X-Message-Number: 4729
Date: 07 Aug 95 03:08:25 EDT
From: Mike Darwin <>
Subject: CRYONICS: APACHE

David Stodolsky passes along a rather biased and nasty post about APACHE; a 
system developed to guide physicians in decision making about continuing 
care for critically ill people.

>From: Lauren Wiener <>
>Subject: Computerized prognoses for critically ill hospital patients

>The 31 July 1995 issue of _Forbes_ includes an article (pp. 136-7) on the
>products of Apache Medical Systems, which predict patient outcomes based 
on
>a database of "400,000 hospital admittances covering 100-odd diseases.  
From
>these statistics Apache's software can predict patient survival with an
>accuracy that can *sometimes* beat that of doctors' hunches."  [fake 
italics
>mine]

>The software is intended to guide the doctor's choice of treatment.  
Several
>examples are given, include a rather chilling one in which the supposed
>objectivity of the computer is enlisted to coax a husband for permission 
to
>take his wife off a respirator and let her die.  The doctor who founded 
the
>company (Dr. Knaus) is quoted as saying he created the system because "I
>wasn't smart enough to figure out what to do in each situation."  Another
>highlight: "Many hospitals adopted the Apache system to cut costs and
>measure quality in intensive care units."

This is all true and the largest and most cost-conscious medical centers 
have been using APACHe software for sometime.  The evil motives which Ms. 
Wiener attributes to APACHE and which David passes along without comment 
are far from the mark.

I spent 8 years of my life working a critical care environment providing 
hemodialysis (artificial kidney treatment) paid for by the US government.  
During that period I dialyzed many hopeless patients who *begged* me not to 
do what I did to them.  The vast majority of these patients were oriented 
enough to understand full well what was happening to them.  When they were 
not spending time in soft restraints (read = TIED UP) while I and other 
like me dialyzed them, they were incarcerated in nursing homes where the 
food was terrible and the lonliness and degradation were worse. These 
patients were kept on a 1 gram PER DAY sodium diet.  Potassium intake was 
kept as low as possible: no chocolate, no strawberries, bannas, potatoes, 
coffee, and on and on and on.  For reference, a couple of bites of Domino's 
or Pizza Hut pizza would max out the sodium allowance for these patients 
for a full day.  Besides, tomoates are high in potassium and are also 
forbidden.

Meat, alas has lots of protein, and raises blood urea nitrogen so it was 
kept to a minimum too. They could suck on all the hard cany they wanted to 
though as long as it didn't have real fruit favoring and the accompanying 
potassium

Hemodialysis did and does make most patients suffer very unpleasant side 
effects from time to time.  Younger patients tolerate dialysis better than 
older ones.  Terrible cramps and nausea and vomiting are very common side 
effects and virtually 100% of the pts treated experience them at one time 
or another.  Based on my experience through the mid-80's about 1 in 2 
treatments (50%) resulted in such side effects on the elderly and 
poly-diseased patients I dialyzed (i.e., those in whom renal failure wa 
secondary to diabetes, disseminated atherosclerosis, liver failure, etc).  
Many patients suffered agonizing complications from infection, closed angle 
glaucoma (one patient had an emergency enucleation screaming in pain down 
the hall), bedsores, amputations and so on.

One shift of patients we dialyzed simply moaned and repeated over and over 
again "Oh Lord, or Oh my God, or please dear God."  We called this the 
gospel hours (4 hours nonstop)  and our only "defense" was to turn up the 
TV to drown out the noise.

If a patient persistently refused treatment and became agitated 
(read=physically protesting) a psych consult was called and the patient 
(surprise!!!!!) was found to be clinically depressed and thus unable to 
make dispassionate and rational decisions about discontinuing hemodialysis. 
 Vitamin H (haloperidol) was dispensed and the treatment continued.  Many 
patients WERE unable to tell what day of the week it was or who was 
president when given psych evaluations.  This should come as news?  I 
wouldn't know YEAR it was let alone the day of the week if I were in their 
place.  These defects in orientation notwithstanding most of thse pts were 
fully able to tell you:

1) Who they were and WHERE they were (i.e., in a hospital).
2) That they were getting artificial kidney treatments.
3) That these treatments were keeping them alive.
4) That they wanted absolutely no part of such care and wanted to die. Now! 
Period.

Listening to the psych consult go through the standard inventory of major 
depressive symptoms was a joke:

"Tell me, Mrs. Smith (a blind 74 year old diabetic with one leg missing, 
two strokes to her credit and nursing home care with no family who cared 
enough to visit more than once a month or so) are you able to enjoy food?  
What about reading or entertainment....Is there anything that gives you 
pleasure in life?  No?  Well...."

