Grief : Death of AIIMS Covid warrior; raises questions https://extinctdoctorgood.com/2020/05/27/grief-death-of-aiims-covid-warrior-raises-questions/
Diseases can be preventable or unpreventable, have good or bad prognosis. But once patient enters hospital, what ever may be the reason or genesis of ailment, it becomes a moral responsibility of doctors. Health care professionals can be trash-talked or ridiculed by media and anyone, even for worst prognostic cases. But large numbers of deaths happen due to preventable causes like accidents , drains, live electric wires, water contamination, dengue, malaria, recurring floods etc. In fact the burden of negligence here is massive and these deaths are unpardonable. Who ultimately carries the moral burden of millions of preventable deaths?
Common causes of such disease, sufferings and death , specially in developing and poor countries:
- Dietary risks and diseases spread by water sanitation and hygiene. These have direct linked with bad sanitation and poor hygiene practices. Poor sanitation is the leading cause of diarrhea, malnutrition, cholera, jaundice ( hepatitis A and E) , worm infestations, typhoid and other enteric fevers, which lead to chronic malnutrition and lowered immunity that further feed the infectious disease cycle. Apart from infectious disease like diarrhea, but also pneumonia and tuberculosis, which are leading killers across all age groups.
- Undernourishment in children will cause them to be underweight, stunted and wasted, and makes them more vulnerable to infections. They are at higher risk of dying of childhood infections.
Working sewage-disposal systems, waste disposal management, protection of water supply from contamination and hand-washing practices are essential components to reduce preventable deaths.
- Poor sanitation, unsafe water and low public health also increase drug-resistant infections in low-income and middle-income countries. Lowering of antibiotic consumption can not be achieved because superbugs , and antibiotic resistance are already in the environment and continue to spread through contaminated food, water and hospital equipment.
Antibiotics overuse is rampant as they are used to treat diarrhea and upper respiratory tract infections. Improving sanitation, providing clean water, adopting personal hygiene and getting vaccinated can reduce infections.
- Air pollution : air pollution is a public health crisis. Masses are forced to breathe in air which contains pollutants in unsafe limits, some are carcinogenic. It is a cause of millions of deaths It is besides many fold of this number live their life with morbidity. Polluting vehicles, industry, lesser trees and plantations, poor practices and not enough governance and policies have resulted in poisonous air to breathe. Diseases like COPD, asthma and lung cancer are few common ailments.
- A::Dog bite (rabies ), Animal poop and Human – animal interface: Not properly disposed animal poop is a cause of generation of infections and diseases, requiring heavy use of antibiotics and consequently leads to emergence of further antibiotic resistance bacteria. This cycle of production of infections and use of antibiotics perpetuates a vicious cycle. Stray animals still defecate at every place. Poop of Stray dogs, cattle and pigs stays in environment and causes life threatening infections. Hundreds of diseases are described due to poor control of human animal interface.
But stray animals and dogs are everywhere. Owner of pet dogs make them defecate outside their own houses and on the roads and wherever their dogs chooses. This poop dried and mixed with dust, acts a source of infection to the community.
| B:: Life threatening infections : dog’s and animal faeces is a big health hazard. It is even worse than a dog bite since it spreads infection in entire community. Animal faeces contain pathogens, which are known to cause severe diseases, infections and organ failure. Many diseases may be spread by millions of these dogs and other animals like pigs, cattle as their faeces contain parasites, bacteria and viruses. These include life threatening bacterial infections by E. coli, MRSA, Leptospira, Salmonellosis, Campylobacteriosis, brucellosis, Rickettsia and parasitic infections like Giardiasis, Whipworm, Hookworm, Roundworms, Tapeworms, Cryptosporidiosis, Echinococcosis, Leishmaniasis etc. Viral infections like rabies, influenza and other viruses may also spread through these animals.
