Skip to main content

Of Placebos and Phantom Limbs

This blog won the 1st Prize in the KEMUNITED 1st All Pak Blog Writing, Competition, 2017, in the Serious Category.

By Asna Safdar, Final Year MBBS (2017)

I
Years ago, on waking up in a hospital bed after a minor surgery that my parents decided I was too young to handle the information of beforehand, as the anesthesia subsided, I didn’t have to ask. I knew, instantly. Something had gone missing inside.
But I had thought that would be all. What I wasn’t going to know for a long time to come was:
You don’t always have to go to an operation theatre, submit to the numbing painlessness of the anesthesia, leave yourself at the mercy of a stranger’s scalpel to have a part of you removed.
For most episodes of loss, life offers no anesthesia, no prior orientation to the process, no drugs to provide insensitivity to the ruthlessness of breaching the sanctity, violating the integrity of your existence, no artful delicacy, no surgical precision. There are no painkillers to help you down the road of healing, no prostheses to be the fake yet, of somewhat practical utility, substitutes to what is lost, no blooming roses by the bedside telling you to get well soon.
There are mornings so blindingly bright yet in your field of vision, everything is stained in the shades of crimson. A hundred scents may grace the air and all you smell is your own blood- oozing in rivulets that no one can see from wounds you cannot locate.
You lie there, slowly progressing to wakefulness and just before reality drops the curtain of blissful forgetfulness, there are those few moments of absolute ignorance and oblivion- an oblivion nearly to equal that of your very first moments of consciousness- somewhere, perhaps, even before the event of your birth.
But then, the moment is lost before you realize its significance to savour the luxury of the ignorance to your heart’s content, too fleeting, to shortlived for you to mourn its loss, too unbelievably good to be true that after a moment’s heartache, your memory of its existence dims to the point where you no longer can grieve its loss.
The recollection of the state where you had fallen asleep and that of everything before it dawns with its complete potency. It hits you hard, shaking and soon after paralyzing you to the core. You lie there. And awareness in all its enormous, magnanimous entirety settles down upon every fiber of you:
You’ve been crippled, disfigured and disabled for life. You will never be whole, ever again. It will not ever be the same.
With the whole stretch of the day hanging over your head too closely, you fail to find one thousandth of the the purpose, meaning and energy within you that it requires to be lived with.
You catch yourself in the mirror and fail to recognize, acknowledge or accept its reflection of your existence, of its misinformed perception of what it sees.
You stand bewildered at the paradox of the parallel worlds, of the antagonism of the surfaces to the depths, to all that is raging in the soul to the little that makes its way to the territories of the mirror’s reflecting medium. The opacity of the mortal cage, flesh and skin to conceal the scars, the gaping wounds of the soul, of how the shell doesn’t give away the secret of the resident-
It is fallacy, it is an outrage.
The dense opacity of the flesh criminally conceals;
The raw superficiality of the mirror shamelessly lies.
If only you had your way, if only there were mirrors that reflected the soul in their images of the body, you would find yourself standing there with the gaping wound in your chest wide open to give away the absolute emptiness of the cavity within. Blood pumped from who knows where, seeping through the wounds where your organs had once found support before that clawed iron hand had thurst through the wall, clasped over the unsuspecting heart and lungs and with one brutal tug wrenched and tore it all out- all without so much as a warning.
And that is the moment where time stood still, the place where a part of you froze while the other stumbled on, the state in all its sheer vividness you startle at not seeing in the mirrors and which if you did come across it, the recognition would have struck you like lightening, the resemblance being of haunting accuracy.
In the thickest, most deeply placed layer of your subconscious,
All the clocks have broken.
The needles have suddenly forgotten to tick.
And
The pendulums oscillate no more.
Time,
Forevermore,
Has come to a halt
At the moment
Where the ghost
Of your fallen self stands-
Sculptured to marble
Cold and unmoving.
Life, the owner of that iron hand with spoils of war, your insides, flung over its shoulder- dripping your blood and leaving a trail that rusts too soon, walks away, in reverse, into the labyrinths of the past.
And you, the mangled remains of what is left of your existence stumbles, fall and crawl into the pitch dark alley of the future, clustered with darker, deeper pits.

