Transplant News Sharing // News from Source www.medpagetoday.com
Following is a partial transcript of this video; note that errors are possible:
Rohin Francis, MBBS: Have you ever wondered how we define death? Like most doctors around my age, “Scrubs” has a very special place in my heart as it was staple viewing throughout medical school. It was a comedy, of course, but it had many really beautifully-written moments before it got crap. One that stuck with me throughout my entire career was actually from Series 1 Episode 1.
Laverne: He crashed. The attending thinks it was a pulmonary embolism. No way anyone could have caught it. Anyhow, you have to pronounce him.
J.D.: Why didn’t anybody page me?
Laverne: Could you just pronounce him so I can go home?
J.D.: I’ll never forget that moment, the way he looked exactly the same, only completely different. The shame that all I could think about was how hard this was for me. Time of death, 0200.
There’s actually more to that little clip than is at first apparent. Laverne asks J.D. to confirm death. We know that the patient died a while before J.D. arrived in his room to pronounce him, but yet he looks at his watch and says “time of death 2 a.m.,” so that time that’s a lapse between his biological death at the end of a resuscitation attempt until J.D.’s arrival is a kind of limbo where life had left his body but from the hospital’s and the law’s perspective he was alive.
We tend to give the duty of confirming death to the most junior member of the team because, let’s be honest, it’s pretty hard to cock that up. I know that there are stories of people being sent to the mortuary and waking up. But if you dig a little deeper, they’re invariably either made up, or sensationalized, or examples of truly appalling negligence, or just criminal behavior. In reality, in a modern hospital, you’ve got experienced nurses who know very well when someone’s died but they can’t legally confirm. It has to be the doctor in most places.
When I was in J.D.’s position as a first- or second-year doctor, often I was covering several wards all on my own and rushed off my feet. If I had a sick patient and a dead patient on my list of people to see, I’m always going to prioritize the living one. That’s just a simple fact of life or death. Once, several hours passed before I could confirm death. I can’t guess and take a few hours off when I get there. I have to put the current time.
Confirming a death involves feeling for a pulse, listening to the heart and the lungs, shining a light into the patient’s eyes. Strictly speaking, you are also supposed to inflict pain and listen for three whole minutes. Some textbooks say a minimum of one minute, but even then it feels completely bizarre to listen to nothing for over a minute, especially when you’ve got a room full of family members wondering what the hell this doctor is doing.
You stand there motionless in a silent room and they probably start to wonder if you have died as well, and then you start succumbing to the pressure of a room full of people desperate for you to hear something. If you’re like me and your finger joints all creak and crunch as you’re holding the stethoscope, you start hearing things.
We had this bible, a sort of junior doctor textbook that we all clung to in our first year, and I remember distinctly reading a passage before my first job which said, “If you’re unsure about whether a patient has died, ask a nurse to connect up an ECG, a heart monitor, or an EEG, a brain monitor.” I thought, “What complete moron wouldn’t be able to tell if someone’s died?” Well, me. I’m the moron.
Now, I never actually asked for an ECG or an EEG. You start to develop a bit of confidence in your convictions, but soon it is really like J.D. says, you can just tell. A patient I might have seen minutes before and if I re-enter their room after they’ve died, immediately it feels completely different. I’m not sure I can even communicate to you what it is, but you just know.
In this legal sense, it’s binary. There’s alive and then with one brief entry in the notes there is dead. But this is on a general ward of a hospital. What about in intensive care?
Modern technology has blurred the lines of life and death to a confusing extent. For most of human history, we used to say the cessation of a heartbeat was death. When I run a cardiac arrest in the hospital, I’m mostly concerned about two organs, the heart and the brain, and those are the two organs that comprise the medical definitions of death.
Using cessation of the heartbeat makes no sense because since therapies like CPR and defibrillation have been invented, say if a 25-year-old has a cardiac arrest and is shocked out of it within seconds and is awake and talking minutes later, it seems ridiculous to say that they were momentarily dead. Aside from when they want to show off to their mates in the pub, which I totally would do as well. But clearly a stopped heart doesn’t mean death.
Otherwise, prisoner Benjamin Schreiber would have had a point when he argued that he had served his life sentence when he had a brief cardiac arrest in 2015. The courts disagreed and he remains incarcerated. “Okay.” You say that’s a momentary pause, but what about when defibrillation and CPR don’t work?
Now we have an incredible tool available that while it was invented in the 1950s has only recently become something available in many hospitals, and still only a minority, and it’s called external corporeal membrane oxygenation, or ECMO, which means oxygenating the blood outside the body. It removes blood from the body, takes carbon dioxide out, puts oxygen in, and then pumps it all back into the body at such high flow rate that it can completely replace the heart and lungs’ function.
