http://timesofindia.indiatimes.com/india/Open-secret-Doctors-take-cuts-for-referrals/articleshow/37350397.cms

Before all of you go tut-tutting in self-righteous condemnation of those this article seems aimed to demonise, it would be worthwhile to go into a few oft-forgotten facts

1. Healthcare is not a service or sacrifice...it is an industry and an economic activity and more so in the private sector. Blatant hypocrisy by couching it under the guise 'social service' has gone on for far too long in this country.
2. Healthcare needs of more than 75% of Indians are met by the private sector and private institutions are preferred by most patients even for primary and secondary care as opposed to poorly managed, inefficient public hospitals bursting at their seams with patients owing to a  merit-last recruitment policies, budgetary constraints, poor salaries and a cornucopia of oft repeated reasons.
3. More than 80% patients in this country pay out-of-pocket for their healthcare and therefore are healthcare clientele or consumers rather than merely patients.
4. Setting up of a healthcare facility in an urban area requires massive investments and capital expenditure owing to high land costs, high import duties on equipment that has low levels of indigenity and human resource costs to provide services to an increasingly demanding clientele.
5. Permissions and licensing of healthcare facility is extremely arbitrary and even if they exist on paper, rules are blatantly violated allowing almost anyone with access to land and funds to setup a healthcare facility.
6. There is hardly any regulation and credentialing of healthcare facilities with regard to outcomes and their ability to offer high-end services from the governments and with low penetration of health insurance, it is a free for all in terms of competitive bidding, promotional activities and advertising to entice patients often looking for a better deal rather than a better service when it comes to their healthcare needs.

While the points above are by no means a complete list, it is important to analyse the origin of this condemn able practice of trading patients for a consideration to hospitals as if they are cattle or commodities.

Economic theory has often more to do with reality than morality in a consumerist society....which however much we may choose to deny, we have already become. Having made huge investments to offer facilities and infrastructure inadequately available or absent at public sector hospitals, private healthcare entrepreneurs are hard-pressed to recover the massive investments made because of the unregulated mushrooming of facilities clamouring for a slice of the pie of  paying patients. Government subsidised health schemes to decongest public hospitals and use under-utilised capacity in private hospitals are mired in red-tapism and impractical costings and therefore not much use in bridging the gap. In such a scenario, to recover their costs, private sector healthcare facilities are compelled to look for out-of-the-box solutions to increase their footfalls sometimes employing processes that could be frowned upon. When supply exceeds demand, it is a buyer's market and since reduction of prices would further harm their balance sheets, private institutions resort react by passing on part of the profits as an incentive or inducement to referring physicians. Once such a practice finds root, everyone is dragged into it to stay on the bandwagon.

Finally patients themselves need to be more discerning and not blindly follow a referral path suggested by their primary physician which I must hasten to add that this is happening already. By no means am I encouraging cynicism towards physicians, but  patients should stop being mindless and ask pertinent questions of their physicians regarding the plan of their management and referral and satisfy themselves to the greatest extent possible. 

The solution remains complex but it is high time we took steps in the right direction. I humbly suggest the following

1. Strict criteria should be followed while licensing healthcare facilities for performance of high end procedures and unregulated mushrooming of centres should be checked.
2. Rather that investing public money and duplicating high end capacity building in public hospitals, extra capacity in private hospitals should be utilised at a sensible price through well monitored schemes. This will help patients as well as reduce massive capex costs to governments while controlling this malpractice of incentives for referrals.

The above is by no means a complete list of solutions but is something that can be implemented without ruffling too many feathers. This will ensure in the intermediate term that referrals are guided by clinical needs rather than other considerations. 

Let me reiterate here that by no means am I condoning or encouraging the cut-practice system that has got stuck in a morass....this posting is merely an attempt to analyse the reasons for this rot. Acknowledgement of the problem is only part of the solution and not a solution in itself . It may allow one to be unabashedly self-righteous and score debating points on ethical forums but it, by no means, brings us remotely closer to a much-needed solution.

Brain death....what is it?

Anatomy of the brain

Traditionally, a person who does not have a beating heart and is not breathing is considered to have died. However with the advent of mechanical ventilation, a person who is not spontaneously breathing can be oxygenated for a significant period of time using a mechanical ventilator.

The human brain is the command & co-ordination center of all body activities. It consists of four parts: the cerebral cortex, the cerebellum, the mid-brain and the brain-stem (pons & medulla oblongata).
The cerebral cortex has multiple functions importantly cognition, sensation, purposeful movement, wakefulness, thinking, speech and memory. The mid-brain among others is responsible for pupillary function and eye movement as it houses the centres controlling nerves responsible for these reflexes. The cerebellum controls co-ordinated movements, gait and balance. The brain stem houses centres for all the other cranial nerves including those for conjugated eye movement, corneal reflex, tracheal and conjugated eye movements. The medulla oblongata houses the critical breathing and vasomotor centres that are responsible for spontaneous breathing and maintenance of coordinated heartbeat and circulation.

