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CONTENTS Page No.
Cover Story
SLMANEWS
THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION
Joint Regional Meeting
03, 04, 06
September 2015, Volume 8, issue 09
SLMA News Editorial Committee-2015 Editor-In-Chief: Prof. Sharmini Gunawardena
News
Committee:
President's Message
02
Malaria Count
02
Joint Regional Meeting
03, 04, 06
Childhood Obesity: Why We Should be Concerned
06, 07
The Multiple Sclerosis Association of Lanka (MSAL)
08, 09
An Ageing Man Pleads
10
Nirogi Paadha (Healthy Feet)
12
Seeking the Origins of Forensic Medicine and Charting its Future
14, 16, 18, 20, 22
Sanga our Cricketing Legend
Dr. Amaya Ellawala Dr. Iyanthi Abeyewickreme Prof. Deepika Fernando Dr. Sarath Gamini De Silva
22
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Official Newsletter of The Sri Lanka Medical Association. Tele: +94 112 693324 E mail: office@slma.lk Professor Jennifer Perera MBBS, MD (Col), MBA(Wales), PgDip MedEd (Dundee), PgDip Women’s Studies(Col). President, Sri Lanka Medical Association, No 6, Wijerama Mawatha, Colombo 7, Sri Lanka.
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1
September 2015
PRESIDENT’S MESSAGE
SLMANEWS
Dear members, We have completed another busy month of work at the SLMA. We have had the regular CPD activities conducted by the SLMA: the monthly clinical meeting, the regional meeting at Ratnapura, and the CPD programmes conducted by the various SLMA subcommittees in association with other collaborating partners. We are currently finalising the corporate plan for the next five years considering measurable targets. During these deliberations the current healthcare needs of the society are being taken into account. The disease paradigms in Sri Lanka have changed resulting in an increase of the healthcare consumer expectations on quality and standards. Plans are underway by the Health Management Subcommittee of the SLMA to organize the annual career guidance seminar. This event which has gained marked popularity among junior doctors is scheduled to be held on 4th October 2015. All specialties, both clinical and non clinical, are represented at this seminar and presentations are being made by senior specialists of the respective professional bodies. Work without play is dull and SLMA is organizing a series of cricket matches, including soft ball games. The soft ball matches with different professional colleges will be held on Sunday the 25th of October 2015 at the University of Colombo grounds. I cordially invite all members to join these friendly games which will enable to build camaraderie and team spirit. The traditional cricket match with the Bar Association of Sri Lanka will be held on 21st November 2015 at the Colts Grounds. If you are willing to play, please come forward and be a SLMA team member. You can either contact the SLMA office or drop an e-mail to office@ slma.lk for further information. The SLMA Foundation Sessions will be held jointly with the Anuradhapura Clinical Society from 28th to 30th Octo-
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ber 2015. A distinguished panel of expatriate speakers has been lined up, and they will travel from UK to enrich these sessions. I extend an open invitation to all of you to join us at the Sacred City of Anuradhapura. The renovation work of the Wijerama House is continuing under the supervision of our administrative officer, Mr. Rajasingham. It is a costly affair but it has become essential in order to prevent further decay of the house, a generous donation to the SLMA by Dr. E. M. Wijerama, one of our very emi-
nent physicians. The EM Wijerama oration, conducted in honour of this great man, will be delivered by one of our Past Presidents, Dr. Sunil Epa Seneviratne during the Foundation Sessions, which is a tradition that has been followed over many years. It is my sincere request to all members to join hands with us in these numerous activities organized by the SLMA, which will strengthen the bonds and team spirit among doctors from all parts of the island. Professor Jennifer Perera
MALARIA COUNT 2015 cases to date
25
All are imported! Let’s keep Sri Lanka
malaria free
SLMANEWS
September 2015
JOINT REGIONAL MEETING OF THE SRI JAYEWARDENEPURA GENERAL HOSPITAL CLINICAL SOCIETY AND THE SLMA By Dr. Shamini Prathapan (Assistant Secretary, SLMA)
T
he joint regional meeting of the SLMA in collaboration with the Sri Jayewardenepura General Hospital Clinical Society was held on the 27th of June 2015 at the Sri Jayewardenepura General Hospital. The President of the Sri Jayewardenepura General Hospital Clinical Society, Dr. Asoka Jayasena, welcomed the gathering and delivered the welcome speech. Prof. Jennifer Perera, President of the SLMA, also addressed the gathering and extended an invitation to attend the 128th Anniversary International Medical Congress of the Sri Lanka Medical Association. The theme of the regional meeting was “New Trends in Medicine” and all speakers adhered to this theme, based on their specialty. It was well attended by medical officers attached to the Sri Jayewardenepura General Hospital and the University of Sri Jayewardenepura. A plaque was unveiled by the President of the SLMA. The first session was chaired by Dr. Chula Herath and Dr. Asiri Rodrigo. The panel of speakers comprised of Prof. Aloka Pathirana (Professor and Consultant Surgeon at the Faculty of
Medical Sciences, University of Sri Jayewardenepura), Prof. R. L. Satharasinghe (Consultant Physician, Sri Jayewardenepura General Hospital), Dr. Indira Kahawita (Consultant Dermatologist, Base Hospital, Karawanella) and Dr. Neelamani S. Rajapaksa Hewageegana (Deputy Director General of Health Services (DDG) Planning, Ministry of Health). Prof. Aloka Pathirana initiated the session with a comprehensive presentation on “Surgery in the 21st Century”. He commenced his lecture with the history of surgery, which began nearly 7000 years ago and the evolution it has undergone with significant milestones such as the discovery of anaesthesia in 1846, endoscopy in
1809 and flexible fibrescope by Harold Hopkins in 1951 to the Single Incision Laparoscopic Surgery. He stressed that today, due to further evolution Robotic Surgery is playing a key role in the field of surgery, with many advantages such as better magnification, easier and precise movements, with elimination of fulcrum effects and tremors. He also pointed out the disadvantages of this technique such as the high cost, the requirement of special operating suites and training and especially the fact that there is no long term follow up available as yet. Prof. Pathirana also informed the audience of other modalities currently in use such as augmented reality or 3D simulation; minimize bleeding by use of Bipolar dissectors, Ultrasonic dissectors and High-pressure water jets; control bleeding by surgical cellulose, Fibrin glue and Argon plasma coagulation. He concluded his lecture by enlightening the audience about a new trend in surgery, the use of Nano Robots or Nanobots.
