Science Friday - Undiscovered Presents: The Magic Machine. Sept. 25, 2018

Episode Date: September 25, 2018

As a critical care doctor, Jessica Zitter has seen plenty of “Hail Mary” attempts to save dying patients go bad—attempts where doctors try interventions that don’t change the outcome, but do��lead to more patient suffering. It’s left her distrustful of flashy medical technology and a culture that insists that more treatment is always better. But when a new patient goes into cardiac arrest, the case doesn’t play out the way Jessica expected. She finds herself fighting for hours to revive him—and reaching for a game-changing technology that uncomfortably blurs the lines between life and death.  Subscribe to Undiscovered HERE, or wherever you get your podcasts.   Resources Talking about end-of-life stuff can be hard! Here are some resources to get you started. (Adapted from Jessica Zitter’s Extreme Measures: Finding a Better Path to the End of Life. Thanks Jessica!)   I want to…  ...figure out what kind of care I might want at end of life: Prepare uses videos of people thinking about their end-of-life preferences to walk you through the steps for choosing a surrogate decision maker, determining your preferences, etc.  ...talk with family/friends about my preferences (or theirs!): The Conversation Project offers a starter kit and tools to help start the conversation.  ...put my preferences in writing (and advance directive):  Advance Directive forms connects you to advance directive forms for your state.  My Directives For those who like their documents in app form! Guides you through creating an end-of-life plan, then stores it in the cloud so it’s accessible anywhere. For those who like their documents in app form! Guests Jessica Nutik Zitter, MD, MPH, Author and Attending Physician, Division of Pulmonary/Critical Care and Palliative Care Medicine, Highland Hospital Thomas Frohlich, MD, Chief of Cardiology, Highland Hospital Kenneth Prager, MD, Professor of Medicine and Director of Clinical Ethics, Columbia University Medical Center Daniela Lamas, MD, author and Associate Faculty at Ariadne Labs David Casarett MD, author and Chief of Palliative Care, Duke University School of Medicine Footnotes Read the books: Jessica Zitter’s book is Extreme Measures: Finding a Better Path to the End of Life. Daniela Lamas’s book is You Can Stop Humming Now: A Doctor’s Stories of Life, Death, and In Between. David Casarett’s book is Shocked: Adventures in Bringing Back the Recently Dead Read the memoirs of Amsterdam’s “Society in Favor of Drowned Persons,” the Dutch group that tried to resuscitate drowning victims (including Anne Wortman!) Learn more about ECMO, its success rates, and the ethical questions it raises (Daniela also wrote an article about it here) Read Daniela’s study about quality of life in long-term acute care hospitals (LTACHs). And for an introduction to LTACHs, here’s an overview from The New York Times Watch Extremis, the Oscar-nominated documentary (featuring Jessica Zitter), about families facing end-of-life decisions in Highland Hospital’s ICU. Credits This episode of Undiscovered was reported and produced by Annie Minoff and Elah Feder. Editing by Christopher Intagliata. Original music by Daniel Peterschmidt. Fact-checking help from Michelle Harris. Special thanks to Lorna Fernandes and the staff at Highland Hospital in Oakland. Our theme music is by I Am Robot And Proud. Our mid-break theme for this episode, “No Turning Back,” is by Daniel Peterschmidt and I am Robot and Proud. Thanks to the entire Science Friday staff, the folks at WNYC Studios, and CUNY’s Sarah Fishman. Special thanks to Michele Kassemos of UCSF Medical Center, Lorna Fernandes of Highland Hospital, and the entire staff at Highland. Subscribe to this podcast. Plus, to stay updated on all things science, sign up for Science Friday's newsletters.

Hi, Cyfry listeners. Have you listened to our new science documentary podcast Undiscovered? Our co-host, Annie Minnoff and Ella Fetter, are back with a second season. Ten amazing stories, so make sure you subscribe to Undiscovered to hear them all. This week, I wanted to share one last episode. It's about a doctor who spends hours fighting to save a dying man's life and then finds herself reaching for a game-changing new piece of technology that blurs the lines between life and death. Here it is the magic machine.

