10 ms·

Wonder how I slided into the world of Fallout? WTF!?! We have plutonium powered pacemakers? http://large.stanford.edu/courses/2015/ph241/degraw2/ http://large

by bhaak 4y ago

Wonder how I slided into the world of Fallout? WTF!?! We have plutonium powered pacemakers? http://large.stanford.edu/courses/2015/ph241/degraw2/ http://large.stanford.edu/courses/2015/ph241/degraw2/ Ah, okay we had. > Despite the often longer life-expectancies, nuclear pacemakers quickly became a part of the past when lithium batteries were developed. Not only did the technology improve, allowing for lighter, smaller, and programmable pacemakers, but doctors began to realize that this excessive longevity of nuclear pacemakers was excessive. Lithium pacemakers often last 10-15 years allowing for doctors to check in on their patients and replace either the batteries or the pacemakers themselves with new and improved technology as it is develops in those 10-15 year spans.

mysterydip 4y ago
> allowing for doctors to check in on their patients and replace either the batteries or the pacemakers themselves I cynically read this as "we needed to get more money out of these patients"
- tomrod 4y ago
  Meh. Maintenance is a good thing when performed well and not excessively. Heart problems are funky.
- konschubert 4y ago
  I read this as: Most patients don’t survive those 10 years anyways.
  - patrickserrano 4y ago
    Glad I'm not the only cynical one ;)
    - KerrAvon 4y ago
      Seems like maybe don’t be cynical outside of your own specialty might be a lesson here.
  - mlyle 4y ago
    A number don't. But as far as the number that needs some kind of pacemaker tune-up or revision during that time-- it's a really big share.
    - sgtnoodle 4y ago
      If battery life doesn't improve much, I don't die prematurely, and I continue to materially benefit from having an implant, I personally could be realistically looking at 3 replacement devices and at least one lead replacement over the years. In the unlikely event that I suffer from ventricle enlargement long term, I'd need two more leads installed as well.
      - mlyle 4y ago
        Yup, there's definitely some patients that would benefit from a nuclear battery. > I personally could be realistically looking at 3 replacement devices and at least one lead replacement over the years. In the unlikely event that I suffer from ventricle enlargement long term, I'd need two more leads installed as well. This is the point I'm making, though: realistically, you have a high chance of needing 2 additional procedures for non-battery reasons, which are likely good times to replace the device, too.
  - kristopolous 4y ago
    I'd rather live an extra 9 years than 0. We're all going to die and an extra 9 years is not bad.
    - konschubert 4y ago
      I did not mean to say that they are not worth it.
    - dghughes 4y ago
      My Dad was diagnosed with a fatal lung illness and was given three years to live. He made it to ten years the last six months were rough. But I can't imagine if he had died after the predicted three years. I see people Dad's age or older driving and walking around and I find it amazing how older people are alive. Elderly people are amazing as people and for their knowledge. Love every day you and your family are here and healthy!
  - jjkaczor 4y ago
    My grandfather got a pacemaker in the late 1970's. He died in 2014, not from heart-related issues. I'd say that was a good return on medical investment.
  - WastingMyTime89 4y ago
    The figures surrounding pacemakers are hard to interpret. Most people are fitted extremely late in their life following serious cardiac incidents. My understanding is that people diagnosed with bradycardia young can expect to survive a long time with the device.
    - konschubert 4y ago
      You are right. When you read the studies, they seem gloom. But of course, most people who are fitted a pacemaker are already very late in their life.
- happyopossum 4y ago
  There’s not a single cardiac surgeon in the world who thinks he’s gonna get rich with once-every-10-years follow up appointments. We produce enough new patients to keep them all sufficiently busy.
  - ecpottinger 4y ago
    Looked at my scales this morning, boy are you right.
  - robocat 4y ago
