Monthly Archives: November 2011

Appropriate technology

tech·nol·o·gy/tekˈnäləjē/
  1. The application of scientific knowledge for practical purposes, 
    esp. in industry: "computer technology"
  2. Machinery and equipment developed from such scientific knowledge

Based on the above technology seems rather a finite concept to pin down. Appropriate on the other hand is a rather abstract idea. So by association the phrase “appropriate technology” is a seemingly straight forward word complicated by an abstract operative. What was essentially all black and white gets painted in a whole gamut of shades of gray.

Making sense of appropriate technology is like dealing with a thicket of woods behind a dense layer of clouds.
One well understands “technology” alright, but what is “appropriate”? By definition, appropriate is loosely defined as being suitable. That however is a hard concept to hammer down. Appropriateness is influenced by a huge array of factors that are hard even to enlist.

Nonetheless, with the proliferation of technology, appropriate technology is an important idea  we are increasingly confronted with.  Do we get enamored by technology for the sake of technology, or do we reason it with a cold rationale of the need, what it achieves vis a vis what it is supposed to be for in the first place?

Nowhere is this conflict of ideas and values more difficult than visible than in present day medicine, that has come to be heavily reliant upon technology, interventions and a tacit understanding that the more and fancier the better; this is very relevant especially in the cusp of runaway health-care costs that threaten to sink the entire ship.

The idea that the more and fancier the better  however hardly pass the muster of a serious examination.

Take this recent example from the New England Journal of Medicine. Two methods exist for the treatment of narrowing of arteries in the brain. Now this is a serious condition that needs treatment for the prevention of future strokes. However up until recently opinion swayed that a seemingly sexy intervention that involved advanced and expensive equipment and the deployment of a stent in the arteries in the brain was the favoured method: until a landmark paper showed that the complicated procedure only a select few could do was deemed less effective than mangement with a few drugs that have been available routinely for a while now.

Stenting as such is  a fascinating  blend of skills, and ingenuity, but is it appropriate?

Or even before that, why is this question important after all? Why bother so much about appropriateness? There are two reasons the thing is important.

First the contention is, if something else is more appropriate- more suitable, more relevant, or simply put if it achieves better results, why bother with the elaborate procedure if it isn’t as good?Just because it requires a fascinating blend of skills, knowledge and ingenuity does not mean it should be the right thing to do.

Second has to do with resources: they are always finite, more so in trying times like these when we have to stretch every possible penny. And we don’t have any means to splurge on means and devices that we can’t afford, we have to closely examine what is the most relevant for the specific situation. or will not achieve as much as the next thing available. Appropriateness for technology thus has to be increasingly defined with in the boundaries set by economic prerogatives as well.

A cursory sketch of the whereabouts of appropriate would thus lead us to areas bordered by effectiveness and affordability.

Any  practically useful derivative of scientific knowledge within the perimeters of these defining precincts will likely find itself accepted for appropriate technology.

Now, if only those precincts were that easy to define!


The ventilator conundrum

Frequently enough people come in really sick to the hospital- to the point that they are not able to breathe on their own; and they have to be put on a breathing machine.

Sometimes the arrangement involves just a scary looking face-mask that’s at the end of breathing machine; more often, things are worse off, and you put a tube down the patient’s throat, attach it to the breathing machine, and make the machine work as the patient’s lungs.

But that is just the start. Things snowball from here on. A tube down the throat is uncomfortable of course; so these people have to be induced to sleep with medications. And sure enough, they can’t eat through there mouths, and they need a tube down their nostrils all the way down to the stomach so you can give them some manufactured liquid food. They can’t hold pee, so you stick another tube all the way from their organ to the bladder so you can drain the pee. Most also end up getting rear ended by another tube so you can drain the poop.

If this is exasperating enough already, hold on for a while. Such patients also need some more tubing going into the veins in the body, so they can give you some fluid. Sometimes, if things are bad enough, they put down a long tubing that goes from one of the larger veins all the way close to the heart, so they can wash a lot more fluid.

And then, there is a paraphernalia of wires that’s stuck all over the chest so things can be monitored. Inflatable wraparounds go on the lower legs and another one on the arms so they can monitor the blood pressure. Sometimes however, they put a small catheter straight down the artery so they can monitor your blood pressure rather more accurately.  An arm band with a bar code goes into the hand. The breathing machine sits on the side, like an ominous looking animal guard at a temple gate;  a technicolor monitor with arcane numbers and graphs imposes on the other, with round the clock patient information on display.

As if all that were not enough, the machines and the IV pumps ding and dong at a regular interval; providing a  delirious sound track to that theater of healing.

So that’s how they dress them up for the battle. From here on, it’s a climb all the way up the slippery slope of recovery.

Some people recover. They come out alive and kicking without the machine- the myriad tubes out of their body- able to breathe on their own again. Many try hard-their bodies try hard-make a varying distance up the slope, and then fall right back. Like that proverbial king Bruce’s spider. Some never really make much of a dent in their condition.

A tube down the throat is not a great sight, but it’s an even worse feeling. After a while it starts to eat into your airway, it erodes the vocal cords, gives a pneumonia and makes one constantly delirious. The tube can’t stay there forever; and it can’t come right out either. Thus compromises are made, the tube comes a few notches down; a hole-called a tracheostomy-is made in the neck, and a shorter version of the tube goes there.

For bonus’ sake, they throw in another called a G tube. A G tube is one that goes straight to the stomach from a hole in the belly, so some manufactured liquid food can be shoved down.

That must make one feel like a stumpy tree, stuck in the bed for ever with tubes growing out of you like rootlets.

For a small fraction of people these measures are temporary. For the vast majority however, such arrangements become permanent. People then are alive alright, but unable to talk, breathe on their own, or eat through their mouth. And of course, one can’t go around walking when there is a ventilator attached to the neck- so they are essentially bed ridden throughout- for most people that is for the rest of the life.

One after the other such patients then end up at special facilities for “vent-patients”. Bed after bed after the other, such facilities are filled with patients attached to a ventilator in perpetuity.

So what if he is not eating, drinking, peeing, talking, waking- they are not dead, right?

It’s a completely different matter that once every month- or sometimes even earlier, such patients run a ritual of a trip in a wailing ambulance to a hospital or one reason or other- for a temperature, a blood count that does not look right, lab work that is not normal, a blood pressure that is a little off normal.

As they get shuttled around from one bed to the other, and one place to the other, their skin on the back sloughs off from the constant lying on bed, they catch one obstinate bug after the other, they get one imaging after the other, accumulating radiation like a frequent flyer accumulates air miles, adding up to the suffering while piling up the costs that were not entirely necessary in the first place.

What then started off as an attempt to save a  human life and alleviate suffering, protracts on to a stalemate where the life is saved, but at a gargantuan cost of immeasurable suffering and runaway costs.

It’s hard to tell who is winning on these battles in the terraces and facades of the hospitals and long term care facilities. But human life sure does not look like the winner here.