HemoDoc, From Doctor to Patient

Pushing Organ Procurement Ethics Over the Slippery Slope

By Peter Laird, MD

The dead donor rule serves organ donors protecting those that can no longer speak for themselves. Tragic cases of death by organ donation are not talked about especially in the renal community yet they are documented and continue to occur in large part due to the lack of uniform brain death criteria throughout the US. Though fortunately rare in occurrence, anyone that has seen the NBC news report on the Zack Dunlap case should seek legislation assuring that no one would ever die as a result of death by organ donation. (here)

Unfortunately, coupled with paradoxical outrage at a Wall Street Journal article documenting the rare cases of death by organ donation, medical ethicists recently turned the discussion to procuring organs prior to the death of the donor. Although there were some ethicists who spoke against this newly proposed donation policy, many supported this new medical ethics paradigm.

The Case for Kidney Donation Before End-of-Life Care

Donation after cardiac death (DCD) is associated with many problems, including ischemic injury, high rates of delayed allograft function, and frequent organ discard. Furthermore, many potential DCD donors fail to progress to asystole in a manner that would enable safe organ transplantation and no organs are recovered. DCD protocols are based upon the principle that the donor must be declared dead prior to organ recovery. A new protocol is proposed whereby after a donor family agrees to withdrawal of life-sustaining treatments, premortem nephrectomy is performed in advance of end-of-life management. Since nephrectomy should not cause the donor's death, this approach satisfies the dead donor rule. The donor family's wishes are best met by organ donation, successful outcomes for the recipients, and a dignified death for the deceased. This proposal improves the likelihood of achieving these objectives.

As a renal disease sufferer, I initially considered pre-emptive renal transplant with donation from my wife. However, after considering both my prior history of cancer and risk of cancer recurrence after renal transplant and the risks entailed for my wife, I declined to pursue that option and then focused on optimal dialysis considerations. After all, renal disease is my disease and my responsibility. I do regret the loss of the kidneys that God granted to me, but I do not believe I have any right to another persons kidney whether dead or alive. It is a gift, it is not a right of any person with renal disease. 

It appears to me that in many ways, the renal community has transformed renal donation into a right over the last two decades. Presumed consent at its heart gives ownership of vital organs by the state for all those that don't opt out of this system utilized in Spain and other nations. While I value the gift of organ donation, I still cherish my civil liberties and I would hope that the demand for renal donation would never preclude our right to liberty and self determination. Once again, it is my disease, not someone else who is a complete stranger to me who has their own right to life, liberty and the pursuit of happiness.  In many ways, I personally would much rather die from my renal disease than see my renal disease used as a means of of encroaching another man's civil liberties.

I fear that I am in the minority opinion among my friends and colleagues in the renal community. It appears that just about any means of increasing renal donation no matter what the ethical implications of those policies and procedures is gladly welcomed by the renal community at large. Presumed consent, abandonment of the dead donor rule, donation by cardiac death and now kidney donation before end of life care infringe civil liberties for society in general and push the organ procurement ethical framework over the slippery slope endangering individual societal rights.

While I am sure that I will likely be in the minority opinion on this issue among the renal community, I must still question whether there are limits we should not cross in providing all available ethical renal donations? Changing the definition of what is ethical is a dangerous slippery slope that poses risks to society at large. Should we not who are most at risk in this society from our own renal disease support the protection of others who can no longer speak for themselves in their own tragic circumstances and forgo our greed for their organs by ever changing medical ethics?

American society decades ago saw the dangers of euthanizing anencephalic children and harvesting their organs recognizing the sanctity of person-hood in these children doomed to a sure death shortly after birth. I suspect our current modern society will re-evaluate that decision as well one day. I don't see these changes in our medical ethics as a positive change in any manner. I believe it shows a callous disregard of our human condition and respect and dignity for the individual and life in general.

We in the renal community must consider that same callous disregard for individual lives could in the end be the same sort of justification given to terminate treatment of those with renal disease as well. We are on the high price, low benefit scale according to many medical ethicists with some questioning how we perform dialysis in America. (here)  The renal community needs to be very careful what we ask for as there are always consequences of seemingly small decisions. 

