A canine can sniff out a disease, even before it’s diagnosed, which means that if your pet is paying special attention to certain parts of your anatomy, don’t ignore it

“He kept sniffing my right breast for a whole 5 days,” a 62-year-old lawyer friend of mine was speaking to me about her Labrador, Oscar, as she narrated the story of how she discovered she had cancer. “He even on occasion dug his snout into my bosom to tell me something was amiss.”

Oscar had lived with her for the past 8 years after the unexpected passing of her husband. She had no children and he was given priority over everything, including her high-profile clients who came to consult her at the home office she worked out of. Oscar was always around – attending meetings, briefings, and the mediations that took place in the office – and if anyone had a problem with him, they were explicitly asked to leave. “My dog knows more law than you do,” she had once told a client who requested for the hound to be taken to another room while discussing a sensitive matter.

“So, for the first few days, I simply passed it off as him being horny,” she said in her usual unruffled style. “But he would not let people get close to me and suddenly became very clingy. I could not understand what was going on!”

“This can happen with pets if you change their routine or they are unwell themselves, if they can’t see or hear properly,” I interjected, having heard a few such stories. “But did you check for a lump, could you feel one in your breast at all?”

“No, I couldn’t feel one!” she exclaimed, gesturing animatedly. “I could only confirm that there was something after I went to my doctor and he pointed it out.” The mammogram showed it was the size of a pea, and she went ahead and got it removed in its infancy. This required her to be only on oral chemotherapy, which she has been tolerating without any side effects, and she is currently in remission.

“He really deserves an Oscar for all the drama he created in making you aware of this and prodding you to get diagnosed,” I told her. “Best male actor in a supporting role!” she acceded with a gratified laugh that this was all behind her now.

Dogs have a sense of smell that is several hundred thousand times stronger than that of humans. It helps them detect various chemicals that the body emits when a person is ill; imagine what bad body odour must do to them! With astounding accuracy, a canine can smell lung cancer on someone’s breath, pinpoint a mammary tumour, or detect bladder or prostate cancer in someone’s urine. If your pet is paying special attention to certain parts of your anatomy, it’s time you do the same.

Some dogs can detect epileptic seizures 30–40 minutes before they occur. They can sniff out the odour of a seizure or may be picking up an energy frequency or vibration that the human emits prior to a seizure. Science can only prove what it knows, but animals know so much more. There are organizations that provide service dogs for people with epilepsy, and, in several cases, this has been lifesaving: the reactions exhibited by these dogs before the onset of a seizure has given epileptics valuable time – time to take their medication, which prevents or reduces the severity of the seizure, and time to move somewhere safer, where an injury is less likely to occur.

Based on this research, scientists are trying to build electronic noses that are as powerful as their canine counterparts. As of now, however, e-noses are not nearly half as effective. Dogs have also been able to diagnose the coronavirus with greater than 95% accuracy, and in some countries they are used to screen patients at airports and railway stations. In our country, they ought to be trained to bite those carrying fake RT-PCR test results to travel.

As part of the Zoroastrian funeral rituals, a dog is brought near the dead body to confirm that the individual is truly dead before they are carried away. It also could be that we Parsis don’t trust our doctors fully and need to wait for one final ‘lab’ result. It is also believed that a dog’s gaze is considered to be purifying and drives off demons. The bridge to heaven, our scriptures say, is guarded by dogs.

I recently went for a trek with a bunch of friends. The moment we got out of our car, a handsome German shepherd appeared at the foot of the hill, the kind whose shaggy neck you couldn’t help but jiggle in your palms. He was black, brown, and golden, and had decided to hike with us as if he was instructed to by some higher power. Sometimes he led the way and other times he walked behind, but he never left my side. He growled at others at the edge of the cliff to secure our path. I wondered if he was sent to protect and guide us, and I felt a deep connect with him. We fell in love instantly. It felt as if a part of my soul was awakened.

But this dog kept doing something strange. He kept sniffing my backside.  Intermittently. After these recent stories I had come across, I wondered if he was detecting a rectal cancer, and I freaked out, my mind’s eye imagining myself post surgery and radiation, sitting with a colostomy jutting out of my abdomen. Until it dawned on me that the dog was really only after the scrumptious chicken sandwiches in my bag pack. The moment we reached the top, he wolfed them all, instantly demystifying all the spiritual significance I had given him so far. In his language, I guess I was barking up the wrong tree.

Animals speak to us all the time. It’s we who need to evolve to understand what they are telling us.

Unsteady gait cannot be attributed to old age alone. A detailed neurological examination may help tackle an otherwise reversible problem

A seventy-two-year-old man was escorted into my clinic by his two able-bodied sons, each of them holding their father’s hand and elbow to support him better. He walked with a robotic tightness but with very little control over where his next step would fall. After about 8 minutes of trying to shuffle into a chair, he finally sat amidst a few moans. “Everything hurts,” he lamented. “My neck hurts, my back hurts, and I just can’t walk without support,” he groaned as he tried to adjust himself through his aches. “I feel like I’m walking on cotton wool,” he explained, narrating what many patients with cervical spinal cord compression specify.

“Any other problems?” I questioned. I usually allow my patients to finish saying everything they have to before I ask any leading questions. “My hands are weak and numb, and stuff keeps falling from them; I can’t button my shirt and my handwriting is like a drunk man’s,” he quipped. “How’s your control over passing urine?” I asked. He shook his head sideways and the corners of his mouth drooped with embarrassment at having to talk about it in front of his grown-up boys. “I’m extremely unhappy with my life,” he concluded.

In patients who have multiple complaints, I usually ask them one direct question to help me with my surgical decision-making. “Out of all your grievances, if there is one symptom I could help you recover from the most, what would it be?”

“I want to be able to count my money,” he said without the slightest hesitation, adding, “especially the 2,000-rupee notes. They just keep slipping out of my hand.” To lighten up the conversation a bit, I told him that I faced the same problem, but without any hand weakness to blame.

