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Giving ‘wrong’ medical advice?



by Dr Upul Wijayawardhana

“Have I given wrong medical advice?” From the time I read the interesting and heart-rending account ‘My 18 week ordeal of double trouble’ by my friend Dr Lakshman Abeyagunawardene (Sunday Island, 25 October) I have been pondering over this question. Poor Lucky has had a double whammy, on top of the lockdown, due to Shingles on his face (Herpes zoster) followed by heart block necessitating a pacemaker implantation. He suffered first due to severe neuralgic pain following Shingles, which is well-known to be one of the most severe and intractable pains, and due to the limitations imposed following the pacemaker implantation. My thoughts were provoked by the following comments:

“I had to go through the procedure of pacemaker implantation while the pain in my right eye persisted. It was after my fainting episode and pacemaker implantation was recommended that I was debarred from climbing stairs. I was confined to the guest room and this is where my agony really started. My wife did not allow me to even go to the living room which was just three steps below. Towards the latter stages, I watched news on the small TV in the kitchen. I had to be satisfied with the laptop computer that my son brought. But it was a far cry from the desktop I was used to. I missed my weekly shot of an alcoholic drink! I had not taken even a beer since the beginning of June.

I think I had a turnaround in my fortunes after the doctor did the Programming on September 27. It was this doctor’s advice that I strictly followed (more so my wife and son) because there was nothing more the Neurologist who was treating my neuralgic pain could do.”

What perplexed me was the advice given not to climb stairs which made my friend’s life miserable. I had never given this advice though I implanted many permanent pacemakers in Sri Lanka as well as in UK. In fact, I can claim credit for starting the permanent pacing programme in Sri Lanka, way back in late seventies, when pacing was in infancy. In spite of the very ‘primitive’ devices I used at the beginning, I did not impose this restriction.

A permanent pacemaker is needed when there is a failure in the electrical conduction system built in the heart to ensure an appropriate heart rate response to bodily needs as well as to coordinate contractions of the four chambers of the heart. The permanent pacing system has two major components. First, there is a ‘box’ with the electronics and a battery. Due to the huge advances in electronics ‘the brain’ of the pacemaker is tiny, the size of the pacemaker depending on the size of the battery. The second component, the leads (electrodes) deliver a tiny current generated in the ‘box’ to the right side of the heart after sensing whether the heart’s own electrical system is functioning properly or not. Invariably, two leads are used, one to the small ‘collecting’ chamber; the atrium and the second to the large muscular chamber; the ventricle. The procedure of implantation is done under strict aseptic conditions. First, the vein underneath one of the collarbones is punctured and the lead is advanced to the heart under x-ray guidance. Once a satisfactory position is found the lead is fixed and connected to the box, which is then implanted in a pocket under the skin.

When I started implantations, batteries lasted only two to five years but today most pacemakers have much smaller batteries lasting more than 10 years, due to improved battery technology. The electronics in the box then was very simple, just discharging a current when it did not sense innate activity but the electronics today is so sophisticated that the pacemaker is able to record and store heart beats continuously. Stored data can be retrieved by interrogating the pacemaker using an externally held device which is also used to programme, to tailor the pacemaker for the needs of each person. Not only the electronic circuitry and batteries but also leads have improved very significantly, becoming slimmer and having fixation devices at the end to make sure the lead tip does not displace. My nightmare, at the beginning, was lead displacement, as there were no fixation devices. This resulted in not infrequent reopening and adjustment, a tedious process.

In spite of refinements lead displacement still occurs, though very rarely, and it is to reduce this that some limitations are imposed. However, I could not find advising against going upstairs in guidelines issued by any renowned Cardiology institution. Patients are advised not to lift the arm of the implant side above shoulder level for four to six weeks. It may well be this recommendation that had been misinterpreted or miscommunicated.

