India is a developing country and 80% of the population of our country cannot afford expensive healthcare. The facilities provided by the govt 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 .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 we have huge load of patients whether it is communicable or non-communicable disease. Added to it is the shortage of man power to treat these patients. As per one study our country has only 20

doctors/10000 population as compared to 650/10000 population in U.S.A. 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 dismissal scenario only alternative to improve upon the services and making each step in health care delivery more justified and economical we need to look at an evolving healthcare delivery system all over the world and even in developed countries like USA and that 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 most costliest way of treatment. It ignores the logistic of benefit vs cost ratio whether it is concerned with writing costly medicines or adopting the most costliest intervention.
Valve based medicine concept is different from the evidence based medicine concept in the sense that we are treating human being and not symptoms or investigations. The treatment planned 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 ratio 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 even be durable so bypass surgery becomes more economical and more durable. So what 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, supportive therapy instead of expensive and high end antibiotics.
Valve based medicine is a mean to compare all health care 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. 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 that 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 24x7 availability.
Similarly if we come to procedures, 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 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 forth coming 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 Nov, 2012 Freedom trail have clearly established and concluded that is multi-vessel disease and diabetes Bypass Surgery scores over drug coated stents in terms of death, second heart attack and second or repeat intervention.

And all patients with multi-vessel disease should be offered Bypass Surgery as the first option for durable economical treatment. So in this scenario Value Based Medicine promotes 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. Still most of the equipment, disposables used in high end surgeries is 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 availability of which should be free and easy and encourage manufacture of disposables and equipment our own country .It will do away the huge profit margin taken by the multinational companies when middle men and the 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 it at all levels .In fact all hospital should be told to use them as the first priority.
The infrastructure resources for the primary ,secondary and tertiary healthcare delivery are very less so a policy need to be made where in govt. and private

sector 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 govt. hospitals today. All it needs is rationalization of compensation to private sector .Today also many govt agencies are utilizing the private resources for tertiary care by reimbursing them the subsidized cost of treatment. Why not it can be applied to primary and secondary care? Public private partnership is another good concept of upgrading and brining secondary and tertiary care in all cities and rural areas. To promote health care delivery in rural area the doctor should be encouraged by arranging for them a good housing ,transport ,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 health care centre within a radius of 20 kilometers and that area on daily basic 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 centers as they will get basic facility and necessities of life for themselves and their family and doctor will 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 programs in true earnest. And then these primary/secondary centres are 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 government and private sector. We need to understand that health is the ultimate necessity of life and is very important for the economic growth of this country. Till we get developed this concept of value based medicine 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.

What are you to do if you have a heart attack

While you are alone.

If you've already received this,

It means people care about you.

The Johnson CityMedicalCenter staff actually

Discovered this and did an in-depth study

On it in our ICU.

The two individuals that discovered this then did

An article on it, had it published and have had it incorporated into ACLS and CPR classes.

It is very true and has and does work.

It is called Cough CPR.

A cardiologist says it's the truth,

If everyone who gets this sends it to 10 people,

You can bet that we'll save at least one life.

It could save your life!
Let's say it's 6:15 p.m. And you're driving home

(alone of course), after an usually hard day on the job.

You're really tired, upset and frustrated.

Suddenly you start experiencing severe pain

In your chest that starts to radiate out

Into your arm and up into your jaw.

You are only about five miles from the hospital

Nearest your home.

Unfortunately you don't know if you'll be

Able to make it that far.

What can you do?

You've been trained in CPR

But the guy that taught the course didn't tell

You what to do if it happened to yourself.
Since many people are alone when they suffer a heart attack, this article seemed to be in order.

Without help, the person whose heart is beating improperly and who begins to feel faint,

Has only about 10 seconds left before losing consciousness.

However, these victims can help themselves by coughing repeatedly and very vigorously.

A deep breath should be taken before each

Cough, and the cough must be deep

And prolonged, as when producing sputum

From deep inside the chest.

A breath and a cough must be repeated

About every two seconds without let up

Until help arrives, or until the heart is felt to be beating normally again.

Deep breaths get oxygen into the lungs and coughing movements squeeze the heart and

Keep the blood circulating.

The squeezing pressure on the heart also helps it regain normal rhythm. In this way, heart attack victims can get to a hospital.

