Was I responsible for his death?

"Sir, Please come fast your patient Mr K is gasping...."
By the time I reached the ICU the electrocardiographic monitor was showing a flat line. The Cardiologist was there and also the Urologist and a few others.They all were trying their best to revive the patient.I was summoned to talk to the relatives sitting outside. They gave me the hard job.
Yes it was a hard job.Mr K was my patient for a long time. He was suffering from Coronary Artery Disease and Chronic Obstructive Pulmonary Disease. He was in and out of ICU many times. But for the last few years he was doing fairly well.No Hospitalisation for 26 months. He was cheerful and pleasant Along with his Cardiac and Lung diseases he was also suffering from benign Prostatic enlargement. The Prostate was large enough to obstruct free flow of urine from the Urinary Bladder. He thus was able to pass Urine only through a permanent Catheter put inside his Bladder. 2 years ago he was evaluated for Prostatic surgery [so that he can pass Urine normally] but the procedure was deferred in view of his poor Lungs and Heart.
Seeing him come to my Out Patient Department every month with this urinary catheter I was tempted to rethink about Prostatic surgery. As his general condition seems to have improved during last few months,I had hope that the Prostate surgery could be done now. I referred him to Urologist. He did a complete evaluation and told me if I and the Cardiologist could give a certificate of fitness for surgery he will go ahead with the procedure. The Cardiologist gave a guarded certificate saying there is mild risk of complications including death due to the pre existing illness.I also gave such an opinion.
Some of the relatives were not willing for surgery.But his son was ready.He asked me again and again about the risks.I explained everything and said even though there is a risk it is negligible and you can give the consent. The patient was ready to comply with his son's and my decision. Finally all gave consent and surgery was fixed.

Today was the surgery day. All went all right till a few minutes ago when he suddenly suffered a cardiac arrest in the post operative ward. The attempts to revive was failing in front of my face.
What can I tell them? They believed in me and hoped the urinary catheter will go away and their father will be happy. But now the father is no more. Will they feel that I am responsible for his death.
I went out to see the anxious relatives. In a hushed tone I told them what all had happened. I told them that everything possible was done but unfortunately we could not save him.
Are their faces showing anger at me?
No only stunned disbelief.
I explained that his lungs and Heart suddenly gave away and even if it did not happen now it might have happened some days later. They took it well and there were no accusations.
But still I continue to ask the question again and again.
Was I responsible for his death? May be yes in an indirect way.

How I got interested in HIV/AIDS?

In the late 1990s, I was working in a small [Government] Taluk Hopsital. HIV 'Positive' persons I saw in my practise were few and I was happy to refer them to higher centres.

Then I got transferred to a busy District Headquarters Hospital in 2001. There I could not escape dealing with 'positive' persons.
Every week the infectious disease ward will see a new 'positive' patient coming to die.
Most of them by then might have spend a fortune on magical remedies. The most infamous among them was the medicines of Fair Pharma from Kochi. For more detailed information about how one Majeed cheated poor patients and build the costliest house in Kerala click here. Now fortunately the 'medicine' is banned in Kerala by the Court after a longstanding legal battle with 'Positive' people and PUCL.

The patients in my hospital were given symptomatic treatment and left to die. Some come and die alone while the more lucky ones have a wife or mother to be with them during their last days.
I was depressed seeing all these deaths.
What can I do for them? I asked myself.
I had no experience in treating HIV/AIDS patients. In the medical college where I studied in early and mid 1990s, 'positive' persons were rarely seen. I knew a lot from the text books but practical knowledge was nil.
Those days the Government was giving lot of training in HIV/AIDS for doctors and other health care workers, but it was only about prevention.
HIV/AIDS is a death sentence. So train yourself and others how not to get it.
This was the message of such trainings. Nobody mentioned treatment. We were not trained to cope with these dying 'positive' patients.
In the developed world by the year 2000, more than 10 drugs were available effective in treating HIV/AIDS. Few were available in India too at that time. They were expensive and somewhat toxic but still they worked. And they were cheaper than the Fake medicines of Fair Pharma.
More over, HIV/AIDS patients need treatment for opportunistic infections that attack them as their immunity is low.
So when a 'positive' patient is sick, first we have to find out which opportunistic organism or organisms have infected him/her. Then give the proper treatment so that he/she becomes better. Later, ART [anti retro viral therapy] was started. Some time in severely sick patient we may have to start both treatments together.

