Hills and Valleys is a podcast that uncovers stories from leaders in healthcare, tech, and everything in between. Straight from the heart of Silicon Valley, we give you a look at the good, the bad, and the future, one episode at a time. Brought to you by Potrero Medical.
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About Dr. Kevin Chung, Chair of Medicine at Uniformed Services University
COL Kevin K. Chung is a graduate of the United States Military Academy at West Point and Georgetown University School of Medicine. After finishing a fellowship in Critical Care Medicine at Walter Reed Army Medical Center, Dr. Chung was assigned to the US Army Institute of Surgical Research (USAISR) where he has served in the capacity of Medical Director of the Burn Intensive Care Unit, Task Area Manager of Clinical Trials in Burns and Trauma, and the Director of Research for the USAISR over the last 12 years. He is currently serving as Chair, Department of Medicine, at USU.
COL Chung holds academic appointments at the Uniformed Services University of the Health Sciences as Professor of Medicine and Professor of Surgery. In his career, COL Chung has authored over 180 manuscripts in peer-reviewed journals, authored 13 book chapters, and has been an invited speaker for over 85 lectures internationally.
His research interests include burn resuscitation, critical care, and organ failure. Specifically, COL Chung is researching the use of CRRT for reversing the negative effects of kidney damage in burn patients.
You can followed Dr. Chung on Twitter @chungk1031 .
An Interview with Professor and Chair of Medicine at USU, Dr. Kevin Chung
- Interviewer: Omar M. Khateeb, Director of Growth at Potrero Medical
- Interviewee: Dr. Kevin Chung, Professor and Chair of Medicine at the Uniformed Services University in San Antonio, Texas
Khateeb: Hi everyone, this is Omar M. Khateeb, Director of Growth at Potrero Medical here for another episode of Hills and Valleys. We are coming to you at the end of the conference day here at the American Burn Association in Sunny, Las Vegas, and we’re very fortunate to be joined by Dr. Kevin K. Chung. Doctor, thank you for joining us.
Chung: Yeah, thanks for having me.
Khateeb: Absolutely, and just want to give a little bit of background on you. So, Dr. Chung is a graduate of the United States Military Academy at West Point and from Georgetown University School of Medicine.
After finishing his Fellowship in critical care medicine at Walter Reed Army Medical Center, Dr. Chung was assigned to the US Army Institute of surgical research, where he has served in the capacity of medical director of the burn\ Intensive Care Unit, task area manager of clinical trials and burns and trauma, and the director of research for the USAISR over the last 12 years. He’s currently the chair at the department of medicine at the USU. I believe now you’ve transferred to Bethesda, correct?
Chung: Well, Bethesda is where the Uniformed Services University is located. That’s where I’m the chair of medicine for that department.
Khateeb: Got it. So just as a back story before we get into it, what got you interested to study at West Point?
Chung: Well, growing up, I paid a visit to West Point when I was in grade school. The minute I stepped onto the parade field I was sold. I knew that that was the only option for me. And so that’s the only school I applied to. I was willing to apply over and over again. If I didn’t get in the first year I was going to apply the next year and the next year and keep going until I got in.
Khateeb: That’s amazing. What did your parents say when you did that?
Chung: They were a little bit disgruntled because you know, we were an immigrant family and my parents specifically took us out of Korea because there’s a mandatory military service requirement. They didn’t want us to do that, and there I go joining the Army.
Khateeb: Wow. Well, you know, just to get a little personal, I too am also from an immigrant family and first generation, and for whatever it’s worth, thank you very much for your service. For people who look and sound like me and my family to live very happily and freely here in the United States, you know, we greatly appreciate it and your service.
Chung: Well, thank you for your support.
Khateeb: Now when in medical school there’s a variety of different things that you can choose to go into. What got you to choose your specialty and what drew you into burn?
Chung: Well, that’s an interesting question. Everything happened in stages. So during medical school, I realized that when you go through the different rotations, really the key is finding your tribe and figuring out what group of people you get along with the most. After rotating through surgery, Orthopedics, ob/gyn, and Family Practice, I realized that internal medicine is where I found it to be most like home and I found others that were just like me.
