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Demystifying Medicine One Month at a Time

Category: transplant (page 1 of 2)

Inspiration, Affiliation, Motivation: Connectors

Last week saw the deaths of three notable Americans:

Transplant pioneer.

Joe Murray–a surgeon who performed the first successful kidney transplant. Murray had struggled with the scientific problem of rejection that occurs when skin or organs transplanted from one individual to another are attacked by the new host’s immune system. Through good fortune and a stroke of insight, a patient dying of kidney failure was lucky enough to have an identical twin brother willing to donate one of his kidneys. Voila: with the same genes and immune system–the transplant was “tolerated.” It took decades longer to develop medications that would allow for cross tolerance of organ transplants in patients without genetically identical donors. Dr. Murray received a Nobel Prize for his work in 1990.

Uniter.

Marvin Miller–a labor lawyer, Miller was a controversial figure in American and baseball history. His success at getting major leaguers to unionize and collectively bargain totally turned the tables on the ‘reserve clause’–the owners’ system of keeping players as chattel for their entire careers and deciding what they could be paid. His innovation created free agency, allowing players to migrate to other teams and offer their services to the highest bidder. His work also led to the astronomical sums that ballplayers currently enjoy (the minimum annual salary of a major league baseball player is near $500,000, with an average of more than $3 million). Miller was despised by the owners and some fans, because union strikes have frequently interrupted baseball seasons. Though his legacy on the game is undeniable, he’s been shunned from the ultimate accolade, enshrinement in the Baseball Hall of Fame.

Motivator.

Zig Ziglar–a motivational speaker who wrote more than thirty books, Ziglar was a ‘typical’ American success story via re-invention of the self. He’d been a salesman until his early forties when he was “saved.” He combined his zeal for Christian morals with irrepressible optimism and salesmanship. He gave seminars and spread his brand all over the world, even sharing the stage on occasion with world leaders. Injured after a 2007 fall, he spent his latter years talking and writing about living with illness–bringing his insights and perspective on aging to his multiple audiences.

I was thinking about these three men, and what we can learn from each of their examples. Then I came across an article by Samuel Shem, the pen name of a psychiatrist who wrote an irreverent novel about medical internship in the 1970s called House of God. The book sold millions of copies, and has been compared to Heller’s Catch-22 as a work trying to find sanity in an insane world (surviving internship as compared to surviving war).

In the current article, Shem reflects on life and medicine nearly 35 years after the book’s publication. Even if you’ve never read it, he shares some real insight about survival, and further, the meaning of life. It’s his theme of connection that I realized tied the three pioneers together. And makes a fitting epitaph. Here’s Shem’s wisdom, distilled into four new “laws,” added to those from his novel:

In The House of God there were 13 “Laws.” I would now add these four:

Law 14 : Connection comes first. This applies not only in medicine, but in any of your significant relationships. If you are connected, you can talk about anything, and deal with anything; if you’re not connected, you can’t talk about anything, or deal with anything. Isolation is deadly, connection heals.

One of the worries in how the new generation of doctors practice medicine is their use of computers. If you have a laptop or smart phone between you and your patient, you are much less likely to create a good, mutual connection. You will miss the subtle signs of the history, of the person. With a screen between you, there is no chance for mutuality, and the connection has qualities of distance, coolness, rank, authority, and even disinterest. The “smart” digital appendages can make you, in human-connection terms, a “dumb” doctor.

This, as more and more studies suggest, can lead — hand in hand with the tyranny of algorithms and other “quality/efficiency/cost-containers” — to more tests, more errors and medical mistakes, lower quality care, and higher costs to all.

Law 15 : Learn empathy. Put yourself in the other person’s shoes, feelingly. When you find someone who shows empathy, follow, watch, and learn.

Law 16 : Speak up. If you see a wrong in the medical system, speak out and up. It is not only important to call attention the wrongs in the system, it is essential for your survival as a human being.