Training myself in HIV/AIDS management, I started treating these patients in earnest. I procured medicines from drug companies directly and thus was able to give it to patients much below market rates. The stigma of buying such medicines from Drug Store was circumvented as I myself provided the medicines.

The results were dramatic. Patients in death bed about to say their final prayers were able to look after themselves with in months. Those who sticked on to the medication schedule for more than a year began working and earn for themselves.

I lost many patients too, but I tried my level best. Some came to me at a very late stage. Many could not continue the medicines because of the high cost of ART. Many by then had become social outcasts and committed suicide.

I urged other Physicians to take up the challenge of HIV. I conducted lectures in the IMA[Indian Medical Association]. I told them that it was ,we the modern medicine doctors, who are making the 'positive' persons go to Quacks like Majeed [Fair Pharma]. As we are not ready to take care of them, they are helpless. Unscrupulous persons squeeze out the last penny from them giving false hopes.

That made some difference. Few of my colleagues started taking up such cases.

By 2003-2004, things started changing in a positive direction for 'positives'. ART drugs became cheaper. India became one of the biggest manufacturer and exporter of cheap generic HIV drugs. Govt of India started giving ART drugs free of cost at selected centres. Kerala Government followed suit.
The emphasis in training of health care workers shifted from prevention to treatment. From a 'death sentence' HIV/AIDS became projected as a chronic manageable disease needing lifelong medication like Diabetes.

Now a 'Positive' person comes to my clinic every other day. Most of them are old patients coming for follow up. A newly detected 'positive' person is seen once or twice a month. Most of them are taking the free ART drugs from Medical Colleges. Some who can afford [and is afraid of perceived stigma at Govt centres] take medicines from me.
Deaths occur but only rarely.

I cherish the sight of happy faces and healthy bodies of all those positive persons. That sight make my life meaningful.

Smoking banned in public places from today

India on Thursday once again imposed a countrywide ban on smoking in public spaces in its fight against tobacco use, four years after a largely ignored earlier prohibition saw people continue to puff away in restaurants, clubs and bars.The ban, aimed at the country's 120 million smokers, has received a good response from people across the country,Health Minister Anbumani Ramadoss asserted.
"It is a continuous process, ... and the message will go across through repeated awareness campaigns by the government and the media," Ramadoss, a tireless anti-smoking campaigner, told reporters.

The new order bars smoking in hotels, eateries, cafes, pubs, bars, discotheques, offices, airports, railway stations, bus stops, shopping malls and parks. People can continue to smoke in private homes and open spaces.The new ban has directed establishments to appoint anti-smoking officers who will be liable if people smoke.

Britain, France, Ireland and Thailand are among the countries that already have similar bans in place.
The fine for violating India's order is 200 rupees (4.29 dollars), but health authorities said higher fines of up to 25 dollars were being contemplated.
The new Smoking in Public Places Rules 2008 came into force on the anniversary of the birth of Mahatma Gandhi the Father of Nation, who was known for his ascetic habits.
Citing a survey that found that 52 per cent of children took up smoking after watching film stars lighting up on the screen, Ramadoss appealed to Bollywood celebrities not to encourage smoking.
"People look up to celebrities and follow them," the minister said. "Our popular film star Rajnikanth has stopped smoking in movies. Other stars should also set an example."
Besides the police, government officers; inspectors of central excise, sales tax, transport and health departments; and principals of schools have been given powers to fine violators on their respective premises.
Officials acknowledged that enforcement might not be easy.


