Alcohol : there is no safe limit

Alcohol or Ethanol intake is increasing in India and gaining social acceptance as we embrace western cultural influences to be part of the Global village. Of course this doesn't mean that alcohol intake is only an import from the west because alcohol abuse has long history even among traditional cultures, events and ceremonies. What western influence has done is to create an impression of alcohol being 'cool' thanks to subtle advertising, promotion of youth events and sports by alcohol manufacturers.

I recently read a newspaper article published in a local daily in Goa that published data from a nationwide household survey among those aged between 10-75 years conducted by teams from Union Misitry of Social Justice and Empowerment. This was called the 'Magnitude of substance abuse in India 2019'. It found that  the national average of alcohol intake prevalence was 14.9% among those between ages of 10-75 and that in males was significantly higher. My personal belief is the survey may have underestimated the data and if the age group was from 15-65 perhaps the figures would be much higher.

Gomantak Times 1st July 2019

Without beating around the bush, let us be clear about one thing....Alcohol is a cellular poison

A miniscule amount of ethanol is produced in our body by process of fermentation. So nearly all ethanol is what we consume.

More than 90% of ethanol consumed is dealt with by the liver. Minor amounts are dealt with by other organs and eliminated through breath or sweat. Ethanol metabolism in liver is a two step process as shown in accompanying diagram...and involves two main enzymes viz Alcohol dehydrogenase and Acetaldehyde dehydrogenase. While this process is very efficient it is neither limitless nor of equal efficiency in all. This is one of the main reasons why ill effects of alcohol are not uniform among all those who consume the same amount.

There are racial, genetic and other variations in how much a person can metabolise and that rate is unique for a person. If one consumes more or quicker than what one can metabolise, particularly in very large quantities over a short time ( binge drinking) or moderately large quantities persistently for many years the ill effects of alcohol are likely to be more severe.

The ill-effects of alcohol can be physical, mental or social. Suffice to say no aspect of a person's life is not at risk when alcohol abuse exists.

In this post I will confine myself to only the physical effects. Without exaggeration, no organ or tissue of the body is not at risk from ill effects of excess alcohol intake. It is a common misconception that alcohol is only a risk for the liver and the pancreas.

The accompanying graphic lists potential risks of alcohol intake but I must mention that a causal association between alcohol and all these disorders has not been firmly established. The statistical data supporting association however is fairly compelling to disregard.

Many people live under false assumptions that 'occasional drinking', 'social drinking'  or 'drinking beer' or ' drinking good quality alcoholic drinks', somehow provides them amnesty against its ill effects. Alcohol in any form or quantity has the potential to cause ill effects. However statistically the risk of liver disease is higher when more than 5-6 standard drinks are consumed by a man or more than 2-3 standard drinks are consumed by a woman in a week particularly if consumed for more than 5 years. I wish to warn the readers that this is only a statistical finding and only as far as the liver is concerned. It does not mean this is a recommended or safe amount because there is no reliable way to estimate an individuals capacity to metabolise alcohol safely.

There is some confusion in people's minds as to what a standard drink means.

1fl oz is about 30ml

The accompanying graphic sheds some light on internationally accepted definition of a standard drink.
As you can see all forms of alcohol can be considered a standard drink.

Alcohol not only can cause ill effects on its own but also amplify the ill effects of other substances as well as metabolic disorders like obesity and diabetes.

I often find patients lamenting their luck or negotiating that despite drinking much more, their friends have no problems. This is a facetious argument as every person is different and just because someone is not showing symptoms doesn't necessarily mean all is well.

So dear readers, don't drink
No amount of alcohol is 'all cool'

Surgical documentation: worth its weight in gold

Documenting surgical procedures performed can be very important and even cost and lifesaving.

Regrettably writing operation notes and documenting procedures is considered a menial task and delegated to the junior most member of the operative team in most places in India. As a result it leaves much to be desired.

I recently operated on a young woman who had as per her discharge undergone a Whipple's surgery ( an operation in which the gall bladder, lower part of the bile duct, head of the pancreas, first part of small intestine and sometimes part of stomach is surgically removed) more then a decade ago at a prominent cancer centre  in Bengaluru.

Whipple's operation

She presented with fever and jaundice and her MRI showed presence of gall bladder and stones in the bile duct with no apparent surgical connection between bile duct and intestines that one expects to be present after such a procedure. This flummoxed us as this picture is unexpected after a Whipple procedure.

Fortunately, the patient was able to procure the detailed records from a decade ago which had clearly documented that the procedure performed was not a Whipple procedure but an unconventional one where the gall bladder was retained and surgically connected to the intestine. This made the picture clear and we were successfully able to sort the problem by performing a second surgery to remove the gall bladder, remove the remaining bile duct and stones and establish a connection between the bile duct and intestine. This successfully relieved her jaundice and she made a full recovery.

I have no hesitation in admitting that it is the detailed record that allowed us to solve the puzzle which otherwise despite requiring multiple and costly scans could still have left us in some doubt before the surgery. The documentation provided us a clear roadmap regarding what to expect and formulate a plan to deal with it beforehand.

As a rule I make it a point to write operative notes on my own. Being the lead surgeon,  I have the experience and insight to document all the necessary details that could be needed later. Writing the notes immediately ensures that details are fresh in memory and not forgotten. 

I often find  myself lamenting this lack of attention to detail when I see patients who have previously undergone surgery with only sketchy or woefully inadequate details available regarding the operative findings and nature of the surgery. These omissions can lead to escalated costs and make reoperative surgery difficult like groping in the dark.

This is a shout out to my surgical colleagues to pay attention to documenting clearly all surgical details ...it could save your patient a lot of angst, cost and even their lives.

Doctors day: acts not words

July 1 is commemorated in India as 'Doctor's day' celebrating Dr BC Roy, a physician politician who was the second CM of West Bengal.

July 1 is both his birth (1882) and death (1962) anniversary.

An award named after him is a much coveted award among doctors in India.

Like many of my professional colleagues, my mailbox and social media is peppered with messages wishing me a 'Happy Doctor's day'. Most of these messages are from patients or their relatives and some from my staff and representatives of pharmaceutical companies.

I sincerely thank them all.

They say feeling gratitude and not expressing it is like wrapping a gift but not delivering it.

However in the light of the current situation of doctor-patient relationship in India, one cannot but feel cynical and reflect.

Are doctors owed any gratitude for doing their professional duty particularly when they charge a fee for their services?

I feel nobody is entitled to gratitude or praise for doing their professional duty whether they do it for a fee or pro bono. Doctors are human beings and trained professionals and therefore susceptible to the frailties and fallibility of both. Medical science like most sciences is evolving and not perfect and ascribing nobility or demigod status to a professional is  inappropriate.

Every dog has his day

This is a pretty well known proverb. So having a Doctor's day without having a healthy relationship with the profession is only a meaningless candyfloss Hallmark moment.

Both the medical profession and society need each other and must find ways to reduce the trust deficit that has got created, mainly in my opinion due to exaggerated reports of medical apathy or lack of sensitivity in irresponsible media. Such negative campaigns have created a confirmation bias that leads people to suspect the intentions of their doctor at every step. If you cannot trust your doctor to act in your best interest, continuing to be his patient is a meaningless exercise.

So a real doctor's day wish to your doctor would be to treat your doctor as a human being who is a trained professional, nothing more and nothing less. He needs your trust not your gratitude and praise for doing his duty. And for some reason if you don't trust him, please move on to some other you trust rather than continue the relationship is an atmosphere of cynicism and mistrust that helps nobody.

Your actions speak so loudly that I cannot hear your words