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

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

The Bone and Joint Decade 2000-2010, Ten years on........

This is an article I am writing for increasing the awareness of bone and joint disorders among the public and the medical community alike.I hope you find it useful

World Health Organisation [WHO] endorsed the launch of “Bone and Joint Decade [BJD]- 2000 to 2010” in Geneva in January 2000. The key goal is “to keep the people moving by prevention and treatment of bone and joint problems. This will in turn reduce the cost and the burden to the individuals, the carers and the society at large”.

BJD-India duly followed with National Action Network launched from Pune by eminent doctors. This was endorsed by the Government of India. As we are on the verge of this decade behind us, it is time for us to reflect and hence this article.

Arthritis affecting a joint such as knee and hips are very common in India. Every other person over the age of 65 in India is affected with arthritis. Unfortunately the treatment is not sought or often delayed.

The road traffic accidents are not only common, but also results in severely injured people. The deaths are frequent and multiple numbers of people are involved in the same accident. This is reflected in the Official statistics of the department of Road Transport and Highways, Government of India.

Unfortunately such affections of the bone and joints leave people with physical disability. The patients become dependent on the family and the society adding to the mental suffering. Some of the patients are left crippled due this pain. The true extent of their suffering is revealed in the limitation of their activities of daily living let alone their limitations in the society.

When one is not able to do even routine activities such as walking, secondary health problems arise. These include sedentary lives, increasing obesity, diabetes, high blood pressure and heart diseases. WHO recognised this growing trend in the society often leaving a financial burden.

Diet and exercise play important role in the health of our bone and joints as much as for our heart. Yet our life style had become sedentary. Increasing incidence of overweight and obesity has aggravated the bone and joint problem such as arthritis. Specific remedies for certain arthritis such as Rheumatoid are not sought. These lead to crippling deformities and disabilities. On the other hand, there is misuse of pain killers leading to other problems such as kidney failure.

Wearing a seat belt is the most effective way to prevent injuries when travelling in a car or a bus. Yet many of us remove the seat belts or consider it a hindrance to wear. Traffic rules and restrictions are rarely followed resulting in serious and disabling injuries.

“A painful advanced arthritic joint can be cured with a joint replacement” is a well known fact to many in a Western country such as UK. However people in our villages are left suffering due to the lack of awareness. This lack of awareness is present even in educated persons living in cosmopolitan cities.

With this launch of Bone and Joint Decade, WHO highlighted the need for the improvement in the diagnosis and treatment of such disorders. WHO encouraged prevention through education campaigns. Ten years on since the Bone and Joint Decade launch by the WHO, the real question had there been an any improvement at all ?

In spite of all being written early in this article, there is certainly more awareness created by this WHO initiative. The government of India through its participation in this Bone and Joint Decade has shown its commitment in prevention and treatment of these disabling conditions.

Government Welfare schemes helping them finance the treatment ensures that poor are not left alone in this treatment reach. One has to mention one such scheme for the people below the poverty line at this juncture which has benefited and continues to a huge number of financially disadvantaged section of our society.

More people are seeking treatment rather than neglecting these ailments. They are asking for the accurate diagnosis as much as the treatment itself. This is especially facilitated when they see others benefited due to the treatment options such as joint replacements. People have started to recognise the fact that “Early and appropriate treatment of injuries prevents long term disability”. Technological advances such as key hole treatment of joint problems with arthroscopy are now known.

Every year many hospitals follow the activity week to focus their year long efforts to the public in October[ 12th to 20th of October of 2010 for this year]. Many hospitals and doctors are conducting free camps to facilitate such an awareness. Their efforts should be lauded with reverence for the public service.

There is certainly a larger section of our public where the awareness has not reached as we still see a significant number of disabled people due to the bone and joint problems. Hence more concerted efforts should be done from the community in general and the medical community in particular.

Education in road traffic accident prevention should reach the “prospective road users” namely our children. Public awareness campaigns should increase in number and reach the inner villages. Medical schools should increase the training given to the doctors in dealing with bone and joint problems. There is a need for the entire community to celebrate this bone and joint week in October.

May I conclude this article saying that “Let the end of the Bone and joint Decade -2000-2010 herald a new beginning in spreading awareness of the increasing number of Bone and Joint problems. These are either preventable and when affected, many of them are certainly curable”

Dr S Chockalingam
Consultant Trauma and Orthopaedic Surgeon
KMC and KMC Speciality Hospitals,
Trichy

Understand the "Shortest Possible Route in the Shortest possible Time" Logic

If you want to succeed in life, you have to be ahead of others. this is applicable in education, work, business and life in general. The logic then sounds right meaning that "it is an efficient way of finishing a job or work", right?. The logic then sounds OK eh!. no not really.

But not really in certain situations. you would understand this very well if you see the traffic in India. When you understand this "shortest possbile route in the shortest possible time" strategy is being followed by the driver on the other side, you begin to explain the so called accidents in road traffic.

In Other words the title logic cannot and should not be followed where you want a system to be streamlined and everyone following the same rule. this not only applies in traffic, also in a work place, education, health sector. In short it should not be followed wherever you need people in a organized area such as work place or society in general to follow a prescribed path.

