The Burden of Medicine on Mt. Kilimanjaro

The imposing mountain of Kilimanjaro in the East African country of
Tanzania stands alone amidst the surrounding flatlands and swallows up the
horizon with its snow-capped peaks. At once alluring and intimidating, its
enormous size provides the kind of thrill and sense of wonder that a child must
feel when it becomes conscious of the seemingly infinite universe.
This impression, I imagine, drove explorers a hundred and fifty years ago to
try to climb

the mountain’s approximately 19,000-foot

peak. In 1861, for example, Baron Karl Klaus von der Decken, a German

attempted to summit Kilimanjaro

with English geologist Richard Thornton. Poor weather prevented the
completion of their trek. A year later, von der Decken tried again, but once more the weather stymied his ascent.
Others made further unsuccessful efforts in the
decades that followed, but in 1889 a German geologist, Hans Meyer, and an Austrian gym teacher and mountaineer, Ludwig Purtscheller, became the first to reach Kilimanjaro’s highest peak.

Since then, thousands have traveled to Tanzania to brave the altitude
sub-zero temperatures and to climb the mountain. A
friend and I, during our last year of
school, were two of those people. We wanted to do something truly unusual, a trip that
would take us as far as possible away from the hospital to a world
we might
never get a chance to see again. It is not unusual for fourth-year
students to take a trip like this — a last hurrah of sorts before
graduation. And, of course, one hopes that after separating oneself
from medicine one would return to the hospital world refreshed,
motivated, and ready to begin the grueling process of residency.

My friend and our guide, about two days before reaching the summit of Mt. Kilimanjaro.
Photo: Aaron Rothstein

One of the most notable aspects of climbing Kilimanjaro is of course
its high
altitude. Because the partial pressure of oxygen in the air
decreases as
one ascends, tissues within the body require higher volumes of blood
to get
the same amount of oxygen. For comparison, at Mount Everest Base
Camp on the Nepalese side (at 5,360 meters or 17,600 feet elevation),
the partial pressure of oxygen is half of what it is at sea level;
Kilimanjaro stands at around 5,900 meters or 19,300 feet. At these
heights the body must adjust to compensate for the drastic
decrease in oxygen availability. During the earliest stages of exposure to
high altitude, the respiratory rate increases to take in more oxygen, the
heart rate goes up to deliver more oxygen to the tissues, and the blood
concentrates oxygen-carrying hemoglobin by getting rid of excess fluid
(this is called

altitude diuresis
 and it is why one urinates more at higher altitudes). Then, if one
spends several months at high altitudes, the body further adjusts by
increasing the number of red blood cells
through the release of erythropoietin,
a hormone that acts on the bone marrow to increase red blood cell

The way exposure to high altitude manifests itself on a step-to-step basis
is remarkable. As my friend and I ascended, it became more and more
difficult to hike. Shortness of breath plagued us at slight inclines or
fast-paced walks. Eventually, at the top, the slow slog felt
like a sprint, our bodies desperately crying out for air. But it wasn’t
just this odd sensation that was new to us. Climbing at these
altitudes comes with certain risks, some of which can be deadly and which we got to experience up close.


The night we began our hike we awoke close to midnight, unzipped
the tent, and stepped out into the bitter cold night air. The
stars playfully glistened in the clear sky reaching out in all
directions. We drank hot tea, ate some porridge, and
headed on our way. Despite the brightness of the moon, we needed
to see the details on the path before us, especially as ice covered
inch of ground. In
the distance we saw other trekkers only by the small lights of their
headlamps, tens of them slowly ascending, enveloped by darkness.

But there was one light that seemed to be getting closer rather than
farther. And it seemed to be trembling, its owner unsteady. It was an
unsettling sight, but we couldn’t keep looking as we were in the midst of trying not to fall, while also sipping water from our backpacks almost continuously so that it wouldn’t
freeze. When we finally managed to look up
again, the light was much closer and we made out two people in the pitch
black: one was a Tanzanian guide and the other was a Caucasian hiker leaning
on the guide for support. As they passed us the hiker slipped, barely able
to stand on his own feet. We turned around and asked what had happened: “He
fell and hit his head and a team is on the way to come help him down,” the
guide answered. It seemed unusual that a head injury would make a patient
this unsteady. But there were no medical supplies, no places
for a med-evac to land, and no oxygen tanks. The only option for the
hiker was to get down to base camp as quickly as possible. So the patient’s guide continued
on, supporting the man as they descended the mountain.