Despite all that, the mirror declares you intact, the world sees you whole and you, once more, attempt to conform your existence to their judgement so as not to betray the horror of the truth that the unscathed intactness of your visible form attempts to painstakingly conceal.
And yet, the mere act of getting up and going on is a trial. You fluctuate between two states:
One, where the hollowness of your insides make you doubt the reality of your existence. You exist; but only in fraction. The air you attempt to breathe out of habit- and that which gushes in through the huge void is acid to every nerve ending that lies bare at the sites where they were ripped apart. In the necessity of breathing, every moment is agony- lived, relived, played, replayed.
There is the promised, short-lived numbness that follows every nightmare of sensory torment but that which is soon replaced by a certain heaviness-
As if lead were poured into every seething, aching nook, corner and hollow of your insides which somehow, for a brief span of time, puts a leash on the pain but which, when you attempt to take a step, makes a faux heart so heavy that it threatens to pin you to the very ground, demanding every particle of strength that still remains to resist surrendering to the load that weighs you down, lures you to give way, to give up.
You know better. Discarding the load will only bring back the pain.

____________________________________________________
II
Standing at one end of the long ward of East Surgical Wing, I pick up a folded, square piece of paper from among twenty-six others, with the number nineteen written inside it. It is the Ward Test. I start walking towards the other end through the passage between the rows of beds lined to the right and left, eyeing the bed numbers over the heads of patients on the filthy, century old walls as they increase as I advance, all the time aware of their sunken, vacant eyes following me- as they did of any face that broke the grim monotony of their days and nights at the place.
I stop by bed number 19.
Approach the patient from the right, I act on the first of the instructions drummed into my head in all these preceding months of early clinical training.
Post-operative, I make another very obvious observation to myself. For once glance at the man before me and the abnormality speaks for itself.
The right thigh is thickly bandaged, slightly above the knee and below it are white sheets, where the knee and a leg should have been.
A quick look at the file, which I’m not supposed to take- diabetic wound infection.  I realize I’ve insufficient preparation for this particular case but, well.
He lies facing the other side. I gather all of my scant confidence to get his attention and introduce myself and ask for his consent to talk to me about his ailment.
He isn’t too eager and justly so but is nevertheless polite and grants it. We both know the compulsion of having this conversation: me to gather a history sufficient to present to the examiner in order to pass the test, he out of obligation for undergoing treatment in a teaching, attached hospital.
There is a brief break as he converses with his wife attending to him. I wait. There is a hundred rupee note in her hand and they’re talking about the things that need to be purchased. They’re not sure what will cost how much and conclude by agreeing she goes to see what can be managed in that amount.
Socioeconomic status: poor, I make another mental note.