I used to reflect on those questions and the REASONS for the negative 
answers: the reasons were as close to my own special idea of what it would 
be like to be in hel as it was possible to temporally come.  And this was 
before daytime TV (their principal diversion) had sunk to its current 
scum-filled depths.

I frequently have nightmares now, alomst ten years later, of being on the 
dock in Nuremberg.  People are asking me if, on such and such a date and 
place, and at such and such a time, I did not willfully restrain and 
torture and then the names come flooding back accompanied by the faces.

My answer is a vigorous "but you don't understand, I was just following 
doctors' orders!"

I posted this commentary on another medical net and I was flooded with 
letter from people who said they had the same kind of thoughts and had 
voiced to their colleagues that what they had done (and in some cases were 
doing) was a moral equivalent to war crimes.  I, at least at the time, was 
spared this realization in its fullness.  We just did what were told.

What I did to those people was NOT health care.  It was assault.  I have 
had a number of years to reflect on it.  I do not like what I have 
concluded about myself and others, many of them fine people and good 
clinicians with many lives saved and usefully prolonged to their credit.

I try to focus on the good I did.  That even some of the worst off patients 
wanted life and I was able to help give it to them.  Sometimes it was so 
someone could see a gradchild born, sometimes it was because no matter how 
beaten down they were by disease some of them just wouldn't give up, and 
the fight itself became their reason for living.  Most of the people I 
dialyzed (probably 2/3rds) benefited from the treatment, or reasonbly could 
be assessed as having justifiable odds to do so,  and were, on some level, 
thankful for it. 
However, two thousand rights don't undo a thousand wrongs.

Why this digression?  Because what happened to these people occurred 
because the worst of collectivism collided with the worst of capitalism in 
the care of these patients.  The evil of no market feedback or choice in 
collusion with capitalism driven greed.

My perception may be wrong, but I have long perceived David as a 
collectivist, particularly where health care and human welfare issues are 
involved.  I want to tell you first hand, David, that I am filled with 
bitterness and hate at the system that did that to people and that involved 
me in it.  Please understand, for my participation I blame only myself.  
Truth be told, I am not sure I would not do it again if I had to, for the 
benefits it gave me personally.  But that is my moral failing to live with 
and ultimately to be judged by. The price was very high.

In the years since I left acute (in hospital hemo) I have a great deal of 
time to reflect on things, including the choices I made (which, at the 
time, seem like hardly choices at all). I judge myself harshly.  But I 
judge others more so.  I did not create the system, and moral or not, I 
take some small comfort in that awareness. For atonement, such as may be 
had, I speak out strongly against collectivism when I can and when I can do 
so authoritatively.

In the middle 70's through the middle 80's this standard of health care; of 
ordering Granny dialyzed whether she could medically benefit from it or 
not, was driven by the fact that it was "free."  The government paid for 
it.  I watched the End Stage Renal Disease program (ESRD) swell to the 
point that 50K patients were costing 1 BILLION dollars a year in 1980 
dollars to keep alive. 

APACHE is a reaction to the inevitable.  As healthcare costs crept up and 
up consuming more and more of the GNP (last I heard it was over 10%) 
something had to be done.  Since the government was paying the bills and 
the health insurance companies were in-bed with government (indeed mere 
extensions of it in most cases) something had to be done QUICKLY.

Remember the Golden Rule: "He who has the gold makes the rules."  Suddenly 
one morning everyobody woke up and the doctor-patient relationship was 
gone.  Now there are HMOs PPOs, DRGs and a mass of paperwork and 
heirarchies of committes determing the kind of care pts would receive, the 
kind of drugs doctors could prescribe.  I see the effects of this almost 
daily in monitoring the many medical lists I do.  The negative impact on 
care and on physician morale is terrible, beyond words.  And it will get 
worse.

APACHE was a reasoned response to insanity.  To beds being filled in ICU 
with patients who had microscopic chances of even survival outcomes (let 
alone functional outcomes) while other patients with good survival chances 
got delayed or inadequate care.  APACHE came about to help objectify the 
shuttling of patients to "the last bed" where they would die in the ICU and 
where care was minimal, but perceived still to be "Intensive" by virtue of 
the fact that the patients were still in ICU.  It was a semi-free market 
response to asking people to do the impossible:"Here, you, doctor take care 
of all these people, be quick about it, fair about it and do for $100 
each."

I damn each and every one of the bastards that created that system out of 
"good intentions" and unleashed a nightmare.  