Contd. on page 4
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SLMANEWS
September 2015 Contd. from page 3
Joint Regional Meeting... Prof. R. L. Satharasinghe in his lecture on “New Trends in Gastroenterology” pointed out that there is an increase in infections associated with contaminated endoscopes, such as metallo-beta-lactamase (NDM)-producing carbapenem-resistant Enterobacteriaceae. He also showed evidence that the efficacy of pentoxifylline for severe alcoholic hepatitis remains unclear. The diagnostic criteria for hepatorenal syndrome for the year 2015, was described. He stressed that patients with spontaneous bacterial peritonitis who develop septic shock have high mortality rates, but early initiation of antimicrobial therapy may result in improved outcomes. Another point that he spoke on was that aminotransferase levels predict relapse in autoimmune hepatitis and that there was an increasing prevalence of nonalcoholic fatty liver disease worldwide. Dr. Indira Kahawita, delivered a lecture on “Leprosy in Sri Lanka: Today and Tomorrow”. She emphasized the importance of this lecture as many health workers and the public are with the opinion that there are no cases of leprosy in Sri Lanka. Sri Lanka achieved the WHO target of elimination of leprosy as a public health problem in 1997. This meant the achievement of a national point prevalence of less than 1 case per 10,000 population. With the declaration of elimination, many health workers and the general public were left with the idea that there were no more cases of leprosy in Sri Lanka. This resulted in doctors not including leprosy in their differential diagnosis. At present, there are approximately 2000 new cases reported every year, with about 10% of children below
4
15 years of age, about 7% with visible disability and only about 40% started on treatment within 6 months of onset of symptoms. She further stressed that Sri Lanka is among the top 17 countries reporting over 1000 new cases every year. The highest burden is reported from the Western Province, while the Eastern Province is the second. She highlighted both the common as well as uncommon ways in which patients could present. The theme of the meeting was further reinforced by Dr. Kahawita who explained regarding many new strategies available for reducing the disease burden. The last lecture for the first session was by Dr. Neelamani S. Rajapaksa Hewageegana on “Communication for Understanding”. She began her lecture by saying that one size may not fit all and that although health is for all, there are many better paths to health, with people having different information needs, keeping in mind that even if they have similar behaviour it does not imply similarity in motivation. It was interesting to note that that up to 80% of patients forgot what their doctor said as soon as they leave the doctor’s room and nearly 50% of what patients do remember is recalled incorrectly. The second session started off after tea and was chaired by Dr. Lalitha Piyarisi and Dr. Shyamalee Samaranayake. The panel of speakers comprised of Dr. Duminda Samarasinghe (Paediatric Cardiologist, Lady Ridgeway Hospital), Prof. Hemantha Perera (Consultant VOG, Sri Jayewardenepura General Hospital) and Dr. Rajitha de Silva (Consultant Cardiothoracic Surgeon, Sri Jayewardenepura General Hospital)
Contd. on page 6
SLMANEWS
September 2015 Contd. from page 4
Joint Regional Meeting... Dr. Duminda Samarasinghe, started the 2nd session with a detailed presentation on “New Trends in Paediatric Cardiology: What is Cost Effective for Sri Lanka”. He singled out the challenges of new trends in interventions and continued his lecture by explaining the need of such interventions such as 3D Rotational angiography, Hybrid interventions, etc. He explained the developments of cardiology in Sri Lanka and continued his lecture by explaining the workload for cardiology in Sri Lanka and cost effective methods in cardiology. The latter part of the lecture showed the need of Cardiac Catheterization with new trends in PDA closure. After a brain storming session on Paediatric Cardiology, Prof. Hemantha Perera showed another view on maternal mortality in Sri Lanka with his presentation titled “Maternal Mortality - Where Are We Going Wrong?” Prof. Perera highlighted on our mortality indicators specially emphasizing that Sri Lanka has not reached a single digit on maternal mortality. With many demographic, socioeconomic, quality of antenatal care indicators that are higher than other
countries in the South East Asian region, he was of the opinion that it is not correct to compare our country’s maternal mortality rate with these countries in the region. He continued his lecture by explaining the modes of management that could reduce maternal deaths. He concluded by showing the barriers to clinical governance and by explaining how clinical governance can be sustainable. This was followed by Dr. de Silva’s presentation on “Keyhole Cardiac Surgery”. He emphasized that the trend is towards minimally invasive techniques and that other specialties have embraced the method with great success and thus the need for keyhole surgeries in cardiac surgery. He explained the indications for Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) and explained the procedure. He highlighted the benefits
of MIDCAB which are less pain, less infection, less bleeding, faster recovery, faster wound healing, faster return to normal activity and better cosmetic results. He underlined that keyhole surgeries are not only performed for coronary bypass but are also used for aortic valve surgeries, ASD closures, arrhythmia surgeries and even for heart failure. He concluded the session by emphasizing that hybrid cardiac procedures are the way forward. The vote of thanks was given by Dr. Shyama Subasinghe, Secretary of the Clinical Society of the Sri Jayewardenepura General Hospital, which was followed by a fellowship lunch. This meeting was sponsored by Kalbe International, A. Baur & Company Pvt. Ltd., Lifeline Pharmaceuticals Pvt. Ltd., CIC Holdings PLC, Ashman Associates, Harcourts Pvt. Ltd. and SMM Halcyon Pvt. Ltd."
