Journal of-general-medicine

Editorial
Welcome to the inaugural issue of our e-version of Journal of
General Medicine. The Journal is specially designed to deliver
quality and varied contents in medical and related fields which will
interest doctors of different specialties and super specialities. The
journal is being mailed to over ten thousand doctors in India and
abroad.
3D echocardiographic imaging has been developed over the last 3
decades with the aim of providing additional anatomic detail and
improved spatial relationships that were not available from 2D
images. It is useful for clarifying complicated cardiac anatomies
and hemodynamics. Both transthoracic and transoesophageal real
time 3 dimensional echocardiography (RT 3D E) imaging have the
ability to improve the diagnostic accuracy of echocardiography in
multiple clinical scenarios.RT3 DE imaging is superior to
traditional 2D echocardiography and is routinely indicated in the
quantification of left ventricular volume and ejection fraction and
quantification of the mitral valve area in mitral stenosis. Will RT 3D
E soon become a standard part of the adult echocardiogram? Dr
Sanjay Rajdev- Interventional Cardiologist, Seven Hills Hospitals,
gives an overview of the clinical applications of this interesting
cardiacimagingmodality.
Not only has clinical presentation of Dengue changed; the rate of
complications has also risen. With GOI & WHO both releasing
newer guidelines, it is imperative for all of us to practice Evidence
Based Medicine. A relook at Dengue by Dr Shamshersingh
ChauhanundermentorshipofProf. DrAlakaDeshpande.
In the quest of reducing post-operative complications, the latest
query is “Is pre-op assessment of Thyroid Function Tests (TFT)
necessary?”. Prof Alaka Deshpande makes a strong case for
achieving euthyroid status before elective surgery and including
S.FT4 andS.TSH estimationsinpre-opevaluationofallsurgeries.
Today, Consumer ProtectionAct covers the medical profession and
the there is increasing awareness among patients about their rights.
Hence, litigation against doctors has risen sharply. Cases are filed
daily in state consumer commissions, tribunals and the district
consumer forums. Having a medical indemnity insurance policy is
important to cover both- the practicing physician and the patient if
something goes wrong during medical care and the patient is
harmed. Dr VP Singh, Associate Professor of Forensic Medicine;
DMC, Ludhiana underlines the importance of taking out an
indemnity insurance policy. Dr. C.H. Asrani, Senior Family
Physiciangivespracticaltipstoavoidlitigation.
Doctors’work hard, many of them are top earners.Medical ability
does not necessarily translate to financial acumen.Attitudes toward
money and investing can create financial challenges later in life. Do
we invest our money wisely? The article on ‘Investments-What a
Doctormustknow’shouldhelpdoctorsplantheirinvestments.
Pleasantreading!
Dr RameshSubramanian
The Journal of General Medicine
Oct-Nov 2015 Vol.1 No.1
Advisory Board:
Padmashree Prof. Dr Alka Deshpande
Dr Sangita Pikale
Dr Sanjay Arora
Dr Sachin Almel
Dr Sanjay Rajdev
Dr Nitin Balakrishnan
Dr R R Shah
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Dr C H Asrani
Scientific Editor:
Dr Ramesh Subramanian
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Dengue; An Update
Prof Dr Alaka K Deshpande & Dr Shamshersingh G Chauhan
Mobile: +91 9869168886
Email: alakadeshpande@rediffmail.com
Abstract
Dengue is the most common arboviral disease in the
world with over 50 million people being affected all
over. Caused by the virus from genus Flaviridae,
manifestations can vary from non-specific viral
illness to devastating disease. Early diagnosis, rapid
identification of the complications and fluid
restoration is the cornerstone of management of this
disease.
Introduction
“Dengue is one disease entity with different clinical
presentations and often with unpredictable clinical
evolution and outcome”. This was the fact that
expert consensus groups in LatinAmerica (Havana,
Cuba, 2007), South-East Asia (Kuala Lumpur,
Malaysia, 2007), and at WHO headquarters in
Geneva,Switzerlandin2008,allagreedon.
These infections may be asymptomatic or may lead
to an undifferentiated fever (or viral syndrome),
dengue fever or dengue haemorrhagic fever
(1)
(DHF)
The word “dengue” is derived from the Swahili
phrase Ka-dinga pepo, meaning “cramp-like
seizure”.
Epidemiology
It is currently regarded as the most important
arboviral disease internationally as over 50% of the
world’s population live in areas where they are at
risk of the disease, and approximately 50% live in
(2-6)
dengueendemiccountries.
Dengue has been present for centuries. The first
epidemic of clinical dengue-like illness in India was
recorded in Madras (now Chennai) in 1780 and the
first virologically proved epidemic of DF in India
occurred in Calcutta and Eastern Coast of India in
(7,8,9,10)
1963-1964. and routine outbreaks keep on
occurring every year with numbers increasing
duringthemonsoon.
Virology
The dengue virus, a member of genus Flavivirusin
the family Flaviviridae, is a single-stranded
enveloped RNA virus. There are four distinct but
closely related serotypes (DENV1–4).They possess
antigens that cross-react with other members in the
same genus such as yellow fever, Japanese
encephalitisandWestNileviruses.
Aedesaegyptiisis the most efficient vector for the
virus because of its domestic habits. The female
bites during the day and these mosquitoes don’t
travel much distance from the area of origin and may
result in all members of the family being affected.
Once a female bites a human with the virus, it
undergoes an extrinsic incubation period of about 8
to 10 days and then is able to infect the humans.
Once infected, the Aedesmosquito can transmit the
( 11 )
virus for about a month. Transovarian
transmission is possible in dengue but it is unclear
how it would affect the epidemiology of the
(12)
disease.
 Hon Prof &Headof Departmentof InternalMedicine,SirJ J Hospital,Mumbai
 MemberNationalBoardofExaminers
 Member,TechnicalResourcegroup, HIVCare&SupportNACO up todate
 Member,ScientificAdvisory Committee,NationalAIDS ResearchInstituteNARI, Pune up todate
 Member,ScientificCommittee,IndianCouncilof MedicalResearch,New Delhi
 Authored6 books + co-authoredover100text-books&publicationsinmedicine&healthcare
 Over 150 training workshops for specialists, consultants, medical officers, private clinicians and paramedical staffs
conductedundertheaegisof NACO, CMAI, DHS, ICMR, andIMA
 Presentedover100 researchpapersatinternational,nationalandlocalmedicalconferences
Page 5
Clinical Section

Clinicalfeatures
After the incubation period, the illness begins
abruptly and, in patients with moderate to severe
disease,isfollowedbythreephases –
 Febrile
 Criticaland
 Recovery.
The WHO has adopted a new method to classify
dengueas:
 Dengue without warning signs-nausea,
vomiting, rash, leucopenia, positive tourniquet
test,bodyachesandpains.
 Dengue with warning signs-abdominal pain or
tenderness, clinical fluid accumulation, mucosal
bleed, hepatomegaly >2cm, thrombocytopenia
andincreasinghaematocrit.
 Severe dengue-severe plasma leakage leading to
shock, severe bleeding, SGOT & SGPT in
thousands causing severe hepatitis. Impaired
consciousness, involvementof otherorgans.
Febrile phase - Patients typically develop a high-
grade fever suddenly, whichlasts 2-7 days, often
accompanied by facial flushing, skin erythema,
generalized body ache, myalgia, arthralgia, retro-
orbital eye pain, photophobia, rubelliform
(17)
exanthema,throatcongestionandheadache.
A positive tourniquet test in this phase indicates an
increased probability of dengue. Mild haemorrhagic
manifestations such as petechiae and mucosal
membrane bleeding (e.g. of the nose and gums) may
(18,19)
beseen.
Critical phase - The onset of the warning signs of
dengue, as stated above, herald the onset of critical
phase. A fall in temperature is accompanied by
plasma leakage which causes exudation of plasma
into the third space compartments causing ascites,
pericardial and pleural effusions. Leakage of plasma
leadstoincreaseinhematocritvalues.
More than 20% increase in haematocrit values from
the baseline signifies hemo-concentration and
demands a good hydration therapy. The rise in
haematocrit precedes fall in blood and pulse
pressure.The significant plasma leakage lasts only 1
to2days.
Other Aedesmosquitoes capable of transmitting
d e n g u e i n c l u d e A e . a l b o p i c t u s , A e .
polynesiensisand several species of the Ae.
Scutellariscomplex. These other species also
transmit the dengue virus but not as effectively as
theAedesaegypti.
Pathogenesis
During the feeding of mosquitoes on humans,
DENV is presumably injected into the bloodstream,
with spillover in the epidermis and dermis, resulting
in infection of immature Langerhans cells
(13,14)
(epidermal dendritic cells [DC]). Infected cells
then migrate from site of infection to lymph nodes
and consequently, infection is amplified and virus is
disseminated through the lymphatic system.
Dissemination from the lymphatic system leads to
invasion of other cells of the reticuloendothelial
system like splenic and liver macrophages,
circulating monocytes and bone marrow. Bone
marrow stromal cells have also been shown to be
(15)
susceptibletoinfectionwithDENV.
Dengue hemorrhagic fever occurs in a patient who
has dengue virus infection and also, in the past had
dengue but with a different serotype. Halstead and
colleagues observed that the incidence of DHF and
DSS peaked in two populations of young children.
His observations led to the conclusion that
subsequent infection of pre-immune individuals
with a different DENV serotype could exacerbate
rather than mitigate disease, a phenomenon that was
claimed to be caused by antibodies and termed
antibody-dependent enhancement (ADE) of
(16)
disease.
Page 6
Clinical Section
WHO theme of

