Glossopharyngeal neuralgia causes pain sudden and severe enough to feel like a phataka go off in your mouth. Awareness about such rare conditions is half the battle won

Mrs. Pednekar walked into the clinic with her husband. They looked like they were both in their sixties. Simple, warm people dressed in pastel shades, they joined their hands in a namaste with bowed heads as they took their seats. “My husband has been in severe pain for the past 10 years,” she told me, her eyes welling up almost instantly. We often see patients break down in the doctor’s clinic within a few seconds of their arrival, even with little being already said or done. I imagine the office seems like a portal where they feel they can release that pent-up angst, anxiety, or energy.

I allowed for her to feel soothed and then continued. “Where is the pain?” I enquired. “In the left side of the throat,” he said, his entire face clenching in a tumultuous spasm simply with the utterance of those three words. “He cannot talk, eat, chew, or swallow when he gets these random bouts of pain multiple times a day – and it’s been several years now,” his wife continued, allowing for his electric shock-like sensation to settle. “But in the past three months, it’s become unimaginably unbearable. He’s lost 12 kilos because he fears eating will trigger a spasm,” she concluded.

“It feels like I have an entire loom of firecrackers bursting in my throat randomly,” he explained once the episode settled. “Well, with Diwali around the corner, you’ll be able to have an internal celebration!” I quipped, wanting to ease the situation and trying to be my usual self, which they understood, but they also wanted me to fathom the magnitude of the problem. “Doctor saab, it’s not funny,” he cautioned with one hand, ready to grasp his own throat if a cracker burst inside. “Imagine you’re fast asleep and someone stabs you in the throat,” he paused, trying to provide another analogy. “Several times over,” he continued. “Every night, many times a night,” he stressed. “You’d rather wish you were dead, but you wake up like a ghost wondering how come you’re still alive,” he stopped with a precise description of what he was feeling. I was now confused if it was Diwali we were celebrating or Halloween.

“We’ve been to so many doctors and taken so many medications and injections that our pain specialist finally referred us to you to try surgery, as they’ve run out of options,” she said as she handed over the MRI films to me. Like I had expected from my clinical assessment, it showed an artery at the back of the brain pressing against the glossopharyngeal nerve, the nerve responsible for sensations in the throat, or what is technically called the pharynx. Sometimes, an elongated piece of the mastoid bone called the styloid process can also cause the same sensations, but he didn’t have that. “When this artery pulsates, its pressing against the nerve and causing this lancinating pain,” I explained to them, adding that as they had tried everything, surgery would be a good idea.

“We’re prepared to get admitted today,” the wife said, clearly unable to see her husband suffer any longer. I adjusted my surgical schedule to accommodate him so that they could check in the next day. Unfortunately, in a preoperative workup for surgery, his echocardiogram showed very poor heart function. “Do you get breathless while walking?” I asked when I saw him on rounds the next day. “Very,” he said. “He’ll need an angiogram of the heart before we can proceed with surgery,” the cardiologist opined, which he performed the same evening.

We sat down again with the family to explain the situation to them. “He has three very severe blockages in the heart,” the cardiologist said, “and needs three stents or a bypass surgery, but if we do that, he’ll have to be on blood thinners and we’ll have to defer the brain surgery to at least 3 months later,” he opined. “If we go ahead with the surgery without the heart procedure…?” the wife asked. “Then there is a very high chance of having a heart attack during surgery,” he completed the sentence for her. “Plus, during this operation, one can have sudden changes in heart rate and blood pressure because we are very close to the brainstem,” I added for them to fully understand the risks of going ahead with surgery in this state.

“I’m willing to die, but I can’t live with this pain,” he said with a certain degree of authority. “You’ll have to sign a consent form that you’re aware of and accept the possibility of there being a death on the operating table,” I said to sheepishly safeguard myself, but knowing that there is a higher force that understands that we were all working in the best interest of the patient. He signed on the paper and his wife countersigned it. They say that when your intentions are pure, nothing horrible will happen. Unfortunately, I have lived and worked enough to know that this is not true.

The next day, we took him into the operating room. His wife stood outside with hands folded. “Everything will be okay,” I reassured her, as I do with every relative before walking into the operating room. We positioned him sideways to make an incision behind the left ear and made a coin-size opening into the back of the skull to get to the artery that had ensconced the nerve so intently. It looked like a cobra that entwins its prey before killing it. As we separated the artery from the nerve, gently untethering the silvery strands attaching the two together, the heart rate suddenly dropped to 50, then 40, then 30, as the alarms went off. “Stop whatever you’re doing!” the anaesthetist alerted.

The moment I released my instrument from the tug it was creating on the brain stem, the heart rate bounced back up. We tried again to gently release the artery but the heart rate crashed once again. “This could strain his heart,” the anaesthetist warned. “We have to release this completely,” I said, “or we won’t do him justice,” I requested them to hold fort. After multiple attempts and a few heart attacks myself, I was able to free the artery completely from the nerve. We inserted a piece of Teflon padding to keep the two apart. Thankfully for him, he survived the operation and was delighted to realise he was pain free within a few minutes of waking up.

“I wish someone had told me that surgery was an option 10 years ago, I wouldn’t have suffered so much,” he said with relief and lament together, the next morning, when I went to see him. I explained to him that it was unfortunate that people are still unaware of such conditions like glossopharyngeal neuralgia, as it is quite rare, but awareness is gradually increasing. I told him he should thank his pain doctor for setting him on the right track.

Three days later, the cardiologist inserted an equal number of stents in his heart, giving him a complete overhaul and getting him ready to be discharged. “Now that your pain is gone, you’ll have to burst real crackers,” I took the liberty of joking again. “I’m not going to burst any crackers, doctor saab,” he said with folded hands, “but every night for the rest of my life, I’ll light a diya for you and your family,” his eyes welled up. “Happy Diwali,” we uttered in simultaneity as we hugged each other goodbye.

In matters of clinical judgement and genuine uncertainty, a middle path can emerge—giving in to neither indulgence, nor self-denial

An elegant family of five walked into my office. The patient was the 80-year-old matriarch; let’s call her Auntyji. She was dressed in a bespoke white and gold salwar kameez with her hair tied back in a school teachery bun. She sat upright in the chair in front of me while her two daughters, probably in their fifties, planted themselves on either side. The two dutiful-looking sons-in-law accompanying them plonked themselves on the examining bed. “We’re two brothers married to two sisters,” one of them spoke up, introducing the fam jam. “How’s that going for the four of you?” I digressed even before trying to find out what was wrong with Auntyji, in a bid to calm the nerves that were palpable in the room. “Well, let’s just say everything has its pros and cons!” one daughter replied. “But there are more pros for sure,” the men jumped in to save the day.

“So, what brings you here?” I asked, finally turning to Auntyji. “I’ve been forgetting stuff,” she said, taking charge of the conversation. “Sometimes I feel giddy and sometimes I have some imbalance while walking,” she continued. “We’ve discussed it, and we don’t feel there’s anything wrong as far as her memory goes,” one of the daughters provided her perspective. “But I feel something is not right with me,” she asserted.

I examined her in detail and ascertained that her strength and co-ordination were good. “We’ve done an MRI,” a son-in-law pulled out the films and I raised them against the beaming light of the October sun peering through my window, which I often prefer to the boring white light of an X-ray box. “You have a 3 cm tumour in your left temporal lobe,” I said, pointing at it, “but it’s mostly arising from the covering of the brain called the dura and not from the substance of the brain itself, making it not malignant,” I went on to explain. It was a meningioma – arising from the meninges or the outer covering of the brain. “However, the swelling around it is a little more than normal,” I cautioned. I wanted to give all the details while I tried figuring out in my head what the best advice would be.

