Why people do not follow rules, the psychology of anti social behaviour and its impact to a common man Part 2

We are in the process of treating a young man who was run over by a lorry. We had to amputate his leg to save his life. His leg was crushed and with in few hours, he as gone to renal failure. We had three patients in short succession of time with road traffic accidents with similar mechanism of injury. The pillion driver of the two wheeler is run over by a lorry.

When you drive in a car, you often do not give due consideration to a two wheeler on the same road. The same applies if you are a lorry driver, you do not worry about the car and so on and so forth. You would think then that the pedestrian or the person on the smaller vehicle will be very careful so that he/she does not get hurt

But the opposite is often the case. Here the person on the smaller vehicle or the pedestrian feels that he has the right of the way. Often he/she does not obey the traffic rules and still feels that what he has done is right.

Now coming back to the person on the two wheeler who got hit by the bus from the last blog. He was behind a smaller vehicle and gave due consideration to the traffic light and stopped when it was red.

The bus behind did not think it was necessary to stop at the red light and decided to drive on, but in the process hit our patient who stopped.

It does now begin to puzzle you to understand the psychology of what is right in a given situation. Should you follow rules, but might get hit in the process. Or should you follow the herd and live like a Roman in Rome.

Now what can be termed anti social. Like stopping at red light and get hit by the bus behind. it could be still within law but may be anti social. Or one might break the law like crossing a traffic light when it is red for example, but within the social norms of the day and the place you are living

Interesting

Going back to the run over incidents in India, the crush is so severe that people lose limbs. Be Very Careful if you drive a two wheeler in India, as you would not know whether the person behind the other vehicle would behave. Anti social, within the law, break the law but within the social norms of driving in India!!!!1

Hope you got the gist of it

Regards

Chockalingam

Why people do not follow rules, the psychology of anti social behaviour and its impact to a common man

Imagine you travelling at night driving a car, you come across a red light at traffic junction. You are the only vehicle at this junction and you are tempted to stop due to the fact that it is red. You look well across all directions. Definitely there is no other vehicle. You then are tempted to go past the red light. If you know that there can be traffic cameras and you might receive a letter with fine and points on your license, then you suppress the temptation of crossing the red light, as you know it is only few seconds before it goes green.

The scenario i have given is a common sense approach. Even though the common sense tells you to override the red signal as there are no traffic, the regulatory fear of traffic camera stops you doing so.

If you had read my previous blog of hazard, risk and incident, then you understand that another moving vehicle or pedestrian is the hazard for you in the car. The risk is very low as it is middle of the night and you reduce the risk by looking well all around. you think the chance of an incident of an accident is so low that you want to take the chance and you are tempted to cross at the red signal.

As the society does not want you to take even that chance, the traffic camera makes you decide to stop.

But then this logic does not seem to work in India while you are driving. One of my patient i am treating at the moment is a handicapped polio patient who was driving a two wheeler. he came to a traffic signal where the signal was red. he duly followed the above logic and decided to stop.
He then landed at our hospital with a fracture of the leg and shoulder.

Why? Why and Why ! these are the questions he asked me and you are probably asking as well

Wait for my blog and i am sure if you are driving in India you already know why

Regards

Chockalingam

Arthroscopic Surgery at our KMC Speciality Hospital, Trichy, India: Key hole surgery

This is the article published in KMC News 2010

Arthroscopic surgery [Key hole Surgery] at our KMC Specialty hospital
Dr S Chockalingam FRCS, FRCS [Trauma and Ortho]

Joint replacements have now become the standard of care for advanced arthritis. These joint replacement surgeries for arthritis of knee, hip and shoulder have become common at our hospitals. The less known treatment method for joint pain in younger individuals will be discussed in this article.

This less known treatment method namely arthroscopic treatment for joint pain is now increasingly used in our city as in the Western world. An arthroscope is a telescope,[ type of endoscope] the size of a pen when introduced into the joint, helps us to evaluate the joint and introduce instruments to repair or remove the injured structures

Professor Kenji Takagi in Tokyo used a cystoscope back in 1919 to look inside the joint. Eugen Bircher a Swiss Politician/Army Physician is considered as the father of arthroscope where he used a thoracolaparascope to view the joint. Japanese surgeon Masaki Watanabe gets the credit for using arthroscopes for interventional procedures rather than for merely diagnosing the problems.

