The Evolution of Critical Care and Respiratory Medicine Departments at CMC, Vellore – A historical perspective
by Dr. Debidas Ray.
Dr. Debidas Ray. FRCP (London) FRCP (Glasgow)
Fellow Emeritus American College Chest Physicians
Consultant Chest Physician
Retd Professor of Medicine &
Head of the Department of Chest Diseases
Christian Medical College & Hospital, Vellore.
Former Emeritus Medical Scientist (I C M R)
Before making any comment on the department itself, it will be necessary to mention the initial respiratory set up - clinical as well as services –which was available and developed over the years before these endevours culminated in establishment of the Department of Chest Diseases with me ( Dr.D.Ray) as the Head, at CMC Vellore (Council Resolution NO:5490:10-81) in April 1984.
In 1972, when I joined CMC as the Chest Physician in the Department of Cardio Thoracic Surgery, the Pulmonary Function Laboratory attached to the Department was catering to the ventilatory care of the post-operative cardiac surgery patients in the Intensive Care Unit in F ward (which later became E ward). Four BennetPR2 respirators and a Bird (Mark 8) respirator of the department were maintained in the Pulmonary Function laboratory. The laboratory technicians also used to provide blood gas analysis service using Radiometer electrodes and an Oximeter of American Optical Company for follow up of the post-operative patients in the ICU. A Poulton spirometer for estimation of FVC and FEV1 by open spirometry was also available.
There was persistent demand for assisted ventilatory care for patients from all wards in CMC outside the Cardio-Thoracic area also and the need was acutely felt. For this purpose, two Bennet PR2 respirators for general service were procured and a mobile ventilatory care service was initiated for such patients. The ventilators were run with pressurized oxygen cylinders fitted with regulators in respective wards and 24 hour clinical support was given by rotating interns of the requesting clinical units while necessary respiratory supervision was provided by me and the laboratory technicians.
As the demands were overwhelming and the respiratory set up was obviously inadequate, a new Brompton Manley and two Harlow ventilators were later added. I also managed to procure one Bird Mark7 respirator from Nellore Mission Hospital and two more Bennet PR1 respirators from U.S Missions through the Friends of Vellore. A Beckman physiological Blood gas analyser was procured in a similar way with which we could estimate PaO2, PaCO2 and pH. The Laboratory with these facilities alone could perform over 4000 blood sample analysis in a year in the nineteen seventies and early eighties.
In the initial stage, I was exclusively involved with ICU care of post operative patients of Thoracic Surgery Department and also with Extra Corporeal Circulation given through Heart-lung machine during open heart surgery in the thoracic theatre. In 1974 itself, I presented the first ever paper on “Problems and Management of Respiratory Intensive Care” in India that was presented in the World Congress on Chest Diseases at Delhi which was later published in the Proceedings of the Congress in 1977. A research paper on effect of extracorporeal circulation on levels of serum magnesium on cardiac surgery patients was also published in the Indian Heart Journal in 1976.
As we shifted to KN ward in 1977, the Thoracic ICU became well organized with Emerson 3PV Ventilators and Bear’s volume cycled ventilators while round the clock blood gas analysis services were given from the PF lab as before. The thoracic technicians provided ventilatory support to other areas also. However, with increasing demand for assisted ventilatory services, a separate area for medical patients needing such care - the EICU - with myself as incharge was established in 1980. A separate area for post-operative Neuro -Surgery patients was already there. They too joined our general respiratory services with their two Bennet respirators. In each of those two ICU’s compressed airlines were installed for running the respirators. The ventilatory support to all wards as before was being provided from the PF lab by the thoracic technicians. Later a separate Respiratory Services unit within the Thoracic Department was budgeted in 1981 and separate technicians for general services were provided. The PF Lab still located in KN ward continued to provide the ventilatory care services and other support including blood gas analysis for all such patients.
In 1983, the Respiratory Services area with the P F Lab moved out of KN ward to its new location (present office of the Division of Critical Care) near the Isotope lab (presently Dept. of Nuclear Medicine). For running the Thoracic Medicine OPD and other clinical work, I remained attached to thoracic department as before. With the establishment of the Department of Chest Diseases in 1984, the clinical area was also separated and separate beds for Chest Diseases in KN ward and C ward were allotted.From then on, the entire area functioned independently paving way for the future exponential growth of this specialty. For the Pulmonary Function laboratory itself, a Corning’s blood gas analyzer was acquired in 1985 and the service was now institutionalized. A Steadwell Spirometer and a Collins / RS System with microprocessor measuring all static and dynamic lung volumes added new dimension to the open spirometry that alone was hitherto available. Gradually many more ventilators were also added to the respiratory service area of the Department (pictures of the equipments used are posted separately).
