Leap of Faith

This post is a little tricky because I have only a basic grasp of the complex medical intricacies. It occurred several months ago so I don't have a perfect memory for the situation, but I wanted to write about it because it was pretty unique.

A patient has multiple complications after a routine cardiac surgery. He develops a severe pneumonia leading to acute respiratory distress syndrome. The infection stuns his already-weak heart, causing him to go into heart failure and even have a cardiac arrest. After resuscitation, he goes to the operating room for placement of a left ventricular assist device, a mechanical pump that aids the heart in pushing blood from the left ventricle into the aorta. The following day, his pneumonia worsens so much that his lung struggles to oxygenate the blood. Because of his respiratory failure, he goes to the operating room again for placement of veno-arterial ECMO. This artificial circuit takes blood out of the venous (right) side of the heart, pumps it through an oxygenator, and sends it back into the arterial (left) side of the body. By now, he has been in the hospital for almost a month struggling to recover after this complicated surgery.

I am covering for a few days on the cardiothoracic ICU service and when I meet him, he is dependent on ECMO and his LVAD. The majority of his blood is sucked out of the right side, oxygenated artificially, and sent back to the left side. What little blood goes through the native circulation gets pumped by his right heart to the left and assisted by the LVAD into the arterial circulation. His lungs are getting better; with supportive care, the infection is being treated and the inflammation suppressed. Tests of compliance - that is, how flexible the lungs are - show improvement. Indeed, since the ECMO circuit acts as artificial lungs, it allows us to rest his native lungs. However, while on the ECMO circuit, it is very hard to test the ability for the lungs to oxygenate the blood.

The problem is simply this. At some point, we will have to get the patient off ECMO. Once we think the lungs are better, the risks of continuing ECMO (bleeding, infection, strokes) will outweigh the benefits. But how do we get him off ECMO?

Every time we try to wean the ECMO circuit and send less blood through the artificial membrane and more to the right heart, the right heart shows signs of failure. During the pneumonia and concurrent inflammation, the right heart was quite strained; it's not used to pushing against a high resistance circuit. It then suffered quite a bit during the cardiac arrest. Now, it's so weak that it cannot push much blood to the left side. Hemodynamically, we're dependent on ECMO. However, this means we cannot test the lung's ability to oxygenate; we cannot send enough blood through the native heart to challenge the lungs.

The solution for the hemodynamic dilemma is to go to the operating room and place a right ventricular assist device or RVAD. This internal device helps push blood from the right ventricle to the lungs. However, when we do this, we would like to take the patient off ECMO. An RVAD would replace the hemodynamic function of ECMO but not its artificial oxygenator. Since we never tested the lungs for the recovery of oxygenation, this would be a leap of faith, assuming the patient's lungs had recovered enough to support life.

This was the dilemma. Each day we waited to place the RVAD and remove the ECMO, we gave the lung time to recover but incurred all the risks of ECMO and the ICU stay. However, there was no way to quantify the recovery and know for sure when to bite the bullet and go for it. All we had was clinical experience, indirect measurements, and a gestalt. At some point, we needed to take a leap of faith and hope that he would make it. After much consultation with the ICU team, pulmonary attending, ECMO expert, and cardiothoracic surgeons, we decided to go for it. Fortunately, he did fine.

Overheard

L: I hope our child has your eyes.
Y: Aww...
L: My visual acuity is terrible.

Then and Now

Over the three day weekend, I visited some friends I've known since college. We had a strange realization about our college friends. We remember them in the context of staying up late, last minute studying, irreconcilable drama, adventurous spirit, soul-searching and identity-finding. We recall tight friendships, hilarious stories, wonderful memories, and spontaneous bursts of creativity. But we also remember some ill-advised decisions and impulsive judgments. The strange realization is that so many of us now are professionals who you never think of in that manner. Our college friends are pediatricians, law professors, entrepreneurs, cryptographers, and policymakers. Thinking of ourselves ten or fifteen years ago, we realize how much we've grown.

Don't Think Too Hard

Sometimes, this is how research feels.

