Reaction to ‘Death’ in this new era of consumerism has become a story of paradox. Massive civil negligence and 141 deaths but there are no punching bags as are doctors for revenge in case of a hospitalized death. Just Compare the media projection, burden of negligence and accountability of hundreds of healthy deaths by civic negligence to the one hospital death by disease.
Death is the inevitable conclusion of life, a universal destiny that all living creatures share. Death can occur through conflict, accident, natural disaster, pandemic, violence, suicide, neglect, or disease.
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. The number of people dying are in hundreds and 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. Timely action could have prevented these normal people from death.
Police in the Indian state of Gujarat have arrested nine people in connection with the collapse of a pedestrian bridge that killed at least 141 people. Four of those detained are employees of a firm contracted to maintain the bridge in the town of Morbi.
Hundreds were on the structure when it gave way, sending people screaming for help into the river below in the dark.
Hopes of finding more survivors are fading. Many children, women and elderly people are among the dead.
The 140-year-old suspension bridge – a major local tourist attraction – had been reopened only last week after being repaired.
Single Death in Hospital due to disease:
Reaction to single “in Hospital” medicalized death is a paradox. The media has 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.
In present era, the expectation of medicalized death has come to be seen as a civic right and Doctors’ responsibility. People now have less understanding and acceptance of hospital death. The death is more perceived as failure of medical treatment rather than an invincible power or a certain final event.
Point to ponder-Misplaced priorities:
Who is to be blamed for the deaths of healthy people which occur because of civic negligence? Here relatives are actually helpless and the vital questions may go unanswered . There are no punching bags as are doctors for revenge. 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.
It is time to check the emotional reactions to single hospital death due to a disease as compared to hundreds of death of healthy people due to civil negligence.
Instead of often repeated statements about high expense on running medical college and projecting it as a hard fact, the amount spent on medical students by all medical colleges should be made transparent by all institutions. The frequent statement is made that cost of making a doctor is very high and gleefully propagated by the private medical colleges to extract millions out of young medical students .
Such statements without any actual public data is repeated to the extent that it is firmly entrenched in public mind without any real evidence.
High cost is the reason with an intention to exploit the young doctors in various ways to get cheap labour and extract millions from aspiring doctors by private medical colleges.
The basis of such calculation should be transparent for every medical college and all institutions.
In any medical college, only the Departments of Anatomy and Physiology are purely for medical students. The remaining subjects taught in medical colleges across the country are related to patient
care and medical education is only a by-product. All the medical teachers are actually doctors involved in treatment of patients, running the hospital and students observe the treatment and learn medicine. The interns and postgraduate students provide the cheap and labour and actually save the costs of running the hospital.
Therefore if some college is actually spending millions to produce one MBBS doctor , it is a either an inefficient model or costs are inflated and exaggerated to exploit the young doctors.
The average cost of producing a doctor or nurse went down across most parts of the world between 2008 and 2018, but almost tripled in China and doubled in India, a Lancet study shows. Despite this, the estimated expenditure per medical graduate in China at $41,000 is higher only than in sub-Saharan Africa and about 42% lower than in India ($70,000) against a global average of $114,000. The pattern was the same for nurses with the estimated expenditure per nursing graduate dropping across the world while it went up by 167% in China and doubled in India. The only other region where the per graduate cost went up was in North Africa, where cost per doctor went up by 47% and by 25% for nurses. Approximately $110 billion was invested globally by governments and students’ families in medical and nursing education in 2018. Of this, $60.9 billion was invested in doctors and $48.8 billion was invested in nurses and midwives, the study estimated.
The paper looks at important developments in medical education to assess potential progress and issues with education of health professionals after the Covid-19 pandemic. Mean costs in 2018 were $114,000 per doctor and $32,000 per nurse. In 2008, China had the lowest estimated expenditure per medical graduate at just $14,000 (Rs 6 lakh) followed by India, where it was just $35,000 (Rs 15 lakh at the 2008 exchange rate of Rs 43 to a dollar). This is much lower than the estimate of Rs 1 crore or more that Indian colleges widely claim as expenditure per medical graduate.
Take example for cough syrup related 66 deaths at Gambia or Injection Propofol related deaths at PGI Chandigarh. If deep investigations are not done, poor quality medicines will continue to be marketed and doctors would be held responsible for the adverse reactions and deaths. Strict regulations for quality of pharmaceutical agents is need of the hour.
Usually every problem related to health is called medical malaise, but that is a misnomer. In fact health care comprises tens of different industries. Complex interplay of various industries like pharmaceutical, consumable industry and other businesses associated with health care remain invisible to patients. Various important components for example pharma industry, suppliers, biomedical, equipment, consumables remain largely unregulated. Collective malaise of all these is conveniently projected as medical problems as blame is conveniently passed on to doctors, as they are only visible component of mammoth health business. Rest all remain invisible, earn money and doctors are blamed for the poor outcome of the patient, as doctor is the only universal link that is visible with patient. By an average application of wisdom, it is easier to blame doctors for everything that goes wrong with patient.
Cough syrup related deaths at Gambia or Injection Propofol related deaths at PGI Chandigarh – two examples are only a tip of the iceberg. In routine, if patient gets fake or low quality medicines and does not get well, gets side effects, doctor will face harassment. Whereas people involved and industry will be sitting pretty and make money.
Therefore strict administration and quality check is required to correct Pharma malaise. It may be a complex issue because of complexity involved in implementation and execution of policies. But recognition and beginning to think of the problem is also an important step.
The WHO has issued an alert over four cough and cold syrups made by Maiden Pharmaceuticals in India, warning they could be linked to the deaths of 66 children in The Gambia
The World Health Organization (WHO) on Wednesday issued a warning over four cough and cold syrups made by an Indian company, saying that they could be linked to the deaths of 66 children in The Gambia. The WHO said that the cough and cold syrups, made by Maiden Pharmaceuticals in Haryana, could be the reason for serious kidney injuries. “Please do not use them,” the WHO said in its advisory.
The four cough and cold syrups that have been linked to the deaths of 66 children in The Gambia are Promethazine Oral Solution, Kofexmalin Baby Cough Syrup, Makoff Baby Cough Syrup and Magrip N Cold Syrup. In a release, the WHO has said that the Indian company has not yet provided guarantees on the safety and quality of these products.
“Laboratory analysis of samples of each of the four products confirms that they contain unacceptable amounts of diethylene glycol and ethylene glycol as contaminants,” the WHO said in a medical product alert. The WHO also warned that while the products had so far been found in The Gambia, they could have been distributed to other countries.
According to the WHO, diethylene glycol and ethylene glycol are toxic to humans when consumed and can prove fatal. Toxic effects can include abdominal pain, vomiting, diarrhoea, inability to pass urine, headache, altered mental state, and acute kidney injury which may lead to death, the WHO said.
New Delhi-based Maiden Pharmaceuticals declined to comment on the matter.
The World Health Organization also said that it was conducting further investigation with the company and regulatory authorities in India regarding the cough syrup linked to deaths of 66 children.
Last month, Gambia’s government said that it has also been investigating the deaths. The government statement came as a spike in cases of acute kidney injury among children under the age of five was detected in late July.
“While the contaminated products have so far only been detected in the Gambia they may have been distributed to other countries,” WHO Director General Tedros Adhanom Ghebreyesus said at a press conference on Wednesday.
The WHO Director General added that WHO recommends all countries detect and remove these products from circulation to prevent further harm to patients.
Meanwhile, the DSCO has already taken up an urgent investigation into the matter with the regulatory authorities in Haryana.
CHANDIGARH: Five patients had died after they were sedated before surgeries on a single day last week at PGI, prompting doctors to sound a red alert to Central Drugs Standard Control Organisation (CDSCO)on Propofol injection – an anesthetic given before any major surgery. In this case, the drug was taken from the chemist shop in the hospital emergency. “Following a complaint from PGI doctors, we came with a CDSCO team to collect samples. The samples have been sent to Central Drugs Laboratory, Kolkata,” said Sunil Chaudhary, senior drug control officer, UT. He said, “The suspected batch of drugs has been stopped for supply till reports are received.” Sources said test analysis will take around two-three weeks and final report will be submitted by the CDSCO team. The five patients had to undergo orthopaedic and neurosurgeries. On deliberating the cause of deaths, doctors found Propofol injection as the common thread.
