Posted in Health Posts

A brave new world with artificially enwombed people in it?

“From the Social Predestination Room the escalators went rumbling down into the basement, and there, in the crimson darkness, stewing warm on their cushion of peritoneum and gorged with blood-surrogate and hormones, the fetuses grew and grew or, poisoned, languished into a stunted Epsilonhood. With a faint hum and rattle the moving racks crawled imperceptibly through the weeks and the recapitulated eons to where, in the Decanting Room, the newly unbottled babies uttered their first yell of horror and amazement.” – Aldous Huxley, A Brave New World.

Last month Partridge et al. at the Children’s Hospital of Philadelphia published an article in Nature Communications called “An extra-uterine system to physiologically support the extreme premature lamb.” In other words, they used what is being described in the lay press as an “artificial womb” to extend the gestational, or in-womb, period using a system outside of the mother’s body for up to 4 weeks. This is not the first such experiment to extend gestation using an extracorporeal system, but so far it has been the most successful. As the authors describe, this system uses a pumpless oxygenator circuit which connects to the fetal lamb using an interface with the umbilical cord. The aminiotic fluid circuit is closed to the outside environment, mimicking the environment of the womb. The pumpless circuit is powered by the fetal heart.

The motivating factor behind this research is the fact that extreme prematurity is the leading cause of neonatal mortality and morbidity in the developed world. The goal is to be able to use this system to allow extremely premature newborns to continue gestational development and reduce their risk of death or of serious complications related to prematurity, including lung and brain problems. This sophisticated system would replace the incubators, ventilators, and feeding tubes that are currently in use in neonatal intensive care units (NICUs) across the country.

The authors of the paper have stated emphatically to the press that their extra-uterine gestational system is meant to be used on premature infants past the age of viability (currently 24 weeks), and that it is unlikely that a system that would start at conception would ever be feasible or successful. And yet, articles that I have read in the lay press have made all sorts of claims including that society will now start routinely growing fetuses in artificial wombs, that this could change how we think about gender and parenthood, and even that “women will become obsolete.” Online articles have brought up “ethical issues,” including the loss of the “human connection,” the “humanity” of the infant, and the blurred lines between fetus and infant.

The immediate practical ethical issues that I see as a physician relate more to the prognosis of the premature infants who use the “artificial womb.” A good intervention would provide better success rates and fewer risks of harm or death than the standard of care currently in use in the NICU. This intervention would be ethically problematic if it instead lead to the prolongation of the life and suffering of an infant who is inevitably going to die in the neonatal period. However, at this stage the “artificial womb” has not yet been used in human infants, and so far in the lamb model it has shown that the animals who survived the 4-week period had normal overall body growth, lung maturation, and brain growth.

Regardless, let us step into Gattaca for a moment and imagine that an artificial womb could replace the human mother’s womb for gestation, and that this was a common and even encouraged practice. I find it difficult to imagine that an artificial womb would be “better” than (providing more benefits and fewer risks) or equal to the average woman’s uterus and body for gestation. This is primarily because artificial interventions require us to troubleshoot logistical problems with medical solutions, which all have inherent risks. For example, the lines carrying the blood through the umbilical interface will clot, so blood thinners are required, increasing the theoretical risk of life-threatening fetal bleeding.

But let us say we got really good at creating an artificial womb, and we could replicate the human gestational environment with minimal risks. Let us imagine that this would allow anyone who so chooses to have a child with the help of an artificial womb, instead of, say, a surrogate mother. This could open more options for women with medical issues that render carrying a child dangerous or impossible for them, same-sex partners, women with demanding careers, and single men.

Some may ask, is the child “human?” And how does this change abortion politics? The child, like all zygotes who become fetuses who become babies, will be of the species Homo sapien, so he or she will be human. The controversial question in the abortion debate is, rather, whether the fetus is a Human Person, or an ethical and legal entity with all of the human and legal rights entitled to you or me.

Another controversial question in the abortion debate is, at what point do the rights of the fetus to continue its gestation outweigh the rights of the mother to decide whether to continue or terminate the pregnancy (always? never? at 12 weeks? at 24 weeks?). In most US states this point has been determined to be the age of viability, around 24 weeks, at which point the fetus, if born, could survive. It is possible that the artificial womb could change the age of viability. Furthermore, it is possible that the artificial womb could give women contemplating abortion another option past 24 weeks (for example, to birth the fetus and place the infant in an artificial womb where they will complete gestation and then be placed in the adoption system).

Though every new advance in medicine, technology, and society can and will have unforeseen and unintended consequences, the advance that is actually happening in 2017 is one that could improve the lives of premature infants and their families. Rather than looking to the future with horror and amazement, let us look at the present advancement with informed, objective, and practical eyes.

researchers-create-artificial-wombImage from Petra et. al 2017
Posted in Medical Experiences, Patients I remember

Last night in the ICU

We brought his family into a separate room with plenty of chairs. Sitting to the right of his father and mother, our attending uttered the first words in the room.

“I think you know what I am about to say.”