CHILDHOOD OBESITY: why we should be concerned Pujitha Wickramasinghe Professor in Paediatrics Department of Paediatrics, University of Colombo
Childhood obesity is well known to be the leading risk factor for the development of Non Communicable Diseases (NCD) later in life. Although most of the NCD’s develop during adulthood, evidence is quite clear that most of the pathological processes begin during childhood. Obesity which is accumulation of fat in the body with adverse health outcomes is diagnosed
6
using Body Mass Index. A percentage fat mass of >25% in males and >32% in females is considered as a prudent cutoff. In Sri Lankan children percentage fat mass associated with the development of metabolic syndrome is determined to be 28.6% for boys and 32.6% for girls (Wickramasinghe et al, Under-review). BMI for Age >+2SD of the WHO 2007 charts (available in the CHDR) is used as the cutoff to diagnose obesity in children. Childhood obesity could affect a child physically as well as psychologi-
cally. Physically it could affect any organ or part of body from head to toe, and psychologically it could lead to bullying, alienation, lack of friends and depression. Some of the most important metabolic complications that have long term consequences are metabolic syndrome (MetS) and non alcoholic fatty liver disease (NAFLD). The prevalence of metabolic syndrome among obese Sri Lankan children is about 20%, but a large population of obese children has at least one or two abnormal metabolic components. Contd. on page 7
SLMANEWS
September 2015
Contd. from page 6
Childhood obesity... If obesity is not corrected more and more adverse metabolic components gather with more and more children developing metabolic syndrome, thus increasing the risk of cardio vascular disease later in life. Similarly NAFLD incidence is rising with more than 20% of obese children developing non alcoholic steato-hepatitis (NASH). NASH is predicted to be the commonest liver disorder in children which could progress to cirrhosis and hepatocellular carcinoma in early adulthood. Physically disfiguring acanthosis nigricans occurs as a thick dark belt of skin around the neck, axilla and cubital fossa (also in groin) and is related to the degree of insulin resistance. With reduction of weight (reduction of adiposity), degree of insulin resistance will reduce. This leads to reduction of acanthosis as well as most of the metabolic derangements.
Management of childhood obesity involves taking food comprising all food groups in appropriate proportions (starch, vegetables, fruits, dairy products and animal food) with limited consumption of sugar, fat and salt. The amount that should be taken could be guided by food based dietary guidelines published by the Ministry of Health. Water intake has to be increased while reducing sweetened beverages as much as possible. High concentrate fruit juices are shown to increase insulin resistance due to high fructose content. Therefore whole fruit squash should be taken (with fiber) with no added sugar. Reducing the portion size of meals is the most important. Children should be given every opportunity to engage in physical activity and screen time has to be restricted to not more than one hour each day.
Excessive eating, decreased physical activity and increased sedentary behaviour are the direct contributors to the development of childhood obesity. High calorie diets of large portion sizes with low vegetable and fruit content leads to development of obesity. Today children have more opportunities to spend time sedentarily. Most children have very high screen times, ie spend time viewing television, are engaged in computer games or in operating smart phones and tablets.
Prevention of NCD’s has to begin from early infancy if not from preconception. More than 75% of obese children become obese adults while less than 10% of normal children end up as obese adults. Therefore the prevention of adult obesity, which is a major risk factor for the development of NCD, has to begin early in life. David Barker hypothesized that low birth weight children exposed to an adverse environment later in life, develop NCDs. This adverse environment could be the nutrition transition that occurred with the socioeconomic transition as there has been a rise in incidence of coronary heart disease and diabetes mellitus over the recent past especially in middle income countries. Further research has shown that full term low birth weight babies having accelerated growth in early life, leads to the development of NCD later in life.
This has contributed immensely to the high physical inactivity. This is further aggravated by their ‘laziness’ which is mostly due to the physiological hindrance to physical activity caused by undue increase in core body temperature. Due to the thick fat layer, children cannot dissipate the heat generated inside their body by exercise, thus compelling them to stop continuing physical activity. Physical inactivity is also increased due to lack of space and excessive protection given by parents to their children.
Therefore it is quite clear that if NCDs’ are to be prevented, it has to begin from a much younger age if not during the antenatal period, by achieving a good birth weight and thereafter
maintaining an appropriate growth rate. Much analysis has shown that children who have a rapid growth during early life are more prone to obesity later in life with an increased risk of developing NCDs. This can be seen quite clearly when low birth weight babies gain weight; they mainly do so by accumulation of fat rather than having growth in all compartments of body composition. Increased fat mass leads to the development of obesity. Obese children have more fat cells than their lean counterparts. During weight losing programmes, fat deposited within adipose tissues decrease, but there is no decrease in the number of fat cells. Therefore when someone is not strict about his/ her diet, they could easily become obese again, thus the majority of obese children become obese adults. Therefore many days of fasting could be lost by few days of feasting. This is the reason why many late interventions to reduce weight are not successful and not sustainable. Therefore prevention of NCDs has to take a life course approach and interventions at every stage of life are equally important. Childhood obesity is on the rise and related metabolic complications begin from a young age. The most important trigger to develop NCDs appears to be the rapid post natal growth in an individual destined to develop NCD later in life. Therefore in order to prevent NCD, the ideal would be for a healthy mother to give birth to a baby with a desirable birth weight (between 2.5-3.5kg) who is provided with proper nutrition, and allowed to grow along the birth centile, maintaining the same trajectory of growth determined by the birth weight, which is guided by close growth monitoring, irrespective of the state of birth weight (low or normal).
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SLMANEWS
September 2015
THE MULTIPLE SCLEROSIS ASSOCIATION OF LANKA (MSAL) Dr Enoka Corea President MSAL
T
he Multiple Sclerosis Association of Lanka (MSAL) is an association bringing together persons with MS, their doctors, caregivers and other well wishers with a view to promoting optimum health and improving the lives of persons with MS. MSAL was started in 2006 by Dr. Hithaishi Weerakoon and is affiliated to the Multiple Sclerosis International Federation. It is a voluntary organization funded by donations and fund raising activities of the association. The main aim of the association is to provide support to persons living with MS. Activities of the Association include providing moral support to patients and caregivers through home visits, organizing talks by experts to help patients understand and cope with their disease and by providing financial assistance, where necessary, for wheelchairs, physiotherapy, purchase of drugs and disposables, for travel to MS meetings and for daily living especially in cases where the bread winner has been affected. The association serves as a support group for patients and their families where they can share their day to day problems and solutions. Through the association, people round the country are made aware of Multiple Sclerosis and that something can be done about preventing permanent disability. The association hopes to raise funds to build awareness, pay for home based physiotherapy, train nurses, attendants and family members, provide rehabilitation accessories, counseling, and support and eventually run a residential home. MS meetings are held in Colombo and Kandy. These meetings provide an opportunity for MS patients to share their experiences and coping mechanisms with other patients and are open to anyone interested in MS. We have had many speakers addressing our meetings includ-
8
ing international specialists in MS, neurologists, urologists, speech therapists, physiotherapists, social workers, occupational therapists, counsellors and nurses, including nurses specializing in rehabilitation.