Death is the inevitable conclusion of life, a universal destiny that all living creatures share. It’s an age-old idea that a good life and a good death go together. Death and dying have become unbalanced in high-income countries, and increasingly in low-and-middle-income countries; there is an excessive focus on clinical interventions at the end of life, to the detriment of broader inputs and contributions.
The story of dying in the 21st century is a story of paradox. While many people are over-treated in hospitals, with families and communities relegated to the margins, still more remain undertreated, dying of preventable conditions and without access to basic pain relief. In this present era, process of dying represents unbalanced and contradictory picture of death.
Even though medical advances continue to increase life expectancy, they have raised an entirely new set of issues associated with death and dying. For example, how long should advanced medical technology be used to keep comatose people alive? How should the elderly or incapacitated be cared for? Is it reasonable for people to stop medical treatment, or even actively end their life, if that is what they wish?
Before the 12th century he describes a period of “Tamed death,” where death was familiar, and people knew how to die. The dying and their families accepted death calmly; they knew when death was coming and what to do; dying was a public event attended by children.
Death can occur through conflict, accident, natural disaster, pandemic, violence, suicide, neglect, or disease. The great success with antibiotics vaccines has perhaps further fuelled the fantasy that science can defeat death. But this temporary success as only has been the result of discovery of germ theory and antibiotics.
In true sense, Death still remains invincible.
The fear of death also involves the fear of separation.
As families and communities want more and more hospital care, when critically sick, health systems have occupied the centre stage in the process of dying. Dying people are whisked away to hospitals or hospices, and whereas two generations ago most children would have seen a dead body, people may now be in their 40s or 50s without ever seeing a dead person. The language, knowledge, and confidence to support and manage dying are being lost, further fuelling a dependence on health-care services.
Death systems are the means by which death and dying are understood, regulated, and managed. These systems implicitly or explicitly determine where people die, how people dying and their families should behave, how bodies are disposed of, how people mourn, and what death means for that culture or community.
Death systems are unique to societies and cultures.
The increased number of deaths in hospital means that ever fewer people have witnessed or managed a death at home. This lack of experience and confidence causes a positive feedback loop that reinforces a dependence on institutional care of the dying.
Medical culture, fear of litigation, and financial complexities contribute to overtreatment at the end of life, further fuelling institutional deaths and the sense that professionals must manage death. Social customs influence the conversations in clinics and in intensive care units, often maintaining the tradition of not discussing death openly. More undiscussed deaths in institutions behind closed doors further reduce social familiarity with and understanding of death and dying.
How people die has changed radically over recent generations. Death comes later in life for many and dying is often prolonged. Futile or potentially inappropriate treatment can continue into the last hours of life. The roles of families and communities have receded as death and dying have become unfamiliar and skills, traditions, and knowledge are lost.
At first only the rich could expect that doctors would delay death. However, by the 20th century this expectation had come to be seen as a civic right.
‘Natural death’ is now the point at which the human organism refuses any further input of treatment.
Corporatization of health care has projected medicine as a purchasable commodity and consequently resulted in an illogical distribution of health care. People, who can afford, spend millions in the last few days of their life, just to have only a few more days to live. Resources spent in such a futile quest are equivalent to thousands of times the money for food and medicines for the poor who lose lives for fraction of that expense.
Death is not so much denied but has become invisible to people. People now have less understanding and less acceptance of death. The death is more perceived as failure of medical treatment rather than an invincible power or a certain final event.
The potential penalty by India’s fair trade regulator could be steep. The CCI (The Competition Commission of India) investigation is the first such action against exorbitant prices of medicines and services fixed by hospitals, which have operated free of regulation so far.
A four-year investigation by India’s fair-trade regulator has concluded that some of India’s largest hospital chains abused their dominance through exorbitant pricing of medical services and products in contravention of competition laws.
The Competition Commission of India (CCI) will soon meet to weigh in on the responses by Apollo Hospitals, Max Healthcare, Fortis Healthcare, Sir Ganga Ram Hospital, Batra Hospital & Medical Research and St. Stephen’s Hospital. It will then decide whether to impose penalties, said people familiar with the matter.
The CCI can impose a penalty of up to 10 percent of the average turnover for the past three preceding financial years of an enterprise that has violated competition laws. The penalties could be steep. Apollo Hospitals posted an average turnover of Rs 12,206 crore and Fortis Rs 4,834 crore in the past three financial years.
The CCI’s director-general found that 12 super-speciality hospitals of these chains that operate in the National Capital Region abused their positions of dominance by charging “unfair and excessive prices” for renting rooms, medicines, medical tests, medical devices, and consumables, according to a copy of the summary report that Moneycontrol reviewed.
Some hospital room rents exceeded those charged by 3-star and 4-star hotels, according to the findings by the DG, who examines anti-competitive practices.
Significance of the investigation
The CCI investigation is the first such action against exorbitant prices of medicines and services fixed by hospitals, which have operated unencumbered by regulation so far. The watchdog’s action could potentially rein in the prices of medicines and healthcare equipment, or at the very least, bring transparency in the way hospitals sell these items, according to competition lawyers.
Of the 12 hospitals that faced CCI scrutiny, six belonged to Max and two to Fortis.
The CCI and the hospital chains had no comment for this article.
Overcharging without checks
Exorbitant pricing is a common thread running through the CCI investigation report. The hospitals were found to charge more for certain medical tests as well as for X-rays, MRI and ultrasound scans than rates offered by other diagnostic centres. For consumables such as syringes and surgical blades, hospitals charged rates that were higher than those of other consumable makers, according to the CCI report.
The only exception was medicines, which hospitals sold at the maximum retail price, although they earned significant profits by procuring them at lower prices.
The CCI selected the hospitals for investigation on the basis of the number of doctors, paramedics, beds, and turnover for the period 2015-2018. The investigation found that these hospitals do not allow the use of purchase of consumables, medical devices, medicines and medical test results from outside, adding that patients use the service of in-house pharmacy and laboratories for ease of convenience.
Investigative reports pertaining to each of the hospital chains were submitted by the DG to the CCI on December 24, 2021. The CCI forwarded a copy of these reports to the hospitals on July 12, 2022, and sought their responses, according to the people, who did not want to be identified.
The CCI has been examining the pharmaceutical sector in India for years, scrutinising the pricing of medicines by healthcare companies. On April 19, 2020, it cautioned businesses, including healthcare companies, against taking advantage of Covid-19 to contravene competition laws.
Depending on the travel destination, travellers may be exposed to a number of infectious diseases; exposure depends on the presence of infectious agents in the area to be visited. The risk of becoming infected will vary according to the purpose of the trip and the itinerary within the area, the standards of accommodation, hygiene and sanitation, as well as the behaviour of the traveller. In some instances, disease can be prevented by vaccination, but there are some infectious diseases, including some of the most important and most dangerous, for which no vaccines exist.
As many of such diseases are infections, general precautions can greatly reduce the risk of exposure to infectious agents and should always be taken for visits to any destination where there is a significant risk of exposure, regardless of whether any vaccinations or medication have been administered.
Modes of transmission and general precautions
The modes of transmission for different infectious diseases are diverse:
Foodborne and waterborne diseases transmitted by consumption of contaminated food and drink.
Vector-borne diseases transmitted by insects such as mosquitoes and other vectors such as ticks.
Diseases transmitted to humans by animals (zoonoses), more particularly through animal bites or contact with animals, contaminated body fluids or faeces, or by consumption of foods of animal origin, particularly meat and milk products.
Sexually transmitted diseases passed from person to person through unsafe sexual practices.
