Medicine Pearls

Thursday, August 14, 2008

On Organ Transplants and Medical Ethics

The issue of when to declare a person dead in order to harvest his/ her vital organs so that another person may live is a very delicate one no matter from which angle you look at it. An issue that's hard to ignore and poses a lot of questions and quite a dilemma to all the parties involved.

There’s an on- going debate as to when to declare potential organ donors dead. The old criterion of brain death as the sole determining factor is now being challenged by a lot of people in the medical field. Many of them are now advocating on a new protocol called Cardiocirculatory death as the new basis to declare a person dead.

The New England Journal of Medicine tackle this issue in its August edition and the Associated Press pick up the story. I copied the said article as the link to the NEJM website and posted them here.

So, read on…

Doctors debate when to declare organ donors dead

By STEPHANIE NANO, Associated Press Writer Thu Aug 14, 3:56 PM ET

NEW YORK - A report on three heart transplants involving babies is focusing attention on a touchy issue in the organ donation field: When and how can someone be declared dead?

For decades, organs have typically been removed only after doctors determine that a donor's brain has completely stopped working. In the case of the infants, all three were on life support and showed little brain function, but they didn't meet the criteria for brain death.

With their families' consent, the newborns were taken off ventilators and surgeons in Denver removed their hearts minutes after they stopped beating. The hearts were successfully transplanted, and the babies who got the hearts survived.

"It seemed like there was an unmet need in two situations," said Dr. Mark Boucek, who led the study at Children's Hospital in Denver. "Recipients were dying while awaiting donor organs. And we had children dying whose family wanted to donate, and we weren't able to do it."

The procedure — called donation after cardiac death — is being encouraged by the federal government, organ banks and others as a way to make more organs available and give more families the option to donate.

But the approach raises legal and ethical issues because it involves children and because, according to critics, it violates laws governing when organs may be removed.

As the method has gained acceptance, the number of cardiac-death donations has steadily increased. Last year, there were 793 cardiac-death donors, about 10 percent of all deceased donors, according to United Network for Organ Sharing. Most of those were adults donating kidneys or livers.

"It is a much more common scenario today that it would have been even five years ago," said Joel Newman, a spokesman for the network.

The heart is rarely removed after cardiac death because of worries it could be damaged from lack of oxygen. In brain-death donations, the donor is kept on a ventilator to keep oxygen-rich blood flowing to the organs until they are removed.

The Denver cases are detailed in Thursday's New England Journal of Medicine. The editors, noting the report is likely to be controversial, said they published it to promote discussion of cardiac-death donation, especially for infant heart transplants.

They also included three commentaries and assembled a panel discussion with doctors and ethicists. Many of the remarks related to the widely accepted "dead donor rule" and the waiting time between when the heart stops and when it is removed to make sure that it doesn't start again on its own.

In two of the Denver cases, doctors waited only 75 seconds; the Institute of Medicine has suggested five minutes, and other surgeons use two minutes.

State laws stipulate that donors must be declared dead before donation, based on either total loss of brain function or heart function that is irreversible. Some commentators contended that the Denver cases didn't meet the rule since it was possible to restart the transplanted hearts in the recipients.

"In my opinion, it's an open-and-shut case. They don't have irreversibility, and they don't have death," said Robert Veatch, a professor of medical ethics at Georgetown University.

But others argue the definition of death is flawed, and that more emphasis should be on informed consent and the chances of survival in cases of severe brain damage.

The Denver transplants were done over three years; one in 2004 and two last year. The three donor infants had all suffered brain damage from lack of oxygen when they were born. On average, they were about four days old when life support was ended.

In the first case, doctors waited for three minutes after the heart stopped before death was declared. Then the waiting time was reduced to 75 seconds on the recommendation of the ethics committee to reduce the chances of damage to the heart.

The authors said 75 seconds was chosen because there had been no known cases of hearts restarting after 60 seconds.