Donation prior to death should never be the standard for organ procurement. I would hope that the renal community would understand this better than the general population since it was the respect for individual life that spurred the 1973 ESRD program funding in the first place. Losing this fundamental ethical paradigm could have untoward outcomes on continued ESRD funding in the future. The demand for kidneys today should not subvert the ethical foundations that secure our future especially in a time of limited resources.

I personally call upon the renal community to stand up and firmly disengage from the pursuit of renal donors at any cost through alteration of long held ethical paradigms. I would hope that the renal community will instead reaffirm the dead donor rule and set limits on the ethics of organ procurement. Respect for all life begins by recognizing the importance of the individual no matter what circumstances they encounter. Is that not the story of the ESRD program in 1973? If we won't stand up for those at risk of death from trauma and other illnesses, who will stand up for us in our time of need that the future shall surely bring.

Men Will Live as Long as Women by 2030

By Peter Laird, MD

Historically, during the twentieth century, women lived longer than men by an average of over five years.  Finally, the statisticians are now offering men a ray of hope that they will actually live as long as their mates. Projecting current trends predicts a convergence of life expectancies for men and woman in the year 2030.

Heart disease classically affects men about tens years earlier than woman providing a partial answer as to why women live longer on average than men in the western nations.  Improvements in the treatment of heart disease is also at the center of the projected convergence. The good news for women is that their life expectancy is also continuing to increase, just not as rapidly as men.  That is the good news for all concerned.

The bad news is that the increased longevitys will pose more burdens upon the health care system. Medicare beginning at the age of 65 was initiated at a time when the average life span was not much longer than the retirement age itself. Today, many in their mid-sixties are still actively engaged and turn retirement into a time of leisure activities and travel. Improvements in health care are behind the progressive increase in longevity, but likewise comes at the price of ever increasing health care costs. While the convergence of longevity is good news for men, those that calculate actuarial costs in health care are left with one more paradox brought about by our own success in modern medicine.  

In a time of ever increasing budget constraints especially in health care, the costs of living longer may in itself adversely affect these trends. No one can predict the future with any degree of accuracy, but I would rather have to deal with living longer and wondering how to pay to stay alive, than to not have to worry about the latter issue.  Sadly, there is no convergence expected for when men will be as intelligent as women as my wife will readily attest.

To Spend or Not to Spend: That is the Question

By Peter Laird, MD

During the course of my career in internal medicine, I have observed the changing of the gaurd from the days of indepth investigation of all symptoms and abnormalities to the new ethics of today that calls for limited investigations and more focused treatments. Many of the new physicians growing up under this new fiscal restraint truncate their considerations of the causes of these symptoms in algorithmic precision. For the majority of patients, this approach will work since what is common is common. However, algorithms fail when patients presents with illnesses not considered within these cook book medical recipes.

The only antidote for those patients is old fashioned, Oslerian methods of investigation of clinical inquiry and focus on the patient as a clinician-scholar making close observations and developing clinical hypothesis from these observations.  There are no short cuts nor cook book medical rhymes that can replace the trained clinician applying the Oslerian medical precepts. Sadly, with the high tech, specialized clinical practice of today, the art of medicine is often overlooked often to the detriment of our patients.

The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Sir William Osler

What is lacking today in many ways is the connection between doctor and patient that technology and fiscal policies dictate to the young clinicians beginning their practices. I observed many new physicians more concerned about getting home by 5:00 than taking the time to observe, collect data, hypothesize and produce a combination of effective diagnostic testing and treatment alternatives. And at the same time instructed the patient to feel comfortable engaging these plans.

Such an approach is not only time consuming but at times expensive. An in depth analysis always generates more questions needed answering than the cook book algorithmic methods of today that usually covers the top 90% of cases, but over looks the 10% that are rare and uncommon. Once again, the new methods work in a cost containing society but fail in the real world of individual patients.

