Is Ignorance Bliss?

Ignorance is bliss, the much acclaimed adage we have been hearing, reading and listening a lot since our school days hardly holds true in this era wherein the generation next is practically reeling under a seemingly endless explosion of knowledge; information and technology that has been transformed in a dramatic way by the advent of high speed internet enabling you to access or rather get joyously entangled into the world-wide-web right from the cozy comforts of your luxuriously cushioned bedroom. The amount of information available today has reached such mind-boggling proportions that even the present generation of readers is virtually clueless about which information to harness and which one is to be best left alone.

The people of the generation of our parents would never thought even in their wildest fantasies that they would be witnessing an information revolution of such an enormous magnitude towards the twilight of their life and careers as well, so much so that many of them are hesitantly unwilling to learn how to operate these intelligent digital machines or the hand held/ palmtop gadgets which have now come to occupy a very important part of the shrinking urban super-nuclear families in their day to day lives or rather hour to hour life schedules; just because they probably are anxiously uncomfortable with the idea of having such massive amount of information virtually on their finger tips, is ignorance really bliss ? , Doesn’t seem to be true any more!

But, as you voyage a few miles into the rural hinterland from any metropolitan city of our transforming incredible India, the above axiom probably still holds true. My parent medical school had a pretty similar location, about 69 km from the largest metropolitan city of central India – the Orange city. The hospital caters primarily to the rural population of Maharashtra and also of the neighboring states such as Madhya Pradesh, Karnataka, and Andhra Pradesh; the patient population constituted primarily of daily laborers w­orking in their landlord’s fields; which since ages have been infamous for self perpetuating history of untimely droughts, poor crop yields, famines, mass suicides by the farmers and so on. This made me staunchly believe that like we humans do, lands must sure be having a destiny of their own, which in a pretty congruent manner influences and gets influenced by the destiny of human beings inhabiting that particular piece of mother Earth. As the very same state has a green flourishing southwestern region which has fortunes just opposite to this poor counterpart of hers and I could never ascertain the reason behind

A major problem that a non-maharashtrian doctor had to tackle while sitting in the out patient department was the substantial language barrier, which is so obviously inevitable when you are encountering patients from four different states in the Indian Republic where the dialect changes faster than the speed of the wind in these relatively barren lands; a true testimony to unity in diversity slogan summing our Nation’s obvious strength with its inherent weakness. Your conscience just does not allow you to get away by making some imaginary “can’t get you signs” in the air above your head to a patient whose language you fail to comprehend beyond a meaningless clutter of words, moans and groans that were never registered with the comprehension center of your supposedly best available grey mater in the country. This patient who has come to see you after purchasing a train ticket from the earnings of his last fortnight, still not sure whether the job he has just relinquished would be there for his taking when he gets back to work again; travels twelve hours in the general compartment of a passenger train crowded beyond its capacity with his wife and kids – as there was no one to take responsibility of the kids in their absence; has two big jute bags one housing the cooking apparatus and other the family beddings both at the moment were supporting the back of his wife, whose lungs were heaving suspiciously hard for her young age.

She was sitting on the floor with hands folded and tears trickling down her eyes, with her two children innocently looking up in absolute confusion towards you, probably trying to figure out something of a white coat demigod in his most animated forms they probably had ever seen, meanwhile vigilantly supporting their mother’s splinted right lower limb with their tender hands meant to play and explore; just because there mother is in pain and a patient who got well at this hospital has in very good faith sympathetically recommended the family to visit this department where supposedly the doctors are from some outer world and can treat probably anything and everything that comes in their way that too at a very meager cost. “Now you have a situation out here, doctor” I mumbled to myself; already feeling the heat of the vertical sun in the tropical summer noon of the year 2002 coupled with an emotionally and academically challenging situation that I unexpectedly found my self into. The lethargy resulting from the lack of a tight previous night’s sleep, which till now was bogging me down had also suddenly stepped back, as if to allow me to summon all my thinking cells into action.