Law 17 : Learn your trade, in the world. Your patient is never only the patient, but the family, friends, community, history, the climate, where the water comes from and where the garbage goes. Your patient is the world.

Amen.

The Gift that Kept Giving

Old guy, generous young guy and his even more generous sister. (Photo: AP)

In case you missed it, there was a heartwarming story in the news about two kidney transplant recipients.

One, a young man with an autoimmune disease that destroyed his kidneys, was lucky enough to receive the gift of a kidney from his sister.

When the new kidney started to fail from the same disease process, he was offered the chance to have it removed so that another, older patient (who did not suffer from the same disease process ) could try to benefit from it.

Charitably, both he and his sister (the original donor) accepted this plan.

It worked!

The older gentleman (who happens to be a retired surgeon) is now in good condition, off of dialysis, and feeling better than he has in years.

According to news reports, this is the first documented U.S. case of ‘kidney recycling.’

For you medical buffs, the disease in question is focal segmental glomerulosclerosis (“FSGS“). And it’s not unusual that it would harm the donated kidney-the disease process occurs independent of the origin of the kidney (i.e. even if the donated kidney had come from an unrelated donor, his FSGS would have started going to town on that one as well). According to the literature, this happens ~40% of the time.

Yet when removed from the FSGS environment, the kidney recovered function and now works well in a new recipient.

Weird science!

Xmas Spirit….or Bah! Humbug?

Are you a yoda or a grinch?

You’re in your 30s. You work hard. You strive to master your craft. You support your extended family. You are liked by both your co-workers and boss.

Problem: You unexpectedly become unhealthy–you find out your kidneys are failing.

Solution: Regular kidney dialysis can keep you alive, by filtering toxins out of your blood.

Problem: Dialysis is time consuming (>3 hours/session, 3 sessions/week) and leaves you feeling tired and weak.

Solution: Your brother, who is a tissue match, offers you the gift of a lifetime–one of his kidneys.

Problem: Because you don’t have health insurance (you are covered under the Medicaid program for your ’emergency’ dialysis only) you are deemed ineligible for the transplant surgery.

Fact: The estimated cost of dialysis is $75,000 per year. The cost of the transplant surgery and care is $100,000, with an additional $10,000/year in anti-rejection medication costs.

Fact: Research shows that transplant pays for itself vs. the cost of dialysis at four years. Beyond that point, transplant is a tremendous cost saver overall. Patients feel better and live longer with transplant, too.

Solution: Surgeons at a medical center agree to waive their fees to perform the transplant.

Problem: The hospital still won’t allow the transplant to go forward.

Solution: Your kind boss offers to pitch in for health insurance.

Problem: You are denied because your kidney disease is a ‘pre-existing’ condition.

Solution: Raise $200,000 to pay the hospital up front for the cost of the operation and any potential complications.

Any readers out there willing to step up?

You can read the full story of this patient’s plight here. Pay attention to the comments below the article to see the extremes of opinion.

The patient in question is an undocumented immigrant. His children were born here and are citizens. He meaningfully contributes to the community.

But because of his status, he’s out of luck in the sweepstakes world of health care.

I welcome your opinions on how this situation should be handled. Comment on the post or send an email.

Happy Holidays. Thanks for reading and sharing GlassHospital.

Whoops!

I write this blog to try to bring transparency to medical practice. In trying to explain and demystify medicine, I’ve found that I use my ‘patient hat’ to explore topics that you want to know about. Even when I wear my ‘doctor hat,’ there are many things that remain inexplicable to me.

As one example, I’ve often wondered: Who had the shocking boldness to try stimulants on people with attention deficit disorder?

Here’s how I imagine that conversation must have gone:

Mmm Mmm Good!

Psychologist: We keep getting these hyperactive kids referred to us for therapy. I wish there was some pill we could give them to calm down.

Researcher: Have you tried sedatives?

Psych: Yes, but the parents complain that their kids just sleep all the time and aren’t doing better in school.

Researcher: Wait! I know! Let’s give them Ritalin and see what happens!