Interestingly, a recent study supports the concepts of the Oslerian method of medicine more so than this new medical ethics focused on cost containment first and foremost. The common denominator speculated by one commentator was that of the pursuit of academic excellence at the bedside in teaching hospitals. The teacher-clinician model of medicine exemplifies the Oslerian method.

Best Care may Be at Hospitals That Spend Most

"Higher-spending hospitals differed in many ways, such as greater use of evidence-based care, skilled nursing and critical care staff, more intensive inpatient specialist services, and high technology, all of which are more expensive," they wrote.

In an accompanying editorial, Karen Joynt, MD, MPH, and Ashish Jha, MD, MPH, of the Harvard School of Public Health in Boston, added that the nature of a hospital's mission could also influence outcomes.

"Features that make a hospital high cost, such as a teaching mission or research mission, may actually be related to better outcomes," they wrote. "Thus, it is possible that it was not spending per se that improved outcomes but rather the teaching intensity or academic expertise more common at high-cost hospitals."

The idealistic aspects of medical training quickly fall to the constraints of time and limited resources for the majority of physicians in daily practice. During my training, one of the aphorisms I heard many times over was the the best medicine in the long run was the cheapest. Preventing complications and further hospital admissions and associated treatment costs is best approached by gettting the diagnosis and treatment alternatives correct the first time around.

I am at times appalled when witnessing the cost containing methods of home dialysis programs that skimp on medically needed supplies such as giving me one roll of tape for an entire month while over looking the tremendous cost savings of a home dialysis program after higher upfront costs are considered. The penney wise and pound foolish approach to medical care in America appears to be the new mantra in the health care industry, and especially for dialysis patients.  Early in my career, I would ponder the consequences of the cost of the evaluation on my own ratings, but I soon put that aside and focused only on the patient. Needless to say, many times over I was less than popular with the bean counters.

The intensity and thoroughness of evaluations and therapies are the most important aspect of high quality medical care as taught by Sir William Osler over a hundred years ago. It all begins with a doctor that can listen and observe. It is time to return to the rudimentary traditions that gave us the most effective health care system ever known.  There is a time to spend and prevent and repair  instead of dealing with the inevitable costs of failing to seek the highest care for each patient that presents to a doctors office. In the end, the best care is the cheapest.

Burning the Midnight Oil: Sleep Disorders Common in Dialysis Patients

By Peter Laird, MD

One of the areas of discord in my home dialysis program is the different sleep patterns my wife and I experience. When we do dialysis in the evening, my wife becomes sleepy before we finish our session, but for me, as soon as the session is over, I usually can't sleep for another two to three hours. It is not uncommon for me to still be awake at two o'clock in the morning while my wife wakes up by seven in the morning.  I suspect she enjoys her quiet time to herself for different errands she does every day, but for me, when I do have to wake early, I have no choice but to condition myself for several days ahead of time and do our dialysis earlier in the day. Sleep disorders are a common complaint of patients on dialysis with insomnia noted in nearly 70% of the dialysis population.

Sleep disorders in patients with end-stage renal disease undergoing dialysis therapy

Results. The questionnaire revealed the presence of insomnia (69.1%), RLS (18.4%), OSAS (23.6%), EDS (11.8%), possible narcolepsy (1.4%), sleepwalking (2.1%), nightmares (13.3%) and possible RBD (2.3%). Eighty percent demonstrated SLEEP+, having at least one sleep disorder. Independent risk factors for sleep disorders were advanced age (P<0.001), excessive alcohol intake (P<0.04), cigarette smoking (P<0.006), polyneuropathy (P<0.05) and dialysis shift in the morning (P<0.001).

Conclusions. The questionnaire showed a high presence of sleep disruption in dialytic populations. Awareness by Italian nephrologists regarding sleep disruption seems to be insufficient. Our data might help nephrologists to deal with uraemic patients with possible sleep disorders. Concerning the high prevalence of possible narcolepsy, further studies using polysomnographic records are necessary to confirm our results.