And so initially, my passion was really directed at Internal Medicine; being a good internist. For me, that meant being a real doctor and asking a lot of questions, being inquisitive, having intellectual curiosity at every turn, trying to figure out what’s wrong with the patient, and taking very complex medical conditions and then simplifying it and diluting it down to what the next step should be for that patient.
That’s what I got into. So I apply for Internal Medicine. Believe it or not my first choice was Walter Reed. But I didn’t get my first choice, and got sent to Eisenhower Army Medical Center in Georgia. That ended up being the most beneficial thing for me, and in retrospect charted the course of my career.
I had a program director there by the name of Bill Brown who had trained at Mayo Clinic as an intensivist in internal medicine and critical care, and he was just inspirational. Just watching him take care of critically ill patients was very motivating and I knew after a few rotations with him as my attending that I wanted to do critical care. He just also happens to be the nephew of Max Harry Weil, who was a giant in the field of critical care of the late Max Harry Weil. If you were at my talk earlier, I talked about lactate and how Max Harry Weil was among the first investigators that basically promoted lactate as an endpoint in the clinical setting and he’s considered widely as one of the fathers of critical care.
Because of that relationship I tagged along with Dr. Brown to various Critical Care conferences and met giants in the field: Dennis Mackey, Jean-Louis Vincent, and others that attended the conference like Phil Dellinger and Dr. Joe Perillo. So these are giants in the field of critical care that basically I had an opportunity to meet face-to-face and interact with them and I really grew to love the field of critical care while I was doing my residency in Georgia.
So when it came time for me to choose I did a chief resident year, which was a very very rewarding year where I took an entire year after graduating residency and took care of the residents as the chief of internal medicine residents.
After that year, I applied for a fellowship in the Army. There’s really only one slot and that was at Walter Reed. So I got up to Walter Reed, and it’s a two-year Fellowship. The nice thing about that program is that you have an opportunity to rotate through all the great hospitals in the Washington DC area, so I had an opportunity to rotate through Maryland Shock Trauma and did multiple rotations there, Washington Hospital Center, Fairfax, Suburban Hospital, which is a community hospital, NIH, and Johns Hopkins, where I did neurocritical care.
So I got a very broad range of different patient experiences, and it was solid training in that it helped me see that different places do things differently and just because you’re in one place there are other ways of doing things that may sometimes even be better. But if you train in only one organization, you may not see that you may have blinders on and only see one way of doing things. That was the benefit of being exposed to eight different sites as well as being at Walter Reed and Bethesda, which at that time was a naval hospital and they were separate.
Being a Resident When September 11 Attacks Happened
One thing that is striking that I should mention: I was a second-year resident when 9/11 happened, and I remember the day I was in the ICU and I heard about it I knew right away that my career trajectory was going to be completely different than what I had imagined before. And knowing that made me want to go into critical care even more.
So right when I started Fellowship in 2003, you may remember that’s when we started taking casualties, a significant number of casualties. The day I started my fellowship at Walter Reed, I had an ICU full of critically ill combat casualty service members, and it was just had a profound impact on me.
Wave after wave of patients would come in and critical care transport teams would bring them in, and it’s not just one or two patients, they would come in 5 to 10 to 12 patients at a time every week, every time there was a flight. So my ICU experience was shaped by a concurrent war that was feeding combat casualties into the ICU at both Walter Reed and Bethesda. And you know, it’s tough dealing with young service members being so severely injured but it helped me as a physician to grow and learn from having the opportunity to treat them.
By the time I graduated, there’s a person in the Army called the consultant that tells you where you’re going to go. I met with that consultant and I told him, “Hey, I really enjoyed Eisenhower and Augusta, Georgia, it’s a small community hospital, they have a great Critical Care team, and I would like to go back there.” And he looked at me and said, “You’re going to the ISR.” And I looked back at him and I said, “What’s the ISR?” I had no idea, and he said the US Army Burn Center, it’s synonymous with the Institute of Surgical Research.
