November 26, 2016

"When this patient loses his pulse... instead of trying to coax the heart back into activity, the surgeon will start pumping the body full of ice-cold saline at a rate of at least a gallon a minute."

"Within twenty minutes (depending on the size of the patient, the number of wounds, and the amount of blood lost), the patient’s brain temperature, measured using a probe in the ear or nose, will sink to somewhere in the low fifties Fahrenheit. At this point, the patient, his circulatory system filled with icy salt water, will have no blood, no pulse, and no brain activity. He will remain in this state of suspended animation for up to an hour, while surgeons locate the bullet holes or stab wounds and sew them up. Then, after as much as sixty minutes without a heartbeat or a breath, the patient will be resuscitated. A cardiac surgeon will attach a heart-lung bypass machine and start pumping the patient full of blood again, cold, at first, but gradually warming, one degree at a time, over the course of a couple of hours...."

From "CAN HYPOTHERMIA SAVE GUNSHOT VICTIMS?/A new procedure freezes trauma patients who are bleeding out in order to buy time to operate."

Experiments have been done with dogs and pigs, but how do you ethically try this on a person? Will the ethicists waive the usual consent requirements?
Prospective patients, being clinically dead, will be incapable of giving consent, and the speed of treatment—the decision to begin E.P.R. has to be made within a matter of seconds—precludes identifying, let alone contacting, the next of kin. (The F.D.A. requires informed consent for all human medical trials, but it does grant exceptions for emergency research.)
There's a whole racial angle to that question, as the idea is to test this at the University of Maryland’s R Adams Cowley Shock Trauma Center in Baltimore:
Of the more than nine hundred people who were shot in the city last year—three hundred of whom died—more than ninety per cent were male, more than ninety per cent were black, and most were under the age of thirty.... Because of the consent issue, an institutional review board at the University of Maryland required [surgery professor Sam] Tisherman to devise a way for people to elect not to be enrolled in advance. He designed a red rubber bracelet.... Anyone wanting to opt out could request one and wear it at all times....
You have to wear a bracelet all the time to say no? Why not make the bracelet mean yes? At one "community-consultation" one man said: "We’re guinea pigs—your body language says it!"
Tisherman winced. The man’s point was essentially unanswerable. African-Americans have indeed been used as guinea pigs, the unwitting victims of full-body radiation or unnecessary surgeries conducted in the name of research. The Tuskegee syphilis experiment, in which lifesaving treatment was withheld from black men for forty years so that scientists could study the disease, is merely the most infamous example. As a result, mistrust of the medical establishment has long been widespread among African-Americans. In 1982, Clive Callender, a surgeon at Howard University, published a study showing that many African-Americans feared that surgeons might actually withhold advanced resuscitation measures from black patients in order to harvest their organs for sick white people.

29 comments:

Rob said...

No brain activity? Apparently it's already been tested on the president of Hampshire College.

Cacimbo Cacimbo said...

"many African-Americans feared that surgeons might actually withhold advanced resuscitation measures from black patients in order to harvest their organs for sick white people."

Plenty of white people refuse to check the organ donor box on their license because they believe doctors will not try as hard to save them because they want their organs. I just never heard a white person blame the decision on race.

buwaya puti said...

This is one of those areas where China has a competitive advantage. They should outsource human testing to China. They dont care.

If it works the Chinese can tell everyone else.

Michael K said...

Hypothermia using blood cooled has been used in heart surgery for years. Many years ago, it was used in children to do big heart cases without bypass. They were cooled and the heart stopped while surgery was performed. I think that was abandoned because many of the children did not have normal neurological function.

The EPR method is being tried but no results are mentioned.

In trauma with exsanguination, closed chest CPR is useless. I have written about this in one of my books. My practice was to open the chest and massage the heart directly. It is much more efficient. If bleeding below the diaphragm is suspected, the aorta is clamped in the chest, I have had many such cases.

Maybe cold saline will work but that would be a very small set of cases I think. Hypothermia does work in head injuries but it is applied externally. The head is packed in ice.

The Godfather said...

So the large majority of people who would benefit from this procedure (if it works) would be Black? Wouldn't it be racist to oppose developing the procedure?

Ann Althouse said...

"Plenty of white people refuse to check the organ donor box on their license because they believe doctors will not try as hard to save them because they want their organs. I just never heard a white person blame the decision on race."

That's right. White people are relieved of this fear. However unrealistic the race-based fear might be, you ought at least to feel some empathy for the people who carry this weight. Acknowledge that it's not based on nothing. The Tuskegee experiment was very real.

What's so sad is that young black men in Baltimore are dying of gunshot wounds and these doctors really do seem to want to figure out how to close wounds before the brain is lost, but the doctors can't be completely trusted. The doctors themselves must know there is a mystery to their motivations. Even they can't really know. They want to figure out how to save people, and they are working very hard. They've put themselves where they can expect to receive trauma patients. And they're not about changing the environment that create these patients. So in a sense, they are taking advantage of a tragedy, seeing it as their opportunity.

coupe said...
This comment has been removed by the author.
Big Mike said...