Increasing the frequency of dialysis improved the symptoms of restless leg syndrome (RLS) in the FREEDOM study (here) and basic sleep hygiene techniques can be helpful. Exercise is one of the key components of preserving health while on dialysis and may help reduce some of the effects of sleep disorders.  For patients with obstructive sleep apnea syndrome (OSAS),  prolonged nocturnal dialysis reduced the severity of symptoms by as much as 50%. (here)  Conventional in-center hemodialysis is complicated by many symptoms including sleep disorders which further compromises patients quality of life. 

While I do still have difficulty sleeping until late at night, overcoming the symptoms and complications of dialysis requires a true holistic approach including close adherence to proper diet, exercise and maintaining sleep habits rounds out the strategies for feeling as well as we can. Daily dialysis and nocturnal dialysis assist greatly in all of those endeavors.

Clostridium difficile Infections Spreading Throughout Health Care Facilities

By Peter Laird, MD

Infectious diseases around the world are becoming more common and prevalent due in large part to the lax hand hygiene standards among health care professionals. One serious infection on the rise throughout America is Clostridium difficile (C. Diff) that causes diarrhea and other serious complications. It is an insidious organism that is easily passed from objects and staff who fail to wash their hands. Sadly, proper hand hygiene and judicious use of bleach on points of contact essentially limits all risks from this growing pathogen that is now becoming resistant to all antibiotics:

Making Health Care Safer: Stopping C. difficile Infections

People getting medical care can catch serious infections called health care-associated infections (HAI). While most types of HAIs are declining, one – caused by the germ, C.difficile – remains at historically high levels.C. difficile causes diarrhea linked to 14,000 American deaths each year. Those most at risk are people, especially older adults, who take antibiotics and also get medical care. When a person takes antibiotics, good germs that protect against infection are destroyed for several months. During this time, patients can get sick from C.difficile picked up from contaminated surfaces or spread from a health care provider's hands. About 25% of difficile infections first show symptoms in hospital patients; 75% first show in nursing home patients or in people recently cared for in doctors' offices and clinics.

As the armaments against infectious disease are rendered ineffective from resistance, returning to simple and capable cleaning measures is once again at the forefront of our defenses against these agents. The specter of disease in this case is not only a danger to patients, but to health care professionals as well. At some point, the realization that health care workers who fail to protect their patients by proper hand hygiene and environmental cleaning of patient rooms will also place themselves at risk as well as their families with these easily transmitted pathogen. Once again, it is not a high tech solution that shall reduce this spread, but only simply following basic hygiene guidelines first championed by Ignaz Simmelweis over a hundred and fifty years ago. It seems his discovery is still ignored today, all to our great demise.

Walking in the Shoes of Your Patients

By Peter Laird, MD

I came across two recent articles on experiencing direct patient care to raise the level of empathy among health care professionals. The first article in MedScape is written by a practicing physician who had several suggestions for medical students to experience before they ever laid hands on any patients:

What Should Medical Students Experience Before They are Allowed to Touch Patients?

The object of this exercise would be to help students develop the sensitivity and compassion appropriate to carrying for patients well. So I'll start of the list of what med students should be required to experience, both men and women, before they are allowed to go near patients, in no particular order: 

1. Placement of an NG tube. 

2. Rectal exam done in the same bent-over position that we ask men to assume for their prostate exams, for both men and women. 

3. Pelvic exam done in the lithotomy position for both men and women. 

4. Venipuncture with drawing of at least 8 tubes of blood. 

5. Upper and lower GI. 

6. BG monitoring at least twice daily for, say, a month. 

7. Urinary catheterization. 

8. Hospital stay of at least 3-4 days as a "mystery patient" with a contrived diagnosis, including access to hospital food only, strict I&O, daily AM fasting labs, multiple dosing of placebos, ordered with specifications around mealtimes, sleep etc. At least one day of strict bedrest. This experience must take place in a teaching hospital under the care of a team not alerted to the identity of the patient. 

