Key Note Address- 1st Anniversary of ANGELS (18/02/2012)

Happy to participate in the 1^st anniversary of ANGELS (Active Network Group of Emergency Life Savers). It is nice to see that this is celebrated as Golden Hour 2012 with a caption: Caring for the people –bridging the gap”. We know that ANGELS is bringing a new culture in emergency medicine. It is bridging the gap-the gap between knowledge & practice.

I am only a fellow traveler of ANGELS, once in a while attending meetings like this. But I could palpate the pulse of this organization, the enthusiasm of its activists. It was evident when we experienced the mock drill at the air port.

I was thinking of pre angels era. Our attempt of emergency care was limited to hospital casualty. We know many patients are brought very late. They need management at spot, management at golden hour were we have to provide care for better outcome. Now at least we know that we could do something if not all.

Think of a cardiac arrest. It can happen at home, on the road, in the hospital. Those occurring in the hospital can be saved to an extent. What about others. Of the more than 300,000 cardiac arrests that occur annually in the United States, survival rates are typically lower than 10% for out-of-hospital events and lower than 20% for in-hospital events.^[When brought to the hospital the valuable time is already spoiled. Suppose we can give cardiac massage at site or defibrillate at site we could have saved the patient.

Targeted education and training regarding treatment of cardiac arrest directed at emergency medical services (EMS) professionals as well as the public has significantly increased cardiac arrest survival rates. Variation of CPR known as “hands-only” or “compression-only” CPR (COCPR) consists solely of chest compressions. This variant therapy is receiving growing attention as an option for lay providers. it is currently accepted that COCPR is superior to standard CPR in out-of-hospital cardiac arrest. The 2010 revisions to the American Heart Association (AHA) CPR guidelines state that untrained bystanders should perform COCPR in place of standard CPR or no CPR. Additionally, studies have shown that survival falls by 10-15% for each minute of cardiac arrest without CPR delivery. Bystander CPR initiated within minutes of the onset of arrest has been shown to improve survival rates 2- to 3-fold, as well as improve neurologic outcomes at 1 month.

Improvements in pre-hospital care have led to more rapid stabilization and transport of critically injured patients to definitive care. Despite this, cardiac arrest caused by trauma carries mortality rates of 81%-100%, even if managed early and aggressively. Increasingly, it has been recognized that continued CPR efforts on a trauma victim in the ED after failed pre-hospital resuscitation are futile and expensive. Study found that patients requiring CPR did not survive if they lost vital signs prior to hospital arrival.

Severely injured trauma victims are at high risk of development of the multiple organ dysfunction syndrome (MODS) or death. To maximize chances for survival, treatment priorities must focus on resuscitation from shock, including appropriate fluid resuscitation and rapid hemostasis. Inadequate tissue oxygenation leads to anaerobic metabolism and resultant tissue acidosis. The depth and duration of shock leads to a cumulative oxygen debt. Resuscitation is complete when the oxygen debt has been repaid, tissue acidosis eliminated, and normal aerobic metabolism restored in all tissue beds. Many patients may appear to be adequately resuscitated based on normalization of vital signs, but have occult hypoperfusion and ongoing tissue acidosis which may lead to organ dysfunction and death.

Another area is mass casualty and disaster management. At present this area is full of chaos. That is because of poor preparedness. There should be a disaster management team always. We know that they will not have any job for most of the time. But they can handle a situation much better than a naïve unit. Better training, available resources and good coordination are all important here. I am sure angels with its net work of life saving ambulances and dedicated team under able leadership can handle any situation what so ever

We are fortunate to have a unit like this in Calicut. Within one year it has spread its wings to whole of Malabar. More attempt at public awareness, targeted training to professionals and public are all need of the hour. In Medical College our attempt is to have a separate emergency medicine department with state of the art facilities and trained man power. We are looking forward to start MD in Emergency medicine and Critical care Medicine so that skilled man power will be siphoned out to this field. Medical College administration consider this as a challenge and a sizeable share of central fund under the scheme PMSSY will be utilized to improve emergency and trauma care. In this venture I request ANGELS to extend a helping hand to us for planning and executive at least in the initial years. Calicut medical College and ANGELS can have a mutually co operative and complimentary role in improving this particular discipline of medicine.

Thanking you and wishing you good luck

Dr C Ravindran

Photos of Book release

Hand Book on "Paediatric Respiratory Illness" Edited by Dr C Ravindran being released by Hon Chief Minister Sri Oommen Chandy on 11.02.2012

ANNUAL CONFERENCE OF KGMOA-2012 AT CALICUT

Respected president KGMOA, Chief Guest and other dignitaries on and off the Dias, KGMOA members and their family

First of all I place on record my deep sense of gratitude to the office bearers of KGMOA for inviting me to deliver the key note address. I congratulate you on arranging such a grand function.

Ever since I was invited I am worried about the content of my talk. Even today I am doubtful of my role. As a person working in another health stream for over 25 years, I can only submit my observations.

