IMA News letter 2017

1IMA KOZHIKODE NEWSLETTER
June 2017 Volume 1, Issue 2
IMA
KOZHIKODE
What’s New in
Medicine!
Coping With Ovarian
Cancer
Remembering
Rajendran Sir
INSIDE
5 169
Journal Scan Talking Point Obituary
Cover Story
End of life care

IMA KOZHIKODE NEWSLETTER2
Life at IMA

Editor-in-chief
Dr. Venugopalan P. P.
Publisher
IMA Kozhikode
Contributers
Dr. Pradeep Kumar V G
State President, IMA
Dr. P. N Ajitha
President, IMA Kozhikode
Dr. S. V. Rakhesh
Secretary, IMA Kozhikode
Dr. Abraham Mammen
Resource Person, PPS
IMA
KOZHIKODE
FEATURES
Journal Scan
What’s New in Medicine!
Page 5
Obituary
Reminiscences of a legend Page 15
Remembering Rajendran Sir Page16
News & Events
News & Events
Page 18
Talking Point
The practises in Infusion Therapy Page 11
Coping With Ovarian Cancer page 13
Cover Story
End of life care Page 7
Dr. Suresh Kumar
Dr. Mahesh B.S.
Many significant changes happened in healthcare and socio-cultural areas in Kerala recently.
It has created tremendous impact in emergency care division across India and especially in
Kerala. The health care system has changed its pattern to the most unscientific way. Presently
Kerala is following the inverted pyramid model with a vast number of super-specialty
hospitals and unproportionate numbers of medical colleges in the top of the pyramid. The
growth of emergency medicine in Kerala is very significant and relatively huge in last decade.
The emergency medicine training emphasis aggressive resuscitation efforts in various life
threatening situation. In other words, recently only we sensitized to the need of adequate life
support training. A Doctor in ED faces the dilemma of succumbing to bystander compulsions,
attack threats, ethical and legal threats and thus forced to do aggressive resuscitation
measures even if no results. The pressure of some institutional policies is also contributing
and worsening the scenario.
Finally, the scene may end up in a state that such patients will land in ICUs and be in an
aggressive mode which drains out the family financially, physically and psychologically. It
creates a lot of unhappiness among family members and hospitals will be blamed for financial
affairs and unethical practice as far as bystanders concerned.
We need specialized training on End of life care decision for our emergency care physician
and he should be able to communicate properly with bystanders. They should get trained to
tackle the crisis by taking into consideration the regional socio-cultural scenario. They should
be informed as well as learn to de-escalate the higher end treatment modalities in unwanted
cases.
India needs separate end of life care rule and guidelines. At present, we have used the
guidelines available in foreign countries which are inappropriate and irrelevant in our
scenarios.
IMA update addresses this hot issue through different point of views of experts
Dr. Venugopalan P.P.
DA, DNB, MNAMS, MEM-GWU Director, Emergency Medicine
Aster DM Healthcare Group
drvenugopalpp@gmail.com, +91 9847054747, 9544054747
www.astermedcity.com
EDITOR
SPEAKS
Message from Leaders
Page 4
Color Doppler
INDIAN MEDICAL ASSOCIATION
Kozhikode Branch
IMA Hall Complex, IMA Hall Road
Calicut - 673 011
Ph: +91 0495 2368715
Email: calicutima@gmail.com
The rights to reproduce any information published in this
magazine are vested with IMA Kozhikode. This newsletter
will be distributed only among the IMA members, and not
meant for sale.
For any querries, contact: 9847 50 8715
Contact Person: Mr. Biju, Manager, IMA Kozhikode
Designed by

H
appy doctor’s day!
Congratulations for bringing out the second
bulletin of Kozhikode IMA on thr doctor’s day. It’s
a day when w have to rededicate our self’s towards services,
ethics and sacrifice in perceeds of the great leader Dr. B C
Roy. I wish all doctor’s peaceful and respectful career a head.
T
he Kozhikode branch of IMA is one of the
most active IMA branches in the whole country,
buzzing with academic, social and cultural
activities all through the year. That said, it is important
to be kept updated on what is happening in our branch.
What else can be a better tribute to our vibrant members
than a newsletter, acknowledging the noble contributions
of our members and leaders to the society in general
and to our medical fraternity? As the second issue of
the IMA Newsletter is getting published, I congratulate
Dr Venugopal for taking up a relevant issue, which is
the need of the hour. End of life care touches broadly
upon all those with a terminal illness, and how it can help
the patient and those assisting the patient in the most
noble way. The other features is also sure to make a deep
impact for the readers. I wish the IMA team the very best
of my wishes to take this forward in the coming years.
From the Secretary’s Desk
President’s Message
Dr. Rakhesh S.V.
(Skin & VD), Consultant Dermatologist
Iqraa Hospital, Malaparamba, Calicut
Aster MIMS, Govindapuram, Calicut, Kerala
Mob: +919447241627
Dr. P. N Ajitha
Gynaecologist
IMA Calicut Branch President
Message

