You can't unring a bell: what it means to propel forward

Irreversible life events: from surgery, to cells, to sport.

One of the facets I cherish about my profession is that it makes you appreciate the mundane, the repetitive, the ordinary aspects of life. It makes you appreciate life. It makes you think twice before succumbing to the urge of whining and complaining. It makes you contemplate the ebb and flow of existence. It makes you embrace both triumphs and setbacks with equanimity. It reminds you that if you are still alive, you are moving forward even if things seem or look otherwise.

I don’t get why we humans are so enamored with the notion of reversibility when life is inexorably irreversible from the very first breath. Despite our forward trajectory, we cling to the idea of reversibility. It gives us a sense of security or maybe a delusive semblance of control? Technology enables us to type and delete, act and undo, purchase and return, all with a simple click. We are copiously surrounded by redundant acts of reversibility so much so that facing irreversible situations becomes a formidable challenge. Our milieu is simply rife with reversible actions. But what if we were at peace with things being irreversible? What if we were to accept that unexpected things do happen, and they are irreversible, and that we have to keep moving forward instead of pondering reversion tactics? What if reversibility mentality halts our progress and provides neither security nor genuine control? What if moving forward is better than reversing events?

In my line of work, reversibility is a double-edged sword. It can lead to delayed or  misguided treatment and a focus on the wrong aspects.

A few weeks ago when I was on call, we had a child coming to the emergency department for a swelling in her face.¹ The first thing emergency physicians do whenever they see anything in the face is to page Oral and Maxillofacial surgery, and so they did.

My resident called me after evaluating the patient. The mass was firm, and there was no collection in the CT scan, which is to say that this was likely a lesion rather than an infection. I asked the resident to admit the patient because the mass had started to affect the masticator space at a relatively high rate, according to the parents, so we had to keep the patient admitted to monitor the airway. We also asked pediatric hematology oncology (heme-onc) to assess the patient, as we needed to rule out malignancy that may not be related to the maxillofacial region.

And sure, we could biopsy the mass in the face, but what if this were one of many? So, we pan-scanned her. And to our dismay, she had masses everywhere in her body. This was a malignancy that had metastasized.

The mother thought that this would be a quick hospital trip. When told about the admission, the need to monitor her child, do more scans, blood tests, and biopsy procedures, and that the treatment would take place accordingly, she was understandably taken aback. Shocked that all these extensive measures were required.

Long story short, the 4-year-old has Burkitt’s lymphoma. This is not a surgical case, so heme-onc has taken over, and the child is responding to chemotherapy.

In the weeks leading up to that case, we had an adult with facial swelling. Now, this was an infection. The patient came to the emergency department in the middle of the night with facial swelling extending just below the orbit and so we had to rush her to the operating room for incision and drainage. Infections don’t subside or go away without intervention. They too progress and move forward through fascial spaces.² Sure, you may impede their progression for a while with antibiotics, but we all know that the crux of treating infections lies in controlling/removing the source.

Now, that may seem reversible compared to the lymphoma. But in reality, that patient bore an indelible scar too. Once a cut is made, there are two undeniable facts: first there is no going back. I have to commit. Second, there will always be a scar, evidence that I have been there. In fact, when we consent patients, we always say there is no such thing as scarless surgery. The face, a conspicuous part of our identity, retains these marks, even if concealed. The scars will be the one thing that can’t be hidden.³

All this to say that the moment you make your incision, that is an irreversible decision. There, that is commitment. There, there is no going back.

Whether it’s chemotherapy or incision and drainage, the mentality of reversibility in medicine is not invariably helpful. Well, apart from considerations in longevity and preventive care domains maybe, but that’s beside the point. The cornerstone of genuine healing lies in acceptance, wherein patients acknowledge the inevitability of moving forward without the prospect of going back. The moment they accept that, they embark on their journey of healing. And it doesn’t matter how we as surgeons perceive the surgery, whether it’s big or small. To the patients, the procedure is always big, always life-altering. But we can always accompany them, take their hands to move forward. We can’t promise them that the medication has no side effects, or the surgery has no potential complications thus we can’t promise reversibility. But we walk them through the recovery period. This is a substantial component of our dialogue. “What does recovery entail?” they ask, and those questions permeate our conversations.  

At the cellular level, numerous irreversible chemical reactions take place. And that’s not a bad thing. It’s just a fundamental fact that was taught to us in biochemistry classes.⁴ Every reaction in the body needs energy. This energy is called Adenosine Triphosphate (ATP). In fact, during our ICU rotation, we had an attending who used to ask about biochemistry/ metabolic pathways and say almost every morning round, “No ATP, no Life.” All cellular functions hinge on ATP. When the body can’t produce ATP through aerobic respiration due to oxygen deficiency, it resorts to anaerobic respiration, because again “no ATP no life.” However, anaerobic respiration is far less efficient, and it also produces lactate (hyperlactatemia) and subsequent acidosis⁵, which is a biomarker that rings alarm bells.⁶

Now, chemical reactions that require lots of ATP (ATP hydrolysis) usually contribute to increased entropy (disorder or non-equilibrium and I’m risking oversimplification here of the second law of thermodynamics) and are irreversible. Typically, cells tend to exist in a state of low entropy. But the more reactions and energy expenditure occur within the cell, entropy rises, accentuating the irreversibility of the reactions.⁷ Still, regardless of the degree of irreversibility, this characteristic remains central to cellular metabolism.

