18-yr underprivileged boy from Kashmir gets new lease of life at Max Super Specialty Hospital, Mohali

His free cardiac surgery was funded by Max India Foundation
CHANDIGARH: Partially deaf by birth, 18-year old Asif Wani sordid tale of despair and victory is heart rending. The sixth child of a daily laborer, Abdul Azeea Wani, Asif was brought to Max Super Speciality Hospital, Mohali with complaints of breathlessness and palpitation.

He was diagnosed with complex birth heart defects multiple conditions of Atrial septal defect, PDA and severe Pulmonary Stenosis (Congenital disorder) comprising of hole in the upper chambers of the heart, along with a flowing channel between main artery of the body and artery feeding the lungs which normally closes soon after birth. The surgery that saved the life of this innocent teenager was not only complex from the medical point of view but also gave a new lease of life to the hapless boy.
Asif’s mother Zareefa Bano was speechless with gratitude as her son narrated the story of their strife to get treatment for their son. Asif had been diagnosed with the multiple congenital heart defects as early as 2 months of his birth. His parents took him to the local doctors at Srinagar but were turned away due to lack of funds. Even the best hospital in Srinagar refused free treatment to the boy. The procedure to save him, the family was told, would cost lakhs of rupees, which was impossible for the destitute daily wager to collect. Through a common acquaintance, Max India Foundation took up the case and Asif was successfully operated upon by Dr. Virendar Sarwal, Senior Consultant, Cardiology at Max Super Speciality Hospital Mohali. The 5-hour surgery involved one week of post operative care under expert supervision of critical care experts.
Belonging to an obscure little village Handwara in the far reaches of Kupwara Distt about 10-12 Kms from LOC, Asif’s parents were devastated when they realized that he was suffering from congenital heart disease. Asif was advised immediate surgery. Helpless and penniless, Asif and his family were in a dilemma as to how they would bear the cost of such an expensive surgery. It was then that he was referred to Dr Sarwal, who volunteered to take up his case. Since Asif belonged to a poor family and his parents could not afford the expensive treatment, an acquaintance, who had been helping the family since last 2 years in arranging funds, approached Max India Foundation for financial assistance. Max India Foundation decided to help the young boy by bearing the entire cost of surgery and offering him world class medical treatment at Max Super Speciality Hospital.
Ever since Abdul Azeea Wani, Asi’s father lost his eyesight 5-6 years back, Asif’s mother has been working as a labourer on a meager daily wage with no other source of income. We have been running from pillar to post for 2 years but all efforts to secure funds for the surgery bore no fruit. Our fellow villagers managed to gather Rs 16000 for our travel and stay once they came to know that Max Hospital was helping us, said .
Dr. Sarwal said that since these were birth defects, these were high risk surgeries. Asif lungs had developed early hypertensive changes and it was a long on pump surgery because of three congenital defects. His pulmonary valve was too small for his age. Asif underwent intracardiac repair on Cardiopulmonary bypass at Max Super Speciality Hospital on October 14 and soon recuperated. He would be requiring regular medication to support his heart condition.
For the past 18 years, my world was full of just pain and helplessness, said an emotional Asif, while expressing gratitude towards Max India Foundation for their support With this crippling disease, all I could do was sit or lie down on my bed and take a few faltering, painful steps to go to the toilet. It was a very depressing state of affairs for my family and me and many times I would wonder what was the point of existing like this, he remarked.
Ms Mohini Daljeet Singh, Head, Max India Foundation said that living up to our social responsibility of an integral part of the core philosophy of Max India Foundation, we were very glad that we have been able to get an opportunity to serve the needy. We would continue doing so in the times to come with sincerity and passion, she asserted.
It may be mentioned here that under various CSR programs like immunization, health awareness and health camps, artificial limbs camp, palliative care for cancer patients, Max India Foundation has now crossed the 1435 free and subsidized surgeries mark. Over 477147 people have benefitted from the various CSR programmes of Max India Foundation till now.
Dr. Ashutosh Sood, GM operations at Max Super Speciality Hospital Mohali said that this whole package bearing cost of Rs 2 lacs, was done entirely free of cost. However, it was well worth it because today Asif presented a heartwarming sight. Having recovered very well, he was up and about, talking and playing like a normal teenager.. The joy on his face was priceless and nothing compared to the satisfaction of having helped tears turn into smiles, remarked Dr Sood.

