Tuesday, May 29, 2007

Bing Bong, the Myth is Dead

Duuuude (said depressingly), college students across the country just let out a collective gasp (with some smoke) as the World Health Organization (WHO) released a statement today asserting that water pipes are probably as bad for you as cigarettes.

"Using a water pipe to smoke tobacco is not a safe alternative to cigarette smoking," the U.N. health agency said in a seven-page document on the practice. "Contrary to ancient lore and popular belief, the smoke that emerges from a water pipe contains numerous toxicants known to cause lung cancer, heart disease and other diseases."

What? You mean the smoke doesn't get "filtered" as it makes that bubbly sound coming through the water? That really smart dude at the end of my hall freshman year explained the whole thing. I remember because he kept talking through the best part of Fluffhead.

But all is not lost, because the WHO really only referred to tobacco products and the use of hookahs - not 3-foot glass tubes with witty names. So maybe it is still true.

Also, those scientists did deliver some positive news for those water-pipe smokers out there: The agency said a person can inhale more than 100 times more smoke in a hookah session than in a single cigarette.

This Is Really Your Life

Only one day after my site, StopPagingMe.com, wrote about a busted Pakistani organ-harvesting ring, news comes from Holland that a new reality show is inflaming medical ethicists all over the world.

The bioethics committees of the world must be really sitting around those tables and philosophizing now. Discussing and mulling; reviewing and reiterating; talking and talking and talking -- all about kidney transplants.

What exactly has their undergarments in a bind? A Dutch reality show plans to have three people compete for the kidney of a terminally ill 37-year-old woman. While viewers at home can register their opinion as they learn about the hopeful recipients, the ultimate decision will be made by the donor herself. So what's the big fuss about? What is so strange about a woman dying of brain cancer auctioning off her kidney to three strangers all on Dutch national television?

Ok. We do see why it could be construed as objectionable of The Big Donorshow (that title is not a joke), but the show's network, BNN, argues that the show highlights the shortage of organ donors and is a tribute to its founder, Bart de Graaft, who died of kidney failure five years ago despite several transplants.

Dutch newspaper De Telegraaf felt differently: "It is a sickening attempt to turn a serious subject about life and death into a form of entertainment, rather than a serious new attempt to try and get more donors," they said in an editorial.

The government has also spoke up about kidney disease becoming the next reality star: "The intention of the program to get more attention for organ donation may be applaudable," quoted Dutch Education and Culture Minister Ronald Plasterk.

"However based on the information I now have, the program appears to me to be inappropriate and unethical because it is a competition," said Plasterk.

While we agree that any attention given to the subject of organ transplantation and donation is probably good attention, we also agree that this may not be the best way to spread the word. It may, in fact, have a negative impact on those who were considering donation as reality shows do not exactly lend credibility to their subjects (see: every reality show ever - except, maybe, The Biggest Loser).

Sunday, May 27, 2007

Organ Vendors

In Lahore, Pakistan yesterday, 6 people were arrested, including 3 doctors and the owner of a private hospital, after authorities identified them as key participants in an illegal kidney transplant "ring"? Can we even call it a "ring"? I'm not sure what one would call that.

Authorities in eastern Pakistan said that many men, like the ones seen here with healing nephrectomy scars, are selling their kidneys on the black market for about $1000 to pay off debts.

Turns out that rumors of people selling organs on the "Black Market" are quite true - as if there was a doubt. They may not be waking up in a bathtub with a note on the wall written in blood but whenever medicine is practiced secretively corners are cut (no pun intended) and there is usually little recourse for those under the knife.

It does bring up an interesting question, though. If done safely and properly, what is the harm of selling an organ that you can safely live without in return for monetary compensation? Before we continue the dialogue though, let me clarify that I would never, ever advocate such a practice - unless, of course, it was sanctioned by our federal government and overseen by a tightly controlling administrative body with all the proper governmental bells and whitsles, etc etc.