“We know all this,” the other son-in-law interjected. “We’ve come here for a second opinion, or rather, a third,” he acknowledged. “Because we are very confused,” his wife added. “Let me explain the conundrum,” the son-in-law went on. “We went to a senior doctor in one hospital, and he said we could leave this alone. ‘It grows at 1-2 millimetres a year and she’ll pass away from natural causes before the tumour can do anything to her’ were the doctor’s exact words,” he told me. They were then forced to take a second opinion by their extended family from another equally senior and renowned neurosurgeon in another hospital. “He said, ‘This needs to be operated upon at the earliest, because she could have a seizure and the brain swelling could have deleterious side effects; it’s better to remove it while she’s well rather than when she has more problems,’”, reiterating verbatim what the second doctor had said. “That’s why we are so flummoxed,” the daughter added, while Auntyji patiently waited for the verdict of someone with 25 years less experience than the other two stalwarts in the field.

Strange as it may sound, this is an age-old occurrence in medicine, that doctors, just like people, will have differing opinions on how to proceed regarding something. I have seen it time and time again, in my field and beyond, that medical professionals with identical qualifications and extremely similar levels of experience will often present diverse views on what to do next for a patient. We call this clinical equipoise – a state of genuine uncertainty. I have seen it with back pain: Some doctors will prescribe bed rest, while others completely denounce it. Cardiac procedures present the same battle: Some doctors prefer to stent while others simply give you blood thinners. In obstetrics, certain doctors are caesarean happy while others will have you labour it out. Like in many aspects of life and living, these seemingly contradictory suggestions are neither right nor wrong; they are simply honest but varying perspectives. I began to realise for the umpteenth time how hard it is for the common man to make decisions about their health when such conflicting opinions are presented. “Use your intuition, not your logical mind, when making important choices,” my wife always tells me.

“There is a grey zone in medicine,” I clarified to Auntyji and family. “When there is no conclusive evidence toward one treatment paradigm over the other, surgeons tend to use their clinical judgement and experience to give you a recommendation. Unfortunately, sometimes, the true nature of the disease is only revealed in the due course of time,” I explained. Just like some people, I wanted to add, but refrained.

I could either agree with one of the two eminent doctors or present my own version and hope that I did not leave them even more confused than when they arrived. The Buddha in me decided to take the middle path, staying away from the indulgence of jumping into surgery and the self-denial of leaving this alone. “Let’s do some gait and balance physiotherapy for three months and see if she’s clinically better,” I suggested. “I want her to be as physically and mentally active as possible, and also to take a walk every day and get some sun,” I added the standard cures of many of life’s problems. “We’ll also repeat an MRI then to see if anything has changed in that time,” I decreed.

The only commonality between the Buddha and me is that even though I am younger, I feel just as old. Unfortunately, in the field of medicine, simply feeling old does not count as experience. Nevertheless, adopting the Buddha’s teachings that day brought with it a certain degree of peace. I stayed non-attached from either extreme – surgery and doing nothing – and assumed the eight-fold path with mindfulness.

The family looked reassured and immensely relieved with the middle path too, which, in my opinion, was the right thing to do. This is what most therapists also endorse: When in doubt, wait it out. It is still too early to say if this was right or wrong, but the decision to wait comes from a good place, and the urge to do what is best for the patient persists. What happens to Auntyji, whether she or her MRI worsen in 3 months’ time or stay the same, and the decisions we take subsequently, will be revealed by time.

Auntyji folded her arms with grace and dignity to thank me. As she left with all her children, one of them said, “Thank you for allowing us to find a middle way.” I couldn’t help myself. “Two brothers marrying two sisters is rather extreme, so it was time for something milder,” I joked, as we all had a bit of a laugh.

In adventure sport—just as in surgery—there’s never just another day at the office

“We have Thursday morning off, before we take the flight back to Mumbai,” my dad reminded me as we were winding up a one-week workcation. “Do you have something specific you’d like to do?” he checked in with me. We were in Australia, invited to speak at the annual meeting of the Neurosurgical Society of Australasia in the lovely resort town of Port Douglas, an hour’s drive from the relatively placid city of Cairns. After having completed our work assignments, we took a few days off to visit the Daintree Rainforest – 1,200 square kilometres of wildlife habitat that was more than 180 million years old, 10 million years older than the Amazon.

I contemplated the question he had just asked me. “Let’s go skydiving,” I suggested, both of us having missed doing it on our individual travels the year before owing to last-minute weather problems. Without batting his 78-year-old eyelids, he concurred. “But let me check first if they have an age limit,” I hurriedly added, “What age limit?” he shot back. “I’m fitter and stronger than you!” It was indeed true. I’m 42 and everything hurts every day.

“Hello, is this Skydive Australia?” I called, making a booking for 4^th October, also enquiring about any of their stipulations for guests jumping off a plane from 15,000 feet. “We don’t have an upper age limit,” he confirmed politely, “as long as you don’t have any serious medical condition and are above 18 years of age and below 110 kg.” We met these criteria. Our bookings were confirmed. After having snorkelled Down Under, in the Great Barrier Reef, it was time to see what it looked like from a little higher up.

On the designated radiant morning, when the sun shone its golden whiskers through the turquoise Aussie skies, a bus picked us up and three other fellow jumpers to drop us off at the office where the first thing we did was sign a waiver: if we died, they would not be held responsible. It was like taking consent before brain or spine surgery. Only today did I realize the tumult of emotions that patients must feel every time we explain the risk of death to them, but they sign the form trusting us in full faith. Today, we were the patients and we had to trust our diving doctors.

We were shown a safety briefing video with gorgeous views from a Cessna biplane soaring up into the skies and people jumping off it like giant bird poop. Olivia was my diving instructor who I going to tandem jump with. “What’s the most common question people ask you?” I asked her, as she put on my harness, double-checking all the locks. “Has the parachute ever failed to open,” she replied. “Has it?” I asked with a little trepidation on the inside but sounding cheery and confident on the exterior. “Ah, a couple of times, mate!” she said casually, “But we always have a standby, so don’t worry!” she laughed. “Let’s slay it,” she gestured, as we took a picture and video together before walking on to the tarmac. “Do you wanna say your final goodbyes to people at home?” they always joke on record. “Not required; we’re coming back soon to haunt them!” I quipped.

“Does this ever cause motion sickness?” I asked the other instructors of their experience. “We’ve had a few people throw up mid-air,” Damien said, unflustered even as he was on his fifth jump of the day. “The first one minute is a free fall at 200 kilometres per hour, and then we open the parachute, which lasts for about 5 to 6 minutes. If it’s windy, you can feel a little nauseous,” he warned, munching on berries.

Damien, my dad’s instructor, was a strong, well-built man with a golden beard and long hair who had four missing fingers on one hand. “Skydiving accident,” he joked. “I’d happily take that if I only lost that much in a skydiving accident,” I told him. “Nah – got chopped off by a saw while doing some carpentry as a kid,” he explained, his voice muffled amidst the roaring sound of the plane nearing us. Just before boarding, I tightened my shoelaces, lest the shoe fly off and hit the person jumping behind me at 200 kmph.