High risk Octogenarian successfully treated for Coronary Artery Disease with Beating Heart Bypass Surgery successfully

 

·         Patient presented with critically blocked and calcified heart vessels which are difficult to tackle surgically

·         Off Pump Coronary Artery Bypass (OPCAB) or Beating Heart Bypass Surgery is a safe and proven option for bypass surgery in elderly patients

 3^rd September, Mohali: Elderly patients, compared with patients of a younger age group, present for surgery with a greater burden of risk factors and reduced functional levels. Short‐term outcomes are hence poorer in them. But symptomatic relief occurs in most patients and is accompanied by excellent rates of long‐term survival and a good quality of life when treated with beating heart surgery. Max super speciality Hospital Mohali recently treated an 84 year old male, Ramnarayan, who had his all three major heart arteries critically blocked. Along with this complication, the major arteries going to his brain were also blocked on both sides by 90% and 60%. The main artery on the left side of the heart (called left main ) was having 90% stenosis- in such critical conditions, bypass surgery becomes an urgent requirement. Also other three arteries, two on the left and one on right side were also blocked by 90% and 99%.

“He was very symptomatic” avers Dr Virendar Sarwal, Principal Consultant and Chief of Cardiac Surgery, his treating physician “Ramanarayan was offered high risk bypass surgery on beating heart at the time of angiography because of his age. In octogenarians, the risk to life becomes very high as all organs of the body are aging due to wear and tear. Reserves  are substantially low which make it difficult for the body to undertake the stress of surgery.”

Ramnarayan decided to take some time off and went home but had to get readmitted twice in the next 10 days because of severe heart symptoms. The family accepted the high risk  involved and the medical team collectively decided to work him up for surgery. “For this category of  patients  beating heart surgery which is now an  established technique  serves as very good  option . But, an individualized risk–benefit profile must be carefully constructed by clinicians, taking into account several different factors and not just age alone.

On investigations, it was found that Ramnarayan’s both carotid arteries (supplying blood to the brain) were also critically blocked and we had to take extra care to avoid brain damage during surgery especially because of acute blood pressure variations. His CT scan had dilated lateral ventricles and cerebral atrophy. As there was no evidence of any major stroke we decided to go ahead with beating heart bypass by taking special precautions in the OT. Three grafts were given to him on beating heart by using octopus stabilizer and maintained higher blood pressure intra operatively.”

Ramnarayan was fully mobilized  on 3rd day and discharged from the hospital on 5th day.

 

Discussing the advantages of off pump coronary artery bypass (OPCAB) or beating heart Bypass surgery as it is commonly called, Dr Sarwal said “ OPCAB is though technically demanding is a safe and prove option for high risk bypass surgery. Doing surgery on a beating heart eliminates the need for heart lung machine,  results in fewer side effects. Some potential benefits of beating heart surgery are lower risk of stroke, fewer problems with memory loss and thinking skills, reduced injury to the heart, fewer heart rhythm problems and shorter hospital stay, less ICU stay and less usager of blood. Long term success of OPCAB includes improvement or complete relief of their symptoms and being symptom-free for several years. They may recover from surgery more quickly than those who go "on pump" and they may suffer from fewer post-operative complications.”

Affordable healthcare only possible with value based medicine

           India is a developing country and 80 per cent of the population of our country cannot afford expensive healthcare. The facilities provided by the government are miniscule in front of the giant problem. Shortage of doctors, basic infrastructure, paramedical staff and expensive medicines makes healthcare even more out of reach for a common man. That is the reason we are still struggling with the certain communicable diseases and now added to that is the burden of non-communicable diseases.