Suddenly a man broke from the queue and stepped in front offering to help me in a seemingly helpless situation, saying that “I can understand some part of this patient’s language and would communicate that to you, sahib”. After some deliberations I reached a conclusion about the history and examination and related the same to my consultant. This twenty eight-year-old female about a couple of months back had fractured her right proximal region of the thigh bone just by twisting her right lower limb while working in the fields; this area of the longest weight bearing bone of the lower limb, femur; is known to give way only when subjected to tremendous forces which are usually encountered in the settings of high velocity road traffic accidents. After about 8 weeks now, the radiogram done at our hospital of her right femur showed a break in the cortical continuity of the sub-trochanteric region that was not showing even the slightest attempt towards healing as if some unknown chemical mediator in her blood circulation had issued stern ‘not to work’ instructions to the ever working bone forming cells as regards to their osteoblastic (bone forming) activity. Only a glance towards the radiographic film was enough for the trained eyes of my consultant to exclaim “Oh Boy! She seems to have a pathological fracture!!” I was in my first year residency programe and was very much impressed by the clinical expertise of this Orthopedique chirurgien. The patient was advised admission in the Orthopaedic ward to ascertain the pathology that had rendered one of the strongest regions of the femur so very weak at such young an age, such that it was more than obliging to split at the slightest hint of the twisting forces that usually would have playfully and innocuously traversed the bony trabeculae in this region and is now just not willing to unite as if some stealth diabolique process was probably unabatedly eating into the very integrity of the broken femur and her spirit as well.

She was urgently admitted, all the baseline blood tests were hurriedly run, an ECG and a chest radiogram were also requested keeping in mind the background whining of her lungs laboring hard for that breath of fresh air that seemed to consume a lot of her energy and was in effect was exhausting her of the meager energy resources that she now seemed to possess. Every effort was made to make her comfortable on , she was helped into loose clothes, a couple of pillows were placed behind her back that helped to prop her up in order to assist in her fight to suck in each vital puff of air, an oxygen cylinder with nasal catheters fixed to her nostrils delivering the seemingly divine gas with every breath she was taking, an intravenous drip hydrating her with some essential electrolytes, glucose, water and some bronchodilators mixed in it with an aim to relax the already pressurized airways and a urinary catheter placed to chart out her output. Blood counts expectantly revealed alarmingly low hemoglobin level, raised renal function parameters which correlated with her clinical status; a thready pulse, low blood pressure, tiny droplets of sweat shimmering on her forehead and the urine bag was empty despite the amount of fluids being administered intravenously since last one hour. A wet X-ray film that was made readily available on request, on the very first glance confirmed what we have been hesitantly expecting; there wasn’t a trace of healthy lung tissue visible in any corner or zone, every inch of the vital lung tissue had been ruthlessly invaded by the white fluffy patches indicating wicked infiltration by that very evil process which probably had also halted the bone pieces form reuniting themselves. The patient was deteriorating with every passing minute; those pleading eyes, drooping eyelids and half visible eyeballs gave an impression as if a black tired sun that had lost most of its fire was preparing to sleep somewhere deep into waiting arms of horizon and soon the curtains would forever be pulled down on the show, ironically challenging the so called demigods of the human race, but probably it was too late in the day to save a life that desperately hoped to live for her innocent couplets and a doting but poor husband.

The primary focus of cancer, the devilish force responsible must have strategically started somewhere inside the body, but does anyone know where? There were now only some possibilities hurriedly jotted down on a piece of white paper under the heading of differential diagnosis daring you to investigate them, but do we have sufficient time to undertake an elaborate combing operation? What is the priority, zeroing onto that primary process just as a part of the so called standard treatment protocols, just to make you feel elated Yes, yes, yes! Now we know the evil resident in her body that had rendered her and us so damn pathetically helpless or just to be humane enough to impart limitless care with utmost sympathy for the fighting spirit trapped in a tired body being egged on to fight a losing battle, a stage where they might be parting forever? How and What should be explained to the patient’s desperate husband, that a bone had broken in her thigh (which he obviously was aware of before us); and that is soon going to die, when he knows for God’s sake at least that fractures don’t kill and that We as bone specialists at a such a big hospital are in fact are as helpless as he is? How is he expected to understand what is killing his beloved wife who was apparently fine till a week back except for a deformed thigh, when we as the so labeled master clinicians and bone setters have no collective clue of the culprit except some black theoretical possibilities on white? Is ignorance really bliss? I really still don’t know, it is very subjective, very situational, I suppose.

Had he knew this was going to kill her; what other things he would have done to reverse the verdict? Where possibly had he erred in providing her with an adequate and appropriate care, which she humanely deserved? What would have been the scenario in case he had reached the hospital steps a week or two earlier? He will think this for all his life and keep cursing himself. He probably was wishing now, that had he earned more money than he was now, or if the same person who had advised him to bring his wife here would have told just ten days earlier?

Caught in a tug of war between my conscience and probably his, I was painfully brought back to harsh reality when suddenly the panic stricken shout of a nurse pierced the calm but chaotic female Orthopaedic ward, “doctor she is gasping, please come fast!” I dashed immediately to her bedside, screening the entire corner bed from the stare of dozens of curious and hopeful eyeballs, as probably nothing in this world attracts more attention than a human tragedy! With beads of sweat on her forehead, my fingers reflexly but frantically searched for her weak radial pulse but no pressure was recordable, there were few drops of urine in the bag and her tired lungs had probably given up at last as she lay still. Her stillness was punctuated only by shallow but painful gasps sucking in a little puff of air, flickers in finger muscles and valiant attempts to open her tired eyes to take one last fleeting glimpse of her beloved family; all these ominous signs were being interpreted simultaneously yet differently by various persons; by them as her willpower fighting to live against the conspiracy of that unknown yet powerful, drowning natural force and by us as a clinically impending end of human life.