The hearts were given to three babies born with heart defects or heart disease. All three survived, and their outcomes were compared to 17 heart transplants done at the hospital during the same time but from pediatric donors declared brain dead.

"We couldn't tell the difference," said Boucek, who's now at Joe DiMaggio Children's Hospital in Hollywood, Fla.

There were nine other potential cardiac-death donors at the hospital during the same period, but there wasn't a suitable recipient in the area for their hearts, the report said.

The parents of one of the infants in the study, David Grooms and Jill Airington-Grooms, faced the devastating news on New Year's Day 2007 that their first child, Addison, had been born with little brain function and wouldn't survive.

After they decided to remove life support, they were asked about organ donation, and quickly agreed.

"The reality was Addison was not going to live," said Jill Airington-Grooms. "As difficult as that was to hear, this opportunity provided us with a ray of hope."

Three days later, Addison was taken off a ventilator and died. Her heart was given to another Denver-area baby, 2-month-old Zachary Apmann, who was born five weeks premature with an underdeveloped heart.

His parents, Rob and Mary Ann Apmann, said they were given several options and decided to wait for a transplant. They agreed they would accept a cardiac-death donation to increase Zachary's chances.

Mary Ann Apmann said she wasn't worried that the first available heart came from a cardiac-death donor.

"At that point, Zachary was so sick. We did have him at home. But we knew it wasn't much longer," she said.

After the transplant on Jan. 4, his condition quickly improved, and his blue lips disappeared.

Now, at 21 months: "He's just a crazy little kid who loves to play and swim and throw rocks," his mother said.

The two families haven't met yet but have been in touch through letters and calls. Coincidentally, David Grooms said he had an older brother who died three days after he was born in the 1970s with the same heart condition as Zachary's. The Grooms now have an 8-month-old daughter, Harper.

"Addison did only live three days in this world, but because of this, she lives on," her mother said.

Here's the link to--
The New England Journal of Medicine

Thursday, July 24, 2008

2008 Philippine Nursing Board Examination Results

Wednesday, July 23, 2008

When Are You Most Likely to Have a Heart Attack?

Heart disease, including heart attack, is the world's No. 1 killer. A person's risk of heart attack depends mostly on a familiar repertoire of factors: exercise, smoking, diet, weight, genes. But our bodies' circadian rhythms also play a role, leaving us more prone to injury during certain hours than others. If you're guessing that the danger zone comes at the end of a stressful workday, guess again. Here to explain is Roberto Manfredini, professor of internal medicine at the University of Ferrara in Italy.

Q: What time of day am I most likely to have a heart attack?

A: The most dangerous times for heart attack and for all kinds of cardiovascular emergency - including sudden cardiac death, rupture or aneurysm of the aorta, pulmonary embolism and stroke - are the morning and during the last phase of sleep. A group from Harvard estimated this risk and evaluated that on average, the extra risk of having a myocardial infarction, or heart attack, between 6 a.m. and noon is about 40%. But if you calculate only the first three hours after waking, this relative risk is threefold.

The cardiovascular system follows a daily pattern that is oscillatory in nature: most cardiovascular functions exhibit circadian changes (circadian is from the Latin circa and diem, meaning "about one day"). Now, a heart attack depends on the imbalance between increased myocardial oxygen demand (i.e., a greater need for oxygen in your heart) and decreased myocardial oxygen supply - or both. And unfortunately, some functions in the first hours of the day require more myocardial oxygen support: waking and commencing physical activities, the peak of the adrenal hormone cortisol [which boosts blood-pressure and blood-sugar levels] and a further increase in blood pressure and heart rate due to catecholamines (adrenaline and noradrenaline), which show a peak when you wake up. All those factors lead to an increase of oxygen consumption but at the same time contribute to the constriction of vessels. So you have reduced vessel size and reduced blood flow to the coronary vessels.

