Thursday, December 27, 2007

Guess what I got for Christmas??

No, it wasn't coal.

When I left the OPO, sadly I also had to leave my laptop. 14" IBM Thinkpad, mostly indestructible. It was basic black, addressed all my needs, wasn't too heavy. It didn't have a disc drive, cause they didn't want us installing programs, I'm sure, but other than that, I loved it and vowed to never have a desktop again.

Husband told me he was going to me a gift that would change my life. Several things came to mind-a trip to India to spend a week with the Dalai Lama? Hmmm, too expensive and he's probably busy. A winning lottery ticket? A chance to meet Johnnie Depp? (that wouldn't change my life, but it would totally rock!) No, none of those.

He got me my own laptop. This is me, typing away on my brandy new acer, with CD/DVD burner and a webcam. Maybe I could do podcasts!? After I lose 20 pounds and get a makeover, of course.

This past week at work was a doozy. I worked Sat, Sun and Mon with the same sick, intubated kid. Nobody was really sure what was wrong with him, but originally they thought he had croup. Last week, I took care of him and he was doing something really weird-for a couple of hours his CVP would be high-19 to 22 and his urine output would drop. Then, without any intervention, his CVP would return to normal and his UO would increase. I told the intensivist on that day and then never heard anything else about it. I was wondering if he had a coarctation of the aorta, but his pressure was low, not high, and I really thought someone would have picked up on it(he's an older child). Turns out, he has a collateral artery wrapped around his aorta and it's not respiratory at all. Always go with your gut.

So New Year's Eve I was asleep by 10pm. Then the next 2 days I was off and basically did NOT ONE THING. So much for time management, but it's been a long time since I've taken a nap without a kid attached and I'm not apologizing for it.

On the organ front, I've been reading about this girl, Nataline Sarkisyan, who was denied a liver transplant by CIGNA. I was pretty appalled but hadn't written about it because I didn't really have time to delve into it. And if there's one thing we pride ourselves (myself) on here at donorcycle, it's avoiding easy answers and half-truths. So today in my emailbox was a surprisingly in depth article on the case from Maggie Mahar at Health Beat. I did think at the time that it was surprising that doctors would transplant an organ into a person with cancer. Except in certain cases, cancer patients don't usually get transplanted because the immunosuppression drugs already put a person at risk for cancer and there's a high risk of coming out of remission with the same or another cancer. But I thought, well, maybe Nataline was cured by the bone marrow transplant from her brother. Now, reading the article, it says that her doctors gave her 6 months to live WITH the transplant.

Of course, if it was our own child we'd take those odds, but here's the thing-there aren't enough livers to go around. So who should get it? The 17 year old who will probably die anyway, or someone else who will live another 5,10, 20 years? It's a hard choice and I'm trying to come up with an analogy but I can't think of anything that involves such a restricted resource with such emotional appeal. Then, too, the hospital asked the family for $75,000 if insurance wasn't going to pay. I guess some have argued that the hospital could have eaten the cost. I'm not sure if that figure was for the surgery and hospitalization. I do know, that for self paying recipients, the hospital wants to see if they have the resources to pay for the first year of anti-rejection meds, which runs around $50-60,000. Again, this sounds really harsh, but the meds are needed or else the organ will be useless. It's the same reason why people are counseled to see if they are up to all the follow up treatment that comes with receiving an organ. Again, I'm not really sure why that gave that dollar amount to the family, who couldn't come up with the money of course, and the doctors are no longer talking.

I don't know where the answer lies. I'm reasonably sure that if the docs at UCLA felt the transplant was worth it, then CIGNA should have covered it. On the flip side, Maher points out that CIGNA approves 90% of all tranplants. And I do agree with her on this point, by reconsidering their position when it was essentially too late, CIGNA now looks like a horse's ass(My words, not hers).

The one thing I am sure of is that this sort of thing happens because organs are scarce. If you could get one just as easily as you could go the pharmacy for a presciption, no one would have to make these choices. I do hope, if nothing else comes out of this, that all those who fought for Nataline will sign their organ donor cards.


PJ Geraghty said...

It was a tough case to read/hear about. And it was an easy, obvious target: big, evil insurance company won't shell out to save the dying little girl's life. You can almost hear the Lifetime Network cameras rolling.

And yet, CIGNA has been treated unfairly by almost any measure. The most optimistic predicted result was a 65% chance of survival at six months. Slightly better than a coin toss, it's still not (in my mind) something to justify using a scarce resource (donor liver) on. well, as the third-party administrator, while CIGNA had no specific financial stake in the decision, they did have a duty to protect the insurance plan from excessive and futile costs. I think CIGNA made the right decision at first (tough though it was) and then caved in to pressure--a bad precedent.

But...had it been a matter of a $75K drug, I'd have a harder time saying they shouldn't have paid the cost, even for six months. Organs aren't drugs, though...there's no stack of livers sitting in a fridge somewhere waiting for a needed recipient. Organs are a scarce resource and everyone involved needs to be a good steward of that resource.

Definitely something where I'm glad someone else had to make the decision!

geena said...

I was hoping you'd weigh in on this particular situation, TC. Good post. It's driving me crazy listening to John Edwards go on and on about the whole thing, though... Just cements in my mind that he doesn't get it.

Perfusionist said...

So interesting blog. Can I ask you: How many heart transplantations performed annually in U.S. ?

TC said...

Perfusionist, here is a site with some data on heart/lung transplants for 1995-2006. Hope it helps, more to come soon.