    A private surgery business that specialised in pacemakers would surely care, because those 10yr repeat customers would be part of the valuation (valued like SaaS with long duration and high churn?). That would matter to a surgeon with an ownership stake on retirement. I agree that a surgeon at a general hospital probably wouldn’t care (little financial incentive).
    - Calavar 4y ago
      Private practice is quickly going extinct in the US. It's generally not an option for US residency and fellowship graduates these days unless they are in one of the specialties that has cash payors (plastics, dermatology, orthopedics, a small number of "concierge" primary care docs and psychiatrists that cater to rich patients, and a small number of ophthalmology practices that carved out a good Lasik business). The vast majority of pacemakers are placed by cardiologists with an additional two years of training in electrophysiology (not by cardiothoracic surgeons, who prefer to do complicated open heart surgeries and generally find things like pacemakers boring). Contrary to the conspiratorial thinking all over this thread, medical society guidelines have scaled back the indications for putting in pacemakers time and time again, so the market has shrunk. Electrophysiologists have to make up for the lost pacemaker volume by doing newer procedures (ablations) that reimburse less per hour of work. Even then, the volume at a lot of shops isn't enough to merit full time work. A lot of graduating electrophysiologists have to take mixed electrophysiology/general cardiology jobs where less than 50% of the work is electrophysiology. All that is to say, no, pacemakers are not a money making scheme. While there is decent money to be made, it's a shrinking market and those who got obscenely rich putting in pacemakers in the 80s and 90s have mostly already retired.
- hwillis 4y ago
  You really should not. 60 beats per minute means that in ten years the leads of a pacemaker will be bent *315 million* times. That's an order of magnitude higher than we typically test fatigue resistance, and even if we were that confident about being able to produce flawless materials, there are millions of different enzymes and acids and temperature fluctuations in the body. Any one of those could impact the fatigue resistance. Additionally, any kind of implanted device is significantly prone to a wide range of problems that range from inconvenient to devastating. The human body is very hostile to foreign objects, often with few warning signs. Clots and fibrous capsules (and eventually, calcified capsules) form around ANY implant, and that's the best case problem. Titanium is extremely biocompatible. It forms a thinner capsule than most materials. It integrates with bones beautifully, due to surface treatments that allow bone to grow into microscopic surface cavities, with strong molecular bonds. But also sometimes, for no apparent reason, all the bone around a titanium implant will just start dying and resorbing. It's rare, but if you get a hip replacement you absolutely need to check on it regularly because if you don't you'll lose use of the leg completely (and quickly, and permanently). In and around the heart is one of the most challenging places to implant things, aside from maybe the brain. Any moving part of the body will constantly stress any mechanical part, and build up scar tissue around and rubbing spots. The only reason the brain is worse is because its fragile and changes size significantly when you sleep. Recently we started using leadless pacemakers. Even before that pacemakers were continually getting smaller, and smaller pacemakers are less irritating and experience less stress and movement. Even if that weren't true, it would still be worth checking in on pacemakers, because they're doing incredibly hard jobs and if they fail people can die faster than they can get to a hospital. EDIT: oh, and heart disease is the #1 cause of death in the US, while heart surgery is one of the most difficult specialties to get in to. They are absolutely never short on patients, lol.
  - NikolaNovak 4y ago
    >>"changes size significantly when you sleep." Wait,what??
    - fennecfoxen 4y ago
