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renee-mariposa · 1 year ago

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Nothing in my day-to-day job shows me the limits of modern medicine like vancomycin does. And it makes me insane.

(extremely long, somewhat incoherent nerd rant below the cut)

See, vanc is really good at, like, three things: treating MRSA (when given IV), treating ampicillin-resistant enterococcus (when given IV), and treating c diff (when administered orally ONLY). Most every use outside of that, like when it’s used to treat methicillin-susceptible staph aureus for “penicillin allergic patients” (don’t get me started on PCN allergies), actually has data that it increases risk of morbidity and mortality (i.e. harm and DEATH).

Unfortunately, due to the prevalence of multi-drug resistant organisms, vancomycin is empiric therapy for a lot of presumed infections. And it's a lot more difficult to actually tell if someone has an infection than you'd think. A lot of medical conditions imitate each other and when time is of the essence to identify what's going on, the most ethical thing is to start an antibiotic and rule out infection as the hospitalization continues. Lab techniques have gotten a lot quicker: I can remember 8 years ago, it would take 3 days just to identify what microbe the patient had in their presumed infection. These days, anno domini 2023, PCR comes back in a matter of hours, identifying gram positive/gram negative staph/strep/bacilli/etc, and it's the sensitivities that take 2-3 days. (Don't get me started on contaminated cultures.) But even with improvements in lab technique, we might not culture any microbe at all or the provider might keep vancomycin on "just in case" because we don't know IF the patient is infected, WHAT they're infected with, or if the infection will get better with a different drug.

And vancomycin is terrible on kidneys. Extremely nephrotoxic. It isn’t as bad as the 80s when the drug first came out and was called Mississippi Mud colloquially, but it will fuck the patient up if not monitored closely.

But finding the correct dose for each patient in a timely manner is nigh impossible. This is because vancomycin is renally eliminated. We have to mathematically estimate how well the kidneys are working. Unfortunately, our mathematic equation is next to useless if you are:

-Less than 50 kg

-Shorter than 5 foot tall

-Have a BMI of more than 40

-Are an adult younger than 45 (twenty-year-olds get astronomical doses that would be destructive in an older patient)

-Are older than 65 (the official definition of 'geriatric', i'm relatively sure)

-Are female (this is really only applicable if the patient is less than 50 kg or older than 65 - think: little old frail lady - we have absolutely no fucking idea how their kidneys are doing until we order the serum drug level. It is next to impossible to accurately dose vancomycin in little old ladies on the first try.)

-Are missing limbs (lots of leg amputations in the older and impoverished diabetic population!!)

-Have a lot of muscle mass (think bodybuilder or really tall guys)

Fun fact: we estimate renal function by looking at height, weight, age, birth gender (few, if any, studies on trans patients taking HRT), and a lab value called serum creatinine. Creatinine is a byproduct of muscle metabolism, I don't know the fine details, but we can generally estimate how well kidneys are working by seeing how much creatinine is in the blood: low creatinine usually means kidneys are excreting it as they 'should' be. High creatinine means there's something wrong, the kidneys aren't able to excrete it as efficiently as they 'should' be. But the effect of low muscle mass and high muscle mass haven't been studied enough to be able to adjust our mathematical equation to compensate for them. And with high BMI: we often overestimate their renal function because we don't know how to estimate their muscle mass vs their body fat.

(I work out in the boonies. ~70% of our patients have diabetes. ~80% of our patients have a BMI of greater than 35. So what I'm trying to say here is: we are shooting in the fucking dark when we're estimating the renal function of the vast majority of our patients.)

Complicating this: vancomycin is useless until it reaches steady-state concentration in therapeutic range. On one side of this problem: a lot, if not most, medical providers assume that vancomycin starts working its magic from the first dose. So we sometimes get orders for "vancomycin 1 gram now and see how the patient is doing in the morning". That isn't going to solve jack shit! That's just going to increase the incidence of microbial resistance!!

