Category Archives: Patient Care

The art of prognostication

One night in the ICU, I told two loving sisters to a 43 year old sickly cancer patient that their little sister was doing well. As the patient’s admitting doctor, the sisters were banking their hopes on me. They were trying to ask me probing questions, but fumbling. Then one of the sisters managed to spew out her fear. “Okay doctor, how is she doing? Is she going to be okay tonight? You can be honest with us”. 

I could see what the harried sister was not  able to put a voice to. I thought I would cut through the sisters’ fears and help them out with an honest answer.

“Are you asking me if she is going to die tonight?” I volunteered.

“Yes”, they nodded in affirmation, probably relieved that I could see through the veiled question.

“No she is not”, I said. “Thank god”, the sisters resounded together in great relief.

Immediately after, a sickening feeling ran through my stomach. I looked around. The nurse who was by the bedside gave me a hidden look of incredulity. I can’t believe you just said that, his eyes seemed to scream. The intern who was working with me walked out of the room. Later I learnt, he had just told the sisters he wasn’t too sure of the prognosis.  

It felt like a weird contortion of the Murphy’s law: the one time you say something isn’t going to happen for sure, it is going to happen. Was my patient going to die just because I had predicted confidently that she was not going to die?  

I had my reasons to feel confident about the patient. A few hours earlier in the ER, she had been in a rather bad shape. She was not breathing well, and appeared to be anxious and confused. We got her upstairs to the ICU, put  her on a breathing machine and she started doing much better- she calmed down, her blood pressure was holding up well. The reversal was very visible. I felt happy.

Calmed by what was to be my ignominious hubris, the sisters decided to leave the hospital and go home. An hour later, I had to call them to say that their sister wasn’t doing well. An hour more or so later, I had to examine the patient with the the two sisters and the rest of the other siblings  by the bedside, and declare her dead.

Talk about eating your own words.

Such is the treachery of the art and science of prognosticating patient outcomes. In order to deal with the complexity of such an arcane endeavor, doctors often resort to defensemanship: an art of ambivalating, avoiding sticking the neck out  and commiting oneself to an answer.  That way you may not really be right about your answer, but then you are never really wrong either. Sadly, the common understanding is that this is the best strategy for the doctor. There is hardly any incentive for the doctor to rightfully predict patient outcomes, whereas there may be a huge amount of liability associated with getting your prognostication wrong.  

Despite all the numbers that you memorise from texts, generous experience and a dollop of common sense, it isn’t very difficult to make an idiot out of yourself trying to predict how a particular patient is going to fare in the immediate or the long term. You sure have tools to calculate average outcomes, but they are just that, at best a rough shot at predicting outcomes averaged over a population. There may be little corelation with the individual patient at hand.

Then how do you prognosticate immediate outcome on a ciritcally ill patient at an acute care setting. Is it even a wise idea to prognosticate outcomes in a critical care setting? Is the standard, this is the ICU, so anything can happen answer still the best we can come up with?

The reason I stuck my neck out and volunteered a definitive answer  with this patient was two fold: first, the patient was really doing better and there was little reason to believe based on clinical experiene as well as the available data that this patient was going to die in the next 12 hours.  Second, always saying I can’t really predict the outcome almost felt dishonest, when I know majority of the times a patient like this is not going to die in a situation like this. So if a more straight forward and honest answer was going to ease the sisters’ anxiety greatly, why not volunteer with an answer?  

It is easy to rationalise this experience as a vital element of learning. Such experiences however, are double edged swords I believe. True, in the future, before I venture out with a definitive answer, I will swallow my words three times over and probably chicken out with an “anything can happen”. I will not get my answer wrong, and thus avoid the ignominy of it, but far more often than that, I will fail to get it right, and thus lose out on a chance to provide some solace to the patient and the family and provide a positive approach around a practise of medicine that is increasingly being usurped by the self defeating black art of the negative and the defensive.

The sisters were understandably shaken, but then they were immensely thankful for the vigil that we’d provided and the care that we had given through their sister’s final hours. They did not hold me up for venturing with an answer- they knew the impossibility of mastering this art. Much like I was able to decipher the intentions of their words, the sisters were able to decipher the intentions of my words- they were grateful that I had volunteered to say them aloud.

Healthcare’s performance report: Virginia

That was Virginia’s second visit to the hospital in the ten days of the new year. It also ended up being the last.

Virginia was a patient we all knew. She came to the hospital frequently. The aphorism of our intern year was, if you had not taken care of Virginia once, you were not going to graduate out of internship. And that was hardly an exaggeration- almost no one in my internal medicine residency class had been through their internships without admitting her at least once. I admitted her twice. She knew our faces- she never really knew our names though- although she would give us a bored “I know you” every time we met her in the ER exam bay for an admission.

