Universal health care through the lens of national history, identity.

The Lancet-The Trap of History

Every country has its own story, its own fears and dark shadows. One of the biggest unacknowledged challenges facing global health is adapting evidence to these national stories, resolving a persistent and troubling discrepancy between knowledge, history, and identity.

A MUST READ. Also though not directly related, an argument for liberal arts education as a grounding force in our science-and-tech obsessed world.

Short but oh-so relevant as we in the US scratch heads and gnash teeth and poor poor policy makers can’t seem to get a handle on HOW DO WE MAKE THESE PEOPLE HAPPY! My dream team that will save US health care: The Social Anthropologist, The Historian, The Sociologist, The Behavioral Economist, The Nurse!, and we’ll have a doc too if Atul Gawande has the time. He we be called The Atul Gawande.

Health policy incontrovertible truths

Sorry y’all for all the personal posts of late. I’ve had some trouble crossing the Lethe that runs between the hospital and my house (rt. 29). Forgive me, that’s the last time “death” becomes a tag in three consecutive posts.

From my policy textbook this AM, I thought I’d share:

The evidence that insurance and the access to care it facilitates improves health, particularly for vulnerable populations (due to age or chronic illness, or both) is as close to an incontrovertible truth as one can find in social science.” -Austin Frakt

Making good news sad (it’s what I do) and a poem/incantation

I am cancer free, 1 year. A reprieve lasting who knows how long. Feeeeelings.

This week I was spared the ax and I saw it come down on strangers. Have I mentioned how odd it is to be consumed with concern for your own mortality when the study of mortality is consuming your days?

Borrowed from Micheal Swanberg, the only guru I’ll accept (if he’ll have me):

Let me respectfully remind you
Life and death are of supreme importance
Time swiftly passes by and opportunity is lost
Let us awaken
Awaken, take heed
This night your days are reduced by one
Do not squander your life.

“This is a lesson in you never know which day will be your last” –ICU preceptor

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At the community hospital we don’t generally see extremely sick patients. We see a lot of patients who are finishing a long battle with chronic lifestyle-related illness. At the end of their rope. Not many in our ICU are in the grip of acute critical illness. Yesterday I saw my first patient in that category. And as we were running three vasopressors, fluids wide open, assisting in placing central lines and arterial lines and monitoring central venous pressure and ever-tinkering with settings on the vent in a desperate attempt to keep our walked-into-the-ED-with-a mild-URI-a-day-ago patient alive, I had a little thought. This is when I want critical care in my life. This is what we do best.

We are no good for the end-stage congestive heart failure patient. We often prolong suffering in the quest for unattainable health, or in the absence of goal setting or planning. See Being Mortal.

But this patient needed all of the antibiotics, all of the drips, all of the chest x-rays, labs, cultures, all of the lines and vent and monitoring, all of the time of the best nurse on the floor. All in a desperate attempt to keep her alive long enough to recover. Which, I can’t stop worrying, was in vain. But even if, this was the patient that could have been given life back by the invasive, painful, and expensive interventions we have on offer in the ICU.

I don’t have an advanced directive at the hospital (don’t tell my nursing profs). I promise that If I had a chronic severely debilitating and worsening illness I would file a DNR/do not resuscitate (but preferably an AND/allow natural death). For now I don’t trust our system to distinguish the scenarios in which I want or don’t want a ventilator. I wrote out a directive and gave it to a loved one along with specific details about what quality of life means to me. If need be they can bring it to the bedside.

You don’t know when trauma or acute illness might give your shoulder a tap. If I’ve got a chance give it to me. And I want your best nurse.

PS- I know I’m on ethically shaky ground. This is my opinion on this day at this time, emotional and not all that well-informed. It’s Wednesday and I am wrung out already.

Two anniversaries

32 years ago on February 1st my mother, 42 weeks pregnant, was buzzing in to the front door of her OB/GYN’s downtown office when her water broke all over the sidewalk. Being February it quickly formed a slip hazard and needed to be salted.

I was born later that day, minting a first-time mom and a first-time dad.I had black hair with frosted tips (I invented that look). I had all my fingers and toes. I had cheeks you could see from the back of my head.

My dad put together a birth announcement using the office xerox machine and a clipping from the day’s Post showing Washington winning the Super Bowl.

I went home to a little house with two bedrooms, two cats, and a dishwasher that your rolled over and hooked up to the sink when you wanted to run it. My dad was good with projects and covered it with wood to make extra counter space.

That is all that I know about my birthday.

One year ago on February 1st I was waiting on a call from a oncologist. Wanting things to be appropriately subdued but needing to be occupied, my parents came to our little two bedroom house and took my little family out for dinner.

It was a Saturday (a Saturday!) so I had no right to expect the surgeon who was not-on-call to call me. He did though, as I walked from the car to my front door. It was bad news, and my dad lingered on the porch for a few minutes. Until it was clear. It was freezing (again, February) and he would tell my mother waiting inside. On the porch, on the phone, I asked about survival statistics and the size of the surgery, adjuvant treatment, recovery time.

The doctor asked, “How old are you?” My answer, “31, today.”

And so my independent study in oncology began. And continues. The year has wrapped, and I am just now considering the implications of survivorship. My former Prof, role model, and if I may be so bold friend Dr.Jess Keim-Malpass studies cancer and its social effects on young adults. Reading this blog post of hers was a bit like looking into a mirror after going all Nell for over a year.