What had actually happened was something far more serious. The hiker had

High Altitude Cerebral Edema (HACE)
. People who live at low altitudes and suddenly ascend are at risk for
this particularly affliction and it can occur at altitudes anywhere
over 8,200 feet. Symptoms initially include altered mental status,
unsteadiness or dizziness, nausea, vomiting, headache, and drowsiness,
progressing over hours to days. With decreased availability of oxygen, there is
an increase in the body’s stress response leading to vessel dilation and
increased blood flow to the brain. Pressure increases within the
vasculature of the brain as autoregulation of pressure is impaired. Fluid
leaks out from the cerebral vessels, creating higher and higher pressures
within the fixed compartment of the skull. With no place left to go, the
brain herniates downward through the foramen magnum
(the hole in the base of the skull through which the spinal cord connects with the brain). This will cause death.

The best treatment for HACE is to descend as quickly as possible to lower
altitude. Supplementary oxygen can help, as can steroids (to
decrease swelling), but these are merely temporary fixes to a deadly
problem. And that night, the climber, with no oxygen, no steroids, and no
chance of descending in time, died from HACE shortly after we passed him. On
our descent we found out the news and even saw his body. A blanket
covered the outline of a human form, still, silent, with no chest rise or

The moment, in some respect, tainted our trip. Was there more we could have
done? It appeared to be a hopeless situation and, in the thick of that
night, gasping for air in the freezing cold as we let the man and his guide move on, we wondered if there was more. Nevertheless, short of helping him down, which would not have happened in
time to prevent his demise, there was no equipment, no medication, no
treatment we could have offered.

Mt. Kilimanjaro, about one day before reaching the summit. Our path took us around to the other side of the mountain before our final ascent.
Photo: Aaron Rothstein

In the 2015 New York Times article
Is There a Doctor in the Marriage?
, the writer Anya Groner discusses her husband’s grueling hours as a doctor.
After he assists with a medical emergency during a plane ride,
she realizes that he is, in some sense, always on call. Work is ever present. Whether there is turmoil in one’s thoughts
about a patient or whether one is being asked advice by
friends or family, the profession demands constant alertness and
preparedness. Even on the slopes of Kilimanjaro, which only a century and a half ago hardly anyone dared to climb, medicine followed us. If we have any sort of
conscience, there is no escaping the practice of medicine. This is why we must
love what we do, but it is also why we must be prepared to live with it wherever we go.

Managing Expectations

“Yes. But could I endure such a life for long?” the lady went on fervently, almost frantically. That’s the chief question — that’s my most agonizing
question. I shut my eyes and ask myself,
Would you persevere long on that path? And if the patient whose wounds you are washing did not meet you with
gratitude, but worried you with his whims, without valuing or remarking your charitable services, began abusing you and rudely commanding you, and complaining to
the superior authorities of you (which often happens when people are in great suffering) — what then?

Fyodor Dostoyevsky, The Brothers Karamazov

I have a collection of idyllic memories from my childhood summers, traveling with family to the sleepy New England town of Lenox, Massachussetts. There we
would go hiking, watch movies, attend concerts by the Boston Symphony Orchestra at their summer retreat in Tanglewood, and swim. And we never failed
to visit the Norman Rockwell Museum in Stockbridge. Rockwell was one of the most well-known American painters
of the twentieth century and some of his famous works appeared on the covers of the Saturday Evening Post. His humorous, sentimental, and occasionally somber paintings capture everyday American life during the early and mid-twentieth century, portraying families eating dinner, children arguing about a basketball game, and teenagers at a lunch counter.

