I cannot do it

Rural and remote medical and surgical practice often parachute practitioners into unfamiliar territory. How we land on uncharted ground is a combination of circumstance, preparation,  and courage.

A classic circumstance I recall is that of a ten year old Nepali boy with a badly malunited fracture of the right forearm, which had united so badly he could not bring food to his mouth. He was the son of a laborer who had travelled to our hospital from Nepal, working his way by hoisting loads onto the tops of public buses, a process which took him one and a half months. Arriving at our hospital, he sat his boy down in front of me, the only surgeon here, and asked hopefully  if his boy’s forearm could be fixed.

I have no training in orthopedic surgery. I expressed that to the father and watched his face fall and his shoulders slump. When I asked him what was wrong, he acquainted me with the process of his arrival in Manali. He went on to say that he really did not have much more money or time to take his boy elsewhere and he would now have to work his way back to Nepal, with his boy’s forearm unchanged.  It was my turn to slump.

What can we do when confronted with such situations? It backs us  up against an unyielding wall of social and economic reality. We can either be quite justified by refusing to emerge from  our field of familiarity and practice, or  choose to engage in an unfamiliar arena.

I asked him to return in a few days, and used those days to read up the available resources I had. I found that  Darrach resection, or resection of the ulnar head could re establish pronation and supination, and restore some degree of function to the malunited wrist. I explained to the father that I was not an orthopedic surgeon, but was willing to perform this operation provided he understood the implications and potential complications.  The father consented and his boy successfully went through this procedure, and healed well.

Later, on my meanders through the Manali market,  I passed the bus stand.  I saw  this little boy clambering up the metal ladder at the back of our public buses, carrying the rope his father uses to hoist loads up to the top. They were both working their way back home, and he shot me a grateful smile that will stay forever in my heart. 

Viewed  from the legal and academic perspective, my reach had extended beyond my lawful jurisdiction. I had taken a risk, and included the patient in that gamble.  In this instance, it paid off.  An  unanswered question is what if the outcome was bad? Would a remote practitioner still be justified and validated in his altruistic attempt? How many risks will we take, and how far will our reach exceed our grasp?

Over the years, I hold  to  some truths that have guided me as a lamp in dark places. Altruism alone, is not justification enough for a bad surgery. We cannot gamble with our patients just because we want to help them.  Neither does a rural or remote location warrant substandard or suboptimal  care. If I can deliver a standard of care that the patient would receive at a higher centre, even if that procedure is one that I am unfamiliar with, I would err on the side of attempting it for the patient, rather than refusing to help him or her in the absence of other alternatives.  This entails much reading, soul searching and preparation, personally and for the team delivering this care. It can mean educating the staff in new techniques and methods. It means rehearsing the procedure in your mind and going through this uncharted territory mentally many times prior to the surgical incision.

And what if our altruism causes complications that beset the best of procedures, intrinsically bound within the fibre of disrupting live anatomy? Will not the lurking doubt rear its ugly head with the question “Maybe I should never have attempted this here?” How can we then live with this question?

We remain in these remote regions reluctant pathfinders through the tangled scrub of good intention mingled with delivering appropriate care, touching lives, or marring them, forever. 

Primary Survey, Secondary Survey

The management of trauma has been altered by the introduction of what is now a routine approach, labeled differently in different continents as a trauma management system. In the United States it is called ATLS (Advanced Trauma Life support).  It is a step wise approach that emphasizes the most important things first the next important next, and comes back to the most important things again, a cycle that propels the victim towards a thorough and safe recovery.  These processes are called Primary survey, and Secondary survey. Primary survey includes the following steps:

·      Airway and cervical spine

·      Breathing

·      Circulation

Secondary survey is a head to toe evaluation of the whole person, looking for injuries systematically and dealing with them.

In Christian life, we are often confronted by very confusing and traumatic circumstances in different arenas of our lives. It may be at home, at the workplace, or with our friends. Our responses vary and are patchy, leaving gaping holes and often times regret that we might have reacted differently given a second chance to do so. Quite often the second chance never comes our way again.

An  ATLS approach to these circumstances may give us a chance to react consistently and correctly every time. The reason we “drop the ball” is that we often have not positioned ourselves in a correct vantage point, which colours the nature and character of our reaction.

Substituting some basics into the mnemonic for Primary survey that applies to every one, all the time, every time, it will benefit us enormously if we realize that:

·      A All have sinned. (Rom 3:23). We forget that we are all sinners, and our position is not one of pedestalled sanctity, but as a sinner ourselves, with no other hope of redemption, just like every one we are dealing with. We are in no position to judge, accuse, or condemn.

·      B Blood. Our only hope of redemption and salvation is the blood of Jesus that was shed for us. It was offered to us not because we deserved it or earned it but because He just allowed us to access it by His undeserved favour. (2 Tim 1:9)

·      C Change. The consequence of A and B is that our perspective is forever changed. We cannot look on the world, our family, or our friends ever again in the same way, but have to regard them through the drizzle of blood that saved our lives, rendering a perspective that has to lead us to think of saving theirs. Every action of ours has to have this perspective and focus. Anger, hurt, disappointment and rancour may undoubtedly be justified emotions, but they are always eclipsed by this view, rendering them no less real, but dwarfed by the possibility of grace that can filter through those very emotions to lead us all to remain at the foot of the cross. Our reactions, consequently, will have to be different, despite our emotions.

In trauma, the surgeon has to occupy a position at the head end of the patient. That is the station from where all evaluation is done. In life, we have to remain at the foot of the cross. Any other position or perspective will always yield a warped view of the world, espousing a reality that excludes our own deprivation and degradation, magnifying the warts on those we are dealing with, changing the reality away from the view of the world from our vantage point A.

Secondary survey then allows us to tackle each situation and instance thoroughly, dealing with sin, and having the grace to allow healing, rather than amputating relationships and causing irremediable hurt in the other person.

This will mean that our own capacity to absorb hurt and negative emotions has to progressively increase, a change that has to happen actively only by the ongoing grace of God allowed to work in our lives.