In the initial years, I was involved in the endoscopic services which were carried out along with the thoracic PG trainees. Thus I began my endoscopy with metal bronchoscope which is a rare experience for chest physicians. As HR.CT scan was not available at that time, bronchograms were routine procedures when necessary. Apart from other percutaneous biopsies I was also engaged in doing regulated oxygen cylinder pressure driven ‘pneumatic drill biopsy of lungs’. The case reports documenting all such clinical investigative works were published in reputed journals.
Highlight of the newly introduced investigative procedures by me in collaboration with isotope Lab in CMC was of course, the Perfusion Lung Scan Studies. The first report of such lung scan study in India was notified by me to the Bhaba Atomic Research Centre (BARC), Bombay from Vellore in 1974 and this work was subsequently published in 1975 in a reputed National journal. With advancement of facilities, like Gamma Camera, ventilation-perfusion scintiscanning of patients with TPE was done and report of the scintiscanning in TPE was published in American CHEST Journal. Many pioneering research papers on tropical eosinophilia, fungal and parasitic lung diseases had been published by me in reputed International journals from 1974 onwards. The other land mark event for the department was the introduction of fibreoptic bronchoscopy which was carried out by me independently in the Department of Chest Diseases using an ACMI fibreoptic (FOB) bronchoscope in year 1987. Other than routine diagnostic work, a research paper on FOB was also published in a national journal (see the attached list of publications).
Apart from clinical research, in 1980 itself I initiated a field study on ‘Tropical Eosinophilia, Tuberculosis and Chronic Pulmonary Diseases,’ in collaboration with RUSHA at K.V.Kuppam, under the auspices of the Indian Council of Medical Research, New Delhi. The project included trial of various drugs regimens in chest diseases including a twenty week short course chemotherapy (S.C.C) for sputum positive tuberculosis) and other major epidemiological studies on Tuberculosis, Tropical eosinophilia and COPD which have all been published in USA, UK and other European Journals. A study of PEFR on 2000 normal people in this community was done and regression equations for the normal population were determined. This work was published in the prestigious UK journal Thorax. The above research project continued till 1986. Thereafter the Department of Chest Diseases carried on with other clinical research work as before.
I have done extensive teaching for undergraduate and post graduate students of CMC. I taught undergraduate students posted to Dept.of Thoracic surgery and was also attached to one of the Medicine units for teaching purposes. As regarding teaching on respirators, ventilatory care, pulmonary function studies, pulmonary physiology and acid base status, it was exclusive preserve of the PF lab and Dept. of Chest Diseases. I myself have taken many classes for Medicine and Anesthesia Dept. PG’s and PG’s of the Dept. of Clinical Biochemistry and also paramedical and nursing students. I was examiner for post graduate examination in the specialty in all major National Universities and Examination Boards. I was a founder Member/Fellow of national bodies like Indian Chest Society, National College of Chest Physicians. I was invited in many national CME’s for giving lectures and also involved in organizing ‘National updates on Flexible Fibreoptic Bronchoscopy’ on a yearly basis in the country from early nineteen nineties.
Now coming to personnel for the clinical side, posts of two senior house officers and a tutor/ lecturers were budgeted. The last of the two SHOs to join the department in 1991 included Dr. D.J. Christopher who after passing his diploma in TB and chest diseases (DTCD) was promoted to the tutor post. And as the Department was going to be left without a ‘Head’ recognized for the specialty and going to lose its teaching status, I recommended Dr. Christopher as eligible for taking the Diploma of the National Board (D.N.B) examination from the Department of the Chest Diseases the day before I retired in 1992. After I left, the P.F. Lab and bronchoscopy services of the department were attached to medicine unit II. Subsequently, this area of respiratory medicine activities developed into the independent Department of Pulmonary Medicine under the leadership of Dr.D.J.Christopher. The Department of Chest Diseases has provided assisted ventilatory support services and care to patients in all non- thoracic wards and this whole area has now developed into the Division of Critical Care with separate surgical, medical and neurological ICU’s. The E.ICU along with the existing respirators and the blood gas machine of the Dept. of Chest Diseases formed the basis of the full-fledged Medical ICU under the leadership of Dr.George John and is now a part of the Division of critical care.