His MRI showed an overgrowth of bone and thickening of ligament that was compressing his spinal cord from the 3^rd to the 6^th cervical vertebrae. I pointed out to him the pencilling of his cord at those four levels. It was like a tourniquet that needed to be released for his spinal cord to be able to breathe again. Owing to the abnormal curvature of his spine that we could see, I explained why we would need to realign the spine by inserting a few screws and rod to contour it back to an elegant lordotic curve.

Within a few days, he was lying prone on my operating table with his head firmly fixed on a clamp. We use intraoperative neuro-monitoring for these cases that allows us to know if we are causing any damage to the spinal cord, because even a little manipulation in a compressed cord could lead to catastrophe. After cleaning and draping him in the usual fashion, we cut deeply down the centre of the back of his neck and separated the muscle off the bone. We then placed the screws as needed and cut a fine trough on either side of the four vertebrae to lift off the compressing element as a single block. This was executed to perfection but as soon as we decompressed the cord, there was a loud bellow from the back. “We’ve lost all our signals!” the physiologist exclaimed. This, in regular parlance, meant that the patient was completely paralysed – both hands and both legs. My heart sank into my stomach. This is the most unnerving piece of information you can ever give a surgeon in the middle of surgery.

The old man’s words, “I’m extremely unhappy with my life,” struck me even harder because I had potentially transformed that into abject misery. He would be awake but quadriplegic. I remembered something I’d read somewhere: “That’s the thing about unhappiness. All it takes is for something worse to come along and you realize it was actually happiness after all.”

Instead of being emotional and fraudulently philosophical, it was time to recalibrate and see if this could be reversed. I asked the anaesthetist to bring up the blood pressure and we started a steroid infusion. I always pray when I’m in deep shit. Within 20 minutes, the signals reappeared, and my heart began to gently rise back into its normal position. Sometimes, sudden decompression of a chronically compressed cord can result in precipitous changes of perfusion (the passage of blood) to and within the spinal cord. This can be disastrous if not recognized and dealt with immediately. To my absolute delight, he woke up without any damage. He stated that he felt much better, and by the time he was discharged, he said he felt less ‘tight’ and more secure in his balance.

Imbalance while walking is not something that should be attributed to old age and left undiagnosed. Deficiency in Vitamin B12, especially in vegetarians or alcoholics, can afflict the spinal cord resulting in the same imbalance that a physical compression would. Diabetes damaging the nerves can cause one’s feet to burn and make them feel unsteady. A lumbar spine stenosis or even arthritic knees can make it difficult to walk. A disruption in the balance centres of the brain, certain brain tumours, or simply an excess accumulation of fluid in the brain can also make one’s gait unsteady. A detailed neurological examination is warranted before it can be attributed to old age; it would be negligent to miss out on corrective treatment for something that’s readily reversible.

Six months later, my patient walked into my clinic with his two sons, this time without holding their hands. He removed a crisp bundle of 2,000-rupee notes from his pocket and began to count them in front of me – effortlessly and cheerfully. Just when I thought (obviously in jest) that I would be at the receiving end of a few of those notes, he stuffed the stack back and gave me an empty but firm handshake. His grip was better than mine, and the power and function in his limbs were back to normal. And to me, that was priceless.

What does it mean for a doctor to be afflicted with the very affliction they have spent a lifetime treating?

“He noticed an unusual tremor in his hand while operating, and that is when he decided to get himself an MRI, as soon as he finished the surgery,” a friend informed me, speaking about a mentor of mine whose scan revealed a high-grade brain cancer. “For someone who was operating on a tumour the same day it was diagnosed in him, it must have been devastating,” he deduced. My mentor was a renowned brain tumour surgeon, crisp and meticulous in extricating tumours from every crevice of the brain, as he had over three decades. I trained with him a few years ago in North America and we operated for long hours together, me tiring much earlier than him, and I was exactly half his age. He was kind and gentle and revered by all those whose lives he touched.

“It is a sad day indeed when one of our own falls victim to the disease we fight daily,” another senior colleague commented in an email, encouraging the neurosurgical community to send prayers and healing vibes his way for a speedy recovery. It made me wonder what it must feel for doctors to be afflicted by the very affliction they’ve been trained to treat. We know every single hidden truth of that ailment, and more often, the focus is on the negative than the positive, especially if the diagnosis involves a malignancy. We know what can go wrong with surgery, the side effects of radiation and chemo, and, worst of all, the finality of the outcome. And in addition, we are surrounded by colleagues who know the exact same things and yet infuse us with an indestructible spirit of hope, the one we are all expected to portray.

Knowing what we know about death and dying, it comes as no surprise that most doctors would not be willing to undergo the surgery we so effortlessly prescribe to our patients. We know enough about modern medicine to know its limits. And if we have a choice in how to go, we will choose to go gently – not with a tube thrust down our throats and someone thumping on our chests trying to revive a failing heart. I know of a doctor who has had the words DO NOT RESUSCITATE tattooed across his chest.

I wonder what it is that afflicts doctors with the very thing they aim to heal in others, and how it affects them when it does. How does an eye surgeon live the last few years of his life having gone blind? How does a movement disorder specialist come to terms with debilitating Parkinson’s? How does an obstetrician deal with her own miscarriage or a psychiatrist with his own bipolar? How does a spine surgeon recover from being paralysed from a large disc herniation or a vertebral fracture? And yet, it seems harmless and okay to poke fun at a urologist dealing with his own erectile dysfunction or a proctologist who has an anal fissure.

It is possible that there are spiritual laws at play here. There must be a deep karmic attachment to what one desires most in life, and the only way to be truly free is to be completely annihilated by it – a little bit like being in love, isn’t it? That is why when doctors survive an illness, they value the suffering of their patients even more. That is why when anyone survives a critical illness, they view life from a different perspective. Leo Tolstoy once famously said, “One must put oneself in every one’s position. To understand everything is to forgive everything.”

