A trauma physician’s view on life and death | Wen-Je Ko (柯文哲) | TEDxTaipei 2013

TEDxTaipei invited me to speak in this “Breaking Through” session. I thought I might as well share my own story. Among all the physicians in Taiwan, I am probably the one ER doctor who has seen the most cadavers. I’ve seen many cases of life and death. Perhaps that’s why I’m suited to share such stories on this stage. There’s a joke about the most famous physician — Dr. Yeh here in Taiwan. After Taichung First Lady’s car accident, a patient went to Chi-Mei Hospital in Liu-Ying city to seek a doctor named Yeh. The staff in the hospital said that there’s no Dr. Yeh. “There is, ” said the patient. “I was told that his name is ‘Yeh Ker-mo’ (ECMO: Extra-Corporeal Membrane Oxygenation). This Dr. Yeh was the one who saved the first lady’s life!” Speaking of ECMO, its concept is quite easy to understand. Blood flows from femoral vein and passes through a pump, also known as an artificial heart. The blood then passes through membrane oxygenator, which acts as a pair of artificial lungs. Afterwards, the blood re-enters the body. So, ECMO is a temporary substitute of a human’s cardiovascular system. From another perspective, it is a host that represents an artificial heart that pumps blood to the oxygenator and back to the body. As a matter of fact, ECMO technique was already available and widely used at the National Taiwan University (NTU) Hospital since 1994 prior to the first lady’s car accident. It was only since her incident that folks in Taiwan are aware of the ECMO technique. It’s similar to the saying: “One can spend decades painting in relative obscurity,” “but the world only sees the artist’s finished masterpiece.” That’s just my personal opinion. ECMO became a household term due to its overexposure from Taiwan’s media press. There’s no doubt that ECMO technique has its relatively successful cases. One prominent example is the case of singer Jay Chou’s backup dancer. One day, this patient was admitted with fulminant myocarditis, and was undergoing cardiac arrest. I would like to show you a photo of her at the time, with the patient lying on her hospital bed. The eyes of this patient were wide open, and were staring straight, reading the flat lines showing on the ECG screen. As a result of fulminant myocarditis, the patient’s heart stopped beating. She suffered a cardiac arrest. This is a biopsy of her cardiac muscle magnified 100 times under the microscope. Even under this type of magnifying power, it’s still quite hard to see. However, magnified 400 times will be much clearer. Those blue spots are lymphocytes. From here, we can see a serious case of fulminant myocarditis. Lymphocytes infiltrated her entire heart, which caused sudden cardiac arrest. The patient stared at the screen, as it displayed no signs of a working heart. After the ninth day, after a heart and a kidney transplant, She returned to dance in less than one month’s recovery. It was a great miracle in modern medicine. In modern medical records, this patient holds the longest record for CPR survival: 4 hours. CPR was performed on her from Cathay General Hospital to NTU Hospital. When physicians tried ECMO technique at the NTU hospital, they found that over 100 doses of cardiotonic drugs were already given to her. When an incision was made to insert an ECMO tube, the patient’s veins and arteries were too narrow. Therefore, CPR had to be conducted again until she was in the operating room. Surgeons had to saw open the patient’s chest to insert ECMO tubes from the top. The entire procedure sounds surreal right now. Every time I recall this case, I always say it’s a modern medical miracle. The fact that a person‘s heart had stopped for 9 days. And after enduring heart and kidney transplants, a 4 hour CPR, she could still survive. Here is another patient case. The headline reads ”World’s First: Miracle of Taiwan”. Man without heart for 16 days. In this case, the patient is a 56-year-old man. He had a tooth decay. Bacteria from the cavity went into the blood, and spread to the portions of the heart. It caused a pus buildup. The patient went to a different hospital where the surgical team opened up his chest, and began to eliminate infected tissues of the heart. The team continued to remove more affected tissues until not much of the muscular organ was left. So what can the team do now? Transfer this patient to NTU hospital. It seems that NTU hospital is the last line of medical defense in Taiwan. NTU hospital has to take patients in. In the first case, the case was cardiac arrest. This case is more extreme. This is a man with not much of a heart left. It was almost all surgically removed. When the patient was transferred to