Survivor's Guilt

I was at the clinic the other day, and I was finishing up the evening shift. A female patient showed up for a review with regards to lab test results. It isn't uncommon for us to end up reviewing a patient on behalf of one of our fellow doctors because their shift might have ended before investigations they'd ordered were complete. I honestly don't mind because it is usually a case that can be handled quickly.

In this case, it turns out that the lady was the one who had specifically asked for the tests. We get this from time to time too: some individual may have suffered from a specific malady in the past, thus they come in on a regular basis just to check on that specific parameter - Lipid profiles (cholesterol), Liver Function Tests, Blood pressure or sugars, Clotting profiles, etc. I pored through the lady's results and everything was essentially normal, which is the best kind of news - no management needed whatsoever.

At that point, the lady decided to let me know what had occasioned the testing. She had lost her last pregnancy in her 3rd trimester, and was considering getting pregnant again. I decided to question her further, and asked her if the baby had any identified malformations; she answered no. Next, I asked her if there were any problems with her blood pressure during the pregnancy; Yes, she answered.

So my mind pretty much knew what the diagnosis had been: Preeclampsia. So I continue to peel away the layers, finding out that she had very elevated blood pressures which had worsened towards the end; she had also developed generalized oedema. With blood pressures towering above the 170/100 mmHg mark at some point, she had generally crossed over into the realm of Severe Preeclampsia. She had been admitted for monitoring, but somewhere along the way foetal movements ceased and the baby passed away - an IUFD (IntraUterine Fetal Demise) at 32 weeks of gestation. To make matters worse, the lady ended up needing to undergo a Caesarean Section to deliver the recently deceased baby.

The hits had just kept on coming during that pregnancy, and almost 2 years down the line, this lady was still coming to me with questions. In some regards, as usual, she still felt that the doctors were at fault and didn't do enough to save her pregnancy; she was obviously hoping that the same thing wouldn't happen in this subsequent pregnancy attempt. In the course of the conversation, I also got the impression that she felt that things would have turned out better if it had been her life lost in the pregnancy and not that of the unborn child.

Being blunt
I had tried to be compassionate and offer up as much empathy as I could while we talked, but at some point it became necessary to give her the cold hard facts.

1. She had experienced preeclampsia in her very first pregnancy; it had been a mild case that had developed in her 3rd trimester, but that was evidence enough that she'd be at risk of suffering preeclampsia in subsequent pregnancies. For this (fateful) pregnancy, the preeclampsia had started earlier (in the 2nd trimester) and progressed even faster. She definitely should have been booked into a High Risk Pregnancy Clinic for her 2nd pregnancy; but I let her know that it was imperative that she start any future new pregnancies with prior visits to her Ob-Gyn before conception.
   
2. Preeclampsia/Eclampsia is no joke. It's one of those conditions that gives doctors nightmares because we don't fully understand its cause, but we have dealt with its ramifications many times. Any organ damage that happens during the pregnancy stands the chance of being irreversible! Let me mention a few of my fine examples
   
   
   • Pre-internship (KNH) 
   • A mother shows up after a normal delivery in Kibera. She seems to be acting particularly aggressive and out of sorts, so we assume it is a case of puerperal (post-partum) psychosis. Only thing gleaned from her discharge notes was that she's had a BP of 160/100 mmHg at one point. 2 weeks into her stay we end up performing a Head CT scan which shows a massive bleed into her brain. A few days later, she's gone.
   • A mother is 20 weeks pregnant, but her whole body is swollen like a grapefruit. We have a special term for this kind of oedema: Anasarca. I have never seen a case of preeclampsia progress this fast! Coming this early in the pregnancy, my consultants have no choice but to terminate the pregnancy to save the mother's life.
     