Dr Virendar Sarwal

India is going to be the world capital for heart disease in 2030 as per the WHO report. Diabetes is rampant and there is total lack of awareness about prevention, lifestyle management, hygiene levels, sanitation and the healthy living with the result that we have huge load of patients whether it is communicable or non-communicable disease. Added to it is the shortage of manpower to treat these patients.
As per one study, our country has only 20 doctors per 10,000 people as compared to 650/10,000 in US. The budgetary provisions for healthcare are so low that even the primary healthcare cannot be delivered efficiently with the result the rural population is the worst sufferers. That is how there is mushrooming of quacks and invaluable lives are at risk.
In such a dismal scenario only alternative to improve upon the services and make each step in healthcare delivery more justified and economical, if we look at an evolving healthcare delivery system all over the world and even in developed countries like US, is Valve Based Medicine. So far, we have been practicing Evidence Based Medicine where in based on the evidence of the disease, we treat it with the costliest way of treatment. It ignores the logic of benefit vs cost ratio whether it is concerned with writing costly medicines or adopting the costliest intervention.
The value based medicine concept is different from the evidence based medicine concept in the sense that we are treating human beings and not symptoms. The treatment plan has to be based on the effective control of the disease with respect to the perception of the patient and his family in terms of benefit as compared to the cost involved in it.
Let’s say in heart disease a patient having coronary artery disease in two or three vessels can be treated with bypass surgery as well as ballooning and stenting. Now, whereas stents will cost him a big money and will also not be durable so bypass surgery becomes more economical and more durable. What the patient wants here is effective quality of life improvement with an economical and durable procedure. So, of course, bypass surgery is the best answer here. Similarly, a sore throat can be effectively treated with low-end antibiotic treatment and supportive therapy instead of expensive and high-end antibiotics.
Value based medicine is a means to compare all healthcare interventions on the same scale and a measure that can be combined with the cost of an intervention to arrive at a cost utility ratio. It provides most effective assessment of the patient perceived worth of an intervention. It also measures quality of life and/or length of life. The irony of healthcare industry is that it is one of the few industries where purchasers or the patients are unable to measure the valve of what they purchase.
So, value based medicine allows highest quality care, maximization of healthcare rupee and incorporation of patient based perception of quality of life. The goal of value based medicine is to promote what is best for the most important people in healthcare i.e. patients. It provides transparency backed by scientific opinion, communication by personal attention, no scare or fear by involving empathy, economics and 24×7 availability.
Similarly, if we come to procedures, the beating heart surgery is value based medicine. Minimal invasive surgery goes a step further in that direction as it makes the patient up and about early and the patient does not lose productive days of earning and is back to work at the earliest with less stress on the body. Also, in terms of logistics there is less ICU stay, less hospital stay, less use of blood products. Value based medicine also incorporates all the forthcoming evidence which is percolated to the patient level and helps in decision making for the patients.
Now, coming to stent vs surgery, two major trials — one in 2009 Syntax trial and the other in November 2012 Freedom trail — have clearly established and concluded that in multi-vessel disease and diabetes, bypass surgery scores over drug coated stents in terms of death, second heart attack and second or repeat intervention. So, all patients with multi-vessel disease should be offered bypass surgery as the first option for durable economical treatment.
In this scenario, value based medicine (VBM) stipulates that when it come to coronary artery disease each and every patient should meet the surgeon with his angiography report to reach to a conclusion whether he needs to go for stents or surgery. The other thing, which our country needs to incorporate into VBM is the availability of cost effective medicines, disposables and equipment. Most of the equipments, disposables used in high-end surgeries is still being imported and thereby making huge loss and leading to escalation of prices of these essentials.
The government has to encourage use of generic drugs, which should be free and easily available and encourage manufacture of disposables and equipments in our own country. It will do away the huge profit margin taken by the multinational companies when the middlemen and dealers add to the cost. There are very innovative products available in India and effort should be done to produce them at mass level and promote them at all levels. In fact, all hospitals should be told to use them as the first priority.
The infrastructural resources for the primary, secondary and tertiary healthcare delivery are very less so a policy needs to be made wherein the government and the private sectors should join hands in making the total available infrastructure at the disposal of all the patient population group. There should not be any differentiation and all available beds should be utilized to the maximum by one and all. It will help in reducing the waiting list and huge queues seen in government hospitals today. All it needs is rationalization of compensation to the private sector.
Today also many government agencies are utilizing the private resources for tertiary care by reimbursing them the subsidized cost of treatment. Why can’t it be applied to the primary and secondary care? The public private partnership (PPP) is another good concept of upgrading and bringing secondary and tertiary care in all cities and rural areas.
To promote healthcare delivery in rural areas the doctor should be encouraged by arranging for them good housing and transport facility and good schooling for their children. In fact, the concept of rural dispensaries should be abandoned and what we need is a good primary/secondary healthcare centre within a radius of 20 kilometres and that area on daily basis should be covered for OPD service by mobile vans with fixed hours backed by strong ambulance service which most states have already adopted. This will help getting the medical and paramedical manpower stationed at these centres as they will get basic facility and necessities of life for themselves and their family and doctors will be able to deliver better healthcare with better facility in terms of equipment and beds in an upgraded hospital environment. It will also help in running the various preventive healthcare programmes in true earnest.
These primary/secondary healthcare centres should be backed by tertiary care centres whether in private or government sectors at treatment cost rationalized by a committee of experts consisting of knowledgeable people from the government and the private sectors.
We need to understand that health is the ultimate necessity of life and is very important for the economic growth of this country. If we get developed this concept of value based medicine, it will see us through in building a healthy and capable society which in turn will produce a workforce which will work hard to take this country forward and will make it a world leader.