India is the third-largest tobacco producer and consumer in the world after China and the United States.
According to a Health Ministry release, more than 2,200 Indians die every day from tobacco use. They are at risk from cardiovascular diseases like heart attacks, strokes and cancer.
A recent study by a team of doctors showed that tobacco smoking would kill 1 million people annually beginning in 2010.
Saying India is in the midst of a "catastrophic epidemic of smoking deaths," the doctors warned that nearly 70 per cent of the million deaths would take place among smokers in their prime.

In this large, nationally representative case–control study, it was found that in both rural and urban India, among men between the ages of 30 and 69 years, the rate of death from any medical cause in smokers was 1.7 times that in nonsmokers of similar age, educational level, and alcohol status (use or nonuse). Among female smokers, mortality from any medical cause was double that among their nonsmoking counterparts.
If you are still not convinced about quitting smoking read this and decide.

'Positive' Grand mother

When we think of HIV positive people, we imagine some one in their 20s or 30s, but there are a few 'positive' women (and men) who are in their 50s and having grand children. HIV testing may be delayed because of the age as the treating doctor may not consider this possibility.

She came with her husband 7 years ago. He was very sick having all the features of defective immunity. His test proved he is 'positive'. She was also found to be positive but with a near normal immunity. She had 3 children all in their 20s. They were all tested and found negative.
At that time, there was no free Government supply of medicines [ART] for HIV/AIDS. I prescribed medicines to prevent opportunistic infections. ART was too costly and he could not afford to take it continuously. He died within 2 years.

Last month she came to me again. She is 52 now and is living with her son. She is the proud grandmother of 3 kids. She came with recurrent fever and weight loss. She had fungal infection in her mouth, and I could make out that her immunity is low. Lab tests confirmed it, and I referred her to Govt ART Centre where she will get free anti HIV medicines. If everything goes well, she will be able to live a near normal life for a long time.

She is grateful for this opportunity to live well because of free ART, but laments the fact that her husband did not get such a chance.

When I started practising Medicine, I had helplessly seen scores of patients with advanced HIV/AIDS dying in my hospital. ART was unavailable or unaffordable. Now the availability of free ART has dramatically changed the situation.
A scientific discovery in health, whether it is a new technology or a drug , should be made available to whole mankind as soon as possible, otherwise such discovery only adds to the pain of the poor.

A happy death?

He was 74. He had diabetes and high blood pressure. He had also suffered from a Minor Stroke. He was a regular in my clinic for last 7 years. He takes his medicines regularly, tests his blood sugar frequently, and follows all my advise religiously. He came for his regular followup 2 weeks ago.

Today morning he is no more. His son called me and told me that he died in his sleep. He was apparently normal when he went to sleep. Today morning he did not wake up. Probably he had a peaceful death.

He wished for such a death. He never wanted to trouble his children and relatives. He never wanted his children to spend their hard-earned money to make him survive for a few more months or an year. He asked me never to admit him in ICU if he fell ill. He was a pensioner and could easily afford the medicines I prescribed, but nothing more than that.

Was he conscious when he died? What was his thoughts then? Did he yearn for a few more days of life? Or was he happy in death? One never knows.

Relief in death

Many of the patients admitted to my hospital are old and of course they are sick. When you are both sick and old and if you are dependent on your children or some other relatives ,you may become a burden to them.

I have many patients in their 80s, very sick, living in and out of the hospital. Most of them are taken care of well by their children, but when I talk to the son or daughter who is taking care, I can feel the burden they feel.
"How many more days Sir?
Why so frequent admissions?
Will some thing happen all of a sudden?
Will these medicines really help?
Is ICU admission really needed?"
In those questions I can feel the financial burden. Also, the strain on the family due to disrupted schedule, lost working days, sleepless nights etc. etc.,.

The death when it finally come is a relief for all. Relief for the patient from misery and also from being a burden to their kids. Relief for the children from the expensive task of looking after their parent. Relief for me so that I need not see both the patient and children suffering.