It follows therefore that irreversible and major damage to the brain function is incompatible with life. Due to autonomic reflex and local mechanisms, some organs including the heart may continue to function for a period ranging from hours to weeks, but long term survival is precluded in the absence of coordination provided by the brain.
The hallmarks of lack of brain and in particular brain-stem activity are
Deep coma ( absence of spontaneous movement, absence of response to deep pain)
Absence of spontaneous breathing
Loss of reflexes coordinated by nerves in the mid-brain & brain stem ie corneal reflex, pupillary reaction, cough & gag reflex, dolls eye reflex, cold caloric reflex

Such severe damage to the brain can result from various causes
Brain hemorrhage
Brain hypoxia (Due to cut-off of oxygen supply)
Brain injury
Rise in pressure in and around the brain (intra-cranial pressure) due to infection or tumours

Once the damage to the brain becomes irreversible, despite having a heart beat, the individual is unable to perceive any stimulus, unable to awaken, unable to move and has no spontaneous breathing. Such a person is considered to be Dead by neurological criteria or Brain dead.

It is important to differentiate this situation form other neurological syndromes like Persistent Vegetative State  or Minimally responsive state. The fundamental difference is that in these other conditions, brain stem function is partially or totally preserved despite the lack of response to stimuli and hence brain death is often also referred to as Brain stem death to emphasize the irreversible loss of brain stem functions.

To diagnose a comatose person on mechanical ventilator to have suffered brain death, the proximate cause of brain injury should be known or identifiable and irreversibility should be established. Generally to diagnose this condition clinically, one should reliably rule out presence of shock (severe reduction in blood pressure), hypothermia (body temperature <35 administration="" also="" anaesthesia="" be="" br="" intake="" narcotics="" of="" or="" out.="" ruled="" should="" soporifics=""> To establish that an individual has undergone Brain death the following is deemed necessary and sufficient

Deep coma (no spontaneous movement or response to call )
Absence of cranial nerve reflexes (corneal reflex, pupillary reaction to light, corneal & tracheal/pharyngeal reflex, dolls eye reflex)
Absence of spontaneous respiration despite rise in CO2 (Apnea test)

The Apnea test is mandatory for the declaration of brain-stem death. After ruling out hypothermia and hypoxia, the individual is pre-oxygenated and is disconnected from the ventilator and oxygen is delivered at 6L/min through a catheter into the trachea after baseline arterial blood gas analysis. Close watch is maintained for spontaneous chest wall movements due to respiratory excursions or actual breaths. After 8 minutes, the individual is reconnected  to the ventilator and arterial blood gases are analysed. If there is no spontaneous respiration despite adequate rise in PCO2 levels (usually 60 mm mercury or 20mm rise above baseline) during disconnection, the test is positive and irreversible brain stem damage is confirmed.

Most experts agree that in a case ( excluding infants) where cause of brain injury is not drug overdose or poisoning, a six hour period is sufficient to gauge for signs of recovery before brain death can be confirmed.

Other tests like EEG, Cranial doppler, Cerebral angiography, Evoked potential study or SPECT are not required to diagnose brain death but may be performed when the testing is equivocal.

With the advent of severe brain stem dysfunction, normal body function is severely deranged. Significant and progressive alterations occur in cardiovascular, metabolic, immune and endocrine systems that if untreated can lead to rapid progression to cardiac arrest.

 Rapid rise in the intracranial pressure can lead to herniation of the brain stem and pressure on the vasomotor centre causing instant cessation of circulation and cardiac death. Slower rises compromise blood flow to the brain and evoke initially a  fall in heart rate followed by sympathetic storm characterised by rapid heart rate and rise in blood pressure. Eventually heart damage and lack of blood supply to the vasomotor centre lead to collapse and cardiac arrest.
Process of brain stem death also leads to deranged function of the pituitary gland leading to reduction in thyroid hormone, anti-diuretic hormone (ADH) and cortisol release.  This derangement (in particular ADH) causes significant changes in ability of body to maintain temperature, blood glucose level and fluid electrolyte balance without significant extraneous support. Diabetes insipidus-like state induced by lack of ADH causes massive urinary water losses leading to cellular dehydration and rise in sodium levels. Brain death also leads to hyper-activation of the immune system, white cell activation and release of inflammatory substances like cytokines in the blood, similar to those seen in a systemic inflammatory response (SIRS) to infection. This further leads to loss of vascular tone, reduced blood supply to cells and shunting further depriving organs of blood and oxygen eventually leading to cell death. All these mechanisms are activated immediately after brain stem injury but the speed of impact may vary and with adequate monitoring and support, hours to days may elapse before circulatory collapse and cardiac arrest. However once brain death is established, recovery is impossible and cardiac arrest is only a matter of time.