A FPI Kar nataka Newsletter

Issue: Volume 5, Issue 1

President's Letter

Dr Swapna Bhaskar (President, AFPI Karnataka)

HELLO READERS!

The year 2021 is coming to an end in a few weeks and what we look forward t* in the coming year is t*e hope for a covid free world. The past year has been a mixture of emotional and physical turmoil for *ost of us who were in the forefront of the battle against the dreaded virus. Family physicians played a pivotal role in the country’s victory against the pandemic - which has made the g*vernment, NGOs and public acknowledge and take note of our contributions. Let us keep this momentum going by continuing to keep our patients in good physical and mental health and be their guide through good and bad times.

This year has been very eventful for AFPI Karnataka with various activities throughout the year. The most important of them was our second state conference held in collaboration with the prestigious St John’s Medical College at their campus. The conference was unique in two aspects - the first of its kind hybrid o*e, and the active involvement of

un*ergraduate students from MSA* and SIMSA! The graduation of the second batch of students of St John’s FFM (Fellowship in Family Medicine) in collaboration with AFPI was held at St. John's. The sec*nd batch of graduates f*om the Primary Healthcare Leadership Fellowship run by AFPI with Karuna Trust was held at Karuna Trust's office. The feedbac* from the graduating fellows has been very positive which has resulted in the current year admissions to double from the past year. We were invited by the VC of Rajiv Gandhi University of Health Sciences as guest speakers for their monthly webinar on home based COVID management. Dialogues with the University for start of MD – FM programs in other colleges are also being initiated. The motto of the organization in promoting family medicine will be continued through many more such initiatives with the support of our esteemed members.

2022 comes with more events to look forward to – the most important being the 5th FMPC to be held at Hyderabad in February. Please

join our Telangana team and make the event a grand success by your active presence. Also looking forward to get meaningful contributions from all the reader* for our upcoming newsletters in the form of practice anecdotes, research papers, medical news updates and other information that can enhance family practice.

Hope this issue too gives you good insights and thought provoking material. Happy reading!

A FPI Kar nataka Newsletter

Issue: Volume 5, Issue 1

Editorial

Akshay S Dinesh (Primary Care Physician)

Experiences in the past many months give me immense confide*ce th*t the leadership crisis

1

of medical profession in India is on the path

to resolution. It is through reimagining primary healthcare as a field and the various roles of healthcare workers that we will get there.

Klaus, et al describes the roles of family

2

physicia* as :

We have seen exemplary leadership all around us. During times of crisis our ability to resist and sustain have been directly related to the amount of leadership embedded among

us. But we have to be critical of ourselves and ask whether we have been able to systematically harness our leadership potential to its maximum. When we train individuals, are we making them highly autonomous and capable of performing as leaders? When we build systems, do we create space for growth and emergence of new leaders?

That is where the family physician's role as more than just a care provider atta*ns utmost signficance. Today, the family physician is presented with a huge responsibility - that of fixing the system of healthcare. How do we drive down inequities in healthcare and drive up the qua*ity and compreh*nsiveness of our healthcare? How do we rebuild trust between the public health system and the citizens? Where do we see ourselves in the next decade and the next pandemic?

We are on the cusp of a transformation. The world now realizes that "l*t us fix the problem when it hits us in the face" is not an attitude that can save us from massive

problems that come unannounced. There is universal acceptance that health infrastructure can't be built overnight. Individuals and organizatio*s everywhere are turning their focus towards fixing this once and for all. What we do today will decide how big of a transf*rmation we are able to bring.

This newsletter issue ha* many inspiring articles. But it is incomplete. It hasn't heard your inspiring story. What transformation are you bringing? What do you want the world to hear about? Let us use this space to inspire each other to perform to their fullest.

Issue: Volume 5, Issue 1

AFPI Karnata*a Activities - 2 021

a unique hybrid conference with more than 200 participants from all over India. Dr Yogesh Jain gave the guest lecture on “Inequity in healthcare during Covid and how family physicians can bridge the gap “. Fr Paul Parathazham - Medical Directo* of St John’s National Academy of medical sciences , Dr George D Souza- Dean of St John’s Medical College and Dr Raman Kumar – National President AFPI were guest of honour for the inaugural function . 31 posters were pr*sented by delegates and cash prizes were given to winners. The conference also saw active participation from medical students of MSAI and S*MSA – the first of its kind.

