A doctor finds parallels between life in the wilderness and inside a hospital as he negotiates the woodlands in the hope of sighting a tiger

We recently hosted an international neurosurgical conference in Mumbai, after which we decided to take some of our foreign faculty to see the tigers of Tadoba National Park. We had warned them that the two-day trip could possibly be renamed as the trees of Tadoba if we didn’t sight the big cats, but we were fortunate.

We hoped onto a late evening flight from Mumbai to Nagpur and drove through obscurity to reach our resort in the blackness of the night. After a two-hour power nap, we got into open top Gypsy cars and watched the sun rise over the expanse of the forest, the crispy chill of the early morning making way for the glowing warmth of dawn. The dense scent of slender bamboo trees flirting with their robust teak counterparts filled the air with an invigorating aura as we spotted deer with long antlers dart away into the bushes as we drove on our stipulated mud paths. The guide pointed out a few sloth bears, jungle cats, and wild boars amidst eagles perched on tall barren trees.

Suddenly, there were a flurry of calls from animals which are best identified in one’s imagination. “This is the call of a spotted dear,” our guide said, adding that it indicated a tiger in the vicinity. I heard another call in another direction from another creature and asked if we could drive there instead, but the sagacity of the seasoned guide revealed itself as he said that that was a mating call and only experience can distinguish the call of fear from the call of sex. “You have to be married long enough to know the difference!” he joked in Marathi.

All your senses are on high alert in the jungle. My gargantuan ears picked up another sound and I excitedly pointed out where it could be coming from, but the driver burst my bubble by stating that it was his cell phone vibrating. Just then, a flamboyant peacock fanning out its iridescent tail feathers ran across in search of his peahen. We didn’t get distracted and continued to drive in the direction of calls of the spotted dear, converging to a point around a pond where several jeeps were parked in wait of the tiger. And out from the grassland came Mowgli. Not the feral child from Rudyard Kipling’s Jungle Book but one of the most majestic young tigers of Tadoba. In a stride that somewhat resembled Sanjay Dutt with jowls that looked like his too, he walked towards us with gentility and grandeur. The number of cameras that shuttered in that one instant would douse any read carpet event in the world. He then made his way to the waterbody, lapped up a few litres, peered at eager tourists with his brooding eyes, and proceeded to walk across, unfazed as several jeeps backed up to make way for the beast as he wandered into the thickness of the woodland – much like the elusive surgeon who only sees the patient once during their entire hospital stay.

We explored other terrains, nosing other jeeps akin to seeking a ‘second opinion’ from another surgeon, but everyone was clueless about where to go next until we reached another waterbody in the distance and found a National Geographic videographer waiting at the spot. He was waiting for Maya to emerge. Maya, who is one of the most famed tigers in the entire reserve and hailed as the Queen of Tadoba. “I’ve been following her for seven years,” he said with a calmness that mitigated our restlessness. “I’ve also spent three days in the same spot waiting for her to emerge,” he added, revealing once again why it takes immense patience and persistence to succeed in anything. “That’s why this is called a game!” he joked. “It’s the equivalent of a long-term follow-up of a patient once you’ve removed the tumour, to know if it’s ever going to come back,” we surgeons remarked, trying to find a parallel with the animal universe as we returned to our hotel without sighting Maya.

Our relationships with our fellow beings reveal a lot about us, and John Berger explores this relationship in his essay Why We Look at Animals, waxing eloquently about how animals are the object of our ever-extending knowledge. Berger writes, “With their parallel lives, animals offer man a companionship which is different from any offered by human exchange. Different because it is a companionship offered to the loneliness of man as a species. Such an unspeaking companionship was felt to be so equal that often one finds the conviction that it was man who lacked the capacity to speak with animals — hence the stories and legends of exceptional beings, like Orpheus, who could talk with animals in their own language.” If I could speak with a tiger, I wonder what I would say. I wonder, first of all, if I would stay.

When we reached the gates the next day, we received information that two tiger cubs had been spotted under a tree, and the jeeps that heard the news started driving at manic speeds over muddy bumps, the dust from revving cars ahead of us filling up our lungs, as all of us attempted to reach the destination in time. I couldn’t help but liken the situation to a doctor being frantically called to the emergency to see a serious patient and all teams being ferociously mobilized before we lost the patient. And when we reached the ‘emergency’, we found the patient lying down and calmly chatting away with the patient next to him; the two cubs were exchanging playful notes. We sat for the next few hours watching them play, while their mother had gone to get them some grub. Just like a patient’s relative who is never available when you need them the most.

“Why are you so excited to search for and see a tiger every time?” I asked the guide after that zealous ride to get there in time. “You must have seen hundreds in your several years of being here and coming into the forest each day,” I wondered. “It’s the same reason how even after seeing thousands of patients over the years, seeing patients everyday makes you happy,” he justified. “Even though you do the same operation every time, you will find something different and exciting.” The parallel he offered made complete sense. We sat there for another hour, mesmerized by the spiritual quality tangible in the air as the two felines gazed back at us.

Having met patients with different kinds of hand tremors, the surgeon explains why astute judgment is necessary to identify and diagnose problems concerning the human hand

“I have a tremor in my hands,” Meenaben Shah explained as she stretched out both her arms in front of me and showed me her fingers gently and rhythmically twitching away as if she were playing a piano badly. She was a middle-aged Jain homemaker in her late fifties. “When I have a cup of tea, my hands shake; when I’m stitching, I have a problem,” she continued in Gujarati. “When I’m cooking and cleaning, it’s alright,” she added, “but when my husband gives me stress, it increases,” she said looking at him with a hint of a smile.

