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Monday, 13 September 2010

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HEALTH WATCH

‘Sick’ channelling in some hospitals

You fall sick and channel a doctor. You visit the hospital at the time mentioned in the channelling receipt. The time given passes. You wait for a few minutes, ..... another few minutes, ...... it become an hour,

...... then few hours! The doctor still does not turn up. After waiting for hours, the doctor turns up. You now think that you can go in. It is not. Read further and find out your own story.......

The doctor goes in and closes the door. The nurse comes in and assists the doctor. You wait impatiently holding your receipt which indicates number one, your number. You think that the story ends when you go in and complain to the doctor for keeping you for a long time. It does not ends there because you do not get a chance to go in !

Men in black

You are still standing in front of the door of the consultation room. In walks the men in black ! They are not two or three. Sometimes there are four or five of them. They are neatly dressed, carry briefcases and eagerly wait to meet the doctor as soon as possible (definitely before all patients who waited hours). They are not sick and do not have appointments to meet the doctor. They are the `Sales Representatives’ from various drug importing companies. They have a `love’ chat with the nurse who play the gate keeper’s role than assisting the doctor to examine patients and go in directly one by one.

Do you think that end now? It does not end there. They go in one by one and start a friendly chat with the doctor. The doctor forgets the patients waiting for hours and carry on chatting with the sales representative. Why ? They are the people who offer foreign tours for the doctor and family members. Therefore sales representatives from drug companies are very important for doctors. The sales representative takes one more hour and then leaves. The patient with number one is still waiting outside the doctor’s room.

You may think that this writer is biased and hates doctors ! No I am not biased or hate doctors. I am an ordinary Sri Lankan who experienced this hardship. Sales representatives help doctors introducing new and latest drugs. It is the patients who benefit from this practice. Therefore there is nothing wrong with sales representatives meeting doctors. But the way it happens is not acceptable. Around three hours has passed since the patient came to see the doctor and the patient is still waiting outside the doctor’s consultation room. Do you think the patient will go in next ?

Woman in red

No. Here comes the woman in red! She is from hospital administration. There is a `patient’ with her. They talk to the gate keeper (nurse) and go in. The patient who is number one is still waiting outside the room. After another 15 minutes they come out and walk away after another friendly chat with the gate keeper.

You may think that the number one goes in and meets the doctor. You are wrong. The patient who is number one still waits outside because there is a long-wheel-chair queue before the patient! What is this wheel-chair queue? They are the in-house patients of the hospital. They are there with attendants to see the doctor. They go in one by one passing the patient who holds the receipt which indicates number one !

Cancellation of channelling appointments is another huge burden for patients.

Some hospitals do not refund the entire amount of money when a patient cancels a channelling appointment. There is no facility to cancel an e-channelling appointment. Most receptions do not offer a warm welcome for patients.

It is not only the rich who channel doctors in our country.The poor and middle class also consult doctors because of their concern on health. Therefore, justice should be done for the hard earned money of patients.

How about the patient who has the channelling receipt which indicates number 39? It is simple. It will get rid of the whole burden of patients.

It will make things easy for all. Patients, doctors and hospital managements can relax if this simple strategy can be implemented. It is, stating the accurate (or average) time of appointment in the channelling receipt and including a special line asking them to be there only five minutes prior to the appointment time. After consultations (channelling doctors/private practice) for years in Sri Lanka both doctors and hospital management know very well how it works and at what time or at least (roughly at what time) the doctors can turn up for private practice after finishing public service and after allocating time for possible emergency operations etc. Therefore time management can be done in an excellent way.

Coordination can be done over the phone instantly and continuously between the doctors and hospital managements and planned adjust the time schedules. But at present it seems doctors and hospitals want patients to suffer !

Some patients are not that innocent! Some arrive at the hospital long before the appointment and block the entrance to the doctors’ consultation room by standing in front of it with files and reports. They never sit even if the gate keeper repeatedly ask them to sit.

Some patients turn up in the middle of the consultation or at the latter part of the consultation time with a receipt indicating number five ! Some patients lie and go in. The most common lies are to get something corrected in the prescription, to get a document or to hand over a document to the doctor.

All problems can be solved if the hospital managements pay little more attention towards organizing things properly while earning good money.


Counselling hotline

The National Institute of Mental Health, Angoda is offering the hot line 1333 for the public to obtain counselling services in connection with mental health.

The hot line operates in Sinhala, Tamil and English from 9.00 a.m. to 10.00 p.m daily.

Institute Director Dr Jayan Mendis said the public can call this hot line free of charge using Sri Lanka Telecom and Mobitel lines. This service will be extended to 24 hours within the next six months enabling the public to access this service at any time.

The hot line is operated by a trained staff of 170 professionals. The confidentiality of the persons who seek the service of this service is protected. The public can obtain counselling for any type of mental problem through this service or obtain relief by describing any problem to the staff.