NTU hospital, because of the state he was in, our medical team had to use two ECMOs. Look at this slide. There are two ECMO devices. This one is even more unbelievable. Since he didn’t have a heart left, so the ECG displayed a completely flat line. There’s not much to explain here. This is his CT scan result. Theoretically, there should have been a heart in his thorax. However, the heart is missing here. There are only tubes. After 16 days, our surgical team performed a heart transplant surgery on this patient. Cardiologist surgeon Dr. Wan showed me this. Dr. Wan said during the surgery, he opened the patient’s chest and had expected a heart in the thorax. However, there were only plastic tubes connecting to the ECMO. The patient had no heart at all. And after 16 days, the heart transplant surgery was completed. The patient was discharged later. Here is the Straits Times of Singapore. A vendor I know sent me an e-mail from Singapore. He told me that we were featured in the Straits Times. 16 days without heart A person had lived for 16 days without a heart. But after receiving heart transplant, he still went home in good shape. This is a third case. He’s a 26-year-old aboriginal Taiwanese. He went swimming even when he was seriously drunk. Jokingly, he probably thought he was Li Bai the poet. The pond he swam in was really unsanitary. He choked on water. As a result, he caught a severe case of pneumonia. He’d relied on ECMO for 117 days. Look at his lungs. After he ingested unclean water, his condition worsened to a severe case of pneumonia. This is called acute respiratory distress syndrome. The lungs became abnormally white. He lived on ECMO for 117 days. We can see clearly from this slide. For one entire month, the patient’s ventilation volume did not exceed 100 c.c. But the patient still recovered. In short, in the these three medical cases, the patient without a heart, the patient undergoing cardiac arrest, or the patient with lung failure, with the help of ECMO, no matter whether 9 days later or even 100 days afterwards, after a heart transplant or lung transplant, their lives were saved. It is really incredible. To be honest… In recent history, ECMO has retained a high level of awareness thanks to the media presses in Taiwan. The reason why folks know about ECMO, is because of past success cases, and also because of the first lady in Taichung, and famed astrologer Nick Yen. However, the media usually only reports on the successful stories. Reporters don’t write failed cases. Hidden from the public eye. As a critical care physician, I am certainly glad to encounter successful patient cases. However, there are cases that are not as successful. This baby was one and half months old. He suffered from a congenital heart disease. After undergoing a heart surgery, the baby still could not live without a heart-lung machine. So, we hooked the baby up to an ECMO. The ECMO was inserted in the baby’s heart. After the procedure, in three days, the baby’s feet turned black. Let’s zoom in. Look at his tiny, blackened feet. So now, as a physician, you have to make a decision. Should you amputate his tiny feet to try to save his life? Or should you just give up and let him go? These types of decisions are incredibly stressful to make. But if you can’t make the call, then the next case is more difficult to gauge. Here is a 7-year-old boy suffering from streptococcus pneumonia. His condition worsened to acute respiratory distress syndrome. So the medical team decided to employ ECMO technique. After using ECMO, however, there were complications. His limbs all turned black. His adorable eyes would look at you, his conscious in a clear state. He could even ask for water when he was thirsty. But as a doctor, you have to make incredibly hard decisions. If you want to save him, you have to cut off his limbs first, and continue with further medical treatment. And if you give up, you have to turn off the ECMO. Now think of this: Between life and death, when the patient is in a conscious state, of course, the doctor’s mind is clear, too. How would you ask the boy? “Hi dear” “If you want to live” “I will need to amputate your limbs.” “Or you’d rather give up,” “and rest in peace?” How do you communicate this type of life and death decision with a 7-year-old? This is the line of work I have to deal with as a critical care physician. In the beginning, I made decisions rather logically. I identified everything by patients. Gradually, I targeted diseases, not patients. A diseased heart, for example. Fortunately, when I turned fifty, I gradually realized that I should treat patient as a whole again. To be quite honest, I consider myself academically inclined. When I reached my 30s, heart