I examined the tone in her limbs to ensure it wasn’t rigid. Her hands were supple. There was no arthritis. Her grip was strong. She had impeccable sensations. “This is called an essential tremor,” I explained, “and it’s not Parkinson’s, which is what most people fear when they start shaking a little. Oftentimes, it’s seen in the family, but this is nothing to worry about,” I comforted her. “Do you drink?” I asked her straightforwardly, but the response I got was as though I had committed blasphemy. She crisscrossed her palms over her cheeks and pulled her tongue out and said “Tauba, tauba!” as if I had invoked the devil. “I’m asking not because alcohol causes your hands to shake, but a small amount of daaru is the prescribed treatment for this tremor,” I shocked her with a broad smile. “Give her problem to me, I will solve it,” her husband suggested, adding, “Just because we’re vegetarian doesn’t mean we cannot drink!” to justify his stance. I wrote her some medication and asked her to see me in a month. “If this doesn’t work, we have a few other modalities we can try,” I told them as they left.

Surprisingly around the same time, I saw another lady, an architect and designer, with exactly the same problem but only affected on her right side. “My hand has this wired tremor; it’s as if I don’t have control over my movements. It’s jerky and unsteady.” I got her to stretch out her arms and the right one drifted away with the hand curling up with some abnormal writhing. “I was told that this is an essential tremor and nothing needs to be done, but I should see you just in case,” she clarified. I looked at her and said, “I’m glad you took the ‘just in case’ option because this is not an essential tremor.” We got an urgent MRI of the brain to find a tumour sitting in her left thalamus and the areas around it responsible for movement. The next day, under general anaesthesia and using computer navigation to guide us, we made a hole in her head and took a biopsy of the tumour. It turned out to be a lymphoma that melted with a few cycles of chemotherapy, and her abnormal movements vanished. She was back to drawing straight lines without the aid of a ruler, moulding clay, and making buildings.

I couldn’t help recalling the vintage classic by John Napier simply titled Hands. Originally published in 1980, Napier blends science and storytelling, observing keenly that ‘the hand at rest is beautiful in its tranquillity, but is infinitely more appealing in the flow of action.’ As a surgeon, nothing makes more sense than this.

“I have severe pain in the left hand that I just feel like shaking off all the time,” another lady came to me. She was a stenographer. “The pain zaps up and down the wrist and I’ve begun to notice numbness in my first four fingers.” “Do you have any pain in the neck going down your arm?” I asked, because sometimes, this pain can be caused by a pinched nerve in the neck. “No,” she ascertained. “So then, in all likelihood, you have carpal tunnel syndrome,” I decreed. “I know. I’ve tried medication, wearing a splint, stopping my work, but nothing’s helped. I need a new hand,” she begged.

We confirmed the diagnosis with a nerve conduction test. We ensured that she didn’t have diabetes because diabetic neuropathy can also cause pain and burning in the hands, but often it’s in both hands and the feet. We imaged her cervical spine to confirm there was no compression. A few days later, we took her to the operating room and made a small cut over her wrist, slicing the fascia that had entrapped the nerve and freeing it up completely. I wrapped up the hand in a roller bandage and tied a red ribbon round it, as if it was a gift and that I was presenting her new hand to her. She was completely pain free. It was the best present she had ever received, she said.

In that bizarre week, I saw another man who came to me with a wrist drop. One morning when he awoke, he could simply not extend his wrist, something as simple as what bikers do to rev the accelerator of their vehicle. He was a high-functioning lawyer, unable to come to terms that something so strange could happen to him. The look on his face was just as numb as his hand. “You must have slept wrongly or there may be a mild viral infection of the nerve causing this or diabetes,” I tried to explain. In all honesty, no one quite understands why this happens. On closely examining him, he had a powerless grip, and while his elbow extension was faint as well, the rest of his arm had good strength. An MRI of the brain ruled out a stroke. “You have a radial nerve palsy,” I told him. “We’ll give you a one-week course of steroids and you’ll be fine,” I pronounced, having learnt about that magic potion from my neurologist. This is exactly what happened, and the next time I saw him, he was beaming. It reminded me of Napier again, who, in his captivating edification, writes, ‘when the hand is at rest, the face is at rest; but a lively hand is the product of a lively mind.’

The human hand is one of the most complex and fascinating anatomical structures we possess. Its dysfunction can result from myriad conditions affecting the brain and spine or the nerves that emanate from it. It can also be a local problem of the bones, joints, muscles, and ligaments. It requires astute judgement to identify the problems that nature alone will heal and the ones we need to aggressively implement a cure for. Each hand has 27 bones and 30 muscles. Hands have the largest area dedicated to them within the brain compared to other body parts.

Our hands are an important part of who we are and how we see ourselves. What we do with them gives us our identity. Holding someone’s hand eases pain, provides comfort, and establishes connection. According to Tiffany Field, director of the Touch Research Institute, ‘holding hands stimulates the vagus nerve, which decreases blood pressure and heart rate and puts people in a more relaxed state.’ Hands have a profound power to heal. If you watched Lady Gaga perform ‘Hold My Hand’ at the Oscars last week, you’ll understand what I mean.

Meenaben came back a month later with her husband. “My tremor is almost gone,” she told me happily. “I can do everything I want to without being bothered by it!” she confirmed. We exchanged pleasantries, and just as they left, she peeked back into my office and shyly confessed. “I did try the daaru you suggested, and I think it worked more than the medicines,” she tiptoed away.

An elderly man struggling with the act of remembering due to a tumour in his brain, forces a surgeon to think about how humbling the loss of memory is

The entire Raichand family sat in front of me. Not the one from Kabhi Khushi Kabhi Gham but the one from Cuffe Parade. The patriarch of the family, 77-year-old Rajeev Raichand, was surrounded by his two sons and their wives. His daughter and her teenage son filled in whatever space remained. They infused the room with a spiffy fragrance. They wore designer handbags, ripped jeans, branded tops and expensive jewellery. Fancy glares were perched on their foreheads late into the evening. It felt like I was in a luxury mall in Dubai. The old man himself was dressed in a simple white pair of trousers and shirt.