Around here in the burn community everybody knows what the ISR is, but at that time as a naive fellow I had no idea and so that got me excited because it was a new experience. My wife wasn’t fond of or thrilled about moving to Texas because we grew up in the east coast. But we made our move, and the day I started as staff during that summer, that was when the burn casualties started ramping up. And so similar to what I was experiencing while at Reed, we were getting wave after wave of burn casualties. The first three years of my experience at the US Army Burn Center, collectively, I took 10 days off. I worked pretty much every day, weekends included.
I just felt obligated to to be there because these are our service members. You can’t go home. So it was a difficult time in that we were extremely busy, we had very very sick patients, and they were coming in all the time. I knew it was temporary, but I felt an obligation to be there.
Generally, when somebody starts as a staff, you may accumulate X number of patient touches over the span of 10 years. Well, I had that experience and shrunk it down to three years. I basically had the ability to and had the experience of following patients from day of admission all the way through discharge; and some patients were there for over a year in the ICU. These are burn patients. When you’re there every day you notice patterns, you notice very subtle things that occurs from a day-to-day and I think that helped shape me as a clinician and it really really made me a better doctor by being at the bedside every day.
The thing that made me alter my work habits and my tempo was my deployment. So in 2008, I got deployed to Iraq and believe it or not the combat support Hospital in Baghdad, the Baghdad ER, is probably the busiest Hospital during that time. Believe it or not, that was a break for me.
Going from the burn center and being there all the time with very very sick patients, and then getting deployed to a combat support hospital. It’s ironic, I know, but that was a break. Yes, we had stretches when we were just, you know, I mean mass casualty after mass casualty events, full ICU, very very busy. But that’s all I had to deal with: just taking care of patients, working out, eating healthy, and sleeping. And so that was a good break.
When I got back, I realized that in order to survive in this field I needed to take care of myself. And so I started cutting back to normal ICU schedules. For example, an intensivist generally Works about 14 to 15 shifts a month. In our model, that equates to two weeks a month or two to three weeks a month.
And so for the other week, I had an opportunity to do admin and research. Not that I wasn’t doing research before, but when I got back I had a ton of projects going and the time that I was not in the ICU I was able to dedicate to research. That’s how I ramped up my research activities and my research portfolio.
I had the fortune of working with John Holcomb, who basically, well he’s just an innovator and I would say a giant in the field of trauma. Also Steve Wolf, who’s a giant in the field of burn. I had the fortune of working with them and really learning from them. They were role models, and I saw how they operated. I mean operated in terms of the way they thought, the way they produced and wrote, the way they came up with clinical questions, and the way they finished projects.
I learned through their example on how to start, execute, and complete research and you know, both of them ingrained in me that a project is not finished until you have a PMID, or pubMed identification. So basically published. If it’s not published then it’s not done.
Obviously, not every project results in publishing material, but by and large, you know, for example, just presenting even in a preliminary session at a major National Conference-you’re only halfway there. You got to get that work published and get it into manuscript that’s generalizable and that’s searchable by anybody anywhere.
Khateeb: That makes sense because when I was looking at your bio earlier, I couldn’t help but see, and I’m going to read it from here, that you have authored over a hundred and eighty manuscripts and peer-reviewed journals and authored about 13 book chapters and you’ve been invited as a speaker to 85 lectures internationally. And, you know, you look fairly young so you’ve done a lot and your story is remarkable.
It sounds like two things came into your life: which is your environment threw unbelievably difficult obstacles at you that really tested you and your character. And two, you had the fortune and luxury to not have one or two or three but multiple mentors that not only guided you and provided their wisdom, but stretched you. So I’m wondering, what was the most memorable thing that you were ever told from all of your mentors? I know that might be tough.
Life at the Institute of Surgical Research (ISR)
Chung: Yeah, so John Holcomb sat me down the first week when we had our initial counseling and basically, we had a nice introduction and he looked at me and said, “Do you know why we’re here?” and I said why? “We’re here at the ISR to change practice. Everything that we do we have to gear it so that we produce some type of new knowledge or some type of therapy that is going to change practice and alter the way we do things. Because the way we do things in the status quo is not good enough.”
I learned that firsthand with my first group of combat casualties that came in who were burned and they were basically a group platoon that were in a Bradley Fighting Vehicle and hit an improvised explosive device. The vehicle caught on fire, and one of the individuals, I can say his name because he passed away and it’s public record, Alwyn Cashe, he was the platoon Sergeant.