   • Internship 
     
     • My introduction to the Obs/Gyne Department: a mortality debriefing. Mother had suffered kidney failure and basically had blood streaming into her urine bag instead of...well, urine. Patient succumbed soon after.
     • A mother had developed seizures in the course of her delivery, and thus ended up being taken to ICU for further treatment.
     • Typical night in the labour ward. Mother transferred in from Lord-knows-where in need of a Caesarean Section (CS). Mother hasn't really had any sort of antenatal clinic visits, so there isn't much for us to glean in terms of past medical history. Anaesthetist hopes to perform a rapid sequence induction using Ketamine, but, with the patient already on the operating table, finds out that the patient's blood pressure is at the 180/100 mmHg. Ends up having to switch to more traditional agents, which have a pressure lowering side effect, and as the surgeon I have to perform as quick a CS as I possibly can, and hope for no complications.
        
   • Post-Internship - a relative comes down with a case of AntePartum Hemorrhage (APH) just 4 weeks prior to her official due date. Investigations prove that she's developed HELLP syndrome, and ends up needing a CS one week later to avoid any further complications.
     
   • Most preeclampsia pregnancies -  with regular doctor's visits and appropriate medication, we are able to ensure a smooth pregnancy. Delivery of the placenta usually results in normalization of blood pressures for the mother; an unlucky few go on to develop chronic hypertension.
     
3. A doctor will NOT risk the life of the mother for the sake of the child. This is not some form of Roe v. Wade permissiveness - this is a real question of life and death where the pregnancy places the pregnant mother's life in immediate harm, possibly of imminent death. We don't particularly like sacrificing the life of an unborn child, but in terms of priorities, it is basically
   

   Save the Mother first; if possible, save the Mother AND Child.

   I do not hesitate in this matter in light of my experience losing Edna. I have been adequately prepared to answer this question by a Philosophy 101 class from my first semester of (Daystar) University. The justification for this is strangely Utilitarian: the mother is a microcosm - she has built up a wealth of relationships, and has very many people who actively depend on her; the foetus is wholly potential. Thus, as a doctor, in weighing the scales, it is more ideal for you to save the mother's life, preserving the already intricate web of relationships that she is a part of.
   
   But then again, life is not so clear-cut and absolute. I remember hearing about the case of a mother who delayed chemotherapy treatment so that she could have a normal pregnancy, and give her unborn baby a fighting chance at a normal birth and life. This was wholly a mother's choice and sacrifice, and a reminder that mothers (and fathers) will on many an occasion make the ultimate sacrifice for their children.
   
   
4. Hindsight is 20/20. Doctors usually get asked to review situations where things have gone wrong, and asked to chime in our thoughts. This is why we typically have Morbidity and Mortality (M&M) meetings, which give us a chance to backtrack and see how things could have been done better. However, we are not always so quick to assign blame because there is the realization that every health situation evolves along a vast array of lines. In this case in particular, someone may argue that the baby should have been delivered earlier. Theoretically, I can think of 2 reasons why the doctor might have chosen not to.
   
   
   • The mother's blood parameters might have been with normal ranges, and it was hoped that adjusting the set of medications that she was on should have allowed the doctors to prolong the pregnancy.
   • It might also have been possible that the baby was considered "small for gestational age". Preeclampsia is one of a host of conditions that can cause Intrauterine Growth Restriction (IUGR), so prolonging the pregnancy would offer a better post-delivery outcome for the foetus.
     
   It is no mere coincidence that I am emphasizing prolongation of pregnancy. Some people may remember a Christian song by the name "Better is One Day". One lyric in that song is particularly poignant

   Better is one day in your house...than thousands elsewhere

The songwriter was referring to being in God's presence...but he might as well have been talking about a foetus in the womb. Nothing we scientifically possess is capable of mimicking the fine-tuned conditions that exist in the womb; thus, as normal a progression of pregnancy is one of the main aims of any OB-Gyn. We usually find that it is ideal to let nature take its course as much as it possibly can.

Conclusion
I think it's worth noting that the patient described me as being "very blunt" at the end of our talk. I don't regard that as a worthy hallmark, nor is it representative of my typical bedside manner. However, she was thankful that I had taken the time to explain things to her in a manner she hadn't experienced before.

In hindsight, it is possible that we sometimes mentions these things to our patients, but they fly right over their heads if they're not yet ready to hear them. Sometimes, we really don't have that much time: I had the chance to go over the situation with her because it was a slow evening at the clinic; I can't guarantee I would've had the same outcome on a busy day. This is why it's probably a good reason to readily recommend some counseling for such patients. Allowing them to talk about the experience often provides more relief than merely doping them up for their depression.

