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M. P. Ravindra Nathan
BETTER HEALTH CARE: ENGLISH OR AMERICAN? PART I
By M. P. RAVINDRA NATHAN, MD, FRCP (LONDON AND CANADA), FACP, FACC

Recently, I had an opportunity to go to London and visit the Royal College of Physicians (RCP) of London, from where I obtained my post-graduate degree in medicine many years ago. This time, I went to receive the honor of Fellow of the Royal College of Physicians (FRCP) and while there, I wanted to renew my links with the college. Having spent nearly four years in England in the 1960s before coming to USA, I have fond memories of my days. This indeed was an opportunity to relive those experiences and get reconnected with the current status of British medicine.

The RCP is one of the oldest and most prestigious medical foundations in the world, incorporated by the Royal Charter in 1518. The ceremonies for the presentation were spectacular – complete with the traditional procession in all its pomp and glory - which we have come to associate with all the royal functions in Great Britain. More importantly, I had a chance to listen to the President Professor Dame Carol Black and other distinguished senior physicians of RCP who discussed the many facets of British medical education and health care.

Professor Black, in her key note address, stressed on the challenges involved in the care of acutely ill patients in the current National Health Services of Great Britain (NHS). She especially noted the importance of “the multidisciplinary nature of clinical practice and the evolution of teamwork and shared competencies.” Fortunately, USA has adopted this policy many years ago. This is the reason that you get occasionally referrals to the specialists when you visit your family doctor. Regarding the international nature of medicine these days, Professor Black said, “Wherever in the world physicians work, we share a common ethos, something that transcends boundaries of nations. Globalization is a new word for a state of affairs that is becoming familiar to medical science and even to medical education. The college is working vigorously to strengthen those (international) bonds, so we can help each other and learn from each other through our different approaches to the fundamental problems of patient care.”

It is interesting to note that NHS has similar concerns and problems such as U.S. Health Services; may be more. For one thing, NHS is facing a serious financial crisis now. “It is a bottomless pit,” said a senior physician who works in a London teaching hospital, when I was casually chatting with him during dinner. “How can you afford all these modern treatments and technology free of charge?” he asks. The British are looking at alternate ways of running their programs, including outsourcing the equipments and even some of their programs to American companies. And they are increasingly favoring privatization there now.

We, in USA, have been grappling with our own set of problems. Flattening revenues for doctors, escalating medical expenses, lack of insurance for nearly 40 million people, malpractice crisis and advent of managed care, which hasn’t made a dent in the skyrocketing medical expenses – all have become emblematic of modern times. Many are clamoring for universal health care, patterned after the English or Canadian model. But are the British happy with their socialized medicine? It was interesting to read the daily newspapers which frequently carried headlines like this:

“NHS is a poor system. Often difficult to get a quick ambulance in an emergency.” (Apparently two people died while waiting for an ambulance!)

“All patient calls are screened by nurses, before they are even taken to the hospital.”

“Getting a doctor’s appointment takes several weeks, and even after you see the doctor, it takes another few weeks to get the results of the tests.”

“NHS doctors have no zeal or enthusiasm. They often go through the motions of doctoring.”

However, Health Secretary Patricia Hewitt was quick to defend the NHS. “No problem here. Everything is media created,” she commented to the press. But the public vehemently objects! Well, now you get the picture. It is true that many NHS trusts are in dire financial straits and there is a sense of doom and gloom among the medical professionals and the general public alike. However, the public still trust their doctors (doctor bashing isn’t a popular sport in U.K. as it is here in USA) and new developmental plans are under way to revamp the whole system.

Part of this article was published in St. Petersburg Times (Hernando) recently.

Cardiologist Dr. M. P. Ravindra Nathan, director of Hernando Heart Clinic in Brooksville and editor-in-chief of the AAPI Journal, lives in Brooksville.




Payal Patel
THE STOMACH VIRUS: AN UPDATE
By PAYAL PATEL, M.D.

