gentlemen.
It is a matter of pride and privilege to be the President of
an active growing organization and I am thankful to both Dr. Rangabashyam
and Dr. Valiathan for their inaugural address and key note speech.
To say the least, I have been extremely inactive in the affairs
of the R.S.I. since I was bogged down with other commitments,
both in Delhi and outside India. I left Delhi to return to my
home town sometime in February but I was summoned back by the
11th of April, to look into the emergency services of hospitals
in the National Capital Territory of Delhi both public and private
(of a bed strength of 150 or more). It was an education par excellence
in the height and depths of hospital care in Delhi, and I thought
I could share with you some of the thoughts that have emerged
out of this study.
Delhi is a highly metropolitan city but it has in it the 2nd
largest URBAN SLUM in the country though it is not concentrated
like “Dharavi” of Bombay in one major area. It has
a very large heterogeneous population from practically every corner
of the country. It has the widest of roads and narrowest of lanes
and areas of immaculate cleanliness and the largest of dumping
heaps. It is estimated that there are 22 varieties of transport
in Delhi with the craziest of drivers in the country which is
benignly called the “Maruti culture” defined as overtaking
and vehicle ahead of you on any side as well as from the top if
possible. Its road accident figures naturally therefore is surpassed
only by Mexico city and Lagos.
In the study I found the public hospitals of Delhi have to cater
26% of its resources to emergency department patients from outside
metropolitan Delhi. They normally come from Uttar Pradesh, Rajasthan,
Punjab, Madhya Pradesh, Jammu & Kashmir, Bihar and from anywhere
else and the hospitals in Delhi spend about Rs.72 crore annually
on these patients who attend only the emergency.
I requested all medical superintendents to answer a questionnaire
submitted to them, which would give a birds eye view of the functioning
of their emergency services. The speciality they tackle the number
of minor and major surgical procedures carried out in the emergency
theaters, the type of anaesthesia they use, the post-operative
infection rate, the morbidity and mortality rate; the state of
their blood banks and the testing of blood donors for various
viral and bacteriological infections (Australia antigen; Non A
+ Non B; hepatitis B, HIV and VDRL) the fractionation of blood
and blood products, availability of the intravenous fluids and
their sterility the availability of disposable needles and prevention
of their re-use, the techniques of sterilization adopted, the
availability of instruments in the theatre, the investigations
that are available (imaging, biochemical bacteriological and pathological
including frozen sections). Questions were also asked about the
kind and level of attention that a patient receives on entry to
the casuality, whether any classification is done of emergency
problem like a triage system (trauma score) Glasgow coma scale
and the types of intervention that could be undertaken in the
casuality itself. For example a laryngoscopy for removal of foreign
bodies. The time taken for admission to I.C.U and I.C.C.U., the
availability of monitoring devices in these two areas, the paediatric
emergency care including neo-natal and the care of obstetrics
and gynaecological emergencies. Neurosurgical emergencies, road
traffic accidents with multiple trauma, were also looked into
and paramedical training and training of nurses in handling of
emergencies were also assessed.
The answers received from various institutions and my own personal
impressions on the functioning of emergency services, were submitted
as a report to the Lt. Governor on the 11th July 1994. It had
a very good enthusiastic reception from the media in Delhi. What
I learnt from this exercise was certain fundamental points which
I believe are applicable to surgeons all over the country, wherever
they might be located.
- Careful clinical examination
and recording of findings preferably in a printed format
is a must on all emergency care. No emergency is a minor
one and this is the only way one could avoid mistakes.
- Basic investigations
are a must and it might only be Hb, TLC, DLC, Urine examination
to exclude diabetes or infection. Simple X-Ray of the
chest or extremities involved.
- Careful transport
of the patient with resuscitative measures when desirable
or necessary (never by an open technique).
- Oxygen with a mask
and I.V. line to maintain fluid in take when desirable.
- Arrest bleeding with
the use of to urniquet or pressure where necessary.
- Cardio pulmonary resuscitation
as and when required.
- An ambulance if available
to be equipped with life saving equipment.