transplants, lung transplants, ECMO technique, youngest chief physician in NTU hospital, chief physician of the Surgical Intensive Care Unit, Initiated the Organ Registry and Sharing Center project, Associate chief physician of the Trauma Unit. All these were accomplished by my 30s. During this journey, I believed that medical knowledge was incredibly powerful. Medical knowledge can cure everything. But in my forties, there were many unsuccessful cases with the use of ECMO. Sometimes the families of the patients asked me, “How come the First Lady of Taichung survived, but my family member didn’t make it?” I don’t know how to answer such questions. I couldn’t say because he or she was not the First Lady, could I? Others ask me, “why do his limbs turned black?” If I’d known the answer, I would have definitely prevented it from happening. I have to admit that I don’t know. So when I was in my 40s, I thought that why couldn’t this patient be saved? Finally, when I was reached my 50s, the concept dawned on me. There’s a Chinese poetry that says: “I’ve searched high and low for her.” “It’s only when I turned around,” “The woman I seek is just standing behind me near a lantern.” That day, it dawned on me that doctors are people, not God. Doctors can only try our best. That’s it. I began to reason this philosophy out. Let’s look at seasons. There’s spring, summer, autumn, and winter. Medicine has its limit. No matter how advanced science is, with today’s technology, a person without a heart, or lungs, or liver, or kidney, can still live. But can we replace our organs with devices or gadgets forever? Medicine still has its limits. So I came to a conclusion. Can gardeners change the seasons? Of course not. Gardeners can only make flowers grow prettier in the four seasons. As a doctor, am I capable of changing nature’s rules to birth, aging, sickness or death? Well, it’s very difficult. As a doctor, all we can do is to enable people to go through life a little easier when they’re alive. That’s all. So gradually, I came to realize that doctors are just the gardeners in the life’s garden. As a gardener, when faced with the withered plants, how to treat them is a great question. As an expert in critical care, how do I face death? From a scientific aspect, or more precisely, from molecular science, a system undergoing physical reaction on a molecular level will tend to minimize energy and maximize entropy. So delta S (entropy) should be greater or equal to zero. Some may ask how delta s is greater than zero. Some believe it’s from the Big Bang theory, as it describes the state of ever-expanding universe. So that’s how delta S is greater than zero. Or you may ask, is anything constant in the laws of this universe? Honestly, I don’t have an answer to this. There’s an old saying “A blind man is no judge of colors.” Visually impared folks can’t distinguish colors so it’s pointless to ask them to judge. Does constant apply to the laws in this universe? Does eternity exist in space and time? Frankly, I don’t know these answers. But at least, within the realm of our discussion delta S is still positive. What does it mean when we say delta S is positive? In theory, objects tends to be in minimum energy and maximum entropy, creating greater disorder. My existence would mean a delta S less than zero, which defies molecular science. Then how should we view life and death? Actually, we often see ourselves only. We don’t realize that we are in the universe. The universe is the combination of us and the environment. So total delta S equals to delta S system and delta S surrounding. So this is an important concept. Any organized group is always in an unstable state. The group disrupts its surrounding. So even if delta S for the group is negative, because the group disrupts its surrounding, delta S total is greater than zero to make the equation positive. So my existence is to disrupt my surroundings until one day when I can no longer do so, that’s when I disrupt myself so Delta S total can remain positive. In essence, our existence is to disrupt. When you’re unable to disrupt the surrounding, you end up disrupting yourself. That is the meaning of death. It’s death from a molecular science aspect. However, as a doctor, I understand molecular science. But what about the meaning of life? One day, when I was in ICU making my rounds I came to realize that humans only have two types of ending. One is with inserted tubes. The other is without. Both represent death. Death is every person’s final journey. So what does death mean to us? I’d like to share a contrasting viewpoint on this. If you ask me what death is. I will ask you: what does it mean to be alive? Everyone here in this audience came to