Commentary

Dr. Michael Ellis DeBakey, pioneer heart surgeon and medical device innovator, died July 11, 2008 in Houston, about 2 months shy of his 100th birthday on Sept. 7.

In his lifetime, Dr. DeBakey was renowned for his immense contributions to the progress of medical science, such that he was declared a "living legend" by the Library of Congress and was this year awarded a Congressional Gold Medal for his lifetime achievements, in particular his pioneering work as a heart surgeon.

Even before Dr. DeBakey received his medical degree from Tulane University in 1932, he began his contributions to modern medicine by developing a small continuous flow–roller pump designed to improve blood transfusion—a device that would later be used by Dr. John Gibbon as a crucial component of his heart-lung machine. And in 1939, with his mentor, Dr. Alton Ochsner, Dr. DeBakey suggested a strong link between smoking and lung cancer.

After internships in New Orleans and surgical training in Europe, Dr. DeBakey volunteered for service during World War II and was assigned to the U.S. Army Surgeon General’s office. From his observations in the field, he became convinced of the need for a mobile surgical unit that would give soldiers access to high-level medical treatment on the combat field and convinced the surgeon general to form what would become the mobile army surgical hospitals (MASH units)—an innovation that gained him the U.S. Army Legion of Merit in 1945.

His government service continued throughout his civilian career, as he helped to establish the Veterans Administration medical center research system. He also initiated the movement that in 1956 took the Army’s poorly housed medical library and used it to create the National Library of Medicine, of which he was first board member and then chairman. He served three terms on the National Heart, Lung, and Blood Advisory Council as well. He was responsible for helping establish health care systems in a host of countries, including Belgium, China, Egypt, England, Germany, Saudi Arabia, Australia, and numerous other Middle Eastern and Central and South American nations.

According to the Web site of Baylor College of Medicine’s department of surgery, where he spent almost his entire postwar career, Dr. DeBakey operated on more than 60,000 patients in the Houston area alone. But these were not all just standard operations. In 1953, he performed the first successful carotid endarterectomy, as well as the first successful removal and graft replacement of a fusiform thoracic aortic aneurysm, and in 1954, the first successful resection and graft replacement of an aneurysm of the distal aortic arch and upper descending thoracic aorta.

In 1955 he performed the first successful resection of a thoracoabdominal aortic aneurysm using the DeBakey Dacron graft—the first artificial arterial graft of its kind.

"If we now tried to develop the Dacron graft the way we developed it, I am not sure we would have it today with the way they regulate things. ...When I went down to the department store . . . they said ‘We are fresh out of nylon, but we do have a new material called Dacron.’ I felt it, and it looked good to me. So I bought a yard of it. . . . I took this yard of Dacron cloth, I cut two sheets the width I wanted, sewed the edges on each side, and made a tube out of it . . . .We put the graft on a stent, wrapped nylon thread around it, pushed it together, and baked it.. . . After about two or three years of laboratory work on my own [including experiments in dogs], I decided that it was time to put the graft in a human being. I did not have a committee to approve it. . . . In 1954, I put the first one in during an abdominal aortic aneurysm. That first patient lived, I think, for 13 years and never had any trouble," Dr. DeBakey related in an interview published in 1996 in the Journal of Vascular Surgery.

And among his other pioneering surgical developments, in 1964, Dr. DeBakey was the first to perform a successful coronary artery bypass, using a portion of leg vein as the graft, in what is now one of the most commonly performed heart operations—coronary artery bypass grafting.

As if surgically repairing failing hearts was not enough, Dr. DeBakey became a pioneer of artificial heart research and of cardiac assist devices. On July 18, 1963, after years of animal research, he performed the first successful human implantation of a left ventricular assist device (LVAD), one which he devised; the patient died after 4 days from causes unrelated to the technology. In 1966, Dr. DeBakey’s redesigned, extracorporeal pneumatic pump was used in a 37-year old woman who could not be weaned from the heart-lung machine after dual valve replacement. After 10 days of LVAD support, she recovered sufficiently for the pump to be removed and she survived. This pump served as the basis of Dr. DeBakey’s first total artificial heart model, created in 1968.

Dr. DeBakey was honored profusely throughout his lifetime by the medical community and the general public. Numerous medical facilities are named after him in this country and around the world. He received countless awards for his technical and social achievements in medicine. Among these honors were the American Medical Association’s Distinguished Service Award (1959), the Albert Lasker Award for Clinical Medical Research (1963), the Presidential Medal of Freedom (1969), and the National Medal of Science (1987). More recently, he was the first foreign member elected to the Russian Academy of Sciences (1999), was given the Library of Congress Bicentennial Living Legend Award (2000), and was awarded the Congressional Gold Medal in April 2008.

In his death, Dr. DeBakey was the first Houston resident given the honor of lying in state at City Hall and, at the request of his family, he lay dressed in his characteristic glasses, scrubs, and white coat for viewing by long lines of the general public.

Suggested readings

Heart Fail. Clin. 2007;3:117-20.

J. Vasc. Surg. 1996;23:1031-4.

Dr. Michael Ellis DeBakey, pioneer heart surgeon and medical device innovator, died July 11, 2008 in Houston, about 2 months shy of his 100th birthday on Sept. 7.

In his lifetime, Dr. DeBakey was renowned for his immense contributions to the progress of medical science, such that he was declared a "living legend" by the Library of Congress and was this year awarded a Congressional Gold Medal for his lifetime achievements, in particular his pioneering work as a heart surgeon.

Even before Dr. DeBakey received his medical degree from Tulane University in 1932, he began his contributions to modern medicine by developing a small continuous flow–roller pump designed to improve blood transfusion—a device that would later be used by Dr. John Gibbon as a crucial component of his heart-lung machine. And in 1939, with his mentor, Dr. Alton Ochsner, Dr. DeBakey suggested a strong link between smoking and lung cancer.

After internships in New Orleans and surgical training in Europe, Dr. DeBakey volunteered for service during World War II and was assigned to the U.S. Army Surgeon General’s office. From his observations in the field, he became convinced of the need for a mobile surgical unit that would give soldiers access to high-level medical treatment on the combat field and convinced the surgeon general to form what would become the mobile army surgical hospitals (MASH units)—an innovation that gained him the U.S. Army Legion of Merit in 1945.

His government service continued throughout his civilian career, as he helped to establish the Veterans Administration medical center research system. He also initiated the movement that in 1956 took the Army’s poorly housed medical library and used it to create the National Library of Medicine, of which he was first board member and then chairman. He served three terms on the National Heart, Lung, and Blood Advisory Council as well. He was responsible for helping establish health care systems in a host of countries, including Belgium, China, Egypt, England, Germany, Saudi Arabia, Australia, and numerous other Middle Eastern and Central and South American nations.

According to the Web site of Baylor College of Medicine’s department of surgery, where he spent almost his entire postwar career, Dr. DeBakey operated on more than 60,000 patients in the Houston area alone. But these were not all just standard operations. In 1953, he performed the first successful carotid endarterectomy, as well as the first successful removal and graft replacement of a fusiform thoracic aortic aneurysm, and in 1954, the first successful resection and graft replacement of an aneurysm of the distal aortic arch and upper descending thoracic aorta.

In 1955 he performed the first successful resection of a thoracoabdominal aortic aneurysm using the DeBakey Dacron graft—the first artificial arterial graft of its kind.

"If we now tried to develop the Dacron graft the way we developed it, I am not sure we would have it today with the way they regulate things. ...When I went down to the department store . . . they said ‘We are fresh out of nylon, but we do have a new material called Dacron.’ I felt it, and it looked good to me. So I bought a yard of it. . . . I took this yard of Dacron cloth, I cut two sheets the width I wanted, sewed the edges on each side, and made a tube out of it . . . .We put the graft on a stent, wrapped nylon thread around it, pushed it together, and baked it.. . . After about two or three years of laboratory work on my own [including experiments in dogs], I decided that it was time to put the graft in a human being. I did not have a committee to approve it. . . . In 1954, I put the first one in during an abdominal aortic aneurysm. That first patient lived, I think, for 13 years and never had any trouble," Dr. DeBakey related in an interview published in 1996 in the Journal of Vascular Surgery.

And among his other pioneering surgical developments, in 1964, Dr. DeBakey was the first to perform a successful coronary artery bypass, using a portion of leg vein as the graft, in what is now one of the most commonly performed heart operations—coronary artery bypass grafting.

As if surgically repairing failing hearts was not enough, Dr. DeBakey became a pioneer of artificial heart research and of cardiac assist devices. On July 18, 1963, after years of animal research, he performed the first successful human implantation of a left ventricular assist device (LVAD), one which he devised; the patient died after 4 days from causes unrelated to the technology. In 1966, Dr. DeBakey’s redesigned, extracorporeal pneumatic pump was used in a 37-year old woman who could not be weaned from the heart-lung machine after dual valve replacement. After 10 days of LVAD support, she recovered sufficiently for the pump to be removed and she survived. This pump served as the basis of Dr. DeBakey’s first total artificial heart model, created in 1968.

Dr. DeBakey was honored profusely throughout his lifetime by the medical community and the general public. Numerous medical facilities are named after him in this country and around the world. He received countless awards for his technical and social achievements in medicine. Among these honors were the American Medical Association’s Distinguished Service Award (1959), the Albert Lasker Award for Clinical Medical Research (1963), the Presidential Medal of Freedom (1969), and the National Medal of Science (1987). More recently, he was the first foreign member elected to the Russian Academy of Sciences (1999), was given the Library of Congress Bicentennial Living Legend Award (2000), and was awarded the Congressional Gold Medal in April 2008.

In his death, Dr. DeBakey was the first Houston resident given the honor of lying in state at City Hall and, at the request of his family, he lay dressed in his characteristic glasses, scrubs, and white coat for viewing by long lines of the general public.

Suggested readings

Heart Fail. Clin. 2007;3:117-20.

J. Vasc. Surg. 1996;23:1031-4.

Dr. Michael Ellis DeBakey, pioneer heart surgeon and medical device innovator, died July 11, 2008 in Houston, about 2 months shy of his 100th birthday on Sept. 7.

In his lifetime, Dr. DeBakey was renowned for his immense contributions to the progress of medical science, such that he was declared a "living legend" by the Library of Congress and was this year awarded a Congressional Gold Medal for his lifetime achievements, in particular his pioneering work as a heart surgeon.

Even before Dr. DeBakey received his medical degree from Tulane University in 1932, he began his contributions to modern medicine by developing a small continuous flow–roller pump designed to improve blood transfusion—a device that would later be used by Dr. John Gibbon as a crucial component of his heart-lung machine. And in 1939, with his mentor, Dr. Alton Ochsner, Dr. DeBakey suggested a strong link between smoking and lung cancer.

After internships in New Orleans and surgical training in Europe, Dr. DeBakey volunteered for service during World War II and was assigned to the U.S. Army Surgeon General’s office. From his observations in the field, he became convinced of the need for a mobile surgical unit that would give soldiers access to high-level medical treatment on the combat field and convinced the surgeon general to form what would become the mobile army surgical hospitals (MASH units)—an innovation that gained him the U.S. Army Legion of Merit in 1945.

His government service continued throughout his civilian career, as he helped to establish the Veterans Administration medical center research system. He also initiated the movement that in 1956 took the Army’s poorly housed medical library and used it to create the National Library of Medicine, of which he was first board member and then chairman. He served three terms on the National Heart, Lung, and Blood Advisory Council as well. He was responsible for helping establish health care systems in a host of countries, including Belgium, China, Egypt, England, Germany, Saudi Arabia, Australia, and numerous other Middle Eastern and Central and South American nations.

According to the Web site of Baylor College of Medicine’s department of surgery, where he spent almost his entire postwar career, Dr. DeBakey operated on more than 60,000 patients in the Houston area alone. But these were not all just standard operations. In 1953, he performed the first successful carotid endarterectomy, as well as the first successful removal and graft replacement of a fusiform thoracic aortic aneurysm, and in 1954, the first successful resection and graft replacement of an aneurysm of the distal aortic arch and upper descending thoracic aorta.

In 1955 he performed the first successful resection of a thoracoabdominal aortic aneurysm using the DeBakey Dacron graft—the first artificial arterial graft of its kind.

"If we now tried to develop the Dacron graft the way we developed it, I am not sure we would have it today with the way they regulate things. ...When I went down to the department store . . . they said ‘We are fresh out of nylon, but we do have a new material called Dacron.’ I felt it, and it looked good to me. So I bought a yard of it. . . . I took this yard of Dacron cloth, I cut two sheets the width I wanted, sewed the edges on each side, and made a tube out of it . . . .We put the graft on a stent, wrapped nylon thread around it, pushed it together, and baked it.. . . After about two or three years of laboratory work on my own [including experiments in dogs], I decided that it was time to put the graft in a human being. I did not have a committee to approve it. . . . In 1954, I put the first one in during an abdominal aortic aneurysm. That first patient lived, I think, for 13 years and never had any trouble," Dr. DeBakey related in an interview published in 1996 in the Journal of Vascular Surgery.

And among his other pioneering surgical developments, in 1964, Dr. DeBakey was the first to perform a successful coronary artery bypass, using a portion of leg vein as the graft, in what is now one of the most commonly performed heart operations—coronary artery bypass grafting.

As if surgically repairing failing hearts was not enough, Dr. DeBakey became a pioneer of artificial heart research and of cardiac assist devices. On July 18, 1963, after years of animal research, he performed the first successful human implantation of a left ventricular assist device (LVAD), one which he devised; the patient died after 4 days from causes unrelated to the technology. In 1966, Dr. DeBakey’s redesigned, extracorporeal pneumatic pump was used in a 37-year old woman who could not be weaned from the heart-lung machine after dual valve replacement. After 10 days of LVAD support, she recovered sufficiently for the pump to be removed and she survived. This pump served as the basis of Dr. DeBakey’s first total artificial heart model, created in 1968.

Dr. DeBakey was honored profusely throughout his lifetime by the medical community and the general public. Numerous medical facilities are named after him in this country and around the world. He received countless awards for his technical and social achievements in medicine. Among these honors were the American Medical Association’s Distinguished Service Award (1959), the Albert Lasker Award for Clinical Medical Research (1963), the Presidential Medal of Freedom (1969), and the National Medal of Science (1987). More recently, he was the first foreign member elected to the Russian Academy of Sciences (1999), was given the Library of Congress Bicentennial Living Legend Award (2000), and was awarded the Congressional Gold Medal in April 2008.

In his death, Dr. DeBakey was the first Houston resident given the honor of lying in state at City Hall and, at the request of his family, he lay dressed in his characteristic glasses, scrubs, and white coat for viewing by long lines of the general public.

Suggested readings

Heart Fail. Clin. 2007;3:117-20.

J. Vasc. Surg. 1996;23:1031-4.

The ready availability of nearly unlimited quantities of biologically-based drugs such as heparin is something that is taken for granted nowadays, such that massive accidental overdoses as recently reported in the news, are considered tragic but by no means incredible. But it is within the memory of living generations that having enough heparin for experimental studies, much less for clinical use, was an impossibility.

Hirudin, the first anticoagulation substance ever isolated, is just over 100 years old. It was first obtained from the medicinal leech in 1905. By 1912, Dr. William Henry Howell discovered that there was a substance similar to hirudin in human and other mammalian blood plasma, and he soon proposed his theory that this "antithrombin" had a role in maintaining the fluidity of blood during in vivo circulation.