That is one question I’ll spare us both the awkwardness of asking.
A feeble yet chilling wave of shame washes over me- standing there in my branded, J. kurta, brand new gold earrings, the android phone in my overall’s pocket and all that in my wallet worth more than perhaps months of income of this family before me.
He resumes with the history.
The apparently healthy left leg was paralyzed in a road traffic accident five years ago, I find out.
There is a disorderly account of other leg currently in treatment, containing a series of events I try to sequence as I clumsily scribble them down while trying to keep up with the new information I’m bombarded with.
A crack in the skin of the heel, unsurprisingly not attended to with appropriate medical care, the wound infected and gangrenous, necessitated amputation. The surgical wound again failing to heal from diabetes and non-ideal living conditions, the same cycle leading to mid-leg amputation. Another cycle of failure to heal and infection. Above-knee amputation, this time.
He finishes his account of what would be put under ‘History of Presenting Illness’ in my badly-written history with the remark:
“Ab behtar hai.”
(It is better now.)
Neither him nor anyone else who’d have happened to look at me while I processed these words would have noticed the slightest change in my countenance.
Whatever it’s influence inside that moment, not in the most vague of suspicions could I have predicted that a statement of this casual, insignificant nature would echo in the darkest of times to come, that the raw simplicity of those three words would remain loud enough in chaos where in depth reminders of hope or courage would not find their voice.
Too many things happened at the same time.
Something hit me, hit me hard. And this time the effect of the blow was not paralysis but rather- the reversal of the one already harbored inside.
As if after a long, hazy nightmare you find youself completely incapable of escaping, you come back to your senses with an invisible thud, the violence of which shakes every particle of you to the core.
It was what life, were it a person and had it slapped you in the face, would feel like, if such a thing were possible.
The second strongest sensation was that of somewhat maddening nature- to confront him, there and then, and demand:
Why- after all that he had gone through- he would still have the heart to say that.
In the parallel universe of my mind,  it sounded blasphemous, criminal, almost. It enraged me like some grave injustice would. As if surrendering to the havoc played by a catastrophe weren’t an idea repulsive enough to me, I stood there witnessing the vivid demonstration of the possibility of acceptance, of reconciliation with it.
But then, like most conversations that really matter, this one did not take place either.

Without a second’s delay or change of expression, I continue my questions:
“Dard hota hai?”
(Does it hurt?)
“Hota hai.”
(It does.)
He answers, staring blankly into space.
“Kitna dard hota hai?”
(How much does it hurt?)
He pauses for a moment that I find too long, before answering, with the expression in his eyes suddenly turning blanker and more unreadable than it had been all this time. I have a feeling he’d rather have snapped at me for the absurdity of my question and the unmistakable obviousness of its answer. As if the question reflected my disgusting ignorance of something so absolute that it deserved not the slightest doubt to ever be brought into question.
But perhaps for the sake of the white coat I has on and all that it signified or the misery of my sorry existence reflected in my face, he only said, through teeth partly clenched and jaw muscles now used to tightening through all the pain that has to be borne:
“Bardaasht se bahar hota hai.”
(It is unendurable.)
____________________________________________________
III
There are hardly many concepts in the course of  medical studies I’ve yet been through that are uncomplicated enough to spark my genuine interest or inspire lasting memory more than the examination system requires and often, even lesser than that.
But some have struck enough chords of literary comprehension and duality of meaning to have stayed and stuck.
‘Placebos’ and ‘Phantom Limbs’ are two of those.
Placebos are drugs or rather ‘dummy drugs’ with no therapeutic effectiveness whatsoever, administered to patients unaware of the neutrality of their action. The purpose being of observing how the human body responds to a treatment psychologically and recovers, not only through the actual therapeutic action of a drug but through intrinsic healing  of its own that is triggered and potentiated by the mere knowledge and belief that an agent with the ability to heal and cure has been introduced to and is at work in the system.
A phantom limb is the sensation of existence of a limb or a portion of it that has been lost or amputated whenever the nerve endings to the site of amputation are stimulated by touch. For they previously had brought sensations from the lost part, the brain falsely perceives the stimulus to be originating in the part no more, hence wrongly testifying to its existence even when all other senses declare otherwise.
The diverse concepts of possession and loss, of beliefs of healing and damaging power of things and all that impacts ones living existence enough to alter the entire course of life- all somehow narrow down and fall into the vastitude of the territories of the above defined pair of terms.
It is all a huge gamble, life.
A game of blind guesses and wild assumptions.
Of thoroughly unquestioned, readily adopted beliefs.
Of uninvestigated, eagerly embraced ideas.
Of giant leaps of faith.
We’re all high on placebos.
Things, people, places, ideas and pleasures thrown in our way by the utter randomness that is life, picked up by us with equal thoughtlessness and absolute lack of insight.
Making sense out of things that were, perhaps, never supposed to make sense in the first place.
Pasting labels of ‘meant to be’s on products of our own flawed perception- things that were, perhaps, never really meant to be.
Our desperation to somehow impart significance to our utter insignificance.
To somehow instill extraordinariness to the sheer ordinariness of our experiences.
Entertaining possibilities of universal conspiracies having a hand in facilitating the tiniest, profoundly meager of happenings in our lives.
The one sunset you witnessed and that you may never forget believing it had anything to do with the state of your mind was no different than that of the day before or after or the day when you’re no more.
The rose doesn’t bloom in tribute to transient affections your heart may be nursing.
Monsoons do not thunder and shower in honor of your passing emotions.
The poet, perhaps, never meant what you think your favourite song means.
The universe couldn’t be more indifferent to your existence.
We’re broken, bruised and diseased- frantic in search of antidotes to our respective afflictions.
And there are none.
We swallow every pill life shoves down our throats and injects into our veins- telling us it is just what we need to be at peace- we reverently embrace the promise in the prospect.
Most of the time, they’re placebos- things we think ourselves into believing are healing us- while all the time we’re decaying and dying.

