Years ago, a 101 year old woman arrives by ambulance. Shortness of breath with an altered mental status. Clinically, she has pneumonia and bacterial sepsis. Her daughter arrives and says she wants everything done for her mother: intubation, ventilator, antibiotics and the rest of the full court press. I talk about the option of making her mom comfortable rather than putting her through an invasive hospitalization with only a remote chance for survival. The daughter is adamant, and I abide by her wishes.
Two hours later, a 105 year old woman arrives extremely short of breath and vomiting feculent material. This pretty much declares a bowel obstruction, and she has undoubtedly aspirated her own feces, which is about the worst thing a person can aspirate. And surprise!! It’s the first patient’s older sister and the niece is her durable power of attorney. Déjà vu, I’m sitting in the office having the conversation, but this time about her aunt. I am colder and more calculated as I tell her that in all my years of medicine, I have never been more certain that a patient is going to die. She still wants every measure taken. There is a thing about a physician not having to provide futile care. But in the heat of battle in an emergency department, it’s problematic to implement. I practically beg. Don’t do this, let me make her death comfortable and dignified. She insists, and I am forced to engage in what I consider to be a crime against humanity.
Near shift’s end, one of the nurses asks about my plans after work. “I’m going to indulge my most sordid instincts,” I grumble, “because I’m going to hell anyway.”
Futility…I’m feeling a lot of that right now as I peer into the next several months. My brethren and I besieged because of the foolishness of others. It’s time to end the daylight savings debate and just roll the clock forward. All the way to spring. Otherwise, this winter will have a cavernous darkness, and the exciting results of the Pfizer and Moderna vaccine trials won’t change its pendulum. It’s tragic really. With good vaccine news and recently released studies supporting more durable immunity for those who have recovered, we just need to buy some finite measure of time through sensible actions. Alas, we are seemingly incapable.
I am ashamed of my country and its people. Whether the behaviors are for reasons of hoax, infringement of personal liberties, Covid fatigue, inconvenience, a mother who was stingy with breast milk or a loathing to embrace sacrifice for the common good. If we were to transport ourselves back in time as the domestic home front of WWII, the military outcome would have been different, and we now would all be eating sushi and drinking German style beers. Uh, okay, let me try a different angle.
During WWII, there was a government created system of rationing. First on the list were tires in January 1942. Other than for essential service exceptions, Americans couldn’t purchase new tires. Personal automobiles followed suit in February. In May of 1942, Americans began to receive ration cards and stamps based on a point system. One had to have the money and the correct stamps/enough points to purchase many items: sugar, meat, dairy, dried fruit, canned goods, cheese, coffee, lard, shortening and other oils. Ditto for gasoline, fuel oil, coal, firewood, silk, nylon and shoes.
Victory Gardens were born to assist in freeing more canned goods for the troops. Pots and pans were donated because metals were in short supply. Other donations included tires, bathing caps, hoses and raincoats. All things rubber. People were urged to limit the length of showers and to lick their plates clean to avoid food waste. With the little bit of meat people could buy, they were encouraged to drain and save the fat, to be turned over as an ingredient in making explosives. All this, lasting several years, in a time when families were bearing the burden of lost sons and on the heels of a decade long Great Depression.
Yeah, we are so not the home front of yesteryear. Patriotism has given way to a nation of whiners. Please wear a mask. Up yours. Please rethink your Thanksgiving plans. Screw you.
In one hiding place, the only food my mother had to eat was pumpkin. For six weeks, only pumpkin, if it could even be found. Her mom and a young man risked their lives foraging at night. It left a specific scar. I never had the traditional Thanksgiving dessert as a kid. And people are feeling uncatered to because the holidays shouldn’t be celebrations as usual? Please, I still haven’t caught up on eating my pro-rated allotment of pumpkin pie.
In such lightly urbanized states as Utah, North Dakota, Oklahoma, Idaho, Montana and Arkansas, hospitals are reporting near capacity utilization of medical floor and ICU beds. Total hospitalizations in the United States are now 24% higher than the April and July peaks.
The most important metric, however, is getting relatively little air time. We can’t make more essential health care workers such as hospitalists, floor nurses, Emergency Department and ICU nurses and doctors. There is no simple cookbook for how to treat the most ill. This disease manifests in many different ways and people have idiosyncratic responses. It requires close scrutiny by those with an elite skill set. One ICU doctor I heard on a podcast said that in other diseases she intubates someone and fairly quickly leaves the room. For Covid-19 patients, she hangs out a good long while to “get to know their lungs.” This means that the patient to provider ratio is the immovable metric. There are going to be a lot of unnecessary deaths because while selfishness can seemingly be cloned, savvy health care providers have a more complex genome.
On June 6, 1944, 2,501 American soldiers gave their lives on the beaches of Normandy. I’ve had the great privilege to sit with those who knew them. Come December/January, when the daily Covid-19 death toll meets and well exceeds this body count, I wonder what those still alive will think about the country they so valiantly served.
I’m at the head of the bed, the sedative and paralytic just pushed. Gently touching the corner of her lips, I open the 105 year old woman’s mouth. Her decayed, left upper incisor plunges into the void. After placing the tube, I search around but can’t find that former sentry, now hiding in the redundant pharyngeal folds. But it’s there, serving as a witness and preserved for posterity on the post-intubation x-ray.
November 18, 2020