      Brain neurons going into sleep mode eject some of the cell contents and shrink, which apparently also helps flush waste because the cerebrospinal fluid can flow better.
- toss1 4y ago
  A friend had one of these units that extended his life for over a decade. He had it upgraded at least once, and the programing updated several times, and noted improvements each time (although he never got the one feature he really wanted [0]). So active maintenance is definitely not spurious or mercenary but is genuinely useful. [0] When the pacemaker detected a problematic arrhythmia it would give a couple of defibrillation shocks just like the paddles but right on the heart muscle. He said this felt like getting kicked in the chest by a horse and came completely out of the blue with zero warning. So it could be quite disruptive. He wanted a feature where it would tingle or beep or something just a few seconds ahead of time so he could mentally prepare; apparently the second one that was expected was a lot less traumatic. Anyway, the docs thought it was a good idea, and passed it up, but it never happened before he passed.
  - leeoniya 4y ago
    > He wanted a feature where it would tingle or beep or something just a few seconds ahead of time so he could mentally prepare; apparently the second one that was expected was a lot less traumatic. reminds me of the pre-safe sound prior to collision https://www.mercedesbenzofnatick.com/new-features-mercedes-benz-comand-system.htm https://www.mercedesbenzofnatick.com/new-features-mercedes-b...
    - toss1 4y ago
      Yes, it does — Thx for reminding me of that!
  - WastingMyTime89 4y ago
    That’s an implantable cardiac defibrillator not a pacemaker. Completely different things.
    - toss1 4y ago
      It had both functions, at least according to my friend; he was an engineer and he described both in some detail.
  - 4y ago
- hkgjjgjfjfjfjf 4y ago
- citizenpaul 4y ago
  >longevity of nuclear pacemakers was excessive Same. In what world can a lifesaving device run excessively long? One with our health system is where...
- derrida 4y ago
  > cynically read this as "we needed to get more money out of these patients" Unfortunately in the OECD I think its possie for an American to read it this way due to the unusual health system. Don't get me wrong... things are changing elsewhere too... it used to be a great shame to go sue a surgeon for anything but reckless intentional negligence... after all we all have bodies that age and decay and the surgeon is provided freely as a public service and their profession is to try as best and compassionately as they can with their training they recieved freely to delay or prevent the suffering inevitable from life... now people sue here for like an orthopetic surgury that simply didn't produce any result ... we are becoming more like america it is sad.
- nshepperd 4y ago
  Medical professionals worry a lot about "compliance". It would not be unusual for a doctor to unironically believe that "leverage" like this—forcing the patient to come in for a check-up instead of letting them make their own decisions—actually benefits the patient. So it's not necessarily about money, but that's not imo saying it's much better.
rwmj 4y ago
Until now I assumed that all pacemakers were nuclear powered, since I read about this as a kid in some children's science book. It's come as a surprise to find out they're unusual.
afterburner 4y ago
> Due to the extremely high risk and toxicity involved with using plutonium, numerous layers and shields were woven into these pacemakers resulting in larger and heavier devices. Despite strong concern of radiation exposure, the actual risk of exposure from these plutonium-powered pacemakers was almost non-existent. What a strange phrase. I would say it was because of the concern of the risk of radiation, not "despite" it, leading to the precautions built into the device, that the risk was reduced to "almost non-existent". Or is this a claim that the shielding was unnecessary?
- michaelt 4y ago
  The claim here is "The risk was tiny due to the superb shielding - but patients were still wary and preferred their implants not have any nuclear material at all"
- jerry1979 4y ago
  I think it reads like: Even though people might worry about radiation from the device, the actual risk (due to all the shielding) is almost non-existent.