His mother took in a deep sigh, her eyes already swollen from inconsolable tears.

“I think he is dead.”

The whole room sank. We were all punched in the gut by those words.

“Oh my God….” his mother cried out, sinking her face in her husband’s shoulder as she was being told that her worst nightmare was her current reality—her 29 year old son was dead.

His girlfriend stared blankly and silently at the wall with glassy eyes, kneading the hands of those next to her with her fingers, not moving or crying or saying a word. She had found him last night on the floor, blue, without a pulse. His parents said that “she kept him alive” for the past two years, “loving him unconditionally” as he struggled with addiction to narcotic pain pills (opioids).

His father was the first to try to address and tackle the death, asking about the logistics of where and when and what now. As we got up he buried his face in his hands and sobbed.

I stood against the wall next to my co-residents, on the 14th hour of a night shift in the intensive care unit, using all my inner strength to not cry.

Amidst a night of putting in central lines, diuresing patients to goal, and repleting patients’ electrolytes, the only moment I will likely remember vividly in 20 years is the moment my stomach sank when his mother learned that he was dead.

Earlier that night my intern and I met his parents and siblings as they sat around his hospital bed praying that he would return to them. Intubated and mechanically ventilated, his heart was still beating because it was receiving oxygen, and his body was still warm. His youthful skin and handsome face belied his morbid condition. His parents hugged and kissed his body and asked us what his chances were of recovery.

“His brain injury was very serious because his brain was without oxygen for a long time. In the morning we will do a test of whether he can breathe on his own, which will tell us if his brainstem is functioning.”

There was no mention of death. We left it at “we need to gather more information.” But all the while I felt that he was already gone.

“He’s a good boy” they said, “my protector,” said his sister. They described him as bright and caring. “But he had an unhappiness inside the past couple years” his mother said. “He got sick.” He had just gone to rehab and was looking forward to his 60 days sober milestone—which would have been today.

His parents found comfort in the idea that he would live on in others by donating his organs. Yet the only time his girlfriend spoke was to say, “I told him not to put that on his license.” “He would have loved to help someone else,” his brother replied.

There is no moral to this story. A man was alive yesterday and today he is dead, and I was there when his family heard the news. This happens somewhere in some way to someone every moment of every day.

The last time I wrote in this blog I wrote a long, dense post about what it means to be brain dead. I chose to play it safe by writing about what I know. About objective facts, things that are written somewhere, that are backed up by evidence. I have not written in a while because I have been busy being a medical resident; but also because I do not really want to write about objective facts. I want to write about my experiences in medicine, what I have seen and what has become ingrained in my mind and in my soul.

Every day in the hospital, I invariably walk through someone’s personal hell on earth. For the most part, nothing I do will pull them out of their inferno. At most I can crawl into that hole with them and, just for a moment, keep them company.

 

Posted in Health Posts

Brain Death and Basketball

In reference to the recent unfortunate events regarding basketball player Lamar Odom, I have heard many inconsistent reports, from declarations that he is “brain dead” to reports that he woke up and spoke. This got me to thinking about how brain death, death, cardiac arrest, and altered levels of consciousness are often inaccurately portrayed in the media, and I wanted to clarify a few misconceptions 

First of all, when someone is brain dead, they are, for all intents and purposes, dead. Death is defined as brain death and/or cardiopulmonary death. If Odom were brain dead, he could not wake up. If he really woke up, he was never brain dead. Brain death = legal and biological death. Brain death means that the person has no function in their cortex (upper brain, which produces consciousness) OR in their brainstem (the “rudimentary” brain, so to speak, which controls functions such as breathing). When someone is brain dead, their entire brain is permanently functionally damaged and can never return to a functioning state in any way.

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Continue reading “Brain Death and Basketball”

Posted in Health Posts, Patients I remember

How Your “Natural” Supplements Could Kill You.

Today during our “morbidity and mortality” lecture, we discussed a case of a woman who suffered a devastating stroke because she was taking naturopathic dietary supplements. She had a list of 70 different homeopathic supplements that she was taking, one of which contained thyroid hormone from animal organs. She presented to the hospital with a heart arrhythmia called atrial fibrillation as a result of the off the charts thyroid hormone levels in her body. Soon after arriving to the hospital she suffered a major stroke which left her permanently disabled (new-onset atrial fibrillation can put patients at risk of forming clots in the heart which can travel to the brain and cause ischemia, or inadequate blood supply, leading to cerebral infarction–commonly known as stroke).