Dr. Madhuri Behari, once the head of the Neurology department at AIIMS, had a stroke while on rounds and was immediately given a clot buster from which she thankfully recovered completely and is still active in practice. In contrast, Dr. Jagjit Singh Chopra, another illustrious neurologist, suffered a stroke while moderating a session at a neuroscience conference; he succumbed in his own ICU, after battling complications of the attack for over a month. Dr. Sorab Bhabha, a benevolent neurologist, passed away from motor neuron disease at the still flourishing age of 52.

The Dr. Ernest Borges road was named after one of India’s greatest surgeons, who spent his life treating cancer at the Tata Memorial hospital; he was struck by carcinoma of the stomach, the very disease he worked so hard to alleviate. Dr. Katy Dinshaw, a leading radiation oncologist who was the director of Tata Memorial Hospital for over a decade, died of cancer herself. Dr. Arun Kurkure, a highly respectable and well-known onco-surgeon, passed away after a two-year struggle with colon cancer. Dr. Nitu Mandke, an eminent city cardiac surgeon, died from a massive heart attack. Legendary cardiologist Dr. BK Goyal, who headed the department at Bombay Hospital, succumbed to a cardiac arrest. Dr. KT Dholakia, a towering orthopaedic surgeon, died after a prolonged illness that resulted from a fracture. The ongoing pandemic has sucked the air out of several intensivists and pulmonologists who fell victim to the virus.

This first of July, we celebrated something called Doctor’s Day. There was an unusual outpouring of love and affection for doctors this year on social media, most of it because of COVID. We were thanked profusely for soldiering the coronavirus war we’ve been fighting, and transiently made to feel like superheroes. And then, as it always happens, a few doctors were beaten up over the next couple of days for a patient who was brought in dead at some hospital and could not be revived. When we are not dying from the diseases we treat, we are dying from injustice and inhumanity and undignified violence – in our country at least.

This year, let’s choose to change things around. Like the famous quote goes, “In a world where you can be anything, be kind.” Don’t curse us; as you can tell, we are already adequately cursed. Instead, pray for us. Pray with us. Pray that we get better in our ability to treat you. Pray that we always do the right thing. And, if you can, spare a few moments and say a little prayer for my mentor as well – a noble man who spent his life healing others. Prayer, if done sincerely, has the capacity to transform, harmonize, and rejuvenate.

“Men die of the diseases which they have studied most. It’s as if the morbid condition was an evil creature which, when it found itself closely hunted, flew at the throat of its pursuer,” wrote a surgeon in a story by Sir Arthur Conan Doyle, a man who gave up the practice of medicine to write stories (for which he was more highly paid) and who, thankfully, died a natural death.

I wonder if I will die operating or writing. Either way, I’ll have a table to lie on.

Restless, devastated and unable to reconcile with their condition, patients often inundate doctors with queries. But, not everything has an answer

“Will I be able to have vigorous sex after surgery?” a robust Parsi gentleman in his late sixties enquired. I had been explaining the procedure for a lumbar spine surgery that would relieve the compression of his pinched nerves. He was in immense pain; his body contoured and tilting to the right in an awkward looking posture gave him some relief. Patients often ask me questions such as how long before they can get back to work, are there any postures they should avoid, will their implants beep while passing through metal detectors at airports, what are the chances of this happening again, was there a possibility that this could lead to paralysis or problems with passing urine or stool, and so on and so forth. I guess, in our community, the priorities are slightly different, or rather, simply elementary. I wanted to understand in some depth his definition of ‘vigorous’ but refrained.

I met him the first day after surgery, when he was completely free of his agonizing pain and walking around like a king in the hospital corridor. On greeting me, he bobbled his head and raised his index finger as if to remind me of the question he had asked me in my office a few days ago. I, in return, gave him a thumbs up. In that single unspoken gesture, I communicated a confirmation that everyone else watching us was baffled by. Two weeks later, he sent me the message “Doc, my back is as good as my front!” followed by an emoji, which suggested he was ‘back in action’.

Some patients have the propensity of asking the same question repeatedly, even if it has been answered just a few minutes ago. A patient who got admitted for surgery the next day asked me, “I have my period, can we still do the cervical spine operation tomorrow?” I reassured her that it was perfectly safe and alright to do so. She then asked the same question to my colleague who would assist me in surgery, the anaesthetist who came in to check on her fitness levels, the nurse on duty, the dietician who recorded her food preference, the janitor lady who came to clean the washroom, and even the ward boy who was left befuddled. Within a few hours, the entire hospital knew that the patient in 1832 had her period.

We have the hardest but most fun times with superstitious patients. “Doctor saab, our pandit has said to do the important part of the operation between  11 AM-12 PM and then between 2 and 2:45 PM… will you?” “Of course!” I say with an ever-pleasant demeanour, wanting to ask if the entire surgical team should simply go for a 2-hour lunch break while leaving his brain open to air. I have replied to so many messages from patients’ astrologers that the word ‘neurologist’ now autocorrects to ‘numerologist’ on my phone.

Another avid Gujrati stockbroker had bought some shares on the morning of his operation for the removal of a tumour from within his spinal cord. As he was being wheeled out of the operating room, I asked him to move his legs, which he did so very well. Then, still groggy and slurred from the anaesthesia, he asked me what time it was. Most patients usually ask how the operation went or how long it lasted, but he was insistent on knowing the exact time. When I told him it was 5 PM, he looked thoroughly dejected, and when I probed a little deeper for why, he lamented, “It’s past 4 PM, I can’t trade on the market anymore today!”

Why did this happen to me? This is the eternal question that most people seem to ponder about and even struggle with. For the longest time as I sought to comprehend how to answer this question for my patients – those who had fractured their spine, slipped a disc, or developed a brain tumour – I used to point at the big guy in the sky or stroke two fingers across my forehead to call it destiny, almost as an escape route. Until, one day, I heard Eckhart Tolle on my drive to the hospital. He says, and I’m paraphrasing here, “Whatever the illness, accept it as if you have chosen it. Always work with it, not against it. Make it your friend and ally, not your enemy, and this will transform your life.” Those who have been able to do this have healed well inside, and soon. But for many others, the struggle of acceptance continues.