This is undiscovered. It's 9.30 on an April morning in Amsterdam, year 1769, and two men are dragging a woman out of a canal. She's soaking, and she might be dead. Her name is Anne Wartman,

or it was, she's not breathing, she doesn't have a pulse. Her skins turned a weird, speckley blue color. But the two men seemed curiously undisturbed by all of this. Yeah, for these guys, and's lack of pulse, it's not a tragedy. It's a challenge. Well, the important thing to know is back in the 1760s, there was a lot of interest in Amsterdam in trying to bring back the recently dead. That is Dr. David Casseret. He writes about

Ann Wartman and his book shocked. And he explains a lot of people were drowning in Amsterdam's canals around this time. This was not just Anne Wartman's problem. And it got to be so bad that saving drowning victims became like a thing. Like it was a hobby. It was so much of a thing. People were actually papering Amsterdam with these instructional pamphlets, you know, how to bring a drowning victim back to life. Because they might look dead?

Like they're speckly and blue. Yes. But with the latest science and technology, anything was possible. And so these two men, they are not about to give up on Ann Wartman. Instead, they... Reached into their bag of tricks. And one of the first things they tried was to drape. per over a log and rolled her back and forth, they said, for 15 minutes.

A bunch of canal water comes out of Anne's mouth, but whatever else this is supposed to do, it doesn't. So plan B, the guys pick up Anne and they bring her not to a hospital, but to the next best thing in 18th century Amsterdam, the pub. Which is actually a popular site for a lot of resuscitation efforts. So they get to the pub, the apothecary arrives, and he warms Anne by the the fire. He gives her this cranial massage with the spirit of rosemary, put a hot water bottle on her feet, and then something less pleasant. They took a knife out of its sheath, cut off the end

of the sheath, inserted the sheath into poor Ms. Wortman's rectum, believe it or not, and used bellows to blow tobacco smoke. What? Yeah. Which might actually be where this expression came from? Blowing smoke up someone's rectum is the technical term. Well, you know if an expression came out of it, then I guess it's still not okay. What possible justification could you have for doing this to a person? Well, maybe this. If you've ever taken a drag from a cigarette, you know that nicotine has the effect of raising heart rate.

Which, maybe if you have no heart rate, maybe that's good. Anyway, we do not know what eventually worked for Anne Wartman. But after a few hours of this, she comes back to life. That's the craziest part of the story. It's the craziest part of the story. She's back. They offer her some booze. And then one last 18th century medical intervention, they bleed her.

Welcome back to life, Anne. I'm Ella. I'm Annie, and you're listening to Uniscovered. So tobacco, smoke, and booze obviously did not bring Ann Wartman back to life, probably because she was not dead to begin with. The point is, doctors have thankfully gotten a lot better at resuscitating people in 250 years. Their tools are more sophisticated, way more effective than a logger tobacco smoke. So effective, in fact, that it raises a whole new set of questions that those guys in the Dutch bar did not have to deal with. Questions like, when you can keep someone alive on machines for months or years, when do you declare someone dead?

Who is actually beyond saving? Well, today, we have an Anne Wartman story for 2018. The story of life and death and miracle machines, and it's got an unlikely protagonist. A doctor who thinks maybe our love affair with technology has gone a little too far. That's coming up on Undiscovered. There's a picture of Jessica Zitter as a kid. She's holding her dad's stethoscope up to her teddy bear. Yet Jessica clearly knew from a very young age what she wanted to be when she grew up.

She comes from a family of doctors. A lot of great uncles, a lot of uncles, my father, my grandfather, all doctors. And they were a particular type of doctor in general. They were surgeons. They were ER docs. They're the kind of doctors who are in the thick of the action, snatching patients back from the brink of death, making those really heroic saves. And so you can understand this is the kind of doctor that Jessica wanted to be. And she never doubted her career choice until the day of her first code.

It was 1992. Jessica was a few weeks into her medical internship at a hospital up in Boston. When over the hospital intercom, she hears Code Blue. And I just ran with the pack, you know, running towards this room. Code Blue means a patient's heart has stopped beating. And it sets off this rush, doctors sprinting to the scene of the emergency, ready to perform CPR. And Jessica had reviewed the CPR protocol so many times. So many times she said she used to dream about it.

You know, how many chest compressions, how many breaths, how many breaths, what medications. But as she's running, she's terrified. But I was like, it's okay. It's okay. I know what to do. I've got these protocols down. This was her chance to save a life.