The five of us got onto the plane tagged to the instructors we would tandem jump with. The plane had no seats, just a low-lying flat couch one could hop on. It had a sliding door that they closed way after the plane took off. As we rose to 5,000 feet and saw the panorama of the world below, tiny ripples gradually started roaring in my stomach. I could feel my heart race. I wondered if this would match the adrenaline rush of performing a difficult surgery, one where there was profuse bleeding, with the patient’s blood pressure crashing and monitors beeping. “Do people ever refuse to jump after being airborne?” I joked around with Olivia as she did the final tightening of the harness onto her and put on my goggles. “Now is not the time to be asking that question, mate! Once we slide the door up, just remember what we rehearsed. As we get to the edge of the plane, curve your legs in, arch your back and make a banana, and jump. When I tap you on the shoulder, pull your arms out wide like you’re soaring.” She gave me a final thumbs up as she tightened the go-pro fixed to her wrist to record the adventure of a lifetime.

Once we reached 15,000 feet, one of the instructors pulled the door open. “1-2-3 jump!” he went out with his jumper in a jiffy. The cold wind blew straight into my face, reminding me of my journey to Everest Base Camp a few months ago. Five seconds later, the next person jumped off. My heart was racing but I had a huge smile on my face. “We’re next!” Olivia slid me to the edge of the plane as I tucked my feet in and arched my back to her face, the force of the wind trying to rip the skin off my face. I felt like the animated version of Jim Carrey in the Mask. I gave a thumbs up to my dad behind me and “1-2-3 jump!” screamed Olivia. We summersaulted out, I not knowing what had hit me, but after the first 3 seconds, I could vividly see the vast expanse of the horizon in front of me. The clear sky with the glimmering sun shone sharp on us. Suddenly, all the rush disappeared, and I felt a sense of calm I have never felt in my life. It was so surreal that I thought of my patients, my family, and my dear friends while plummeting into the clouds below us. Even though was I rocketing down at 200 kmph, I felt like I was afloat, suspended in space and time. True freedom means not longing for anything to be other than what it is. This is what freedom felt like, I thought, even though I was attached to Olivia. We both smiled into the camera and took what looked like soothing pictures mid-air.

As we descended into the clouds, she pulled on the parachute and both of us transformed into eagles, buoyant in the air, enjoying the beauty of the terrain below with the Gods looking on above. It was ethereal. We swerved with the wind, making gentle circles in the air, chatting about surgery and skydiving – both professions were never just another day at the office – as we gracefully approached our landing. “Pull your knees into your chest and straighten your legs,” came the instruction, as we made a smooth landing onto the soft verdant grass – a kind of earthing one would have never imagined. I quickly turned around to catch a glimpse of my dad, who was 10 seconds behind me, land right next to me. We had experienced an adventure of a lifetime. Both of us were grinning from ear to ear as we kissed and hugged each other once we were free from all the strappings. “Paisa vasool,” were the first words that came out of his mouth. I couldn’t agree more.

Sometimes, you need more than just a tool for surgery—you need a hand, a head, and a heart

“Which instruments will you use to cut open my spine?” Rasiklal asked me after I examined him for a herniated lumbar disc. I had just explained to him why he was a candidate for spine surgery. He was a tailor in his mid-fifties, slightly potbellied, and wearing a white shirt that, in his own words, “used to fit him well before he put on some weight.” He had tried everything to avoid an operation – medication, physiotherapy, ayurveda, homeopathy, acupressure, and acupuncture. He had visited a chiropractor, osteopath, and even a ‘baba’ who claimed to cure slip discs by kicking people on the bottom. Needless to say, his pain was much worse after that experiment, and now, he was unable to cut fabric sitting on the floor. He needed to stand to do it, and that too just barely, before his back pain shot down his legs – the classical sciatica that people with disc disease describe.

When I asked him to sit, before doing so, he removed a large 10-inch pair of metal scissors from his pocket and placed it on the table. You could feel the intense sharpness of its blade just by looking at it. The bronze metal handles mixed with shades of silver had been softened by years of usage. “This is my tool; I never leave my house without it. It’s been part of my entire life. If I must have surgery, I need to know what you will be using.” He had made his point; I understood what he was trying to say.

“We do this operation with what we call minimally invasive technology,” I told him, explaining that we didn’t have to cut any muscle like they did in the good old days. “We’ll first use a knife to make a 2-cm incision into the skin and then dilate the back muscles with a series of tubes, each a size larger than the other. We’ll dock the tube on the bone of the spine, and using a fine drill that rotates at sixty thousand revolutions per minute, we’ll shave a portion of the lamina of the spine that covers and protects the dura,” I described. He was listening intently. “You need to have a rock-steady hand to be able to work the drill, because one slip and we could rip apart all the nerve roots of the spine,” I said, showing off slightly to make what we do sound more complex than what it is.

“Then, we identify the nerve root that is being compressed by the disc, and once we expose the bulging disc, we cut into it with a sharp knife,” I showed him an aminated video. Sometimes, the disc is just lying there, waiting to be popped out, and in those cases, we use forceps to grasp it and pull it out, thus relieving the pressure on the nerve root, which, in turn, relieves the pain. On occasion, we need to use a curette to scrape the disc, making sure there is nothing floating free to pop back out again. “You don’t ever need to use scissors?” he asked, slightly disappointed that we were neglecting his favourite tool. “We do – to cut the stitches we make when we sew you back up,” I said to a look of delight on his face. “If you don’t trust the ones we have, we could use yours,” I joked, “but actually, they’re a little too big,” I dismissed the idea before he could agree.

“You don’t use a laser?” he then asked. I wasn’t surprised; this is another question every patient has, especially those who come from the Middle East in lure of having laser spine surgery. “People use the term ‘laser’ only to make it sound fancy and attractive,” I acknowledged. “The use of an actual laser if very limited in this field,” I explained, “but we do the entire operation with a high magnification and brilliant illumination microscope and the focus point is a sharp red dot of light, which looks like a laser, if it makes you feel any better!” I concluded.

“At the end of the day, while the tool is extremely important, it is what you do with your hands, your head, and your heart that makes all the difference,” I said. “For instance, I could never cut fabric the way you do if you gave me your scissors,” I tried to explain. I told him how clinical decision-making was the key to any successful surgery, and emphasized how one needs to have the heart and the courage to deal with a complication if it were to occur. But I understand why, for some patients, it is very important to know what a surgeon will use, especially if they use a tool themselves: artists and architects, plumbers and painters, cricketers and carpenters, musicians and maestros never cease to ask me what I will use to open up their spine or brain.

When we operate on the brain, we mainly use a suction in one hand and an instrument in the other, which could vary from bipolar forceps to buzz bleeding vessels and tissue to micro scissors to cut what we have coagulated and an entire spectrum of micro dissectors  of varying shapes, curves, and sizes to get into nooks and corners of the brain that were once deemed unapproachable. We even have instruments that have lights at their tips to further illuminate what we’re looking at so that we cut only what is intended to be cut. And we also use dyes that light up tumours and help us differentiate it from normal brain tissue.

There are several surgeons who, when they operate in multiple hospitals, travel with their own tool kit comprising instruments they are familiar with. The touch and feel of using your own tool (no pun intended) provides a certain sense of comfort and control. The joy of owning your own instruments and looking after them like you would after your own children is unparalleled. I know an orthopaedic surgeon who carries his own portable operating table with him for joint replacement surgeries. There is a neurosurgeon from Japan who used only his own gold-plated microscope to perform his surgeries. In the interiors of India, just like farmers ask for a tractor in their dowry, surgeons ask for instruments, ultrasonic aspirators, and microscopes. These are extensions of a surgeon’s hands, head, and heart, also called our second wife by a few of us, and the first wife by most others. Don’t ask me which group I fall into.