I am thankful for opportunities to practice medicine, and chances like this to clarify things to my patients. I hope this patient gets the outcome that she desires, and can get the true healing that she needs from the events in her past.

God Bless.

The Huduma Number Fiasco

You can obviously tell that I'm already peeved about this Huduma Number registration exercise. Just the manner in which it has been rolled out amid mystery and mistrust, and the immediate threats that have followed is an immediate cause for concern. However, before you go on to condemn me as some unpatriotic critic whose only intent is to curtail development, let me give you some reference for my misgivings.

Let's take it back to my medical internship, circa mid 2014. The government had suddenly become overwhelmed by its "ghost worker" problem, so they had decided that they would conduct a biometric registration program of its civil servants to fix the issue. So summarily, they decide that within a small window of time (~2 weeks in my recollection), all civil servants would have to be registered, or run the threat of not getting their salaries.

In my mind I'm thinking "what the hell is this?" I had been posted to Kisii Hospital in May that year, reported on June 1st, received my paperwork that I needed to present to the Ministry of Health (at Afya House) on June 2nd; after making all the submission of the required data, I had reported back to my work station on June 8th and started working. So they basically had all my fresh data,  but now we were going to add biometrics. Well, when threats abound, you just make your peace with the situation and try to find time in your schedule for such things.

This registration turned out to be a little tricky. The hospital served as a registration centre for some days (not given out in advance), then there was the functionality of the biometric registration kits (questionable), and the speed of the exercise. I remember that the most convenient time for me to register fell on the morning right after I had been on the night shift during my surgical rotation; hence, I made up my mind to show up for the registration early the next morning before I departed for home. Morning rolls in and I get down to the designated area (close to the cafeteria), and I find a large line has formed. There are some clinical and other hospital staff in the queue, but, surprisingly, the bulk of the people in line are other county workers from Lord knows where.

The registration workers arrive and the exercise starts. It moves slowly: only 2 of the 3 biometric registration kits are working. Then the usual tomfoolery ensues with grown men and women just cutting in line or being mysteriously moved ahead of others unceremoniously. By 12pm, I still wasn't any closer to being registered, and I was basically running on fumes from a busy night shift. I cut my losses and decided to head on home, and try my luck on a different day. The rest of the day turned out to be a similar nightmare: lights went out, meaning I couldn't charge my phone which also dabbled as my alarm; I thus overslept past my reporting time of 8pm, waking up to multiple missed calls from fellow interns once I eventually plugged in and charged my phone. (In retrospect, this might be one of the reasons that I had supplementary weeks added to my surgical rotation).

I eventually had to get myself registered at the county offices some time later (as usual, the date for the exercise had had to be extended), and life went on as it should...but I was pretty sure that the ghost worker issue would rear its ugly head again

All of a sudden, in 2019, we apparently have ghost workers in the Police Force. I'm not exactly sure if Police count as civil servants, and neither am I sure whether they were expected to be registered during that last (eventful) program of 2014, which was of course run under this same Jubilee Administration. This all boils down to the same thing: we have a mediocre set of systems that have been set up to manage us. A proper management system would register employees, make regular updates to cater for changes in their status/upgrades, and lastly account for attrition in the work force, occurring through resignation, dismissal or retirement. The fact that we have ghost workers masquerading in the system merely means that the system is not being regularly updated (to weed out past employees), or someone with a higher level clearance is introducing bogus data into the system. Needless to say, the majority of the good hardworking people will suffer for problems originating from levels that are "way above our pay grades."

So now we have the Huduma Number, our Saviour-du-jour. As with all things of this generation, we are first reminded that it is digital and biometric; in addition, it is meant to bring together all disparate data and numbers that are essentially tied to each Kenyan, and basically make life easier. This isn't really anything new. I remember that some time before the most recent elections, some government spokesperson had shown up on TV and spoken of the need for a new card (and number) to oversee our other numbers. And even then I had still thought it was a ridiculous idea.


