Requests » Dr. A

REQUESTS » DR. A.

“Mark, you said «We win or they die?» You and I ‘win’ in some way or everyone else dies?”

“Yes”

“I wish you would say a little more than that.” I am getting pretty frustrated by his terseness. It is not like him to be this terse.

“Yes, either we work out a reasonable solution for the thirty five thousand homeless so they are safe, warm, dry, watered, and fed going into their future, or we don’t. If we don’t, then those homeless will die or live miserable lives. Lives you and most dialysis patients would not pick if given a choice. Lives people would not consider fair if society did not do its best to prevent… and those people ended up with that life because of a coin toss.

So, if we don’t work out a solution for them, I will not work out a solution for the thirty five thousand dialysis patients that are now at risk due to a ‘resource shortage’.”

“There is not a resource shortage related to dialysis. We have been building up infrastructure for decades. There are thousands of clinics and hundreds of thousands of workers, machines, and patients.”

“And how many vampires?”

“Tens of thousands. We discussed this months ago.”

“And which of these ‘clinics’, ‘workers’, ‘patients’, ‘machines’, and ‘vampires’ is the limiting quantity?”

“Vampires are clearly the most limiting, although it takes a while to train workers.”

“So tens of thousands of vampires are doing dialysis for hundreds of thousands of patients. Say ten patients per vampire. What would happen if ten thousand vampires stopped showing up for dialysis”

“They would cease to be. ”

“OK… they would cease to be. But what else would happen?”

“A hundred thousand patients would need to be reallocated to other vampires and clinics.”

“Would that actually work? Have you tried increasing patient-pervampire ratios that high? You would be asking a vampire to spend additional time in dialysis that they don’t need to survive. My guess is that it also does not work: if you could have had fewer super-vampires enslaved for 24 hours every day, I suspect you would have gone that route. It would enable one vampire to support hundreds of patient, so you could have had much fewer vampires, more redundancy, more secrecy, and other benefits. It would not be morally very nice, but I recall you saying «Undead don’t have many rights, including the right to complain».”

“Yes, I am not aware that increasing patient-to-vampire works. It could have been tried but that is above my pay grade. So assuming it does not work, there are thirty five thousand — ”

“A hundred thousand in the current scenario”

“Right. There are a hundred thousand patients no longer getting dialysis. In a few weeks after dialysis is no longer viable for them they will die — ”

“Or a bit longer if they share dialysis with other patients, but that puts more patients at risk. Or maybe you could get a lot of kidney donations?”

“And you have ten thousand vampires willing to die — ” “cease to be”

“ — willing to cease to be, to kill a hundred thousand patients” “No”

“No?” The strange terseness again. A nervous stutter? A power play? Legalese?

“No, I do not have ten thousand vampires willing to cease to be to kill a hundred thousand patients. I have a bit less who are willing to make you save a hundred thousand patients. But those vampires will continue to be. ”

DOCTORS » DR. A

“We could do a marketing campaign to get kidney donors” proposes Doctor X.

“We could convert people further from death” proposes Doctor Y.

“Run the existing vampires for longer? Somehow make it so their bodies can process more waste?”

“Harvest genetically modified kidneys from pigs”

“Switch everyone to peritoneal dialysis”

“Prioritize dialysis patients.”

I wrote each of these proposals on the white board, both to have an agenda and to help anyone brainstorm a new idea. Doctors X and Y were the most vocal, but many of their suggests were murmured by other doctors in the room.

There were twelve of us: like a jury that needs to determine the sentence… the fate… of more than thirty thousand dialysis patients. They were already convicted by whatever caused their kidneys to fail. The obvious sentence was simply death. But hemodialysis can prevent that, if we have enough resources for it. How do we return to the same level of dialysis resources now that thousands of vampires went on strike?

“Let’s walk through these one-by-one and describe their details and characteristics. Starting with ‘donors’ ” I begin for the group. Again Doctors X and Y tend to vocalize what others in the room murmur… their accents were similar enough it was even hard to tell them apart with my back turned to write, so I started to think of everyone as just ‘the room’.

“Donors: Massive marketing campaign to get people to provide one of their two kidneys. Start transplanting kidneys into the pool of dialysis patients. An advantage is we know all this technology. A disadvantage is we only do a few thousand living donor transplants a year. This would be a massive increase in that double donor-torecipient surgery procedure. For thirty thousand patients the cost would be about five billion dollars. It would take years to successfully transplant all of them, assuming a mass willingness of the public to

donate. And we might have to explain to the public why the sudden mass request.” Responds the room.

“I think the last one could simply be a heavier promotion of normal marketing: «people can live longer and better lives with one of your two kidneys… help them with minimal risk to yourself»”

“But that has never worked. We are years behind in kidneys: a dozen people die every day while waiting for a kidney. With the reduced dialysis capacity that could double, and time will solve the problem”

“OK, that is very pessimistic, but I believe I captured all of that on the board. Next, ‘conversion’. Can you explain that Doctor?”