In these circumstances my consultant advised DNR – “Do Not Resuscitate” protocol to be followed, as in such cases wherein a systemic pathology conquers and exhausts all the energy resources and the compensatory processes in the body as well, the attempts to resuscitate are obviously doomed and in fact the resuscitation only painfully prolongs the end for the spirit, the body and the relatives as well. Contrary to what it means, the decision appears unethically remorseless to the ignorant onlookers; and I had a feeling that this probably was being interpreted by the husband and onlookers as a negligent lack of effort on the part of doctors or are they also a part of the conspiracy? Is Ignorance really a bliss or is it not?

To digest this happening from any of the infinite points of view in the space probably is not the easiest; but again there is no denying the fact that such situations precipitate in life with recurrent inevitability. The answers are apparent, science has its own limitations and humbly accepting them should not make one weak but all the more strong, as it knocks onto our conscience that we are not just by ourselves, that we are a infinitely miniscule part of a seemingly endless single vibration, Universe, that connects us all and then there are designs that this universe secretly plans and conspires as well; but with all its energy is at your disposal, its you only who can realize this and no one can make you feel or talk you into this. Though I had never believed this and one premise, when ignorance was a pleasurable bliss for me, which had propelled me into this noble profession was the glamour and magical high of miraculously raising the dying or the dead like a phoenix; but is ignorance still bliss for me? No! Not now, it doesn’t seem to, wait or may be it still is; as I am still in the infancy of this amazing journey of discovering the not so apparent feeling that the world that exists outside you is finitely limited than the world that persists inside you, is beyond your craziest and wildest imagination ever.

Nothing is Absolute in this World, be it Science or be it Religion, be it Information or be it Ignorance, be it Love or be it Hatred, be it Profession or be it Passion, be it Aspirations or be it Introspections; actually nothing I feel can ever come close to being absolute other than the delusion of unidirectional totality that the term ‘Absolute’ itself represents. Everything is extraordinarily Relative with respect to Time, Place, Person and Situation and yet no one can introduce you to the relativity of this Universe, except You yourself, and that too certainly not with your material aspirations but with honest spiritual introspections slowly but surely over time. As you voluntarily make an effort to try and get gradually but irreversibly addicted to this divine yet scientific art of introspection, you will require tremendous patience and time as well but till such time let ignorance prevail within You and let it be a bliss at your own peril.

The League of Extraordinary Surgeons...!

After about a month of completing my postgraduate training in Orthopaedic surgery at India’s first rural medical college, whose foundation stone was laid by none other than our late Father of Nation himself; I joined a multi-specialty hospital owned and managed by the Asia’s largest corporate health care provider situated in the capital city of the Indian Republic . As could be anticipated, I was taking my own sweet time in coming to the terms with a diametrically differing set of circumstances, both at home as well as at the hospital. In the spring of 2004, on a sunny Friday morning while I was on routine ward rounds with my consultant, he told me that after the rounds we would be seeing a patient referred to us from the surgical specialty for a wound on finger.

There was this elderly gentleman lying lazily on a propped-up bed with bandages wrapped on both the arms, legs lying like logs of wood with intra-venous drip hydrating him leisurely, wrinkled loose skin with visible, subcutaneous hemorrhagic patches covering his limbs but still he was managing to flash a welcome smile through his visibly tired face. Looking at all him, I barely expected a heavy confident voice emanating out of his rough, rusty throat to greet us straight in our faces – “Hello! How are you doctor”? The consultant had some patients waiting for him in the out patient department, so was in a bit of hurry; he engaged the patient in talks and asked me to quickly wear gloves and examine his right index finger. This finger had developed osteomyelitis (infection of bone) of middle phalanx secondary to some soft tissue injury sustained years back and had been operating all these years with an ulcer sitting on it. The bone was wickedly glancing at us through a chronically painful, foul-smelling and non-healing ulcer at the inner aspect of the finger.

The decision to amputate that chubby right index finger was obvious in those circumstances; this was elaborately communicated to the patient; as if he had been discreetly anticipating the same, promptly came the question, as a form of reaction, barely expected by us whenever we take such decisions – “So, when can we do it, doctor?” The consultant addressed his query and left asking me to dress up the wound nicely. I completed one of the most gentle dressings of my lifetime and was about to say bye to this old man when he interrupted my thoughts by saying “sit down for a while, son”, feeling very hungry I just wanted to leave and tried to bluff him by saying that I would be back after finishing my rounds. But, a definite air of authority in his request just compelled me to sit and I found myself seated on a near by chair even before I could voluntarily take a decision regarding the request–cum-order.

