First Day in the ICU

As I write this I am sitting in an ICU family waiting room.  I have often sat in rooms like this, comforting families and explaining to them what is happening to their loved one or discussing treatment options. Today, it is my family I am sitting with, and my family member in neurosurgery.  The ten of us are sitting in a circle.  The comfort of being together is inexpressible.  We sit and talk alternately of trivialities and of life and death.  One knits, another is on the laptop posting updates to Facebook, I am writing a blog entry.  The surgeon figured it would take three hours.  That was over four hours ago.

This was in none of our plans for the weekend.

***

The surgeon finally came out.  It was worse than he anticipated.  He was trying to be positive, but let slip words like “heroic measures” and “if she makes it.”

It is all very surreal.  Someone says, “I feel like I’m watching a movie.”  The whole gamut of emotions pours out, opposites juxtaposed incongruously:  shocked looks, tears, laughter at a suddenly resurrected old joke.  We pray.

***

The surgeon just came back out, a few minutes later.  A terse, hurried report this time:  the post-op CT scan shows swelling, and they need to do emergency surgery now to relieve it.  Silence, everybody together but alone with their own thoughts.  Someone passes out snacks.

***

I hate being a doctor and knowing what’s going on.  Or maybe I just hate what’s going on.  Is it more terrifying to hear cryptic references to “dilated pupils” and “midline shift” and have no idea what they mean, or to know exactly what they mean, and their implications, and get a queasy feeling of impending doom?

***

Some of us eat snacks.  Some read waiting room magazines.  Every once in a while an attempt at small talk, an attempt at normalcy.  Mostly quiet.  I’m glad we’re all together.

***

It’s been another hour, and no word.  That can’t be a good sign.

***

Hurry up and wait.  Another half hour has passed.  We’re a little more lively group now, laughing and kidding each other.  It’s hard to maintain that serious aspect through the long, anxious watch.

***

 

At last — the surgeon has come back.  He is guardedly optimistic.  He looks weary.  I walk out with him for a doctor-to-doctor talk out of everybody else’s earshot.  He is more frank about how he feels;  in some way, we can understand each other.  When I return to the group, the atmosphere is much more relaxed.  Not that the news is that great, but at least the uncertain waiting is over.  One round of waiting, that is;  everything depends now on how she will wake up, and how she does over the next couple of weeks.

***

 

The next moment of truth;  the nurse has just come out, and told us that in about ten minutes the family can come in to see her, two at a time.  Deep breaths:  we’re about to dive in, and God only knows what the water will feel like.

***

Psalm 121.   I lift up my eyes to the hills — where does my help come from?   My help comes from the LORD, the Maker of heaven and earth.   He will not let your foot slip — he who watches over you will not slumber;   indeed, he who watches over Israel will neither slumber nor sleep.   The LORD watches over you — the LORD is your shade at your right hand;   the sun will not harm you by day, nor the moon by night.   The LORD will keep you from all harm — he will watch over your life;   the LORD will watch over your coming and going both now and forevermore. (NIV)

***

Just back from visiting her room.  The ICU smell!  Intubated, sedated, tubes everywhere, the Darth-Vader hiss of the ventilator, monitors, drips, her head wrapped with a little blood seeping through the right side of the bandage . . . I talk to her as if she can hear, I kiss her on the side where she still has cranium.  I come back to the waiting room and I am trembling.

***

Exhaustion.  I was tired before this started;  I am almost numb and staring now.  If this were a novel, I would have to fight turning to the last page to find out how it ends.  It is a little like a novel, or a movie.  Sometimes I want life to have a plot.  Well, it does today:  suspense, unexpected turns, hope and despair and snatches from the jaws of death, heroic actions, a beautiful damsel in mortal peril.  God knew what he was doing when he made life full of more routine than plot.  I don’t think we could take too much of plot.

***

***

It is too easy as a busy physician to forget in the rush that all patients have stories, have families.  It is all too easy to objectify people, to think of them as their disease, to fall into thinking of “the asthmatic in room 39” instead of “Mr. Brown, who is a forester with a wife and three children and who has just been laid off and is here because his asthma is worse.”  Or to say, “The drunk is back” instead of “Mrs. Smith, who desperately wants to stop drinking but her daughter came over with a bottle and she couldn’t resist so she is back here looking for help and does she ever feel awful.”  It is a good reminder, this being on the other side of medical care.  I have cried (and laughed) a little bit more readily with my patients this last week.  I don’t think that’s a bad thing.