Image is from xkcd, drawn by Randall Munroe, shown under Creative Commons Attribution License.

Money and Medicine

I am a strong believer that how much money you have shouldn't influence the care you get, at least in my specialties. If you are getting anesthesia for a surgery or you are admitted to the intensive care unit, I believe incredibly strongly that who you are, what you do, and what you have shouldn't matter. My anesthetic or ICU decision making should be the same whether someone is homeless or if they are a start-up executive.

There are some domains in medicine where this is not the case. Elective plastic surgery, concierge medicine, and reproductive endocrinology (IVF) tend to be medicine-for-the-rich. Perhaps these fringes are acceptable, but for the most part, medicine should be blind to money.

As an ICU fellow, I handle transfer requests from other hospitals. When I talk to physicians about whether their patient should be transferred to us, the most important question is one of medical need. Will Stanford be able to provide care that another hospital cannot? Sometimes, small community hospitals don't have services like interventional radiology or thoracic surgery. Larger hospitals may not have ECMO or continuous renal replacement capabilities. Even if another hospital could technically take care of a patient, we might transfer them if their condition is exceptionally complex or if the patient is "ours"; that is, if she sees our oncologist or liver specialist. Finally, we may consider taking a patient because of a family request, whether to be at a big academic center or to be closer to home. This last reason for transfer is the weakest one; depending on how many free beds we have, the insurance status, and other factors, we may decline a "family request."

Recently, we had a family request to move a patient to our intensive care unit. The patient had been admitted to the ICU for bleeding into her lungs, and he was isolated for concern for tuberculosis. The physician on the other end felt comfortable with the medical complexity and felt that his facility could handle all their medical needs. The patient was not a patient any of our physicians had seen in the past. Thus, this was a pure family request. As we had only one free bed in the ICU (which could potentially be an isolation bed), I declined the request; I had to triage resources. In addition, the patient's insurer was unwilling to pay for this transfer since there was no medical need. The outside physician agreed with my assessment and we went on our merry way.

Several hours later, I hear from our transfer center that the patient's family again wanted him over at our hospital. They'd even agreed to be self-pay and opened up a credit line of several hundred thousand dollars for this purpose. In reassessing the situation, I kept my ground; I only had one free bed, and it needed to be reserved for a code or an ED admission. The transfer center agreed and let the other hospital know. A few hours after that, I heard that the family was contacting progressively higher administrators, even up to the chief medical officer of the hospital. Evidently, the family was incredibly wealthy and felt that their money should buy them the care they wanted.

When things get above my pay grade, I don't fret about them. I do what I think is medically and ethically right, and I let everything else play out as it will. But this incident bothered me because I really believe medicine should be blind to money.

Bay to Breakers

Though I've been in the Bay Area over 12 years, this year was the first that I went to the Bay to Breakers footrace. It was really fun. It's amazing how small San Francisco really is when you can traverse it easily in an hour and a half. With the house parties blasting music, swing bands in Golden Gate Park, and the incredible costumes, we had a blast. I thoroughly enjoyed a "third blind mice" costume (complete with walking sticks and letters on the back spelling "see how they run"), the salmon swimming upstream, and a Star Wars party along the concourse. It's a real San Francisco tradition.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Salt

Salt is a mysterious substance. If we take in too much, our kidneys suffer and our blood pressure goes up. However, I recently had a mysterious case of the opposite problem. A highly functioning executive is brought in by her neighbor because she has been acting strange. For the last few weeks to months, she has been falling quite a bit, to the point that she has multiple rib fractures of varying ages, a bleed within her head, and bruises all along her arms and legs. She also has lapses in her memory and can't give us a good history. She lives alone, and there is no real suspect for violence or abuse. Her vital signs are stable but she's pretty confused; she can't even tell me the month or year.

Usually, patients like this don't come to the medical intensive care unit. If trauma is a big factor, they may go to the surgical trauma service; otherwise, general internal medicine or neurology wards should be sufficient to stabilize the patient and figure things out. I was called, however, because of a surprising lab finding. Her sodium level was 110; normal is 135-145. This is probably the lowest sodium I've ever seen, and it's life threatening. With so little salt in her body, she was at risk for seizures and coma.

