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Medicine without Bounds or Organ-therapy in Intensive Care Units

By M.H. Nadjmabadi, Tehran
Translated by Roya Monajem

The patient is a thirty years old man, hospitalized in ICU with a broken femur following a car accident. He is breathing through a tube inserted in his trachea, connected to an artificial respirator. His general conditions are so grave that if disconnected from the respirator for even a few minutes his heart will stop.

He is under the treatment of a group of specialists from internists, cardiologist, lung specialists, to general surgeons and specialists in infection diseases, who by prescribing a few medicines each tries to help the patient.

Diagnosis, or better to say, diagnoses that led to prescribing at least ten different medicines for the patient are of a wide range. It started from head injury, to septicemia, cardiac insufficiency, renal (kidney) failure and finally ended with lung failure. With such a therapeutic plan, the condition of the patient is unfortunately deteriorating and although when admitted and hospitalized he had no problem other than a broken femur, he now can no longer survive without artificial respiration.

Everybody involved here, from doctors and nurses to the patients' relatives, all know that such an approach is not helping the patient. And the interesting point is that it is only the patient who has no word to say here as not only he can not breathe, but due to the effects of the wide range of the drugs infused to him, he has lost almost all his mental functions.

It is not very clear how all this happened, but one can imagine that at the beginning he suffers from pain and slight anxiety that in turn leads to an increase in his heart beat. Later due to shock, inflammation and hemorrhage resulting from the same broken bone, he develops fever. Gradually, due to extreme exhaustion resulting from insomnia and low liquid intake, his fever, pain and anxiety intensifies leading to mental failure.

In reality the involvement of various specialists here is 'the beginning of an end,' as his high fever is taken as the sign of infection, his mental state as head injury, and his palpitation as cardiac insufficiency and so the treatment is started with prescription of a wide range of different drugs ending with putting the patient on the artificial respirator because of the final diagnosis of lung failure, while all these symptoms are in fact the manifestation of the body's natural reaction to inflammation and shock.

With the onset of artificial respiration, new drugs are added to the old list. In addition, everybody is now happy that they no longer need to be that much worried about the doses of the drugs they use to lower the patient's brain activity and respiratory function, and so with the excuse of his reluctance and resistance to accept the artificial respirator, narcotics and muscle relaxants are now prescribed boundlessly. In this way the patient is paralyzed and it is now impossible to make any emotional and mental contact with him.

>From this minute on, he is even less regarded as a whole integrated human being, but more as an assembly of various organs. Each specialist assumes the task of treating one of his organs, but nobody takes the responsibility of his condition as a whole. And although the reason for adoption of such a therapeutic approach -- that can be called multi-specialist or organ therapy - lies in our present social, economic and scientific attitudes, nevertheless it has many grave consequences that should be explored separately.

Today, the prevalent approach to a patient put on an artificial respirator is to automatically prescribe a number of drugs such as antibiotics and anti-acids as a routine of intensive care departments. This is not a right approach due to the following reasons. Clinical experience shows that the use of antibiotics in a patient on artificial respirator not only does not prevent lung infection, but on the contrary by disturbing the normal biologic function of the lungs, it can very well prepare the ground for lung infection. Similarly, use of anti-acids for prevention of gastric hemorrhage not only does not block gastric bleeding at least in certain cases, but may enhance the excessive growth of bacteria that in turn can cause gastric bleeding and/or due to proximity with the tracheal tube may spread to the lungs and produce lung infection.

On the other hand, in many cases, regardless of the etiology, only correct supervision of the normal physiological reactions of the body against pathological factors is enough to treat the symptoms. For example, hypovolumia can easily lead to a drop in blood pressure and by checking the volume of the blood we can easily correct it without the use of any medicine. Similarly, development of arrhythmia and cardiac insufficiency may very well be due to a decrease in blood potassium, and the cause of renal failure may very well be low liquid intake and unnecessary use of antibiotics and the management of these pathological conditions is quite possible without the use of any or much medicine.

When there is no correct logical basis for the use of drugs, we can sometimes find up to 10-12 different drugs in the list of medicines used for such patients, with each drug having its own specific side-effects. Thus in practice not only we subsequently are faced with the emergence of various secondary symptoms (that may very well require other drugs for their treatment), but due to the similarities of the side-effects of some of the drugs, we would never know which drug is the main producer of the side-effects. Not only that, but usually none of the specialists involved are ready to consider their prescribed drug as the one producing the harmful secondary effects.