On Ending Aging

 

While we all may agree that the idea of avoiding aging or prolonging life has its appeal, very few people would attach themselves to the pursuits of Aubrey de Grey. He is a passionate man dedicated to the quest of ending the leading cause of death–aging.

At great length Grey has written and spoken about SENS; “to repair or obviate the accumulating damage and thereby indefinitely postpone the age at which it reaches pathogenic levels.”

Though my mentioning of him may seem strange, I was reminded of this beautifully bearded man when I came across an article about a study done on the horrible and rare genetic disease, progeria.

In this article, Dr. Francis Collins proposes the common assumption that “the aging of cells and of individuals was just a matter of everything running down,” is just not right.  “The same mechanism that causes children with progeria to age seven times the normal rate may play a role in normal aging as well.”

So, what does this mean?

In layman’s terms, Collins claims his study shows aging to be an active biological mechanism that is programed into cells not a passive wearing out of cells.

 

 

For those of you who know of Aubrey’s proposal, are there any conflicts between his views and this recent development?

Do you think this could be an initial step at accomplishing Aubrey’s ambitions?

Do you think that substantially extending the human life is even possible?

 

 

X-Men and Eugenics

By Heather Zeiger

For my inaugural post, I might as well come clean that I am a nerd. Part of my nerd-background is that I am a comic book fan, and am especially fond of Marvel’s X-Men. Therefore, I was pleased to watch X-Men: First Class, but don’t worry, I didn’t don the yellow and black uniform to the theaters. I did, however, walk away from this movie thinking on the two views of human nature represented in the main characters, Eric and Charles.

One of the elements that attracts me to the X-Men series is the complexity of the characters. Often the comic books would portray the mutants as dynamic, tortured, and complex. Much like fantasy/science fiction book genres, the mutants in X-Men live in a different world than our own, but one that we can certainly relate to. In this world, some people have a mutation that gives him or her special abilities, however the mutation usually has a cost. Perhaps that price is an odd appearance, as was the case with Hank (Beast) and Raven (Mystique), or unwieldy energetic powers, or in some of the cases in the comic books, inability to have physical contact. In the comic book world, the mutants would keep themselves in hiding because they feared being ostracized from society. Some mutants felt ashamed, some of them dealt with shame from their families. Some were bullied. Some were abandoned. Some ran away. The movie dealt with the hiding for fear of being ostracized. The two mutants with the most drastic physical features discussed wanting to be “normal” and what it means to be ashamed of their appearances.

Here people do not have mutant super powers, but, certainly, we have a concept of normal. And, as is often the case in sci-fi/fantasy, by putting the reader (or viewer) in a different world, we are able to evaluate ourselves. The mutants in X-men are gifted, but their gifts come at a price. I was always intrigued by the storylines in which the characters wrestled with their flaws including other people’s response to their “abnormality.”

X-Men: First Class dealt with this head on in Eric’s background as a persecuted Jew in a WWII concentration camp. In probably the darkest scenes of the movie, Eric, as a child, is torn from his mother and father as they are lead to separate areas of a concentration camp. When a scientist, later revealed as Sebastian Shaw, sees that Eric can move metal, he brings him in for questioning. Shaw has a line that should send chills down anyone’s spine who has read about eugenics and Nazi Germany: “The Nazi’s methods certainly do work.” If you see the movie, the context of this line, makes it all the darker. But it is true; the Nazi’s methods of de-humanization and blatant disregard for human life certainly did “work.”

