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Saturday, 8 December 2012

Step by step method of treating acute emergencies


(A synopsis of my power-point presentation at the HMAI seminar and Alumni meet at Belgaum. Watch the presentation and video cases by clicking on the `Youtube' icon on the footer of the Home-page)

Management of acute case requires certain precautions to be taken when compared to `cold’ or chronic cases. The pitfalls of handling such cases homeopathically must hence be known to every practicing Homoeopath. The duty of the doctor is to set the patient on the road to recovery as soon as possible with the least time lost in philosophical reverie.

The following guidelines may be observed which by far are neither exhaustive nor complete, but may be adhered to as the bare minimum.

  1. Ensure your medical diagnosis is right.
  2. Assess the patient’s clinical condition well vis a vis his general condition.
  3. Assess your own ability to treat the case i.e. your previous experience with such cases, confidence level, your knowledge and familiarity of the Homoeopathic doctrines applicable to the case.
  4. Explain the seriousness of the patient’s condition and take the relative’s informed consent before treating the patient.

Having passed the first four check points, it is now down to Homoeopathic management.

Get a good case history. First, note down the disease symptoms to justify the medical diagnosis. Below each symptom that is elicited note down the concomitants and below each such concomitant, note down the modalities. Do not be discouraged by the absence of modalities especially the thermals. In infants thermals are difficult to elicit and the mothers narration may not be accurate – exercise care while attaching importance to these. In pediatrics, the child may narrate modalities but may only reflect the mothers imposition of her opinions e.g. preference for warm drinks/clothes etc.

 It is important to note down the sequential order of appearance of the symptoms and their concomitants. In infants, mentally challenged individuals and in unconscious patients, it may be difficult to elicit accurate modalities and concomitants. Here, observation of the patient’s particulars (objective symptoms) noticed by you and few symptoms as told to you by the relatives will have to do.  Do not justify any symptom, concomitant or modality as the fait acompli of the disease.

Exercise caution in assigning importance to any symptom stressed upon by the relatives. In their anxiety, truth may be the first casualty; they may exaggerate or attempt to focus your attention on to symptoms they regard as important or serious, especially during follow-up. Take an unbiased and unprejudiced case history. Symptoms will be evaluated only after the complete history is noted. Train yourself to note the finer points of objective symptoms and modalities since infants, mentally challenged and unconscious patients will not contribute any symptoms. OBSERVATION is the watch word.

Do not delve too deep into the past history. It may be irrelevant. Take care not to assign too much importance to the causative factor as told to you by the relatives – make your own evaluation of this aspect. Many ailments especially pneumonias are known to be seasonal i.e. < winter, monsoons.

Some of the symptoms expressed by the patient/relatives may be iatrogenic. Rule these out of the therapeutic totality.

TOTALITY is not in the number of symptoms you have collected. Anybody claiming to take a case history over several hours or even days appears not to have understood Homoeopathy and Hahnemann’s teachings. Hahnemann clearly said `The physicians sole mission is to cure the sick’; not `take the case history’. Read Lesser Writings – Kent and Boenninghausen.

The PQRS symptoms are nothing but the concomitants and their modalities and never the disease symptoms. (Read Guernsey, Kent’s lectures on the use of Guiding symptoms)

While repertorizing the case, involve as many general symptoms as possible. Do not go too deep into the particulars where you will get lost in rubrics having drugs with one mark. E.g.  (In complete repertory)
EXTREMITIES PAIN: Lower limbs: Sciatica: morning < rising after: colo;
This rubric has only one drug with 1 mark. Go back to the rubric `Sciatica’.

MIND: absent minded: morning: shows 5 drugs all with 1 mark. Go back to `absent minded’.
Avoid all rubrics with drugs carrying 1 mark. Rubrics having few drugs with 1 mark are best avoided unless the patient very strongly stresses on that symptom and modality. Attempts to involve such rubrics will end up in a disjointed repertorial totality where no single drug is indicated with any certainty.

PRESCRIPTION: The indicated drug is the simillimum and vice versa. The simillimum is the only drug which can cure, hence it is given in the appropriate potency irrespective of whether it is `deep acting’, `long acting’, Psoric, syphilitic or sycotic. The miasmatic theory is applicable chiefly in chronic cases. Its applicability in acute cases is limited.