Notwithstanding allegations of overdoing procedures for gain in the private sector, some of which are true unfortunately, I am well aware that the standards of practice of cardiology are very high in Sri Lanka. As a ‘veteran’ who contributed to the establishment of the speciality of cardiology on a firm foundation I can look back with a sense of satisfaction. Therefore, these comments are not meant, in any way, to be critical of the Electro-Physiologist who implanted the pacemaker but to highlight the importance of communication in medicine; an art we had to master on our own. I do not know whether things have changed since and Medical Schools are teaching how to communicate.

Am I guilty of having given wrong advice to patients? Yes, but in my defence, it was mostly ‘authenticated’ wrong advice. What do I mean by that? We give medical advice on the basis of existing medical knowledge which on hindsight may prove wrong. Concepts change with advancing knowledge; accordingly, we change management as well as advice. When I was a young doctor, we advised patients with heart attacks to have strict bed rest for six weeks. It transpired later that it did more harm than good. With new evidence we changed and treatment revolutionised. Now, a patient with a heart attack has an angiogram straight away and the ‘culprit’ vessel is dilated with a stent. Patient is out of bed the next day! I can go on giving many examples. Medicine keeps changing, like any other science. That is the difference from religion where belief is the foundation, not exploration and experiment.

When I was in active practice, I found it difficult to keep pace with advances in my speciality till the world wide web came into being. Since then updating knowledge has become so easy. Before that, I may have given wrong advice without realising that knowledge has passed me by. At least, we know our limitations but wonder whether those who practice static systems of medicine protected for political and historical reasons realise that they are giving outdated advice. We need to be in touch with new developments and revise our advice accordingly. Admittedly, it is no easy task but one that should be done, as misguided advice can make life intolerable for patients, as Lucky’s story clearly illustrates.

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Strong on vocals



The group Mirage is very much alive, and kicking, as one would say!

Their lineup did undergo a few changes and now they have decided to present themselves as an all male group – operating without a female vocalist.

At the helm is Donald Pieries (drums and vocals), Trevin Joseph (percussion and vocals), Dilipa Deshan (bass and vocals), Toosha Rajarathna (keyboards and vocals), and Sudam Nanayakkara (lead guitar and vocals).

The plus factor, where the new lineup is concerned, is that all five members sing.

However, leader Donald did mention that if it’s a function, where a female vocalist is required, they would then feature a guest performer.

Mirage is a very experience outfit and they now do the Friday night scene at the Irish Pub, in Colombo, as well as private gigs.



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Dichotomy of an urban-suburban New Year



Ushered in by the ‘coo-ee’ of the Koel and the swaying of Erabadu bunches, the Sinhala and Tamil New Year will dawn in the wee hours of April 14. With houses to clean, preparation of sweetmeats and last-minute shopping, times are hectic…. and the streets congested.

It is believed that New Year traditions predated the advent of Buddhism in the 3rd century BC. But Buddhism resulted in a re-interpretation of the existing New Year activities in a Buddhist light. Hinduism has co-existed with Buddhism over millennia and no serious contradiction in New Year rituals are observed among Buddhists and Hindus.

The local New Year is a complex mix of Indigenous, Astrological, Hindu, and Buddhist traditions. Hindu literature provides the New Year with its mythological backdrop. The Prince of Peace called Indradeva is said to descend upon the earth to ensure peace and happiness, in a white carriage wearing on his head a white floral crown seven cubits high. He first plunges, into a sea of milk, breaking earth’s gravity.

The timing of the Sinhala New Year coincides with the New Year celebrations of many traditional calendars of South and Southeast Asia. Astrologically, the New Year begins when the sun moves from the House of Pisces (Meena Rashiya) to the House of Aries (Mesha Rashiya) in the celestial sphere.

The New Year marks the end of the harvest season and spring. Consequently, for farming communities, the traditional New Year doubles as a harvest as well. It also coincides with one of two instances when the sun is directly above Sri Lanka. The month of Bak, which coincides with April, according to the Gregorian calendar, represents prosperity. Astrologers decide the modern day rituals based on auspicious times, which coincides with the transit of the Sun between ‘House of Pisces’ and ‘House of Aries’.

