[HSF] Death

Tue Mar 6 21:21:02 EST 2007

I certainly meant no personal criticism. It is hard to say no to someone in extremis. I was just talking numbers. There are 1000 patients a day (350,000/yr in USA) that currently are dying of end stage (mostly) ischemic heart disease. If we aim a little (or a lot) sooner, we may be of more help. I imagine even with all the LVAD and transplant centers we don't save a week's worth.
My apologies,
tea

----- Original Message ----
From: Edward Bender <ebender001 at charter.net>
To: OpenHeart-L at lists.hsforum.com
Sent: Tuesday, March 6, 2007 10:03:59 PM
Subject: Re: [HSF] Death

After reading you response, Tea, I felt strangely dirty.  There are  
fates worse than death for sure: quadriplegia, locked in syndromes,  
voting Democratic, etc.  The trick is predicting the outcomes.  I was  
looking for just one more chance to have a good outcome instead of  
death.  It sure would have been easier on my sleep patterns to have  
bowed my head along with the cardiologist and declared defeat.   
Another tragic death - maybe the rest of the family would like to  
come in for a stress test.

So here is the follow-up on the patient.  Transferred Saturday to a  
major university, they allowed the patient to awaken from the  
sedation to confirm that there was indeed a sentient being attached  
to that pump - and there was.  The patient got very combative,  
fighting the ventilator and straining severely.  The patients lungs  
"whited out" in spite of good cardiac output, urine output, etc  
(barotrauma?).  Couldn't be oxygenated, and then allowed to die today  
after family discussions and goodbyes.

Your adage holds: dead people stay dead and dying people usually die.

It feels crappy.  Victory  is a fleeting illusion.

Ed Bender, MD

On Mar 6, 2007, at 10:10 AM, Tea Acuff wrote:

> An odd preoccupation encouraging cadiologists to find dead hearts  
> for LVADs. This was a tour de force. You were honest in your self  
> description of trying to make a person's last inch an inch and a half.
>
> Since we can't strictly tell the dead from the nearly dead, I quess  
> the recently dead is our best guess...and which is probably the  
> most important detail that you left out.
>
> You now have a live patient with presumably a dead heart. The good  
> solutions for that are about in the  same percent chance of getting  
> to where you are now from where you have come. If your patient had  
> awoken with quadriplegia, would that be a good result? Are we  
> looking for good, or just looking? I don't have any answers and I  
> realize that somewhere under some rock is a new species, but there  
> are a lot of things we can encourage that likely have much better  
> solutions.
> tea
>
>
> ----- Original Message ----
> From: Edward Bender <ebender001 at charter.net>
> To: OpenHeart-L <OpenHeart-L at hsforum.com>
> Sent: Sunday, March 4, 2007 6:28:01 PM
> Subject: [HSF] Death
>
>
> Last week I was called to the cath lab for a 59 year old male with a
> 100% left main occlusion and cardiac arrest undergoing CPR. The
> cardiologist had a pacing wire in the RV triggering a balloon pump,
> giving a BP of 40/10.  I wire was passed through the LM occlusion and
> the left system became visible, with a residual 80% LM and LAD
> stenosis and TIMI 2 flow.  The RCA was dominant and patent.  Believe
> it or not, an LV gram was subsequently performed, showing that the
> inferobasal portion of the LV moved a little - the anatomic
> confirmation that there is some mechanical activity in patients
> exhibiting pulseless electrical activity (PEA or the old term EMD).
>
> Since we are trying to encourage cardiologists to use our services
> for VAD support in MI's complicated by cardiogenic shock, I took this
> patient to the OR.  When I opened his chest, there was no BP or
> cardiac rhythm.  I estimated by looking at the time sheets that he
> was in PEA for about 30 minutes with only brief periods of CPR (less
> than 10% of the time).  To make a long story short, I placed him on
> bypass to get an LVAD in (we only have the abiomed BVS5000).  The
> blood was so desaturated and acidotic, that it took a full minute
> before I could see a color difference in the venous and arterial
> cannulae.  He was fixed and dilated in the OR, but developed reactive
> pupils 6 hours post-op.  He woke up 20 hours post-op.  He had a
> creatinine of 1.6 and good urine output.  I transferred him to a
> major midwestern university for destination therapy vs. transplant
> (its their problem now).
>
> My question is how long do you think it is possible to successfully
> "reanimate" a human with the support of IABP triggered by the pacer
> alone?  In other words, is there enough flow generated by
> counterpulsation to sustain life (or should I say suspend death) for
> longer periods than one would think?
>
> Ed Bender, MD
>
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