Norman Rockwell, Doctor and Doll (1929)
Curtis Publishing

One painting in particular sticks out in my mind, Doctor and Doll, drawn for the Saturday Evening Post cover of March 9, 1929. A dapper physician in a suit and tie sits in a chair. A young girl in her winter clothes with a hat,
scarf, and mittens scowls at the doctor, reluctant to let him examine her. She’s upset, as so often children are, to be seeing a physician. She holds her
doll up to him as he gently pretends to listen to the doll’s heart with his stethoscope. He plays along with the young girl, earning her trust so that he
can, perhaps, listen to her own heart next. The doctor does not look down at a note or a chart while taking care of his patient. He’s not
rushing to leave. He merely attempts to establish trust and takes the time necessary to earn it. It is the paradigmatic image of what we want a doctor’s interaction
with a young patient to look like, an idealistic portrayal. And Rockwell realized that this was true of many of his paintings. He
once said: “The view of life I communicate in my pictures excludes the sordid and ugly. I paint life as I would like it to be.”

But hyperbole, though an artistic
strategy, is not always evident to children on family vacations. While the Rockwell painting does not
exactly illustrate my expectations of medicine, it does exemplify a certain naïveté with which I approached medical school. I knew I would work incredibly
hard and I also knew, after reading firsthand accounts from several physicians, that I would see horrible things. However, I retained some of that boyish
optimism about medicine and imagined that the majority of my interactions with patients would be as depicted in Rockwell’s painting.

Since then, however, much has changed. I was recently chased down the hall by a psychiatric patient who had a low sodium level (which can lead to seizures).
We needed to get a sample of his blood to recheck his electrolytes, but he refused and when I tried to explain to him why we needed to get labs, he jumped
out of bed and ran after me, saying: “I’m going to f***ing show you how I do things.” Another patient recently told me “I don’t need to f***ing be here” and ran out as I chased after him. I have been called an “idiot” and a “fraud.” I have also been screamed at, given the middle finger, and physically threatened. Yet another patient threatened to report me to the New York Times because his room
was too hot. I have tried convincing countless numbers of patients (sometimes successfully and sometimes not) to take life-saving medications. I
saw a patient fall out of her bed, micturate on the floor, and go into cardiac arrest. Another patient threatened to slap me after I ordered an
EKG to examine his arrhythmia more closely. There have been
times when I have had to choose between spending time writing notes and speaking with patients and their families — and have paid the price for choosing the former. I have performed CPR more times than I’d like to think about. And there is, I am certain, more to come.

None of this is evidence that I have come to dislike practicing medicine. I selectively edited out the brighter episodes to make a point:
medicine is a universe away from what most of us perceive it to be. It is far more dark, depressing, and quick-paced than anything I imagined. It is, in short, messy.
But I believe it has always been this way. Samuel Shem’s The House of God, published in 1978, is a satirical novel filled with familiar yet horrific stories and
bizarre interactions that characterize a physician’s first year of residency. (I’ll write about this book in another post.) That experience of some forty years ago is hauntingly similar to my own. The passage at the beginning of this post from The Brothers Karamazov, completed in 1880, resonates with me as well.

Residency has altered my expectations. Humans have always been sick and will probably always face sickness and death. And sickness and death are deeply unsettling experiences that sometimes prompt strange
and disturbing behaviors. They challenge our youthful notions of invincibility and immortality. They expose our weakness and decrepitude and force us to
confront an end that none of us can face with a straight spine. A hospital lays bare these notions — and the whole experience makes it difficult to be calm, reasonable, and
understanding. Who can be levelheaded in this perpetual twilight?

For that we must return to Rockwell’s comforting painting, a glorified image of what we want from medicine. If we look closer we may see the painting differently.
The doctor has made little progress with his patient. The girl has not removed her hat, scarf, or shoes. She has not yielded one bit. She merely lets her doll be the “patient.” And yet the doctor readies himself to do whatever it takes to help her. Almost imperceptibly smirking, he patiently listens to the doll’s
chest. He is not angry or frustrated but sympathetic. Perhaps we can face the daily frustrations of the hospital better with some of that Rockwellian spirit to strive for life as we would like it to be.

Opioid Overdose in the Emergency Department

Image via Shutterstock

I had just finished introducing myself to the resident when the EMTs wheeled in a patient on a stretcher. The patient’s face was completely pale and expressionless and his eyes were closed; his hair looked disheveled and unwashed. He wore tattered jeans, a soiled white t-shirt with holes, and white sneakers with untied shoelaces. His age, according to the EMTs, was 34, but he looked as if he were 50, with a sagging face and prominent wrinkles that no 34-year-old should have.