“Hypothetically there may be ways we could increase the pool of candidates for vampiric conversion. Let us call this ‘over-conversion’. There would be no fiscal cost to enlarging this pool, so the only cost would be the vampire conversion itself. What are our current vampire conversion costs?”

“It costs about the same as a liver transplant, so about a million dollars. It is worth it because the revenue of hemodialysis is more than a half-a-million dollars a year per vampire. Over the ‘lifetime’ of the vampire, it is a huge return on that million dollar investment”

“OK. So each vampire costs a million dollars but is worth more like three million dollars as a revenue stream. “

“Except we already had that revenue stream with the current striking vampires” Chimes in Dr. X.

“Right, so we are just recouping a loss. In any case, it is a million per vampire, so it will cost a few billion dollars to do a mass conversion to vampires. And I glossed over the risk of exposure from overconversion. And any costs we want to consider around morality.”

BUTTERFLIES » DR. A

“Next: Run Longer ” I continue, to skip certain issues that might come up with the conversion variation.

“Right.” The room comes out of a bit of a daze: apparently they were pondering the morality question already. “We can run the vampires longer and for more patients if we can figure out how to ‘overclock’ their bodies: make them consume more unwanted elements in the blood stream per hour. Or if we can extend their effective dialysis period, so they consume more elements per session. Either of these would not be a problem if required more blood, because that requirement would be over more patients, as long as the two-to-three tablespoon per patient loss is the same.”

“And you know how to overclock or extend a vampire? Like hard physical exercise or weight lifting consumes more calories for a living human?”

“Uhm. No”

“Anyone?” All the heads in the room went down, up, left, right, and every variation other than looking at me. Sometimes I wish I was talking to Mark: he always looks straight at me during our conversations. A bit intensely at times, like he is trying to see my brain or soul through my eyes, but at least he is focused on me and what I am saying. Not on the chittering of a pretend fly on the ceiling. “Anyone?”

“OK. Next. Sadly, even I know pig-organs aren’t real yet. And peritoneal dialysis has a large number of issues, mostly in that patients don’t like it, but also that it is much less effective than vampiric hemodialysis. So patients will be dying from it in larger numbers and our stats will show something is wrong.” I am pretty sure I know what the next one means, but continue… “Next: Prioritize?”

“Yes. We know we will lose patients, so we prioritize patients based on some criteria. Probably by ability to pay the full cost of dialysis, because we will have less ability to cover those that need help.”

“You are proposing that full-pay patients are prioritized over the equally needy poorer patients?”

“Yes, we need to balance the books”

“This isn’t balancing… you are saying we need to continue to make the same level of profits that gave us millions per vampire vs. keeping poorer patients alive”

“Well… yes. I believe the people running the program will insist on this, whether we like it or not. At least we need to give up profits only as a final measure.”

“Are we actively trying to prove Mark and his vampires are right? Or are we just stupid, greedy bastards?”

“So it sounds like we have to options of: (a) increase donors, (b) expand conversion, and (c) prioritize death… as viable alternatives. I will take this to higher pay grades, but my guess is they will prioritize it as ‘a’, ‘c’, and ‘b’ where we will do all three and use ‘b’ (and I am hoping profits) as a control nob. Trading one almost-past life for several longer future lives seems a very likely approach. Premature vampiric conversion of some for the benefit of the community.” I say all this with military stoicism. Inside I am losing breakfast and every other meal I have had recently. I can feel my left eye glistens from a single tear. Mark would have seen it, but these elite doctors are now studying a swarm of imagined butterflies.

DONATIONS » DR. A

They spent several million dollars hitting the airwaves and social media with the ‘Save a life… give a kidney’ campaign. The uptick in people getting evaluated for donations was noticeable within the first week. More than ten times as many people (two thousand) discussed kidney donation with their doctor or transplant clinic in that week alone than the number of undirected donations in a normal year. That sounds like a pretty effective marketing campaign, but…

Of the two thousand, less than a quarter were allowed to donate. Many of the potential donors were excluded due to health conditions: diabetes, obesity, smoking, and even being physically unable to walk up an incline without getting winded. All of these are good predicters of deadly complications from the physical stress of surgery. Other of the donors could not deal with the financial hardship and potential job loss of being unable to work for four or more weeks. Since this was an elective procedure, it would not be considered a disability and employees would be at the whims of their employer.

Passing any laws to help with the financial issues would likely take years. An executive order would be faster if the president was on board. But both approaches required explaining why we suddenly had a desperate need, and opening the conversation with “We have had an insurrection from our vampires”… would likely be unwise.

So, if we accepted the current acceptance rate, we might get an additional thousand donated kidneys over the next year. More likely this would be much less as the pool of ‘adventurous angels’ (a reasonable term for someone willing to cut out one of their own organs to give it away) went dry. Of the tens of thousands that could die, one thousand would be saved by their fellow citizens and patriots.

VENICE

Cargil ‘mines’ salt from enormous salt flats spread throughout the Bay Area, especially two locations: Redwood City and Newark.

“We will give you Cargil” Dr. A. says with abrupt succinctness.