And I got into this room. There's a patient on the bed, a resident above them doing chest compressions, throwing their weight on this patient's chest. And all of a sudden I realized that, you know, that this patient, I couldn't tell if it was a man or a woman, it was just this body that was so shrivel. and had been sick clearly for so many, probably years with chronic illness, there was not like an ounce of fat or muscle on this person's body. And I thought, oh, my goodness, what is this?

This seems like it's not going to work. And I hear this clicking noise. It sounded like really a clock. And my friend said, who was standing next to me, oh, my gosh, the chest is breaking. And then I was called into the fray. Chest compressions are really hard work. most people get worn out after a minute or two. So doctors rotate.

And I'm on top of this patient doing compressions on a breaking chest on this body that really has been so diseased for so long. And I know this person's never going to survive this. What are we doing? It wasn't really conscious that way. It was, and it took years for me to understand kind of this feeling of ineffectiveness. But in that moment, I just felt that something wasn't. right. Jessica couldn't put her finger on it at the time, but years later, she can. And she thinks

it's not just the brutality of the code that was bothering her. It was this feeling that they all knew what they were doing wasn't actually going to help. This wasn't treatment to help the patient. This was treatment for the sake of treatment. It was just the sense that, you know, give it 30 minutes a round number, shows that we've tried everything, even though we knew it wasn't going to help. Like a performance almost. A protocol. A protocolized performance. An act. Jessica's done chest compressions on patients whose chests were breaking, who wanted a miracle and didn't get one. She's put in breathing tubes for people who won't come off them.

And it's convinced her over time that in medicine, more is not always better. In fact, sometimes more treatment can hurt. Today, Jessica works in an intensive care unit, but she's also an activist. She writes opinion pieces. She wrote a book. She wrote about that first code with the patient with the breaking chest, because she wants us to understand what can happen when the medical miracle doesn't come through, which is why this next story kind of disturbs her a little bit. It's not like those cautionary tales that she's told before.

The beginning's familiar, though. This story starts with a code blue. That day, I was the attending in the intensive care unit. It's a November morning in 2016. Jessica is leading ICU rounds at the hospital where she works in Oakland, California. And that's when she hears it. Code blue. Up in the hospital's cardiac catheterization lab, someone's heart has stopped beating.

And Jessica runs. The residents run. Half a dozen people are huffing and puffing up three flights of stairs to this lab where this code is happening. And when they bust through the lab doors, we see this guy who's on the table. And we see somebody doing chest compressions. The man on the table looks like he might be in his 50s. And he's already surrounded by the scrum of people, nurses, cardiology staff. And presiding over this controlled chaos is the cardiologist.

He's this calm, white-haired guy wrapped in a hot pink lead vest. With a Tasmanian devil-stitched on the front. Yes. His name is Tom Frolic. It all happened pretty quick. Tom's job is hearts. And half an hour ago, he'd been trying to fix this guys. A guy'd come into the hospital with a heart attack. Tom found a major artery that carries blood to the front of the heart.

It was completely blocked. And he was trying to open it when... He arrested. The man went into cardiac arrest, which means his heart wasn't beating regularly anymore. Instead, it was quivering or wiggling. We call like a bag of worms. This is actually how every medical textbook describes this. It actually is wiggling.

like a bag of worms and completely ineffective. That wiggling rhythm is called ventricular fibrillation, or V-Fib. And every minute of V-Fib is another minute that this man's organs, including his brain, are not getting oxygen. And so Jessica launches into life-saving mode. They strap on a machine that does automatic chest compressions. Literally, it's like a jackhammer. Pushing on this guy's chest. going down at 100 beats per minute.

They get a ventilator set up, pumping oxygen into the sky's lungs, and every few minutes, Jessica pauses, calls for another shock. A jolt of electricity. Slapping the heart in the face. It's like saying, you know, point yourself together. In between all this, Tom is attacking that blocked artery. He's nudging it open. He actually succeeds, inserts a stent.

He even gets the heart to beat again for eight minutes, And then nine and ten. And then it goes back into V-Fib. Bag of worms. So it became clear to me, I think, by about 1230, that we had done pretty much everything that we could do. Tom and Jessica were an hour into this now. They'd shock this man at least a dozen times.

They'd given him every medication, multiple doses. Nothing was working. So Tom and Jessica step aside for a huddle. The facts of this case have not changed. The ventilator is still pumping oxygen into this man's lungs. The compression machine is still jackhammering away, trying to circulate that oxygen to his organs and to his brain. But these machines cannot be this guy's heart and lungs.