It was not until 1916, however, that Dr. Jay McLean working in Dr. Howell’s laboratory at Johns Hopkins University, Baltimore, reported his partial isolation of heparin. Dr. Howell and Dr. McLean performed animal studies to confirm the activity of the new phosphatide anticoagulant, but were unable to proceed beyond preliminary clinical experiments because of its toxicity.

There was some evidence later of ill-feeling by Dr. McLean, who felt that his role in the discovery of heparin had been downplayed in the literature in favor of Dr. Howell who ran the laboratory and who coined the name heparin as they isolated it originally from dog’s liver.

But even before Dr. McLean’s death in the late 1950s, heparin researchers, including Dr. Charles H. Best as a notable example, made efforts to reiterate his role as the initial discoverer. This was in part due to Dr. McLean himself who "became quite sensitive regarding his role in the discovery of heparin. Writing to . . . Charles Best in 1940, McLean complained that Howell had received disproportionate credit for the discovery which McLean claimed was his own." Dr. Howell continued research on heparin and worked to improve its purification. However, it remained for others to take heparin to fruition as an ultimately valuable clinical tool.

It was not until 1929 that Dr. Best (the codiscoverer of insulin with Dr. Frederick Banting) and his colleagues, chemists Dr. Arthur F. Charles and Dr. David. A. Scott at the Connaught Laboratories at the University of Toronto, began the work that led to the production of a crystalline, barium salt of heparin from beef liver that was 100 times more potent than the original crude extract and was free of toxic side effects such that it could be used in large doses in numerous animal experiments leading to clinical trials.

By 1932, Dr. Best and Dr. Gordon D. W. Murray at the Toronto laboratories and Toronto General Hospital were investigating the use of heparin in dogs as "a prophylactic in those conditions which lead to postoperative pulmonary embolism, and as an adjuvant in those operations based upon blood vessels in which the outcome has been so doubtful, because of the tendency of thrombosis to occur at the site of the operation," they reported.

Blood vessel work prior to this time was primarily the province of physiologists, and not clinicians, because "blood flow in the operated vessels failed in a few hours, blocked by the formation of a thrombus and clot. A few hours was sufficient time for a physiological experiment which was completed in one working day, but [was] of no value for the treatment of patients," according to L. B. Jacques, D. Sc., a student of Dr. Murray’s who was instrumental in the early research.

In 1938, Dr. Murray and Dr. Best reported on the method of "regional heparinization" which they developed in dogs. Heparin was injected "into an artery proximal to a suture line to affect the clotting time locally in that vessel and in the blood returning from that extremity, but not to change the clotting time of the whole blood stream."

Dr. Murray would go on to become the first surgeon to make use of the drug in human trials, beginning in May 1935, having the advantage of working with Dr. Best and the world’s best source of heparin. He was not working in isolation, however. Similar work was being carried out by Dr. J. Erik Jorpes, Dr. Clarence Crafoord and others in Stockholm, using heparin prepared in the manner developed by Dr. Best and his colleagues.

By 1940 Dr. Murray was using heparin not just to prevent deep vein thrombosis and pulmonary embolism, but as an intraoperative adjunct to vascular surgery where he found it greatly improved arterial patency after arterial repair.

Dr. Murray would become one of Canada’s most famous cardiac surgeons, performing numerous congenital heart operations; though his career would end in controversy and isolation, when he announced a surgical cure for traumatic paraplegia that did not stand up to scrutiny. But the benefits from his early and innovative use of heparin are uncontested.

Apart from heparin’s clinical benefits in vascular surgery, the anticoagulant also proved to be an invaluable boon to the development of blood manipulation and analysis devices. In fact, before the days of Teflon tubing, heparin made possible the development of the first kidney dialysis machine when it was used to coat glass tubing to prevent coagulation. Heparinization also became key to preventing the formation of thrombus resulting from the implantation of artifical cardiovascular grafts—whether as blood vessels, patches, or heart valves.

It wasn’t until the mid-1970s and early 1980s that the true structure of heparin and its molecular mechanism were finally worked out by several research laboratories. Scientists such as Dr. Robert Rosenberg and Dr. Ulf Lindahl and their colleagues and competitors discovered that the molecule acts as a binding activator of the protease inhibitor known as antithrombin, enhancing its activity at preventing the coagulation cascade. Chemical synthesis of the components of heparin was reported by Dr. Pierre Sinay, Dr. Maurice Petitou and colleagues around 1984 and quickly other researchers worked out its biosynthetic pathway.

Today commercial, injectable heparin is still isolated from animals—in this case porcine intestinal mucosa. However, researchers at Rensselaer and the University of North Carolina at Chapel Hill, recently reported synthesizing hundreds of milligrams of heparin using engineered enzymes (J. Biol. Chem. 2005;280:42817-25).

BOXED QUOTE:

‘First it was necessary to determine the effect of the heparin . . . in the dogs which were to be used for the thrombosis test.. . . After three weeks of testing and as I was about to use a very large dose, I received a phone call from Dr. Best’s office to drop whatever I was doing and come over immediately. When I arrived, Dr. Best asked what I had been doing. I showed him my record book. He said "that’s all very well Jacques, but do realize you have used up the world’s supply of heparin?" ’

—L. B. Jacques, D.Sc., reflecting on his days as a student assistant with Dr. Best and Dr. Murray in the early days of heparin research (J. Ortho. Med. 1993;8:139-148).

More information

1. "Heparin: The Contributions of William Henry Howell" (Circulation 1984;69:1198-203).

2. "Preparation of Heparin and Its Use in the First Clinical Cases" (Circulation 1959;19:79-86).

3. "The Use of Heparin in Thrombosis" (Annals of Surgery 1938;108:163-77).

The ready availability of nearly unlimited quantities of biologically-based drugs such as heparin is something that is taken for granted nowadays, such that massive accidental overdoses as recently reported in the news, are considered tragic but by no means incredible. But it is within the memory of living generations that having enough heparin for experimental studies, much less for clinical use, was an impossibility.

Hirudin, the first anticoagulation substance ever isolated, is just over 100 years old. It was first obtained from the medicinal leech in 1905. By 1912, Dr. William Henry Howell discovered that there was a substance similar to hirudin in human and other mammalian blood plasma, and he soon proposed his theory that this "antithrombin" had a role in maintaining the fluidity of blood during in vivo circulation.

It was not until 1916, however, that Dr. Jay McLean working in Dr. Howell’s laboratory at Johns Hopkins University, Baltimore, reported his partial isolation of heparin. Dr. Howell and Dr. McLean performed animal studies to confirm the activity of the new phosphatide anticoagulant, but were unable to proceed beyond preliminary clinical experiments because of its toxicity.

There was some evidence later of ill-feeling by Dr. McLean, who felt that his role in the discovery of heparin had been downplayed in the literature in favor of Dr. Howell who ran the laboratory and who coined the name heparin as they isolated it originally from dog’s liver.

But even before Dr. McLean’s death in the late 1950s, heparin researchers, including Dr. Charles H. Best as a notable example, made efforts to reiterate his role as the initial discoverer. This was in part due to Dr. McLean himself who "became quite sensitive regarding his role in the discovery of heparin. Writing to . . . Charles Best in 1940, McLean complained that Howell had received disproportionate credit for the discovery which McLean claimed was his own." Dr. Howell continued research on heparin and worked to improve its purification. However, it remained for others to take heparin to fruition as an ultimately valuable clinical tool.

It was not until 1929 that Dr. Best (the codiscoverer of insulin with Dr. Frederick Banting) and his colleagues, chemists Dr. Arthur F. Charles and Dr. David. A. Scott at the Connaught Laboratories at the University of Toronto, began the work that led to the production of a crystalline, barium salt of heparin from beef liver that was 100 times more potent than the original crude extract and was free of toxic side effects such that it could be used in large doses in numerous animal experiments leading to clinical trials.

By 1932, Dr. Best and Dr. Gordon D. W. Murray at the Toronto laboratories and Toronto General Hospital were investigating the use of heparin in dogs as "a prophylactic in those conditions which lead to postoperative pulmonary embolism, and as an adjuvant in those operations based upon blood vessels in which the outcome has been so doubtful, because of the tendency of thrombosis to occur at the site of the operation," they reported.

Blood vessel work prior to this time was primarily the province of physiologists, and not clinicians, because "blood flow in the operated vessels failed in a few hours, blocked by the formation of a thrombus and clot. A few hours was sufficient time for a physiological experiment which was completed in one working day, but [was] of no value for the treatment of patients," according to L. B. Jacques, D. Sc., a student of Dr. Murray’s who was instrumental in the early research.

In 1938, Dr. Murray and Dr. Best reported on the method of "regional heparinization" which they developed in dogs. Heparin was injected "into an artery proximal to a suture line to affect the clotting time locally in that vessel and in the blood returning from that extremity, but not to change the clotting time of the whole blood stream."

Dr. Murray would go on to become the first surgeon to make use of the drug in human trials, beginning in May 1935, having the advantage of working with Dr. Best and the world’s best source of heparin. He was not working in isolation, however. Similar work was being carried out by Dr. J. Erik Jorpes, Dr. Clarence Crafoord and others in Stockholm, using heparin prepared in the manner developed by Dr. Best and his colleagues.

By 1940 Dr. Murray was using heparin not just to prevent deep vein thrombosis and pulmonary embolism, but as an intraoperative adjunct to vascular surgery where he found it greatly improved arterial patency after arterial repair.

Dr. Murray would become one of Canada’s most famous cardiac surgeons, performing numerous congenital heart operations; though his career would end in controversy and isolation, when he announced a surgical cure for traumatic paraplegia that did not stand up to scrutiny. But the benefits from his early and innovative use of heparin are uncontested.

Apart from heparin’s clinical benefits in vascular surgery, the anticoagulant also proved to be an invaluable boon to the development of blood manipulation and analysis devices. In fact, before the days of Teflon tubing, heparin made possible the development of the first kidney dialysis machine when it was used to coat glass tubing to prevent coagulation. Heparinization also became key to preventing the formation of thrombus resulting from the implantation of artifical cardiovascular grafts—whether as blood vessels, patches, or heart valves.

It wasn’t until the mid-1970s and early 1980s that the true structure of heparin and its molecular mechanism were finally worked out by several research laboratories. Scientists such as Dr. Robert Rosenberg and Dr. Ulf Lindahl and their colleagues and competitors discovered that the molecule acts as a binding activator of the protease inhibitor known as antithrombin, enhancing its activity at preventing the coagulation cascade. Chemical synthesis of the components of heparin was reported by Dr. Pierre Sinay, Dr. Maurice Petitou and colleagues around 1984 and quickly other researchers worked out its biosynthetic pathway.

Today commercial, injectable heparin is still isolated from animals—in this case porcine intestinal mucosa. However, researchers at Rensselaer and the University of North Carolina at Chapel Hill, recently reported synthesizing hundreds of milligrams of heparin using engineered enzymes (J. Biol. Chem. 2005;280:42817-25).

BOXED QUOTE:

‘First it was necessary to determine the effect of the heparin . . . in the dogs which were to be used for the thrombosis test.. . . After three weeks of testing and as I was about to use a very large dose, I received a phone call from Dr. Best’s office to drop whatever I was doing and come over immediately. When I arrived, Dr. Best asked what I had been doing. I showed him my record book. He said "that’s all very well Jacques, but do realize you have used up the world’s supply of heparin?" ’

—L. B. Jacques, D.Sc., reflecting on his days as a student assistant with Dr. Best and Dr. Murray in the early days of heparin research (J. Ortho. Med. 1993;8:139-148).

More information

1. "Heparin: The Contributions of William Henry Howell" (Circulation 1984;69:1198-203).

2. "Preparation of Heparin and Its Use in the First Clinical Cases" (Circulation 1959;19:79-86).

3. "The Use of Heparin in Thrombosis" (Annals of Surgery 1938;108:163-77).

The ready availability of nearly unlimited quantities of biologically-based drugs such as heparin is something that is taken for granted nowadays, such that massive accidental overdoses as recently reported in the news, are considered tragic but by no means incredible. But it is within the memory of living generations that having enough heparin for experimental studies, much less for clinical use, was an impossibility.

Hirudin, the first anticoagulation substance ever isolated, is just over 100 years old. It was first obtained from the medicinal leech in 1905. By 1912, Dr. William Henry Howell discovered that there was a substance similar to hirudin in human and other mammalian blood plasma, and he soon proposed his theory that this "antithrombin" had a role in maintaining the fluidity of blood during in vivo circulation.

It was not until 1916, however, that Dr. Jay McLean working in Dr. Howell’s laboratory at Johns Hopkins University, Baltimore, reported his partial isolation of heparin. Dr. Howell and Dr. McLean performed animal studies to confirm the activity of the new phosphatide anticoagulant, but were unable to proceed beyond preliminary clinical experiments because of its toxicity.

There was some evidence later of ill-feeling by Dr. McLean, who felt that his role in the discovery of heparin had been downplayed in the literature in favor of Dr. Howell who ran the laboratory and who coined the name heparin as they isolated it originally from dog’s liver.

But even before Dr. McLean’s death in the late 1950s, heparin researchers, including Dr. Charles H. Best as a notable example, made efforts to reiterate his role as the initial discoverer. This was in part due to Dr. McLean himself who "became quite sensitive regarding his role in the discovery of heparin. Writing to . . . Charles Best in 1940, McLean complained that Howell had received disproportionate credit for the discovery which McLean claimed was his own." Dr. Howell continued research on heparin and worked to improve its purification. However, it remained for others to take heparin to fruition as an ultimately valuable clinical tool.

It was not until 1929 that Dr. Best (the codiscoverer of insulin with Dr. Frederick Banting) and his colleagues, chemists Dr. Arthur F. Charles and Dr. David. A. Scott at the Connaught Laboratories at the University of Toronto, began the work that led to the production of a crystalline, barium salt of heparin from beef liver that was 100 times more potent than the original crude extract and was free of toxic side effects such that it could be used in large doses in numerous animal experiments leading to clinical trials.

By 1932, Dr. Best and Dr. Gordon D. W. Murray at the Toronto laboratories and Toronto General Hospital were investigating the use of heparin in dogs as "a prophylactic in those conditions which lead to postoperative pulmonary embolism, and as an adjuvant in those operations based upon blood vessels in which the outcome has been so doubtful, because of the tendency of thrombosis to occur at the site of the operation," they reported.

Blood vessel work prior to this time was primarily the province of physiologists, and not clinicians, because "blood flow in the operated vessels failed in a few hours, blocked by the formation of a thrombus and clot. A few hours was sufficient time for a physiological experiment which was completed in one working day, but [was] of no value for the treatment of patients," according to L. B. Jacques, D. Sc., a student of Dr. Murray’s who was instrumental in the early research.

In 1938, Dr. Murray and Dr. Best reported on the method of "regional heparinization" which they developed in dogs. Heparin was injected "into an artery proximal to a suture line to affect the clotting time locally in that vessel and in the blood returning from that extremity, but not to change the clotting time of the whole blood stream."