Another factor that leads to excessive use of drugs is the possibility of utilization of modern medical devices such as artificial respirator that gives the specialist the chance to prescribe any amount of narcotics, muscle relaxants and/or drugs that lower brain activity that they wish and in this way by wrong manipulation of the natural defensive function of the body at time of inflammation - a function developed during millions of years of natural evolution - the patient is put in great danger despite our well-intended attempts.

Before the appearance of intensive care units which is not very long time ago, the patient had the opportunity to have a word in his treatment and defend himself in case his body rejected or was disturbed by the use of a drug and/or its side-effects. Through these natural bodily reactions, the patient himself or his attending relative could attract the attention of the therapist who could thereby modify and revise his treatment plan. But today, the patient and his attending relatives are deprived of playing such a vital role.

Another important defect of the existing therapeutic approaches in intensive care units is the fact that the patient - as mentioned before -- is not considered as a whole, integrated human being. Different specialists take care of different organs of the body in isolation and with little knowledge of other organs For example, an orthopedist generally knows as little about the appropriate treatment and management of cardiac insufficiency as a cardiologist knows about the treatment of kidney dysfunction.

Finally, what is forgotten in most clinical set-ups is the role of emotional relationship between the patient and the therapist, a point that was not ignored by the physicians of the past. However, fortunately the emergence of the new medical field of psycho-immuno-neuropathy is helping to pay more attention to many emotional, psychological and mental factors that modern medicine had sent to oblivion. Today, it is known that under certain psychological conditions, specific proteins such as interleukins are produced in the brain that by stimulating the most important cells of our defensive system, i.e. lymphocytes, enhance their role in fighting against bacterial infections. No antibiotics can replace the function of our T-lymphocytes against bacteria. Other proteins and hormones such as interferons and cathecholamines are vital in regulation of our bodily reaction against inflammation and their artificial use in prescriptions can never achieve the same optimum results.

In the case of the above patient with broken femur, once all the drugs were cut down and washed away from the body by daily infusion of four liters of saline, it was possible to remove him from the artificial respirator in two days, and have him ready to be operated for his broken femur within a week, and have him discharged from the hospital in ten days.

Every medical doctor has surely witnessed similar cases of revival or 'miracles' in his clinical work, but that a patient be driven toward death is a new phenomenon that can happen only in a boundless medical practice.

Let us leave the final word to our great poet Hafez.

Better for my pain to stay hidden from the eyes of claimed doctors
To be healed by the concealed treasure of the divine

About the author:
Dr. Nadjmabadi graduated from Medical School of the University of Dusseldorf is one of the first pioneers in using dopamine in (Nadjmabadi M. H., Purschke R., Tarbiat S., Lennartz H., Bircks W. Comparing studies on the influence of dopamine and orciprenalin of heart and renal function of patients after cardiac surgery. Thoraxichirurgie 23:552 1975). And Nadjmabadi: Influence of Dopamine on the Pulmonary Pressure and Shunt Volumes after Cardiac Surgery, Anaesthesist, 26:274.1976) and catecholamine in combination of vasodilators in cardiac surgery (Nadjmabadi M. H et al, Simultaneous Dopamine and Sodium Nitroprusside Therapy following open heart surgery, Japanese Heart Journal, Vol. 21. 1981). He is also the first person using Svan-Ganz catheter via subclavian vein (Nadjmabadi M.H., Rastan H: Subclavian approach for cardiac catheterization with balloon tipped pulmonary arterial catheter. American Journal of Cardiology, 39: 471. 1977), and peritoneal catheter in pediatric cardiac surgery (published in Iranian Heart Surgery, 2000). He has organized intensive care unit of the heart surgery department of Tehran Heart Hospital in 1974, Khatamolanbia Hospital (1989), Shariati Hospital (1990), and finally Sorkheh Hesaar Hospital (1992) where 8000 heart surgeries (including 4000 children) were carried out in 8 years. In addition to "Lung in Shock," he has written a book on Pediatric Heart Surgery, together with his colleagues in Sorkheh Hesaar Hospital published two years ago in Tehran.

... Payvand News - 2/25/03 ... --

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