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October 2015, VOLUME 08, ISSUE 10
THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION
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3rd Clinical Nutrition Meeting
The Death Penalty
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Current Specialist Practice
Malaria Count 2015
Child Safety Week 2015
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CONTENTS
Page No.
Cover Story
SLMANEWS
THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION
October 2015, Volume 8, issue 10
3 Clinical Nutrition Meeting
03, 04, 06
rd
SLMA News Editorial Committee-2015 Editor-In-Chief: Prof. Sharmini Gunawardena
News
Committee:
President's Message
02
Annual General Meeting
02
3rd Clinical Nutrition Meeting SLMA Dance 2015
03, 04, 06
07
Dr. Amaya Ellawala Dr. Iyanthi Abeyewickreme Prof. Deepika Fernando Dr. Sarath Gamini De Silva
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The Death Penalty
08
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Joint Regional Meeting of The Ratnapura Clinical Society and the SLMA
Thoughts on Current Specialist Practice The Hospital Miscellany Malaria Count 2015
09
10, 12
14
14
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Child Safety Week – 2015
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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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PRESIDENT’S MESSAGE
October 2015
SLMANEWS
Dear Colleagues,
W
e have had a busy month again both in terms of internal SLMA activities and collaborations with others. One of the main components of the annual medical congress was to provide a forum for researchers to share their research findings. At the conclusion of the annual academic sessions, a meeting of researchers whose work was directly relevant to practice was held with a view to moving their research results towards practice level. Subsequently at a meeting with the DGHS the researchers made presentations of their findings and the way forward was discussed for implementation or further research. This we thought was important as most locally relevant research results are not made use of for change or improvement of practice. The SLMA continues its objective of continuous professional development through regional meetings, symposiums and clinical lectures delivered by experts. The September regional meeting was held in Vavuniya and was very well received by the young enthusiastic consultants serving the
Vavuniya Hospital. They requested to that this be made a regular annual activity of the SLMA agenda.
regarding health services and to seek his views on the CEPA agreement with India.
One of the main functions of the SLMA is to advocate on national issues relevant to health and disease. The most recent discussion was on reintroduction of the death penalty as a mode of punishment. His Excellency the President was written to informing our opposition to the introduction of the death penalty with reasons for taking such a stand. This issue of the newsletter is carrying more details of the stand the SLMA has taken with reasons for such a decision. A panel discussion on the death penalty and related topics will be organized next month in collaboration with the legal and prison authorities in Sri Lanka.
Several social activities are being lined up. Friendly six a side soft ball cricket matches on 25th October, to the more serious matches with the Bar Association of Sri Lanka on 22nd November, are in the pipeline. Please do contact SLMA for further details.
The SLMA working committee on Trade in Services was reactivated with the renewed national interest in bilateral agreements. The working group has decided to seek a meeting with the Hon Minister of Health to apprise him of the need for the Ministry of Health to be involved in negotiations
The main social event for the year is the Medical Dance. Put your dancing shoes and join this night of extravaganza with music, dance and delectable food which will be held at Waters Edge Hotel on 12th December 2015. The famous bands Flame and Black would be providing the music. The package includes gift packs for all, with numerous raffle draws and special prizes for lucky ones. The tickets, each priced at Rs 6000/-, are available at the Sri Lanka Medical Association office. Please do not hesitate to invite your friends to join your table and enjoy. With best wishes, Professor Jennifer Perera
ANNUAL GENERAL MEETING: 17TH DECEMBER 2015 The Annual General Meeting of the Sri Lanka Medical Association will be held at 7.00 p.m. on Saturday, 17th December 2015, at the Lionel Memorial Auditorium, “Wijerama Mawatha, Colombo 7. All members are cordially invited to be present. Any proposals / resolutions to be taken up at the AGM should reach the Honorary Secretary, SLMA, on or before 27th November 2015. The agenda of the meeting is given below. Dr. Ranil Jayawardena Honorary Secretary, SLMA
Agenda for the Annual General Meeting: 17 – 12 – 2015 1. Reading of the notice calling for the Annual General Meeting
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2. Observation of 1 minute silence for departed members of SLMA
7. Secretary’s Report for 2015
3. Adoption of the minutes of the last Annual General Meeting held on 20th
8. Treasurer’s Report for 2015
December 2014.