“This all started about a year ago, when our dad started having some memory issues,” the daughter began. “He would forget where he kept his glasses or keys, and we didn’t think much of it until he started mixing up the names of family members,” she went on. I do that all the time and I’m only in my early forties, I mused, refraining from voicing it aloud. “He goes to the club to play cards every evening,” one of the sons continued, “and his friends started telling me that he was getting confused between a diamond and a heart, and that he would call a club a spade and mess up the game.” In these diplomatic times, very few people call a spade a spade, I once again thought to myself, but kept silent, unsure if they were ready for some jocularity. “We finally went to our family physician, who said it was early onset Alzheimer’s or Dementia and started him off on some medication,” they said, emptying his medication from a Gucci pouch.

“Unfortunately, he kept getting worse over the next 6 months, so we saw a neurologist who asked us to get an MRI of the brain, but because he’s claustrophobic, we delayed it,” the other son added, while the wives were busy scrolling their diamond crusted phones. “Now he’s reached a point where he can barely speak a sentence without mixing up names of people and things,” he concluded, looking at his dad in despair, as though he was haunted by the ambiguous loss of a man he once knew to be his father, who was now slowly turning into a stranger.

I picked up my phone and asked him to say what it was. “It’s a computer,” came the reply. I showed him a pen. “It’s a stick,” he said, fumbling. I removed my wallet and he called it a book, I picked up a cup of coffee and he called it a flower pot. I asked him what colour my black scrubs were and he called them purple with a strange confidence. I couldn’t help but recollect what the famous neuroscientist Antonio Damasio observed in his landmark work on consciousness, that we often “use our minds not to discover facts but to hide them.”

“So, finally, did you get an MRI?” I asked them, and they nodded sheepishly in unison. “The neurologist asked us to see you,” they said, handing over the films. “I’m absolutely fine, doctor,” the old man insisted as I plugged in the films into the viewing box. “I don’t have any headache, my hands and legs are moving well, I go to the club every day, and I don’t know why Raj and Karan are so worried about me!” he said, looking at his sons. “Those are not their names,” the daughter sitting next to me whispered silently, as we could all witness the dementia fraying his mind in front of our eyes.

“He has a large tumour in his left temporal lobe, eating away at the centers of the brain responsible for speech output, comprehension, and naming,” I told the family.  They seemed to acknowledge the description, having read the report before seeing me. “This clearly seems malignant to me,” I said, finally calling a spade a spade. “We have to remove what is safely possible and then give him radiation and chemotherapy, but the prognosis is not good,” I concluded firmly but lovingly. They accepted it with a calm and stoic fatalism.

“Were we late in getting an MRI?” one of them asked anxiously. I wanted to say yes, but instead told them that it is always best to get one done when we begin to notice unusual symptoms in the elderly. Even though most often these can be attributed to ageing, that is not always the case. Anyone who has a bothersome forgetfulness should be evaluated by getting an image of the head. “It is imperative to rule out a structural cause before labelling someone as having dementia,” I explained. “Most often, dementia is not reversible, so it’s best to scout for treatable causes, many of which can be identified with an MRI and some basic blood tests, the commonest being a deficiency of Vitamin B12,” I explained, so that no one felt any guilt. They left after having understood details of what the operation would entail.

Tumours don’t read textbooks. All brain tumours don’t present with headaches. Some can present with inattention, absentmindedness, and forgetfulness. All headaches are not brain tumours, but doing an MRI can resolve any conflict and pick up cancer early, allowing it to be treated better.

Action hero and Hollywood movie star Bruce Willis has now brought to the forefront this diagnosis of hisAphasia – a disorder affecting language and speech, which later progressed to affecting his cognition and leading to something known as fronto-temporal dementia. He probably had the same symptoms as Mr. Raichand but he didn’t have a brain tumour. He had atrophy or shrinkage of his temporal lobe, which too can be diagnosed on an MRI but can’t be reversed. A neurologist can help slow it down with medication and therapy, but we still don’t have a cure, just like we don’t have a cure for high-grade brain cancer.

Mr. Raichand eventually got operated by a more renowned neurosurgeon in the city and made an excellent recovery. He was getting tired from the radiation and chemotherapy, but he was finally calling a spade a spade. His family had kept in touch and was grateful for my time and for giving them a patient understanding of the condition.

I have often wondered if people who have their mind syphoned by a cognitive illness lead happier lives than people who are still all crisp ‘up there’. I think dementia is a gentle ‘letting go’ of all attachments. The bling begins to blindfold itself; the sounds begin to muffle. You initially forget things and places and then people. Eventually, you fail to remember who you are. The ego drops. You are at the mercy of anyone who is willing to fill the gaps. Everyone around you may be at their wit’s end, yet you experience nothing but joy, peace, and serenity.

I googled synonyms for forgetfulness. One of them was ‘nirvana’.

A badly compressed nerve can be the source of all discomfort. Nipping it in the bud instead of playing wait-and-watch is never foolhardy

Jay walked into my office wearing a cervical collar. Not the soft fluffy one that makes the neck feel cosy, but the hard sturdy one that supports the chin in front and braces the back of the head down to between the shoulder blades. It made him look like a character straight out of RoboCop. He was 6 ft tall and able-bodied but walked with such caution that each stride seemed programmed and motorized. I allowed him to gingerly seat himself on the examining bed while his wife and mother perched themselves on chairs in front of me.

“What happened?” I asked curiously. “I’m a civil engineer,” he introduced himself, “and I was at a construction site on the second floor,” he laid the premise. “A colleague of mine accidentally slipped off the edge of the building and luckily I was right there. As I stretched out to grab him, my neck felt a solid jerk,” he continued with minimal animation, extending his burly arm but then wincing. “All of his 65 kilos were hanging on my left hand and I somehow managed to pull him up,” he said, heaving a sigh of relief.

“How’s he doing?” I amused Jay, wanting to know the repercussions of dangling off a building at someone’s mercy. “He’s tip-top,” he said in his Gujarati accent. “But I have severe pain in the neck going down my left arm like an electric shock and I can’t lift this arm up from the shoulder. My forearm and hand feel like there are pins and needles running through them,” he concluded, describing the classical textbook description of nerve compression. “When there was no relief for two weeks, my doctor put me in a collar, told me to get an MRI, and asked me to see you. Now you need to decide what to do for me,” he surrendered, folding his hands in an agonizing namaste.