Differentialdiagnosis
 Malaria - also as endemic in India as dengue, has
almostthesameclinicalfeaturesas dengue.
 Leptospirosis - prominent myalgia(s) with
especially calf tenderness can point to
leptospirosis.
 Chikungunya - usually occurs in localized
outbreaks, has similar intensity of bone pains as
dengue,thus adifferentialinearlyphase.
 Viral hepatitis - liver enzymes in thousands
point towards an infective aetiology like
Hepatitis A,B,E but severe dengue can cause
hepatitis which can elevate the enzymes to such
proportions.
 Influenza - pharyngeal and conjunctival
injection with abdominal pain can mimic
influenza.
Recovery phase - After 48 hrs of the critical phase,
resorption of the leaked out fluid occurs. Some
patients have a confluent erythematous or petechial
rash with small areas of normal skin, described as
(20)
“isles of white in the sea of red”. Many patients
havegeneralizedpruritusintherecoveryphase.
If the critical phase continues, and adequate
hydration has not been received by the patient, then
thepatientsmaylandintodengueshock syndrome.
Page 7
Clinical Section
Table- 1Atypicalmanifestations of dengue.
(24)
ARDS , pneumonitis
CNS
GIT
Renal
CVS
Respiratory
system
Encephalitis, mainly amnesia,
dementia, manic psychosis, Reye’s
syndrome, Guillian Barre syndrome,
transverse myelitis and acute
disseminated encephalomyelitis all
have been reported to occur in
(21,22)
dengue.
Acute hepatitis, especially on the 9th
day, Acute pancreatitis, acalculous
(21)
cholecystitis
ARF mostly due to accompanying
(22)
shock andDIC
Pericarditis, effusions,
(23)
myocarditis
Dengue virus_Atomic-level structure.

 Thrombocytopenia of moderate degree is a usual
finding associated with dengue, the reasons for
(34-38)
which are multifactorial, and falling
platelets is the cause of hospitalization9s) and
worries for thetreatingclinicians.
 Immature platelet fraction (IPF) is a laboratory
parameter which helps in diagnosing the cause
of thrombocytopenia. The IPF is elevated in
cases of thrombocytopenia which happens due
to peripheral destruction and is depressed when
the cause is bone marrow suppression. One
study has found out the relationand utilityof IPF
in dengue. According to it, when the IPF is
repeated after obtaining it basal value on day
one, and it shows a rising trend, then, the rise in
(39)
plateletcountis imminentwithin24-48hours.
Thus prophylactic transfusions of platelets can
beavoidedinmanycases.
Treatment
For a disease that has such complex pathology and
such diverse clinical features, the treatment remains
fairly simple. Adequate hydration can well save a
patient suffering from severe dengue and decrease
boththemorbidityandmortalityfear.
The WHO has formulated complete guidelines on
the management of dengue including the admission
(31)
anddischargecriteria.
The following patients, who are diagnosed with
dengue,needtobehospitalized:
 Any patient with warning signs of dengue(see
above)
 Unable to tolerate oral feeds and dehydrated,
toxiclook
 All pregnant patients and patients with other co-
morbidities like diabetes mellitus, anaemia and
obesity.
 Infantsandelderly.
 Rickettsial infection - Rickettsial disease in
India has been documented from Jammu and
Kashmir, Himachal Pradesh, Uttaranchal,
Rajasthan, Assam, West Bengal, Maharashtra,
Kerala andTamil Nadu with Batra has reported a
high magnitude of scrub typhus, spotted fever
(25-28)
and Indian tick typhus caused by R. conori.
Fever, headache, rash myalgias can confuse
with dengue and other common infections we
seedaily.WeilFelixtesthelpsindiagnosis.
 Crimean Congo virus - CCHF is a zoonotic viral
disease caused by tick-borne virus Nairovirus
(family Bunyaviridae). The typical course of
CCHF infection has four distinct phases-
incubation period, prehemorrhagic phase,
hemorrhagic phase, and convalescent phase.
The incubation period for CCHF virus is in the
range of 3-7 days. The mean duration is largely
influenced by the route of infection, viral load,
and source of infection-blood or tissue from
(29)
livestock.
 Severe sepsis - it can mimic DHF and DSS but a
(30)
normalESRcandifferentiatethetwo.
Diagnosis
Specific tests are widely used to detect the presence
of dengue.Denguecanbedetectedusing:
 Antigen - detection of ns1Ag in sera upto 3 days
offever.
 Seroconversion - detection of IgM titres in sera
fromanegativestatus.
 Virusisolation-using RT-PCRtechniques.
Page 8
Clinical Section
ns1Ag
Test
Test (Contd.)
IgM antibody
Viral isolation
Detection of ns1Ag in sera upto 3 days of
fever.
From the 3rdday onwards IgM antibodies
begin to form and is detected in 50% of
patients by days 3 and in 98-99% patients
(31)
byday9of illness.
Intracerebral inoculation of newborn
mice, inoculation on mammalian cell
cultures, intrathoracic inoculation of
adult mosquitoes, and inoculation on
(32,33)
mosquito cell cultures but they are
done only in a handful of patients and in
researchcentres.
Liver enzymes, complete blood counts,
prothrombin time, may all show
derangement.
RT-PCR
Other tests
According to the World Health
Organization (WHO), RT-PCR is a
powerful method to be used for dengue
diagnosis, but it still needs to be better
standardized.