10. The graduation ceremony of the second batch of Primary Health Care Leadership Fellowship by AFPI and Karuna Trust was conducted on 29 October at the Karuna Trust Premises. Five doctors obtained the fellowsh*p this year and the coming year has an enrolment of 7 aspiring primary care physicians. Dr Sudarshan, Dr B C Rao, Dr Swapna Bhaskar, Dr RK Prasad, Dr Soumya Vivek, Dr Jyotika Gupta, Dr Akshay S Dinesh, Dr Dwijavanthi Kumar (online), and

Dr Swathi S B (online) presided over the function. AFPI is looking to upscale t*e program by involving more faculty and continued training in broader aspects of primary care.

A FPI Kar nataka Newsletter

Issue: Vol*me 5, Issue 1

COVID Diaries

Dr Devashish Saini (Family Physician and Founder, Ross Clinics, Gurgaon)

I often ask my patients to record their measurements at home in a diary, and bring them to the next app*intment. I find that this improves the self-efficacy of the patients and their family members in taking care of their illnesses, and helps us doctors take better care of them! At the same time it's an ideal, and reality loves to wash away our best laid plans

Some patients do check their parameters, some don't. Some of those patients w*o do go to the trouble of measuring them regularly, may not record them! And those who diligently record them may forget to bring those readings when they come for a follow- up consultation! And *ome of those who keep meticulous records, stop after a few months.

I often tell my patients, "Your proper treatment will only start when you start maintaining a record, till then we're just playing with your illness!" And truly, the home record is vital in adequately managing Hypertension and Diabetes Mellitus, and I've

found it useful in other illnesses too, like Typhoid fever, and Food allergies.

I keep *ondering how to inspire patients and family members to keep better records. I think I got some answers last year

All of us battled the pan*emic in the last 12 months in our own way. And as we did, we and our patients became more comfortab*e with and attached to our gadgets. And I'* not just talking about the comfort of attending Zoom meetings in pyjamas! Even taking care of COVID patients at home was different than expected, with technology at our service

Most patients of COVID-19 recover without any complications. However, some patients, even without co-existing illnes*es, do end up getting complications, and such patients can deteriorate very rapidly. So it's vital for the patients or their family members to regularly measure their vital signs, especially temperat*re and oxygen levels, and share with the doctor once a day.

So, during the first teleconsul*ation with a patient with a positive COVID test, towards the end I would give them instructions to measure their Temperature, Pulse *ate, and SpO2 three times a day, and record them on a piece of paper, and share with me once a day (and *eport imm*diately if SpO2 less than 95*). I would also write these instructions in the prescription.

I hoped that since the follow-up was going to happen *ver WhatsApp chat or video, it would be easier to *et to the readings! I took ca*e of about 200 COVID-19 patients, and it was an interesting experience to see the different ways in which they interpreted the above instructions, and followed them, each in their own unique way!

There were of course some patients who steadfastly ignored these instructions, and did not share even a single reading. One patient didn't even buy a Pulse oximeter! Ironically, these were the same patients who got expensive Corona Panel tests done, at the suggestion of family and friends, and forwarded them to me for interpretation. So probably the cost of the Puls* oximeter was not an issue.

Some others insisted on saying their parameters were normal, and because they were normal they didn't note them down! I wish there was an easy way to explain to such patients why doctors need to see normal figures too, without getting into confidence intervals, trends, high-normal, etc I trie* telling them that normal figures make doctors happy, please record them for our happiness! This seemed to work for some patients

To balanc* out such patients were those who measured their parameters 20-30 times a day, and concernedly reported when the oxygen levels dropped from 98% to 96%, or the heart rate rose from 72 to 84 per minute! Many an hour was spent as a counsellor *o listen empathetically, explain gently the normal ranges, and calm dow* their ruffled feathers

Now coming to the "normal" minority, who followed the instructions obediently! The records that they shared ranged from too simple to too co*plicated! Some used paper and sent me screenshots, some sent W*atsApp texts, and one even gave me access to his Google Sheet of vital signs!