I must confess I don't know what medical students experience in school any longer, but we used each other to practice several of these tasks such as NG tubes and blood draws.  It was rather comical to see an NG tube coming up and out the mouth on the first nervous attempts instead of going correctly down into the stomach. Unfortunately, throughout my training there were many examples of fellow students with serious illnesses. I was one of those in medical school who suffered such an example with a testicular cancer in my third year of medical school. After I healed from the operation, I underwent daily radiation treatments and then went to my OB/GYN rotation seeing "real" patients right after the radiation. I learned to appreciate Lomotil which saw me through those three weeks.

Dr Belding Scribner often stated to be a good physician, you first must be a patient. Being able to identify with individual fears and suffering tempers the grandiosity also associated with being a doctor, especially in the early years of a career. However, other than venopuncture and NG tube placement which we did on each other, I could not recommend the other procedures on the this list because they are associated with side effects and risks of complications that precludes this sort of unnecessary torment. 

When I was nineteen, I worked as an orderly covering the shifts for three other orderlies on their days off. That meant I worked all three different shifts each week since the other three orderlies all had set work times. During the night shift, I worked in the Emergency Room and the majority of the time, I did the initial triage evaluations on patients seen during those late hours. I would take vitals and briefly interview the patient about their symptoms and concerns. I would then wake up the doctor asleep in his call room and stay and assist him during his examination. The most notable patients were trauma patients who came in covered in blood. It was my job to clean up their bloody wounds before the doctor placed sutures.

Invariably, every single time I saw someone in pain and bleeding, I had a visceral reaction with chills running up and down my spine. Fortunately, I have never experienced that type of trauma and I hope to never in the future, but I didn't need to experience directly those injuries to understand the impact it was having on the patients laying before me.  This reaction never prevented me from doing what I needed to do, but I would hope most people are uncomfortable when they see other people in pain and suffering. When we graduated, my medical school class chose the Oath of Maimonides instead of th Hippocratic Oath. Today, I believe it expresses well the necessary temperament needed of physicians to view patients as fellow creatures in need:

The Oath of Maimonides

The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily decieve me and make me forgetful of my lofty aim of doing good to Thy children.

May I never see in the patient anything but a fellow creature in pain.

Grant me the strength, time and opportunity always to correct what I have aquired, always to extendits domain; for knowledge is immense and the spirit of man can extend indefintely to enrich itself daily with new requirements.

Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.

The second example of sampling the life of their patients was among renal dietitians who took their own advice for five days by experiencing a renal diet.

The "Walk the Talk" challenge at St. Michael's Hospital

It's my last day on the renal diet....I MADE IT!! (barely!)  It was not an easy week...and I have to admit that I cheated today and had whole wheat bread.  My colon was begging me for some fibre!   

I also went out for dinner last night for a friend's birthday, and the birthday girl decided on Chinese food.  Since I have been depriving myself of fluid and feel quite dehydrated, I had an extremely difficult time controlling my thirst after our salt-laden Asian meal.  Actually, I went home must have drank a litre of water!  I'm positive that if I were a dialysis patient, I would be fluid overloaded right now!

This week has been an eye-opener.  My colleagues and I realized just how difficult it is to change life-long habits, and we only changed one small aspect of our lives.  Our patients on dialysis have so many more changes they have to face - being on a machine 4 times a week, taking an abundance of medications at different times of the day, limiting their favourite foods, not travelling as they please, not being able to work....the list could go on and on. 

I do applaud those that participated in this renal diet challenge, but as some commentators on IHD noted, the renal diet as restrictive as it is still affords a broad enough selection to eat well. I tell people that I do have a restriced diet, but I am not deprived especially since starting on daily home hemodialysis. I eat oranges, bananas, spaghetti, potatoes, tomatoes, ice cream  and pizza, all in moderation of course.  Sodium is the worst contender along with phosphate preservatives and additives. While it is difficult to find food items acceptable to a renal diet, anyone that has tried Zach's famous chunky chile would tell the renal diet challenge folks to lighten up and use their imaginations a bit more to make the renal diet much more palatable. (here)

When I first started on dialysis, my renal dietitian recommended a book called: Cooking for David. The devoted wife of a dialysis patient spent years developing and cataloging renal friendly foods that her husband enjoyed. My wife and tried several of the recipes and I used to enjoy her Pita Pizza recipe on a regular basis. My life was restored from the first day of home hemodialysis training with potatoes, oranges and bananas for the first time in two years.

