Monday 10 April 2023

All wired up but not ready to go

I am still digging into the bran-tub of ear-book delights that is Borrowbox. The integrated search algorithm is laughably useless. If you search hopefully for essayist Anne Fadiman, Borrowbox is as likely to deliver Anne of Green Gables or a biography of Anne Boleyn as Best Hit as anything written by, say, Anne Fadiman.  There is a little more utility in Bbox's if you liked that you might like this feature. Come what may, butterfly me will be happy with a wide variety of reading matter - mainly non-fiction; but I'll take a good novel if a) I've not read it before and b) someone I know (and who knows me) recommends. I also browse hopefully through the N=3,000+ non-fiction inventory: I've been agreeably surprised before

It doesn't altogether surprise me that I've just found and romped through another ear-book about end-of-life issues. Death Interrupted: How Modern Medicine Is Complicating the Way We Die [2022] by Canadian ICU doctor and former chopper paramedic Blair Bigham. As you see [R] Bigham is young and fit with knotted sinewy fore-arms - all the better to deliver a heart massage for you my dear. In the earlier version of his caring self, as a paramedic, doing CPR - on roadways, at the bottom of stairs or on his chopper - was what he did. Having delivered the client to the ambulance bay at the nearest emergency care hospital, Bigham and his para-partner could return to base job done. After a mentor had persuaded him to enroll as a grown-up in med school, the 30-something got a more holistic / skeptical view of this as an end-point.

In ICU, there is a lot of kit, some very expensive, and the hospital pharmacy is bursting with meds to try on- and off-label. At the beginning of the pandemic in early 2020 I zoomed into a couple of lab meetings run by my old boss in Immunology. A couple of ICU doctors at one of the great Dublin teaching hospitals were also on these calls because they were getting a higher higher degree researching the innate immune response to viruses. These two young doctors were between mighty sessions intubating, pain-killing and racking their brains for something - anything - which might keep these deeply ill patients alive rather than, like, dead. Most covid patients who rocked up in ICU didn't make it. We know that. What was not really talked about were those who were discharged from ICU and later from the hospital. Later on, Long Covid was recognised as A Thing: people whose QALY - quality adjusted life years - had taken an uncompromising tumble to feeling crap pretty much every waking moment. 

One phenomenon to which Bigham gives some side-eye are the facilities in the USA known as LTACs - long term acute care facilities. It's gotta be an oxymoron? acute means severe / emergency / in-the-moment; it can hardly be long-term and still in the English language. But LTAC is big business - consuming $5billion annually - since Congress 40 years ago authorized increased payments for patients who required more care. It became a new business model: keep the bodies breathing and the bonus Medicare checks would keep rolling in. No expectation that clients would ever leave the facility except in a box. The perverse incentives were cranked up when ICU discharge was deemed to be successful if the patient was still alive 365 days later. Bigham implies that your loved one's care will step down to 'warehouse' on that crucial 1st anniversary of admission. It might be worth asking cui bono? who benefits from this way of life - but not as we know it outside, Jim.

It is welcome to have an insider's skeptical take on modern Western medical practice as it impacts the end of our days. I got much less sense of skepticism from the discussion of transplants; or organ harvesting as some call it. Is it true that the PRC obtains kidneys for party apparatchiks from condemned members of Falun Gong - or is that just othering the existential threat from Asia? For Bigham, using the usable parts of someone who has recently checked out is A Good Thing. With a new liver, kidney, heart-valve or cornea, a very sick person can get an enormous fillip in their QALYs. But whoa! perverse incentives alert. As dead bodies becomes increasingly an asset in parts, the definition of death, especially the timing of death has had to shift its ground. Social researchers from 2053 will look back on current practice with a different perspective. It won't be dissimilar from our current acceptance / embrace of boxing as a sport. That may seem like a wtf non sequitur but both boxing and keeping the dead alive is - for reasons [ie ca$h mon€y] - meting out a casual cruelty on human beings. . . by creatures who drive around in status cars.

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