Some patients were good at giving structure to their records, noting do*n the date, the time, the nu*bers, and the units, one record in one l*ne. If there were multiple family members, each person's name, age and sex was clearly mentioned on top. Enough to bring a tear of joy to the doctor's eye! I happily shared such beautiful records with other patients as examples of how to do this best!

Some patients just sent the numbers, without any date or time, or even whether that 84 on their record was pulse rate or oxygen *evel! This led to some skipped beats on the part of the doctor, and a call or two to finally cla*ify,

that 84 was indeed the pulse rate and the oxygen level was a very relaxable 98%!

All in all, it was just like asking pa*ients to drink more water or to take frequent breaks from prolonged sitting. Recording and sharing of measurements is just another behaviour change that we want from our patients, and each patient is on their own journey, from Contemplation to Planning to Action and Maintenance. As doctors, all we can do is gently nudge them to t*e next stage, and build their self-efficacy to avoid relapses and continue the progress!

I woul* like to believe that with every patient, I learnt something more about record keeping itself, about how to give complicated instructions in simple language, about empathetic counselling, and I feel I am now better equipped to get patients to monitor their health regularly. Of course, I'm sure the next patient will throw up a bigger challenge, as they always do, to keep us always on our toes!

Issue: Volume 5, Issue 1 Practice Experience

Dilemmas of a GP (Case 2 )

Dr Swapna Bhaskar (President - AFPI Karnataka; HOD - Family medicine, St. Philomena's Hospital)

How and when should we cut down an extended co*sultation?

A young man walks in with his wife into my clinic one night jumping the queue saying he is very sick, running very high fever and is too tired to wait. Although I see patients with appointment only, these kinds of walk-in ill patients are let in by my receptionist with a warning that they do not have an appointment and are replacing another patient’s time*

He definitely looked sick and dehydrated (unlike quite a few who come with “supra- cortical” illnesses) , had a temperature of 104.8 degree fahrenheit, low BP, but did not have any particular *ocus of infection. He gave a past history of vitamin D and B12 deficiency but had stopped treatment a few weeks ago.

Since it was the dengue season in Bangalore and wanting to rule out other infections too – I advised for a preferable admission and worked up for the routine infections. Meanwhile I started noticing that his wife was constantly interrupting the consultation talking about her Vit*min B12 deficiency, her sister’s deficiency and how different the symptoms were for each of them. I did give him a paracetamol injection which I load and give myself as my small clinic does not have a trained nurse for it. Overall the consultation was overshooting the normal stipulated time which started making me a little restless by now.

Denying my advice for admission, the patient said he will get the investigations done and review. He slowly walked out of t*e clinic for payment but his wife wasn’t ready to go. And to my dismay she started asking about the lesions on her lips since 2 weeks (herpes l*bialis), the reasons for it and what she could do to alleviate it!

As a GP now my dilemmas crop up –

Still she deems it appropriate to discuss trivial issues. Can we cut short *uch statements without hurting their sentiments and losing our temper?

A FPI Kar nataka Newsletter

Issue: Vo*ume 5, Issue 1

Choose Primary Health Care: An address to young medical students and doctors

Dr Pavitra Mohan (Co-founder, Basic HealthCare Services)

I was invited to speak to medical students of Mahatma Gandhi Institute of Medical Sciences, located in Wardha, part of the Reorientation of Medical Education p*ogram.

I spoke on choosing primary healthcare as a career and life choice. I was overjoyed at the interest, understanding and deep concern for India's inequitable healthcare system among the students. If physicians are indeed "attorneys of the poor", I saw many attorneys in that room. That filled me with an unbearable hope.

Here is an excerpt of my address.

Hello dear students and friends,

I am so happy to be speaking to you today. Besides the joy of speaking to young students of a medical college that promotes a culture of service among its medical students, I have another important reason to be happy.

My own desire to get in Wardha Medical College

Thirty-six years ago, I was *reparing to get admission to a medical college. And since MGIMS had its own medical entrance exam, I was preparing for it separately. One of the paper that you needed to clear for getting admission in MGIMS was Gandhia* Thoughts. I read through Gandhi’s autobiography and decided *his is where I really want to study medicine. In the exams, I did well in Gandhian thoughts, but flunked in Biology! My dreams for studying in MGIMS shattered – I did study medicine though. I am therefore happy that I am speaking to students of the medical college, where I dreamt of studying, but failed to get admission!

