Wednesday, January 30, 2008

Chimera? What's a Chimera?

The Chimera is a mythical creature, as described by Homer in the Iliad, as "a thing of immortal make, not human, lion-fronted and snake behind, a goat in the middle, and snorting out the breath of the terrible flame of bright fire".

Chimerism in scientific terms is when an animal has two or more different populations of genetically distinct cells that originated in different zygotes; if the different cells emerged from the same zygote, it is called a mosaicism. (From Wikipedia, see here for the whole article). A male tortoiseshell cat is a chimera.

Microchimerism is the presence of a small number of cells, genetically distinct from those of the host individual(also from Wiki). In some cases, fetal cells can find there way into the mother's circulation and remain there for as long as decades. This has also been found in some severely immunocompromised trauma patients who have received blood transfusions.

Even more startling is the case of a woman who was found to have two sets of genetically distinct cells. It was discovered when she and her family went for tissue typing because she needed a kidney transplant. From the New Scientist, November, 2003, this is a really interesting story on it, and explains it very well. As researchers have looked into it, genetic material can be transferred from mother to children and vice versa, or between twins in the womb. There is even speculation that a mother can receive cells from her fetus, carry them in her circulation for years and pass them on to future children that she carries, all without anyone having a reaction to what should be seen as a foreign invader by the body. Could they be blast cells? Like a stem cell transfusion? Even more perplexing is why this should happen.

I'd be lying if I said I really understood this. Chimerism first came to my attention this past fall when I was doing research on transplantation. I had never heard of it while working as a TC, but immediately it was clear to me why transplant researchers would be so intrigued by this. One of the biggest, (the biggest?) problem with transplant is rejection. The recipient's immune system sees the new tissue as an invader and tries to destroy it. Not only is it a problem with the life of the organ and the life expectancy of the patient, but also the the cost of the antirejection drugs, which can be $50,000 a year, are a big factor in people's financial ability to pay for a transplant. Imagine not having to take antirejection drugs. Imagine being able to extend the viability of a tranplanted organ. Some centers, like Northwestern Memorial in Chicago, among others, have been transplanting stem cells from living kidney donors into the recipients. The logistics of both stem cell and organ transplantation make this currently unfeasible for cadaveric organ donation.

Just when things can't get any weirder, comes this story from Down Undah. 15 year old Demi-Lee Brennan received a liver transplant. Nine months later, her doctors discovered that her blood type had changed to that of her donor's. More importantly, they found that stem cells from the donor liver had penetrated her bone marrow, changing her immune system and allowing her to come off anti rejection drugs. While transplant surgeons have known about stem cells "floating about" in the recipient's body, this is the first time anyone has, in effect, received a stem cell transplant and changed their immune system. If they can find a way to replicate this, it could change the field of organ donation.

Imagine taking on your donor's DNA. Makes that new Jessica Alba movie seem downright tame.

Monday, January 21, 2008

Winter of My Discontent**

Can you believe we're halfway through January? December, according to my horoscope, was supposed to be a banner month for me:Jupiter was in Sagitarrius or Venus was trining with Mercury or some such. Mostly, though, it felt like my head was in Myanus. Work continues on. RSV season started early and the hallways are cluttered with yellow isolation carts. Let me tell you, there's nothing like spending 12 hours in a blue hefty bag to make a girl smell, well, less than fresh.

It seems everytime I turn around, there's a new job opening for a transplant coordinator. Not on the procurement side, even I'm not that masochistic, but on the recipient side. The hours are usually good, 9-5 Monday to Friday. Call consists of making phone calls from home. Not too shabby, but I like the PICU. I like the work, I like my bosses and coworkers and I like 99% of the doctors. If one of these jobs had been available when I left the OPO, I would have gone for it. So, do I stay with the what's close and comfortable or do I search for greener pastures?

As for that 1%. There is one doctor who I have a problem with. Initially, I liked her. She's very bubbly and friendly and confident. Then, during rounds, I started hearing her tell the residents things that were just wrong. Like dopamine doesn't make your heart rate go up. That Levo only effects beta, not alpha receptors(or was it alpha and not beta? Either way-it effects both). That a person can't have an O2 saturation of 90% and a PO2 in the 50's. Recently, my patient was an organ donor. She mentioned to the resident that the family can bring up a religious objection to brain death at any time (my state says that people can reject a diagnosis of brain death based on a religious objection, in which case the person would stay on the vent until they cardiac arrest). I respectfully told her that the law says that the objection must be brought up by the family at the beginning of the process. She countered and gave an example of some family somewhere who sued the hospital. I said that anyone can sue at anytime, but it doesn't mean they're going to win. She did not like that I challenged her wisdom, in front of a resident no less. Ever since she's been quick to find fault with me, usually during rounds when she has an audience. Then I spoke with another attending, I found out that many people have been having a problem with her, attendings, residents and nurses alike. I'm trying to just stay on my toes, cover by butt and otherwise keep my big mouth shut-not easy for me.

So I've christened her Doctor Betty. Just like Renee Zellweger, whose Nurse Betty gets bonked on the head and thinks she's a nurse, so I believe that this woman was bonked on the head while watching Grey's Anatomy and now she thinks she's an intensivist. Don't mess with me, sweetheart, I've got a blog and I'm not afraid to use it.

So, a couple other things happened with Dr. Betty during the organ donor. First, we were waiting for rounds, the TC and I, because we had some management concerns. The team passes by to the next room. I ask them if they're going to round on our donor and she says, in the hallway, VERY LOUDLY, "we don't round on dead people." Now, next door is another young girl with a brain injury and her mother is very, very aware of the organ donation going on next door. She's standing in the hallway when the Dr. Betty says this.