Eric (Magneto) and Charles (Professor X) always had a complex relationship in the comic books. They are archenemies, and yet formerly friends. Both wanted to help mutants accept themselves and use their powers, but they eventually parted ways because Eric wanted to overpower humans while Charles wanted to work with them. The movie did not disappoint in developing these complex characters and their entangled relationship. Eric and Charles are two sides of the same coin; they are two different responses to human nature, each of their response based on their backgrounds: Eric as a Nazi science experiment and Charles as an aristocratic academic in England. Eric ends up becoming Magneto, a complex and perhaps sympathetic villain. Charles becomes Professor X who leads our heroes, the X-men. Eric’s past plays into his low view of human nature and certainty that society will de-humanize mutants, using them as instruments for personal gain. Charles, on the other hand, has a more positive view of human nature. He tends to see the good in people and the possibilities. As a point, Charles is a telepath while Eric can manipulate metal.

Throughout the movie, we get a much more obvious parallel between eugenics, Nazi Germany, and how mutants may be received in the real world. We see a range of responses to the mutants, but most importantly we also see how some would consider them less-than-human. And in case the normal movie-goer doesn’t get it, Eric’s character reminds us that these were the same kinds of sentiments said by the Nazis in regards to the Jews.

Fiction serves to hold a mirror up and show us ourselves and it serves to help us imagine an experience without having to live it. As a viewer, you root for the mutants and you hate those that would de-humanize them. And yet, how would we respond to the freakish, the abnormal, or even the less-than-beautiful?

Ethics and Atheists

Jim Spiegel, a colleague of mine at Taylor University, published a book last year titled The Making of an Atheist. In the book he contends that the rejection of God is a matter of will, not of intellect.  He suggests that immoral behavior leads to an inability to see the clear evidence for the existence of God.  Atheists choose to reject God for psychological reasons such as the lack of a loving human father and because they do not want a God to exist to whom they would be accountable for their immorality.

Not surprisingly, his book did not go over very well with the atheist community, but there is the seed of an idea there that suggests a way ethics can be used to draw those who reject God toward truth about God.  Many who reject God still believe that there are things that are intrinsically right and wrong.  While a desire not to be subject to ethical standards leads a person to atheism, the understanding that there are ethical standards is the first step toward God.

So the next time someone who does not believe in God disagrees with you on an ethical issue commend them for their belief that morality is something to be concerned about.  Taking morality seriously can be the first step toward the one who is the source of all that is good.

There is no “welcome mat”

Last week (June 7) I noted that some gains have been made by the pro-life movement after all.  But how should Christians view these advances?  Does it suggest that the “welcome mat” is out and the door is wide open to push for further pro-life legislation?  I don’t think so.  Although there have been some setbacks to the pro-choice movement, Christians shouldn’t expect pro-choicers to admit defeat.  In other words, we may be free to knock on the door, but don’t anticipate opponents to invite us in for tea and cookies.

Regardless of the response, I would like to offer the following thoughts about Christian engagement in the public square.  I define the public square as that realm where citizens from a plurality of perspectives convene to deliberate on matters (e.g., laws, policies) that concern national and local community life.  Like the apostle Paul, Christians can use the “marketplace” when possible to present truth (e.g., Acts 17, Paul in Athens).  But wasn’t Paul primarily concerned with preaching the gospel?  This is true, but my point is that Paul had an important message and he worked within the “system” to communicate that message.  So the question is, “What can be done to promote life human dignity within the current system?”  Although there is disagreement about strategies and the extent of engagement, Scripture clearly teaches or implies the following:

1) Scripture neither encourages nor forbids participation in the political arena.  Thus, a Christian is free to follow his or her calling if that calling includes active involvement in political matters.

2) Christians have a duty to be good citizens which includes submitting to governing authorities.

3) Christians have moral obligations that do not apply to the general public (e.g., observance of the sacraments, prayer, church discipline, etc.).

I realize that I could be accused of an argument from silence, but whereas Scripture gives guidelines on church government, it says very little about political involvement.  However, Scripture does not even remotely suggest:

*that Christians should impose onto the world the teachings of Scripture

*that Christians should have decision-making priority or the last word in the public arena

*that only Christians should be in positions of political or legal authority

*that Christians should attempt to establish a political theocracy

On the Death of “Dr. Compassion?”