That evening I was signing out in the ICU after a rather long shift; an attending physician came asking if we knew about a certain patient who had died in the OR the previous night. “Some Vivian Hunt or something”, he said. “She used to come frequently to the hospital”. You mean Virginia Hunt? I suggested. “Yes that’s the one”.

She died? A sigh of incredulity escaped my mouth; it suddenly felt as if a wall had fallen off the room we were standing in. Virginia had become some sort of an irrefutable constant in our working lives- I had met Virginia in the ER just a few day ago, she was in with some cold- and the constant was suddenly gone.

Memories flooded my mind on the drive back home. The first time I met her must have been sometime in October 2010, when I was still a greenhorn of an intern. She had come in with chest pain. “Are you my doctor?”, she asked, when I walked into the room. Yes I am, I said. “I need my Benadryl. I take 25 mg four times a day. And don’t give me the pills, they don’t do me no good. I need IV.” I was almost taken aback by my patient’s surefootedness. Her skin was dry all through, maybe it’s the kidney failure giving her the itch, I thought.  I ordered the Benadryl. Virginia was happy.

On any given day, Virginia was as sick as anyone able to walk on two legs could get. She had a barely pumping heart  with valves that leaked like a sieve, her kidneys did not work- she was on dialysis, she had seizures, she had had strokes in the past, her heart rhythm was abnormal and without blood thinning medications, she had a chance upward of 10 percent of being felled with a blood clot in the brain year on year. Barely in her early 50s, and  Virginia was already walking in and out of death’s door everyday.

Every other week or so, she would come to the hospital with chest pain, or some variation thereof. Although the vessels in her heart were not blocked, she had enough reasons to have heart related symptoms. The constant fuelling on heroin did not help. Yet Virginia was rather unapologetic about her habits- any conversation about the risks of drug abuse ended with a terse “I know”.

In April 2011, Virginia had a major heart surgery to replace the leaky valves in her heart. The surgery went well, but within a week or so she was back in the ER. We were worried the new valve may have something to do with the chest pain she came with. The valve appeared okay, it was the surgical wound on the chest that was hurting. She had also managed to lay her hands on some heroin.

Every time she came in with something like chest pain, she would often develop some other problem in the hospital completely unrelated to the first one, like an infection. She would be discharged in a few days and then she would be back in  a week or two. This went on in an unending loop. Virginia’s being in the hospital at any time was almost a given, not to mention the times she was admitted to some other hospital.

Stunned by her death, the next day I sat at a computer to reflect on her hospital visits. In 2012 she had been to the hospital 19 times. In 2011 she was in the hospital a whopping 51 times. After her surgery in 2011, we changed her primary care provider. She had 4 visits with him in the 20 odd months since then. She had a home health nurse visiting her every so often. In the last few years, she had had in excess of 100 x-rays, close to two dozen CT scans and every other kind of test imaginable. The only test she did not get done seemed to be a urine study- she just did not make any urine.

That fateful evening when she died Virginia had a fall at her home. She was dizzy when she came to the hospital. An initial CT scan was normal however within a few hours she was progressively worse. She was then found to have bled in her head. She was whisked to the OR and the blood collection evacuated. However she was not able to make it out of the OR- after half an hour of desperate resuscitation Virginia was declared dead.

Virginia is the very reflection of our healthcare system, it’s performance report: everything that is wrong and right about it, from over and inappropriate use, poor coordination, goals and priorities that are at times misplaced,  to the availability of modern advances and plenty resources at our disposal. Too bad such bottomless resources were not able to save Virginia’s life. Worse still, our failure to steward such resources threatens to pull the entire economy, and everybody else down together in a landslide.

Name changed.

I don’t know what’s wrong with you lady

I think my patient hates me! Okay I will admit I am sure she hates me. If it’s any consolation, she hates all her doctors at the hospital. Up until this morning I’d been thinking she hated me a little less than everybody else, by the afternoon I managed to gravitate right to the top of her hate list.

The 78 year old codgette is not entirely without charm though. This morning, for a change, I wasn’t running around like a squirrel, so during my morning rounds I drew up a chair by her side and had a rather longish conversation. She seemed to appreciate that. She even gave me what looked like a begrudging smile.

Resentment however, was still the overbearing emotion during the entire conversation. The lady thinks she has no business being in the hospital. I don’t blame her for that. She thinks I am keeping her here for no reason.

How would you feel if you were brought to the hospital because your daughter thought you were a little short of breath, and the doctors at the ER admitted you because they found a fever on exam which you never experienced, all the while you never really had any inconvenience or felt anything?

