Not Just A Number

“When we are no longer able to change a situation, we are challenged to change ourselves.”

—Viktor Frankl, Man’s Search for Meaning

I just pored through Viktor Frankl’s book, Man’s Search For Meaning for the nth time. It is an eye-opening and brain-enriching piece of work. Essentially, it tells us that finding meaning in life is one of the most important things to find out to enjoy one’s existence. This enables us to push through adversity.

Why do we go through tough exams as medical students?

Because we know that after all the hardships, we can be doctors who can make a difference in the lives of others.  Through the long hours of study and sacrifice, we see an end that is meaningful and productive. Future earnings may be a good motivation, but once a certain amount is reached, having more may no longer inspire.

Passing through this current medical crisis and the challenges and heartaches it carries is taxing to the psyche. It also exposes the different ways people react to trials. Some become numb and resigned to fate. Some become ultra-aggressive and take advantage of others. But a few find the courage to live through the pandemic by being of service to others.

Frankl tells of how the prisoners in the Nazi camps of Auschwitz were dehumanized and reduced to mere numbers for identification and segregation. The only things that were left were his belt and his eyeglasses, as all including his family was lost. What kept him going was his ability to see the world as it is and find meaning to it. Being human is always directed towards something or someone. Self-actualization is a transcendence of the human self. The fulfillment of a human need is only attained through others.

As a physician, this is what we must be able to emphasize to our patients. We tend to paint a picture of life’s beauty for those who have lost hope in living, imposing our will in the process. Probably, a better approach would be to give our patients a “new pair of eyes” to see meaning without imposing. It is indeed more therapeutic when you discover meaning by yourself. This makes you own the goal, and with the support of others, this makes the goal a shared ideal which can foster bonding and camaraderie. Maybe it’s time to shift the patient’s focus to something other than their own predicament.

Suffering ceases to be suffering once it finds meaning. We might mourn indefinitely for our loved ones who suffer from debilitating diseases and die, impacting our daily existence. When this happens, we must look for hidden tenets of wisdom to make sense of the situation. What if you were in the situation of your loved one? What would you have wanted them to do under the circumstances? The truth is, we may have to flip the page to see the other side of the passage.

We are not just numbers or pieces of DNA. Science tends to do this — reduce us to mere pieces of data to find objectivity. However, life is never fully objective and impartial, for we are human. We have feelings. It is what makes us who we are. It is the essence of our existence.

IS SINOVAC EFFECTIVE?

With the concern about the efficacy of vaccines being questioned, the timing of the medical worker outbreak in Indonesia raises valid concerns. Hundreds of health workers were said to have been infected after being given complete doses of Sinovac, a biopharmaceutical company. Some patients were hospitalized with decreasing oxygen saturation levels, which indicate a serious condition.

There are a few issues that need to be addressed in this latest outbreak. Let us try to look at them and see if we can find the answers based on the information available.

First, the World Health Organization (WHO) approved emergency use of Sinovac's vaccine as it showed at least 51% of recipients benefitted from having less severe COVID-19 symptoms, leading to less hospital stays. None of the tested patients were hospitalized for COVID-19. However, this puts into question the strain of COVID-19 that was tested in this study.

The Delta Variant, first detected in India in October 2020, poses the greatest concern, as it is said to be driving the current outbreak. This variant shows increased transmissibility and virulence. It is feared that the Sinovac vaccine is ineffective against this strain. However, there is a need to do further studies on this. Nothing is conclusive.

The second issue involves the decreased vigilance among the populace. Some of those given the full dose of the vaccine mistakenly believe that they are now immune to the disease, so they become less careful. This includes the health workers who were among the first to be vaccinated. During public holidays, the increased movement of people becomes a risk for transmission.

What is important, however, is that we follow safety protocols. Being fully vaccinated is not a license for us to lower our guard. We must still wear masks when we go outside until we are able to control the spread of this menace.

Why are there different COVID-19 strains?

Just like most living organisms, adaptive mechanisms enable us to survive in adverse conditions. For viruses, mutation is the mechanism to improve “survival” even though they cannot replicate outside a living cell – or outside the human body. Viruses are known to mutate easily. This enables them to “escape” destruction and identification by the immune system. The changes in their structure leads to the development of different COVID-19 strains. When a virus is spreading, the likelihood of the virus mutating increases. The more opportunities a virus has to spread, the more it replicates.