9. Election of Office Bearers and Council members for the year 2015.
4. Confirmation of new members of the SLMA who joined in 2015
10. Appointment of Auditors
5. Resolutions
11. Address by the new President
6. President’s address
12. Any other business
SLMANEWS
October 2015
3RD CLINICAL NUTRITION MEETING 2015 Compiled by Dr. Jeyanthakumar, Demonstrator, Faculty of Medicine, Colombo and reviewed by Dr. Ranil Jayawardena, Secretary, Sri Lanka Medical Association.
H
ippocrates, the father of Western medicine, stated “Let the food thy medicine and medicine be thy food”. It is clearly evident that nutrition has been considered a key area in patient management since ancient times. Nutrition contributes to at least six of the ten leading causes of death, yet medical education lacks specific training for its use in patient management. Studies have shown that among hospitalized adult patients, 40% to 55% were found to be either malnourished or at risk of malnutrition. A large part of these cohorts are undernourished when admitted to hospital and in a majority, under nutrition develops further while in the hospital. The Sri Lanka Medical Association (SLMA), as the apex medical professional body, has clearly identified this need and has taken the initiative to conduct clinical nutrition meeting annually in collaboration with other stake holders. The third Clinical Nutrition Meeting, which was organised by the SLMA in collaboration with the Nutrition Society of Sri Lanka, Sri Lanka Medical Nutrition Association and Sri Lankan Society of Critical Care and Emergency Medicine, was held on Sunday, 20th September 2015, at the Hotel Taj Samudra, Colombo, from 8.00 a.m. onwards. The speakers’ panel comprised of three foreign speakers including Professor Alastair Forbes, Dr. Ravinder Reddy and Dr. Triin Jakobson. Professor Alastair Forbes is the Professor of Medicine (Gastroenterology and Nutrition) at University of East Anglia, UK. He is the current President of the British Association of Parenteral and Enteral Nutrition (BAPEN). Dr. Ravinder Reddy is a Consultant Surgeon at Care Hospital, Hyderabad and Honorary Professor in Clinical
Nutrition at National Institute of Nutrition, Hyderabad. He is also the President of the Indian Society for Enteral and Parenteral Nutrition (ISEPN). Dr. Triin Jakobson is an Anaesthetist and Intensivist at Tartu University Hospital, Estonia and the President of Estonian Society for Enteral and Parenteral Nutrition. The audience included nutritionists, dieticians, medical officers of nutrition, doctors, academia from various faculties, nutrition care nurses and medical and nutrition students. The meeting began traditionally with the lighting of the oil lamp and the national anthem. Professor Jennifer Perera (President, SLMA) welcomed the gathering and delivered the welcome speech. In her address, she emphasized the importance of the clinical nutrition meeting and the need for collaboration of different stakeholders in this regard for better patient care. She also thanked the resource persons and other collaborators who made this meeting a reality. The first session was chaired by Professor Jennifer Perera. The panel of speakers comprised Professor Alastair Forbes and Dr. Ravinder Reddy. Prof. Alastair Forbes initiated the session with a comprehensive presentation on “Nutrition support for liver diseases”. He commenced his lecture with the discussion on nutrition in acute liver disease where patients are usually in good nutritional
condition before the acute illness. He explained the metabolic changes in acute liver failure which includes the risk of hypoglycaemia due to diminished gluconeogenesis, depleted glycogen stores, increased glycolysis and hyperinsulinaemia, increased resting energy expenditure (REE), increased protein catabolism and hyperammonaemia leading to hepatic encephalopathy. He concluded the first part of his presentation stating that the nutrition management of acute liver disease should be as for any other patient with severe acute illness with careful monitoring and special attention to glycaemic control. Contd. on page 4
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SLMANEWS
October 2015 Contd. from page 3
3rd CLINICAL NUTRITION... The second part of his presentation on nutrition support for liver disease was focused on nutritional support in chronic liver disease. In this part, he explained the possible reasons for malnutrition in chronic liver cell disease (CLCD) which are loss of appetite, malabsorbtion and increased energy expenditure. He highlighted the current evidence that malnutrition and hyper metabolism worsen the prognosis in cirrhosis. He continued to talk about the metabolic alterations in CLCD including glucose intolerance, increased protein requirement and vitamin and mineral deficiency, especially thiamine, pyridoxine, zinc and magnesium. He stressed the importance of proper nutrition care for a favourable outcome following liver transplantation. He stated that protein depletion in cirrhosis will lead to impaired muscle function including muscles of respiration and adversely affecting the prognosis. He introduced the concept of bioelectrical impedance in cirrhosis and phase angle of prognostic value. He concluded with a discussion on the issues related to salt restriction in ascites and protein restriction in hepatic encephalopathy. Following Prof. Alastair Forbes, Dr. Ravinder Reddy delivered a lecture on “Nutrition for patients with burns�. He began with the initial assessment and resuscitation of a patient with burns and the systemic response due to burns which include changes in cardiovascular and respiratory function, changes in metabolism and immunology. He explained clinical benefits of albumin and the lack of evidence for the use of albumin as a volume expander or as a nutrition supplement in burns. In his discussion on nutritional recommendations in patients with burns, he stressed the importance of early establishment of feeding preferably by enteral route. Contd. on page 6