He started off by saying that he first developed the injury on his right index finger a good thirty five years back when he was a fresh, enthusiastic surgeon motivated to serve the under privileged masses in southernmost regions of rural India. I blinked my eyes in disbelief, man – all this while I had been talking to a surgeon of yesteryears now struggling to keep up with the pace of life, which had dramatically turned around for him after he had sustained a presumably trivial fall prior to which he was absolutely independent and now is almost bedridden; all this happening within a surprising span of minutes when he unfortunately managed to lose his balance. Now, I realized why that professorial authority emanated from his seemingly fragile frame and from the every word that just whistled past through his thin, puckered lips. Having served in rural India for the last decade – at a time when India is being hailed as an emerging economic superpower and the health care infrastructure deeper in villages being worst than what the word dismal summarizes it up for you. I could hardly imagine what kind of facilities and problems he must have encountered while he was struggling to keep rural masses healthy in those times when the yellow light of a tungsten filament bulb was a celebrated luxury afforded only by the rich and influential, though it still is the case even now in some parts of this poor, over populated but rapidly transforming economy hailed as the next superpower.

He used to work when hospitals were as good as make shift huts or dispensaries were more of a rarity near by or in a village; he used to first administer the anaesthesia himself and then operate upon the patient assisted by auxiliary nurse midwives. He at this moment knew more about anaesthetic drugs & their doses than I could barely recall or would ever try to know in my lifetime, in spite of trying hard to keep myself in the thick of academics as far as possible; he had operated on human body from head to toe which is hardly possible for a single surgeon today, coz surgery as a specialty is fragmenting with every single day that passes by; he had encountered and successfully managed more complications than I would probably ever be a part of in my specialist surgical career. An hour quickly passed by just as a few minutes would do, as if I was glued to my television soap. Only when a nurse peeped in from the partially ajar door and requested him that his bed needs to be made, that he permitted me to leave on the promise that I would return back after finishing my ward chores.

Next day, when I met him in the pre-operative room, he was cool as a cucumber with out displaying any signs of anxiety what-so-ever; he just requested to be shifted on to the operating table very delicately as he was concerned more about his painful legs than the index finger of his once operating right hand. While performing amputations in his career as a surgeon, he must have hardly realized that the same surgical blade would be doing the similar honors for the most active finger of his dominant upper extremity. He was wheeled into the theater leisurely, shifted onto the table very diligently and as soon as he looked towards the ceiling mounted operating lights he whistled in delight and exclaimed in ecstasy “wowww..!!...doctor you are damn lucky to have such beautiful crystal-clear prismatic surgical lamps out here” later mumbling slowly, “I hardly used to get the services of a candle or a torch”. Ironically his joy was quite short-lived and was interrupted rather painfully when one technician suddenly but inadvertently lifted up his swollen legs to adjust the sheets below him, he just screamed in agony “oouchhh..!!!...please, please don’t touch them, they hurt very much.......oh god!” and was almost in tears. The anesthetist embarrassingly apologized and calmed him down saying “sir, please do not worry, no one would even touch them now”.

He was prudently offered a median nerve block at the wrist to knock off the sensations from the part to be amputated, which he gladly accepted knowing well the efficacy and comfort of operating in a nerve block and its benefits to the patient too; for which he was obviously more concerned, as for once in his lifetime now he was lying over the operating table. Ironically then, my consultant explained everything about the procedure to a patient, who as a doctor had been doing this for all his life. But, believe me on that day I realized how important this step was and then wittingly this patient requested my consultant to be cosmetic in closing the amputation stump saying “doctor, please avoid dog ears”. The operation was over quickly, and then I glanced at the finger that was moving with poise just a few minute earlier, now was lying lifeless in the kidney dish, like a fish that had been brutally pulled out of water. He surprised us all, by immediately asking, “do you know that I have now joined the league of a famous surgeon who operated whole his lifetime without the services of his right index finger?” the answer was obvious, Sir Hamilton Bailey, the great British surgeon. I saluted this old man’s die-hard positive attitude towards life.

A couple of days later he was discharged from the hospital after taking a look at his surgical wound which was doing fine. Wandering in the wards about a week later, I chanced to pass by the room where I first met him; I just wondered what would have been the result of the histo-pathological examination of that excision biopsy. I immediately reached out for the phone on the nursing station and rang up my consultant; he whispered slowly - "doctor, it was squamous cell carcinoma".