Bloodborne diseases transmitted by direct contact with infected blood or other body fluids
Airborne diseases involving droplets and droplets nuclei. Droplet nuclei <5 µm in size are disseminated in the air and breathed in. These droplet nuclei can remain suspended in the air for some time. Droplet nuclei are the residuals of evaporated droplets. Droplet transmission occurs when larger particles (>5 µm) contact the mucous membranes of the nose and mouth or conjunctivae of a susceptible individual. Droplets are usually generated by the infected individual during coughing, sneezing or talking.
Diseases transmitted via soil include those caused by dormant forms (spores) of infectious agents, which can cause infection by contact with broken skin (minor cuts, scratches, etc).
The main infectious diseases to which travellers may be exposed, and precautions for each, are detailed in the Chapter 5 of the International travel and health situation publication. The most common infectious illness to affect travellers, namely travellers’ diarrhoea, is covered in Chapter 3 of the International travel and health situation publication (WHO). Because travellers’ diarrhoea can be caused by many different foodborne and waterborne infectious agents, for which treatment and precautions are essentially the same, the illness is not included with the specific infectious diseases.
Information on malaria, one of the most important infectious disease threats for travellers, is provided separately (WHO).
The infectious diseases listed below have been selected on the basis of the following criteria:
Diseases that have a sufficiently high global or regional prevalence to constitute a significant risk for travellers;
Diseases that are severe and life-threatening, even though the risk of exposure may be low for most travellers;
Diseases for which the perceived risk may be much greater than the real risk, and which may therefore cause anxiety to travellers;
Diseases that involve a public health risk due to transmission of infection to others by the infected traveller.
Amoebiasis
Angiostrongyliasis
Anthrax
Brucellosis
Chikungunya
Coccidioidomycosis
Dengue
Giardiasis
Haemorrhagic fevers
Hantavirus diseases
Hepatitis C
Hepatitis E
Histoplasmosis
HIV/AIDS and other sexually transmitted infections
Legionellosis
Leishmaniasis (cutaneous, mucosal and visceral forms)
Leptospirosis (including Weil disease)
Listeriosis
Lyme Borreliosis (Lyme disease)
Lymphatic filariasis
Malaria
Onchocerciasis
Plague
SARS (Severe Acute Respiratory Syndrome)
Schistosomiasis (Bilharziasis)
Trypanosomiasis
Typhus fever (Epidemic louse-borne typhus)
Zoonotic influenza
Some of the diseases included in this chapter, such as brucellosis, HIV/AIDS, leishmaniasis and TB, have prolonged and variable incubation periods. Clinical manifestations of these diseases may appear long after the return from travel, so that the link with the travel destination where the infection was acquired may not be readily apparent.
Special feature
Vaccine-preventable diseases
Vaccine-preventable diseases
Cholera
Hepatitis A
Hepatitis E
Japanese encephalitis
Meningococcal disease
Rabies
Tick-borne encephalitis
Typhoid fever
Yellow fever
Information about available vaccines and indications for their use by travellers is provided in the pdf entitled vaccine-preventable diseases and vaccines beside. Advice concerning the diseases for which vaccination is routinely administered in childhood, i.e. diphtheria, measles, mumps and rubella, pertussis, poliomyelitis and tetanus, and the use of the corresponding vaccines later in life and for travel, is also given in the section Vaccines.
Brucellosis is a common zoonotic infection caused by bacterial genus Brucella. Brucellosis is an old disease known by various names including undulant fever or Mediterranean fever. This is one of the infectious diseases transmissible between animals and humans.
Global distribution of Brucellosis-
This infection is more common in Mediterranean areas, the south and the center of America, Africa, Asia, Arab peninsula, Indian subcontinent and the Middle East. The maximum incidence in the world had been reported in Syria.
Other names:
Brucellosis, undulant fever, Mediterranean fever, Cyprus fever, and goat fever.
Summary:
‘Malta fever’ is a bacterial disease caused by various brucella species, which mainly infect cattle, swine, goats, sheep and dogs.
Malta fever is transmitted to humans through direct and indirect contact with infected animals.
Infection is most likely caused by ingesting unpasteurized milk or cheese from infected goats or sheep.
It causes flu-like symptoms, including fever and lethargy.
There is no human vaccine to prevent Malta fever, but it is important to take precautions to avoid it.
Overview:
Malta fever is a bacterial disease caused by various brucella species. Infection is transmitted to humans through direct and indirect contact with infected animals. It mostly affects individuals who work in the livestock sector. The consumption of raw milk and cheese made from raw milk (fresh cheese) is the major source of infection in man; however, human-to-human transmission is very rare. On the other hand, Malta fever remains a problem globally, because it is the most common bacterial infection spread from animals to humans around the world, as animals may be carrying the bacteria without showing any symptoms of illness.
Types of Brucella bacteria:
Types of brucella bacteria:
There are 8 known species of the brucella bacteria, but only four of them cause brucellosis in humans:
Maltese Brucellosis (B. melitensis): This type is the most common and most severe, and is found in lambs.
Pig Brucellosis (B. suis): This type infects individuals who come in contact with animals. It has a severe impact on humans.
Brucella abortus (B. abortus): It infects cows and is moderately severe.
Canine Brucellosis (B. canis): It infects individuals who come in contact with dogs and is moderately severe.
Other animals are also considered a primary source of the Brucella bacteria, including wild animals.
Cause:
Brucellosis is the result of being infected with the brucella bacteria.
Transmission:
Humans contract brucellosis by consuming unpasteurized dairy products and undercooked or raw meat of infected animals.
Direct contact with an infected animal or its bodily discharge (such as tissues, blood, urine, vaginal discharge, aborted fetuses, and placentas), via cracked skin, can also occur.
The disease can also be transmitted to humans through inhaling airborne agents in barns, stables, and sometimes laboratory and slaughterhouse.
Rare Means of Transmission:
From mother to fetus through the placenta
Sexual contact
Blood transfusion or marrow transplant from a person infected with Brucella
Few cases result from accidental pollination of an animal with brucellosis.
Incubation Period:
Symptoms usually appear within 5 to 60 days, and sometimes they takes several months to appear.
Who is at risk?
Vets
Livestock farmers
Slaughterhouse workers
Hunters
Microbiologists
Medical lab workers
Symptoms:
Malta fever can cause several symptoms. Some of them last for a long period of time. Initial symptoms include:
Fever
Sweating
Chills
Loss of appetite
Headache
Muscle, joint, and back pain
Fatigue and lethargy
When to see a doctor?
When a rapid rise in temperature, muscle pain or unusual weakness and persistent fever occurs. It is also crucial to see your doctor if you are among the groups at a higher risk of contracting the disease.
Complications:
Endocarditis (an infection of the endocardium, which is the inner lining of the heart or valves)
Arthritis
Orchitis (inflammation of the testicles)
Spleen or liver inflammation
Central nervous system inflammation.
Diagnosis:
Clinical examination
Laboratory tests: They involve searching for the bacteria in samples of blood, bone marrow, or other body fluids.
Treatment:
Treatment aims to relieve symptoms and prevent complications. It depends on the timing and severity of the disease. The disease may take a few weeks to several months to be cured. Patients take antibiotics for at least six weeks.
Prevention:
There is no human vaccine that can prevent Malta fever, so it is important to take precautions to prevent it with the following steps:
Make sure to cook meat well at a temperature of 63-74°C.
Do not drink or eat unpasteurized dairy products, including milk and cheese.
Take safety precautions at workplaces (e.g. during handling samples in laboratories).
Wash your hands before and after handling animals.
Wear rubber gloves and protective clothing and glasses if you work in a field where you come in contact with animals.
Ensure that wounds are covered with a bandage.
FAQs:
How long do brucella bacteria live outside the body?
Brucella bacteria are resistant to natural conditions, and they can survive for several hours up to over 60 days if the surrounding environment is moist.
How long should meat be cooked?
Meat and liver should be well cooked at 63°C for half an hour.
Women who are pregnant and have been exposed to Brucella should consult with their obstetricians/healthcare provider for evaluation. Prompt diagnosis and treatment of brucellosis in pregnant women can prevent complications including miscarriage.