He got out and saw the vehicle burning in flames and knew that his squad mates and his platoon mates were trapped inside the vehicle. So he went back into the fire and pulled his men out. He was the most severely burned. There were about six of them, actually eight, and six were critically injured.
What we observed once we received the patients is that, in retrospect, what had happened is that they got excellent care downrange, but there was no record of the resuscitation and how much fluid they received. From evacuation point to evacuation point we call them echelons of care. And so by the time they got to Germany, they had had three or four different handoffs with no documentation or very little documentation of what they had received in the prior echelon.
All six of the critically ill patients developed abdominal compartment syndrome because they were all over resuscitated and so they need to be decompressed. And if you know anything about burns, having a major burn and adding to it the stress of an open abdomen is a death sentence.
I experienced that firsthand with this group. Within the first 48 hours my first guy died. Within three weeks all six service members that were received that day died. That left me and the entire team just scratching our heads.
It just so happened that something called the joint trauma system had just been set up from the ISR. They coordinated a teleconference, a simple teleconference with every combat support hospital in theater and there were dozens, as well as level two facilities, which are one step below combat support hospital.
We were able to communicate not only with those downrange hospitals, but also with launch tool and Walter Reed. We got together every week to discuss patients that were transported through launch Tool, and so through that mechanism of The Joint trauma system we were able, and this still exists today – they still have calls every week and they do CME and lectures, so on and so forth. But back in the day, we would basically go over every patient, and so when we experienced this group of patients and the outcomes that resulted, we talked about it online and to everyone involved.
And so we put our heads together and we decided hey, we need to figure out how to document resuscitations better. Overnight the launched whole team, combined with the ISR, came up with a flow sheet with burn practice guidelines over the weekend. By Monday, we had a burn flow sheet and practice guidelines that we pushed forward to every single provider in theater. And by that next Thursday when we had the weekly conference, we emphasized that if you get another burn patient, you need to use this burn flow sheet and this burn flow sheet must follow the patient throughout the evacuation.
So what that did is helped us as a system sort of record and figure out exactly what was going on with the patient, because you were recording it every hour. And it allowed in this system for providers when they were getting the hand-off to know exactly where they were at.
That intervention alone cut our combined end point of abdominal compartment syndrome and death rate by half, it decreased mortality and improved outcomes by 50%.
We published that experience and that was among the few first few papers that we published. Having gone through an experience like that where you see a problem and you come up with a solution, and this was a collective effort, and you document it and you show it and you see a significant impact. That was very motivating.
Furthermore, when these patients died they died of shock, overwhelming shock. There was nothing I could do despite me getting high-quality, state-of-the-art training during my two years at Walter Reed. I was out of options, there were no other interventions that I had in my tool bag at that time.
When you lose somebody that you shouldn’t have lost that’s a powerful motivator. And so with the burn flow-sheet effort, we basically converted it into an automated algorithm and patented the idea. Now it’s in license and is known as the burn navigator. They’re here at the American Burn Association. It’s an FDA cleared device that tracks the resuscitation of a patient and you’re able to use graphics as well. So that’s the result of this experience.
Concurrently, I’d dealt with shock and AKI, and at that time the options available to us were not sufficient. For example, we only had the ability to contact Nephrology for intermittent hemodialysis. In a patient that is 20 liters positive on multiple pressers and then they go into severe, stage 3 AKI, intermittent hemodialysis ain’t cutting it. You need to do something else. Patients don’t hemodynamically compensate, they just can’t tolerate the hemodialysis.
And so it became a pattern where we would consult Nephrology because we only had intermittent hemodialysis capability, they would say well, the patient is not going to tolerate it. Even if they did put them on, they would be on for an hour or half an hour and they would drop the pressure and stop therapy and move on.
I was fortunate to have an experience in multiple ICUs during my training at Washington Hospital Center, Shock Trauma, and the NIH where they had continuous renal replacement therapy and they had mature programs. And so I learned that technique during that experience and among the few things that John Holcomb sort of directed. When I first showed up, he said you’re going to start a CRRT program because we need to have this therapy available for these really sick patients. At that time, I was met with a lot of resistance.
