Holistic Approach to Medical Care

There is Medicine & there is Holistic Medicine..........and there is holistic approach to Medical Care


I so often come across situations where just to the point advise & treatment may not be enough.There is this issue of patients window shopping -its a phenomenon on the rise...A part of it is economic reasons & some of it could be the doctors approach & relationship with the patient.

Especially when we advise surgery -we should not scare the patients.All possible option should be given.
If urgent -it should be properly explained.

For example-1.Adenotonsillectomy which can wait till school holidays
                      2.Safe Ear Drum Perforation Repair which can wait till appropriate off work can be arranged.

Ofcourse above situations demand precautionary measures like avoiding refrigerated & spicy food in case 1 & preventing water entering ear in case 2.
There should also a quick wayof getting in touch with your doctor-it could be opd visit or phone or email.
Lets see where our approach is going....
I went through web for definitions of each...
Medicine is the field of applied science and the art of healing...{note the art part of it...does it exist anymore or only scans & tests exists}


Holistic medicine focuses on how the physical, mental, emotional, and spiritual elements of the body are interconnected to maintain wellness, or holistic health. When one part of the body or mind is not working properly, it is believed to affect the whole person.


Holistic approaches focus on the whole person rather than just on the illness or part of the body that is not healthy.


In fact, the World Health Organization (WHO) has defined health since 1948 this way:

"Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."

Clinical holistic medicine actually dates as far back as Hippocrates.An holistic approach to patient care was also suggested by Percival in his book - the first textbook of medical ethics - first published in 1803. Percival stated: "The feeling and emotions of the patients require to be known and to be attended to, no less than the symptoms of their diseases".


 
Doctors should no longer see patients as walking pathology . 

I get blamed to take a lot of time in opd consultations & am told to be quick...I decide which patient needs time spent with & who does not.It may be a simple problem & long consultation & vice versa.It all depends on the patients acceptence & understanding of the problem.
My approach differs with each person who comes & sits in front of me though the medical assessment & diagnosis may remain the same in all of them.

Ear Disorders * Singled Sided Hearing Loss In Children * California Ear Institute * Ear Doctors * Palo Alto * Bay area

I have been every year picking up a few children with single sided deafness.Majority of them had normal MRI/HRCT Temporal bone scans normal.Just a couple of them,we have picked up inner ear congenital anomaly in scan.
However it becomes so difficult to convince parents to get the child hearing aid for the deaf ear.This is especially so in children where speech & language skills are already developed.However we still give them the options & discuss with them hearing solutions available for single sided deafness.

I found this leaflet from California Ear Institute very educative & pleased to share with all....

Ear Disorders * Singled Sided Hearing Loss In Children * California Ear Institute * Ear Doctors * Palo Alto * Bay area

Steam Inhalations & Vapour Rubs

Being an ENT Surgeon,I often keep telling patients to do steam inhalations.Next comes a query- how to do steam inhalations?

The simple way is sitting with your head over a bowl of hot water. Place a towel over your head, close your eyes and breathe deeply. Avoid getting the hot steam in your eyes.

Adding menthol, eucalyptus, camphor, thymol or pine oil to the water may help,however plain water also does the job of loosening the mucus.

Steam inhalation in children as described above should be avoided due to the risk of scalding in babies & younger children. Instead, a child may benefit from sitting in a hot, steamy bathroom.

There are now steamers available in the market which prevent the risks of accidental burns & scalding.However get a good product as my personal experience with a local made product has been mould in the equipment if left unused for some days!

Vapour rubs are also traditionally used.However it is not advisable to put them in steam/hot water.Apply the rub to your chest and back. Don't apply it to their nostrils because this could cause pain and breathing difficulties

Pediatrics - Pediatric Emergencies News Article | Who needs admission among infants with acute otitis media |3961771

Pediatrics - Pediatric Emergencies News Article | Who needs admission among infants with acute otitis media |3961771


We have had a few cases of acute otitis media in young babies & this dilemma always exists whether to admit & give intravenous antibiotics or oral antibiotics.Between me & referring pediatrician ,we take a joint decision of intravenous antibiotics in a neonate or very young baby.

This article describes below 2 months as very young babies who needed admission in their study.The older babies i.e. above 2 months were followed up out patient basis.Doing septic screening is also a valid point.

I always insist upon the parents the preventive aspect.No water should enter the babies ears for 4 weeks following infection & ear buds should never be used.As far as ear buds are concerned they should not be used in any baby or adults.Ear is self cleansing organ & people who produce lot of wax need ear suction done by a medical professional.

Nose bleeds or epistaxis

Nose bleeds can be very frightening experience.Though all nose bleeds are not dangerous,it is better to seek help if it is recurrent & of course continous/profuse.

1 in 7 of us will have some episode of nose bleeds in our lifetime.Nose bleeds are common in children aged 2-10 & the elderly.