Advances in the fiber optics in the 1970s and 1980s have now helped to the current design of these arthroscopes which come in various small sizes for various joints. We now have this facility to treat joint problems and I have shown the use of this surgical technique in managing joint problems at KMC Speciality hospital

The following conditions are some of the patients who have been treated at KMC Speciality hospital with our state of the art instruments using this technique.
1. Diagnosis of unexplained knee pain where Tuberculous synovitis, synovial chondromatosis and other conditions and treatment of septic arthritis of all joints.
2. Meniscal tears:This is one of the commonest indication for this procedure. Even though sports injury is a common mechanism of these meniscal tears, it is fairly common in middle aged women and men in India.
3. Cruciate ligament tears. Ligament reconstruction of the anterior cruciate ligament done through this minimally invasive technique has perfected this reconstruction
4. Shoulder pathologies. The shoulder is only second to the knee in the numbers where this technique is being used here at our hospital. Decompression of the subacromial space and Shoulders that dislocate repeatedly are common indications
5. Ankle and other joint pathologies. So far we have treated variety of pathologies with this minimally invasive technique at KMC


Regards

Chockalingam

Arthroscopy surgery at Trichy to cure joint problems of knee, shoulder and other joints

Sports Injury Service and Advanced Arthorscopic Surgery Service At KMC Speciality Hospital

Sports is becoming more of a passion as much as a hobby in our Country. Winning World level events has attracted more of our young boys and girls to partake in sports and even take this as their profession. As each profession carries its risks, sports poses us the biggest risk to these young generation in the form of injuries.

Injuries in sports mostly affect the musculoskeletal system. The muscles, tendons, bones and the joints are the components of this system. The joints are complex structures having cartilage, ligaments attached to the bone through soft tissues.

Most sports injuries are managed initially with the following fundamental principles. Remember the mnemonic RICE whenever one gets injured. Rest the injured part, apply Ice, apply Compression and Elevate the injured part. The practice of applying warmth in the form of hot water pack/bottle to the injured part is not recommended.

Physiotherapists either at the sports arena or at the hospital can treat majority of minor injuries to the muscles and tendons. The spasm associated with the muscle and tendon injuries can be treated with stretching and local treatment as described above. Some of these injuries especially the minor ligament injuries need rehabilitation by attending a dedicated physiotherapy department.

KMC Speciality Hospital has a dedicated Physiotherapy department to treat these injuries. The devices available in the department cover all areas of the body. They are designed to treat with mobilisation, stabilisation and retraining.
Though the initial pain and suffering improve with these simple measures and physiotherapy treatment, the long term recovery depends on detection and treatment of major injuries. These major injuries often feel like minor injuries after rehabilitation. However the key to return to sports and normality relies on recognising these as needing further treatment.

Hence we need experts who can diagnose and be able to treat them with the modern treatment methods. At KMC Speciality Hospital, we have surgeons trained and practiced abroad in treating these injuries. Treating them with modern treatment methods practiced in western countries is the key for getting back to normality.

Modern methods of treatment of the sports injuries often involve keyhole surgery to the joints. This is called Arthroscopic Surgery. Arthroscopy started as far as back in 1910s, though the treatment with this technique was possible after 1970s in Japan.

The Advanced Ortho Care at KMC Speciality Hospital has a dedicated state of the art High Definition Arthroscope with HD monitor for excellent visualisation and treatment of the injured part. The supportive power instruments, electronically controlled pump system and Radiofrequency Ablation techniques are at par with the most advanced hospitals in the world.

The problems, which can be treated with these Arthroscopic techniques, are many and can only be listed as a guide as follows.
1. Cartilage injuries of the knee: Meniscus Injuries in the knee and Wrist cartilage injuries
2. Ligament Injuries: Anterior and Posterior Cruciate Ligament Injuries in the knee
3. Tendon injuries of the muscles in the shoulder: Rotator Cuff Injuries and SLAP lesions
4. Recurrent Dislocations: Dislocations of the shoulder and kneecap, which often recur in young sports people
5. Recurrent and persistent pain in joints: Impingement of the joints, which affect mostly shoulders, ankles and elbow
6. Post trauma stiffness of the joints
7. Instabilities of the joints: shoulders and ankles
8. Infections of joints
9. Arthroscopic fusions of joints especially ankle


Some of the other Advanced Ortho treatment Methods provided at KMC Speciality Hospital are as follows
1. Joint Replacements of Knee, Hip, Shoulder, Elbow and Ankle using imported implants with international standards [Swedish, UK and Australian Standard]
2. Partial joint replacements with implants originating from Oxford,UK.
3. World Class treatment methods of simple and major Trauma using principles of international Swiss [AO] and American Standards [ATLS]
4. Treatment of deformities in Children with Ponseti Method [Canada]
5. Treatment of complex trauma and deformities using Russian Technique [Ilizarov technique]
6. Treatment of Fractures in Children using French Technique [Nancy]

Chest Injuries in trauma: The major killer in India after road traffic accidents: Seat belt should be worn in cars and buses

Breathing and Chest Trauma

Dr S Chockalingam

One of the major killer injuries is Chest Trauma. In fact the chest trauma is the commonest killer for a driver behind a steering wheel especially when not wearing a seat belt. Chest trauma is one of the injuries, which is treatable in a patient who can reach a hospital alive. Appropriate treatment can save many lives if recognised promptly. This appropriate treatment is often a simple intervention as opposed to a thoracotomy. Any doctor irrespective of their specialist interest should safely perform these simple interventions.