That said, the benefits to private citizens selling kidneys could, if done properly, save billions of dollars in the United States alone - not to mention thousands of lives. Hundreds of thousand of kidneys fail each year and patients often end up on chronic hemodialysis, despite the fact that renal transplant is the treatment of choice. Dozens of studies have shown that a successful kidney transplant improves the quality of life and reduces the mortality risk for most patients, when compared with maintenance dialysis. Chronic renal failure is a major cost burden on our health system and also brings with it or accelerates a slew of other concomittant diseases, like coronary artery disease, heart failure, hypertension, liver disease, stroke, and on and on and on.

In the US, there is an ever-rising incidence and prevalence of kidney failure and the number of patients enrolled in the end-stage renal disease (ESRD) Medicare-funded program has increased from approximately 10,000 beneficiaries in 1973 to 86,354 in 1983, and to 452,957 as of December 31, 2003. Impressive? How about this: The total cost of the ESRD program in the US was approximately $27 billion. Now, of course, not all of these patients who are maintained on dialysis would be candidates for a transplant, but if we had more kidneys, we would also be able to loosen our restrictions on who can and who cannot receive a kidney. Restoration of renal function to these patients not only changes the way theiur kidneys function but allows these patients to get back a significant portion of their life that is spent sitting in chairs receiving HD for 3-4 hours thrice weekly.

And what of the seller's role in all of this? Healthy kidney donors actually function quite well with one kidney. Is it better to have a back-up? Of course. But perhaps the seller really needs the money for his own health or children or whatever. We allow people to sell everything and anything in this country, why not body parts? In order for one to give up body parts , they actually have to be dead. And they don't even make any money from it? [Which brings up another interesting question? If they paid families for the organs of relatives that passed away, would the frequency of organ donation increase?] What about American football players? Are they not indirectly selling their body parts for a salary? A knee? A shoulder? A brain?

Another potential benefit to the practice of buying and selling kidneys on the free market would be the negative impact it would have on the so-called "black market". The desire to seek out dingy hospitals in the Third World to avoid waiting on the transplant list would be quelched if you could do the same thing at a strictly regulated American hospital.

In 2002, Charles Erin an John Harris put forth a rough sketch of how they thought this could work in the Bristich Medical Journal:

The bare bones of an ethical market would look like this: the market would be confined to a self governing geopolitical area such as a nation state or indeed the European Union. Only citizens resident within the union or state could sell into the system and they and their families would be equally eligible to receive organs. Thus organ vendors would know they were contributing to a system which would benefit them and their families and friends since their chances of receiving an organ in case of need would be increased by the existence of the market. (If this were not the case the main justification for the market would be defeated.) There would be only one purchaser, an agency like the National Health Service (NHS), which would buy all organs and distribute according to some fair conception of medical priority. There would be no direct sales or purchases, no exploitation of low income countries and their populations (no buying in Turkey or India to sell in Harley Street). The organs would be tested for HIV, etc, their provenance known, and there would be strict controls and penalties to prevent abuse.

So what is the argument against allowing citizens to sell organs in a controlled and organized fashion? I suppose that it might pose a significant health risk in that there is a surgical organ extraction and that later on down the line there might be an additive health risk associated with having one kidney or half of a liver. Actually the short-term complication rate of kidney donation has hovered around 20%, while the mortality rate is less than 1%. Moreover, the risk of chronic renal failure amongst those donating their kidneys is equal to that of the general population.

Perhaps people have a "moral" objection to the business of body parts? But synthetic or manufactured body parts are okay - just not organs that come form a living human?

Some have argued that the rich will benefit while the poor will continue to suffer and be more likely to represent the majority of organ sellers. And that differs from the current system how? No matter what schema or health care plan we use in this country, those with money will always obtain "better" (i.e. more expensive) care because they can pay for it, and ostensibly they have a higher level of education enabling them to ask the right questions and find the right people. However, if anything, legalized organ doantion levels the playing field as more organs will become available and a regulated system of organ procurement will prevent those with all of the advantages ftrom taking advantage.

