Easy as ABC

I recently had a profound learning experience that I would like to share with you. It filled me with a lot of guilt and saddened me no end. On the other hand, it taught me a lot about myself.

I was driving somewhere one day. On the way, I saw a crowd of people gathered around a smashed-up car, the typical picture of an accident in our city. Being an emergency physician, I pulled my car over to the side and ran over to help. There was a woman on the tarmac, apparently unconscious in a pool of what looked like blood. I yelled at the police and the crowd to give me space. No one really heard me so I wormed my way over to her. To my relief, she was awake but a bit groggy. My medical training kicked in. ‘Airway (and neck), breathing , circulation’, the ABCs of resuscitating a sick person. I stabilized her neck with my hands to protect that part of her spine. This is vital because the cervical spine connects the brain to the rest of the body and controls virtually everything from breathing to movement. A tear in this delicate and exposed area of the human body and one can become paralyzed for life at best and dead at worst. I then looked at her chest and was relieved to see both sides of her chest rising regularly and equally. That meant her breathing was alright. Next, I needed to check her pulse. That would mean removing my hand from her neck, something I wanted to avoid. Luckily, the fact that she was awake and breathing significantly reduced the chances of her heart not beating so I put that off. I then yelled for a recount of events leading to the accident. Multiple people began to simultaneously recount their versions of the event. I cannot go into the exact details (due to privacy reasons) but suffice it to say that she had met with an accident after some disturbing events in her life. I then made a glaring error. I removed my hands from her neck to check her pulse (which I felt immediately quite strongly).

Nothing dramatic happened. Her neck did not snap, she did not become paralyzed and she continued breathing as before when everyone propped her up. That is besides the point. As a trained emergency physician, I HAVE to follow the ABCs mentioned above. I cannot just leave her neck based on a garbled history. I saw a smashed-up car (which indicates a high velocity accident) and a groggy woman. Ordinarily in a hospital setting, that is more than enough for me to secure her neck. Over here on the road I needed to follow my training. Perhaps, me being out of my comfort zone made me forget. Perhaps the fact that everyone else had moved her around without any obvious medical consequences lulled me into a false sense of security regarding the state of her neck. However, that is no excuse. As an emergency physician, it is my job to keep calm under pressure. If something had happened, it would be my fault alone. It costs nothing to stabilize her neck. Yet, the possible consequences of letting her neck go are devastating.

To decide if a neck can be let go, one can choose one of two famous algorithms- the NEXUS criteria and the Canadian C-spine rule. The former is simpler to follow and more relaxed about the neck as compared to the latter. The Canadian C-spine rule is marginally better but it is not unreasonable to depend on the NEXUS criteria alone. The NEXUS criteria allows you to relax about the neck if all of the following 5 criteria are met:

1)      The person is awake, alert and oriented to time, place and person,

2)      There is no evidence of intoxication,

3)      There is no focal neurologic deficit (i.e. no paralysis, loss of sensation anywhere among other things),

4)      No pain when pressing midline at the back of the neck, and

5)      No distracting injuries (simply put, a bleeding wound with say, the bone sticking out in the leg is bound to distract the victim from any pain in the neck)

With her, I could only reliably say that she met condition 1. I couldn’t confirm that she wasn’t intoxicated, given the bizarre circumstances of her accident and the fact that although she was oriented to time, place and person, she still wasn’t replying to all my questions consistently (likely due to the pain, but again, it costs nothing to keep her neck stable). She told me she couldn’t move her leg due to the pain. I also couldn’t do a proper examination to reassure myself regarding conditions 3, 4 and 5. Therefore, even by the relatively lenient NEXUS criteria, I should not have moved my hands from her neck till I could evaluate her properly or get a CT scan of her neck. Hence, the guilt.