Last week, I responded in my blog to the death of Jack Kevorkian, known to his medical colleagues first, and the world later, as “Dr. Death.” Over the past week, I have followed the national media’s treatment of Kevorkian’s passing, and among the various responses, one editorial letter published online by the Washington Post (June 7) caught my particular attention. In that letter, retired Episcopalian priest Edward Morgan III commented,

“Recently I was invited to speak at a retirement community on ‘faithful dying.’ Toward the end of my presentation, one man asked me what I thought about Dr. Kevorkian. Not wishing to overstay my time limit, I kept it simple: ‘I know he has the nickname ‘Dr. Death,’ but I call him ‘Dr. Compassion’ . . .  I am not worthy to address the complexities faced by medical practitioners — God bless them all! — but consider one of the Hippocratic Oath’s first charges: ‘That into whatsoever house you shall enter, it shall be for the good of the sick to the utmost of your power.’ When physical healing is not possible, is not what Dr. Kevorkian sought for his patients the higher good?”

As I thought about Morgan’s invocation of the Hippocratic tradition in defense of Kevorkian, my first thought was, “what about ‘do no harm?’” From my prior studies, I knew that while those words are not explicitly stated in the Hippocratic Oath, they do represent a major thrust of this long-honored code. More to the issue of Morgan’s concern, I specifically recalled the Hippocratic injunction against physician involvement in euthanasia, which, per the late  Ludwig Edelstein, reads as

“I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.”

Assuming Morgan was familiar with the Oath in its entirety, his appeal to the venerated Hippocratic tradition struck this reader as a case of proof-texting writ large.

Out of fairness, however, I considered the possibility that Morgan was misinformed (i.e., working from a poor translation of the Oath). As best I can tell, he is quoting from a modernized version that the American Medical Association used to reprint in their Code of Medical Ethics.  Here is how the AMA version renders the passage in question:

“That you will exercise your art solely for the cure of your patients, and will give no drug, perform no operation, for a criminal purpose, even if solicited, far less suggest it”

In this version, the Hippocratic condemnation of medically-assisted suicide has been softened as bad ethics is reduced to mere criminality. Yet, the demand that physicians work for the  “cure” of their patients seems to preserve the core principle as to kill, most assuredly,  is not to cure. So, even if Morgan is working from the AMA’s version of the Oath, his subsumption of Kevorkian “medicine” within a Hippocratic ethic still exceeds the bounds of credulity.  To state the obvious, Kevorkian was no Hippocrates.

As for the appellation of “Dr. Compassion,”  I won’t deny that Kevorkian viewed his advocacy of PAS as an expression of compassion for patients beset by intense suffering and pain. I do reject, however, the notion that slipping a patient a syringe full of poison can rightly be considered compassionate medicine, much less facilitative of a “higher good” per Morgan.

The Business of Drugs

I went to my first drug rep dinner the other night at Smith & Wollensky in Houston’s Highland Village.  The high-end steaks and 20+ bottles of wine left nothing to be desired by the nurses and physicians in attendance.   Research shows that being wowed with a nice meal influences later decision-making.  Yes, I could see how the memory of one of those juicy steaks could prompt a doctor to select a particular medication.

Special thanks to Joe Gibes for bringing to light how pharma business practices stymie important medical treatments.  I worked in business for over 7 years, and I saw two types of businesspeople.  One type focused on presenting the merits of the product and gave the buyer room to evaluate it and make a decision on a purchase.  This person would refrain from the pressure sales pitch and would frankly state what the product could and could not do.  Sometimes this went so far as recommending a competitor who sold a product that fit the customer’s needs better.  The other type of salesman I encountered had a different approach.   Marketing techniques were more about allurement rather than presenting one’s ware.  These folks were jovial types always given to conversation, but all the backslapping often left the customer with an uneasy feeling.

Business reform in general is needed in our country, but more is at stake when unethical business practices impact the field of medicine.  Since a person’s well-being is in the balance, extra care and protections must be employed.  I often hear medical students comment, “I can’t really do anything about the drug business.  It’s just the way things are.  I might as well enjoy the free meal.”  But don’t we owe it to our patients to remove any taint from medical care when their very lives are concerned?  Our Savior was a humble man, and there is no doubt his humility opened the door for His effective healing ministry.  Such a disposition sets an entirely different tone for healthcare, which our medical system desperately needs.