We know that heath sector in Kerala has advanced so much during the last decade or so. This is evident both in medical education as well as in health service. Be it in infrastructure, patient care, service benefits etc. But how well all these have percolated to the public at grass root level is still a question mark. Perception of the common man on health scenario is different. Their expectations are always high. We are no where near to that. And often we see the reactions of these.

The two branches of Health Dept namely Medical Education and Health Service are not working complimentarily. That is one huge problem we face. All the district hospitals where there is no proximity to med college are working like a huge establishment. But in districts where there is a medical college the district hospital is not developed like that. We both blame each other. Truth is entirely different. We never thought of complimenting each other.

Here we have to think of referral system. But what I see is that both at Medical Education level and Health Service level this is being opposed. Nobody come with a solid proposal or approach it with sincerity. The reason is not known to me.

I feel that we should bring the family practice to the forefront. If there is a referral system we can do this. The primary care level can concentrate on family practice. This will give us an opportunity to prepare the disease registry across the state. This will help us to plan the approach both at preventive and treatment aspects. Secondary level should be empowered to deliver the standard of care they are expected to. Tertiary level should be the teaching institution for treatment of patients referred from secondary level, teaching and research. The present load should be released from Medical colleges.

There is a growing concern that the public health activities are not taken seriously now. Once three tiers Local Self Government came many of the PHC were put under gramma panchayath or block panchayath. What happened after that I don,t know. But it is alleged that immunization, sanitation etc are not properly cared for. Every year we are getting new epidemics and thousands of people are affected. This creates a heavy burden on health system. But no concrete solution is being developed. There should be comprehensive approach, a combined act where medical college can also contribute to conduct field study and look for solutions. Field work in the health sector should be revived.

Another problem is the shortage of staff in the rural areas. Whatever steps the Govt. is taking we have problem in getting people to work at periphery. The latest is the CRS. I talked to many interns regarding this. They are not enthusiastic in pursuing CRS. One problem is our attitude to bonded labour. Most important is many of them do not understand the importance of working in rural areas. We are always promoting a specialized practice and our children are also not different.

It is important that we should create a cadre for rural service. They should be offered better incentives including a PG seat. Most important is that the system should recognize their service for future incentives too, that is giving them placement of their choice. In that case we can abolish CRS and only those who are interested will come for rural service.

I am sure that there are some positive initiatives in this line. There is a plan to start family medicine specialty in Medical colleges to give training in that line. Govt also is considering the system of cadre development during MBBS itself as practiced in AFMC. Initial discussions are started on developing the referral system in health sector. Only thing is that our approach also should be proactive and we should be able to give positive feed back on all hot issues in health sector in our state. We only can improve it. I thing KGMOA the largest service organization of doctors in the state can take initiatives in this line.

Thank you

Inaugural address-Diagnostics &Surgicals Dealers Association-Annual meet

Corporate social responsibility means taking proactive steps to help others, rather than just make money. In this era of Social Innovation, businesses can do many things by investing in local communities, improving labor practices, greening supply chains, and generally giving back. Businesses are beginning to be in the business of doing social good as well. Many companies shift to incorporate environmental, social, and welfare-based themes into business plans and products, and look to increase both profit and human development.

As surgical firms your first responsibility is to the doctors, nurses and patients, to mothers and fathers and all others who use your products and services. In meeting their needs everything you do must be of high quality. You must constantly strive to reduce the  costs in order to maintain reasonable prices. Customers' orders must be serviced promptly and accurately. The suppliers and distributors must have an opportunity to make a fair profit. You are responsible to the employees, the men and women who work with you throughout the world. Everyone must be considered as an individual. We must respect their dignity and recognize their merit. They must have a sense of security in their jobs, and must provide competent management, and their actions must be just and ethical. We are responsible to the communities in which we live and work and to the world community as well. We must be good citizens--support good works and charities. We must encourage civic improvements and better health and education. We must maintain in good order the property we are privileged to use, protecting the environment and natural resources. Business must make a sound profit. We must experiment with new ideas. Research must be carried on, innovative programs developed and mistakes paid for. New equipment must be purchased, new facilities provided and new products launched. Reserves must be created to provide for adverse times.

To quote an example Johnson & Johnson started in 1800s as a small unit producing dressing materials. Through hard work they could reach a level that today they are the leaders in manufacturing surgical equipments, sterilizing products, cosmetics and baby products. In their growth they had to face unethical competition which they survived. 7 patients died of taking Tylenol and they had to with draw the whole stock. Not only money but the reputation also was at stake. Later this was found to be a tampering at retail level. Sale of the competitive products went up and it was proved to be an unethical competition. Such things should be avoided.

Many firms now use the amount for charities to give kick backs. This is another unethical way of making money. This creates a nexus between corporate, doctors and paramedics. This practice definitely exploits the poor patients.

Dear friends in corporate sector you are permitted to make profit, but a portion of it should be given back to the society we represent. More over profit making path should be clean and ethical.

DR C RAVINDRAN,28/01/2012