The Emergencies We Never Meet Prevention from an ICU Doctor

If this is happening right now

Prevention can wait ten minutes. An emergency cannot.

Face drooping, arm weakness, slurred speech, sudden loss of balance or vision — that is BE-FAST, and it means stroke until proved otherwise. Note the time the symptoms began, or when the person was last seen normal, because clot treatment has a window of about 4.5 hours and that clock has already started. Chest pain, pressure or heaviness — especially with sweating, breathlessness, or pain spreading to the jaw, back or left arm — is a heart attack until a hospital says otherwise.

In either case, call 108 now. The ambulance is free, arrives with a trained technician, and the network knows which centre nearest you is equipped for time-critical treatment. PPK Hospital’s 24/7 emergency department and intensive care unit stabilise patients while that is arranged.

Stroke — what to do now →Chest pain — what to do now →

Why an ICU doctor writes about prevention

An intensive care unit is where a district’s health arrives late. A man is brought in from a rubber estate at four in the morning, and by the time his family has finished answering our questions we know that his blood pressure was high at a camp three years ago, that nobody rechecked it, and that he had been calling the chest tightness gas trouble for a fortnight. None of that is negligence. It is simply how silent conditions work: nothing hurts, the fields and the shop do not pause, the bus to the clinic goes at an inconvenient hour, and the report is folded into the almirah along with the ration card.

So most of the beds in this unit are booked years in advance — and that is the hopeful half of the sentence, because a booking made years in advance can still be cancelled. The cancelling is unglamorous. A blood-pressure reading. A sugar test — sugar, as everyone here says it, meaning blood glucose. A pulse felt for thirty seconds. A foot looked at every night. A chest pain taken seriously the first time instead of the fifth. Every page below is one of those cancellations, written out in full.

What critical care actually involves →

The heart: four ways a warning gets missed

Chest pain in this region is negotiated before it is examined. It is eaten with, walked off, treated with soda and a hot-water bottle, and named — gas trouble — long before anyone has looked at an ECG. Heart attack or gas trouble? How to tell, and when not to try teaches the differences that genuinely exist, and then refuses to let them decide the matter: relief after an antacid rules nothing out, and unexplained chest pain is an emergency until a hospital says it was not.

Then there is the age assumption. Heart attacks before 40 covers why young Indian hearts fail earlier than textbooks written elsewhere would predict — the collapse at the gym, the unaccustomed exertion, the supplements bought without advice, the diabetes that arrived at thirty-two.

The third miss is a piece of paper. “My cholesterol is normal” is said in this consulting room every week, by someone holding a report judged against a range built on other populations. Why that report doesn’t clear an Indian heart explains what the standard panel does not measure and what to ask for instead.

The fourth is the cruellest. Diabetes can switch off the very pain that is supposed to save you. The silent heart attack is about what arrives in its place — sudden breathlessness, unexplained exhaustion, a vague sense of being unwell — and why all of it counts as cardiac until somebody has checked.

Stroke: the emergency with the clearest homework

Stroke carries the plainest prevention list in medicine, and blood pressure sits at the top of it. In Indian studies untreated hypertension is the largest single contributor, and it produces no symptom whatever until the day it produces a catastrophe. Preventing stroke: blood pressure, an irregular pulse, and 30 seconds a week covers home monitoring done properly — the machine, the posture, the timing — and the wrist-pulse check for an irregular rhythm, a badly under-diagnosed condition that multiplies stroke risk several times over and that anyone can learn to feel for in half a minute.

The second stroke page exists because of a sentence we hear too often: it went away, so it must have been nothing. A “mini stroke” is a full warning explains why weakness or speech trouble that resolved within minutes needs assessment within a day or two, not a wait-and-see week — and why, while it is happening, the response is still 108.

When diabetes is the one driving

Three of the most preventable admissions in this unit belong to diabetes, and all three announce themselves well in advance.

The first begins with a sentence spoken in complete good faith: I wasn’t eating, so I skipped the insulin. Fever, vomiting, high sugar: the sick-day rules sets out what illness does to sugar, why insulin is usually needed more during a fever rather than less, and the specific signs — repeated vomiting, deep rapid breathing, drowsiness — that mean hospital tonight rather than a review tomorrow.

The second runs in the opposite direction. High sugar takes years to do its damage; low sugar takes minutes. Low sugar at home: the 15-15 rule and the night signs families miss covers what to do when a reading falls below 70, the night-time signs a sleeping person cannot report, and the one rule that never bends — nothing by mouth for anybody who is not fully awake.

The third is measured in feet. In Indian studies the great majority of non-traumatic amputations begin as a diabetic foot ulcer that nobody saw, because the nerve that should have reported it had already stopped working. The two-minute foot check is the cheapest examination in medicine, and the one most worth teaching to a family member with good eyesight.

The two pages every household should read

Fever is the commonest reason a family here spends a night wondering whether this is a hospital night, and the wondering peaks with the monsoon. The fever itself is almost never the danger; what rides in behind it can be. Fever: when home care ends and the hospital begins gives the red flags that end wait-and-watch — confusion, fast breathing, very little urine, cold mottled skin — and the special case of the elderly and of people with diabetes, who can carry a serious infection with barely any fever at all.

And then the ten minutes nobody plans for. Someone collapsed. The next ten minutes. is hands-only CPR — 100 to 120 compressions a minute, no mouth-to-mouth needed — along with the law that protects a bystander who steps in, and a plain correction of the coughing advice that circulates on WhatsApp every few months. It is the one page here that puts the saving in an ordinary person’s hands.

The report nobody acted on

Look behind almost everything written above and you find a piece of paper. A sugar reading in the borderline band. A blood pressure noted at a camp and never repeated. A lipid panel handed over with “everything is fine, just reduce the oil.” Prevention, in practice, is whatever happens in the fortnight after a result like that — and that fortnight is where it usually fails, not for want of knowledge but because nothing was actually scheduled.

If diabetes is already in the house — yours, or a parent’s — the diabetes practice is where the day-to-day work lives: targets, tablets and insulin, food that belongs to this coast rather than to a magazine, and reviews that keep the numbers honest. Critical care is the far end of the same road, worth reading once while calm so that a family understands what an ICU does before they ever need one.

What to do in the next seven days

None of this needs an appointment to begin. Have your blood pressure measured — at a clinic, a pharmacy, or on a home machine used properly, seated and rested. If you are past thirty-five, or diabetes runs in the family, get a fasting sugar or an HbA1c done rather than assuming. Feel your own pulse for thirty seconds and notice whether the beat is regular. Look at the soles of both feet tonight if you or a parent has diabetes, and again tomorrow. Put 108 into the phone of whoever in the house does not have it — usually the elderly parent who will be alone when it matters. And take one chest pain seriously the first time. That, honestly, is the whole syllabus.

Related

• Critical care & ICU at PPK Hospital
• Stroke — what to do now
• Chest pain — what to do now
• Diabetes care with Dr. Ruskin