Since the admission almost a week ago, it has been just more of the same. Everyday the lady thinks nothing is wrong with her. We however, ever so cautious in tracking the fever, manage to find one spike of fever at least every day that makes us nervous. Okay there are reasons: she is on on an immunosuppressant, and her temperatures records are rather high. However I still don’t have an adequate explanation for the lady.

The enterprising and ever so inquisitive doctors that we are, we never fail to dig. First we start lowbrow, with a simple infection screen. We fail to find anything, and the digging gets deeper. In no while, the digging is walrusian. Yesterday we got a few CT scans, we do the blood works every day. If anything the lady thinks she is starting to get weaker due to the constant blood draw.

I have a hard time justifying all that we are doing. A snippet of our conversation this morning.

Lady: Why are you keeping me here?

Me: You have a high grade fever. We think its viral, but we are not sure. We are trying to find out why.

Lady: So what did you find?

Me: Well, really nothing thus far.

Lady: So what are you going to do now?

I wanted to say we wanted to do a few more tests, but I simply did not have the liver to verbalise that. I kept mum and gave her a vacant stare.

I did not have to. The lady already knows that.

Yesterday the attending physician had ticked her off on a possible spinal tap if the CTs came up to nothing. The lady was livid. We pitch the idea to her daughter. She has been having headaches now. She complains of weakness. And the fevers. With the suppressed immunity, there are reasons to be worried.

The lady half heartedly approves the procedure, all the while not really hiding her indignation toward all of us. We plan the tap for the afternoon today. I tell her not to worry, the procedure will be over in 10 minutes. Let me try that on you first- she retorts!

Afternoon comes. The lady asks who is going to do the procedure. I tell her I will. The lady is incredulous; she invokes the name of god. Her barometer rises, I can see her fuming. Right there I ascend to the top of her hate list.

The procedure thankfully is smooth. I ask the lady to lie down afterward. She does, and our eyes cross. She rolls her eyes away from me. I don’t really have to guess how she feels about me. What are you going to do now, she asks me, while she looks out of the window. I am going home, I tell her. Good for you she says, the sarcasm very visible.

I call up the hospital later in the day to find out the preliminary results of the tap. Everything normal. I can already imagine my conversation with the lady for tomorrow.

Between heaven and earth

Miss K came to the hospital as a wreck of a person: 48 going on 88, lives at a nursing home, has no immediate family, weighs twice what is considered healthy, can’t breath on her own- is tied to a breathing machine through a tube in her neck, and can hardly speak; has big wounds in the back and all sorts of scary resistant bugs, has been brought to the hospital because she has a fever and her blood pressure is almost non-existent.

The sight was eerily familiar for a hospital in that part of Chicago, with its predictable demographics and illnesses. The pathos was increased only by the intensity of the events.

Wonder what it would feel like to hear this story as a lay person: no matter how hard I try, as a doctor, my opinions on such matters are bound to be  fore-shadowed by the layers of experiences and education. Pulling yourself out of a set of learned behavior and patterned thinking is very very hard indeed.

No matter what your vantage point into these events is though, it’s hard to miss a discomforting undercurrent of thought: how would anybody feel living Miss K’s life anyway? Every morning as I made my daily rounds on my patients, Miss K seemed to be choking up on thoughts that she could not let out; constipated with emotions that she wanted to vent off. Her being on a breathing machine for so long had left her unable to verbalise speech. She would make a great attempt to motion her lips and tongue to try and help me understand what she wanted to say, but despite her best efforts I would still not “get it”. She would not drop the attempt that easily though, still to no avail. I would try and make a very sincere guess at trying to understand her, but my apparent stupidity would perhaps baffle her.

Then we would turn the tables, I would start asking her a few close ended questions, expecting a nod for a yes. Still all I got was a very difficultly maneuvered sideward motion of the neck to denote a no. Writing to communicate was out of question; her hands had long fallen out of use due to gross swelling, as had the rest of all her body parts. The repertoire of my ability to predict her thoughts, and that hardly amounted to much anyway, severely limited such means of communication. Sometimes Miss K used to get so frustrated at the inadequacy of what she was able to communicate with me, she would just drop the attempt, stare into the ceiling and fall into a slumber of deep despair.

This was in her best day. On the others, she would never be aware enough to try and communicate; she would either dip in and out of lucidity, or she would just flop in the bed unconscious.

And then there would be the scary days. Days when we would be so close to losing her, we would start a vigorous attempt of resuscitation, when we would make last-ditch attempts at reviving the heart. One of those times, we ended up breaking her ribs; more than once- we shocked the chest with  electric current powerful enough to rattle the whole body. Somehow she managed to comeback from such gates of death, though she had to go through a ride-through-hell doing so.

