Consumption (53 page)

The societal effect of obesity is now beginning to outweigh technological progress in treating vascular disease: we are fatter than our drugs can compensate for. We have not grown steadily healthier at all, but rather less healthy, less robust, and vastly more indolent—though we have for a time disguised the effect of this with our pills. But the essence of us seems indeed to have changed rapidly and recently. Cars have been widely available to Americans—the fattest of all, and the fastest growing—for half a century, but lately it appears we walk much less than ever we used to. People point to joggers in the park, but they are mere window dressing on the great immobile mass that we have become. For the bulk of us, the truth of our bulk is revealed by the numbers: the incidence of diabetes, adjusted for age, is growing faster than any other lethal illness.

More people in South Africa die of diabetes and vascular disease than of HIV. In Malaysia the prevalence of childhood obesity in 1980 was half of 1 per cent. By 1999, it was 5 per cent—a 1,000 per cent increase in twenty years. In America, it increased from 3 per cent to 12 per cent between 1989 and 1999—a 400 per cent increase in a decade. In most illnesses, and especially infections, these sorts of increases plateau quickly after their prevalence becomes commonplace. But the growth curves for obesity are accelerated. Obese children in America have the arteries of forty-five-year-old smokers. This, despite all the money and technology in the world being thrown at us. Perhaps because of all the money and technology in the world being thrown at us.

A plague is coming to us. Already the sailors in Constantinople are falling ill.

It is important not to distort the matter with nostalgia and sentiment. The Inuit led harder, more painful lives when they lived on the land and this is why they have chosen not to return to it. The children died one after the other and their mothers sobbed with grief undiminished by the regularity with which it was summoned. Hunters who were merely affectionate
fathers, imaginative storytellers, and tender husbands—and not adept trackers and good shots—could not feed their families. It was not a romantic life. It rewarded only a narrow set of attributes: focus, endurance, and distance vision.

And yet. Something about the way we have constructed ourselves now leads us, and anyone who tries to live like us, to immobility and engorgement.

Our habit of staring into lit screens is part of it. But more generally, we have become laden with fear. The young Inuit are withdrawing from the tundra, forgoing even weekend trips in fine weather, to the dismay of their parents. In New Jersey, parents nervously scan the sidewalks and parks, will not push their children out into them, draw them instead into their bedrooms and keep them there with glowing boxes. Fear. And why shouldn’t we be afraid? We have so little experience with genuine peril: all the threats were defeated years ago.

Opiate Addiction

Vascular Access

If mammals moved as slowly as trees, they would not require hearts and the complex web of vasculature feeding into and out of all their organs, their muscles, their always hungry tissues. But because they do sprint, and think and love, they cannot rely on passive diffusion for the circulation of their nutrients. There is a price for needing blood and blood vessels: when we are pierced we bleed to death. No gradual upwelling of self-sealing sap or starfish juice for us. Teeth and projectiles and damaging collisions free our blood to slide into lungs and belly, or out onto the ground, growing crimson beneath our shuddering forms.

When the injured survive long enough for a doctor to treat them, one of the first priorities is to place tubes in the injured person’s own tubes: intravenous cannulae, to pump salt water in, replacing the volume of blood and giving the heart something to pump. The best places to do this are the brachial veins, thick and close to the surface of the straightened elbow. IVs the size of pencils are shoved quickly in, and connected to bags of saline, wrapped in turn by blood pressure cuffs—squeezing the fluid in, optimistically, as fast as it escapes.

But when the injured have bled a great deal, and are in shock, blood pressure falling and the skin mottling, there is too little blood left in the system to distend even the lax veins of the arms, and it is sometimes impossible to insert such tubes in the arms or anywhere. With children, whose bones are still
growing, the right thing to do then is to hammer a hollow metal spike into the shin bone and leave it there. Fluid pumped into the body through this route joins the vasculature quickly through the rich plexus of veins feeding the child’s marrow. Nobody ever does this without the taste of fear in their mouth. Imagine the faces of the child’s parents as you do this. (Imagine the mauling severe enough to prompt it, the shredded tendons, the violation.)

There are people in whom the veins aren’t close enough to the surface of their skin to be felt. Apart from the severely volume-depleted child, there are also the chronically unwell, who have had so many IVs started that all the visible veins have become scarred and nonpatent—cystic fibrosis kids are like this, and patients receiving chemotherapy.

But the most difficult people in whom to establish vascular access are the IVDUs—the intravenous drug users. These are regular attenders of every city emergency room. The same habit of mind that inclines them to stick needles in their arms seems also to put them in the path of knives, at the mercy of infections and in septic shock, requiring intravenous antibiotics and fluids.

Their bodies are battlefields of penetration. The arm veins are dispensed with, typically, within a few years of the habit, and then the feet, the hands, the neck, the groin: all marked by linear puncture scars, tracking the path of this corrosive appetite. Men take to injecting themselves through their genitalia. This strategy is unavailable to women, though pregnant addicts commonly inject the distended veins in their breasts. By this point, the ignominy of the habit has long since become an abstraction. The use of surprising injection sites matters little beside the betrayal of every other single thing in the addict’s life.

