Shoot First, Ask Later Policy – Of Giving Antibiotics

Shoot First, Ask Later Policy – Of Giving Antibiotics

(Disclaimer : I have tried to avoid medical jargon and simplify this as much as possible for everyone to read and understand- some of my fellow medicos might call it oversimplification- but I want people to understand the issues and form their own opinions. As always I would love to answer your comments and questions related to this post)

This morning I saw a patient in her early twenties who had undergone a open heart surgery for valve replacement in the heart a couple of years ago and the patient shared the story of how she had suffered from frequent knee pains in her younger years and how it developed into a heart disease without being diagnosed. Joint pains followed by valvular disease of the heart is known as rheumatic heart disease- a misleading name - since it is caused by a bacterial infection from a bacteria called Streptococcus (Strep Pyogenes)- the same one responsible for sore throat disease- cough and cold and sniffling nose, anyone?.

Streptococcal sore throat is often mistakenly diagnosed as a common cold -which is caused by a virus and is self limiting and is automatically cured after a week or so. But if the strep infection is not diagnosed and treated by giving antibiotics at the initial stage itself then the heart and its valves are damaged resulting in uneven pumping of blood by the heart and hence by the time the disease is finally confirmed the only treatment left is open heart surgery for replacement of the diseased heart valve by a new artificial valve. And to think that it could have been easily prevented - if someone had diagnosed it early and prescribed the correct antibiotics to kill those bacteria in the throat itself. Makes you wonder doesn’t it?

Which brings to mind an interesting online conversation I had a few days ago based on one of my recent blog posts- with a couple of fellow medicos (Sai Sriram and Sulaiman)- on antibiotic abuse. I want to share the same here on the blog as there were several interesting points made which would be of use to everyone. And I hope, would also offer you an insight on the thought processes of doctors and how and why certain prescriptions contain antibiotics and others don’t.

Every single doctor when he/she undergoes the basic course and during residency training is taught about the inviolability of evidence based medicine- that is treating diseases based on best practices developed by research and published in journals. There are clearly defined protocols for each and every disease treatment- developed internationally and standardized for treatment all over the globe and doctors are expected to follow it in all countries and circumstances. But practical realities differ from country to country and play a major role in actual prescription writing.

For example, a doctor practicing in a country like the United states of America with a robust and well developed emergency medicine facilities can often adopt a wait and watch approach when it comes to certain diseases like infections -to see if it really develops into a major disease (life threatening) or if the persons normal immune system can deal with the infection on its own without need of taking any medicines. But in a country like India where emergency facilities are more often swamped by accident cases, suicide patients etc and there are very few infection specialists and many more general practitioners -the treatment of infections is radically different on the ground. Here doctors prefer the prevention is the best cure formula rather than patience is a virtue formula practiced abroad. Let me explain my point with examples.

When a patient, let’s say a child is brought to the doctor with a sore throat, cold and fever -it is clinically difficult to differentiate whether the sore throat is caused by a virus or by a bacteria and investigation like culture method to diagnose the organism responsible takes a few days at least to come out with the results. In such cases some doctors prescribe antibiotics immediately -just to cover the bases but other doctors don’t- for they reason that if it’s a viral infection, it is soon going to go away on its own, so why should we give something of no use -for antibiotics don’t work on viruses.

And there are so many evidence based medicine guidelines which scream that easy availability of antibiotics- pill popping even when unnecessary -is causing widespread antibiotic resistance and require stronger and stronger antibiotics in future for even simple infections. So following international guidelines and out of best intentions - the doctors don’t prescribe any antibiotics and nine times out of ten the infection is viral and heals quietly. But rarely, in the rarest of rare cases-the infection spreads throughout the body and attacks the heart and other important organs. And that’s when the doctors start second guessing themselves about whether they should have given antibiotics - just to play safe. And believe me it is as traumatic for the doctor who could have done something but didn’t do it -as it is for patients themselves.

In India most practitioners prefer not to take this risk and by routinely prescribing antibiotics make sure that the  rare case does not happen to their patients- antibiotic over use protocols be damned. Most doctors are either not trained to communicate all the reasons for not giving antibiotics or they just don’t have the time to confront an  anxious parent of a sick child and try to convince them to wait and watch before taking any concrete step to cure the child -masterly inactivity technique of treatment (with apologies to Warren Hastings).

