The patient always comes first, but to deny that doctors are human would be foolish. The last over of a test series against Australia caught in the OT proved it 

AIYYO!” the nurse exclaimed, as I heard something simulating the sound of wood falling to the ground in the operating room. A neurosurgeon knows that reverberation with certitude when he hears it. To most of us, this has happened at least once in our training. And trust me, once is enough.

When it fell for me, over a decade ago, it gripped me with an intense fear of being circled by a python and suffocated by its constricting squeeze. You freeze from the momentum of that strike—not from concern about what will happen to the patient but what you’re going to tell the boss.

It’s not the metallic clink of an instrument dropping or the robust thud of a plastic saline bottle slipping from the IV pole. It’s the unnerving softness of the bone flap hitting the floor. It’s a part of the patient’s skull that is sawed out during a craniotomy—to be replaced once the brainwork is over so that the skull may retain its conventional form. And if it has fallen to the floor by accident, it’s not something that you can impulsively pick up in a five-second technique similar to what I use with my kids for edible items that land on the floor.

This is akin to a baby slipping out of an obstetrician’s hands soon after delivery. A piece of a patient’s body that is supposed to go home with the patient is suddenly lying on the floor in front of you. The nurse looked at me with her eyes welling up. In this case, I was the python. Life is a cycle, I thought to myself. Sometimes you are the pigeon, and sometimes you are the statue. I pardoned her and asked for the bone to be kept aside, because luckily, our plan in this case was not to replace the bone, but to tuck it into the abdomen until later use. This surgery was being performed for a hypertensive haemorrhage with malignant brain swelling, and the bone was to be replaced only a few weeks later.

In other cases, however, where the intention is almost always to replace the bone, one either disinfects it with betadine or autoclaves it and then puts it back (albeit with an added risk of a postoperative infection) or otherwise restores the contour of the head with a titanium mesh. “What will you tell the family, sir?” my assistant asked wryly. “If there is one guiding principle when you leave this hospital after finishing your training with me, it should be…?” and I stared at him waiting for him to complete my sentence. “Always speak the truth,” he muttered underneath his mask. It may seem like it’s the most onerous thing to do, but it almost always calls for worthwhile outcomes. After surgery, we went out and spoke to the relatives together, explaining to them what had happened and taking full responsibility, and they were simply happy that he was alive.

Patients often ask me how many such cases I have handled when they see me in my clinic with a brain or spine condition. What my successes and failures are. Am I lying when I say a couple of hundred—because that allows me to play within a span of 900. What should younger surgeons say when they’ve only assisted tons of these cases but never actually performed one independently? If I were to say this is my first time handling that specific medical condition, would any patient show up to the party? Truth and transparency (sometimes with a little tact) with patients, however, goes a long way in building trust.

Occasionally during spinal surgery, we may inadvertently cause a spinal fluid leak. Even if we’ve sealed it well, I make it a point to mention it in the operation notes and tell the patient about it. It can often rear its ugly head a few days or even weeks later, and if the patient is being treated elsewhere later for any reason, the treating physician ought to have a detailed account of what transpired at surgery for optimal management.

I once cemented a fractured vertebra of a 70-year-old man. The needle, positioned accurately, transgressed right through the osteoporotic bone into the chest. This happened because I had to use some additional force to inject the rapidly solidifying cement. I removed it in a flash, but it could have punctured his lung or, even worse, his aorta, and he could have died on the spot. Luckily, nothing happened. He was discharged the next day and several years later remains pain free. Every time I see him, I debate if I should tell him what happened at surgery; I wonder if I’m not honouring my own guiding principle.

Not long ago in January 2021, I was operating on a complex brain tumour at 4 o’clock in the afternoon and the buzz in the operating room went up a few notches. Suddenly, the entrances and exits of people become a little quicker; there was palpable energy in the room. The anaesthetist bumped up the volume on her cell phone and I hear cricket commentary amidst the beating of the monitor. I paused for a moment and turned my gaze outside the microscope, enquiring, “Guys, what’s going on? I’m insides someone’s frontal lobe! Can we have the volume down in the room please?” “India is on the brink of a historic test series win against Australia—6 runs to win in three overs, but only three wickets to spare!” came the retort with no regard for my request.

For a change, I didn’t want to be a party pooper, and as I wasn’t at a critical stage of the operation, I packed the cavity with some cotton patties, stood up, and walked towards the phone while keeping one eye on the huge monitor displaying the surgical field.