Parameters that should be monitored include vital
signs and peripheral perfusion (1-4 hourly until the
patient is out of the critical phase), urine output (4-6
hourly), haematocrit (before and after fluid
replacement, then 6-12 hourly), blood glucose and
other organ functions (such as renal profile, liver
profile,coagulationprofile,asindicated).
Patients who have severe plasma leakage, severe
end organ involvement require aggressive fluid
management. Fluid boluses at rate of 10-20ml/kg
may be required over 15-30minutes may be required
inDSS.
If the shock persists and the haematocrit increases or
is still high (e.g. haematocrit > 50%), repeat a
second bolus of crystalloid/colloid solution at 10-20
ml/kg/hour for one hour. After this second bolus, if
there is improvement continue with crystalloid
solution and reduce the rate to 7-10 ml/kg/hour for
1-2hours, thencontinuetoreduceas above.
If haematocrit decreases compared to the initial
reference haematocrit (especially if the repeat
haematocrit is below the baseline, for example < 35-
40% in adult females, < 40-45% in adult males), and
the patient still has unstable vital signs, this may
indicate bleeding. Look for clinical evidence of
severebleeding.
Cross-match fresh whole blood or fresh packed red
cells and transfuse if thereis severe overt bleeding; if
there is no bleeding, give a bolus of 10-20 ml of
colloid, repeat clinical assessment and determine
thehaematocritlevel.
If the condition improves then, give the fluid
according to the patients who do not have shock (see
above).
Parameters to be monitored include: alertness and
comfort levels, vital signs and peripheral perfusion
(every 15-30 minutes until the patient is out of shock
then 1-2 hourly).Adecrease in haematocrit together
with stable haemodynamicstatus and adequate urine
output, indicates haemodilution and/or reabsorption
ofextravasated fluids. In this case intravenous fluids
must be discontinued immediately to avoid
pulmonaryoedema.
Some plant extracts and antiviral drugs are showing
promising inhibitory effects on dengue virus,
howeverclinicaltrialsareawaited.
Other patients can be effectively monitored at home
under close supervision of the primary health care
provider.
 Adequate hydration using coconut water, juices,
ORS can be administered to the patient. If he
cannot tolerate the same then, admission to a
hospitalisnecessary.
 Paracetamol upto 4g/day can be used for fever.
NSAIDS should be avoided as they may increase
the risk of bleeding by functional defects of
platelets and also may precipitate Reye’s
syndrome,especiallyinchildren.
 Tepid sponging can be used to decrease the
temperaturesas well.
 Daily, or in resource limited settings, every third
day, hematocrit and platelet counts needs to be
donetomonitorthedisease.
Patients who are admitted in the hospital need
hydration by oral and preferably by intravenous
route.
Intravenous FluidTherapy
Step-wiseapproach:
 A reference haematocrit is obtained before
intravenousfluidtherapybegins.
 Only isotonic solutions such as 0.9% saline,
Ringer's lactate or Hartmann's solution is
recommended.
 It is started with 5-7 ml/kg/hour for 1-2 hours,
then reduced to 3-5 ml/kg/hour for 2−4 hours,
and then further reduced to 2-3 ml/kg/hour or
less accordingtotheclinicalresponse.
 The clinical status is reassessed and haematocrit
is repeated. If the haematocrit remains the same
or rises only minimally, fluid at the same rate is
continued (2-3 ml/kg/hour) for another 2-4
hours.
 If the vital signs are worsening and the
haematocrit is rising rapidly, the rate is to be
increasedto5-10ml/kg/hourfor1-2hours.
 The clinical status is reassessed and haematocrit
is repeated and fluid infusion rate is adjusted
accordingly.
 Principle is to give the minimum intravenous
fluid volume required to maintain good
perfusion and urine output of about 0.5
ml/kg/hour.
 Intravenous fluids are usually needed only for
24-48 hours.
Page 9
Clinical Section

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Although corticosteroids are not mentioned in the
WHO guidelines on the management of dengue,
clinicians use corticosteroids empirically based on
the presumed immunological basis of the
complications of dengue. The evidence base for the
benefit or lack of benefit of corticosteroids in
dengue is limited; the effect of corticosteroid
treatment in adults with dengue infection has not
(40)
beenevaluated.
Dengue vaccines in development are of four types:
live attenuated viruses, chimeric live attenuated
viruses, inactivated or sub-unit vaccines, and
(1)
nucleicacid-basedvaccines.
One is a chimeric tetravalent vaccine in which the
structural genes (prM and E) of each of the four
dengue viruses were inserted individually to replace
those of yellow fever virus in the backbone of the
yellow fever 17D vaccine and are currently in phase
(41)
IandIItrials.
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Page 10
Clinical Section

Introduction to 3D Echocardiography
Dr Sanjay Rajdev
DM, MD, DNB, MNAMS
Consultant and Head, Department of Cardiology, SevenHills Hospital
Mobile: +91-9768427300
Email: sanjayrajdev@hotmail.com
 MD, DNB, MNAMS
 DM at Seth G S Medical College and KEM hospital, Mumbai in 2004. Fellowships in Interventional
CardiologyattheUniversityofAlabamaatBirmingham,USA(2006), MountSinaiMedicalCentre,
NewYork, USA(2007)
 ConsultantandHead,DepartmentofCardiology, SevenHillsHospital
 Specializes in the use of angiojet thrombectomy device, intravascular ultrasound (IVUS), rotational atherectomy and in the
endovasculartreatmentof symptomaticperipheralarterialdiseases
 Reviewerfor 6national/internationaljournals;Over 25 publicationsinindexedinternationaljournals
 Invitedasfacultytoseveralinternationalmedicalworkshops andconferences
 Holds theLimcaBookofRecords
Introduction
Conventional systems of non-invasive cardiac
imaging focus around single and two dimensional
plain image acquisitions and their interpretation.
Three dimensional (3D) echocardiography has been
a recent advance which helps better understanding
of the anatomy of heart. It gives a detailed and
complete assessment of cardiac structures and their
(1)
interrelationship. It correlates better with cardiac
M R I t h a n s i n g l e o r t w o d i m e n s i o n a l
echocardiography and hence is closer to the “real
truth”thataninvestigatorislookingfor.
TechniqueofAcquisition of3D Echo
Acquisition of images is done just as in a 2D
echocardiographic examination. Patient is asked to
lie in left lateral decubitus, a phased array transducer
is placed at the point of interest, patient asked to
hold his breath for about 4 seconds and image is
acquired. The different image sectors are then
stitched along time axis to generate a pyramidal
shapedrawdataset.
There are two basic modes of display as the image is
being acquired. The real time 3D transthoracic
echocardiography (TTE) and the live 3DTTE.In
addition to the two basic modes of acquisition, the
3DTTE also permits color Doppler examination.
The color Doppler data set is smaller (30 degree x 15
degree)as therealtime3DTTE.Ittakeslongertime
Figure1: Thicker 3D transducer (X3-1) as compared to
thinner 2D transducer (S5-1).
Although 3D echocardiography has provided newer
insights into the cardiac anatomy, imaging quality
relies on obtaining a good 2D echocardiography
window. Subsequent analysis of the acquired image
(2)
datasetsprovidesthenecessaryinformation.
(6-8 cardiac cycles) to acquire and provides a useful
3 dimensional data set for exploring the vena
contracta area and is useful for assessment of
valvular heart lesions. Most recent introduction is
3D trans-esophageal echocardiography (3DTEE)
where imaging is done by inserting a probe in the
esophagus.
 fastest heart attack care in the country, primary angioplasty with stenting done in a record door to balloon time of 16
minutes
 maximum number of cases in catheterization laboratory processed in a single day, with more therapeutic procedures
than diagnostic (Total 19 Cases, 11 angioplasties, 8 diagnostic studies)
 maximum number of coronary angioplasties in a single day, during routine hours (16)
 IndiaBookof Recordholderfor maximumcasesdoneinasingleday(Total22)
Clinical Section
Page 11

Figure 2: Triangular shaped parts of image acquired over 4
seconds, stitched together to form pyramidal shaped data set
which can then be analysed offline. Source JASE.
PrincipalApplications 3DTTE
1.BetterUnderstanding oftheCardiacAnatomy:-
3DTTE represents a major advance into the
understanding of the normal anatomy of the heart.
The surface of the mitral and tricuspid leaflets from
the ventricular as well as the atrial side have been
visualized for the first time employing this
technique. The enface atrial and ventricular septal
surfaces have never been visualized before.
Visualization of the 3-dimensional structure of the
papillary muscles, the chordae, the moderator band,
the venous valves, great vessels, ventricular
myocardium was not possible before the advent of
3DTTE. In addition, the cropping plane may cut at
any angle and in any direction to visualize any
structure under consideration. One can virtually
navigate inside the heart looking at structures from
differentanglesandanydesiredperspective.
volumes. The 3D-Q software allows for
quantification of both mass and volumes while the
3D-QA software allows for quantification of
ventricular volumes, ejection fraction and also
allows segmental contribution towards total stroke
volume. The software also allows for a
semiautomatic endocardial border detection
algorithm, which can be turned to manual tracing
mode when desired, for calculation of the
ventricular chamber volumes. The results are then
displayed in a graphical format with volume
contribution to stroke volume of each of the 17
segments for LV. The chamber mass can also be
calculated by applying the 3D-Q software which
permits endocardial and epicardial border semi-
automatic tracking and calculation of LV mass.
Similarly, the ventricular volumes can be calculated
by applyingthe3D-QA(advanced)software.
2. CalculationofCardiacMasses andVolumes:
The iE 33 Philips ultrasound system has the
software called the Q-Lab which permits accurate
calculationof LV,RV,LAandRAmassesand
3.Assessment of stenotic and regurgitant valve
orifices
The 3DTTE allows calculation of areas of stenotic
orifices, for example, orifice area of mitral and
aortic stenoses can be calculated after obtaining an
enface view of the stenotic orifice size. This allows
much more accurate computation of the valve areas
as compared to the 2DTTE. Similarly the
assessment of vena contracta area by sequential and
systematic cropping and obtaining an enface view
of the regurgitant orifice size gives an accurate
assessment of the severity of regurgitant lesions like
(3)
mitral, tricuspid and aortic regurgitation. The
etiology of many of these lesions (infective
endocarditis, flail leaflets, etc) can also be
ascertainedusing 3DTTE.
Figure 3: Oblique cropping plane (arrowheads) dissecting
the ventricle from below.
Figure 4: As case of LV outflow obstruction due to
supravalvar calcific spurs. Demonstrated well by arrow
head. Aortic valve seen in non stenotic.
Clinical Section
Page 12