Anne Heche, 53, had spent several days in a coma at the Grossman Burn Center at West Hills (California) Hospital and Medical Center after her Mini Cooper ran off the road Aug. 5 and smashed into a two-story home.
On Friday- Anne Heche (Hollywood actress ) had been declared brain dead, although she remained on life support for organ donation, a rep for the actress told The Hollywood Reporter on Friday. According to the actress’ publicist Holly Baird, Heche is “legally dead according to California law.” However, her heart is still beating and she has not been taken off of life support so that “OneLegacy can see if she is a match for organ donation.”
The actress’ team had previously shared an update on her health Thursday, stating that she suffered a severe anoxic brain injury and wasn’t expected to survive following an Aug. 5 car crash.
According to Baird, the star had been hospitalized in a coma and in critical condition since the accident. The actress crashed her car into a two-story home in L.A.’s Mar Vista neighborhood, sparking a fire, according to a Los Angeles Fire Department report.
In the statement Thursday from Heche’s rep, it “has long been her choice to donate her organs” and she was being kept on life support to determine whether her organs were viable.
The shortage of organs is virtually a universal problem but Asia lags behind much of the rest of the world. India lags far behind other countries even in Asia. It is not that there aren’t enough organs to transplant. Nearly every person who dies naturally, or in an accident, is a potential donor. Even then, innumerable patients cannot find a donor.
Situation of shortage of organs in India
There is a wide gap between patients who need transplants and the organs that are available in India. An estimated around 1.8 lakh persons suffer from renal failure every year, however the number of renal transplants done is around 6000 only. An estimated 2 lac patients die of liver failure or liver cancer annually in India, about 10-15% of which can be saved with a timely liver transplant. Hence about 25-30 thousand liver transplants are needed annually in India but only about one thousand five hundred are being performed. Similarly about 50000 persons suffer from Heart failures annually but only about 10 to 15 heart transplants are performed every year in India. In case of Cornea, about 25000 transplants are done every year against a requirement of 1 lakh.
The legal Framework in India
Transplantation of Human Organs Act (THOA) 1994 was enacted to provide a system of removal, storage and transplantation of human organs for therapeutic purposes and for the prevention of commercial dealings in human organs. THOA is now adopted by all States except Andhra and J&K, who have their own similar laws. Under THOA, source of the organ may be:
Near Relative donor (mother, father, son, daughter, brother, sister, spouse)
Other than near relative donor: Such a donor can donate only out of affection and attachment or for any other special reason and that too with the approval of the authorisation committee.
Deceased donor, especially after Brain stem death e.g. a victim of road traffic accident etc. where the brain stem is dead and person cannot breathe on his own but can be maintained through ventilator, oxygen, fluids etc. to keep the heart and other organs working and functional. Other type of deceased donor could be donor after cardiac death.
Brain Stem death is recognized as a legal death in India under the Transplantation of Human Organs Act, like many other countries, which has revolutionized the concept of organ donation after death. After natural cardiac death only a few organs/tissues can be donated (like cornea, bone, skin and blood vessels) whereas after brain stem death almost 37 different organs and tissues can be donated including vital organs such as kidneys, heart, liver and lungs.
Despite a facilitatory law, organ donation from deceased persons continues to be very poor. In India there is a need to promote deceased organ donation as donation from living persons cannot take care of the organ requirement of the country. Also there is risk to the living donor and proper follow up of donor is also required. There is also an element of commercial transaction associated with living organ donation, which is violation of Law. In such a situation of organ shortage, rich can exploit the poor by indulging in organ trading.
Government of India initiated the process of amending and reforming the THOA 1994 and consequently, the Transplantation of Human Organs (Amendment) Act 2011 was enacted. Some of the important amendments under the (Amendment) Act 2011 are as under:-
Tissues have been included along with the Organs.
‘Near relative’ definition has been expanded to include grandchildren, grandparents.
Provision of ‘Retrieval Centres’ and their registration for retrieval of organs from deceased donors. Tissue Banks shall also be registered.
Provision of Swap Donation included.
There is provision of mandatory inquiry from the attendants of potential donors admitted in ICU and informing them about the option to donate – if they consent to donate, inform retrieval centre.
Provision of Mandatory ‘Transplant Coordinator’ in all hospitals registered under the Act
To protect vulnerable and poor there is provision of higher penalties has been made for trading in organs.
Constitution of Brain death certification board has been simplified- wherever Neurophysician or Neurosurgeon is not available, then an anaesthetist or intensivist can be a member of board in his place, subject to the condition that he is not a member of the transplant team.
National Human Organs and Tissues Removal and Storage Network and National Registry for Transplant are to be established.
There is provision of Advisory committee to aid and advise Appropriate Authority.
Enucleation of corneas has been permitted by a trained technician.
Act has made provision of greater caution in case of minors and foreign nationals and prohibition of organ donation from mentally challenged persons
In pursuance to the amendment Act, Transplantation of Human Organs and Tissues Rules 2014 have been notified on 27-3-2014
Directorate General of Health Services, Government of India is implementing National Organ Transplant Programme for carrying out the activities as per amendment Act, training of manpower and promotion organ donation from deceased persons.
National Organ Transplant Programme with a budget of Rs. 149.5 Crore for 12th Five year Plan aims to improve access to the life transforming transplantation for needy citizens of our country by promoting deceased organ donation.
Issues and Challenges
High Burden (Demand Versus Supply gap)
Poor Infrastructure especially in Govt. sector hospitals
Lack of Awareness of concept of Brain Stem Death among stakeholders
Poor rate of Brain Stem Death Certification by Hospitals
Poor Awareness and attitude towards organ donation— Poor Deceased Organ donation rate
Lack of Organized systems for organ procurement from deceased donor
Maintenance of Standards in Transplantation, Retrieval and Tissue Banking
Prevention and Control of Organ trading
High Cost (especially for uninsured and poor patients)
Regulation of Non- Govt. Sector
Objectives of National Organ Transplant Programme:
To organize a system of organ and Tissue procurement & distribution for transplantation.
To promote deceased organ and Tissue donation.
To train required manpower.
To protect vulnerable poor from organ trafficking.
To monitor organ and tissue transplant services and bring about policy and programme corrections/ changes whenever needed.
NOTTO: National Organ and Tissue Transplant Organization
National Network division of NOTTO would function as apex centre for all India activities of coordination and networking for procurement and distribution of organs and tissues and registry of Organs and Tissues Donation and Transplantation in country. The following activities would be undertaken to facilitate Organ Transplantation in safest way in shortest possible time and to collect data and develop and publish National registry.
At National Level:
Lay down policy guidelines and protocols for various functions.
Network with similar regional and state level organizations.
All registry data from States and regions would be compiled and published.
Creating awareness, promotion of deceased organ donation and transplantation activities.
Co-ordination from procurement of organs and tissues to transplantation when organ is allocated outside region.
Dissemination of information to all concerned organizations, hospitals and individuals.
Monitoring of transplantation activities in the regions and States and maintaining data-bank in this regard.
To assist the states in data management, organ transplant surveillance & Organ transplant and Organ Donor registry.
Consultancy support on the legal and non-legal aspects of donation and transplantation
Coordinate and Organize trainings for various cadre of workers.
For Delhi and NCR
Maintaining the waiting list of terminally ill patients requiring transplants
Networking with transplant centres, retrieval centres and tissue Banks
Co-ordination for all activities required for procurement of organs and tissues including medico legal aspects.
NOTTO will assign the Retrieval Team for Organ retrieval and make Transport Arrangement for transporting the organs to the allocated locations.
NOTTO will maintain the waitlist of patients. needing transplantation in terms of the following:-
Hospital wise
Organ wise
Blood group wise
Age of the patient
Urgency ( on ventilator, can wait etc.)
Seniority in the waitlist (First in First Out)
Matching of recipients with donors.
Allocation, transportation, storage and Distribution of organs and tissues within Delhi and National Capital Territory region.
Post-transplant patients & living donor follow-up for assessment of graft rejection, survival rates etc.