I examined Jay to find that his left deltoid was extremely weak, as were his biceps. He could not raise his arm above the shoulder or flex his elbow easily. “This is a sign that one of your nerves is badly compressed,” I warned, and confirmed it on the MRI he had brought along. “The disc between your fourth and fifth cervical vertebra has herniated out from the impact and is pinching against the nerve responsible for shoulder abduction and elbow flexion,” I explained, drawing a framework of bones and nerves so that the civil engineer in him could understand the structural flaw and complications of something shifting. After all, the spine is the central support system of the body – physically, emotionally, and spiritually. The spine is the axis of our being.

“What do we do now?” he asked the next logical question. “If you had only pain, I would say, wait it out with the medication because over 90% of patients get better with time. As you have a profound muscle weakness, I would suggest freeing up the nerve with an operation. It’s the only real hope of it recovering,” I confessed. He remained silent; patients are always suspicious of doctors who suggest surgery as the first option. “If you let it be, it’s only the instagram-wala hope you read about in quotes,” I added, trying to make him smile. “If you didn’t have neurological dysfunction, I would have suggested that you wait and bear the pain,” I reiterated. His mother and wife nudged him to agree to surgery because they had seen him suffer, and he consented.

Two days later, we made a skin-crease incision into his neck along the normal neck lines and opened it up. Dissecting through the layers of the neck, we reached the disc space between C4 and C5. I cut into the disc and curetted out the soft jelly-like substance until I got to the part that had sneaked in under the bone to pinch the nerve. I held it with a forceps and got that migrated chunk out, happy to see the nerve bounce back into position. “That’s going to take care of everything,” I told my assistant, as we placed a titanium cage in the disc space to maintain the curvature of the spine and secured it with screws.

The next day he was absolutely pain free and there was even a slight improvement in his strength. “This will take a while to improve completely,” I explained to him, reminding him off our pre-operative discussion, which most patients tend to forget once they are completely rid of the pain. He returned three months later having recovered his arm strength completely. This time he brought along the friend whose life he had saved. “I saved his life and you saved mine,” he told me.

I asked him how he felt. “I’m perfectly fine and things are fully back to normal, except that I find it hard to sleep comfortably at night. The neck is just a little uneasy,” he tried to explain. I told him to try using a cervical pillow and warned, “Place it correctly below your neck!”

He looked perplexed at my insistence, and I decided to explain. “A few months ago, I had a young patient who came to me with neck and lower back pain,” I told him. “Her MRI was alright and I suggested that she do some physiotherapy and use a cervical pillow. She ordered one online and used it for a month and came back to me upset that it hadn’t helped. My intuition made me question how she used it. I wanted to know if she rested on the correct side of the curve. She stared at me flatly and said, ‘What do you mean show you how I use it? I put it between my legs up against my cervix!’ Professionally, I’m expected to keep a straight face, but in her case, I actually burst out laughing,” I told Jay.

“I calmy explained to her that the word cervical is derived from the Latin root word ‘cervix’ which means ‘neck’. For this reason, the word cervical pertains to many areas where tissues narrow to a neck-like passage, not only in your neck. While the neck of the uterus is also called the cervix, the cervical pillow was for her neck and not her cervix. ‘Oh,’ she said, slightly embarrassed. ‘I thought it was for the lower back pain because everything is in and around the area,’ she covered up with a goofy smile. ‘You doctors are so silly; just name different body parts differently next time!’ she said, as we all had a good laugh.”

I believe Jay got the memo. Even if he hadn’t, I was pretty sure he didn’t have a cervix.

When you can’t promise your patient 100 per cent recovery, giving them some hope won’t hurt

Rahul walked into my office with a limp. Not the kind where one leans off to a side in pain and needs the help of a stick or a crutch to support themselves. Here, he needed to raise his right leg high, almost as though he were climbing a step and bend the knee to take a step forward. He was unable to flex the ankle such that the heel makes contact with the ground before the rest of the foot does, which is how we normally walk; walking is such a subconscious activity that we barely realize it. Every time he took a step forward the foot came down with a slap to the ground like a blob. Surprisingly, he had no pain.

“When did this start?” I asked, after he settled his heavy frame down into a chair. He was in his early 40s and had curly biceps with tattoos of various Gods extending down to the forearm. I am always intrigued by people who have the ability to permanently ink themselves with a symbol, picture, quote, or anything else that seems relevant to their existence. I once had a patient who tattooed onto his back the screws and rods we placed inside his spine. I have also had the secret desire to tattoo my initials on the scalp of every brain tumour I remove, but I have vetoed that idea as my initials are MT, and when read aloud, would not be a good indicator of someone’s brain status.

“About six months ago,” he said, shuffling in his chair. “Initially it was very mild; I had some low-level back pain going down the leg, but that pain went away with some medication and I didn’t bother about it,” he proclaimed, clearly having taken charge of his own health. “What you had then is what we typically call sciatica,” I interjected. “But since the past 3 months, I just can’t seem to lift my right foot off the ground. I’ve been doing physiotherapy but it’s not helping.”

“Why did you wait for 3 months?” I asked, intrigued. He looked at me shaking his head sideways, not having an answer. “I guess I hoped it would settle down,” he said, trying to find himself an explanation. “Finally, I went to a neurologist, who examined me and said my nerve was damaged, which is what has caused the foot drop. He ordered an MRI and sent me to you,” he concluded, sounding frustrated. I asked Rahul to get up and walk, showing him how it was easy for him to walk on his toes, but that his knees buckled if he tried to walk on the heel. He just could not lift the heel up, and sensations along the distribution of the sciatic nerve in the right leg were diminished.

“The neurologist said that sometimes the nerve could be affected by diabetes or a vitamin deficiency, but not in my case,” he tried to explain. I am also always intrigued by patients’ interpretation of their previous doctors’ explanations, and he was doing a good job, although often, it’s more like Chinese whispers. I showed him on his MRI that there was a sizable disc prolapse in his lumbar spine between L4 and L5 that was compressing his nerve and flattening it out, which is why his neurologist had sent him to me.

