There are two specific chemical compounds found on the surface of the influenza virus. The first compound “Hemagglutinin” locks the virus to the cell surface so that the virus can enter the cell and cause infection.  The second compound “Neuraminidase” helps release the virus from a previously infected cell so that the virus can spread.  There are 16 known types of hemagglutinin and 9 known types of neuraminidase.  These number types are used to subclassify the flu virus such as H1N1.  Drugs that inhibit neuraminidase are used to treat influenza.

The severe flu pandemic of 1918 was of type H1N1.  The current flu virus appears to lack the virulent features that produced an over reaction of the immune system causing widespread illness and death.

There is no storage shelf of organs awaiting handout after insurance company approval.  At any given time, there are 100,000 Americans waiting for donated organs.  Due to a chronic shortage, only a small fraction of those will ever get a transplant.  For liver transplantation, there are more than 17,000 people on the waiting list with only about 5,000 liver transplantations available each year. After years of experience, there has evolved a fair but painful system to deal with transplantation issues.   The transplantation selection process takes place thousands of times a year by volunteer committees trying to fairly pick the best patient for each donated organ.

The goal of transplantation is to give replacement organs to patients with the best chance of survival and a long productive life.  With major breakthroughs in surgical technique and anti-rejection drugs, this miracle can be delivered.  In otherwise healthy patients, the one-year survival for liver transplantation approaches 90% and five-year survival is over 75%.  Patients who are extremely sick with multiple organ failure or other diseases are often denied. It’s not to play God, but a necessity to give the limited supply of donor organs to patients with the best chance of survival.

Deciding who needs a transplant and how to procure donor organs offers a major ethical challenge.  There has evolved a process of compartmentalization of each step of the transplant evaluation.  The process starts when the patient’s doctor believes a transplant will help.  A formal Transplant Committee reviews the request and determines if the patient will be put on the transplant waiting list.  It also assigns a priority score reflecting the urgency of the need.  The patient’s doctor usually does not sit on this committee because each doctor should naturally favor his own patient.  The transplant committee may be separated into organ donation and procurement sections.  The procurement section does public education for the need for organ donation and sponsors events  showcasing transplant recipients.

After the transplant committee has carefully reviewed each case, it decides whether or not to place the patient on a list of those awaiting a transplant usually through central organizations like the United Network for Organ Sharing.  The transplant committee also creates a score for each patient indicating how critical the need is.

Insurance companies including Medicare have a less well-defined role in the transplant process.  They don’t directly decide who needs a transplant or who will get one.  Their decision is to agree to cover the cost of the transplant if they have a contractual obligation to do so.  This does indirectly exert great influence on the transplantation process.

Cynics will say insurance companies only decide transplant issues on the basis of economics.  Proponents say decisions are necessary to spend money wisely and to keep health care cost down.  Bankruptcy of the medical system would occur if every possible transplant need were met without regard to outcome.
Many would argue that the transplant system crisis shows the need for government control.  Statistics don’t support that.  Countries with government-controlled health care appear to do far less transplants than the United States. The United States is the transplant leader in the world doing about 52 kidney transplants per million population.   Canada does about 33 kidney transplants per million, Europe does only about 27 per million, and Asia does only 3 per million.

Most would agree the least desirable way to manage transplantation issues is to let the legal system decide.  This would give transplants to patients with the most vocal attorney.   There would be huge legal cost and long delays leading to a waste of donor organs.

There is also a larger story that we are not hearing.  In this case, it is likely that a donated liver went to another patient with a much better chance of survival.  As painful as the process is that’s the way the system has to work.

Many practicing physicians perceive a major disconnect with the academic community over this issue. In the rarefied atmosphere of academic medicine there is frequently an abundance of physicians. Many patients have multiple caregivers with medical students, interns, residents, and staff physicians assigned to them. Also, in a few large urban areas there is an oversupply of physicians. But in most of the United States there is a chronic physician shortage, which is compensated for by the available physicians working long hours.

Residency training offers the opportunity to learn to condition yourself to combat fatigue and improve performance under stress. Many perceive the training period to be the ultimate boot camp preparing physicians to serve under the most adverse conditions. To adapt a phrase from the military, practice like you train, and train like you practice. For most physicians, artificially limiting work hours is not a realistic simulation of the real world. You can’t train for a marathon by limiting training sessions to a couple of miles. Artifical limits on training hours would condition young physicians to expect the same conditions in their future practice.

In the real world, much of medicine operates in the crisis mode. There is no obstetrician who has not worked over 30 continuous hours doing multiple complicated and unpredictable deliveries. There are not many trauma surgeons who have not worked over 30 hours treating mass causalities from sequential or large accidents. Limiting work hours in training seems like a good idea, but until it translates to an adequate physician supply to staff real world challenges it will be largely meaningless and counterproductive.

Everyone would agree that under ideal circumstances a physician should be completely rested and alert. We would also agree that in a crisis, physicians should not abandon patients because of arbitrary work rules. The problem with work limit rules is that much of medicine is practiced in the crisis mode. Until the physician manpower shortage is solved, physician work limits are an empty promise.