Why the sadness though? As an ER physician, my daily bread and butter is this city’s dark underbelly. Consequences of its poverty, illiteracy, violence and mental strife are just another day in the ER. Therefore, quite naturally, I have developed a high level of immunity (and cynicism) to what most people would quail at. Whether that is good or bad is beside the point. It is necessary for me to remain detached so that I can function effectively as a doctor. Yet, seeing the very same thing I see everyday in the ER in a non-ER setting jolted my humanity awake and reminded me that the ‘guy on bed number so-and-so’ is not just another guinea pig that the conveyor belt-like triage has sent my way. Here was a woman with a horrible backstory (from what I gathered. Again, cannot go into details). Whatever the complete truth was, the end result was a devastated, injured woman with a mountain of problems. An uphill battle if ever I saw one.

What saddened me was how the police dealt with the case. I will not comment on the legal, administrative and police side of things (as it is not my place to do so), but I can give my two cents on how they handled the medical side of things. It is imperative that the police have some basic first aid training, enough so that they do no harm. Moving an accident victim about without any know-how of protecting the neck is criminal. They need to have SOPs in place that deal with this. They won’t always have a doctor at hand to help them out. While they all meant well and were most obliging to me, their lack of first aid knowledge proved a hindrance. Too much time was spent deciding whether they should keep the door of the car open to let her have some fresh air and constantly asking me if they could give her some water, despite my clear instructions regarding this. They also refused to send her to the hospital immediately. The reason they gave me was that she was wearing gold and if they took her immediately and the gold went missing along the way, they would be in hot water. Additionally, there were other logistical barriers that I cannot comment on. I later asked them that if she had looked like she was going to die any second, would they have reacted the same way? They vehemently insisted that they would have sent her to the hospital immediately. That is what bothers me. These medical decisions should not be in their hands. I understand that our emergency services leave a lot to be desired but in such circumstances, one would think the best option would be to get victims at the earliest to where they can be helped.

What did I learn about myself? I am not as authoritative as I should be. I have emergency training from arguably the best hospital in the country. I know exactly how to proceed in such situations. I must have confidence in myself and my abilities. There is a lot of research that backs everything that I do in such situations. I should learn to trust it, especially in such situations where I am the only advocate for my patient.

The Death of Comedy?

Recently, an eminent professor at my university cracked a joke on twitter that implied that women at an infectious disease conference were busy posing for photographs while the men were in the trenches fighting everybody’s friendly neighbourhood infectious disease- the coronavirus. The tweet quickly became viral and enraged a lot of people at the university. They complained to the appropriate persons and the professor shortly tweeted an apology, saying it was a joke and all in good fun. This got me thinking: when does a joke stop being something to get a few laughs and start becoming malicious? What implications does this have on the general application of humour? As someone who regularly shoots his mouth (I’ve always maintained that I spew more feculent matter from my top end than my bottom- pardon my French), I’ve had to deal with the consequences of a joke gone wrong multiple times. However, I have never really given much thought as to why this happens until today. This article is for me as much as it is for the reader and will hopefully give me the clarity I need to manoeuvre through my non-existent stand up comedy career.

Historically, those perceived as weak have been ridiculed. At a community level, select groups that lack the ability to retort are easy targets due to a socially untenable position in society. Often the ridiculing party truly believes their objects of derision are inferior. Examples include Jews in the holocaust, blacks throughout much of America’s history and the female sex since time immemorial. On an individual level, people who lack the ‘gift of the gab’ and do not conform to society’s perception of what is normal make the easiest targets.

However, are those making fun of others always malicious? Aren't most jokes targeting a group done in humorous vein and not because people are closet KKK? If you're a Pakistani, Memons and Pathans are regular fodder. For Americans, many a snide comment will be passed about Asian drivers, the Village, WASPs, ghettos and everybody 'Boooorn in East LA!' We expect people to have a certain level of thick skin. Standup comics thrive on it. Just because it is accepted, does that make it morally correct? On the other hand, when it comes to our daily dealings with people, we all agree that making fun of anyone is wrong, malicious or not. Isn't this a contradiction in our moral code?