Besides more often we see that the most popular doctors are the "take immediate action" types and the average patient prefers a doctor who prescribes antibiotics rather than just give advice. And we cannot find fault with them for it’s easier to trust a doctor who give medicines than the doctor who shows you reams of statistics and dozens of scientific evidence about antibiotic abuse but does nothing else. Every patient prefers to go home with some medicine or the other- even if it’s just for mental satisfaction.

And don’t mistake me, not for a moment am I suggesting that we give drugs based on the whims and fancies of the patients. No we don’t and we shouldn't. We should as far as possible follow the best practices of evidence based medicine and give only the treatment actually required. But we should also remember that we are treating people and not just diseases. And it’s up to us to reconcile the dilemmas involved by listening to our patients- spoken and unspoken complaints.

Medical diagnosis is not often cut and dried- it involves a degree of subjectivity and guess-work. No doctor intentionally plans to give unwanted drugs (at least most don’t-exceptions are always there) to any patient. The simplest and most obvious reason for giving antibiotics is   they assume they are treating a bacterial infection and not a viral infection. If it’s a bacterial infection the patient gets well immediately. And even if it is a viral infection the patient is going to get well anyway. And so unless we are absolutely sure that the benefits of giving prophylactic antibiotics is outweighed by the risks involved I vote that we continue to prescribe antibiotics where necessary.

So to get back to my original premise of the title - should we shoot antibiotics first and then decide later? Or should we not? In my view- there are no clear cut solutions for this problem- it is complicated, confusing and most of the time it requires a bit of compromise to suit the particular patients condition. Horses for courses is the only solution I would recommend. Rather than follow a guideline based medicine I would suggest an individualized medicine paradigm where patients are at the center of everything and not rule books framed in a distant laboratory.

So I rest my case by saying that -"If the shoe fits wear it. If not- don’t cut off the foot trying to cram it into the shoe."

P.s. The introduction of the American model of Defensive medicine where doctors have to keep justifying every single clinical decision of theirs to insurance companies which are the paymasters is ill-suited to Indian conditions. What we are seeing now is just the crest of the wave- the tsunami will soon be here.

Care Walk - 2013...

                                                                   Care-Walk - 2013                            

As regular readers of my blog know, I often walk the streets of Chennai as part of a photo walk group – which has these regular walks scheduled once a month- to document the changes of our rapidly evolving city and to preserve the memories of what was once there and will be no more. This month’s walk was special as it coincided with the celebration of Madras Day and hence the walk was associated with the local British council for a charitable purpose - cancer relief and called as Carewalk-2013.

The walk was flagged off from the premises of the British Council Library at Mount Road (Anna Salai) which is right behind the Madras District Library – the Devaneya Paavanar Library- the place where a thousand civil servants were made in those pre-coaching center days for a lot of civil service aspirants used the library as a study point for preparing the civil service exams. 

The British Council Library on Mount Road

The British Deputy High Commissioner Flagging off the walk

The Assembled group of photographers

The library’s second floor had a fantastic collection of old medical books- which was my attraction point- and I had spent many pleasant hours in the past- going through the old textbooks and reading up the changes in medical treatment with every new edition. Many times I was reminded by my friends that it was totally pointless towards scoring good marks in our exams- to learn about historical medical treatments now out of fashion- but I have always been fascinated by history and I couldn’t think of a better way to spend a lazy summer afternoon- especially as the reading section of the library was fully air-conditioned- a luxury in our hot summers. And if I got bored of reading medical stuff, then there was always the British Council Library right next door with a fantastic collection of general books- and an especially good travelogue section- my favorite kind of lazy read. Anyway, that’s more than enough about books and libraries; let’s get back to the walk.