Working in Delhi, exposure to misery and illness, and magic of modern medicine

Subsequently, I studied and worked at government hospitals in Delhi during my MBBS and MD, where I was getting exposed to realities of harsh lives that so many people lived. When they came to the hospital, they would be in tatters, no money in their pockets and no food in their bellies. Children would die of neonatal tetanus and measles.

However, I also learnt the beauty and magic of modern medicine: we could still snatch the kids out of jaws of deaths. Antimalarials would be magical, so would the correct treatment of Nephrotic Syndrome.

Udaipur, exposure t* rural areas and advice

After my MD, I got an opportunity to live and work in Udaipur, at RNT Medical College, as a faculty in Paediatrics. At Udaipur, for the first time, I saw a real village, and understood how rural administration and health systems work.

However, I was still seeing much deaths, much misery among children and their families who would come to the hospital. While some would be treated, many others, I would realize would still fall ill again, return to the hospital again, as they had nothing to eat or no one to care.

Frustrated, I went to my mentor professor MK Bhan, one of the most beloved paedia*ricians and public health researchers that country has produced. He listened to me and then said “first get trained in public

health, then we will speak”. I did take it seriously and took a year off to pursue MPH. It opened up new world for me, new skills, new perspectives.

UNICEF and exposure to realities of healthcare in remotest areas

During my stint at UNICEF in Rajasthan and Delhi – I was heading the child health and health systems work of UNICEF India Country Office, I would visit the remotest areas of India, where I found that our health services do not reach. No one reaches.

A large population, tribals, dalits etc are left to fend for themselves. They do not have the money and means to seek healthcare, and when they do, high costs and indifferent, almost hos*ile behaviour they receive make them poorer.

That rankled me. W*atever we did at national or state level does not reach these populations. I realized that there are no easy answers, and solutions would lie in actually jumping in the field and finding answers.

Dilemma: Clinical care and public health

When I was a clinician I was happy that I could save lives: I was able to save lives of many children due to severe malaria, diarrhea, newborn sepsis, tuberculosis,

nephrotic syndrome. However, I was frustrated by the fact that many diseases I saw in ch*ldren had social origins. When I saw child die of measles, I would th*nk why did she not receive a simple inexpensive vaccine? Th*t drove me towards public health* I wanted that I should spend my time and energy not in treating one child at a time, but should be able to improve health of the communities. It was a mana*ement problem to be fixed.

When I studied and researched public health, I *as happy that I was able to influence health of the populations: when I led t*e health program* of UN*CEF in Rajasthan, with some effective planning and execution, childhood immunization coverage in the state increased from 24% to 48% in four years- time. I presume that would have led to saving lives of thousands of children.

Social *nd political milieu affects health

However, I realized that why some people are healthy and some are not does not depend on new new drugs or new vaccines or because we did not know how to manage programs. It depends on social and economic inequities. No one cares for the poor populations, I le*rnt. For example, I found out from a research that a simple health service such as immunization is provided far from where poor peopl* live, making it difficult for them to access. If it was an equitable world, health services would be closer to those who need it the most.

I also found that when people from under- privileged castes would reach a health facility, they would be treated poorly, shabbily. When we took over a Primary Health Center from government, people from so called higher castes would barge in the OPD, as if it was their entitlement to be seen before everyone else. Those from under- privileged families would keep waiting, as if this was their destiny. If after five years of running this PHC, there is one thing I am proud of, it is that we have changed that. It is first come, first serve. NO privileges, no preferences.

Anyway, that led me to pursuit *f origin of these inequities. I understood how the cutting of jungles for economic gains and centuries of exploitation by privileged castes have led to food insecurity, and scarcity of water in the tribal areas, leading to rampant malnutrition and disease. It is not because people did not know what to eat: if they did not, civilization would not have survived for thousands of years. Such an understanding led me to explore social sciences and economy and politics.

