Your expectations, our limitations! - Guest Blog by Dr Sanwar Agrawal

dr sanwar agrawal

 

Saturday, May 07, 2016

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Your expectation.

"Doc! I am travelling with family day after; can you give my daughter medicine so that she is free of fever when we travel?"

My limitation!

I honestly do not know in a given patient when the fever is actually going to go away. Or, I do not have luxuries to choose from various treatment regimens to suit one or the other social obligations.

Another example.

Your expectation.

You wish to know and rightfully so, when your unconscious patient is going to gain consciousness?
Probably you have heard a doctor in a movie saying that a patient will regain consciousness in 24 hours!

My limitation!

No neurologist worth the salt can make a prediction. There is no way to know how long it will be?
There is no way to know when a failed kidney is going to resume its function, if at all!
There is no way to know if a failed liver is going to restart functioning, and again, if at all!
The truth of the matter is whenever a body organ fails to perform its functions, we have to keep supporting and supplementing, sometimes substituting its function (Dialysis is called kidney replacement therapy, it does not cure kidney disease). With the hope that in due course of time it starts functioning, it may or it may not!
Often times, especially in critical illnesses we are confronted with questions like when he will be off ventilator or when will he stop needing supplemental oxygen, we do not have numbers to give it to you. You expect us to come out with a number, and as we do not, you find it unacceptable, and increasing number of people see it as a sinister design of a commercial mind.

Your expectation.

You shove a report under my nose (you haven’t even got the patient) and wish to know all the answers to your patient’s illness! You may be right in your assertion because you have in black and white a report that should tell me all!

My limitations!

It does not (Tell me all!)

Blood tests are not done to first diagnose and then fit the patient to conform to the test results, they are (or should be) ordered to confirm or refute a clinically made diagnosis. How do I explain to a patient something I have learnt assiduously over years, and still grappling to come to terms with, what is a pre test probability of a test coming positive, what is a false positive, what is a false negative, what is positive predictive value, what is negative predictive value. How do I explain to you that prevalence of a disease in given community affects the positive predictive value of a test?

I can ad nauseam cite innumerable examples of difficulties and limitations of interpretation of a test, when a test is positive in certain percentage of normal population, when a test may come positive in more than one disease, when a test can continue to be positive despite adequate treatment and clinical cure (and patient continues to repeat the test in a hope to get rid of the disease report wise). This is beyond the scope of this blog and is wisely left enshrined in medical curriculum! The idea is to convey 2+2 do not make 4 in medicine! Not always! Sounds too complicated? It is!

Everything in medicine does not come in such sharply divided black and white, there are more often than not, grey zones and that’s what makes medicine interesting and challenging. Medicine is not mathematics, it’s a dynamic science, ever evolving, resulting from a host of interactions.

I have a known treatment modality, I have a standardized treatment guideline to treat your patient, yet I have absolutely no way to know how your patient is going to respond. And I have no modalities to govern or modulate an individual’s response. 

You will be surprised to know that even in this 21^st century when medical science is expected to know everything, it does not. In a child with pneumonia the choice of antibiotics is largely a calculated risk, you hazard a guess and often times you are right, but before hand you do not often have a bacteriological proof to guide your treatment!

You vaccinate a child and you expect him to be 100% protected, but the limitation is that we do not know how his body is going to respond in terms of producing the desired protective antibody! If he fails, you can always cry foul, and say the doctor did not give the injection properly!

Often, one thing which scores in minds of many patients and to some extent propagated by practioners of other systems is the “propensity” of allopathic medicines to cause side effects. The beauty of our science is that we know what the side effects are, if you have to adequately control fits, you may have to cope up with some initial sedation and that is the side effect. But there are effects which are based on individual’s response to a given drug. Such idiosyncratic response are unpredictable and come to fore only after the patient takes the drug! Sometimes the side effects may be advantageous to the patient. A drug used to control tremors may cause dryness of mouth and may be advantageous to a drooling octogenarian!

A patient often equates my science’s limitation to my individual ignorance. The science does not and cannot have answers to each question life throws at it. That science progresses to limitless boundaries which is aware of its limitations and these limitations constantly nudge and urge to go beyond. My allopathic science is a vibrant kicking science, tries as much as possible to be evidence based, and is in constant search of answers which are elusive and evasive.

Too many expectorations are truly the cause of too many heart burns and unrealistic set points will cause them more!

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Dog bite AFTER taking Rabies vaccination - how long does it protect in India?

Q: Dear sir,

Good evening, 

I am research scholar in mathematics department in Birla Institute of Technology and Science Pilani campus.

I want to discuss one thing with you.

Sir I am previously vaccinated with 5 doses of rabies vaccine in last of May 2016. On 1 July, I am again bitten by a dog so I take two doses of rabies vaccine as required. But after one day of completion of two doses course of rabies vaccine, I am again bitten by a street dog. What should I do sir? Can previous two doses course protect me? How long this two doses course protect me from another bite?

Please help sir, I shall be grateful to you.

With regards, 

A: Hi,

Generally speaking, the Rabies booster doses protect you for around 1 year.

So you do not need to take a booster shot for this particular bite.

Always talk to your doctor before taking any specific decision about your health,

Warm regards

Dr. Gaurav Gupta.

www.travelsafeclinic.com 

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Do Johnson products cause cancer ? Here is what the evidence says ...

Doubt with the Bathwater

Johnson & Johnson reformulated their shampoo to remove formaldehyde, but that occurred years ago and was based on consumers' unrealistic fears of chemicals.