Journal Scan
What’s New in
Medicine!
W
e suggest not giving venom
immunotherapy (VIT) to
patients with reactions to
stinging insects limited to cutaneous
systemic symptoms and not involving
other organ systems (Grade 2C).
However, VIT is effective in reducing
the severity of future reactions and may
still be offered in selected situations.
Venom immunotherapy (VIT) for
the treatment of patients with anaphylactic
reactions to stings of Hymenoptera
insects (eg, bees, yellow jackets, wasps,
hornets, and fire ants) is highly effective in
preventing future anaphylactic reactions.
However, in an updated practice parameter
from the American Joint Task Force,
VIT is no longer suggested for adults
with systemic reactions limited to the
skin (ie, generalized erythema, pruritus,
urticaria, or angioedema) as studies
suggest these patients are at low risk for
serious future systemic reactions [8].
This change brings the American
approach into closer alignment with
guidelines of other countries and is
similar to the existing recommendation
for children. Despite this revision, VIT
may be appropriate for certain adults with
cutaneous systemic reactions (eg, those
with underlying medical conditions or
medications that could affect the outcome
of asystemicreaction,frequentunavoidable
exposure to Hymenoptera, or impaired
quality of life due to fear of future stings).
F
or most patients with chronic
HBV infection who initiate therapy
with tenofovir, we recommend
tenofovir alafenamide rather than tenofovir
disoproxil fumarate (tenofovir DF)
(Grade 1B). We also suggest that those
initially started on tenofovir DF switch
to tenofovir alafenamide (Grade 2B).
Tenofovir disoproxil fumarate is a first-
line therapy for chronic hepatitis B virus
(HBV) infection. A newer formulation
of tenofovir, tenofovir alafenamide, was
approved by the US Food and Drug
Administration in November 2016 for the
treatment of chronic HBV in patients with
compensated liver disease. In two large
randomized noninferiority trials among
patients with chronic HBV infection (both
treatment-naive and experienced, and
including patients positive or negative for
HBV e antigen), tenofovir alafenamide
resulted in similar rates of HBV suppression
and fewer adverse effects on renal function
and bone density at 48 weeks compared
with tenofovir disoproxil fumarate.
Given these findings, tenofovir
alafenamide is our preferred formulation
for patients with chronic HBV who
initiate therapy with tenofovir. We also
favor switching those initially started on
tenofovir disoproxil fumarate to tenofovir
alafenamide. Given limited available
safety data, we do not currently use
tenofovir alafenamide in pregnant women.
F
or individuals younger than 15 years,
we advise administration of human
papillomavirus (HPV) vaccine
in two doses separated by six months.
Those 15 years and older should continue
to receive a three-dose vaccine series.
For individuals younger than 15 years
receiving human papillomavirus (HPV)
vaccination, two vaccine doses administered
at least six months apart are now
recommended by the Centers for Disease
Control and Prevention in the United
States. This new vaccine schedule is similar
to schedules used in other countries and is
supported by data demonstrating that two
vaccine doses in young females have similar
immunogenicity to three doses. However,
the efficacy of fewer than three doses for
prevention of cervical neoplastic disease
has not been directly established. Three
doses are still recommended for individuals
older than 15 years because they have lower
immunologic responses to HPV vaccination.
ALLERGY AND IMMUNOLOGY
(February 2017 )
Immunotherapy for stinging
insect hypersensitivity in
adults
INFECTIOUS DISEASES
(December 2016)
Tenofovir alafenamide for the
treatment of chronic hepatitis
B virus infection
INFECTIOUS DISEASES
(December 2016)
HPV vaccine dosing for
individuals younger than 15
years
Practice changing updates from uptodate

Journal Scan
C
onsistent with WHO updated
guidelines for patients with
multidrug-resistant tuberculosis
(MDR-TB), we suggest a shortened
9 to 12-month MDR-TB regimen for
nonpregnant patients who have no
extrapulmonary disease, an isolate known
to be susceptible to fluoroquinolones and
injectable antituberculous agents, and
no prior exposure to second-line agents
for more than one month (Grade 2C).
The conventional treatment regimen
for multidrug-resistant tuberculosis (MDR-
TB) consists of a fluoroquinolone, an
injectable agent, and at least two other core
second-line agents for a total duration of
20 to 26 months. Updated World Health
Organization (WHO) guidelines present
the option of a shortened regimen for
nonpregnant patients with MDR-TB who
have no extrapulmonary disease, an isolate
known to be susceptible to fluoroquinolones
and injectable antituberculous agents,
and no prior exposure to second-line
agents for more than one month. The
shortened regimen consists of an intensive
phase (four to six months of high-dose
isoniazid, ethambutol, pyrazinamide,
gatifloxacin [or moxifloxacin], kanamycin,
prothionamide, and clofazimine) followed
by a continuation phase (five months of
ethambutol, pyrazinamide, gatifloxacin [or
moxifloxacin], and clofazimine). Support
for this regimen comes in part from a large
study from Bangladesh that reported high
rates of favorable bacteriologic outcomes
with a similar 9 to 12-month regimen. The
new WHO guidance also indicates that
patients with rifampin monoresistance
should be treated as for MDR-TB.
Patients with known or suspected MDR-
TB who do not meet criteria for the
shortened MDR-TB regimen should be
treated with the conventional regimen.
F
or postmenopausal women with
nonmetastatic hormone receptor-
positive breast cancer who have
completed a five-year course of an
aromatase inhibitor (AI) and who have
higher-risk disease (eg, node-positive or
≥T3 disease), we suggest continuing the
AI for an additional five years (Grade 2B).
For postmenopausal women receiving
adjuvant treatment with an aromatase
inhibitor (AI) for hormone-positive breast
cancer, the minimum duration of treatment
is five years. While data from the MA17R trial
demonstrated that extending the duration
from 5 to 10 years improved recurrence-
free survival [9], preliminary results from
the NSABP-B42, DATA, and IDEAL
trials, reported at the San Antonio Breast
Cancer Symposium, have not confirmed
this benefit. No study has demonstrated
a benefit in overall survival with extended
adjuvant AI therapy, and bone-related
toxic effects are more frequent among
those receiving extended treatment. While
variations in methodology likely account for
the differences in recurrence-free survival
between the studies, the magnitude of any
potential benefit is likely to be greatest
for those at highest risk for recurrence.
While we previously had recommended an
extended course of AI adjuvant therapy
for most postmenopausal women with
nonmetastatic hormone-positive disease,
based on the new data, we now suggest
offering extended adjuvant aromatase
inhibitor therapy to those with high-risk
disease (eg, node-positive or ≥T3 disease)
ONCOLOGY, ADULT PRIMARY CARE (July 2016, Modified February2017)
Duration of adjuvant endocrine therapy for breast cancer
INFECTIOUS DISEASES (May 2016)
Option for shortened MDR-TB regimen in updated WHO guidelines
F
or patients receiving cisplatin and other highly emetogenic
chemotherapy regimens, we suggest the addition of
olanzapine on days 1 through 4 to standard antiemetic
therapy (a combination of a 5-HT3 receptor antagonist,
dexamethasone, and an NK1R antagonist) (Grade 2B).
The antipsychotic olanzapine may be a particularly useful agent for
preventing delayed chemotherapy-induced nausea and vomiting,
which is often poorly controlled with conventional antiemetics.
The effectiveness of adding olanzapine to a standard antiemetic
regimen was shown in a trial in which 380 patients receiving
highly emetogenic chemotherapy (cisplatin or doxorubicin/
cyclophosphamide for breast cancer) were randomly assigned
to dexamethasone, an NK1R antagonist, and a 5-HT3 receptor
antagonist plus either olanzapine (10 mg daily orally on days
1 through 4) or placebo. The proportion of patients with no
chemotherapy-induced nausea (the primary endpoint) was higher
with olanzapine both in the first 24 hours after chemotherapy and
in the delayed period. Rates of complete response (no emesis and
no use of rescue medication) were also higher with olanzapine over
a five-day period. Patients receiving olanzapine had more sedation
on day 2 (severe in 5 percent), which resolved despite continued
olanzapine. On the basis of this trial, we now suggest the addition
of olanzapine on days 1 through 4 to standard antiemetic
therapy for patients receiving highly emetogenic chemotherapy.
ONCOLOGY, PALLIATIVE CARE (August 2016)
Olanzapine for prevention of nausea and vomiting induced
by highly emetogenic chemotherapy regimens
No study has demonstrated
a benefit in overall survival
with extended adjuvant AI
therapy.