Consequently, the ending of the old year, and the beginning of the new year occur several hours apart, during the time of transit. This period is considered Nonegathe, which roughly translates to ‘neutral period’ or a period in which there are no auspicious times. During the Nonegathe, traditionally, people are encouraged to engage themselves in meritorious and religious activities, refraining from material pursuits. This year the Nonegathe begin at 8.09 pm on Tuesday, April 13, and continues till 8.57 am on 14. New Year dawns at the halfway point of the transit, ushered in bythe sound of fire crackers, to the woe of many a dog and cat of the neighbourhood. Cracker related accidents are a common occurrence during new year celebrations. Environmental and safety concerns aside, lighting crackers remain an integral part of the celebrations throughout Sri Lanka.

This year the Sinhala and Tamil New Year dawns on Wednesday, April 14, at 2.33 am. But ‘spring cleaning’ starts days before the dawn of the new year. Before the new year the floor of houses are washed clean, polished, walls are lime-washed or painted, drapes are washed, dried and rehang. The well of the house is drained either manually or using an electric water pump and would not be used until such time the water is drawn for first transaction. Sweetmeats are prepared, often at homes, although commercialization of the new year has encouraged most urbanites to buy such food items. Shopping is a big part of the new year. Crowds throng to clothing retailers by the thousands. Relatives, specially the kids, are bought clothes as presents.

Bathing for the old year takes place before the dawn of the new year. This year this particular auspicious time falls on April 12, to bathe in the essence of wood apple leaves. Abiding by the relevant auspicious times the hearth and an oil lamp are lit and pot of milk is set to boil upon the hearth. Milk rice, the first meal of the year, is prepared separate. Entering into the first business transaction and partaking of the first meal are also observed according to the given auspicious times. This year, the auspicious time for preparing of meals, milk rice and sweets using mung beans, falls on Wednesday, April 14 at 6.17 am, and is to be carried out dressed in light green, while facing east. Commencement of work, transactions and consumption of the first meal falls on Wednesday, April 14 at 7.41 am, to be observed while wearing light green and facing east.

The first transaction was traditionally done with the well. The woman of the house would draw water from the well and in exchange drop a few pieces of charcoal, flowers, coins, salt and dried chillies into the well, in certain regions a handful of paddy or rice is also thrown in for good measure. But this ritual is also dying out as few urban homes have wells within their premises. This is not a mere ritual and was traditionally carried out with the purification properties of charcoal in mind. The first water is preferably collected into an airtight container, and kept till the dawn of the next new year. It is believed that if the water in the container does not go down it would be a prosperous year. The rituals vary slightly based on the region. However, the essence of the celebrations remains the same.

Anointing of oil is another major ritual of the New Year celebrations. It falls on Saturday, April 17 at 7.16 am, and is done wearing blue, facing south, with nuga leaves placed on the head and Karada leaves at the feet. Oil is to be applied mixed with extracts of Nuga leaves. The auspicious time for setting out for professional occupations falls on Monday, April 19 at 6.39 am, while dressed in white, by consuming a meal of milk rice mixed with ghee, while facing South.

Traditionally, women played Raban during this time, but such practices are slowly being weaned out by urbanization and commercialisation of the New Year. Neighbours are visited with platters of sweetmeats, bananas, Kevum (oil cake) and Kokis (a crispy sweetmeat) usually delivered by children. The dichotomy of the urban and village life is obvious here too, where in the suburbs and the village outdoor celebrations are preferred and the city opts for more private parties.



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New Year games: Integral part of New Year Celebrations



Food, games and rituals make a better part of New Year celebrations. One major perk of Avurudu is the festivals that are organised in each neighbourhood in its celebration. Observing all the rituals, like boiling milk, partaking of the first meal, anointing of oil, setting off to work, are, no doubt exciting, but much looked-forward-to is the local Avurudu Uthsawaya.