OR, like in the multiple situations I dealt with this afternoon, you make an educated guess on what regimen is going to work for the patient. You get a level 48 hours after the dose starts. And you find out that you fucking guessed wrong and the patient is subtherapeutic. It has been two fucking days and the patient hasn't started being treated for their (presumed) infection yet!! And we've increased the possibility of microbial resistance! *muffled screaming in frustration*

So what I'm trying to say here is: on almost every presumed infection that comes into the hospital (which we're guessing like 30%? 50%? of the time), we're starting an extremely toxic drug, oftentimes 100% guessing what regimen will be therapeutic, only finding out in 2 days that it is not therapeutic, and it can sometimes take days and days to titrate the dose sufficiently to find a therapeutic regimen. And sometimes we're really fucking unlucky and we destroy the patient's kidneys temporarily (or permanently! but kidneys can be very resilient so that's thankfully rare) because we guessed a regimen that's too high!! This is a fucking nightmare!!!!!!!!

And if all of this wasn't bad enough, we don't really have any drugs that do what vancomycin does therapeutically. We have things that can be used to cover some of what vancomycin does, but nothing that's equivalent AND less toxic.

Like, to fix this situation, we need:

-Better education to providers on what drugs are appropriate empiric therapy for different presumed infections (we're working on it, we are working on it)

-Better ways to estimate kidney function (there needs to be more research on kidney function in patients with BMI greater than 35!! And little old ladies!! And patients with low body weight and high body weight and amputations and...)

-Better prognostic tools to tell 1. when the patient is infected (looking at you, sepsis!!!) 2. what they're infected with

-Less-toxic antibiotics AND/OR better ways to treat infection (this would be the evolution of medicine as we know it)

And I want to be clear: vancomycin isn't bad. It's an extremely effective tool when used correctly but we often either don't have enough data to use it correctly or the provider doesn't understand that this tool is fucking useless for the job they're trying to perform.

#some days i'm just smacked in the face by the limits of modern medicine #there is so much we don't know!!!#we're doing the best we can!!!#negativity #personal #us healthcare #i understand other hospitals will have a different experience than this #but my corporation is extremely stingy and we get all the new grads #so educating providers and nurses is a never-ending wheel at my facility #and we don't treat anything complicated except orthopedic surgeries #some days I just get overwhelmed by how little we know #if you can guess my profession on the first try please keep it to yourself i'm trying to maintain a low profile here okay #also if you ask me medical questions don't expect an answer #i was a Cs Get Degrees student all I know i've learned on the job and I don't know shit

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good-to-drive · 1 month ago

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Abuse, Silence, And Why Kevin Can Fuck Himself

I recently finished watching Kevin Can Fuck Himself on Netflix, and, aside from being the most brutally honest portrayal of domestic abuse I have ever seen, I discovered a beautifully written examination of narrative as power and silence as abuse and how this manifests in our larger culture.

Without going into too much detail, the show is filmed in two distinct styles that are interleaved throughout each episode to tell a cohesive story. Allison and Kevin’s relationship as seen by the rest of the world is told through a multi-cam, laugh-track sitcom that depicts a very typical “goofy husband, shrewish wife” mainstream comedy. Allison’s life through her own eyes is told through a single-cam drama/thriller about Allison planning to murder Kevin to escape his abuse.

It’s an absolute masterclass in screenwriting, but more than that, every episode explores the difference between truth, fact, and reality, and how none of these things are quite as much or as little as story. But while the process of transforming the chaotic and plotless reality of life into a story is as involuntary and essential as breathing, misogyny and the degradation of women is just as ubiquitous in our society, and a story that exists at the expense of another person’s lived reality is a refutation of their humanity.

It's also just a great show for anyone who likes to engage with history (or reality TV or true crime or “real life stories” in general), because while we have to tell ourselves stories about her own lives, we have to tell ourselves stories about other people as well. Eternal silence is narrative death, and the perpetual silence of an unspoken narrative is often the last death we can visit on someone whose story we’d rather ignore.

I also pulled up some books – Lolita and Disgrace – that dealt with similar themes, but from the perspective of the abuser. And what strikes me the most is that, across three beautifully written stories about narrative and silence within a culture that normalizes abuse, Allison, who began her story within a state of narrative death, was the only point-of-view character who had any chance of surviving.