I don't see the ethical issue at all. If you try regular therapy the patients are dead anyway. Probably. Almost certainly.

Michael K said...

My information is that blacks are much less likely to volunteer for organ donation. This has been cited as a problem with black potential recipients, I've never heard of a white resistance to organ donation. When I ran a trauma center we had a coordinator who spoke to the family as soon as it looked like we had a donor. The treating doctors NEVER did this. It was always a third party, usually a nursing supervisor who was especially interested in transplants.

Who went for years without ever having a family refuse to donate a loved one's organs.

William said...

What if the patient wakes up with an insatiable craving for the taste of human brains?

Cacimbo Cacimbo said...

"White people are relieved of this fear."

Whites have also been experimented on without consent. Wikpedia lists a variety of cases. "The Plutonium Files" exposed decades of experimentation. Blacks have no special claim on being unwilling guinea pigs. Empathy in this case sounds like an attempt to justify the inexcusable. Not only are blacks less willing to donate organs. they do not even donate blood at the levels their community requires. Blood donation rates of African Americans are 25-50% of that of white individuals. Rather than excusing their fear blacks need to be held to the same expectations of every other ethnic/racial group.

https://en.wikipedia.org/wiki/The_Plutonium_Files

The article describes this as a procedure of last resort. Most next of kin would want every possible means used to save a previously healthy young man.

Harold said...

Not only are blacks less willing to donate organs. they do not even donate blood at the levels their community requires. Blood donation rates of African Americans are 25-50% of that of white individuals.

Be interested where you found that particular state secret mentioned. Every time I give blood, I fail to see any minorities of any type in the donation room. What's interesting though, in the few local blood drives at the local VFD I've been to, I've seen Amish and Mennonites giving. My schedule doesn't allow me to get to the local drives very often...

All the posters on the walls of the blood donation centers show PC race and sex balanced posters showing happy blood donors. Well, almost. There seems to be scarcity of white males in the posters. The nearest city blood donation center used to have pictures mounted on the wall of 10, 15, and 20 gallon donors. The vast majority, over 90%, or the 10 gallon donors were men. All of the 15 and 20 were men. ALL of the donors on the were, by appearance, white. Used to have pictures. They were taken down.

Blood donation is an entirely volunteer activity that can be undertaken by any healthy civic minded individual who meets the donation criteria. My guess is the pictures were removed because it was impolite to point out that over the long haul, it appears that those people tend to be white males. According to the latest census, the black population of the county the city was in is 11% black. The city itself, where the blood donation center was located- 30% black. About 5% Asian for both county and city.

coupe said...
This comment has been removed by the author.
Hari said...

Why doesn't Baltimore just elect a Republican mayor?

The Drill SGT said...

Harold said...My guess is the pictures were removed because it was impolite to point out that over the long haul, it appears that those people tend to be white males.

Those of us who are Boomer males (e.g. Army Draftees) remember being marched down to the troop clinic to give blood on a regular basis. Whoa be it, that any trooper didn't want to donate. The upside rationale was obvious to all of us. Later, when I was a commander, the direct overt arm twisting had been reduced, but giving was strongly encouraged. I suspect that that habit of responding to blood drive requests became ingrained in Vets. I'm certain that blood drives are still very well supported by the military, police and Fire departments. I know that since leaving the Army, I have worked primarily for firms whose business base was Defense oriented. Corporate blood drives have been well subscribed.

I wonder how well blood drives work at UW? or for that matter Whole Foods, Apple, Facebook, or any of the other Left of center organizations. Althouse? Given blood lately?

protestmanager said...

Prospective patients, being clinically dead, will be incapable of giving consent

When I took CPR class, I was told that someone who was still alive could refuse Heimlich maneuver / CPR, but once they stopped breathing and moving they were dead, and "implied consent" meant you could make any lifesaving attempts you wanted at that point.

The same would seem to apply here.

Harold said...

When I took CPR class, I was told that someone who was still alive could refuse Heimlich maneuver / CPR, but once they stopped breathing and moving they were dead, and "implied consent" meant you could make any lifesaving attempts you wanted at that point.

Unless they've done something like have "DNR" tattooed on their chest, which apparently some people are doing. At that point, you stop and let them die. Even if it's obvious cessation of breathing was due to some stupid accident and resuscitation won't result in their being tied to a machine for the rest of their lives.

holdfast said...

What if the patient wakes up with an insatiable craving for the taste of human brains?

Duh! Headshot.

exhelodrvr1 said...

Harold,
I've had a very similar experience with blood donations. I give platelets fairly regularly (average about 15 times a year) and rarely see minorities donate, even though the donor location is in an area that is probably close to 50% minority inhabitants.

tim maguire said...

Prof., have whites been relieved of this fear? Or have they never been trained to have this fear? You can have empathy for those who suffer from hyper race focus without ignoring the source of their affliction. And if we want to address the problem, the source must be named and shamed.

tim maguire said...