You have to remember that blood coagulation is important in the genesis of what we call thrombi, the blood clots that can block the blood vessels and cut off supply to the heart. When we wake up, platelets, the particles in the blood that make thrombi, are particularly adhesive to the vessels. Usually we have an endogenous system - it's called fibrinolysis - to dissolve the thrombi. But in the morning, the activity of our fibrinolytic system is reduced. So we have a greater tendency to make thrombi that can occlude the coronary vessels. This contributes to further reduction of coronary blood flow. Thus, at the same time that you need more blood flow, you have less.

All these changes, however, probably are not so harmful in healthy people. But for a person with a plaque in the coronary vessel, if these changes occur at the same time and peak at the same time, the final result is a higher risk of heart attack during that specific window of morning hours.

Why is the risk also higher during the last part of sleep? Usually, during the night, the cardiovascular system is "sleeping," which is characterized by low blood pressure and heart rate. But the last stage of sleep - REM, or rapid eye movement, sleep [when we believe most dreaming occurs] - is a risk period for cardiovascular emergencies because when you dream, you have a dramatic increase of activity of the autonomic nervous system - even more than when you are awake. Probably each of us can remember waking up in the morning sometimes feeling very tired. That's because during that stage of dreams, we were running or facing some danger. Your heart was running, so it was consuming oxygen. And for similar reasons to those when you're awake, that activity is risky if you don't have a good vessel system.

It's probably difficult for people to minimize the effects of their own biological rhythms. For example, you cannot avoid your morning risk by simply waking up later. Some researchers have tried an experimental model, in which people were instructed to stay in bed for four hours after they woke up before rising. But the same pattern simply occurred four hours after waking, because the risk is linked to our activities. We can't be afraid of the catecholamines and the peak in blood pressure in the morning. It's part of our physiology. And for healthy people, it's not a problem.

It's important for doctors, however, to remember this risk when we give therapy. Usually people take hypertensive drugs in the morning, when they wake up. But this is already the higher-risk period - so is the last hour of activity of the pill they have taken the day before [and not all pills give 24-hour coverage]. We have to be sure that the pill we're prescribing is still active when patients need it most. It's not as easy as simply asking patients to take pills before bed instead of first thing in the morning, because during sleep we have a low heart rate and blood pressure. If you lower your blood pressure too much during the night, you risk reducing blood supply to the brain, and that can be harmful too

--Laura Blue
TIME.com

Tuesday, May 6, 2008

Life & Death

The new United States guidelines on who should and should not get care in catastrophic events and disasters that was released yesterday by a multi- disciplinary task force whose members includes people from various medical groups, military, academe and government agencies such as the Centers for Disease Control and Prevention, the Department of Health and Human Services and the Department of Homeland Security will surely elicit a lot of criticisms from various sectors by citing that Doctors and Health Practitioners should not be given the God-like task to determine who should receive treatment or not or to put it more bluntly, who should live or die.

The said guidelines is an ethical nightmare anyway you look at it since it will affect a lot of people and it is quite understandable for some people to oppose the said recommendations.

And it is never easy for any person, more so to people who have sworn to save lives to the best of their abilities to be confronted with this kind of dilemma but we need to bite the bullet when the worst- case scenario occur to preserve vast needed resources both in manpower and supply.

Aside from the obvious that cover people with the highest risk of death or very slim chance of survival owing to the degree or severity of an injury or illness, the guidelines also include-

• People older than 85.
• Those with severe trauma, which could include critical injuries from car crashes and shootings.
• Severely burned patients older than 60.
• Those with severe mental impairment, which could include advanced Alzheimer's disease.
• Those with a severe chronic disease, such as advanced heart failure, lung disease or poorly controlled diabetes.

In this age of terrorism and super- bugs, I deemed it as a wise move (although with reservations) from the authorities to come up with the guidelines to follow in the event of a massive catastrophe so as to avoid the same confusion that occurred in various hospitals following the 9-11 Terrorist attacks where medical personnel were overwhelmed by the sheer volume of casualties.

