IndiaMedToday Nov 2018

NOVEMBER 2018, VOLUME 2 ISSUE 11 `200

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SPECIAL FEATURE AMERICAN ACADEMY OF EMERGENCY MEDICINE

CEO’S PERSPECTIVE DR. HARISH PILLAI,

CEO – ASTER HOSPITALS & CLINICS

INNOVATE PROTEMBO CEREBRAL PROTECTION SYSTEM

What AilsEMERGENCY

MEDICINEin India

Lack of standardisation, fragmented training landscape and distrust relation among doctors

M Neelam Kachhap

EDIT NOTE

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NOVEMBER 2018

EDITORIAL

Editor Neelam Kachhap editorial@ indiamedtoday.com

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CONSULTING EDITOR

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Challenges in Emergency Medicine

EMERGENCY MEDICINE leaders will meet at the 20th Annual National Conference on Emergency Medicine EMCON2018 which opens at Bengaluru shortly.

Among the clinical advancement and professional camaraderie, this elite group of specialists will also discuss on challenges of getting the emergency medicine community united to further the cause of the specialty. Consensus, Advances and Innovation is the theme of the event.

Although, EM is regarded as the fastest growing new discipline in the field of healthcare worldwide and shares an interest with every other existing medical discipline, in India it has still not gained the importance it should get. The emergency and trauma care in India still lacks fervor and the fragmented professional community does not help either.

There is no consensus on who brought EM to India and therefore no “Father” or “Mother” of emergency medicine in India

For instance, there are two associations and leaders belonging to both these associations claim they got the MCI to recognise EM as a specialty. There is no consensus on who brought EM to India and therefore no “Father” or “Mother” of emergency medicine in India.

The rift among the different EM professional associations on training modules and development of the specialty has become evident in the past few years. There are a number of overlapping issues regarding betterment of EM in India. However, despite the potential for cooperation these associations remain elusive and without defined strategic mission.

Despite denials that all is well among the professionals complains regarding illegal certification and practices continue to emerge in the media. The lack of concurrence and cooperation will not benefit the patients and certainly not the young individuals enthusiastic about EM.

Let’s hope that this gap is bridged soon and will pave way for consolidation and all round development of EM in India.

As always, if you have any comment on the magazine or are interested in contributing, please contact editorial@indiamedtoday.com

Editor M Neelam Kachhap

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NEWS REPORT

Making Markets Work for Affordable Healthcare

Competition Commission of India brings out Policy Note on Healthcare Market

OVER THE nine years of enforcement of the Competition Act, 2002 (the Act), the Competition Commission of India has received 52 cases pertaining to the pharmaceutical and healthcare sector. The Commission, while deciding on the cases, has observed that information asymmetry in the pharmaceutical/healthcare sector significantly restricts consumer choice. In the absence of consumer sovereignty, various industry practices flourish which have the effect of choking competition and are detrimental to consumer interest. Such practices may not always violate the provisions of the Act, but they create conditions that do not allow markets to work effectively and healthy competition to drive the market outcomes. The response to these issues can, in many instances,take the form of appropriate regulations that can pre-empt market-distorting practices and help create pro-competition conditions.

As the competition authority of the country, the Commission felt the need for close examination and focused deliberations on these issues, which have implications for markets and competition in this sector of critical importance. In pursuance of the same, a series of initiatives has been taken up by the Commission over the years in the pharmaceutical and healthcare sector, which culminated in a Technical Workshop on ‘Competition Issues in the Healthcare and Pharmaceutical Sector in India’ organised on August 28-29, 2018 in New Delhi with representatives of all stakeholder groups, including pharmaceutical industry, healthcare

service providers, civil society organisations, regulators, healthcare think tanks.

The issues identified and recommendations suggested by the stakeholders have been documented in a Policy Note by the Commission titled ‘Making Markets Work for Affordable Healthcare’.Thekey issues and recommendations are as under:

Role of intermediaries in drug price build-up

� One major factor that contributes to high drug prices in India is the unreasonably high trade margins. The high margins are a form of incentive and an indirect marketing tool employed by drug companies. Further, self-regulation by trade associations also contributes towards high margins as these associations control the entire drug distribution system in a manner that reduces competition.

� Efficient and wider public procurement and distribution of essential drugs can circumvent the challenges arising from the distribution chain, supplant sub-optimal regulatory instruments such as price control and allow for access to essential medicines at lower prices.

� Electronic trading of drugs, with appropriate regulatory safeguards, could be another potent instrument for bringing in transparency andspurring price competition among platforms and among retailers, as has been witnessed in other product segments.

16 November 2018

INTERVIEW

Emergency Medicine Department: CEO’s Perspective

medico legal cases, there is an emerging trend of setting up a full-fledged Emergency Department. An Emergency Medicine Department greatly adds to the seamless continuity of care, especially in the management of poly trauma and mass incidents.

A well trained cross functional team equipped with clinical pathways can be highly successful in saving lives during the “golden hour” window period.

