Sunday, July 15, 2012

How can we prevent deaths at Amarnath Yatra ?

Preventing Amaranth Yatra Deaths

This year again people have died during the Amarnath Yatra. There have already been 67 deaths in 16 days of yatra. This is despite medical examination being made compulsory. Probably the organizers are accepting fake medical certificates. The certificate required is only from a GP. The fitness required for travel to altitudes above 10,000 feet usually should be from a specialist.
I think the easiest test which the government should stipulate is the 6-minute walk test. The purpose of this test is to assess exercise tolerance in chronic respiratory disease and heart failure. The test is also used as a performance-based measure of functional exercise capacity in other populations including healthy older adults.
The six-minute walk test measures the distance an individual is able to walk for six minutes on a hard, flat surface. The goal is for the individual to walk as far as possible in this duration. The individual is allowed to self-pace and rest as needed as they traverse back and forth along a marked walkway.
The six minute walk distance in healthy adults has been reported to range from 400m to 700m. The median 6MWD is 580 m for healthy men and 500 m for healthy women.
When the 6MWD is reduced, a thorough search for the cause of the impairment is warranted. The following tests may then be helpful: pulmonary function, cardiac function, ankle–arm index, muscle strength, nutritional status, orthopedic function, and cognitive function.
A fall in SpO2 of more than 4 % (ending below 93 %) suggests significant desaturation.
A 6-minute walk distance of ≤300 m is a simple and useful prognostic marker of subsequent cardiac death in patients with mild-to-moderate heart failure (Tex Heart Inst J 2007;34:166–9).
According to the American Thoracic Society, patients of idiopathic pulmonary fibrosis (IPF) who can cover less than 680 feet (200 m) during the six-minute test are four times more likely to die than those who can walk greater distances.
Minimal clinically important difference (MCID) is defined as the smallest meaningful change, judged by the patient or experts, determined by questioning or observing the patient. This change is necessarily larger than the change due to measurement error and day-to-day variability.
An improvement of more than 70 m (54-80) or 10% in distance walked appears to be clinically important and noticeable to patients.  Estimates of the minimum decrease in distance walked that are important to patients range from 24 to 54 m.
To sum up, it can be said that anyone with less than 200 m distance covered in the 6-minute walk test should not be allowed to go to the Yatra. Those who can cover a distance of 200-300 m need further tests.  Only those who can cover a distance of 500 meters should get a clearance from a GP without further testing.
My take: A very important piece of topical medical news, which is easy to do, requires no special expertise, & makes a lot of common sense, something not always seen in the field of medical testing !
I would also like to highlight that this practice of issuing 'fake' medical certificates needs to be curbed by at least sensitizing the doctors or sending notices to the ones responsible for giving certificates, regarding people dying on Amarnath Yatra. I believe that most doctors are not doing this for extra money, but to make it 'convenient' for people to travel to Amarnath Yatra. This is taken as a simple formality, and unfortunately leads to avoidable deaths. I recently read about a 24 year old mother of a child from Chandigarh, who died during this yatra, and I can imagine what trauma this would cause to the entire family. I would shudder to think that a medical certificate for this mother could have been issued by me, if they had come to me. This has made me even more careful regarding medical certificates, and I would urge other doctors to do the same. 

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