Physicians, Technicians, Clinicians, and Providers

A few weeks ago I had lunch with two doctors who are currently in a residency training program.  In a moment of candor, both of them remarked, “I feel like I’m being trained as a technician.”

This comment struck me as tremendously important (and not just because I am heavily involved in their training and their words highlight my failure as a teacher!).  Because if their perception is correct — if we are indeed instilling in future physicians the ethos of the technician — then we had best be prepared for the inevitable results.  “To a man with a hammer, everything looks like a nail;”  to a technician, every problem looks like a technical problem, one which needs to be solved by a technique or technology.  The dizzying upward spiral of health care costs is driven largely by the increasing use of increasingly expensive technologies;  training a technician workforce can only exacerbate the problem.  The technical bias towards the automatic, unreflective use of technology simply because it exists will lead to more of the inappropriate use of technological interventions that are the bread-and-butter of hospital ethics consultations.

But more importantly, not all problems in medicine are technical problems;  some are singularly resistant to simplistic, technical solutions.  For some conditions, the doctor is the best drug:  his or her human, caring, and compassionate presence, just being with the patient.  Yet to the technical mindset, this simply attending to the patient (from which we get the expression “Attending Physician”) is discounted in favor of doing things to patients;  and while both the being and the doing are necessary for the practice of good medicine, the standardization, mechanization, and industrialization of medicine in our day has heavily favored the latter at the expense of the former.  More often than our technical mindset acknowledges, it is better not to do something to the patient;  but this option is not in the purview of the technical mindset.  We always feel we must do something, and medical caring  often suffers as a result.  The central economy of medicine, the physician-patient relationship, is lost in the technical mindset.

The ongoing industrialization of medicine is reflected in and driven by the terms we use to describe doctors.  In the May 25th JAMA, the authors of an essay entitled “Dear Provider” wrote of the replacement of the title “clinician” with “provider.”  The authors believe that this semantic change could be subliminally altering professional self-concept and behavior, “shifting the clinical encounter from patient-centered to task-oriented.  Nowadays, patients are quickly ‘plugged in’ to templated workups;  progress notes have become computerized inventories of completed tasks;  and when we ask residents on teaching rounds ‘What do you think?’ we often hear ‘I think I want to get an MRI.’  It appears that the time and effort spent by providers packaging patients through the system is displacing most other clinical activities.”

Packaging patients through the system. Sounds like a technician’s handiwork to me.  How did we get to this?  Do we turn back or go on?

 

Another Point for Adult Stem Cells?

A recent development in (Adult) Stem Cell research has proven effective in repairing the heart muscles of mice after a heart attack! Although the procedure has only proven effective–thus far–on mice, the promise of cell reactivation repairing muscle after a heart attack is nothing to sneeze at.

“The researchers examined the hearts of mice at various time points after the operation [procedure that replicates the effects of a heart attack]. They found heart cells expressing Wt1 just two days after the injury. The cells were initially in the heart’s outer layer, but by two weeks after surgery they had moved inside and clustered around the site of the injury. The cells had also changed in size and shape, and looked just like cardiomyocytes.”

This success is another reminder that we (scientists and researchers of today) are still needlessly pursuing the less than ethical embryonic stem cell research that requires the destruction of human embryos, the ending of human lives.   When comparing the two it is difficult to not concede to the preeminence of embryonic alternatives, and still the federal government wishes to fund the destruction of embryos.

While the battle continues, it looks like embryonic alternatives still have the upper hand.

For more information on stem cell research check out this website.

 

 

 

 

Thanks, GAVI!

In a world full of inequities in health care including a child mortality rate in some developing countries that continues to be alarming, it is good to recognize those who are making a difference.  The Global Alliance for Vaccines and Immunisation (GAVI) recently announced that they had entered into agreements with several vaccine manufacturers to obtain vaccines for developing countries at reduced costs.

GAVI is an international organization that attempts to unite donor nations, private donors, developing nations, international organizations, and immunization suppliers to meet the goal of saving children’s lives and protecting people’s health through better access to immunizations.  In the ten years from 2000 to 2010 more than 288 million children were immunized with GAVI-funded vaccines, and an estimated 5 million deaths prevented.

Organizations like GAVI deserve our thanks and support for making a positive impact on the lives of children around the world.