During the Second World War, the Royal Air Force of the U.K. had exceptionally brave pilots. They took out their Avro Lancaster bombers, went deep into enemy territory and bombed, despite heavy German ground-to-air gunfire. The planes took multiple hits, sustained bullet holes, but most made their way back to the airbase. The battle-hardened, brave-heart pilots and their aircraft shared an unusual bond; human emotions and reinforced steel glued in a do-or-die unseen tether of fait accompli.
After months of carefully studying the aircraft, looking at the distribution of the bullet holes, the service engineers could see a pattern emerge. The German gunfire damage was more discernible around the wingtips and the fuselage, while the wing-base, cockpit and engine bay remained relatively unharmed. They came up with a novel idea of strengthening those areas by bolstering them with a strong layer of lightweight bulletproof metal.
Abraham Wald, a statistician, was called in for a second opinion. Wald was a Jewish Hungarian, who fled Nazi-occupied Austria, to join the allied forces. He studied the aircraft and came up with a diametrically opposite opinion.
“Bolster the areas not hit by bullets, because planes with such hits went down and never returned,” he said. “You are looking at aircraft that survived despite the holes, and that doesn’t matter much,” he opined. Today we know this statistical concept as “survivorship bias”.
Now, meet a senior bank manager. Customer meeting in the morning, audit review in the afternoon, a party late in the evening and the T20 telecast in between, his day was tightly packed. The well-planned schedule suddenly got disrupted without notice. The nagging two-day-old “gas” pain worsened, and he became breathless with profuse sweating. ECG at the emergency room showed a major heart attack. His chest was getting congested by the minute with fluid, a condition called acute pulmonary oedema, and he was connected to a ventilator. An urgent angioplasty was done to remove the block. After a 24-hour critical period, his condition started stabilising. By next morning, he was breathing on his own. By the end of day four, he was checking his e-mails and ready to go home, promising never to smoke again.
Heart attack is a nightmarish experience. Not just the pain of the disease, the torture of multiple injections, the stress on the family and the unexpected expenses but also the sudden loss of self-confidence and control over one’s life. It’s an experience no one wants a repeat of. So even the most difficult “I-don’t-care” patients become a “good boy” after a heart attack. Many doctors feel that during follow-up after a heart attack, most patients maintain a better lifestyle, good control of BP, cholesterol and sugar.
But during the follow-up, the bank manager looked a little frail. “How are you,” I asked. “Not too bad.” His wife stopped him midway and jolted forward. “Doctor sir, two days ago, he ate banana fritters full of oil, when I was away from home for a few hours, our maid told me. And one day, I smelled cigarette smoke in the bathroom. I never told him all this, because he will get angry at me, which is bad for his heart. At night, I keep an alarm in my cellphone and wake up at least three times to check his breathing.”
Bedside monitoring, electronic surveillance, bathroom smoke detector, parametric alarm; what kept him safe sounded better than the equipment in our intensive cardiac care unit. I felt sorry for him.
“Same here, even without a heart attack,” I wanted to tell him, but I kept quiet.
There are many Indian wives who are like RAF pilots, sharp, astute, brave, cautious and extremely possessive about the equipment they handle. Even if they know that their husbands are as cold as a machine when it comes to choosing a sari or the shade of nail polish, they still care. The wife makes sure that the man is fine and ready to fly, notwithstanding the bullet holes. The tools she uses might be old-fashioned, her logic might stun the cardiologist, her reasoning might be funny, but all these work. The plane flies again.
My prayers for patients who don’t come back for follow-up with a worried wife. They are like the planes who got shot down and did not make their way back home. An unflustered wife or an unmindful pilot is bad news for an unwell husband or a bullet-ridden aircraft.
Abraham Wald would have surely agreed to that.
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