All these perspectives: clinical, public health and socio-political were correct, when looked in isolation. Modern medicine could treat people and alleviate their suffering; effective public health programs could save thousands of lives, and addressing the social and political arrangements would correct historical inequities.

Primary healthcare is one discipline where *ublic health, clinical care

and social development merges beautifully.

Where does one begin then? Primary healthcare seemed to me to be the best fit.

We set up AMRIT Clinics in remote, rura* and tribal areas of South Rajasthan. They provide preventive, promotive and curative care. We co*duct relevant research and we advocate for more responsive health systems for the poor.

Primary healthcare is healthcare of the people, for the people and by the people. It is no coincidence that democracy has the same definition, replace healthcare by government.

Primary healthcare system provides preventive, promotive, curative and rehabilitative care. It uses evidence based care. It does not frag*ent a patient into different systems but looks at a person as a while, in context of his or her family and community. It tries to understand and address social (and political) determinants of health*

Here I seemed to have found a path; that integrates clinical medicine, public health and social development.

Primary Clinical care is exciting because it looks at the patient a* a whole and does not f*agment him or her into different systems. For example, a person with TB has malnutrition. Family would have needs for food, and maybe a single woman who needs connect with the pension.

It is evidence based so you need to keep reviewing scientific evidence: for example, few years ago, there was a conclusive evidence that Tranexamic acid helps in managing PPH. Or that community KMC hel*s in reducing deaths among LBWs.

It requires clinical courage, how else would you deliv*r a primi with breech with five grams haemoglobin with no place to refer to? It requires a deep understanding of communities and their customs, other*ise how would you manage a situation where the customs do not allow you to conduct a childbirth, which is considered to be polluting in front of a temple?

It requires understanding and engaging communities in their own health, and development.

It require* understanding of public health to prevent and manage malaria epidemic in your community. It requires understanding and addressing social determinants: to promote food security for example.

And finally, it requires addressing political determinants and raise you* voice, using your credibility and grounded understanding, to raise voice against social injustice. Why don’t health centers fun*tion in areas where marginalized people live?

Myths associated with primary healthcare

There are several myths associated with primary healthcare.

Firstly, that primary healthcare means managing a few priority or simple illnesses. It is farthest from truth. In primary health care clinics that we run, nurses and young physicians treat anything from diarrhea, severe malaria, diabetic ketoac*dosis, rheumatoid arthritis to deli*ering a primi with breech.

Second, and a related myth is that providing primary hea*thcare requires m*ch less skills than a specialist or a super-s*ecialist (the term supe*-specialist is used only in India* everywhere else it is called sub-specialist!). An absolute lie. You require knowledge and skills of different kinds, and have to be ingenious as you have to really apply all your knowledge and skills. Also a range of social s*ills, since you are embedded in the community. And management skills.

Another one, (I find new lies peddled from time to time), that primary healthcare is less effective than specialised care. Several studies have confirmed that counties with strongly evolved primary healthcare systems have much better health outcomes (at a lower cost), than those which have strong primary healthcare systems.

Specialising in primary healthcare

You are an inferior doctor if you are not a “specialist” of some kin*. You can of c*urse

“specialise” in community medicine, public heal*h or family medicine. And spend months and years in practicing primary healthcare in different settings. A travel fellowship convened by Tribal Health Initiative offers that opportunity.

My own journey and joy

I have enjoyed every moment of my journey in primary healthcare in rural areas for last ten years –a p*oof I have spent ten straight years without looking back. I had never spent more than five years in one job before that!

I have grown as a person because I got enormous opportunities to love and be loved, by the patients, by community members and colleagues. Every day, I am moved, and challenged to do more. I have honed up my clinical skills, have built some lovely networks, and have conducted some relevant research.

Our organization has hosted some wonderful young people, with wonder in their eyes in fire in their bellies. Some have stayed back and others hav* moved on to do more work in more areas that need it. And we travel to work among beautiful jungles, ponds, waterfalls and sunsets.

With my own experience I can say that primary healthcare is a wonderful, joyous, glamorous and wholesome option *or young medical graduates like yourselves. A path to grow, soar and serve.

Lots of luck and blessings for your future!

