LETTER TO EDITOR

CUT AND EXTRACT LOOSE BENT KUNTSCHER NAIL

instead of unlocked intramedullary nail surgeon should have opted for locked intramedullary nailing or other suitable methods of osteosynthesis. We removed both the fragments of nail through nonunion site, as they were lying loose in both proximal and distal ends of bone. No extensive dissection or periosteal stripping was required due to presence of butterfly fragment. Otherwise; we recommend standard method of removing Kuntscher nail through proximal end after straightening or transecting it. Our method is simple and effective, as it does not produce metal debris and heat while cutting, allowing extraction of the bent nail. It may be useful even in high strength nails to produce sufficient weakening to straighten by manual manipulation; in the event one is not able to transect the nail completely. The procedure has also its application in peripheral hospitals, where advanced gadgetries for transecting the nail may not be present.

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REFERENCES 1. Dencker H. Errors in technique and complications specific to intramedullary nailing. Acta Orthop Scand 1964;35:164-9. 2. Patterson RH, Ramser JR. Technique for treatment of bent Russell- Taylor femoral nail. J Orthop Trauma 1991;5:506-8. 3. Nicholson P, Rice J, Curtin J. Management of a refracture of the femoral shaft with a bent intramedullary nail in-situ. Injury 1998;29;393-4. 4. Burzynski N, Scheid DK. A modified technique for removing a bent intramedullar y nail minimizing bone and soft tissue dissection. J Orthop Trauma 1994;18:181-2. 5. Apivatthakakul T, Chiewchantanakit S. Percutaneous removal of a bent intramedullary nail. Injury 2001;32:725-6. 6. Al Maleh AAF, Nielsen KS. How to remove a bent Kuntscher intramedullary nail. A technical note. Acta Orthop Scand 1998;69:638-9. 7. Ontuska H, Yokayama K, Tonegava M, Higashi K, Itomanm. Technique for removing a bent intramedullary nail: A case report. J Orthop Trauma 2001;15:299-301.

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INDIAN JOURNAL OF MEDICAL SCIENCES

LETTER TO EDITOR QUALITY DRUGS IN ‘STRIP PACKING’ CONSTITUTES AN ESSENTIAL COMPONENT OF MEDICAL CARE RIGHTS Sir, The maintenance of the drug quality is an essential component of medical care. This letter argues that the right of a patient to ‘quality drugs’ in ‘strip packing’ construes an essential component of the ‘Right to life’. In a landmark judgement,1 the Supreme Court of India has upheld the right to health and medical aid of a worker according to Article 21, Articles 39(e), 41, 43, 48(a) of the Constitution as a fundamental right. Justice Agrawal2 had also ruled that government health services have to provide adequate treatment to all citizens’ and its denial violates the right to life and is compensable under Articles 32 and 226. In two other cases, the Court had directed reimbursement for unavailable treatment facilities in government hospitals and had banned quackery. In 1987, in response to a Public Interest Litigation, 3 the Cour t had among others, passed stringent directions on maintenance of dr ug quality standards and had emphasised exemplar y punishment for breaches. The repor ting of sub-standard drugs in India is a routine matter, for instance, The Centre for Science and Environment had reported of seizure of spurious life saving antibiotics as Netromycin in 2002. While

Indian J Med Sci Vol. 58 No. 10, October 2004


browsing the Food and Drugs Act (FDA) Maharashtra site, disturbing statistics of spurious and sub-standard drugs are seen. In 2003, a task force had detected many spurious and sub-standard drugs of reputable firms, including multinationals; unearthed unlicensed medical shops and violations; and seized millions of Rupees worth of drugs and equipment. On Dec. 18, 2003, the Times of India and a Press Release by the Ministry’s website announced, the Union Cabinet’s approval to amend the Act to provide death penalty for those involved in manufacturing, selling and dealing with fake drugs and making it a nonbailable offence. On Januar y 15, the Federation of Medical and Sales Representatives’ Associations of India handed to the President of India, a memorandum bearing 2 million signatures from people against the menace of spurious dr ugs. Genuine Phar maceutical Manufacturers have expressed similar sentiments as they are economically affected. The Mashelkar committee set up in 2002 has also recommended the death penalty for spurious drug manufacturers, earlier it varied from a five years prison term to life imprisonment. A news item by Times of India, on Jan. 17, 2004, had reported of a prestigious drug company, which was producing spurious Dexamethasone tablets. The tablets were marked with ‘G’ symbol, indicating that they