“Let’s all watch the last over peacefully,” I said to everyone’s relief. After about eight minutes, a boundary commenced celebrations and everyone’s smile could be seen beyond their masks. “And now, can we get back to some surgery?” I taunted with a grin. We removed the rest of the tumour much faster than we expected and the patient made an excellent recovery, but should I have told him of the little fun we had while his head was open?

When I think back on these incidents, I am reminded of how doctors are, after all, human. They may seem indestructible—but they feel and care just like the others, they are excited by the same passions that drive the rest, and make mistakes and create miracles just like everyone. To be a doctor is to know when to rise above it all and treat someone with singular focus, putting the patient’s dignity and one’s own ethics above all else.

 

 

A whole year of being emergency doc, potential Covid prey and responsible Mumbaikar makes me realise one year into a pandemic is that all we have is “this”

WHAT insight did you gain from one year of the pandemic?” I asked family and friends as we dipped crisp Parle G biscuits into hot pudina chai, sitting on a swing on the outskirts of the city. We had taken off for a weekend, ironically, after a year that seemed to be full of only Sundays.

“I realised I have more than enough,” my mum said proudly.

“I understood the value of being self-sufficient,” said another, who used to have five house helps, with his wife chiming in with “but some corners of the house are just impossible to clean!”

“There was nowhere outside to go. So, the only option was to look inside, and it turns out, there were many more corners to clean there,” another one professed with perspicacity.

“COVID covered our faces but it forced us to look into each other’s eyes,” introspected another with some sagacity.

“Life is complicated and unexpected, and we should be okay with that,” concluded someone else.

Yes, my people are more interesting than I am.

The COVID-19 phenomenon has been truly global. It has stirred every corner of the world in a way no one alive has experienced before. There wasn’t a business that was not impacted, an economy that wasn’t jolted, a relationship that wasn’t tested, and an industry that wasn’t affected; the spectrum of change vacillating from woe to wonder. The veil of our inadequacies was lifted and a mirror placed in front of us, which kept cracking as each month of the lockdown progressed. For some, the mirrors eventually shattered, while others allowed for the light to come in through the cracks.

One would imagine that the entire medical fraternity would have been preoccupied with an illness of this magnitude, but that wasn’t the case. While physicians were at the forefront to begin with, surgeons stepped in when we began to experience macabre complications of the virus that could be solved only by the knife. Endlessly tired, people just wanted to overcome the problem and make it go away. But the truth, taught by each wave of COVID-19, is that things don’t really get solved. They come together and then fall apart. They come together again and fall apart again. And in the midst of this strangeness, we had to make room for all our emotions: grief, sorrow, misery, relief, and joy.

The staff at the Wockhardt Hospital which I am associated with, faced a bit of a predicament in the nascent stages. In a series of unfortunate events, close to hundred of them were infected. We had to transport existing patients to other facilities, quarantine and treat our own personnel, shut the building down, and refurbish and open it up to treat only COVID-19 patients. Most of the staff pugnaciously returned to work, donating their resplendent and rich plasma for patients for whom it was valued more than its weight in gold. Having treated over 3,000 cases, our mortality rate for COVID-19 was nearly half when compared to the average of other hospitals in South Mumbai. Stories of courage and resilience continue to satiate our corridors; there is seldom a day we go hungry.

While this malady has set into motion a train of misfortune, the most tragic derailment—especially for doctors—is that it has taken away the comfort of touch. The joy a patient experiences when you bend forward and hold their hand while they lay in bed on the day after surgery, or when you help them up and make them walk for the first time since, can never be equalled by simulating the sequence on a flat screen, even if you do light it up with a panoply of emojis. A pat on the back, an arm around the shoulder, a simple hug is what COVID-19 has taken away from us. Now, when we meet friends, even those we know well, we hesitate before greeting them: should we shake hands, bump fists, or nudge elbows? There is an awkwardness in the way we greet—an absurd but amusing oddity.

When patients see you in the clinic, they expect you to touch their lumps and bumps, press where it hurts, straighten out what’s bent. They want you to shine a torch in their eyes and have you look inside their mouths and say “Aaah!” even if it’s a backache they’ve come to see you for. Those who need surgery give you permission to examine them when they are awake, to discern if you will do justice to them when they will be asleep. It’s unfair to those who were operated during the lockdown; we recognise them only from the scars we’ve left behind.