Some strains can still be neutralized by the currently available vaccines.  This has been proven in studies that came out this year.

According to the World Health Organization, the COVID-19 vaccines that are currently available are expected to provide at least some protection against new virus variants. This is because these vaccines elicit a broad immune response involving a range of antibodies and cells – meaning the mutants will still be neutralized by the drugs.  Alterations in the structure of the virus should not make vaccines completely ineffective. In the event that any of these vaccines prove to be less effective against one or more variants, it will be possible to change the composition of the vaccines to protect against these variants.

Should we avoid Sinovac because of this?

The simple answer is no. Science has proven the effectivity of the vaccine, despite the recent news articles stating otherwise. It is understandable to have certain apprehensions when there are doubts as to the effectiveness of prevention due to outbreaks. However, unless our health authorities say that it is unsafe or ineffective, there is no reason to doubt science. After all, it is science that will enable us to pull through this crisis.

Life After COVID-19

The coronavirus pandemic has changed our way of life. And if you were infected, there may be certain signs and symptoms to watch out for.  According to health experts, some COVID-19 patients develop long-term organ damage and have a prolonged stay in the hospital before making a complete recovery.  Most patients also report changes in breathing patterns and blood clotting mechanisms after recovering from the infection.

After COVID-19, there is a residual damage to lung alveoli and to endothelial cells that line the blood vessels, leading to persistent respiratory symptoms and excessive blood clotting across the body. Some of them succumb to eventual pneumonia and cerebrovascular disease. This so-called post-COVID syndrome happens after the initial infection of COVID-19 is over and the patient is deemed to have recovered.  Patients may have a recurrence of symptoms such as lethargy, body aches, and itchy throats.  This may have an effect on their mental state leading to anxiety and depression. It is therefore of essence to monitor patients after infection or discharge from the hospital.

Co-morbidities or other illnesses, exposures, or demographic characteristics such as smoking, diabetes, hypertension, and renal disorders also contribute to immune compromise and added risk for complications.  Gender differences have not been observed, but some studies indicate more distressing signs and symptoms among males compared to females.

It is important for COVID survivors to monitor oxygen saturation, which must not dip below 95% using a pulse oximeter.  Respiratory symptoms must also be monitored, taking note of the presence of cough or difficulty of breathing.

Temperature must also be monitored, which must not exceed 37.8 degrees centigrade. There must also be no signs of easy fatigability, sleepiness, and change in sensorium.  Patients with Diabetes Mellitus should regularly monitor their blood sugar levels.

There is a need to have a regular check-up with a trusted doctor after one week of being deemed recovered, and every 3 months thereafter.  Blood investigations may be warranted in order to screen for signs of inflammation.  Some would recommend chest imaging studies after 3 months to ensure pulmonary recovery.

The most dreaded complication would be the emergence of a cytokine storm, where immune cells attack vital organs such as the lungs and the heart. Another complication is a blood clot that can manifest as a heart attack or stroke. Therefore, blood pressure readings that fluctuate or go down must be reported at once.

Vaccination must be made available to post-COVID patients to help minimize infection and viral transmission. So far, all vaccines available in the market have shown an increase in antibodies after administration of the vaccines. There is also an increasing trend towards immediate administration of the vaccine after COVID symptoms have been resolved. This means that you no longer need to wait for a long time before you can avail of the vaccine’s preventive benefits.

However, the most important message after being infected is that there is hope. We have made great strides in the prevention and treatment of COVID-19.  We must trust that in these situations, science will prevail, and the human race will move on and learn from this crisis.

Left Behind

When a person leaves us, their lives must achieve closure. We arrange their funeral, we manage their finances, and we take care of the things they leave behind.

The job of handling personal and legal details of the dead falls on the living. It could be an overwhelming task for the inexperienced.  You may still be grieving, yet work must be done fast to facilitate a smooth transition for everyone.

But one must not carry the burden alone. Help is needed and must be provided.  Professionals such as lawyers, physicians, and accountants may need to be on-hand to give advice. It might be costly to make a mistake at times, so one must be well-versed.