Avurudu Krida or New Year games are categorised as indoor and outdoor games. All indoor games are played on the floor and outdoor games played during the Avurudu Uthsava or New Year festival, with the whole neighbourhood taking part. Some of the indoor games are Pancha Dameema, Olinda Keliya and Cadju Dameema. Outdoor games include Kotta pora, Onchili pedeema, Raban geseema, Kana mutti bindeema, Placing the eye on the elephant, Coconut grating competition, Bun-eating competition, Lime-on-spoon race, Kamba adeema (Tug-o-War) and Lissana gaha nageema (climbing the greased pole). And what’s an Avurudhu Uthsava sans an Avurudu Kumari pageant, minus the usual drama that high profile beauty pageants of the day entail, of course.

A salient point of New Year games is that there are no age categories. Although there are games reserved for children such as blowing of balloons, races and soft drinks drinking contests, most other games are not age based.

Kotta pora aka pillow fights are not the kind the average teenagers fight out with their siblings, on plush beds. This is a serious game, wherein players have to balance themselves on a horizontal log in a seated position. With one hand tied behind their back and wielding the pillow with the other, players have to knock the opponent off balance. Whoever knocks the opponent off the log first, wins. The game is usually played over a muddy pit, so the loser goes home with a mud bath.

Climbing the greased pole is fun to watch, but cannot be fun to take part in. A flag is tied to the end of a timber pole-fixed to the ground and greased along the whole length. The objective of the players is to climb the pole, referred to as the ‘tree’, and bring down the flag. Retrieving the flag is never achieved on the first climb. It takes multiple climbers removing some of the grease at a time, so someone could finally retrieve the flag.

Who knew that scraping coconut could be made into an interesting game? During the Avurudu coconut scraping competition, women sit on coconut scraper stools and try to scrape a coconut as fast as possible. The one who finishes first wins. These maybe Avurudu games, but they are taken quite seriously. The grated coconut is inspected for clumps and those with ungrated clumps are disqualified.

Coconut palm weaving is another interesting contest that is exclusive to women. However men are by no means discouraged from entering such contests and, in fact, few men do. Participants are given equally measured coconut fronds and the one who finishes first wins.

Kana Mutti Bindima involves breaking one of many water filled clay pots hung overhead, using a long wooden beam. Placing the eye on the elephant is another game played while blindfolded. An elephant is drawn on a black or white board and the blindfolded person has to spot the eye of the elephant. Another competition involves feeding the partner yoghurt or curd while blindfolded.

The Banis-eating contest involves eating tea buns tied to a string. Contestants run to the buns with their hands tied behind their backs and have to eat buns hanging from a string, on their knees. The one who finishes his or her bun first, wins. Kamba adeema or Tug-o-War pits two teams against each other in a test of strength. Teams pull on opposite ends of a rope, with the goal being to bring the rope a certain distance in one direction against the force of the opposing team’s pull.

Participants of the lime-on-spoon race have to run a certain distance while balancing a lime on a spoon, with the handle in their mouths. The first person to cross the finish line without dropping the lime wins. The sack race and the three-legged race are equally fun to watch and to take part in. In the sack race, participants get into jute sacks and hop for the finish line. The first one over, wins. In the three-legged race one leg of each pair of participants are tied together and the duo must reach the finish line by synchronising their running, else they would trip over their own feet.

Pancha Dameema is an indoor game played in two groups, using five small shells, a coconut shell and a game board. Olinda is another indoor board game, normally played by two players. The board has nine holes, four beads each. The player who collects the most number of seeds win.

This is the verse sung while playing the game:

“Olinda thibenne koi koi dese,

Olinda thibenne bangali dese…

Genath hadanne koi koi dese,

Genath hadanne Sinhala dese…”

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