The stethoscope was invented in 1816 by a French physician who was too embarrassed to put his ear to a female patient’s chest to listen to her heart and lungs (as was the norm at the time), opting, instead, to roll 24 sheets of paper into a cone to create some distance between them. To say that a few doctors might not be too happy with that invention is simply a matter of jest. But touch not only examines but also heals. Even prior to the pandemic, some of us were guilty of treating images and not patients, not examining patients in depth, not talking enough to the relatives. The already-existing chasm between doctor and patient was cleaved further by COVID-19. We hope that with time, we will not only be able to touch again but also feel more deeply. Until then, there shall be a sense of impending ‘Zoom’.

Everyone’s lives now have an element of Zoom to them. Doctors have transitioned to seeing patients online, and it works better in some specialities than others. I’m guessing gynaecologists and urologists must be having a really hard time; I’m blessed to deal with the brain and spine—parts of the body that are easily dealt with online and offline. With the vaccine being rolled out, the fear of walking into a hospital is being alleviated, and with time and experience, we have mastered for our patients to feel safe and assured. Everyone who can must get vaccinated for us to move on.

The one question that still plagues me is this: On a universal scale, did COVID-19 do more good or bad? The ones who lost loved ones will undoubtedly and unequivocally state, ‘bad’. The ones who spent this past year learning more about themselves and what they really needed from life might opt for ‘good’. But there are also those who don’t know yet because they continue to battle—the virus, their anxiety, their fears for the future—and who knows what the future might bring? And then, we have those who acknowledge perhaps the most important truth of all: There is no such thing as good or bad, there is only what is.

Maybe we’ll know the answer another year from now, maybe it’ll take us a decade, or maybe we won’t know at all. Until then, in the words of Ram Dass, be here now.

 

 

 

The story of a 90-year-old who arrived with a compression fracture in his vertebrae is a good example of how doctors shouldn’t sell surgery, even if in their favour, but get patients to buy it.

“My father has not been able to get out of bed for over 2 months,” lamented Jagdish Sanghvi, as his 90-year-old dad lay helplessly on a stretcher that jutted obliquely into my consulting room. In his tenth decade of life, the old man had a full mop of dishevelled silver hair and a perfectly curated face that wrinkled every time he winced in pain at attempts to adjust his recumbent posture. “He had a fall 8 weeks ago and has been unable to walk since then,” continued Jagdish amidst short ragged breadths and heaving sobs. I let him talk, handing him pieces of tissue and placing a glass of cool water on the table.

I have never been uncomfortable watching men cry in front of me. I, too, have cried when the occasion demands it. It’s a basic expression of grief across all ages and sexes. Why should stoic men be exempt from expressing it? Jagdish must have been in his mid-60s and was unable to comprehend how his completely independent father, while remaining cognitively crisp, was reduced to frail dependency within a few weeks, physically worn out from the pain in his mid-back. I gently got him on his side and started pressing his back lightly, eventually reaching a point where it unleashed such an intense scream from the injured man that it got a few nurses running into my room. The area I had palpated corresponded to a compression fracture of the tenth thoracic vertebrae that was lit against the luminance of the X-ray box into which I had plugged in the film.

“There it is – that’s the cause of his problems, ”I told the son excitedly, pointing to a slightly collapsed triangular vertebra compared to the healthy and nicely squared others. I completed the examination noting the strength in the patient’s legs, which was good. He wasn’t moving only due to the pain. “The family doctor said to just keep him comfortable, that no surgery should be attempted at this age, so we’ve kept him home, but this is only getting worse and hence we came to see you. The medication or physiotherapy is not helping at all,” he finished in a fresh burst of uncontrollable weeping.

Both father and son had lost their wives and were each other’s only pillars of support. The son bolstered the father physically and the father was his son’s emotional strength; even through his own pain, he had a sympathetic smile on his face, silently conveying to me that it was his son who really needed to be taken care of and not he.

I explained to them vociferously that surgery was a very good option in his case. All we needed to do was inject some cement into the collapsed vertebra and fortify it; the heat generated from the cement would then numb the nerve endings in the bone that generated the pain. “We can do this under local anaesthesia,” I implored, setting to rest a gnawing concern of theirs. There were apprehensions about his age, him being able to lie awake on his belly for the entire duration of the procedure, management of his high blood pressure and diabetes… I navigated all their copious questions and got them to finally agree on surgery.