Yes, by all means consider methods of teaching health care professional empathy for their patients, but I would avoid first of all avoid advocating for any test that care potential risks which eliminates nearly all of the list above and secondly, use a bit of imagination to not only survive a renal diet, but also to thrive. After all, day and day out, the renal diet is one of the most important aspects of remaining healthy on dialysis and life is too short to not enjoy a pot of spaghetti from time to time. All things in moderation gives me little I can't eat if only to get what I call a taste of taste. We are all one of God's creatures and healthy or not, all of us have had our share of pain and suffering. Perhaps that is the prerequisite needed to be a doctor or other health care professional.  Yes, Dr. Scribner is absolutely correct that to be a good doctor you need to be a patient first, but short of that, perhaps all that is needed is to simply have a heart.

Marvels of Modern Medicine: The Skin Gun

By Peter Laird, MD

Modern medicine is replete with examples of new technologies that have helped relieve the suffering of patients with various conditions. One area of medicine that has evaded progress is those with severe burns which are hampered by the inevitable infections that cause the majority of deaths after severe burns. An acquaintance posted the following video on Facebook that may revolutionize the treatment of burns.

 

Perhaps one day, regeneration of organs will be the operative method of treating many illnesses.  For those on dialysis, being able to regenerate your own renal tissues in a functional manner or repair your own damaged kidney may one day prove to be the optimal renal replacement therapy and give the term RRT a very new meaning. Many researchers believe that the type of advance in the video above with the skin gun, may in fact become the reality of nephrology in the future.

Kidney regeneration

Neonephrogenesis, the capacity to regenerate renal tissue, is a distinctive feature of fish but not usually of mammals. However, evidence exists for kidney repair in response to insulting agents for animals and human beings. Studies have therefore been designed in the past few years to clarify the cellular and molecular basis of renal repair, with the aim to investigate the potential regenerative capacity of animal and human kidneys. Three main questions are being addressed by this research: whether terminally differentiated cells in adult animal kidneys have regenerative capacity; whether multipotent progenitor cells exist in kidneys; and whether renal repair can be favoured or accelerated by cells of extrarenal origin migrating to the kidney in response to injury. In this Review, we describe evidence of cellular and molecular pathways related to renal repair and regeneration, and review data from animal and human studies that show that the kidney might have regenerative capacity.

Renal repair and regeneration sounds much better than being hooked up to my dialysis machine hour after hour. Mind you, I am ever bit grateful for the modern marvel called dialysis, but just as "spray painting" skin stem cells onto a severe burn providing a permanent cover in a matter of days would have sounded as crazy as does regerating an entire kidney. For now, I can only be thankful that one less group of patients with severe suffering is now looking to a much brighter future with essentially a cure leaving no scars and eliminating months of expensive medical care with a high morbidity and mortality. Most importantly, the elimination of weeks and months if not years of pain and suffering that often results in severe disfigurement and disability may be the greatest benefit of this new technology.

The genius of man by God's grace when applied to relieving pain and suffering is nothing short of a modern marvel. Between the time that a regenerated kidney becomes a reality if these hopes are one day realized, renal replacement therapy is an area of modern research where new and innovative technological marvels could themselves relieve much pain and suffering seen across America each and every day. Today, we still have the essential components of dialysis which were invented in the 1960's. Perhaps one day, the technological breakthrough coupled with the will to relieve pain and suffering will propel renal replacement treatments into an entirely new realm. We can only hope and dream and pray for God's wisdom and grace that it would be so.