Rasiklal came for a follow-up two weeks after his spine surgery, completely pain free and delighted that he could get back to doing what he loved the most. “Here, try this for me,” he said, pulling out an elegant formal shirt and pant he had stitched for me. “This is my gift to you for making me walk again,” he insisted, his eyes welling up as he insisted that I try it on in front of him. Without any reservation, I removed my clothes and put on his. They fit immaculately. “But you didn’t even take my measurements!” I exclaimed. “Sometimes, you need more than just a tool – you need a hand, a head, and a heart,” he reminded me of what I had told him. I spent the rest of my day in the clothes he had stitched for me so affectionately.

Training a young medical student from Germany, a surgeon dips into the learnings from his formative years at the Grant Medical College to dole out important life lessons

I recently had a medical student intern with me for a few weeks. Rukin had finished two years of medical college in Germany, and as he was interested in neuroscience, he decided to shadow me during his vacation. He was a sharp, well-groomed boy with a deep husky voice and full crop of thick black hair – none of the qualities I had possessed as a medical student.

He was 21. I am 42. Looking at him, I couldn’t help but remember my time as a medical student. About a little more than two decades ago, I stood meekly outside the administrative office of Grant Medical College and Sir JJ Group of Hospitals, immensely grateful to have secured admission with a little bit of merit and a lot of luck. In 1999, ours was the first batch that discounted the HSC marks and had a separate medical entrance exam. I remember 200 of us gathered in the voluminous anatomy lecture hall, where pigeons used to routinely fly across the room during lectures. Our anatomy professor was a pleasing roundish gentleman with buck teeth that allowed the air to pass through smoothly every time he spoke. “Anatomy is something everyone has, but in my opinion, it looks better on a girl,” was his icebreaker, amidst a few giggles and many glares.

“Do you get to dissect dead bodies?” I asked Rukin, who was scrubbing in beside me on a case we were about to work on. “Yes, but not like you get them in India,” he confessed. “Here, whenever you need a body, it can be made available to us!” I joked, adding, “Let’s not jinx it for this patient today, though.” Nothing paralleled the thrill of dissecting a dead body allotted to you, I told him. At Grant’s, as it was fondly called, we had called our cadaver John and considered him to be British – because he was fair and had a stiff upper lip. The dissection hall in the department of anatomy was where the dead taught the living. It was also a place where we resuscitated our colleagues who fainted at certain sights, the smell of formalin making deep inroads into their gentile infrastructure. Over the course of one year, John taught us more than our textbooks did. It was also the only place where we washed our hands before going to the bathroom.

The surgery today was on someone’s cervical spine. “Go ahead and make the incision,” I said, handing over the knife to Rukin, who took the knife a little warily. I added, “Be careful – the carotid artery is right underneath it!” and he handed it right back to me. I didn’t know if I was inspiring someone to become a surgeon or deterring him from it.

While I operated, I told Rukin more about Grant Medical College. Nearly every famous doctor in the world, we claimed, was from this legendary institution. Some even went on to act in movies or became singers, business tycoons, and CEOs. We were given a well-rounded training very different from that given by other medical colleges, who only concentrated on education. I remember being awestruck back in the day when I learned that pioneering work on malaria was done at Grant’s, when a new blood group was discovered there. “Did you know that besides the regular A, B, AB, and O blood groups, there’s something called a Bombay blood group?” I asked him. He shook his head behind his mask. “Grant’s made this discovery!”

Waldemar Haffkine worked on and perfected the inoculation of the plague vaccine in the Framji Dinshaw Petit Laboratory of Grant Medical College, which then became the pharmacology lecture hall where we ended up snoozing in every class; little did we know that it was here that the foundation of the Haffkine Institute was laid. Robert Koch worked on cholera and TB in our labs. Henry Vandyke Carter discovered the pathology of spirochetes in relapsing fever on our premises. Even the founder dean of our rival college, KEM, trained at Grant’s. From a 2-room teaching hospital on an area of 4 acres, Grant Medical College and Sir JJ Group of Hospitals stand on 44 acres today, I reminisced proudly.

Back then, however, in our first year of medical school, different kinds of poignant and extremely significant discoveries were made: that the canteens had more items on the menu thanks to us, the boys’ common room was kept open beyond the permitted hours, the college festival lasted one week instead of the usual 4 days, and couples found newer places to express their love. Study leaves became longer but were utilized for everything but study. Teachers became friends and friends became teachers… but attendance continued to remain a problem. In all the fun and frolic, we continued to be aware of our responsibilities. We were focused and determined as we walked into hospital each day with a smile on our face and a song in our hearts, not forgetting to pay our respects to the robust statue of our founder, Sir Jamsetjee Jejeebhoy, and seek his blessings.

On his part, Rukin told me that it was becoming apparent to him how different his medical training was as compared to the one I had received. At his college, they are compelled to separate the theory from the practical aspects of medicine. Cadavers, for them, were supplementary sources of education that aren’t heavily emphasised, and he’d taken it upon himself to read MRI and CT scans on his own time, because he wanted to prioritise practicable knowledge over memorising textbooks.

“What kind of exams do you have in anatomy once you finish your first year?” I asked Rukin. “Two practical exams, one on models and one on a computerized cadaver, apart from the theory,” he explained. “In our scenario, everything is real,” I told him. “Real specimens, real cadavers!”

I vividly remember my first-year anatomy exam viva. One of the test questions was to identify a body organ that had been stored in a formalin jar for decades and talk about it for a few minutes. Out of a few dozen jars in the anatomy lab, the professor would place one on the table in front of us and ask us to speak at length. He was jovial but intimidating. Even if we couldn’t describe its anatomy in detail, he said, it was important that we identify the organ correctly to be able to pass. I was sitting on a stool 3 feet behind the boy whose turn it was before mine, and the examiner placed a shrivelled specimen of a uterus in front of him, which I could identify with ease even from a distance. The examinee was having a hard time figuring it out, however; he turned the jar in all directions to decipher what it could be and the ashen look on his face revealed he was clueless. “I’ll give you a hint,” the professor prodded with a smile. “It’s something you and I don’t have.” With a slight sense of relief, he composed himself and gave it a shot. To his own disbelief and that of everyone else in the room, he answered, “Brain?” Needless to say, he was asked to re-appear for the exam six months later.

At the end of his internship, Rukin left us feeling both elated and a little melancholy: elated because he couldn’t picture himself not being a surgeon in the future, and melancholy because he realised he wouldn’t be able to be inside an OR for a long while. In his own words, “You gave me a sense of belonging and something to really look forward to at the end of my studies. I didn’t want to be a surgeon because of the pressure originally, but you let me discover something that I truly love, and I am not scared anymore.

To do the surgery or not? A surgeon is faced with the conundrum twice in the last two months and takes home different lessons

In the past two months, I operated on two patients who didn’t need surgery, or so I thought. But this is not one of those stories giving credence to the popular public opinion of doctors advising surgical interventions to patients who may get well even without them. This is deeply complex, emotional, and heart-wrenching. Greed, money, power, and ego have no place in stories battling life and death, where hope and faith combat the eternal question of where one draws the line of acceptance that the end is near – the most difficult and the most beautiful conundrum in simultaneity.