Cover Story
End of life care
An interview with Dr Suresh Kumar , who is the Consultant in Palliative
Medicine and Director, WHO Collaborating Centre, India & Senior
Research Fellow, Bradford University, United Kingdom
The term End of life Care is
a fairly new one in Kerala,
and for the common person
it would be a bit difficult to
understand what it means.
Can you please explain it?
My focusis on Palliative care. The concept of
Palliative Care has developed considerably
over the last 20 years in Kerala, especially
when you look at its spread in other states
and countries. There is some facility or the
other everywhere, including the Panchayats.
End of life is a component that comes
within Palliative Care. It depends on
how in each country it is defined. In
America, both palliative care and End
of Life care are the one and the same.
But in several other places, End of life
is a factor within the Palliative Care.
A person suffering from a serious illness
or life-threatening disease is given all the
emotional, social and psychological support,
along with medicines and treatment. It is a
kind of supportive care. But if the disease
is incurable and the patient continues to
deteriorate, then this kind of curative
support will be stopped. This is when the
patient needs terminal care, end of life care.
In Kerala, we are able to give good care
to the patient, including the emotional
and psychological support, but what
is missing is the care that is required
when the patient is nearing death.
My focus is on Palliative care, and what
we are trying to address is the gap that
is there in palliative care. Hence, the
additional focus is on End of life care.
What are the major
goals in End of life care?
In palliative care, we care for the patient
during his/her last days of life, and try to
keep their quality of life as near as normal.
In the end of life, we concentrate on the
aspect “Can this patient die comfortably?”
It is a complicated aspect. We all die, it
happens to all. If birth is natural, so is
death. While birth happens in a healthy
and happy environment, most of the time.
But death is different, it often happens in
an unhealthy and unhappy environment.
The basic question that comes with this
is - Can death be happy and healthy? To
look at practically, what is that makes
death so miserable? Can any factors be
modified there. Can death be more peaceful.
Is the same team that focuses
on Palliative Care focussing
on End of life care as well?
This is a clearly stated agenda of Palliative
care. The patient must live comfortably
till the end. In Kerala, the main focus
on the patient’s comfort till the end,
while the other part is largely ignored,
so we have to improve that, capture it
back. That is what we are planning to set.
What kind of patients require
End of life care?
We aim for comfortable death for patients.
Everyone dies. Only the method of death
and the level of distress vary. End of life
care is a universal package.
Death is as such is a suffering situation,
but a natural process. Only perhaps 1% of
the people can have a natural death. For a
cancer patient, there is some amount of
predictability on when death can happen.
But for a non-cancer patient, that is not the
situation. A person of 85 could have chronic
diabetes and respiratory diseases, but he
could live for long. We cannot predict death
there. We are looking at factors like what is
preventing people from dying comfortably.
This is not just the case of a cancer
patient, or a person suffering from stroke.
“
In Kerala, we are
able to give good
care to the patient,
including the emotional
and psychological support,
but what is missing is the
care that is required when
the patient is nearing death.
By Athira Narayanan