I actually managed to get my hands on one of the forms in advance, and I was able to start filling it out, but the only details I was missing were the expiry date of my passport and my driving license number. Looking at the form is simply infuriating because it just makes you realize that you've already filled in these details on multiple prior occasions when registering for your NSSF, NHIF, KRA and even driving license. And here's the kicker: you needed your ID card to register for all those other cards!

Anyway, filling out the form was easy enough, with the exception of these administrative divisions (county, sub-county et al.) which are pretty much a foreign concept to me. After it's all filled out, you have to sit and wait in line for your turn to be registered using the biometric capturing kits. Fortunately, I was being registered at my place of work and did not have to face the prospect of standing in a ridiculously long queue. Understand that the time it's taking for people to be registered is more along the average mark of 15 minutes, and there are some outliers that are even exceeding 30 minutes. That means that for every 4 people ahead of you in line, you should expect to wait about 1 hour if only one registration officer is working, or 30 minutes if you have 2 registration officers on duty. And that's hoping that the machines work the way they are supposed to! Rumours abound of the biometric kits being unable to capture biometric data if their battery charge dips below the 40% mark. Forget about that ease of registration display they show you when they register the President and other high ranking politicians. That is the demo version. You, on the other hand, are guaranteed to have a more tedious and nerve-racking time when you settle down for the process.

However, since this is Kenya, more frustration abounds when people fail to show common courtesy. How on earth do people grow up to be full blown adults and never ever learn to queue properly? People are already on edge because of the length of time the whole process takes, and the usual bunch of hiccups that ensue. Nothing grates the nerves more than seeing someone mosey up to the front of the line like they're entitled royalty. At our registration centre, someone had the foresight to draw up a register to keep track of people's order of arrival. This came in handy because we ended up switching to a larger room, and that kept things from devolving into free-for-all chaos.

The process itself merely consists of having everything transferred from the form to the Biometric kit, having your picture and finger prints taken, and also having pictures taken of some of the documents that you bring along with you. I think it only took 10 minutes to have my stuff over and done with. I can attest that my registration officer was a pretty stand-up guy...but then they did show up at 8.30 am instead of the previously stated 7.00 am.

Anyway, I have a little acknowledgment slip as proof that I've actually gone through the process. It still doesn't change my misgiving about the whole process. I don't really think this will improve anything. Sure there's all that talk of improved service delivery and rooting out ghost workers, but if this was something that was meant to be taken seriously they'd have started out with some civic education. Some people might try to explain it as the Kenyan citizenry being propelled into the future with a new digital number; this will basically save us the hustle of needing a whole bunch of other cards and numbers that are currently part and parcel of our daily lives. In theory, that would seem intelligent...if it weren't for the fact that our ID cards are already a key field item: they are basically the singular item tying us to our passports, KRA pins, NSSF and NHIF cards, and even our driving licenses. Someone may argue that the IDs may not be digital, but then the simpler solution would be for them to issue a New Generation ID card, and make sure that this time it is machine-readable. (the last generation ID card already included capturing of biometric parameters).

The common mwananchi is even more confused about what this new number will be able to do. Thanks to threats from government allied officials, people basically think that they won't be able to get bank cards, or perhaps that they may lose their cell phone numbers, or that they won't be able to register for things like passports (my personal fear). Sometimes in this country, unfounded fears can be something you should really consider seriously. I'm just thinking of the government clerks who will unduly frustrate people using this Huduma number as some sort of sifting criteria. These Hudumu Number cards won't even be ready for the next foreseeable couple of months (at least 3 - 6), and we will still need to use our IDs for most things, but one should never assume government offices are places where sound reason abides.

It's business as usual in this country. We haven't even passed legislation that's guaranteed to protect our data and honour our privacy. The politicians wrongly think that this matter is handled with as much carelessness as they form their political vehicles of the day: come up with the party first, then eventually tack some sort of manifesto and meaning much later on. Too much politics and tenderpreneurship has seen us sacrifice the soul of this nation for the vested interest of a few individuals. Politicians the world over are more likely to implement something new (affording them the chance to attend lavish ceremonies with ribbon-cutting theatrics) rather than retooling or fixing an old FUNCTIONAL system. The wisdom of the old saying still stands:

It is better to measure ten times and cut once than to measure once and cut 10 times

Any sort of critical thinking would convince anyone that this operation is half-baked; why else would they need to resort to the lowest form of manipulation  - intimidation - to get this pushed through? Kenyans are not an abrasive bunch of folk who merely routinely oppose the government for kicks - we can be reasoned with. The courts have tried to protect us from this hasty government decree, but this current government is renowned for ignoring court orders and bulldozing their way forward. The likelihood is that reason and justice will not prevail here.