Analysis of some MS Patients in Sri Lanka This analysis is based on data available on 56 MS patients out of about 104 MS patients listed with the Multiple Sclerosis Association of Lanka (MSAL).
on, using the funds of the MSAL and with the help of other organisations such as the Inner Wheel Club of Colombo Midtown. Since its registration on 19 September 2006, the Multiple Sclerosis Association of Lanka has built a membership of over a 100 patients from all over the island, their care givers, family members, doctors and well wishers. Available data show that the majority of patients are in the middle aged groups when diagnosed. It is seen that the average age when MS patients get diagnosed is 34 years, with a minimum of 6 years to a maximum of 66 years.
The MS patients whose detailed information is available with MSAL are distributed in 13 districts, with the majority 52 percent from Colombo and 16 percent from Kandy, where the organization is maintaining branches. Expanding the services to patients in other districts with adequate publicity is needed.
We have published articles on MS and interviews with MS patients in the newspapers, in both English and Sinhala, in our effort towards creating greater public awareness and are hoping to have some publicity in the Tamil language newspapers as well. The latest venture of the association is a programme to conduct a needs assessment of each patient in their own home environment so as to generate recommendations for patient care, physiotherapy, assistive devices and alterations of home infrastructure needed to improve the quality of life of MS patients and their caregivers. The needs assessment is carried out by a trained occupational therapist and his recommendations have been acted
The MSAL would like to invite all persons with MS to join the MSAL and contribute to its activities. We will be grateful if doctors who care for MS patients would inform patients of this association and its activities and refer them to the association or send us the names and addresses of patients. MSAL can be contacted at msalinfo@ sltnet.lk or MS Association, 144 Vipulasena Mawatha, Colombo 10, or at the following number 0777319333. More information can be found on our website www.mssrilanka.com. Contd. on page 9
SLMANEWS
September 2015
Contd. from page 8
The Multiple Sclerosis... etc. The association welcomes donations which will be used to further its’ objectives. Donations could be made to The Multiple Sclerosis Association of Lanka, Commercial Bank A/c Number 1100037477.
When social status of the patients considered it is seen that 64 percent of them are married, 25 percent single, 5 percent divorced and 4 percent widowed. Nearly two third of the patients (62%) are not wheel chair bound but some of them use a walker or walking stick when going out. Bedridden MS patients are about 4 percent. Wheel chair bound patients are about 30 percent. (Data analysis, tables and charts by Mr Karunasena Jayasinghe) The proportion of female MS patients is as much as twice that of male patients. Only one fourth of the patients are reported to be working. Considering gender disaggregation, it is seen that among female patients only 16 percent are working while 44 percent of male patients work. Only one fifth (20%) are the main bread winners of the respective families. Again the gender disaggregation indicates that among female patients only 5 percent are in this category while 50 percent of male patients are the bread winners.
“Getting the MoSt out of life�
The MSAL is a voluntary organization funded by donations and fund raising activities. Fund raising activities are held regularly and include benefit shows, movies, jumble sales, sale of Christmas cards and key tags
9
SLMANEWS
September 2015
AN AGEING MAN PLEADS The smallest print I easily read Aid of lenses there is no need Roam in the dark I'll give the lead Never grow old, that is my breed
I look too young my patients told Refused drugs, feet getting cold To dye the hair white I was bold Now hair is grey, but I am not old
The ageing men with raven hair Keep on dyeing with utmost care Forget the ritual don't you dare Overnight greying, a nightmare
Till early morning I sleep well Ready to rise to an alarm bell Waterworks fine, jets like hell Hearing is good, so is smell
Legs are strong, back doesn't ache I can sprint, or even do the shake Don't feel tired for the stress I take. Aren't I young, for heavens' sake?
Benefits of ageing now I mention Time has come, deadline for action Still feeling fit to continue function Retire early, for a higher pension!
Yet I am always ready for old age To leave in grace the center stage In good trim my every appendage Keep with care my youthful image.
Dr. Sarath Gamini de Silva Written years ago when a higher pension was offered to those retiring early and when the writer was much younger!