The Devaneya Pavanar Madras Public Library

As I said the walk was flagged off by the British Deputy Commisioner from the lawn of the library. We had a slightly latish start at around 8:30AM compared to our usual 6:30AM start but on the plus side we had a police escort throughout the walk which meant that not once was our organizer Ramasamy N. (of Chennai Daily Photos fame) had to stop and explain to random cops why we were walking around with cameras so early in the morning. As I have mentioned in my previous posts - the early morning patrol cops are the “Alert Arumugam” types- and they have never failed to stop the photo walk group at least a couple of times on every single walk to enquire and check our ID’s- as if Al Queda terrorists openly walk about in groups photographing street signs and shop name boards. Don’t they now do it direct on Google street view? Anyway Ram Anna as he is fondly called by the photo walkers has the unenviable task of dealing with the zealous cops every time. And so it was a pleasant surprise to see that for this walk the British High Commissioner had arranged a police escort for us on the entire route- making Rams’ work easy and allowing him to concentrate on the thing he loves- capturing images.

The Erstwhile Anand Theatre under the Metro Rail construction debris

The 30 year supplier of Cd's to Chennai

Sonna Puriyudha?

Did you know that a Xerox gives a "DITTO" copy?

The 3-way split of Anna Salai

 The walk started off from Mount Road and passing by the now defunct Anand Theatre- a once prominent landmark for the city’s film buffs- and skirting around the dug up roads for the upcoming Metro rail project, we turned into Greams Road. As one of the history buffs in the group- Chandra Choodan or CC as he is called explained- the road started off being called Greame’s Road in honor of an erstwhile prominent resident Mr.Greame, of Irish origin. With time the “e” was lost and an “s” was added to the name by the local corporation officers- and hence Greams Road. But this contraction of the late Mr. Greame’s name doesn’t seem to be the end of the story – as I saw quite a few shop name boards with creative spelling of the original street name – Indian ingenuity at its best.

Is it Greams Road?

Or Grimes Road?

 After passing the mid way point of the walk at the designated – TAFE workshop- a place where almost all Chennai car owners would have service their cars at one time or another, we turned back into the opposite side to pass the MRF showroom with its distinctive “Man bearing Tire” display in imitation of the mighty Atlas of Greek Myths. From there we crossed over to the other side of Mount Road into Peter’s Road and the Thousand Lights Mosque- which gives its name to the Thousand Lights Area behind it. As we were there on a Sunday and a non-prayer time we could enter the mosque and enjoy its beauties without inhibitions- a first time for me and a few others too. After photographing the minarets and domes of the Thousand Lights mosque – the walk was officially ended and we broke up to go home for breakfast and a long lazy Sunday.

The Chinese Triads are here ?

A prayer for every ill -on specific days

Atlas Reborn- Tyre man of MRF

Welcome to India- where guests are God

I have my "EYE" on you

The immortal Tramp - Charlie Chaplin- evergreen humor man

R.I.P.- A grave headstone

The Thousand Lights Mosque

The Minarets of the Thousand Lights Mosque

Interior of Mosque

A stained glass window

View through a window

 

P.S. the second walk for this madras month celebrations is scheduled for next Sunday and would cover the Nandambakkam area starting from MIOT hospital. Do join us if you are free that today.

Our Leader - Ramasamy N - of Chennai Daily Photos

A new walker - rings the bell

Chennai Express – Film Review

Chennai Express – A Review.

 It’s been long since I did a film review. Not that the films I watched in-between where not review worthy, just that, what with live tweeting and facebook status updates from the movie theatre itself, I have run out of things to say on the movie by the time I came home and sat down to do a proper review on the blog. But as they say, a time comes for everything and Shah Rukh Khan has made me write a review post again with his new film Chennai Express. 

The film is produced by Red Chillies Entertainment, his own banner and helmed by Rohit Shetty the man who has made an art form of re-making southern blockbusters into Hindi movies. Chennai Express is again one such re-make of the Mahesh Babu starrer Okkadu (in Telugu) later remade as Gilli in Tamil starring Vijay- both of them taking the lead actor known for his romantic hero’s role and establishing them as the action heroes of their industry. But if you go expecting an out and out action film with the promos in mind, you will be surprised for this film is more of a comedy than an action thriller- quite unlike the originals.

The story, well to tell the truth, there is not much of a story, but you don’t miss it that much with the engaging screenplay with never a dull moment on screen. Anyway the story starts with Shahrukh’s granddad dying off and making a last wish for his ashes to be dissolved in the sea off Rameshwaram. Shah Rukh, free at last of his overbearing and controlling grandfather, who has brought him up all these years with an iron fist after his parents’ death in a car accident, plans to take a side trip from Rameswaram to Goa. For as per the story the hero is a 40 year old bachelor who has spent all his time looking after their ancestral sweet stall business rather than do normal stuff like dating or getting married. 

