-by Jaya Pathak
Corporate India has gone native speaking when it comes to risk. Currency exposure, founders’ fears of running out of runway, investors’ valuation of regulatory uncertainty and boards’ new questions about succession are just some of the topics discussed by the various stakeholders.
But the human body, unfortunately, isn’t one thing that you can look at the end of a quarter and see if it poses risks. Some risks may be silent and non-dramatic and individuals who are at risk may be working, traveling, negotiating without any apparent issues.
An abdominal aortic aneurysm is a dangerous bulge in the main artery (aorta). The issue is a part of the wall of the artery dilates and bulges. When it ruptures, it can bleed rapidly, profusely and fatally.
One of the things that is so disturbing about AAA is that it will actually often go unnoticed. A lot of individuals find out about it by chance. A scan may come up with an aneurysm that has been developing without causing any symptoms if it is done for abdominal pain, kidney stone evaluation, a pre-operative scan or for another reason.
It’s a very sobering moment. A person who thinks he came in with a minor complaint goes out with a vascular diagnosis that could require the need to be followed up for years, lifestyle changes, specialist review and in some instances surgery.
The reasons are not out-of-the-way but complicated. One of the strongest factors is the age. Men are more likely to be on risk, and men over 65 are more susceptible, especially if they have a history of smoking. Other causes include high blood pressure, atherosclerosis, family history and other vascular diseases.
In less frequent instances, infection, inflammation or injury is a factor. Although not as common, risk assessment for women may be more complicated and the averages are not an adequate argument for dismissing aneurysms in women.
India is yet to pay attention to this condition. Not because clinicians are not aware of it though, since public health time and focus has been diverted to diabetes, heart attack, cancer and infectious disease. These are bigger problems, and more common dangers.
However, AAA seems to be in danger in the no-man’s land between personal health and system readiness. It is not uncommon enough to be significant, but not so common as to be harmless; not so dangerous that it cannot be respected, but so it should be.
Symptoms may be non-specific. In some cases, there is severe abdominal, back and/or side pain in the body. Others might feel a “pulsating” feeling in the abdomen.
Many don’t feel anything. The missing part is that. On the other hand if there is a rupture the picture changes drastically at once; extremely severe pain, collapse, fainting, low blood pressure, rapid pulse and symptoms of shock. That’s when appointment scheduling or second opinions is no longer an issue. It is an emergency.
This condition is also a reflection of the limits of the Indian attitude of the executive towards health culture. The premium health checks have been scaled-up and uppresented in urban hospitals, with efficient logistics. Reports are neat. It’s a comfortable experience. It is a convenience that is valuable to busy professionals.
However, a nice stack of test results may give the appearance of a completeness. Cholesterol numbers or a normal treadmill test does not necessarily mean that the vascular system has been completely evaluated. Aorta can be on the outside of the frame.
This is not to say that this is an excuse for scanning indiscriminately. Medicine can be more than used than it can be underused. Testing can cause anxiety if it is not needed, result in unnecessary interventions and costs, and do not necessarily enhance outcomes. It’s a sensible position that is more selective.
There is greater need for physicians to discuss aneurysm with their patients who have a family history of the disease, patients who have developed vascular disease, and older men who have had a history of smoking. An abdominal ultrasound, although relatively simple, is valuable when utilized for the appropriate patient, at the right time and with a plan to follow.
The last part of the sentence is important. There’s more to detection than just that. The treatment is determined by the size, growth rate, symptoms, anatomy and patient’s overall fitness once an AAA is identified. Smaller aneurysms sometimes can be left alone. This can leave the patient feeling like nothing was being done about all the serious findings, which could make him or her feel disappointed.
But in the case of vascular medicine, restraining can be a facet of treatment. It may be better years to wait for regular imaging, blood pressure control, cholesterol management and smoking cessation and for attention to other cardiovascular risk factors.
There are two general surgical solutions, open surgical repair or endovascular aneurysm repair (typically EVAR). Open repair is the outdated and more serious method in which the damaged area is replaced with a graft and this method is more invasive. EVAR is a procedure that is done inside the blood vessels and an artery is stented to support the weak artery.
Generally, provides a more rapid early recovery and is obviously preferable to patients/families. The hospitals also have a better communication. The term ‘minimally invasive’ has a commercial impact.
The latter is not necessarily better, however, as it’s “more modern sounding”. Follow-up imaging is necessary with EVAR to make sure that the graft stays in place and that there is no leakage around the graft. Open repair may be more challenging initially, but can be long-lasting for certain patients.
It will depend on the anatomy, the risk of surgery, life expectancy, and capacity of the hospital and its ability to obtain follow-up. You should never consider a procedure that doesn’t have follow-up to be a treatment plan.
It is here that the Indian healthcare market needs to be taken up for a good hard look. The top hospitals are now able to carry out complex vascular surgery. That is encouraging. However, there is a need for trained vascular teams, excellent imaging, emergency response, intensive care and disciplined systems for post-discharge care for AAA management.
Technology is a commodity — it can be bought. Continuity is something that needs to be developed. The market often values interventions and fails to invest in long tail of interventions that make interventions meaningful.
There’s another meaning when it comes to the founders, promoters and senior executives and that’s AAA. In private enterprise, the sudden sickness of one of the chief members can lead to an interruption in the management and financing of the business, succession and confidence in the market. Businesses get ready for tax raids, for merged business failures and for demand shocks.
They are not as well equipped to deal with the avoidable health crisis of a health care provider who failed to have the necessary scan and/or failed to follow up. This does not change companies into private healthkeepers but it will certainly make the area of leadership health more of a reality of continuity thinking.
Little part of this conversation is about the wellness industry, which could be one reason for its lack of discussion. No sexy measurement, no add-on to the price, no change in appearance.
The work is not showy, only when someone is at risk will they seek medical advice, only when they need will they scan selectively, only when they have to will they monitor carefully, only when they must will they intervene, and only when they must will they consider smoking and blood pressure as serious conditions and not background ones.
The message for the patient should be weighed. A family history of aneurysm, or prolonged hypertension or abdominal or back pain that doesn’t seem to have any cause should warrant a thorough medical evaluation. Severe pain suddenly; collapse/shock like symptoms needs emergency treatment. It’s certainly comfort when there are no symptoms but only to a point. Early warning of the body is not compulsory.
At the end of the day, it’s a humbling lesson from AAA. The disciplined, rich and informed can in no way see the risk. It can lie underneath a productive life, underneath business travel, underneath check-ups that are impressive, but don’t go far enough, underneath annual check-ups.
More complicated packages won’t be the key to the future of serious healthcare – it will be better judgment: knowing which risks to pay attention to, which patients to screen, and when failing to speak-up is no longer an option.