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SLMANEWS
September 2015
NIROGI PAADHA (HEALTHY FEET)
P
roblems of the diabetic foot require special focus on secondary prevention through the detection of high-risk feet. The unacceptable outcomes of this complication include chronic wounds, prolonged hospital stay, disability and limb loss. A point prevalence study at the National Hospital Colombo in 2006 revealed that 40% of hospital admissions of diabetics was due to foot complications that required inward care for an average of 42 days per patient. This aspect of diabetes care in Sri Lanka is sub-optimal. Patient education on an islandwide basis was initiated by Nirogi Lanka through capacity building of healthcare workers, especially nurse educators in 2009. Phase 2 of Nirogi Lanka prioritized further training of medical officers in parallel with community empowerment. The need for a coordinated islandwide intervention of low-cost footwear was pioneered by the SLMA with the focus on health education regarding daily care of the diabetic foot. A national guideline for the management of Diabetic Foot care was compiled in 2013. In order to pilot the implementation of this guideline, the Ministry of Health chose ten specialist centres committed to a dedicated service for Diabetes supervised by Consultant Endocrinologists. DIABETIC FOOT CLINICS to provide holistic care in order to reduce amputations among diabetics was initiated by the Ministry of Health along with the establishment of databases. This model is expected to expand to all District General Hospitals of the country within the next few years. Teaching Hospitals that have established
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these services include Anuradhapura, Jaffna, Kurunegala, Galle, Kandy, Colombo-South and the National Hospital Colombo. Technical support such as hand held Doppler machines were distributed to these centres with locally developed monofilaments and other related equipment for foot care along with IEC Materials developed by the NIROGI Lanka Project. The manufacture of low cost diabetic footwear was spearheaded by Dr. Palitha Karunapema (Consultant Community Physician and Director Ragama Rehabilitation Hospital). Training of Prosthetic & Orthotic technicians was initiated through the Sri Lanka School of Prosthetics and Orthotics (SLSPO), Ragama. 'Training of trainers' programmes in India were arranged for experienced technicians from SLSPO and the D. Samson & Sons (Pvt) Ltd (DSI Group of Companies). Transfer of knowledge and skills to other technicians was arranged by the Ragama Rehabilitation Hospital in collaboration with the Sri Lanka Association of Prosthetics and Orthotics (SLAPO). A Memorandum of Understanding was signed between the SLMA and DSI in 2013, followed by the production of low-cost Diabetic shoes by DSI. This novel shoe line commenced in 2014 and was re-launched under the brand name ‘NIROGI’ on 14th August 2015. Prof. Jennifer Perera (President SLMA), Mr. Nandadasa Rajapaksa (Chairman DSI) and Prof. Chandrika Wijeyaratne (Chairperson NIROGI Lanka Project), were present for this momentous occasion. Trilingual health education material on "How to Care for your Feet" is provided for every customer free of
charge at the point of sale. It is noteworthy that the number of Diabetic shoes purchased in the first seven months reached nearly 4500 in over fifty showrooms islandwide. We are happy and proud that the SLMA has initiated this new trend in health education through the shoe industry. The NIROGI Lanka Team is engaged in providing on-site foot screening and education facilities for the general public, including Diabetes Day activities at Kolonnawa in conjunction with the NIROGI Diviya. The collaboration between Paadha and Diviya has helped to incorporate Health Promotion for diabetic foot care. Over 1600 community based patients were screened in NIROGI Diviya of whom a large proportion of high risk patients were detected and referred to specialist centres. State of the art equipment for early diagnosis of vascular complications of chronic diabetes was recently purchased for the National Hospital. The use of sophisticated equipment alongside continuation of the national project will further enhance service, training and research in the field of Diabetic Foot Care.
SLMANEWS
September 2015
SEEKING THE ORIGINS OF FORENSIC MEDICINE AND CHARTING ITS FUTURE Dr. Sameera Anuruddha Gunawardena Senior Lecturer and Specialist in Forensic Medicine University of Colombo
“I’ll get the vaginal swabs done and start on the autopsy today itself” says the young forensic protégé eager to please his mentor.
Prologue
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ To most of you, this scenario would be a familiar depiction of the mystifying abilities of the forensic expert portrayed through numerous TV shows, films and crime fiction novels. In reality however, forensic practice is not as dynamic as depicted in these shows and does not always give rise to the breath-taking deductive skills portrayed by these characters. Many are surprised at how mundane actual forensic practice is. In fact more than three quarters of the cases are actually sudden deaths where in almost all of them, the cause follows a natural event. Violence and crime are only a handful of the workload of a forensic practitioner.
The door opens to reveal a dimly lit room. The faint light falls on the silhouette of a bed lying askew in the middle of the room. The bed sheet is drawn back and falls over the edge onto the floor. The pillows are scattered on the ground. Two gentlemen in white overalls with gloved hands, stand at the edge of the door surveying the room. One considerably older than the other. They duck under the black and yellow vinyl strip reading “crime scene - do not cross” and enter the room. “Caucasian female approximately 25 years old, lived alone, didn’t report to work this morning. Sister checked on her at around 1500 this afternoon and found this….” reads the younger gent, summarizing the case history from the file in his hand. “Her neighbour saw her last night coming home with some guy. Says she looked drunk or high. Saw them go into the room and didn’t hear anything after that” His senior partner squats beside the body and carefully examines the arborescent pattern of green lines extending across her arms and chest. “He’s lying! She’s been dead for 24 hours at least. Look at the veins, they’re already green.” He then looks at the large gaping wound running along the side of her neck and studies the angle and disposition. “There are definitely two slashes even though it looks like one. From the blood spatter I’d say the carotid is cut. That’s an arterial spurt. She’s broken two finger nails on her right hand. Must have put up a fight. Tell the cops to check if the neighbour has any scratch marks on his body”
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Forensic medicine distances itself from other medical specialties due to numerous reasons. Unlike the clinician or surgeon, the forensic practitioner cannot always have the patient’s best interest at heart. His primary goal is not the treatment or relief from suffering but ensuring that justice prevails. Whilst most other specialties race against time to preserve life, the forensic practitioner usually takes over after all hope for life is lost. This article is not an attempt to entice or encourage any reader to take up forensic practice nor is it intended to glorify forensic medicine. It is merely a reflection on the development of forensic medicine with time and an exploration on how forensic medicine could evolve to serve a higher purpose within the medical sphere.