4
SLMANEWS
October 2015 Contd. from page 4
3rd CLINICAL NUTRITION... He also discussed the energy requirements, protein turn over and intake, importance of micronutrients and the role of an immune modulatory diet. The first session was followed by a fellowship tea. The second session was chaired by Ms. Vishaka Tillekeratne, President, Nutrition Society of Sri Lanka. Dr. Triin Jakobson addressed the gathering on “Critical Care Nutrition”. She began with the current research evidence on the importance of proper feeding for ICU patients since starvation or underfeeding in ICU patients is associated with increased morbidity and mortality. She outlined the negative outcomes of starvation and underfeeding which include increased mortality, increased risk of complications, increased length of ICU and hospital stay, delay in recovery and increased health care cost. She discussed the importance of early establishment of enteral feeding in the appropriate patients. She continued to discuss protein and energy requirements in critically ill patients, different routes of feeding in ICU and the associated complications. She discussed the issues highlighted in the study on early versus late parenteral nutrition in critically ill adults, which has concluded that early initiated parenteral nutrition is not beneficial in the critically ill. The role of glutamine in critically ill, the current evidence and recommendations and flaws of the REDOXS study which has concluded that glutamine is pointless and might be even harmful, were discussed. Following the comprehensive lecture by Dr. Triin Jakobson, the first series of clinical cases were presented by a medical registrar and medical officers working in different state hospitals as Medical Officer in Nutrition. Each case was followed by expert opinion and discussion. All three foreign speakers congratulated the medical officers who were able to achieve successful targets in their patient management
6
with regard to nutrition with limited resources and practical difficulties. The use of locally available modes of nutrition was highly appreciated. It was noted that there is a considerable delay globally in referring patients to clinical nutritionists by the other team members of patient care. This delay was shown to adversely affect the recovery and prognosis. The case discussion was followed by a fellowship lunch. Following lunch, the third session was chaired by Dr. Damien de Silva (Secretary, SLMNA). The session began with Prof. Alastair Forbes’ address on “Principles and practical aspects of Enteral and Parenteral nutrition”. He started off with the history of parenteral nutrition which dates back to 1658 when the first intravenous infusion was given to dogs. He continued to highlight the evolution of enteral and parenteral nutrition for humans along the timeline. He discussed about patient assessment with regard to nutritional requirements, nutrition prescription to patients, monitoring and follow up of nutritional interventions and the necessary modifications in these interventions. He concluded with a discussion on the complications of enteral and parenteral nutrition and with a note about the future of nutrition care. This was followed by Dr. Ravinder Reddy’s presentation on “Nutrition in Intestinal Failure”. He began with the definition of intestinal failure and the functional and pathophysiological classification systems of intestinal failure. He continued to describe the gastro-intestinal physiology and the effects of intestinal resection or diseased intestines. Management of intestinal failure including assessment, optimising hydration, different enteral feeding regimens, role of parenteral feeding in intestinal failure, judicious use of pharmacotherapy to augment nutrition, surgical options
and the long term follow up plan were discussed. As the final event, the second series of clinical cases were presented, followed by the expert panel discussion. To conclude the 3rd Clinical Nutrition Meeting, Dr. Ranil Jayawardena (Clinical Nutritionist and the Secretary, SLMA) addressed the gathering with his closing remarks. He stressed the importance of this clinical nutrition meeting. He also stated that SLMA and its collaborators are highly dedicated to strengthen the knowledge and skills on nutrition management among medical practitioners and other healthcare workers. He thanked the foreign speakers for their presence and valuable presentations and expert opinion. He extended his gratitude to all who made this meeting a success. Following this, all speakers were presented with tokens of appreciation. The third clinical nutrition meeting concluded with a fellowship tea.