However, there just might be some light at the end of the tunnel. I believe that the veracity of the data can be maintained beyond this exercise. This Huduma Number can eventually be written out of our collective consciousness, and we can get the ideal ID card we've been longing for. Fundamental to all this would be the fact that we build up a foundation of institutions and systems of integrity that will safeguard the dignity of the people of Kenya, and root out all the "conflict of interest" that is sucking our lifeblood dry. The land and people of Kenya will outlive the prevailing politics and trends of the day, and thus, we owe them something congruent to that. The glow and trappings of new technology will not be our saviour: a culture of integrity and respect for justice is all we really need, and something we will eventually get.

God Bless

 

Avengers: Endgame - "SPOILER" Review

By Eileen Steinbach

SPOILER ALERT!





This movie is a work of art! The Russo Brothers certainly have made some of the best MCU installments to date, but the soul sapping Infinity War was an extremely horrendous gut-punch that left the world (both real and MCU) in a dark place. We just needed to see how things were meant to end. They had to tie up a lot of loose strings.

Gladly, they followed up with Endgame. I am not going to do a blow-for-blow recap of the movie, but I will address some salient points that really stood out to me. I am happy that they put us in the thick of things, pretty much shortly after Thanos' snap: the world was awry, and the Avengers were still scrambling to make some sense of the world, finding some sort of solace in heroics. By the time that arc is resolved (shortly afterwards), they are plunged into true despair, and it is only then, after a well placed time jump (ahem... "Venom") that the mechanics for righting the world finally show up with the appearance of Ant-Man (yep, the Quantum Realm).

The seamless integration of all the various MCU characters started earlier, but cemented in Infinity War, continues to shine through in this movie: the Guardians of the Galaxy (GoTG) roster is basically only Rocket and Nebula, Tony's basically retreated into family life and has abandoned the Avengers (specifically Captain America); Black Widow is basically running point for Avengers operations, Hawkeye has become the anti-hero Ronin, and Bruce Banner has managed to bring forth the Professor Hulk identity thanks to some Gamma experimentation.

Thor has a really sad arc to his story (it's just been a steady decline), but the Russos can't resist the urge to poke more fun at the character, in much the same way that Taika Watiti started off in "Thor: Ragnarok". After the jump, Thor pretty much turns into "The Dude"from "The Big Lebowski" (I managed to catch the "On your left..Lebowski" on rewatching the movie). I haven't even watched that particular movie yet, but I recognized the character immediately he strapped on some shades and a cardigan. They really did Thor dirty!

The movie is not as fast paced as Infinity War in the beginning, but that is certainly not a weak point; Infinity War was pretty much a heist movie that was moving to the beat of Thanos' frenetic plans. This movie is a character study of the survivors, many of whom are dealing with "Survivor's Guilt", the pain of loss, and ultimately DEFEAT. People need to pick up the pieces before they can really become the heroes that we need them to be. Thor is about the worst possible manifestation of how far someone can fall; however, wise words from his mother Frigga end up putting him on the right track.

"Everyone fails at who they're supposed to be. The measure of a person, a hero, is how they succeed at being who they are"

The trippy mechanics of the Quantum Realm gave the directors a wonderful opportunity to reinsert future characters into a lot of past moments with future hindsight as something of a boon. It was also a chance to flesh out some going-ons that were merely glossed over/ segued out of in prior MCU installments. It was great to see that the Ancient One (Tilda Swinton) did her part to protect NY during Loki's siege. It was also a joy to see the Shield/Avengers politics that played out regarding Asgard's jurisdiction with regards to Loki's judgment. All in all, it was just wonderful to see the vast roster of characters - villainous and heroic - that have been a part of this MCU-world reprise their roles, even if only for short cameos. Not only was it great fan service, but any excuse to heap more layers on already developed characters is a worthy endeavour in my books.