It is important to remember that a) the reason cracking jokes at someone else’s expense is wrong because they may be hurt by it and b) they may not necessarily be empowered enough to voice their displeasure at being made the object of someone’s joke, no matter how light-hearted it may be. Most people know how to laugh at themselves and will enjoy a good old ribbing. However, the key word here is ‘most’. If even one person feels slighted by a joke cracked, should it have left the speaker’s mouth in the first place? Collateral damage sometimes cannot be avoided. This isn't one of those times.
Today, women empowerment is perhaps the strongest it has ever been in recorded history. Israel is a very powerful nation. Police brutality against blacks in the US has created an uproar and has fuelled #BlackLivesMatter. In the current zeitgeist, it is impossible to crack Jewish Mother/Light bulb jokes, tell a woman to make her man a sandwich and one needs to get a license to use the N word if non-black. Yet, such things were considered a normal part of comic nomenclature in recent history. Yet I am sure women, Jews and blacks were just as offended back then as they are today. They just did not have the lobby back then to remind the world that ridiculing them was morally reprehensible. The Republicans in the US, although in power politically, do not dominate the entertainment industry and therefore have no leverage there. In a way, they could be considered a minority and hence a 'weak' group in Hollywood. The Mullahs in Pakistan (a group particularly close to my heart), while very powerful among the masses, do not have the same traction in the upper middle class and are therefore a 'weak' group here. Does that therefore give the circles where they are 'weak' the license to make them the ‘Whipping-boys-of-the-day’? I am in no way comparing the struggles of women, Jews, blacks and other objectively marginalized groups with the ridicule Mullahs and Republicans face for their often ludicrous policies. The common pattern in humour I am alluding to related to all these groups is that they are made fun of where they are considered 'weak', where they have no voice and where they cannot respond on an equal footing. That is a cowardly move and often counterproductive (I am SPECIFICALLY referring to jokes cracked at their expense. Criticism with intention to correct what is wrong is always a good thing. It is just important to remember that the line separating constructive criticism and satire can be seen from outer space.You may disagree with someone and what they do may be plain wrong, but ridiculing them will never change their minds. If anything it will push them further away. The human ego is a powerful entity).
So what does this imply for the comic industry in its various forms (certain TV shows, Fox News, stand up, Comedy Central roasts)? The stars of some of our favourite comedies have said their shows would not stand in today’s climate. ‘Friends’, a perennial favourite, has strong homophobic themes. ‘The Office’ is notoriously sexist. Keeping principles a) and b) from paragraph 4 in mind, the implications of what I am saying are huge. The death of most standup. The death of roasts. The death of many of our beloved TV shows. And perhaps most applicable to me, the death of the traditional Pakistani young male ‘session’.

To Be or Not to Be

This post is specifically geared towards doctors on the ‘AKU - Giving Back’ page. I do hope however that others benefit from it. Heck, I hope I do.

Remember those ‘Choose your Own Adventure’ novels we used to enjoy as kids? The ones where each page featured a gripping narrative requiring us to make a choice (often based on the scantiest of information)? Each choice would have an accompanying page number, to which we would have to turn to discover the consequences of our actions. Of course, I hate surprises so I’d just flip to the last page of the book and work my way backwards. Adventures are a lot more fun if you save the world and get the girl right off the bat.


The reason this forgotten pastime has wormed its way out of my subconscious is its comical similarity to this whole Sharmeen Obaid Chinoy/AKU doctor media circus.

Page 1: Sharmeen Obaid Chinoy tweets:



Parhlo Pink latches onto the story. It goes viral.

