October 6, 2021

The headlines today were about the total number of Covid deaths in 2021 exceeding the total number in 2020. It’s not a totally fair comparison. Covid didn’t take hold in the US until March 2020 and didn’t begin to cause significant mortality until April 2020 so for statistical purposes, 2020 was only nine months. We’re now in early October, just over nine months into 2021 when we hit the equivalency mark so we’re actually at roughly the same place. The issue, of course, is that with our continued high levels of willfully unvaccinated individuals, we’re likely to see much higher levels of mortality continuing over the remaining three months of 2021 than we should. Will we see the same kind of numbers in 2022? Time will tell.

We definitely seem to be on the downside of the Delta wave here in the Deep South. Hospital censuses are declining and new diagnoses are fewer. Why is the wave receding? Hard to say. It’s likely multifactorial and may involve slight changes in public behavior in regards to interacting in groups as the wave was intensifying in August. Small increases in vaccination rates might have large ripple effects. There may be climatic issues at place. With luck, we’ve seen the worst of it for a while. However, human behavior being what it is, a general relaxation of masks and social distancing may lead to numbers going back up again as we start crowding indoors in colder weather. Things are certainly not improving yet in the Mountain West and in Alaska where the hospitals are past the breaking point and various triage measures have been put in place to protect scarce resources.

Should there be national standards for such things? Americans are loathe to deny anyone anything once they actually become patients in the health care industry. For forty years now I’ve observed what I call pit bull medicine. The system will sink its teeth into certain complex critically ill individuals, hang on for dear life and shake them until death or payments stop, whichever comes first. It’s become less common than it was several decades ago with the rise of palliative care, hospice programs and other more humane ways of dealing with the human condition but it hasn’t been completely eliminated. When looking around at various regional differences, I’ve always found it most prevalent in Florida and it’s one of the reasons I took the job here in Alabama over several possibilities in that state back when I relocated.

A somewhat related story about relatively recent medical history. In the not too distant past, kidney failure was a death sentence. There was nothing that could be done for someone who had nonfunctional organs charged with processing and removing the toxic byproducts of metabolism. These compounds would accumulate and their poisonous effects eventually overwhelm the body. In the mid 1970s, researchers at the University of Washington invented the first practical hemodialysis machines. Word got around about this wondrous new technology and every nephrologist was eager to have their patients selected for this life saving intervention. It was still experimental and there wasn’t money to produce dialysis machines in quantity so the slots available for patients were limited. How to decide who would live and who would not? A committee was formed. It’s membership was (and remains to this day) secret. It included physicians, ethicists, clergy, patient representatives etc. It was soon dubbed the god committee as patients would make application for dialysis and based on their rankings, some received dialysis and some did not. The federal government got wind of the concept and was upset about the idea of Americans sitting in life and death judgment over other Americans. What to do? The solution was money. Legislation was passed to make the diagnosis of End Stage Renal Disease requiring dialysis an automatic qualification for Medicare and, with a steady stream of revenue now in place, more and more machines could be built and in short order, anyone who needed dialysis could get it. The down side of this is that the profit motive has led to any number of people who other health systems would consider unsuitable candidates for a medical procedure (comatose, end stage dementia etc) to be regularly dialyzed in the American system as there’s money to be made.

I advise my patients in their 80s and above to think long and hard about committing to dialysis as it’s rough on the body, rough on life styles, and rough on families. It’s ultimately not my choice, but theirs and I will support them in whatever they choose. Those who do not choose it, but who will pay attention to diet and fluid balance and the like, will often do just as well and live just as long as those who do. The elder body can often adapt in spectacular ways if you let it and it doesn’t take that many nephrons to keep it going. Doing this sort of counseling, of course, takes time and a good rapport and knowing your patients as individuals. Learning who my patients are and their stories are what keep me interested in my professional life.

One of my rural house call patients died this past week. He was 94 so it wasn’t unexpected but he had been in quite reasonable shape. He had a sudden cardiac decompensation at home and died within 48 hours at the local hospital. He didn’t suffer unduly and he had been independent up until his final illness. He was a long time widower without children who lived in a small house in Jasper. He had a younger brother who would check up on him once a week or so. His next door neighbors were friendly and helped him out when they could. He was quiet and unassuming. We admitted him to the VA house call program about three years ago after a bad fall onto concrete in his carport which served as a wakeup call that he needed a little more monitoring than he could give himself. He was a World War II Vet, having joined the Navy in the waning days of the war. On V-J day, he was in Times Square, 18 years old and dressed in his ill fitting sailor’s whites, walking through the crowd and, through serendipity, he walked into immortality. Photographer Alfred Eisenstead, taking pictures of the revelry, snapped a photo of a kiss that afternoon that became one of the most iconic images of 20th century America and my patient unknowingly was part of it. His goofy grin as he looked at the couple helped make the picture what it was and still is. Rest well Mr. Hicks, I salute you.

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