Dr. Murray would go on to become the first surgeon to make use of the drug in human trials, beginning in May 1935, having the advantage of working with Dr. Best and the world’s best source of heparin. He was not working in isolation, however. Similar work was being carried out by Dr. J. Erik Jorpes, Dr. Clarence Crafoord and others in Stockholm, using heparin prepared in the manner developed by Dr. Best and his colleagues.

By 1940 Dr. Murray was using heparin not just to prevent deep vein thrombosis and pulmonary embolism, but as an intraoperative adjunct to vascular surgery where he found it greatly improved arterial patency after arterial repair.

Dr. Murray would become one of Canada’s most famous cardiac surgeons, performing numerous congenital heart operations; though his career would end in controversy and isolation, when he announced a surgical cure for traumatic paraplegia that did not stand up to scrutiny. But the benefits from his early and innovative use of heparin are uncontested.

Apart from heparin’s clinical benefits in vascular surgery, the anticoagulant also proved to be an invaluable boon to the development of blood manipulation and analysis devices. In fact, before the days of Teflon tubing, heparin made possible the development of the first kidney dialysis machine when it was used to coat glass tubing to prevent coagulation. Heparinization also became key to preventing the formation of thrombus resulting from the implantation of artifical cardiovascular grafts—whether as blood vessels, patches, or heart valves.

It wasn’t until the mid-1970s and early 1980s that the true structure of heparin and its molecular mechanism were finally worked out by several research laboratories. Scientists such as Dr. Robert Rosenberg and Dr. Ulf Lindahl and their colleagues and competitors discovered that the molecule acts as a binding activator of the protease inhibitor known as antithrombin, enhancing its activity at preventing the coagulation cascade. Chemical synthesis of the components of heparin was reported by Dr. Pierre Sinay, Dr. Maurice Petitou and colleagues around 1984 and quickly other researchers worked out its biosynthetic pathway.

Today commercial, injectable heparin is still isolated from animals—in this case porcine intestinal mucosa. However, researchers at Rensselaer and the University of North Carolina at Chapel Hill, recently reported synthesizing hundreds of milligrams of heparin using engineered enzymes (J. Biol. Chem. 2005;280:42817-25).

BOXED QUOTE:

‘First it was necessary to determine the effect of the heparin . . . in the dogs which were to be used for the thrombosis test.. . . After three weeks of testing and as I was about to use a very large dose, I received a phone call from Dr. Best’s office to drop whatever I was doing and come over immediately. When I arrived, Dr. Best asked what I had been doing. I showed him my record book. He said "that’s all very well Jacques, but do realize you have used up the world’s supply of heparin?" ’

—L. B. Jacques, D.Sc., reflecting on his days as a student assistant with Dr. Best and Dr. Murray in the early days of heparin research (J. Ortho. Med. 1993;8:139-148).

More information

1. "Heparin: The Contributions of William Henry Howell" (Circulation 1984;69:1198-203).

2. "Preparation of Heparin and Its Use in the First Clinical Cases" (Circulation 1959;19:79-86).

3. "The Use of Heparin in Thrombosis" (Annals of Surgery 1938;108:163-77).

In the first years of the 20th century, Dr. Alexis Carrel (1873-1944) introduced three-point end-to-end vessel anastomosis, a technique that revolutionized vascular surgery. His method, still in common use today, helped earn him the 1912 Nobel Prize in Physiology or Medicine and has led many to call him "the father of anastomoses."

Dr. Carrel was not only the youngest person to ever be awarded the Nobel Prize, but he was also the first Nobel winner whose work was primarily performed in the United States—even though he was a native Frenchman who emigrated from Lyons and maintained his French citizenship.

The inspiration for his work in vascular repair has been traced to the assassination of French President Sadi Carnot, who was stabbed in the abdomen in 1894. Carnot’s physicians made no attempt to repair the lacerated portal vein, and Carrel criticized them severely after the fact. Nearly all physicians at the time would only ligate—not attempt to repair—blood vessels, which meant that survival or preservation of limbs was possible only in cases of damage to vessels that had duplicates, such as those distal to the knee or elbow. Dr. Carrel argued with his superiors that the portal vein should have been repaired, and the incident "inspired him to begin his historic research in vascular anastomosis," according to Dr. Catherine Boulay and Dr. Mark A. Hardy (Current Surg. 2001;58:300-9).

In 1902, Dr. Carrel published his most important—and still used—technique of vascular anastomosis. (See box.) Although the majority of his work was done on experimental animals, he and others rapidly adapted it for use in humans. In his Nobel presentation speech, Prof. J. Ackerman, a member of the committee on medicine or physiology, stated: "Alexis Carrel was the first person to invent a better and more reliable method of sewing vessels together.. . . [When he made a suture, he] enlarged the opening using three retaining stitches located at equidistant points which converted the round opening into a triangular one." The key benefit of this technique was its ability to prevent thrombosis and infection.

Interestingly, the method relied not only on Dr. Carrel’s profound skill as a surgeon, but on the help of his mother’s embroidery circle. He "adapted fine lace needles and silk embroidery thread for use in delicate surgery."

His method was quickly adapted to the performance of routine anastomoses in vessels ranging from major arteries to minor veins. The technique formed the basis for bypass surgery, and allowed the use of graft vessels from donors or other parts of the body, or artificial implants. Still later, his anastomosis technique would become the foundation for revascularizing organs during transplant, work that Dr. Carrel pioneered in animal experiments.

In his career, Dr. Carrel also helped to make major advances in the area of heart surgery. He collaborated with Dr. Theodore Tuffier, describing procedures for mitral valvulotomy, annuloplasty, and coronary artery bypass graft at the American Surgical Association meeting in 1910. And in 1935, toward the end of his American career, he—along with aviator and engineer Charles A. Lindbergh—helped create the first pump-oxygenator for organ perfusion, thus laying the groundwork for future heart-lung machines.

Among Dr. Carrel’s many other technical successes was his ability to safely perform complex surgery in the preantibiotic era. During World War I, he returned to France and created a model facility with funding from the Rockefeller Foundation for hospitalizing soldiers close to the front. Working with his nurse-wife and a colleague, Dr. Henry Drysdale Dakin, he devised a wound irrigation solution consisting of sodium hypochlorite (0.45%-0.5%) and boric acid (4%) in order to promote antisepsis.

As part of their methodology, Dr. Carrel and Dr. Dakin monitored wound cultures frequently, and did not close the wound until these cultures came up negative. Dr. Carrel was widely criticized for this procedure, despite his successes, and the method was not adopted until more than a year later by the allied forces. Dr. Carrel then went to New York to train medical officers in the Carrel-Dakin technique.

As he grew older, Dr. Carrel’s interests widened significantly beyond vascular surgery, and he began to focus on cell, tissue, and organ culture. In 1912, for example, he cultured heart cells from a chicken embryo; these were maintained successfully for 34 years, outliving Dr. Carrel himself. He drifted into areas beyond science and became a philosopher, a religious apologist, and an armchair sociologist. His book, "Man, the Unknown" (New York: Harper & Bros., 1935) was an international best seller and caused him endless trouble with his peers.

"Scientists shunned him for his gullibility," noted Dr. Boulay and Dr. Hardy, because of his support of the study of clairvoyance, telepathy, water divination, auras, and the healing power of prayer.

Even more controversial were his support of eugenics, his belief that democracy was doomed to failure because men were not equal, and his advocacy of euthanasia for criminals and the criminally insane—views that ultimately led many to consider him a Nazi sympathizer.

Dr. Carrel returned to France in 1939, shortly before the start of World War II, when his unpopular views and sometimes abrasive personality helped to keep him from getting a stay of mandatory retirement at age 65 from the Rockefeller Foundation, where he had worked for over 30 years.

Dr. Carrel was known to despise Hitler. But his published views—and the fact that he agreed to work for the Vichy government in occupied France to create and head a new institute of man, called the "Foundation Française Pour l’Étude des Problèmes Humains"—made him suspect. The German propaganda machine embraced Dr. Carrel and his work at the institute, helping to contribute to his vilification in the allied nations. In the backlash after France was liberated, Dr. Carrel was accused of collaboration, his institute was dismantled, his health failed, and he died shortly afterward, on November 5, 1944, all the while fearing arrest as "a racist, a Nazi apologist, and a Nazi eugenicist."

It was a fate starkly in contrast to his earlier achievements as a pioneer of vascular surgery and organ transplantation.☐

"The love of gain penetrates everywhere.. . . It operates in that great doctor who is always insisting to his pupils and patients the efficacy of some remedy when, all the while, he is being secretly paid by its manufacturers."

—Alexis Carrel, M.D., in "Reflections on Life" (New York: Hawthorn Books Inc., 1952)

In addition to Dr. Boulay’s and Dr. Hardy’s article, "Alexis Carrel—The French Dervish of Surgery (Current Surg. 2001;58:303-9 [Epub doi:1016/S0149-7944(01)00416-0]), more information about Dr. Carrel can be found in the following sources:

• "Alexis Carrel’s Legacy: Visionary of Vascular Surgery and Organ Transplantation" (Transplantation Proc. 2000;34:1061-6).

• "Nobel Lectures, Physiology or Medicine, 1901-1921, (Amsterdam: Elsevier Publishing Co., 1967; available online at http://nobelprize.org/nobelfoundation/publications)

In the first years of the 20th century, Dr. Alexis Carrel (1873-1944) introduced three-point end-to-end vessel anastomosis, a technique that revolutionized vascular surgery. His method, still in common use today, helped earn him the 1912 Nobel Prize in Physiology or Medicine and has led many to call him "the father of anastomoses."

Dr. Carrel was not only the youngest person to ever be awarded the Nobel Prize, but he was also the first Nobel winner whose work was primarily performed in the United States—even though he was a native Frenchman who emigrated from Lyons and maintained his French citizenship.

The inspiration for his work in vascular repair has been traced to the assassination of French President Sadi Carnot, who was stabbed in the abdomen in 1894. Carnot’s physicians made no attempt to repair the lacerated portal vein, and Carrel criticized them severely after the fact. Nearly all physicians at the time would only ligate—not attempt to repair—blood vessels, which meant that survival or preservation of limbs was possible only in cases of damage to vessels that had duplicates, such as those distal to the knee or elbow. Dr. Carrel argued with his superiors that the portal vein should have been repaired, and the incident "inspired him to begin his historic research in vascular anastomosis," according to Dr. Catherine Boulay and Dr. Mark A. Hardy (Current Surg. 2001;58:300-9).

In 1902, Dr. Carrel published his most important—and still used—technique of vascular anastomosis. (See box.) Although the majority of his work was done on experimental animals, he and others rapidly adapted it for use in humans. In his Nobel presentation speech, Prof. J. Ackerman, a member of the committee on medicine or physiology, stated: "Alexis Carrel was the first person to invent a better and more reliable method of sewing vessels together.. . . [When he made a suture, he] enlarged the opening using three retaining stitches located at equidistant points which converted the round opening into a triangular one." The key benefit of this technique was its ability to prevent thrombosis and infection.

Interestingly, the method relied not only on Dr. Carrel’s profound skill as a surgeon, but on the help of his mother’s embroidery circle. He "adapted fine lace needles and silk embroidery thread for use in delicate surgery."

His method was quickly adapted to the performance of routine anastomoses in vessels ranging from major arteries to minor veins. The technique formed the basis for bypass surgery, and allowed the use of graft vessels from donors or other parts of the body, or artificial implants. Still later, his anastomosis technique would become the foundation for revascularizing organs during transplant, work that Dr. Carrel pioneered in animal experiments.

In his career, Dr. Carrel also helped to make major advances in the area of heart surgery. He collaborated with Dr. Theodore Tuffier, describing procedures for mitral valvulotomy, annuloplasty, and coronary artery bypass graft at the American Surgical Association meeting in 1910. And in 1935, toward the end of his American career, he—along with aviator and engineer Charles A. Lindbergh—helped create the first pump-oxygenator for organ perfusion, thus laying the groundwork for future heart-lung machines.

Among Dr. Carrel’s many other technical successes was his ability to safely perform complex surgery in the preantibiotic era. During World War I, he returned to France and created a model facility with funding from the Rockefeller Foundation for hospitalizing soldiers close to the front. Working with his nurse-wife and a colleague, Dr. Henry Drysdale Dakin, he devised a wound irrigation solution consisting of sodium hypochlorite (0.45%-0.5%) and boric acid (4%) in order to promote antisepsis.

As part of their methodology, Dr. Carrel and Dr. Dakin monitored wound cultures frequently, and did not close the wound until these cultures came up negative. Dr. Carrel was widely criticized for this procedure, despite his successes, and the method was not adopted until more than a year later by the allied forces. Dr. Carrel then went to New York to train medical officers in the Carrel-Dakin technique.

As he grew older, Dr. Carrel’s interests widened significantly beyond vascular surgery, and he began to focus on cell, tissue, and organ culture. In 1912, for example, he cultured heart cells from a chicken embryo; these were maintained successfully for 34 years, outliving Dr. Carrel himself. He drifted into areas beyond science and became a philosopher, a religious apologist, and an armchair sociologist. His book, "Man, the Unknown" (New York: Harper & Bros., 1935) was an international best seller and caused him endless trouble with his peers.

"Scientists shunned him for his gullibility," noted Dr. Boulay and Dr. Hardy, because of his support of the study of clairvoyance, telepathy, water divination, auras, and the healing power of prayer.

Even more controversial were his support of eugenics, his belief that democracy was doomed to failure because men were not equal, and his advocacy of euthanasia for criminals and the criminally insane—views that ultimately led many to consider him a Nazi sympathizer.

Dr. Carrel returned to France in 1939, shortly before the start of World War II, when his unpopular views and sometimes abrasive personality helped to keep him from getting a stay of mandatory retirement at age 65 from the Rockefeller Foundation, where he had worked for over 30 years.

Dr. Carrel was known to despise Hitler. But his published views—and the fact that he agreed to work for the Vichy government in occupied France to create and head a new institute of man, called the "Foundation Française Pour l’Étude des Problèmes Humains"—made him suspect. The German propaganda machine embraced Dr. Carrel and his work at the institute, helping to contribute to his vilification in the allied nations. In the backlash after France was liberated, Dr. Carrel was accused of collaboration, his institute was dismantled, his health failed, and he died shortly afterward, on November 5, 1944, all the while fearing arrest as "a racist, a Nazi apologist, and a Nazi eugenicist."

It was a fate starkly in contrast to his earlier achievements as a pioneer of vascular surgery and organ transplantation.☐

"The love of gain penetrates everywhere.. . . It operates in that great doctor who is always insisting to his pupils and patients the efficacy of some remedy when, all the while, he is being secretly paid by its manufacturers."

—Alexis Carrel, M.D., in "Reflections on Life" (New York: Hawthorn Books Inc., 1952)

In addition to Dr. Boulay’s and Dr. Hardy’s article, "Alexis Carrel—The French Dervish of Surgery (Current Surg. 2001;58:303-9 [Epub doi:1016/S0149-7944(01)00416-0]), more information about Dr. Carrel can be found in the following sources:

• "Alexis Carrel’s Legacy: Visionary of Vascular Surgery and Organ Transplantation" (Transplantation Proc. 2000;34:1061-6).