We have arrived into the peak season of RSV virus, as well as the flu virus, which I talked about in my last two articles. Another crucial illness among children is the stomach virus known as gastroenteritis. The most common virus that causes vomiting and diarrhea among children is the rotavirus along with other viruses. The rotavirus does tend to occur in the colder winter months from November-April with the peak in Florida being March and April. In the United States, most children have at least 1-2 episodes of gastroenteritis by the age of 4.

The infection usually begins with vomiting followed by diarrhea. The vomiting usually lasts for 1-2 days and then subsides. Usually there can be 10-20 bowel movements a day in healthy children. Symptoms last from 3-7 days with a gradual decrease in the watery diarrhea. Most children have a primary episode that is more severe then the following episodes, since immunity develops after the first rotavirus infection. Most adults do not acquire this infection because of immunity, but if they themselves have a mild episode then the children are likely to be infected with symptoms. The younger the child, (3-24 months) the more chances of a severe infection. The infection is acquired most commonly by touching rotavirus contaminated toys, food prep areas, and toilet facilities.

Prevention

The most important method of prevention is through hand washing. The rotavirus can easily contaminate surfaces because of the large amount of viral shedding in an infected child’s stool. The virus can survive for days to weeks on surfaces, toys, etc. The usual disinfectants such as bleach are ineffective. Cleaners with alcohol or 95 percent ethanol are most effective.

Another key measure is vaccination. The Rotateq is a 3-dose vaccine given by mouth at the age of 2, 4 and 6 months. This vaccine decreases the likelihood as well as the severity of the infection. This vaccine was recently made available and is recommended for all infants.

Management

There is no treatment for the Rotavirus or any other stomach viruses. The goal is to keep the child hydrated with fluids such as Infalyte, Pedialyte and simple things like water. Juice is not a good choice for children with diarrhea since it contains fructose and can make diarrhea worse. Also avoid sodas and other sugar filled drinks like Kool-Aid since they are not appropriate for rehydration. For a formula-fed infant with frequent diarrhea it may help to change to soy formula or lactose-free formula until the episodes decrease.

It is more important to get the vomiting under control in 12-24 hours for the child to be rehydrated. Because a child’s stomach will be upset from the virus, it is key to give small amounts of fluids for any child that is vomiting. For any child less than 1 years of age, use Pedialyte, or Infalyte or Kao-Lectrolyte if the child is vomiting greater than two times, since the child will be less able to tolerate regular formula. Give small amounts, usually half of what the child normally takes, or sometimes even a quarter of the normal amount, but more frequently. Once the vomiting is under control, then reintroduce formula slowly as tolerated. For children 6 months and over, you also can return to cereal, mashed bananas, etc. as tolerated.

For a breast-fed baby, feed smaller amounts more frequently. If the child vomits more than two times than nurse only nurse for 5-7 minutes but every half an hour to an hour. Once the vomiting is controlled for greater than eight hours, then continue normal breast-feeding schedule. For an older child greater than one, give small amounts of Pedialyte or water sometimes even 1-2 tablespoons every 15 minutes or so and increase as tolerated. After half a day of no vomiting, increase the fluids slowly and add a diet containing crackers, rice, bananas, bread, mashed potatoes, apple sauce. Normal diet can be continued after 24 hrs of no vomiting. If your child wants to sleep at night, do not wake him/her up if there is no immediate threat of dehydration. When the child rests, the stomach also gets a break and helps recover the stomach from the viral gastroenteritis.

If the child wears diapers and has diarrhea, it is very likely that the skin surrounding the anus will get irritated from the diarrhea and break down causing diaper rash. It is best to wash the child after each episode of diarrhea to decrease the irritation from wiping so much and also to protect the area by using diaper rash cream such as Desitin, Balmex, etc., and coating it further with Vaseline.

Warning signs: Call your pediatrician or go to the Emergency Room Signs of dehydration are no urine production in more than seven to eight hours, or no tear production when crying, or very sleepy and hard to wake up, or any drastic change in the child’s behavior. If the diarrhea or vomit is bloody.

If the child has persistent vomiting and is unable to keep even small amounts of fluids down or if the diarrhea occurs frequently with eight episodes in eight hours or less.

Dr Payal Patel , a board-certified pediatrician in Tampa, can be reached at payalpp@hotmail.com




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