C:: Environmental health Hazard: Storm water runoff due to extensive rainfall can wash off all these droppings into drains, many of which are connected to river systems and water sources. This can lead to a widespread source of waterborne illnesses. Dry poop on the roads is mixed with dust particles and in the air. So everyone is living in a highly infectious environment.
6. Mosquito borne diseases: millions die because of vector borne disease , as mosquito control has been inadequate. Malaria, dengue, chickengunya and many other lethal diseases spread due to mosquitoes.
7. Preventable natural disasters exacerbated by human activity: floods, famine, disease outbreaks.
8. Road, rail accidents and other accidents: are mostly preventable errors.
The role of health care professionals in present day circumstances remains misunderstood and underappreciated, as they assume the responsibility for continuous care of the sick or injured. People who have never treated a patient in their life time influence health policies, which effects millions. Excessive preventable deaths are just a symptoms of a larger problem. Who is the one who feels moral burden of millions of preventable deaths?
There is a infernal difference in the kind of media projection, burden of negligence and accountability of preventable multiple healthy deaths by civic negligence as compared to one hospital death occurring due to severe disease. In fact the burden of negligence here in healthy deaths is massive and these deaths are unpardonable. But reality is opposite. Strangely “alleged and perceived negligence” ( with no proof and no investigation ) in death of someone already having disease and death in hospital during treatment attracts more scrutiny and stringent punishment as compared to a naked “negligence in deaths of healthy people” in such cases of civic negligence.
Massive civic negligence leading to entirely preventable loss of lives. These incidents bring fore the misplaced priorities of media and society which too have contributed to some extent to these unabated ongoing preventable deaths of thousands of healthy people.
The bench, said the number of deaths from 2013 to 2017 in accidents due to potholes indicated that the authorities concerned were not maintaining the roads. The Supreme Court Thursday expressed concern over 14,926 people being killed in road accidents due to potholes in last five years and termed it “unacceptable”. A bench said the large number of deaths caused due to potholes across the country was “probably more than those killed on border or by the terrorists”. Terming the situation as frightening, the top court had asked the Supreme Court Committee on Road Safety to look into the matter. The bench had also said that people who have lost their lives as a result of accidents due to potholes should be entitled to compensation.
Multiple Deaths in healthy people by civic negligence :
Large numbers of death and morbidity happen amongst absolutely healthy population due to preventable causes like open manholes, drains, live electric wires, water contamination, dengue, malaria, recurring floods etc. These deaths of people are in thousands, and are almost entirely of healthy people, who otherwise were not at risk of death. In fact the burden of negligence here is massive and these deaths are unpardonable
Single Death in Hospital due to disease:
The media has always, instead, focused on the stray and occasional incidents of perceived alleged negligence in hospital deaths which could have occurred due to critical medical condition of patient. However an impression is created as if the doctors have killed a healthy person. It is assumed without any investigation that it was doctor’s fault. Media has been responsible for creating a misunderstanding about the whole process of treatment and creating something sensational out of nothing.
Point to ponder-Misplaced priorities:
Who is to be blamed for the deaths of healthy people which occur because of civic negligence? Here relatives may be helpless and the vital questions may go unanswered or taken as a routine. There are no punching bags like doctor for revenge. But on the contrary, any stray incident of death of an already ill patient is blown out of proportion by media forgetting the fact that thousands of patients are saved everyday by doctors. But media instead chose to defame medical profession by igniting the emotions of people by sensationalizing death of diseased and ill, who probably were already at risk of death and did not give due importance to highlighting prevention of healthy and absolutely 100% preventable deaths.
Right issues raised at right time will save thousands of healthy preventable deaths. Multiple healthy deaths should carry more burden of negligence than one death due to disease.
There are lot of discussion going on about live baby handed over to parents by Max Hospital Delhi, as dead. Every one including media has as usual jumped on to the favorite topic of doctor bashing. Facts are still under investigation. But as a doctor, I can not reach conclusions without scientific discussion, least possible by media talking superfluously. There can be number of possibilities, which we will know with time after proper investigation. But whatever the result, doctors bashing had already been done by media , with or without knowing facts.