LETTER TO EDITOR

were meant for supply to gover nment hospitals.4 This incidence highlights the fact that spurious drugs are still being manufactured and sold in the country and the Union Cabinet’s intentions are not bearing fruit. I would opine that the poorest citizens who routinely utilise government healthcare facilities and consume such medicines as the hardest hit in line with the inverse law. It is also likely that once these spurious drugs reach the hospitals, they might evade detection. Through, the previously mentioned examples and discussions, I would like to construe that ‘Right to Life’ according to Ar ticle 21, includes Right to ‘Quality Drugs’. I would like to include strip packing in the concept of ‘Quality Drugs’. The loose drugs do not mention the name of the dr ug, its manufacturer, neither the date of manufacture nor the date of expir y. The manufacturers are also more likely to adhere to quality standards in case the drugs bear their name. The quality of loose drugs is also more prone to deterioration in improper conditions. This step could also reduce the r isk of dispensing a wrong dr ug. The dispensing of labelled drugs would also reduce the doctor- patient asymmetry, as the patients would become aware of their prescriptions. Current many practitioners give loose drugs to their patients and the patients are unaware of the dr ugs that they are consuming and in case they later reach a referral hospital, sometimes they do not have a prescription nor do they know the drugs that they have consumed ear lier. This sometimes poses a dilemma, for instance a patient with fever had received some

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medications and later comes to another health facility it becomes difficult to ascertain whether the patient had received Chloroquin or not, especially when we have such a large number of quacks still practicing in India. Accordingly, I would strongly urge the Government and the Judiciary alike to debate the matter of banning the dispensing and selling of loose drugs in India, in addition to strict enforcement of quality standards in consumers’ interests. It would be ridiculously foolish to be penny wise and pounds foolish. If we can afford to buy a medicine than we should equally afford its strip packing. It could be wor th exploring economic packing materials. In the interim, the details as mentioned before ought to be printed on every loose tablet. Rajkumar Bansal Professor and Head Community Medicine & I/c. Dean, Surat Municipal Institute of Medical Education & Research, Umarwada, Surat - 395 010, India. E-mail: [email protected] / [email protected]

REFERENCES 1. Consumer Education and Research Centre and others v. Union of India and others. All India Reporter- 922 Supreme Court 1995;82:922-4. 2. Paschim Banga Khet Mazdoor Samity and others v. State of West Bengal and another. All India Reporter- 2426 Supreme Court 1996;83:2426-32. 3. Vincent Panikurlangara v. Union of India and others. All India Reporter- 990 Supreme Court 1987;74:990-8. 4. Times News Network. Unit booked for sale of spurious drugs. Times of India (Ahmedabad). 2004, Jan. 17. p. 5, Col. 4-5.


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INDIAN JOURNAL OF MEDICAL SCIENCES

ORGAN DONATION IN MENTAL RETARDATION: A CLINICAL DILEMMA

based on full understanding, disclosure and should be voluntary, based on the educational background of the donor.

Sir, As the Hippocratic Oath stipulates, an informed consent is a must before any health care intervention. The basic tenets of informed consent are based on the elements of infor mation, decisional capacity and voluntarism. An individual’s decision to give or withhold consent cannot be considered valid unless he or she has the capacity to make that decision. We were placed in an ethical dilemma when a mentally challenged lady was referred to us for assessment of giving consent to donate her kidney. She was the only HLA match available and was willing to donate her kidney and after counseling she had a reasonable understanding of the procedure that was planned. Her IQ score ranged 54-60.

According to the guideline the donor should have psychosocial suitability for the transplant programme and active psychosis, severe mental illness precludes a person from donation. The donor should be evaluated for guilt, depression, substance abuse, coping skills. The presence of a psychosocial problem should not automatically exclude a person from being a donor but should prompt more intervention and discussion into these areas.1 There is no mention of mentally retarded individuals in this guideline. In India neither the Organ Transplant Act, 1994 nor the Mental Health Act, 1987 provide any light.

For the clinicians it raises many controversial but pertinent questions like, is she competent enough to understand the complexities of the issue? In order to assess her competence in this regard what all criteria need to be looked upon? Any decision on the part of the clinician should be ethically sound and for the beneficence of the patient. According to a recent Consensus Statement on Live Organ Donors “the person giving consent for transplant should be competent, willing to donate, free from coercion, medically and psychosocially suitable and fully informed of the risks, benefits and alternative treatment available to the recipient”. 1 The consensus demands that the informed consent should be


As the number of transplant procedures will increase, the ethical issues of the role of mentally retarded individuals in transplant programmes are of concern. There is a need to develop criteria and guidelines for assessment of mentally retarded individuals in transplant programme and to protect their rights. S. Malhotra, Y. P. S. Balhara, S. T. Varghese Department of Psychiatry and National Drug Dependence Treatment Centre, Centre for Behavioral Sciences, All India Institute of Medical Sciences, AIIMS, New Delhi - 110029, India. E-mail: [email protected]

REFERENCES 1. Abecassis M, Adams M, Adams P, Atkins CR, Barr ML, Bennett WM, et al. Consensus statement on the live organ donor. JAMA 2000;284:2919-26.