“You must never sell an operation to a patient,” I remember a professor once telling me, “you must get them to buy it.” And more often than not, this is a philosophy I adopt, simply laying down the pros and cons and allowing the family to decide. But sometimes, when you have a cogent solution that will almost certainly relieve your patient of their malady, the only reasonable thing to do is to be unreasonable about it and goad them into making the right decision. The elderly are an extremely valuable asset to our community. They bring with them a grit and grace, a courage and compassion that comes with the wisdom of living a long life. There is a lot to learn from them. It is our moral obligation to care for them to the best of our ability.

The next morning, Mr. Sanghvi lay prone on bolsters, shivering in a freezing operating room. We armed him with a warmer that soothed him a little. After cleaning and draping him in the usual fashion while our anaesthetist kept him preoccupied with the latest in the stock market, and after giving him some local anaesthesia to numb the area, I directed the needle to our target using intraoperative X-rays and injected 5 ml of toothpaste-like cement into the vertebral body. Live images showed the cement seeping into cracks and crevices augmenting the injured area. Very rarely, the cement can extravasate into the bloodstream and enter the lungs, causing a sudden collapse, but knock on wood – we were okay. I withdrew the needle and sealed the entry point with a stitch.

We flipped him over and asked him to wiggle his toes and bend his legs, the first thing we do after every spine operation to ensure we haven’t caused any harm. He did so effortlessly, without even a wince. A few hours later, I went and saw him in the ward. He lay in bed smiling, chatting with his son. “Would you like to try and walk?” I interjected. They gawked in disbelief. I put the side rails down and extended my hand for him to get a grip as he seated himself at the edge of the bed gingerly for the first time in 2 months. Then, he reluctantly planted both feet on the ground and stood up, taking his first step. For his son, it was like watching Neil Armstrong take his first step on the moon; he once again wept vehemently. Tears are a most confusing body fluid: they express themselves the same way even in diametrically opposite extremes of emotion.

The next morning, Mr. Sanghvi had taken a shower on his own, had oiled and neatly partitioned his dishevelled silver mop, completed a walk around the corridor, and then sat upright in his bed reading the newspaper. “How do you feel this morning?” I asked. “Younger than my son,” he quipped, and his perfectly curated face wrinkled again – not with pain but with a hearty laugh.

How a worldly-wise teenager, who overcame every health failure with fortitude, taught a resident doctor to believe in the impossible.

Once upon a time, there was a boy name Arkojjwal. He was unlike any 13-year-old with a brain tumour that I have ever seen. In 2008, when I was an exhausted resident doctor training to be a neurosurgeon in Vellore, he was admitted to the pediatric ward that I was assigned to look after. He had a curly mop of hair that sat off-centre on his head, and wore a pair of thick glasses gingerly balanced on the tip of his nose, giving him the quintessential professor look.

“One day, whilst I was sitting in class, I suddenly noticed double-vision,” he said in his chaste Bengali-English as I noted down his history meticulously. “And when I reached home, my mother saw a squint in my eye.” His MRI showed a craniopharyngioma – a tumour that is hard to pronounce but even harder to remove. It arises from the pituitary stalk, and in his case, had ensconced the right optic nerve with chunks of calcium encircling important arteries of the brain. Not only that, it pressed firmly against the hypothalamus – the seat of consciousness.

It was unfathomable to imagine a monstrosity like this sitting inside one of the brightest minds I had ever seen. At the end of each day, way past midnight, when I used to sit down at the computer in the ward to type out discharge summaries of patients, send off investigations for the next day, and pore through progress notes, Arkojjwal would pull up a chair and come sit next to me for an hour or two. “Did you know Zoroastrianism is the oldest monotheistic religion in the word?” he questioned, after having known that I was Parsi. I nodded, slightly befuddled. Each day, he would educate me with some trivia that broadened my worldly knowledge, and in return, I taught him to read MRI scans. He helped me file paper work and write up lab tests for other patients. I indulged him with the anatomy of the brain. We were a team. He was 13 and I, 26. He wrote me a poem every day to read out to me when we met on our midnight rendezvous.

A few days later I assisted my mentor with Arkojjwal’s operation. The brain was softly dancing to the beat of the heart as we opened. This gentle rhythmic bouncing that the brain does connects you directly to the cosmos. I watched in awe under the microscope as my mentor peeled off the tumour digging its heels into the optic nerve. I nimbly assisted as he removed small glistening pieces of calcium, almost like a miner unearths diamonds floating in fluid that looked like molten gold. The more we dug, the more jewels we found, until all that was left was the cyst wall stuck to the hypothalamus. As he peeled that off with the sleight of a magician, I found myself praying that Arkojjwal would awaken after surgery. Every bit of tumour visible to the naked eye under the magnification of the microscope was eventually removed. I was lucky to have witnessed such symphonic mastery.

