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GENERAL PRACTITIONERS’ SECTION
Changing Responsibilities of A GP in Some Medical Emergencies - OP Kapoor
OP Kapoor
Medical science is expanding at a very fast pace. The family physician should be knowledgeable and offer the best and the latest treatment to his patients, if they can afford it. The following medical emergencies are some good examples:
1. Myocardial Infarction : Till late, urgent thrombolysis was the best treatment after a patient was brought to an ICU equipped with a DC shock machine. However, lately the view has changed. Every patient of myocardial infarction should undergo primary angioplasty. I have heard of many patients, who had acute myocardial infarction and have died after this procedure. The point to be noted is that the angioplasty procedure is not being done on a non-infarcted heart. Like thombolysis, a routine coronary angioplasty can be performed and the same should be promoted even in small hospitals, if there are absolutely no contraindications to thrombolysis and in case of the latter, the cardiologist doing the procedure should have enough experience and should select easy patients having circumscribed proximal blocks, etc.
However, patients of myocardial infarction have to be shifted to a big institution, where top experienced cardiologists are available. In Mumbai, special heart hospitals have recently come up. Some of the private hospitals also have very good cardiac departments though the “software” (cardiologists) of these hospitals are often unknown in academic fields.
2. COPD patients often die due to acute exacerbations following an infection. The method of diagnosis of this situation is exactly opposite to that of acute myocardial infarction, which is relatively very easy. A COPD patient has a low SPO2 (e.g. around 90%) and the patient has learnt to live with his dyspnoea. Often on such an occasion, the patient may develop “more” dyspnoea. Blood tests like SPO2 or pH must be done to diagnose an “acute” exacerbation of COPD, which can kill the patient. Nowadays, NPPV (Non Positive Pressure Ventilation) has led to better management of these patients. Formerly, ventilators were used after doing invasive tracheal intubation, but often it was late.
Nowadays, non invasive ventilation is available with the help of a mask. Since this is easier, all patients having the above problem can be put on NPPV. It reduces the hospital stay of the patient, helps early recovery and reduces the death rate. Thus, if possible and affordable, every serious patient or a patient who is sinking, should get the benefit of this procedure. This is possible even in small hospitals or well equipped nursing homes, having a good resident doctor. In fact, I would advise senior family physicians to buy NPPV apparatus and offer it to all patients of COPD with an acute exacerbation, where the SPO2 is less than 90%, in whom it can prevent a bad respiratory failure.
3. Pulmonary Embolism is a difficult diagnosis. But in a patient with a high risk background, onset of acute, one sided pain and/or dyspnoea with a normal X-ray Chest and ECG and a low SPO2, it should raise a strong suspicion. For additional safety, nowadays a lot of preparations of LMW Heparin (for example Inj. Fraxodi) are available which can be used and the patient need not be admitted to a hospital. Inj. Fraxodi can be administered once a day by anybody (with a disposable syringe and needle) and can be started, even if the diagnosis is doubtful. Rupees 1000 per day for a week or ten days is more affordable compared to hospitalisation expenses. In patients, who have not been given LMW, a second episode may be fatal!
4. TIA : If an attack of TIA aborts in less than one hour, there is no problem and aspirin can be started. If neurological deficit persists longer, an urgent CT Scan is required. But if negative, (and haemorrhage is ruled out), a contrast CT scan and MRI should be urgently done. Thus, if a diffusion/perfusion mismatch can be demonstrated, urgent thrombolysis should be done as soon as possible, preferably within 2-6 hours. If a 2D echo study shows a thrombus, an anticoagulant should be started.
5. Unstable angina includes “New onset Angina”, Accelerated Angina, Angina at low workload, Post infarction Angina and Angina at rest. Even today, it is difficult to be sure of the diagnosis, and yet these patients can die suddenly or develop acute myocardial infarction. A GP can always start LMW Heparin as described above but preferably in larger doses or double doses. Thus hospitalisation can be avoided and complications can be reduced.
6. Stroke : All stroke patients should be advised urgent admission in stroke units. If such units are not available for service, the procedure described under TIA should be followed.
HIGH HOMOCYSTEINE CAUSES CARDIOVASCULAR DISEASE
Wald and colleagues provide evidence of a causal association between homocysteine and cardiovascular disease. Their meta-analyses show that a mutation in the MTHFR gene, which reduces folate metabolism, significantly increases cardiovascular risk. The authors report that consuming 0.8 mg of folic acid could decrease serum homocysteine, reducing the risk of ischaemic heart disease by 16%, deep vein thrombosis by 25%, and stroke by 24%.
BMJ, 2002; 325 : 1202.
( Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.)
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