A FPI Kar nataka Newsletter

Issue: Volume 5, Issue 1

Back Bencher: A view of life and continuing medical education from the back benches

Dr B C Rao (Mentor, AFPI Karnataka)

I am comfortable sitting at the back in any function, be it a continuing education meeting, a wedding reception or a civic get together. This habit I acquired some 50 years back in medical school. Then it gave me an opportunity to unobtrusively leave the hall through the large french windows placed strategically on the sides of the lecture hall. Those days the lecturers if they noticed one’s absence, took no off*nce.

This habit has stood me in good stead and give* me ample opportunity to leave mi*way without offending the speaker *r the organizers. On rare occasions, when I had to don the mantle of a speaker I keep a subtle watch on the back rows to see if any one leaving midway, a sure sign of *oredom/ inattention. I am rather fortunate that it has not happened often.

In those bygone days, the continuing education programs were simple affairs with a lunch or high tea thrown in at the beginning or at the end. The speakers mostly depended

on memory and experience and spoke extempore. Naturally some of them bored us to death. Then too being a back-chair occupier came in handy to take unobtrusive leave.

Has the advent of advanced audiovisual aids motivated me to occupy front seats? Sadly no. I find it has made matters worse. The modern-day speakers, with rare exception*, have taken to reading these projected slides and not really addressing the audience. Droning voice combined with dimmed lighting is conducive to sleep and it's with difficulty that I keep my head up and eyes open. This goes unnoticed if you are a back seater. When I compare the speakers of yesteryears to the present ones the ones of the past get a higher score. May be, being old myself, I may be biased. I remember vividly my Neu*ology teacher professor late M.K Mani miming grand mal and petite mal (now the modern neurologists have named these differently) while speaking on epilepsy. Similarly, I remember another M.K Mani (

great teacher, alive and kicking) speaking on hypertension, though with the help of slides but hardly looking at them.

Lately I am facing a piqu*nt situation. Thanks to my seniority and mop of grey hair, I am easily spotted and given our penchant for recognizing (respecting?) old age, I am forcefully escorted to the front row of chairs to my discomfort. Here again there's is some hierarchical distinction. The front most row is generally is a row of cushioned sofas or well- padded chairs meant for VIPs and thankfully the organizers have not recognized me as one and they usually make me sit behind these.

The front row occupants *enerally come late and the importance is based on the position they hold rather than to any achievement academic or otherwise. Needless to say, by arriving late, they also hold up the proceedings. In one such meeting a serving police official of ill reput* was the chief guest in a professional function. I felt happy that I was not in that front row sitting with this worthy.

It's a different matter in social functions like weddings and receptions. Being the family doctor for generations of families, I often get invited to many of these which even includes ceremonies associated with death. Often, I have the dubious distinction of having presided over these deaths. Readers should not get the impression tha* I am another Dr Herold Shipman [who killed many an elderly]. In my case these patients who died under my care at home were terminally ill and I saw to it that unnecessary

hospitalization and the *e*ulting expense were avoided. Weddings however *re joyous occasions. Normally I try and avoid the*e ostentatious and wasteful ceremonies. But sometimes I have to attend as the families concerned are too close for me to no* to.

Recently I went to a wedding. The *irl, a third-generation patient, I have known since her birth. She is now placed in the US and the young man; her groo* is a German. The girl’s father and mother and the grandparents from both sides also are/were my patients.

Both the grandfathers are dead (*nder my care at home), but the ailing grandmothers pushing 80 are very much alive. So this intimate relationship made it impossible to avoid this wedding.

The simple wedding ceremony was over and the time arrived to bless the couple. Normally the elders of both sides take the first honor followed by other relatives and friends. In this wedding* this tradition was br*ken and I was ceremoniously escorted to the platform where the bride and groom sat and was requested to initiate the process. It must be a spectacle to the well-dressed gathering to see this chappal clad, shirt and trouser wearing, nondescript old person belonging to another caste and community, being escorted to initiate *he holy process.

This kind of affection, respect and love makes us family physicians feel that we made the right choice in choosing this branch of medicine.

A FPI Kar nataka Newsletter

Issue: Volume 5, Issue 1

Essential oils with pro-convulsive effects: Are physicians and patients aware?