The first patient was a lady in her sixties. She had had two previous surgeries elsewhere a few years ago for a malignant brain tumour, followed by radiation and chemotherapy. In the past week, her health had deteriorated. She was in a semi-comatose condition, partly paralysed in her left arm and leg. Her husband and son had done everything they could have over the past 5 years to keep her going – taken her for opinions abroad, administered targeted therapy beyond regular chemotherapy based on the genetic analysis of her tumour, and enrolled her in an experimental wonder drug trial. “The tumour has returned, this time even more vociferously,” I told the family, who came to me with her reports while she was admitted at another facility in the ICU on a ventilator.

Their oncologist, who had primed them that further surgery may not help, sent them to me for an opinion. After carefully peering through sheaves of reports, I told them, “We can remove the tumour, but I don’t think it’ll make her better. Her brain has taken a toll over the years, and now, it is best we let her be,” I said, convinced that further surgery may neither improve her survival or the quality of it. “But we’ll never know if we don’t try,” her son rightfully reasoned, knowing that their herculean efforts had already prolonged her survival beyond the average expectation for a glioblastoma by 3 years. “We understand all the complications and everything that can go wrong, but you’ve come highly recommended, and we’d like you to operate.”

These are statements that flatter a surgeon’s ego, elevating us onto a superior realm, making us feel invincible. Most surgeons know how to put these words aside and focus only on the patient and what’s best for them. But even amongst surgeons, opinions are divided: Some physicians argue that a patient who will not benefit from surgery should not be operated upon, and will vehemently oppose any such request from the family, no matter how much they plead, while others argue it’s our duty to do the best we can as long as the intention is to help the patient, with full disclosure to the family that even the contrary might happen. No matter which set we belong to, all of us know that if the family insists on an operation, it is because they don’t want to bear the burden of guilt of not having tried enough for a loved one.

“Okay, I’ll do it,” I said reluctantly, as we transferred her to our hospital and operated a few days later. I operated half-heartedly – because somewhere deep down, I knew I wasn’t going to get the result I wanted – but removed the tumour fully. After surgery, we kept her in the ICU for a few days before the family shifted her to back to a hospital closer home, where she passed away a month later. I couldn’t help but wonder that if we hadn’t operated, it would have saved her loved ones much-prolonged anguish and several exorbitant expenses.

Within days of this patient’s passing, I was contacted by the wife of another patient of mine, whom I had operated upon twice for a malignant brain tumour. They lived in another country, and he too had surpassed the mean survival time for his brain tumour, again a stage 4 cancer. “He was well until two weeks ago, but now, gradually, he’s unable to move his left side, is slurred in his speech, and is unable to participate in any conversation,” she told me, her fear for him and for their two teenage children twisting through every word she spoke. The tumour had not only returned but spread to parts of the brain that were inoperable, and doing any more surgery had a chance of harming more than helping him. “It’s best you keep him at home and try palliative therapy,” I explained in great detail, knowing that now nothing more could be done. He was only 40 years old.

Despite this, they were on the next flight to Mumbai. I refused to operate, knowing fully well he could be much worse after surgery. “Do it for me, doc,” his wife, implored with brooding and piercing eyes. “Even a few extra months will give his children joy,” she pleaded, not allowing me to be rational. “Spend the time he has left in the condition he is in now, because he might get worse after surgery,” I urged her to understand, but she was adamant, wanting to leave no stone unturned.

I gave in and operated on him the next day. When I opened his brain, it was tense and angry. We removed a large chunk of tumour from the frontal and temporal lobes, after which the brain seemed soft and docile. I hoped that relieving the pressure would make a difference, but the next day, he was even more unresponsive. “This is what happens when you mess with a brain that is deeply and diffusely infiltrated by tumour,” I told his wife, subconsciously trying to cut myself some slack. The next morning, there was still no change. “I don’t think he’s going to make it,” I told her, but we continued making every effort in the likelihood that he would.

The CT scan wasn’t alarming and the EEG did not show any abnormal activity, which made it all the more puzzling that he wasn’t waking up despite a nicely performed operation. Three days went by with no sign of improvement. I cursed myself for not having learnt from the previous case. In my defence, I had laid all the cards on the table, but I also know that deep within there is a moral obligation that a doctor has first to himself and then to his patient – and I was unable to decipher if I had violated it.

Every day as physicians, we are battling decisions of right and wrong. On most days, the answer is simple, but on some days, simple is hard. Oftentimes, spine surgery gets a bad name because of contrasting opinions from varying surgeons: While one opinion might be to have urgent surgery, the same patient might be advised to wait it out by another surgeon, leaving patients confused and suspicious of doctors. But the truth is, every now and then, there is no right answer, and despite having made prodigious progress in medicine, we have to admit there are many things we still don’t know. “Keep the company of those who seek the truth – run from those who have found it,” discovered Vaclav Havel after a lifetime of searching.

The next day when I went for my rounds, dreading to see him and give the same bleak news to his wife, he surprised me by showing up wide awake with almost a sparkle in his eyes. To my surprise, he was even moving his arms and legs well. A few days later, we were able to pull out his feeding tube and he started eating on his own. By the end of two weeks, he was swift and coherent and flew back home to a smiling family. She sent me pictures of their kids hugging their father. How long he has left is nature’s call, but for the time being, his wife’s call stood tall. Maybe after all, in their context, he did need that operation which I had deemed futile.

Nothing brings more despair to a surgeon than finding a tumour they thought they had removed

Preeti was just 40 years old, but she walked into the office holding her elder brother for support. Her right leg swerved around the ground with every step, the kind of walk you see in people who have had a stroke. Nonetheless, she sat down comfortably with a surreal smile on her face, rearranging the dupatta of her purple salwar kameez for propriety. Her speech was slow but purposeful and penetrating, as she insisted on telling her story rather than allowing her brother to do it.

“I was operated for a brain tumour in 2006,” she started, mentioning the name of her previous doctor and hospital. “They told me it was benign,” showing me the biopsy report of a grade 1 meningioma – a tumour that arises from the outer covering of the brain, the meninges. Not a malignant tumour for sure, I confirmed. “But one year later, it came back,” she continued with a disarming smile. “I had my second surgery in 2007,” she confirmed, the precise date clearly etched in her memory. “For two years I was alright, but it recurred again,” she noted, without any sense of alarm. “This time, my doctor suggested we give it radiation after removing it,” she said. “Even though it is benign, he told me, it seems locally aggressive,” she repeated his exact words. So, after my third operation, I underwent radiation in 2009,” laying out all the reports in front of me.

She mentioned that she got married and had two beautiful children in the decade that followed, when, in 2019, she noticed that something was wrong again. The MRI showed a new large tumour on the other side of the brain. “I had no option but to have my fourth surgery,” she said, parting her hair and showing me the maze of scars on her scalp. “Then COVID happened and I couldn’t get an MRI for 2 years,” she confessed. “I didn’t have any problems until one month ago, so I didn’t bother, but now, my right hand and leg have slowed down considerably,” she acknowledged, pulling out her latest MRI with some difficulty. Her previous surgeon had retired, which is why she had come to me, she said.