Dr. Harish Pillai, CEO – Aster Hospitals & Clinics, India Aster DM Healthcare

Why is it difficult to set-up and run an emergency medicine department ? An Emergency Department is usually a vast and advanced setup which aims to manage any criticality. This is greatly different from a Casualty Department which mostly consists of just 2-3

greater. Moreover, the acute shortage in qualified human resources in India to serve in such departments adds to the challenges.

Tell us about the ED set-up in India? Majority of the hospitalsin the bed category of 50 to 200 usually have a smaller Casualty Department. However, with the rising expectations of patients and incidents of

What are the hallmark of successful EM department It should be part of the comprehensive clinical program and strategy of the hospital. The space planning,

planning with recruitment and retention of talented personnel ranging from doctors, nurses and technicians. An important aspect is the robust Post- Graduate training program to enlarge to pool of human resources. There should be outreach programmes between the main hospital and peripheral centers and community based engagement programmes to reduce the incidents of trauma.

Efforts should be made to embed the Emergency Department as part of a larger public emergency response network. There should be adoption

the hospital should frequently conduct of mock drills, disaster drills and trauma codes.

24 November 2018

SPECIAL FEATURE

Emergency Medicine: Gaining Grounds

Girish Bobby Kapur MD, MPH, FAAEM, FIFEM Chief of Emergency Medicine Division Jackson Memorial Hospital Miami, Fl American Academy of Emergency Medicine: Board of Director

David A. Farcy MD, FAAEM, FACEP, FCCM. Chairman, Department of Emergency Medicine Director, Emergency Medicine Critical Care. Emergency Medicine and Critical Care Attending Mount Sinai Medical Center Miami Beach, FL. American Academy of Emergency Medicine: President

EMERGENCY MEDICINE (EM) is a relatively new specialty within medicine. Although internal medicine and surgery have a historical context that goes back more than a century, the first organized delivery of emergency care by dedicated physicians working 24 hours a day in hospital Emergency Departments only began in the 1960’s in the USA and UK. At that time it was recognized that physicians working in the Emergency Department did not have the breadth of training that covered the vast and complex nature of presentations of a multitude of different diseases. One example that often has been used is “how much training did a general surgeon have in the interpretation of an electrocardiogram (EKG)?”

The Beginning In 1971, Dr. David Wagner created the first three-year EM residency, and by 1975, there were more than 31 residency training programs in the USA.

In the US, The American Board of Medical Specialty (ABMS) initially turned down (in 1976) the request for the creation of the American Board of Emergency Medicine (ABEM) as a primary board but approved it as a secondary board.In 1979 ABEM became the 23rd recognized medical specialty, and 10 years later, ABMS

had formed an organization called the American Academy for Emergency Medicine in India (AAEMI), which

is now a chapter within the American Academy of Emergency Medicine (AAEM). The Medical Council of India approved Emergency Medicine as the 29th specialty in 2009.

Today’s ED What separates Emergency Medicine from other specialties is the need to evaluate and diagnose patients with undifferentiated symptoms (chest pain, fever, abdominal pain) in a rapid manner to address potentially time-sensitive conditions using risk stratification. For example, a patient

issues facing Emergency Medicine globally. Emergency Physicians do not have the luxury to order every test or make sure they have the right diagnosis. They need to maintain the flow and assure that every patient is evaluated, treated and has a plan of care based on EM training. This decision for disposition determines whether the patient needs immediate emergency care, stabilization, admission for continuous management, or safe dischargefor outpatient treatment.

Emergency Care Delivery First, health system development requires a well-organized prehospital care system to transport patients with acute medical conditions (such as stroke and heart attack) or

26 November 2018

PULSE

Training in Emergency Medicine

Gerald Jaideep, CEO, Medvarsity Online Ltd

IN THE course of a medical career, the most difficult challenge that a doctor might face is dealing with an emergency case, as it involves a lot of critical thinking, analysing the patient, evaluating

Need for EM Specialist There are close to 2 lakh hospitals in India, but only about 100 Emergency Medicine (MD) seats available each year to MBBS graduates for specialisation. Most fresh graduates that are hired yearly to work in emergency departments are

India were preventable if the proper emergency care and follow up protocol had been observed. Therefore, better emergency services and better training to existing emergency medicine physicians has a direct impact on this mortality number.

in this field and a need for them is only increasing. Any training program in the specialty needs to have a good curriculum and a lot of commitment to carry it out in a proper manner,” says Dr NitinJagasia, Head Emergency Medicine Apollo Hospitals Mumbai.

28 November 2018

INNOVATE

ProtEmbo Cerebral Protection System

IMT Team

PROTEMBIS, A medical device start-up company with its R&D base in the engineering and technology city of Aachen, Germany has developed a Cerebral Protection System called the ProtEmbo, to minimize the risk of stroke and other neurological injury in heart valve interventions.

