番茄社区app

If you take acute-care physicians aside these days, and get them to open up when they're weary, you'll hear a common thread. It goes like this: "Everybody is just so sick!"

Sure, that's our job. But people seem even sicker than ever -- which is ironic since medical science has come a very long way, even in the three decades I've been at it. But I believe there's a connection between our advancements and the worsening plight of our patients.

We seem to have transcended our ability to provide care for significant numbers of the population. Maybe a better way to look at it is that physicians often seem to be dealing with a whole new kind of biology; a whole new pathophysiology of Homo sapiens.

What do I mean exactly? Let's look at some examples of the plights of the modern man.

Cardiac interventions have saved countless lives. Men and women who would have perished from a heart attack get stents placed in occluded vessels and go home. But sometimes their cardiac function is compromised and their heart muscle and heart rhythms can be difficult to manage.

We have patients with obesity who are sometimes too large to put into CT scanners and who are very difficult surgical patients. Even examination can be difficult. Understanding the physiology of a person who has extreme obesity can be challenging at best. Dosing their sedation, their antibiotics, and their antihypertensives is tricky.

Some of our patients have liver disease, both alcoholic and non-alcoholic, which also requires a delicate balance of medications to keep them alive. Meanwhile, the ammonia that they cannot process makes them confused and agitated, but their blood pressures may be too low for sedation.

Drug abuse has ravaged generations, and in particular the injection of fentanyl and methamphetamine cause complicated infections. Our smaller hospitals are often out of their element -- lacking infectious disease specialists, cardiac surgeons, or neurosurgeons -- but find themselves unable to transfer these patients because every other large center faces the same population and is overwhelmed.

To make it worse, these patients have often exhausted all of their IV access, requiring central access. But, send them home with a permanent IV port and they are at risk of injecting their drugs of choice. These patients are notoriously septic but too often leave the hospital early because of the affliction of their addiction.

Without psychiatrists, and sometimes with them, we have no idea how to manage the complicated interaction of mental illness with assorted drugs, including everyone's darling, marijuana. What will marijuana and its assorted products do to health in the future? It's hard to say but I predict more schizophrenia, more heart disease, and more cancer from those who smoke it. And the potential effects of street drugs on those with underlying mental illness (and other diseases) are wildly complicated.

Of course, all of this is complicated by the addition of new medications, which can be great in their own right, but which have side effects and interactions that we're only just seeing and understanding. GLP-1 agonists are a great example. Hardly a week goes by that we don't see complications, as well as successes, with this class of drugs. Meanwhile, immune modulators are widely prescribed for autoimmune disease. And honestly, who isn't on a potent anticoagulant? They're like vitamins for older adults.

I could go on and on. A reader of another column of mine described our patients now as living "on the knife's edge of homeostasis." I couldn't have said it better.

But there's another factor here. Our hospital systems -- in particular those administrations that hoped to make great profits -- have run into a wall. The patients they wanted have arrived in vast numbers. But they are so sick that they cannot stay out of the hospital long (and this is despite the financial punishment for early readmission, which patients apparently ignore when they're sick.)

These patients are so complicated that their care demands enormous resources in staffing and material. And after a while, they are out of money, or their insurers can scarcely afford what the patients need.

So, using my long-dormant zoology degree, I realized that we've almost created a new species. Humans are known as Homo sapiens, thinking man. But we seem to have rapidly transformed a subset of our population into Homo infirmus, sick man.

Or maybe better, Homo fragilis, fragile man.

Homo fragilis is increasingly dependent on a healthcare system that can barely provide people, drugs, space, or equipment. The pandemic illustrated this, but future struggles will make it more evident. How long will Homo fragilis survive without a constant flow of resources and the constant attention of armies of physicians, nurses, and others?

Homo fragilis, at least as a diagnostic category, begins earlier and earlier in life and often results not only in a tribe of people dependent on medications but also, "relying on the kindness of strangers." No, maybe better put, "demanding the kindness of strangers." These individuals require food, shelter, medication, affirmation, and often money from others because they cannot function in the wild. I'm not being mean; the causes are legion, from poor family structure to mental health challenges to social media. But fragility is everywhere.

Maybe this is why our shifts feel so overwhelming. Maybe this is why my young colleagues already have that look in their eyes and are considering real estate licenses and storage facilities as a way out of the profession they were assured would make for great lives.

They're practicing traditional medicine on an entirely different, nontraditional kind of human being, in a system that never expected such successes and never planned for the survival, complexity, and in some cases, poor health (through bad luck or bad choices) of those dependent on it. None of this was covered by or .

My colleagues and I are now held to a standard of care, and an expectation of medical success, that we were never prepared to face. And we're doing it in a system that planned for profit and isn't up to the task at hand.

Welcome to the land of Homo fragilis, where all of the old rules of biology, the old ways of medicine, and the business of healthcare are slowly fading away, and nothing works the way it should. I hope we can figure it out before it's my turn on the stretcher.

A version of this piece was originally published on Leap's blog, .

Comment