Thursday, February 7, 2013

A hospital tries to save Japan's first 'Criticality' victim

Environmentalists have a terrible time with energy production. Coal, nuclear, wind, solar, natural gas-each falls in and out of favor in turn. Recently, it's been nuclear power's turn at being bashed, although perhaps the talking heads with turn to wind farms changing air currents soon.

A Slow Death: 83 Days of Radiation Sickness by the NHK-TV “Tokaimura Criticality Accident” Crew could so easily have been just another diatribe against nuclear energy. It could have been manipulative, full of the authors' condemnation of nuclear proliferation and misinformation about nuclear science and history.

Instead, A Slow Death is a critical look at the regulation of an industry, the ethics of experimental medicine, and end-of-life care and its effects on both the family and the healthcare workers involved. Ouchi's fate was determined the moment he saw the Cherenkov light and his body was bombarded with neutron beam radiation, but the events of the next three months are a look into the inner-workings of a medical system woefully unprepared for what was wheeled into their emergency room that day.

The first failure is, of course, on the part of the private uranium processing facility for which Ouchi worked. Completely ignoring international regulations regarding the processing of uranium, the plant had the workers pouring components into the precipitation tank via bucket and funnel, rather than the components being added by a pump. On top of this, the precipitation tank was shaped differently, allowing a build-up of the fissionable Uranium-235 to form. On top of this, it seems that Ouchi was never informed that this was not the standard operation protocol; he had no idea that the job he was doing had any inherent risk at all.

Being so near Tokyo, Ouchi was immediately taken to one of the finest hospitals in Japan. Attached to the University of Tokyo Department of Medicine, Ouchi was to have the best doctors and nurses available taking care of him. Kazuhiko Maekawa, the doctor who would be in charge of Ouchi's treatment plan, was a master of emergency medicine. Able to treat anything that might roll in his doors, from stroke patients to trauma victims, at the suggestion of a colleague only recently started looking into the treatment of radiation victims. The framework by which a radiation exposure patient would be assessed and treated was completely nonexistent at the time, so Maekawa would be treading in unknown water.

In this aspect, the book is absolutely not a condemnation of the facility or its staff. No patient exposed to more than 8Sv of radiation had ever survived more than a week. In living for almost three months, new ground was being tread almost every day. For example, it takes two weeks for epidermis cells to go from creation to the top layer of the skin. Ouchi's chromosomes were shattered, so no new skin could be generated. As the existing skin across his body went through its natural life cycle, there would be no new skin to take its place. Marks from removing the tape that held his IVs and other medical devices in place would never heal, and eventually the use of medical tape was forbidden. As muscle tissue was destroyed, traumatic rhabdomyolysis - Crush Syndrome - developed. The massive release of myoglobin into the bloodstream overwhelmed his kidneys and caused them to begin to shut down. Even a stem-cell transplant from his sister to boost his decimated immune system created macrophages that attacked his own systems.

In the beginning, Ouchi was in very good spirits, accepting the often painful treatments that the doctors and nurses performed. As is still the practice in Japanese hospitals, neither the patient nor the family is told of how bleak the situation truly is. Because of this, although the staff valiantly tried to keep Ouchi alive, he and his family had no information by which to decide when treatment should be ceased. Not until Day 81, 22 days after a cardiac arrest left him unresponsive, did Maekawa finally explain the current situation to his family, and suggest that a DNR order be put in place. 

The question this raises is at what point would the family, and perhaps Ouchi himself, have decided to end active treatment and simply decided to wait for the inevitable with palliative care? Ouchi's brain waves never actually flatlined: could he have experienced locked-in syndrome for weeks after his ability to communicate failed? How many dressing changes, how many skin grafts, how much isolation in an ICU ward transpired after all hope should have been set aside? These are the questions that the doctors and nurses involved in the case carry with them to this day.

A Slow Death is a hard book to read. From the beginning, the reader knows the end of the story. Each new treatment, each moment of hope, must eventually end in failure. Parts of the book read awkwardly, perhaps journalistic writing transposed into a book form is to blame, or maybe translation difficulty. Even with these hurdles, it is still a quick book to read, totaling only 141 pages. This is a contemporary look at a very rare situation, and with so much firsthand information and interviews, it's equal parts fascinating and horrifying throughout.

Highs: Inset 3, the micrograph of his chromosomes 'destroyed into pieces' shows the reader, perhaps better than any external photo could, the amount of damage that a split-second of radiation can do to a living creature.

Lows: The back-and-forth between the clinical science of the situation and the emotional impact of a human being going through such pain can be jarring.

Verdict: An important look at both corporate and medical ethics, and short enough to be read in an evening, A Slow Death imparts a lot of knowledge quickly, and leaves the reader a lot to ponder.

Further Reading: The Immortal Life of Henrietta Lacks

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