SLMANEWS
October 2015
7
SLMANEWS
October 2015
THE DEATH PENALTY: THE DILEMMA FACING THE MEDICAL PROFESSION AND A WAY FORWARDS Saroj Jayasinghe Professor, Department of Clinical Medicine Faculty of Medicine, University of Colombo Hon Consultant Physician, NHSL and Council Member SLMA
T
here is growing public concern about homicidal attacks and violence, especially those targeting vulnerable women and children. This has led to demands to carry out the death penalty in Sri Lanka. Though the courts of the country commit those convicted to execution, fortunately it has not been carried out for a number of years, partly due to the reluctance of Heads of State to authorize these legitimized murders. There are two ‘non-medical’ arguments against the death penalty. Firstly, there are religious or moral arguments. I will not dwell on this area, other than to say that there is almost unanimity among major religions against carrying out the death penalty. Secondly, there is the crucial fact that justice systems do make errors. There are several examples, even from technically developed countries, where DNA evidence has proven that the wrong persons were jailed and executed. Therefore, carrying out the death penalty in Sri Lanka too may lead to wrong persons being executed. This was proven recently when a juvenile and several other poor villagers were allegedly tortured to obtain a confession to the murder of a child. If anyone of them had confessed under duress, and unfortunately had not alibis, he may have ended up in prison or executed. Of the ‘medical’ arguments, the first is that Sri Lanka has hardly utilized its potential to tackle criminal behaviour. As a profession we are in a unique position to lead this drive. Compared to other professions we have a special in-depth understanding of the workings of the mind. We are more
8
knowledgeable about psychology and forensic sciences. We meet people of all walks of life, and have the opportunity to hear life-stories that would put Charles Dickens to shame. From these insights and available research we know that criminal behaviours are often the end result of childhood deprivations, growing up in the midst of violent families, or the impact of sexual, physical and emotional abuse. Sometimes these behaviours are the result of intolerable abuse and triggers (e.g. homicide by a wife who is repeatedly abused and beaten by the spouse). We, therefore, should view some criminal behaviours in the context of tortured minds of human beings, rather than behaviours of evil sub-humans who are conveniently labeled as ‘criminals’. It is well known that those with extremes of behaviours such as psychopaths, have permanent abnormalities in their brains (e.g. from functional MRIs), suggesting that there could be an underlying disorder that contributed to their violent behaviour. It is therefore unacceptable that we are even considering executions instead of at least scratching the surface of these underlying problems of criminal behaviours. The second ‘medical’ argument against the death penalty relates to our profession. Our profession’s main goal is to improve the health of people and save lives. We are trained and guided by ethical principles such as ‘never to do harm’, ‘always relieve pain and distress of whoever who seeks your help’, and ‘save lives’. We spend hours struggling to save lives of human beings, irrespective of who they are, be it prisoners, members of parliament or a pauper from the street. The drill we follow with all these people is the same….we do the best we can to save lives and relieve distress. If this is our moral foundation, taking another human being’s life as a form of punishment or as a lesson to oth-
ers, should be automatically and totally abhorrent! What the country needs at this juncture is not a knee jerk reaction to commence executions. Instead, we need urgent reforms to our judicial and prison systems. For example, we need to identify social and other causes of criminal behaviours (e.g. criminology, forensic psychology etc.), promote the application of advances to genetics and forensic sciences to track those suspected (e.g. DNA matching) and strengthen efforts to rehabilitate persons who commit any crimes (using a range of techniques such as counseling, meditation, spirituality, vocational training etc.). The medical literature in psychology, psychiatry, forensic sciences, criminology, and genetics is flooded with effective interventions and technologies in all these areas. Simultaneously we need to address the anxieties of those who are concerned about safety of society from persons who may repeat their criminal actions. In order to accommodate for the latter, an alternative to death penalty would be to amend laws to ensure that those convicted of specific serious crimes (e.g. child rape and murder), will NEVER be pardoned by political decisions and released back to society. This will at least give the convicted a fair chance to correct errors in judgment, while ensuring that society is safe from harm’s way. I feel it is the duty of national organizations such as the Sri Lanka Medical Association (SLMA) to contribute their expertise to the Minister of Justice, the legal profession, correctional authorities, and other policymakers.
