I'm not really all that mysterious

war and surgery (a metaphor revisited)

The problem with health care professional talking about the Iraq War is that we always seem to find ourselves with mixed metaphors.

Back when this bogus war first ran up, I was frequently accosted by the comparison of war with surgery. If you run with that, then internal medicine is diplomacy, and attacking Iraq was a little too much like taking a knife to someone and taking out a known mass, never mind that you didn’t really know it was malignant, and that it happened to be encasing a lot of important nerves and blood vessels, and now you’ve got a guy who is paralyzed and is a bloody mess that’s going to take several months before he can even remember how to talk again.

A lot of people feel like it’s really only the surgeons who cure things, and in most cases, this is true. The things that internists deal with are frequently either things that just go away on their own anyway, or things that are incurable. So you can see the big difference in philosophy and mindset.

But besides diplomacy, I think internists are better at letting things go. Meaning, we know how to deal with the end of life. Some people seem to think that death is an optional thing, and we’re here to tell you that there is such a thing as dying well and dying very horribly (not to mention excruciatingly painfully)

So, again, if we use a terminally ill patient as a metaphor for Iraq, well, it’s like the Republicans (in response to those poll numbers, and now, in response to the election results) suddenly realized that their beloved war is not going to make it, and the question is whether we keep going, or if we decide to withdraw.

Most sane internists will tell you that, when it’s clear that the endpoint is going to be imminent death, it’s better to give up earlier rather than later. “Staying the course” when the course inevitably leads to death frequently leads to nothing much more than horrific pain and suffering, for the patient, and for their loved ones. When you go for the full court press, your ribs are going to get cracked, your skin is going to get cooked, and plastic tubes will be sticking out of all of your natural orifices (mouth, nose, ass, even your urethra) as well as some manmade holes (arterial line, central venous catheter, G-tube, colostomy, nephrostomy, tracheostomy, ventriculostomy) This is not a nice way to go. (But go you will.)

You may be lucky and find yourself encephalopathic or otherwise in a coma when you end up in the ICU, but there are actually a good number of people who are completely conscious while being kept alive by machinery, very aware of the plastic breathing tube eroding the back of their trachea, or the rubbery catheter stuck through their penis into their bladder. Can you imagine a week like this? A month? A year?

But I digress. The point was the metaphor. It’s like the Republicans just realized Iraq is in a terminal state. No matter what we do, Iraq is doomed, and it’s just a matter of how many U.S. soldiers get killed in the process.

Like a good internist, I’ve always recommended never trying for extraordinary measures in the first place. The first rule is always “Do no harm” and I think this is a pretty good rule for life in general. But now that we’ve got you intubated and on pressors, the next question is how long are we going to keep doing this? I mean, I’m not going to pull the plug on you unless you say so, but I’ve got to tell you, things are probably not going any better. The longer you stay this way, the more likely things are going to be irreversible. Such are the laws of thermodynamics.

The humane thing to do would be to withdraw from Iraq. Anything more that we try is going to be futile.

The problem is that W is beholden to the religious nut-jobs who don’t believe in withdrawing care (see Terry Schiavo, for instance) even when it’s clearly futile. What a bunch of shitheads.

My heart goes out to the soldiers who have to risk their lives in service of this flatulating dumbass that we call our president.

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