Arkojjwal woke up just fine, reciting Shakespeare on the evening of the operation as he was tethered to tubes preventing him from writing poetry. These patients, in whom such tumours are resected aggressively from the pituitary stalk (which is responsible for the transportation of hormones), develop sodium and water imbalances that can be laborious to treat, requiring the monitoring vital parameters every hour. After fairly tight control of his electrolytes, on the 8^th postoperative day, his sodium levels saw a swift swing from rock bottom to sky high and he slipped into a coma with alacrity, remaining in this state for over a month. The entire team was despondent, but we kept fighting on reminded of something I had read a long time ago: “In taking up another’s cross, one must sometimes get crushed by the weight.”

When he seemed to awaken 56 days later, he couldn’t move at all, except for an involuntary tremor in all his limbs. Owing to the rapid fluctuation in his sodium levels, he had sustained damage to his brain stem and the basal ganglia responsible for movement. After about 3 months of intense rehabilitation, which included his mother physically flexing him 8 hours a day and talking to him about his past for another 8 hours, there came about some semblance of an ability to walk and regaining of his lost memory. He was finally discharged on a great many hormonal replacement and growth hormone injections, as his body was no longer secreting hormones on its own.

He followed up with us in Vellore each year, walking a little better, shaking a little less, seeming a little sharper. Over the course of a few years, he underwent a hip replacement, as the steroids he was taking had affected his hip joint. His school allowed him to have writers so that he could complete his ICSE, and he passed giving his exams lying down because he could not yet sit up. He had to replace 10 teeth in each jaw as the enamel had decayed from the side effects of the medication he was on. And then he developed a second brain tumour in his cerebellum, at the back of his head, which we also removed successfully. He was family to every staff member and every doctor in the hospital. He overcame every ineluctable failure inexorably with a fortitude worth emulating.

I had left Vellore in 2014 and hadn’t heard from him for a few years, until a few weeks ago, when he messaged me with a poem:

Dear Dr. Turel,

You are always present in my mind to the extent that none can reach,

The memories with which you teach,

How to overcome any problem,

And claim happiness by God’s grace,

Sweeping away each and every sorrow,

Thus you’ve become to me an influencing hero.

Your beloved,

Arkoj

I was just a resident doctor at the time and not befitting of such praise, nor could I take credit for any medical outcomes or successes, but I was so excited to hear from him! I began reminiscing about all the wonderful times we had in the four months we had spent together in the hospital, two of which he spent oblivious. I picked up the phone and called him. “Hieee!” I bloviated, allowing for the time we had spent apart to collapse into a capsule, much like the ones he swallowed on a daily basis.

“I’ve completed my MA in English at Jadavpur University,” he said, in slightly more refined Bengali-English this time.

“Wow,” I exclaimed. “What next?”

“I’m doing my PhD now,” he said with sated joy.

“In what?” I enquired, as that is the first question you ask anyone who tells you that they are doing their doctorate.

With a tender note in his voice backed by the certainty of a brighter future, he proclaimed, “Fairy tales.”

 

 

That’s usually the question that dictates the speciality a surgeon chooses

“I have these drops of liquid trickling from my right nostril for the past week,” expressed Sheila, a very concerned, visibly overweight 45-year-old business executive. She was dressed in a suit and wore her hair in a tight bun, like a school mistress, as she leaned slightly forward and bent her head to elucidate what she was saying. Crystal clear driblets trickled down, one every few seconds like they do from a tightly shut but slightly leaky tap whose washer needs to be replaced. I collected a few bubbles in a sterile glass bottle to test. “Initially, I thought that this was just a runny nose, but then, I have no other symptoms apart from a headache and this just felt odd, so here I am,” she gestured with animated hands, in a way used by most people when something unexpected shows up.

“Do you feel a slight salty sensation at the back of your throat when you lie down?” I asked, to confirm my suspicion of this being no ordinary liquid but sacrosanct cerebrospinal fluid (CSF). “Yes, yes, yes!” she interjected, relieved to know that I’d already diagnosed her problem. After a detailed assessment, I emphasise that she was lucky not to have had any fever; if the fluid got infected, it could lead to meningitis. I ordered a specialised MRI and CT scan to be able to exactly pinpoint the specific defect in the base of the skull from where the brain fluid was likely to be leaking from, and had her see me back at the earliest.