Atrial septal defect is an abnormality present in a person from birth where there is a hole in the partition between the upper chambers of the heart called the atria. As a rule many times if it is small it can close on its own by 2yrs of age beyond that[a1] if it is of simple nature then one comes to know of it only in second decade. If the type of this defect is atypical which is called Sinus Venosus type of defect then symptoms happen earlier and needs early intervention also. Here most of times one vein carrying pure blood from lungs which was to drain into left upper chamber is opening into right upper chamber this increasing the flow to lungs. Or some time all veins from right lung are opening into the superior Vena Cava (Vein draining impure blood from upper parts of body to right upper chamber) along with large gap in the partition between the two upper chamber. In such a situation the flow to the lung increases markedly and permanent damaging changes start setting in and a stage comes when resistance of lung vasculature increases so much that blood flow direction reverses. Normally it is left to right but then it becomes right to left and patient start becoming blue also. This is a stage where surgery is not possible and patient become in-operable. Otherwise if heart surgery for this carried out at the right age and time is suitable and patient becomes absolutely normal for rest of his /her life.


Recently a 21yrs female who had given birth to a child 4 months back presented to us at Alchemist Hospital, Panchkula with severe breathlessness and palpitation. On examining we found her to be having a hole in the heart in both the upper chamber and investigating her with echo-cardiography and going through her previous record we found that she had atypical sinus venous type of atrial septal defect which manifested after child birth but along with her pressure in the lung vasculature had become very high almost equal to the body’s blood pressure. In view of this outside other peripheral hospitals had denied her surgery in view of very high risk including the risk to life. Infact she was sent Delhi for opinion.


When she presented to us we also felt the same way but then we decided to further investigate looking at her young age. The only chance for correction or treatment through surgery was now and otherwise it could be fatal. We admitted her and did a cath study on her. The lung pressures had peaked to 110mmHg which was equal or slightly more than her own blood pressure and shunt across the defect got reduced to 1.3:1 (normal criteria for surgery is shunt more than 1.5:1 or 2.1). The pulmonary vascular resistance came out to be 12 wood units, close to the terminal limits, where one becomes in- operable. Only positive finding in the study was that she was still maintaining almost normal oxygen levels in left side of upper chamber i.e left atrium about 97% that was a sign that she was not de-saturating but other parameters pointed towards non-operability.


We decided to plan her treatment and give her a chance. We started her on certain newer drugs to lower her lung pressure before surgery, talked to the family of high risk involved and total picture and need to prepare her for about a week before surgery by drugs including lungs pressure lowering drugs, to flush out extra fluid from body and to give rest to right heart and also some thing to improve the contractions of right heart.


Looking at the literature again she was in that rare group where surgery was not possible. After nine days of preparation we decided to do a repeat echocardiography and she did responded to medication but marginally and also there was no bluish discoloration involved, so we felt that changes were not irreversible. On 17.06.2011 she was operated for open heart surgery and her hole was closed with a patch made out of the outer layer of heart called pericardium, diverting all the right lung veins which were connecting to lower part of superior Vena Cava to the left. We did one more innovation in creating a flap- valve type of patch in her case. The idea of this is that incase after surgery the right heart pressure increases the flap valve allows the right chamber to dicompresss by opening up. Heart muscle was protected well during surgery with various newer Techniques. She responded well to treatment and surgery and her lung pressure came down to 50% of arterial pressure in the immediate post- op period. They further were controlled with the new drugs which we had started earlier in the pre- op period. Over all she responded very well and lung pressure almost came to normal range.


She was discharged on 8th day with detailed explanation about the medications and precaution and on her follow up visit on 1st June it was very heartening to see her healthy and progressing well. Well thought of strategy and extra effort in treatment goes a long way in saving these high risk patients along with a good and skilled infrastructure and highly experienced team of doctors. 6 Senior doctors were involved in her care on day to day basis and it was very satisfying for all of us to save this young life. She was operated by a team headed by Dr Virendar Sarwal, Head- Dept. of CTVS, Alchemist hospital, Panchkula, Dr Arath Nahak, Dr Ajay Sinha, Dr Deepak Oberoi, Dr N Srivastava and Dr Dheer







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