Medicine’s deadly gender gap

By Anne Kingston - Monday, April 30, 2012 at 11:01 AM - 0 Comments

Betsie Van Der Meer/Getty Images

In 2004, Barbara Colbourn began experiencing pain in her legs when walking. The 61-year-old London, Ont., office manager tried to ignore the discomfort at first. Six months later, she went to her doctor, who diagnosed peripheral artery disease, or PAD. Colbourn had never heard of it—and was shocked to learn it was a chronic disease caused by atherosclerosis, or hardening of the arteries, of the legs, feet or arms that puts people at higher risk of stroke, heart attack and death. When she was asked to participate in a 24-week international treatment trial organized by London clinical trials nurse Marge Lovell, a PAD awareness advocate, she agreed. Like many women over 60, Colbourn’s health concerns were fixated on breast cancer and heart disease. “Hardening of the arteries was something my grandma had,” she says.

Now 69, Colbourn takes baby aspirin and a cholesterol-lowering drug and exercises daily to prevent the disease’s progression and stave off invasive surgery. There were warning signs she ignored, she says. She had to give up curling in her 50s because her feet were always cold. “Never in my wildest dreams did I think it could be serious.” Just how serious was made clear in a study in the January 2012 American Heart Association journal Circulation: it called PAD an unsung “pandemic” that afflicts more women than men, contrary to previous assumptions. Research in women has lagged behind, says cardiologist Alan Hirsch, a professor at the University of Minnesota medical school who chaired the study. Just as heart disease manifests itself differently in women, so does PAD, says Hirsch, whose study revealed that women with PAD, which afflicts some 800,000 Canadians, are more likely than men to have a limb amputated.

Diagnosed by a simple test that compares arm blood pressure to leg blood pressure, PAD is the “most common, deadly and costly cardiovascular disease that the public hasn’t heard of,” says Hirsch; in 90 per cent of cases, it’s asymptomatic. That so few women have heard of PAD doesn’t surprise Hirsch, who says women have been routinely overlooked in vascular research: “It is embarrassing how many hypertension, lipid studies, and stent trials were done with low [female] enrolment. Every vascular disease I know of except aortic aneurysm is more common in women—venous diseases, lymphedema, PAD—yet we don’t know why and we don’t talk about it.”

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In conversation: Dick Teresi

By Brian Bethune - Tuesday, March 13, 2012 at 10:44 AM - 0 Comments

Photograph by Tim Gray/Getty Images

Dick Teresi is the former editor of Science Digest and author of The Undead, a newly released and unsettling inquiry into the demands of organ transplanting, and when and how the medical community decides someone is dead.

Q: You began this project to explore how death is now determined, assuming that medical advances have surely pinned down the moment a person dies. What did you find?

A: That determining death has been a problem since the beginning of civilization. In ancient times, doctors and others who mistakenly called a living person dead were often stoned. Death was not the domain of doctors; it was too important to be left to them. People set up vigils over their relatives and friends to make sure they were dead, because one of the worst things one could do was bury a living person. Doctors became more involved, but the real change occurred in 1968: a committee of 13 men at Harvard Medical School endorsed brain death as legal death, and this became U.S. law in 1981. Doctors were now the sole arbiters of who is dead and who is alive, and they lowered the bar for death—it is now easier to be declared dead than any time in human history.

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Can donating organs be painful even after you’ve flatlined?

By Julia Belluz - Friday, March 9, 2012 at 3:37 PM - 0 Comments

Sean Kirkpatrick/Flickr

Sometimes, there’s no better place for science-ish speculation than at the dinner table. Last weekend, my mother was offended that she didn’t know her children and husband had signed up to donate their organs. My father, a man of reason, couldn’t see why one would get emotional about the issue: “What does it matter once we we’re dead?” That’s when my dear aunt piped up: she insisted she’d heard somewhere it’s possible to feel pain while the organs are extracted in that final act of altruism.

The claim seemed absurd at first. But Science-ish learned that she was actually speaking to a wider controversy about organ donation and the complex question of when a person is dead. In fact, as Dick Teresi, author of the forthcoming book The Undead, told Maclean’s in an interview for this week’s issue: “It’s easier to be declared dead than ever before.” He also added: “(Deceased donors’) brain stems aren’t working, but vital organs still function—you’ll pee, maintain your body temperature, and your wounds will continue to heal. You may—it’s not certain, but you might—feel pain during surgery. You’re in this weird undead zone. It’s during that time your organs are taken.”