Dr Thomas Mathew MD, DNB, DM (Professor and Head, Department of Neurology, St John’s Medical College Hospital, Bengaluru)

Essential oils are not ess*ntial to humans but are essence or concentrates of plants or plant parts. Esse*tial oils of various plants can have pro-convulsive effects. Notable among them are eucalyptus and camphor. Camphor and eucalyptus oil have been implicated as a cause of seizure, epilepsy, migraine and cluster headache. Both camphor and eucalyptus contain 1-8 cineole, a monoterpene, which has been proved in animal models to be epileptogenic. These essential oils are commonly present in various over the counter balms and oils and are often used by people for common ailments like headache, common cold and backache.

A group of neurologists from three majo* hospitals in Bangalore, south India described 10 cases of eucalyptus oil inhalation induced

1

seizures. They als* published a paper on

Essential Oil Related Seizures due to balms and various preparations containing the mixture of essential oils of eucalyptus and

camphor in the recently in the journal

2

epilepsy research. They observed that many

of the cases of the so called “idiopathic seizu**s” are indeed induced and provoked by essential oils of eucalyptus and camphor* In their case series it wa* found that inhalation, ingestion and even topical application can trigger seizure. Surprisingly the commonest mode of exposure was topical application on the fore head, face and neck. Physicians who are not aware of the pro-convulsant properties of these e*sential oils, rarely enquire about the exposure to the*e in their history taking. They may falsely treat an essential oil induced seizure as idiopathic seizure. Essential oil exposure also is an important cause of break through seizures. If you do not identify the true cause, patients may be falsely labeled as “refractory seizure.”

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A survey of the literature shows essential oils

4

of 11 plants to be powerful convulsants. The

essential oils with pro-convulsant effects are eucalyptus, camphor, fennel, hyssop,

pennyroyal, rosemary, sage, savin, tansy, thuja, turpentine, and wormwood. They contain highly r*active mon*terpene ketones, such as cineole, pinocampho*e, thujone, pulegone, sabinylacetate and fenchone. Camphor is a known convulsant for the past 500 years and was used to be given both orally and by injection to tr*at schizophrenia and bipolar disorder. Common over-the- counter medications which cont*i* the essential oils of eucalyptus and camphor are Vicks, Amrutanjan, Tiger Balm, Zandu balm, Axe oil, Olbas oil, Equate etc. These herbal products tend to be used and quite often abused to treat common ailments such as cold and headache by both the people with epilepsy and general public, who are oblivious to the epileptogenic effects of these products. People often use them thi*king they are natural and safe. People also presume topical applic*tions do not result in systemic absorption. It is high time that public especially those with seizure and epilepsy should be counseled to avoid these preparations which contain essential oils with pro-conv*lsant properties. These cases of essential oil related seizures should sensitize commercial companies and regulatory authorities to put labels on products with pro- convulsant essential oils *tating “potentially pro-convulsant and to be avoided by people with epilepsy”. This may prevent many cases of essential oil related seizures espe*ially those sec*ndary to usage of camphor and eucalyptus.

4,5

The researchers have classified essential oil related seizures into Essential Oil Induced Seizures (seizure primarily caused by

essential oil exposure) and Essential Oil Provoke* Seizures (break through seizure in a known case *f epilepsy). Without the necessary knowledge of the epileptogenic potential of the essential oils, these cases would have been misdiagnosed as idiopathic seizures and the usage of these potentially deleterious produ*ts would have gone unnoticed if not for specific inquiry regarding their usage. Most physicians in the world do not check for exposure to eucalyptus oil or camphor for the lack of mention in textbooks of medicine and neurology. Oblivious *o the epileptogenic nature of these essential oils, the patients would have continued to use them, possibly causing their seizures to worsen and prove to be refractor* to prophylactic treatment. *he proportion of seizures resulting from preventable e*posure to eucalyptus oil and camphor is unknown. However, a significant amount of seizure burden and unnecessary anti-epileptic treatment, which carries side-effects, may be prevented by spreading awareness about the epileptogenic potential of these substances. Essential oil related seizures may turn out to be the most unrecognized preventable cause of seizure. Essential oils are also implic*ted