The following content focuses briefly on the essential anatomy, physiology of the chest. The main focus is then on recognising these injuries and acting swiftly to save one’s life. Early recognition of these injuries will also help in preventing late deaths.


Essential Anatomy:

The Chest is comprised of the lungs and pleural cavity, heart and pericardium, mediastinum and its contents, chest wall with the ribs and the muscles, diaphragm.

Essential Physiology:

The function of the chest is mainly two fold, gas exchange chamber and a safe haven for the heart and major vessels.

1.The lungs with the bronchial tree and alveoli function as gas exchange chamber. Oxygen gets in to the circulation and CO2 is excreted. The Chest Wall with the pleural cavity and the diaphragm acts as the motor behind to facilitate the gas exchange.

2. A safe place to keep the important organ, the heart and the main blood vessels.

Recognition and treatment of the chest injuries:

In our Medical School, we are taught the art of clinical Medicine. These would be taking a detailed history, thorough examination and ordering appropriate investigations before instituting treatment. The management of trauma is a clear exception to this approach. Hence we have to recognise the injuries and treatment the life threatening injuries before proceeding to the next step. This is most appropriate in chest trauma.



Recognition of Chest Injuries:


A patient who had trauma should always have the primary survey starting with

Ensuring a patent Airway with Cervical Spine Protection before moving on to the chest injuries. The injuries to the airway presents with similar features to the chest injuries. Airway obstruction with
1. Strider
2. Inability to talk
3. Broken tooth
4. Secretions in the pharynx
5. Gross swelling of the neck

Should be managed before moving on to the chest injuries.

The recognition of the chest injuries is essentially two fold.

1. Assess the breathing
2. Assess the cardiac function

These are done by

1. Look
2. Feel
3. Percuss
4. Auscultate
5. Use adjuncts

Look:

1. Equal chest wall movements
2. Engorged veins in the neck
3. For open wounds
4. Abnormal chest wall movements

Feel:

1. Tenderness
2. Crepitus
3. For equal chest wall movements
4. Pulse rate
5. Tracheal position, midline or deviated



Percuss:

1. Hyper resonance
2. Dull note on percussion

Auscultate:

1. Air entry on both sides
2. Heart sounds
3. Abnormal sounds suggesting obstruction
4. Blood pressure

Adjuncts:

1. Pulse oximetry, Pulse, Blood Pressure assessments
2. Chest X ray
3. ECG

Serious Injuries to be recognised promptly:

1. Conditions which affect mainly breathing
a. Massive air collection around the lungs: massive pneumothorax
b. Massive blood collection around the lungs: massive hemothorax
c. Chest wall injuries leading to flail chest
d. Open chest wound with pneumothorax

2. Conditions which affect the heart and circulation

a. Massive blood collection around the heart: Cardiac Tamponade
b. Massive blood collection around the lungs: massive hemothorax


Treatment as you recognise these serious injuries

1. Needle decompression and chest drain for massive pneumothorax
2. Cover open wounds with air tight dressings immediately
3. Resuscitate with oxygen and blood prior to
4. Chest Drain for massive hemothorax
5. Ventilate with oxygen, ambo bag for flail chest before intubation
6. Needle decompression of pericardium in rare instances

The rest of the chest injuries can wait until we complete the primary survey and management of other major injuries.
Other Injuries, which will become life threatening in due course and hence should be recognised and treatment started. These are

1. Pneumothorax which is not massive
2. Hemothorax which is not massive
3. Major airway injury of tracheobronchial tree
4. Blunt injury to the heart
5. Major vessel injury such as aorta
6. Mediastinal often open injury
7. Injury to the diaphragm
8. Multiple rib fractures

Please remember the power cable for chest wall function is “the intercostals nerves and the phrenic nerve and the brain” ultimately. Hence any injury to the spinal cord, brain and the phrenic nerve will affect breathing even when the chest wall is not injured.