And not too less often, we’re prescribed poisons- sweet enough to bring about the strongest of placebo effects, all the time killing us in silence and in fractions.
Apparent recovery tricks us into believing we’re healing while all the time being poisoned beyond the possibility of its reversal. And when, from one reason or another, they’re withdrawn, the mightiest of placebo withdrawal surfaces.
We die from the sudden withdrawal of something that was always, always meant to kill us in the end.
And then there are phantom limbs. Limbs that made you walk, run, reach out and grab whatever you sought to possess,  vital organs that pumped, breathed and disseminated life into you.

Lost- lost in the violent ruthlessness of accidents met on life’s insane high road.
Or diseased- diseased gravely enough to threaten to take your life altogether if not cut and separated from you.
It, unfairly enough, ceases to matter what crucial significance that part of you had held all this time, what stronghold it had been or all that it could have been capable of doing. The terror of disability and disfigurement, the grave, crippling   incompletion of that which would remain of you when it is gone becomes secondary when it begins to threaten to take your very life, to inflict greater amounts of pain and anguish in case you let it remain attached to yourself.
And, thus,  even when the slightest touch at the site of wound reminds you of what once was, of what you once were and even when the greatest magnitudes of excruciating pain rip your insides out every time, you still are able to say through locked jaws and clenched teeth:
“Ab behtar hai.”

____________________________________________________

Comments

Here's more you should read...

USMLE Step 1 Experience by Ayaz Mehmood (Score : 99/266)

USMLE Step 1 Experience by Ayaz Mehmood (Score : 99/266)
Salam everyone, let me start in the name of Allah who’s the greatest benefactor of all mankind. I am going to write a detailed composition regarding preparation for USMLE Step 1. I am a final year student at King Edward Medical University and I took my exam on June 10th. Final year is the year before internship/ house job in Pakistan. I just got my scores: 99/266



Let me introduce some myths surrounding USMLE Step 1 which are especially prevalent within Pakistan; I am not too sure about India because I heard their students typically appear in their final years.


 Myth number 1:Do not appear for USMLE Step 1 within your graduation

 Verdict: Baseless, illogical reasoning

Explanation: This is so prevalent in Pakistan it’s almost pathetic. One of the biggest concerns surrounding our students is that Step 1 is a huge risk to be taken before graduation. Let me put it in another way: Step1 would always remain a risk whenever it is taken, …

Australian Medical Council AMC Part 1 Guide - Experience and Tips

AMC Part 1 by Dr. Asad Khizar Malik (Rank : 77/620) Australian Medical Council  Guide - Experience and Tips
Salam people, let me start in the name of Allah who’s the greatest benefactor of all mankind. Hope everyone is doing great. I'll try to write as much as I can for the people who are due to various reasons more interested in joining Australian Hospitals for post-grad training as compared to the USMLE pathway.

