While a patient may think they know what’s good for them, it’s our job to convince them that we know better
Sue demanded to be seen as soon as she arrived from Zimbabwe. She was escorted from the airport straight to the hospital and admitted in a deluxe room, typically reserved for overseas patients, complete with wooden floors, crisp linen, a recliner for relatives, and a panoramic view of the verdant green racecourse and cerulean blue sea. Its neatness, however, was brusquely defiled by her messy way of unpacking and the acrid whiff of cigarette smoke that made the hair in my nostrils stand on end.
She shoved the cigarette packet under the pillow as soon as she saw me walk in – the kind of thing little kids do to ensure their toy is not taken away. Even though you’ve seen it ensconced, you’re supposed to pretend you haven’t. We exchanged pleasantries and I introduced myself and my team, politely suggesting we open up some windows.
She was in her mid-fifties. Her hair was short and wavy with dry streaks of white and gold. She had a raspy voice, which turned crustier when she began describing her story. “I have this agonizing back pain that shoots down my buttock and the back of my left thigh and calf,” she said, tracing her finger along the site of pain distribution. “It’s killing me. I can’t even walk for a few minutes.” She was operated on her lumbar spine 3 years ago. When the surgery didn’t make any difference, she was recommended another back operation, this time to insert some screws and rods to help rid her of her pain. She chose to come to India to get it done. “Thank you for agreeing to do this surgery; I can’t trust the doctors in Zim(babwe) anymore,” she said matter-of-fact.
One thing I learnt very early in my practice is never to believe what an unhappy patient says of their previous doctor, or, at the very least, take it with a pinch of salt. It’s a trap. It’s their often subconscious ploy to make you feel like you’re the best – which is obviously incorrect. Another thing I learnt (this one fairly late in life) was to accept reality as it is, not as one would like it to be or even as one imagines it to be. This patient’s pain was real. Her interpretation of its source was probably not, even though she had symptoms of sciatica with textbook fidelity.
After examining her carefully, I took a deep look at her MRI, scrolling back and forth on the computer, my discerning eyes scanning carefully. Apart from the tiny footprints of the previous surgeon, there was nothing on the MRI that could explain such agonizing pain. I had to squint hard to ensure I wasn’t overlooking something minuscule pinching on the nerve. The X-rays did not show any instability even when taken in extremes of movement: flexion and extension of the spine.
As artist Richard Avedon says, “All photographs are accurate, [but] none of them is the truth” – a lesson we learn over and over again from social media. The MRI was hers. The X-rays were hers. They were accurate. But did they tell the ‘truth’ about her condition? I needed to look for other causes, as I was convinced she wasn’t faking her plight (which can also sometimes be the case).
I went back to her the next day to say I was certain she didn’t need spine surgery. Her face changed colour, wondering if she had met another duplicitous doctor who was here to disappoint her. “I flew 3,000 miles to have this operation. I can’t stand for 5 minutes – my leg feels like someone’s eating into it – and you’re telling me you’re not going to operate on me? I am not leaving here without surgery. Open me up again, take a look, and see what you can fix. They tell me there could be some scarring. Even if I don’t get better, at least I’ll know I tried everything I could. I think that would be best for me.” She turned around and looked at her daughter, who nodded back in agreement at the finality of this decision.
I understood her despair and calmly asked her to lie down. I needed to examine for other possibilities. I held each of her feet in the palm of one hand. The left foot was distinctly cooler. On closer inspection, the colour too was imperceptibly different. The warmer foot was a rosy pink, while the cooler one was an ashen spectral white. I rolled my fingers to feel the contour of her pulse on the dorsum of the foot and behind the ankle: while it bounded on the right, it was entirely impalpable on the left.
“Smoking has damaged the arteries supplying blood to your legs,” I announced. “They’re crying in pain for oxygen and nourishment. We’ll have to do a Doppler and CT angiography of the legs to find a block that we can open up. I will surely not operate on your back,” I reiterated, this time with an arrogance of finality. But medicine also requires a tender balance of firmness and kindness. “Give me 24 hours,” I requested, “and for anything we do to work, you have to stop smoking now,” I implored.
The angiogram showed a 5 cm occlusion of the left iliac artery, where it branched off from the aorta. There was severe atherosclerosis causing narrowing of the artery. We called a peripheral vascular surgeon who inserted a stent, opened up the vessel, and started her on antiplatelets. Her pain was gone the next day – not a trace of it. “It feels like I have a new leg!” she said with a smile on her face for the first time since she had arrived. “You still want me to operate on your back?” I cheekily taunted. “I’m sorry for being so silly,” she acknowledged, giving me a hug, ready to head back to Zimbabwe.
A while ago, I wanted to present this case at a clinical meeting and emailed her to check on the longevity of our procedure, so that I could be truthful about the outcome. She replied in a single sentence: “Three years, no pain; thank you for not operating on my back.” I smiled, reflecting philosophically on the truth of the adage that what one thinks one wants isn’t necessarily what’s best for you. I had learned so much myself from this one case.