“Ideally, this compression should be relieved by surgery, but I’m uncertain how much your foot will recover, because your nerve has stayed pressed for too long,” I confessed. “Then why do the operation if you can’t guarantee a cure?” he shot back, slightly hostile and understandably so. I went on to draw a few diagrams and explain on models that I have in my office (not the ones that walk the ramp but 3D acrylic specimens of the spine) that most often we operate for unrelenting pain, even though anecdotally, there are patients who miraculously improve on their own despite a foot drop. “When a weakness sets in, it’s best to do it at the earliest. If the nerve has been damaged beyond a point, sometimes even relieving the compression will not help it recover, but if you don’t remove the compression, it will almost certainly stay like this,” I went on. “In short, you’re telling me to get operated with no certainty of it changing anything,” he summarized. I nodded in agreement. “But my gut feeling is that it’ll help,” I added, trying to instil some faith. “I’ve done this on quite a few people in the exact same situation and even I have been surprised by the body’s ability to heal.” We shook hands and he left, slapping his foot as he walked away.

A few weeks later, he was on the operating table. We made an incision, half the size of a thumb, into his back and got to the space between L4 and L5. We cleanly drilled a bit of the bone and nibbled away at the ligament covering the dura. The nerve root that is usually round and thick was flattened and stretched like a pad Thai noodle. Angling the microscope and without stretching the nerve any further, we got into the disc space and removed a mammoth piece that sat there like the Rock of Gibraltar. We freed up the area all around the nerve to ensure that nothing else was pressing against it. “Do you think he’ll improve?” I asked my colleague assisting me while closing. Even if he’s uncertain, he’ll always say, “Yes, sir,” which is sometimes exactly what you need.

The next day, there was no change in his power in his right ankle, but Rahul said he was able to feel a different sensation in his foot. “As if there is some energy flowing through it,” he tried to explain. “I feel like there is some life to it!” he beamed. I discharged him and told him to continue the physiotherapy.

He came back to me 3 months later having completely recovered. He could walk on his toes and heels. His sensations had returned to normal. He was delighted. He had tattooed a photo of Zarathustra in a space left on his arm and showed it to me proudly. “Only the Parsi God was missing, but now, thanks to you, even he’s here!”

“Will you make a tiny tattoo of me on your foot?” I asked, being knowingly cheesy. “Then, every time you take a step, you will remember me,” I added, ever my filmy self. “You are already tattooed in my heart,” he smiled and gave me a tight hug, taking a selfie.

Overconfidence at the operation table need not always translate into a successful surgery; it’s this unpredictability that keeps most doctors on their toes

Mrs. Patil walked into the clinic with her daughter. She was in her sixties, wore a hand-woven saree, and tied her hair in a bun. She was the principal of a renowned school and rested her glasses low on her nose to complete the look. When she spoke to me, her eyes peered above her spectacles, taking me back to my school days, when our teachers glared at us when they wanted to appear to be strict. Unfortunately, she had a problem with her vison. “I am unable to see on my sides,” she mentioned. “When I’m attempting to cross a road, I can’t tell if a car is coming, and I keep bumping into things in the house,” she went on to explain.

Her eye doctor was quick to realize that this was a sign of optic nerve compression and asked for an MRI of the brain, which her daughter pulled out amidst sheaves of other reports. After I examined her, I wedged the films into the viewing box and went on to explain what we all knew. “She has a gigantic tumor arising from the pituitary gland in the center of the head that’s grown large enough to push the optic nerves up. Both sides of her visual fields are affected because the tumor is compressing the junction of both optic nerves as they leave the eye,” I tried to explain simply.

“Will you be able to remove this from the nose,” she asked point blank, obviously having done her research and taken a few opinions before coming to me – because the other option is to excise it by sawing the head open. This time I peered at her with eyes above my glasses. “I don’t want to open up my head,” she said categorically. “It’s possible to remove this from the nose,” I said after studying the MRI more carefully, “but it’ll be slightly risky,” I confessed, showing her a part that was probably stuck to an artery and another part that had extended beyond the line of vision. “We’ll have to do an expanded endonasal approach,” I said, to make it sound fancy. I explained the risks of death, paralysis, coma, infection, bleeding, and hormonal imbalance, and saw her complexion turn ashen. I quickly reassured her that more often than not, everything goes well. Until it doesn’t, I said to myself.

The human nose is one of the most fascinatingly designed parts of our anatomy. The Parsi nose of course, does not fit this description. But, irrespective of gender or race, when you look at the nose through an endoscope, it is visually spectacular – once you’ve gotten past the hair in it. Entering the nose to reach the brain is like trekking from Manali to Leh: the turbinates, with their shades of pink and brown, resemble the rugged valleys and mountainous terrain of that scenic route. Once we went pass those, we enter the gaping sphenoid sinus, its topography changing completely to something more cavernous, with thin bony septa guiding us up further to our destination. Just as trekkers find it adventurous to identify various peaks around them while climbing, surgeons like to do the same with anatomy.

We like to demonstrate to everyone in the operating room where we are in our journey to our final destination, and in doing so, we reached the widened floor of the sella, a saucer-shaped bony structure that housed the pituitary tumor and was thinned out by it. I took a diamond drill and caressed it as bone turned into dust, which we washed away. I then drilled a little more ahead so we had access to the extensions of the tumor. We made enough room for us such that we could operate through both nostrils using four hands, two of mine and two of my ENT colleague’s. I cut into the bottom of the tumor and it was soft and gooey, like they most often are in this location. Using a suction in one hand and a curette in another, I kept gently dislodging tumor and allowed it to descend into the cavity we had created.