Nowadays, the calcified native aortic valve can be replaced by an artificial heart valve, which is advanced via a catheter into the left ventricle, specifically to the site of the calcified native valve. This procedure is called transcatheter aortic valve implantation (TAVI or TAVR). TAVI is a quicker and less invasive procedure and is conducted while the heart is beating; it is associated with less pain and a shorter hospital stay than the alternative open-heart surgery.

In both methods, however, there is a risk that calcific debris from the native heart valve or aorta is detached and then migrates to the brain via the bloodstream, where it can cause stroke or other neurological complications. The drugs used before, during and shortly after the heart valve procedure do not provide complete protection against this risk. The heart valve prosthesis is opened, presses the old and defective native valve against the vessel wall and thus takes over its function.

“Literally every TAVI intervention leads to particle migration to the brain” says Karl von Mangoldt, co-managing director and co-founder of Protembis. “Recent clinical studies have shown that up to 9 percent of TAVI patients suffer a stroke” adds Conrad Rasmus, also comanaging director and co-founder of Protembis. The Protembis team wants to minimize this risk with its novel device.

The ProtEmbo is a catheter-based filter device which is advanced intuitively, safely and quickly via the radial artery of the left arm before the start of a TAVI procedure and removed again at the end of the procedure in order to prevent the migration of particles to the brain. The permeable material of the filter covers all arteries leading to the brain while allowing free passage of blood cells and

30 November 2018

APPROACH

Advances in Stroke Management

Dr NK Venkataramana, Founder & Chief Neurosurgeon, Brains, Bengaluru

STROKE (BRAIN ATTACK) is a sudden catastrophic condition where, either the blood supply to the brain gets blocked or reduced leading to paralysis termed as Ischemic stroke, or on the other hand bleeding into the brain called, Haemorrhagic stroke.

In both the situations, the consequence can be dangerous resulting in paralysis, loss of vision, loss of speech and loss of balance and also death depending upon the magnitude. When the blood supply to the brain cannot meet the demands of metabolism the resultant effect or

deficiency will result in a stroke. This can be either due to the abnormalities of the blood or the blood vessels. In addition to this, a host of auto-immune conditions were identified recently as one of the significant causes of stroke leading to both loss of blood supply as well as bleeding into the brain.

When the extent of a stroke is large, one can become unconscious and this in turn can cause secondary events like brain swelling, fits, electrolyte disturbance adding further as complications.

34 November 2018

Q&A

ASK THE EXPERT

Running a private medical practice in India comes with the risk of lawsuits and property damage. As a medical professional, you are probably well aware of the devastating effects of legal cases and security threats that await doctors who face the blunt of an angry patient. We encourage you to share your queries and concerns regarding legalities of practicing medicine in India to learn more about legal framework, legal cases and the experience of fellow doctors

Prof ( Dr ) R K Sharma, President, Indian Association of Medico-Legal Experts , New Delhi will answer questions from our readers. Please send in your queries to editor@indiamedtoday.com

Q: What should be the process to follow if an adult comes to emergency with a fracture requiring surgery and he claims there is absolutely no one for him and no relatives will ever come and is willing to pay the required advance and insists on proceeding with the surgery. If any untoward complication occurs and the patient dies what process should be followed?

Dr. Anton Job Romesh Prasad Ans: Adult person is competent to give consent for any operation even without presence of attendants even if it is risky and can cause death.Inform police if such person dies as state has responsibility to take care of such eventuality. Police will find out relatives or dispose of body if none is there. Do take ID of this person before proceeding for operation.

Q: If some online app hires any consultant then what is legal responsibility for both?

Dr Pratik Vora Ans: Please remembers both have legal responsibility although responsibility will differ. Consultant is fully responsible for all actions he performs and is liable individually in criminal prosecution. Online app has vicarious responsibility to all actions of consultant.

Q: If a patient comes in OPD for UGI Endoscopy undersedation and he is alone. Can signature by patient himself and doctorconstitute full consent or signature

of witness by third person ismust? Please clarify?

Dr V R Gupta Ans: Consent alone by a competent patient is sufficient for legal purposes. Please remember that signature of indifferent witness is must to complete the document legally.Signature of doctor is also must on consent form.

Q: I am an MBBS graduate from India and then went to UK. I am fully trained gastrointestinal surgeon and have acquired the FRCS. I do not have a postgraduate degree in India. I have now relocated back to Bangalore for good. I wanted to know what would be the legal implications for my practice here. Thank you for your advice?

Raghu Ans: Please note that FRCS from UK is recognised medical qualification by Medical Council of India, so there is no problem for you. It is advised that you add this qualification in your Indian medical registration certificate from Karnataka medical Council.

Q: Doctors charge a lot in India, is it correct?

Ans: The following is fee structure of doctors of allopath in India. In tier 3 cities - Rs 100 per consultation include medicines; in tier 2 cities- Rs 300 per consultation that may include medicines in some cases; in tier 1 cities – Rs 400 per consultation; in metropolitan cities- MBBS doctor charge Rs 500 per consultation,

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