They can only keep him alive for so long. And now Tom and Jessica are running out of things to try. But Tom's been thinking. And this is where he suggests something a little radical. I said, well, the only thing I think that is, remote possibilities if we could get ECMO for him. What about ECMO? ECMO is extra corporeal membrane oxygenation.

For adult patients, this is a pretty new thing. It's a therapy that can replace your heart and lungs. Say those organs stop working. ECMO can do their jobs for days, for weeks, for even months. It works like this. The ECMO machine pulls the blood out of your body, filters out the CO2, swaps in oxygen. Just like your lungs do.

Exactly. and then it pumps that oxygenated blood back into your body and circulates it around. Like your heart would do. Exactly. Which for certain patients can have a pretty nifty effect. It can put a pause button on death. So maybe Tom's thinking, Ecmo can buy this patient enough time for his heart to restart. This is the idea that he's pitching Jessica.

And there's no question. Like, this is a Hail Mary pass. Most CPR attempts, they don't go past 20 minutes. Tom and Jessica, they've been at this for an hour. That's an entire hour this man's brain hasn't been getting enough oxygen. So maybe they should stop, right? This is an actual option. I mean, remember, Jessica is the person who thinks more treatment is not always better.

But she says that in this case, it didn't feel like a choice whether or not to bring this miracle machine in. Because this guy, he was moving. The guy was moving his arms and legs. Were you surprised to see that? I mean, shocked. Yeah. Ever since this guy went down, he had been resisting. He wasn't like awake or talking to them.

But he could feel everything that they were doing and he was trying to make it stop, you know, pushing his doctors away, trying to push away that CPR machine that's pounding on his chest. And this is really huge because it means even after an hour of CPR, this man's brain is working. There is someone in there to save. You wouldn't stop. I wouldn't stop on a guy like this. And so Jessica's on board. Do ECMO. This is a chance for technology to do some good.

One problem. Neither Tom or Jessica has actually ever seen an ECMO machine. This is still a pretty new technology for a lot of hospitals. Their hospital doesn't even have this machine. But Tom knows that you see San Francisco across the bay. They do. And so he calls his colleague there Dr. Klein. I said, do you have ECMO to go?

Like basically is this thing portable? And Dr. Klein says, I think I might be able to pull together a team. Let me get back to you. While we're waiting for Dr. Klein, a bit more about ECMO. Putting a pause on death, that is the upside to ECMO. There are some downsides. It gets harder to die.

Yeah. That's Dr. Ken Prager. He's a bioethicist at Columbia University Medical Center here in Manhattan, which is one of the leading ECMO centers in the U.S. And Ken realizes how nonsensical this sounds that ECMO making it harder to die could be a bad thing. Although that sounds great, who wants to die? We all must die at some point. And people do die on ECMO. The mortality rate can be as low as 3 in 10 patients or as high as 7 in 10. A lot depends on what you're using it for and on who. Ken's point is for the patients that it can't save, ECMO can make death worse.

It can draw it out. Ken remembers the case of one woman he calls Ms. Elle. Ms. Elle was an accountant who lived with her mother. She also had terrible lung disease. And her doctors put her on ECMO hoping to keep her alive long enough to get a lung transplant. But after being attached to ECMO, Ms. Elle got worse. Her lung collapsed. She got a drug-resistant infection.

And soon she was too sick to get a transplant. And so here you have a patient who is awake and who is alert. who has zero chance of surviving and the patient knowing that they are on death's row, as it were. This is a horrible situation. Mizal knew how this was going to end, but she couldn't bring herself to agree to turn off the ECMO machine. It's hard enough to reckon with the fact that you are dying, but to actually pick a day to make it happen, Ken says not a lot of people can do that. It would be a full month and a half.

That's a month and a half of increasing pain and withdrawal. before Ms. Elle was so far gone that her family agreed to turn off ECMO. And Ms. Elle finally died. She was 42. So these are gut-wrenching situations that our technology has created. And again, I'm not anti-technology. Don't get me wrong. I have seen amazing and wonderful cases when we have saved lives that would have been lost without this technology.

There is a flip side. So this is the gamble that Jessica and Tom have taken. Their patient could get better with ECMO. He could even go back to his life. Or he might die. A longer, drawn-out death connected to ECMO or a shorter one without it. They're hoping for the best-case scenario. That's why they picked up the phone to UCSF.