• "Nobel Lectures, Physiology or Medicine, 1901-1921, (Amsterdam: Elsevier Publishing Co., 1967; available online at http://nobelprize.org/nobelfoundation/publications)

In the first years of the 20th century, Dr. Alexis Carrel (1873-1944) introduced three-point end-to-end vessel anastomosis, a technique that revolutionized vascular surgery. His method, still in common use today, helped earn him the 1912 Nobel Prize in Physiology or Medicine and has led many to call him "the father of anastomoses."

Dr. Carrel was not only the youngest person to ever be awarded the Nobel Prize, but he was also the first Nobel winner whose work was primarily performed in the United States—even though he was a native Frenchman who emigrated from Lyons and maintained his French citizenship.

The inspiration for his work in vascular repair has been traced to the assassination of French President Sadi Carnot, who was stabbed in the abdomen in 1894. Carnot’s physicians made no attempt to repair the lacerated portal vein, and Carrel criticized them severely after the fact. Nearly all physicians at the time would only ligate—not attempt to repair—blood vessels, which meant that survival or preservation of limbs was possible only in cases of damage to vessels that had duplicates, such as those distal to the knee or elbow. Dr. Carrel argued with his superiors that the portal vein should have been repaired, and the incident "inspired him to begin his historic research in vascular anastomosis," according to Dr. Catherine Boulay and Dr. Mark A. Hardy (Current Surg. 2001;58:300-9).

In 1902, Dr. Carrel published his most important—and still used—technique of vascular anastomosis. (See box.) Although the majority of his work was done on experimental animals, he and others rapidly adapted it for use in humans. In his Nobel presentation speech, Prof. J. Ackerman, a member of the committee on medicine or physiology, stated: "Alexis Carrel was the first person to invent a better and more reliable method of sewing vessels together.. . . [When he made a suture, he] enlarged the opening using three retaining stitches located at equidistant points which converted the round opening into a triangular one." The key benefit of this technique was its ability to prevent thrombosis and infection.

Interestingly, the method relied not only on Dr. Carrel’s profound skill as a surgeon, but on the help of his mother’s embroidery circle. He "adapted fine lace needles and silk embroidery thread for use in delicate surgery."

His method was quickly adapted to the performance of routine anastomoses in vessels ranging from major arteries to minor veins. The technique formed the basis for bypass surgery, and allowed the use of graft vessels from donors or other parts of the body, or artificial implants. Still later, his anastomosis technique would become the foundation for revascularizing organs during transplant, work that Dr. Carrel pioneered in animal experiments.

In his career, Dr. Carrel also helped to make major advances in the area of heart surgery. He collaborated with Dr. Theodore Tuffier, describing procedures for mitral valvulotomy, annuloplasty, and coronary artery bypass graft at the American Surgical Association meeting in 1910. And in 1935, toward the end of his American career, he—along with aviator and engineer Charles A. Lindbergh—helped create the first pump-oxygenator for organ perfusion, thus laying the groundwork for future heart-lung machines.

Among Dr. Carrel’s many other technical successes was his ability to safely perform complex surgery in the preantibiotic era. During World War I, he returned to France and created a model facility with funding from the Rockefeller Foundation for hospitalizing soldiers close to the front. Working with his nurse-wife and a colleague, Dr. Henry Drysdale Dakin, he devised a wound irrigation solution consisting of sodium hypochlorite (0.45%-0.5%) and boric acid (4%) in order to promote antisepsis.

As part of their methodology, Dr. Carrel and Dr. Dakin monitored wound cultures frequently, and did not close the wound until these cultures came up negative. Dr. Carrel was widely criticized for this procedure, despite his successes, and the method was not adopted until more than a year later by the allied forces. Dr. Carrel then went to New York to train medical officers in the Carrel-Dakin technique.

As he grew older, Dr. Carrel’s interests widened significantly beyond vascular surgery, and he began to focus on cell, tissue, and organ culture. In 1912, for example, he cultured heart cells from a chicken embryo; these were maintained successfully for 34 years, outliving Dr. Carrel himself. He drifted into areas beyond science and became a philosopher, a religious apologist, and an armchair sociologist. His book, "Man, the Unknown" (New York: Harper & Bros., 1935) was an international best seller and caused him endless trouble with his peers.

"Scientists shunned him for his gullibility," noted Dr. Boulay and Dr. Hardy, because of his support of the study of clairvoyance, telepathy, water divination, auras, and the healing power of prayer.

Even more controversial were his support of eugenics, his belief that democracy was doomed to failure because men were not equal, and his advocacy of euthanasia for criminals and the criminally insane—views that ultimately led many to consider him a Nazi sympathizer.

Dr. Carrel returned to France in 1939, shortly before the start of World War II, when his unpopular views and sometimes abrasive personality helped to keep him from getting a stay of mandatory retirement at age 65 from the Rockefeller Foundation, where he had worked for over 30 years.

Dr. Carrel was known to despise Hitler. But his published views—and the fact that he agreed to work for the Vichy government in occupied France to create and head a new institute of man, called the "Foundation Française Pour l’Étude des Problèmes Humains"—made him suspect. The German propaganda machine embraced Dr. Carrel and his work at the institute, helping to contribute to his vilification in the allied nations. In the backlash after France was liberated, Dr. Carrel was accused of collaboration, his institute was dismantled, his health failed, and he died shortly afterward, on November 5, 1944, all the while fearing arrest as "a racist, a Nazi apologist, and a Nazi eugenicist."

It was a fate starkly in contrast to his earlier achievements as a pioneer of vascular surgery and organ transplantation.☐

"The love of gain penetrates everywhere.. . . It operates in that great doctor who is always insisting to his pupils and patients the efficacy of some remedy when, all the while, he is being secretly paid by its manufacturers."

—Alexis Carrel, M.D., in "Reflections on Life" (New York: Hawthorn Books Inc., 1952)

In addition to Dr. Boulay’s and Dr. Hardy’s article, "Alexis Carrel—The French Dervish of Surgery (Current Surg. 2001;58:303-9 [Epub doi:1016/S0149-7944(01)00416-0]), more information about Dr. Carrel can be found in the following sources:

• "Alexis Carrel’s Legacy: Visionary of Vascular Surgery and Organ Transplantation" (Transplantation Proc. 2000;34:1061-6).

• "Nobel Lectures, Physiology or Medicine, 1901-1921, (Amsterdam: Elsevier Publishing Co., 1967; available online at http://nobelprize.org/nobelfoundation/publications)

Well before the American Civil War, without benefit of anesthetics and without antiseptics, Dr. Valentine Mott performed some of the first successful operations on the large human arteries, becoming best known for performing the first successful ligation of the innominate artery.

A native of Long Island who received his medical degree from Columbia College, New York, in 1806, he became one of the most highly regarded American surgeons in his own lifetime (1785-1865).

Throughout his long career, Dr. Mott occupied prestigious medical appointments at Columbia College (now University), the now defunct Rutgers Medical College in New York City (which he helped to found), and the University Medical College of New York (now New York University Medical College) where he was chief of operative surgery, and from which he finally retired. There he was known as an exceptional teacher and initiated the system for formal hospital clinics. His contributions to vascular medicine were so significant that he has been given the title "father of American vascular surgery" by physician and medical historian, Dr. Ira Rutkow.

Dr. Mott summed up some of his own major vascular accomplishments in a letter written toward the end of his career:

"I have enclosed a list of my original operations. They were performed without having heard or read of their being done by anyone before. . . . Tying the arteria innominata. Tying the primitive iliac . . . Cutting out two inches of the deep jugular vein inseparably embedded in a tumor and tying both ends of the vein. Closing with a fine ligature, wounds of large veins of a longitudinal or transverse kind, and even when an olive-sliced piece has been cut out.

"These I have seen, and by pinching up the wound with forceps and applying a small ligature, the wound has healed without obliterating the canal of the vein. In this way I treated successfully the great axillary and the deep jugular . . ..

Although Dr. Mott became world renowned for being the first surgeon to ligate the innominate artery for aneurysm with the survival of the patient (in 1818), using a tincture of opium as the only anesthesia, that patient survived only 25 days, dying from a secondary hemorrhage. But this was enough to ensure Dr. Mott’s reputation and to stir general interest in attempting to repeat his success. However, despite the efforts of more than a dozen other surgeons in the intervening years, no other such operation was successful, even in Mott’s hands, until 1864.

Then, a single patient operated on by Dr. Andrew Woods Smyth at the Charity Hospital in New York had the good fortune to survive 11 years, in part due to luck, in part due to surgical improvements, but mainly due to the advent of anesthesia. With such poor results, the operation became generally known as a deadly one, with failure most often the result of ligatures cutting through the artery due to infection.

It was not until 1889, after the advent of antisepsis and decades after Mott’s death, that a second patient showed long-term survival following ligature of the innominate. Thereafter, there were only four successful innominate ligations reported until after the turn of the century, when the operation became common.

In his own era, Dr. Mott was also a political force in medicine, something of a patient advocate and a visionary. He was commissioned to write a report to the U.S. Sanitary Commission during the Civil War, in which he extolled the role of modern anesthetics in pain management and in the improvement of surgical outcomes.

And although his writing often foreshadowed the goals and beliefs of modern pain management advocates, his perspective always remained that of the surgeon:

For after patient benefits and the humanity of pain management, "There is another reason for employing anesthetics which must not be forgotten. The insensibility of the patient is a great convenience to the surgeon . . . , he wrote.

"How often, when operating in some deep, dark wound, along the course of some great vein, with thin walls, alternatively distended and flaccid with the vital current—how often have I dreaded that some unfortunate struggle of the patient would deviate the knife a little from its proper course, and that I, who fain would be the deliverer, should involuntarily become the executioner, seeing my patient perish in my hands by the most appalling form of death! Had he been insensible, I should have felt no alarm."

During his long and innovative career Valentine Mott performed at least 57 femoral artery ligations; 51 external carotid ligations; 10 popliteal ligations; 8 subclavian, 6 external iliac, 2 internal iliac and comon carotid artery ligations; and 1 each of the common iliac and innominate arteries.

Even more remarkably, these operations were performed before the era of anesthetics and the antiseptics era, and without the benefit of blood transfusions.

Dr. Mott spent the final years of his life in humanitarian pursuits. He died April, 26, 1865, less than 2 weeks after the assassination of Abraham Lincoln.

"By the use of anesthetics, also, the shrieks and cries of the patients are prevented; so that the surgeon’s powers are not additionally taxed, either to nerve himself to a very unpleasant task or to control and encourage the attendants."

—Valentine Mott. Military Medical and Surgical Essay (Philadelphia: J. B. Lippincott & Co., 1864).

Well before the American Civil War, without benefit of anesthetics and without antiseptics, Dr. Valentine Mott performed some of the first successful operations on the large human arteries, becoming best known for performing the first successful ligation of the innominate artery.

A native of Long Island who received his medical degree from Columbia College, New York, in 1806, he became one of the most highly regarded American surgeons in his own lifetime (1785-1865).

Throughout his long career, Dr. Mott occupied prestigious medical appointments at Columbia College (now University), the now defunct Rutgers Medical College in New York City (which he helped to found), and the University Medical College of New York (now New York University Medical College) where he was chief of operative surgery, and from which he finally retired. There he was known as an exceptional teacher and initiated the system for formal hospital clinics. His contributions to vascular medicine were so significant that he has been given the title "father of American vascular surgery" by physician and medical historian, Dr. Ira Rutkow.

Dr. Mott summed up some of his own major vascular accomplishments in a letter written toward the end of his career:

"I have enclosed a list of my original operations. They were performed without having heard or read of their being done by anyone before. . . . Tying the arteria innominata. Tying the primitive iliac . . . Cutting out two inches of the deep jugular vein inseparably embedded in a tumor and tying both ends of the vein. Closing with a fine ligature, wounds of large veins of a longitudinal or transverse kind, and even when an olive-sliced piece has been cut out.

"These I have seen, and by pinching up the wound with forceps and applying a small ligature, the wound has healed without obliterating the canal of the vein. In this way I treated successfully the great axillary and the deep jugular . . ..

Although Dr. Mott became world renowned for being the first surgeon to ligate the innominate artery for aneurysm with the survival of the patient (in 1818), using a tincture of opium as the only anesthesia, that patient survived only 25 days, dying from a secondary hemorrhage. But this was enough to ensure Dr. Mott’s reputation and to stir general interest in attempting to repeat his success. However, despite the efforts of more than a dozen other surgeons in the intervening years, no other such operation was successful, even in Mott’s hands, until 1864.

Then, a single patient operated on by Dr. Andrew Woods Smyth at the Charity Hospital in New York had the good fortune to survive 11 years, in part due to luck, in part due to surgical improvements, but mainly due to the advent of anesthesia. With such poor results, the operation became generally known as a deadly one, with failure most often the result of ligatures cutting through the artery due to infection.

It was not until 1889, after the advent of antisepsis and decades after Mott’s death, that a second patient showed long-term survival following ligature of the innominate. Thereafter, there were only four successful innominate ligations reported until after the turn of the century, when the operation became common.

In his own era, Dr. Mott was also a political force in medicine, something of a patient advocate and a visionary. He was commissioned to write a report to the U.S. Sanitary Commission during the Civil War, in which he extolled the role of modern anesthetics in pain management and in the improvement of surgical outcomes.

And although his writing often foreshadowed the goals and beliefs of modern pain management advocates, his perspective always remained that of the surgeon:

For after patient benefits and the humanity of pain management, "There is another reason for employing anesthetics which must not be forgotten. The insensibility of the patient is a great convenience to the surgeon . . . , he wrote.

"How often, when operating in some deep, dark wound, along the course of some great vein, with thin walls, alternatively distended and flaccid with the vital current—how often have I dreaded that some unfortunate struggle of the patient would deviate the knife a little from its proper course, and that I, who fain would be the deliverer, should involuntarily become the executioner, seeing my patient perish in my hands by the most appalling form of death! Had he been insensible, I should have felt no alarm."

During his long and innovative career Valentine Mott performed at least 57 femoral artery ligations; 51 external carotid ligations; 10 popliteal ligations; 8 subclavian, 6 external iliac, 2 internal iliac and comon carotid artery ligations; and 1 each of the common iliac and innominate arteries.

Even more remarkably, these operations were performed before the era of anesthetics and the antiseptics era, and without the benefit of blood transfusions.

Dr. Mott spent the final years of his life in humanitarian pursuits. He died April, 26, 1865, less than 2 weeks after the assassination of Abraham Lincoln.

"By the use of anesthetics, also, the shrieks and cries of the patients are prevented; so that the surgeon’s powers are not additionally taxed, either to nerve himself to a very unpleasant task or to control and encourage the attendants."

—Valentine Mott. Military Medical and Surgical Essay (Philadelphia: J. B. Lippincott & Co., 1864).

Well before the American Civil War, without benefit of anesthetics and without antiseptics, Dr. Valentine Mott performed some of the first successful operations on the large human arteries, becoming best known for performing the first successful ligation of the innominate artery.

A native of Long Island who received his medical degree from Columbia College, New York, in 1806, he became one of the most highly regarded American surgeons in his own lifetime (1785-1865).

Throughout his long career, Dr. Mott occupied prestigious medical appointments at Columbia College (now University), the now defunct Rutgers Medical College in New York City (which he helped to found), and the University Medical College of New York (now New York University Medical College) where he was chief of operative surgery, and from which he finally retired. There he was known as an exceptional teacher and initiated the system for formal hospital clinics. His contributions to vascular medicine were so significant that he has been given the title "father of American vascular surgery" by physician and medical historian, Dr. Ira Rutkow.