CSF is a colourless, odourless liquid that bathes the brain and spinal cord. About half a litre of this fluid is produced daily and gets recycled while nourishing the brain, washing away all the toxins that get absorbed via a drainage system curated flawlessly by nature. A slightly higher content of sodium and chloride gives it its saliferous taste. It also protects the brain by acting like a shock absorber for the central nervous system. A tear or hole in the covering of the brain (meninges) coupled with even a tiny bony defect in the base of the skull could cause CSF to seep out from the nose as it’s all interconnected. In health, the nose is a ‘stairway to heaven’ as far as the journey of breath to the brain is concerned; in disease, however, when directions are swapped and there is an egress of CSF, it can potentially be a ‘highway to hell’.

Sheila returned with her reports a few days later, and as expected, one could easily trace the exodus from a tiny defect in the base of the skull into the right nostril. “We must seal the leak before you develop an infection that could be calamitous,” I forewarned. “We’ll do it through the nose itself, so we don’t have to open up the head.”  “I’m ready when you are,” she replied resolutely.

The next day, alongside my ENT colleague, we navigated into her cavernous nostrils, an endoscope in one hand and an instrument in the other to flatten out the nasal turbinates against the lateral wall of the nose. Navigating through the nose with an endoscope is like driving a car. I remember my days as an assistant doctor: my chief would honk “Peep, peep!” which was an indicator for me to move the scope ahead or out of the way without bumping into any structure to avoid fogging the lens. We did a little drilling along Sheila’s nose to smoothen out bumps and edges. After searching a fair bit, we could identify clear CSF weeping from a 3mm defect in the base of the skull. A little bit of redundant brain was also trying to push itself out unsuccessfully.

Every surgeon has their cardinal body liquid, which often dictates the speciality they choose. Being fascinated and mesmerized by blood is not enough; that is simply a basic denominator. For ENT surgeons, it’s mucus and phlegm. The ophthalmologists are busy with tears. Dentists only have access to saliva. Hepato-biliary surgeons love bile. Cardio-thoracic surgeons enjoy the pericardial fluid that cushions the heart. General surgeons are attracted to pus. Orthopaedic surgeons make do with synovial fluid that lubricates joints. Cancer surgeons deal with lymph quite a bit. For nervous surgeons, their own sweat suffices. Gynaecologists are smitten by amniotic fluid. Urologists have urine, but they are also enamoured by prostatic fluid – the yellowish straw-coloured sticky juice that nourishes the sperm. Colorectal surgeons, unfortunately, need to be satisfied with diarrhoea. I, for one, am blessed to work with CSF.

CSF is the most angelic liquid present in the human body – spotless, sanctified, and seraphic. It is, however, both the boon and bane of neurosurgeons. When handled tenderly and released gently, it relaxes the brain, allowing for surgery to proceed virtuously. When CSF flows over the tips of tiny metallic instruments, it looks like an immaculate waterfall inside the brain under the microscope. Rarely, when it isn’t possible to create a watertight seal of the meninges, CSF seeps out from a cranial or spinal wound like a ghoulish adversary one has to fight till the very end for the patient’s survival. Any infection of the CSF can turn into a lethal rampage. The sight of CSF within the brain or spinal cord is resplendent, but when you see the same fluid outside, it can be utterly demoralizing. After a valiant operation, to see a postoperative wound leak CSF is disheartening. Only another neurosurgeon can fathom the joy and exultation of a CSF leak ceasing.

In Sheila’s case, we cleanly delineated the defect and sealed it using some fat, glue, and a flap we had harvested from the nose itself. We injected fluorescein dye to see if there was any further leak and inspected the entire panorama to ensure that it was dry. “The first chance is always the best chance for any surgery,” I coached my assistant, “revisions and re-dos are never pleasant.” I concluded by reminiscing about two cases where I had needed to go back a second time to seal the defect. “Sir, every surgery of yours has a take-home message,” my assistant added wryly, cheekily imitating what I often say after each operation. We packed the nose with nasal packs, similar to tampons, and kept them in for 48 hours. When we removed them, there was no further leakage. She walked around merrily and was happily discharged a few days later.

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.

“Mazda, you have to speak at the Global Tipping Point Summit,” Coomi called to tell me in her usual erudite fluency that reminded me why Parsis are the direct descendants of the Queen. She was in the process of conceptualizing a comprehensive event to revolutionize the future of education. “We have to create healthy learning and nurturing ecosystems by combining knowledge with self-awareness and wisdom, to transform our lack-based consciousness to one rooted in abundance,” she went on eloquently, making me realize she she’s not only related to the Queen but also to Shakespeare.