6.Assessment ofcardiacmasses
One of the biggest advantage of 3DTTE is in the
comprehensive assessment of cardiac masses.
Tumors, thrombi and other space occupying lesions
can be studied in a systematic manner using this
technique. The thrombi can be cut by a cropping
plane and the inside of the thrombi can be looked
into. The degree of ongoing lysis inside the
thrombus is visualized as echo lucent areas within
and is predictive of response to anticoagulant
therapy. The tumor can be volume and size
quantified, dissected to understand the composition
andthepresenceorabsenceofstalkcanbeknown.
7.Assessment ofseptaldefects
Defects in the interatrial and interventricular septum
can be visualized enface using 3DTTE. This gives a
3-dimensional perspective to the operating surgeon
which helps him understand the anatomy better
before the operation. The exact size, its relationship
to the atrioventricular valves can be assessed, much
(5)
betterthantheconventional2DTTE.
5.Assessment ofCardiomyopathies
The volumes and ejection fractions of patients in
heart failure carry important prognostic
information. 3DTTE offers a precise technique for
the measurement of these parameters. The offline
analysis using the Q-Lab provides an accurate
assessment of the left ventricular volumes.
Similarly mass can be calculated with precision in
patients with hypertrophied ventricles and thus
(4)
prognosticatethemaccurately.
Figure 6: Communication between the great vessels like the
aorto-pulmonary widow can also be seen enface and the
exact area measured.
Figure set: Use of 3D TTE for assessment of ventricular
septal defect. Defect can be seen enface with all borders well
delineated and exact size measured.
8. Applications in assessment of congenital heart
disease.
The spectrum of 3DTTE also extends to involve
congenital heart diseases. The understanding of the
spatial relationship between different anatomical
structures, which is very crucial to pediatric
echocardiography,iswellaccomplishedby theuse
4.Assessment ofMitralValveProlapse
Using the 3DTTE and by systematic cropping of the
raw data set, the leaflet structure, surface and the
area of the prolapsing leaflets can be ascertained.
This gives a good idea to the operating surgeon
about the exact areas which need to be addressed
duringsurgery.
Figure 5: Short axis views of the cardiac valves as seen from
the ventricular and atrial aspects. AML is fleshy and seen
prolapsing into the LA from the atrial aspect.
Clinical Section
Page 13

of 3DTTE. Various disease entities amenable to
study by 3DTTE include ASD, VSD, AVSD, PDA,
AP Window, TOF, TGA, Ebstein’s anomaly,
pulmonary atresia with intact ventricular septum.
Thelistis everincreasing.
9.Intrauterinescreeningofcongenitalanomalies.
3DTTE is not only helpful in understanding
congenital anomalies after birth; it also allows
studying these entities in utero. Given the poor
resolution and low frame rate of the technique at this
point of time, it may not be employed routinely for
assessment of suspected congenital anomalies but
hold great promise for the future with improved
resolutionandhighframerates.
M i s c e l l a n e o u s A p p l i c a t i o n s o f 3 D
Echocardiography:
1.TranscatheterclosureofASDs obviatingtheneed
ofintraoperativeTEE
2.Assessment ofaorticdissection
3.Assessment oftrueandpseudo aneurysms.
(6)
4.CRTtherapyevaluation
5.Rightparasternalapproachforimagingproximal
aorta,SVC andpulmonaryarteries
6.CoronaryarterytoLVfistulaeassessment
7.Coronaryarteriesvisualizationincluding
ALCAPA
8.Assessment ofLVNon Compaction
Although quite impressive, 3D echocardiography at
best remains a useful adjunct to conventional 2D
echocardiography. It provides useful additional
information over and above that provided by 2D
echocardiography. It is not widely available,
equipment and hardware is expensive and there
aren’t many trained operators. Till the time more
doctors are trained in this art, hardware is made
widely available and procedure made cost effective,
we continue to rely on 2D echocardiography as the
modality of initial screening for cardiovascular
disorders.
References-
1. Real-time three-dimensional echocardiography: a current view of what
echocardiography can provide? Hage FG, Nanda NC. Indian Heart J. 2009
Mar-Apr; 61(2):146-55.
2. Real time three-dimensional echocardiography: specific indications and
incremental value over traditional echocardiography. Nanda NC, MillerAP. J
Cardiol.2006 Dec;48(6):291-303.
3. Assessment of aortic regurgitation by live three-dimensional transthoracic
echocardiographic measurements of vena contracta area: usefulness and
validation. Fang, L., Hsiung, M. C., Miller, A. P., Nanda, N. C., Yin, W. H.,
Young, M. S., Velayudhan, D. E., Rajdev, S., Patel, V., Echocardiography -
2005 Oct
4. Real time three-dimensional echocardiography for the evaluation of
cardiomyopathy. Hage FG, Dean P, Raslan S, Nanda NC. Echocardiography.
2012;29(1):76-87.
5. Usefulness of live/real time three-dimensional transthoracic
echocardiography in the characterization of ventricular septal defects in
adults. Mehmood, F., Miller,A. P., Nanda, N. C., Patel, V., Singh,A., Duncan,
K., Rajdev, S., Enar, S., Singh, V., Nunez, A., McGiffin, D. C., Kirklin, J. K.,
Pacifico,A. D., Echocardiography-2006May
6. Relation of right ventricular free wall mechanical delay to right ventricular
dysfunction as determined by tissue Doppler imaging. Rajdev, S., Singh, A.,
Am J Cardiol-2006 Feb 1
Clinical Section
Page 14