Awareness, Advocacy and training workshops and other activities for promotion of organ donation
ROTTO: Regional Organ and Tissue Transplant Organization
Name of ROTTO
States covered
Seth GS medical college and KEM Hospital, Mumbai (Maharashtra)
Maharashtra, Gujarat, Goa, UTs of DNH, Daman, Diu, M.P., Chhattisgarh
Govt. Multispecialty Hospital, Omnadurar, Chennai (Tamil Nadu)
TN, Kerala, Telangana, Seem Andhra, Karnataka, Pondicherry, A & N Islands, Lakshadweep
Institute of PG Medical Education and Research, Kolkata (West Bengal)
SOTTO: State Organ and Tissue Transplant Organization
It is envisaged to make 5 SOTTOs in new AIIMS like institutions.
Govt. supported Online system of Networking
A website by the name www.notto.nic.in has been hosted where information with regards to the organ transplantation can be obtained. An online system through website is being developed for establishing network for Removal and Storage of Organs and Tissues from deceased donors and their allocation and distribution in a transparent manner. A computerized system of State/Regional and National Registry of donors and recipients is also going to be put in place.
Death is an evolving and complex concept. Philosophers and theologians from around the globe have recognised the value that death holds for human life. Death and life are bound together: without death there would be no life. Death allows new ideas and new ways. Death also reminds us of our fragility and sameness: we all die.
Death is the inevitable conclusion of life, a universal destiny that all living creatures share. Even though all societies throughout history have realized that death is the certain fate of human beings, different cultures have responded to it in different ways. Through the ages, attitudes toward death and dying have changed and continue to change, shaped by religious, intellectual, and philosophical beliefs and conceptions. In the twenty-first century advances in medical science and technology continue to influence ideas about death and dying.
ANCIENT TIMES
Archaeologists have found that as early as the Paleolithic period, about 2.5 million to 3 million years ago, humans held metaphysical beliefs about death and dying—those beyond what humans can know with their senses. Tools and ornaments excavated at burial sites suggest that the earliest ancestors believed that some element of a person survived the dying experience.
Ancient Hebrews (c. 1020–586 B.C.), while acknowledging the existence of the soul, were not preoccupied with the afterlife. They lived according to the commandments of their God, to whom they entrusted their eternal destiny. By contrast, early Egyptians (c. 2900–950 B.C.) thought that the preservation of the dead body (mummification) guaranteed a happy afterlife. They believed a person had a dual soul: the ka and the ba. The ka was the spirit that dwelled near the body, whereas the ba was the vitalizing soul that lived on in the netherworld (the world of the dead). Similarly, the ancient Chinese (c. 2500–1000 B.C.) also believed in a dual soul, one part of which continued to exist after the death of the body. It was this spirit that the living venerated during ancestor worship.
Among the ancient Greeks (c. 2600–1200 B.C.), death was greatly feared. Greek mythology—which was full of tales of gods and goddesses who exacted punishment on disobedient humans—caused the living to follow rituals meticulously when burying their dead so as not to displease the gods. Even though reincarnation is usually associated with Asian religions, some Greeks were followers of Orphism, a religion that taught that the soul underwent many reincarnations until purification was achieved.
THE CLASSICAL AGE
Mythological beliefs among the ancient Greeks persisted into the classical age. The Greeks believed that after death the psyche (a person’s vital essence) lived on in the underworld. The Greek writer Homer (c. eighth century–c. seventh century B.C.) greatly influenced classical Greek attitudes about death through his epic poems the Iliad and the Odyssey.Greek mythology was freely interpreted by writers after Homer, and belief in eternal judgment and retribution continued to evolve throughout this period.
Certain Greek philosophers also influenced conceptions of death. For example, Pythagoras (569?–475? B.C.) opposed euthanasia (“good death” or mercy killing) because it might disturb the soul’s journey toward final purification as planned by the gods. On the contrary, Socrates (470?–399? B.C.) and Plato (428–348 B.C.) believed people could choose to end their life if they were no longer useful to themselves or the state.
Like Socrates and Plato, the classical Romans (c. 509–264 B.C.) believed a person suffering from intolerable pain or an incurable illness should have the right to choose a “good death.” They considered euthanasia a “mode of dying” that allowed a person’s right to take control of an intolerable situation and distinguished it from suicide, an act considered to be a shirking of responsibilities to one’s family and to humankind.
THE MIDDLE AGES
During the European Middle Ages (c. 500–1485), death—with its accompanying agonies—was accepted as a destiny everyone shared, but it was still feared. As a defense against this phenomenon that could not be explained, medieval people confronted death together, as a community. Because medical practices in this era were crude and imprecise, the ill and dying person often endured prolonged suffering. However, a long period of dying gave the dying individual an opportunity to feel forewarned about impending death, to put his or her affairs in order, and to confess sins. The medieval Roman Catholic Church, with its emphasis on the eternal life of the soul in heaven or hell, held great power over people’s notions of death.
By the late Middle Ages the fear of death had intensified due to the Black Death—the great plague of 1347 to 1351. The Black Death killed more than twenty-five million people in Europe alone. Commoners watched not only their neighbors stricken but also saw church officials and royalty struck down: Queen Eleanor of Aragon and King Alfonso XI (1311–1350) of Castile met with untimely deaths, and so did many at the papal court at Avignon, France. With their perceived “proper order” of existence shaken, the common people became increasingly preoccupied with their own death and with the Last Judgment, God’s final and certain determination of the character of each individual. Because the Last Judgment was closely linked to an individual’s disposition to heaven or hell, the event of the plague and such widespread death was frightening.
From the fourteenth through the sixteenth centuries, Europe experienced new directions in economics, the arts, and social, scientific, and political thought. Nonetheless, obsession with death did not diminish with this “rebirth” of Western culture. A new self-awareness and emphasis on humans as the center of the universe further fueled the fear of dying.
By the sixteenth century many European Christians were rebelling against religion and had stopped relying on church, family, and friends to help ease their passage to the next life. The religious upheaval of the Protestant Reformation of 1520, which emphasized the individual nature of salvation, caused further uncertainties about death and dying.
The seventeenth century marked a shift from a religious to a more scientific exploration of death and dying. Lay people drifted away from the now disunited Christian church toward the medical profession, seeking answers in particular to the question of “apparent death,” a condition in which people appeared to be dead but were not. In many cases unconscious patients mistakenly believed to be dead were hurriedly prepared for burial by the clergy, only to “come back to life” during burial or while being transported to the cemetery.
An understanding of death and its aftermath was clearly still elusive, even to physicians who disagreed about what happened after death. Some physicians believed the body retained some kind of “sensibility” after death. Thus, many people preserved cadavers so that the bodies could “live on.” Alternatively, some physicians applied the teachings of the Catholic Church to their medical practice and believed that once the body was dead, the soul proceeded to its eternal fate and the body could no longer survive. These physicians did not preserve cadavers and pronounced them permanently dead.
THE EIGHTEENTH CENTURY
The fear of apparent death that took root in the seventeenth century resurfaced with great intensity during the eighteenth century. Coffins were built with contraptions to enable any prematurely buried person to survive and communicate from the grave.
For the first time, the Christian church was blamed for hastily burying its “living dead,” particularly because it had encouraged the abandonment of pagan burial traditions such as protracted mourning rituals. In the wake of apparent death incidents, more long burial traditions were revived.
THE NINETEENTH CENTURY
Premature and lingering deaths remained commonplace in the nineteenth century. Death typically took place in the home following a long deathbed watch. Family members prepared the corpse for viewing in the home, not in a funeral parlor. However, this practice changed during the late nineteenth century, when professional undertakers took over the job of preparing and burying the dead. They provided services such as readying the corpse for viewing and burial, building the coffin, digging the grave, and directing the funeral procession. Professional embalming and cosmetic restoration of bodies became widely available, all carried out in a funeral parlor where bodies were then viewed instead of in the home.