SLMANEWS
October 2015
JOINT REGIONAL MEETING OF THE RATNAPURA CLINICAL SOCIETY AND THE SLMA By Dr. Ranil Jayawardena (Honorary Secretary, SLMA)
T
he joint regional meeting of the SLMA in collaboration with the Ratnapura Clinical Society was held on the 28th of August 2015 at the auditorium of the General Hospital Ratnapura. The President of the Ratnapura Clinical Society, Dr. Shantha Indralal, welcomed the gathering and delivered the welcome speech. Prof. Jennifer Perera, President of the SLMA, also addressed the audience and elaborated on the importance of having a continuous professional development programme. The first session was chaired by Dr. Athula Fernando and Prof. Jennifer Perera. The panel of speakers comprised of Dr. Mithree Chandrarathne (Consultant Gynecologist and Obstetrician, General Hospital, Ratnapura), Prof. Jennifer Perera (President SLMA, Dean and Senior Professor of Microbiology, Faculty of Medicine, University of Colombo) and Dr. B. J. C. Perera (Senior Consultant Paediatrician and Past President SLMA).
ity. Participants actively engaged in the discussion with Dr. BJC Perera.
Dr. Mithree Chandrarathne initiated the session with a very important lecture on Nutrition in Pregnancy. In his lecture he discussed current recommendations of energy and nutrient intake during different stages of pregnancy. He highlighted the current trend of gaining excessive weight during pregnancy and associated complications. Prof. Jennifer Perera delivered a lecture on “Pneumococcal vaccination – Widening the scope”. She illustrated the importance of vaccination of children as well as adults. The last lecture of the morning session was an interactive one on the management of acute childhood asthma by Dr. BJC Perera. He demonstrated an evidence-based protocol for treating childhood asthma with different sever-
Dr. Asiri Rodrigo started the session with a presentation on “Eating disorders”. He highlighted the mental health aspect of various eating disorders and possible treatment options including psychotherapy. Next, Dr. Priyanthi Palihakkara, gave an update on the nutritional management of critically ill patients. She highlighted the practical challenges of handling ICU patients and the limitation of current clinical practices. Finally, Dr. Ranil Jayawardena spoke on nutritional concepts and controversies in obesity management. He explained reasons for common misconcepts of obesity and provided practical dietary advice to handle obese patients. The audience actively engaged in the discussion that followed.
The second session which was after tea was chaired by Dr. Udayangani Ramadasa and Dr. Asiri Rodrigo. The panel of speakers comprised of Dr. Asiri Rodrigo (Consultant Psychiatrist, CNTH, Ragama), Dr. Priyanthi Palihakkara (Consultant Anaesthetist, General Hospital, Ratnapura) and Dr. Ranil Jayawardena (Clinical Nutritionist, Nawaloka Hospital).
The vote of thanks was given by Dr. K. M. N. L. Konara, Secretary of the Ratnapura Clinical Society, which was followed by a fellowship lunch. This meeting was sponsored entirely by the State Pharmaceuticals Corporation.
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SLMANEWS
October 2015
THOUGHTS ON CURRENT SPECIALIST PRACTICE Dr. Sarath Gamini De Silva Consultant Physician
A
medical specialist is someone highly trained in a particular branch of medicine, possessing or involving detailed knowledge or study of a restricted topic. In a rapidly advancing discipline like medicine, such specialization is essential as one cannot keep pace with new developments in all areas.
Consultant and a Specialist In local parlance, both these are used in a similar context. A specialist invariably becomes a consultant to others less conversant in the field. However a consultant need not necessary be a specialist. It is up to the referring doctor or the patient seeking advice to decide whether the person he is consulting is qualified for that purpose. However it should imply that a specialist becomes an ordinary practitioner in other areas in the vast field of medicine. The influx of foreign specialists brought the controversy regarding the required qualifications to the forefront. It was argued that many of them, though having qualifications on paper recognized by the respective medical councils, were not experienced enough to work as specialists. In fact some of them were supposed to be getting trained on the job over here, as they did not have enough opportunities in their home country. What about the situation for Sri Lankan specialists? Could they be considered as specialists as soon as they are board certified as such? We know in a practical field like medicine, experience counts. Shouldn’t this requirement be incorporated into the definition of a specialist?
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Can a physician trained in general medicine be a specialist in any field, unless of course he has gained more experience in one area, say with a special interest in gastroenterology, diabetes etc. Or he could be a specialist generalist, competent to manage multiple illnesses, seeking the advice of system specialists only when necessary.