I examined her scans. Her ghoulish tumours had returned. This time, it wasn’t one, but five of them in varying locations over the entire left hemisphere of the brain, with the largest one pressing against the motor strip, causing the weakness in her limbs. It was 6 cm in size. The others were 2–3 cm each. I peered deeply at the images. “We’ll have to remove all five,” I decreed, never having done that before. “But repeated surgery is not the solution to this,” I paused. “We’ll have to do some genetic studies on the tumour and then give you immunotherapy or chemotherapy,” I announced, knowing that it was important to find out why these kept coming back. She smiled peacefully, as though resigned to her fate.

A few days later, we made a large opening in the entire left side of the head. I removed the big tumour first, meticulously separating it from the brain scarred by previous surgeries. It was firm and multilobulated. We were excavating boulders from a pink mountain; luckily, there was no landslide. It didn’t bleed much either. I went around circumferentially, methodically removing the rest of them until we were convinced we had gotten them all out. We scrupulously reconstructed the covering of the brain called the dura (some of which had to be removed with the tumour). When she awoke from surgery, she was able to lift her right hand way higher than she had ever been able to in the past month, indicating her strength was back. She beamed with delight, her smile broader and brighter than I had seen before. “We’ll do a CT scan tomorrow morning to make sure everything is clear and then shift you out of the ICU,” I told her, with her family by her bedside. I was amazed at myself for have pulled this one off.

The next morning when I came to see her in the ICU, she was sitting up and eating breakfast on her own. Nothing gives a surgeon more joy than to see a radiant patient the morning after surgery. The nurse handed me the CT scan to review, which I held up against the morning light beaming though the ICU window. And my heart sank. I literally felt it slump two inches lower. Nothing gives a surgeon more despair than to find tumour on a scan he thought he had removed completely. I seemed to have left behind one of the five tumours, which, on studying the image carefully, was a separate tumour and not a lobule of the main tumour. It had probably been hidden by a sliver of brain. This wretchedness is what ages me many years in a few hours.

“If this was anyone else, I would leave this tumour alone because they almost never grow,” I told her family, “But in her, I’m requesting you to allow me to go back and remove it. Because if we don’t, all our effort would be wasted.” I was gutted; just yesterday, I had told her that this would be her last surgery, and today, I was going back on my word. But in my experience, if you tell patients the truth, they more often than not understand what you’re saying and tend to see things from your perspective. “Go ahead, doctor, do what you think is best,” Preeti told me, amidst silent sobs as she tried to hold on to her dampened smile.

The next morning we opened her head up again, undoing our labour of love. Like I had predicted, the tumour was hidden beneath a sliver of normal brain, but it had indented and lifted the motor cortex from below. The previous tumour had pushed it down from above. I worried that while the first operation had redeemed her function, this one would destroy it, given its precarious location. I remembered a famous surgeon once tell me, “There may be few patients which we may not be able to heal, but there are none we cannot harm.”

Unfortunately, he was right. She woke up paralyzed on the right side. I should have just let it be, I told myself, but also comforted myself knowing that this weakness is often transient, and as the swelling in the brain subsides, it gets better. By day three, she was walking independently, and one week later, when she was ready to be discharged, her hand grip was as firm as mine. I was able to absolve myself.

Just when I thought I’d never see anything like this again, a few days later, I saw another lady in my office. She was in her fifties. All she had had was a headache that had persisted for a week. Her MRI showed five round balls of varying sizes close to each other. “This could be TB or this could be tumour,” I told the husband and wife, who were petrified that the seeming insignificance of her symptoms had yielded something so dramatic inside the brain. The PET scan did not reveal any source of a possible metastasis. We’ll be lucky if this is TB; she’ll have a cure, I hoped.

I removed them all. This time I was doubly cautious, and the postoperative scan confirmed a total excision. She went home in pristine condition, relieved of her headache, which had occurred owing to raised intracranial pressure. Unfortunately, this set of five tumours weren’t harmless; it turned out to be a grade 4 cancer.

The purpose of joy

Joy can be found in the widest expanses of nature and smallest of rooms, in the grandest of gestures and simplest of pleasures. This Parsi New Year, remember to choose joy always.

“Do you know what makes me really happy?” my seven-year-old daughter asked me one day as we were sitting on the bed chatting about random stuff. “Candy!” I replied instantly. “No,” she said, adding equally quickly, “I love candy, but there is something else that makes me really happy.” She wanted me to guess further. “French fries?” I decided to go down the list of items she yearns for, not realizing I was way off track. “It’s not a food item,” she gave me a clue. “It’s something I like doing,” she steered me. “Playing with Lego?” I dove down the activity route. “I love Lego, you’re right,” she affirmed like a school principal, “but I’m looking for another answer,” she waited with anticipation.

“Swimming?”

“No.”

“Hide and seek?”

“No.”

“Playing on the iPad?”

“No… oh, one sec,” she course corrected. “I love the iPad, but I use it mostly to get ideas for arts and crafts. That’s not the answer I’m looking for,” she started rolling her eyes a little, probably realizing how little her father knows her.

“What do I do every day?” she gave me a hint. “Go to school,” I said matter-of-factly, “and I know you love going to school,” I added, because she’s the only child in my awareness who expresses a desire to go to school even when she’s unwell. “But that’s a mundane thing to make you really happy,” I cautioned, “that I would be really disappointed if that was going to be your answer after so much drama!” “No, no,” she insisted. “So you like coming back from school in the bus and playing with all your friends?” I gave it one final shot. But it wasn’t to be.

“See, dadda,” she enthusiastically gesticulated, ready to reveal the source of her inner joy. “When I come back from school, I put my bag down and sit on the couch. Sometimes, when it rains in school, water goes into my shoes and my socks become sticky and my feet are moist. And I keep curling my toes in my socks to dry my feet because we’re not allowed to remove our shoes in school,” she demonstrated. “So,” she continued, with a prolonged emphasis on the ‘o’ after the ‘s’, “when I come home, I sit under the fan and remove my dampy shoes, and then my soggy socks, and open my toes wide to let the air enter my feet,” she said with a big grin on her face, her eyes half-closed as she re-lived that moment. “It’s the best sensation in the world! It makes me so happy to feel the air go in and out of my toes as I wiggle them,” she said with profound excitement, peering into the gaps between her tiny stubby toes. This child was all heart. “The more we live by our intellect,” Tolstoy noted, “the less we understand the meaning of life.” I was struck with bewilderment that my daughter had expressed such a simple yet intricate gesture of joy.

The conversation made me immediately recall my days as a neurosurgery resident where I worked 18–20 hours every day wearing cramped trousers. Don’t ask why, but working in comfortable scrubs became fashionable in India only after COVID; until then, we wore formal pants to work all day. I routinely and laboriously used to return to my 100 sq. ft hostel room after midnight. I still pleasingly reminisce about sitting on the bed to remove my pants and get into a pair of breezy boxers for the 4 hours of sleep that we barely survived on. For me, that daily singular moment of freedom gave me the most amount of inner joy, a bliss that is vividly ingrained in my hippocampus. I also remember being deeply scarred on occasion by the phone call I used to get to go back to work moments after being refreshed by those airy boxers. Like Eleanor Roosevelt said, “With freedom comes responsibility.”

Nature, I believe is the greatest provider of joy. To make the most of the delightful weather, a bunch of us took our kids for a monsoon hike to Garbett Plateau, which was at a 2-hour drive to its base village, Diksal, close to Matheran. Ten children aged 7-17 with an equal number of childlike adults packed ourselves into cars at 6 AM, leaving behind the greyness of Mumbai only to be quickly ensconced by its verdant outskirts. After a streetside breakfast of samosas, vada pao, and chai, we began our ascent. We walked the perimeter of a placid lake that had dunes of malachite erupting from it. We waded through tiny streams that became huge waterfalls in the distance. “We’ll have to remove our shoes,” my daughter said, as we contemplated the knee-deep river we needed to cross. “Let them get wet,” I urged, and we held hands balancing ourselves precariously over the bedrock against the swift stream that toppled a few of us completely over.