Page 15

Undetected Hypothyroidism: Surgical Challenges
Padmashree Prof. Dr Alaka Deshpande
Mobile: +91 9869168886
Email: alakadeshpande@rediffmail.com
 Hon Prof &HeadofDepartmentofInternalMedicine,SirJ J Hospital,Mumbai.
 MemberNationalBoardofExaminers
 Member,TechnicalResourcegroup, HIVCare&SupportNACO up todate
 Member, ScientificAdvisory Committee,NationalAIDS ResearchInstituteNARI, Pune up todate
 Member, ScientificCommittee,IndianCouncilofMedicalResearch,New Delhi
 Authored6books + co-authoredover100text-books&publicationsinmedicine&healthcare
 Over 150 training workshops for specialists, consultants, medical officers, private clinicians and paramedical staffs conducted under the
aegisof NACO, CMAI, DHS, ICMR, andIMA
 Presentedover100researchpapersatinternational,nationalandlocalmedicalconferences
Dysfunction and anatomic abnormalities ofThyroid
are common endocrine problems.These patients
may have to undergo surgery for non-thyroid causes
or even for thyroid related ailments. The main role
of thyroid hormones is in body metabolism, which
may be altered in stress situations. Surgery also
being a stressful situation, Management can be a
challenge!
Patientscanundergo surgeryfor
 Surgeryotherthanthyroidgland
 For thyroidgland
Thyroid function tests are not ordered unless
clinically suspected. Hypothyroidism in early
stages may be asymptomatic or has protean
manifestations therefore may not be clinically
suspected. If such a case with undetected
hypothyroidism undergoes surgery for non-thyroid
causescouldtherebeperi-operativecomplications?
Is pre-op assessment of Thyroid Function Tests
(TFT) necessary?
There are no Randomized Controlled Trials. Since
thyroid hormone estimation is at present easy,
inexpensiveandsensitive,should itbedone?
The clinical features of hyper thyroidism are
apparent; are noticeable both to the patient and the
doctor; thus TFTs are usually ordered. But
hypothyroidism has protean manifestations. Mild
and moderate disorders can be, and are clinically
missed. Would they pose management challenges if
hypothyroidism remains undetected preoperatively
andhenceuntreated?
The alteration in physiological parameters in
untreatedhypothyroidismarehighlightedbelow.
Clinical Section
Hypothyroidism&Surgery
 Hypometabolism
 DecreasedCardiacOutput,HR, contractility
 Hypoventilation
 Respiratorymuscleweakness
 Inadequate respiratory response to hypoxia /
hypercarbia
 Decreasedgutmotility
 Hyponatremia
 Increased creatinine
 Decreaseddrugclearance
 DecreasedVitK depclottingfactors
 DecreasedRedcellmass
 Normocyticanemia
Onecanponderoverfollowingobservations:
SurgicalOutcomes
Although there are no Randomised controlled trials,
the observations of case controlled studies can be
considered. In addition there are many cases of
undetected hypothyroidism undergoing
planned/emergency surgery developing various
serious complicationsthathavebeenreportedin
Page 16

medical literature. These reports come mainly from
anaesthesiologists because they are managing the
case from pre-operative evaluation to intra and post-
operativemonitoringandmanagement.
Theimportantobservationsare
 FallinBP
 CVcollapse
 Increased sensitivity to narcotics, sedatives and
anaesthesia
In addition to systemic complications in
hypothyroid cases, the anaesthetists may have
difficulty in intubating a patient in presence of
goiter.
For example, Grave’s Disease is characterised by
hyperthyroidism, Ophthalmopathy and goiter. The
retrosternal extension of the gland remains hidden
or a huge goiter may cause tracheal shift, tracheal
compression and tracheomalacia making intubation
challenging. Many people are not aware of goitrous
hypothyroidism. In autoimmune thyroid disorder
in early stages pt may be asymptomatic but has a
goiter. It may be mistakenly diagnosed as
physiological goiter and may be inadvertently
subjected to surgery. All cases presenting with
goiter should be assessed for thyroid functions.
Morphological evaluation of the thyroid gland and
trachea will be helpful both to the anaesthetist and
surgeon.
Study 1
A retrospective study of surgeries in untreated
hypothyroid patients and age/sex matched
euthyroid controls did not reveal any difference in
followingparameters.
 Normalvs hypothyroid patients n=120
 No differencewas notedin
Study 2
This case controlled study includes 40 untreated
hypothyroidcasesand80 euthyroidcontrols.
The outcome in untreated hypothyroid cases
revealed
 More events of peri-operative fall in blood
pressure.Intra-operative and post-operative BP
monitoringis crucial.
 Cardiac surgery was associated with congestive
heartfailure.
 Neuropsychiatric abnormalitieswere more in
hypothyroidcases.
 Post –op ileus was more frequent inuntreated
hypothyroidgroup.
 Patients with infections had fewer episodes of
fever than euthyroid controls thus misleading
treatment.
 Othercomplicationswere
n=40hypothyroid&n=80control
InHypothyroidgroup:
 hypotension,CHF
 >GI, neuropsychiatricabnormalities
 <feverwithinfection
No differencewas observedin
 Bloodloss, durationof hospitalstay
 Arrhythmia
 Hypothermia
 Hyponatremia
 Wound healing
 RespComplications
The clinical features of severe hypothyroidism are
characteristic however conformation comes from
serum TFTs. The risk of anaesthesia and surgery in
severe untreated cases of hypothyroidism is of
serious concern.Itmaybecomplicatedby:
 Myxoedemacomarisk
 Highmortality
 Hypotension
 Hypothermia
 Hypoventilation
 Bradycardia
 DecLOC
 hypoNa,hypoglycaemia
 CHF,pericardialeffusion
 Operation Room duration
 Cardio-vascular outcomes were
comparable.
 Time to extubation/post op ventilation
remained comparable.
 Bleeding
 Fluid/ electrolytes
 Sepsis
 Time to discharge
 Delayed recovery from anaesthesia and
abnormal haemostasispossibly due to
acquired form of von Willebrands
disease.
 Hypothermia and hyponatremia needed
close monitoring.
 Respiratory complications like retention
of CO2 were noted and required close
monitoring.
Clinical Section
Page 17

However severe hypothyroidism presents with
classicalclinicalprofile,whichnecessitatesTFTs.
Considering high morbidity and high mortality in
severe hypothyroidism, except emergency surgery
all other cases should be adequately treated and
euthyroid status assured before surgery. Even in
case of emergency surgery, close monitoring and
institution of thyroid replacement as shown below
needstobeinstituted.
 SevereHypothyroidism
 No good dataof whattodo
 Only emergencysurgerysincehighrisk
 L-T4200-300mcgtaperedto50mcgod
 L-T3 5-20mcg tapered to 2.5-10mcg q8h x 2
days or tillalert
 If suspicion of adrenal insufficiency & no time to
testthenadminister
 Stress doseglucocorticoids
Monitor
 Hemodynamics
 Fluid/electrolytes
 Ileus
 Neuro-psychiatricabnormalities
 Infectionwithoutfever
Mild to moderately severe hypothyroidism adds to
the peri-operative morbidity. Presence of above
described complications may arouse the suspicion
of hypothyroidism; serum TSH estimation is
advisable. However unlike severe cases, immediate
hormone replacement may not be necessary.
Supportive treatment can tide over the situation but
close monitoring is needed. As soon as FT4 and
TSH reports become available oral thyroxine may
beinitiatedinlowdose.
Emergency surgery is generally safe in
unsuspected/undetected hypothyroidism although
planned or elective surgery in a hypothyroid case
should bedeferreduntileuthyroidstateis achieved.
Cardiovascular surgery in hypothyroidism is a
special situation. Treatment with L-T4 may
aggravate angina but absence of treatment may
aggravate cardiac failure. Study reveals no
difference in mild/moderate cases without
thyroxine;howeverclosemonitoringis essential.
Considering the paucity of symptoms or protean
manifestations of mild/moderate hypothyroidism,
is it imperative to include serum FT4 and S.TSH
estimationinpre-operativeevaluation?
S.TSH is a good screening test for thyroid
dysfunctions. Presently S.TSH estimation is
included in pre-conception evaluation of the
prospective mother; if not it is estimated in the first
ante-natalvisit.
Similarly it is advisable to measure the S. FT4 and
S.TSH in a pre-operative evaluation of planned
surgery. Hypothyroidism if detected should be
correctedpre-operatively.
Surgery in hypothyroid patients is associated with
an increased risk of several minor perioperative
complications, which should be anticipated and pre-
emptively managed in the course of their
anaesthetic and surgical care. Emergency surgery
should not be postponed but patient should be
rigorously monitored for evidence of CO2
retention, bleeding, ileus, infections and
hyponatremia.
Apart from surgery for non-thyroid indications,
Patients with goiters can be subjected to surgery. It
maybefor
 Goiterwithcompressivesymptoms—
 ThyroidMalignancy
 Goitrous hypothyroidism—Autoimmune
thyroid disorder in early stages presents with
goiter. Many of these cases are inadvertently
subjected to surgery as the patient may be
asymptomaticor duetopaucityoflabfacilities.
 All the goiters need functional evaluation with
TFTs as well as morphological evaluation by
ultrasonographicorCTimaging.Itisnecessary
 t r a c h e a l s h i f t / c o m p r e s s i o n ,
tracheomalacia
 FollicularAdenoma
 Cold nodule with suspicion of
malignancy
 Toxic goiter—Surgery is not the choice of
treatment in view of Radioiodine therapy
and anti-thyroid drugs.It is absolutely
essential to control hyperthyroidism
beforesubjectingtosurgery.
Clinical Section
Page 18