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The patient on arrival at the hospital must be assessed by a doctor/para
medical personnel well versed in the management of emergency. A
quick recording of pulse, respiratory rate, blood pressure should
be done and E.C.G. obtained if available and considered clinically
desirable. A routine thorough clinical examination from head to
toe for exclusion of depressed fracture of the skull, ocular and
facial injuries papillary re-action, Glasgow Coma scale, injury
to neck, thorax, position of apex beat respiratory excurision, percussion
of chest to exclude hemo or pneumo thorax, pulse in upper extremity
lower extremity and carotids, abdominal examination including the
presence of fluid of blood. Examination of urinary bladder, genitor
urinary examination and presence or absence of reflexes both sensory
and motor and examination of all four extremeties for evidence of
any damage or injury. Though this is primarily scheduled for examination
of trauma victims it would point out other medical surgical, obstetrics
and gynaecological problems that are likely to emerge in any casualty.
Classify patients that come into casualty after clinical examination
into most serious and ordinary and always admit patients if there
is any suspicion of progress in symptoms or signs on careful observations.
If there is any other complication admit the patient (diabetes,
blood pressure or previous history of cornonary infarction). With
the consumer protection act becoming a reality, in most places
the medical profession has lost its charm and is being classified
as “a commercial enterprise”. And it would not be
too long before all doctors face, mal-practice, charges, particularly
since we as a nation do take after western attitudes. Therefore
it is always desirable to have indepth analysis of your own establishment
and have a critical review of your performance based on three
criteria.
- Infection rate post
operative or otherwise this-includes transfusion related
problems.
- Morbidity rate as
for example development of complications because or inspite
of intervention.
- Mortality rate particularly
within 24 hours after any intervention in the hospital
(this should include cases which have been packed out
of many hospitals just prior to death).
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One of the major problems any surgeon is likely to face is an unacceptable
infection rate. The permissible infection rate in closed interventions
is 1% and in open injuries 6% according to the U.S.A. bureau of
hospital standards (C.D.C. Atlanta data). In our public institutions
the infection rate is as high as 25%.
It is therefore important to establish an infection control cell
in any institution which renders inpatient and operative services.
This should be preferably in charge of para medical or medical
personnel not involved in the theatre managements. The infection
control cell must have an independent bacteriological assessment
(both aerobic and anaerobic organisms) of the theatre complex
including the scrub rooms, the water supply the outlet pipes,
the oxygen and suction machines, the air-conditioning equipments
the lights the operating tables and any other equipment that might
enter the theatre (such as a portable X-Ray unit). It would also
be wise to have a monthly throat culture done of all individuals
who enter the theatre complex. A sporadic and spontaneous culture
of all hands of persons who take part directly in the operative
procedure or those who handle equipment. This aspect of surgical
care has not been given adequate emphasis, and should be a matter
of priority for organizations like ours.
Another important avenue, that we should explore is the question
of informed consent for a surgical procedure, either minor or
major done with or without general/local anaesthesia. Informed
consent is defined as explanation of the relevant surgical procedure
as either emergency or elective, with reasons for the intervention,
the complications that are likely to occur immediately within
week or 10 days or long term. It should also include the explanation
of the nature of anaesthesia to be used, the anaesthetic risks
and the expected morbidity and mortality of the intervention.
These should be explained to the patient if he is conscious and
to the relatives preferably the first descendant or the wife/husband.
If the patient is illiterate, there must be 2 witnesses to the
thumb impression. This document should also be signed by the surgeon
as stating that he has explained to the patient and his relatives
of the likely complications that are likely to arise as a result
of the intervention. I believe the time has come A.R.S.I. must
within the next one year standardize informed consent forms for
the following 12 commonly performed surgical procedures.
- Laparotomy including
appendectomy
- Hernia repair including
strangulated hernias & hydrocele
- Haemorrhoidectomy
- Routine delivery and
Fistula in Ano forceps application “C” section,
Complications to both mother and child as for example
asphyxia neonatorum
- D & C
- Tonsillectomy
- Supraputic Cystostomy
- Tracheostomy
- Suction drain in the
chest
- Closed reduction of
common fractures and complications of P.O.P application
- Upper G.I. tract bleeding
and application of sengstaken tube or coagulation
- Nasal bleeding heomoptysis
and its scare.
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I believe these are common enough problems that should be looked
into, and it is the function of our association to safe guard the
patient as well as the surgeons.
I hope we act quickly and firmly and set a pace for other organization
and Associations to follow.
Thank you for your patience.
Dr. Balu Sankaran
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