I’m very drawn to people who are passionate, and Coomi Vevaina is not only an ardent and internationally acclaimed educator but also a faithful futurist. She’s a vivacious storyteller and has written loads of books on children’s education. “We have learnt more about the human brain in the past five years than in the previous hundred,” I explained, “and I think it’s time to bring the evidence provided by neuroscience into the classroom. We can talk about neuro-education,” I agreed enthusiastically. If you want to sound super-intelligent about anything, just prefix it with ‘neuro’. One can even get away with being sexist by calling it neuro-sexism. After training for 9 years in South India, all I learnt of the language was neuro-Tamil.

The human brain has about a hundred billion neurons that make a complex network of about a trillion synapses. From their interactions with each other emerges a whole spectrum of abilities that we called human nature and human consciousness. It is this consciousness that everyone is suddenly so interested in tapping into. The brain weighs only 2–3% of one’s body weight, yet consumes over 25% of its energy; more electrical impulses are generated in a single day by one brain than all of the cell phones in the world.

In the talk I gave at the Summit, I went on to explain how students and teachers are not uniform raw materials or assembly-line workers but a diverse collection of living, breathing human beings with complex evolutionary histories, cultural backgrounds, and life stories. If we are to move forward, we must admit that a one-size-fits-all model of education is doomed to fail the majority of students and teachers. We have to tap into the individual potential of each child and cater to their strengths. Just like we have evolved in precision medicine, we must in precision education.

Human beings have undergone an evolutionary change over the last 30,000 years and will continue to do so. With this current generation, our craniums have become larger and the sockets of our eyes bigger, which probably has something to do with the information overload that comes our way each day. Just as dendrites get chopped, churned, and pruned when not used, or as new connections form when we develop a new skill, learn to play the violin, or master a foreign language, our physical structure is also undergoing a metamorphosis governed by the external stimulus we interact with constantly.

What do we know about the brain that we did not know a few decades ago? Neurogenesis. While most of the neurons are formed at birth – and it was once believed that we only have a fixed number to live our whole lives with – we now have evidence that we can generate new neurons in those areas of the brain that represent learning, formation of memory, regulation of emotions, and spatial navigation. Everything the doctor’s been telling you – eating less, exercising more, replacing saturated fats with omega-3 fatty acids, being mindfully less stressed, and getting more sleep – promotes neurogenesis.

There is also the concept of neuroplasticity: the ability of our grey matter to thicken or shrink, improve connections between neurons, create new neurons, and destroy old ones. Parts of brain function can be transferred to other areas of the brain and even hemispheres can switch function. When we perform epilepsy surgery, for example, we can disconnect one brain hemisphere entirely from the other; the functioning half then works effortlessly overtime, seamlessly taking over entire brain function.

I once had a patient who had a tumour in the left temporal lobe, one of the language areas. She had a seizure, which is how the tumour was diagnosed. Interestingly, after the seizure, she switched her choice of language from native Marathi to fluent Hindi – something she hadn’t spoken at home for 2 decades. A few months after surgery, she returned to Marathi harmoniously. It has to be said that while these are the patients who are supposed to help us study brain structure and function better, end up confusing us even more.

We are gifted to be alive in an age of technology, to have decades of research in brain function behind us, and to have increasing data-based interventions associated with improving the health of our children or to realize that age-related cognitive decline may be slowed, arrested, and even reversed.

We have studied the importance of art, music, movement, and storytelling in the overall development of children. As part of the action project of this summit, we aim to study if we can simulate an objective response in children by systematically introducing these paradigms into their curriculum’s. The art of education is more important than any other, as we are forming souls and shaping the future of humanity. Interestingly this conversation will be carried on at the Global Tipping Point Summit: Re-thinking Parenting from 8th to 31st January, weekends only (from 4 to 5.15 p.m.) and people can join us for free by registering on www.gtps4change.org.

Neuroscience teaches us that story telling can impact the brain in innumerable ways. It releases oxytocin and teaches children to empathize. It activates mirror neurons, which is said to have shaped civilization. Stories can ignite ideas. They can stir up feelings of awe, wonder, inspiration. They can make us jump out of our seats in surprise or terror. Stories hold powers greater than we may have imagined. “Stories are memory aids, instruction manuals and moral compasses,” says Aleks Krotoski.

But more than the stories we tell our children, we should take time to reflect on the stories we tell ourselves. Like Carl Jung said, “The most important question anyone can ask is: What myth am I living?”