Buying and selling of human organs is not a new topic of discussion. It is a popular topic of conversation in the medical literature - especially amongst those in the University and Hospital Ethics departments, where procrastination and idle discussions are a favorite pasttime.

The truth is, this would never happen in the U.S. - not becaue it is wrong, but because we value opinion and discussion and democracy. And there are just too many people that would make fighting this their cause. For what reason? Your guess is as good as mine, but if you doubt it, just look at how stem cell research - probably the most promising new technology of our century - has fared. Literally stifled by the President of the United States. And I have never heard him speak intelligently about that.

Thursday, May 24, 2007

Top 5 Worst Hospital Jobs

1. Sharps Box Changer Guy – This guy is just plain crazy. His task in life is to remove plastic containers overflowing with butterfly needles and discarded IV’s contaminated with Hep C, HIV, and God knows what else. These guys should have a reality show and carry anti-viral medications in their pocket. The funny thing is that these guys never seem to wear any protective gear - I’d be wearing steel gloves and a football helmet.

2. Nurse’s Aid -
It is difficult to imagine that there is a worse job in the world, let alone the hospital. A typical morning will involve weighing six to eight combative and/or demented patients. Then comes “bathing” time, in which the term “bathing” is used loosely; then re-cleaning them 30 minutes later when their Dulcolax has kicked in. This is often followed by the business end of the “Out of Bed to chair” order in which they get to lift the patient to a geri-chair. Finally, the shift ends with a round of vital signs. The only thing smaller than the qualifications needed for this job, is the pay that they receive. But at least they have their union.

ECG tech – Can you imagine a worse job than removing 20 patients’ gown(s), getting all up in their chest fat and breasts, and occasionally shaving excessively hairy individuals in order to paste on some stickers? Welcome to the wonderful world of the ECG technician. The best part? They get to it again 3 minutes later when they have to remove the stickers. And then come back the next day and repeat the process. Wanna really be grossed out? Stay tuned for our upcoming documentary: “Things Found in the Folds – the Story of one ECG tech and his battle to leave his job.”

4. Laundry –
Ever wonder where those melena-laden sheets go after they’re thrown in the soiled utility? These people don’t. They use to smell them coming down the laundry chute but lost their olfactory senses a long time ago as a protective measure. Blood, shit, puke, urine, and all other bodily secretions end up in the laundry and these brave souls remove them. God bless them.

5. Intern - Take all the jobs above and add phlebotomist, proctologist, transporter, and general, all-around hospital bitch. That's an intern.

Tuesday, May 22, 2007

Tough Break for Paula

Someone above is looking out for StopPagingMe. We have been looking for an excuse to talk about the upcoming finale between the Keane-like, beat-boxing Blake and the smiley, It-factor-laden Jordin.

Our excuse to come clean about our Idol affinity came in the form of a broken nose. Not just any nose either, the nose of our favorite supportive and sedated judge, Paula!

According to numerous reports, the oft-slurring Abdul was trying to avoid her dog and wound up taking a nasty spill, telling Extra that she tore cartilage in her nose and broke a toe. Ouch! The dog was okay, though.

Paula has a well-documented history history of pain killer affinity so hopefully she was premedicated.

Getting medical though, schnoz fracture is the 3rd most common break and the most commonly broken facial bone. As in Paula's case, blunt trauma is the most common cause (85% of cases) but the management is by no means straight-forward or easily agreed upon. One can be sure though, that if there was some significant damage, the physical exam portion was not comfortable for the former Laker Girl.