by bhaak 4y ago

mysterydip 4y ago

> allowing for doctors to check in on their patients and replace either the batteries or the pacemakers themselves I cynically read this as "we needed to get more money out of these patients"

tomrod 4y ago
Meh. Maintenance is a good thing when performed well and not excessively. Heart problems are funky.
konschubert 4y ago
I read this as: Most patients don’t survive those 10 years anyways.
- patrickserrano 4y ago
  Glad I'm not the only cynical one ;)
  - KerrAvon 4y ago
    Seems like maybe don’t be cynical outside of your own specialty might be a lesson here.
- mlyle 4y ago
  A number don't. But as far as the number that needs some kind of pacemaker tune-up or revision during that time-- it's a really big share.
  - sgtnoodle 4y ago
    If battery life doesn't improve much, I don't die prematurely, and I continue to materially benefit from having an implant, I personally could be realistically looking at 3 replacement devices and at least one lead replacement over the years. In the unlikely event that I suffer from ventricle enlargement long term, I'd need two more leads installed as well.
    - mlyle 4y ago
      Yup, there's definitely some patients that would benefit from a nuclear battery. > I personally could be realistically looking at 3 replacement devices and at least one lead replacement over the years. In the unlikely event that I suffer from ventricle enlargement long term, I'd need two more leads installed as well. This is the point I'm making, though: realistically, you have a high chance of needing 2 additional procedures for non-battery reasons, which are likely good times to replace the device, too.
- kristopolous 4y ago
  I'd rather live an extra 9 years than 0. We're all going to die and an extra 9 years is not bad.
  - konschubert 4y ago
    I did not mean to say that they are not worth it.
  - dghughes 4y ago
    My Dad was diagnosed with a fatal lung illness and was given three years to live. He made it to ten years the last six months were rough. But I can't imagine if he had died after the predicted three years. I see people Dad's age or older driving and walking around and I find it amazing how older people are alive. Elderly people are amazing as people and for their knowledge. Love every day you and your family are here and healthy!
- jjkaczor 4y ago
  My grandfather got a pacemaker in the late 1970's. He died in 2014, not from heart-related issues. I'd say that was a good return on medical investment.
- WastingMyTime89 4y ago
  The figures surrounding pacemakers are hard to interpret. Most people are fitted extremely late in their life following serious cardiac incidents. My understanding is that people diagnosed with bradycardia young can expect to survive a long time with the device.
  - konschubert 4y ago
    You are right. When you read the studies, they seem gloom. But of course, most people who are fitted a pacemaker are already very late in their life.
happyopossum 4y ago
There’s not a single cardiac surgeon in the world who thinks he’s gonna get rich with once-every-10-years follow up appointments. We produce enough new patients to keep them all sufficiently busy.
- ecpottinger 4y ago
  Looked at my scales this morning, boy are you right.
- robocat 4y ago
  A private surgery business that specialised in pacemakers would surely care, because those 10yr repeat customers would be part of the valuation (valued like SaaS with long duration and high churn?). That would matter to a surgeon with an ownership stake on retirement. I agree that a surgeon at a general hospital probably wouldn’t care (little financial incentive).
  - Calavar 4y ago
    Private practice is quickly going extinct in the US. It's generally not an option for US residency and fellowship graduates these days unless they are in one of the specialties that has cash payors (plastics, dermatology, orthopedics, a small number of "concierge" primary care docs and psychiatrists that cater to rich patients, and a small number of ophthalmology practices that carved out a good Lasik business). The vast majority of pacemakers are placed by cardiologists with an additional two years of training in electrophysiology (not by cardiothoracic surgeons, who prefer to do complicated open heart surgeries and generally find things like pacemakers boring). Contrary to the conspiratorial thinking all over this thread, medical society guidelines have scaled back the indications for putting in pacemakers time and time again, so the market has shrunk. Electrophysiologists have to make up for the lost pacemaker volume by doing newer procedures (ablations) that reimburse less per hour of work. Even then, the volume at a lot of shops isn't enough to merit full time work. A lot of graduating electrophysiologists have to take mixed electrophysiology/general cardiology jobs where less than 50% of the work is electrophysiology. All that is to say, no, pacemakers are not a money making scheme. While there is decent money to be made, it's a shrinking market and those who got obscenely rich putting in pacemakers in the 80s and 90s have mostly already retired.
hwillis 4y ago