Dr. Mott summed up some of his own major vascular accomplishments in a letter written toward the end of his career:

"I have enclosed a list of my original operations. They were performed without having heard or read of their being done by anyone before. . . . Tying the arteria innominata. Tying the primitive iliac . . . Cutting out two inches of the deep jugular vein inseparably embedded in a tumor and tying both ends of the vein. Closing with a fine ligature, wounds of large veins of a longitudinal or transverse kind, and even when an olive-sliced piece has been cut out.

"These I have seen, and by pinching up the wound with forceps and applying a small ligature, the wound has healed without obliterating the canal of the vein. In this way I treated successfully the great axillary and the deep jugular . . ..

Although Dr. Mott became world renowned for being the first surgeon to ligate the innominate artery for aneurysm with the survival of the patient (in 1818), using a tincture of opium as the only anesthesia, that patient survived only 25 days, dying from a secondary hemorrhage. But this was enough to ensure Dr. Mott’s reputation and to stir general interest in attempting to repeat his success. However, despite the efforts of more than a dozen other surgeons in the intervening years, no other such operation was successful, even in Mott’s hands, until 1864.

Then, a single patient operated on by Dr. Andrew Woods Smyth at the Charity Hospital in New York had the good fortune to survive 11 years, in part due to luck, in part due to surgical improvements, but mainly due to the advent of anesthesia. With such poor results, the operation became generally known as a deadly one, with failure most often the result of ligatures cutting through the artery due to infection.

It was not until 1889, after the advent of antisepsis and decades after Mott’s death, that a second patient showed long-term survival following ligature of the innominate. Thereafter, there were only four successful innominate ligations reported until after the turn of the century, when the operation became common.

In his own era, Dr. Mott was also a political force in medicine, something of a patient advocate and a visionary. He was commissioned to write a report to the U.S. Sanitary Commission during the Civil War, in which he extolled the role of modern anesthetics in pain management and in the improvement of surgical outcomes.

And although his writing often foreshadowed the goals and beliefs of modern pain management advocates, his perspective always remained that of the surgeon:

For after patient benefits and the humanity of pain management, "There is another reason for employing anesthetics which must not be forgotten. The insensibility of the patient is a great convenience to the surgeon . . . , he wrote.

"How often, when operating in some deep, dark wound, along the course of some great vein, with thin walls, alternatively distended and flaccid with the vital current—how often have I dreaded that some unfortunate struggle of the patient would deviate the knife a little from its proper course, and that I, who fain would be the deliverer, should involuntarily become the executioner, seeing my patient perish in my hands by the most appalling form of death! Had he been insensible, I should have felt no alarm."

During his long and innovative career Valentine Mott performed at least 57 femoral artery ligations; 51 external carotid ligations; 10 popliteal ligations; 8 subclavian, 6 external iliac, 2 internal iliac and comon carotid artery ligations; and 1 each of the common iliac and innominate arteries.

Even more remarkably, these operations were performed before the era of anesthetics and the antiseptics era, and without the benefit of blood transfusions.

Dr. Mott spent the final years of his life in humanitarian pursuits. He died April, 26, 1865, less than 2 weeks after the assassination of Abraham Lincoln.

"By the use of anesthetics, also, the shrieks and cries of the patients are prevented; so that the surgeon’s powers are not additionally taxed, either to nerve himself to a very unpleasant task or to control and encourage the attendants."

—Valentine Mott. Military Medical and Surgical Essay (Philadelphia: J. B. Lippincott & Co., 1864).

I’m actually not a football fan, I didn’t even know who Ray Rice was until I saw on CNN the now-infamous elevator video of him punching his then-fiancee an elevator and then dragging her unconscious body through the door. But after only 10 minutes of watching the different experts weigh in, including the ex-wife of Mike Tyson/domestic-violence–survivor Robin Givens, I realized my shoulder muscles had started to tense. I was getting the same knot in my stomach I get when faced with an impossible social problem in the hospital that I can’t fix: the alcoholic in awful withdrawal who refuses to go to treatment; the homeless man with heart failure who won’t follow-up at his appointments; the unfunded dialysis-dependent immigrant who gets dialysis only once a week, emergently, in the ED; the very elderly women with a fractured hip who insists on going home. And, of course, suspected elder-abuse or domestic-abuse victims, who are discharged back to the house they had come from.

©Makitalo/thinkstockphotos.com

Rice’s wife, the former Janay Palmer, issued a statement essentially saying everyone needed to mind their own business and that she would support her husband.

She is, of course, correct; it is their business. But as is so often the case when something tragic happens to or regarding a celebrity (whether it is Robin Williams’s suicide or Philip Seymour Hoffman’s drug abuse) their life in the spotlight then becomes a mirror to society’s woes and a platform, for better or worse, to discuss issues that affect the masses.

As I watched the news, the frustrated part of me, the controlling-fixer part, wanted a more logical and just (in my mind) outcome: a declaration that she is leaving the relationship, his suspension causing him to enter a life of counseling and successful reform. But the realistic part of me – the part that saw my mom stay with my dad despite years of pathologic alcoholism and then, once she had kicked him out, go directly to another women who then supported not only his drinking but also his unemployment for 13 years until the day he died from the disease – knows relationships are complicated and often pathologic.

I also know from both my own experience and my experience as a physician, that until the victim, whether it is the drug addict, the alcoholic, or the elder abuse and domestic abuse victim, decide for themselves that they want to change, those of us who want to help are relatively helpless.

In most of my patients with drug and alcohol addiction, and in my handful of suspected abuse cases, the outcome is almost always the same disappointing but almost scripted scenario. Addiction or abuse is suspected by one of the providers, house staff, nurse, medical students, or me because of the clinical situation, something overheard by a nurse, or the concerns of a family member. We try to gain more insight or information by talking to the family or patient.

We consult social work and the note inevitably says "patient denied problem/refused treatment at this time. Resources and contact information were provided to patient and family."

When I read those words, I get the same muscle tension and helpless knot in my stomach as when I was watching the news. My body aches as my mind makes the painful realization and transition from, "There must be something we can do" to "There is nothing more we can do."

We discharge the patient, "resources" in hand, and simply hope.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

I’m actually not a football fan, I didn’t even know who Ray Rice was until I saw on CNN the now-infamous elevator video of him punching his then-fiancee an elevator and then dragging her unconscious body through the door. But after only 10 minutes of watching the different experts weigh in, including the ex-wife of Mike Tyson/domestic-violence–survivor Robin Givens, I realized my shoulder muscles had started to tense. I was getting the same knot in my stomach I get when faced with an impossible social problem in the hospital that I can’t fix: the alcoholic in awful withdrawal who refuses to go to treatment; the homeless man with heart failure who won’t follow-up at his appointments; the unfunded dialysis-dependent immigrant who gets dialysis only once a week, emergently, in the ED; the very elderly women with a fractured hip who insists on going home. And, of course, suspected elder-abuse or domestic-abuse victims, who are discharged back to the house they had come from.

©Makitalo/thinkstockphotos.com

Rice’s wife, the former Janay Palmer, issued a statement essentially saying everyone needed to mind their own business and that she would support her husband.

She is, of course, correct; it is their business. But as is so often the case when something tragic happens to or regarding a celebrity (whether it is Robin Williams’s suicide or Philip Seymour Hoffman’s drug abuse) their life in the spotlight then becomes a mirror to society’s woes and a platform, for better or worse, to discuss issues that affect the masses.

As I watched the news, the frustrated part of me, the controlling-fixer part, wanted a more logical and just (in my mind) outcome: a declaration that she is leaving the relationship, his suspension causing him to enter a life of counseling and successful reform. But the realistic part of me – the part that saw my mom stay with my dad despite years of pathologic alcoholism and then, once she had kicked him out, go directly to another women who then supported not only his drinking but also his unemployment for 13 years until the day he died from the disease – knows relationships are complicated and often pathologic.

I also know from both my own experience and my experience as a physician, that until the victim, whether it is the drug addict, the alcoholic, or the elder abuse and domestic abuse victim, decide for themselves that they want to change, those of us who want to help are relatively helpless.

In most of my patients with drug and alcohol addiction, and in my handful of suspected abuse cases, the outcome is almost always the same disappointing but almost scripted scenario. Addiction or abuse is suspected by one of the providers, house staff, nurse, medical students, or me because of the clinical situation, something overheard by a nurse, or the concerns of a family member. We try to gain more insight or information by talking to the family or patient.

We consult social work and the note inevitably says "patient denied problem/refused treatment at this time. Resources and contact information were provided to patient and family."

When I read those words, I get the same muscle tension and helpless knot in my stomach as when I was watching the news. My body aches as my mind makes the painful realization and transition from, "There must be something we can do" to "There is nothing more we can do."

We discharge the patient, "resources" in hand, and simply hope.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

I’m actually not a football fan, I didn’t even know who Ray Rice was until I saw on CNN the now-infamous elevator video of him punching his then-fiancee an elevator and then dragging her unconscious body through the door. But after only 10 minutes of watching the different experts weigh in, including the ex-wife of Mike Tyson/domestic-violence–survivor Robin Givens, I realized my shoulder muscles had started to tense. I was getting the same knot in my stomach I get when faced with an impossible social problem in the hospital that I can’t fix: the alcoholic in awful withdrawal who refuses to go to treatment; the homeless man with heart failure who won’t follow-up at his appointments; the unfunded dialysis-dependent immigrant who gets dialysis only once a week, emergently, in the ED; the very elderly women with a fractured hip who insists on going home. And, of course, suspected elder-abuse or domestic-abuse victims, who are discharged back to the house they had come from.

©Makitalo/thinkstockphotos.com

Rice’s wife, the former Janay Palmer, issued a statement essentially saying everyone needed to mind their own business and that she would support her husband.

She is, of course, correct; it is their business. But as is so often the case when something tragic happens to or regarding a celebrity (whether it is Robin Williams’s suicide or Philip Seymour Hoffman’s drug abuse) their life in the spotlight then becomes a mirror to society’s woes and a platform, for better or worse, to discuss issues that affect the masses.

As I watched the news, the frustrated part of me, the controlling-fixer part, wanted a more logical and just (in my mind) outcome: a declaration that she is leaving the relationship, his suspension causing him to enter a life of counseling and successful reform. But the realistic part of me – the part that saw my mom stay with my dad despite years of pathologic alcoholism and then, once she had kicked him out, go directly to another women who then supported not only his drinking but also his unemployment for 13 years until the day he died from the disease – knows relationships are complicated and often pathologic.

I also know from both my own experience and my experience as a physician, that until the victim, whether it is the drug addict, the alcoholic, or the elder abuse and domestic abuse victim, decide for themselves that they want to change, those of us who want to help are relatively helpless.

In most of my patients with drug and alcohol addiction, and in my handful of suspected abuse cases, the outcome is almost always the same disappointing but almost scripted scenario. Addiction or abuse is suspected by one of the providers, house staff, nurse, medical students, or me because of the clinical situation, something overheard by a nurse, or the concerns of a family member. We try to gain more insight or information by talking to the family or patient.

We consult social work and the note inevitably says "patient denied problem/refused treatment at this time. Resources and contact information were provided to patient and family."

When I read those words, I get the same muscle tension and helpless knot in my stomach as when I was watching the news. My body aches as my mind makes the painful realization and transition from, "There must be something we can do" to "There is nothing more we can do."

We discharge the patient, "resources" in hand, and simply hope.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

At 6 a.m., our medical team arrives at the Ebola case-management center in the Kailahun district of Sierra Leone to take blood samples. At our 80-bed center here near the borders of Liberia and Guinea, 8 new patients were admitted yesterday, 9 need to have a repeat test 72 hours after their symptoms began, and some we hope to discharge today: at least 18 blood samples to obtain. The center currently houses 64 patients in all, 4 of them children less than 5 years of age. We have already seen 2 patients die today.

I have been here for 7 weeks, working as a nurse and emergency coordinator for the Médecins sans Frontières (MSF) Ebola response. Today we're lucky: it's raining, so we won't be too hot in the personal protective equipment (PPE) we must wear. We control who goes into the isolation area, how often, and for how long. No one should wear the PPE for longer than 40 minutes; it's unbearable for any longer than that, but it's easy to lose track of time, so we have to monitor our colleagues. The process starts in the dressing room, where getting into the PPE takes about 5 minutes. We have a designated dresser, responsible solely for making sure that we are wearing our equipment properly and that not a square millimeter of skin is exposed. In case one layer is accidently perforated, we wear two pairs of gloves, two masks, and a heavy apron on top of the full-body overalls. When we exit the isolation area, we are sprayed down with chlorine solution and peel off the PPE layer by layer. Some of the equipment — goggles, apron, boots, thick gloves — can be sterilized and used again. Everything else — overalls, masks, headcover — is burned.

The center has two sections: the low-risk area, containing the pharmacy, dressing rooms, laundry, laboratory, water-chlorination points, and staff meeting area; and the high-risk, or isolation, area, where patients are admitted and staff must wear the full PPE. Our medical and water-sanitation teams go into the high-risk area with a clear plan: check vital signs, administer medication, serve meals, and clean the 10 tents. There are also teams that help new patients settle in, prepare patients for discharge, and disinfect and remove the dead.

Everyone working in the isolation area must follow the protocols and procedures to the letter. We use a buddy system — we're responsible for ourselves but must also put our lives in the hands of colleagues: one mistake could be deadly. The isolation area is divided into separate tents for patients with suspected, probable, and confirmed Ebola virus infection. Suspected cases are defined by fever and three or more other symptoms of the disease; probable cases, by symptoms plus known contact with someone who's had Ebola or with the body of someone who's died of the disease. There is a clear separation between the tents for these two types of patients, who are given instructions for minimizing the risk of cross-contamination — by washing their hands, for instance, and not touching other patients or their belongings. For the same reason, the staff follows a strict circuit, moving from the suspected-case tents to the probable-case tents and finally to the confirmed-case tents.

The isolation area also contains a waste area, laundry, latrines, showers, and the morgue. The staff works in three shifts a day, around the clock, but everything is organized to minimize the time we spend in the high-risk area. In reality, it's one of the safest places to be during this outbreak, because we know that the patients have Ebola, so every protective measure is in place.

In the suspected-case tents, most patients look quite well, but the probable-case area is a different story. Patients here have fever, pain, anorexia — but these symptoms could indicate malaria. In the on-site laboratory, a polymerase-chain-reaction test can determine whether a patient has Ebola, usually providing results on the same day or the next day. When the result comes in, the patient is either moved to the confirmed-case tents or discharged. Knowing what it means to be moved to these tents, patients are understandably frightened. We have a psychologist, a counselor, and health promoters to help and support patients, but there are just too many of them.

Standard treatment for Ebola is limited to supportive therapy: hydrating patients, maintaining their oxygen status and blood pressure, providing high-quality nutrition, and treating any complicating infections with antibiotics. Supportive treatment can help patients survive longer, and that extra time may be what their immune system needs to start fighting the virus.

There's also a tent for the most severely ill patients. I try to spend more time there than in the other tents, if only to hold patients' hands, give them painkillers, and sit on the edge of their beds so that they know they're not alone. But spending time is always difficult — there are so many patients waiting for help.