I met Judy a few years ago. She was a 51-year-old mother who came in with a blocked left main stem coronary artery, which is the most important artery in the heart. She was conscious on arrival, talking. I unblocked the artery but she had a cardiac arrest. We put her on ECMO rapidly, so I knew that she had only had a short period with no heartbeat, her brain must be intact.
However, her heart had now stopped completely, but the ECMO machine was ensuring her organs were receiving oxygenated blood. She had no pulse but she had a blood pressure. There’s no top or bottom number with ECMO. It’s not a squeezing pump. It’s just a continuous blood pressure. Now, I don’t think anyone would argue that Judy was dead, would they, but she had no cardiac activity.
Soon afterward I would attend a fairly rare operation. Teresa was born with a hole in her heart, a very big one, so by her 40s, her heart had started to struggle. The pressure in her lungs had also become so high that any new heart that you put in would be unable to pump blood through them and would immediately fail, wasting the most precious of resources. She needed a heart and lung transplant and they’re pretty rare.
I had met Teresa a few times before her op and I was keen to see one taking place. Now, I wasn’t doing the operation or anything. I was… well, to be honest, I was just getting in the way. The surgeon who was removing her heart and lungs worked quickly, so quickly, in fact, that he had finished before the heart-lung block, as it’s referred to, had arrived. We got an ETA about 15 minutes away, so he and the assistant surgeon flung off their gloves to go and have a last cup of coffee before the mammoth surgery began. I was left on my own with Teresa.
Her chest was completely open and I peered inside. There was no heart and no lungs. I thought to myself, “How many people have ever seen this sight?” I could recognize anatomy that I hadn’t seen since dissection class 15 years earlier. I could pretty much insert my entire head into her chest… I didn’t do that.
I thought to myself, “This woman’s entire torso is empty and yet she’s alive.” Her lungs sat in a deflated heap on a table and her heart next to them, valiantly still trying to beat. Modern anesthesia had put her brain to sleep and a heart-lung bypass machine had replaced her missing organs, so hopefully, you will agree that the lack of a heartbeat is an inadequate model for death. Surely, the brain defines death.
It’s appropriate that we’re on the subject of heart transplants because it was that operation that led to the very definition of death changing. In the 1960s, America’s supremacy in the world was becoming clear. They had won the race to the moon. They were a true superpower, but it was South Africa that achieved another first that made front-page news around the world, the first human heart transplant. I always found it a bit odd that it was little South Africa, but it was in part due to a looser definition of death.
Today, most heart transplants are after brain death as opposed to circulatory death i.e. the heart is still beating, but the person is brain-dead, perhaps from an extracranial traumatic insult or an intracerebral catastrophe. It’s a concept we’re all familiar with now, but it wasn’t recognized in 1967.
In the U.S., which had up until then done all the animal research leading up to transplant, there was staunch theological opposition to changing the definition of death, which was the lack of a heartbeat. Any transplant surgeon had to wait until the heart stopped before proceeding. Whereas in South Africa, Christiaan Barnard only required the state forensic pathologist to agree that Denise Darvall, a road traffic accident victim, had no brain activity and was therefore dead before he could transfer her heart to Louis Washkansky. Her heart did stop beating, but only because she had been removed from life support with the express intention of using her organs for transplant.
Norm Shumway, who had done all the lion’s share of preparatory work before the transplant and had taught Barnard, and is regarded as the father of transplant, had been beaten to the post. He criticized the American Boy Scout definition of death. The US recognized brain death in 1968 and many countries followed.
If South Africa was an overperforming country in cardiac transplant, one very advanced country significantly underperformed. I was a school kid visiting Japan when a huge story broke, a heart transplant. It was all over the national news, but this was 1999. Why the big fuss? Because Japan hadn’t performed a heart transplant for 30 years.
In 1968, shortly after Barnard, Shumway, and Adrian Kantrowitz had entered the history books, Juro Wada put Japan on the heart transplant map with their first heart transplant. Instead of being hailed a hero the same way the aforementioned surgeons were, he was arrested and charged with murder. He was acquitted, but it left its mark on Japanese medicine.
Japan did not perform any beating-heart organ transplants for three decades until finally, in 1999, brain death was legally recognized. Pediatric transplants were only legalized 10 years ago, meaning thousands of adults and children were denied a chance of life in one of the most advanced countries in the world.
Incidentally, Japan is also a world leader in minimally-invasive cardiac stenting procedures like the ones I do, as the idea of cutting open the chest for something like a bypass operation, which we would do here, is regarded as deeply inauspicious, allowing the soul to escape. Brain death emerged as a concept, but one that has been plagued with controversy. Many accused doctors of pushing through legislation to increase the pool of organ donors, which has some truth to it. That was an intention, but it was also to recognize futile care. However, it meant families, religious leaders, politicians accused them of prematurely diagnosing death, and cartoons of doctors as vultures and harbingers of death were commonplace.
