Post Date December, 02 2023
When the life-saving machine is not enough
What if we already know how to treat patients with renal failure, but we don't have so many machines to treat all patients? Who decides who can survive while others have to die? This seems to be an incredible problem now. In the United States before 1973, it was a real dilemma.
This is the little-known "life and death" committee system. What is the Life and Death Committee? What is its background? How does it work? How did it end up?
These questions, let's listen to Cargo slowly.
Development history of dialysis
In the 1940s and 1950s, the dialyzer was still a drum dialyzer invented by the Dutch doctor Kolff in 1943. This is a wooden wheel structure composed of many wooden planks, with 30-40 meters long cellulose membrane wrapped around it. By soaking in the dialysate, the blood and dialysate have a diffusion exchange effect, thus completing dialysis treatment.
At that time, it was very advanced. But at that time, the problem of vascular access had not been well solved. During dialysis, a small operation was needed: to separate an artery and a vein from the body, and then connect it with the external pipe, so as to complete dialysis treatment. After the treatment, the two vessels need to be ligated again.
Because of its complexity and the fact that the patient did not have too many blood vessels to withstand such twists and turns, this measure was only used for patients with acute renal failure at that time. However, even though this measure seems so clumsy at present, it was revolutionary progress at that time: before that, there was basically no effective treatment for renal failure. Therefore, this technology was quickly popularized in European and American countries.
During the Korean War from 1950 to 1953, that is, during the War of Resistance against the United States and Aid to Korea, the US military has applied this technology to the rescue of acute renal failure in the battlefield. At that time, the average treatment time was only 30 minutes, but that was only half an hour, which could greatly improve the survival rate of acute renal failure caused by war injury.
Think about our volunteer army on the opposite side of the battlefield. What we emphasize is the fearless revolutionary spirit of a mouthful of dry food and a mouthful of snow. It's very sad when compared with each other.
It goes too far. Back to dialysis technology.
Acute renal failure can be saved, but what about chronic renal failure? It is impossible for patients to have surgery every time they dialysis! If the problem of vascular access is not solved, the treatment of patients with chronic renal failure cannot be put on the agenda.
Finally, in 1960, a doctor named BeldingScribner invented a device to connect an artery and a vein in vitro with a plastic tube. During dialysis, disconnect this tube in the middle and connect it with the dialysis machine. After dialysis, connect the tube again.
This is the long-lost "arteriovenous fistula" in the Jianghu.
The long-lost external arteriovenous fistula in the Jianghu
Although today it seems that this design is very stupid, because you can think about it with your thighs and know that the risk of bleeding, tube blockage, infection and so on is too high. But at that time, this was another revolutionary progress: finally, the patients with chronic renal failure had a play to play!
Unfortunately, data shows that only one in 50 patients who need dialysis are suitable for establishing external fistula. That is to say, only one in every 50 patients who need dialysis is able to establish external fistula. It is conceivable that this one in 50 lucky children must be young and vigorous, with blood spurting.
In 1962, American LIFE magazine published a feature article in November, telling the story of a uremic patient named John Myers who had survived for 11 months after receiving hemodialysis treatment.
Myers is a typical patient with chronic renal failure: hypertension, heart failure, edema, anemia We have all the symptoms we can have. Everyone estimated that he would not live long, but he survived through hemodialysis twice a week through an external fistula. The kidney disease center in Seattle, where he was given dialysis treatment, had only a few dialysis equipment at that time. Although the proportion of patients who could establish external fistula was small, the total number of patients who needed to be treated was very large. At the same time, because there was no proper medical insurance reimbursement system, the high cost of dialysis treatment was borne by the patients themselves. This has caused a great contradiction: the contradiction between the social demand for hemodialysis and the obvious shortage of dialysis equipment and talents.
How to decide "life and death"
How to solve this problem? Draw lots? Number in sequence? Sort by how much?
None of them In order to solve this problem, the hospital set up a seven-person organization called "Hospital Artificial Kidney Permit and Policy Committee". These seven people are citizens of noble conduct, completely voluntary, and completely free service. In fact, there is only one doctor among the seven, not a nephrologist, but a surgeon. The other six were a lawyer, a priest, a banker, a housewife, a state official, and a labor leader
In other words, these seven people decide who needs dialysis treatment, and who can not receive treatment, but only choose to die. Therefore, the name of this committee is also called the "Life and Death" committee, and a more derogatory name is the "God" committee. Myers, as mentioned earlier, is a lucky person selected by the committee. So how does this committee work? In the article of LIFE, we can see a general idea. The key question is what is the principle of selecting the selected population. In fact, when the seven people came together, they basically had no concept of this problem, that is, no principle. However, in their discussions, some unwritten rules were gradually formulated. For example, people who are older than 45 years old are basically not considered, because these patients have more complications and are difficult to deal with; Another example is that children don't think about it, because under the conditions at that time, doctors are not sure what will happen to the dialysis treatment for children. After several quarrels, some principled things were finally agreed. For example, the selected subjects should be able to afford expensive treatment costs, the patients' contributions to society are relatively large, and the patients' education level is relatively high
Although the rules have been formulated, there are still problems in the actual implementation. For example, a mother of three children and a musician are two patients before the committee. How should they choose? Musicians have contributed a lot to society, but what about the children if their mother dies?
So, after working for a long time, the members of the committee are basically schizophrenic, because it is too cruel. Fortunately, this situation does not last long. Benefiting from the further progress of hemodialysis technology, such as the invention of hollow fiber dialyzer in the late 1960s, such as the invention of arteriovenous fistula in 1968, and the large-scale development of hemodialysis related industries, by 1972, the United States Congress finally passed Public Law 92-603, the medical insurance plan for end-stage renal patients. This plan stipulates that all ESRD patients who participate in social insurance have the right to receive renal replacement therapy, and its scope covers hemodialysis and kidney transplantation. Since then, the "life and death" committee organization, which was a flash in the history of dialysis development, has finally died.
Today, standing on the other side of the ocean in the United States, we will revisit this period of history. In addition to watching the excitement, we can not help but think of our country's health insurance policy.
Cargo sighed
Although we have not experienced this "life and death" test, but think about it, just a decade ago, many patients, especially those in rural areas and laid-off workers in cities, did not give up treatment because of the lack of a good reimbursement system? Even at a time when the situation has changed a lot, due to the dual structure of urban and rural areas in China, there is a huge difference between the reimbursement of medical insurance for rural patients and urban residents. Isn't it actually a choice between life and death?
Fortunately, history is only history after all, and the future must be better than today.