As opposed
to us, where
death can
happen any time,
which we probably
don’t accept or
believe. Fear of
death is a constant
companion. And if
fear is there, you will
not die comfortably.
In the case of a person with an advanced
disease, we believe they are likely to die
soon. As opposed to us, where death can
happen any time, which we probably don’t
accept or believe. Fear of death is a constant
companion. And if fear is there, you will
not die comfortably. That is what we are
trying to address. Dying due to cancer, dying
after a trauma, but the basic question, is can
we make death more comfortable for the
patient. It is often not possible for death to
be a happy event, especially for the family.
But when the individual passes away in peace,
the family will be able to cope with that.
In palliative care, we look at the physical
symptoms, we aim to address this. The
doctors and nurses should know how to
handle this. Death has emotional issues
as well. Dying comfortably means not
just looking at the physical symptoms. It
also handles acceptance of death. It is
very difficult to discuss the topic of death
with a seriously ill person. The patient can
also discuss the things he/she wishes to
complete before dying. How do you want to
die? What are your worries and concerns?
These issues must be handled carefully. I
have talked to many people regarding their
own death at their deathbed. They discuss
their concerns with me. Not everyone does.
Some people are ready discuss their death
with their family, but families react and
object saying it is not the time to discuss
these things. In end of life care, patients can
talk in a secure and safe environment to one
particular doctor. It is in those circumstances
that we realise that most people need to
have a comfortable death. Some people,
a good percentage of them would like
to extent their time, say, 6 months more,
thinking what they would do differently.
Societies should realise that it is ethical.
Unlike the palliative care programs targeted
towards patients with chronic illness,
what we call the end of life, though it
is part of palliative care, it is targeted at
the broader society because the roots
of lying miserably lies in the society.
In foreign countries, there
are rules and regulations
regarding End of care life? Is
there something like that in
India?
The dying patient will be linked with the
emergency room in a hospital. If you look
at the developments in End of care life in
the past 10 years, you can say that a lot of
improvements regarding the policies and
rules regarding an End of life care patient.
About 25% of the patients die in the ICU,
so the ICU should be skilled in looking
after the patient. The Royal College of
Emergency Medicine in the UK and the
The Australasian College for Emergency
Medicine all follow certain protocols on
what they should do should a patient die.
There are national guidelines on what
kind of patients should be admitted, we
don’t have guidelines. The policies are
usually made by the hospital, there are
no national guidelines. If you look at the
medical journals for the past 10 years,
you can see the advanced made in critical
medicine, what to do regarding a death
in the hospital, where did it go wrong
and so on. This is happening all over the
world. And very soon it will come in India
soon. Advances in medicine will not take
much time to come to India as it once did.
Hospital based discussions are going on,
but community based discussions are yet to
happen.
What are the major
challenges faced by the End
of care life program?
The lack of awareness in the society
is a major challenge. The attitude of
the society must change. There are no
proper guidelines or policies within the
government level or at the hospital level.
There is also a lack of skills in the doctors
and nurses.
The future of End of life care?
A change has to come. There are situations
in ICU that must change. When there are
miserable deaths, it affects the family a
great deal. When they look back, they feel
they have done the wrong thing. It affects
even the staff. They get affected, burnouts.
The good news is that the changes that
have been happening in the Western
hospitals is going to come to India too.
In the West, more people are dying in the
ICU, but in India the number of people
dying in the ICU is less because people
are financially not sound. The awareness
about death and dying must be spread here.
That can be done through discussions
and interactions in the society level. The
society has a misconception that dying is
a medical event. That is not true. Dying is
not a medical event. The medical institution
may have a role in aiding in a good death.
Dying is a social event with a lot personal,
emotional and psychological implications.
What does the society do a when a person
is about to die? Immediately he is taken to
the hospital, because they think the medical
institution has some power. This is why
a lot of work is left. It is important for
the doctors in the emergency medicine to
have the skill to handle all this. Otherwise
they will not be able to survive. If you
apply for a job in a hospital, immediately
they will ask about your expertise and
communication skills. Doctors have a very
important role in dealing with patients
about to die. Death cannot be indefinitely
postponed and there are limitations in
medical science. Everyone knows it but
they are not ready to accept it. Social
awareness about death and dying have to
be improved. Discussions and talks have
to be done. Protocols will be introduced
in hospitals because the hospital is not the
best place to die. It should be seen only as
an alternative.

An interview with Dr. Mahesh B.S. Chief Intensivist,
Aster MIMS, Kozhikode
Seeing a patient
dying in front of
you is so difficult.
If there is a plan in
place, then this need not
happen, the patient can
die without much pain.
Those are the importance
of having this kind of care.
What is the status of End of
Life Care in our country now?
We don’t have a proper End of Life process
in our society, at least in India. So there
has been a few issues when we tried to
implement the End of Life care and even
the legal system is not that clear to back us
up if something goes wrong. So the whole
End of life care is not at its best, presently.
So the problem of not having an End of
care system in our country is that at least for
the ICU patients, it can cause a lot of issues.
For one, we tend to increase the cost for the
end of the day for the patient, where we
know it is not going to change the outcome
for the patient. For example, if somebody
has terminal cancer, and if that End of
life care process is not known, when they
deteriorate they come to the ICU for critical
illness care. This is a normal process. At that
point we will be doing a lot of aggressive
management which not necessarily will
change the outcome, especially when it is
terminal cancer. When we are doing these
things, we are basically increasing the cost
for the patient and the bystanders. And
we are actually taking the patient through
a lot of suffering as well, and this is not
necessarily needed because by doing all
this if we can change the outcome, then it
makes sense. But if we cannot, then it is just
waste of time. And it is basically not good
for the patient because we are increasing
their suffering when they are about to die.
If there is no End of life care plan
in place, then that can actually lead to
unnecessary expectations for the family.
The family may not know the whole process
of what is going on, even when the patient
is almost about to die. The family might
expect them to come back to life. If there
is an End of life care plan or process in
place, the family will be involved in making
those processes. It would kind of get the
family ready for accepting the inevitable.
When I was having a
conversation with Dr. Suresh,
who deals with Palliative care
department, I would like to
know whether the critical
care and end of life care go
with each other.
Yes, that does go. I have been working in
Australia for almost 15 years. There we have
proper systems in place, unlike in India,
where there is no legal system in place. So
we can actually initiate the End of life care
in ICU, and we can actually make sure the
patient die in distress or pain. We can ensure
that the patient is comfortable. The problem
here is that when we give them medication to
relieve their pain, and if they get drowsy and
the relatives might not like it because they
think it is medication that makes the patient
drowsy. So they don’t understand the whole
process of it, so it is not easy at the moment.
Especially when the legal system is thinking
that it is Euthanasia or mercy killing, and
that makes it illegal. Here we are not doing
that, because here we are making the process
of death less distressful or painless. We can
at least make them die peacefully, but this
is not legal in India. So we attempt to give
them the best End of life care possible to the
patient. There is no doubt about it. But do
they have to come to the ICU, that’s another
issue because that’s always expensive.
And it gives the patient the wrong hope.
WhenapatientcomestotheICUthefamily
might think he might improve, but actually
it doesn’t happen and the cost will increase.
Unreasonable expectations rise and this
Cover Story