Cemeteries changed as well. Before the early nineteenth century, American cemeteries were unsanitary, overcrowded, and weed-filled places bearing an odor of decay. That began to change in 1831, when the Massachusetts Horticultural Society purchased seventy-two acres of fields, ponds, trees, and gardens in Cambridge and built Mount Auburn Cemetery. This cemetery was to become a model for the landscaped garden cemetery in the United States. These cemeteries were tranquil places where those grieving could visit the graves of loved ones and find comfort in the beautiful surroundings.
Literature of the time often focused on and romanticized death. Death poetry, consoling essays, and mourning manuals became available after 1830, which comforted the grieving with the concept that the deceased were released from worldly cares in heaven and that they would be reunited there with other deceased loved ones. The deadly lung disease tuberculosis—called consumption at the time—was pervasive during the nineteenth century in Europe and the United States. The disease caused sufferers to develop a certain appearance—an extreme pallor and thinness, with a look often described as haunted—that actually became a kind of fashion statement. The fixation on the subject by writers such as Edgar Allan Poe (1809–1849) and the English Romantic poets helped fuel the public’s fascination with death and dying. In the late twentieth and early twenty-first centuries the popularization of the Goth look is sometimes associated with the tubercular appearance.
Spiritualism
By the mid-nineteenth century the romanticizing of death took on a new twist in the United States. Spiritualism, in which the living communicate directly with the dead, began in 1848 in the United States with the Fox sisters: Margaret Fox (1833?–1893) and Catherine Fox (1839?–1892) of Hydesville, New York. The sisters claimed to have communicated with the spirit of a man murdered by a former tenant in their house. The practice of conducting “sittings” to contact the dead gained instant popularity. Mediums, such as the Fox sisters, were supposedly sensitive to “vibrations” from the disembodied souls that temporarily lived in that part of the spirit world just outside the earth’s limits.
This was not the first time people tried to communicate with the dead. Spiritualism has been practiced in cultures all over the world. For example, many Native Americans believe shamans (priests or medicine men) have the power to communicate with the spirits of the dead. The Old Testament (I Samuel 28:7–19) recounts the visit of King Saul to a medium at Endor, who summoned the spirit of the prophet Samuel, which predicted the death of Saul and his sons.
The mood in the United States in the 1860s and 1870s was ripe for Spiritualist s´ances. Virtually everyone had lost a son, husband, or other loved one during the Civil War (1861–1865). Some survivors wanted assurances that their loved ones were all right; others were simply curious about life after death. Those who had drifted away from traditional Christianity embraced this new Spiritualism, which claimed scientific proof of survival after physical death.
THE MODERN AGE
Modern medicine has played a vital role in the way people die and, consequently, the manner in which the dying process of a loved one affects relatives and friends. With advancements in medical technology, the dying process has become depersonalized, as it has moved away from the familiar surroundings of home and family to the sterile world of hospitals and strangers. Certainly, the institutionalization of death has not diminished the fear of dying. Now, the fear of death also involves the fear of separation: for the living, the fear of not being present when a loved one dies, and for the dying, the prospect of facing death without the comforting presence of a loved one.
Changing Attitudes
In the last decades of the twentieth century, attitudes about death and dying slowly began to change. Aging baby boomers (people born between 1946 and 1964), facing the deaths of their parents, began to confront their own mortality. Even though medical advances continue to increase life expectancy, they have raised an entirely new set of issues associated with death and dying. For example, how long should advanced medical technology be used to keep comatose people alive? How should the elderly or incapacitated be cared for? Is it reasonable for people to stop medical treatment, or even actively end their life, if that is what they wish?
The works of the psychiatrist Elisabeth K¨bler-Ross (1926–2004), including the pioneering book On Death and Dying (1969), have helped individuals from all walks of life confront the reality of death and restore dignity to those who are dying. Considered to be a highly respected authority on death, grief, and bereavement, K¨bler-Ross influenced the medical practices undertaken at the end of life, as well as the attitudes of physicians, nurses, clergy, and others who care for the dying.
During the late 1960s medical education was revealed to be seriously deficient in areas related to death and dying. However, initiatives under way in the late twentieth and early twenty-first centuries have offered more comprehensive training about end-of-life care. With the introduction of in-home hospice care, more terminally ill people have the option of spending their final days at home with their loved ones. With the veil of secrecy lifted and open public discussions about issues related to the end of life, Americans appear more ready to learn about death and to learn from the dying.
Hospice Care
In the Middle Ages hospices were refuges for the sick, the needy, and travellers. The modern hospice movement developed in response to the need to provide humane care to terminally ill patients, while at the same time lending support to their families. The English physician Dame Cicely Saunders (1918–) is considered the founder of the modern hospice movement—first in England in 1967 and later in Canada and the United States. The soothing, calming care provided by hospice workers is called palliative care, and it aims to relieve patients’ pain and the accompanying symptoms of terminal illness, while providing comfort to patients and their families.
Hospice may refer to a place—a freestanding facility or designated floor in a hospital or nursing home—or to a program such as hospice home care, in which a team of health-care professionals helps the dying patient and family at home. Hospice teams may involve physicians, nurses, social workers, pastoral counsellors, and trained volunteers.
WHY PEOPLE CHOOSE HOSPICE CARE. Hospice workers consider the patient and family to be the “unit of care” and focus their efforts on attending to emotional, psychological, and spiritual needs as well as to physical comfort and well-being. With hospice care, as a patient nears death, medical details move to the background as personal details move to the foreground to avoid providing care that is not wanted by the patient, even if some clinical benefit might be expected.
THE POPULATION SERVED. Hospice facilities served 621,100 people in 2000; of these, 85.5% died while in hospice care. Nearly 80% of hospice patients were sixty-five years of age and older, and 26.5%were eighty-five years of age or older. Male hospice patients numbered 309,300, whereas 311,800 were female. The vast majority (84.1%) was white. Approximately half (46.6%) of the patients served were unmarried, but most of these unmarried patients were widowed. Nearly 79% of patients used Medicare as their primary source of payment for hospice services.
Even though more than half (57.5%) of those admitted to hospice care in 2000 had cancer (malignant neoplasms) as a primary diagnosis, patients with other primary diagnoses, such as Alzheimer’s disease and heart, respiratory, and kidney diseases, were also served by hospice.
Sciatica pain is caused by an irritation, inflammation, pinching or compression of a nerve in the lower back. The most common cause is a herniated or slipped disk that causes pressure on the nerve root. Most people with sciatica get better on their own with time and self-care treatments.
True sciatica is an injury or irritation to the sciatic nerve, which starts in your buttock/gluteal area.
What is sciatica?
Sciatica is nerve pain from an injury or irritation to the sciatic nerve, which originates in your buttock/gluteal area. The sciatic nerve is the longest and thickest (almost finger-width) nerve in the body. It’s actually made up of five nerve roots: two from the lower back region called the lumbar spine and three from the final section of the spine called the sacrum. The five nerve roots come together to form a right and left sciatic nerve. On each side of your body, one sciatic nerve runs through your hips, buttocks and down a leg, ending just below the knee. The sciatic nerve then branches into other nerves, which continue down your leg and into your foot and toes.
True injury to the sciatic nerve “sciatica” is actually rare, but the term “sciatica” is commonly used to describe any pain that originates in the lower back and radiates down the leg. What this pain shares in common is an injury to a nerve — an irritation, inflammation, pinching or compression of a nerve in your lower back.
If you have “sciatica,” you experience mild to severe pain anywhere along the path of the sciatic nerve – that is, anywhere from the lower back, through the hips, buttocks and/or down your legs. It can also cause muscle weakness in your leg and foot, numbness in your leg, and an unpleasant tingling pins-and-needles sensation in your leg, foot and toes.
What does sciatica pain feel like?
People describe sciatica pain in different ways, depending on its cause. Some people describe the pain as sharp, shooting, or jolts of pain. Others describe this pain as “burning,” “electric” or “stabbing.”
The pain may be constant or may come and go. Also, the pain is usually more severe in your leg compared to your lower back. The pain may feel worse if you sit or stand for long periods of time, when you stand up and when your twist your upper body. A forced and sudden body movement, like a cough or sneeze, can also make the pain worse.