It's the children who distress me most. In the confirmed-case tents, I cared for a 6-year-old boy and his 3-year-old sister. Their parents and grandmother had died from Ebola. A midwife in their village then took care of the children, but they began to show symptoms of Ebola and were sent to us. Sadly, they came too late. When the boy died, we tried to console and calm his sister, but the PPE made it difficult to touch her, to hold her, even to speak with her. She died the next day. The midwife who had taken care of them also ended up at our center, and she, too, died. Another patient told me he doesn't remember how many members of his family have died — he thinks about 13. All he knows is that he is now alone.

For caregivers, there is a sad frustration in seeing patients arrive too late — and in knowing that many sick people are hiding, fearing the effects of a diagnosis of this stigmatized disease. Although community health care workers have received training, some of them still don't recognize Ebola.

But we are sometimes fortunate. Today we can discharge four patients who survived Ebola. The discharge criteria call for a negative blood test and 3 days without symptoms. People who have recovered from Ebola are immune from the strain of the virus that infected them. Discharging a patient is our happiest moment — we gather outside the center, clapping and dancing in a celebration that motivates us to keep going. And motivation is important, because today we also received eight new admissions.

The new patients sometimes arrive eight to an ambulance, those with suspected cases and those with probable cases all mixed together. We've given the ambulance drivers basic PPE to distribute to patients, but they're afraid to get close enough to hand it out.

One day, a surveillance officer from the Ministry of Health is admitted to the center. He was one of the few people who had come from Freetown, the capital city, to help in Kailahun, joining the surveillance team to assess new patients and deaths. He told me he'd come because the people here are his community, his friends, his colleagues. We laughed together, commiserated with one another, and then he was admitted to our center and, sadly, later died.

The Ebola outbreak has been out of control for months, but the global health community has taken a long time to react. All organizations have limits, and here in Kailahun, MSF's limit is in case management. The current international Ebola response remains dangerously inadequate. Last week, 250 contacts of infected persons were identified for contact tracing, but given the number of confirmed cases, there should have been more than 1500. The alert system — whereby an investigation team (and, if needed, an ambulance) is sent to a village when a suspected case or death is reported — is not functioning properly, and the Ministry of Health has only four ambulances in a district with about 470,000 people. Our health promotion teams are still visiting villages where no other health care provider has been. Every day sees deaths in the community that are surely caused by Ebola, but they are not counted by the Ministry of Health because the cause has not been confirmed by laboratory testing. The epidemiologic surveillance system is nonfunctional. We need to define the chains of Ebola transmission to interrupt them, but we lack key data.

My time in Kailahun has been frustrating and disappointing, because I know from previous outbreaks what is required to control this one. No single organization has the capacity to manage all that is needed to stop the outbreak. Other organizations must attack this outbreak in all its facets. But the response has been too slow. We need people who are hands-on and on the ground. We need to be one step ahead of this outbreak, but right now we are five steps behind.

Reprinted with permission from the New England Journal of Medicine (DOI: 10.1056/NEJMp1410179).

At 6 a.m., our medical team arrives at the Ebola case-management center in the Kailahun district of Sierra Leone to take blood samples. At our 80-bed center here near the borders of Liberia and Guinea, 8 new patients were admitted yesterday, 9 need to have a repeat test 72 hours after their symptoms began, and some we hope to discharge today: at least 18 blood samples to obtain. The center currently houses 64 patients in all, 4 of them children less than 5 years of age. We have already seen 2 patients die today.

I have been here for 7 weeks, working as a nurse and emergency coordinator for the Médecins sans Frontières (MSF) Ebola response. Today we're lucky: it's raining, so we won't be too hot in the personal protective equipment (PPE) we must wear. We control who goes into the isolation area, how often, and for how long. No one should wear the PPE for longer than 40 minutes; it's unbearable for any longer than that, but it's easy to lose track of time, so we have to monitor our colleagues. The process starts in the dressing room, where getting into the PPE takes about 5 minutes. We have a designated dresser, responsible solely for making sure that we are wearing our equipment properly and that not a square millimeter of skin is exposed. In case one layer is accidently perforated, we wear two pairs of gloves, two masks, and a heavy apron on top of the full-body overalls. When we exit the isolation area, we are sprayed down with chlorine solution and peel off the PPE layer by layer. Some of the equipment — goggles, apron, boots, thick gloves — can be sterilized and used again. Everything else — overalls, masks, headcover — is burned.

The center has two sections: the low-risk area, containing the pharmacy, dressing rooms, laundry, laboratory, water-chlorination points, and staff meeting area; and the high-risk, or isolation, area, where patients are admitted and staff must wear the full PPE. Our medical and water-sanitation teams go into the high-risk area with a clear plan: check vital signs, administer medication, serve meals, and clean the 10 tents. There are also teams that help new patients settle in, prepare patients for discharge, and disinfect and remove the dead.

Everyone working in the isolation area must follow the protocols and procedures to the letter. We use a buddy system — we're responsible for ourselves but must also put our lives in the hands of colleagues: one mistake could be deadly. The isolation area is divided into separate tents for patients with suspected, probable, and confirmed Ebola virus infection. Suspected cases are defined by fever and three or more other symptoms of the disease; probable cases, by symptoms plus known contact with someone who's had Ebola or with the body of someone who's died of the disease. There is a clear separation between the tents for these two types of patients, who are given instructions for minimizing the risk of cross-contamination — by washing their hands, for instance, and not touching other patients or their belongings. For the same reason, the staff follows a strict circuit, moving from the suspected-case tents to the probable-case tents and finally to the confirmed-case tents.

The isolation area also contains a waste area, laundry, latrines, showers, and the morgue. The staff works in three shifts a day, around the clock, but everything is organized to minimize the time we spend in the high-risk area. In reality, it's one of the safest places to be during this outbreak, because we know that the patients have Ebola, so every protective measure is in place.

In the suspected-case tents, most patients look quite well, but the probable-case area is a different story. Patients here have fever, pain, anorexia — but these symptoms could indicate malaria. In the on-site laboratory, a polymerase-chain-reaction test can determine whether a patient has Ebola, usually providing results on the same day or the next day. When the result comes in, the patient is either moved to the confirmed-case tents or discharged. Knowing what it means to be moved to these tents, patients are understandably frightened. We have a psychologist, a counselor, and health promoters to help and support patients, but there are just too many of them.

Standard treatment for Ebola is limited to supportive therapy: hydrating patients, maintaining their oxygen status and blood pressure, providing high-quality nutrition, and treating any complicating infections with antibiotics. Supportive treatment can help patients survive longer, and that extra time may be what their immune system needs to start fighting the virus.

There's also a tent for the most severely ill patients. I try to spend more time there than in the other tents, if only to hold patients' hands, give them painkillers, and sit on the edge of their beds so that they know they're not alone. But spending time is always difficult — there are so many patients waiting for help.

It's the children who distress me most. In the confirmed-case tents, I cared for a 6-year-old boy and his 3-year-old sister. Their parents and grandmother had died from Ebola. A midwife in their village then took care of the children, but they began to show symptoms of Ebola and were sent to us. Sadly, they came too late. When the boy died, we tried to console and calm his sister, but the PPE made it difficult to touch her, to hold her, even to speak with her. She died the next day. The midwife who had taken care of them also ended up at our center, and she, too, died. Another patient told me he doesn't remember how many members of his family have died — he thinks about 13. All he knows is that he is now alone.

For caregivers, there is a sad frustration in seeing patients arrive too late — and in knowing that many sick people are hiding, fearing the effects of a diagnosis of this stigmatized disease. Although community health care workers have received training, some of them still don't recognize Ebola.

But we are sometimes fortunate. Today we can discharge four patients who survived Ebola. The discharge criteria call for a negative blood test and 3 days without symptoms. People who have recovered from Ebola are immune from the strain of the virus that infected them. Discharging a patient is our happiest moment — we gather outside the center, clapping and dancing in a celebration that motivates us to keep going. And motivation is important, because today we also received eight new admissions.

The new patients sometimes arrive eight to an ambulance, those with suspected cases and those with probable cases all mixed together. We've given the ambulance drivers basic PPE to distribute to patients, but they're afraid to get close enough to hand it out.

One day, a surveillance officer from the Ministry of Health is admitted to the center. He was one of the few people who had come from Freetown, the capital city, to help in Kailahun, joining the surveillance team to assess new patients and deaths. He told me he'd come because the people here are his community, his friends, his colleagues. We laughed together, commiserated with one another, and then he was admitted to our center and, sadly, later died.

The Ebola outbreak has been out of control for months, but the global health community has taken a long time to react. All organizations have limits, and here in Kailahun, MSF's limit is in case management. The current international Ebola response remains dangerously inadequate. Last week, 250 contacts of infected persons were identified for contact tracing, but given the number of confirmed cases, there should have been more than 1500. The alert system — whereby an investigation team (and, if needed, an ambulance) is sent to a village when a suspected case or death is reported — is not functioning properly, and the Ministry of Health has only four ambulances in a district with about 470,000 people. Our health promotion teams are still visiting villages where no other health care provider has been. Every day sees deaths in the community that are surely caused by Ebola, but they are not counted by the Ministry of Health because the cause has not been confirmed by laboratory testing. The epidemiologic surveillance system is nonfunctional. We need to define the chains of Ebola transmission to interrupt them, but we lack key data.

My time in Kailahun has been frustrating and disappointing, because I know from previous outbreaks what is required to control this one. No single organization has the capacity to manage all that is needed to stop the outbreak. Other organizations must attack this outbreak in all its facets. But the response has been too slow. We need people who are hands-on and on the ground. We need to be one step ahead of this outbreak, but right now we are five steps behind.

Reprinted with permission from the New England Journal of Medicine (DOI: 10.1056/NEJMp1410179).

At 6 a.m., our medical team arrives at the Ebola case-management center in the Kailahun district of Sierra Leone to take blood samples. At our 80-bed center here near the borders of Liberia and Guinea, 8 new patients were admitted yesterday, 9 need to have a repeat test 72 hours after their symptoms began, and some we hope to discharge today: at least 18 blood samples to obtain. The center currently houses 64 patients in all, 4 of them children less than 5 years of age. We have already seen 2 patients die today.

I have been here for 7 weeks, working as a nurse and emergency coordinator for the Médecins sans Frontières (MSF) Ebola response. Today we're lucky: it's raining, so we won't be too hot in the personal protective equipment (PPE) we must wear. We control who goes into the isolation area, how often, and for how long. No one should wear the PPE for longer than 40 minutes; it's unbearable for any longer than that, but it's easy to lose track of time, so we have to monitor our colleagues. The process starts in the dressing room, where getting into the PPE takes about 5 minutes. We have a designated dresser, responsible solely for making sure that we are wearing our equipment properly and that not a square millimeter of skin is exposed. In case one layer is accidently perforated, we wear two pairs of gloves, two masks, and a heavy apron on top of the full-body overalls. When we exit the isolation area, we are sprayed down with chlorine solution and peel off the PPE layer by layer. Some of the equipment — goggles, apron, boots, thick gloves — can be sterilized and used again. Everything else — overalls, masks, headcover — is burned.

The center has two sections: the low-risk area, containing the pharmacy, dressing rooms, laundry, laboratory, water-chlorination points, and staff meeting area; and the high-risk, or isolation, area, where patients are admitted and staff must wear the full PPE. Our medical and water-sanitation teams go into the high-risk area with a clear plan: check vital signs, administer medication, serve meals, and clean the 10 tents. There are also teams that help new patients settle in, prepare patients for discharge, and disinfect and remove the dead.

Everyone working in the isolation area must follow the protocols and procedures to the letter. We use a buddy system — we're responsible for ourselves but must also put our lives in the hands of colleagues: one mistake could be deadly. The isolation area is divided into separate tents for patients with suspected, probable, and confirmed Ebola virus infection. Suspected cases are defined by fever and three or more other symptoms of the disease; probable cases, by symptoms plus known contact with someone who's had Ebola or with the body of someone who's died of the disease. There is a clear separation between the tents for these two types of patients, who are given instructions for minimizing the risk of cross-contamination — by washing their hands, for instance, and not touching other patients or their belongings. For the same reason, the staff follows a strict circuit, moving from the suspected-case tents to the probable-case tents and finally to the confirmed-case tents.

The isolation area also contains a waste area, laundry, latrines, showers, and the morgue. The staff works in three shifts a day, around the clock, but everything is organized to minimize the time we spend in the high-risk area. In reality, it's one of the safest places to be during this outbreak, because we know that the patients have Ebola, so every protective measure is in place.

In the suspected-case tents, most patients look quite well, but the probable-case area is a different story. Patients here have fever, pain, anorexia — but these symptoms could indicate malaria. In the on-site laboratory, a polymerase-chain-reaction test can determine whether a patient has Ebola, usually providing results on the same day or the next day. When the result comes in, the patient is either moved to the confirmed-case tents or discharged. Knowing what it means to be moved to these tents, patients are understandably frightened. We have a psychologist, a counselor, and health promoters to help and support patients, but there are just too many of them.

Standard treatment for Ebola is limited to supportive therapy: hydrating patients, maintaining their oxygen status and blood pressure, providing high-quality nutrition, and treating any complicating infections with antibiotics. Supportive treatment can help patients survive longer, and that extra time may be what their immune system needs to start fighting the virus.

There's also a tent for the most severely ill patients. I try to spend more time there than in the other tents, if only to hold patients' hands, give them painkillers, and sit on the edge of their beds so that they know they're not alone. But spending time is always difficult — there are so many patients waiting for help.

It's the children who distress me most. In the confirmed-case tents, I cared for a 6-year-old boy and his 3-year-old sister. Their parents and grandmother had died from Ebola. A midwife in their village then took care of the children, but they began to show symptoms of Ebola and were sent to us. Sadly, they came too late. When the boy died, we tried to console and calm his sister, but the PPE made it difficult to touch her, to hold her, even to speak with her. She died the next day. The midwife who had taken care of them also ended up at our center, and she, too, died. Another patient told me he doesn't remember how many members of his family have died — he thinks about 13. All he knows is that he is now alone.

For caregivers, there is a sad frustration in seeing patients arrive too late — and in knowing that many sick people are hiding, fearing the effects of a diagnosis of this stigmatized disease. Although community health care workers have received training, some of them still don't recognize Ebola.

But we are sometimes fortunate. Today we can discharge four patients who survived Ebola. The discharge criteria call for a negative blood test and 3 days without symptoms. People who have recovered from Ebola are immune from the strain of the virus that infected them. Discharging a patient is our happiest moment — we gather outside the center, clapping and dancing in a celebration that motivates us to keep going. And motivation is important, because today we also received eight new admissions.

The new patients sometimes arrive eight to an ambulance, those with suspected cases and those with probable cases all mixed together. We've given the ambulance drivers basic PPE to distribute to patients, but they're afraid to get close enough to hand it out.

One day, a surveillance officer from the Ministry of Health is admitted to the center. He was one of the few people who had come from Freetown, the capital city, to help in Kailahun, joining the surveillance team to assess new patients and deaths. He told me he'd come because the people here are his community, his friends, his colleagues. We laughed together, commiserated with one another, and then he was admitted to our center and, sadly, later died.