The three technicians, appointed to the department of chest diseases and trained by me were Mr. H. Arthur Sadhanandham, Mr. R. Kathavarayan and M. Karunakaran. It is apparent that after I retired they were the only personnel left who had been trained by me in various pulmonary function techniques and ventilators as well as respiratory care services. Besides, they assisted me in fibreoptic bronchoscopy and were familiar with the set up and procedures of FOB. After I left CMC, it was in fact hey who provided the background technical support for further development of the specialty of Respiratory Medicine as well as Critical Care at CMC, Vellore.
In the end, I acknowledge the earlier contribution of Dr.J.S Milledge of U.K who initially set up the facilities of respiratory services and pulmonary function studies in the Dept. of Thoracic Surgery. Actually it was Dr.Milledge, who before returning to UK, met me in Delhi ,where after coming back to India from UK after a decade , I was working as a lecturer in Maulana Azad Medical College and persuaded me to join CMC for developing this area and the Respiratory medicine as a whole which I did in August 1972.
Soon after I joined CMC, Dr. C.R. Collier a Visiting Professor from the Southern University of California who was a Pulmonary Physiologist joined as a full time consultant to the Department of Physiology at CMC and the Pulmonary Function Laboratory at CMCH, Vellore in October, 1972. He enlightened us in the newer Pulmonary Function techniques, PF laboratory equipments and also on functional diagnosis of pulmonary diseases, blood gas analysis and acid base evaluation and treatment. I personally benefited a lot for the knowledge thus gained and I am grateful for that.
Starting with a Douglas bag for measuring exercise ventilation, a Haldane’s apparatus for measuring mixed venous Pco2, an Astrup pH meter (type 22) to determine pH and Pco2 while estimating Sao2 of arterial blood by an Oximeter of American Optical Company and calculating base excess of blood and plasma bicarbonate using a blood gas calculator of Severinghaus (1966), the Pulmonary Function Laboratory along with few Respirators and the Thoracic medicine clinics, the specialty has come a long way providing vast areas of service at the CMC Hospital. When I look at this huge banyan tree of the specialty that has grown with its branches, the seed that was sown seems very small, I feel humbled. I am confident that many more branches of this specialty will grow from subspecialty to individual status as Critical Care and Pulmonary Medicine have done. It gives me extreme joy when I look at the panorama of this evolving specialty which afflicts a major part of the population of this country. That the Department of Chest Diseases has been the fountain-head of all such developments and specialized activities at CMC is a matter of pride for the institution and satisfaction for me personally.
A. PUBLICATIONS IN INDIAN JOURNALS
1. Chronic Respiratory Failure. Ray D. Journal of the Christian Medical Association of India 1973;48:426-429.
2. Lung Function in Tropical Eosinophilia. Ray D. Indian J Chest Dis 1974; 16:368-373.
3. Hydatid Disease of the Lung. Kulpati D D,Hagroo A A, Talukdar CK, Ray D. Indian J Chest Dis 1974; 16:406-410.
4. Lung Function in Tropical Eosinophilia (Abstract). Ray D. Indian J MedSci 1975; 29:1:42-43.
5. Lung Scan in Diagnosis (A preliminary study) Ray D. Indain J Chest Dis 1975; 17:113-118.
6. Pulmonary Agenesis associated with Crossed Renal Ectopia. Ray D, Hrudayanath P, Pulimood B M. Indian J Chest Dis 1975;17:90-94.
7. Wolff-Parkinsons – White Syndrome – a review of forty two cases. Ray D and Danino E A.Indian Heart Journal 1975; 27:13-18.
8. Liver in Thyrotoxcosis (A functional and structural study). Talukdar C K, Ray D, Kulpati D D,Singh Varma N P, Vaishnava J, Indian J Med Assoc 1975; 65:37-40.
9. Endotoxemia in Typhoid Encephalopathy. Nag A K, Saha K, MehrotraA N, Ray D. Indian J Med Res 1975;63:1273-1279.
10. Succinic dehydrogenase and glucose-6-phosphate dehydrogenase activities in brain of mice after administration of salmonella typhyEndooxin. Nag A K, Saha K, MehrotraA N, Ray D. Indian J Med Res 1976;64: 9-16.
11. Effect of extracorporeal circulation on levels of serum magnesium. Ray D, Indirani N, John S. Indian Heart Journal 1976;28:130-136.
12. Problems and Management of Respiratory Intensive Care. Ray D. Published in, “ Advances in Chronic Obstructive Lung Diseases”: Proceedings of the World Congress on Asthma, Bronchitis and Allied conditions held in New Delhi, 1974, edited by :Viswanathan R, Jaggi O P. Published by Asthma and Bronchitis Foundation of India 1977.