Let’s just hope that the medical personnel that will be manning the triage if ever the circumstance calls for it will be knowledgeable and competent enough to handle this life and death questions in their midst.

You can read the controversial guidelines from the May 2008 issue of Chest, the American College of Chest Physicians Journal entitled DEFINITIVE CARE FOR THE CRITICALLY ILL DURING A DISASTER

Thursday, April 17, 2008

The Vicente Sotto Memorial Medical Center Scandal

Primum non nocere

This morning, I saw the so- called Vicente Sotto Memorial Medical Center Scandal on YouTube and I was appalled by the way those medical professionals handled the situation wherein some doctors and nurses of the said hospital were seen laughing, videotaping and boisterous while performing an operation on an unidentified patient to remove a canister of body spray stuck inside his rectal vault.

Copies of the said video is now roaming the world wide web as well as in the form of multimedia messages being passed around on cell phones of every Juan and Juana de la Cruzes both in the Philippines and abroad which will further damage the already soiled reputation of the medical profession that is under fire and scrutiny after the exposé regarding the cheating perpetrated by some unscrupulous individuals in collusion with some Review Centers during the Nursing Board Examinations two years ago.

Based on my experience a case like this in the Philippines is quite unusual and you can expect that word will certainly travel fast in the four walls of the hospital, a patient’s privacy and confidentiality be damned (which is never practiced or observed anyway).

Also given the penchant of Filipinos for gossips and making other people’s business theirs, it’s not surprising that what could have been a hush- hush affair has turned into a circus that one could only imagine in a carnival freak show.

I have encountered several cases in similar situation in the United States wherein a patient will come in with abdominal pain or rectal pain and after a thorough physical and medical examination, we discovered to our horrors, foreign objects (e.g. toothbrush cases, soda cans and bottles, umbrella handles, etc.) stuck in places wherein they should not even be present.

In an ideal world, this could have been dealt with without any incident but in the real world even among doctors and nurses and other members of the medical profession who are supposedly and should be well- versed on patient‘s right to privacy and confidentiality, cases like the one that was seen in that Cebu hospital will always elicit curiosity, laughter and even ridicule for after all, humans are not perfect and we are prone to succumb to its frailties.

And yes, even in a country like the United States of America where you are expected to be always politically correct in everything, people in the medical field would react the same way like their brothers and sisters in the profession in any part of the world when confronted with the same scenario. The difference though is people here usually talk and make light of the situation privately and amongst themselves without resorting to histrionics and more importantly no jerk will take a video or a picture and worst, post it in YouTube for the entire world to see.

I’ve been in a similar situation in the past but I can say that all the people who were involved in the procedure as well as the staff who were curious enough to drop by and see for themselves the “unusual case” conducted themselves in a more appropriate and professional manner.

Obviously there was a failure in discipline and ethics here since the head of the team that operated on the patient allowed the unthinkable to happen under his watch. Add to the fact that this incident occurred in the presence of both medical and nursing students make it even worse!

And then we ask ourselves--

Did the members of the Medical- Surgical Team of the Vicente Sotto Memorial Medical Center violate the rights of the said patient?

Definitely.

Did the members of the Medical- Surgical Team renege on their duties and responsibilities as medical professionals?

Certainly.

Did the members of the medical- surgical team break their oath as medical practitioners?

Without a doubt.

Those involve should be held accountable for their actions and be meted the necessary sanction that merit the gravity of their indiscretion.

Lest we forget, aside from the Hippocratic Oath, members of the Medical profession should always bear in mind this fundamental tenet of Medicine---

First, Do No Harm (Primum non nocere).

Here's the video of the said scandal and watch it at your own risk. Let me just reiterate that the posting of this video here is not meant to cast aspersion on the character of the patient who will remain unidentified but done so for educational purposes only so that people in the medical profession will not commit the same mistake again.

Here's the latest news from ABS- CBN--
3 doctors, nurse face raps over YouTube 'rectum scandal'