And sure enough, 45 minutes later, Dr. Klein calls back. ECMO? On its way. But it's going to take a while. They've loaded the machine into the back of an ambulance. Now that ambulance has to get all the way across the Bay Bridge. in traffic, which is not what Jessica wants to hear, because it's becoming increasingly clear that her patient is getting worse.

I said to Dr. Frolic, I'm having trouble oxygenating him. The ventilator and the compression machine are still going, but it's starting not to be enough. The man's oxygen level is plummeting. And the fact that he's still thrashing around, it's not helping. To give the ventilator a fighting chance, Jessica sedates and paralyzes the man. And the moving stops. That was when I started to feel, oh, okay.

You know, the reason we've all been kind of going for it here is because we see this guy moving and we know there's something in there. Now, what is this? You know, what is this thing? Did people say that? Yeah. There were a few people saying, what are we doing? You know, this is never going to turn out well. We'd been so kind of, I had been so gung-ho.

like, let's do this. And now I started to feel worried. Was this treatment or was it an act? Jessica wasn't sure anymore. But maybe it didn't matter. There's a whole sort of freight train of energy that's been set in motion. It was going. And there wasn't really any turning back at that point.

Coming up on Undiscovered, the arrival of the miracle machine. Hey, Annie and Ella here. We're doing a friend raiser. That is what we call a friend. fundraiser where you don't have to give us any money, which is my favorite kind of razor. So here's how it works. If you like Undiscovered, please tell a friend, fill out a very short form. We'll email your friend a link to Undiscovered. Don't worry, we're not going to spam them. And we'll send you an Undiscovered sticker.

They are blue. They have our logo on them. Looks amazing on your laptop, water bottle, forehead, wherever. So go to Undiscoveredpodcast.org slash stickers. That's Undiscoveredpodcast.org. slash stickers. The ECMO team did finally arrive at 4.9 p.m. By that time, Jessica had been trying to resuscitate this man for four and a half hours. When Tom had picked up the phone to call ECMO, he'd been optimistic. But not anymore, because this man's oxygen levels were so low. Normal oxygen saturation is in the high 90s, this man's oxygen is skimming 20%.

They came in and they surveyed the situation very calmly. And they were quietly surprised at how long we had been doing this, as were we, obviously. But they got to work. The ECMO machine, it's about the size of a laser printer. And it's got two big catheters coming out of it. The surgeons connect one catheter to a vein, another to an artery to complete the circuit. When they turn on the machine, blood comes out one tube gets oxygenated inside the machine and gets pumped back into the body through tube number two.

And when the UCSF doctors turned on the machine, Tom and Jessica could hardly believe what they were seeing. Out of one tube came blood that was dark, dark maroon. Very dark, almost black blood. Which shows us that it's completely unoxygenated, very low oxygen level. And one revolution through the ECMO machine, and it comes back out to go back into the other side. And it was bright red. Bright red filled with oxygen. There's a quote by the sci-fi writer Arthur C. Clark about magical machines.

He says any sufficiently advanced technology is indistinguishable from magic. That is a great quote because that's how it felt. There were gasps in that room. And by the way, these are all really experienced cardiac catheter personnel, a bunch of ICU personnel, lots of people who've seen a lot of stuff. And there were gasps. And with that, the code ended. six hours after it had started.

They stopped the compression machine. With ECMO going, the patient's heart didn't need to beat. He was loaded into an ambulance, and pretty soon, he was gone. Taken away to UC San Francisco. It started with the code blue at 1145 a.m. Now, it was almost 7 o'clock at night. Jessica went into medicine over 20 years ago, dreaming about making heroic saves. And this? Keeping a dying man alive for six hours getting him on to ECMO, this was a save.

So you might think Jessica would feel thrilled. I was numb. Really numb. I didn't know what was going to happen to the sky. And to be honest, I didn't think it was going to be very good. ECMO was new to Jessica, but the concept of miracle machines, that was not new. She knew about ventilators and vads and dialysis machines. And she knew that the saves that doctors make with those devices, they're not always the saves we patients think they're going to be. When a lot of people imagine the worst, it goes something like this.