So if your organs are working, are you dead?

Science-ish called Dr. Andreas Kramer of the Hotchkiss Brain Institute at the University of Calgary to find out. He explained that organ donation used to be performed in Canada only in “neurologically devastated” individuals who fit the criteria of “brain death” that Teresi referred to in conversation with Maclean’s. Brain death was a concept established at Harvard in 1968, when a committee of researchers determined that a person could be declared dead legally if, among other things, blood flow to the brain stopped even though other organs continued to work. Needless to say, people who suffer brain deaths are perfect candidates for organ donation.

As Dr. Kramer explained: “(With brain death) there is no evidence of brain activity, even very basic physiological functions, such as respiration. The only reason that the heart continues to beat is because they are on life support at the time that they progress to brain death and a ventilator continues to breathe for them.”

More recently, though, another definition of death has cropped up: cardiac death, or the irreversible cessation of circulatory and respiratory function. In other words, when you’re heart stops beating. Today, in Canada, either of these two conditions are sufficient to declare a person dead and treat her as an organ donor.

So an individual—say, the sufferer of a stroke—can meet the criteria for cardiac death, despite the fact that they are not brain dead. In this case, after life support is discontinued and palliative care administered, Dr. Kramer explained, doctors wait to see “if the patient’s heart stops within a predefined period—usually two hours—then they can proceed to organ donation.” After the heart fails, physicians (who are notably not transplant surgeons so there’s no conflict of interest) wait for several minutes before declaring the patient dead.

This is where things become more interesting: that wait period varies across jurisdictions. “In Canada, the U.K., and Australia, almost all hospitals use five minutes,” said Dr. Kramer. “In the U.S, some hospitals use two minutes. In Europe, some hospitals use ten minutes.”

What about the pain?

Given the blurry lines around the final curtain call, can someone who meets the clinical criteria for brain death or cardiac death be aware of pain as their organs are extracted?

In the case of cardiac death, according to Dr. Neil Lazar, an associate professor of medicine at the University of Toronto who has written about deceased organ donation: “if you ask whether a person whose brain has not been receiving blood flow for five minutes is able to experience pain, the answer to that is that it’s very unlikely. The brain is no longer getting blood flow. . . You can ask, ‘What if somebody came along and tried to restart the heart or artificially got blood flowing to the brain–would that brain be able to recover to any extent?’ The answer to that is uncertain.” He emphasized that the patient is almost always so close to the edge that any kind of resurrection would be next to a miracle.

The possibility of feeling pain is extremely remote with brain death as well, for two reasons. Declaring someone clinically brain dead requires, among other things, making sure that the patient does not respond to external stimuli, including pain. “So it’s hard to imagine under those circumstances there would be some unconscious awareness or pain,” said Dr. Lazar.

Could one study pain in dead organ donors? Dr. Kramer said,  “one could theoretically use electroencephalograms (EEG) in donation after cardiac death patients at the time that death is declared—five minutes after cardiac arrest—but this does not definitively tell you whether a patient has any awareness.” Besides, in brain dead patients, the EEG is flat because there is no brain activity, and with cardiac death, the EEG usually flattens in less than five minutes. So while we don’t have evidence to prove an organ donor can’t feel pain, we also don’t have evidence to indicate that they could, and the latter is extremely unlikely.

All of this makes Science-ish wonder about the big question: how do you really know when a person is dead? Is it about the cessation of brain function? A heart beating its last? “If people say you have to be dead to be an organ donor, there will always be individuals who will say, ‘I don’t agree with that diagnosis of death. The heart is still beating, so how do you call that person dead?’ ” said Dr. Lazar, “death is a social construct. It just so happens that doctors are the professionals who have been given the authority declare it.”

Science-ish is a joint project of Maclean’s, The Medical Post, and the McMaster Health Forum. Julia Belluz is the associate editor at The Medical Post. Got a tip? Seen something that’s Science-ish? Message her at julia.belluz@medicalpost.rogers.com or on Twitter @juliaoftoronto