Choice A: You go girl! Somebody must step up and put an end to this nonsense. Zero-tolerance is the word! #metoo *Turn to Facebook*
Choice B: How dare she turn this into a Pakistan thing? And harassment? It’s just a friend request for God’s sake! What’s next? The doctor appearing on How to Catch a Predator? Witch hunting every oil-slathered, paan-spitting launda in Dolmen Mall? And twitter is certainly not the forum to air this! *Agree it was unethical but turn to Facebook anyway*
Choice C: Fight! Fight! Fight! *Make a meme and turn to Facebook*
Choice D: Interesting story. I don’t think I have enough information to comment. Right, enough Facebook for the day. *Switch off computer and go outside*

Page 2: Doctor in question fired (Can’t find a definite source to confirm this).
Choice A: Liberté! Egalité! Fraternité! Sexualité! *Stay on Facebook and lob grenades at everyone who wants to bring back the corset. Burn some bras too for good measure*
Choice B: That’s harsh. Definitely deserved a rap on the knuckles but termination? IT WAS JUST A FRIEND REQUEST FOR GOD’S SAKE! *Stay on Facebook and throw the grenades right back*
Choice C: *Popcorn anyone?*
Choice D: Glad I didn’t comment earlier. I’d be looking pretty stupid right about now. *Switch off computer and go outside again*

Page 3: Turns out the doctor has a history and was already under investigation. Also, suspended, not fired. (Can’t find a definite source to confirm this either).
Choice A: A-HA! (TAAAAKEE ONN MEEEEEE!!! TAAAAKKEEE MEEEE ONNN!!!) *Stay the course. We’re bringing it home guys*
Choice B: Well, this information should have been made public beforehand *Patch on some hastily compiled defenses to save the sinking ship you’re on*
Choice C: This beats any Oscar-winning documentary any day of the week. *Put second batch of popcorn in microwave*
Choice D: *Nothing. You’re already outside*

Page 4: To be continued…

Very Itchy and Scratchy/Spy vs Spy-esque, eh? I know. But who’s right and who’s wrong? Or is there some middle ground we can stand on? Well, that’s not what this post is about. People have already said enough about this to fill a book and will continue to do so well into next week when the book is thicker than War and Peace or our increasingly short attention spans are distracted by another inane Guinness World Record attempt (whichever comes first).
No, this post is about the importance of making an informed decision. And what to do when you don’t have enough information to do so. I highly recommend the fanfic 'Harry Potter and the Methods of Rationality' by Eliezer Yudkowsky for a great take on the field. Also, Amos Tversky’s and Daniel Kahneman’s 'Judgement under Uncertainty: Heuristics and Biases' is one of my all-time favourites, right up there with ‘The Hitchhiker’s Guide to the Galaxy’ and ‘The Kama Sutra’.
Truth be told, we all know how to make informed decisions. Or at least be reasonably good at it. After all, the guidebook for doing so is just a collection of clichés; “Look before you leap”, “Before passing judgement, Walk a mile in the other person’s shoes”, “History is written by the victors”, “Beware of the half-truth. You may have gotten hold of the wrong half” etc. Why do we then consistently fail to pass balanced judgements?
A number of studies have shown the various fallacies we fall prey to when deciding what’s right and wrong. Accuracy decreases with an increasing required effort to come to a decision. (Einhorn HJ, Hogarth RM, 1990). Then there’s confirmation bias: the tendency to search for, interpret, favour, and recall information in a way that confirms one's pre-existing beliefs or hypotheses, instead of the other way round.
The first questions to always ask oneself: Will MY deciding and therefore holding an opinion on this matter improve my life or the lives of those around me? Or will it do more harm? Conversely, will NOT forming an opinion improve/adversely affect my life? These screening questions really filter out all the grime of life we have a tendency to collect, dramatically opening up time for other more fruitful pursuits, like getting laid.
If your answer to the above questions (be honest with yourself, bury your ego here) tells you to stop, do just that. Treat yourself to a cookie. If it tells you to plough on, get ready. It only gets tougher from here. The next question to ask yourself is, “Exactly HOW will deciding improve lives?” I mean a tangible mechanism, much like the ‘Materials and Methods” section of a scientific paper. Spell it out. No vague “It’s important to be aware of such issues” here. How will being aware improve lives? A cause-effect relationship is needed here.
Once you have that in the bag, question group three is, “What evidence do I have to make a decision? Have I heard both sides to the story? Is the evidence I have reliable?” This is where we must avoid confirmation bias. We have a natural tendency to give preference to only that information that confirms what we already know, instead of evaluating all data and then using it to form conclusions. This is very hard to do and we all do this to a certain extent, but it is an exercise that improves one’s life no end.
Next, form your decision. Go for it. If you’ve come this far, and have been honest with yourself, you deserve it. In fact, I’d go as far as to say not making a decision at this stage would be intellectual laziness and a disservice to oneself. You owe it to yourself to come to a knowledge-based decision where doing so will definitely benefit people. However, keep in mind that the decision you’ve come to is not necessarily representative of the truth. If you’re within that middle part of the bell curve of intelligence and intellect that most people are at, there is a fairly good chance your intellect has failed you and you didn’t compute some variable in your decision, making it incorrect (statistically speaking, you probably are of average intelligence. You, like the rest of us, also probably think that you’re an exception to that rule and are special in your own unique way, just like everybody else). Therefore, keep an open mind to change as new information comes to light.
Now, I’ve said all this but I’ll be the first to admit I very rarely go through this whole exercise myself, sadly. Doing so for every little thing every day is mentally consuming. I therefore carry on with little thought to the consequences of my decisions. Which is probably why the Prophet (SAW) was so harsh about the matter in the following hadith:

“Al-Tirmidhi narrated that the Prophet (peace and blessings of Allah be upon him) said to Mu’adh (may Allah be pleased with him), after teaching him some of the laws of Islam, “Shall I not tell you what is the foundation of all that?” I [Mu’adh] said: “Of course, O Prophet of Allah.” He took hold of his tongue and said, “Control this.” I said, “O Prophet of Allah, will we be held responsible for what we say with it?” He said, “May your mother be bereft of you, O Mu’adh! Will the people be thrown into Hell on their faces or on their noses for anything other than the harvest of their tongues?” Classed as Saheeh by Al-Albani.” The medical principle of ‘Doing no harm’ comes to mind.

As an example, let me run my decision about the SOC affair through the aforementioned process.
ME deciding who was guilty will not affect my life or those around me. However, this whole affair encourages me to read up the ethics of using social media as a doctor, both for my own good and so that I can educate my students when I am a consultant inshaAllah. End of process.
Keep in mind this is only MY evaluation of the event in the context of MY life. I could be wrong, given my intellectual limitations (in which case I’d love it if you could correct me). YOUR evaluation however will be completely different from mine. If say, you are in AKU’s admin, or rub chins with its higher-ups, the algorithm completely changes. You could possibly have access to information the rest of us don’t. You could also be in a position to affect (if required) the outcomes for either one or both of the concerned parties. The point of this article was not to tell you what was right or wrong about the case, but to reflect on the process you used to come a decision. If that has a solid grounding, you will be able to become a more productive member of society, instead of a mere talk-show host on the hunt for ratings. And that’s what Christmas is all about, Charlie Brown.

Strike while the Iron's Hot

I wrote this after Dr. Shakil Auj’s murder but forgot to post it:

My wife is a student at Karachi University. What follows is a synopsis of our discussion after teachers there went on strike due to Dr. Shakil Auj's murder (May Allah SWT grant him a place in the highest level of Paradise). We were wondering when strikes are morally okay (as in this case, the students suffered for no sin of their's) and when they are effective (Was the desired end achieved?). I shall discuss the latter only.

A few words about what follows: a) For the sake of simplicity, I shall refer to those on strike as strikers (in this case, the teachers) and those the strike is against as the strikees (in this case, the government/KU administration) and b) My discussion seeks to prove the following 2 statements:

1.       A strike is only effective when the service/product that is being removed by the strikers has value

2.       The strikers can only be defeated when the strikees remove a service/product that the strikers find of greater value than their own removed service/product.