You really should not. 60 beats per minute means that in ten years the leads of a pacemaker will be bent *315 million* times. That's an order of magnitude higher than we typically test fatigue resistance, and even if we were that confident about being able to produce flawless materials, there are millions of different enzymes and acids and temperature fluctuations in the body. Any one of those could impact the fatigue resistance. Additionally, any kind of implanted device is significantly prone to a wide range of problems that range from inconvenient to devastating. The human body is very hostile to foreign objects, often with few warning signs. Clots and fibrous capsules (and eventually, calcified capsules) form around ANY implant, and that's the best case problem. Titanium is extremely biocompatible. It forms a thinner capsule than most materials. It integrates with bones beautifully, due to surface treatments that allow bone to grow into microscopic surface cavities, with strong molecular bonds. But also sometimes, for no apparent reason, all the bone around a titanium implant will just start dying and resorbing. It's rare, but if you get a hip replacement you absolutely need to check on it regularly because if you don't you'll lose use of the leg completely (and quickly, and permanently). In and around the heart is one of the most challenging places to implant things, aside from maybe the brain. Any moving part of the body will constantly stress any mechanical part, and build up scar tissue around and rubbing spots. The only reason the brain is worse is because its fragile and changes size significantly when you sleep. Recently we started using leadless pacemakers. Even before that pacemakers were continually getting smaller, and smaller pacemakers are less irritating and experience less stress and movement. Even if that weren't true, it would still be worth checking in on pacemakers, because they're doing incredibly hard jobs and if they fail people can die faster than they can get to a hospital. EDIT: oh, and heart disease is the #1 cause of death in the US, while heart surgery is one of the most difficult specialties to get in to. They are absolutely never short on patients, lol.
- NikolaNovak 4y ago
  >>"changes size significantly when you sleep." Wait,what??
  - fennecfoxen 4y ago
    Brain neurons going into sleep mode eject some of the cell contents and shrink, which apparently also helps flush waste because the cerebrospinal fluid can flow better.
toss1 4y ago
A friend had one of these units that extended his life for over a decade. He had it upgraded at least once, and the programing updated several times, and noted improvements each time (although he never got the one feature he really wanted [0]). So active maintenance is definitely not spurious or mercenary but is genuinely useful. [0] When the pacemaker detected a problematic arrhythmia it would give a couple of defibrillation shocks just like the paddles but right on the heart muscle. He said this felt like getting kicked in the chest by a horse and came completely out of the blue with zero warning. So it could be quite disruptive. He wanted a feature where it would tingle or beep or something just a few seconds ahead of time so he could mentally prepare; apparently the second one that was expected was a lot less traumatic. Anyway, the docs thought it was a good idea, and passed it up, but it never happened before he passed.
- leeoniya 4y ago
  > He wanted a feature where it would tingle or beep or something just a few seconds ahead of time so he could mentally prepare; apparently the second one that was expected was a lot less traumatic. reminds me of the pre-safe sound prior to collision https://www.mercedesbenzofnatick.com/new-features-mercedes-benz-comand-system.htm https://www.mercedesbenzofnatick.com/new-features-mercedes-b...
  - toss1 4y ago
    Yes, it does — Thx for reminding me of that!
- WastingMyTime89 4y ago
  That’s an implantable cardiac defibrillator not a pacemaker. Completely different things.
  - toss1 4y ago
    It had both functions, at least according to my friend; he was an engineer and he described both in some detail.
- 4y ago
hkgjjgjfjfjfjf 4y ago
citizenpaul 4y ago
>longevity of nuclear pacemakers was excessive Same. In what world can a lifesaving device run excessively long? One with our health system is where...
derrida 4y ago
> cynically read this as "we needed to get more money out of these patients" Unfortunately in the OECD I think its possie for an American to read it this way due to the unusual health system. Don't get me wrong... things are changing elsewhere too... it used to be a great shame to go sue a surgeon for anything but reckless intentional negligence... after all we all have bodies that age and decay and the surgeon is provided freely as a public service and their profession is to try as best and compassionately as they can with their training they recieved freely to delay or prevent the suffering inevitable from life... now people sue here for like an orthopetic surgury that simply didn't produce any result ... we are becoming more like america it is sad.
nshepperd 4y ago
Medical professionals worry a lot about "compliance". It would not be unusual for a doctor to unironically believe that "leverage" like this—forcing the patient to come in for a check-up instead of letting them make their own decisions—actually benefits the patient. So it's not necessarily about money, but that's not imo saying it's much better.

rwmj 4y ago

Until now I assumed that all pacemakers were nuclear powered, since I read about this as a kid in some children's science book. It's come as a surprise to find out they're unusual.

afterburner 4y ago

> Due to the extremely high risk and toxicity involved with using plutonium, numerous layers and shields were woven into these pacemakers resulting in larger and heavier devices. Despite strong concern of radiation exposure, the actual risk of exposure from these plutonium-powered pacemakers was almost non-existent. What a strange phrase. I would say it was because of the concern of the risk of radiation, not "despite" it, leading to the precautions built into the device, that the risk was reduced to "almost non-existent". Or is this a claim that the shielding was unnecessary?

michaelt 4y ago
The claim here is "The risk was tiny due to the superb shielding - but patients were still wary and preferred their implants not have any nuclear material at all"
jerry1979 4y ago
I think it reads like: Even though people might worry about radiation from the device, the actual risk (due to all the shielding) is almost non-existent.