There are those moments of clarity that come from tempestuous thoughts: a eureka moment indifferent to time or space. Thoughts like the zephyr that fill the sails of a sloop on a once quiet lake.
Judgment interrogates our experience and knowledge in the same breath. What use is the theory of movements or ordained trajectories in flight with indifference to wind or a gathering storm? Judgment requires a spate of intuition boiled in a vat of reality. Intuition is immediate after the business of reason is finished.
In the world of aviation, a preflight is meant to prevent the potential of a catastrophe. The correct conduct prior to a flight: checking the free movements of the control surfaces, draining the fuel, or checking the oil before takeoff, flight charts, and checklists on hand, all stem from the collective experience of aviators.
As in aviation, so too in medicine, judgment is an important determinant of a physician’s management of 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 a purposeful intuition as Rebecca Elson envisions:
And purpose is a momentary silhouette.
Backlit by a blue anthropic flash,
A storm on the horizon.
No rulebook contains the collective experiential reference based on human knowledge. In both aviation and medicine, there is a need for the instructive modicum of intuition.
Ask physicians in the throes of a busy emergency room, how they keep the questioning mob of the infirmed from inundating them. Most would reply: “I focus on each individual patient.” But, how do you prescribe which medicine or therapeutic option? “I first listen to and examine them. Then my knowledge and experience come into play,” they respond. Exasperated, with these equivocations, you ask, “But how do you know what the right treatment is? Do you follow some guidelines?” They stare back at you, shake their head, and walk away to the next patient seeking help.
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. Intuition, judgment, knowledge, and experience convey that “impalpable sustenance.”
An 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. No second-guessing by armchair experts of his decision, could have achieved similar results.
Another such event occurred in 1989 on a United Flight 292 under the command of Captain Al Haynes. The DC-10 aircraft experienced a catastrophic rear engine failure, 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 operating engines and using thrust vectoring for directional control, he crash-landed the aircraft and saved 189 lives. Fifty-five 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 COVID-19 frontlines brought forth another example of human ingenuity and good judgment in an attempt to save a life. A patient developed severe shortness of breath after being infected by COVID-19. Ventilatory support did not offer much help as the patient’s life continued to ooze away. The physician considered the possibility of multiple clots as the reason for the sudden shortness of breath and administered an anticoagulant. Although the therapy stabilized the patient for a short while, she succumbed. However, this physician’s insight led to a new therapeutic option for other severely ill patients with similar complicating features of COVID-19.
One cannot relegate human intuition/judgment only to the written word from academic experts. There is in the minds of each physician-scientist who faces extraordinary charges — a genius. An inspiration that the nitpicking of retrospective legalism overlooks. Physicians use that kernel of impalpable sustenance when facing unparalleled adversity. To suppress such impalpable sustenance would lead us all into the waters of mediocrity and stagnation. 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, we all rush to the same shore but each with a different voice and understanding. As Walt Whitman wrote:
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.
It is fitting to end with Walt Whitman’s “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.
Parvez Dara is a hematology-oncology physician.
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