Can sciatica occur down both legs?
Sciatica usually affects only one leg at a time. However, it’s possible for sciatica to occur in both legs. It’s simply a matter of where the nerve is being pinched along the spinal column.
Does sciatica occur suddenly or does it take time to develop?
Sciatica can come on suddenly or gradually. It depends on the cause. A disk herniation can cause sudden pain. Arthritis in the spine develops slowly over time.
How common is sciatica?
Sciatica is a very common complaint. About 40% of people in the U.S. experience sciatica sometime during their life. Back pain is the third most common reason people visit their healthcare provider.
What are the risk factors for sciatica?
You are at greater risk of sciatica if you:
Have an injury/previous injury: An injury to your lower back or spine puts you at greater risk for sciatica.
Live life: With normal aging comes a natural wearing down of bone tissue and disks in your spine. Normal aging can put your nerves at risk of being injured or pinched by the changes and shifts in bone, disks and ligaments.
Are overweight: Your spine is like a vertical crane. Your muscles are the counterweights. The weight you carry in the front of your body is what your spine (crane) has to lift. The more weight you have, the more your back muscles (counterweights) have to work. This can lead to back strains, pains and other back issues.
Lack a strong core: Your “core” are the muscles of your back and abdomen. The stronger your core, the more support you’ll have for your lower back. Unlike your chest area, where your rib cage provides support, the only support for your lower back is your muscles.
Have an active, physical job: Jobs that require heavy lifting may increase your risk of low back problems and use of your back, or jobs with prolonged sitting may increase your risk of low back problems.
Lack proper posture in the weight room: Even if you are physically fit and active, you can still be prone to sciatica if you don’t follow proper body form during weight lifting or other strength training exercises.
Have diabetes: Diabetes increases your chance of nerve damage, which increases your chance of sciatica.
Have osteoarthritis: Osteoarthritis can cause damage to your spine and put nerves at risk of injury.
Lead an inactive lifestyle: Sitting for long period of time and not exercising and keeping your muscles moving, flexible and toned can increase your risk of sciatica.
Smoke: The nicotine in tobacco can damage spinal tissue, weaken bones, and speed the wearing down of vertebral disks.
Is the weight of pregnancy the reason why so many pregnant women get sciatica?
It’s true that sciatica is common in pregnancy but increased weight is not the main reason why pregnant women get sciatica. A better explanation is that certain hormones of pregnancy cause a loosening of their ligaments. Ligaments hold the vertebrae together, protect the disks and keep the spine stable. Loosened ligaments can cause the spine to become unstable and might cause disks to slip, which leads to nerves being pinched and the development of sciatica. The baby’s weight and position can also add pressure to the nerve.
The good news is there are ways to ease sciatic pain during pregnancy, and the pain goes away after birth. Physical therapy and massage therapy, warm showers, heat, medications and other measures can help. If you are pregnant, be sure to follow good posture techniques during pregnancy to also ease your pain.
SYMPTOMS AND CAUSES
What causes sciatica?
Sciatica can be caused by several different medical conditions including:
A herniated or slipped disk that causes pressure on a nerve root. This is the most common cause of sciatica. Disks are the cushioning pads between each vertebrae of the spine. Pressure from vertebrae can cause the gel-like center of a disk to bulge (herniate) through a weakness in its outer wall. When a herniated disk happens to a vertebrae in your lower back, it can press on the sciatic nerve.
Degenerative disk disease is the natural wear down of the disks between vertebrae of the spine. The wearing down of the disks shortens their height and leads to the nerve passageways becoming narrower (spinal stenosis). Spinal stenosis can pinch the sciatic nerve roots as they leave the spine.
Spinal stenosis is the abnormal narrowing of the spinal canal. This narrowing reduces the available space for the spinal cord and nerves.
Spondylolisthesis is a slippage of one vertebra so that it is out of line with the one above it, narrowing the opening through which the nerve exits. The extended spinal bone can pinch the sciatic nerve.
Osteoarthritis. Bone spurs (jagged edges of bone) can form in aging spines and compress lower back nerves.
Trauma injury to the lumbar spine or sciatic nerve.
Tumors in the lumbar spinal canal that compress the sciatic nerve.
Piriformis syndrome is a condition that develops when the piriformis muscle, a small muscle that lies deep in the buttocks, becomes tight or spasms. This can put pressure on and irritate the sciatic nerve. Piriformis syndrome is an uncommon neuromuscular disorder.
Cauda equina syndrome is a rare but serious condition that affects the bundle of nerves at the end of the spinal cord called the cauda equina. This syndrome causes pain down the leg, numbness around the anus and loss of bowel and bladder control.
What are the symptoms of sciatica?
The symptoms of sciatica include:
Moderate to severe pain in lower back, buttock and down your leg.
Numbness or weakness in your lower back, buttock, leg or feet.
Pain that worsens with movement; loss of movement.
“Pins and needles” feeling in your legs, toes or feet.
Loss of bowel and bladder control (due to cauda equina).
DIAGNOSIS AND TESTS
Straight leg raise test helps spot your point of pain. This test helps identify a disk problem.
How is sciatica diagnosed?
First, your healthcare provider will review your medical history. Next, they’ll ask about your symptoms.
During your physical exam, you will be asked to walk so your healthcare provider can see how your spine carries your weight. You may be asked to walk on your toes and heels to check the strength of your calf muscles. Your provider may also do a straight leg raise test. For this test, you’ll lie on your back with your legs straight. Your provider will slowly raise each leg and note the point at which your pain begins. This test helps pinpoint the affected nerves and determines if there is a problem with one of your disks. You will also be asked to do other stretches and motions to pinpoint pain and check muscle flexibility and strength.
Depending on what your healthcare provider discovers during your physical exam, imaging and other tests might be done. These may include:
Spinal X-rays to look for spinal fractures, disk problems, infections, tumors and bone spurs.
Magnetic resonance imaging (MRI) or computed tomography (CT) scans to see detailed images of bone and soft tissues of the back. An MRI can show pressure on a nerve, disk herniation and any arthritic condition that might be pressing on a nerve. MRIs are usually ordered to confirm the diagnosis of sciatica.
Nerve conduction velocity studies/electromyography to examine how well electrical impulses travel through the sciatic nerve and the response of muscles.
Myelogram to determine if a vertebrae or disk is causing the pain.
MANAGEMENT AND TREATMENT
How is sciatica treated?
The goal of treatment is to decrease your pain and increase your mobility. Depending on the cause, many cases of sciatica go away over time with some simple self-care treatments.
Self-care treatments include:
Appling ice and/or hot packs: First, use ice packs to reduce pain and swelling. Apply ice packs or bag of frozen vegetables wrapped in a towel to the affected area. Apply for 20 minutes, several times a day. Switch to a hot pack or a heating pad after the first several days. Apply for 20 minutes at a time. If you’re still in pain, switch between hot and cold packs – whichever best relieves your discomfort.
Taking over-the-counter medicines: Take medicines to reduce pain, inflammation and swelling. The many common over-the-counter medicines in this category, called non-steroidal anti-inflammatory drugs (NSAIDs), include aspirin, ibuprofen and naproxen. Be watchful if you choose to take aspirin. Aspirin can cause ulcers and bleeding in some people. If you’re unable to take NSAIDS, acetaminophen may be taken instead.
Performing gentle stretches: Learn proper stretches from an instructor with experience with low back pain. Work up to other general strengthening, core muscle strengthening and aerobic exercises.
How long should I try self-care treatments for my sciatica before seeing my healthcare professional?
Every person with sciatic pain is different. The type of pain can be different, the intensity of pain is different and the cause of the pain can be different. In some patients, a more aggressive treatment may be tried first. However, generally speaking, if a six-week trial of conservative, self-care treatments – like ice, heat, stretching, over-the-counter medicines – has not provided relief, it’s time to return to a healthcare professional and try other treatment options.