As with any movie that focuses on time travel, this movie sought to put its own spin on the time travel trope and put a lot of previous time travel movies on blast (usually through Ant-Man/Scott Lang). It did set us down some confusing paths in the process. I can understand that they returned the Infinity Stones back to the past from which they stole them to preserve the timelines as the Ancient one had hoped. (Definitely couldn't have Dr. Strange "bargaining" with Dormammu without the Time Stone!) But what about them taking Mjolnir away from Thor in his Dark World outing. Mjolnir was pretty important in Thor's battle against an overpowered Malekith. Or are we just meant to consider that Odin might have commissioned "Storm Breaker" to be made earlier in the new setting?

(Addendum: Cap just returned Mjolnir when he went back in time. Y'know, for a moment there, I'd thought that Mjolnir had become his new weapon of choice, but in all likelihood, he returned it just like he did the Stones.) 

Also, they never let us know how Valkyrie, Korg, Miek and the other Asgardians were able to escape from Thanos' clutches between the events of Thor: Ragnarok and Infinity War. I mean, I knew New Asgard was definitely going to be included in this continuity, but they owe us a resolution to that little missing bit of info (along with the whereabout of Lady Sif). It is plausible that he could've just killed half of them and let the other half go, but if they could show us that for Gamora's world, they could certainly have shown it for Thor and the Asgardian remnant. Another thing that was also glossed over was how Thanos was able to steal the Power Stone from the Nova Corps. Infinity War just had a Power Stone wielding Thanos show up to obliterate Thor's ship, and Thor - while talking shop with the GoTG crew - mentioned that the Power Stone was stolen from the Nova Corps and that Thanos would be headed for Knowhere to get the Aether (Reality Stone). It seemed sad that this important event was relegated to the realm of exposition in such a summary fashion. I had hoped that this movie's time travel plot would at least have given us a glimpse into the raid on the Nova Corps

The Black Order is also a very overlooked element; their role was even smaller this time around (though Ebony Maw is an enticing character no matter how little screen time he receives). It would have been insightful to see how they came to serve the mad Titan, but that would have taken this movie beyond the epic length it already had. We know what their final destiny is, but I hope that there are plans to continue to use them in MCU stories about the past - similar to what was done with Capt. Marvel - and that way a full story can be told about the denizens of the Black Order.

Anyway, these few questions/ruminations aside, this movie remains a work of art. We have received fitting ends to the character of Tony Stark and Steve Rogers. Tony suffered character assassination under the reins of Shane Black, but his appearances in Russo movies (Civil War, Infinity War) and Spider-man: Homecoming actually made him a more well-rounded and likeable character; and here, he shines like never before. Cap finally got his last dance, and to live a fully realized and enriched life - no longer that fish out of water. He's handed the Capt. America mantle over to Falcon, but it could just as easily shift over to Bucky (something that's already happened in the comics). It seems like it was curtains for Black Widow, but then we know she has a solo movie in the works; I pray that it contains a team-up between her and Hawkeye, and we can finally get to see the "Incident at Budapest" that they've been referring to since the very first Avengers movie.

Hawkeye and Nebula got the biggest character boosts from this movie. On a team of superpowered individuals, having someone who's merely an olympic-level athlete at peak fitness with no other augmentation means that Hawkeye typically has gotten overshadowed. However, as Ronin, he was very much in his element, taking the fight to street level thugs and handing out summary justice on the fly. Just like Age of Ultron, he now has another death on his hands, and it'd be interesting to see how things progress;  he probably will name one of his children after Natasha...but first we need to see him in a Widow movie. Nebula on the other hand usually had limited range as an angry sneering individual. This time around we see the full switch with her bonding with Tony, and then Rocket, and even becoming part of a team. Everything comes full circle when her present self is juxtaposed against her subservient past. I think she will make a great anti-hero.