On the other hand, how competent is a person trained in one area mainly, say an endocrinologist or a gastroenterologist, be called a specialist in treating hypertension, heart disease or neurological disease? These are matters of concern in Sri Lanka where there is no referral system through a general practitioner. It is the patient who decides whom to consult. A simple headache like migraine goes to a neurologist and gets an MRI done. A muscular pain goes to a cardiologist and gets an echocardiogram, exercise ECG etc done. When everything turns out to be normal, the ignorant patient is quite happy as everything has been done. In both these examples the specialist has the excuse that the patient first came to them expecting such investigations to be done! But in the end the specialist has reduced himself to the level of a technician just pleasing the instincts of the patient. Just imagine the happiness of someone who has had a MRI or CT scan of the head, not indicated in the first place, is told that there is nothing inside his head! I had once requested an ultra sound scan of the abdomen in a patient with hypertension. The radiologist in Matara who did the scan told the patient that he should have gone to a cardiologist for treatment of hypertension. So the ignorance pervades the medical profession as well.
Recently, an A&E medical officer in a private hospital called a senior physician to see a young patient with fever and headache of one day. Upon inquiry it was found out that the patient was seated on the bed talking to the doctor. The physician asked to do a full blood count and to wait until he came in the next hour or so. Then the MO mentioned that he had already informed a young neurologist because of the headache. His instructions over the phone had been to do an urgent CT scan of the head and start on meropenam before he even saw the patient. The physician asked him to withhold all that until the patient was seen by him. A clinical diagnosis of acute frontal sinusitis was made. The patient went home relieved of the symptoms after a course of amoxicillin and symptomatic treatment. The long experience of the physician was obviously more useful to the patient than the anticipated exploits of a recently qualified neurologist. It is well known that the more experienced one is, the less likely he is to do non essential investigations or to readily use newly developed expensive drugs in preference to well established older ones. Contd. on page 12
SLMANEWS
October 2015 Contd. from page 10
Thoughts on... A patient consulting two or more specialists concurrently for different system illnesses may end up getting several long prescriptions each probably written with no reference to the others. Thus I have seen aspirin and statins being taken each in two different brand names simultaneously. We know that all recently qualified specialists are trained in various modern investigation procedures. However we would expect them to be judicious and use discretion in using them. Doing an endoscopy in everyone complaining of abdominal discomfort, or various cardiac investigations in everyone with chest complaints, or head scans on everyone with a headache, defeats the very purpose of training as a specialist. This situation is fast becoming the rule rather than the exception in Sri Lanka. The proliferation of facilities for investigation in the private sector is partly responsible for this abuse. The main purpose of the private sector obviously is profit, welfare of the patient coming a distant second. They have invested millions in acquiring equipment and would not like them to be lying idle. They would favour those who would use them. I know some private hospitals even maintain a register of the number of procedures done by individual specialists. But isn’t it unethical for members of a noble profession to be subservient to commercial interests at the expense of their patients? A similar situation prevails in the use of expensive drugs, for example, antibiotics. Those who use meropenam and the like as the first choice in the empirical treatment of pyrexias are preferred by the A&E departments to those who start with amoxicillin. Those belonging to the old school, rejoice when most of the patients respond to penicillin, amoxicillin, tetracyclines or erythromycin. It is interesting to note that, as these older drugs are less commonly used now, most organ-
12
isms are becoming sensitive to them. Few rarely seen side effects like grey baby syndrome in chloramphenicol, or blood dyscrasias, are being used to discredit them. Their main disadvantage as I could see in modern practice is that they are too cheap!
physicians has contracted. However, increasing numbers of acute admissions end up in a general medical ward with fewer beds. This obviously causes much decline in the standards of care in our well established conventional healthcare system.
Many newly trained specialists get posted to outstations with minimum facilities for practicing what was learnt. Many get frustrated and join the private sector well endowed with required facilities. While the society may consider them to be self seeking without serving the people, it should be realized by the authorities that it is not possible to keep a highly trained professional purely in a basic service role without adequate facilities.
A specialist with years of experience in the practice of his art, keeping himself updated with what is new, yet will not readily replace the well established treatment tools with newly acquired but little tested ones, knows what the guidelines dictate but is brave and rational enough to act in his own way with discretion, is a blessing to his patients.
