Friday, September 3, 2010

Poised Between Hope and Terror

The paradox of these modern times is that it's hard not to buy into the promise of technology. Something better just around the corner, except what if you don't make it around the corner? You feel cheated, almost, and it's hard not to fall into the dreamy expectation that if you just hang on long enough you might be able to live forever . . .

Greetings reader! Your recently less-than-faithful correspondent has been laid low yet again by a mysterious "stroke" of what would seem incredibly bad luck. I've landed in some kind of ER 4 times now across maybe two and a half years, and each time seems medically unrelated to the others. But I have to tell you, it's messing with my poise and equanimity (who coined that phrase anyhow?).

First there was what ended up being called mania with psychosis. In layman's terms, I climbed into my own overheated narrative, and managed to replace the one everyone else inhabits (my memory of the event remains intact, if as strange even to me as some of my own writing when I revisit it).

Next, a pulmonary embolism last Christmas Eve which I experienced pretty much like I was a denizen of some Dune dystopia and someone pulled my plug. Then, following a fun evening with close friends involving too much strong drink too quickly, I was diagnosed with dehydration, even though the reason I redirected my morning walk to the ER was that it felt, internally, precisely like my PE on Christmas Eve.

Then, just now, they say I suffered a Trans Ischemic Attack or TIA/mini-stroke. Jeepers! It's as if I don't belong among the living.

As a kind of capper to these events, the only other time that I've visited the ER was another Christmas Eve, this one in 1990, when I had my appendix taken out. Now before the medical doctors among you (can there be "among" onesies??) attempt an armchair diagnosis, let me warn you that I swim against that tide.

We could try these for starters: Alcohol is an underlying constant, but not in my life and not in the same way to each episode. Alcohol might be related to stress or certainly to having fun (I lost my mind upon return from an extremely uncharacteristic bout of good times on someone else's nickel, since I never could have afforded it on my own), so it might be a good proxy for some other issue. Digging deeper, then . . . .

I have genetic factors, one which increases my propensity to clot - a fine discovery gracias nearly dying - and one which, very apparently, gives me a prodigious capacity for drink. I have a lifetime's scars from self-indulgence of various sorts, including smoking as a younger man, bartending and bar frequenting, and in general finding dissolution to be conducive to good interlocution, social bonding and general intellectual stimulation.

I've spent years cruising or day tripping on my sailboat, where beer was the hydration of choice. Talk about perverse. My theory is that you get a beer gut - of which I remain the proud owner, pathetically enough - to provide the function of a camel's hump, since the alcohol in the beer is basically fighting your body's need for water. Some alchemical re-adjustment gets accomplished to separate the water from the alcohol. (Don't fret, I'm not about to attempt to defend that theory) So, this anti-dehydration factory on my gut is now implicated as yet another "risk factor".

And hey, I'm getting old and there's lots of stuff I just shouldn't be doing any more.

Just now I spoke with my severely mentally ill cousin, who confided to me as I now do to you, that he will be glad when the Lord retrieves him from his hellish life. He doesn't consider himself unhappy or suffering unduly, but he does regard life as less than pleasant, and a good deal of that derives from his sense that mentally ill individuals remain judged for their illness. And that judgement comes most painfully from family.

So, before you judge me, consider that I am probably more moderate of habit than you are. I do very little to excess other than to challenge accepted wisdom. This does indeed sometimes lead me to take certain kinds of risks - social, mental, financial, emotional - which you might not be inclined to take. But by and large I lead a sober and low-key life. Well, apart from my perverse insistence that it's worth the risk to not capitulate.

I'm not drawn to sexual adventures, extreme sports, drugs, debauchery, challenging the law or the Man in any very direct way. You might say I'm plenty boring, although I'd give you a run for your money on that diagnosis. Even those bygone days when I would ride my motorcycle a bit too fast were tempered by a pretty darned reliable agility and judgment. I rode paranoid, which is, more literally, how my cousin lives. It kept me alive. Our Father . . . Hail Mary . . .  I believe in God . . .