13. Relapsing Tropical Eosinophilia. Ray D. Indian J of Chest Dis 1977; 19:65-71.
14. Pulmonary Metastases in Solid tumours. Roul R K, Ray D, Paterson D E, Tiwari D, Singh A D. Indian Journal of Radiology 1978; 32:141-148.
15. Serum Immunoglobulin and Complement profile in parasitic diseases. Saha K, Sarkar N, Paul D N, Ray D. Ind J Med Res 1979; 70:22-32.
16. Immune Response against depolymerised Flagella (A T-cell dependant antigen) In Lepromatous leprosy.Saha K, Whittingham S, Ray D, Mittal M M,Beohar P C. In Aspects of Allergy and Immunology 1980; 12:155-161 Edited by: Agarwal M K: Published by V.P.Chest Institute, Delhi-7.
17. Base excess of extracellular fluid in acute hypo and hypercapnic state. Ray D. Indian Journal of Anaesthesia 1982; 30:278-281.
18. Improvement of Lung Capacity in Tropical Pulmonary Eosinophilia following Diethyl Carbamazine Therapy. Ray D. Lung India 1983; 1:153-154.
19. Arterial Desaturation in Tropical Eosinophilia. Ray D. Indian J of Chest Dis & Allied Sci January-March 1984; 26:1:34-37.
20. Bronchial Response to Inhaled Isoprenaline in Tropical Pulmonary Eosinophilia. Ray D. Lung India 1986; 4:25-28.
21. Tropical Eosinophilia. Ray D. Letter to the Editor, Lung India 1986; 4:80.
22. Relative Functional efficacy of Methyl Xanthine and Beta2 Agonists in maintenance therapy of COPD. Ray D, Abel R. Lung India 1991; 9:82-85.
23. Diagnostic value of Bronchial washing through flexible fibre-scope. Ray D. Lung India 1991; 9:149-152.
24. Perfusion Lung Scan in Tropical Pulmonary Eosinophilia. Ray D, Jayachandran C A. Indian J Chest Dis & Allied Sci 1992; 34:73-75.
25. Serum Immunoglobulin E levels in Tropical and worm infested pulmonary eosinophilia - a comparative study. Ray D, Srikrishna K. Lung India 1992; 10:7-9.
26. Giant Emphysematous Bullae of Lung. Ray D, Christopher D J, Jairaj P S. Indian J Chest Dis & Allied Sci 1992; 34: 219-223.
27. Total Immunoglobulin E in patients with positive Casoni’s skin Test. Ray D, Srikrishna K, Jairaj P S. Lung India 1993; 11:64-66
28. Experience with mobile assisted ventilatory care: An analysis over 15 years. Ray.D. Lung India 1993, 15:173-72
29. Serum Immunoglobulin E – Response in sputum positive patients with Pulmonary Tuberculosis. Ray D, Saha K, Srikrishna K, Indian J. Med Res 1993; 97:151-13.
30. Chest Malignancies and serum ImmunoglobulinE Ray D, Saha K, Jairaj P S. Indian J Med Res 1993; 98:278-2823
31. Post-operative total IgE in Pulmonary hydatid. Ray D,SrikrishnaK ,Jairaj, P S. Lung India 1994; 12:23-24.
32. Serum Immunoglobulins (A.G & M) and alpha1 – antitrypsin in patients with pulmonary hydatidosis. Ray D, Kanagasabapathy A S , Jairaj P S,Lung India 1994; 12:81-82.
33. Evolution and utility of a pulmonary function laboratory – Experience of two decades. Ray D. Lung India 1994;12:140-142.
34. An Evaluation of the Assess Peak Flow meter on human Volunteers. Venkatesan E A, Walter S. Ray D. Indian J PhysiolPharmocol 1994; 38:285-288.
35. Resolution of Cryptocoecal meningitis and associated granuloma Lung with anti fungal Therapy – Report of a Case.Ray D, Gnanamuthu C. Indian J Chest Dis & Allied Sci 1994; 36:153-158.
36. Hypereosinophilia in association with pulmonary tuberculosis in a rural population in South India. Ray D, Abel R. Indian J Med.Res. 1994; 100:219-222.
37. Nocardia Empyema – a case report. Ray D, Christopher D J. Lung India 1994; 12:195-197.
38. North American Blastomycois in a South Indian Girl. Ray D, Jairaj P S, Date A. Indian J Tubercl. 1995,42:43-45.
39. A 5-year Prospective Epidemiological Study of Chronic Obstructive Pulmonary Disease in Rural South India. Ray D, Selvaraj K G. – Indian J Med Res. 1995; 101:238-244.