to assess the trachea as well as retrosternal extension
of the goiter. It will facilitate anaesthetist’s
management.
Recommendation
 Itis thereforesuggested
 S.FT4 and S.TSH estimations should be a part of
pre-opevaluationofallsurgeries.
 Euthyroid status should be achieved before
electivesurgery.
 Close monitoring of above described parameters
inintra-op/peri-operativeperiodis necessary.
References-
1. Outcome of anesthesia and surgery in hypothyroid patients - WeinbergAD;
Brennan MD; Gorman CA; Marsh HM; O'Fallon WM -Arch Intern Med 1983
,May;143(5)893-7
2. Complications of surgery in hypothyroid patients.AU Ladenson PW; Levin
AA;RidgwayEC;DanielsGH SOAm J Med1984Aug;77(2):261-6.
3. Anesthesia and thyroid surgery: The never ending challengesSukhminder
Jit Singh BajwaandVishal SehgalIndian J EndocrinolMetab. 2013 Mar-Apr;
17(2):228–234
4. Anesthesia and hypothyroidism: a review of thyroxine physiology,
pharmacology, and anesthetic implications.Murkin JM.AnesthAnalg. 1982
Apr;61(4):371-83.
5. Undetected hypothyroidism and unexpected anesthetic complicationsP
Sudha,Rachel Cherian Koshy,andViji S PillaiJ Anaesthesiol ClinPharmacol.
2012Apr-Jun;28(2):276–277
6. Complications of surgery in hypothyroid patients.Ladenson PW,Levin
AA, RidgwayEC,DanielsGH.Am J Med.1984Aug;77(2):26.
7.Harrison’s principalsof InternalMedicine 18thedition
8.WilliamsTextbookofEndocrinology,10thedition
Clinical Section
Page 19

Doctors & Investment
Dr Anonymous
MBBS, DCH
Author is MBBS, DCH. In practice for over 10 years. She started dabbling in investing right from college
days – small bits from her pocket money and subsequently from practice; today she has amassed a small
fortune. She does not wish to reveal her identity and will keep sharing financial tips and tricks for doctors since only a doctor
knows anotherdoctor's fears,concernsandinsecurities,wheremoneyisinvolved.
Why isinvestingimportant?
It is often observed that people (we doctors as a
community are no exception) generally mix-up the
meaning of saving and investing. For many, it's one
and the same. And that's where the basic mistake of
personalfinancearises.
We all work hard and earn our living and decide to
stack that money in a back account earning a
nominal 4% or a maximum of 7% (offered by select
private sector banks).As the digit grows, so does our
happiness, which leads us to thinking we have done
thebestwecouldwithour money.
I would say this is one of the primary mistakes that
needs to be corrected, and quick. Allow me to
explainwhy…
The average inflation in India over the last four
years has been hovering between 6-7%. This means
that the money I am earning as interest from the
bank account is not even beating inflation. In fact, it
is giving a negative return, which means that the
purchasing power/value of my money has, in effect,
diminished. This is where investing comes to the
rescue.
Differencebetweensaving and investing
It's often said that a penny saved is a penny earned.
Saving means, you are putting away a certain
amount which you think may be needed in the near
future to meet your needs (recurring or non-
recurring in nature). You basically do not expect to
earn anything aggressively out of it. For example:
Keeping Rs one lakh at home or in a certain bank
accountalways,tofaceanyemergency.
This isSAVING.
INVESTING, on the other hand, is saving our hard
earned money through a financial instrument in the
expectation of that sum multiplying over number of
years. It may be for a specific goal that you wish to
accomplishinthelaterdays ofyourlife.For
example:planninga second home,buildinga corpus
for kid's overseas education or retirement planning.
Simply put, investment is a means to enhance /
createourwealth.
Please understand that investing is not a random or a
default action like buying gold or property
whenever you have money. It needs to be well
planned. This is because every investment
instrument has a tax angle to it, which needs to be
understoodbeforeyou makethatmove.
Please understand that investing is not a random or a
default action like buying gold or property
whenever you have money. It needs to be well
planned. This is because every investment
instrument has a tax angle to it, which needs to be
understoodbeforeyou makethatmove.
Following are some of the benefits of investment
thatIhavenoticedfrommyexperience:
 Investment makes money work hard: I have
invested in stock markets via mutual fund. This
is because, I hardly understand equity market
and for sure, I can't easily recognise a good
companyfromabadoneandmostimportantof
Non Clinical Section
Page 20

 all, I don't have the time to follow stock market
and indulge in regular trading; not till I plan
semi-retirement. But, we all have the option of
taking the benefit of a professional fund manager
sitting in a mutual fund company who is an
expert at the game. He not only invests my
money in good stocks but also generates decent
returns.
 Means to keepyour money inflationproof: When
I said decent returns in the last point, I meant a
five-year return of nearly 15% (my experience).
This not only keeps my money inflation proof
but also allows me to actually earn more than
fixed deposits. By the way, this money is tax-free
as itis classifiedunderlong-termcapitalgain.
 To enjoy the power of compounding: Compound
interest is one of the most beautiful aspects of
financial world and is that secret ingredient
which helps money multiply in the long run.
Compound interest not only helps you earn on
the principal amount invested but also on the
interestamountaccumulated.
 Keeps us on a financially sound track to reach
our goals: When we diligently invest a fixed
amount every month, no matter how small it is, it
silently grows in a huge corpus over the years,
which is sure to surprise us positively. The
returns generated through this process will be
higher than the inflation, thanks to the cost
averaging which the money undergoes over a
period of time. Disciplined and planned
investing has helped me to be on a financially
soundtrack. I am prepared to face any adversary
because I know my family and me have a sound
corpus tofallbackon.
Therefore, investment allows our money to grow,
slowly and steadily. Remember there is no magic
that can make us rich, overnight. So, be patient and
refrain from being greedy. When in need of advice,
seekhelpfromqualifiedpersons.
Everything I have written in this article is from my
personal experience. Incase you haven't made any
investment, yet, I implore you to correct your action
andinviteyou toenjoythefruitsof investing.
Good Luck!
Page 21

Avoiding Litigation
Dr C H Asrani
Mobile: +91 9820007703
Email: drchasrani@cmhs.in
A 35 yr old man- no comorbidities, non-smoker had
a convulsion on the road side and fell unconscious;
was shifted to a major medical institution (non-
Governmental) in Delhi and was diagnosed to have
bleeding AVM; was pronounced inoperable. Later
that night a doctor from their family (from Mumbai)
urged a top neurosurgeon connected to a private
hospitalto takethe riskand operate.The patientwas
operated upon after detailed explanation of what all
can go wrong on the table and subsequently. The
family was also made to sign a high risk consent.
Patient responded initially but expired 7 days after
surgery; in the intervening 7 days, detailed history
was sent to doctors in US & UK (by the patient’s
family) and they concurred that the best that could
be done was done. 3 months after the death, his
father slapped a 1 crore case on the surgeon making
the referring doctor an accomplice and alleged that
neurosurgeon had called them to his hospital with
assurance of recovery. Fortunately, all paper work
was perfect (neurosurgeon was trained in UK) and
the case never reached the court but he was
harassed by meeting lawyers, preparing a 80 page
replytochargesleviedetc.
ThisisatruestoryandIwasthereferringphysician.
Why should ‘we’becareful?
Litigation against doctors has risen 400% in last 10
years; so what if only 10-15% may reach the court
and decided against the doctors; ask the involved
ones of agony undergone plus time and money
spent!
Why this incidencewillalways continueto rise?
 Over 1,30,000 deaths due to road traffic
accidents/ other injuries; this number will
continuetorise!
 Approximately 50% of first ever myocardial
infarctions meet a sudden death i.e. within 1st
hour and most are not even aware that they have
thedisease;thisalsomaygetworse.
 Acute infections viz. dengue, malaria etc getting
more aggressive/ turning fatal; year on year
scenariowillbeworrisome.
With such unexpected death toll rising; and with
patients/ families and so called social workers
getting more judgemental; fuelling public outrage
through social media and comparing treatment
given by a doctor against what is shown on
YouTube/ Google - such instances will keep
increasing. The definition(s) of Acts of Omission
and Acts Commission notwithstanding, people are
going to jump to the conclusion that doctor did NOT
do whathe/she was supposed todo.
A more important fact is that we are NOT God and
some of our patients will succumb to illness/ injury;
very few may even meet their end most
unexpectedly; so, our prime motto is to manage our
practice(s)thatour patientsandtheirfamilies/well-
 DiplomateNationalBoard(FamilyMedicine);MBBS
 38yearsofquality, comprehensiveclinicalpracticeinfamilyhealth&Corporatehealth
 Co-foundedIndianDoctors Guide- India's largestportalexclusivelyfor practicingdoctors
 Co-founderINCHES group - Country's firstenterprisefor HealthEducationandHealthservices
 EstablishedTeacherofFamilyPhysicians,bothclinical/non-clinicalsubjects
 Medico-legalExpert
 RegularContinuingMedicalEducationfor practicingphysicians(conductedover500 lecturesectionsfor doctors)
 Editorof variousmedicaljournals
 PresentedInvitationpapers/Panelist– over200 events
 25talksonAllIndiaRadio(Hindi&English)
Page 22