Climbing the Sedentary Mountain of Apathy: College Students Are Exercising Less

By Peter Laird, MD

Exercise is one of the most important cardiovascular health interventions at any age and is an important adjunct for reducing the risk of CKD later in life. Diabetes, HTN and obesity are all related to the trend in American society to not engage in enough physical activity to maintain heart health. An interesting and yet disturbing study shows that physical activity actually declines for young adults while in college:

Physical Activity and Other Health-risk Behaviors During the Transition Into Early Adulthood:

Results

Overall, there was a 24% decrease in physical activity (equivalent to 1 MET/day) across the 12-year period. A significant three-way time X gender X educational trajectory interaction (coefficient= −0.189, SE=0 .09, p<0.05) emerged in the physical activity analysis; main effects in time² (coefficient= −0.114, SE=0.01, p<0.01) and time³ (coefficient=0.028, SE=0.01, p<0.01) were significant for binge drinking and smoking, respectively.

Conclusions

Physical activity decline was evident during young adults' transition into early adulthood, with declines being steepest among men who entered a college/university. Although there were increases in several health-risk behaviors during adolescence, individuals tend to grow out of binge drinking and smoking as they mature.

I read this report in somewhat of dismay remembering my own time in college where I ran cross country and track and engaged in my most physically active years, even more so than in high school where I played football in my senior year. As a child growing up in Alaska, we were essentially outside playing, riding bikes, hunting, fishing and playing neighborhood games with up to 50 other kids at the same time. We only stayed indoors on the very coldest of days even when we lived in Nome Alaska.

Today's children start out with a markedly reduced level of physical activity from the age of 12 and to witness a study documenting that this level of physical activity sharply declines during the college years does not bode well for reducing the number of patients entering the ESRD program later in life.  Sadly, there appears to be little that the health care industry can do to reverse this with the failure of dozens of programs over the last two decades. Society is no longer able to allow children to run around town unsupervised as we did just one generation ago if for nothing more than their own safety in this changing world.

The only hope in many ways is for parents to recognize the challenge to imbue their children with the opportunity and the desire to be physically active from an early age. Turning off the TV and video games is still under their control. Unfortunately, many parents today use these devices as a domestic baby sitter starting the process of sedentary lifestyles from an early age. School systems are discarding physical education programs in exchange for more computer time. High fructose corn syrup permeates not only our snack foods and sodas, it is also in many of our processed foods popular today. Perhaps it is too late to turn back the hands of time, but it is certainly not too late for individuals to take action. In many ways, society is nothing more than individuals setting priorities and acting upon them in the first place. Truly, it all begins at home.

Harbor-UCLA Infection Control Deficiencies: A Climate of Disregard

By Peter Laird, MD

Harbor-UCLA medical center made headline news recently for severe public health infection control issues cited in a 55 page report. (here, here)  Reading though this lengthy report reveals a climate of disregard for basic infection control procedures that affected every aspect of medical care throughout the entire hospital. The Federal government responding to these serious deficiencies with a threat of withdrawing Medicare funds should the hospital fail to correct the outcomes of the report. Hospital officials responded to local news blaming the deficicies on the age of the building:

Inspectors: Harbor-UCLA Hospital Unsanitary

Harbor-UCLA executive Delvecchio Finley said the hospital has addressed all the concerns raised by inspectors, according to the Times. Nevertheless, Finley told the Times, issues continue to arise because of the age of the hospital, which was built in 1963.

"It's an old building," he told the newspaper's Anna Gorman. "Because of that, there are certain challenges."

However, despite the fact that some of the deficiencies were related to the infrastructure needs of the hospital, many more were blatant failures to adhere to simple hygiene standards expected of health care professionals. My medical training at Boston City Hospital was in a building over 100 years old, but I learned to wash my hands and scrub properly for surgical procedures, a task that I took seriously not only for the prevention of nosocomial spread of disease to my patients, but also to my own family when my work was completed.  Infection control begins with an attitude of professionalism understanding hygiene standards and caring enough to take the time to perform them with each and every patient, every time.