But those darned slings and arrows have challenged me quite a few times - especially lately. There was the time Mom tells me that she slammed the door on the doctor making a house call (imagine!!!) when I had scarlet fever. There was a near drowning - amazing that there has been only one considering the time I've spent underwater. There have been the usual near misses on the highways. Sailing mishaps. And then, of course, these ER visits. I feel like I'm leaving out a bunch of stuff, but suffice to say I feel pretty darned lucky to be alive. Not that I deserve any favorable judgement upon any guidance I gave my fate. As if.

You know, when you're in the hospital you are surrounded by an army of devoted and diligent professionals who are struggling mightily to diagnose what happened to you. They desperately want to be able to repair it. But it is also sadly true that the system we rely on is broken.

Each person on the hospital team, when taken aside, will subtly try to earn your confidence by mild expressions of their cynicism toward the system they represent. "The doctors are all in cahoots with the drug companies, and that's why they prescribe the brand names instead of the generic I use myself." "This damned hospital does every test [billable service] in the book [are you a doctor?]/ it's the damned lawyers who force us to practice defensive medicine and do every test in the book." Overall, there is an assumption that the system must be working for someone, but not for me and you, wink wink, nod nod.

Medical diagnosis relies on research, most of which is at its base correlational. Research traces pre-conditions to outcomes. Drugs are developed by massive hi-tech shotguns to ferret out which compounds stick, and then to backfill, without theory, until you have a hit. Research can demonstrate which factors are correlated to which outcomes, and thus I find that I am more likely than most to suffer blood clots by my genetic predisposition. Four to eight times more likely. Yikes!!

But hang on now, I still might live among the vast majority of individuals who never have and never will suffer blood clots, since the vast majority of those with this clotting factor never get them (either!). This statistical fallacy is commonly exposed by those versed in Bayesian statistics. It relates to, but is not identical with, the more commonly understood misinterpretation of correlation with causation. Causation requires a theory. It's no stretch to say that a bullet to the brain killed the person, and similarly that a clot to the brain caused a stroke, but it's quite a stretch to find what caused the clot. All you can do is to mitigate risk and, perhaps, catch the outfall before it hits the mat.

"When I consider the miracle of being alive against the improbability of just me . . . [blah blah blah]" Indeed, the probability of just you being alive is precisely ONE since you are, demonstrably, alive. Where's the miracle in that? The probability of my suffering a life threatening blood clot is precisely one as well, since I've already been there, done that. The alarm goes off and I want to know the probability of number two. I know I'm at greater risk than you are.

Does education as an "input" increase economic productivity because some sort of intelligence is engendered, because individuals are socialized to the system in which they will produce, or because it provides an efficient sorting mechanism according to which wheat can be distinguished from which chaff or according to which roles can be assigned???

I studied these issues for a while, and it's deuced difficult to tease out causation. Fact is that educational expenses as "input" are themselves of dubious value unless you cook the statistics by making the "proper" assumptions going in. Education, like mass literacy, comes along as epiphenomena according to stage of economic development. It's as obvious an outcome as Jerry Seinfeld driving a Porsche, and it sure wasn't the Porsche that made him rich.

Most famously, recently, the commonly and sometimes militantly demanded mammogram was debunked as offering very little to the overall wellbeing of women in America. That's because the overwhelming majority of positives belong to the falsies (sorry) since there are so many more people without breast cancer than with.

I'm oversimplifying for sure, but in the case of blood clots, it should be pretty clear that while I may have to be more careful than you about, say, sitting for endless hours in a car or on a plane, that's not quite the same as to say that the sitting caused the clot. Or the drinking or the stress or the hormonal fluctuations due to over-excitement of the frontal lobes.

(OK, so the sitting probably "caused" the clot, but how many times have I sat for that long without one?)

Misunderstandings of statistics are incredibly useful to sellers of drugs or medical procedures. Why else would the whole world be taking anti-cholesterol drugs? The older we get the longer the list of drugs which are meant to lower our odds of ending up in the ER or cold on a gurney. But they don't exactly address the root cause, nor can they. You can't win if you don't buy a lottery ticket, but buying one is hardly prevention against being accurately deemed a damned fool for doing so.