Anyway with grandpa’s ashes in tow Shahrukh boards the Chennai express planning to get off halfway and visit Goa to have fun with “foreign” girls- as his friends advise him to do. Unfortunately for him in a straight lift off from his mega hit Dilwale Dulhaniya Leh Jayegi movie- he gives a hand to the heroine Deepika Padukone who is running hard to try and board the train. In aparody of that famous scene - SRK also gives a hand to lift up four other guys who are running behind Deepika. And then starts the non-stop fun.

 Hero learns that the heroine is being chased by goondas, the same fellows he helped board up the train and he does what any self respecting action hero would do- frightened, he climbs up and lies down shivering on the upper birth to conceal himself from the goondas. This is one of the most hilarious scenes in the movie as the hero learns the entire back-story from the heroine through an antakshari competition- for while heroine can speak hindi, her kidnappers cant. So hero and heroine communicate exclusively through singing old hindi songs and adapting the lyrics to the situation. 

Anyway the goondas on being asked for their tickets by the railways TTE throw the Ticket Examiner out of the train for which hero becomes an unwilling eye witness. Hence they make him get down with them (and the heroine) at their hometown railway station- planning to kill him off at their own sweet time. And heroine trying to save the hero’s life, tells her dad- the Don of their town- that she is in love with the hero and poor hero who doesn’t know the language they are talking in, nods his head in agreement. And then the fun starts. All this is within the first half an hour of the movie.

The rest of the movie is about how the two escape from the village and flee down south to Rameswaram where Shahrukh fulfils his grandfathers dying wish and on the journey slowly fall in love with each other- until Shahrukh decides to man it up and return to heroines village – to bash up the baddies in the climax and prove that true love always wins with the awesome (clap worthy) dialogue – “I have decided to stop running and face my problems- your father”. A dialogue which I am sure a lot of guys in love would borrow in coming years.

Satyaraj as the heroine Deepika’s father – Periyathalai, underplays himself with nods and grimaces and not many dialogues till the climax where he spoofs Amrish in DDLJ (again) by saying “Meena thera”. Most of the film is a spoof on one or the other SRK’s films and unless you are a fan boy of Bollywood you would miss most of the inside jokes. For me the joke of the movie is when ShahRukh tells Deepika about his parents death and says that since he was 8 years old he has lived a lonely life and then the heroine asks (in a first for hindi movies) – “so after that for Pachees saal (50 years) you have lived alone?”. The entire theatre broke out in claps at this dig on aged heroes of Indian cinema romancing heroines half their age. But it took a Shah Rukh Khan to boldly agree to such a dialogue not minding his superstar image.

There are no fights as such in the movie- till the very end when hero shows “the power of the common man”. Songs are hummable but may not stick to your mind for very long. Except for the Thalaiva song- a tribute to Rajnikant- which plays with the end credits and is such a good song that it’s wasted there- so don’t leave immediately after the climax fight. The item song with Priyamani and Shah Rukh doing a Kuthu dance- goes something like 1,2,3,4 get on the dance floor sound eerily similar to a recent song starring Rani Mukherjee and Prithiviraj- but I am no expert on music and can’t say for certain and leave it to better judges.

Downers? Well if you are in the mood to nitpick then there are always a dozen things you can pick on – like how there is a been there/seen that feel to the storyline and how the hero rahul continues to call the heroine meenamma, using the tamil honorific amma after the characters name- meena, even after he is told her real name. And Deepika’s “tameel” accent jars a bit which makes me wonder why no one corrected her at least during the dubbing. But taking all, the downers pass over pretty swiftly because of the smart screenplay.

Verdict- For those who love spoof movies – this is the movie of the year and not to be missed. SRK spoofs everybody, including himself mercilessly and the result is highly entertaining. The film is a laugh riot from beginning to end, except for some sagging romantic bits in the middle. There’s an insane bit of tomfoolery with the midget actor Kingkong and Shah Rukh miming various modes of transport, just before the interval, which had me in splits. My overall verdict is – the movie is full paisa vasool. If you need some mindless entertainment for stress relief – this is the movie to watch. And King Khan’s back with a bang.