Seeking the Origins Quoting Sir Sydney Alfred Smith, regarded by many as a legend in forensic medicine and famed in Sri Lanka
for his involvement in the enthralling Sathasivam murder case; “It is justifiable, no doubt, to contend that Medicine originated in the very dawn of human history, when first a cry of pain prompted a fellow-being to experiment with simple forms of assuagement. Similarly, the Law may be said to have its origins in the earliest sanctions which were doubtless applied to disturbers of the peace in the most primitive communities. We cannot begin to think of forensic medicine as an entity, however, until a stage of civilization is reached in which we have, on the one hand, a recognizable legal system, and on the other an integrated body of medical knowledge and opinion. Furthermore, we cannot know much about such matters until some means of recording them has been achieved, and our earliest records take us back only about five thousand years1.” In tribal civilizations, the roles of healer and prosecutor were entrusted to a single individual whose judgment would be unquestionably accepted by the community. One can only imagine the dangers of a single person wielding such power. With the development of more intricate and cultured communities, these roles are likely to have separated out into the medical and legal fractions each forming their own codes of conduct2. Historians believe that the Hammurabi Code dating back to 2200BC is the earliest example of a fundamental legal system within ancient civilizations3. The code said to have been enacted by the sixth Babylonian king Hammurabi also includes a legislation that relates to the topic of medical malpractice. Interestingly even in such early periods in history, liability for improper and negligent medical care was established and penalties ranged from financial compensation to cutting off a surgeon’s hand!4. Contd. on page 16
SLMANEWS
September 2015 Contd. from page 14
Seeking the origins... Egypt, being the earliest civilization known to have an elaborate record of their life and culture provides the earliest evidence of a medicolegal expert; a physician who was officially designated to examine those whose deaths were unforeseen and those where poison was suspected. During the initial periods these examinations would only have been done superficially as dissection of a human body was considered a sacrilegious act5. It is believed that King Ptolemy I who ruled Egypt during 323-283BC, broke this traditional concept and permitted dissections in humans. He even established universities in Alexandria to encourage the study of the human body through dissection6. By then Alexandria was already famous as a hub of learning. Scholars from other regions of the world where dissections were not permitted would come to Alexandria to learn this revolutionary concept7. They later returned to their respective countries with the intention of spreading their new found knowledge. The decline of Egypt coincided with the expansion of the Roman Empire and the name Julius Caesar stood out as arguably the most famous of the Roman Emperors. Through the assassination of Julius Caesar arose one of the earliest recorded medicolegal autopsies. A surgeon by the name of Antistius examined Caesar’s body and claimed that out of the twenty three stabs, only one; the stab on his left chest between the 2nd and 3rd rib bones, was fatal8,9,10. It is reported that he further concluded this wound to have been caused specifically by the stab inflicted by Senator Gaius Casca, an opinion which would hold very poor ground in modern courtrooms. Given that human dissection was still outlawed, it is unlikely that Antistius actually performed a full autopsy on Caesar’s body. It is more likely to have been an external examination and superficial exploration of the stabs using
16
perhaps a probe. Nevertheless, this ‘autopsy’ is the first recorded instance where a medical expert provided his opinion in a homicide investigation. Some believe that the word ‘forensic’ arose from this incident which in Latin means “before the forum”11. History shows a strong rivalry between science and religion. Knowledge gained through human dissection threatened many of the existing theological concepts and therefore religious establishments retaliated by depriving the academia of the opportunity to further explore the human body. Diseases and suffering were promoted as resulting from supernatural involvement or atonement for sins. Prayer was advocated over other forms of therapy. Religious extremists portrayed all other forms of healing as heathenism. Dissections on the human body were soon banned and only animal cadavers could be studied. Similarly the clergy also took over the role of investigating suspicious and unnatural deaths12. As was evident in the massive witch hunt that took place during the European plague13, sudden deaths and even accidents were sometimes believed to be the result of witchcraft and curses for which ‘offenders’ were then punished14. It was almost a civilized reenactment of tribal justice. Records exist of a strange and peculiar form of test termed “cruentation” in murder trials. The dead victim’s body was laid on the ground and the accused person was made to approach the body calling the victim’s name and later stroke the mortal wounds with his hands. If the wounds began to bleed, or if foam appeared at the deceased’s mouth this was regarded as a sign of divine intervention which confirmed the accused to be the murderer!15 Despite the dominance of religious establishments, many scholars still continued their quest to decipher the human body. One of the most famous physicians to arise during this era was
the Greek physician, Claudius Galen, whose extensive studies on primates popularized medical literature. He served as a physician in the Roman Empire from 162 AD. His work reinforced ancient Aristotle and Hippocratic teachings that disease was an imbalance of four elements or ‘humours’; blood, phlegm, yellow bile and black bile16. His work persisted through the ages and became the stepping stone to advancement of medicine. Interestingly, both Christianity and Islamic religions did not antagonize his work since his teachings maintained the concept of a ‘creator’17. It wasn’t until the Renaissance period around the 14th century, that scholars were finally at liberty to study the human body without having to face the wrath of religious establishments18. Andreas Vesalius was perhaps the most fervent of these scholars and performed numerous dissections under the patronage of the Roman Emperor Charles V. Often regarded as the father of modern Anatomy, he ascended to the rank of Professor of the University of Padua. His book on “De humani corporis fabrica (On the Fabric of the Human Body)” is perhaps still regarded as the first comprehensive guide to Human Anatomy19. Many scholars continued to study the human body and immortalized themselves in the medical domain. Gabrielle Falloppio, William Harvey, Francis Glisson are some of those famous names that resonate in anatomical texts. Their findings extended beyond the field of medicine and also enchanted many of the renaissance artists including the great Leonardo da Vinci and in later years Michaelangelo who used these dissections to study the human form more elaborately20. In return these artists provided wonderful illustrations for many of the anatomical textbooks of this era. This fusion of scientific exploration and art symbolizes the profound fecundity of the mind during the Renaissance period21. Contd. on page 18
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SLMANEWS
September 2015 Contd. from page 16
Seeking the origins... Almost two centuries later Giovanni Batista Morgagni followed in the same esteemed rank in the same institution as Vesalius. He too showed a keen interest in the dissection of the human body but unlike his predecessor, he focused on exploring the abnormal changes in the body. Until then, very few literary works were available that spoke of the alterations in internal organs and tissues following disease22. It is Morgagni’s work that firmly established the domain of morbid anatomy which indeed is the main cornerstone of what we call Pathology today. The interest grew exponentially. Physicians began to realize that by studying the bodies of those that died of disease, one could better comprehend the nature and cause of the disease itself. The signs and symptoms were now explainable. The course of the illness could now be predicted. Treatment options became clearer. To paraphrase Sir William Harvey; “… accumulating knowledge of normal and morbid anatomy through dissecting the human body not only led to a better understanding of nature, but also defined the identity of the people who engaged in this activity.”23 Ancient chronicles provide a glimpse of well planned legal processes within the pre-colonial Sinhalese kingdoms. There has been in existence a well structured system that dealt with administering justice. With the king being the ‘supreme’ administrator of justice, powers were delegated to Royal courts, comprising of Royal officials namely Adigars, Disaves, Korales etc and then to smaller organisations such as Gamsabhava, Ratasabhava which undertook legal issues at lower levels. Among these organizations was a tribunal by the name of “Sakki Balanda”, formed by a group of prominent individuals within a given area, who were required to investigate into sudden and possibly violent deaths24. It is very likely that many among these prominent individuals were native physicians or Ayurvedic physicians
18
whose medical expertise would no doubt have played a key role in their judgments. However no religious or archaeological records in Sri Lanka have indicated any form of human dissection during these early times.