In case your interested, here are the indications for open and closed reduction of the nasal fracture from eMedicine (feel free to skip right by it):

Closed Reduction:
Unilateral or bilateral fracture of the nasal bones
Fracture of the nasal septal complex that is deviated less than one half of the width of the nasal bridge
Indications for open reduction are as follows:
Extensive fractures
Deviation of the nasal pyramid greater than one half of the width of the nasal bridge
Displaced fracture of the caudal septum
Open septal fracture
Persistent deformity after closed reduction

Ice packs and head elevation are the mainstay of treatment in the majority fo cases. If the reduction is not going to be done that day, then a period of 3-5 days precedes further evaluation. Fractures that are not displaced do not require treatment. Because as many as 30% of patients have a deviation that was present prior to injury, in many cases, obtaining photographs for review is helpful. God, woudl we love to see those pics - where's TMZ.com when you need them?

Other famous broken noses?

Remember when Geraldo sported his massive rhino-dressing?

Or how about when Cameron Diaz dinged her sniffer while surfing (she had a nice rhinoplasty following).

And then there's this guy. After a surgical repair for nasal trauma they used leeches when the graft was failing. Ok, it has nothing to do with Paula's accident but it's cool nonetheless (we are doctors, ya know?):

Tuesday, May 15, 2007

The Mighty Have Fallen

Crusading televangelist and father of the Christian Right, Jerry Falwell, has passed away.

CNN is reporting that Falwell was found unresponsive in his Liberty University office and despite aggressive resuscitative measures, could not be revived.

Falwell founded the Moral Majority in 1979 and is a nationally known voice for conservative Christian views.

The Associated Press reported that Dr. Carl Moore, Falwell's physician, said the evangelist had a heart rhythm abnormality. Most likely, this is atrial fibrillation for which Falwell probably took a blood thinner, i.e. warfarin (Coumadin).

While this may not have helped things, a-fib was almost certainly not the cause of death. Much more likely was the pastor’s history of coronary disease for which he had a stent placed in 2005.
When someone dies suddenly it is typically classified as a sudden cardiac death (SCD) and SCDs are usually the result of a very fast and unstable heart rhythm like ventricular tachycardia (VT) or ventricular fibrillation (VF).

Thursday, May 03, 2007

Doctors Sue Back

According to the Associated Press, a group of doctors has filed suit against the state of Louisiana seeking $100 million they say they are owed for providing free care to poor and uninsured patients following Hurricane Katrina.

In all, 381 physicians at West Jefferson Medical Center, says the state failed to reimburse them for treating indigent patients since the Aug. 29, 2005, hurricane closed the state-funded Charity Hospital in New Orleans.

Despite many years of poorly reimbursed training, excessively long hours, and thousands of dollars in loans, you would be hard-pressed to find anyone crying for doctors. And I’m not saying we should start the water works just yet. But I am proud of my fellow colleagues for standing up for themselves and not simply accepting the role of martyr while everyone else collects a paycheck. I am quite sure the rest of the hospital staffers and administrators got their compensation – the union would make sure of it.

For years, physicians have taken a passive role in their reimbursement for a number of reasons. Firstly, they rightfully believe that people must be cared for regardless of compensation and like me, have a slight complex about “fighting” for money. Next, by convention, doctors are hard-working individualists who have to deal with complex billing systems and shrewd insurance companies. This makes for big trouble when trying to advocate on their behalf. Lastly, no one cries for doctors as most are quite comfortable.

It was probably a very difficult decision to sue the state of Louisiana after such a tragedy and I am sure it was not an easy undertaking to get these physicians to sign on. Many will scowl at the thought of doctors suing – as if they need the money. Evidently, they do. And they are not suing the indigent who received care, they are suing the state that is supposed to provide for their constituents – rich and poor, black and white, blue collar, white collar or no collar.

I am (quietly) proud of these physicians for taking a stand and not becoming the good martyrs in this instance. They trained long and hard for their degree and the privilege to call themselves physicians and they deserve compensation like everyone else. Chalk one up for the white coats – at least until the next billing scandal.