Other treatment options include:
Prescription medications: Your healthcare provider may prescribe muscle relaxants, such as cyclobenzaprine. to relieve the discomfort associated with muscle spasms. Other medications with pain-relieving action that may be tried include tricyclic antidepressants and anti-seizure medications. Depending on your level of pain, prescription pain medicines might be used early in your treatment plan.
Physical therapy: The goal of physical therapy is to find exercise movements that decrease sciatica by reducing pressure on the nerve. An exercise program should include stretching exercises to improve muscle flexibility and aerobic exercises (such as walking, swimming, water aerobics). Your healthcare provider can refer you to a physical therapist who’ll work with you to customize your own stretching and aerobic exercise program and recommend other exercises to strengthen the muscles of your back, abdomen and legs.
Spinal injections: An injection of a corticosteroid, an anti-inflammatory medicine, into the lower back might help reduce the pain and swelling around the affected nerve roots. Injections provide short-time (typically up to three months) pain relief and is given under local anesthesia as an outpatient treatment. You may feel some pressure and burning or stinging sensation as the injection is being given. Ask your healthcare provider about how many injections you might be able to receive and the risks of injections.
Alternative therapies: Alternative therapies are increasingly popular and are used to treat and manage all kinds of pain. Alternative methods to improve sciatic pain include spine manipulation by a licensed chiropractor, yoga or acupuncture. Massage might help muscle spasms that often occur along with sciatica. Biofeedback is an option to help manage pain and relieve stress.
When is surgery considered?
Spinal surgery is usually not recommended unless you have not improved with other treatment methods such as stretching and medication, your pain is worsening, you have severe weakness in the muscles in your lower extremities or you have lost bladder or bowel control.
How soon surgery would be considered depends on the cause of your sciatica. Surgery is typically considered within a year of ongoing symptoms. Pain that is severe and unrelenting and is preventing you from standing or working and you’ve been admitted to a hospital would require more aggressive treatment and a shorter timeline to surgery. Loss of bladder or bowel control could require emergency surgery if determined to be cauda equine syndrome.
The goal of spinal surgery for sciatic pain is to remove the pressure on the nerves that are being pinched and to make sure the spine is stable.
Surgical options to relieve sciatica include:
Microdiscectomy: This is a minimally invasive procedure used to remove fragments of a herniated disk that are pressing on a nerve.
Laminectomy: In this procedure, the lamina (part of the vertebral bone; the roof of the spinal canal) that is causing pressure on the sciatic nerve is removed.
How long does it take to perform spine surgery and what’s the typical recovery time?
Discectomy and laminectomy generally take one to two hours to perform. Recovery time depends on your situation; your surgeon will tell you when you can get back to full activities. Generally the time needed to recover is six weeks to three months.
What are the risks of spinal surgery?
Though these procedures are considered very safe and effective, all surgeries have risks. Spinal surgery risks include:
Bleeding.
Infection.
Blood clots.
Nerve damage.
Spinal fluid leak.
Loss of bladder or bowel control.
What complications are associated with sciatica?
Most people recover fully from sciatica. However, chronic (ongoing and lasting) pain can be a complication of sciatica. If the pinched nerve is seriously injured, chronic muscle weakness, such as a “drop foot,” might occur, when numbness in the foot makes normal walking impossible. Sciatica can potentially cause permanent nerve damage, resulting in a loss of feeling in the affected legs. Call your provider right away if you lose feeling in your legs or feet, or have any concerns during your recovery time.
PREVENTION
Can sciatica be prevented?
Some sources of sciatica may not be preventable, such as degenerative disk disease, sciatica due to pregnancy or accidental falls. Although it might not be possible to prevent all cases of sciatica, taking the following steps can help protect your back and reduce your risk:
Maintain good posture: Following good posture techniques while you’re sitting, standing, lifting objects and sleeping helps relieve pressure on your lower back. Pain can be an early warning sign that you are not properly aligned. If you start to feel sore or stiff, adjust your posture.
Don’t smoke: Nicotine reduces the blood supply to bones. It weakens the spine and the vertebral disks, which puts more stress on the spine and disks and causes back and spine problems.
Maintain a healthy weight: Extra weight and a poor diet are associated with inflammation and pain throughout your body. To lose weight or learn healthier eating habits, look into the Mediterranean diet. The closer you are to your ideal body weight the less strain you put on your spine.
Exercise regularly: Exercise includes stretching to keep your joints flexible and exercises to strengthen your core – the muscles of your lower back and abdomen. These muscles work to support your spine. Also, do not sit for long periods of time.
Choose physical activities least likely to hurt your back: Consider low-impact activities such as swimming, walking, yoga or tai chi.
Keep yourself safe from falls: Wear shoes that fit and keep stairs and walkways free of clutter to reduce your chance of a fall. Make sure rooms are well-lighted and there are grab bars in bathrooms and rails on stairways.
OUTLOOK / PROGNOSIS
What can I expect if I have been diagnosed with sciatica?
The good news about sciatic pain is that it usually goes away on its own with time and some self-care treatments. Most people (80% to 90%) with sciatica get better without surgery, and about half of these recover from an episode fully within six weeks.
Be sure to contact your healthcare provider if your sciatica pain is not improving and you have concerns that you aren’t recovering as quickly as hoped.
LIVING WITH
When should I contact my healthcare provider?
Get immediate medical attention if you experience:
Severe leg pain lasting more than a few hours that is unbearable.
Numbness or muscle weakness in the same leg.
Bowel or bladder control loss. This could be due to a condition called cauda equina syndrome, which affects bundles of nerves at the end of the spinal cord.
Sudden and severe pain from a traffic accident or some other trauma.
Even if your visit doesn’t turn out to be an emergency situation, it’s best to get it checked out.
Is the sciatic nerve the only source of “sciatica” pain?
No, the sciatic nerve is not the only source of what is generally called “sciatica” or sciatica pain. Sometimes the source of pain is higher up in the lumbar spine and causes pain in front of the thigh or in the hip area. This pain is still called sciatica.
How can I tell if pain in my hip is a hip issue or sciatica?
Hip problems, such as arthritis in the hip, usually cause groin pain, pain when you put weight on your leg, or when the leg is moved around.
If your pain starts in the back and moves or radiates towards the hip or down the leg and you have numbness, tingling or weakness in the leg, sciatica is the most likely cause.
Is radiculopathy the same as sciatica?
Radiculopathy is a broader term that describes the symptoms caused by a pinched nerve in the spinal column. Sciatica is a specific type, and the most common type, of radiculopathy.
Should I rest if I have sciatica?
Some rest and change in your activities and activity level may be needed. However, too much rest, bed rest, and physical inactivity can make your pain worse and slow the healing process. It’s important to maintain as much activity as possible to keep muscles flexible and strong.
Before beginning your own exercise program, see your healthcare provider or spine specialist first to get a proper diagnosis. This healthcare professional will refer you to the proper physical therapist or other trained exercise or body mechanics specialist to devise an exercise and muscle strengthening program that’s best for you.
Can sciatica cause my leg and/or ankle to swell?
Sciatica that is caused by a herniated disk, spinal stenosis, or bone spur that compresses the sciatic nerve can cause inflammation – or swelling – in the affected leg. Complications of piriformis syndrome can also cause swelling in the leg.
Are restless leg syndrome, multiple sclerosis, carpal tunnel syndrome, plantar fasciitis, shingles or bursitis related to sciatica?
While all these conditions affect either the spinal cord, nerves, muscles, ligaments or joints and all can cause pain, none are directly related to sciatica. The main causes of these conditions are different. Sciatica only involves the sciatic nerve. That being said, the most similar condition would be carpal tunnel syndrome, which also involves a compression of a nerve.
A final word about sciatica
Most cases of sciatica do not require surgery. Time and self-care treatment are usually all that’s needed. However, if simple self-care treatments do not relieve your pain, see your healthcare provider. Your healthcare provider can confirm the cause of your pain, suggest other treatment options and/or refer you to other spine health specialists if needed.
Evolution of Medical profession-Extinction of good doctors 