POTENCY: The indicated drug (simillimum) in any potency, will invariably act, (note confusion created by Stuart Close, Hahnemann, Boericke) but quicker results may be achieved if susceptibility is taken into account. The chief indicators of susceptibility are:
  1. Age of the patient
  2. Organ affected.
  3. Acuteness of onset of the disease (time taken for the disease to establish or overwhelm the patient).
  4. Duration of disease
  5. Previous treatment taken
  6. Mental symptoms – more the mentals, higher the potency
For further details read Dudgeons lectures and B.K.Sarkars commentary on the Organon.
Constitution does not help much in acute diseases; can be relied upon only as a last resort with paucity of symptoms. Read also Boenninghausens Lesser writings (case histories) regarding use of high potencies and drugs in alternation as well as complementary drugs.

 REPETITION: In acute cases frequent repetition is permissible. Read Organon aph: 247, foot note to 247; aph.248 (compare with Vth edn.). Read also Dudgeons lectures, Stuart Close, Kent’s lectures, Boenninghaussens Lesser writings, Borland’s Pneumonias. Remember, the stalwarts practice was based on the 5th edition of the Organon, where-in Hahnemann left repetition largely to the discretion of the physician. This method was used with great success and no untoward incidents.
Opinions may vary, but practice shows, repetition in diluted form (in water) succussed before administration,  does not harm the patient.

HOMOEOPATHIC AGGRAVATION: The best bogey to scare the young homeopath so that he never attempts to treat an acute case. A case of more smoke than fire. Read Dudgeons and Andre Saine’s views on the same. This topic in Homoeopathy has more confusion, contradictory opinions and theories after posology. In fact, a rarely seen phenomenon, my opinion (in both acute and chronic cases) is that it depends upon:

  1. The preconceived notions of the doctor
  2. False indoctrination of the patient
  3. The physicians lack of knowledge of the disease and its progression.
  4. Sudden cessation of previous treatment (allopathic) causing exacerbation of disease symptoms.
  5. Imperfect case taking; omitting disease symptoms in search of PQRS.
  6. Reliance upon symptoms related by the mother or relatives; ignoring your own observation. The patient must be brought to the clinic for every follow-up and examined thoroughly to ascertain improvement or deterioration. Run through all general symptoms narrated by the patient during the first consultation. Note decrease or increase in intensity of each sign (objective symptom).

Note aph.160. “… a dose of the appropriate Homoeopathic medicine, …. does always, during the first hour after its ingestion, produce  perceptible homoeopathic aggravation of this kind.”
In acute cases, is such immediate action of Homoeopathic medicine without an interlude (while the disease is checked) possible, or is there a brief progress of the disease before the Homeopathic medicine revitalizes the Vital force and overpowers the disease?

RECOVERY: The concomitants subside first. The concomitants disappear in the reverse order of their appearance, hence the previously expressed requirement of sequential recording of the symptoms. The disease symptoms of cough, fever go last, also in reverse order of their appearance. However, adventitious sounds (in Lower respiratory diseases) which are due to pathology may not obey this rule.
Indication of the drug being the simillimum and the potency being right is better assessed by the following phenomena as observed in a serial study of 300 cases of Pneumonia/ Broncho-pneumonia & 500 cases of Chikungunya.
  1. Deterioration of condition is arrested in 2-3hrs after giving the simillimum.
  2. Patient shows less irritability/restlessness and calms down some what.- 24hrs
  3. In lower respiratory ailments: Cyanosis decreases – 24-36hrs
  4. Air entry improves on auscultation – 36-48 hrs
  5. General condition visibly improves. Patient becomes aware of surroundings and people other than the mother (in children) – 24 -72 hrs.
  6. Patient asks for food or milk – 48-72 hrs.
  7. Fever starts declining. 48 – 96 hrs. Will touch normal after 3-4 days.
  8. Cough decreases last after 8-10 days. (in pneumonia)
  9. Occasional patient may have mild diarrhea or a nasal discharge at the end. This condition often needs to be treated as a separate entity, hence may not be a natural accompaniment of the curative action of the drug.                                                                                 
  A FEW TRICKS TO IDENTIFY THE SIMILLIMUM
A quick way to reduce the burden of going through the materia medica is to ask the patient about his/her thirst. This rubric will help divide the M.M into thirsty and thirstless drugs. Being a general symptom, it assumes great importance in any prescription.
Use thermals cautiously especially in children who in India are invariably over dressed in the event of fever. The perspiration stage of fever is today almost completely useless due to the use of anti-pyretic drugs like paracetamol which many patients will use despite being discouraged. Use of such drugs causes immediate profuse perspiration which is not a natural phenomenon.
Disease nomenclature and its inclusion in repertorial analysis has limited use except in established disease states such as Typhoid, Malaria, Pneumonia (Inflammation lungs) etc. But the prescription need not be based on this rubric.

