Annals of medicine: The Gone-A-Gram

"Have I got this right? When you reach 80 points, you're gone?"

"Yes sir. That's right."

"But if you have 79...you're still here?"

Young Dr. Harry Crenshaw looked into the faces around the conference table. Why didn't the hospital research committee take his project proposal seriously? The study was valid and clinically applicable.

Maybe his wife was right: He shouldn't have called it "The Gone-A-Gram."

"Your statistics, the numbers, seem fine, son," old Doc Scattergood warned, benignly shaking a gnarled finger at Crenshaw. "But you might have trouble with public acceptance. Will a man understand if you tell him that dear Uncle Mortimer is going to die because he has 83 points, just three over the limit? It's certainly a pity to kill someone for a few lousy points."

"Sir, we won't actually kill anyone," Crenshaw protested hoarsely. "We'll just stop taking care of them."

Charlie Scattergood— who had been around since the days that a surgeon could go to church and take out an appendix in the same suit— twisted in his chair: "Stop taking care of patients, you say?"

Objective indicator

Lance Needleman, representing the Department of Surgery, threw down the remnant of a salami sandwich that had survived three earlier interviews as well as a trip to the men's room. "So you use your computer to terminate care!" Needleman shouted, in a tone he usually reserved for sleep-deprived interns who had the temerity to pass out during quadruple heart bypasses.

"No, that's not what I mean," Crenshaw stammered. "We just use the Gone-A-Gram as an objective indicator of the patient's chances of recovery. When patients reach 80 points they cannot survive. Mortality is 100%."

Burt Phillips, director of Nephrology, had one final question: "Do you ever have double coupon days?"

Crenshaw suddenly realized that he had made no provision for user-friendly methods of introducing patients to the Gone-a-Gram.

"No, sir," he stammered, sweating profusely. "We don't use gimmicks. We just add up the points. One point for every antibiotic after the first two. They're free." His collar was now darker than the rest of this shirt and his tie was a bit spongy. "Add eight points for every week on a respirator and five if your blood pressure falls below 80 for 72 hours. The chart on page 12 lists what you get if your pupils are unequal, if you vomit blood, or if one of your big toes falls off. When you have more than four I.V. lines, you...."

Reason vs. emotion

"That's fine, Harry," Dr. Hastings, the committee chair, interrupted. "We have the full list. But since you don't terminate care at 80 points, what's the purpose of your system?"

Crenshaw explained, as he wrung out his tie, that it was merely a guide to help families make decisions about high-tech studies and other life-saving treatments, such as baboon heart pumps and pig liver perfusion. "If the patient has more than 80 points," Crenshaw explained, "we would tell the family not to do it."

"And, of course, the families listen to that advice."

"No sir," Crenshaw replied, wiping his face with pages 47 and 48 of his report. "That's one problem with the Gone-A-Gram. The families never listen."

"Why do you suppose that is?" Hasting wondered.

Ulterior motives

"I can't say for sure, but maybe at those critical times they react emotionally rather than logically." The committee appeared ready to accept that premise, but Crenshaw continued:

"Sometimes the families have motives that we don't know about. Turn to page 37, for example: the case of Arnold T. Sylvester. He was admitted last August with a massive stroke. His blood pressure was high, his blood count was low and his kidneys shut down when he had 89 points. We told his wife that he would die if he didn't have dialysis, but we didn't recommend it because he had too many points. Mrs. Sylvester said, "'Do it anyway.'''

"Didn't you explain that according to the computer, her husband had no chance of recovery?" Hastings asked.

"We did," Crenshaw replied. "But she insisted. So we did the dialysis. Then a week later, a social worker told me that Mr. Sylvester gets a monthly disability check. If he was dead, he would not be considered disabled, and his wife wouldn't receive the $547 payment. Mrs. Sylvester and his sister Irene need the money. If they can't come up with a sick relative when Arnold dies, one of them will have to find work outside the home."

"You don't mean that he's still alive?"

"Well, sort of. He's all curled up and we can't uncurl him any more. He has a feeding tube, a trach and a pacemaker, and we had to sew his eyes shut to keep them in their sockets." Harry puffed out his chest. "Now he has 477 points."

Nuclear-powered gall bladder

Orville Hastings rolled up Crenshaw's report and tossed it on the table. "Thank you, Harry," Hastings said. "We will announce the winner of the Louis Pasteur-Walter Reed Award in ten days."

As Harry slithered out of the conference room, the research committee members stretched and redistributed themselves among the various reports submitted by the finalists.

"I'm voting for Terry Robinson's nuclear powered, implantable gall bladder," Lance Needleman announced. "It's a great engineering concept."

"Yeah, what an incredible breakthrough," Phillips rebutted sarcastically. "Can't you see hordes of folks lined up to have radioactive pumps shoved under their livers so that they can digest pepperoni pizza?"

"Well," Needleman huffed, "it may not fill an immediate need, but it's a prototype for other replacement parts."

Atomic body-density mass

"Great, just great," Phillips sneered. "Now a doctor will never know when a water-cooled patient might walk into his office, blow up in his face and level the city."

"Burt's right," Hastings added. "We need safe, practical projects like David Tressler's density-mass study. The technology is already in place, and there will be no meltdown or radioactive turds. We've done 50 atomic absorption studies to determine average body density. When we install the new magnetic scanner, we will program it for total body volume."

"But why would anyone need precise body density and volume figures?" Phillips asked.

"That's just the point," Hastings replied, banging his fist on the table. "When you multiple the volume and the density you get the patient's total body mass."

Phillips had heard enough. "You can get the same results by stepping on a damn bathroom scale," he noted.

"If you want to look at it that way, I guess you could," Hastings acknowledged. "You could use a scale if you wanted to stop medical progress. But no one weighs patients any more. And furthermore," he added with a conspiratorial wink, "we can bill $1,200 for each study."

Monkeys as surgeons

"I agree," said McAllister, director of the Genetics Laboratory. "We must never stand in the way of imaginative and profitable technology. But that's why I favor Bergman's project: programming rhesus monkeys to do vascular surgery."

"It'll never work," Needleman insisted.

"Why not?" McAllister asked. "Have you ever watched monkeys pick fleas out of their buddies' ears? They have terrific small motor coordination. Bergman just inserts a computer chip in their right frontal lobe and programs it to direct those muscles appropriately. He's almost ready for a clinical trial."

Scattergood broke in: "How will a patient react when he meets his surgeon and he's bouncing up and down scratching his belly?"

"That happens all the time already," Hastings observed. "Besides, patients and their families almost never meet the surgeons. No one has to know."

"Right," McAllister chirped. "We can hide the cages and put human names on the bills. When you think about it, the thing really does make sense."

"But what would happen if the computer chip slipped and the monkey could only perform orthopedic surgery?" Dr. Bob Reynolds asked. "Technology is supposed to be our servant, not our master."

"That's enough philosophizing, fellas," Hastings reprimanded them. "Time to vote."♦


To read a response, click here.