Khateeb: We have some medical students and residents who listen to the program, can you explain what CRRT is?
Chung: Continuous renal replacement therapy. It’s used instead of doing dialysis over a two to three hour session, which is basically this huge osmotic shift. You’re trying to remove two to three liters during that session. And so it’s pretty, you know, you’re going to have some hypotension.
In an already hypotensive, unstable patient it’s not the best option if you want to do renal replacement therapy. Continuous renal replacement therapy, on the other hand, you hook up the patient with reasonable blood flows and reasonable replacement fluid and you’re connected 24/7. I choose continuous veno-venous hemofiltration as a modality of choice for various reasons.
And so if you want to remove fluid, for example, you can do it at a hundred CC’s an hour. That’s a more gentle way of removing fluid. So it’s much better tolerated hemodynamically and easier on the kidneys. You’re applying it in patients that already have AKI. In some patients, there are other reasons for CRRT, they don’t necessarily have to meet the traditional criteria.
Some of them they may be hypotensive on pressors and they stopped making urine. At that point they’re already acidotic and they’re 20 liters positive. That’s a patient where the writing’s on the wall. You don’t have to meet arbitrary criteria of, oh they must be uremic with your uremic symptoms. This patient needs something done or else things are going to go awry.
And so we started this program, and I can tell you another story about prior to starting the program on a patient who died because we just didn’t have the therapy available. We weren’t ready yet and that was just heart crushing. To almost be ready with a CRRT capability but not be able to offer it to this patient and Nephrology couldn’t do anything either because they they can only offer intermittent. If the patient is on three pressors, they’re not going to tolerate intermittent, but we had didn’t have the program set up yet.
So once we set up the program, we started treating patients and immediately we saw results. The first 30 or so patients we documented compared to historical controls during the time when we didn’t have this therapy available and our mortality went from 90 percent to 60 percent. 60 percent is the average mortality, and now it’s down to about 50% mortality in patients that get replacement therapy. It’s just better hemodynamically tolerated and it’s now more widely accepted.
But at that time in 2005-06 it was not ubiquitous. There had not been enough trials to demonstrate that this was standard of care for these very unstable patients with AKI. We just we had no other option, we were desperate. In the Burn Unit there were patients that are dying left and right and, you know, we can’t just sit there and just let that happen. Knowing that there was this therapy available, I don’t really care what the data showed, the fact of the matter is they can’t tolerate intermittent. You need some form of renal replacement therapy.
We didn’t have sled at the time which is sort of a slower more gentle form of renal replacement therapy, intermittent replacement therapy. So this was the solution and starting that program involved and required a lot of teamwork. The nurses were totally on board and we were just very fortunate to have a couple of nurses who were former dialysis nurses who are on the burn team. They became super users. They trained everybody else.
It also just so happened that technologically brand new machines were on the market right at that time. So timing was perfect and we started this program, published our results in critical care, that then later translated into a multicenter trial. We got funded by the DoD for three million dollars to conduct a burn-specific multicenter trial. It took a long time to publish that study, nine years in fact, so that’s available in critical care.
And then we concurrently did an observational study and by that time I had presented enough times at this meeting, ABA, that other centers started adopting this very aggressive technique. Applying renal replacement therapy or continuous renal replacement therapy in burn patients, which has now become sort of routine.
Now what I’m sort of advocating, and we have a session on this tomorrow on ECMO in Burns, which is providing lung support via extracorporeal therapy. It’s called ECMO, or extracorporeal membrane oxygenation in those that cannot oxygenate and ventilate on their own. And there are patients that we’re combining ECMO with renal replacement therapy, and we have an entire session dedicated to that tomorrow. So that’s the next step or the next level in terms of moving and changing the standard of care.
Khateeb: That’s really interesting. A mentor of mine who actually went to West Point as well, Christopher Prentiss, had a quote that he would always tell me. He said you either accept the status quo or you challenge it and invent the future.
So I’m wondering Dr. Chung, what do you see right now as the status quo that Physicians need to challenge and what’s the future that needs to be invented?