In the final - sorry - analysis, assigning a cause is identical to assigning blame. Some of us blame people for being black or ugly or gay or credit them for being saintly or intelligent or beautiful, but "congratulations" for your good luck is not exactly how most of us want to be remembered. In the end.

This blame the victim thing is highly functional for our economy, if by that you might mean growth and overall wealth, regardless of its distribution. If something you did or didn't do is the cause of your "condition" then you will pretty much accept those slings and arrows and pay against them. If we can get everyone to both feel good and pay at the same time, then the economy grows and we can rationalize the good of the drug company getting filthy rich. Its principals, I mean.

But consider how the game is rigged. There are plenty of vicious feedback loops built into all our systems. Breast exams are highly lucrative, but I am certain that not a single soul on either side of the transaction is feeling gypped. It seems you feel gypped only if you can't get one. You get the exam, you feel cleared. You give it, you feel virtuous. But you're - da both of ya - just kidding yourself if you think it was a good idea.

It might be a good idea to get a mammogram if you're about to have a procedure which will kill you depending on if you have breast cancer or not. But then you'd be likely to go beyond the mammogram to approach something more like certainty.

What if the procedure you're about to do is the "nothing" procedure to assume that you don't have breast cancer??? Well, that is the least harmful in terms of causation. Cost/benefit analyses really do have to be done against the gaming of our knowledge of statistics by the healthcare industrial complex. Is there a procedure a doctor wouldn't do if there existed a possibility that he could be sued if he omitted it?

These things could be redressed. Pay the patient a portion of the omitted procedure, right? Create a marketplace in body parts, say. Don't make him sign away "rights." Just have him sign away the right to sue based on the omission of that particular procedure.

But how the hell do you educate the patient enough to be able to make the choice? I don't really think you can, you know, and so he's left - I'm left - with the need to trust my doctor. Except that I don't have any "my doctor" anymore in the hospital. I have a team. And the team is, each one, at odds with the whole. Neurologists don't need no stinkin' hematologist to second-guess their recommendations, but I might. Was yesterday's hospitalist the Man, or is it today's? Which one is proxy for my Man on the outside?

And how the hell do we reconcile the fact of our helplessness in the face of those slings and arrows against the implicit or explicit hope held out by our doctors that we might be able do dodge them? How much is the hope worth? And what about the terror during the process of receiving treatments?

* * *

OK, sorry. Too much. I go on and on. There was a nun next to me in the ER and she had come a lot closer to death than I was getting. She had been puking up blood which had been leaking into her stomach, and somehow the result of being brought back into balance was that she would fart like an old nag.

What a relief! For me, I mean, to have a cause for mirth and a proper context for our collective exposure. I almost wish I had her faith in God. But never her patriarchal God of subjugation. You know, just that last Word at the point where all meaning fails. Where finally outrageous fortune takes you home to meaningless sound and fury.

These fates then, how do they do? Wisdom from psychologists reminds us that we may not control the behaviors of those we encounter. We have influence only over our own response. Prepare prepare and respond with poise and equanimity, I guess. Your body will act before you do, although I'd challenge you to find the you in that one.

You can't pay attention to everything and so miraculous coincidence could be something prior to your consciousness sorting and sifting among the miracles you can stand to notice. The ones you see, by definition, have found their probability of ONE. What can you do but smile at them?

We are not so limited as we think by our skin, by other boundaries. Some are terrorized now by the evident fact that we have stripped the earth of all her easy pickings. That our future will be grim once the oil runs out and we have no way to get to the ellusive stuff to power our electromagnetic ways. That knowledge will not matter, that know-how will crest onto the shore of nothing to build with.

And yet we must remain abstracted, eating genetically modified farmed fish, for example, no different from the fatted calf who never could survive in the wild without us. Or can we remain embedded and enriched thereby? Our minds cannot be reverse engineered any more than they were engineered in the first place, you silly anti-creationists you. Context is innered and love is outered. That's all there is an ever shall be. Unless you know how to engender a decontextualized dot. Well, I do, but I've gone on for long enough . . . . .

1 comment:

Anonymous said...

Great post, been looking for something like that =D