Confused? Let's look at an example.

From 1974-75, British coal miners' union (National Union of Mineworkers) went on strike. The service being pulled in this case was coal, an essential requirement for the British populace, given oil's rising price after the 1973 crisis. Mines were shut down and coal production came to a virtual standstill. The British government instituted a 3 day work week with smaller working hours for the general public to reduce coal consumption to contest the strike. They failed and the government toppled.

From the above example, we see that the strikes are essentially a test of stamina and the ability to outlive the strikee. Both parties, the striker and strikee have reserves. The strikers have reserves of salaries which they get via subscriptions from their members so that they can pay the strikers when they are on strike. The government has reserves of coal. So in the end, the side that wins is the one whose reserves last longer. In 1974, the workers won. In 1984, the government did. The object of value was coal, something the population could not do without, leading to the government losing elections. But let's say the workers' reserves finished. Why couldn't the strike continue? Because no matter what principles one stands for, they all go down the drain when you're looking at starvation or a change in lifestyle, especially for those who depend on you. And those workers weren't exactly of the 1%. In 1984, the same NUM lost because the strikes outlasted the strikers, and the service removed was their salaries, something the strikers needed more than the government needed coal.

Often, our countrymen plunge headlong into strikes without properly calculating the practical consequences of their efforts. Let's look at political protests. When protesting, what product/service of value are they pulling? I can think of 2: the physical problems such as traffic caused by the protest and media coverage making the government look bad in the eyes of the international community. Both of these 2 types of value-pulling have not worked in the past because it doesn't really affect our government. It has very little bearing on the outcome of the next elections and 'the man' has no qualms about blocking roads for VIP movement anyway. Also, media coverage is too intangible an object of value. Will the media have the far-reaching effects strikers intend it to or does it just look good on paper?

Some political parties understood this and created what I term to be secondary services/products of value, i.e. when you have nothing of value, you create it. An example of secondary value is violence. Arming a political party to spread fear and using it as leverage creates value. People listen to them because they fear for their lives.

Now let's look at what value a student at a university has for the administration. What leverage can they garner when fighting for their rights? Unless said student is exceptional, none. Unless they can get the university grants through some brilliant ideas of theirs, the only object of value they have would be their fees. This works if the university is new and they need all the money they can get. But KU's fees are a joke and since it's an old established, economically feasible university, they won't ever be lacking for applicants. The only value that remains is that these students are future recruiters. They will go on to become leaders in their fields, putting their alma maters in a good light. However, this is too abstract and dicey a product of value. Besides, by the time these students go on to do great things, administrations would likely have changed by then, leaving the current administration no incentive to keep their students. Understanding this, many students form parties/unions or join political parties in school. This also explains campus violence.

Next I'll talk about civil disobedience movements. Keeping the above paradigm in mind, I believe civil disobedience will not work in today's world. Gandhi lived in a different world from ours. His India was a rural India, i.e. relatively self sufficient. Aside from modes of transportation and irrigation systems, what did the British do for India that would make the locals dependent on Britain? On the other hand, Britain needed fertile India's resources. Gandhi understood this and knew civil disobedience would hurt Her Majesty's coffers more than India's. The British government did not have a product/service of value that they could pull to hurt the largely independent Indian man without jeopardizing their own operation in India.

Fast forward to today. Urbanization dominates the country. We are miles deep in debt to the world. Globalization means we require Western products/services. Another intangible yet significant product of value is Western culture. Remember, there is only one Jessica Alba but many countries from where you can import cotton. Suddenly, the dynamics have changed. Taking to the streets to protest foreign interference in our country won't help much because frankly, my dear, we need 'em more than they need us.

I think that if we keep these few principles in mind, we as a nation can become wiser to when it's practical to go on strike and when it's just an ill-thought emotional response to injustice. Don't always strike while the iron is hot, or you may end up striking out.