A specialist needs to keep abreast of his art. It is up to the employer, in our case the department of health services or the universities, to give him opportunities to get himself updated regularly. As it happens now, the specialist in government service depends on the opportunities provided by the pharmaceutical industry even to attend a conference abroad, hardly a way to maintain and sharpen the newly acquired skills in a specialty. A programme for continued professional development with regular assessment and accreditation is a must if one were to remain a specialist competent in his field. However, no such programme is feasible if the specialist is not provided with the facilities mentioned already. A system where a family physician decides on referring a patient to an appropriate specialist when required is a must for the best utilization of the specialists’ expertise as well as the expensive equipment. In many hospitals, taking in acute admissions has become complicated. With many system specialists being appointed, the field of general medicine with conventional general
A newly qualified specialist with all necessary qualifications but little experience, following to the letter, the guidelines developed elsewhere, doing all possible investigations more to cover up his insecurity or ignorance, is likely to be a burden to the healthcare services. As such in the definition of a specialist, the degree of experience has to be included.
The summary in rhyme!
For every problem that they face Using tests as the diagnosing base Treating the patient only as a case Will eventually lose in the rat race One who specializes in a certain art Keeping updated from the very start Using not only the brain, but the heart Over the years, will become quite smart Let not the patient be used as bait Left helplessly, resigned to his fate Rectifying matters can’t be left to the state Let the profession act before it is too late Seeking expert advice of the medical specialist The patient is not just a number in a long list Treat him with compassion, no unethical twist Of what I said, with malice to none,
that is the gist!
October 2015
SLMANEWS
The Hospital Miscellany Physicians, cream of medical luminaries Accounting for many patient recoveries Working so hard despite measly salaries How sad they succumb to early coronaries Surgeons like kings in the theatre stand Doing wonders with their gloved hand So quick they remove lump and gland
MALARIA COUNT
2015
Keep working till they are dads grand!!! Anaesthetists mostly of the fairer kind In them comfort patients always find On call day and night they don't mind Without them, to a halt surgeons grind Pathologist, everyone's friend in need To quench their thirst we have to bleed
cases to date:
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In getting to the root how well they lead For all our maladies they find the seed
All are imported!
To all my friends this is only for fun Goodwill to all and malice to none If you are hurt with what I have done Most sincerely I do beg your pardon!!! Dr. Sarath Gamini de Silva 14
Let's Keep Sri Lanka
malaria free
An Aster DM Healthcare Venture
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SLMANEWS
October 2015
CHILD SAFETY WEEK – 2015 28th September – 4th October 2015
E
very year around 600 children die and nearly 270,000 are admitted to hospitals due to injuries in Sri Lanka. With more and more surviving children with disabilities, childhood injuries has assumed a priority area.
Prof. Asvini Fernando and Dr. Kapila Jayaratne were featured in the “Niskalanka Hathahamara” programme of the premier TV channel ITN on child injury prevention.
The Expert Committee on Ergonomics of the Sri Lanka Medical Association, in collaboration with the Ministry of Health, Family Health Bureau and the UNICEF, organized a Child Safety Week starting from 28th of September to 4th of October coinciding with the 1st of October – which is the World Children’s Day. Various activities to improve the awareness of the public regarding injury prevention and child safety were implemented throughout this week with the participation of various stakeholders such as the National Poison Information Center, Ministry of Law & Order and Prison Reforms, Sri Lanka Police, Education Ministry, National Child Protection Authority and Ministry of Child Development and Women’s Affairs.
Ministry of Health / Family Health Bureau 1. Distribution of child injury prevention posters among healthcare workers and institutions
Activities Conducted Media Briefing
Child Safety Week started on 29th September with a media briefing held at the SLMA Auditorium. More than 30 media officials from leading paper and electronic media organizations, participated at the briefing.
Prof. Jennifer Perera, President – SLMA, Dr. Kapila Jayaratne – Chairperson – SLMA – ECE, Mr. GDAK Senaratne – DIG Traffic Sri Lanka Police, Ms. Caroline Bakker – UNICEF addressed the gathering. This media briefing resulted in the appearance of a number of articles in newspapers and news clips and teleprogrammes on prime TV channels.