Developing clinical detachment isn’t easy. Doctors experience pain and grief in equal measure when a patient is long gone.

A few months ago, I had operated on an elderly lady for a behemoth tumour arising from her pituitary gland. We take down these tumours through the nose using an endoscope. Surgery went off immaculately. Her vision, which had been expeditiously deteriorating, improved almost instantly after the operation and she returned home within a few days of surgery. Her two sons, who worked as servers in a restaurant, were delighted with the outcome and grateful to us for doing it at a nominal cost.

A week later, I got a phone call at 7 AM from the son, indicating that the mother was refusing to wake up. “She’s breathing but appears to be semiconscious,” he said tersely, not able to make sense of the situation. I quickly ran a laundry list of possibilities in my mind for delayed deterioration after an operation of this nature: infection, sodium-water imbalance, hormonal disturbance, hydrocephalus, hypoglycaemia, stroke… the list went on. “Get her to the emergency department of the hospital immediately,” I bounced back, charging to reach there myself, making innumerable phone calls on the way to get the team geared to deal with the myriad possibilities I was considering. We put the scheduled cases for surgery on stand-by in case she needed to be taken back to the operating room.

When I saw her, she was gasping. I grabbed a breathing tube and shoved it down her throat to secure her airway and connected her to a ventilator while the others fixed an intravenous access to collect blood samples and run some fluids. A nurse put in a urinary catheter and a litre filled the bag in a whiff. I tugged on her neck to see if it was stiff. It was log-like. “Shit,” I winced, diagnosing, “She’s got meningitis.” My assistant looked at me with raised eyebrows and the unspoken question of “How the hell did this happen?”

We ran her through the CT scan machine and noted that her ventricles or fluid-filled cavities of the brain had blown up. We paced her to the operating room and placed a drain in the ventricle to release pressure as well as to test the fluid for infection. Cerebrospinal fluid, which is often chaste, was dirty and turbid in her case. The results of the analysis were ominous. The highest doses of antibiotics were administered as we shifted her to the ICU to place some more lines and tubes as she lay there tethered to a tower of infusions.

After two hours of commotion, I finally sat down with the family. “Did she have any fever or leakage of fluid from the nose?” I inquired. “No,” they said, “she was absolutely fine until she went to sleep,” they lamented. “It’s very unusual for such a dramatic presentation,” I told them, but convinced that brain fluid had been leaking from somewhere that had been infected, perhaps not coming out through the nose but probably trickling down the throat. Their eyes welled with silent tears trying to make sense of this unexpected turn of events.

Over the next few days, their mother made a steadfast recovery, her eyes opening to mild pain, her limbs making random purposeful movements. Sighting a window of opportunity, we took her back to the operating room to seal the suspicious leak. We found it and packed it with fat, sealing it with glue and a little prayer. We changed the drain in the head on two occasions over the next two weeks; leaving it long enough inside the brain risks infection as well. I spoke to the family for an hour each day, sometimes 2–3 times a day. I answered phone calls from several other relatives and from other doctors they were known to, appraising everyone involved.

After about 3 weeks and noticing only a marginal improvement, they were running out of money and hope. I helped arrange for some social workers to aid them. I organized a GoFundMe campaign through some charities. The hospital too benevolently deducted whatever they could. Later that week, her level of consciousness dropped again. An MRI showed multiple tiny strokes in the areas responsible for her consciousness. The infection had gnawed away at the tiny arteries supplying these areas. The blood pressure was labile, the urine output began to drop, the liver started giving up – all signs of a malevolent sepsis.

One month had passed since she had been admitted. The sons had exhausted their mind, spirit, and sinew. I answered every question and replied to every text message at odd hours of the day and night, surrendering my time at home to alleviate their anxiety. I offered to shift her to the public hospital where I worked so that further treatment would be cost effective. She passed on within a few days of transfer after battling for 36 days. The body was wrapped in a shroud and cremated within a few hours.

I didn’t hear from either son after that. Their names no longer showed up in my most frequently contacted section on WhatsApp. It was as if I didn’t exist for them anymore, while in my head and heart, I had felt as though I’d become a member of their family, fighting for a common cause.

“It’s hard for me to fathom how people can be so ungrateful for the things you do for them,” I despondently said to a colleague one day, wondering why they could not even say “thank you” – not at the time of death, of course, but a few months later.
“Their mother died. You have no right to be upset with them,” he pounced.
“But I do,” I said, without any guilt.