“You will give us the Cargil salt flats across the 101 highway from where we are standing?”

“Yes, we will give you the Redwood City salt flats to put your homeless people on, in exchange for certain quid-pro-quos”

“You will give us 1400 acres of salt flats, worth a few billion dollars, in exchange for certain quid-pro-quos? What are these ‘quids’?”

“First, the vampires come back to work in California. We will work out how they can both work for us and also do what you call ‘cave dialysis’ if they want, so they do not feel they are slaves to our dialysis clinics. They are simply choosing to work for our clinics in exchange for payment, the enjoyment of helping others, and the wonderful company of their coworkers.”

“OK. And?”

“Second, you and the other vampires don’t mention anything about being vampires, how dialysis works, the details of this transaction, and so on. Consider yourselves under a ‘gag order’. “

“OK. And?”

“Third, you develop Cargil yourselves. No more favors (‘quos’) from the government or the health system. Further, you can utilize only 25% of the land/salt/water as part of that development. We need that for environmental appeasement ‘by the numbers’. You only use about a quarter of the area and preserve the rest.

Further, you develop that 350 acres of human-livable space out of the 1400 acres esthetically and with environmental-awareness. It can’t be ugly. It can’t dump human waste into the water. You have all ‘the best’ treatment facilities and rules for minimizing the human impacts.”

“To make environmentalists and our children’s children happy? OK. The only issue is that development will cost a lot of money. Maybe equal to the value of the land.”

“If you can’t convince people to put in the money for obviously good causes, then you should get out of the game. ”

“OK. Valid point. ”

“Finally, you make sure your development will not flood when sea levels rise. Say: your development can handle an eight-foot rise.”

“An eight-foot rise? As in a ultra-modern Venice? Or effectively a floating city?”

“Yes. We would not like the PR of «35,000 Bay Area residents died during the tidal peak of 2040» ”

“Done.”

“Done?”

“Yes… done. That is a fair offer: a fair contract. It may take me a while getting the vampires to come back, but I suspect you have a bit of work to do on your side as well. But I commit to fulfilling my side of the contract. Consider it an unbreakable vow.”

“You seem to treat everything that way.”

“You know me too well doctor. We can put into the press release: ‘I think this is the beginning of a beautiful friendship’ “

“We already know each other. And you plagiarized that line”

“I am pretty sure no vampire has said it publicly before me… although there are rumors about him being one of the first. Are they true?”

“Above our pay grade”

- 122 -

EPILOGUE

- 124 -

‘El Toro’ and I have been on Interstate 80 for more than a day now: we left New Venice shortly after my dialysis session in our main Voyager facility. The song ‘Jacksonville’ is playing on the radio: this playlist is the one I created when I thought I had to travel several days to Florida for a liver transplant.

Different regions of the United States distribute ‘deceased donor’ livers within that region. Livers can only survive a limited period after the death of the host, so they need to be within relatively short travel times: they need to be in a new host within 24 hours. So there is not a national liver bank because a liver in Boston couldn’t make it to Palo Alto in time. Each deceased donor’s liver has a destination within about a 12-hour travel-perimeter for a patient that is prepped for the transplant upon the helicopter flying it in. Human organs travel in style.

Within a region, liver transplants are not based on a first-come-firstserved or a highest-bidder model. Instead it is based on how needy a patient is, which is calculated as a MELD (Model for End-stage Liver Disease) score. The higher the score, the more and sooner you need a liver. The lower the score, the more time you potentially have before death. It is a little more complicated in that if you get too sick, you can’t handle the transplant. Not exactly a catch-22, but requires luck or sophistication to play the transplant game optimally.

California and Arizona are in Region-5 so all livers ‘produced’ within that region are distributed to patients within that region, with the transplant priority based on the patient’s MELD score, compatibility, ability to be ready for surgery, covid test result, and a few more aspects. Most of these aspects a patient cannot control, or ideally they are making ‘worse’ (as in dropping their MELD score). If you get in better health, your MELD score can drop significantly. So for some there is no hope of getting a liver in Region-5.

My playlist was created when I thought moving to Jacksonville, Florida (Region-3) would dramatically improve my chances of getting a liver. The balance of donors to recipients is dramatically different in Region-3, potentially due to the lack of helmet laws. Turns out crashing a motorcycle into an 18-wheeler rarely harms the liver, nor do lesser injuries like simply tipping your bike over and hitting your head on the curb. To get to Florida would take several days by land, and I expected to drive ‘El Toro’ so I could continue to do hemodialysis along the way,

and would have a car when I arrived. It was a 72-hour playlist, so was perfect for any significant road trip.

Then I became a vampire.

ABOUT THE AUTHOR

Mark L. Fussell lives (or lived) with his wife Rebecca, and two daughters Maya and Katrina, in Palo Alto, California. He makes a living through consulting for companies including Apple, Intel, Sony, and HP. He makes a life through the loving relationships he has with family, friends, and even mere acquaintances. He was a little strange before this adventure, and now he is even more so.

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