 

 

 

 


‘Miscarriage - a main problem in pregnancies’

Consultant Obstetrician and Gynaecologist Dr Vijith Vidyabhushana expressed views on miscarriages during an interview with the Daily News. Excerpts from the interview

Q - What is a miscarriage?

A - Miscarriage is a loss of a pregnancy (after confirmation following a urine test) before the first 23 weeks or if gestation (number of weeks from the date of last menstrual period) is not known, birth weight of lost fetus (baby) being less than 500 grams. Before 23 weeks the fetus is not viable or cannot survive if born, with or without medical help. A loss after this time is called a stillbirth. More than 90 percent occur before 12 weeks of pregnancy, but some occur later.

Q - How common is this?

A - The incidence is said to be around 15 to 20 percent if 100 women become pregnant, 15 to 20 would end up with a miscarriage. This is the incidence of miscarriage after confirmation of pregnancy. But the incidence of it before a pregnancy test (usually the pregnancy test is done after missing a period and at that time on embryo is about two weeks) may be around 50 percent according to research. This is because in many cases a very early pregnancy can end up in a miscarriage even before you miss a period, and therefore, before you are aware that you are pregnant.

Q - What are the causes?

A - Most occur spontaneously as ‘nature’s selection’. Most of these fetuses are found to have some abnormality in their chromosomes, arising by chance during cell division. Usually there are no abnormalities found in parents of these cases. It is thought that most early miscarriages are caused by a ‘one-off’ chromosome fault. This is usually an isolated genetic mistake, and rarely occurs again. There are other less common causes of miscarriage including: hormonal imbalance; abnormalities of the womb; weakness of the cervix; certain infections like listeria and rubella. Investigations into the cause of a miscarriage are not usually carried out unless you have three or more miscarriages in a row. This is because most women who miscarry will not miscarry again. Even two miscarriages are more likely to be due to chance than to some underlying cause. If it happens for once or twice usually there is no specific cause for it. But if this happens consecutively for three times or more one has to investigate to find a cause as there can be a treatable cause.

Q - Are there any misunderstanding on miscarriages?

A - There are some wrong ideas about the causes of miscarriages. After a miscarriage it is common to feel guilty and blame the miscarriage on something you have done or failed to do. This is almost always not the case. In particular, miscarriage is not caused by lifting, travelling in bus, motor bicycle, three wheeler, straining or working, constipation or straining at the toilet, stress or worry, sex, eating spicy foods or pineapple or papaw or normal exercise. There are many myths about the causes of miscarriages. As this is so common it is easy to point your finger at something you have done as a cause for the miscarriage.

Q - What are the signs and symptoms?

A - 1.Bleeding - red or brown, heavy, with clots or light spotting.

2. Abdominal pain, backache, period like pain(NB- severe abdominal pain, faintness, slight bleeding with a positive pregnancy test can be features of an ectopic pregnancy,specially in early pregnancy. If you are high risk for ectopic pregnancy an ultrasound scan is needed to exclude an ectopic pregnancy - a pregnancy outside the womb).

3. Loss of pregnancy symptoms

Q - What are the types and possible outcomes?


There are some wrong ideas about the causes of miscarriages

A - There are four types of miscarriages that you should be aware of. One is `threatened miscarriage’. It is common to have some light vaginal bleeding sometime in the first 12 weeks of pregnancy. This does not always mean that you are going to miscarry. Often the bleeding settles and the growing baby is healthy. This is called a ‘threatened’ miscarriage. You do not usually have pain with a threatened miscarriage. If the pregnancy continues, there is no harm to the baby.

In some cases, a threatened miscarriage progresses to a miscarriage. If the heartbeat is seen in the ultrasound scan, there is more than 98 percent chance of an uneventful pregnancy.

Delayed miscarriage (also called early fetal demise, missed miscarriage, silent miscarriage)is another type. In some cases there are no symptoms, and sometimes there may be very minimal symptoms. The baby dies, but remains in the womb. In some cases the small embryo may not be seen and only the empty gestation sac is seen. Some may have no pain or bleeding. Sometimes there may be slight brown discharge. This may not be found until you have a routine ultrasound scan. The ultrasound can demonstrate heart beat in 95 percent of pregnancies at six weeks when the embryo (the growing baby) is as small as five millimetres! Therefore a competent doctor can make this diagnosis without repeating after a week.

Incomplete miscarriage is the third type. The usual symptoms are vaginal bleeding and lower abdominal cramps. You then pass some ‘tissue’ from the vagina. In many cases, the bleeding then gradually settles. The time it takes for bleeding to settle varies. It is usually a few days, but can last two weeks or more. In most cases, the bleeding is heavy with clots, but not severe - more like a heavy period. However, it can be severe in some cases. In these cases there will be some pregnancy tissue left inside the womb and therefore is called an incomplete miscarriage.