Other than this, we knew nothing about him. An anonymous person had called 911 and reported that this gentleman was “not awake.” This is not uncommon, as many folks who get into gunfights or use drugs do not want to be caught by police, and associate the medical profession with the law. As further contribution to our complete ignorance, the unconscious patient could not tell us what had happened.

Moreover, he was apneic, which means his breathing rate was dangerously slow. Without adequate oxygen intake, his heart and brain
would perish. As I wrote about in my post on running a trauma code, one of the most important aspects of a patient’s care in the ED is the airway — physicians ensure that the system that takes in oxygen works. With diminished breathing, this patient needed oxygen. Thus, the ED resident rushed to set up tools for intubation: sticking a tube down the patient’s throat to provide a space for oxygen entry.

When a patient like this comes into the ED — unconscious with no clear history — the ED physicians give the patient a few basic drugs that can save his life. These therapies target the most common causes of AMS (altered mental status) or total lack of consciousness. One therapy is glucose or sugar administration. Hypoglycemia (low blood sugar) can affect a person’s mental status. The brain primarily uses glucose for its processes; without glucose, it starves, leading to unconsciousness. One of the other therapies is naloxone, also known as narcan. Naloxone is an opioid antagonist, a term that describes its inhibitory actions at opioid receptors in the nervous system. Opioid agonists include drugs like morphine and heroin that cause sedation and respiratory depression. Naloxone acts quickly to reverse these effects in patients who overdose on opioids.

A fellow student and I watched as the attending physician injected a dose of naloxone into the patient’s IV. The patient shot up in bed, trembling, sweating, and breathing rapidly, his eyes wide open. That’s the catch with the agonist and antagonist relationship: because their effects oppose each other, their manifestations also oppose each other. While opioids sedate, naloxone stimulates. The patient screamed at the nurses and physicians and threatened them. He hurled expletives at the healthcare staff and swung his arms at the nurses while demanding to leave the hospital, as spittle flew from his mouth.

The reason, as the attending ED physician explained to the patient, that they kept him in the hospital is that naloxone has a very short life in the body’s system and wears off in about an hour. But some opioids can be long-acting; ergo, this patient could become dangerously sedated again once the naloxone wore off. And he could not, given his mental status, make individual decisions for himself. The patient continued to thrash around until a police officer from another part of the ED came over. Not surprisingly, the patient calmed down.

Watching this elicits mixed emotions. What if this person did become more violent? Would I actually need, physically, to defend myself from this drugged individual — a man who clearly has little sense of what is and is not reckless and harmful? And then there’s sympathy; how unfortunate that such a young person could fall into a life of drugs. Further, what will his fate be? Will he ever give up using drugs? I also could not help but find it humorous that as soon as the police officer came into the room, the patient calmed down. The law and its enforcers have a potent effect, indeed. Lastly, this was an incredible physiologic feat of saving someone’s life using a drug with an antagonistic molecular construction — another wonder of modern medicine to put on the list of scientific achievements.

We may soon witness scenes like this in a more public sphere. The wonder that is naloxone is currently being distributed to police officers in big cities to use on people overdosing on opioids, according to The New York Times. The same thing is happening in New Jersey, too. Government agencies are responding to a rapid increase in the use of opioids: “Gov. Andrew M. Cuomo committed state money to get naloxone into the hands of emergency medical workers across New York, saying the heroin epidemic in the state was worse than that seen in the 1970s, and the problem is growing.” Of course, this is not going to rid us of addiction, but it will certainly save lives. And as the New York City Health Commissioner noted of naloxone, “It’s really quite miraculous. Anyone who’s ever reversed an overdose will never forget it. People wake up.”

Are “Hostile Wives” Too Cool Toward Science?

I recently reviewed Chris Mooney and Sheril Kirshenbaum’s book, Unscientific America: How Scientific Illiteracy Threatens our Future. I note the shallowness of those science-policy arguments that pretend that the issues — like embryo-destructive stem cell research, or proposals to mitigate climate change — are purely scientific and that disagreement over them results chiefly from differing literacy in and enthusiasm for science.
Transhumanism, of course, has inherited much from the ideologies that spawned this scientism, and so falls prey to it as well. Consider a recent example from that reliably credulous disseminator of scientistic tropes, Michael Anissimov.