wishers do not think (even erroneously) that we
missed out something and if we had been more
careful, their patient would be alive! The fact 85-
90% cases either do not reach courts or are decided
in doctor’s favour tells us that these complaints are
baseless but all the same ‘WE’ have been
complained against and we have to respond; appoint
an advocate; prepare replies and wait with a bated
breath…
Prevention,thus, isthekey!
Talking of prevention, since we medicos always talk
in terms of primary prevention and secondary
prevention;letus begininthesamemanner.
First primary prevention is like taking a vaccine –
our Indemnity Insurance (Dr V P Singh has penned
anarticlejustfor you).
I would highlight only two points here for ensuring
weareNOTcomplainedagainst:
 Regularly updated knowledge (no one should
ask us, ‘doctor saab, aapko nahin samjha
*
kya ?’
 Proper & open communication: even if the
family is in doubt, they should approach us for a
heart-to-heart talk and we should be able to
clarifytheirdoubts.
Regularupdates
Medicine is changing almost by the hour; it is
tougher for family physicians to update in all 20
disciplines but update they must. Best way is to have
data connectivity in the clinic and refer to relevant
information (even in front of patient; takes barely 2-
3 minutes) and patients also gets a feel that we have
taken some effort for them. Ensure we are only
referring latest information on credible websites/
books online to get insights into standard treatment
guidelines.
Communication isthekey!
A senior physician was murdered in Mumbai and
the reason was he did not answer the brother when a
patient was dying; he said “kya batayega tumko?
**
Bola na, usko kucch nahin kar sakta hai ”.
Imagine saying this, if a patient is hospitalized under
our care???
a. Most doctors can not break bad news (in a survey
done of practicing doctors 61% agreed that they
cannot) as no such training is imparted during
medical education and most of us carry the
experience of our teachers speaking badly to
relatives.
b. When we are talking to a patient/ family member;
weareactuallycommunicating
andcommunicationis dividedthus:
 7% words: Words are only labels and listeners
puttheirown interpretationon speakers’words.
 38% Paralinguistics: The WAY in which
something is said (ie accent, tone, inflection) is
veryimportanttoalistener’s understanding.
 55% facial expressions: What a speaker looks
like, while delivering a message, affects the
listener’s understandingthemost.
 And we must believe that a patient’s antenna is
very strong; they easily decide, ‘aaj kal doctor
***
saab dhyan nahin dete ’. And we need one
such misunderstanding to be pulled to court,
should amishapoccurduringour treatment.
SecondaryPrevention
Once a case has been filed against us, the aim is to
have the case decided in our favour and for this, our
records (MIS in modern lingo) can be our saviour. It
is hence necessary for each practitioner to document
and preserve all clinical notes (examination findings
& treatment suggested including diet and physical
activity advice given). Experience says most family
physicians do not have records (some may have case
papers or diaries for family patients) but consultants
in private practice/ own hospitals do not keep any
records; all files and prescriptions are given to
patient and in case of a litigation all the patient has to
say ‘lostthefileinrickshaw’.
* Doctorsaab,youdidnotunderstandthisisgoingtobecritical?
** What to tell you? Didn’t I tell you once, nothing can be done for him
*** Nowadays, doctor is paying attention
Page 23

Following is the list of scenarios, which if looked
into, couldsave us fromlitigation.
Achecklist:
1. Do you give out diagnosis to patients/ family
withoutevidence? Yes No
2. Are you referring patients to someone, whose
clinical acumen / quality of work you are not sure
of? Yes No
3. Do you assure patients more than the situation
demands? Yes No
4. Are you giving false certificate(s) to patients for
insurance purpose regarding duration of ailments or
thattheydon’texist? Yes No
5. Are you busy on your mobile when patient is in
your cabin? Yes No
6. Do you speak rudely/ in anger with your patients/
family? Yes No
7. Do you refuse first aid in an unknown patient with
eitherRTA, poisoningorotherMedicolegalissue?
Yes No
*
8. Are you using suffixes as MIMA or similar
whicharenotqualifications! Yes No
9. Do you keep a copy of prescription/ certificate
you give? Yes No
10. Do you give prescription as per Supreme Court
guidelines? Yes No
11. Do you address all concerns of patient/ family
voicedtoyou? Yes No
12. Do you support the patient when he/ she talk ill
of anotherdoctor? Yes No
13. Do you keep a copy of the note while referring
the patient (especially in critical condition) to a
hospital? Yes No
14. Canyoubreakbadnews, withconfidence?
Yes No
15. Is your staff courteous? Yes No
16. Do you keep confidential history really
confidential? Yes No
The correct answer(s) to Qs 1 to 8 is NO; and to the
rest of Qs is YES. Check the score; higher the score
of incorrect answers, higher are the chances that
someday someone will get angry and pull us to
court!
TakeHomeMessage
In a nutshell, practice within guidelines; refer
rationally (other side is defensive medicine, which
should be avoided); do not assure more than
required; keep patients notified of the concerns on
our mind; learn to break bad news; most
importantly,learntocommunicateandnotjusttalk!
Our patient today loves us; trusts us. Let us NOT
shakethattrust!
References-
1. http://sites.ndtv.com/roadsafety/important-feature-to-you-in-your-car/
2. http://circ.ahajournals.org/content/96/9/3215.full
3. http://www.firstpost.com/india/dengue-claims-five-more-lives-in-delhi-
death-toll-rises-to-37-2449722.html
* Member of IMA
Page 24