The common causes of nose bleeds I see in my practice are

-Trauma:any fall or injury over the nose/face,nose picking

-Exposure to warm dry weather leading to dry crusty nose

-People on blood thinners eg Aspirin

-Medical conditions i.e.Liver conditions & high blood pressure

-Nasal foreign bodies in children

-Allergic rhinitis & deviated nasal septum

-Vigorous nose blowing


However there are less common causes of nose bleeds like bleeding disorders,leukemia,nasal tumors & autoimmune diseases like Wegeners disease.Especially with recurrent nose bleeds,we should be on the look out for more than common causes.We diagnosed two cases of Osler Weber Rendu disease last year in patients with recurrent nose bleeds.Careful examination revealed classical telangiectasia over the septum & nostrils.Proper diagnosis & treatment is a team work & we send them to other specialists for further work up & management.

Here I would like to mention that various medical conditions first present to ENT surgeons with initial symptoms.Though rare conditions are difficult to diagnose-if we are on the look out & pick it up early,it is of great benefit to the patients.For example:Wegeners Disease,Osler Weber Rendu Disease.
In children there is a vast range of symptoms which present to ENT's .It can be nasal polyposis in children leading us to cystic fibrosis or a speech delay child can have deafness or be in autistic spectrum.As an ENT surgeon,I need to be looking beyond just checking ear,nose & throat.

Coming back to nose bleeds-they can be divided as anterior or posterior bleeds.Anterior bleeds are from the Little's area (Kiesselbach's Plexus) over the septum & can be managed with chemical[silver nitrate] or electric cautery in the opd.
Posterior bleeds need much more attention & usually need admission in the hospital.Bleeds which do not settle with local pressure need anterior or posterior packing of the nose.
For refractory posterior bleeds which do not settle even with anterior & posterior packing need endoscopic ligation of artery commonly the sphenopalatine artery.

Below are the pictures of anterior & posterior bleeds & vessels/arteries mainly involved.

A-anterior nose bleeds
B-posterior nose bleed

In the end,I would like to write about what you should do first when facing a nose bleed :

• Remain calm.
  
• Sit up straight and lean slightly forward.
  
• Lean your head forward. Tilting your head back will only cause you to swallow the blood.
  
• Pinch the nostrils together and apply direct pressure with the thumb and index finger for approximately 10 minutes. Time it to make sure the nostrils are not released earlier.
  
• Spit out any blood in the mouth. Swallowing blood may make the affected individual vomit.
  
• This technique will stop the majority of simple nosebleeds

However anything more than this -you need to go to your nearest emergency department.

Food or Feed !

I had organised a workshop on swallowing difficulty i.e.dysphagia on 1st Feb.It was worth all the efforts I put in for the last one & half months.Indian Speaker Dr Jayakumar Menon's talk was taken very well by the audience.I am still getting phone calls from ENT's & Neurologists -thanking me for getting him to Bangalore.The U.S.faculty Dr Shirit Yarkony also presented her work which can be a good addition to dysphagia diagnostics & management.

As Hippocrates said
"The wise man should consider that health is the greatest of human blessings. Let food be your medicine."

As an ENT Surgeon,I come across patients with swallowing problems routinely.Swallowing is a sequential process in which food is prepared in the oral cavity then propelled into the back of the mouth & quickly it passes from the pharynx into the oesophagus.Finally from the oesophagus it reaches the stomach.The first two parts are under our control (voluntary) while the latter occurs involuntarily.



ENT Surgeons take care of oropharyngeal part of swallowing difficulty  while gastroenterologists take care of oesophageal part of swallowing disorders.
The commonest presentations ,I am seeing & diagnosing in my practice are in the folowing order:
gastro esophageal reflux disease (GERD)
stroke or progressive neurological disorders, which may impair sensitivity, muscular coordination, or render individuals unable to control or move the tongue
The presence of a tracheostomy tube, vocal cord paralysis, tumors in the mouth, throat, esophagus, or surgery in the head, neck, or esophageal areas

The assessment starts with a detailed history & clinical examination.

The diagnostic evaluation includes
Trans nasal endoscopy,FEESST & Fluoroscopy/Barium swallow.

Some pictures of FEESST(flexible endoscopic evaluation of swallowing & sensory testing)

The gold standard radiodiagnosis is fluoroscopy in which the special dye coated liquid or solid food is given to the patient & the whole process of swallowing is examined.


After the level of  swallowing problem is diagnosed -the management is planned.Most of the GERD need medical management.The neurological cases need swallowing rehabilitaion therapy.Many cases will initially need tube feeding.

Some may need tube for long term & tube is inserted into the stomach as shown

However what they get is the feeds through these tubes-nutrition is taken care of .These patients always wait to taste & eat the food through the mouth.

Just to remember 1/3rd of stroke patients are at risk of aspiration pneumonia & there still stroke patients dying of this complication all over the world.

The swallowing rehabilitaion should be started as early as possible even though patient is tube fed.Surgery has a role to play in selected few cases.

The elderly population of the world is increasing & we need to understand & learn dysphagia mechanism far better even for these normals.

What we aim for is normal eating ......

 Nothing would be more tiresome than eating and drinking if God had not made them a pleasure as well as a necessity.
   ~Voltaire

Fact sheet: Hearing tests in newborns and babies - PubMed Health

Fact sheet: Hearing tests in newborns and babies - PubMed Health