A few weeks ago, the New York Times Magazine published a feature article on the men who want their heads chopped off and frozen when they die, the women who love them, and the marital strife that results when they both keep at it. Attacks of spousal common sense are, of course, a barrier to icy immortality, and so cryonicists safely package them up and stick them on a shelf with the label “hostile-wife phenomenon.” The article explores the bizarre and often sad features of romantic relationships of cryonicists, and focuses on one couple in particular, prominent transhumanist Robin Hanson and his wife Peggy Jackson, who happens to be a hospice worker.
Anissimov, writing about the Times article, bundles up “hostile-wife phenomenon” even more neatly: “My explanation for the phenomenon is pretty simple: gender differences in enthusiasm towards science.” Okay, but “enthusiasm for science” — if we do truly just mean science — means enthusiasm for empirical facts and the discovery and understanding of them. But the article makes it sound as if Ms. Jackson is as curious and intelligent as her husband, and as well-informed of the empirical facts of cryonics. How can her differing enthusiasm for cryonics then be a matter of differing enthusiasm for science? Might there be something else at stake?
As the article notes, her hostility to the idea is “rooted less in scientific skepticism than in her personal judgments about the quest for immortality.” It continues, “Peggy finds the quest an act of cosmic selfishness.” “[T]o be rocketed into the future — a future your family either has no interest in seeing, or believes we’ll never see anyway — is to begin to plot a life in which your current relationships have little meaning.” Indeed, lending some support to her judgment, the article notes that Robert Ettinger, the father of cryonics, advised his followers in the late 1960s, “Divorce your wife if she will not cooperate.”
Ms. Jackson’s level of enthusiasm for science itself can’t explain her differing judgment from her husband on the good and bad of cryonics.
(In fact, notably and rather hilariously, the first commenter on Anissimov’s post was Robin Hanson himself, and, though he falls for the same trope, he does so by way of succinctly countering Anissimov’s argument: “Women are actually more enthusiastic about most medicine than men. Women go to the doc more often, and push men to go more often than men push women. So this isn’t about women not being as pro science.”)

Peter Singer’s utilitarianism increases human suffering

They told you life is hard, Misery from the start, It’s dull, it’s slow, it’s painful. But I tell you life is sweet In spite of the misery There’s so much more, be grateful. -Natalie Merchant
Peter Singer recently published a New York Times blog post seriously posing the question of whether the human race should allow itself to go extinct. Most of the post is built around the arguments of philosophy professor David Benatar, author of the book Better Never to Have Been: The Harm of Coming Into Existence. Singer writes:

We spend most of our lives with unfulfilled desires, and the occasional satisfactions that are all most of us can achieve are insufficient to outweigh these prolonged negative states. If we think that this is a tolerable state of affairs it is because we are, in Benatar’s view, victims of the illusion of pollyannaism. This illusion may have evolved because it helped our ancestors survive, but it is an illusion nonetheless. If we could see our lives objectively, we would see that they are not something we should inflict on anyone.

There is a simple riposte, of course, to anyone seriously claiming we should not exist: one simply need note that no rational being is capable of posing such a claim, for once he believes it, if he is fully consistent in his conclusions and convictions, he should immediately kill himself, and so never have the opportunity to communicate the argument. Of course, I’m not suggesting that extreme utilitarian philosophers should kill themselves (though one could consider their existence as a special sort of suffering), and the fact that they don’t do so should be the first indication that something is amiss in their arguments. They live, like the rest of us, based on the notion that their lives are worth living, even though they are uniquely incapable of understanding that they are and why.
Even the most hardcore of evolutionary psychologists can agree with the notion that an organism that has lost the will and drive to continue its own existence is deeply sick — indeed, not just sick, but suffering from sickness. And it is a sickness of the highest degree, overwhelming as it does the most fundamental imperative of any organism or rational being: to exist, to maintain the prior condition for any state of goodness, joy, or wellbeing. We consider this true for animals so ill they have ceased to eat; and we consider it even truer for human beings who are suicidal: over and above whatever suffering has caused their state, we understand the state of not wanting to live to be itself a profound form of suffering — literally, the deepest form of existential despair.