hear a lecture. I hope you can do one thing when you leave. Before falling asleep tonight, when you’re lying on your bed, ask yourself this question: “What does it mean to be alive?” Because this question leads us to contemplate on the meaning of life. My answer to the question is this: “When you’re searching for the answer to the question, it is the answer to the question.” Everyone dies eventually. No one will set death as his or her goal in life. Therefore, life is just a process. In this process during one’s entire lifespan we keep searching for the answer to the meaning of existence. So when you’re searching for the answer to existence that is the very answer to the question. Death is not the goal of life. Life is just a process. Recently, I’ve been sharing the story of feces. My teacher was going to retire, he said, “I am going to retire, treat me to somewhere fancy.” I said of course. So my teacher, schoolmate, and I went to the Sheraton to celebrate in a French restaurant. The three of us spent 26,000 NT dollars. I was astonished when I got the bill. How could I eat something so expensive? I’d never been to the restaurant before. We ordered some random unknown dishes. When I saw the bill, 26,000 NTD, I was too shocked to speak. The next morning, in the toilet, I examined my feces carefully. I thought in my mind, I’d spent 9,000 NT dollars producing this. After careful examination, I concluded that this “poo” looks the same as meals in the NTU hospital cafeteria which cost 70 NT dollars per meal. I couldn’t tell the difference. On the toilet, I came to realize that all the wealth one desires turns out to be crap. Confucianism is the most important philosophical system in the Chinese culture. The advantages of Confucianism are that its philosophy is about human virtues. Let’s take a look at the Analects of Confucius. “How does one understand death if one does not even know how to live?” “While alive, one must respect others; so that upon death, one’s body will be respected.” Confucianism refused to talk about life and death. Instead, Confucius gave answers to sacrificing life for justice and how man holds no regret once he understands “the way”. To Confucius, death is a topic to be avoided. He offered no direct answers. So optimistic viewpoints opposes Confucianism philosophy and instead focuses on individualism and self-reliance. This approach also doesn’t address death as well. The following is what I think. In Chinese culture, Confucianism is the most crucial philosophy. But back then our forefathers didn’t discuss life and death. Such matters were greatly avoided. There’s a saying from Sun Tzu’s Art of War: Force soldiers to see the face of death; they will fight to stay alive. Only when we face death, or when we begin contemplating death, that’s when we can reflect what life is. We will all die one day. Life is just a process, process of searching for the meaning of existence. That’s my humble opinion. Actually, I consider myself a smart person. My physical strength is pretty good too. I’ve biked around the entire Taiwan island on my first attempt. Because I’m a smart person in active shape can I use these blessings to bully or to take advantage of others? Definitely not. So those who are blessed should be grateful. Those who are capable should help others. Acts of kindness will make bring meaning to your life. Life is about gratitude. When I went to Dharma Drum Mountain, the Dean, Guo Dong, spoke to me about gratitude. Being grateful. Give kindness instead of complaints. “I know you are misunderstood,” he said, “but you can’t complain. Channel the energy to help others instead.” Lastly, let me share a concept called “a to the power of n.” If a is greater than 1, a to the power of n is infinity. If a is less than 1, a to the power will approach zero rapidly. What does that mean? If what I give to the society is greater than what I get from the society, a is greater than one. Our society will become better and better. If what I get from the society is greater than what I give to the society, a will be less than 1 Our society will become worse. I end the my speech, with these words. “The most difficult thing isn’t facing setbacks and frustrations but facing them without losing enthusiasm for life.” Thank you very much.

15 comments

  1. 柯醫師,大智慧者。生死門內外,正向能量的向上提升與往下衰減與否,會決定下一次能量再現的狀態與型態。存在不可能沒有意義,但那是一種能量轉換的過程,一種沒有時間座標的能量=Delta S/t。

  2. 既然標題都已經寫英文了 ,為何不加個英文字幕. 應該很多外國人點進來,發現聽不懂就又離開了吧

  3. As an outsider looking into Taiwan. I am really amused by the present Taipei Mayor, He really act like a Clown. How can he be doing good to Taipei?? I saw some about him in Youtube…..really a BIG CLOWN. my God !!!

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