Earlier this month I took care of a patient who died of metastatic breast cancer because she refused conventional treatment. She was diagnosed with breast cancer in her 40s, 7 years prior to her death. At that time, she had a very good chance of being cured with surgery and local radiation alone. However, she was a firm believer in naturopathic medicine, which essentially teaches that the body can heal itself, and she refused conventional or allopathic treatment. She was an educated person, and she had received a doctorate in a branch of alternative medicine. Eventually, her cancer became metastatic, infiltrating her liver, her bones, a diffusely throughout her tissues (known as “carcinomatosis”). She did agree to some chemotherapy towards the end of her life, but by that point it was too late. When I met her, she was bed bound, in severe pain all over her body, with chest tubes in place draining up to 2 liters per day of pleural fluid (fluid from around her lungs). The morning I met her I assisted her husband in draining her chest tubes, a task he meticulously completed every day. They were a very loving couple, speaking gently and kindly to each other in the most frustrating of circumstances, and she was a very sweet lady. After she died, after I left her room, I went somewhere private to cry. I had bonded with her. After some time passed, I also felt ashamed that she had died a preventable death. Somehow, we as allopathic doctors had failed her by not doing a good enough job of convincing her to allow us to treat her with evidence-based medicine. Maybe we hadn’t pushed hard enough, because we thought it was a losing battle.

Continue reading “How Your “Natural” Supplements Could Kill You.”

Posted in Health Systems

PCPs, PPOs, and Premiums: De-coding Health Insurance Terminology

Hello, blogosphere. The interview trail has kept me busy, so I apologize for the gap between these last posts. In light of changes with Marketplace insurance plans (i.e. Affordable Care Act, or “Obamacare,” plans), the purpose of today’s post will be to define all of the terminology commonly used regarding health insurance.

I will be using a fictional family, the Waytes, for illustration purposes. The Waytes family consists of husband Bill, wife Sandra, and young children Timmy and Susie.

Healthcare Provider (or Provider): your physician (medical doctor, MD or DO), nurse practitioner (NP), physician assistant (PA), podiatrist (DPM), or other similar professional who provides you with medical care.

Primary Care Provider (PCP) vs. Specialist: A PCP is a physician or other provider who is your “main” doctor or provider. He or she is a generalist and can evaluate and address most of your healthcare needs. When you have a more complex health issue, your PCP will refer you to a specialist, who is more extensively trained in a particular field.

  • Sandra and Bill regularly go to see their PCP, Dr. Garcia, an MD who is board-certified in family practice. She performs their annual wellness exams, coordinates immunizations, manages Bill’s hypertension, and prescribes antibiotics for Sandra when she has a UTI. Sometimes, however, Dr. Garcia consults specialist providers for the Waytes’ care, for example referring Sandra to dermatologist for a funny-looking mole.

Referral: the directing of a patient to a medical specialist by a PCP or other provider, usually requiring documentation of such (eg. a paper slip signed by the provider). Continue reading “PCPs, PPOs, and Premiums: De-coding Health Insurance Terminology”

Posted in Health Posts

What is ALS?

Over the last few weeks, many of us have seen video after video of friends and celebrities taking on the “Ice Bucket Challenge” to benefit ALS research. So, what is ALS? And why does it need to be researched?

In a sentence: Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease, is a progressive neurodegenerative disease for which there is currently no cure.

What it looks like clinically, and what’s causing it to look that way:

–ALS is “neurodegenerative” because “motor neurons,” or nerve cells that control movement, are damaged. Motor neurons are damaged because they accumulate a build-up of “inclusions,” or clumps of dysfunctional proteins, which cause the cell harm. These damaged neurons then cannot signal muscles to contract and release as they normally would. As a result, patients with ALS develop muscle weakness and, eventually, paralysis.

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–Loss of motor neurons eventually impairs the function of limbs, head and neck muscles, spinal muscles, and respiratory muscles. That means that, eventually, people with ALS will not be able to walk, speak, eat, or breathe.

–In ALS, the motor neurons in both the brain (“upper motor neurons”) and the brainstem and spinal cord (“lower motor neurons”) are affected. Signs of upper motor neuron involvement include increased reflexes, “spasticity” (increased muscle tone leading to muscle tightening), and lack of coordination. Signs of lower motor neuron include muscle atrophy and “fasciculations,” or muscle twitches.

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–There are different variations of ALS where the initial symptoms and areas affected differ, and where additional symptoms such as dementia are present.

Who gets it? ALS most often affects people between ages 40 and 70, but can affect individuals in their 20s and 30s. Sometimes it runs in families, but most often people with ALS have no known affected family member. There are about 2 cases per 100,000 in the US population newly diagnosed each year (about 5,600 new cases per year). About 30,000 people in the US are currently living with ALS.

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Left: baseball player Lou Gehrig (right) after whom the disease was named. Right: Professor Stephen Hawking, living with a form of ALS.

Is it life-threatening? Yes. Respiratory failure is the most common cause of death in ALS. The median survival from the time of diagnosis is three to five years.

What are the currently available treatment options? Though there is no cure, some treatment options modestly modify the disease. A drug called Riluzole which targets the pathway of the neurotransmitter glutamate is the only drug shown to impact survival, and even so only increases lifespan by months. Otherwise, patients must be given supportive care to assist them with functions of daily living.

What could we use in the future? There are several therapies being tested in animals and humans, and there are therapies that have been proposed for future trials including drugs, stem cell treatments, and gene therapy.

The aim of the ice bucket challenge is to raise money for ALS research by encouraging donations to the ALS organization.

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