Back to the traffic analogy, driving in a country like UK where the people are prepared to take a longer route so that there is an order is easier and safer, as they do not follow the logic as safety is more important.

however this does create a problem. if everyone follows the exact route, you do not get eccentrics who are often the one who would move in leaps and bounds and often change the world. so you do need eccentrics who are going to be different and think laterally. hence you do need to nurture them and not discourage them completely. for example a person who leaves a college in the middle of his course may be thought of not following the order. but he might be the next Richard Branson!

Back to the title, sounds right and it is right in certain situations. But not really in lot of situations where you do need order when many people are involved.

Hence the best thing we can do is to understand the logic and see the benefits and use them. It is also important to understand when there are dangers when this logic is being used.

For example in Indian Traffic, when you see a pedestrian or cyclist crossing in front of you in a car attempting to move forward. instead of thinking, " is he a maniac trying to kill himself being hit by my car", you would think " go on, i understand your logic"


I will detail how understanding this logic helps you in other situations in future blogs

Regards

Chockalingam

A Typical Road Traffic Accident in India -Seat Belt is important

A middle class family now can afford a car or can certainly rent a car for their trip on the road. I have now treated several accident victims at Trichy for the last two years. The injuries are quite typical.

1. The driver either dies or suffers from chest injuries with multiple rib fractures. He would end up having pneumo or hemothorax namely collection of air or blood around the lungs which can be life threatening.

2. The front seat passenger suffers from facial injuries, head injuries as he or she is thrown on to the windscreen and either dies or presents to the hospital. They have problems with air going to the wind pipe and may die if not recognized. As they are trying to protect themselves going forward, they put their hands forwards and suffers from upper limb injuries on both sides. They may also suffer from disocated hip joints

3. The rear seat passengers suffer from lower limb and upper limb injuries, chest injuries and abdominal injuries. They are like the toy within a shell which is popular toy with the children. you shake the shell and the toy inside rattles inside. The rear seat passengers are rattled inside the hard car shell and get multiple injuries.

4. Children often escape due to the pliability of the tissues though it is not guaranteed.

Now the big question then is, what should one do

1. understand the local traffic paths. most accidents happen when a driver goes into an area without experience of local traffic. Meaning that the traffic path of pedestricans, cyclists, two wheelers, tractors, lorries, buses can be in any direction at a given place. hence following traffic rules in India is not enough, but understand the traffic rules as followed by the other person.

to understand the first point, remember the shortest possible route would be taken by an Indian wherever he or she goes and whatever possible method of transport he is using.

2.Always wear a helmet and Seat Belt when riding in in a two wheeler and a car respectively. The injuries as i had listed can be largely prevented by seat belt and i stress most of the times.

3. Remember using a vehicle such as a two wheeler or a car is for comfort and not for speed of access to reach a given point. I am not saying that you should not go fast, but keep telling yourselves that i am having a nice comfortable ride as opposed to going in a crowded bus .i am not using the car to go quickly from point A to B

4. Do not drive the car if you are the driver if your passengers would not wear a seat belt, i.e your family for example. This should be one of the golden rules you must follow to protect your family. do not yield to reasons for not wearing seat belts.

5. When driving during the day time, be aware of smarties driving into your lane from the opposite side. the left lane is safer in a dual carriage way

6. when driving at the night time. be aware of smarties who have parked their vehicles or driving without any lights at the back. you will smash to their back

7.If you can avoid, and i must say that you should avoid any night time driving as a family or in business. It is not worth it

8. Traffic awareness is not there in India with most road users and when combined with lack of speed awareness, then it is a lethal combination.

One of my good friends advised that preferrably avoid going anywhere or reduce the amount of time you spend travelling to increase your chances of living in India.

I felt sad when i learnt of the death of the minister today and i felt that it is time i Shared some of the road safety issues to you

Chockalingam

health awareness activities at Trichy

I am adding some of the articles written in press and some of the photos of the health awareness activities done at Trichy with KMC speciality and KMC hospitals.

Orthopaedic problems of bones and joints are many and we took on only four issues last year at KMC Speciality Hospital named by WHO bone and Joint Decade. they are 1. osteoporosis 2. arthritis 3. road traffic accidents 4. back and neck problems.

We have done Meet our Patients Meet where the press and the public could freely interact with our patients benefited from advanced ortho care treatment at KMC and KMC speciality hospitals.

We have done Bone and Joint Walk to raise awareness on Bone and joint problems as listed above.

We have given awareness talks to senior citizens who are pensioners in a standard format.

We have done first aid program to traffic personnel twice in the last two year to raise awareness on road traffic accidents 2. we have done many free orthopaedic consultations starting in march 2009 at KMC Speciality hospital both as camps and regular free clinics on Fridays for patients who cannot afford to attend a hospital such as ours. These have mainly targeted arthritic patients though osteoporosis and back problems have been covered.

We have done two ATLS type courses named Essentials of Initial Trauma Management at KMC Hospital for doctors sponsored entirely by KMC Hospital and all the consultants have gifted their time and efforts to teach the fundamental principles in trauma management.

I will elaborate all our activities in the next blog and list them and post more articles.

Regards

Chockalingam