Life and death are still far beyond the reach of science and obviously of doctors as well. There are still a lot more unknown than known story about human life. I just wish to draw the attention of my readers about an entity, which is quite mysterious. Condition is called “ Lazarus syndrome”. Also known as auto resuscitation after failed cardiopulmonary resuscitation, is the spontaneous return of circulation after failed attempts at resuscitation.
A little bit about this rare phenomenon.
Lazarus syndrome, also known as auto resuscitation after failed cardiopulmonary resuscitation, is the spontaneous return of circulation after failed attempts at resuscitation. Its occurrence has been noted in medical literature at least 38 times since 1982. It takes its name from Lazarus who, as described in the New Testament of The Bible, was raised from the dead by Jesus.
Occurrences of the syndrome are extremely rare and the causes are not well understood. One hypothesis for the phenomenon is that a chief factor (though not the only one) is the buildup of pressure in the chest as a result of cardiopulmonary resuscitation (CPR). The relaxation of pressure after resuscitation efforts have ended is thought to allow the heart to expand, triggering the heart’s electrical impulses and restarting the heartbeat. Other possible factors are hyperkalemia or high doses of epinephrine.
-A 27-year-old man in the UK collapsed after overdosing on heroin and cocaine. Paramedics gave him an injection, and he recovered enough to walk to the ambulance. He went into cardiac arrest in transit. After 25 minutes of resuscitation efforts, the patient was verbally declared dead. About a minute after resuscitation ended, a nurse noticed a rhythm on the heart monitor and resuscitation was resumed. The patient recovered fully.
-A 66-year-old man suffering from a suspected abdominal aneurysm who, during treatment for this condition, suffered cardiac arrest and received chest compressions and defibrillation shocks for 17 minutes. Vital signs did not return; the patient was declared dead and resuscitation efforts ended. Ten minutes later, the surgeon felt a pulse. The aneurysm was successfully treated and the patient fully recovered with no lasting physical or neurological problems.
-According to a 2002 article in the journal Forensic Science International, a 65-year-old deaf Japanese male was found unconscious in the foster home he lived in. Cardiopulmonary resuscitation was attempted on the scene by home staff, emergency medical personnel and also in the emergency department of the hospital and included appropriate medications and defibrillation. He was declared dead after attempted resuscitation. However, a policeman found the person moving in the mortuary after 20 minutes. The patient survived for 4 more days.
-Judith Johnson, 61, went into cardiac arrest at Beebe Medical Center in Lewes, Delaware, United States, in May 2007. She was given “multiple medicines and synchronized shocks”, but never regained a pulse. She was declared dead at 8:34 p.m. but was discovered in the morgue to be alive and breathing. She sued the medical center where it happened for damages due to physical and neurological problems stemming from the event.
-A 45-year-old woman in Colombia was pronounced dead, as there were no vital signs showing she was alive. Later, a funeral worker noticed the woman moving and alerted his co-worker that the woman should go back to the hospital. A 65-year-old man in Malaysia came back to life two-and-a-half hours after doctors at Seberang Jaya Hospital, Penang, pronounced him dead. He died three weeks later.
-Anthony Yahle, 37, in Bellbrook, Ohio, USA, was breathing abnormally at 4 a.m. on 5 August 2013, and could not be woken. He was given CPR, and first responders shocked him several times and found a heartbeat. That afternoon, he coded for 45 minutes at Kettering Medical Center and was pronounced dead. When his son arrived at the hospital, he noticed a heartbeat on the monitor that was still attached. Resuscitation efforts resumed, and the patient was revived.
-Walter Williams, 78, from Lexington, Mississippi, United States, was at home when his hospice nurse called a coroner who arrived and declared him dead at 9 p.m. on 26 February 2014. Once at a funeral home, he was found to be moving, possibly resuscitated by a defibrillator implanted in his chest. The next day he was well enough to be talking with family, but died fifteen days later.
