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Monday, December 11, 2017

What is a "Lumbar Puncture"?

This post pertains to a particularly important procedure that doctors need to perform on children (and adults) with certain specific kinds of illnesses. 

The procedure is known as a LUMBAR PUNCTURE. In this procedure, we insert a needle under sterile, aseptic conditions into the spine of a child to extract a few millilitres of CEREBROSPINAL FLUID - the watery fluid that bathes our brain and spinal cord - to analyse it to diagnose neurological conditions and nervous system infections. 

In children, we do not remove the CSF with a syringe; rather, we collect as it drops into a bottle

The most common diagnosis we are trying to corroborate is MENINGITIS. This means infection or inflammation of the meninges - the covering of the brain and the spinal cord. Children with suspected meningitis present with a short illness of high fever, inability to stare or to look at bright light, a stiffness of the neck and, in cases where the doctor is not consulted acutely, other significant neurological symptoms like headache, pain in the limbs, inability to flex one's legs on to the abdomen, and, in severe cases, loss of consciousness, or even fits.

A non-blanching rash may also be a harbinger of a particularly sinister kind of bug - the meningococcus. See my OTHER post on this kind of rash. 

While the exact procedure for a lumbar puncture varies from country to country or system to system the general steps are the same. Consent from a parent/parents is required. This may be verbal or written, depending on where this is being done. For example, in India, we take written consent, while in the U.K., it is all right to take verbal consent. The consent must include the fact that not only is the procedure explained, but also its side-effects. 

The child is laid on a flat-topped bed or procedure bed. He is turned on one side. The doctor aims to puncture in the centre of the back where the spine is located; he must be adequately immobilised by helper members of the medical crew. Usually, parents are advised NOT to stay beside the child but to wait outside the procedure room. A support worker may be allocated to stay with the parents for support. 

After cleaning the back, a needle is passed into the space between two of the back vertebrae till it is inside the cerebrospinal fluid. As the CSF drops, it is collected into bottles for examination and for organism culture studies. The needle is then withdrawn and disposed of safely. The puncture site is sealed with "OpSite" a kind of plastic dressing spray. This is then covered over with a small, circular bandage and the child is handed over to the anxious parents. 

The common side-effect of a lumbar puncture is a minor headache. Usually, there are no other harmful effects. Theoretically, there is a risk of introducing bugs through the puncture into the nervous system. This is very rare, however. 

Results of the tests are usually available within the hour. Based on the initial results, doctors will advise parents on which way the treatment is likely to go ahead. Usually, if an infection was suspected, doctors will have ALREADY started antibiotics or antiviral drugs, or both, even before a lumbar puncture is carried out. Usually, such antibiotic or antiviral therapy is then continued till the culture results from the fluid are made available - which could be up to 3-5 days later.

To summarise:

1. A lumbar puncture is putting a needle into the centre of the back to collect cerebrospinal fluid
2. Usually, this procedure is done to prove/disprove the presence of infection of the nervous system organs or tissues, usually, the meninges.
3. The procedure needs verbal consent in most countries. 
4. It is carried out with the strictest antisepsis. 
5. The procedure is generally safe and tolerated well by almost all children,
6. Theoretically, there is a rare risk of introducing infection. 
7. Results of the test will guide further therapy. 

Thank you.

Tuesday, October 24, 2017

Rights of a Patient - Right to be informed of harm occurring to them because of the medical system

I am writing this post to make patients all over the world aware that there is a significant risk of harm occurring to themselves or to their near and dear ones who are receiving medical care in a hospital. This is because human error is always possible - even in the best hands. Apart from human errors, there can be machine-led errors, systemic errors and other forms of misfortune that can befall users of medical systems.

As per prevailing ethics, patients or their wards have the right to be informed about any and every form of such errors that cause them any kind of misfortune. This is called the duty of candour or honesty all over the developed world. In the U.K., where I work, this duty of candour has been in place since the past few years. 

Doctors are expected to contact you in person, be empathetic and inform you in detail about what happened, why it happened and what is being done to mitigate the effects of this mistake. They are also expected to report the event on their medical system through what is known as the "Incident Report". They will have to inform their line managers as well. A detailed conversation must include the assurance that the incident will be investigated thoroughly, and responsibility will be fixed. The patient/caretaker must also be told that this investigation would guide the hospital to take steps that would prevent a repetition of the same error in the future.

So, there you have it. You have a right to know if you/the patient you are responsible for has been harmed in any way through a preventable error made by a faulty system.