Nietzsche said, “He who has a why to live can bear with almost any how.” So, also, he who has no why to live cannot bear with almost any how. Walker Percy claims that postmodern man “has forgotten his bad memories and conquered his present ills and … finds himself in the victorious secular city. His only problem now is to keep from blowing his brains out.” Singer et al. turn this problem into the explicit question of why we shouldn’t, and when it exposes the gaping vortex of nihilism at the center of their philosophy, they attempt to divert our gaze with posturing of bold discovery and heroic honesty.

What we risk suffering from most deeply is not the physical anguish that concerns the utilitarians, but the very existential despair they so eagerly prescribe. By defining the value of our lives as simply the absence of physical suffering, philosophers like Singer may actually markedly increase human suffering. Not only does their philosophy provide an active reason for people to be suicidal, but it commits extreme utilitarians to arguing that the profound suffering of being suicidal is itself good reason for the suicidal to go ahead and commit suicide. (Notably, I know of no utilitarian philosophers who have had sufficient confidence in their convictions to openly advance such an argument.)

It is indeed a profound loathing for most of human existence that undergirds Singer’s philosophy. At the end of his post, he poses the question to the readers, “Is life worth living, for most people in developed nations today?” Though Singer allows, both here and in the conclusion to his post, that life is under the right circumstances worth living — presumably, under circumstances similar to his own — it is apparently taken for granted in this question that life is not worth living for people in undeveloped nations. And it must be even more taken for granted that life was not worth living for the thousands of generations of ancestors to whom we owe our own (at last potentially worthwhile) existences. Posterity, then — the accumulated infliction of the suffering of existence by each generation on the next — must be an injustice of unthinkable proportions.

It is in this understanding of the meaning of posterity, of course, that Singer most profoundly misses the worth of life, as available to today’s poor and to our impoverished ancestors as it is to affluent college professors. As a commenter on the Singer post, Pierce Moffett, puts it:

Maybe most normal people enjoy their lives to a greater extent than the typical philosopher does. It wouldn’t surprise me. I don’t know about you, but I’m glad I’m here. I have unfulfilled desires, but I have also had a great deal of enjoyment. I experience a few minutes of profound joy every morning when my 5 year old gets out of bed, comes to my office, and crawls up into my lap for a still-sleepy hug — and by having her, I’ve made it possible for her to have that joy herself someday if she has a child of her own. This sort of utilitarian, weigh-everything-on-the-scales approach is the worst sort of academic pseudo-philosophical nonsense.

As a philosopher, Dr. Singer is surely aware that the notion that [the] world is getting worse every year has been around among philosophers for a very long time. But out in the real world, people do the millions of things they like to do — from roller skating to playing computer games to solving differential equations to flying hang-gliders … and many of these things we love to do involve our children.

The Singularity is Near the New York Times

In case you missed it, the New York Times recently published a front-page (ask your parents) business-section article on the Singularity. The article is actually remarkably unremarkable. It narrowly explores Kurzweil and the Singularity University, but it’s pretty credulous and uninformative. Science writer John Horgan more or less accurately characterizes it as an “enormous puff piece.” It’s notable mostly just because it’s a lengthy piece in such a prominent venue; conferencegoers mentioned it frequently and with excitement at the recent H+ Summit at Harvard, just because it was a piece in the Times.
But there were a couple wonderful anecdotes in the article, such as:

One executive sullenly declines to participate in another robot design exercise because no one in his group will consider making a sexbot.


Daniel T. Barry, a Singularity University professor, gives a lecture about the falling cost of robotics technology and how these types of systems are close to entering the home. Dr. Barry, a former astronaut and “Survivor” contestant with an M.D. and a Ph. D., has put his ideas into action. He has a robot at home that can take a pizza from the delivery person, pay for it and carry it into the kitchen. “You have the robot say, ‘Take the 20 and leave the pizza on top of me,’” Dr. Barry says. “I get the pizza about a third of the time.”

Macaulay Culkin had better luck with this sort of thing in Home Alone with a VCR (ask your parents again).
And here’s one that’s just sad on several levels:

Sonia Arrison, a founder of Singularity University and the wife of one of Google’s first employees [and a senior fellow at the Pacific Research Institute, and an H+ board member], spends her days writing a book about longevity, tentatively titled “100 Plus.” It outlines changes that people can expect as life expectancies increase, like 20-year marriages with sunset clauses.

Sunset indeed.