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Vijyoti, creating awareness among stakeholders and medical practitioners for ROTEM

Vijay G. Pande, currently the Managing Director of Vijyoti Management And Communications Learning Institute Pvt. Ltd., of which he is a co-Founder, and Founder – President of Vijyoti Education Foundation, is a J.N. Tata Scholar, is an alumnus of the London School of Economics

He began his career as a Tata Administrative Service (TAS) Officer moving on to work with the Ministry of Commerce, GoI, as the Chief R & A Division of the Trade Development Authority, and then to the Ford Foundation as the Deputy Representative for India, Nepal and Sri Lanka, and thereafter to the International Development Research Centre (IDRC), Canada, as the Regional Director for South Asia, and subsequently to the Heron Technology Corporation, Canada, as the Managing Director – India and South Asia.

Vijay G.Pande, in conversation with Ekta Srivastava, Health Technology

Could you please share the brief overview of the status of the blood bank in India?

There is an estimated 25% shortage of bloodin India, as per WHO estimates. As against the  requirement of about 12 million units in a year the collection is only 9 million units resulting in a  shortage of 3 billion units. As a result of this scarcity, illegal blood market has developed, which is profiteering from scarcity of blood supply without realizing its adverse societal impact. So far as blood banks are concerned, the government is doing a very good job, no question about this but they are also constrained by the excess demand of the product. For this, there is a need for concerted effort by the government to address blood scarcity in consultation and partnership with civil society. .

This is where we come in, by catalyzing  judicious use of transfusion medicine through an appropriate Patient Blood Management Program (PBM). Right now, for any excessive bleeding, the first response of a medical practitioner is to transfuse blood in the patient, without realizing that transfusion leads to increase in infections, morbidity, mortality and other health issues. Reason, blood is an organ of the body and whenever you introduce any foreign body, blood included, it creates anti-bodies that could and in many cases do lead to hazardous complications. So, the moral of the story is that blood transfusion should be done only when it is absolutely necessary, that is it should be evidence based rather than behaviour based..

In this context, in 2012 WHO asked all 193 WHO member states to implement the concept of PBM (Patient Blood Management) in a timely manner to ensure that blood transfusion is done only when required. Fortunately, by then a technology had developed to assist in PBM by visco elastic testing of blood. This technology was developed in 1948 by Professor Hartert (1948) but commercialized much later. Today we have a vastly improved version of this technology – Rotational Thromboelatometry (ROTEM) which makes judicious and targeted use of blood products at the point-of-care, a reality. In the case of excessive bleeding in patients, when blood is subjected to examination by ROTEM, you get results in 10-15 minutes, identifying the cause(s) of bleeding through colored graphic presentation of results that assist the surgeon in making evidence-based therapeutic interventions

What role do you play with ROTEM in blood conservation strategy?

We, at Vijyoti, as exclusive India partner of Tem International GmbH, Munich, Germany, are engaged in creating awareness about PBM and to catalyse practitioners of transfusion medicine to adopt an evidence-based approach towards blood transfusion aided by the ROTEM system. Today medical practitioners in India are generally using the conventional behavior based approach for addressing excessive bleeding control – blood transfusion. This is like filling a leaking bucket with more and more water rather than fixing the leak.As we say in TEM, if a bucket is leaking and you go on filling it with more and more water, you don’t solve the problem. You have to stop the leakage. For that, you have to find out where are the leakage points and what is causing the leakage. ROTEM helps in this by way of providing critical diagnostic information on efficacy of the therapy that minimizes use of blood and blood products and is, therefore, an important tool for blood conservation.

We are also sensitizing stakeholders to develop a protocol for PBM in pursuance of the WHO directive to member states. As of date there is no PBM protocol in India. The Government of India is yet to take steps  to move towards this end.

Excessive bleeding  occurs in significant number of patients both  intra-and post-operatively in cardiac surgery, liver transplant procedure, trauma, and during child birth. A PBM protocol and use of ROTEM can effectively address the problem with significant saving of blood and blood products as is well known through several scientific papers published in reputed medical journals. That this works has been well demonstrated by Sri Lanka that significantly reduced  the PPH related deaths of women during child birth and achieved the Millennium Development Goal of  MMR using the PBM concept and the ROTEM system.

This leads me to ask  a question: why is PBM not practiced in India and why is the ROTEM system not used in India even when our neigbours –  Srilanka and Pakistan – have adopted PBM and are using the ROTEM system.

What do you think are the challenges; India not adopting this technology?

The real challenge is to change the mind set of the stakeholders including the medical fraternity.  We humans are always reluctant to respond to changes specially those changes that require us toi do thing differently. When a new technology comes in and interferes with your conventional ways of doing things you hesitate to accept it. It is, therefore, not surprising that the medical practitioners generally don’t want to come out of their comfort zone of conventional wisdom adopt the new PBM concept and the new ROTEM system. They are using traditional ways for controlling excessive bleeding rather than using ROTEM technology  as they  are worried about, something going wrong for which they would be blamed.

What is required, is massive amount of education and awareness creation about PBM and ROTEM, and about the need to conserve blood and improve patient outcome.

So, what role does Vijyoti plays here?

We have become the exclusive India Partners of TEM International GmbH, Munich, Germany. Developed by TEM International in Munich, Germany, ROTEM plays an integral role in blood conservation strategies by significantly reducing usage of blood products and components. This technology will allow rapid and reliable treatment decision to be made during emergencies and is a solution for detecting, managing and monitoring haemostatic during cardiac surgery, liver transplant, trauma patients and obstetrics. It also helps to prevent unnecessary transfusions of blood and generate quicker and accurate results during variety of surgeries.

We have brought this device to India, and quite apart from marketing, we have taken upon ourselves the responsibility of educating the stakeholders, including policy makers, and medical professionals. This is entirely different from the process of selling a product. It’s concept selling, where our core responsibility is to change the mind-set of the stakeholders regarding transfusion medicine from behaviour-based approach to evidence-based approach.

So, are you in any talking terms with the government?

No, we haven’t as yet started talking to policy makers but we will As of now, we are talking to medical professionals and surgeons to understand their perspectives regarding PBM and to explain the ROTEM system. Till now, we have  visited 136 hospitals and had discussions with 152 doctors.

What are the major challenges that blood bank industry is facing today?

Shortage of blood, is of course a major challenge that has remained unsolved till date due to other challenges. First, is the challenge of coordination and networking. There is very little coordination between the government and blood banks. Also, there is poor coordination between the blood banks which are run by trusts, private players, and NGO’S.  They are all functioning as independent units. And in my opinion if we have to address the issue of blood shortage and blood conservation in a way that makes a difference then we must involve all the stakeholders in a consultative and collaborative mode with a strong communication and network.

Another challenge is that of inventory management in respect of blood and blood products.  This is evidenced by the fact that despite the shortage of blood, there is considerable wastage of blood due to the low shelf-life of blood. For example, it is reported that in January 2012, 140 units of packed red blood cells were disposed of in a hospital because they had expired.

Why is blood trade still thriving in India?

Black market in blood is thriving in India because of excess demand. Shortages of any product inevitably lead to black and grey markets, and blood is no exception.

Further, absence of a central blood collection agency in India, along with taboos against getting transfused with blood from persons of different castes, accentuates the shortage problem. It further fuels a vast illegal market, despite a 1996 Supreme Court ruling that banned paid donors and unlicensed blood banks. Little has changed since then. Demand still outstrips supply.


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