I don’t want to be mindless of reversible cell reactions. But I think we should learn from cells. Some reactions are reversible, but some are strictly irreversible. Trying so hard to reverse the irreversible not only squanders ATP but also overlooks untapped opportunities. In fact, sometimes the state of chaos/entropy and irreversibility can pave the way for new and great events if we allow it to do so.

I’ve always been fascinated with the concept of entropy, so much so that I procured this artwork that literally says “entropy” on it. Then I took it up a notch with a matchy-matchy book.

Honestly, I had a hard time wrapping my head around the whole reversibility concept in the sport I’m into. My coach picked up on that. “Don’t stress about the outcome. Once it’s done, it’s done. What matters is nailing the form, getting the alignment right, and executing it well. That’s something that will be fruitful with time,” he said. Over time, this concept has percolated over me.

It’s funny because what got me into this whole sport in the first place is the thought that it’s a reversible act. I currently have an intensive training program at the gym. The last time I dove into such a crazy intensive training routine was in high school, where every morsel of my diet was monitored, and the meticulous calorie count as well as micro and macro nutrients tracking became the norm. Then here and there in my undergraduate years. But I certainly abandoned all of that during residency training and postgraduate years. So, it’s been a while, but this is not a weird spot for me. 

At first, I thought to myself if I don’t like it, then I can always go back to my other less crazy workout routines. Then, I so much liked the mental growth in that sphere. And, I also liked the fact that my fitness trainer did not know or ask a lot of questions about what it is that I do exactly other than that I work at a hospital. I’ve been training for a specific sport, so she kept the focus on that. It’s not that I evaded such conversations, but I certainly wasn’t keen on talking about my job at the gym. I just didn’t want to bear the weight of expectations falling heavily on my shoulders outside the hospital, even though I’ve got no issues with the literal weight. So, I kept it as the casual person training at the gym for a specific sport who can retain the option of backtracking on that decision if need be.

My sports coach, on the other hand, never asked a single question about my profession. Oh well, at least at the beginning. But he gives me a beatdown if I miss. He is sharp and focused on the game, and he makes sure that I shoot every shot precisely. I like precision. It’s what I do for a living. Still, even in sports, there is also no going back. Once you shoot, you have to follow-through of course, and that’s it. You either hit or you miss.

One day, I missed the shot, and I was so mad that he noticed. “It is ok,” he said. “That’s not surgery. Keep going.” According to him, I’m good at this sport, or well, have considerable potential. Yet, there are days when my performance really sucks. So badly. It’s as if I have never played this sport ever before. It’s as if it were my first day learning the ABCs of this sport. There are days when I feel that I’m just plain exhausted after leaving the hospital, barely have any ATP for this sport, and I feel like I hate it, even though I really love it. There are days when I’m all over the place, playing with no head or game. So he shouts, “Head in the game, Razan. HEAD. IN. THE. GAME.” I don’t want to tell him that I had a long long day at the hospital or that my muscles are sore from the gym or surgery. I hate making excuses and it’s the one thing that drives me crazy when people do. But then I tell myself that if I could just go back in time, maybe I would have yielded a better shot. Then he interjects the entropy of my thoughts, “Give it your 100%, go,” he shouts again. So, I do, and I don’t miss this time. Or maybe, I do.

Looking backward, you actually move forward. Even when you think you are falling, faltering, and nothing works, and all your shots are all over the place. You still move forward. Sometimes, the forward movement is so sluggish that you don’t notice it. Sometimes, you may want to go back thinking that you could do better but that moment is already behind you. You may have doubts. You may not be certain. You may feel that you want to give up. You may want to just leave. These are temporary feelings. These may or may not hold true.

But the only thing I am sure of in life is that we propel forward. We never go backward. And everything must come to an end for a new beginning to hug us. As we say in French: Il faut aller de l’avant, which translates to “we must move forward.”

1. Please note that storied data on this blog adhere to privacy laws and regulations.

2. Ever tried peeling a hard-boiled egg and noticed that outer whitish membrane beneath the shell, or that super thin layer on mandarin? Well, that’s how fasciae look. They’re thin and whitish/ translucent in color. Fasciae wrap around muscles. Normally, there are no spaces between the fasciae and the surrounding tissues. But when there’s pus, for example, things change. The spaces start opening up as bacteria and pus move through them.

3. I mean we can camouflage them, and even revise them. Geometry matters in designing your incision/flap, thus facilitating the hiding of the scar. But that's another essay.

4. Loaded with reactions, pathways, and cycles, which you start appreciating when you get pimped about the Krebs Cycle, par example. But, in all seriousness, you develop a sense of appreciation for biochem when you truly want to understand pathophysiology, and that makes the learning experience more enjoyable and filled with Eureka moments.

5. This is somehow a contentious topic. But hey, if you feel like having fun exploring it, there you go.

6. Rising lactate levels are linked to higher mortality. The body eventually starts to shut down unless it’s dealt with.

7. While heightened entropy is associated with greater energy expenditure, it doesn’t necessarily result directly from high-energy reactions.