The fourth type is Complete Miscarriage. Symptoms may be similar to an incomplete miscarriage, but bleeding settles, neck of the womb closes and ultrasound scan will show an empty cavity of the womb.

Q - Does she need to go to hospital?

A - She should always report any bleeding in pregnancy to her doctor. It is important to get the correct diagnosis as miscarriage is not the only cause of vaginal bleeding.

If one bleeds heavily with clots, she should go to the hospital immediately.

Most women with bleeding in early pregnancy are seen by a doctor who specializes in pregnancy. It is usual to have an ultrasound scan.

This helps determine whether the bleeding is due to a ‘threatened’ miscarriage, (the baby will be seen to be alive). Some other cause of bleeding (such as an ectopic pregnancy or bleeding from the neck of the womb).

Q - What do the doctors do when she goes to hospital?

A - A complete history will be taken before the examination. A general examination will be done to see if you are pale, blood pressure will be checked, abdomen will be examined and finally a speculum ( an instrument inserted through the vagina to visualize the neck of the womb) examination may be done. Speculum examination is usually uncomfortable but not painful and will not harm the pregnancy in any way. Speculum examination may be done after or before an Ultrasound scan. Your blood group and haemoglobin level will also be checked.

Q - How is the diagnosis made?

A - With the history, examination and an ultrasound scan usually a diagnosis can be made. For most patients an ultrasound scan is needed unless one can see pregnancy tissue in the neck of the womb during speculum examination. Occasionally a repeat ultrasound scan will have to be done to arrive at a diagnosis.

Q - Does she need any treatment?

A - Once the cause of bleeding is known and the type of miscarriage is confirmed, her doctor will advise on options she has. If it is a threatened miscarriage there is more than 98 percent chance of a good outcome to have a normal pregnancy and a healthy baby.

According to research bed rest will not improve the outcome. Some doctors give a medication which should be taken orally or as an injection. It contains a hormone called Progesterone. But there is no scientific evidence to suggest that it is effective and therefore one should not regret of not having this hormone injection as it is not proven to prevent a miscarriage.

For many years it was common to do a small operation (Surgical management) to ‘clear the uterus’ (commonly called in our country as a ‘womb wash’. The correct word is evacuation or D & E) following a missed miscarriage or partial (incomplete) miscarriage. This is done under general anaesthesia.

The logic was that this would make sure all pregnancy tissue is gone and may prevent infection or prolonged bleeding. However, if ultrasound reveals no or very minimal tissue, an evacuation is not needed as it is a complete miscarriage.

Many women in developed countries now opt to ‘let nature take its course’.In most cases the pregnancy tissue is passed out naturally and the bleeding will stop within a few days. It is called expectant management.

As this is a natural form of cure not involving anaesthesia or medication these are considered as the advantages of this kind of management. Since there is no threat to the mother’s life it is safe to wait for the ‘natural cure’.

The main disadvantage is its unpredictability as to when this is going to happen. An ‘operation’ to ‘clear the uterus’ can still be an option if the bleeding does not stop within a few days or if the bleeding is severe.

Other option is to have some medication to make the womb contract and expel the products and is called ‘medical management of miscarriage’. Unfortunately we do not have this medications as termination of pregnancy for social reasons in not legal in our country.

The advantages in this method are its quick nature and, it does not involve any anaesthesia and therefore minimal side effects.

Q - How long can she bleed or have discharge?

A - After a miscarriage usually one can bleed for a week or two and occasionally for about three weeks. If the discharge or bleeding is increasing or has a foul smell or if you have fever and lower abdominal pain you should contact your doctor.

Those may be signs and symptoms of infection, but infection is not a common occurrence following a miscarriage.

Q - When can she plan a pregnancy again?

A - It is up to her and her husband to decide. There is no strict rule not to get conceived for three to six months. Some may consider a miscarriage as a loss to their family, and need some time before planning a pregnancy again. But they should understand that after a miscarriage an ovulation can take place at any time and one can become pregnant even before missing a period. If you are planning for a pregnancy soon, it is always better to wait until you have your first period after miscarriage so that you can date the pregnancy.

Q - When can she have sex again?

A - Usually when the discharge or bleeding stops. Otherwise it can give rise to infection as blood is a good culture medium for bacteria etc. If you are not planning a pregnancy very soon, it is always necessary that you use a reliable method of contraception(family planning) as you can get pregnant even before missing a period.

It is only a couple who have had a miscarriage who feel how distressing it is. Although some take it lightly, feelings of shock, grief, depression, guilt, loss, and anger are common among these couples. It is best not to ‘bottle up’ feelings. Talking and discussing with your husband, friends, or with a doctor, or with someone who can listen and understand will help to overcome that. As time goes on, the sense of loss usually becomes less. However, the time this takes varies greatly. Pangs of grief sometimes recur ‘out of the blue’. The time when the baby was due to be born may be particularly sad especially if it is a late miscarriage after 12 weeks.

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