Psych: [Groans.] Oh sure, great idea! Take some amped up kids and give them uppers. Yeah, that’ll work.

I remember learning about this in medical school. It still doesn’t make any sense to me. But it works. Was it clever neuroscience or just dumb luck?

Similarly, there are often examples of medical errors where the natural reaction is, “How on earth could that happen?”

The most outrageous of these are the stories of wrong site surgery. Imagine going in to have part of your leg amputated (not so easy, I imagine) then waking up to find out the wrong leg had been removed. That would be pretty upsetting. This is the reason that medical authorities have come up with the idea of “never events:” things that should never be tolerated in the world of medicine.

Well, add one more to the list.

Last month a hospital in the U.S. admitted that a kidney was transplanted into the wrong patient. Oops!

As egregious as this seems, it’s not so difficult to imagine. All kidneys look pretty much the same. And even though they are typed (i.e. blood typed) and have identification, it can be easy to confuse things like “the type O kidney goes into the blood type B patient (type O is acceptable to anyone)” or “we need to save that type O kidney for this type O patient.”

Huh? I’m confused already, and we’re only talking about one kidney. Imagine having several operating rooms going at one time (multiple donors and recipients), and you can imagine it’s not that hard to get confused. One transplant surgeon told me that at big centers that do multiple transplants on the same days, the error that happened is not all that far-fetched.

Two good things happened here:

  1. The recipient of the wrong kidney didn’t wind up getting sick or rejecting the kidney, since in fact it was a type O (universally accepted) kidney.
  2. The hospital admitted its error and apologized for the mistake. Oh wait. At least I hope they did. They did in fact temporarily shut down their program to investigate the error and hopefully find ways to prevent something like it from happening again. [As of this post, they are up and running again.]

Which gets me to the bottom line of this week’s post: March 6-12th is national Patient Safety Awareness Week, so declared by the not-for-profit National Patient Safety Foundation. If you’re interested further, there are some worthwhile blog posts and podcasts offered up on the interesting “Engaging the Patient” blog, hosted by the for-profit, but high-purposed, Chicago-based Emmi Solutions. [Imagine: a business created around the idea of improving patient experience…..]

I’d be interested in your thoughts on the quality and content of their blog. Anyone knowing the origin of psychostimulants for ADD is also encouraged to comment.

GlassHospital

 

Cheney’s Got Heart

But should he get a new one?

Dick Cheney’s heart troubles have been well-documented. Now comes the news that the former Vice President is considering a heart transplant.  On January 30th he turns seventy, an age at which most transplant programs in the U.S. consider patients too old for the rigors of transplant surgery.

A markedly thinner Cheney has started appearing in public again.

Currently, Cheney’s life depends on an artificial pump known as a left ventricular assist device (LVAD). LVADs (pronounced “EL-VADS”) have only been in mainstream clinical use for the last fifteen years. They are an adaptation of heart-lung bypass machines, used for decades in coronary artery bypass surgery. Cardiothoracic surgeons realized that damaged hearts could themselves be bypassed to keep patients alive while awaiting a new pump–either the mechanical kind (an “artificial heart,” still a work in progress) or a heart from a cadaveric donor. Over the years, LVADs have been refined to the point where they weigh only 500 grams (slightly more than a pound) and can safely be powered by external batteries. Consequently, patients with LVADs are now able to move around freely and leave the hospital, unlike the early days of assist devices, when patients were literally tethered to the wall.

An LVAD is placed under the skin of the abdominal wall (in front of the stomach), with its blood entry port inserted into the heart’s left ventricle, and the exit spout directed into the aorta, the body’s main blood vessel. The LVAD’s power wire (about the thickness of your pinkie, called a “drive line”) tunnels from the device under the skin of the abdominal wall, and out the right side of the abdomen where it’s connected to a battery. When at home, a patient like Cheney needs to always be vigilant to charge his batteries so that he can have adequate range. The batteries are worn externally, ideally tucked in the pockets of a garment like a hunting vest.

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