Some even have a more arrogant attitude to illness. They say “I don’t deserve this. I have never harmed anyone in my life. I have never done a single bad deed or even told a lie. How can I have cancer?” To this, I simply say, nobody deserves anything. The rich don’t deserve to be rich and the poor don’t deserve to be poor. Mediocrity doesn’t deserve success and extra-ordinary talent doesn’t deserve failure. Princess Diana didn’t deserve to die the way she did, but no one asked if she deserved to be a princess in the first place.

“How we spend our days is of course how we spend our lives,” the prolific American author Annie Dillard wrote in her timeless reflection on presence over productivity. Doctors spend a large part of their day answering all kinds of questions. Often, it’s the same spiel on the surgical procedure, its possible complications, and what recovery would look like. Sometimes, the questions are insightful and make you ponder; sometimes, they are repetitive and make you wander. Occasionally, they are heart-breaking. Periodically, they are accusatory. Consistently, they are hilarious, and that’s what makes up for all the other kinds.

“Will I be able to play the piano after surgery,” a Christian guy in his mid-forties asked me after I explained the need to remove a brain tumour pressing down on the motor cortex of the brain that is responsible for hand function. My reflex reaction was to say “Of course!” but the therapist in me resorted to asking him a counter question instead: “Could you play the piano before surgery?” Very serenely, he nodded his head sideways and said, “No.”

I was done for the day.

There’s a need to ‘recognise, celebrate and salute’ the untiring job of caregiving, which has become doubly challenging in the pandemic.

What would happen were your life to completely turn around in a day? The unexpected and heart-breaking loss of a loved one, the impulsive conception of a baby, the fortuitous reunion with an adopted twin, the unanticipated life-imprisonment for a crime not committed, the prodigious inheritance of an undeserved fortune or the startling loss of all your material possessions, an acid attack or an awakening, the loss of sight or deeper insight… would we be ready if any of these were to happen to us?

A few years ago, my cousin delivered a gorgeous cherubic baby boy. Ours is a family of over a hundred people, so there is no such thing as a contained celebration; the hospital security found it hard to regulate visitors. And then we were given unnerving news. On day 4, just as they were to return home, the baby was observed as having some unusually brief jerky movements in his limbs. He began blinking his eyes unconventionally. His mother knew instantly that something was amiss, and an astute neurologist recognized these to be seizures, or, as we understand them, epileptic fits. An EEG confirmed the diagnosis and an MRI done at one week of life showed an abnormality over the right half of his brain.

“We have to start him on anticonvulsants, and if the seizures cannot be controlled, we might even have to operate to disconnect the abnormal focus from firing,” the neurologist proclaimed. We brought him home on a plethora of medication. “We can’t operate until the child weighs at least 5 kg and is about 3 months old,” I cautioned. “It’s too risky, as this surgery involves some blood loss, and if we can’t replace it, we might lose him,” I concluded, seeing him twitch in front of our eyes. It happened 40-50 times a day, each time damaging a little more of his precious brain.

She gave up a flourishing career to focus on him. She overdosed him on her breast milk so that he would put on the weight required to withstand surgery. She fed him his medication like clockwork. While the phones of other parents are filled with giggling kids, hers was brimming with variations of seizure activity to send to the neurologist so as to adjust his medication. We huddled as a family, consulted with doctors across the globe, discussed his case at various epilepsy meetings, and finally flew down to a centre of excellence in South India for the operation.

“It was overwhelming to see this baby of mine come out of the operating room with a huge scar across his head, and drains and pipes sticking out from every orifice of his body, but the greatest blessing has been that he’s been seizure free since surgery,” she said with a smile that never left her through her stoicism.

They brought him home a month later, but the real work of paddling her canoe upstream had just begun. It was time to get him up to speed with the cognitive development that the seizure activity had taken away thus far. Every single day for the last three years, it has been a routine. She sleeps past midnight and wakes up at 6 AM, cooks his food herself, then wakes him up, brushes his teeth, gives him a shower with a loofah to provide adequate tactile sensory input, gives him towel compressions, and then does a series of vestibular exercises to zone him in. After some breakfast, they go to the terrace to get some sun and indulge in physical play, which, after a few years of diligent work, now includes football, learning how to cycle, running, and crossing obstacles.

Before the pandemic she used to take him to the physiotherapist and occupational therapist 5 days a week, to the speech therapist once a week and do a follow up of all the therapies at home post the sessions. However, thanks to the lockdown its all shut and she’s turned into all the therapists herself learning the do’s and dont’s from each of them and then teaching them to her son.  There are daily vision, oro-motor, sensory exercises to be done. And in all of this she still has to ensure he gets his medication on time.

Evenings is usually sibling play with actions, song, and dance. “I cook, clean, and take care of all my other stuff whenever he’s napping,” she says without sounding exasperated. “And I couldn’t do any of this without the support of my husband and everyone else at home,” she smiled, giving him a huge whack on his back while talking to me. “I’m filled with joy to see our son do the things we always wondered how he’d ever do… and he completes our family in the most unique way.”

While the centre of every illness is the patient, we often tend to neglect the immediate caregiver. We ignore their struggles, assume their resilience, and never pause to ask them how they are doing. We have no idea what they think about in their quiet moments, what their fears and insecurities are. It’s unfair to believe that they don’t need to be fortified no matter how tough they appear. We need to ensure that their cup is always full; only then can it overflow. There is a caregiver in almost every other home of e

very street in every corner of the world who is looking after a child or an adult with the resoluteness of helping them get better. We need to recognize, celebrate, and salute them.

A couple of weeks ago, she phoned me. “Madzu,” as she fondly calls me,” I’ve been having fever and a sore throat for two days, what do I do?” “Get tested for COVID,” I reflexively retorted. “But who’ll take care of my son? I can’t afford to fall sick for a single day.”

“This is your chance to get a vacation. Take some time off, get some rest; you really need it. There are four others in the house and they’ll manage at least half of what you do; it’ll be okay. Go, put your feet up!”

The test result came back positive and she gleefully retreated into her room for a 2-week break after being on duty for 3 straight years. We talked about the music she would listen to, the movies she’d watch, the yoga and meditation she’d indulge in, how she could light some incensed candles and order gourmet food.

