Tachycardia and Other Tales

by Matt Lambert

  And it was the suppressions that got them into trouble early on. The computer misinterpreted the heart rhythm of a young woman who had previously had a very expensive Trisomy 18 baby who had passed away before the age of 2. She went into SVT, which could have easily been treated with adenosine delivered via a mobile intervention, but the computer counted the cost of her deceased child against her spend and misread the tracing as ventricular tachycardia. After her husband drove her to the emergency department where she received treatment, he complained to the hospital and to a friend of his who was a reporter for The New York Times. The subsequent investigation involved the 911 dispatcher, the ambulance company and was getting closer to the insurer. Luckily, the investigative reporter found her “dead peasant” policy before they found out about the CRM. Dead peasant insurance, is where the employer takes out life insurance on their employees, without their knowledge while naming themselves as the beneficiary. Also known as corporate life insurance, it is usually applied selectively to employees who have the lowest premiums and highest payouts, such as women of child bearing age. These policies are illegal in most states and the courts and the media got so distracted by the employer’s policy, and subsequent lawsuit, that they didn’t look any deeper into the practices of the insurance company. There were other similar near misses, but the company was able to pin one on a paramedic with a history of drug problems and another on a mid-level city manager in Chicago.

  It turned out, however, that this new technology was still constrained by the old, basic limitations of a medical test, sensitivity versus specificity. Tachycardia, as described above, is an incredibly sensitive test meaning that it very rarely absent in acute illness. On the downside, it is not very specific. Tachycardia is present in a variety of disease states described above and can also be present in non-disease states. A certain level of tachycardia when you exercise has been part of training regimen goals for decades. The commercial exercise equipment in the gym can track it. Your heart rate goes up during sex or when your favorite team scores late to win the game. Some people have tachycardia at rest. As they iterated on CRM logic, the software developers once again brought in the clinicians, this time to approve certain decisions in real time. To keep an eye on people performing such sensitive work, they required employees to work onsite, in the basement of the Fed building.

  Back in the basement, he popped another Tums by the water cooler and under his breath, he cussed the tomato sauce at Rao’s for once again giving him heartburn. It had been a pretty slow morning and over the last few months, he had noticed that fewer cases were coming up for human review, a sign that the computer algorithms were managing more cases on their own. When he did get a pop-up, he would get a brief description of the case and a computer suggested intervention. He would then toggle to review the heart rhythm and the medical history and, as emphasized by his supervisor, pay special attention to the real time tracking feed before signing off on the computer-generated intervention or selecting his own. He dismissed a young man with sinus tachycardia who was streaming porn. He did the same for a tachycardic woman with a right bundle branch block secondary to her mitral valve prolapse who had checked in at the gym, using her fingerprint, twenty minutes prior. He dispatched a mobile intervention to a 43-year-old father of three who was in atrial fibrillation. He would have selected an active intervention but the natural language processing from the emr revealed that he didn’t feel the palpitations due to his diabetes. He suppressed someone on Phoenix and texted a patient in Portland.

  This part of the job reminded him of the old days in the ER, moving from one acute case to another, and still doing it at this age was the reward for a life lived by doing the right thing. But doing it from a basement and selectively denying care to certain people was his new truth. And truths, like lives, come and go. He reached again for the Tums, but this time he felt nauseous and got diaphoretic. He had been tachycardic all morning. He stood to get another drink of water and maybe some fresh air when he fell to the ground and clutched his chest. He yelled for help and he was sure someone had heard him crash to the ground and knock his chair across the cubicle. In his years as a clinician, he observed that people lose consciousness relatively quickly when dying as if it were some sort of protective adaptation of evolution. He could feel that he was about to go out. The only light he saw was not from the divine, but from the glow of his monitor. With his last thought on earth, he realized that he had been suppressed.

  Her Elevens and Nines

  Once again, she found herself on a city rooftop in the early morning hours contemplating an uncertain future. The morning light was illuminating the surrounding buildings and the top of the Washington Monument in the distance, but the rising sun itself was blocked from her direct view by the steeple. It was very warm for the ninth of November and she was glad to be outside wearing nothing but sweatpants and an old thermal shirt. The streets below were still quiet, there were a few lights on amongst the neighboring apartments, and a plane leaving Reagan National lifted into her view and looked like it was aiming for Venus. She pulled her eyes down from the black, come blue, come orange sky to the metallic gray railing on which she was leaning and continuing on until they met another pair of expecting black ones near her feet. The glare of anticipation from the puppy reminded her why she was outside at this hour in the first place and now that the constitutional deed had been done, it was time for a treat. She pulled the snack from her pocket and slowly lowered it to the French bulldog who lunged up at it just as he was bred to do from the time of English bull baiting. He took the treat to the ground held between his paws and began to devour it while the whiteness of his coat contrasted against the cement floor and the green AstroTurf mats spread about the terrace. The deck had temporarily been converted to a canine latrine used for urgencies until both pet and master were better at a down the hall, down the elevator, and down the block routine. As for other constitutional deeds, through the open door to the apartment she could hear President-elect Trump’s acceptance speech looping on CNN. It had been doing so since she woke up to this new reality just a few moments ago.