Friday, September 15, 2017

Invited Post on Cleft Lip Surgery options in India

Cleft - A Smile Is What We Need

Cleft is an orofacial condition where the baby is born with a gap in the lip (cleft lip) or roof of the mouth (cleft palate) or both. It is a birth defect during pregnancy when different areas of the face that developed individually join together, but fail to join properly near the mouth and the lips leading to a split or a cleft. If the separation occurs near the lips then it is known as cleft lip, and if it is near the mouth then cleft palate.
It may or may not be detected during pregnancy by an ultrasound test. One in every 700 children is found to have this birth defect.
A definite reason behind it hasn't been detected yet, but several cases related to clefts are thought to be a result of genetic and environmental combinations. Vitamin deficiencies like lack of folic acid during pregnancy along with consumption of alcohol, anti-seizure medicines and steroid tablets, and smoking are the most common cases why this occurs.
If not treated on time, Cleft can have multiple adverse effects on the child. Apart from feeding problems, the child can become susceptible to infections related to ear, nose, teeth and speech, along with psychological and social problems at a later stage. Special advice from feeding or speech therapist must be sought while breastfeeding the baby affected with the cleft lip as it may find it difficult to form a grip around the breast, and it may choke due to cleft palate if not positioned carefully.
Luckily there are affordable surgery packages in India for treating cleft lip and cleft palate deformities in India. Plastic surgeons can close the cleft by connecting the muscles of the soft palate and rearranging the tissues to close the palate. The surgery takes 1 - 2 hours to complete and requires 4 - 5 days of stay in the hospital for recovery.
Surgery can be conducted once the child is two to three months old. It is important to monitor the child's growth to ensure that it is ready for the cleft lip surgery and cleft palate surgery.
  • Care must be taken with the child's diet to ensure that it is healthy and gains weight before the surgery.
  • Child's blood type and count must be checked.
  • A thorough physical examination of your child must be done along with complete medical history examination.
  • Share all the details regarding the medicines consumed by your child with the doctor.
  • Get complete clarity regarding the medicines that can be consumed on the day of, and post-surgery.
A pink light scar can be visible after cleft lip surgery. Soreness and irritability are commonly experienced after cleft palate surgery. Chances of infection while in the hospital can be minimized by prescribing antibiotics. Clear instructions for general care and feeding must be sought for from the doctor right after the surgery. The stitches need not be cut open surgically as it usually dissolves during the recovery period.
The cost difference between cleft lip surgery and cleft palate surgery in India and in the West is huge, where India charges only one-tenth of what is charged across shores.

There are numerous success stories behind these surgeries. Each child is entitled to an uninhibited smile so let's make that happen by taking action!

Friday, March 17, 2017

Welcome the bundle of joy

As a woman embarks on the journey of pregnancy, she brings with her a lot of hope and happiness for her family. Right from her food to her lifestyle directly or indirectly impacts the baby in the womb. The extra care that is taken during these intense periods of foetal development, go a long way in having a healthy baby. An expecting mother should always be treated with care and love by her near and dear ones, to keep her positive and happy. This combination of physical and mental wellbeing is imperative to create a positive pregnancy experience.
Here are some of the things the mother and her family can follow to prepare themselves in welcoming the bundle of joy.
·         Eat healthy foods rich in iron, calcium, vitamins and folic acid. Eat at regular intervals and do not stick to the three-meal a day regime. During the initial months of nausea, keep your body well hydrated and eat foods that are filling and healthy.
·         Practice a fitness routine by doing simple walking or pregnancy yoga. It not only helps to stay active but also helps in strengthening the muscles that are essential during childbirth.  Choose the exercises that are suitable to the corresponding stage of pregnancy and always learn it from a trained professional.
·         Always keep the mind and thoughts positive. Read books that are motivational in nature and listen to soft music to keep the mind always calm.
·         Do not skip any doctor visits and scans, as regularly monitoring the health of the mother and baby is very important.
·         Always verify facts or clarify from your doctor about any kind of myths related to pregnancy. Many varied opinions about what is the best food or what is the right sleeping position can be offered to the expecting mother. Clarify it with your doctor and understand the scientific basis behind the suggestions before following them blindly.
·         Towards the end of the third semester keep a bag of essentials ready to be taken to the hospital. It will be very handy to the caregivers during and after the delivery.
·         Try to find some help during the post-partum period as it can be overwhelming for the mother and the baby. Especially first-time mothers can choose a person who they are very comfortable with, to help them with the baby right after the delivery.
·         After the delivery, take the help of the doctor or a good lactation consultant to establish breastfeeding. Breast milk is the most nutritious fluid for a baby and mastering the art of feeding a baby can be tricky without proper guidance or help.
·         Family members and husband, in particular, can help the mother with the newborn and give her some much-needed rest. The entire pregnancy and childbirth can be a very energy draining process for the woman and helping her to get adequate rest can help her get back to normalcy quickly.

There are many world-class maternity hospitals in India today that offer premium pregnancy care for expectant mothers. Choosing the right hospital with proper pre and post-partum care can make the birthing experience very smooth and joyful. 

P.S. This is a sponsored post.

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Dr. Fuhrman

Dr. Fuhrman