IMPALPABLE SUSTENANCE

There are moments of clarity that in their tempestuous presence, far exceed in gains than the comprehension, prolonged excruciating and time-robbing pensive deliberations, when nothing moves or advances. These eureka moments arise indifferent to time or space. Like the zephyr filling the sails of a sloop on a quiet lake. 

Judgment inquires, about experience and knowledge in the same breath. It is not about theorizing movements, or ordaining trajectories of arrows in flight with indifference to wind or a gathering storm. Judgment requires a spate of intuition boiled in a vat of reality. 

Taking a certain object away from a child to prevent harm, is based on the past experiences of others under similar circumstances. Rubberizing a sharp edge has equal protective value for an infant. In the adult world of aviation, a preflight is meant to prevent the potential of a catastrophe. Checking the free movements of the control surfaces, draining the fuel or checking the oil before takeoff heed to the same convention of prevention. All stem from the experiences of others and self, about using the correct conduct prior to a flight. I remember upon embarking in an airliner, my son upon looking into the cockpit asked, why the pilot and the copilot had their pilot operating handbooks on their lap. “Are they learning how to fly the plane?” He asked with incredulity.

In medicine, judgment is an important determinant of a physician’s management of any illness. True care of a patient is not a repetitive mantra of this for that. It is not the guideline metric of “Less is More,” or “Choosing Wisely,” as envisioned by the wisdom of the ones who ordain the trajectories of their version of the medical discipline. It is as Rebecca Elson put it, 

“And purpose is a momentary silhouette

Backlit by a blue anthropic flash,
A storm on the horizon.”

It is a collective experiential reference based on knowledge and with that instructive modicum of intuition.

Ask any physician in the throes of a busy Emergency Room work-day, how he or she is able to keep the collective mob of ailing people from inundating their decision and judgment on the singular patient they are tending to? “I refocus on each one as I go along,” most will reply. But, how do you know what medicine or therapeutic option to offer? “I look at them and my knowledge and experience come into play, each time,” they respond. Exasperated, with these equivocations, you ask, “But how do you know what the right thing is to do. Do you follow some guidelines?” They stare back at you and then shake their head and head to the next patient moaning for their help. Is it intuition or judgment or an inkling? A fair question.

Walt Whitman squares this argument thus, “impalpable sustenance of me from all things at all hours of the day.” There is a flow of an ethereal transfer of information between humans, the kind that unifies us as humans. This flow ebbs and flows to the beat of human desire. Intuition, judgment and inkling are all words that imbue the essence of that “impalpable sustenance.”

Another example where such judgment comes to the forefront is in piloting an aircraft. The virtue of experience and knowledge is compacted into that tiny moment of decision-making when things go silent and fear shakes the bones. When the engines shuddered, while ingesting geese and the aluminum behemoth becomes a glider. Sullenberger, the pilot using his “impalpable sustenance” was able to glide the US Airways Flight #1549 an Airbus 320 into the Hudson River, NY and saved all the lives on board. Even second-guessing by armchair experts, of his decision, could not achieve the same fate.

A not dissimilar event happened in 1989 on a United Flight 292 under the command of Captain Al Haynes. The DC-10 aircraft experienced a catastrophic engine failure in its rear engine, which triggered a loss of hydraulic fluid. That loss of hydraulic fluid caused all control surfaces (rudder, flaps, ailerons) to malfunction. The flight was diverted to Sioux City, IA and after judiciously manipulating the two engines still operating and using thrust vectoring for directional control, he was able to crash land the aircraft and save 189 lives. 55 test pilots given the same scenario in simulators failed to achieve similar results. You may call it “experience” or “intuition” or “judgment” in those critical moments, but surely it transcended all written words in some manual!

As recently as yesterday a report from the COVID19 frontlines brought forth another example of human ingenuity and good judgment in an attempt to save a life, that has won over many other physicians. A patient developed severe shortness of breath after being infected by COVID19. Ventilatory support did not offer much help as the patient’s life continued to ooze away. The physician considering the possibility of multiple clots as the reason for the sudden shortness of breath gave an anticoagulant as a form of therapy. That therapy stabilized the patient for a short while, but she succumbed. However, the physician’s insight has led to a new therapeutic option for other severely ill patients with similar complicating features of COVID19.

One cannot always relegate human intuition/judgment/inclination to the back seat or to the written word from academic experts. There is a blossom of colors in the minds of each physician-scientist who faces extraordinary charges and must be allowed without the nitpicking of retrospective legalism, to use that kernel of “impalpable sustenance” however implausible it might seem in face of unparalleled adversity. To any future charges, the physician-scientist must also be able to answer such questions to the best of his or her ability as to why such actions were taken. Suppressing such “impalpable sustenance” would lead us all into the ocean of mediocrity and stagnation and soon that sustenance will wilt and die, leaving us as nothing more than a non-thinking collective, what Star Trek called the “Borg.”

And I, being you, “Just as you feel when you look on the river and sky, so I felt,
Just as any of you is one of a living crowd, I was one of a crowd,
Just as you are refresh’d by the gladness of the river and the bright flow, I was refresh’d,
Just as you stand and lean on the rail, yet hurry with the swift current, I stood yet was hurried,” (Walt Whitman stated), we all rush to the same shore but each with a different voice and understanding.

It is fitting, therefore, to leave you with this short Walt Whitman poem:

WHEN I HEARD THE LEARN’D ASTRONOMER
When I heard the learn’d astronomer,
When the proofs, the figures, were ranged in columns before me,
When I was shown the charts and diagrams, to add, divide, and measure them,
When I sitting heard the astronomer where he lectured with much applause in the lecture-room,
How soon unaccountable I became tired and sick,
Till rising and gliding out I wander’d off by myself,
In the mystical moist night-air, and from time to time,
Look’d up in perfect silence at the stars.