is not going to help them. So End of
life care can be done even before they are
coming to the ICU, this can stop them from
coming to the ICU. These pain medications
can be given and their family can be
around them. Once we cannot change the
outcome, or cure the disease, our aims
should be to make it easier for the patient.
There are a lot of other issues as well.
A patient coming to the ICU for just dying
basically, it is an inappropriate allocation.
For example, let’s say there are 10 beds
in ICU, and this is the last bed, a patient
is about to die, and another patient with
critical illness or trauma comes in. This is a
difficult situation. We have a patient in one
of the beds, for whom we cannot change
the outcome, he is definitely going to die,
but the other patient, if he doesn’t get timely
treatment, will definitely die. Those kind
of resource allocations can be abnormal
and that needs to be looked in. The ICU
beds must be given to patients who will
benefit from it. Then adding to it will be
the emotional stress not only to the family,
but to the health care providers as well. Any
patient dying in front of us is not a good
scene. We all go through the emotional
stress and trauma, especially when we know
that nothing can be done. Seeing a patient
dying in front of you is so difficult. If
there is a plan in place, then this need not
happen, the patient can die without much
pain. Those are the importance of having
this kind of care. If we have a proper
intensive care like in Australia, where all the
units are monitored and where we compare
the mortalities and the data, these kind of
patients who cannot benefit will actually
affect the mortality rates of the ICU, and
this will badly affect the ICU and tag it as
badly performing. But in reality this is not
so, because we are taking a lot of pains just
for the families sake. So all these are issues
when we are thinking about End of life care.
Ideally, there should be plan where these
kinds of terminally ill patients are identified
and detailed discussions are conducted
with the family, and come up with a plan in
place in case things go wrong. For example,
patients with cancer, stroke and patients
with incurable diseases or bedridden for
5 years, it is unreasonable for the relatives
to assume that the patients will get better.
We can do all kinds of stuff, but whether
that will benefit the patient. In the case of a
young patient, if anything can be reversed,
then definitely we can go to any extent. It is
more of an education for the public, what
all things can be offered, how much we
can do, whether it will benefit the patient.
If it is a young patient, a lot can be done,
but if it is a terminally ill elderly patient.
How do the hospitals in
Kerala approach the End of
life care scenario?
As I said, not many hospitals have
palliative care. That is something that is
slowly coming up. We have a palliative care
team here, but the end of life decision
making is always a problem. Because that
is always a multidisciplinary team, it is not
just one doctor; they cannot decide. It has
to be from all the teams looking after the
patient. And the experience has to be put
in. The family has to be informed; it has to
be a joint decision with the family. As our
legal system is not clear, it is very difficult
to implement the End of life care decision.
In many hospitals the concept of Palliative
care is coming up, but slowly. Palliative care
may call for more time, but it is in end of
life care where the problems start.
So where does the End life
of care stand in the legal
system?
End of life care is basically the care
given when the patient is dying. In the
intensive care point of view, it is basically
the medication that’s given to reduce the
pain, to calm down, and to make sure the
patient is peaceful in their last moments
of life. The thing is that some of the
medications are strong painkillers, they
decrease your breathing, so that is the
worry what people had. When we are giving
an infusion of medicine, it will reduce their
respiration, even though it is a great pain
reliever. People would become worried,
they might complain and that might pose
an issue for us. So the legal system as such
doesn’t back that up. So we cannot force
the medication for the patient, that decision
cannot be made in India. In other countries,
the family can decide and say, “My dad
has gone through so much, I don’t want
him to have medication anymore. And no
CPR also. They will not put the patient on
a ventilator. Here that is not the decision
here. If the patient is crashing or dying,
if we don’t give the CPR or life saving
methods, then we can request it. So this
all happens when there is a legal formality,
and when people understand it. But it is
important that there is a legal back up. The
Indian Society of Critical Care Medicine
and the Indian Association of Palliative
Care jointly had put in a guideline kind of
thing for practicing End of life care and
Intensive care. But the problem is if there is
no legal backup and basically all the mobile
resources will be mobilized if the patient is
deteriorating. So that is one of the things
which we need to wait. The Indian Society
of Critical Care Medicine and the Indian
Association of Palliative Care are trying
to pressurize the government to pass a
bill for palliative care. Unfortunately, when
they try to talk about this before, it went
into a completely wrong direction. Even
the general public needs to understand
because we are not trying to kill patients,
we are trying to help the patients and the
education should be there so the palliative
care and the end of life care decisions can
be made easily.
If it comes, it would be a
different department, like
other departments?
Ithinkthereshouldbeaseparatedepartment
with a multidisciplinary approach, with the
help of other departments. For example,
if it is a person with severe Parkinson’s
disease and has been bed-bound for the last
5 years, and then he had a trauma, things
are different. So that gets it more deeply
involved. Here it is not just one department,
that department should look after Palliative
care, so making decisions should be a
multidisciplinary approach. For a cancer
patient, an oncologist should be there, if it
is a liver patient a gastroenterologist must
be there. The decision will be made along
with the family, so that’s the way it should
go. It is easier said than done. In our society,
we need to educate the people, a lot of
work has to be done in this field, and I think
we are just starting.
So from a common man’s
point of view, palliative care
and end of life care seems
different. So how do you
differentiate between the
two? In the case of Palliation, we
cannot treat and cure the patient, but
we can at least decrease the distress or
pain. A patient with advanced sclerosis,
by taking that fluid off, we are reducing
the distress. But if he deteriorates and is
about to die, then we are not keeping him
in the ventilator because he is not likely to
survive. So we make sure that he is not in
pain or distress. That is End of life care.
Palliative care does include End of life care.