On day 2 of quarantine, she called again. “Madzu, everyone else in the house including my son also has fever – and everyone’s tested positive. Vacation over!” she hung up playfully. She was back to tending to her husband, schooling her daughter, caring for her son, and feeding her parents, all without any remorse and with the same fervour and zest I’ve always seen in her. She lives up to Maya Angelou’s famous words: “You may encounter many defeats, but you must not be defeated.”

When all’s not well, surgeons often rely on voices in their head, where ideas and uplifting thoughts are sometimes replaced with self-questioning

“Wake up, Elizabeth, your operation is over; everything went off very well. Now, open your eyes,” I heard the anaesthetist bellow as they went through their routine of reversing the anaesthesia to awaken the patient and remove the breathing tube.

It was an operation to clip an unruptured aneurysm arising from the bifurcation of the right internal carotid artery. I sat in one corner of the operating room writing down the post-op orders, feeling a kind of inner joy as I typed out my notes for having performed a masterful surgery. After I finished, I made a quick dash with my team to round on all our admitted patients, and an hour later, headed to the ICU to check on Elizabeth. I was brusquely informed that she hadn’t been shifted yet.

“That’s strange,” I said to myself, swiftly climbing the stairs that led to the operating room to hear four words from the anaesthetist that no surgeon wants to ever hear: “She’s not waking up.”

The anaesthetist peered right into my eyes. “The muscle relaxant has been reversed, blood gas analysis is fine, but she’s just not opening her eyes,” she finished, looked at me with the finality of not having a plausible explanation for this on her end. This was also her polite way of saying, you’ve done something wrong inside; now fix it.

I went through the steps of surgery in my mind, running my hands through my scanty hair. Could it be because we buzzed a surface vein? Have I taken a perforating artery supplying the hypothalamus in the clip? Did we retract the brain too much? Is the main artery kinked by the clip?

The self-introspection then made way for chatter. Should I have operated on her in the first place? I should have just asked the interventional radiologist to coil the dam aneurysm. She’s a mother of two, have I destroyed her family? Do I really think I have the skill to do these complex cases? Who am I trying to impress? And at whose expense? Better do something before it’s too late. Or is the damage already done? It’s a sickening feeling when someone you’ve operated on doesn’t wake up the way you expect them to. It is literally gut-wrenching; your intestines feel as though they are physically being squeezed.

I looked at the numbers on the monitor and then at the anaesthetist repeating the same words over and over: “Wake up, Elizabeth, wake up – your surgery is over.”

“Raise the blood pressure to 170-180,” I ordered, thinking that some crucial vessel might be in spasm. She transiently opened her eyes, but within a few seconds went back into a deep slumber. We got an urgent MRI done but that was clean; no area of ischemia or infarction. No blood clot as well. The clip was positioned perfectly, and we ruled out her having subclinical seizures too. We shifted her to the ICU on the breathing tube as my gaze vacillated between the monitor and her body lying motionless, when it should have been sitting up in bed and talking to me instead.

The chatter turned to a full-blown tirade. Am I missing something here? Should I call someone and ask for help? Should I just give this some time? What would I do if someone else operated on this patient and I was called to opine on how to proceed? I use this last analogy a lot when I’m in distress: I try and distance myself from the problem at hand and adopt the fly on the wall approach. It’s easier said than done, of course, but all you have to do is zoom out. I remember reading somewhere “The only people who see the whole picture, are the one’s who step out of the frame.”

There is a Chinese proverb that says, “He who blames others has a long way to go on his journey. He who blames himself is halfway there. He who blames no one has arrived.” I was halfway there. The countless permutations and combinations of the infinite possibilities of things that could have gone wrong kept buzzing in my head.

We all have a voice in our head. We tune into its incessant chatter to look for ideas, guidance, and wisdom. Sometimes, these conversations uplift us and sometimes they sink us into the deep, dark hole of despair. Ethan Kross, a renowned experimental psychologist and neuroscientist and one of the world’s leading experts on how to control the conscious mind, has written a book called Chatter: The Voice in Our Head, Why It Matters, and How to Harness. In that he states, “In recent years, a robust body of new research has demonstrated that when we experience distress, engaging in introspection often does more harm than good. It undermines our performance at work, interferes with our ability to make good decisions and negatively influences our relationships.” Instead, he reveals tools you need to harness that voice so that you can be happier, healthier, and more productive. “Chatter doesn’t simply hurt people in an emotional sense, it has physical implications for our body as well, from the way we experience physical pain all the way down to the way our genes operate in our cell,” he warns.

I hadn’t read the book at the time and my head was spinning with thoughts as I stood at the edge of her bed for 3 hours, waiting for her to move just a little. I was following the old age adage of ‘just give it time’ when dealing with this unsettling experience. And so I did – I gave it time. After a long, painful wait, Elizabeth moved a little. And then a lot. She opened her eyes and made chewing movements and brought her arms to the tube as if to denote she wanted it out. We took it out once she was fully awake and briskly obeying commands, indicating to us that she was conscious, alert, and aware.

I am still intrigued about why she took so long to wake up – Probably it was a tiny artery that went into spasm but opened up later. But the relief of shifting her out of the ICU the next morning and then home with the family in a few days was intense. Finally, there was no one to blame.

Why becoming a successful surgeon requires the same grit and dedication expected from a married couple, negotiating complexities of love and loss

“Neurosurgery should be your first wife, not your mistress,” a patriarch old-timer neurosurgeon was famous for telling all married resident doctors interviewing for a post-graduate training seat in the specialty. “And if you’re not married,” he used to caution, “it’s better to stay that way. It’s very hard for a relationship to blossom in the stressful environment of a residency program.” Those who interviewed for the post pretended to accede to his suggestion, although most married as soon as they got into the course – with varying outcomes, of course.