Implications The Lazarus phenomenon raises ethical issues for physicians, who must determine when medical death has occurred, resuscitation efforts should end, and postmortem procedures such as autopsies and organ harvesting may take place.
Medical literature has recommended observation of a patient’s vital signs for five to ten minutes after cessation of resuscitation before certifying death.
In Popular Culture
In the TV show Grey’s Anatomy, a patient had a heart attack and after 42 minutes of resuscitation efforts they declared her dead. And 20 minutes after death has been declared, the patient vital signs returned and regained consciousness.
Lazarus syndrome. (2017, September 2). In Wikipedia, The Free Encyclopedia. Retrieved 16:51, December 4, 2017, from https://en.wikipedia.org/w/index.php?title=Lazarus_syndrome&oldid=798456668
A young man in mid twenties was wheeled in to intensive care. He was unable to breathe and his oxygen levels and blood pressure was falling within moments. Within no time he became unconscious following which CPR was started along with other supportive measures. Echocardiography was managed meanwhile was suggestive of pulmonary embolism. CPR was continued and simultaneously, thrombolytic drugs were pushed in. His pulse kept on coming and vanishing with monitors sometimes showing activity of heart and improved oxygen levels. A team of around nine doctors and nurses was taking care of airway, central and other lines. There was almost an orchestrated movement of staff with drugs being administered with superfast speed. Commands being given by the treating doctor were followed in split seconds. In the same trice, the team leader had to think far ahead about how he would be handling the challenging dynamics of that young human life who was almost at its fag end. He had to recognize, analyze and mitigate the situation within few seconds. He had to make split decisions and still had to be flexible with his decision and plans, altering them according to the responsiveness of the patient. Doing every bit in an electrifying instant, he had put in all his energy and experience to full use in those few seconds essential to save the young life. After around 35-40 minutes of high adrenaline rush time, the efforts paid off and silent smiles on faces of the team indicated that tornado had become manageable. The doctors and nurses, with sweat on foreheads, smiled quietly with mutual admiration. There was no clapping or cheering in this match of life and death to which the doctors and nurses are well accustomed. There were no spectators to encourage the team. The return of a robust pulse is all the cheering this team needed. There was no one to witness and applaud the zeal and anxiety of these performers, not even patient himself.
Incidents such as one described above are common occurrences in medical practice. It takes a lot of inner mental as well as physical strength besides emotional resilience to tide through such situations. Even relatives, when required, are not able to sustain the adrenergic drive required at these times.
Unlike the case above, the result may not be favorable in certain cases. It is not uncommon for relatives, to then question and start sparring match with doctors and nurses in case they fail in their brave attempt. Often even in successful resuscitations, questions are asked in preposterous manner about the incident. Doctors and nurses may even be verbally and physically abused if they fail despite their best efforts. Relatives can be vengeful and drag them to court to harass and punish them. Common assertion about the wrong injection is almost universal, even in most difficult scenarios. Courts and lawyers, deliberating over years with luxury of time, may find something or other to punish the savior, by doing retrospective analysis or by the wisdom of hindsight. Even if court rules after years that the doctor was right, revenge of patient’ relatives, monetary benefit to lawyers and harassment of doctor, both mentally and emotionally is complete. But they still carry on their noble job and though pained by these issues, doctor will just go to another bed and see what he can do for another patient. This cycle continues, every minute, day and night, all year round. Thousands get gift of life every minute by this wonderful community of doctors and nurses, irrespective of injury inflicted on them.