The Standard of Care with ECMO
Chung: Well, back to ECMO, the current standard and the current philosophy is that in order to execute ECMO, you have got to fully anticoagulate the patient. It’s relatively contraindicated in Burns because burn patients bleed a lot and they need surgeries like skin grafting procedures that result in significant amount of bleeding.
And so the conventional wisdom and the experience of the past suggested that this is not an option for patients who have acute respiratory distress syndrome and can’t oxygenate. You just can’t do ECMO in these patients because they’re going to do worse than they would after not doing anything at all. So it was not offered.
And so back to the CRRT program at Brooke Army Medical Center, when we started our CRRT program we started getting consults from the trauma ICU when patients were starting to develop AKI. The burn center is very unique in that it’s a hospital within a hospital, the US Army Burn Center is. Although it’s structurally based within the Brooke Army Medical Center, it’s under a different command.
And so that’s why it was possible for us to start the program, but when we started the program and it was very successful other clinicians around the hospital realized the benefit. There were also residents that rotated with us and saw with their own eyes how helpful it could be in helping stabilize a patient.
And so they would call us, they wouldn’t call Nephrology they would call us. We had about 10 such patients until the hospital Commander said, “why do we have two standards of care?” asking what’s going on here. And basically he directed that this program, the continuous renal replacement therapy program, would be offered throughout the entire hospital. So we started the program for the entire hospital.
They grew and because of that experience when the possibility of starting an ECMO program came to be. ECMO became popularized after the Caesar trial that was published in, I forget, 2011 or something like that. And then the H1N1 experience that was published in Jama around that same time demonstrated that, for adults, veno-venous ECMO saves lives. So we decided to start an ECMO program.
Naturally, it’s a really nursing technician dependent therapy. You need to have nurses that are super trained and willing to go above and beyond to administer this therapy. We already had nurses with that mindset of I’m going to do what it takes to take care of this patient. I don’t care if it’s extra work, and they’re not getting paid anymore for the extra work that they’re doing . They saw it as an additional skill.
The Link Between CRRT and ECMO
And so our CRRT nurses were the perfect people to identify as ECMO nurses and we trained them up to do ECMO and basically took that opportunity to start an ECMO program. The first patient we treated had bad toxic epidermal necrolysis where the skin was falling off, but also everything in the airway was sloughing and we could not oxygenate or ventilate. That was our first ECMO patient and from there we haven’t looked back since.
That program has now treated over a hundred and twenty patients. It’s a fantastic program. Of the over one hundred patients, a good percentage of them happened to be burn patients. At first I was a little bit nervous about putting a burn patient on because of the potential bleeding complication.
We also started adjusting our anticoagulation strategy, where before we were putting them on full dose of Heparin and we’re really nervous about the membrane clotting off. But then after some experience, we realized we could take it easy on the Heparin, shoot for lower levels, and the bleeding complications became less and less of a problem. And for the burn patients we decided as a team that we can just stop the Heparin and just run the ECMO without Heparin for a specified period and they would do okay. Sometimes the membrane, we would need to change it out, but that became so routine that it wasn’t even a problem either.
So you asked what is the status quo? Well, the status quo is shifted now. We’re treating burn patients with ECMO, actually more than half require concomitant renal replacement therapy. So now we’re providing multi-organ support.
You ask what’s the future? The future is that you’re going to be able to do multi-organ support. Maybe to include liver support, maybe to include sepsis, or extracorporeal sepsis support therapy all within one system. The challenge I’m running into now is that these therapies exist in different silos.
And so ECMO is in its own right now. The Lion Share of the market is owned by McKay, the company, and renal replacement therapy companies are completely different. Trying to combine the modalities, that’s something we are able to do in the clinical setting. But asking the industry to combine it into one machine, that’s a little bit of a challenge.
Not only that, the FDA is a challenge because the renal branch, those folks that evaluate renal products and devices, is very different from the cardiopulmonary branch. And so it’s two different departments evaluating the same system, but they need to get together and we’ve talked about this.
Anyway, there are multiple hurdles that need to be overcome, but the future is ultimately delivering multi-organ support therapy from one machine and being able to leverage that efficiency to treat whoever we want. They have to meet the clinical criteria based on evidence and experience, but for the right patient we need to, as intensivists, be able to treat and replace the kidney if needed, replace the liver if needed, and do it all from one machine.