As for Hulk, the MCU needs to do him justice. The Professor Hulk is interesting, but he is not the strongest Hulk incarnation there is. Louis Letterier's Incredible Hulk was a travesty to the character, and managed to do much less with the character than Ang Lee's seminal Hulk movie. (Besides have Hulk utter the line "Hulk Smash!"). Perhaps they should consider a similarly serious approach to the character as was the case with Ang Lee; they could always throw in Joe Fixit for added measure. There's a lot to unearth here, and I'm sure the MCU could do it right.

In summary, my biggest highlights from this movie:

1. "On your left"
2. "Avengers assemble"
3. Captain America is worthy!
4. "Hail Hydra"

Strange that they all involved Capt. America. From the applause that rocked the cinema during the first three of these, I think that everyone else in attendance also agreed.

Here's to the close of one chapter, and the promise of a new and better lineup of movies with great stories to tell.

God Bless

Avengers: Endgame - Spoiler-Free Review

By Eileen Steinbach

One does not merely watch Avengers: Endgame and leave without having a life altering experience. This movie has touched my heart so much so that this time around I made sure that I'd have both a Spoiler-Free and Spoiler review for this movie...and I basically ensured this by writing the Spoiler version first. But you need not worry, I won't be spoiling the Endgame for anyone: I would love for everyone to walk into this movie with the little info gleaned from the trailers (trust me, it is very little) and walk out of it with a sense of utter joy and satisfaction.

This was a great companion piece to Avengers: Infinity War. After all the darkness that Thanos' snap introduced into the universe, we needed a whole lot of light to put things right again. Infinity War was basically Thanos 1.0; it was really astounding how a villain who had only previously appeared in a handful of cameos was able to steal the show so easily. In fact, Thanos as a villain is such a complex and compelling character. Similar to a character like the Joker, he is deeply invested in his villainy: in the Joker's case, there is obvious insanity tied to the character, but Thanos comes off as an Obsessively Compulsive individual who fully embraces his psychosis, and takes it as serious business. No laughs are to be had where Thanos is involved. The way they continue to evolve him this time around is as logical a progression of his madness as you'd expect.

This movie is the flip side to the chaos of Infinity War. For this reason, the pacing is slightly slower (only slightly). I couldn't even really call it a "slow burn" because every little bit of the heroes coming to terms with their vulnerability, loss and previous defeat is an interesting character study. You get to see the whole spectrum of reactions from ambivalence to obsession. However, once the pieces start to fall into place, the heroes rise up to the task and make us proud. I guess coming from all those previous wins that they'd had in their careers, it always seemed like winning was an inevitability. Thanos thus became the true litmus test for what it means to be a hero when you are brought down to your lowest point. I guess the best summation for this sentiment comes from one of my favourite movie quotes:

"Why do we fall? So that we can learn to pick ourselves up!"

There is a growth to all these characters that have come to be a part of our lives in this 11-year journey, and that is palpable throughout the course of the movie. I daresay that Hawkeye, who hasn't had that much to do since they introduced him in the first Thor movie, gets the biggest character development from this movie. It is good to see him getting the respect that he deserves, and I've always felt that he should definitely be a big supporting character in the Black Widow movie that will definitely be getting off the ground in the coming future.

The epic 3-hour runtime felt well earned for this movie. If you can sit back long enough to enjoy excellent world-building and storytelling, the time will pass by very quickly. From my previous Infinity War experience, I was peeved about having to watch this type of movie in a theater where kids are in attendance. As if fate was trying to spite me again, there were even more kids in attendance this time around; but, to my shock, they kept it together for the whole show. Their parents must've threatened to disown them if they embarrassed them in public! (Or maybe the movie was just that compelling!)

However, in that last hour, when the action goes down...it goes down (Russo style). Scores in attendance became child-like again, and people were cheering wildly. (When you do watch the movie, you'll understand what I'm talking about!). Having watched this movie twice, I can definitely tell you that it pays to be watching it with a "good crowd". The enjoyment level will be infinitely better for the action scenes. And they bring things to a good conclusion, that'll have you leaving the theater and feeling very satisfied, whether you're slightly teary-eyed or holding those tears on the inside.

I highly recommend this movie as a wonderful time at the theaters for the whole family. A+ movie making and storytelling. It feels just like catching up with an old friend.

God Bless