One of the main themes of Kevin is that a compelling story is often a story that reinforces what we already believe or like to believe, and while the story may be factual and true it often also exists at the expense of someone's lived reality. The exact same series of events can be a silly joke or a harrowing tale of abuse depending on the lens through which we view it, but historically we've only been willing to see the multicam, laugh track, sitcom perspective on unbalanced relationships.

The alchemical process of turning a series of disjoint facts and experiences into a narrative creates something new and compelling, and erases much of what previously existed. In this way, it’s entirely irreversible. We spin our experiences into a very thin thread, a story we can tell ourselves that elicits something within us, something we need in order to live with the complex, uncertain, and unsatisfying reality of life. In think in many ways the thing we elicit in ourselves is truth. But truth is both more and less than fact, often more a reflection of our own beliefs and desires than the events of our lives. And in telling that truth we may never stray from the facts, but we almost by definition cannot give voice to another person’s reality.

There's a scene in season 2 of Kevin when Allison is hit by a door – a la the classic excuse – because of Kevin’s carelessness. And while he absolutely did not hit her, the way it's written is such an incredible allegory for how Kevin has curated their story and curated their friends' and family’s perceptions of their story such that even if she tells everyone the exact, unvarnished truth of what's happening to her and begs for help, they will only be capable of seeing the laugh-track, sitcom, “Kevin is a harmless goofball and his wife is a total shrew” perspective on the events of their lives.

As so often happens with abuse, their friends and family saw Allison being hurt because of Kevin. But the alchemy of creating a narrative around Kevin and Allison is irreversible, and the series of events they witness can only be spun together to a joke, an accident, a silly, childish mistake. Allison’s reality, Allison’s pain and fear, is completely elided. Like a lost sound in the middle of a sentence, her experience goes silent, and their larger understanding of her relationship never has to change. And you feel so acutely how Allison lives her entire life in that silence.

Storytelling is human, it’s essential, there’s no other way to engage with our own lives. And it’s not lying. It’s never lying to tell the truth. But it doesn’t reflect every reality, either, because another person’s reality can’t be reflected within our own narrative, because that’s what it means to be another person. To spin two different threads.

And because narrative is the essential process by which we understand our reality, denying someone their own narrative, or denying that this narrative be heard, is inherently abusive. To allow someone a voice is to give them humanity, and to suppress it is to strip that humanity away.

Disgrace, by J.M. Coetzee, follows the story of a professor, David, who rapes a student and then fails to protect his daughter, Lucy, from being raped by intruders in their home. He destroys his daughter’s life – not through failing to protect her, but through twisting her rape into a story about why the rape of his student wasn’t wrong. The main theme of the book is generally considered to be exploitation, but Coetzee doesn’t deal with the exploitation of the rape. That’s too direct, too immediate, too easy for the reader to understand as misogynistic and wrong. Rather, Coetzee delves into “the innocuous-seeming use of another person to fill one's gentler emotional needs” (Ruden).

The rape is how we understand David as a fundamentally exploitative person, a person who denies others their humanity by converting them into a vessel for his own desires, who erases their voice in order to speak through them and give himself the things he needs. And that’s how we recognize that the way he absorbs and claims the stories of his daughter and his student is another kind of violation of their humanity. Another way of turning women into vessels for men’s pain and fear and need.

What’s fascinating is that David's student finds her voice – files a complaint against him – and is eventually able to continue with her life. The woman he raped is less damaged by him than his own daughter, because she was the woman he couldn’t permanently silence.

In Lolita, another brilliant novel about abuse, dehumanization, and storytelling, Humbert turns to the reader at the end and says, “Imagine us, reader, for we don’t really exist if you don’t.”

It’s not that Humbert knew he was fictional, but that he knew everyone was fictional. Believed the entire world only truly existed in his own mind, because anything beyond that was irrelevant to his needs. He coped with the collapse of his ability to dehumanize Dolores (who he called Lolita) by demanding that his voice be resurrected. Demanding immortality. Demanding his narrative exist in another person’s world, and thereby be given the existence and humanity that Allison and Dolores and Lucy and David’s student were denied.