2. Organization of activities related to prevention of childhood injuries at MOH office or nearest town with the participation of community organizations and other relevant stakeholders 3. Awareness of mothers at antenatal, child well-baby, immunization and well-women clinics about child injuries and prevention methods (health talks) 4. Inspection of houses under care using the safe home checklist and advise on safety by PHM Contd. on page 18
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Child Safety... 5. Inspection of all school premises for injury risks by PHI 6. To organize road safety activities in liaison with the Traffic division of Police 7. Screening of School Van Drivers for vision and appropriate referral by MOOH & PHI 8. Initiation of an Injury Record Book at all schools 9. Facilitation of provision of a First Aid Box for all schools 10. Situation analysis –collection of data from death registrars, police and hospitals on child injuries and deaths during last 6 months. Compilation of collected data. Child injury risk assessment within the MOH area – to assess the impending risks, places for injuries within geographical boundaries (eg. rivers, roads etc.), pre-schools, day care centers by PHI. National Poison Information Center Launch of a CD on childhood poisoning –“Prevent Household Poisoning”
Dr. Waruna Gunathilaka, Head of National Toxicology and Poison Information Department, NHSL coordinated the activity. Non-Communicable Disease Unit Launching of “Safe Communities” concept in selected cities.
The College of Surgeons of Sri Lanka, Family Health Bureau & Lady Ridgeway Hospital –Educational workshop for 110 first contact doctors in three districts (Gampaha, Colombo & Kalutara) on “care for the injured child”. Dr. Ranjan Dias and Dr. Ranjith Ellawala of the CSSL coordinated the workshop.
SLMA Expert Committee on Ergonomics -"Knowledge Sharing Forum on Child Injuries in Sri Lanka" – an evidence synthesis symposium on child injuries in Sri Lanka. SLMA–ECE recognized the lacunae in scientific evidence on childhood injuries and organized a research forum during the Child Safety Week – 2015 to collate available information, highlight the issue and initiate a dialogue within the scientific community. The objective of this activity is to apply research into practice and utilize available resources and systems together to prevent deaths, disabilities and unnecessary tragedies to children, families, and communities. The workshop included 3 plenary presentations and 7 free papers. All presentations were published in a booklet. Dr. Sameera Senanayake and Dr. Manjula Danansuriya coordinated the activity.
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College of Paediatricians of Sri Lanka –launching of a booklet on child injury prevention “Ran Ruwan Lamun” written by Cybil Wettasinghe targeting parents and children. Dr. Kalyani Guruge, Consultant Paediatrician initiated the activity. Contd. on page 20
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Child Safety... Educated general public on ensuring road safety as pedestrians. Described three-wheeler safety and highlighted the need for having child restraints in vehicles. Ministry of Law and Order Initiative to cover unprotected wells in each village through Civil Defense Committees. National Child Protection Authority Awareness among wardens of children’s homes on injury prevention Sri Lanka Children Safety, a community group along with Ministry of Education conducted creative educational activities on injury prevention for children.
on Sunday, the 4th of October, 2015 at the Bandaranaike Memorial International Conference Hall premises. A large number of people including key figures (Dr. Rajitha Senaratne – Minister of Health, Dr. Sudarshani Fernandopulle –State Minister of Urban Planning and Water management, Mr. Nishantha Warnasinghe – Minister of Health Western Provincial Council) and celebrities of the country took part at this event. Dr. Hemantha Beneragama, Director – Family Health Bureau, welcomed the participants. Dr. Palitha Mahipala, Director General of Health Services highlighted the importance of child injury prevention and the awareness of general public. Dr. Iyanthi Abeywickrama, President Elect – Sri Lanka Medical Association represented Prof. Jennifer Perera, President – SLMA. A drama organized by Dr. Lakmini Magodaratne, Consultant Community Physician – National Institute of Health Sciences, Kalutara was performed prior to the walk.
Sri Lanka Police Island-wide education programme on child helmets –parents carrying children on motor bikes were educated on the need of protection with a helmet and pasted a sticker on the petrol tank.
Child Safety Walk – 2015 The peak event of this programme, the “Child Safety Walk”, took place
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A team led by Dr. Kapila Jayaratne, Consultant Community Physician – Family Health Bureau and Chairperson of Expert Committee on Ergonomics of the Sri Lanka Medical Association, Dr. Sameera Senanayake – Convener of SLMAECE, Dr. Manjula Danansuriya, Dr. Danaja Kawshalya, Dr. Kshyama Weliwagamage, Dr. Hemali Jayakody, Dr. Samanthi De Silva and Dr. Teklani Nadeeka organized and coordinated the activities of the Child Safety Week. UNICEF rendered technical and financial support for the Child Safety Week – 2015.
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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