40. Opportunistic Pulmonary Aspergilloma Treated with Surgical Resection. Ray D, Date A,Jairaj P S. Indian J Tuberc. 1995; 42:169-171.
41. Outcome of patients with Fulminant Guillian-Barre Syndrome on mechanical ventilatory support. Gnanamuthu C, Ray D. Indian J Chest Dis & AlliedSci. 1995;37:63-69.
42. Tropical pulmonary eosinophilia co-existing with pulmonary tuberculosis. Ray D, Harikrishna S. Ind.J Tub. 1997; 44: 201-203.
43. Serum c3d levels in Tropical Pulmonary eosinophilia. Debidas Ray, SudhaSubramanyam, S. Harikrishna, V.D.Ramanathan. Indian J Med Res 2010, 131: 555 – 558.
44. Acquired alpha 1 – antitrypsin deficiency in tropical pulmonary eosinophilia. Debidas Ray, S.Harikrishna, Chandra Immanuel, Lalitha Victor, SudhaSubramaniyam, V.Kumaraswami. Indian J Med Res 2011; 134:79-82.
B. PUBLICATIONS IN FOREIGN JOURNALS
1. Excavating pulmonary metastases in carcinoma of the cervix.Kirubakaran M G, Pulimood B M, Ray D. Post Graduate Medical Journal 1975; 51, 243-245.
2. Primary Malignant Tumours of the Mediastinum and their Management. Das P B, Bakthaviziam A, Gupta R P, Kanhare M H, Jairaj P S, Ray D, John S. Australia and New Zealand Journal of Surgery 1975; 45:42-48.
3. Surgical Management of pyogenic pericarditis. Das P B, Ray D. International Surgery 1976; 9:483-485.
4. Serum Immunoglobulin and Complement levels in Tropical Pulmonary Eosinophilia and their correlation with primary and relapsing stages of the illness. Ray D, Saha K. Am J Trop Med Hyg 1978; 27:503-507.
5. The above work is quoted in manson’s tropical disease, Eighteenth edition. Edited by P.E.C. Manson-Bahr and F.I.C. Apted. Published by BailliereTindell London.
6. Impairment of Jones – Mote Hypersensitivity and specific antibody response against depolymerisedFlagellin in Lepromatous Leprosy. Saha K, Whittingham S, Ray D, Mittal M M, Beohar P C. Scandinavian Journal of Immunology 1979; 10:31-38.
7. Tropical Pulmonary Eosinophilia “Communication to the Editor”. Ray D. Chest 1991; 100:2:587.
8. Peak Expiratory Flow Rate in rural residents of Tamil Nadu in India. Ray D, Abel R, Richard J, Thorax 1993; 48: 163-166.
9. Clinical Spectrum of Pulmonary Hydatidosis and raised serum IgE levels in the Indian Southern Peninsula. Ray D, Saha K, Srikrishna K, Jairaj P S. Journal of Tropical Medicine & Hygiene 1993; 96:212-214.
10. Alpha 1 – antitrypsin in Tropical Pulmonary Eosinophilia. Ray D, Srikrishna K. Chest 1993; 104:487-492.
11. Ventilation-Perfusion Scintiscanning in Tropical Pulmonary Eosinophilia. Ray D, Jayachandran C A. Chest 1993;104: 497-500.
12. Serum Immunglobulin E response in sputum positive patients with Tuberculosis (Abstract) Ray D, Saha K, Srikrishna K. JAMA 1993; 270, pp2922.
13. Epidemiology of Pulmonary Eosinophilia in rural south India – Aprospective Study from 1981-1986. Ray D, Abel R, Selvaraj K G. J Epidemiol Community Health 1993; 47 : 469-474.
14. Pulmonary Eosinophilia in Children. Report of a School survey in rural Tamil Nadu. Journal of Tropical Pediatrics 1994; 40: 49-51.
15. Study of Alpha 1-antitrypsin and implications of its deficiency in Patients with Chronic Obstructive Airways and other Pulmonary diseases – An Indian Report. Ray D, Kanagasabapathy, Jairaj P S. Ceylon Med J 1994; 39:77-81.
16. Raised serum IgE levels in chronic inflammatory lung diseases with special reference to disorders of the Bronchial tree. Ray D, Saha K, Date A, Jairaj P S. Ceylon Med J 1994; 40:14-18.
17. Incidence of Smear positive pulmonary tuberculosis during 1981-1983 in rural area under active health care programme in South India. Ray D, Abel R. Tubercle & Lung Dis. 1995; 76:190-195.