When does the sanctity of life lead to medical waste?

A true story.
There was a patient that arrived in the ER with acute abdominal pain. Imaging revealed air in his abdomen, indicating a perforated bowel. The patient had a very complicated medical history, the most outstanding component of which was a late-stage glioblastoma multiforme tumor. This is the worst kind of brain cancer you can get. It is inoperable, highly resistant to chemo or radiation and has a prognosis of 3-8 months without treatment from the time of diagnosis. Median survival is 14 months with treatment.

So the question for doctors in the ER, the patient and his family members is: what, if anything, should be done about the bowel? Normally this would require an operation to remove the damaged bowel or suture the hole. But any kind of surgery carries complications - which are compounded in this patient's case considering his illness and current anti-cancer medications - and bowel surgery in particular can result in the patient requiring tubes to assist in feeding or defecation. Plus there is the financial cost. Is any of this worth it for someone who has a terminal disease and is expected to die in 2 months?

You might say, well, that's up to the patient. But you might also say, unless that patient is going to pay for the operation out-of-pocket then it is not entirely up to the patient because we, as a community, are going to being paying. Say the operation and hospital fees amount to 50K. Is it ethical to spend this sort of money - public money, let's say - on a terminal patient rather than say a non-terminal patient, or child? Plus we need to consider the health care costs in case their are complications (remember, he is high-risk). We like to pretend that economics don't, or shouldn't, matter when it comes to medical treatment. But they always do impinge.

A last nugget to ponder.
The patient was on a new type of chemotherapy call Avastin which targets a chemical messenger involved in the formation of new blood vessels. Tumors love to make new blood vessels as they grow, so attacking their supply of nutrients and oxygen has shown to be an effective strategy. In some cancers. Avastin is indicated for only a few types of cancer, namely colon. There is little to no evidence that says the drug works against the kind of brain tumor this patient had. Avastin itself is very expensive. A year's course including medical fees is around 200K. Wow! Now, that, is some serious money to drop on a dying patient when there is no evidence it will change his prognosis. On the other hand, there is no evidence to say it won't.

[Update Actually Avastin costs up to 44K for a 10-month treatment, but that is the medication alone, not including the hospital stays and support. Some people have complained to Genentech about the price]

You can find situations like this every day in every hospital. I know it sounds cold-hearted to suggest that this is wasted money, but money spent on a dying patient is money not spent on a living one. Always think of kids, who are, unfortunately, the most under-insured demographic in the country, but who have the most to gain from medical intervention and the most to give back to the public if those interventions work.

ATV now or bypass later?

rangelMD.com has an insightful commentary on Americans' personal financial decisions regarding health care. Without a doubt our health care system is broken and unaffordable. Nevertheless for many middle class Americans it is possible to save and plan for future health care - or retirement - although few do.

It has become customary in the US nowadays to forgo saving for the future (such as for health care one will need as one ages) for expensive, gratify-me-now consumer items purchased with credit cards. Credit card debit has balloned in recent years and although some of this is a result of costly health care, most is not. As Rangel points out, it ultimately will be younger taxpayers that will foot the bill (assuming Medicare is still around!) for irresponsible spending as the middle class ages with their huge credit card debit.

Saturday BT, Tasha, and I skinned up the Palmer Glacier on Mt. Hood. It was a warm, sunny, spring-like day, but the snow - if you could call it that - was bullet-proof ice above the Palmer lift. We decided not to carry on to the hog's back and instead enjoyed a leisurely lunch at 8500 feet, talking with other climbers and skiiers.

The hike up from Timberline Lodge was not so bad except for the fact that I did not have heal raisers on my skis. The pitch is pretty steep and one does not ascend with switchbacks. While we were up there we ran into the climbing party that required rescue the next day. These were all of friends of BT and Sasha. People ask "what were these guys doing up there is such bad weather?" The fact is, there is always a weather risk with outdoor activities, and especially so with mountaineering. The weather Saturday was so nice that it was hard to image every needing help getting of the mountain, but in extremely low visibility the simplest operations become very difficult. The rescue stirred a nation-wide media blitz because of the three climbers that died on Hood in December and the "courageous" little Velvet, the black lab that tumbled down into White River Canyon with Matty and the two women.

Anyway, on Saturday the three of had Indian food and saw "Host," a horror-genre spoof/political satire from South Korea about a giant river monster that terrorizes Seoul and the impotent and incompetent response from the Korean government, the WHO and the CDC.

Sunday Naomi and I watched another film from the International Film Festival (it has been really fun seeing the films this year), "Hula Girls" from Japan. The Willamette Week shredded this movie in a short review, which was really a shame as we both thought it was good film. Of course it was not a self-consciously clever indie film or a slick Hollywood production, which is what the reviewer seemed to be expecting.

This week I had a small epiphany. I know that neurosurgery is not a reasonable option considering my diverse extra-career interests, but it is what I really would like to do, and what I would do if I was 10 years younger. Now that I am nearing the end of the neuroscience course I can say with certainty that nothing else in school so far has piqued my interest as much. So I will make an effort to do some extracurricular work with the neurosurgery department, perhaps with trauma, since that will be most useful for emergency medicine and anesthesiology.