Acute Kidney Injury and Organ Perfusion
Khateeb: One thing that seems to come up on the back end of a lot of conversations is the effects and the injuries that kidneys sustain, especially with burn and fluid replacement therapy.
Even for me coming out of medical school, I don’t remember seeing these sort of facts and figures about how many lives are taken by acute kidney injury and how many people have their kidneys affected. What can be done there?
Chung: So I’m not a nephrologist. This is sort of a joke, but I’m not a single organ doctor.
So I think in terms of the global perfusion and so what’s going on in shock is that, it’s good to monitor the kidney and what’s going on in the kidney, but it’s a sort of a marker of what’s going on globally.
So in the setting of shock, the body’s trying to shunt blood to compensate shunting blood away from the kidney and the gut and the skin to the vital organs like the heart the lung and the brain. And so focusing on the kidney is just the portal to what’s going on globally. In a burn patient, you do the normal things like try to maintain renal perfusion, making sure the patient is euvolemic, treating their shock and making sure their blood pressure is adequate so on and so forth. That’s the standard of care. Avoiding nephrotoxins means making sure the fluid balance is right.
The next level of therapy that right now we don’t have is protecting the kidney and sort of applying the concept of suspended animation to some degree. At the cellular level, there’s mitochondrial dysfunction that occurs when the cells start to have decreased perfusion. And at the cellular level that’s called dysoxia. There’s only a certain duration of decreased perfusion that the cells can take, about 30 minutes is all. Maybe up to an hour, but beyond that the the cell will die.
Is there a way to protect at the cellular level, you know, the organ such that it’s able to tolerate longer periods of decreased perfusion and dysoxia. There are multiple efforts underway to evaluate this, and we call it extending the golden hour or extending the time period and the tolerance of the organ to injury to decreased perfusion.
The extreme is suspended animation and basically taking somebody and freezing them to sub-freezing temperatures and then protecting all their organs. That’s obviously not realistic, but at the end organ level, specifically for the kidney, if there was a drug that either slowed down the metabolism or somehow protected the mitochondria and protected the sequence that resulted in cell death, that’d be ideal.
There are some candidate drugs out there. For example, valproic acid is being looked at that has sort of that mechanism in that it increases tolerance of certain organs to injury. But there are other candidates out there. I think that’s the next sort of phase and that’s when we’re going to make another leap is when we have a candidate drug or therapy that allows the kidney to tolerate various degrees of insults and just makes it a little bit more robust and resilient. That’s really the next step.
Khateeb: Well Dr. Chung, thank you again for taking time with us, especially at the end of a conference day. I’m sure your feet are hurting like mine, but we appreciate you spending time with us. Real quick for all our listeners, what’s the best way for them to find and keep up with you?
Chung: So I just got on Twitter believe it or not. My handle is @chungk1031 and I’m Kevin Chung and you’ll find me on Twitter and that’s how you can contact me if needed.
Khateeb: Well you’re great on Twitter, you shared a lot of great slides with us. One final sort of Rapid Fire question for you, because again your stories on leadership and overcoming obstacles from the time that you applied to West Point and everything else. I have to ask for everyone, what’s one or two leadership books that you give to people?
Books on Leadership
Chung: Outliers. It’s not necessarily a leadership book, but it sort of gives you insight, and this is from Malcolm Gladwell. It gives you insight as to why people excel; it’s not the smartest people that succeed, it’s not the most privileged, it’s not the lucky few, it’s not the hardest working, it’s a combination of all those things and so it provides great insight into the people around you.
Seven Habits is a great book by Stephen Covey, but everybody knows that. It’s a must read. If you’ve not read The Seven Habits of Highly Effective People you’re way behind because everybody’s is on that train.
I read something recently that I’m blanking on… Oh, Good to Great by Jim Collins. Good to Great is an excellent leadership book and it’s helped me as a chair to conceptualize my strategy for how I’m going to move the department in the organization and help align my efforts with that of the university. It’s a great book that gives you many different levels of items to implement that will help your organization. And so those are the three books right there.
Khateeb: Fantastic. Again, thanks for spending time with us and looking forward to checking out your talk tomorrow.