Protestmanager, good point. I recently took a CPR class and that was THE main message of the instructor--the person is dead so you can't make things worse. Worried about breaking a rib? They're dead, they don't care. Worried about aggravating a back injury by moving them into better position? They're dead, they don't care.

But there are special rules around experimental surgery, and when there is a standard protocol, you'll need some kind of waiver to depart from that standard in favor of the experiment.

lemondog said...

Don't know how legit this information is but it appears various populations have been used and very frequently military:

A History Of US Secret
Human Experimentation

lemondog said...

I recall reading about the 1960's subway experiments.

Secret Testing in the United States

Bruce Hayden said...

I've never heard of a white resistance to organ donation.

Well, my partner is, I think white, and has told me to refuse for her, for the same reason that Blacks appear to be refusing - that the trauma people won't work as hard if they have a lot of good organs to harvest. Not sure though if I would follow her requests, if faced with the reality of her death. (Luckily, she can't read this). I have had Organ Donor on my DL for decades, but she has asked that I remove it the next time I replace it. We shall see.

I need to talk to friends of mine who worked trauma for decades and see what they say, and if they agree with Dr. K. (One of them helped pioneer some of the back end of this process, in order to save people whose body temps had dropped precipitously - often, I think, from falling down drunk into snowbanks and the like).

Daniel Jackson said...

Fact is, there is a high demand and low supply in the organ market today. And no matter what the arguments to the contrary, the organ donor card is "placing a stumbling block before the blind." Like a DNR directive, there is a tendency to lighten up on medical services for organ donors.

There is a waiting list for organs; but, there is also the Mickey Mantle effect: http://jnci.oxfordjournals.org/content/88/8/484.full.pdf or transplant tourism as in China, http://www.thenewatlantis.com/publications/chinas-organ-market

In a few hospitals in the Baltimore area, motorcycles are referred to as donorcycles given the high prevalence of very bad head injuries.

In fairness, there is a special team of transplant staff who arrive at the hospital to perform the process. What is truly ghoulish are the professional closers who arrive to convince the families to "part out" Dad or Mom.

There is no doubt that organ transplants are a social benefit. But, it would be foolish to think that there is not pressure to render a problematic patient into a harvest field.

It's a bit like Soylent Green.

Jupiter said...

Ann Althouse said...

"They've put themselves where they can expect to receive trauma patients. And they're not about changing the environment that create these patients. So in a sense, they are taking advantage of a tragedy, seeing it as their opportunity."

It does make one wonder, doesn't it? What would all these highly-trained (and highly-paid) liberal urban doctors and lawyers do with their "skills" if they didn't have feckless black idiots to clean up after? The "altruistic" white liberals pay themselves handsomely out of their neighbors' pockets, and write little squibs that end up in The New Yorker, about how hard they work, how little they accomplish, and how deeply sensitive they are. The feckless black idiots die, or end up in prison. Whatever. There's always plenty more feckless black idiots, so I guess that works out pretty well for everyone, doesn't it?

Jupiter said...

On a practical note, they need to consider the Mexican bus driver rule. If some hapless cog in the wheel is dragged into your emergency room, shot full of holes, and bleeds out on the table -- Well, everyone did their best, everyone gets paid, and everyone's a happy camper. Next patient!

But if he somehow survives, and his family drags him into a courtroom in a wheelchair, twitching and throbbing and howling in pain, unable to feed himself, condemned to a hellish death in life by the ghoulish "experimental procedures" he was subjected to by all these rich white people ...

Jupiter said...

Daniel Jackson said...

"There is no doubt that organ transplants are a social benefit."

No doubt? None whatsoever? An awful lot of resources go into an organ transplant. Medical economists say that it is much easier and cheaper to save young lives than old ones, and would arguably produce a much greater societal benefit. The difficulty is that the people who control the assets the doctors would like to receive for their trouble tend to be old.

Perhaps growing up in a medical family makes me cynical, but I tend to think that doctors are second only to priests in their outrageous cost-to-benefit ratio. We malign lawyers as ambulance-chasers, but the doctors are the ones who actually employ an ambulance system to gather unfortunates from whom they can profit. The lawyers are just trying to get there before the doctors claim it all.

Daniel Jackson said...

Response to Jupiter on my comment.

I was a hospital chaplain in Baltimore for a few years. I know the drill; I know doctors. My issue is the rush given current procedure. I have never been comfortable with the process of legal death in these situation, let alone the need to shave, trim nails, or bathe them while the team waits a few days for the recipient to be prepped.

You are correct: the Mickey Mantle Syndrome means that young bodies give healthy organs to older patients who generally command more social resources.

I raised this issue with the head of the ethics board where I was chaplain. He said that generally some poor schmuck has little chance; but, if you donate a wing to the hospital for a new ward, "we docs" can keep you alive forever.

On French radio, tonight, I heard a new publicity announcing the mandatory organ donor registration for all French citizens. If you object/refuse, your name is place on a nationwide registry. Otherwise, you come into emergency fucked up like the story we are threading, there is absolutely no problem of consent. Like an old Ford, you get parted out immediately.

Patient's right? What's that?

Now THAT'S Fraternitie.