Charting the future The ease at which we study medicine today does not reflect the sacrifices made by these great patrons who laid the foundations of this wonderful science. It is sad that human dissection no longer reflects the sanctity and fascination experienced by these scholars of yore. Although it is an ideal opportunity to learn, study and reflect on rare and complex diseases and even their management, practicing clinicians rarely get involved in pathological or judicial autopsies and there is a declining attitude towards autopsies among health professionals25,26,27 Perhaps one of the main reasons for this lack of enthusiasm is the limited resources that are allocated to forensic work. Accepted recommendations are that mortuary facilities should maintain a Biosafety Level 3 environment and should be prepared to deal with even biohazard level 4 situations28,29,30. Sri Lanka is yet to have such a mortuary facility. The bulk of the autopsy cases within the country are done in hospital based mortuaries. Very few of them have facilities for microscopic study. Obtaining special stains or imunohistochemical studies are virtually impossible. The facilities for quantitative assessment of biochemical parameters, drug levels and metabolic abnormalities are extremely limited. Proposals and requests to upgrade these facilities often fall on deaf ears. To a health policy maker there is no observable direct link between autopsies and health promotion. Rather the primary beneficiaries of forensic services are the courts and other legal embodiments such as departmental inquiries and medical boards. The National Maternal Mortality Review is
perhaps the only health related forum to which the forensic practitioners directly provide their expertise. Therefore the state based health authorities see no purpose in improving the facilities for forensic medicine. This is a vicious circle that has been plaguing forensic practice in this country for a long period now. Without proper facilities for a thorough and comprehensive investigation, forensic practitioners cannot provide unequivocal answers to issues raised. Clinicians and to an extent the public thus tend to lose faith in the necessity and value of the autopsy process. Following the Gandhian ideology where in order to elicit change in others one must first change oneself, it is perhaps time for us forensic experts to rethink our role. At present the death investigation system of our country whether it is a sudden natural death or death following violence, focuses heavily on identifying or excluding culpability or any litigious components related to the death. It does not seek to provide a holistic picture of the deceased individual. Sometimes pathological conditions are identified that could significantly affect the living relatives; transmissible diseases such as tuberculosis, HIV, meningococcal meningitis or, hereditary conditions such as thrombophilias, heart diseases, malignancies. Even in such cases our death investigation system is not geared to enforcing a preventive care package for the next of kin. Similarly, when deaths from medical negligence arise, the prime focus is litigation and compensation rather than identifying and correcting the flaws in the health delivery system. Similarly there is complete dissociation between the legal death investigation process and the health statistic monitoring process. Sudden deaths or violent deaths that occur outside the involvement of hospitals are directly investigated through the inquirer into sudden deaths or the magistrate. Contd. on page 20
SLMANEWS
September 2015 Contd. from page 18
Seeking the origins... These deaths may then be directly brought to the forensic practitioner for autopsy. Even though these autopsies take place within the hospital settings there is no formal process of collecting these data for mortality statistics. Even in ward deaths that require inquests, the hospital authorities have no formal procedure to receive feedback from the investigating authorities. Forensic practitioners themselves do not provide detailed reports back to the hospital staff and as previously mentioned only the Maternal Death Review demands the forensic practitioner’s input as an essential requirement. In all other cases feedback from the forensic practitioner is mostly limited to scribbling the cause of death on the first page of the Bed Head Ticket. Today medicine is gifted with technological support that transcends our perceptions into sub-atomic levels. Imagine the mysteries that would have been unraveled if scholars like Galen or Morgagni were provided with such technology. Medicine could be taken to a whole new dimension. Forensic practice in Sri Lanka provides the golden opportunity for in-depth analysis into the human body with very few restrictions, yet this facility is grossly underutilized. Perhaps it is because the role of the forensic practitioner has been narrowed towards that of a medical investigator and not towards health advocate or researcher. There have been accusations that medical progress in areas such as cadaveric organ transplantation, molecular genetic research has been impeded by the steadfast legal procedures within the death investigation process. Forensic practitioners have been accused of basing their opinions on outdated knowledge and personalized experience rather than evidence based information. The veracity of these allegations is arguable. Nevertheless, it is clear that we need to regain the confidence of the medical fraternity and market our role as a guiding force in medicine. More than half a century
20 14
ago, Professor G S W de Saram in his capacity as Professor of Forensic Medicine conducted a study on the temperature cooling of dead bodies and how that can be used to determine time since death. This was a formidable study which provided one of the earliest population studies which were later used to develop the globally accepted temperature method in assessing time since death. Since then, very little pioneering work has arisen from forensic practice in this country. Cadavers are a poorly-utilised resource in research and experimental studies31,32. The fascination appears to have shifted from the human body towards complex artificial machines with intricate technologies. Hospitals invest millions in equipment like high definition radiographic scanners, sequential multiple analysers and laser clot blusters which are programmed to detect pre-identified patterns and treat accordingly. But it should be borne in mind that despite their sophistication these machines are only capable of confirming or excluding facts that we already know how to look for whereas the human body has always been the treasure trove of new information. The more deaths we investigate the more we perceive the frailty of the fabric of human life and ironically, the more answers we find, the more questions we get. It is time we realize that we have still only chartered the surface of this vast ocean of the human body and there are still myriads of crevasses, abysses, mysteries and secrets waiting to be explored by newer generations of forensic experts. At the entrance of the Institute of Forensic Medicine and Toxicology formerly referred to as the Office of the Chief Consultant Judicial Medical Officer, hangs a board; it refers to a Latin quote from Morgagni translated into English; “Let conversation cease; let laughter flee…
This is the place where death delights to help the living” Allow me to emphasize….where death delights to help the living! Smith, S. (1951). History and development of forensic medicine. British medical journal, 1(4707), 599.
1
Smith, S. (1954). Development of Forensic Medicine and Law-Science Relations, The. J. Pub. L., 3, 304.
2
Wecht, C. H. (2005). The history of legal medicine. Journal of the American Academy of Psychiatry and the Law Online, 33(2), 245-251.
3
Bal, B. S. (2009). An introduction to medical malpractice in the United States. Clinical orthopaedics and related research, 467(2), 339-347. 4
Finkbeiner, W. E., Connolly, A., Ursell, P. C., & Davis, R. L. (2009). Autopsy pathology: a manual and atlas: expert consultonline and print. Elsevier Health Sciences.