The Ebola outbreak has been out of control for months, but the global health community has taken a long time to react. All organizations have limits, and here in Kailahun, MSF's limit is in case management. The current international Ebola response remains dangerously inadequate. Last week, 250 contacts of infected persons were identified for contact tracing, but given the number of confirmed cases, there should have been more than 1500. The alert system — whereby an investigation team (and, if needed, an ambulance) is sent to a village when a suspected case or death is reported — is not functioning properly, and the Ministry of Health has only four ambulances in a district with about 470,000 people. Our health promotion teams are still visiting villages where no other health care provider has been. Every day sees deaths in the community that are surely caused by Ebola, but they are not counted by the Ministry of Health because the cause has not been confirmed by laboratory testing. The epidemiologic surveillance system is nonfunctional. We need to define the chains of Ebola transmission to interrupt them, but we lack key data.

My time in Kailahun has been frustrating and disappointing, because I know from previous outbreaks what is required to control this one. No single organization has the capacity to manage all that is needed to stop the outbreak. Other organizations must attack this outbreak in all its facets. But the response has been too slow. We need people who are hands-on and on the ground. We need to be one step ahead of this outbreak, but right now we are five steps behind.

Reprinted with permission from the New England Journal of Medicine (DOI: 10.1056/NEJMp1410179).

A friend of ours, Dr. Sam Brisbane, died recently. He was a Liberian doctor, and he died from Ebola, a horrible, nightmarish disease.

Information coming out of Liberia has been scarce. Since Dr. Brisbane's death, we've learned that other doctors and nurses with whom we've worked have also contracted Ebola and have died or are being treated in the types of rudimentary facilities we see on the news. As we live in dread of each phone call, questions about how we die and what we're willing to die for have been weighing on us.

The ancients had a concept of a “good death” — dying for one's country, for example, or gloriously on the battlefield. Solon, the sage of Athens, argued that one couldn't judge a person's happiness until one knew the manner of his death. The Greeks recognized that we're all destined to die and that the best we can hope for is a death that benefits our family or humanity.

For emergency-medicine clinicians like us, the concept of a good death can seem too abstract, intangible. Rarely are the deaths we see good or beneficial. We see young people who die in the throes of trauma; grandparents who die at the end of a long, debilitating illness; people who kill themselves; people who die from their excesses, whether of alcohol, food, or smoking.

Last year, as part of a new disaster-medicine fellowship program, we developed a partnership with John F. Kennedy Memorial Medical Center in Monrovia, the only academic referral hospital in Liberia. We collaborated with the hospital administration to develop disaster-planning and resilience programs and teamed up with the emergency department (ED) staff to enhance medical training and establish epidemiologic studies of trauma. It was there that we met Dr. Brisbane, the ED director. He immediately struck us as a genuine ED doc — at once caring and profane, light-hearted one minute, intense the next. A short, bald man with weathered skin and thick glasses, he spoke openly and easily; his laugh was best described as a giggle, and he swore frequently.

When we conducted an initial vulnerability analysis for the hospital, we discussed our concerns about severe supply and personnel shortages, regular power outages, and occasional electrical fires. Dr. Brisbane replied that what scared him the most was the potential for an epidemic of some viral hemorrhagic fever. He was right to be scared. We encountered rationing of gloves, a limited supply of hand soap, and an institutional hesitance to practice universal precautions, probably because of the limited resources. The hospital was not prepared for the kind of epidemic it's now facing — nor was the city of about 1.5 million people.

During our time at JFK, we became friends with Dr. Brisbane. We learned that he'd trained in Germany in the 1970s, had returned to Liberia to work, and had chosen to stay through the civil war and during Charles Taylor's despotic rule, continuing to see patients despite the bloodshed around him. He had welcomed the country's new democratic leadership and a new female administrator at the hospital — a first. He ran a successful coffee plantation and gave us bags of coffee every time we visited him. He was the father of eight biologic children and six adopted children, and he had numerous grandchildren around the world.

Within a few days after our return to Monrovia in June 2014, the city's first patients with Ebola presented at Redemption, the county hospital, and we soon got word that a doctor and some nurses there had died. Rumors were rampant, and staff quickly abandoned that hospital. At JFK, our colleagues grew nervous. There were tensions between the hospital administration and the public health ministry. There was no clear plan for what to do if a patient suspected of having Ebola showed up at the hospital. How would staff members protect themselves? How would they isolate the patient? How could they move the patient to one of the ministry's isolation centers? Dr. Brisbane was a wreck. He chattered nervously, his smile disappeared when he thought we weren't watching, and he openly wondered how he could protect himself. He told us bluntly, “Leave Monrovia.”

Then one morning, we arrived at the hospital at 7 o'clock and ran into Dr. Philip Zokonis Ireland, one of our young doctor friends. He was agitated, his fear evident in his face: there was a patient in the ED with suspected Ebola. The patient had lain in a bed in one of the small, crowded treatment areas for 6 hours, surrounded by nurses and other patients, until someone recognized his symptoms. We rushed to the room and met Dr. Brisbane and Dr. Abraham Borbor, the head of internal medicine. Others were sensing that something was wrong. Patients and their family members quickly disappeared, and nurses hung far back in the hallway.

The first priority was to get the patient out of the common room and into an isolation room, but the bed he was lying on was too wide for the doorway. So Dr. Brisbane, Dr. Borbor, and two custodians hastily donned gowns, gloves, and masks, then lifted the patient — mattress and all — and carried him into the isolation room, nearly dropping him in the process. The man had begun gasping for breath, and despite their efforts, within 5 minutes he was dead. Later that day, laboratory tests confirmed that he was indeed infected with Ebola virus. His body stayed in the now-otherwise-empty ED until it was retrieved hours later by the health ministry.

We remained in Monrovia for the next week and helped however we could. Dr. Brisbane brought his own thermometer and checked his temperature religiously, fearing the telltale sudden fever. He wore a fedora in the hospital as a protective talisman. And yet he still joked with us, displaying a sort of gallows humor.

A few days after we'd returned to the States, we got a call from a friend in Monrovia saying that Dr. Brisbane was in isolation and had tested positive for Ebola. The next call informed us of his death and hasty burial on his plantation. By late August, Dr. Ireland and one of the nurses we knew had contracted Ebola and were fighting for survival, and Dr. Borbor and a physician assistant who'd worked in the ED had died from the virus.

Dr. Brisbane didn't have to stay at JFK and continue to care for patients. He could easily have retired to his coffee plantation with his wife and children and grandchildren. He was terrified of Ebola, and yet we knew that every morning when we entered the ED, we'd find him there, seeing his patients.

Doctors and nurses have a duty of care toward their patients.1 We're expected, on the basis of our training and an unwritten social contract, to fulfill that duty even in less-than-ideal circumstances — in the face of depleted resources, for example, or undesirable patients. But we also have a duty to ourselves and our families, and when our work becomes life-threatening, we have to decide what benefit we will be to our patients and what cost it will exact from us. In such circumstances, we cannot be expected to uphold the same duty of care. But during the world's worst Ebola outbreak to date, clinicians like Dr. Brisbane are on the front lines — and are dying as a result. They care for patients despite the risks to themselves, despite the inadequate supplies and infrastructure, despite their insufficient training in infection control.

Dr. Sam Brisbane's death diminishes us as a people. But with apologies to his wife and family, who saw him die horribly and unjustly, and despite the deep loss we feel, we believe our friend died a good death — as did all the nurses and doctors who have sacrificed themselves caring for patients with this awful disease.

Note: This article was reprinted with permission of the New England Journal of Medicine (10.1056/NEJMp1410301).

References

    1. Sokol, D.K. Virulent epidemics and scope of healthcare workers' duty of care. Emerg Infect Dis 2006;12:1238-1241

A friend of ours, Dr. Sam Brisbane, died recently. He was a Liberian doctor, and he died from Ebola, a horrible, nightmarish disease.

Information coming out of Liberia has been scarce. Since Dr. Brisbane's death, we've learned that other doctors and nurses with whom we've worked have also contracted Ebola and have died or are being treated in the types of rudimentary facilities we see on the news. As we live in dread of each phone call, questions about how we die and what we're willing to die for have been weighing on us.

The ancients had a concept of a “good death” — dying for one's country, for example, or gloriously on the battlefield. Solon, the sage of Athens, argued that one couldn't judge a person's happiness until one knew the manner of his death. The Greeks recognized that we're all destined to die and that the best we can hope for is a death that benefits our family or humanity.

For emergency-medicine clinicians like us, the concept of a good death can seem too abstract, intangible. Rarely are the deaths we see good or beneficial. We see young people who die in the throes of trauma; grandparents who die at the end of a long, debilitating illness; people who kill themselves; people who die from their excesses, whether of alcohol, food, or smoking.

Last year, as part of a new disaster-medicine fellowship program, we developed a partnership with John F. Kennedy Memorial Medical Center in Monrovia, the only academic referral hospital in Liberia. We collaborated with the hospital administration to develop disaster-planning and resilience programs and teamed up with the emergency department (ED) staff to enhance medical training and establish epidemiologic studies of trauma. It was there that we met Dr. Brisbane, the ED director. He immediately struck us as a genuine ED doc — at once caring and profane, light-hearted one minute, intense the next. A short, bald man with weathered skin and thick glasses, he spoke openly and easily; his laugh was best described as a giggle, and he swore frequently.

When we conducted an initial vulnerability analysis for the hospital, we discussed our concerns about severe supply and personnel shortages, regular power outages, and occasional electrical fires. Dr. Brisbane replied that what scared him the most was the potential for an epidemic of some viral hemorrhagic fever. He was right to be scared. We encountered rationing of gloves, a limited supply of hand soap, and an institutional hesitance to practice universal precautions, probably because of the limited resources. The hospital was not prepared for the kind of epidemic it's now facing — nor was the city of about 1.5 million people.

During our time at JFK, we became friends with Dr. Brisbane. We learned that he'd trained in Germany in the 1970s, had returned to Liberia to work, and had chosen to stay through the civil war and during Charles Taylor's despotic rule, continuing to see patients despite the bloodshed around him. He had welcomed the country's new democratic leadership and a new female administrator at the hospital — a first. He ran a successful coffee plantation and gave us bags of coffee every time we visited him. He was the father of eight biologic children and six adopted children, and he had numerous grandchildren around the world.

Within a few days after our return to Monrovia in June 2014, the city's first patients with Ebola presented at Redemption, the county hospital, and we soon got word that a doctor and some nurses there had died. Rumors were rampant, and staff quickly abandoned that hospital. At JFK, our colleagues grew nervous. There were tensions between the hospital administration and the public health ministry. There was no clear plan for what to do if a patient suspected of having Ebola showed up at the hospital. How would staff members protect themselves? How would they isolate the patient? How could they move the patient to one of the ministry's isolation centers? Dr. Brisbane was a wreck. He chattered nervously, his smile disappeared when he thought we weren't watching, and he openly wondered how he could protect himself. He told us bluntly, “Leave Monrovia.”

Then one morning, we arrived at the hospital at 7 o'clock and ran into Dr. Philip Zokonis Ireland, one of our young doctor friends. He was agitated, his fear evident in his face: there was a patient in the ED with suspected Ebola. The patient had lain in a bed in one of the small, crowded treatment areas for 6 hours, surrounded by nurses and other patients, until someone recognized his symptoms. We rushed to the room and met Dr. Brisbane and Dr. Abraham Borbor, the head of internal medicine. Others were sensing that something was wrong. Patients and their family members quickly disappeared, and nurses hung far back in the hallway.

The first priority was to get the patient out of the common room and into an isolation room, but the bed he was lying on was too wide for the doorway. So Dr. Brisbane, Dr. Borbor, and two custodians hastily donned gowns, gloves, and masks, then lifted the patient — mattress and all — and carried him into the isolation room, nearly dropping him in the process. The man had begun gasping for breath, and despite their efforts, within 5 minutes he was dead. Later that day, laboratory tests confirmed that he was indeed infected with Ebola virus. His body stayed in the now-otherwise-empty ED until it was retrieved hours later by the health ministry.

We remained in Monrovia for the next week and helped however we could. Dr. Brisbane brought his own thermometer and checked his temperature religiously, fearing the telltale sudden fever. He wore a fedora in the hospital as a protective talisman. And yet he still joked with us, displaying a sort of gallows humor.

A few days after we'd returned to the States, we got a call from a friend in Monrovia saying that Dr. Brisbane was in isolation and had tested positive for Ebola. The next call informed us of his death and hasty burial on his plantation. By late August, Dr. Ireland and one of the nurses we knew had contracted Ebola and were fighting for survival, and Dr. Borbor and a physician assistant who'd worked in the ED had died from the virus.

Dr. Brisbane didn't have to stay at JFK and continue to care for patients. He could easily have retired to his coffee plantation with his wife and children and grandchildren. He was terrified of Ebola, and yet we knew that every morning when we entered the ED, we'd find him there, seeing his patients.

Doctors and nurses have a duty of care toward their patients.1 We're expected, on the basis of our training and an unwritten social contract, to fulfill that duty even in less-than-ideal circumstances — in the face of depleted resources, for example, or undesirable patients. But we also have a duty to ourselves and our families, and when our work becomes life-threatening, we have to decide what benefit we will be to our patients and what cost it will exact from us. In such circumstances, we cannot be expected to uphold the same duty of care. But during the world's worst Ebola outbreak to date, clinicians like Dr. Brisbane are on the front lines — and are dying as a result. They care for patients despite the risks to themselves, despite the inadequate supplies and infrastructure, despite their insufficient training in infection control.

Dr. Sam Brisbane's death diminishes us as a people. But with apologies to his wife and family, who saw him die horribly and unjustly, and despite the deep loss we feel, we believe our friend died a good death — as did all the nurses and doctors who have sacrificed themselves caring for patients with this awful disease.

Note: This article was reprinted with permission of the New England Journal of Medicine (10.1056/NEJMp1410301).

References

    1. Sokol, D.K. Virulent epidemics and scope of healthcare workers' duty of care. Emerg Infect Dis 2006;12:1238-1241

A friend of ours, Dr. Sam Brisbane, died recently. He was a Liberian doctor, and he died from Ebola, a horrible, nightmarish disease.

Information coming out of Liberia has been scarce. Since Dr. Brisbane's death, we've learned that other doctors and nurses with whom we've worked have also contracted Ebola and have died or are being treated in the types of rudimentary facilities we see on the news. As we live in dread of each phone call, questions about how we die and what we're willing to die for have been weighing on us.

The ancients had a concept of a “good death” — dying for one's country, for example, or gloriously on the battlefield. Solon, the sage of Athens, argued that one couldn't judge a person's happiness until one knew the manner of his death. The Greeks recognized that we're all destined to die and that the best we can hope for is a death that benefits our family or humanity.

For emergency-medicine clinicians like us, the concept of a good death can seem too abstract, intangible. Rarely are the deaths we see good or beneficial. We see young people who die in the throes of trauma; grandparents who die at the end of a long, debilitating illness; people who kill themselves; people who die from their excesses, whether of alcohol, food, or smoking.