Friends found on Hood

What a nerve-racking day. I'm glad these guys, whom I've met through a medical school friend of mine, are back safely. Here's the latest story.

These are pictures I took of three people in the climbing party on Saturday - when the weather was gorgeous and balmy. On Saturday BT, Tasha, and myself skinned up Palmer glacier and met their friends for chat.

So let the Japanese hunt whales!

Here is a good review of the whaling issue and Japan, although I was a disappointed that the "scientific evidence" was not discussed either for or against whaling.

From an environmental viewpoint this really doesn't seem like it should be a problem. Whales are like any other animal that we exploit, and so there should be some empirically-based management policy people can agree on. I cannot image that such a policy would completely ban whaling - which is precisely what most European countries, the US, New Zealand and Australia want. How much of this is driven by emotional sympathy for the beloved cetaceans is unclear, but I am sure that in-your-face environmentalists like Greenpeace are happy to exploit those feelings. Japan, Iceland, and Norway, on the other hand, want the ban on whaling to be lifted (they are all taking whales anyway, the Japanese claim it is for scientific research) and say that they have plans for sustainable whaling and only hunting non-endangered species.

In Japan at least, the whaling industry has withered to a fraction of what it used to be. Whale meat is not popular anymore and the industry if cut from its government subsidies would not survive. The pro-whaling stance in Japan is not at all about the need for food. It is about national pride and taking a stance against non-whaling countries that have denounced Japan as barbarous and the heritage of whaling as evil. Even though I know the US beef industry is horribly unsustainable and inhumane, I too would be pissed off if India tried to force us to stop eating cows because it was immoral (to them). So the reaction in Japan is complicated by emotions too.

Why not lift the ban, make the whaling nations hunt under a sustainable protocol that has been agreed upon by the International Whaling Commission, put in place a monitoring system, and pressure whaling governments to end taxpayer subsidization of the industry?


A side note - the fight over whales is one more ominous sign of the stress that human populations are placing on natural marine resources that cannot be farmed or harvested. Today it may be whales, and Chilean sea bass, but tomorrow it will be mackerel and tuna.

This last weekend Naomi, Brain C, Toshimi, and Yulija and I drove down to Bagby Hotsprings for a good, long soak. The water was super hot, and the trail - bulletproof ice the whole way. Lucky for Naomi and I, Brian, Yulija, and Toshimi had snowshoes with spikes.

The hotspring itself was not to crowded - probably only about 30 people the whole day, but you can just image how trashed it must get in the popular summer months. Even in the dead of winter there was garbage laying around. It baffles the mind why people shit in the place they come to enjoy.

That night we went over to their house for some Russian pork dumplings with dill and white wine. After eating Brain showed us photos from their recent family vacation in Turks & Caicos islands and then we watched the coral reef episode from Blue Planet. Naomi was in dreamland - oh, me too of course

Big pharma comes to med school - for a nice talk

We had a provocative session at school last week regarding the role of big pharma in medicine - mostly discussing the ethical considerations of direct-consumer marketing of drugs and the ever-more aggressive marketing to doctors.

Drug companies spend millions of dollars trying to persuade doctors to use their product, and they are not shy in their methods. It is commonplace today that drug companies provide free lunches or coffee during grand rounds, small gifts like stationary stuff, huge gifts like trips to the Bahamas for a symposium on the products, large gifts like tickets to big name sporting and musical events or green fees a golf course. And even if there are no gifts, every doctor, resident, and medical student has seen a drug company sales rep lurking around the clinic or hospital. Many of them make visits several times a week.

So one of the panelists worked for Merck. His main defense was that we, as medical students, should not prematurely shut any doors to gaining information about drugs. We should keep an open mind and be critical of all information - not just that coming from the drug companies. It is a actually a very familiar argument made by the tobacco and firearms industries: the government should not legislate behavior since ultimately it is up to every individual to make responsible judgments.

Texan gov wants mandatory vaccinations

Wow, can't believe Texas's governor passed a law requiring mandatory vaccination of girls for HPV. This is great news, and in a so-called morally conservative state like Texas too.

Opponents of the vaccine come from a few sides, but to break it down in real simple terms there are those who oppose it for on sexual-moral grounds (typically conservatives) and those who opposite on conspiracy-theory grounds (typically liberals).

Anyway, it represents an interesting example of bioethics. Some parties involved are:

1. The public that makes a modest investment in vaccination for a huge return in life-long protection from a deadly disease
   
2. The girl who may get the cancer if the vaccination is optional and her parents refuse
3. The girl who may have a rare side effect of the vaccine if it is mandatory (autism in the worst case, although this link is not proven)
4. The parents who lose autonomy to decide care of their child if vaccination is mandatory
5. Merck, who is the sole manufacturer of the vaccine
   

Maryland parents freak out over vaccine for girls

The HPV vaccine bill in Maryland was yanked, and for no really good reason. People claimed it would promote promiscuity (I'm sure a lot middle-schooler girls are not having sex because they're afraid of getting cervical cancer in 10 years, right); others simply knee-jerked against the idea of more vaccinations, as if these things were poisons or something.

The saddest thing is the failed effort of the medical community and local government to educate people out of the ignorance for huge public health impact vaccines have.