5
Choo, T. M., & Choi, Y. S. (2012). Historical Development of Forensic Pathology in the United States. Korean Journal of Legal Medicine, 36(1), 15-21.
6
7
Von Staden, Heinrich. "The discovery of the body: human dissection and its cultural contexts in ancient Greece." The Yale journal of biology and medicine65.3 (1992): 223. Fisher, R. S., & Platt, M. (1980). History of Forensic Pathology and related laboratory sciences. Spitz WU, Fisher RS. Medicolegal Investigation of Death. 2nd Edition. Springfield: Charles C Thomas.
8
Gradwohl, R. B. H., Camps, F. E., Robinson, A. E., & Lucas, B. G. (1976). Gradwohl's legal medicine. J. Wright.
9
Hirt, M., & Kováč, P. History of Forensic Medicine.
10
11
http://bambooinnovator.com/2014/03/16/ autopsy-report-on-julius-caesars-deathgave-rise-to-the-term-forensic-in-latinwhich-means-before-the-forum/ Butler S. Forensic Medicine in Medieval England. Taylor and Francis 2015 Contd. on page 22
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September 2015 Contd. from page 20
Seeking the origins... Sidky, Homayun. Witchcraft, Lycanthropy, Drugs and Disease: An Anthropological Study of the European Witch-Hunts. Vol. 70. Wipf and Stock Publishers, 2010.
liam Harvey, dissection, and dispassion in early modern medicine." Vesalius: acta internationales historiae medicinae 8.2 (2002): 45-52.
13
Wecht, Cyril H. "The history of legal medicine." Journal of the American Academy of Psychiatry and the Law Online 33.2 (2005): 245-251.
14
Brittain, R. P. (1965). Cruentation: In Legal Medicine and in Literature. Medical history, 9(01), 82-88.
15
Singer, Charles. "Galen as a Modern." Proceedings of the Royal Society of Medicine 42.8 (1949): 563.
16
Shoja, Mohammadali M., and R. Shane Tubbs. "The history of anatomy in Persia." Journal of anatomy 210.4 (2007): 359378.
17
Malomo, A. O., O. E. Idowu, and F. C. Osuagwu. "Lessons from history: human anatomy, from the origin to the renaissance." Int. J. Morphol 24.1 (2006): 99-104.
18
Silverman, M. E. (1991). Andreas vesalius and de humani corporis fabrica.Clinical cardiology, 14(3), 276-279.
19
Botega, N. J., et al. "Attitudes of medical students to necropsy." Journal of clinical pathology 50.1 (1997): 64-66.
25
Loughrey, M. B., McCluggage, W. G., & Toner, P. G. (2000). The declining autopsy rate and clinicians' attitudes. The Ulster medical journal, 69(2), 83.
26
Payne, Linda. "" With much nausea, loathing, and foetor": Wil-
23
Will Srilankan cricket ever be the same?
Hailing from Kandy’s Trinity famed for its education He matured fast as a cricketer to represent the nation Honing his skills with each passing year In batting or wicket keeping he had no peer For the national team he was an automatic choice The selectors agreed all in one voice Leading by example he inspired the team
Scoring centuries with ease without any trouble
Sharma, B. R., & Reader, M. D. (2005). Autopsy room: a potential source of infection at work place in developing countries. American Journal of Infection Diseases, 1(1), 25-33.
29
31
Adams E W. "Founders of Modern Medicine: Giovanni Battista Morgagni.(1682-1771)." Medical library and historical journal 1.4 (1903): 270.
In golden letters he etched his name
Nolte, K. B., Taylor, D. G., & Richmond, J. Y. (2002). Biosafety considerations for autopsy. The American journal of forensic medicine and pathology, 23(2), 107-122.
28
Park, Katharine. "The criminal and the saintly body: autopsy and dissection in Renaissance Italy." Renaissance quarterly (1994): 1-33.
22
That brought Srilanka everlasting fame
And therefore was held in highest esteem
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21
Sanga our cricketing maestro retired from the game
Charlton, R. (1994). Autopsy and medical education: a review. Journal of the Royal Society of Medicine, 87(4), 232-236.
27
Malomo, A. O., O. E. Idowu, and F. C. Osuagwu. "Lessons from history: human anatomy, from the origin to the renaissance." Int. J. Morphol 24.1 (2006): 99-104
20
22
Cooray, L. M. (1992). An introduction to the legal system of Sri Lanka. Lake House Investments.
24
Sanga our cricketing Legend
Nolte, Kurt B., et al. "Medical examiners, coroners, and biologic terrorism."Morbidity and mortality. MMWR Recomm Rep 53 (2004): 1-27. King, A. I., Viano, D. C., & Mizeres, N. (1995). Humanitarian benefits of cadaver research on injury prevention. Journal of Trauma and Acute Care Surgery, 38(4), 564-569. Cornwall, J., & Stringer, M. D. (2009). The wider importance of cadavers: Educational and research diversity from a body bequest program. Anatomical sciences education, 2(5), 234-237.
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In the international scene he made his mark Earning well deserved praise as a bright spark His prowess with the bat was truly remarkable While being an active player, a lecture to deliver A rare honour – ever bestowed before? – never! In the Mecca of cricket after his lecture on “Spirit of Cricket” His fame as an orator soared as a rocket The ICC Chairman described him as a legend of the game And ‘little master‘ Sunil Gavaskar of everlasting fame Added to tributes and accolades earned by Sanga Our cricketing ambassador of the game as ‘real Mega’
Having agreed to play county cricket before retirement We presume it will be less stressful than international However the county will be expecting Sanga’s usual commitment And hope that it satisfies his needs as a professional Wherever and whatever he does we wish him well We expect unstinted contribution to county as well Even after retirement may he live up to expectation And confirm the fact that he is worth more than the reputation
Dr. Nanda Amarasekara Colombo
SLMANEWS
THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION
If undelivered return to : Sri Lanka Medical Association. No. 6, Wijerama Mawatha, Colombo 7 Registered at the Department of Post Under No: QD/42/NEWS/2015