Secondly, she says, again to the resident, that the bronchoscopy we need can't be done until the patient is pronounced because it's unethical. In truth it's because the OR only has 2 bronch carts and they're both in use until later in the day. But now my hackles up, because this chick wouldn't know ethical if it bit her in her not-so-small posterior. (See-my hackles are raised just thinking about it.)

So that got me thinking about the whole donor process and what's ethical. There are a couple of ways to break down the process-before death and after death, before consent and after consent. Here's the referral process in a nutshell: hospital staff identify potential organ donors based on neurologic criteria. These neurologic triggers were proposed by the HRSA collaborative based on what worked at hospitals with high consent rates. Patients with a Glasgow Coma Score of 5 or less and or loss of 2 or more cranial nerve reflexes meet the triggers to be referred to the hospital's OPO. The family is not told of this referral. Why? Because at this point, a bunch of things can happen. Very often, the call is made and the person is ruled out over the phone; they're too old, they have cancer, AIDS, multisystem organ failure, etc. For some reason, these referrals always seem to come in at 3am. You can almost hear the nurses, "Hey, has anyone called this guy in yet?" "No, we'll let the night nurse call it in when she has a chance."

Or, the person is not brain dead and may not be close to being brain dead. They may still be sedated and/or paralyzed. Then, why are we called so early? Because it is hard to know how slow or fast a brain injured patient will deteriorate. They may never become brain dead. They may be brain dead tomorrow. We've followed patients for weeks only to finally tell the hospital to re-refer them if they get worse. Sometimes they get better, sometimes they stay in that suspended state of not dead but not waking up either. That's a post for another day.

Should families in the above situations be told that the patient is being referred for an organ donor evaluation? Like so many of the controversies surrounding donation, it's complicated because of people's emotions. If a patient possibly needed to be trached, an ENT would be consulted. The family would be told. Maybe the patient would wind up with a trach, maybe not. Maybe the family wouldn't consent or maybe they'd want more time to see if the patient improved.

The same thing when a referral is made for a potential organ donor, when the OPO is consulted about whether the patient could be an organ donor. More than likely, they won't fit the criteria. Only 1% of all deaths are medically suitable to be organ donors. From my experience, if you tell the family at this stage, one of two things will happen:they will really want the person to be a donor and their hopes will be crushed if they're ruled out or they will get upset that anyone is talking about organ donation from their still-alive loved one. All right, add a third reaction-they don't get upset, but they say no, and then they OPO will look like they're hounding the family if they keep asking the family.

But does that make it right, not to tell? Families should be kept informed of what's going on regardless of what their perceived reaction will be. It boils down to having a different approach because organs are a limited resource. I'm sure ethicists have a word for this. In order to be an organ donor, even if you meet the requirements, a lot of variables have to be taken into consideration to get the best possible outcome in a short time period. If organs were plentiful, we could just do whatever and not worry about the family's reaction, because another donor will come along. If we had all the time in the world to let families think about it and not ask them to make a tough decision at the most stressful time, it would be easier to get consent. But we don't. Even if every medically suitable, brain dead patient's family consented, there still wouldn't be enough organs for everyone on the list. And the timing is short-families must make this decision while they are still realing from the death of a loved one.

Am I making sense? It's hard to make a cohesive argument when I have to start and stop every paragraph, being pressed into mommy duty. Anyway.

It's similiar to when I would introduce myself to families. I say, "Hi, I'm a nurse who works with the families of brain injured patients. I'm here to help you with some end of life decisions." Or words to that effect. Not a lie, but concealing the truth. In order to spend time with the family, see what their needs are and how best to approach them. This is generally how the TC's in my OPO do it-other OPO's may vary. Friends of mine have quit over stuff like this-they feel it's too misleading. I still go back and forth with it, but in order to be a successful TC, I did have to make my peace with it early on. I wonder if it would just be better to be introduced at the family meeting and say right from the onset who we are. This way, we're trying to develop a rapport with the family. One one hand, this is good:the family gets some usually well needed emotional support and someone who can act as a laison between them and the hospital. Some hospitals already have a person like this in place(social worker, patient rep, etc), some don't.

The problem with the rapport approach, that I have, is that at times it feels like you're a used car salesman. Here, let me get you information, keep you updated on the patient's progress, get you tissues, etc. All so that when it comes down the request, you'll say yes because, doggonit, you like me. I suppose that could be considered condescending to the families I've talked to. I'd like to think that each and every one make the right decision for them. Again, it's an emotional time and how something is presented can have a big impact on what decision they're going to make. I guess, though, when it gets right down to it, I don't ever remember feeling like I twisted someone's arm to donate. And the people who aren't there, with the families, can say how it's such an important cause and we're just trying to do the right thing and be advocates for the people on the waiting list. But when you're right there in that room with the family who's grieving and looking to you for guidance, it can feel like a mighty fine line.

**Now is the winter of our discontent

Friday, January 18, 2008

New Music-yes! New Posts? Workin' on it

New Music for the New Year. Which was 2 weeks ago, I know. Toddler. That's all I'm saying. A really tall, extremely smart toddler with a long reach. Anyway, I've got three new posts in the shute, all at various stages of completion, all about organ donation. Love Monkey promises me some time to myself this weekend to write, so stay tuned and enjoy the tunes.