I am a graduate of King Edward Medical University, class of 2004-2010. I did my 6 months house job after graduation in Mayo Hospital, and after that, i gave my AMC Part 1 in November, 2010 from Brisbane. With the grace of Allah, I passed that in first attempt.

So lets start with the discussion here, but PLEASE NOTE THAT IT IS ENTIRELY MY PERSONAL EXPERIENCE AND REASONING WHY I PREFERRED AUSTRALIA OVER USA FOR RESIDENCY.

First thing in mind that comes with post grad training in Pakistani doctors minds is: Which way to go after graduation? That is a very tough decision that is …

FSc Premedical Guide - How to fly high..

FSc Premedical Guide - How to fly high.. Unsa Athar Your 40% needs to be excellent to get into KEMU or  some other good place.
(Dedicated to my teachers who not only taught me the fsc books but also many priceless lessons of life)
(Unsa Athar)
The tree that never had to fight For sun and sky and air and light, But stood out in the open rain And always got its share and rain, Never became a forest king, But lived and died a scrubby thing… Good timber does not grow with ease, The stronger wind, the stronger trees.
Getting yourself educated in the desi manner i.e. through the Board of Intermediate and Secondary Education is one of the top most challenges of today’s society. Matriculation seems difficult at that time, but when you enter FSc, you realize that matric was the easiest job in the world.  Those obese books of intermediate part I and part II are the worst enemies one can ever have.  People say Medical is tougher, but I find one basic difference in both. When you enter a medical college, y…

HISTOLOGY SLIDES AND HANDMADE DIAGRAMS

Anatomy/Histology Gallery
Read the instructions here 1st Year

Histology Slides for Professional Exams
Folder 1- Labelled Folder 2 - Labelled Folder 3 - Labelled
Histology Revision Slides Updated (2011)
by Laiba Khalid
Lower Limb Anatomy Spotting Labelled
http://kemunited.blogspot.com/2013/05/lower-limb-spotting-labelled.html

Embryology Models Some models are labelled and others mentioned in comments

Anatomy Museum Models (unlabelled) This album covers Upper limb, Lower limb and Thorax regions of anatomy

2nd Year
HISTOLOGY Diagrams Hand-drawn CARDS 2ND YEAR MBBSThese are hand-drawn histology diagrams by Demonstrator Dr. Shaista (Dept of Anatomy, KEMU) and submitted by Anosha.NEUROLOGY/ Neuroantomy SPOTTING  (LABELLED SPECIMEN) 2ND YEAR  Each structure is labelled and a great job done by Anosha. Neuroanatomy / Brain 2nd Year Important topics by LaibaNeuroanatomy Models Labelled  Gross models labelled by Maryam Shahid Abdomen & Pelvis Anatomy Spots Labelled Excellent job by Maryam Shahid
Anatomy Learni…

USMLE Step 2 CK experience by Rizwan Khan (254)

IN THE NAME OF ALLAH THE MOST BENEFICENT AND MERCIFUL

     I recently got done with Step 2 CK exam & I want to elaborate my experience and the mistakes that I made during my prep so that any of my colleagues who are preparing for this exam might benefit from them. I wont go much in detail about how to prepare and where to prepare from since it is already highly debated on the forum and in the previous posts but would focus more on my personal experience and the bad choices which I made during the preparation phase.
SELF-ASSESSMENTS AND QBANKS Uworld 74% Kaplan Qbank 69%
Kaplan diagnostics  = 80% (70 days before exam) Kaplan Simulation Exam 1 = 71% (50 days before exam) Kaplan Simulation Exam 2 = 76%  (40 days before exam) Fred simulation for CK = 84% (39 days before exam) NBME 2 (offline) 21 mistakes (30 days before exam)
NBME 4  =    263 (13 days before exam) UWSA =  259 (2 days before exam)
Real exam = 254