Her God would not let her live. And modern medicine would not allow her to die in peace. Miss K in the middle, was tearing apart in this stalemate.

For me this was an uncomfortable and an unfamiliar emotional territory. Having been brought up, educated and  thus far trained in a different cultural and socioeconomic milieu altogether, I have never had to go through such a gut wrenching upheaval of emotions, even as a care-provider along the sidelines of many a deathbed. In my culture, death was never really contested this intently between man and the forces, leaving behind horrifying remains of a bloody, grisly war. When it was sufficiently clear that death was imminent, it was accepted with a modicum of decorum as an eventuality that offered no escape.

Such shoulder-dropping at the altar of death sometimes appeared unfair- at times even cruel. Back then, many a times we were left wondering of the life that could possibly have been saved: the mother who meant the entire world to her children, the son who was the only reason the elderly parents lived their life for, the kid who would not see his sixth birthday, for the want  of a little more advanced medicine, a little more sophistication, a little more resources. Technology and more advanced medicine, at such times appeared to be the  all curing panacea for our health woes; that was until I came to the US and saw technology’s underbelly. Modern medicine could save lives, but sometimes preventing a natural death without  a concern for what remained of a life was repackaged and dished out as a life saved; or at least it was mistaken for a life saved.

In the back rooms, in the hallways in the unit, care providers often wondered if they would ever subject themselves to such agony as an appendage of the machine; with Miss K it was hard to gauge where man ended and the machine started. They of course had the luxury of not having to be in that unenviable position, the very edge of the precipice of death from where modern medicine could not exactly bring you back to life, but could still manage to prevent you from hurtling down to death right away- forcing you to die the agonising death of a slow poison instead of a swift and honourable transition in peace.

As if all this was not troubling enough for all of us who had seen Miss K suffer, we did not know if all this that we had been doing to her was what she really wanted for herself. What if she did not want this torment tied down with the machine? Time and often, such feelings of guilt tore us apart. We would ask her if she wanted the tube down her throat, attached to the machine huffing and humming, and the vigorous compressions when her heart stopped. Most often she would just return a vacant stare. Every once in a while though, the stares would be punctuated by tears that welled up in her eyes; still not be able to let a sob out. She would just give a very gingerly negotiated side-ward motion of the neck. Guilty emotions choked our hearts.

With all the ingenuity of modern medicine, when we thought we were finally beginning to checkmate death itself, we are now beginning to realise may be we were double-crossed.  Our intelligent science, the sophisticated tools, the wizardry of our care providers was clever by half after all: we are still losing the war and oftentimes we are being thoroughly disgraced en-route.

One day we gathered up her close relatives by the bedside: a sister and the sister’s two daughters. The sister seemed visibly distressed with all that her sister, younger to her by almost 10 years, had to go through. What’s all the pain for: she seemed to question. Every day she would religiously turn up at the hospital, look at her little sister and mutter “poor thing” part out of benevolence and part out of desperation. It was not hard to gauge the sister’s torn state of being. One half of her seemed to suggest may be it was time to let go; to let nature take its own course. The other was even more lost in the possibility that a miracle could possibly materialise out of the deep recesses of modern science to bring her back.

The sister however could not decide how to proceed with with Miss K’s further care; the onus of making that decision fell onto her two twenty something daughters, who were in fact the powers of attorney. They were even more bewildered they had to make the decision, so they put the question back to her aunt. “What do you want auntie? Do you want them to compress your heart when it stops beating?” Miss K held her gaze for a long time. She seemed to be lost in her own reverie, not caring the least about the commotion that was going on around. After a while, she nudged her head down. “See that” the two nieces said. “She said wants the compressions.” A look of relief crossed their eyes.

This has come to be modern medicine’s quicksand; enthralled by the armamentarium of tools and skills we have come to gather, modern medicine has been making promises of an infinite loop of health and life; and suddenly death has come to be a distant concept for us. No is not an answer; letting nature take it’s course when medicine has run out of options somehow appears grossly incompetent. Put such hollow promises in place, couple that with a system where patients and their surrogates are always expected to make their own decisions, with doctors too happy to play second fiddle, and we have a potent recipe for disaster.

After that event Miss K closed her eyes. She would not really wake up even if we called out her name. She moved in and out of consciousness. A few days later, the family made a decision to move her to another hospital. They said may be she would get better there. I for all my training and education, could not figure what we could possibly have done different, done better. Or, what the other hospital for that matter could do different.  Well, they did advertise on the radio that not only did they practice cutting edge medicine, but they created it. It was not hard for the harried sister and nieces to buy into that promise of a miracle. At least, they had the radio ads to fall upon; may be that was where the miracle they were looking for was.