A vocation does need the exact kind of commitment one seeks from a marriage. You have to be imbued with grit and gumption. Our vocations (not professions) give us purity of desire and unity of purpose. “If you really want to make a wise vocation decision,” writes David Brooks, “you have to lead the kind of life that keeps your heart and soul awake every day.” In my opinion, this also applies to the decision of marriage. What you do for a living and whom you decide to marry would probably be the most important decisions of one’s life. But these too are not set in stone. You can course correct anytime. I know of doctors who have switched to politics, engineers who’ve turned actors, businessmen who’ve become monks and monks who’ve become millionaires.

A vocation, like a marriage, is a cure for self-centeredness. You are devoting yourself to a cause that’s greater than you. You tend to see how your patient or partner will benefit from you, rather than the other way around. And mastery in both requires that you do the same thing again and again, with the belief that it gets better and better. Like the big man Aristotle once said, “We are what we repeatedly do.”

Passion is the key element in both a vocation and marriage. When we were kids, every aspect of my life had a surgical correlation, as my dad, a surgeon himself, was so passionate about the vocation. “You have to learn to eat with a fork and knife,” he badgered us at every meal. “How else will you lean to be a good surgeon?” He taught me to use both hands simultaneously for everything. Often, food items on the dinner table were linked to tumours and other malformations we could correlate surgical pathologies with.

I later deciphered for myself that the art of diagnosis in medicine also lends itself to marriage. You look at a tumour on an MRI the same way you look at a potential life partner. Is it smooth at the edges or jagged? What does it do to the structures around it – just push them a little or encase them completely? Does it seem aggressive or peaceful? But most importantly, you ask, what does the core look like – is it solid or mushy? Is the tumour telling you the truth about itself and are you able to understand where it comes from? What feeds its soul?

You then understand and assess your own ability to handle such a case. Is this something you can operate on or need to refer to someone with greater experience, skill, and insight? Because while in most cases perception matches reality, on occasion, you can be surprised. What you think is benign sometimes turns out to be malignant, what sometimes seems ghoulish turns out to sweet and simple, or, like my kids would say, easy-peasy.

Often, you struggle through the entire operation but in the end, that struggle seems worth it. Rarely do you get into a tumour and very quickly realize it’s best to back out. Usually, you follow the middle path, and even if it’s hard, you keep at it. You work on it piece by piece wondering where it’s going to take you. You’re scared of injuring the wrong nerve or buzzing the wrong artery. If you want to give up somewhere in between, your assistant will goad you, the anaesthetist will encourage and egg you on some more, but after giving it all you’ve got, you realize that’s its best for both you and the patient to stop at this stage to avoid any further damage. Your patient came in smiling; you want to ensure they go back the same way.

Because, at surgery, just like in a marriage, you don’t want to have a complication you can’t get out of. “A failure”, says Atul Gawande “does not have to be a failure at all. However, you have to be ready for it. Will you admit when things go wrong? Will you take steps to set them right? Because the difference between triumph and defeat you’ll find isn’t about willingness to take risks, it’s about mastery of rescue.” The best doctors and hospitals don’t fail less, they rescue more. In my opinion, the same logic applies to marriages. We all need the ability to face complexity and uncertainty. Which means we all fail.

Primum no nocere is the Latin phrase that means, “First, do no harm.” In some variation, it is part of the Hippocratic oath that medical students take when becoming doctors. More than “Till death do us part,” I think, “First, do no harm” is a befitting marriage vow.

“We did the small things right,” said a famous team of surgeons after separating a pair of twins, conjoint at the head, over several staged surgeries, each lasting 24 hours. I believe these are the exact words most couples in long and joyous marriages use.

However intrinsically beautiful an operation is or how nightmarish it eventually turns out to be, whether you get into it with faith or fear, whether you come out of it smilingly or scathed, whether you end up hurting or healing, a few hours of complex surgery is like the years one spends in a marriage. After all, blood is involved – sometimes someone else’s, sometimes your own.

All of us have a protective mother that nestles inside us. This Mother’s Day, we salute her resilience and valour.

“We have a 50-year-old man with a large haemorrhage inside his brain and he is unconscious,” came the call from the emergency room. I ran down to the casualty and made an entrance (Hindi movie style) to speak to the family. Sometimes, doctors like to do that, pretend they are important. We push hard on doors, we ring the bell twice, and we take the steps instead of waiting for the elevator. We believe that by doing this, perhaps we can salvage the calamity at hand – and my gosh, how wrong we are sometimes.

“He was watching television when he complained of a severe headache. Before I thought of getting him a paracetamol, he fell to the ground and collapsed,” said his wife, looking nervous amidst the heightened activity around him. I shone a torch in his eye and noticed that both pupils were reacting, but that the right one was larger, a sign that we needed to rush him into the operating room. After I checked that he wasn’t obeying any of the simple commands – a straightforward way to assess consciousness – I dug my fist into his chest in a way to check his response to deep pain and he brought his hands to stop me from doing it, an indicator that he wasn’t completely stuporous.

I scrolled ardently through each slice of the CT scan to discern if there was an underlying pathology for the bleed and suspected it to be the rupture of a right frontal arterio-venous malformation. “We don’t have time to do an angiogram, so let’s see what we find when we open,” I instructed for a swift transfer to the operating room. Within the hour, we had made a large incision on his head shaped liked a question mark. We call it the question mark flap because we often don’t know what we might find inside. We removed the bone flap in a set of quickly mechanized moves, with my assistant and me making the best use of four hands working simultaneously. Surgery is like ballroom dancing; it’s romantic no matter who your partner is.

The dura, which covers the brain and is often crumpled and leathery, was stretched thin to the point of rupture. Usually opaque, it distended such that its silvery white hue had turned transparent, enough for us to see the underlying brain that gnawed angrily at us the moment we cut into it. The brain was under so much pressure that it jumped up a few centimetres and seemed to settle only once we zealously and expeditiously removed a large chunk of the clot. We circumferentially coagulated all the arterial feeders supplying the malformation and finally the abnormal vein that entered the dural venous sinus. The brain looked so much nicer at the end of surgery as compared to before we started. The dura breathed gently as it lay over the now soft and pulsating brain. We kept the bone out in sterile storage; to place it back over the brain a few weeks later, when the brain regained normalcy and the patient was better.