The inspectors focused mainly on the surgical and in-patient areas, but they also found serious procedural errors in the dialysis unit including failure to respect patient privacy, improper chloramine testing, failure to test for endotoxins since 2007, no policy and procedure for endotoxin testing and no policy for notification by the water utility for changes in chloromine concentrations. All of these irregularities place patients at risk each time they undergo hemodialysis in this unit.

Canada promotes a new climate of infection control through their Stop! Clean Your Hands Day annual promotion. Thousands of patients die each year by the lack of attention to simple and basic concepts by the people they trust with helping and curing their illnesses. Over a hundred and fifty years since Ignaz Semmelweis first showed the benefits of washing your hands between patients, it remains one of the most serious health care issues today. Dr. Semmelweis was ridiculed, insulted and castigated for his suggestions that doctors were causing the deaths of the obstetrical patients attended shortly after they performed autopsies. The fact that Canada has to remind healthcare professionals about the most basic infection control procedure demonstrates the remarkable personal and collective failure of doctors, nurese, lab techs and all of the people employed throughout this industry.

The ghost of Dr. Semmelweis haunts the halls of every hospital throughout the world with the knowledge that many health care professional are still the cause of death to thousands of patients entrusted in their care through a lack of personal handwashing. Until the health care industry develops an attitude of infection control at every level, there remains little hope that this climate of disregard shall ever end. 

Transplant Candidates Aided by Bariatric Surgery

By Peter Laird, MD

Many patients with end organ damage face the challenges of staying alive with only the hope that they will receive a transplant in time. For obese patients in need of a healthy organ to stay alive, many are without any hope due to weight restrictions for transplant candidates. However, with the advent of bariatric surgery for weight loss, some transplant centers are expanding the pool of eligible candidates by utilizing weight loss surgery prior to graft donation. In one remarkable case, a patient in need of a heart transplant underwent bariatric surgery while supported by an artificial heart.

Weight-loss surgery aids transplant candidates

Martha Magdaleno suffered from an enlarged heart that left her perennially breathless.

"I couldn't do anything, like shower," the 55-year-old mother of four in Inglewood said through an interpreter. "Even when I brushed my teeth, I would be out of breath."

Her condition grew so severe that, in 2006, cardiologists implanted an artificial heart to assist her failing organ and put her on the waiting list for a transplant. That pump died after eight months, and doctors had to replace it. . .

But Dr. Jon Kobashigawa, director of the heart transplant program at the Cedars-Sinai Heart Institute in Los Angeles and Magdaleno's cardiologist, was determined to get his patient back in shape for a transplant. He sent her to the Khalili Center for Bariatric Care in Beverly Hills, where Dr. Theodore Khalili performed a gastric bypass operation on her in early 2010. As far as anyone knows, it is the only time such weight-loss surgery has been performed on a patient with an artificial heart.

The risky procedure paid off. Magdaleno began losing weight, "about a pound or 2 a week," she said. By February, her weight had dropped to 165 pounds, and Kobashigawa placed her back on the waiting list. On a Sunday afternoon in June, she had a successful heart transplant, receiving a new organ from a 27-year-old man who died in an accident.

This procedure may become a standard treatment for ESRD patients who fail the initial assessment due to obesity. For patients to experience the full benefits of bariatric surgery, the patient must understand that it is a tool to combat obesity, but it is not a cure. Many patients will regain all or most of the weight lost initially if they do not change unhealthy habits and learn to eat well and exercise. Unfortunately, obesity is also a significant cause of ESRD combined with the co-morbidities most often associated with obesity, diabetes and HTN.

After observing several patients undergo bariatric surgery and the many complications that can occur, despite the utility of this procedure, the better part of valour is to avoid morbid obesity at an early age when life style changes have their most dramatic effects. Unfortunately, as efficacious as bariatric surgery is in the case of Martha Magdaleno, it will inevitably add to the financialy burden of a population already at the highest end of medical care utilization. That in the end may become the most important determinant of how often this combined surgical treatment will become.