The Tyranny of Diagnosis

“I don’t know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model is a very difficult question.” (1)

– President Barack Obama, after the death of his Grandmother from cancer related complications, 2 weeks after a hip replacement surgery

Just having read THIS ARTICLE on the NEJM Health Policy and Reform blog, I must say, I totally identify with the issue at hand. Especially since I started working in the Critical Care Unit, I have started seeing more and more people who want to “do everything” for their sick family, sometimes, when even everything that modern medicine has to offer is too little, too late.

I dread having to face the situation where the patient is so far gone that there is little sense in prolonging the pain, but since our hands are bound by law, and the fear of long-term (legal) and short term (physical) retaliation is a reality, we prod on. I remember the 89 year old gentleman, with a HUGE hemorrhage which had wiped out half his bran. He was, of course, totally unconscious, and there was absolutely no chance he could make it out of this. Of course, his family wanted everything to be done, and we did, until a week later, he passed away after we had significantly prolonged his pain trying to “do everything” when there was literally nothing to be done.

This side of the story is very common for us. But the NEJM blog talks of another mentality: “There is a fracture, I have to fix it!” And although it comes from (what I assume is) the pen of an anesthesiologist, it is indeed a brave indictment of all us doctors. For some of them, it is the tyranny of cure, whilst for the others, it is the tyranny of diagnosis.

This obsessive need to “do something, anything” in order to cover up for the fact that there is a lot beyond the purview of medicine and its machines, is a reality we need to face up. It is a difficult thing to do, because,it renders us, our fancy degrees, our immodest machines, all slave to nature’s will. But until and unless we have the courage to face this diagnosis of our own malady face on, and take action, we will be chasing expenses which may have been better spent.

Another practical pointer before I conclude: just the other day, when my unit was already chock-a-block filled, a series of patients were transferred in from Medicine wards because they needed “critical organ support” and it was not possible to manage them in the wards. Out of the four new patients, two were >85 years age, with little, if any chance of making it through (they were, anyways, being blasted with drugs of all sorts to keep their failing organs going). This effectively occupied all the beds and resources we had to offer (meager, considering the large hospital I work in) and we were forced to refuse admission till further beds opened up! It was at this juncture that a call came through from the ER. A 17 year old girl was being taken to the OR for emergency surgery following a road traffic accident and they thought that since there was significant risk to the patient, post-op monitoring in the Critical Care Unit would be needed. I duly informed them that our unit had no vacancies, and put her name on the roster and waitlisted her on an emergency basis: should an opening come up, she was the one to get it.

No openings came up. While that is usually a good thing (because it meant no one died on my watch, but then again, that’s not saying much) just as I was leaving, a call came in from the Surgery OR. 30 minutes post op, the 17 year old girl had gone into shock, followed by a cardiac arrest and she was being resuscitated. They needed her to be put in the unit in order to keep her alive. I had to tell them that there was no openings and offered to go over and help them, since my shift was over anyways. They were cordial enough to say that they could manage the resuscitation, but , there was little point in it. This might sound strange, but because our wards are so poorly equipped, it is not possible to keep a keen watch on the patients who are doing poorly.

Anyways. I walked out with a load on my conscience, though I knew I had nothing I could do. I reached home, and called up the unit to see how things were faring. The nurse on duty informed me three of the new transferred patients had died, and the girl who was being resuscitated in the Surgery wards had also expired.

Lose-Lose, that’s the tyranny of healthcare.


1. Leonhart D. After the great recession. New York Times Magazine. April 28, 2009.


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