Talking Point
The Best Practices in
Infusion Therapy
Dr Shilpi Sarwan
National Clinical Marketing Manager, South Asia
Medical Affairs BD India.
G
lobally, healthcare-
associated infections
(HAIs) are associated
with significant
morbidity, mortality,
and economic implications. Intravascular
catheters are indispensable components in
medical settings; however, they are the major
contributors to healthcare-associated blood
stream infections. Catheter-related blood
stream infections (CRBSIs) can be broadly
categorized into central line-associated
blood stream infections and peripheral
line-associated blood stream infections.
The use of a central venous catheter poses
a greater risk of device-related infections
compared to other types of medical devices.
Furthermore, central line-associated
blood stream infections are one of the
most common and lethal complications
of catheter use. They are also associated
with significant morbidity, mortality, and
cost implications to the healthcare settings
of a country. On the contrary, while the
incidence of PVC-related infection (0.2–
0.7 episodes per 1000 calendar days) is
reportedly lower than for CVCs, the far
greater number of PVCs in use means
that the absolute infection rates for PVCs
approach the absolute infection rates for
CVCs ( Lolom et ., 2009; Maki et al., 2006).
The economic burden of catheter-
related BSI is substantial. The major
burden of catheter-related BSIs is the
cost associated with the treatment of
these infections. In view of the enormous
impact of CRBSIs, it is imperative to
prevent infections associated with the use
of central and peripheral venous catheters.
If we have high rates of CRBSIs, we
have 2 options: Diagnose and Treat a
CRBSI (it causes Increase length of stay,
Increase mortality, Increase cost, Reduce
bed availability, Increase bacterial resistance,
Increase antibiotic use) Or Prevent CRBSI 1
For preventing CRBSIs we need to have
Safe Infusion Practices. The Infusion
Nursing Society defines safe infusion
as delivering the prescribed therapy to
the patient while limiting the risk of
injury to the patient or the clinician. The
Center for Disease Control focuses their
recommendations on infection prevention
strategies while OSHA (Occupational
Safety and Health Administration)
provides guidance on practice to reduce
potential exposure to the healthcare worker
during the provision of infusion therapy.
Safe infusion practice could happen
through the care bundles. The Care Bundles
encompass a set of evidence-based infection
prevention practices recommended by
international organizations.2,3 International
organizations such as the CDC, INICC,
and the Joint Commission International
have put forth care bundles to prevent
CRBSIs.4,5,6,7Evidence indicates that
consistent application of care bundles
can result in sustained and significant
reductions in the rates of CLABSIs.
In view of the
enormous impact
of CRBSIs, it is
imperative to prevent
infections associated with
the use of central and
peripheral venous catheters.

The INICC recommends the use of a
multidimensional approach to support the
appropriate use and management of vascular
access devices and thereby prevent CRBSIs.
The INICC Multidimensional Approach
(IMA) includes
• A bundle of infection prevention
practice interventions – Includes best practices
for Insertion/Maintenance/ Removal of
catheters
• Education and training of h e a l t h c a r e
personnel
• Outcome surveillance
• Process surveillance
• Feedback on HAI rates and consequences
• Performance feedback
The impact of INICC strategy on CLABSI
rates in the ICUs of 15 developing countries
was studied and it showed reduction in the
incidence rates by 54% while the mortality
reduced by 58%. 8
The Care bundles have mainly 2 components:
A. Behavior which includes:
a. Hand hygiene
b. Maximal barrier precautions upon insertion
c. Optimal catheter site selection, with
avoidance of the femoral vein for CV access
in adult patients
d. Sterile dressings to cover the VAD
insertion site
e. Remove CL when is not needed
f. Remove PL when is not needed
g. Don’t Replace of CL at fixed intervals
h. Don’t Replace of PL at fixed
intervals
i. Scrub and disinfect catheter hub,
ports and needleless connectors
j. Replace IV administration sets every
96 hrs
k. Don’t use of multi-dose vials as b
source for flushing and locking
B. Technology which includes:
a. Clorhexidine skin antisepsis
b. Use single use device for flushing
c. Sterile chlorhexidine impregnated
dressing at insertion site
d. Needleless connectors as IV
connection devices
e. PL with integrated extension and
needleless access ports
f. Closed IV fluid containers
g. Daily bath with 2% chlorhexidine-
impregnated wash cloth in patients with CL
Talking Point
1. Rosenthal VD, Kanj SS, Desse J, et al. Bundle of the International Nosocomial Infection Control Consortium (INICC) to Prevent Central
and Peripheral Line-Related Bloodstream Infections. International Nosocomial Infection Control Consortium (INICC)
3. The Joint Commission. CVC Insertion bundles. Available at: https://www.jointcommission.org/assets/1/6/CLABSI_Toolkit_Tool_3-
18_CVC_Insertion_Bundles.pdfAccessed on 30 January, 2017.
4. Singhal AK, Mishra S, Bhatnagar S. Recent advances in management of intravascular catheter related infections. Indian J Med PaedOnco.
2005;26(1):31-40.
5. Parameswaran R, Sherchan JB, Varma DM, et al. Intravascular catheter-related infections in an Indian tertiary care hospital. J Infect Dev
Ctries. 2011;5:452–8.
7. The Joint Commission. CVC Insertion bundles. Available at: https://www.jointcommission.org/assets/1/6/CLABSI_Toolkit_Tool_3-
18_CVC_Insertion_Bundles.pdfAccessed on 30 January, 2017.
8. Rosenthal VD, DG Maki, et al (2010). Impact of INICC strategy on CRBSI rates in ICU of 15 developing countries. “Infection control &
Hospital Epidemiology
REFERENCES

Can you describe your
experience after becoming a
cancer survivor?