  Her memory of the previous night was Clinton leading as the polls closed and then lots of falling. The puppy fell to sleep by the fireplace and then Ohio fell to Trump. She fell next, on the couch with the volume low, and then apparently Pennsylvania, Michigan, and Wisconsin all fell to Trump as well. She fell asleep moderately concerned, but still believing that Clinton and the reasonable among us, would prevail. When she woke, she rolled over to see the red crawler reading “Trump becomes 45th President of the United States” with one eye and the puppy beginning to squat with the other. She scooped him up and carried him upside down (as if the position would overcome gravity and peristalsis) to the deck where his defecation and her contemplation began. Unable to tolerate the tone of the campaign, she had been off social media for months, but a quick check of her feeds made it seem as if the sky was falling too. There were posts and links that looked dubious, but news had yet to be labeled fake and for the time being, a fact was without alternative. She thought of how unprepared the world was for the confluence of demagoguery and social media and how any good populist slogan had to have less than 140 characters almost by definition. Some friends were gloating, some were whining, some crying. Since when did the popular vote mean so much? She knew that it hadn’t mattered much since Lincoln won with 40 percent of the vote as a Republican in 1861. But what did this mean for her future? For our future? There hadn’t been a president this impetuous and vindictive since Nixon. Where was Hunter S. Thompson when she needed him? She found herself strangely, somehow longing for a Bush.

  The only question she didn’t have, that many others on TV and social media did, was if her country was in decline. She knew it was and she knew it long before this morning. She knew the country was in decline because she had been told so, years ago, by her father.

  For the record, her father “hated fucking Americans” and his
lack of response to his young daughter’s reminder that his children were American still lingered all these years later. He and her mother arrived in America via Italy from Poland. When sentiments against the tribe flared up again in 1968, Italy was among the nations offering visas for those who had to leave Warsaw after declining to convert to Catholicism. They left their homeland as permitted by the government with five dollars in their hand and as forbidden, with a fifty in each shoe. In Rome, the father studied. He studied medicine as a means of vocation and advancement, but more so, he enjoyed studying Rome. He studied the art and architecture and sometimes to excess, he studied the wine and food. But it was mostly the history that fascinated him. He studied the ebbs and flows of the republic and the dictators. He learned that even at the height of the republic they would suspend the Senate and appoint a chief executive in times of crisis. He studied the expansion and contraction of the empire. He developed the theory that if the first Western empire went this way, then the rest of them would fall as well, in the order they were formed. He brought this belief with him to the empire of the day when he arrived at the friendly Brooklyn beachhead established by family and friends before him.

  Poland. Italy. America.

  He continued his medical training as the family grew, but his experience in the New World only solidified his Roman blueprint theory. Even though she was mostly focused on ice cream and toys during their time together, she was taught repeatedly on Sunday morning strolls through the park, on trips to the museum, or during three-hour father/daughter lunches that all western civilizations would collapse under the weight of their own bureaucracies. Or more precisely, they would all collapse under the weight of their own bzdura, Polish for bullshit. She was comfortable with this theory before she had her first peanut butter and jelly sandwich, knew anything about baseball, or learned anything about American history. Trump’s election was perhaps an accelerant, but her father also shared with her Newton’s theory that falling things accelerate, and this was just part of the natural order.

  The only thing exceptional about America’s decline, or so the father’s theory went, was that it coincided with the decline of humanity. The parabolic arc of human history was so wide and flat that few had noticed that the best was behind them. But the father noticed it, and like all things he noticed, it was studied. And like all narratives with any staying power, his theory had a mystic quality and was full of either contradiction or divinity, depending on your inclination for religion. It went as follows:

  The peak of human existence occurred when an American king re-claimed his crown, after being persecuted for his faith, in a democracy founded on religious freedom.

  This king was of a descendent of slaves and naturally, a man of color. A Muslim who was marvelously loquacious while being terribly dyslexic. It involved Americans in the heart of Africa, in the remnants of what was once King Leopold’s Congo, at 4:30 in the morning on October 30, 1974. The apex of all humanity was the three minutes of Muhammad Ali’s performance in the fifth round of the “Rumble in the Jungle.” No one before or since has synthesized as many desirable human qualities into such a narrow piece of time while fulfilling their destiny. No one has ever combined such athleticism, beauty and cunning with such a sense of moment, purpose and place. Going into the fifth, when he still found the physically superior George Foreman between he and the title that was taken from him, he summoned the metaphysical. He spent the first 150 seconds of the round using his mind and his mouth to deceive, with an endless stream of trash talk, baiting Foreman into thinking he could win if he only punched harder and faster. He used his body to block these assaults, transferring much of the energy to the ropes on which he was swaying, “rope a doping” back into space and time, and then forward again into the moment. He absorbed blow after blow, which were toxic to his neurons and nephrons, but to which his heart and spirit were somehow impervious. Both were there when he called for them in the final thirty seconds of the round, as he unleashed a series of terrific blows against a fading fighter. Clinching as the bell sounded, Foreman’s remaining spirit was absorbed by Ali’s which was already bursting from the ancestral support of the soil and souls surrounding him in Zaire. Sixty thousand in attendance and millions around the world watching on satellite feed in movie theaters cheered wildly and marveled at the greatness of the “The Greatest.” It is unclear, however, if any of them realized that they were witnessing the pinnacle of human history and Ali, who thought that everything he did was of the ages, acknowledged this feat by sticking his tongue out and winking to his corner.