The dura mater, Latin for tough mother is a thick durable membrane that covers the brain. The dura mater is the mother of the brain: mater, rooted in the universal maa, means mother. The primary function of the dura, akin to that of a mother towards its child, is to protect the brain – and what a fabulous job it does of that. Like a mother for her family, the dura guards the brain’s internal environment.

When there is an impact to the head, the dura takes the first brunt, shielding the underlying brain no matter what its age. Over certain parts of the brain, the dura folds over itself to add an additional layer of protection. When certain tumours grow within the folds of the dura and reach ginormous sizes, it almost never gives way by thinning itself out, ensuring that the baby within is not hurt.

The current wave of COVID has unleashed a deadly fungal infection: Mucormycosis. This fungus is seen a few weeks after patients have received steroids to treat their COVID associated pneumonia. It travels up from the nose and decimates the nasal structures, often infiltrating the eye. Were it not for the defensive barrier that the dura provides, almost each such patient would have been dead by brain infiltration from this ghoulish adversary. Like most mothers, however, the dura also has an endurance threshold: at some point, it needs to give way for the child to realize what it is capable of. While it is an extraordinary saviour, it is also a tough teacher.

The dura has venous lakes and channels (sinuses), which carry blood from the brain to the heart. This covering extends all the way down to the spinal cord. It holds cerebrospinal fluid, or CSF, with sanctity. If there is a spontaneous tear in the spinal dura, the CSF can leak out leading to severe headaches, as it is this fluid that maintains the buoyancy of the brain. This kind of headache gets better only on repairing the leak, but some say even after lying down or, strangely, after drinking coffee.

A few weeks later, once the gentleman had made an excellent recovery, we brought him back in to replace the bone. The dura had refashioned itself healing beautifully, a sign of resilience and inner fortitude, just like the mothers we know. We put the bone back as if to say thank you, because those who constantly defend us sometimes need to be shielded too.

So, this Mother’s Day, I wish my mother, the mother of my children, and every mother in the world a happy and awakened Mother’s Day. Whether you are a literal mother or a metaphorical one, the mother of a child or an adult, a pet or a zoo, a home or an organization, you need to be aware that you are our protection and our nourishment. If you are intact, we are safe. Stay strong, stay superb!

Don’t say, ‘forget it!’ when you repeatedly forget. It demands brain imaging and some lab tests to see what’s messing with your memory—blood collection, tumour, thyroid or simple B12 deficiency 

A septuagenarian couple was seated in my consulting room. The wife started to talk as soon as she caught her breath. “He’s been forgetting a lot of things these days,” she complained. “He doesn’t remember what he’s eaten this morning or how much money he withdrew from the bank the other day.” She sounded a tad exasperated of taking care of him.

“Does he remember past events like which school he went to, his wedding date?” I questioned, hoping to give him some brownie points. “March 31, 1975,” he shot back, putting a gentle smile on her tired face. “He fumbles a little in his speech as well, I’ve been noticing.”

I asked him to close his eyes and stretch his arms out straight in front of him, parallel to each other with palms facing the ceiling as I demonstrated the action myself. After a few seconds, I noticed his right arm drift downwards while his left was able to resist gravity. I explained to them that this was probably owing to something pressing down on the left side of his brain.

“Do you drink?” I questioned innocently to postulate a diagnosis in my head. Husband and wife looked at each other and then at me. He shook his head sideways and she, up and down. “A few pegs a week doesn’t classify as drinking,” he reasoned.

I asked them to get a CT scan done right away on the ground floor, and within the hour they were back at the clinic. “It shows exactly what I expected,” I said with slight cocky arrogance, even though most of the time that I order a scan for forgetfulness, it usually comes back normal. “You’ve got  a chronic subdural hematoma,” I stated, describing it as collection of blood between the bone and brain and probably responsible for his symptoms. “You must have bumped your head somewhere without realising it,” I continued, explaining that this can happen in the elderly even without any definite trauma. The brain atrophies with age and if a tiny vein between the brain and its covering (the dura) snaps, it can cause blood to accumulate over time and cause this symptom. “It needs to come out,” I concluded, even before they could ask how we should go about it.

The next morning with zealous quickness, we made two small incisions on his scalp and drilled two holes into the skull, a few inches apart, following it up with a cut into the dura. Dark altered blood emanated under high pressure. Although this is technically the easiest operation in our field and I must have done several hundred by now, I’m excited every single time I cut into the dura. With the delectation of a child, I’m eager to see what comes out. Each time the colour of the blood has a varied hue of red, it jets out at a force that’s different every time, and the underlying brain is at disparate distances from the bone. I often joke with my dextrous orthopaedic colleague that this is one neurosurgical operation I can teach him to perform, because all it involves is drilling a hole into the bone.

After ensuring that all the blood was out, we closed in the usual fashion. The next morning, his absentmindedness was gone, and at dinner, he was crisply responsive about what he had eaten for breakfast and lunch.

Dementia is a collective term used to describe various symptoms of cognitive decline. Forgetfulness is a symptom that plagues all of us at all stages of our life. As physicians, we need to discern which patient needs an MRI, or more importantly, in which cases can this condition be reversed. As the French philosopher Montaigne pointed out, you can be knowledgeable with another man’s knowledge, but you can’t be wise with another person’s wisdom. Surgical wisdom is just as hard to attain as the spiritual one.

In my opinion, any elderly patient who has a recent onset of forgetfulness should have their brain imaged. While blood accumulation is not uncommon, on occasion, I have also found tumours in the frontal lobe—the area that aids in planning, execution, processing feelings, and memories. I’ve also picked up an extra accumulation of fluid in the ventricles, which, when drained, reverses these symptoms. More importantly, forgetfulness is commonly seen in those having deficiencies of Vitamin B12 and low thyroid levels and can be easily reversed by supplementing them. So, before we start prescribing pills for dementia, let’s try and take a look at what’s going on inside; also because there’s a high chance your patient won’t remember taking the pills!