Last year, as part of a new disaster-medicine fellowship program, we developed a partnership with John F. Kennedy Memorial Medical Center in Monrovia, the only academic referral hospital in Liberia. We collaborated with the hospital administration to develop disaster-planning and resilience programs and teamed up with the emergency department (ED) staff to enhance medical training and establish epidemiologic studies of trauma. It was there that we met Dr. Brisbane, the ED director. He immediately struck us as a genuine ED doc — at once caring and profane, light-hearted one minute, intense the next. A short, bald man with weathered skin and thick glasses, he spoke openly and easily; his laugh was best described as a giggle, and he swore frequently.

When we conducted an initial vulnerability analysis for the hospital, we discussed our concerns about severe supply and personnel shortages, regular power outages, and occasional electrical fires. Dr. Brisbane replied that what scared him the most was the potential for an epidemic of some viral hemorrhagic fever. He was right to be scared. We encountered rationing of gloves, a limited supply of hand soap, and an institutional hesitance to practice universal precautions, probably because of the limited resources. The hospital was not prepared for the kind of epidemic it's now facing — nor was the city of about 1.5 million people.

During our time at JFK, we became friends with Dr. Brisbane. We learned that he'd trained in Germany in the 1970s, had returned to Liberia to work, and had chosen to stay through the civil war and during Charles Taylor's despotic rule, continuing to see patients despite the bloodshed around him. He had welcomed the country's new democratic leadership and a new female administrator at the hospital — a first. He ran a successful coffee plantation and gave us bags of coffee every time we visited him. He was the father of eight biologic children and six adopted children, and he had numerous grandchildren around the world.

Within a few days after our return to Monrovia in June 2014, the city's first patients with Ebola presented at Redemption, the county hospital, and we soon got word that a doctor and some nurses there had died. Rumors were rampant, and staff quickly abandoned that hospital. At JFK, our colleagues grew nervous. There were tensions between the hospital administration and the public health ministry. There was no clear plan for what to do if a patient suspected of having Ebola showed up at the hospital. How would staff members protect themselves? How would they isolate the patient? How could they move the patient to one of the ministry's isolation centers? Dr. Brisbane was a wreck. He chattered nervously, his smile disappeared when he thought we weren't watching, and he openly wondered how he could protect himself. He told us bluntly, “Leave Monrovia.”

Then one morning, we arrived at the hospital at 7 o'clock and ran into Dr. Philip Zokonis Ireland, one of our young doctor friends. He was agitated, his fear evident in his face: there was a patient in the ED with suspected Ebola. The patient had lain in a bed in one of the small, crowded treatment areas for 6 hours, surrounded by nurses and other patients, until someone recognized his symptoms. We rushed to the room and met Dr. Brisbane and Dr. Abraham Borbor, the head of internal medicine. Others were sensing that something was wrong. Patients and their family members quickly disappeared, and nurses hung far back in the hallway.

The first priority was to get the patient out of the common room and into an isolation room, but the bed he was lying on was too wide for the doorway. So Dr. Brisbane, Dr. Borbor, and two custodians hastily donned gowns, gloves, and masks, then lifted the patient — mattress and all — and carried him into the isolation room, nearly dropping him in the process. The man had begun gasping for breath, and despite their efforts, within 5 minutes he was dead. Later that day, laboratory tests confirmed that he was indeed infected with Ebola virus. His body stayed in the now-otherwise-empty ED until it was retrieved hours later by the health ministry.

We remained in Monrovia for the next week and helped however we could. Dr. Brisbane brought his own thermometer and checked his temperature religiously, fearing the telltale sudden fever. He wore a fedora in the hospital as a protective talisman. And yet he still joked with us, displaying a sort of gallows humor.

A few days after we'd returned to the States, we got a call from a friend in Monrovia saying that Dr. Brisbane was in isolation and had tested positive for Ebola. The next call informed us of his death and hasty burial on his plantation. By late August, Dr. Ireland and one of the nurses we knew had contracted Ebola and were fighting for survival, and Dr. Borbor and a physician assistant who'd worked in the ED had died from the virus.

Dr. Brisbane didn't have to stay at JFK and continue to care for patients. He could easily have retired to his coffee plantation with his wife and children and grandchildren. He was terrified of Ebola, and yet we knew that every morning when we entered the ED, we'd find him there, seeing his patients.

Doctors and nurses have a duty of care toward their patients.1 We're expected, on the basis of our training and an unwritten social contract, to fulfill that duty even in less-than-ideal circumstances — in the face of depleted resources, for example, or undesirable patients. But we also have a duty to ourselves and our families, and when our work becomes life-threatening, we have to decide what benefit we will be to our patients and what cost it will exact from us. In such circumstances, we cannot be expected to uphold the same duty of care. But during the world's worst Ebola outbreak to date, clinicians like Dr. Brisbane are on the front lines — and are dying as a result. They care for patients despite the risks to themselves, despite the inadequate supplies and infrastructure, despite their insufficient training in infection control.

Dr. Sam Brisbane's death diminishes us as a people. But with apologies to his wife and family, who saw him die horribly and unjustly, and despite the deep loss we feel, we believe our friend died a good death — as did all the nurses and doctors who have sacrificed themselves caring for patients with this awful disease.

Note: This article was reprinted with permission of the New England Journal of Medicine (10.1056/NEJMp1410301).

References

    1. Sokol, D.K. Virulent epidemics and scope of healthcare workers' duty of care. Emerg Infect Dis 2006;12:1238-1241

Our team has been involved with a patient whose hospital stay is measured not in days, weeks, or months but in years. The scope of the problems surrounding not only the medical issues but also the family dynamic, out-of-hospital support system, and social situation can easily make the most seasoned providers feel paralyzed. It is fair to use words such as helpless, hopeless, overwhelmed, angry, confused, and conflicted for how the dozens of team members caring for this patient feel on a regular basis.

While the details of this case would eat up multiple columns, it might better for the reader to recall when a patient whose case you’ve been involved in has brought out strong, and often times, negative emotions from the faculty and staff that resulted in conflict. Finding a path to resolve conflict can be one of the most rewarding aspects of working within a system that relies on teamwork for desired, successful outcomes.

©iStock/thinkstockphotos.com

Toxic feelings build up easily in cases in which it seems like there is no end, no chance for our good intentions and hard work to salvage a patient’s spiraling course. Conflict with those we work with is almost inevitable. Hospitalists disagree with the surgeons, nursing staff and the pain team aren’t on the same page, hospital administration might seem to have the C-suite agenda. It is in times like this that conflict resolution smarts can preserve the peace. While maintaining a collegial attitude might not ultimately transform the patient’s outcome, the presence of on-going conflict amongst health care professionals is well studied and studded with unwanted outcomes.

There are conflict resolution books, courses, and even graduate degrees. For the hospitalist on the run, what principles can be applied immediately?

• Don’t react. Think it through. Emotions are strong and feelings differ. This is the crucible for doing something we might later regret. If you hear or read something that makes you upset, then first assume that your colleague has attempted to craft the absolute best plan for the patient. Before making statements or casting judgment, ask many questions. Never send a text or e-mail, make a phone call, or approach someone when you’re having trouble suppressing strong emotions.

• Practice active listening. This takes concentration, so rid yourself of distractions while engaging in listening. Use body language such as smiling or nodding to acknowledge the other person’s message. Pay attention to their gesticulations and nonverbal cues to their position. Avoid interruptions and defer judgment until they have finished. Summarize what you’ve heard from them to demonstrate that their message has been received. Even when you heartily disagree, show respect. We have the ability to find ways of being both candid and kind in our responses.

• Always go after the problem. It is too easy to attack a person rather than the underlying issue. Everyone involved in the care of a patient has the potential to contribute to the solution. By staying focused on the problem and not the people, you are building trust with your colleagues.

• Continue to show up. We all tire and become jaded with these marathon cases. Throwing your hands up in surrender and failing to remain a participating member of the team will send a message that you are not accepting responsibility. Showing up shouts that you’re committed.

• Be mindful of the words used in communication. Focus on "I" statements rather than "You" statements.As in "I need feedback on the plan of care I’ve proposed," rather than "You haven’t provided me with feedback on my plan." ... "I need more information before deciding on whether this procedure would be beneficial," rather than, "You haven’t told me why the procedure needs to be done now."

• Find common goals. Don’t spend time picking apart a nurse’s point of view or your consultant’s idea to work-up diagnoses that seem farfetched. Instead agree upon a goal or two and ask how we can get there together.

• Look toward tomorrow. Focusing on what has happened in the past leads only to war, litigation, or stagnation. Talking about how you can go forward from here can help reset the dynamic.

Like negotiation tools we’ve previously written about conflict resolution skills have broad applicability outside the work place and can make life better in a variety of situations.

As always if you’d like suggested readings or resources please contact us.

Dr. Bekanich and Dr. Leigh A. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern residency programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog.

Our team has been involved with a patient whose hospital stay is measured not in days, weeks, or months but in years. The scope of the problems surrounding not only the medical issues but also the family dynamic, out-of-hospital support system, and social situation can easily make the most seasoned providers feel paralyzed. It is fair to use words such as helpless, hopeless, overwhelmed, angry, confused, and conflicted for how the dozens of team members caring for this patient feel on a regular basis.

While the details of this case would eat up multiple columns, it might better for the reader to recall when a patient whose case you’ve been involved in has brought out strong, and often times, negative emotions from the faculty and staff that resulted in conflict. Finding a path to resolve conflict can be one of the most rewarding aspects of working within a system that relies on teamwork for desired, successful outcomes.

©iStock/thinkstockphotos.com

Toxic feelings build up easily in cases in which it seems like there is no end, no chance for our good intentions and hard work to salvage a patient’s spiraling course. Conflict with those we work with is almost inevitable. Hospitalists disagree with the surgeons, nursing staff and the pain team aren’t on the same page, hospital administration might seem to have the C-suite agenda. It is in times like this that conflict resolution smarts can preserve the peace. While maintaining a collegial attitude might not ultimately transform the patient’s outcome, the presence of on-going conflict amongst health care professionals is well studied and studded with unwanted outcomes.

There are conflict resolution books, courses, and even graduate degrees. For the hospitalist on the run, what principles can be applied immediately?

• Don’t react. Think it through. Emotions are strong and feelings differ. This is the crucible for doing something we might later regret. If you hear or read something that makes you upset, then first assume that your colleague has attempted to craft the absolute best plan for the patient. Before making statements or casting judgment, ask many questions. Never send a text or e-mail, make a phone call, or approach someone when you’re having trouble suppressing strong emotions.

• Practice active listening. This takes concentration, so rid yourself of distractions while engaging in listening. Use body language such as smiling or nodding to acknowledge the other person’s message. Pay attention to their gesticulations and nonverbal cues to their position. Avoid interruptions and defer judgment until they have finished. Summarize what you’ve heard from them to demonstrate that their message has been received. Even when you heartily disagree, show respect. We have the ability to find ways of being both candid and kind in our responses.

• Always go after the problem. It is too easy to attack a person rather than the underlying issue. Everyone involved in the care of a patient has the potential to contribute to the solution. By staying focused on the problem and not the people, you are building trust with your colleagues.

• Continue to show up. We all tire and become jaded with these marathon cases. Throwing your hands up in surrender and failing to remain a participating member of the team will send a message that you are not accepting responsibility. Showing up shouts that you’re committed.

• Be mindful of the words used in communication. Focus on "I" statements rather than "You" statements.As in "I need feedback on the plan of care I’ve proposed," rather than "You haven’t provided me with feedback on my plan." ... "I need more information before deciding on whether this procedure would be beneficial," rather than, "You haven’t told me why the procedure needs to be done now."

• Find common goals. Don’t spend time picking apart a nurse’s point of view or your consultant’s idea to work-up diagnoses that seem farfetched. Instead agree upon a goal or two and ask how we can get there together.

• Look toward tomorrow. Focusing on what has happened in the past leads only to war, litigation, or stagnation. Talking about how you can go forward from here can help reset the dynamic.

Like negotiation tools we’ve previously written about conflict resolution skills have broad applicability outside the work place and can make life better in a variety of situations.

As always if you’d like suggested readings or resources please contact us.

Dr. Bekanich and Dr. Leigh A. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern residency programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog.

Our team has been involved with a patient whose hospital stay is measured not in days, weeks, or months but in years. The scope of the problems surrounding not only the medical issues but also the family dynamic, out-of-hospital support system, and social situation can easily make the most seasoned providers feel paralyzed. It is fair to use words such as helpless, hopeless, overwhelmed, angry, confused, and conflicted for how the dozens of team members caring for this patient feel on a regular basis.

While the details of this case would eat up multiple columns, it might better for the reader to recall when a patient whose case you’ve been involved in has brought out strong, and often times, negative emotions from the faculty and staff that resulted in conflict. Finding a path to resolve conflict can be one of the most rewarding aspects of working within a system that relies on teamwork for desired, successful outcomes.

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Toxic feelings build up easily in cases in which it seems like there is no end, no chance for our good intentions and hard work to salvage a patient’s spiraling course. Conflict with those we work with is almost inevitable. Hospitalists disagree with the surgeons, nursing staff and the pain team aren’t on the same page, hospital administration might seem to have the C-suite agenda. It is in times like this that conflict resolution smarts can preserve the peace. While maintaining a collegial attitude might not ultimately transform the patient’s outcome, the presence of on-going conflict amongst health care professionals is well studied and studded with unwanted outcomes.

There are conflict resolution books, courses, and even graduate degrees. For the hospitalist on the run, what principles can be applied immediately?

• Don’t react. Think it through. Emotions are strong and feelings differ. This is the crucible for doing something we might later regret. If you hear or read something that makes you upset, then first assume that your colleague has attempted to craft the absolute best plan for the patient. Before making statements or casting judgment, ask many questions. Never send a text or e-mail, make a phone call, or approach someone when you’re having trouble suppressing strong emotions.

• Practice active listening. This takes concentration, so rid yourself of distractions while engaging in listening. Use body language such as smiling or nodding to acknowledge the other person’s message. Pay attention to their gesticulations and nonverbal cues to their position. Avoid interruptions and defer judgment until they have finished. Summarize what you’ve heard from them to demonstrate that their message has been received. Even when you heartily disagree, show respect. We have the ability to find ways of being both candid and kind in our responses.

• Always go after the problem. It is too easy to attack a person rather than the underlying issue. Everyone involved in the care of a patient has the potential to contribute to the solution. By staying focused on the problem and not the people, you are building trust with your colleagues.

• Continue to show up. We all tire and become jaded with these marathon cases. Throwing your hands up in surrender and failing to remain a participating member of the team will send a message that you are not accepting responsibility. Showing up shouts that you’re committed.

• Be mindful of the words used in communication. Focus on "I" statements rather than "You" statements.As in "I need feedback on the plan of care I’ve proposed," rather than "You haven’t provided me with feedback on my plan." ... "I need more information before deciding on whether this procedure would be beneficial," rather than, "You haven’t told me why the procedure needs to be done now."

• Find common goals. Don’t spend time picking apart a nurse’s point of view or your consultant’s idea to work-up diagnoses that seem farfetched. Instead agree upon a goal or two and ask how we can get there together.

• Look toward tomorrow. Focusing on what has happened in the past leads only to war, litigation, or stagnation. Talking about how you can go forward from here can help reset the dynamic.

Like negotiation tools we’ve previously written about conflict resolution skills have broad applicability outside the work place and can make life better in a variety of situations.

As always if you’d like suggested readings or resources please contact us.

Dr. Bekanich and Dr. Leigh A. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern residency programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog.