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Focusing on breath
Spotlight
Bodenham, LTH NHS Trust/Science Photo Library
Film Extremis: a sensitive look at life (and death) in the ICU
Published Online September 12, 2016 http://dx.doi.org/10.1016/ S2213-2600(16)30273-9 Extremis 24 min. Dan Krauss 2016 USA
Halfway through the superb short documentary Extremis, two critical-care doctors confer over the prospects of one of their patients. Is the situation beyond remedy, or are there glimmers of hope? The discussion flares up and soon sputters out, yet we sense there will be further debate. The intensive-care unit (ICU) in the documentary thrums with activity. The staff are full of purpose and machines whir and beep with noises of operative efficiency. However, there is chaos here—not anarchy, but uncertainty. This is not an environment where predictions can be trusted. “Is there any definitive test that will tell you that absolutely, positively, there is no way she will recover from this?”, asks the brother of one patient. The answer, cruel and inevitable, is no. End-of-life decision making is a process that comes with few guarantees. Often, it is even unclear what kind of advice the doctors should offer. “The ethics of this are murky”, sighs a bearded physician during one discussion. Some patients seem destined to end up in an ICU. Donna has end-stage myotonic dystrophy. After the physicians remove her endotracheal tube as per her instructions, she whispers to a family member “tell everyone to calm down”, and dies the following day. On other occasions,
one wonders whether it was all avoidable. Another patient, Selena, could not afford the US$2000 ambulance fare, so when she began to have symptoms of ill health she asked her daughter to drive her to the hospital. On the way, Selena had a prolonged cardiac arrest; in the hospital, she went into a coma and died after a while. In different circumstances, with the right equipment and the money to pay for the ride, who knows what might have transpired? Extremis starts and finishes with one of the physicians tending to unseen patients. In the 20 min or so of the documentary we hear snatches of conversations and pay brief visits to bedsides. Such is director Dan Krauss’ narrative gift that these scenes, edited together with rare sensitivity and skill, seem to be both stories in themselves and also part of a greater narrative. His film touches on some of the most urgent and long-running issues in medicine: patient autonomy, the role of the doctor, and the limits of treatment. After all, an ICU is a place where physicians, perhaps more than anywhere else, live with the knowledge that medicine is by no means an exact science.
Talha Burki
Jayne Wilton
Focusing on breath
For more on Schlieren imaging see P K Panigrahi, K Muralidhar. Heat 23 and Mass Transfer, SpringerBriefs in Thermal Engineering and Applied Science, 2012. DOI:10.1007/978-1-46144535-7_2
780
When I recorded the breath of patients with chronic obstructive pulmonary disease at the Royal Brompton and Harefield Hospitals, several of them talked about how difficult they found it to exhale. In looking for tools that were capable of registering even the most subtle of expirations, Peter Hobson (Department of Electronic and Computer Engineering, Brunel University, London, UK) and I decided to explore the potential of Schlieren imaging which can visually depict the flow of fluids or gases of varying density. Prof Hobson provided an appropriate optical setup at Brunel University (London, UK) where we explored the possibilities of this process to record the exhaled breath. The optical Schlieren system is capable of recording subtle differences in refractive indices, such as those
created by warm breath in cold air. Light diverging from a laser source is focused by a spherical, concave mirror onto a knife edge (which provides a sharp line to precisely allow specific elements of the laser beam to be selected). Breathing warm air close to the surface of the mirror disturbs the light rays so that, when focussed, some bypass the knife edge and can be recorded by a camera positioned behind the system. Prof Hobson provided the breath, which I photographed to record the patterns produced by the warm breath turbulently mixing with the cool laboratory air. The image was recorded digitally directly into the camera and is therefore circular.
Jayne Wilton
www.thelancet.com/respiratory Vol 4 October 2016
Bodenham, LTH NHS Trust/Science Photo Library
Film Extremis: a sensitive look at life (and death) in the ICU
Published Online September 12, 2016 http://dx.doi.org/10.1016/ S2213-2600(16)30273-9 Extremis 24 min. Dan Krauss 2016 USA
Halfway through the superb short documentary Extremis, two critical-care doctors confer over the prospects of one of their patients. Is the situation beyond remedy, or are there glimmers of hope? The discussion flares up and soon sputters out, yet we sense there will be further debate. The intensive-care unit (ICU) in the documentary thrums with activity. The staff are full of purpose and machines whir and beep with noises of operative efficiency. However, there is chaos here—not anarchy, but uncertainty. This is not an environment where predictions can be trusted. “Is there any definitive test that will tell you that absolutely, positively, there is no way she will recover from this?”, asks the brother of one patient. The answer, cruel and inevitable, is no. End-of-life decision making is a process that comes with few guarantees. Often, it is even unclear what kind of advice the doctors should offer. “The ethics of this are murky”, sighs a bearded physician during one discussion. Some patients seem destined to end up in an ICU. Donna has end-stage myotonic dystrophy. After the physicians remove her endotracheal tube as per her instructions, she whispers to a family member “tell everyone to calm down”, and dies the following day. On other occasions,
one wonders whether it was all avoidable. Another patient, Selena, could not afford the US$2000 ambulance fare, so when she began to have symptoms of ill health she asked her daughter to drive her to the hospital. On the way, Selena had a prolonged cardiac arrest; in the hospital, she went into a coma and died after a while. In different circumstances, with the right equipment and the money to pay for the ride, who knows what might have transpired? Extremis starts and finishes with one of the physicians tending to unseen patients. In the 20 min or so of the documentary we hear snatches of conversations and pay brief visits to bedsides. Such is director Dan Krauss’ narrative gift that these scenes, edited together with rare sensitivity and skill, seem to be both stories in themselves and also part of a greater narrative. His film touches on some of the most urgent and long-running issues in medicine: patient autonomy, the role of the doctor, and the limits of treatment. After all, an ICU is a place where physicians, perhaps more than anywhere else, live with the knowledge that medicine is by no means an exact science.
Talha Burki
Jayne Wilton
Focusing on breath
For more on Schlieren imaging see P K Panigrahi, K Muralidhar. Heat 23 and Mass Transfer, SpringerBriefs in Thermal Engineering and Applied Science, 2012. DOI:10.1007/978-1-46144535-7_2
780
When I recorded the breath of patients with chronic obstructive pulmonary disease at the Royal Brompton and Harefield Hospitals, several of them talked about how difficult they found it to exhale. In looking for tools that were capable of registering even the most subtle of expirations, Peter Hobson (Department of Electronic and Computer Engineering, Brunel University, London, UK) and I decided to explore the potential of Schlieren imaging which can visually depict the flow of fluids or gases of varying density. Prof Hobson provided an appropriate optical setup at Brunel University (London, UK) where we explored the possibilities of this process to record the exhaled breath. The optical Schlieren system is capable of recording subtle differences in refractive indices, such as those
created by warm breath in cold air. Light diverging from a laser source is focused by a spherical, concave mirror onto a knife edge (which provides a sharp line to precisely allow specific elements of the laser beam to be selected). Breathing warm air close to the surface of the mirror disturbs the light rays so that, when focussed, some bypass the knife edge and can be recorded by a camera positioned behind the system. Prof Hobson provided the breath, which I photographed to record the patterns produced by the warm breath turbulently mixing with the cool laboratory air. The image was recorded digitally directly into the camera and is therefore circular.
Jayne Wilton
www.thelancet.com/respiratory Vol 4 October 2016