“How do I keep my brain sharp?” a lot of people ask me. “Clean living and keep moving” is my standard response. There is really no rocket science here. Exercising, healthy eating, a bedtime routine, sound sleep, yoga, meditation, and expressing gratitude is what every single self-help book will tell you.

The other day, three lovely old ladies came to take the vaccine at my hospital. They were in their 80s and I had made arrangements for them to be taken care of, as one of them needed a wheelchair. I came down to visit them in the waiting area where they relaxed for the mandatory 30 minutes once they took the jab. “Hi!” I said, happy to see them dressed in nice floral skirts, their faces powdered in the characteristic way that elderly Parsi women step out in the afternoons. “Can you give me some medication for my memory, please?” the one in the centre said. “I’m forgetting a lot these days.”

“And she fumbles with her words too,” her friend added.

“This COVID is driving us insane,” the first justified. “It’s so depressing. Plus, we live alone. What if we get it? There are no vibrators available anymore!”

There was a delightful silence. I know she meant ventilators, but I didn’t have the heart to correct her, I wanted to enjoy the moment. Also, I don’t judge.

While laughter is said to be the best medicine, a recurring one, without rhyme or reason, might just be a cause for concern

I GOT a little worried when he started laughing at his brother’s funeral two weeks ago,” said a concerned wife, as Rusi, her 55-year-old husband, sat in front of me shaking his crossed legs with his hands clasped on his belly. He wore a chequered shirt with a grey pant that complemented his pepper hair, and a confused look for why everyone was so perturbed about a few laughs.

“The other day, our cat had diarrhoea and defiled our expensive Persian carpet, and all he did was sit on the couch and laugh.” “Not only has it been ruined, it doesn’t smell as good anymore either!” Rusi added with a huge grin followed by a cachinnating guffaw.

“See, isn’t this ludicrous,” she pointed, almost instructing me to fire him for having switched from being a caring and loving man to a callous embarrassment. “He chuckles at old people being unable to cross the road. He laughed so much, he snorted when I mentioned to him that our son and his wife got COVID-19. He has started behaving like that man from the movie Joker.”

“Not the Raj Kapoor one!” Rusi interjected as I burst out into a bit of a giggle myself. “Yes, the actor whose name no one can pronounce properly,” his wife concluded with exasperation, as she pulled out an MRI scan of the brain that their family physician had ordered.

“So, he’s laughing at all the wrong things,” I said, summarising her woes as I plugged in the MRI into the luminance of the X-ray box, “and this is why.” With the back of my pen, I went on to circle a 3.5-cm tumour arising from the trigeminal nerve and pressing onto the brainstem. “A tumour in this location is  known in extremely rare cases to produce pathological laughter,” I explained, as they looked at me befuddled. “We’ll remove it and he’ll be fine,” my confidence coming from seeing a similar outcome in my training days of this common tumour with an arcane presentation.

A couple of days later, we tucked under his right temporal lobe, drilling into a little quadrant of bone obscuring our vision. Neurosurgeons take a look into the glistening opalescence of the brain every day, but the view is a tad different on each day. The brain is a variant shade of beige-pink, the nerves a diverse spectrum from white to yellow, and the corridors to access these tumours keep changing, making it a wondrous journey into enthralling nooks and crannies. There is a new treasure to be excavated every day. “Can I cut this?” is the commonest question I voice aloud to the amusement of the team watching the surgery on the big screen. Most often, you know what you’re about to cut, but on occasion, you end up nipping something you can’t identify in the hope it’s a part of nature’s abundance.

We peeled the tumour off the nerve it originated from, and when we removed it completely, the dent it had made on the brain stem gently ballooned back to take its original form. “You think he’ll stop laughing after surgery?” I indulged my assistant as we closed, a time of the operation where we resort to prosaic yet philosophical questions of life. “I think he has a great sense of humour; your surgery is only going to ruin it for him!” came the reply.

The morning after surgery, when neurosurgical patients are fully awake and alert, we check if they are oriented to time, place, and person, and do a thorough neurological examination to check for motor or sensory impairment, seeing if things had become better or worse. In Rusi’s case, we needed to say or do something strange to see if he laughed. “We’ll leave that for his wife to assess, after she spends the whole day with him,” I decreed as we wrote orders to transfer him out of the ICU and into the ward, which deemed everything was perfect.

Two days later, we got a call from the emergency department about a 67-year-old lady who began crying violently and inconsolably for two hours after a glass of water slipped from her hand and smashed to the floor. On checking further, we realised that she wasn’t hurt nor did the glass have any emotional value for her. The psychiatrist who was called in to opine was also confused. Our astute neurologist ordered an urgent MRI that showed a stroke in the left thalamus. She was administered a clot-busting drug and we could see her tears dry up as the last few drops of medication emptied into her veins.

Pathological laughter and crying are uncommon manifestations of common neurological conditions. They don’t have a motivating stimulus nor are they triggered by an impulse that would not have otherwise led to this reaction. Scientists term this as “emotional incontinence” and it is often seen in patients with amyotrophic lateral sclerosis, a form of motor neuron disease. We have also seen this in patients with multiple sclerosis, Parkinson’s, and in some brain tumours.

We went to check on Rusi on the day of his discharge. I could hear a roar as I knocked on the door. “We haven’t cured him, have we?” I turned to my colleague. “Hi Doc,” he smiled as the door opened. “Is he still laughing at stuff he’s not supposed to?” I turned to his wife. “Nothing crazy so far,” she said, her hands folded in gratitude. “Then what was he laughing at when we walked in?” I asked, my curiosity piqued. “Someone sent him a neurosurgeon joke!” “Let’s hear it,” I said, preparing myself to be embarrassed.

“How many neurosurgeons does it take to change a light bulb?” he asked, and then followed up with the answer after a sly grin from me. “Just one: he holds the bulb and the world revolves around him.” I smiled, shaking my head at the comical impression people have of us, but appreciating the humour nonetheless.

The next time you see someone laughing nonsensically, don’t hesitate to get a scan on him. If the scan is normal, you can safely diagnose him to be Parsi.