Dr. Lalitha: I was 60 when I was diagnosed
with cancer. I encourage people to take Pap
smear test, X-rays and chest examination.
Though I used to advice these to my patients,
I never did a check up myself. Perhaps its
because most doctors feel that they will be
untouched and remain disease-free. Right
from the age of 16, when we deal with
patients all the time, we get the immunity and
even if we fall sick, then it is difficult.The pain
started in the stomach first, I thought it was
caused due to playing with my grandchild. I
was about to let it go, but my family forced
me to take a scan, and thought it was a kidney
stone. A surgery was done to remove the
stone, the doctor discovered that there were
two ulcers just below the liver. They were too
small, just one millimetre. The surgeon was
very experienced, and since I was the patient,
he took a biopsy. That’s when cancer
was discovered. The pathologist was a
professor of mine, and she was reluctant
to say that I have cancer. She herself
took the opinion of many people
before she told me the diagnosis.
The operation was the next day.
Ovarian cancer is known as the
silent killer. You will not know
until the moment you die that
you have ovarian cancer. It
is not possible to know that
you have something like that
within you. If it cystic growth,
then you are lucky because it will
grow, and you will have symptoms like
difficulty in urination, flatulence.
Normally, people go to other doctors
before ovarian cancer is even detected.
Ovarian cancer is very hard to
detect on its own. Mine was not detected
in scans. They did a CT scan, 3 MRI scans
before discovering thecancer on one side.
Anyway it was discovered and they did the
surgery. My case was s p e c i a l
because in
a span of 6
weeks, they
cut open my
s t o m a c h
5 times.
There is an
org anism
known as
MRSA, its
a very rare
bacterium and I
was the first
patient in the hospital where it was ever
detected. The hospital is 35 years old and I am
the first patient with a positive MRSA patient.
After the last surgery, the plastic surgeon had
to use a special kind of imported adhesive
because of lack of skin in the area. But the
adhesive was not drying, and once when I
was taking bath, the finger almost went in.
That’s when I understood that the wound is
not drying, and it was almost one and half
months and time for my chemo. The plastic
surgeon treated me for that and on the 12th
day, I was put on chemo. For 3 to 6 months
this went on and I tied a belt in the area.
My hernia was popping out and after 6
months of chemo they suppressed the hernia
through laparoscopy, and checked all the other
glands, but it all came out negative.
But exactly one year later,
problems started again.
The problem with
ovarian cancer is that
when we cough,
the cells will keep
spreading, so it can
recur anywhere in
the stomach. So
you cannot say
it is secondary, it
will keep coming.
But ovarian cancer
is 100% curable.
But they say that
if you stress, it can
cause a recurrence.
But this can be
detected because you
have to conduct a blood
test every 6 months, and I
used to do my tests regularly.
Talking Point
Coping With
Ovarian Cancer
True stories of people who combated the deadly disease of cancer and won the battle are truly
inspirational and informative. Here is one such survivor, Dr. Lalitha, who conquered the tough
time in her life through her willpower. Let’s listen to how she won her battle with cancer
By Athira Narayanan

Never trust
the internet.
This time when
I checked in the
internet, I saw
only negative
reviewsaboutthe
medicines I am
taking, this can
be nerve-racking.
Listen to what
your doctor says.
Talking Point
The first time, I lost hair and became totally
bald. The next year when they noticed the
growth in the KCS 125 report, they started
me on the chemo right away. After the
injections, the report will register normal
results. That’s what I have to tell everyone. It
is very important to do follow ups if you were
ever diagnosed with cancer. That way if there
is a recurrence, you can start the treatment
right away. I can say that I am alive right now
because I did my second treatment on time. It
is important to complete the chemo treatment
even if you will feel tired. For the second
and third chemo, I didn’t even take leave
because I continued working, took chemo
in the evenings and went home in the night.
Now I have come for my 4th chemo. This
time they are giving me some strong drugs,
but I have grown accustomed to it, or tired.
As for food, I have to be very careful because
I have no skin in my stomach, and I mostly
drink rice gruel that’s juiced.What I have to
tell cancer patients is that they have to see this
as any other disease. Don’t worry about dying.
And you can work also. My husband is also
workaholic, so he can easily understand me. It
is impossible for me not to work, because it is
almost like killing me. Working is not energy
draining, but rather energising me. And if
there is a family history, then it is important
to do the checkups. My family has history of
cancer, both from my paternal and maternal
side.It is important to detect cancer quickly
and to take proper medical treatment. And
believe in what the doctor says. And have
belief in yourself. Sometimes the doctors
may lie, they shielded the truth from me
many times. Never trust the internet. This
time when I checked in the internet, I saw
only negative reviews about the medicines I
am taking, this can be nerve-racking. Listen
to what your doctor says. Chemotherapies
are angels in disguise. They are meant to save
you, so never hate them. Adjust to the chemo
sessions. See cancer just like any other disease.
I went to visit my professor from
Thiruvanthapuram, Dr. Ravi Pillai. He
advised me to do physiotherapy, for muscle
pain, psychotherapy for depression. This is
also known as post-traumatic psychosis for
diseases like this. Some people get affected
mentally when they come back from serious
illnesses. Even cancer patient go through
emotional imbalances like too much anger,
crying. And spiritual therapy is important.
It is also important to do regular checkups
so you can detect if there is a recurrence.
Most people do not do that, thinking it is
alright. If ever you have cancer, do not feel
fear because fear and immunity are related.
Just see cancer as any other disease. There
are people who take experimental drugs,
even those that have not received approval.
Be mentally prepared. You can day dream,
and when you are taking rest, remunerate
on your life, do a self-evaluation. You
might want to become a refined individual,
stop fighting for small things, be a good
person. I take medication after consulting a
psychiatrist. There is nothing to be ashamed
of in that. Psychiatric drugs help me to talk
with you, otherwise I might start crying. So
it is important people understand getting
psychiatric treatment is very important for
recovery. The hospital is now involved in
several project. There are so many new
departments now, several were started ever
since I came here for my first chemo. Then
if you employ a good team, then you will see
success. Its important to love them because
that’s the most valuable weapon that God
has given us. So it is important to love who
are with us, because then they will return
the same feelings. Understand their feelings
and they will do the same. The hospital is
like a family. Even the patients are happy.
They tell us that it is like meeting one’s own
family member. Whether it is for a staff or
a patient, it is important to give them love. I
always feel that women run institutions better
because we rule with the heart. The decisions
are always taken by me and my daughter. My
husband has given me all the freedom to run
this hospital. I have many dreams for this
hospital. I am remodeling another building
and expanding. I don’t have time to think
about any negative things. I have a lot of
dreams and I think about those and it gives
me a positive feeling. I daydream when I sit
in the car (my driver drives, of course), I
dream about implementing new things in my
country. Even this hospital was the fulfillment
of a dream. I can do whatever I like in
whatever budget I am planning, and a lot of
charity works. Even the domestication didn’t
affect us. I believe that my dreams will let me
live longer. I pray to God to extend my life.
What is your message to the
community?
Community support is very poor. It is
important guests who come and sympathize
with you. Always be positive. Cancer is
curable; there are many people who live with
the disease, and who get cured. It is also
important to avoid quacks. Once cancer is
treatment is over, it is important to do follow-
ups regularly. Otherwise you will never know
if the cancer has spread anywhere. Always
be positive. Tell yourself that you will live
to see the marriage your children, see their
grandchildren and if you are an entrepreneur
then dream about growing your business. The
community must also understand that people
afflicted with cancer are emotionally drained,
so they must be given the support and life.
In the past, cancer was not curable, but
now it is not so. Cancer can be cured. Cancer
treatment and oncology has evolved so much.
Certain lifestyle changes, complete with
proper diet and hydration is important. If
there is proper waste disposal and if people
avoid burning plastic, then a lot of things can
change. Simply blaming the government is
not enough because citizens also have to do
their bit. People also have to avoid consuming
organically grown fruits and vegetables. The
government must take the responsibility
for growing organic fruits and vegetables.