Something horrible happens to you. Perhaps you die. But if you don't die, you probably get better. That's Danielle Lamas. Like Jessica, she's an ICU doctor. She works at Brigham and Women's Hospital in Boston. And like Daniela says, you know, two options. You die or you get better.

Those are kind of the two poles. But this idea that there's this middle that might last forever, that's something that I really don't think is in the public sphere. Once upon a time, there were just two ways to go. If you think back to Anne Wartman and the Dutch pub 250 years ago, she was either going to die or she was going to live. And what Danielle is saying is that that's not really true anymore. Because now there's this third trajectory, this thing Danielle is calling the middle.

These middle patients are saved by our life support technology. They do not die. But here's the key thing. They don't really get better necessarily either. They're not getting back to their lives. So a few years ago, Daniela got curious about these middle patients. She wanted to know what their lives are like. And so she went to one of the places where they often end up, a place called an Elton.

It's a long-term acute care hospital. Up on the L-TAC's third floor, Daniel remembers hearing familiar ICU sounds. You hear the heart rate monitor, regular sort of staccato beeping. You hear the beeps that ventilators make when a patient needs suctioning. This was the ventilator unit. Every patient on this floor relies on a machine to breathe. You walk into a room and a patient might be sitting up in bed, hooked to a ventilator, kind of staring at the wall, staring out the window.

Other patients, you can tap them on the shoulder, maybe they'll turn toward you, but they won't make any meaningful response. These patients couldn't answer Danielle's questions. But other patients could. They could speak or they could mouth words, and they described a quality of life that a lot of us might not want. They described hunger, thirst, difficulty communicating, boredom.

One patient described as time. at the El-Tac as torture. Torture. He actually had to mouth the words. He said it's torture. All day like this, it's awful. But most people didn't think they'd be at the El-Tac for that long. This was just a stopover on their way to recovery.

The goal was to go home. There was one man who told me that he wanted to get back to a ping-pong group that he was part of. Like they played ping pong tournaments. He's a sweet guy. Of course, what Daniela knew was that many El-Tac patients don't go home. Only one in ten are home and living independently after a year. Half have died. This is what Daniela means by a middle between life and death.

And it didn't really exist until a few decades ago. And what changed was basically technology. Ventilators got better. Suddenly we had these miracle devices to prop up failed organs. Better dialysis machines to support failed kidneys, vads, these mechanical pumps that take the place of the heart. And for many patients, these machines have been truly miraculous. They have kept them alive. Maybe it's not the same life they had before, but it's life.

But for other patients, it's a life they didn't want. And that's what worried Jessica in the days after the code. We may have a guy who the best that we could hope for will be a persistent vegetative state, where he will be living on a machine for the rest of his life, which could be quite a long time, actually. He's a young guy. and we didn't know anymore what his outcomes were likely to be. But then this happened.

I'm just looking at my text messages. Tom, the cardiologist, he'd been texting with Dr. Klein, the doctor over at UCSF, asking, how's our patient? And he starts getting these messages back. Got a note back from Dr. Klein saying he's alive. Which was not a given, but still no heartbeat. Still with no cardiac function. But then a little bit later, another message from UCSF, and now there is a heartbeat. Holy crap.

I mean, he spent 14 hours in V-Fib. No more bag of worms, this man's heart is beating. Jessica gets the news in the middle of rounds. I keep calling, Tom, what's going on with that guy? I was shocked. It got more and more unbelievable. A few days later, a colleague of Dr. Kleinz chimes in with this little bit of information. Yeah, well, he seems to be responding, and I said,

said, what? Say what? What are you talking about? And he says, well, you know, the nurses tell me he's responding to commands, and I think he is, too. It just, each step, it just seemed like... Are you kidding me? You've got to be kidding. It kept on like that for a few weeks.

The man was being moved down to the step-down unit. His breathing tube was coming out. He was going to rehab. And guess what? He went home. The man who made it all happen. A year after their big save, I went and I visited Tom and Jessica at Highland Hospital, a place where this all happened in Oakland, California.

Even a year later, good news was still coming. You want to say hi to Dr. Frolic? You never met him, but he's the guy who... Jessica talked to the patient after the code, but Tom hadn't. And he wondered if he'd ever get to talk to the man again. He had to say, you know, congratulations and how are you feeling? And now Jessica was on the phone with the patient. Sure, here he is. This is Dr. Tom Frolich. Hold on one second.

