February 2014

The Medicine

by Karen Hitchcock

Medicine's mission to Mars

Transplants, out-of-body organs and limits to treatment

When I was a trainee doctor, I worked for a time with a physician who would conduct his limits-to-treatment discussions like this: he’d lean over the gravely ill person in the bed and say, “You know the reason we don’t send people to Mars? It’s not because we can’t get them there, it’s because we can’t get them back.” He’d nod slowly, as if sharing a moment of sad understanding with the patient. Then he’d walk out of the room.

There’s a lot of talk around the wards about limits to treatment. No one wants to prolong a patient’s agony or squander resources for little gain. A researcher recently wanted to quantify how much of what we did on our general medical ward was futile. It sounded interesting, until we realised that futility could only be judged in retrospect. If the patient died, then what we had done was torture; if they lived, we were bloody heroes.

At base, doctors in hospitals tend to your threatened organs: we treat them and support them. Increasingly, we can also replace them.

A few years ago, I saw a guy walking out of the cardiac ward with a neat black briefcase on wheels. There were wires running from the briefcase to his belt. “What’s that?” I asked the cardiology fellow. “It’s his heart,” he said. “You know, a VAD – ventricular assist device.” I didn’t know. I’d never seen a VAD before. I didn’t know you could walk around with your heart in a suitcase. What if someone tried to steal it? What if someone accidentally kicked it and it went skidding across the road? How did the patient summon the courage to leave the house, to leave their chair? The cardiac fellow thought that was funny. “They get the VAD so that they can leave their chair.” The case contained the battery that powers a pump sewn into the patient’s failing heart. It was a temporary measure to buy some time until the surgeons could cut the whole lot out, chuck it in the bin and replace it with a fresh heart, harvested from a brain-dead body. Now it’s possible to keep your VAD indefinitely; the briefcase battery has shrunk to a holster you can clip on your belt.

Mechanical organs that hang from your body are everywhere, redefining futility, liberating limits to treatment. There are a couple of ECMO machines in our intensive care unit. ECMO means extracorporeal membrane oxygenation: external lungs. A steel cannula as thick as your garden hose is inserted into a vein in your neck to suck your entire circulation through a hose into a machine that looks like a mini front-loading washing machine filled with blood; another line pours it back in. If it breaks down, the ICU doctors can use the back-up hand crank to keep it spinning. If you’re about to die unless your lungs and heart get a few days’ respite, then ECMO is for you. You can even stand up and do some physio, as long as someone holds your hoses of blood. I always stand at the door, my ankles aching with the fear that I’ll trip over those hoses. I know I would never have been brave enough to imagine diverting all that blood into a washing machine, let alone to try it out.

Extracorporeal organs aren’t as good as real flesh, and doctors can pretty much transplant every organ except the brain. Kidneys, livers, pancreases, corneas, skin and hearts do very well. Lungs are harder: they’re fragile, secretory nets, exposed to a toxic world with every breath. I saw a young man with severe cystic fibrosis in ICU a day after his lung transplant. I asked him how he felt. He was groggy but he looked up and said, “It’s incredible. I breathe in” – he took a deep breath, winced at the pain from the surgical incisions, and smiled – “and, for the first time in my life, I don’t feel all the crackling of my breath pushing through gunk.” It was thrilling, but a few months later the young man was dead: his new lungs had become catastrophically infected.

It seems like a fresh start, but you’ve just swapped one disease for another. You get rid of the old organ and replace it with a chunk of someone else that your body will attack for the rest of your life as if it’s an intruder. The organ transplant physicians are the most heroic of doctors. When an organ fails, they don’t give up. They get the patient a new one and treat the hell out of it.

Organ transplantation is a wildly expensive undertaking. And these extra­vagant, cutting-edge programs are rarely threatened by budget-slashing governments. Our resources and efforts could arguably be directed towards the more pedestrian afflictions of the global masses. Malnutrition, diabetes and malaria require access to a little medicine, a bit of food, a trickle of clean water. The money spent on one transplant could save hundreds, even thousands. But please, allow me to grab that old physician’s aerospace metaphor and run. Trying to fly to outer space might be seen as a reckless waste of resources. A lot of ugliness could be fixed with that kind of money. But that grainy black-and-white footage of Neil Armstrong bouncing on the moon also instils in me a crazy kind of hope, like, “Look at us, insignificant, but leaping for the universe with our scraps of science and gigantic imagination.”

We need to work towards a minimum for all, but that’s not enough. We set aside some of what we have for scientists to dream, so that what is futile today may be routine tomorrow. This is why doctors can plug someone into a VAD or ECMO, why they subject a patient to the brutalities provoked by an alien organ, why we tolerate the huge resource expenditure and the terrible risks taken with the would’ve-been-dead. Pack them up, send them to Mars; one day we might be able to bring them back.

Karen Hitchcock

Karen Hitchcock is a doctor and writer. She is the author of a collection of short fiction, Little White Slips, and the Quarterly Essay Dear Life: On Caring for the Elderly.

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