SECOND PRESCRIPTION: The greatest challenge facing the physician is the patient follow-up. In acute cases, wait for atleast 24 hours before taking a follow-up. In cases of very acute diseases such as Cholera, Gastro-enteritis etc; the results should be evident within two to three hours, Often-times in 15-20 minutes. Do not rely on the patients narration of his physical state. Call and examine him in the clinic.
1. Patient says he is better: Continue repetition of the medicine but space out the dosage. i.e. from hourly to 4 hourly or thrice daily, until the patient is symptom free for atleast 24 hours.
2. Patient says he is not relieved: Always physically examine the patient and look for signs of the disease. Improvement in signs of disease e.g. in respiratory diseases, decrease in body temperature in fevers or even decrease in the flushed discoloration of the face- any change can be an important sign of the medicine being the simillimum. If symptomatic relief is not evident, repeat his WBC counts. A decrease in the total count in infectious diseases is a sure sign of improvement. Repeat all other blood tests which were abnormal at the first consultation. Any change towards normality is a sign of the correct simillimum.
3. Patient claims partial relief: If the improvement is in the General symptoms, the drug given is the simillimum, even if the Particulars have not changed or are worse. Wait for another day for the medicine to act and continue the repetition as before. If Particular symptoms improve and the General symptoms worsen, re examine the repertorial analysis. If sure of the simillimum, increase the potency. If remedy does not cover the Generals, change the drug.
4. New Particular symptoms become evident: Check your medical diagnosis. Repeat the blood tests and add any relevant tests if needed. If the diagnosis changes, retake the case history and add the new particulars to the repertorial analysis. If the diagnosis remains the same, re-check your repertorial analysis and patient susceptibility. If confident of your prescription, continue the same or increase the potency from 30C to 200C or 1M.
5. New General symptoms arising: The prescription has missed its mark. Retake the case and work again on the analysis of the case.

SECRET OF THE ZIG-ZAG CURE: Many acute cases need more than one drug to complete the cure. Be alert to this need and act fast. Either due to paucity of symptoms or a not so perfect case taking, the remedy given will be decided on the basis of KEY NOTES. This if it can be so said, is a necessary evil due to the acute nature of the case and the patient's inarticulate or unconscious condition. Key note prescriptions often cause a partial cure; or else, accessory symptoms may reveal themselves after the first remedy is administered. The second prescription will have to take these symptoms into consideration and a change in remedy will be necessary. Another situation is when a well selected remedy fails to give the desired response. A deep acting Psoric (often Sulphur) or sometimes a Syphilitic remedy (most often Merc Viv) may need to be administered to reactivate the Life force or to remove the Syphilitic impediment. Such intercurrent use of drugs even in acute cases I have relied upon often in my career spanning 35 years and can vouch for their revolutionary effects. I would like to remind readers here that many remedies carry more than one miasmic trait and cannot be straight-jacketed as Psoric/ Syphilitic/ Sycotic etc.

IN A NUTSHELL
1. Take a quick but good case history with investigations that support your diagnosis
2. Concomitants and modalities are the PQRS or the repertorial totality
3. Key note prescriptions are the key to success.
4. More acute the disease, higher the potency - 30th to 1M is the range I use.
5. Simillimum must be repeated frequently depending on the threat to life of the patient
6. Results should be evident within a few minutes or hours of starting the treatment. More acute the ailment, faster the results obtained.
7. Second prescription depends on remedy response - Zig zag cures are often the rule.
8. Physical and pathological monitoring of the patient is a continuous every hour/day process.
9. Homeopathic aggravation is a debatable issue. Do not let it affect your prescription.
10. After a reasonable effort, if the patients condition deteriorates, do not hesitate to refer the patient to a higher medical center.


CONCLUSION:
It is imperative that we treat acute cases not only because they are challenging, but also due to the ease and speed with which we achieve dramatic results. Doctors of the allopathic school who refer patients to me describe the effect as nothing short of miraculous.
I am very much against the practice of discussing single cases in conferences and seminars because a single case is not indicative of the inherent curative powers and efficacy of homeopathy. A single case does not instill confidence in other homeopaths. Single cases can be manipulated and the approach can never be standardized, hence nothing can be learnt from such efforts. If honestly presented with documented proof of cure, single cases carry nothing more than academic value. A patient's testimony on video is meaningless and unscientific. It opens further reasons to doubt the veracity of the claim of cure. Well documented acute cases will dispel all claims of placebo effect and faith healing from the lexicon of our skeptics and opponents - the Allopathic school. A compilation of cases can give excellent statistical analysis of the efficacy, methodology and choice of simillimum leading to an exhilarating learning and teaching experience. The LANCET can still be lanced!


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