The challenge was to get to the part that had insinuated itself into the frontal lobe of the brain. It was harder, not as mushy as the rest of it, and I had to hold it with forceps and gently tease around it to free it up from spiderweb-like strands to remove it completely. Just as the last bit got extricated, there was a sudden onset of torrential bleeding and the nose filled up with blood like a volcanic eruption, blurring the lens of the endoscope. It was akin to a trekker slipping off the top of the summit and rolling down the mountain, splattered in blood. I put in a much larger suction, got the anesthesiologist to lower the blood pressure, and briskly identified a small twig that was bleeding, buzzing it with a bipolar cautery. Three thousand thoughts must have crossed my mind in the three minutes it took to control this. The scenic vistas, temporarily marred by what looked like a forest fire, were once again restored to their pristine glory. The brain was soft and pulsating gently, the optic nerves free from what was burdening them. We closed meticulously in the usual fashion, layering the base of the skull to seal the defect from below. I walked out of the operating room with broad shoulders, tapping myself on them for having performed a great operation.

She woke up with completely restored vision, which was a miracle in itself, and was transferred out of the ICU the next morning. A few days later, she was sitting up in her bed, hair oiled back, spectacles low on her nose, reading the newspaper. She looked at me from above her glasses as I walked in to meet her. Neither of us could believe she had massive brain tumor surgery just a few days ago. I explained to her how modern surgery had evolved, and that with improvements in technology and visualization, we are now able to do what was previously the unthinkable. She was discharged after a week once everything was in check. Not only did I walk about with broad shoulders, I pumped my chest out a bit as well. This is how most neurosurgeons routinely walk.

But medicine, as we know time and again, is a great leveler. Two weeks later, I got a call from the ER saying she had returned with severe headache and vomiting. While she was conscious when she came in, she was no longer responding within the next few minutes. A CT scan, which had been clean when she was discharged, now looked like a bomb had burst in her head. An angiogram was not able to reveal the source of the bleed. I suspect that the twig we had coagulated had probably opened up again, but I wasn’t able to prove it. Over the next few weeks, we got her off the ventilator as she showed some signs of improvement and was on her way to recovery that was slow but sustained.

The case that had made me want to show off my surgical skills a while ago had made me want to give up operating a few weeks later. The case that had showed me breathtaking views of the mountains only a few days ago, had them crumble and collapse on me in an instant. The case that had showed me the light to be able to push the boundaries of modern medicine, had, within a matter of time, swallowed it up into a silent scream of darkness. The nose, which until some time ago was a stairway to heaven, had turned out to be a highway to hell. Such is life…

At a time when technology is reshaping how we diagnose, a patient with an autoimmune disorder compels a doctor to turn to old school hacks

Robert came to us from southern Africa. He had had surgery on his cervical spine one year ago for a compression of his spinal cord that had made it difficult for him to use his hands and legs. He made an exemplary recovery from his symptoms and regained his lost function in a span of 8 months.

However, he began to notice something funny. His voice began to undergo a consistent change; it started developing a nasal twang, the kind that would make one believe he was from the Philippines. Within a few weeks, he also found it arduous to swallow food and even drink water. He choked on tiny morsels of grain; food would sometimes make its way down the windpipe instead of the food pipe, which would cause him to asphyxiate. The doctors back home inserted a nasogastric tube prohibiting him from consuming anything orally. They even made a hole in his windpipe, doing a tracheostomy to safeguard him from suffocating in his own secretions. He lived this way for an entire year before they sent him to us to figure out what was wrong. It was puzzling; an MRI of the brain was clear and the spine too had been adequately decompressed at the level they operated on but there was some mild stenosis above. They told him he might need more surgery and put him on a plane.

When I first saw him, he looked emaciated, with a tube stuck in his nose and another one popping out of his throat which he blocked with a finger for his voice to be audible. He was 6 feet tall and weighed about 50 kg; he had lost half his weight in the past few months. “Why does one of your eyes look a little smaller than the other?” I asked after listening to his entire ordeal. His wife jumped off the couch to check on my observation, and after peering closely, agreed. “The left one, correct?” she asked, surprised at how she hadn’t noticed it in the past year. “Does that mean anything?” she continued, perturbed. I explained that there is always some subtle asymmetry in the human body: often, one breast or testicle is slightly smaller than the other, or one half of the brain is slightly larger than the other, and then there are people who have an indistinct difference in the size of their hands or feet and sometimes even the eyes. The key is in understanding what is clinically significant to our diagnosis.

“Do any of your symptoms worsen as your day progresses?” I enquired further. “Yes,” he said emphatically, once again blocking his tube to be heard, the voice becoming more nasal, the fatigue more pronounced. I told them I had an idea what we were dealing with and that I needed to check with our neurologist, who confirmed the diagnosis in a few minutes of seeing him. “Without a doubt, this is myasthenia gravis,” he said with an air of authority, explaining to Robert that the disorder indicated grave or serious muscle weakness. “This is a disease in which antibodies are made by a person’s immune system to prevent certain nerve muscle interactions,” he continued. “This affects certain groups of muscles causing them to get weak, more so as the day progresses.” Turning to me, he announced, “We’ll give him a few drugs to block the antibodies and he’ll be okay in no time!” his excitement palpable as he snapped his fingers at me.

There is an exhilaration in recognizing what is staring you in the face. The joy of making a concrete clinical diagnosis in medicine in today’s AI-driven metaverse is a simple example of that. We now live in a time where images and investigations show us the way forward, but once in a while a Robert comes along to keep the light aflame; one clear look at his eye told us what was going on. Senior clinicians look back lamentingly on the days when they spent hours getting to know a patient, sitting at their bedside and talking to them gently, examining them with excruciating detail, until they were able to discern what was going on, only to be thrilled at making the correct diagnosis and seeing the results of their treatment pan out in front of them. Today, most of us glance at reports and films to know how to move forward and focus on technical nuances. After all, it is also imperative that we use all the modern technology available to us to enhance our surgical outcomes.

The eye is a direct extension of the brain. Looking into someone’s eyes gives us so much information – medically, emotionally, and spiritually. You can diagnose something as simple as a cataract, conjunctivitis or jaundice, copper deposition (indicating liver disease) or thyroid dysfunction, or something more sinister such as a retinal detachment or neuritis. Looking into the eye can tell you if there is raised pressure inside the brain, and if you look a little deeper, you can even diagnose increased pressure inside the heart. The important thing is to look hard enough. Looking into patients’ eyes while talking to them builds trust and confidence. It allows them to share their real story. It tells us parts of their story that words fail to express.