After the abovementioned incident of successful CPR, I just went to doctor’s room to have tea and a cricket match was going on, streamed live on TV. On the screen, thousands of people were seen clapping and cheering the player who was swinging his arm ready to throw the ball and also the batsman. But to me, the adrenergic rush here was no match to what I had just experienced in the ICU. The cricket match was merely a trifling entertainment with a futile outcome. Every day in each hospital, there are one or more magnificent matches of life and death played without any spectators. Many a times our players (doctors and nurses) win and thousands of lives are salvaged back from brink of death. These extraordinary matches finish with just quiet smiles. There is no one to clap or cheer and no recognition or prizes to the player for winning these match of life and death. Few good patients and relatives, who do realize the magnitude of the act offer heartfelt thanks. The respect, trust and support of the relatives at such times is all that a doctor needs to rev up for his next case, a real match in true sense. In comparison to this frantic match of life and death, rest of all matches are insensate.
The death pronouncement is one of the most sensitive and complex part of communication in and out of hospital, intensive care. It comprises more than the actual declaration of death. It may be a relatively straight forward when the death is expected and the family is mentally prepared and accepting the outcome. However, when the doctor is interacting with a grief-stricken family, dealing with the death of a child, or coming to terms with the death of a personal patient, a death pronouncement becomes complex. Problem is compounded often in presence of violent relatives, non acceptance of death, medico legal cases and especially in cases of unnatural causes for the death. Relatives often refuse to accept death and within no time mobs swell in number, threatening of physical and verbal assaults and revenge against the doctor in various forms. Although there can be specific protocols and hospital policies, it will still depend upon the timely thoughts and skills of the doctor, how to handle the situation. Doctors should be better trained for handling of death as it can put them in risky situation, because of following reasons.
- Death itself is a complex issue. Even today modern science has not reached scientifically at the bottom of life and death.
- Communication of death is complex. It varies with each patient, type of relatives, place, country and every situation in same hospital is different.
- Declaration of death is a legal matter. How a doctor verifies death, communicates and documents death, it can create legal and other problems for doctor.
Any problem related to declaration of death is immediately picked by media and the initial reaction is to blame the doctors. The doctors in such cases are projected as incompetent and callous, and that makes a media news. Invariably one stray incidence is used as to project whole medical community in negative manner. Later inquiries and further inquiring continue, and even later truth emerges, that is not enough to bring back the lost prestige for medical profession.
Take for example the latest news of “ Alive Baby declared dead.”
Later after two days, news was “ hospital enquiry claims No negligence in alive baby declared dead”
Above news just conveys the complexity of situation, doctors often face. My aim here is to convey that communication of death is a very complex subject. Ironically no structured training of emotional, communicative and legal issues is imparted to medical students. But they are supposed to face the situation everyday, when they function as doctors.
Most legal determinations of death are certified by medical professionals who pronounce death when specific criteria are met. Two categories of legal death are death determined by irreversible cessation of heartbeat and breathing (cardiopulmonary death), and death determined by irreversible cessation of functions of the brain (brain death).
Especially new doctors need to realize that the structure of modern society is to make life and death, medical and then legal matters, and to subject the most basic elements of our existence to professional authority. The birth certificate and the death certificate are signed by doctors, and then registered by the civil authorities. Because of all these sensitive issues, emotional aspects and legal dimensions of death being huge, so need more attention. .
In remote areas doctors are totally alone and helpless, so security issues will remain. There is no solution in sight for these problems. Already I have written about a “real story of female doctor assault”.
Problem is that doctors during training days or residency are not trained in such kind of communication. Although while doing their duties they observe seniors and learn how they are communicating. But still when actual situations arise, which can be diverse, complex and challenging, and everyday getting more demanding. In view of current scenario against doctors, they need better training on these issues. Basic question is, if doctor needs help, where can he turn to for help or information. The resources, other staff and the setup is not of much help in difficult scenarios. It is not uncommon that doctors are left to themselves, if a difficult situation arises. Medical education and Hospital systems need to be better equipped to provide more support to doctors in present era. For doctors, if they make a mistake, there is no one to support them or save them from verbal, physical assaults, law and medico legal cases.
Harassment is tremendous. Therefore doctors, be careful – save the patient, but save yourself also.