Obituary
A
t a meeting of IMA office
bearers with Mayor, even before
the meeting began, a visibly
anguished Mayor, was not very much
pleased with IMA not holding public
condolence meeting on Dr. Ramanadhan’s
death. He thought he was too big than IMA
confines and his presence in city for more
than half century warranted much more.
Truly, Dr. Ramanathan, grew
with this city, gave everything
in his life to it, serving its
population in his own
humble way
Dr.Ramanthan’s
clinic, was an
abode for the
average citizen,
the treatment
costs matching
his purse.
Un assuming,
always pleasant,
his bedside manners
were exemplary.
He would walk miles
to see a patient and had
surgery done in the shade of
petromax light, anecdotes
he would regale you with relish.
He had varied interests, education, music,
religion, horticulture, to name a few.
ThyagarajaMusicfestivalwashisideaandhe
nourisheditwithallsincerityanddedication.
His IMA connection is legendary. Starting
from its inception, buying the land, until
recently, he had no rivals for the treasurer’s
post a rare feat indeed. My memory of Dr.
Ramananthan, trudging into veranda of
a discrepit it IMA building, Dr. Capt. AB
Das, the secretary, cycling down to meet
a small group with C R Parasuram, Dr.
Anandasivan, Dr. Haridas,
Dr. MA Abdulla, not to
leave Dr. Thyagarajan
still lingers.
Harassment by
Drug inspectors
was the most
talked over
subject in
those days.
Montgomery
said it is not
death but it
is dying that
alarm me. Not for
Dr. Ramanathan pangs
of suffering, death came to
him as a friend not as an enemy.
They say old men go to death,
death comes to the young: Dr. Ramanathan
cannot die out of this world. When he
goes, he leaves behind much of himself.
Dr. Hamza Thayyil
Shiba hospital
Surgery & urology center
MBBS, MS, MCh(Uro), Consultant Surgeon and Urologist
Reminiscences
of a legend
Not for
Dr. Ramanathan
pangs of suffering,
death came to him as a
friend not as an enemy
Dr. Ramanathan

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Just like the famous
poet Kadamanitta
R a m a k r i s h n a
had sung about sadness
Rajendran Sir was a person
capable of giving relief from
pain to many people I knew
Dr. Rajendran

News & Events
District Medical Strike – Discussion with Vadakara IMA office
bearers at Vadakara IMA Hall at 3pm on 3rd may 2017
IMA executive meet on 5th 2017
Secretary Dr. S.V. Rakhesh took awareness class on ACNE at
Malabar Tourism Expo & Food Festival 7th May 2017
IMA Kerala State Action Committee meeting at IMA
Hall, Kozhikode on 7th May 2017
Medical dharna at collectorate reg. Badagara Asha
Hospital attack from 10 am to 1pm on 3rd May 2017.
: Branch president Dr. P.N. Ajitha inaugurating the seminar on
“AMMA ARIYAN” in connection with Mother’s Day – organised by
EraamalaGramaPanchayat, Orkattery on 9th May 2017
Dr. P.N. Ajitha President IMA Kozhikode inaugurating the
awareness class on Well Reacharge in association with
Yuvajana Sports Club & Library, Chevarambalam on 11th
may 2017
Emergency executive committee meeting reg. Medical dharna at
Collectorate on 2nd May 2017.

News & Events
Kozhikode IMA hoisting 254th State
Working Committee meeting at IMA Hall,
Kozhikode on 14th May 2017
Condolence meeting -Dr.Mathai at 7.30pm.
on 19th May 2017
IMA State Level inauguration of Schizophrenia Day
at IMA Hall in association with Thanal.
Chief Guest Sri. KaithapramDamodaran on 24th
May 2017
Public awareness programme on Monsoon
Diseases – Precautions. at IMA Hall,
Membership campaign at Dept. of
Radio Diagnosis, Govt. Medical College,
Discussion with the management of Mathrubhumi
on 27th May 2017
LEAP(Life Style Evaluation & Awareness for Police). A joint of
venture of IMA & Police Association at Police Club on 28th May 2017
State Level launching of Brain Club in
association with Rotary Club, Calicut
Smart City at IMA Hall, Kozhikode on 23rd
May 2017
World No Tobacco Day – IMA State
level inauguration at Sports Council
Hall, Kozhikode in association with
APCCM, Calicut Pedallers, Rotary
Club of Calicut Beach and INPAAR
Organised Awareness Cyclethone by
Calicut Pedallers at LIC Corner. Branch
President Dr. P.N. Ajitha flagged off at
7.30 am. Followed by a panel discussion
on “Tobacco – a Threat to Development”
at Sports Council Hall. Dist. Legal Service
Authority Secretary and Dist. Sub Judge
Sri. R.L. Baiju inaugurated the programme.
IMA State President Dr. V.G. Pradeep
Kumar presided over the function.
Branch President Dr. P.N. Ajitha welcomed
the gathering. Dr. T.P. Rajagopal, Dr.
K.P. Sooraj, Dr. Vipin Varkey, Sri. V.S.
Ramachandran, Sri. Dinkar Karunakaran
and Adv. Shijo Joseph are participated the
seminar. Programme Co-ordinator Dr. A.K.
Abdul Khader proposed vote of thanks.

IMA in News
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IMA News letter 2017

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IMA News letter 2017