Friends are an indispensable resource for unknown surprises. One may be the decision-maker, but the execution must be considered as a team event.  You may take the lead in planning, while others pitch in for execution. Even loners may find it difficult to pass through this stage in solitude.

If your loved one was confined in an institution with medical experts on hand, the medical staff can take care of the paperwork to complete the death certificate. This is important because the death certificate will allow permission to process the remains.

If someone dies at home, a medical professional must be contacted to ascertain death. You can call a doctor when you do not detect any sign of life, such as the absence of breathing or pulses. Since most often, you do not have a death certificate form on hand, you may need to contact the physician again to have the form signed on another day. That is why it is advisable to have this form handy in case you are expecting a deteriorating condition, no matter how morbid it sounds.

It is not recommended to do cardiopulmonary resuscitation on a patient who is in the terminal phase of their condition. However, it is strongly recommended to have advance care directives. The decision on resuscitation must come before the actual need to carry it out arises. Keep in mind that resuscitation is not to be offered by clinicians when it is deemed to be futile.

Immediately after the declaration of death, spend some time with the body. This is a moment of peace, quiet, and rest. Reminisce and work on accepting the inevitability of the moment. It is not bad to cry or show emotion, but it is also fine to be just a listener and a stabilizer of feelings.

Tell friends and family about the demise so they can pay their respects. One may need to go through the deceased's email and phone contacts. Inform co-workers and the members of any social groups or church the person attended and tell them to spread the word. A word of caution: never spread word on a patient’s demise unless the family gives instructions to do so.

If you know about the person’s wishes for funeral or burial, start looking at ways on how to carry it out. Contact the funeral services. Look for and secure any papers pertaining to purchased memorial lots and services. Call the funeral services once you are satisfied with the time spent after demise, so they can come over at home and prepare the body.  Call a family meeting to have the first conversation about what the funeral will look like. Will it be cremation or not?  This is critical if the deceased left no instructions.

Secure the property and belongings. Finances must be looked into, including any last wills. Don’t forget social media portals – they may need to be archived so that posers or scammers will not use them. Even pets must be cared for.  Cancel any services like phone or internet services that are no longer needed. Close all financial accounts that are available

If the deceased is employed, inform the employers. He or she may be entitled to some benefits, so make sure to do this early as it can help in your initial planning.

Doubting Thomas

In the Bible, there is the well-known story of the apostle Thomas, a man who doubted the resurrection of Christ. He tried to look for evidence by saying, “...unless I see the wounds on His hands, I will never believe.”  Of course, we know that his Master eventually showed Himself to Thomas and let him touch and feel His hands. He also said – “...you believe because you have seen Me. Happy are those who have not seen and yet believe…”

We are beset by many doubts in our existence. This may be due to our desire to make sense of the environment we are in. Humans are naturally inquisitive, looking for reasons in things. However, there are also times when we throw away all reason and jump in without thinking much. Love, for example, makes us do this.

Scientific reasoning and the instilling of doubt makes us question how things are done, and this makes us understand things better and innovate. In the case of vaccine development, we are now beset with doubts on its efficacy. There are also discrepancies in the research findings for the vaccines, but will this stop us from procuring them?

We may not have much of a choice given the existing circumstances.

Doubts are part of how we humans are wired to decipher and comprehend what is in existence. It is this inquisitiveness and critical thinking that separates us from other animals. It is also our curse, when we second guess ourselves due to external influences. Sometimes we just need to follow our gut and hope for the best.

To erase doubt, one has to find out the consistency of outcomes. Will it be the same even if the process were to be repeated? This we can see by the number of samples analyzed, or the number of witnesses who testified to the veracity of the event.  The facts that can be gathered must also be subjected to scrutiny before they are disseminated to ensure that they are authentic. This is how we are able to counter the effect of fake news.

Now, there are situations where doubt is instilled. Fake news items are one, and they can be particularly harmful to the uninitiated. The irresponsible spread of misinformation creates a scenario of disbelief that can poison the efforts of those seeking for truth. This is why those with knowledge and integrity must work doubly hard to dispel these non-truths. It is these people with integrity whom we must believe and not those who seek to spread chaos and uncertainty.