Page 25

Introduction
The Supreme Court's verdict of granting Rs. 11.41
crore compensation in Kunal Saha's case has
shocked the medical fraternity. There is an
apprehension amongst the medical fraternity that
such a huge compensation awarded by the Apex
Court has set an alarming standard regarding the
quantum of compensation. The effect of this
judgment may result in a culture of awarding
skyrocketing compensation in medical negligence
cases. There is a feeling of insecurity amongst
doctors, which may stop them from taking decisions
at crucial moments fearing that, 'if things go wrong,
theywouldbedragged tocourt'.
In current scenario of ever increasing risk of
professional liability lawsuits and unbearable
compensation claims against the medical
professionals and healthcare establishments,
professional indemnity insurance gives a sigh of
relief at least against the monetary losses. Even
today, a large percentage of medical professionals
have not secured themselves under this professional
insurance cover. It is recommended that all the
doctors rendering professional services to the
patientsmustgetthemselvessufficientlyinsured
Indemnity Insurance: why we must have it?
Dr VP Singh MD, LLB & Dr Rajendra S. Bangal Professor & Head, Dept. of Forensic Medicine & Toxicology
Medicolegal Consultant and Associate Professor
Dept. of Forensic Medicine & Associate Toxicology, DMC & Hospital, Ludhiana, Punjab.
Mobile: +91 98154 77722
Email: singhvp@gmail.com
and maintain the continuity of coverage till few
yearsaftertheystop thepractice.
There is a feeling of financial insecurity amongst
doctors due to such high quantum of compensation.
Regardless of the outcome of the professional
liability lawsuit, legal cost of defending a lawsuit
alone may be financially crippling particularly in
casesthatlingeronforyears.
While practicing medicine in such set of
circumstances, it is imperative for the medical
professionals to protect themselves from financial
crisisby gettingprofessionalindemnity
Professional Indemnity Insurance
The concept of indemnity is based on a contractual
agreement made between two parties, in which one
party agrees to pay for potential losses or damages
caused by the other party. Though indemnity policy
is not a compulsory policy like vehicle insurance,
still it is strongly recommended that all doctors
should get themselves sufficiently insured.
Allegation of medical negligence can occur on the
first day of one's practice or on the last day of the
practice.
Dr. VP Singh is a medicolegal consultant working as anAssoc. Professor, at Dayanand Medical College
& Hospital, Ludhiana, Punjab. He is qualified in Medicine as well as in Law. He did his MBBS and MD
(Forensic Medicine) from GMC Patiala and LL.B. from UILS, Punjab University. Dr. Singh is a strong
promoterof healthcarequality, patientsafety, andmedicolegalawarenessamongstthemedical
fraternity. He isactivelyinvolvedinteachingmedicolegalissues tothedoctors.
Dr. Singh has been working in the medicolegal domain for over 17 years now. From his years of studies and experience, he has
deep rooted understanding of medical laws and ability to provide effective solution to the medicolegal conflicts. He has delivered
many guest lectures on various medicolegal issues. He has organized numerous CMEs on medicolegal issues, and workshops on
medicolegalreportwriting.
He is editor of a book, “Legal Issues in Medical Practice; Medicolegal Guidelines for Safe Practice” The book is a step by step
guide that provides basic understanding of medicolegal principles in a simple language, and enables a busy practitioner to
establishsafeclinicalpractice.
Page 26

What does itcover?
The terms and conditions of every professional
indemnity insurance may vary slightly, but all of
them cover only the civil liability i.e. claims arising
out of civil negligence are payable under these
policies. Liability arising out of any criminal act or
act committed in violation of any law or ordinance is
notcovered.
The policy covers all sums which the insured doctor
becomes legally liable to pay as damages to third
party in respect of any error and/or omission
committed on his/her part, while rendering
professional service. Legal cost and expenses
incurred in defense of the case, with the prior
consent of the insurance company, are also payable,
subjecttotheoveralllimitofindemnityoptedfor.
Howmuch insuranceissufficient?
While deciding on the amount of insurance, you
mustconsiderthefollowingaspects
1.Nature of medical practice: whether you are a
family practitioner, a specialist, super-specialist,
full-time practitioner or honorary consultant and
natureofspecialization.
2.Geographical location of practice (rural/ urban/
slums/elitearea)
3.Type of patient population (literate/ illiterate/
Indians,NRIs, foreignnational)
Pecuniary jurisdictions of the consumer courts (At
present the pecuniary jurisdiction of district
consumer forums is up to Rs. 20 Lakhs. So it is
advisable that the minimum sum insured (even by a
family physician) should at least be Rs. 20 Lakhs.
Other specialists and super-specialist may apply for
higher sums depending on other factors. (As per the
proposed amendments in CONSUMER
PROTECTION (AMENDMENT) BILL, 2014, the
quantum of pecuniary jurisdiction of District
Consumer Disputes Redressal Fora has been
enhancedtoRs. 50lakhs.
In case of any event likely to give rise to a liability
claim as described above, insurance company
s h o u l d b e i n f o r m e d i m m e d i a t e l y a n d
acknowledgement received. One should also insist
on obtaining the claim number. In case any legal
notice or summons is received, it should be sent to
the insurance company.The company has the option
of arranging the defence of the case. The event
giving rise to the claim should have occurred during
theperiodofinsuranceorretroactiveperiodandthe
claim first made in writing against the insured
during the subsequent policy period (provided the
policyisrenewed).
Essential concerns while getting Indemnity
Insurance Cover
1. Provide the correct and complete information to
the insurance company. Any inaccuracy,
nondisclosures or incorrect information might
resultinyourclaimgettingrejected.
2. Always inform correct information about your
previous claims, number of beds, qualifications of
staff,unqualifiedstaffetc.
3. Always preserve a copy of your complete
proposal form for future reference. Do not rely on
the insurance companies to preserve your proposal
form.
4. Verify the correctness of the contents of the policy
copy once you receive it. In case of any errors, get it
correctedimmediately.
5. Always check and confirm the retroactive date
mentioned in the policy issued every year. If wrong
getitcorrected.
6. As the claims under indemnity policy are almost
always retrospective, so preserve all the copies of
your previous and current policies in order to prove
thecontinuouscoverage.
7. Always renew the policy well in advance. Do not
relyonyourinsuranceagentsforrenewals.
An Ideal Indemnity Insurance Policy: Proposed
Components
Though the indemnity policy is a 'must have' for all
the medical professionals, the protection provided
by the policy is far from being adequate. The
premiums are low and as such, the insurance
companies are disinterested in this insurance, as
neither they have any expertise to deal with these
matters nor is there any machinery in place to
process the claims. As a result, when a claim is
intimated to them, doctors generally experience
apathy, disinterest and a tendency on the part of
insurance company to reject the claim. Hence there
is urgent and great need to formulate a
comprehensive mechanism to address all these
issues.
Some of the issues that generally arise after a claim
occur,canbeeffectivelyaddressedby optingfor
Page 27

group policies and negotiating with the insurers for
providing certain additional features which are not
provided by the general policy (i.e. to have tailor-
madepolicies).Someoftheseare:
1. Provisions to cover expenses incurred for
defending complaints before State and Indian
medicalcouncils
2. Provisions for the insurance company directly
compensating the patient after the court order, rather
than the doctor having to pay first and then getting it
reimbursedfrominsurer.
3. Out of court settlements (after following the due
process, mutually agreed by the insurer and the
group)
4. Provisions to cover the costs incurred for
defending cases of medical negligence before
criminalcourts
5. Provisions to cover entire defence cost including
incidental expenses like documentation costs, fees
for expert advise, conveyance costs etc. in addition
totheadvise fees.
6. Provisions to appoint a pre-approved panel of
advocates (by mutual consensus between the
insured group and the insurer); decide their
professional fees, in order to enable the insured to
appoint an advocate at the shortest possible time
whenneeded.
7. Provisions to have a single insurance office for
processing all claims under this policy for all
membersofthegroup.
8. Provisions for reduced premium after a doctor
stops his practice but only wishes to continue the
cover in case of any claim that might arise from his
acts/omissions committed during his previous years
of service (during which period he has paid the
completepremium).
Alternatively, some other mechanism may be
devised for financial security against court orders in
cases of medical negligence. They may be either on
the lines of Medical Defense Union, UK, modified
as per Indian needs and scenario or in the form of
professional self-insurance schemes, as being tried
inAhmedabadandKerala.
Conclusion
In cases of medical negligence lawsuits, doctor’s
reputation as well as money is at stake and also much
of their quality time is consumed in defending the
allegations. Although the reputation and the time
lost cannot be indemnified, professional indemnity
insurance can at least indemnify the monetary
component of the crisis. As of today, professional
indemnity policy is an intelligent decision to get
secured against the pecuniary compensations
awarded by the courts in cases of medical
negligence liability lawsuits. Doctors should not
ignore the ever growing problem of medical
malpractice litigation, and run for the cover. It is
betterbesafethansorry!
Acknowledgment
This article is an abridged version of the chapter,
“Professional Indemnity Insurance: Better Safe than
Sorry” published in a medicolegal book, “Legal
Issues in Medical Practice: medicolegal Guidelines
for Safe Practice” cited as: Bangal RS. Professional
Indemnity Insurance: Better Safe than Sorry. In:
Legal Issues in Medical Practice: medicolegal
Guidelines for Safe Practice. Delhi: Jaypee
Publishers; 2016. p. 97-102.The article has been
publishedwithduepermission.
Page 28

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