Miss K was in the hospital for a total of 21 days. During that period, at least 4 dozen notes were written on her- replete with daily exam reports, assessments, plans and just plain question marks of uncertainty; an equal number of doctor’s rounds were made, round the clock down to the minute nursing care was provided,  close to 30 odd x-rays were done with more than half a dozen CTs and MRIs, medications worth just a few cents to those over a thousand dollars were administered. We scratched our heads, sweated hard, pondered and questioned, tried something one day, and tried the opposite the other. Nothing really worked. Nothing changed. Miss K went from being miserable to miserable.

And this is how things have been for Miss K for the last 2 years. In and out of one hospital to a nursing home to another hospital, intercepted just by the wail of one ambulance siren to the other.

How could things have gone so wrong for Miss K, and for our health care system? Why did Miss K have to suffer the way she did? How come our health care system has come to tolerate and even encourage such gross misappropriation of resources? Why did she go on getting aggressive, expensive care  when it was not really care; when doctors more or less knew they would not be able to make things any better for her, this way or the other in terms of the quality of life? Was it because the family “wanted all that could be done”? Was it because the doctors did not have the spine to talk to the family and firmly say, any further care would not be beneficial? Was it because someone was benefiting out of the whole sordid affair?

At the end of it all, the hospital ran a bill in excess of  $ 200,000. Later I learnt, the hospital had been reimbursed a quarter of the amount of the total bill.

One night at about 2 in the morning an ambulance came to whisk Miss K away to the other hospital. A fresh new patient; a fresh new doctor; yet another admission note.  A glimmer of miraculous hope for the family. What all this meant for Miss K, I don’t know. I had a feeling she sunk further down into her shell; bowing and nodding for every one else’s convenience, waiting in the balance for the transition to arrive.


The runaway patient

My patient ran away from the hospital.

This ordinarily is almost common place for a hospital bordering the south side of Chicago. In the last two years at the hospital, I had first grown surprised, and then helpless and finally weary to such mysterious absconding. This time however, it struck a chord.

Long before Mr B ran away, I had an inkling the new diagnosis of HIV would be difficult for him to accept. I had thus decided to recruit the help of counselors to join me discuss the diagnosis with him. If that was a thoughtful decision, it wasn’t any useful nonetheless. My patient showed little emotion during the discussion of his new diagnosis; however a little while later he was nowhere to be found.

Patients usually bolt out of the hospital because the pull of the street is too strong for them to resist. They come to the hospital when their bodies can’t take it anymore, but as soon as their as they gain any bit of composure, they are out of  the door. I have however, thus far, not had a patient who had bolted out because he was apparently traumatised by his new diagnosis.

A few years ago when I was a doctor halfway across the world, patients met a similar diagnosis with uncharacteristic resignation. Young housewives, growing up in grinding poverty, social oppression and lack of education had never really had any say whatsoever about how their lives had shaped up thus far. So if their husbands came home one day and then gave them the virus, that was just another of the upteen unfair hands life had dealt at them; there wasn’t anything for them to say or react about that. While their predicament was  profoundly unfortunate, their reaction was absolutely muted.

To these women HIV meant perennial ill-health, and burdensome stigma and discrimination in what was already a much marginalised existence. Here in America such barriers were not easily visible: treatment options were available and stigma if any was banished to the underground. Examples abound of people who had been able to overcome the crippling effects of the infection and lead a healthy and productive life. Rights groups and patient advocates were available. More importantly, my patient here had made informed choices about his own life; he had the chance to be the master of his own destiny. So while I had expected him to be shaken by the diagnosis, his running out of the hospital took me by a little surprise.

A few hours later, we traced our patient, and he returned to the hospital. He was visibly sorry for having run out, but it was not hard to gauge that he had been overwrought. By his own description, he blanked out and did not know what to do, so he ran away in a nervous frenzy.

I could not help rationalise how upsetting this new found diagnosis must have been for Mr B, but then my mind did a throwback to those housewives half way across the world; for them even an upset emotion was a luxury they could not afford; the grind of an overly unfair life had blunted their emotional responses to such an extent, their bodies did not even know how to react to a horribly unpleasant event. These women had been robbed of their ability to emote.

Such reminder brought me peace of mind- Mr B might as well have tripped into a hole right now, but is was no where the bottomless hole life could summarily consign you to. So what if he ran away from the hospital, that still is much comforting than an unaffected silence and an emotional void for a response.

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.