Another thing that can provide the seeds to remain doubtful is the inconsistency of decisions and outcomes. When there is a discrepancy in the things that are said and done, there will be doubts, and it would take more effort to correct the fallacy. Just think about how inconsistencies in relationships can spell doom for couples or business partners. We must make every effort to analyze these outcomes not just based on singular findings, but on how consistently they come out.

Finally, there is always a science to reason based on logical-mathematical reasoning. In the eyes of an ordinary individual, some facts may be twisted by emotions or biases. But science can remove those blinders, making the results more objective and believable. The progress that we now have in the medical field is brought about by this untiring adherence to the scientific method. If medicine did not progress to become more evidence based, who knows what kind of treatments we may be made to suffer all because of some unfounded practice?  Science has made the art of treating disease result in better outcomes.

 But science can remove those blinders, making the results more objective and believable.

However, where science ends, there is this one aspect that can erase doubt. Thomas experienced this. And we have too. The overwhelming love that we experience can erase all doubts as to what is truly essential.

And when we seek the truth, at times, we make this leap of faith. That faith is what will eventually save us all.

 

Gene Therapy In Hospice Care

As I was reading some articles on gene therapy, I was astonished at how far we have progressed in pursuing applications of this technology. Immunotherapy, oncolytic virotherapy, and gene transfer has been revolutionary, and there is no let-up in the number of researches being done. Using genetically modified cells or altered DNA sequences from different viruses, common cancers of the lung, pancreas, and prostate may be given another chance for survival. Considering that the 5-year survival rates of these diseases hover around 5 to 15 percent, any increase in the life span could mean a lot to these patients.

According to Christine Karim, “It is tremendously rewarding to see how our work, starting in the test tube, can positively impact society by creating the groundwork for new medical treatments.” The beauty of gene therapy is that it treats the problem right at its source. As current treatments have a lot of adverse effects, it offers a ray of hope for those who feel resigned to the ravages of tumor metastasis. These methods can alleviate death and suffering once they are developed and incorporated into mainstream medicine.

“It is tremendously rewarding to see how our work, starting in the test tube, can positively impact society by creating the groundwork for new medical treatments.”

— Christine Karim

 Mechanisms to decrease cancer aggression include lysis of the tumor cells, decreasing the blood supply of the neoplastic cell, and introducing genes that will restore the normal phenotype. In other words, gene therapy may not kill the cell directly like chemotherapy does, but it will cause subtle changes that will annihilate the cancer.  Gliomas, pancreatic cancer, and liver cancer are leading candidates for these types of treatment.

Just as in any new modality, there are safety concerns. Patients have died due to gene therapy in the past. While the death was not due to gene therapy for cancer, but due to a metabolic illness (a urea cycle deficiency called ornithine transcarbamoylase defect), safety remains of paramount importance. Flu-like symptoms, just like that being experienced by many who have taken the COVID-19 vaccine, are very common in gene therapy.

At present, gene therapy is being used to create recombinant cancer vaccines. Unlike for infectious diseases, these vaccines are meant to provide cure, not prevention.  The immune system is trained to recognize the cancer cells by presenting it with highly antigenic and immunostimulatory cellular debris. Cancer cells may be harvested from the patient (autologous transfer) or from established cancer cell lines. Cytokines may also be enhanced by gene therapy to recognize the abnormal cells as foreign bodies. Hopefully the genes would produce proteins that will promote synthesis of antitumor antibodies.

The challenge in the medical community is to utilize these processes prudently. They give hope, but they are not yet accepted as mainstream treatment. The issues of safety and beneficence need to be revisited, not to mention the justification of the expense involved for such novel treatments. There are stories regarding unproven alternative methods which are quite expensive, and in the wrong hands, these genetic technologies may be manipulated for selfish motives.  It is quite disturbing to think that one would take advantage of the desperation that hospice and palliative care patients are feeling, and giving them unwarranted treatments could erode their trust in the medical field.

In due time, targeted therapy for cancer will become the norm, changing the lives of patients with cancer and other chronic illnesses. We still have a long way to go to realize this, but it may be sooner than we expect. After all, the survival of the human race rests on the creativity of those who are in it.