Every medical student learns the differential diagnosis - possible causes - of low sodium or hyponatremia. However, it was not so easy figuring her out. She had no evidence of heart failure, kidney failure, or cirrhosis. She didn't have profound bleeding or diarrhea or volume loss. We began looking for occult cancers, thyroid problems, adrenal insufficiency. We began wondering about her diet, though she didn't appear to have severe malnutrition.

Over the next few hours, the story became stranger and stranger. Normally, when someone has low salt, the body conserves water by producing less urine. However, she was peeing up a storm. This suggested that she was driving her salt levels down by drinking profound amounts of water. It takes an unbelievable amount of water to bring one's sodium down to 110; in fact, most of the time we see this condition (primary polydipsia), it is due to psychiatric illness. Sometimes, the mental illness is so severe that patients will drink from a toilet to get that water. We still don't know why she has primary polydipsia.

Meanwhile, she develops a fever. She is given antibiotics in the emergency department, and she develops a profound rash. Her labs then show a dropping platelet count, so severe that we can't even do a spinal tap for her. Lastly, scans performed in the emergency department raise the possibility of an incredibly rare cancer, carcinoid tumor.

From time to time, we do, of course, run into medical mysteries. We have the infection we cannot trace, the bleed we cannot locate, the cause of liver disease we cannot identify. But a case this bizarre I haven't had in a while. Overnight, we stabilized her and began the diagnostic battery, but we shall see if answers turn up in the next few days.

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Book Review: Lock In

I was drawn to John Scalzi's book "Lock In" because of its medical premise. This novel, set in the "near future," describes the aftermath of a virus which causes 1% of its victims to experience something similar to "locked in syndrome." Locked in syndrome is a terribly scary disease where a brainstem injury such a stroke causes someone to be completely paralyzed but cognitively intact (eye control is usually preserved). Scalzi imagines a world where a significant portion of the population has this syndrome, and so technologies, industries, and government regulations have all been developed to cater to these victims. In this science fiction book, those who are "locked in" are able to mentally control mechanical robots, and in some cases, control other consenting humans. The novel is a police procedural novel that raises questions about free will when a person seemingly controlled by a locked in person commits a crime. Lately, I have been reading a good amount of science fiction, and as far as that genre goes, this book was hard to put down. More than just a crime thriller, it engages questions of societal discrimination, philosophy and ethics, and possibilities in futuristic science.

Image shown under Fair Use, from Wikipedia.

Book Review: How Google Works

I recently listened to an audiobook version of New York Times bestseller How Google Works. Written by executive chairman Eric Schmidt and senior vice president Jonathan Rosenberg, it uses Google's successes and stories as case studies on how technology companies have changed in the last few decades. It focuses its premise on how to employ "smart creatives," exceptional engineers motivated to create superior products. Although it doesn't directly apply to physicians in medicine, I learned a bit hearing their perspective on how to attract talent, manage priorities, orient strategy, and deal with competitors. However, to someone outside the business world, the book also seems like a parade of Google's success stories; there was no humility. Ultimately, this detracted from my opinion of the book and of Google itself. I think my intention in listening to the book (something to entertain me while driving to the Valley) doesn't make me the intended audience, and hence, its tone and content simply didn't impress me.

Image of Google's original homepage from 1998 shown under Fair Use, from Wikipedia.

Ursa Major

Though the Latin word Ursus bears (ha ha) little resemblance to the English word bear, we are nevertheless surrounded by this root. Ursodeoxycholic acid is found in high concentrations in bear bile, where perhaps it helps reduce gallstones. The purified version marketed as Ursodiol is a common medication for cholelithiasis, cholestasis, and primary biliary cirrhosis. While we commonly think of medicines coming from herbs, plants, or venoms of lizards, even our larger mammals have something to offer.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Brain Death

There are a lot of uncertainties in medicine, but death ought not be one of them. It seems like among all the things doctors know, we should know when someone is dead. And though these remarks seem facetious, they're not entirely off base. In fact, in 1981, a law was passed in order to define when someone is dead, the Uniform Determination of Death Act (UDDA). The American Medical Association, American Bar Association, and a commission on ethics all weighed in to figure out when someone dies. There are two ways to meet the criteria; the first is straightforward: irreversible cessation of circulatory and respiratory functions. But the second criteria has proved complicated: irreversible cessation of all the functions of the entire brain including the brain stem.