Pushing his needs, finally, onto the reader, because we are the only person he has left, and a person like him can only exist through the use of another. In that way, Humbert was powerless. In that way, Kevin and David were powerless, too.

In Disgrace, David’s dream is to write an opera, and at the end of the book he realizes he’ll never finish his magnum opus. He’ll never be able to terminate the process of converting himself, his world, into a story. But he does learn to decenter himself in that narrative. And it’s when he loses all fear of death, and any conception of the self, that he gains the ability to give dogs – who he generally equates to women – a voice within his opera, his life’s work.

It’s in death that we discover our true unimportance as human beings, that we learn to let go of vanity and our conception of the self entirely. And David had degraded women so thoroughly in order to justify how he used them to meet his own emotional needs that it was only in losing all value for his own life that he could gain the ability to see them as equal voices. To actually put those voices into his own life story. It's at the cost of himself that he allows other people to truly exist, in the death of the self that he finally allows the world to exist outside of himself. It’s almost a positive character arc. Almost.

When Kevin finally loses the ability to abuse Allison, he, like many abusers, loses all desire to live. His world was built on a structure of superiority and inferiority, on beings and vessels, on the inherent value of men and the inherent meaninglessness of women’s lives. The system on which he based his entire reality has been destroyed by Allison’s declaration of the self. And, if he was a being because she was a vessel, then in losing the ability to treat her as a vessel, to fully and completely dehumanize her, he has lost his own humanity.

It may be perfectly summed up here: “Become major. Live like a hero. That's what the classics teach us. Be a main character. Otherwise, what is life for?” (Coetzee).

If you’re not to be a main character, if there indeed is no split between major and minor characters, between people and the paper dolls that populate their story, between living beings and the vessels into which they pour their need – what is life for?

Nothing. At least, not for people whose narrative must exist at the expense of another.

And that’s why I say that only a narrator like Allison could survive this kind of story. Despite beginning her story trapped in eternal silence, her reality fully elided no matter how immediate and obvious it became, Allison was the only point-of-view character of any of these three stories who didn’t establish her power through the degradation of another. Who didn’t conceptualize the world via being and vessels. Whose narrative didn’t exist, by necessity, at the expense of another person’s humanity. Whose thread could exist in a larger tapestry without destroying her sense of self.

Don’t get me wrong, she’s not generally a likable character. She’s misogynistic, cruel, selfish, jealous, desperate, afraid, and in pain. Like anyone in an abusive relationship, she’s not at her best, and she’s often pushed to do things that are ugly and disturbing because she’s simply been pushed too far.

But, for me, the power in her character is in how her last scene never felt like a final scene. Her story didn’t have to be killed, her conception of the self didn’t have to be killed, in order to reveal the brutal reality of stories twisting and intertwining without any inherently superior truth or narrative among them. Allison’s story was one of declaring herself. And that’s why it didn’t feel like it ended at the end. Instead, this felt like a beginning.

#this is probably the most egregious 'post that no one asked for' that I've ever written #but man this show HIT me y'all #and then I went back and reread parts of disgrace and that hit me too #it also made me reconsider my online presence and how I myself engage with narrative in the very small little world I'm a part of #I caught some shit a while ago and made a conscious decision to never comment on the narrative around the beatles #and to be clear I was just talking about a general narrative in society at large I wasn't bringing up anything specific or attacking people #more how larger social narratives filter into and sometimes come to define individual stories #but it was upsetting to people and I figured instead I can just try to express a compassionate perspective on the mentally ill myself #but now I wonder if I've gone too far #idk without naming any names I'm getting unblocked by people who should definitely still find my mindset intolerable to their worldview #and I don't blame them because we all have reasons for the things we believe and we're all just doing our best #but it's a canary in the coal mine #it makes me think I've become so focused on not ruffling feathers that I'm tacitly approving some disturbing beliefs #and I think I could have happily ignored that if I hadn't just watched this show #posts that no one asked for #kevin can fuck himself #kevin can f*** himself #op #longer rambles

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