February 2014

The Medicine

Medicine's mission to Mars

By Karen Hitchcock
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.

There is nowhere quite like The Monthly. We are told that we live in a time of diminished attention spans; a time where the 24-hour-news-cycle has produced a collective desire for hot takes and brief summaries of the news and ideas that effect us. But we don’t believe it. The need for considered, reflective, long-form journalism has never been greater, and for almost 20 years, that’s what The Monthly has offered, from some of our finest writers.

That kind of quality writing costs money, and requires the support of our readers. Your subscription to The Monthly allows us to be the home for the best, most considered, most substantial perspectives on the state of the world. It’s Australia’s only current affairs magazine, an indispensable home for cultural commentary, criticism and reviews, and home to personal and reflective essays that celebrate and elevate our humanity.

The Monthly doesn’t just comment on our culture, our society and our politics: it shapes it. And your subscription makes you part of that.

Select your digital subscription

Month selector

From the front page

Kim Williams seen through window with arms half-raised

The interesting Mr Williams

At a time when the ABC faces more pressure than ever before, is its new chair the right person for the job?

Exterior of the Department of Treasury, Canberra

Tax to grind

Tax reform should not be centred on what we want, but on who we want to be

Rehearsal for the ABC TV show ‘Cooking with Wine’, March 13, 1956

Whose ABC?

Amid questions of relevance and culture war hostilities, the ABC’s charter clearly makes the case for a government-funded national broadcaster

Tony McNamara in New York City, January 2024

Pure things: Tony McNamara

How the Australian screenwriter of ‘Poor Things’, who cut his teeth on shows such as ‘The Secret Life of Us’, earnt his second Oscar nomination

In This Issue

‘Blue Is the Warmest Colour’ and ‘Nebraska’ film reviews

New work from directors Abdellatif Kechiche and Alexander Payne

Scott Morrison at Shirelive

Presents, prayers and asylum seekers

Rebecca Mead’s ‘The Road to Middlemarch’

Text; $32.99

Andrew Upton goes solo

It’s a new era for Sydney Theatre Company’s artistic director


Online latest

Osamah Sami with members of his local mosque

In ‘House of Gods’, Sydney’s Muslim community gets to be complicated

Plus, Barnaby Joyce shines in ‘Nemesis’, Emma Seligman and Rachel Sennott deliver ‘Bottoms’, and Chloë Sevigny and Molly Ringwald step up for ‘Feud: Capote vs. The Swans’.

International Film Festival Rotterdam highlights

Films from Iran, Ukraine and Bundaberg were deserving winners at this year’s festival

Two women on a train smile and shake hands

‘Expats’ drills down on Hong Kong’s class divide

Plus, Netflix swallows Trent Dalton, Deborah Mailman remains in ‘Total Control’ and ‘Vanderpump Rules’ returns for another season

Image of a man playing music using electronics and the kora (West African harp)

Three overlooked albums of spiritual jazz from 2023

Recent releases by kora player John Haycock, trumpeter Matthew Halsall and 14-piece jazz ensemble Ancient Infinity Orchestra feel like a refuge from reality