I was wonderstruck at how relentless the little kids were in climbing the steep slopes amidst frequent bursts of cold pouring rain, which they licked off their lips to quench their thirst. The adults meandered in front and behind them. After a 3-hour gruelling climb, we surfaced on the vast expanse of the chromatic plateau, where an ethereal combination of steamy Maggi and spicy makai butta greeted us. We gorged on it to warm our insides as frosty clouds kept bursting above us.

After an hour’s relaxation, we sauntered our way down, some of us covering long distances simply by slipping down them on our bums, causing the rest of us to smile. “Pain is the rent we pay for being human,” notes Richard Rohr, “but suffering is usually optional.” With aching bodies, bruised buttocks, and soaking shoes, we returned to the base village. The locals were kind enough to allow us to dry up and change in their homes before we got into our cars to head home.

My daughter and I sat on a bench. Removed our shoes. Pulled off our socks. Spread our toes wide and allowed for the wind to blow air into the gaps of our toes. We felt the water evaporate off our feet with big smiles on our faces and even bigger ones in our hearts.

This is what gave us joy. What brings you joy? This New Year, if you can figure out the simple things that make you really happy, it will be a year to look forward to, a year worth living. No matter what, look for the joy. Choose joy always.

As this fortnightly column completes a century, we honour the indestructible force of the human spirit, and look back at the miracles and disappointments that dot the landscape of medicine.

It’s time to celebrate! The article you are reading happens to be the 100^th in the series of fortnightly medical anecdotes. Over the past 4 years, the many (or should I be honest enough to say, few) people who read this column regularly have been through the entire gamut of human emotions with me, with added revelations of truth and untouched horizons of mystery.

At the very beginning of these 100 articles, I had written about how I nervously burred my first hole in the skull of an alcoholic and evacuated a blood clot to see him instantly awaken from a stupendous coma. And in one of the last few ones, we’d evolved to extricating tumours from parts of the brain in a way that was once inconceivable a few years ago. In all these stories, we’ve honoured the indestructible force of the human spirit, but we’ve also learnt that nature has the final word. In an attempt to provide the reader with a glimpse into the life of a surgeon, I’ve shared some deeply personal experiences – the highs, the lows, the resilience of families, the determination of doctors, and the dissonance of nature. I’ve laid bare what it means to lose patients you care for with savage tenacity and the exuberance of saving lives that were deemed impossible to survive. I believe these narratives have allowed the layperson an honest entry into a world of medicine that there are so many presumptions about.

I write to you today after having gone through the archives, reminiscing of patients’ skulls being opened and operated upon while they are fully awake, a pea-sized tumour in the pituitary gland in the brain being the cause of a couple’s infertility, someone who almost died on the operating table and made a complete recovery, and someone who had a perfect operation but died soon after. There were patients who insisted on admission before sunrise and discharge before sunset and on the surgeon making an incision at an hour approved of by their pandit. We learnt how disconnecting a short circuit in the brain can cure intractable epilepsy, and how some patients who go to a dentist for a toothache actually need brain surgery. There are stories of how little children have battled multiple surgeries and unsurmountable odds to lead normal lives, and then there are stories of no matter how hard surgeons try, they can’t always vanquish fate. I’ve met patients who’ve dealt with their afflictions with such grit and grace it has given me goosebumps. I’ve told you about how a brain tumour was the source of one man’s pathological laughter, and how an excess accumulation of fluid in the head was the cause of an old lady’s dementia. I have written about how we got a paraplegic bride walking two weeks before her destination wedding, and I have cautioned against how spinal stenosis is misdiagnosed as Parkinson’s and how a brain tumour can mimic a slip disc. I have also counselled that not all back and neck pain are muscular, and that all forgetfulness cannot be attributed to old age. I have mentioned the influence that mentors, nature, faith, luck, and animals have on the work we do. I have described in heartbreaking detail what it means for a doctor to be afflicted with the very affliction they have spent a lifetime treating. And why closure is often a myth.

I believe that these vignettes of love, laughter, sorrow, and triumph have also been educational, empowering people to take serious charge of their own health and that of their loved ones in a fun way. People now know to get an MRI scan of their brain for a headache that does not seem like it’s going away and one of their spines if a back or neck ache seems pesty. People now know that all visual disturbances are not solely related to the eye and all loss of hearing cannot be attributed solely to a problem within the ear. I believe that these articles have helped people look deeper, both literally and metaphorically.

Suffering from an ailment is a great leveller. It makes no distinction between the affluent and the indigent, race and religion, or the umpteen genders we now know about. Each and every one of us has, at some point in our life, felt pain. And just when I thought I had seen everything in my field, I came across something I’d yet to see.

“I’ve had this vague pain in my mid back for the past three months,” said Neha, a high-functioning executive in her 30s, who had come to me with her MRI scans. She wore her hair in a bob and sported a fashionable nose ring. She gave me directions: “A little to the left… slightly higher…” as I narrowed onto the spot between her shoulders blades when she finally winced in agony. I couldn’t feel any swelling, but the MRI showed a 4 cm chunk of something within the paraspinal muscle at the mid-thoracic level that was shaped like the eye of a tiger, slightly ovoid at the periphery with a perfectly round centre. “This is outside the bone of your spine but within the muscle,” I emphasized on the anatomy to reassure her that there was nothing within the spine and would not paralyze her, which is the worry of most people when they hear the word spine. “It could be a tumour, it could be a cyst,” I added, “I’m not exactly sure, but if it’s causing you so much pain, just remove it,” the surgeon in me proclaimed. “I don’t want to go under the knife,” she admitted reluctantly. “We have other instruments we can cut with!” I joked, reassuring her that this was a daycare operation and that she would be able to go home a few hours after it. After a very detailed discussion, she left me with a “I’ll think about it.”

Two weeks later, she called saying she wanted to schedule surgery because the pain was becoming unbearable. When I met her the evening before surgery, I explained that we would localize the lesion with an ultrasound and get the radiologist to mark the exact spot of the swelling so we could cut right over it the next morning, as there was no palpable lump on examination. “On second thought, let us do the ultrasound in the operation theatre itself, after flipping you prone,” I instructed the team, as there was no point in duplicating work because we had a machine in the OT. So, the next day, after giving her general anaesthesia and turning her on her tummy, we brought in the ultrasound machine to localize the lesion.

I smeared the skin with jelly and placed the ultrasound probe over it, directly over an intricate tattoo of the letter N that she had on her back. To our bewilderment, we couldn’t see any ‘eye of the tiger’ anymore; it wasn’t even the eye of a little kitten. We adjusted the parameters of the machine but still nothing. We called in a senior radiologist to find it for us. She said there was nothing there. We rechecked if the MRI she had come in with was hers; it had her name on it. But it had been two months since she had gotten the scan done. “Let’s just open her up and see what we find,” one of my colleagues suggested, “It has to be somewhere there,” was his justification. “And if we don’t find anything, we’ll just have ruined her tattoo!” I guffawed. Instead, we shifted her to the MRI room under anaesthesia to understand what was going on. The lesion had completely disappeared. We all looked at each other’s faces with foolish grins ensconcing our surprise and confusion. “To live wonder-smitten with reality is the gladdest way to live,” I had read somewhere in Maria Popova’s writing.