Summary

We have to be familiar with understanding of the following features associated with major chest injuries

When observing the patient

1. Chest pain and air hunger
2. Distress in breathing
3. Sucking open, but often-small wounds in the chest wall.
4. Flail chest

When eliciting the signs

5. Absent breath sounds
6. Engorged neck veins
7. Subcutaneous emphysema
8. Tachycardia and Hypotension
9. Deviated trachea
10. Muffled heart sounds
11. Cyanosis

When assessing with
12. Abnormal saturation with Pulse oximetry
13. Chest x ray abnormalities in trauma
14. ECG changes of blunt cardiac injury

The key message of this review on Chest Trauma is never underestimate these injuries as often these injuries kill a patient within few hours of injury and if not will adversely affect the outcome in the first few days of admission to the hospital

Total Knee Replacement: India What we know and our Experience at KMC Hospitals Group

Total Knee Replacement: What we know and our Experience at KMC Hospitals Group
Dr S ChockalingamD.Ortho, FRCS [UK],FRCS [Tr & Ortho], Dr P R Ramasamy MS [Ortho], FRCS [UK]

This is an article I wrote for KMC News which is distributed to Referring and primary care doctors in Trichy Region on 14th December 2009

Total Knee Replacement is one of very successful and common Orthopaedic Operations we do at KMC Hospitals. The incidence of this surgery increasing in number reflects what is happening around the world.[Ref 1] The reason is why it is not more popular than it is at the moment is the cost of the surgery. This is obviously the point I would like to start of this brief about this surgery. The reason it is expensive at present to the reach of the common man is the technology that goes behind in the implant that is used.[ref 2]

The implant often made of strong Cobalt Chrome alloy, though titanium and ceramic are used in some designs. Any metal however polished, will have surface irregularities if one looks under the electron microscope. The surface finish and the material then become very important in reducing this irregularity and thus help in reducing the wear of the material with which this articulates.[Ref 3 and 4]

The material with this metal articulates is a specialized plastic called Ultra High Molecular Weight Polyethylene. Newer highly cross linked Polyethylene has come into use in hip replacement surgery.[ ref 5] However the quality of the Plastic used is controlled in the way this plastic insert is manufactured. This helps in the long term success of the knee replacement surgery.

The long term success of the knee replacement surgery is more important that looking at short term benefits of this surgery.[Ref 6] Any material placed between the end of the femur and tibia will relieve the arthritic pain. What is more important however is the durability of the material in staying without damaging the underlying bone!

The damage to the underlying bone is the worst scenario when faced with the failed knee replacement surgery. One fears this as the damage often starts without any warning such as pain. When one faces a failed knee replacement, the surgical challenges becomes daunting and more importantly becomes very expensive.
This brings me back to the opening paragraph of this brief, the cost of this joint replacement surgery.

A little bit more cost at the initial replacement surgery has been shown to reduce the chances of revision surgery in the long run. Revision surgery after total knee replacement is not something an ordinary individual can tackle not only as a patient but also financially. One cannot expect the Government to subsidize that cost as well as it will be impossible.

What we do at KMC Hospitals to ensure the long term success of this surgery are as follows.
We have a dedicated team involved in this surgery. The chances of infection developing after such surgery should be kept to absolute minimum and we do this by controlling the theatre environment and the personnel involved. We have only used prosthesis which has follow up data in the long run. Post operative protocols have now been developed to suit our working conditions. There are specific appropriate pain control and rehabilitation in place for these patients, both of which go hand in hand.

I have shown some examples of patients we have operated and what they look like and what they can do after such major surgery!

After total knee replacement this patient is able to sit cross legged! and riding a two wheeler at four weeks!, a patient works as a security at the age of 70 going to work by bicycle|!




Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005 Jul;87(7):1487-97.

Kester MA, Herrera L, Wang A, Essner A. Knee bearing technology: where is technology taking us? J Arthroplasty. 2007 Oct;22(7 Suppl 3):16-20

McEwen HM, Barnett PI, Bell CJ, Farrar R, Auger DD, Stone MH, Fisher J. The influence of design, materials and kinematics on the in vitro wear of total knee replacements. J Biomech. 2005 Feb;38(2):357-65.

Lancaster JG, Dowson D, Isaac GH, Fisher J The wear of ultra-high molecular weight polyethylene sliding on metallic and ceramic counterfaces representative of current femoral surfaces in joint replacement. Proc Inst Mech Eng H. 1997;211(1):17-24.

Wang A, Yau SS, Essner A, Herrera L, Manley M, Dumbleton J. A highly crosslinked UHMWPE for CR and PS total knee arthroplasties. J Arthroplasty. 2008 Jun;23(4):559-66. Epub 2008 Feb 13.

Ritter MA. The Anatomical Graduated Component total knee replacement: a long-term evaluation with 20-year survival analysis J Bone Joint Surg Br. 2009 Jun;91(6):745-9.
.