So, now the pendulum swings back.  Precious few doctors can afford to 
practice without contracts with HMOs, PPOs and so on, unless they are 
plastic surgeons (and good Dr. Kessler of the FDA towed them into line over 
the silicone breat implants, and bankrupted a couple of fine companies in 
the process without a stitch of evidence that the prouct caused any of the  
illnesses associated with it).  That means that now doctors are forced to 
see patients they do not want to see.  And patients see doctors they would 
not have chosen.  Patients with life threating agitation on a ventilator 
get diazepam instead of propofol because diazepam costs $2.00 a day and 
propofol costs $200.  Never mind the fact that diazepam (Valium) is nearly 
worthless for such problems and further, rapidly loses what little effect 
it has and then causes serious side effects.  Some "suit", as the critical 
care docs call them, up in administration has decided that Valium will be 
the ONLY drug the pharmacy stocks for that use.  In short, the physician's 
medical judgment has been effectively seized by bureaucrats. My only hope 
is that these morons find themselves in the ICU, ET tube down their throat, 
multiple lines in place, blinding pain, and they are paralyzed with 
pancuronium or metubine. Let them see how well Valium works in such a 
situation. (Incidentally, for those of you who are medically naieve, the 
scenario of chemical paralysis of a patient on a ventilator which I 
describe is a common one and is taking place NOW in a large ICU near you).

If only so many (indeed the vast majority) of physicians didn't so RICHLY 
deserve exactly what they are getting I would be even angrier.  But they 
asked for it, begged for.  Never has the admonition "when you sup with the 
Devil, be sure and bring a LONG spoon."


>The article closes with a brief discussion of the ethical issues, in which
>Dr. Knaus says: "If I were [the patient], I would want to be judged on 
Apache.
>It knows only those facts that are relevant to my condition, not race or
>insurance coverage, which have been used to allocate care in the past."

>In other words, the computerized system is good because it is an 
improvement
>over a deeply flawed, inequitable, and racist system?

Racist, inequitable?  Not hardly.  Doctors were no fools in the 70's and 
80's.  They got paid just as much whether a person was black, white or 
green.  They got paid almost as much whether or not s/he had insurance or 
not.  It only started to matter when the money ran out. Until then, 
everybody was an equal opportunity nephrologist.

So, here we are. It's triage time.  The government decides to contain 
health care costs by simply not paying very much for it.  In fact, dialysis 
rates of reimbursements have not even kept pace with overall rises in cost 
of living since I left, and by that time not only were we reusing the same 
artificial kidney up to a dozen times, we were also resusing the blood 
lines (i.e., extracorporeal circuit) which cost only a  few bucks a set. 
Patient ratios had gone to 2 to 1 to 3 to 1 (3 pts to 1 staff) to 4 to 1 in 
out patient.  And in hospital it was not unusual for me, a 
"nonprofessional" to have three critically ICU patients to dialyze at the 
same time. (Dialysis technicians are now, by law, no longer allowed to do 
acute care patients, only liscensed personnel (RNs) are now allowed to to 
this.)

Enter APACHE.  APACHE is much smarter than the average Intensivist in 
predicting outcome.  It's success rate in predicting certain death cases is 
in the 90% plus range.  I am intimately familiar with APACHE's criteria and 
I strongly second Dr. Knaus' opinion that if I were in the ICU I would want 
APACHE to be calling the shots, not just for me, but for the other patients 
who, like me, may need either to be freed of the nightmare of futile care, 
or, given a decent shot at recovery.

Incidentally, I have intermittent access to APACHE via a critical care MD 
friend.  I have run a variety of scenarios through it.  It is highly 
predictive of outcome in the cryonics cases I have data on.  You can bet 
that I will (if I have the chance) be using APACHE to determine cryopatient 
standby response status. And, you can KNOW that I'll be damned grateful to 
have it.

Finally, even in a free market-medical-care-scenario APACHE would come into 
existence.  It would be badly misused many times.  Greed, stupidity and 
countless other human foibles would see to it.  Indeed, capitalism is just 
as "stupid" as collectivism because at the root of both systems are human 
beings.  The difference is that while capitalism may produce a million 
ethical abortions and nightmares, it will ultimately end up focused on the 
more desirable path based on people's real needs, and measured by their 
willingness to pay for those needs.  Collectivism, by contrast, is like the 
Eveready Bunny of the Damned: it is driven to find the most degraded level 
of service people will accept and then go one step further and rely on guns 
to MAKE them accept it.  Once it is in place, it just keeps rolling along, 
chopping up its victims along the way, practitioners and patients alike.

By any criteria, APACHE*could* be godsend.

How it will be used of course is open to debate.  In a system like the 
current one, it will no doubt be misused.  But then, its hard to imagine 
things getting any worse; unless of course you spend time talking to MDs 
fleeing the former USSR who are now working at McDonald's here in the US 
and grateful to be doing so in the bargain.

Mike Darwin

And people wonder why I'm such a beacon of cheer.  As I was told when 
gowing up: "pick a satisfying career and everything else just falls into 
place."


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