Man on a Wire

A 5-year-old girl rolls into the pediatric intensive care unit with a subarachnoid hemorrhage. She was playing with her brothers on the swings outside this afternoon, developed a severe headache, and collapsed on her front lawn. Before today, she was the picture of life: vibrant, healthy, young. Now her eyelids, fingers, and toes are painfully swollen from the fluid accumulating in her body. She breathes on a ventilator. She does not awaken. Deep in a coma, she waits for us to bring her back. Standing at the side of her bed, we rack our brains and wonder if it is possible.

Illness does not discriminate. Instead, it strikes as lightning does – a random, focused beam of electrons that swoops down into this world to take those it will. It does not avoid or target anyone in particular – and yet, the casualties abound. A 25-year-old with a heart attack. A 28-year-old with a carotid dissection. A 21-year-old hit by a bus. And then there is a juxtaposition to these casualties – Mr. Philippe Petit, man on a wire, who walked – danced, really – on a wire between the twin towers in 1974 for all to see.

Our lives are not unlike Philippe Petit’s walk. The only difference is that, if that wire is life, then we walk it until we fall – and, inevitably, each one of us will fall. Philippe Petit did not. I often wonder what it would feel like to wake up one morning and be on that wire, balancing in the wind on a thread thinner than a finger’s breadth. The intensive care unit is another kind of wire – a live wire, strung from one room to the next, from one beating heart to another, until the moment when one decides to stop…


And so it goes…

I have avoided this blog as much as I have avoided the hospital in the last few weeks. In short, it has been wonderful. As I enter the doors of the emergency room again tomorrow morning, I will be facing the world as a resident yet again. This next stretch, two months of intensive care back to back, will mark the finale of my most difficult months of residency. I will finish out most of my 30-hour nights in the hospital and will be more than halfway done with second year by the time  it ends. By this time, the last of the leaves will have fallen from the trees and we will have gotten our first frost and likely our first snow. The holidays will have come and gone in the midst of far too many call nights, and it will be a new year, 2011. This new year marks the end of one long trek and the beginning of a new one – hopefully not as strenuous.

A controversial article appeared in The New York Times and The Wall Street Journal today, CT Scans Can Reduce Lung Cancer Deaths, Study Finds. There have been several recent discussions among health professionals, both in and out of the emergency department, about the risks and benefits of CT scan. Refer to a prior post, To Scan or Not to Scan: The Use of CT, for more information. The study to which it refers, National Lung Screening Trial, is currently being performed by the National Cancer Institute. The preliminary results, which were just released, indicate that there are some potential benefits to CT scan for detecting lung cancer in a high-risk population of current or former heavy smokers. These benefits are not without risks. Until a more comprehensive analysis of study design, participants, and results is released, the information is interesting at best but does not provide sufficient evidence to establish any guidelines for clinical practice.

Researchers found 20 percent less lung cancer deaths among trial participants who were screened with low-dose helical CT as compared to chest x-ray. First, these results only include participants who were at high risk for developing lung cancer. Secondly, the main objective of the study is to assess the number of deaths due to lung cancer – a more important question may be whether or not CT scan reduces overall deaths in this population. Thirdly, other imaging modalities including MRI and PET scan were not included in the study – these may be worth examining before developing screening guidelines.

As with much in medicine, it will take time, further analysis, and additional studies to determine what the best clinical practice should be. And, as with everything in medicine, it is important that we weigh the risks and benefits of any test or intervention. The radiation associated with CT scan poses a significant cancer risk to patients, and recent studies are beginning to estimate that these risks may be greater than we had anticipated.


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