The eye is also a surgical corridor to the brain. Instead of sawing through the skull bone, for certain pathologies, we can make a tiny incision behind or through the eyelid and then make a small hole through the eye socket to reach the brain. We like to call it ‘natural orifice’ surgery. I’m not sure if this makes the idea of brain surgery less or more terrifying.

Robert’s diagnosis was confirmed with a few lab tests and nerve conduction studies. He was started on a cocktail of medication by the neurologist that improved his voice and strengthened the muscles he needed to eat, chew, and swallow within a matter of days. His eye opened up like it was ready to bloom. We removed his nasogastric tube and closed his tracheostomy over the next 2 weeks. His smile had never been broader because he was able to eat like a normal human being for the first time in a year; he even polished off the food that came for his wife. He put on 9 kg while he was admitted with us. It was the perfect start to the new year.

The tumultuous emotions witnessed during the FIFA World Cup final is the everyday story of a surgeon

I must confess that while I’m not a big football fan, I jump onto the bandwagon once every four years and watch the last few matches of the world cup. And what an eclectic final we witnessed! Probably one of the greatest world cup matches ever played. Every conceivable emotion that humans are capable of experiencing came alive in a span of three hours across the globe. Joy, sorrow, hope, fear, and passion were not just simmering but boiling in the same pan. Devastatingly beautiful. The certainty of Argentina’s success was transformed almost irrevocably in a matter of minutes by the French. However, the exuberance of Mbappé’s youth was eventually silenced by the resilience and wisdom of Messi’s experience.

The morning after the dust had settled, I couldn’t help but think about the similarities between soccer and surgery. It’s a different thing that when soccer players end their careers, surgeons start theirs, but every surgery performed on the brain (if not spine) is like a football match – if not always a final, definitely a knockout. It’s you versus the tumour. Only one can win.

You need to know when to attack and when to defend. You need to find the correct corridor and get to the tumour without conceding a foul to a neighbouring blood vessel. Unlike in football, in neurosurgery there are no yellow cards, only red ones; one mistake and you’re out of the game, and there’s certainly no referee to argue with save for God. An operation is indeed akin to a football match. For most of the game you’re passing (instruments) and occasionally you’re dribbling (as some of the instruments need to be controlled by foot). There are many, many minutes of boredom and a few moments of terror. Like in football, it is those moments of terror that test your grit and grace.

Younger surgeons (the Mbappés), having just learned all the skills in the game, are often more aggressive. They walk into the operating room with their chests popping out; they have the brashness of a footballer and attack a tumour by destroying everything that comes in their way. This pugnacious attitude often works, and is, in fact, needed in the right dose, but overdoing it might harm both the player and the team.

Tempered surgeons (the Messis) know when to pick their battle. They’re gentler with tissue, and take their time to dissect and attack in short bursts when time and space is on their side. This makes them surer and more efficient even though it may seem like they may take longer to complete the task. They know how to get themselves out of trouble, something that comes only with the wisdom of experience. Like the famous surgeon and writer Atul Gawande says, “The difference between triumph and defeat, you’ll find, isn’t about willingness to take risks. It’s about mastery of rescue.” Good doctors and hospitals don’t fail less; they rescue more. Argentina were able to rescue themselves from where they were. There was a certain cockiness about France when they thought they had the win in the bag.

Taking a penalty is like removing the last bit of tumour stuck to an important artery or nerve. At that given instant, everything you’ve trained for all your life becomes important to the solution of the problem. You can’t do it later. You can’t scroll down on your phone for help. You must have the exact precision, speed, and timing for that one move. Your heart is racing beyond measure and yet your hands must be still as a rock that is oblivious of the raging winds. Everyone is watching what you’re doing on giant monitors in the operating room amidst the deafening silence of beeping monitors. Either you score or you are annihilated. And both those things can happen in the span of one operation. The emotions we witnessed in the world cup final are those that surgeons experience regularly, but thankfully, they aren’t broadcasted live on world television.

Oftentimes we score, but sometimes we stand defeated. And when we lose, we too cry like grown up footballers, but it happens in the isolation of our closed spaces. We don’t have people telling us it’s going to be okay. Like the famous surgeon René Leriche (it’s not a coincidence that he was also French) said, “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray – a place of bitterness and regret, where he must look for an explanation for his failures.” Every footballer probably does the same for every penalty they miss. Every sportsperson does that for all the chances they lost. Michal Jordan once said, “I missed more than 9000 shots in my career. I’ve lost almost 300 games. 26 times, I’ve been trusted to take the game winning shot and missed. I’ve failed over and over and over again in my life. And that is why I succeed.” And that is what Messi showed the world on that fateful Sunday. That is what surgeons across the world do when they go out each morning like gladiators stepping into the arena. “Neurosurgery is a contact sport,” the famous aneurysm surgeon Juha Hernesniemi once told me.

As we draw closer to the end of another glorious year, most of us sit back and reflect on our hits and misses, wins and losses, triumphs and disasters. We deliberate on where we went wrong and what we need to do to course correct. We forgive those who hurt us and seek forgiveness from whom we have harmed. We strive to take the next small step in the right direction. We hope that in the coming year we will be a better, stronger, gentler, and kinder version of ourselves.

We wish that each of us eventually has a story to tell, because as Gawande says, “Life is meaningful because it is a story…and in stories, endings matter.” Just like it did for Argentina and Messi.

I hope the end of 2022 allows you to start a new beginning. Here’s wishing you all a Merry Christmas and a Happy New Year.

