Nowhere to go . . .

It was the festival of colors early this week. The whole country was in celebration. With our Prime Minister getting a major boost to his 'make India great again', the celebratory mood was well felt in every nook and corner of our communities. There were major things coming for the poor . . . the rich will be taken to task . . . there will be no more corruption . . . no-one will ever go hungry . . . there will be no more deprivation . . . there will be no more need for charity . . . 

I'm encouraged . . . I see a glimmer of hope for the marginalized and the poor in our communities. 

On the day of the Holi festivalI had just the sort of patient, who I feel should not exist in 2022, when the country celebrates it's 75th Independence Day. 

Mrs. A was not an unknown face. In fact, quite a many members of her family comes to us when there is a serious medical issue. In fact, it was just few weeks back that her nephew was brought to us with clinical meningitis and he made a miraculous recovery. I've known Mrs. A since the day we reached here. She was a known hypertensive and had been on irregular treatment. But, the last time we saw her was in October, when we diagnosed her to also have quite severe Ischaemic Heart Disease with some amount of cardiac failure and a bad pneumonia. 

As with the majority of our patients, she did not want to be taken to a higher centre. The maximum we could do to evaluate her was a Peripheral Smear and an ECG. Yes, not even an X-Ray. She made a miraculous recovery. 

But, she never returned for treatment. Alas, we also did not notice that she had not turned up for her regular medications. 

Her husband brought her in a miserable state sometime late morning last Monday (Holi). She was coughing with quite a lot of phlegm. Clinically, she got a bad pneumonia again which was causing quite a lot of stress on her badly damaged heart. I told the family that she needs evaluation. They told me that the maximum they could spare today was 500 INR. As usual they were not willing to take her ahead.

Over two days with some medicines to treat her lower respiratory infection and support her flailing heart, she made a miraculous recovery.

Reasons for her not coming for regular treatment for her high blood pressure and cardiac failure - they are very poor. There is one son who goes to work in the nearby town. He cannot go far as he has to look after his aged parents. There are couple of other sons who are earning a living in faraway places. They hardly come.

Now, it would be a great thing if such patients are taken care of. There are two ways to do it. The first is to ensure that the public health care system is robust.

And the other is to imagine that they don't exist. If the latter is the solution, people like me remain busy. 

Issues of the Heart

Few days back, one of my senior colleagues shared an article on how deaths from heart attacks have dramatically come down in the United States. However, as I read it I know very well that only a minuscule of patients in our country who suffer a heart attack would ever undergo emergency angioplasty.

Angioplasty - that's the name given to the way they save the heart by opening the blocked artery by pushing in a catheter, inflating a tiny balloon and inserting a stent which will keep the artery wall patent. And this has to be done fast . . . very fast. 

Take the example of 2 patients whom I saw in emergency over the last couple of days at KCH. We worked fast to ensure that both the patients are referred to a higher centre. When we referred, the minimum we expected was that both the patients would be given Streptokinase to dissolve the block in their coronary artery. 

The first patient, a 38 year old mother of three with well documented anterior wall myocardial ischemia, was prescribed Aspirin, Atorvostatin and Clopidogrel and sent back home. 

The second patient was a 60 year old gentleman with typical symptoms of Myocardial Ischemia. He did not have typical features on ECG, but since the symptoms were typical, we referred him. Couple of days, the relatives came back saying that he had a heart attack with elevated enzymes. 

The guy was luckier as from the prescription, it seems that he got low dose heparin. 

There are 2 aspects. 

The first is the cost involved in treatment. The latter patient incurred a cost of 60,000 INR for treatment at the cardiac specialty centre he went to for a 3 day stay. No small amount for a middle class family, leave alone for the majority of my fellow citizens. 

The second aspect being the number of intervention cardiologists available in the country. I wonder if the total number of intervention cardiologists in the whole country is even a 4 digit number.

The third aspect is about where you'll be treated. The first patient was seen by cardiologists in a public healthcare set up. The second patient in a private tertiary cardiology care centre.

When we look at it - Yes . . . there's a lot of people dying out there or more than that getting debilitating heart damage due to ischemic heart disease, all because of high costs and non-availability of specialists. 

Well, the future looks bleak in a country which is still grappling with maternal deaths, children dying of diarrhoea and respiratory tract infections, tuberculosis and malaria. 

As for the time being the best option for us remains - 

1. Healthy eating habits

2. Good exercise

3. Control of risk factors such as diabetes and hypertension. 

From the policy, we would need to see - 

1. If thrombolysis treatment can be authorised in primary care.

2. Short courses for medicine consultants in the public health secondary care institutions to do angioplasties.

Till those happen, the 3 cardinal rules to have a healthy heart remains the best option in the country . . .