I'm doing fine. I'm really thrilled that you're doing fine. They chatted for a while, Tom and the man. And I could watch Tom's smile just get wider. After he handed the phone back to Jessica, he got quiet for a second. That's just amazing because I knew he went. home. I knew that he got out of rehab. And in talking to Jessica, I knew that he was doing okay. But okay means many different things. From where he started, okay could mean just being able to feed himself. But, you know, he sounds normal. You know, it's pretty, it's unbelievable.

Both Tom and Jessica used the same word to describe this story. They called it a miracle. A miracle. which for Jessica is kind of a problem. Don't get her wrong. She is thrilled that this case has a happy ending. But at the same time, the fact that it ended up with this guy walking away

and being at home now confuses me a little bit. How does she make this story fit with all of the other stories that she's heard and told people about patients living in limbo in Eltax about Ms. Elle? Was it even the right decision to call for ECMO?

when the odds were that bad. That question at least, she thinks she's answered. Would you do anything differently? No. I would have done the same thing. The same thing with a lot of qualifiers. Jessica would do the same thing for a patient who is relatively young and relatively healthy, who went into cardiac arrest in the hospital where you could get great high-quality CPR from minute one.

The honest truth is, in a situation like this with a reasonably young and healthy person, I do believe that it was appropriate to do what we did. And I think we did it well. And I think it was, even though we did it well, I think it was very likely that there would have still been a poor outcome. But I think it was appropriate to try. ECMO is still pretty new for a lot of hospitals. There is so much to learn about who exactly can benefit from this kind of, you know, Hail Mary Pass. Why did this guy do so well?

What was different? So here's something we have learned. For patients like Jessica's, people who are relatively young, who don't have a bunch of pre-existing conditions, ECMO can be a game changer. People have actually gotten transplants they never would have gotten a few years ago. They've recovered from flus that would have killed them, right? These people would have died. And now they're going home.

They're not ending up in the middle. And so what worries Jessica now, it's not that they made the wrong choice calling for ECMO. It's what happens next. Because the thing about medical technology is once we have it, we like to use it. And we like to use it on everybody. Take ventilators. They started off as a stopgap. Iron lungs kept kids with polio alive until they could breathe on their own.

Now we've kicked polio, but for thousands of patients in Eltax, ventilators are not a stopgap anymore. They're the new normal. As for ECMO, we're using it on adults exponentially more than we were just a decade ago. and on patients who are a little older and a little sicker. And that could mean more amazing saves. It could also mean people save to lives that they might not want. Jessica wouldn't blame ECMO for that. She says the problem isn't the machine.

It's how we're looking at it. We're not looking at it with open eyes, but with hope that we can cheat death, that our loved ones can get better, even in those cases where we know that's probably not true. This story? It's not about ECMO. It's not about a ventilator. It's about this idea of a magic machine. It's about an idea.

So here are some ideas that we would like to leave you with. Because there might come a time someday where you have to make a decision about how hard to push and how much to hope, whether it's for you or for someone you love. There is a man walking the streets of Oakland maybe right now whose heart stopped beating for six hours. He would not have been alive a decade ago. Our technology did that.

And there are many thousands of people who have not been as lucky as that man. They're lying in limbo, attached to their own miracle machines. Machines they might not get off in their lifetime. Don't forget them. Our technology did that too. Undiscovered is reported and produced by me, Annie Minoff.

And me, Ella Fetter, editor is Christopher and Taliyata, and our composer is Daniel Petershmit. The patient ultimately decided he didn't want to be interviewed for this story, but we want to wish him the very best with his recovery. And if this episode left you wanting to know more about end-of-life decision-making, how you can have some control over this stuff and how to talk about it with your friends and family and doctors, we got you. There are tons of links up at our website, Undiscoveredpodcast.org.

That's Undiscoveredpodcast.org. Jessica Zitter and Daniela Lamas also have books that are great resources for this kind of stuff. Jessica's book is called Extreme Measures, Finding a Better Path at the End of Life. Daniela's is You Can Stop Humming Now, a doctor's stories of life, death, and in-between. We got fact-checking help from Michelle Harris. I am robot and proud wrote our theme. Special thanks to Lorna Fernandez and the staff at Highland Hospital in Oakland, California. Thanks also to Sarah Fishman, Danielle Dana, Christian Scotta, and Brandon Ector.

We'll see you next. week.