Kim LaCapria

Sep 18, 2015

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Claim:   Johnson & Johnson admitted their products contain "cancer-causing formaldehyde" in August 2015.

   MOSTLY FALSE

WHAT'S TRUE:   In January 2014, Johnson & Johnson products announced the completion of product reformulation to remove formaldehyde due to consumer fears.

WHAT'S FALSE:   The level of formaldehyde contained in shampoo has been proved to pose a cancer danger to humans.

Example:   [Collected via e-mail, September 2015]

Just saw this on Facebook: Johnson & Johnson Admits: Our Baby Products Contain Cancer Causing Formaldehyde. I am having a hard time
believing this.

It has been posted on healthnutnews.com that Johnson & Johnson has admitted that there baby products contain carcinogenic chemicals. Is
this true? Thank you!

Origins:   On 14 August 2015, the blog Healthy Food House published an article titled "Johnson & Johnson Admits: Our Baby Products Contain Cancer-Causing Formaldehyde" that claimed:

Although the company claims that the amount of formaldehyde isn’t large enough to be detrimental to humans — even infant humans — the fact is that it still has allowed this chemical for as long as they have been making the No More Tears shampoo.

But now, the company has announced the removal of formaldehyde from that shampoo and they are removing it from one hundred other products that they manufacture as well.

It could be seen as a sign of good intentions that the company is removing it from their products.But the real question is: why hasn’t it been removed before now?

Actually, the "real question" about removing formaldehyde from their shampoo products had been addressed by Johnson & Johnson nearly two years earlier, as noted in a 17 January 2014 New York Timesarticle titled "The 'No More Tears' Shampoo, Now with No Formaldehyde":

What’s different about the shampoo, and 100 other baby products sold by Johnson & Johnson, isn’t so much about what’s been added; it’s what’s missing. The products no longer contain two potentially harmful chemicals, formaldehyde and 1,4-dioxane, that have come under increasing scrutiny by consumers and environmental groups.

In response to consumer pressure two years ago, the company pledged to remove both chemicals from its baby products by the end of 2013, and this month, it said that it had met that goal. The reformulated products are making their way to store shelves around the world and will replace existing products over the next several months.

The push for removing formaldehyde to which the Times referred was not a recent occurrence: it had occurred as early as 2012, according to a Scientific American article. Moreover, Johnson & Johnson expressed at the time that the reason behind their reformulation was entirely rooted in implicitly baseless consumer fears:

Johnson & Johnson pledged last August [2012] to eliminate formaldehyde, parabens, triclosan and phthalates from all baby products. For adult products, it has removed triclosan and phthalates, but will keep using three parabens, and use formaldehyde in exceptional cases where other preservatives wouldn't work, according to the company’s new policy.

Driving Johnson & Johnson's initiative is the consumer. In recent years, its customers have been asking questions about chemicals in the products, said Samantha Lucas, a corporate spokeswoman, in an interview from its New Brunswick, N.J., headquarters.

"We've been replying with evidence of the science that ensures safety. Now we have to go beyond science and be responsive to our consumers because it's really about their peace of mind,” she said.

A 3 March 2014 Slate piece on "chemophobia" titled "No More Formaldehyde Baby Shampoo: How Chemophobia Made Johnson & Johnson Reformulate Its Product" examined how social media users spread outsized fears about common and non-harmful ingredients:

So why did Johnson & Johnson remove quaternium-15 if it’s safe? ... [E]very minute of every day on every inch of this planet, formaldehyde is all around you and inside you. Always.

Yet we’re not all dropping dead from cancer. That’s thanks to one of the most fundamental principles of toxicology: The dose makes the poison. “Unfortunately, all molecules are potentially toxic,” says American University chemist Matthew Hartings. “Toxicity is not just about the molecule but is about both the molecule and its concentration.”

The concern about formaldehyde in personal care products reveals a bit of chemophobia, which Dartmouth chemistry professor Gordon Gribble defines as “an irrational fear of chemicals based on ignorance of the facts.” He says, “people don’t know how small molecules are, and they believe that single molecules of some chemical pose a health threat.”

The article also noted that formaldehyde occurs naturally in fruits and vegetables, and that any link between formaldehyde and cancer hinged on exposure that included inhalation and involved both long-term and large-quantity usage:

In fact, the only studies that link formaldehyde to cancer are related to humans inhaling it, and inhaling large amounts of it. Funeral industry professionals with more than 34 years of experience or who had performed more than 500 embalmings and factory workers who spent years working around formaldehyde before the 1990s had higher risks for leukemia and Hodgkin’s lymphoma. The amount of exposure required to cause cancer is so high that other studies of factory workers have been inconclusive.

Formaldehyde occurs naturally in common fruits and vegetables (even organic ones). “Unless people calling for removal of quaternium-15 are also keeping their children from eating apples and french fries,” Hartings says, “I think their activism might be misplaced.”

Finally, a larger point of diminishing returns exists when it comes to "chemicals" (primarily of the preservative type) and consumer safety. Personal care products formulated without the use of common preservatives are not without attendant health risks of their own, as grooming formulations of that type are more susceptible to becoming compromised (such as by the growth of mold) in the absence preservatives.

So while it's true Johnson & Johnson reformulated its products due to growing consumer "chemophobia," the decision was driven by a marketing initiative and not a proven health safety issue. Moreover, the reformulations were announced in 2012 and completed in late 2013; they were not at all recent by September 2015.

LAST UPDATED: 29 January 2016

ORIGINALLY PUBLISHED: 18 September 2015

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