© Paramount Pictures
When Star Trek hit the airwaves in the 1960’s it was a sci-fi sensation. It quickly gained a dedicated following almost unheard-of at the time, and when it was prematurely cancelled by short-sighted network execs it was several years before the Trekkies could get another fix, in the form of a feature film sequel inspiringly titled Star Trek: The Motion Picture.
The film was rather underwhelming, but thankfully it gave Paramount Pictures enough confidence in the idea that they went forward with Star Trek II: The Wrath Of Khan. Khan was a real gem and made all the waiting worthwhile, and arguably saved the franchise.
In Khan’s opening sequence we find a Vulcan officer by the name of Lieutenant Saavik (played by a youthful Kirstie Alley) in temporary command of the USS Enterprise. The Enterprise receives a distress call from the Kobayashi Maru, a civilian ship which is severely damaged and stranded in the Neutral Zone. For those non-Trekkies out there the Neutral Zone was a buffer space between the Earth-based United Federation of Planets and the Klingon Empire and was clearly inspired by Korea’s DMZ: any incursion into the Zone by a military vessel is an act of war. Saavik’s choice is tremendously difficult: does she risk war to enter the Neutral Zone to save the Kobayashi’s crew, as mores would dictate, or does she respect the legal restrictions of the Earth-Klingon treaty and abandon the civilians to certain death? Her choice is to save the crew (admittedly an odd choice for an aggressively dispassionate Vulcan). The Klingon response is swift and within minutes a squadron of enemy cruisers appear that beat the Enterprise to a pulp.
At this point we find the entire scenario is a simulation when the walls of the bridge peel back and now-Admiral James T. Kirk steps in to give his assessment of Saavik’s performance. Saavik is disappointed in herself that she was not able to resolve the scenario satisfactorily, but Kirk points out that the simulation is specifically made to be unwinnable. Either course of action will turn out badly. ‘It’s a test of character’, he explains. The caveat to this, though, is that many years before Kirk himself was the only cadet to beat the scenario—by reprogramming the simulator!
The significance of this sequence to the rest of the film is that Kirk soon finds himself in a real-life unwinnable situation, and this time he can’t cheat his way out of it. He pulls it out of the fire in the end (almost literally) but the resolution costs him the life of his closest companion, the ineffable Mr. Spock.
Physicians often are faced with similar situations. Not every time are they flat-out unwinnable, but often one can’t fix one problem without making another one worse (see my post on ‘doing no harm’ here). The trick is to replace an emergency situation that’s difficult to fix, with another, less urgent issue that’s easier to manage. Take septic shock as an example: the systemic inflammatory response will cause all one’s blood vessels to dilate dramatically, and blood pressure will plummet. If something isn’t done about the blood pressure, brain death and multi-organ failure is going to make fighting the infection that started it pointless. So we drive in IV’s and pump fluids just as fast as we can until our poor patient looks like the Michelin Man. This has its own dangers: IV fluids are perfect in the short term but won’t have the right osmolality for proper sustained function of the body’s systems, and the massive fluid overload can back up in the lungs, effectively drowning the patient. But this problem doesn’t require instant action. Now that the patient isn’t crashing, we have time to start oxygen, monitor and add proper electrolytes, and gradually remove that excess fluid as the body starts to restore its own balance.
Another common example is heart failure when there’s also impaired kidney function. I’ve mentioned before the struggles I’ve had trying to reconcile the advice of a heart specialist vs. a kidney specialist. Kidneys love fluids. The more the merrier! They’ll lap up normal saline like a drunk on New Year’s Eve. But hearts? Not so much. They’re intimately connected to the lungs, and like their spongy counterparts they don’t like getting too much fluid either. This is, in fact, the reason the fluids back up in the lungs—the heart’s pumping just can’t keep up. So the heart guys want to wring people out like a dishrag, and the kidney guys want to top them off. Keeping them both happy can be a bit of an artful challenge at times, and sometimes just isn’t possible. Sometimes you have to ding the kidneys just to keep the heart pumping and worry about dialysis later.
Then there are times you just can’t help but completely forgo one thing to save another. A diabetic foot ulcer can get infected very easily (for reasons a little too involved to explain in this post) and if the infection gets into the bone, or worse, the bloodstream, there’s little option left but to amputate. Yes, you live, but like Kirk, you’ve lost your Mr. Spock.
It’s this kind of thing that usually leads to a patient’s demise. Eventually the care required for two problems in opposition to each other diverge increasingly until it’s just not possible to treat both. The interventions are too drastic, the side effects too severe, and we are left with nothing to be done.
Sometimes these opposing health issues are the result of bad genetics. Sometimes it’s from a lifetime of bad decisions. And, unfortunately, at times it’s due to the actions of another person entirely. Whatever the cause it’s important to note a couple things here: first, your health is precious and you should take care of it. The fewer health problems you have the less chance they will compete for attention. Second, sometimes you can do everything right and things will still fail, and that isn’t anyone’s fault. But the flip side is that you should be careful what you are doing every step of the way. There’s usually a lot of space between having one problem being a nuisance, and having two that are trying to kill you.
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