Every day

Every day will I bless thee; And I will praise thy name for ever and ever.

Every day

The sun rises, bathing the cloud shrouded mountains

Warmly

Birds sing invariably sweet

Breaking

The night black silence

Heralding a new day

Every day

I will bless thee

Enough

Are the blessings

Showered

On me

Thanks

Rising softly

Ever upwards

For your goodness

In the day

Every day

Cycle through

A symphony of praise

Rising

Eternal

Always

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. 

Judas in the shadows

Judas is associated with all that is evil, bad, frail and treacherous. Could we disregard these labels for a while and extend the  grace of considering him as a person?

When we look at life from his perspective, we are confronted with an awful image in the mirror that could very easily be…. ours. Judas lurks in the shadows, not only of history but also in shadows of each of our lives.

• He was attracted to Jesus, and became one of the disciples. He too chose to follow him.  

Each of us has reasons to follow Jesus. All these reasons may not be the right ones. Judas was a Zealot, who expected and anticipated the return of the Messiah as a conqueror, overturning and crushing the Roman  eagle to the Judean dust. Jesus fulfilled every desire and held the key to every promise Judas eagerly anticipated. He surely was the one worth following.

Why do we follow Jesus?

• Is it because He attracts us with ideals that we cherish and resonate with?
• Is it because He holds the promise of better things to come?
• Is it because He has demonstrated His omnipotent power in our puny lives that leaves us without a shadow of doubt that He is God?

While all the above reasons are valid and true, they still are not on the path that leads through Gethsemane to the cross, but are  attractive neon lit signposts on the way to Akeldema, the field of blood where Judas died.

• The means to the end could involve compromise.

Judas held the purse strings of this band of followers, and the Bible records that he often dipped into it himself. (John 12:6)  I am sure he did not start out that way. But after following for a while, one can justify almost anything from an altruistic perspective.  The altruistic perspective dims our vision of the Saviour, blinding us to see dollars in feet being washed and caressed by a desperate love. It attaches an economic price tag to every act of  service, and seeks to tailor all service to extract maximum “bang for the buck”.  Extravagant love mingling with tears and spilling onto a dusty middle eastern floor can only be considered a frightful waste.  Judas said this, not because he cared for the poor, but because he was in the practice of stealing from the coffer. We always need a reason to justify our greed. Those who don’t steal need no reason at all.

• When our idea of service conflicts with Jesus’s we reach a crossroad that leads to Akeldema. The bible records in John 12 that when Jesus sanctified and edified the extravagant worship offered by Mary, Judas left. Jesus’s ideas are often at variance with popular opinion. He sees into the souls of people, and accepts their worship. Such worship may contradict with our ideas of service.  When looked at from an economic perspective, it may not make any sense at all, and may even reek of  extravagance and be a frightful waste of resources. This is the crossroad that leads to self destruction.  We really have  only two choices, either to continue to follow Jesus on His terms by accepting his perspective and altering our  world view, or leave him and continue in our “service”  along our premeditated path.

• It is at such times when we say “We have to do something about it”. Jesus is just not following the road he is supposed to take. He is not filling the seat that is rightfully his. We need to help him. We need to act. We need to manipulate circumstances and people and plan to elevate Him onto the throne.  One sincere thought that Judas might have had in considering so great a betrayal was that “If  I yield Him up to the chief priests then surely Jesus will declare himself, and show himself for who He is.” Judas had no misconceptions on the either the Lordship or authority of Jesus. He knew His master.  But that knowledge did not foster obedience. Knowledge alone is  a faulty compass on the road to discipleship. It is not enough. That very knowledge led him to diabolically betray His master. Was it because on many a smaller occasion earlier, the end had justified the means? Was it because the coins that had passed through his fingers earlier drove the nail through Jesus’s  hands?  Did those earlier unaccounted for red marks in the accounting ledger paint the path to his field of blood?

• So it was with a sincere kiss, that Judas handed the Son of the God of the Universe over to a smattering of soldiers bravely wielding toothpick swords. Judas may have  anticipated a great unveiling, and a glorious ascension to the throne of the world. Our plans, not His.  Our way, not His. Our path, not His. Yet that path shrouded in the midnight hour, was an elusive deception. Judas may have counted on the fact that the Sanhedrin had no authority to kill. They could only judge according to the law. Jesus then had to be set free, and the only thing he could do was to  declare himself as the Saviour, since that was the truth. The path was predictably secure. It was the sure road to success.

• Alas,  as the night progressed, a nightmare awakened, as Judas watched Jesus handed over to the Roman empire. The Romans had every right to torture, maim, lash and crucify. The unthinkable nightmare suddenly was stained with real blood.  The “perfect plan” was out of his hands, and it had run away. There was nothing he could do but watch in horror from the sidelines on the bloody course  of this unwritten script. It was too much for him to take. Deep down, the small compromises had led him to betray the one person he had looked up to and held most dear. He could not watch Him being nailed to the cross, knowing that his hand too, had helped drive that nail into the beam. Judas checked out. He took his life. Judas was truly sincere, but  he was sincerely wrong.  His world had no room for the crucifixion and therefore, was also denied the resurrection.  A potters field is his heritage, even to this day.

Today, our misplaced missions leave Potters fields in our arenas of service, mausoleums and monuments to a life sincerely lived, but which may also have been sincerely wrong. And many a mission is maligned by the stains of blood that lace our life offerings, as we design castles in our vineyards where maybe God only planned turned earth and broken soil.

May God have mercy upon us all to see Judas lurking in the shadows of our lives, and grant us the grace to go to Golgotha, rather than spilling our insides out after a life of service that leaves only a field of Blood.

Take care of me

She held my hand tightly, almost desperately. “Take care of me” she said. She was seventy one years old, and had just survived her first heart attack. She was brought in with severe chest pain and we had thrombolysed her and she had come out of the icu only yesterday. Not anticipating any trouble, I had reassured her that she could be now shifted to a step down ward and probably be discharged in a day or two.  

This was a false prophecy, since a little later in the day, she developed a second heart attack, was put on the ventilator back in the icu and two days later she passed away. I still remember the desperation in that hand clutch. 

Did she know? Could we have known? One aspect of medicine that we are not taught is serependity and the inclusion of “patient instinct”.