Nothing hurts as much as a patient delaying, denying and deflecting the imminent

Rahul was a biker dude who limped his way into my office one day. He wore a French beard and a tight-fitting Harley Davidson T-shirt. An interlocking brass chain around his neck and steely skull-shaped rings on his fingers sealed the look. He had formidable forearms, but they were wrapped around his puny sister, who helped him into a chair. His robust face wrinkled with pain. “I have very severe back and right leg pain,” he mourned, running his palm along the back of his thigh and calf to show me how it travelled. “I can barely stand, sit, or walk,” he continued. “It’s been going on for over a month and I initially took bed rest for a week but there was no relief. Then, another doctor asked me to start physiotherapy, which didn’t help either, and another gave me an epidural injection, but it’s only getting worse. I saw two other surgeons and they’ve suggested surgery, but I don’t want to have spine surgery because of all the horrible things people say about it. Someone told me I’d get paralyzed, someone else said my pain would only get worse,” he prattled on.

I sat there listening patiently to ‘his story’. That is why this is called taking ‘history’. “I’ve also been feeling numb in my balls since the past 2 days,” he suddenly said, unfiltered. That made me sit up a little. I asked him if he had faced any difficulty in passing urine, to which he shook his head sideways. I had him hobble over to the examining bed to check his motor function, which was good, but he said he was numb all over the back of his leg and around his buttock and groin – a term we call ‘saddle’ anaesthesia. Imagine riding a horse (or in his case, a Royal Enfield). The part of his body that made contact with the saddle or the seat was numb. It was an ominous sign. His sister removed the MRI films that I plugged into the viewing box only to find a very large disc prolapse pressing on the nerves that go down into the leg and also subserve bowel, bladder, and sexual function. I put my fingers briefly on my forehead, much like a doctor in a Hindi movie about to declare bad news.

“You need surgery without a doubt,” I asserted. He asked if he could wait some more before deciding and I shook my head firmly. “I think you should get admitted today and that we should operate on you at the earliest,” I replied, which is something that I say only a couple of times a year. He laughed a little; perhaps he thought I was joking. I wasn’t. Most patients with sizable disc herniations and even severe pain can safely be managed without surgery and recover completely, but when there is a motor weakness or sensory impairment of this nature, immediate action is warranted. If the pressure exerts beyond a critical point where the nerve gets irreversibly damaged, recovery of function is not guaranteed.

Unfortunately, many patients are of the opinion that when doctors suggest immediate or urgent admission, they are out to fleece them or deter them from taking a second opinion. “I’m going to have to discuss this at home and then get back to you in a couple of days,” he concluded, clearly keen on finding other avenues to avoid surgery. I accepted his decision and reminded him of any warning signs to look out. I don’t like to frighten patients, but this is important when they haven’t understood the gravity of your advice.

“Surgery is a big deal for anyone; you can’t just except for someone to instantly agree to going under the knife,” a friend retorted when I told him Rahul’s story. “It’s much easier for them to accept the notion of surgery when it’s an issue with the brain, such as a head injury or stroke and it’s a question of life and death,” he reasoned. “But isn’t leg function equally important? Or bladder function, or erectile function?” I questioned, continuing, “Which 40-year-old would be willing to risk not having sex for the rest of their lives?” “Maybe you didn’t scare him enough!” my friend said and we laughed about it, and the next day I completely forgot about Rahul, although subconsciously he lingered.

Three days later, it was 11 PM on a Saturday evening. I was out dancing at a friend’s wedding and my phone rang. “I’m Rahul’s sister,” she quickly introduced herself. I walked out of the room that was playing my favourite retro music just then at full volume to be able to have a conversation. “He’s been unable to pass urine for the last few hours,” she said in panic. “His bladder is full but urine is not coming out,” she explained, “and he can move his legs but can’t feel the ground he’s standing on!” she said, somewhat ambiguously. “Something is happening to him, but we are unable to figure out what!”

I knew exactly what was wrong. The disc had further compromised his nerves, exactly what I had been worried about, as I reminded her. “Get him to the ER now. We’ll have to operate on him urgently or he’ll be bedridden for life,” I said, oscillating between anger and concern. “Can we try and see if he passes urine through the night and then come tomorrow morning if he doesn’t?” she asked. I felt like smacking her with a gong on her head but instead hung up in frustration, uttering a few profanities as I did so. She must have heard them because 5 minutes later, she sent me a message saying they were arranging for an ambulance to pick him up. I informed the hospital to keep everything ready and they arrived at the ER at 3 AM. On examining him, we realised that his bladder had reached his nipples. The ER doctor stuck in a catheter and drained 2 litres of urine, indicating that his bladder had distended way beyond its physiological capacity, which had certainly damaged its walls.

Once we did the needed investigations, we took him to the OR and flipped him on his back after the anesthesiologist put him to sleep – something that we should also have been doing at 5 AM, but we were dealing with one man’s nitwittery instead. “Why are you getting so irritated with him?” my colleague asked as we painted and draped him in the usual fashion. “Because a perfectly healthy 40-year-old may have to live his life on a catheter when it was completely avoidable,” I countered, making a tiny incision into his skin and docking a 20 mm tube onto the bone through which we would operate. We drilled a bit of the bone and found the extruded fragment of the disc waiting to be pulled out. It was like a chunk of macerated flesh, and once I removed the disc fragment, the swollen and inflamed nerve which was stretched to its limit once again came back into position. “You know what Albert Einstein said once?” I asked my colleague as we closed. “What?” he said, exhausted from a night of being awake. “Two things are infinite: the universe and human stupidity.” There was a silence at the other end. “And he wasn’t sure of the former,” I finished, taking the last stitch and then removing my gloves with a flourish, much like Dr. Derek “McDreamy” Shepard does in Grey’s Anatomy.

Rahul was pain-free a few hours after surgery. He walked again with the panache of a biker dude. Days later, we removed his catheter after a trial of clamping it and he was able to pass urine normally. He must have accrued some karma from a previous life, I reckoned. Three months later, he came back smiling because his numbness had also been resolved.

When he walked into my office, my desk was strewn with the paraphernalia of a science experiment; I was in the midst of a discussion with a college student who had come to get insights from me on a brilliant idea he had. Intrigued by the mess, Rahul asked what I was working on. Not having forgotten his behaviour, I gave him a bright, cheeky smile and said, “A possible vaccine for stupidity!”