“In the Bed”

I know little about human evolution, but my superficial reading in the subject allows me to say that most scholars and researchers assert that at some point we became truly bipedal and spent most of our time standing erect and that was the game-changer.  At that point the humanoid creatures were able to range out of the forest and on to the sunlit savanna of Africa and walk their way to becoming the great predator of  earth. Everything changes. The human hand and brain continued to evolve, the human skin developed intense pigment to protect itself from the sun, and the creature goes north and west.  This is the great walker of the world.

It turns out that we can also consider ourselves to be “obligate” bipedal walkers.  When we do not walk, research repeatedly shows, bad things happen.  Even when you are ill, bed rest is bad for you.  Obesity, diabetes, cardiovascular disease, functional decline, venous thrombosis is all associated with too much “rest’ from the task that evolution has bequeathed to us.  It is sad to reflect that the automobile and the fast food joint are perhaps the cultural guarantors of the modern American physician’s livelihood.

The medical community “knows” this.  Thus when I roam the hospital corridors hither and yon I continue to be perplexed by the fact that our patients are “in the bed.” Observers of this note that the failure to get older patients out of the bed documents the deleterious effects.  They speak about the negative effects of “tethering” patients to intravenous lines, cardiac monitors and urinary catheters, the fall risks we increase by the opiates and anticholinergics we prescribe and the rapidity with which this  “rest’ causes motor decline.

But here widens, once again, the great chasm between knowing and doing.

One of the most important variants of American English is what is called the African American vernacular English.  One of the phrases I have learned and heard spoken only by some African Americans is “in the bed.” I noticed that the phrase had a meaning or implication that whoever was “in the bed” was near death, that if a speaker of this vernacular said, “He be in the bed,” it meant that the person was very seriously ill.  A medical colleague who worked in a hospital in the Deep South and served a rural community of African Americans who spoke this colloquialism told me they would almost exclusively use the phrase for fatal conditions.  Vernacular speech often yields words  layered with meanings.  The message embedded in this phrase has always been for me, “Get them out of the bed or they are going to die soon.”

“The Doll syndrome” is how I describe the condition of many of the patients I encounter.  A few days ago I encountered a patient who had an exacerbation of chronic bronchitis. She was also centripetally obese, had obstructive sleep apnea, tended to be hypo ventilator, retaining CO2 and complaining of chronic back pain.  The medical/nursing approach to treating her was to keep her in the bed for seven days, on IV medications, on a cardiac monitor for which there were no indications and offer her liberal doses of PRN IV and oral narcotics.

Admittedly, it is NOT FUN to get obese patients who are “in the bed,” up on their feet, to stimulate their respiratory centers, to try to wean them off the narcotics amidst their complaints and cries of anguish while beckoning them to return to their bipedal  obligation. It is much easier to treat them like a ragdoll, in the bed, virtually motionless, narcotized and stirring only to order a meal or operate the television by remote.  Yet, PLEASE COLLEAGUES do your job. When I encounter these patients, I am reminded of the famous opening lines of T.S. Elliot’s poem, The Lovesong of J. Alfred Prufrock:

“Let us go then, you and I
when the evening is spread out against the sky
like a patient etherized upon a table.”

These “doll syndrome” patients are close to being “etherized upon a table.” The therapeutic window of ether is very small; a bit too much and the patient “in the bed” is dead.