There are deeper, larger veins that feed blood directly into the heart, called the central veins—the femoral, jugular, and subclavian veins in the groin, neck, and shoulder, respectively—which form the superior and inferior vena cavae, the vessels that join directly to the right atrium of the heart.

The Seldinger technique is how large catheters are placed in these vessels. A needle is fed under the collarbone, or into the side of the neck, or beside the femoral pulse, as the piston of the syringe is drawn back. When blood flashes
into the barrel of the syringe, the syringe is removed and a wire is fed through the needle. Then the needle itself is removed, leaving the wire in place. A thicker plastic cone-shaped cylinder is then fed over and around the wire, dilating the tissue surrounding these deep veins, and then is drawn back. A venous catheter is then fed over the wire into the vein. The dilator and the wire are then removed, leaving the catheter in place. When it has been placed well, the tip of the catheter will lie just outside the heart.

There are many things that can go wrong with this operation. The lung can be punctured by the needle, causing air to leak into the pleural space surrounding the lung. As air accumulates here, it compresses the lung and the vessels feeding through it into the heart. Suddenly, the already-troubled patient is blue and pulseless and has not been helped at all. A chest tube will then have to be hurriedly inserted into the chest to release the air, but if things were tenuous before, now they will be dire. A problem doesn’t lessen when another is stacked on top of it.

Along every great vein also lies a great artery, and in the initial blind-but-hopeful placement of the needle, it sometimes enters the associated carotid, subclavian, or femoral artery. If the blood is not recognized as being arterial, rather than venous, too bright and too vigorously pulsing, and the procedure continues—the dilator expanding the hole in the artery—this becomes an even more serious problem. If the vessel punctured is the carotid, or the subclavian artery, under the collarbone, then it cannot be compressed while waiting for a clot to form. The right thing to do is to leave the catheter in place and make an embarrassed call to a vascular surgeon, with a view to having the vessel sewn up.

Addicts love these lines. When they are feeling well enough to walk around again, they slip into washrooms and car parks beneath the hospital to inject effortlessly, for once, their preferred balm. This agitates their doctors and nurses, who feel like they are facilitating the terminal process that brought the patient into their care in the first place. At the same time, it’s probably safer for them to inject one of these lines than their armpits and groins. Very quickly, the lines are infected anyway, and must be removed, usually over the objections of the addict, who would leave them in place until the end.

In every large hospital there will be a number of physicians who do not wonder about what motivates people to stick needles in their arms for relief. Vials of morphine and fentanyl and hydromorphone flow through operating rooms in large and poorly counted quantities. Anaesthetists, in particular, develop this habit. Driving home one day, they discover a mislaid vial in their pocket. Clean needles being as available to physicians as bad marriages, they find themselves in their little apartment, surrounded by pictures of estranged children, and they discover relief.

Doctors are the hardest to identify of all the junkies; they do not develop hepatitis and AIDS, generally. They do not share or even reuse their needles. By long training they are fastidious phlebotomists, cleaning and preparing their injection sites. Weeping infected ulcers do not appear in their arms and hands, their heart valves are not shredded by infection, and so they are able to sustain themselves and their habit without such visible damage for far longer than street users. They find their solace alone, in secret, and are thus less likely to have a knife thrust into them by a suddenly agitated friend. They use drugs of known potency, and understand enough of pharmacokinetics that they do not die of overdose.

But betrayal is as much a feature of their lives as it is of the lives of all junkies; anaesthetists administer half-dose narcotics to their agonizing patients in order to have more drugs for their own use. Internists and surgeons write illegitimate prescriptions they fill themselves in pharmacies where they are not known; they rifle through the drug cabinets on the wards where they attend. The only thing about them that is genuinely more pure than other addicts is what they inject into themselves.

They baffle their colleagues, these men and women. Why would they feel such a void that doctors would be inclined to do this in the first place? Look at what they do for a living.

This question contains its own answer. The novitiates of the various priesthoods are the most devout. In some that faith is maintained. In others it isn’t.

The most stressful thing in the world is boredom. Trauma surgeons are not the ones who become morphine addicts. What they do is dangerous and fast and dramatic; they do not get worn down the way the rest of us do, forgotten family doctors in small towns and anaesthetists facing a lifetime of hernia repairs. We are designed to be confronted by difficulties that often surprise and sometimes defeat us. In the absence of that, humans wither. Or rather, they swell.

When I came here I was twenty-seven years old and skinny. Everyone I knew here was as skinny as I was. There was food then too, available at the Northern Store. Canned bacon and white bread and all the things that make men fat. But no one was. I was not yet so lonely, and the families were only freshly off the land, and still spent months at a time out there. Bear maulings and drownings were common.

Now, the people I treat, especially the ones that need me the most often, have withdrawn from the land, and live like my brother and his family do, in Newark. They work under fluorescent lights and eat prepared food, recoiling from imagined dangers with a zealousness that looks each year like simple cowardice. Everyone in town wears a helmet when they ride their quads and the dogs are kept well away, out on the ice. One is not allowed to use a rifle, or even buy ammunition, without a firearms safety course. All of which is reasonable. I do not see the head injuries and the dog maulings that I used to. Many of the young men I know who have good jobs in town don’t even own a rifle. They marry Kablunauk women who worry, rightly, about their children shooting themselves. Together they all waddle in to see me, and together we all talk about how we might control our diabetes better.