In medical school, we learn how to perform the brain death exam, and we learn that a patient who is brain dead is dead. A year and half ago, these accepted medical standards were challenged with the case of Jahi McMath. She was a thirteen year old girl who had complications from surgery, suffered a cardiac arrest, and was declared brain dead by multiple pediatric neurologists. The tragedy of this perioperative pediatric death has not been the focus of media attention, but rather the family's challenge that the patient was not, in fact, dead. The family filed legal action to keep the patient on life support. The court ruled that based on independent neurologic exams, EEG, and perfusion studies (the latter two are not necessary, but are adjuncts), the patient was indeed dead. At this time, the family argued that application of the Uniform Determination of Death Act was a violation of constitutional and privacy rights. There may be some precedent for this; in New Jersey, state law allows religious objection to declaration of death by neurologic criteria. As a result, the patient was kept on life support, though the exact religious objection to the UDDA is not clear to me. Then, there is an odd circuitous circumstance where the body is released to the coroner who issues a death certificate but then released to the mother. The mother then moves the body to New Jersey, where a tracheostomy and a feeding tube are placed.

This all seems crazy to me, especially since the cost of a lot of this is shouldered by society in general. However, it's even more crazy when we encounter this situation. This last month, an elderly patient presents with a devastating stroke. She is declared brain dead by two separate examinations. However, the family refuses to believe she is, in fact, dead. They object to the withdrawal of life support and ask us to seek other hospitals who may be able to accept this brain dead patient. Ethically, we feel that we can (and perhaps should, given limited resources) withdrawal life support. However, given the temporal and geographic proximity of the McMath case, felt that our hands were tied. Ultimately, the patient progressed with anuric renal failure and cardiopulmonary death so the situation was resolved. However, it taught me a lot about how medical perception and public perception of brain death may be quite incongruous.

In Memoriam

Saudade is a word in Portugese and Galician with no direct English translation. It conjures a state of intense nostalgic or profound longing for an absent something or someone. There is a repressed knowledge that the object of longing may never return.

I've been holding off on writing this blog, to allow some space, some distance. It is about a physician and writer, who I knew, if only in crossed paths, who died recently of cancer. When I read his writings, I feel saudade. It is a window into his heart and mind that is intensely meaningful and strange because we've probably only shared a handful of words, all work, nothing personal.

Paul Kalanithi was a neurosurgery resident when I was an anesthesia resident, and he was courteous and smart and helpful and professional. Like the vast majority of all the other residents, medical students, fellows, and attendings I encounter, our paths diverged, I thought nothing more of him, and he was merely a blip in my professional life. Earlier this year, I encountered his writing, and I was shocked. He had, at the end of his residency, been diagnosed with metastatic cancer. In his brief and brilliant essay Before I Go and his opinion piece How Long Have I Got Left?, he speaks with such clarity about this time in his life: learning about the diagnosis, deciding to finish his training despite hospitalization and chemotherapy, reflecting on death and dying. He wields his words like a surgeon in the operating room: no wasted movement, each phrase stunning and precise and deliberate. The last paragraph of Before I Go, where he addresses his daughter cannot elicit anything but saudade. How many of us could express such love in so many words, and then put it out into the open? He was thirty seven when he died, and I am awed by his courage, his brilliance, and his humanity.

I think many of us - residents, fellows, young physicians - were struck because of his age, his unexpected cancer, and his untimely death. He was similar to all of us. But I personally am less struck by that than by the admiration for someone who accomplished so much in the life he had, who skirted the technical demands of neurosurgery and wrote with such compassion and beauty.