I explained to her mother and sister who came along that there was nothing there to remove anymore. “In hindsight, I should have repeated an image before taking her to the OT,” I confessed. “It was probably a cyst that has disintegrated or a nodular inflammation of the muscle that went away with the anti-inflammatories, the pain taking its own time to resolve, is my understanding,” I explained.

When she awoke from anaesthesia, I told her what had happened. “Why do I still feel pain?” she asked, equally confused as me but happy that she had avoided surgery. “It’ll pass,” I reassured her, without understanding why but knowing that most pain does. A week later, her pain was gone.

There is a rare entity described in medicine called disappearing lesions. They are most often cysts. Some of them can be seen and felt to go away on their own. But others, like Neha’s, do so when you least expect them to. Everything that is possible is real, even the things that may eventually disappear.

As we live and learn, I’ll see you at a hundred and one.

A pillion rider’s accidental fall and nightmarish battle for life, is a reminder for everyone to stay helmeted when on a bike

“There’s a 62-year-old lady in the ER,” I got a call just as I was leaving late in the evening after an exceedingly active day. “She was sitting behind on a two-wheeler at a signal when she lost her balance and fell backwards, the back of her head slamming the road,” the physician in the emergency told me quite casually in contrast to his gruesome description of the fall. In the matter of seconds, I had already imagined in my mind a fractured skull with brain tissue splattered all over the road, had cancelled the dinner I was supposed to go out for, and was wondering – for the umpteenth time – why pillions don’t wear helmets. “How is she?” I asked to verify if my imagination matched the reality in front of him. “She’s absolutely okay!” he said, probably wondering why I sounded so edgy. “She’s fully alert, quickly obeying commands, moving all limbs well, and her pupils are briskly reacting to light,” he described, giving me the low-down on her neurological examination. I promptly uncancelled the dinner in my mind, replacing it with an image of the spare ribs I was so looking forward to.

I lugged my backpack over my shoulder and left my office to swing by the ER before I could call it a day. Apart from a tiny bruise on her occiput, she was immaculate. I was intrigued to see that her hands were covered in ornate mehndi from the tips of her fingers up to her elbows. It was so fresh that I could smell cloves from 2 feet away. I asked her what the occasion was. “My son is getting married tomorrow afternoon,” she said, the longing to be present at the wedding clearly visible in her eyes, “and I need to go home tonight,” she requested. “I would have sent you home, but your CT scan shows a thin sliver of blood in the brain, so it’s better you stay the night and go home tomorrow,” I reasoned. Her overbearing family started loudly concluding that nothing was wrong and that she would be taken care of at home. Just then, she vomited once. “We should not only keep her overnight but also watch her in the ICU,” I cautioned sternly. They found it hard to argue with that and reluctantly agreed. I am certain most patients are of the opinion that doctors and hospitals only want to fleece patients when they suggest an admission for something that is seemingly harmless and where recovery is possible at home.

As I left to feast on burgers and spare ribs with truffle fries, I promised her family that I’d come see her the first thing in the morning and discharge her soon after. At dinner, I asked my friends if they had ever been advised admission by their doctor that they thought they didn’t need, and three of the five raised a finger. They couldn’t elaborate because their mouths were stuffed with chunks of meat. We had the kind of meal that induced a food coma the moment I reached home way past midnight.

At 3 AM, while I was in the deepest stage of sleep, my phone rang. I picked it up with my eyes still fully closed. “Kamlaben has suddenly become unresponsive and she’s not moving her right hand and leg. She’s not able to verbalize,” the intensivist reported. “What does the scan show?” I slurred. “The blood has massively increased, causing severe pressure on the underlying brain. I’ve sent it to you,” he said, raising his voice slightly to awaken me. I scrolled through the video he had sent me and sat up startled. “Get her to the operating room now,” I instructed, putting on my scrubs to go to war. Over a few phone calls, the army was deployed. The OR was prepared, blood was arranged, her head was shaved. She was intubated and shifted for surgery.

Within the hour, I entered the hospital with a heavy heart and an even heavier stomach. I spoke to the son, confirming that we had to operate or else she would not survive. He wished me luck. I wished him back – in case he decided to get married.

“Thank God I insisted on admitting her,” I told my colleague as we made a big skin flap to expose the bone. We drilled a few holes in the bone, the burning dust smelling like the charcoal on the barbeque that was still being digested in my belly. The brain was tense as we lifted the bone off. As I cut open the dura, a large subdural hematoma – brain bleed – delivered itself like an overweight baby way past its due date. There was a large contusion within the lobe that we removed, after which the brain regained some semblance of normalcy.

“Would you get married if your mom was undergoing surgery on the morning of your wedding?” I asked my colleague as we started closing. “I don’t know about my mom, but if my mother-in-law was undergoing surgery, I would,” he joked. As we placed the final stitch to close the skin, we placed bets on whether they would go ahead with the wedding; I said they would, my colleague said they wouldn’t.

As we wheeled her into the ICU from the OR, we saw the son waiting outside, his mehndi-laden hands folded in prayer. I told him that surgery had gone well and that she should recover, but it would all depend on how soon we’d be able to get her off the ventilator. “How is it possible that she was okay for the first 7–8 hours after the fall but became unconscious later?” he asked me, clearly having pondered this while waiting outside. “There is something called as a lucid interval in patients with a head injury,” I explained. “After a transient unconsciousness from the impact of the injury, patients are fully ok. If a CT scan is done emergently, it may not show too much blood. But if active bleeding continues in the head, the pressure builds up and patients then deteriorate after a few hours.” I wanted to tell him that these are patients are often termed ‘talk and die’ in medical parlance, but I didn’t want to burden him with negative thoughts. In cases of a mild head injury, it is sometimes a dilemma even for the doctor to determine which patients should be admitted and which can be sent home.

While it is mandatory in most countries for the driver of a motorcycle to wear a helmet, fewer countries have put laws into place for the well-being of the pillion rider, even though statistics show there is no significant difference between the head injuries sustained by motorized two-wheeler drivers and their pillion riders. In fact, before the Motor Vehicle Act of 1988 came into effect, a study found that only 0.6% of all pillion passengers were helmeted. While Delhi made helmets compulsory for even the pillion rider about 30 years ago, Mumbai brought this rule into effect only a year ago. It is for each one of us to recognise how vulnerable the pillion rider is and insist on a helmet whenever we ride pillion. After all, Kamlaben hadn’t even been in an accident; she simply fell off the bike.

We saw the son return in the evening, straight from his wedding; I had won the bet. He had on his vibrant wedding head gear. He also wore a nose ring and multiple earrings in both ears. Chains adorned his bare chest, and he wore a piece of golden cloth that looked like a combination of a dhoti and kilt. Without asking, he applied the ritualistic haldi and kumkum on his mother’s forehead and left a box of sweets by her bedside, holding her hand for a while.

The next morning, Kamlaben woke up with a smile on her face, surrounded by her loved ones. She heard in great detail about the wedding she’d missed while her new daughter-in-law fussed over her and pressed her feet. A gentle-mannered woman, she thanked me profusely for saving her life and asked when she’d be able to have a bite of the celebratory mithai her visitors had brought her. “One tiny bite, right away. The rest of it, once you’re out of here!” I joked, patting her hand.