  The following three rounds were anti-climactic, which was fitting for we were now on the downslope of the fight, the nation and as a species. All three entities now with an imperceptible downward trajectory. Ali, now firmly in control of the fight and of his destiny, worked cautiously to remove his opponent from his path. Foreman fought as bravely as a soulless man can fight, and falling to the canvas was the first step that would lead him, via the route of a clergyman, on a decade long path to competitive and spiritual redemption. After the ten count, many onlookers rushed the ring and danced joyfully without pretense as Africans are prone to do and Ali spoke of prophecies fulfilled during post-fight interviews from the locker room. The victory was so improbable, that Hunter S. Thompson missed the fight, choosing to party at the hotel pool in Kinshasa instead of witnessing what he (and most observers) thought would be at least humiliation, and most likely harm, for his Louisville brethren. The achievement came with such a cost to Ali’s body that he was never quite the same, even in Manilla, and it marked the beginning of the end of fighting career that began with the defeat of a Polish man in Rome to win an Olympic gold medal.

  Poland. Italy. America.

  She realized the parallels paths of the men, even though this was never directly discussed, not even during the many times they had watched the fight together. The father’s appreciation for the achievement was higher than any particular medium and they watched it in many forms over the years. She had watched it on the wall, cast by an 8mm projector, with her head sideways on his knee. She saw it while sitting next to him, on a television re-run or when it was used as a filler for a Wide World of Sports fight stopped short on a Sunday afternoon. She watched it on VHS across the room from him with the menorah casting light on the waning hours of a holiday. Or over his shoulder from the doorway, in the dark, when a case at the hospital had gone bad earlier that day. They watched it together through her tears, posthumously, when Ali died that previous June and ESPN replayed for 24 hours.

  She had the realization that this theory had, in part, prepared her for this particular morning and she glanced down to see that the puppy had moved on to a chew toy and then her mind moved on to that other morning on a rooftop.

  The morning of September 11, 2001 was for her, an extension of the previous night. The evening began with the Jamiroquai show at the Hammerstein Ballroom where the band was promoting the release of 2001: A Funk Odyssey. The opening act, Giant Step, was playing their only US date that year so they went on late and played long. She was there with two friends, Karen from childhood and Sara from college, and she scored in the middle of the trio on the sanity scale at that stage of their lives. The band had moved from the new material to the old stuff and as they started into Virtual Insanity, the ladies made their move for backstage. They talked their way past the security guard as young and attractive women could do before what would transpire in a few hours and a few blocks away. Once backstage, they set up in a prime location in the green room and as it was filling up they drew the attention of the shadiest character of any band, the bass player. After introductions and a few more drinks, they were off to Lotus for the after party. Instead of walking the few blocks up to 38th Street, they rode the limousine with the band and after being escorted through the back door, they settled into a partying pace that allowed them to enjoy all the accoutrements that one should while in New York, in their mid- twenties and in the
last few hours of a less complicated world. Sara, the best adjusted of the three, went home around 2:30 am, but she and Karen left as the sun was rising. Given the hour and her condition, she decided to not go home to her place uptown, but instead to Karen’s place in Hell’s Kitchen for a shower and a quick nap. Karen, who was still attending NYU and didn’t have class until the afternoon on Tuesdays, fell asleep quickly in the bedroom while she tried to sleep on the couch in the combined kitchen/living room, but the neurotransmitter party in her head was still kicking. She showered- first cold, then hot- borrowed a new shirt for the otherwise same outfit, and then walked down 9th avenue to Chelsea Market and to her job at a streaming media company. The start-up company shared the offices at the market with New York One and each morning, every television in the building was showing their programming. It was here, surrounded by broadcasted images of a building ablaze, did she realize that a plane had hit the north tower. The office was a cyclone of human movement and upon entering, she was tossed a lasso of cables, and was directed up the back stairs and to the roof where her company’s film crew had set up next to the New York One team.

  It was a beautiful morning minus all the dying and destruction and the lack of clouds accentuated the smoke pouring out of the World Trade Center. For the first seventeen minutes, those who were there could speculate aloud on motivations, question one another about who saw what, and consider viable theories that this had been an accident. Those operating the cameras, and those sharing that view on television, were spared her rooftop perspective of the vicious deliberation with which the second plane hit the south tower. At 9:03am there were shrieks of surprise and then silent reflections that people have when they realize they are being attacked.