Now, you may ask, “If someone can control their temperature, their hormones, blood pressure, kidneys, and in some very dramatic cases even gestate a baby, can they be said to be dead?”
Now, it’s important not to confuse coma or persistent vegetative state with brain death. These are all different states. The testing for brain death is too complicated to go into here, but — and this is just my personal opinion — I believe it is a good model. It’s been refined and improved over the years, but it’s fair to say that it is not the same in every country or even in every state, in terms of how it’s put into practice, and this leads to added controversy.
In New York and New Jersey, a family can legally oppose the diagnosis of death if it contradicts their religious belief. In a single car journey you can go from West Philadelphia born and died to living it up in the Big Apple. To make matters more difficult, especially for family members, is the human body is just freaking weird. Even with a completely non-functional brain, muscle groups can twitch, maybe causing grip to momentarily tighten, giving hope to loved ones.
Even more dramatic is the spinal cord can fire off without any involvement from the brain, causing the arms to flex, collapse onto the chest, known as the Lazarus sign. Of course, named after Lazarus of Bethany, who was said to have been raised from the dead by Jesus after four days. Just like religion, this involuntary sign can provide hope without actually affecting the likelihood of recovery.
Ultimately, one will always struggle to define death without defining life, another deeply complicated and unresolved area of philosophy, and biology, and, if you’re so inclined, theology, but let’s look at the question from a less metaphysical and more human viewpoint. What is being alive?
In 2009 a team of doctors published a paper I wish I’d thought of. They just watched a whole bunch of TV — it was mostly British medical TV shows, which are dire, by the way — and found that survival rates of cardiac arrest on TV were roughly in line within real life. Interestingly, in 2015 another team did a similar study with “House” and “Grey’s Anatomy” and found that survival rates were double that of reality.
Now, I could make some grand statement about the differing responses to the pandemic by Americans and Brits as somehow linked to the unrealistic beliefs they get about medical care based on television they watch, but I think, actually, it’s mostly just because Brits are such miserable bastards we can’t even make our TV shows happy.
But either way, the key point I want to make here is that there’s a tendency for TV to make things binary. On TV, cardiac arrest patients either die or they live, and by “live” I mean that they pretty much go back to normal. While some doctors get sniffy about TV shows getting cardiac arrest wrong and they shock the wrong rhythms, or the patient comes back too quickly, my main objection is this binary good and bad.
In reality, there is a huge range of outcomes between someone walking out of the hospital feeling fine and death. When we discuss resuscitation status with patients and their families, this is the bit I find most people don’t know about. If it was truly a binary choice, we’d resuscitate everybody, but it isn’t.
If I do a prolonged resuscitation attempt on a 60-year-old and manage to restart their heart after 20 minutes, even with the best CPR in the world, there’s a chance they will never wake up. Or if a 50-year-old has a huge heart attack and suffers brain damage, that means that they can never come off a ventilator. Or if a 40-year-old recovers enough to have continuous seizures for weeks on end before being discharged to a long-term neurological care facility where they’re fed through a tube for the rest of their lives, have I done any of these people favors?
These are all real patients of mine. Cardiac arrest has more than just two outcomes. It’s not binary. Nothing in biology is. We’ve debated when life begins for hundreds or thousands of years, but do you have an opinion about when life ends? Judy died the day after she was admitted. Her heart never restarted. Despite being on the ECMO it began swelling and filling with clot. Teresa had a rocky month in hospital, but she went home.
A few weeks down the line when Teresa was with her family and Judy’s ashes had been scattered by her family amongst the flowers in her garden, the difference between Judy and Teresa seemed so clear, binary, in fact. But at one point, they were in the same state of superposition, both alive and dead simultaneously, until the box was opened and they collapsed into their quantum states.
Maybe one day, cryonic technology will allow us to truly preserve consciousness beyond death and we will again have to redefine our understanding of life and death. But ultimately we all know with certainty one thing, that death will come for us. While it’s natural to fear suffering, we shouldn’t fear death itself.
Until then, make your answer to the question “What is life?” a good one. Who can forget Johann Wolfgang von Goethe’s immortal words from Clavijo, “Man lebt nur einmal indervelt,” ably translated by one of our great philosophers, Zachary David Alexander Efron, “YOLO?”
Rohin Francis, MBBS, is an interventional cardiologist, internal medicine doctor, and university researcher who makes science videos and bad jokes. Offbeat topics you won’t find elsewhere, enriched with a government-mandated dose of humor. Trained in Cambridge; now PhD-ing in London.
Transplant News Sharing // “Lung Transplants” – Google News from Source www.medpagetoday.com