A tumour stuck to an ‘arrogant’ vein reminds this surgeon about the need to exercise discretion

A 28-year-old slammed his MRI films on my desk, profusely sobbing away without my having the slightest clue of what was going on. He was lean, well-built and wore track pants and a tight-fitting white shirt. I waited patiently till the wailing ebbed and made way for intermittent snivels, which he wiped away with the tissue I’d handed him. His wife sat next to him with her hand on his back, gently patting it until his face was dry, his eyes remaining swollen and bloodshot.

“I have a 6-cm malignant brain tumour,” he lamented, his first words to me as he tried to come to terms with how his life had changed with a single scan of the head. “What prompted your doctor to get a scan?” I enquired in my ‘I’ve got his under control’ voice, calmly guiding the conversation to become less dramatic. “I had headaches for a week, which weren’t getting any better, and then I started waking up with them,” he answered. “Any blurring of vision, nausea, vomiting, imbalance while walking?” I asked as a routine follow-up question, a yes to which might suggest raised intracranial pressure. “No!” he shook his head in disbelief, clearly thinking that at least a few of those symptoms should have been present if his headache was this serious.“They don’t have to be,” I replied, explaining, “Headaches don’t read text books. I’ve gone hoarse telling people that if a headache doesn’t settle down in a few weeks, it warrants a scan. Nine times out of ten it’ll be normal,  but I can show you dozens of patients with brain tumours, and all they had was a dull aching headache!”

On examination, I found his neurological status to be intact. His eye movements were okay, the motor and sensory function in his limbs was fine, and he walked heel to toe without losing his balance. I plugged the MRI films into the viewing box and peered through it very intently. I went through the entire set of 8 films that showed the tumour in different dimensions. I scanned through the accompanying report once again. The couple waited with trepidation for my verdict.

“This is not malignant for sure,” I decreed. “But the report says it’s a medulloblastoma,” the man exclaimed, “and I’ve been reading about it online and it’s supposed to be a highly malignant tumour. I’ve been devastated all weekend knowing I have only a few years to live.” I reached over to reassure him. “This is a meningioma. It’s a benign tumour arising from the tentorium, the dural layers that separate the forebrain from the hindbrain. Because its grown so big, it’s compressing the 4^th ventricle and the brain stem and pushing the cerebellum apart. The guys at the scan centre have mistakenly inferred this to be a malignant tumour because one is commonly seen in this location. Trust me, I know what I’m talking about,” I reiterated, carefully studying the frayed margins of the tumour on the scan and pointing it out to him.

“This is a huge relief, that this is not malignant,” he said, still looking at me in disbelief. “But we still have to take care of your headache by removing this, and it’s a technically formidable operation,” I admitted. “It’s stuck to the vein of Galen, one of the main veins that drains the deep venous system. If that gets injured, you could be in a coma. Galen was the Greek physician to describe it,” I said, adding on some trivia to lighten the mood. I explained to him all the possible routes we could use to reach the meningioma given that it was smack in the centre of the brain. He was ready. I called up and booked the operation theatre for a 12-hour slot the following week.

A few days later we positioned him Concorde. It’s where the patient is turned prone and the head is raised above the level of the body and then flexed to resemble the design of the plane. This gives us a straight shot at the target. We made an incision down the back of his head up to where it met the neck, getting down to the bone, which we removed as a flap to put back later. The cerebellum was very tense. We drained some cerebrospinal fluid after opening the dura and appeased it. “Never retract a swollen brain,” I remembered the teachings of my mentor. We kept releasing the brain fluid until the cerebellum was almost sulking.

Choosing a narrow corridor below the tentorium and above the cerebellum, we encountered the tumour. As I had predicted, it was attached to the under-surface of the tentorium. I coagulated it with bipolar forceps, killing its blood supply and turning a fiery ball into its ashen counterpart. I used an ultrasonic aspirator and gobbled up the core, allowing the tumour to fall on itself, after which we daintily peeled it off the surrounding brain that it was pushing against.

The surgery carried on elegantly for several hours until we approached the very end, when my assistant cut into the last bit of tumour and it bled profusely. “Shit,” I swallowed a few expletives, “is that the vein of Galen?” My heartbeat was racing uncontrollably. We controlled the bleeding in a series of quick synchronized manoeuvres and concluded that it was a tumour vessel. The vein of Galen was just behind it, pulsating arrogantly, cautioning us to beware of it. Not wanting to tempt fate, we left a few millimetres of the tumour on the vein. “It’s benign,” I told my colleague, “Nothing’s going to happen.” Discretion is the better part of valour, we’ve learned in medicine.

Galen was the author of more than 500 papers, and gave his name to the great cerebral vein (of Galen) and also to the nerve of Galen, the communicating branch of the internal laryngeal nerve with the recurrent laryngeal nerve, all of this before he died in 200 AD. During his brilliant career, Galen compiled more than 300 books, of which around 120 are still available for our study. It is a small wonder, then, that this medical colossus reigned like a dictator over the world of medical science for almost 1,500 years.

Our patient woke up the next morning with his speech slightly slurred, his eyes bobbling a little and his balance all over the place. “All these are indications of where we’ve fiddled around, and it’ll settle down,” I reassured him, and he noticed the improvement himself over the course of a few days. By the time he was discharged, he wanted to ballroom dance with me. There, too, discretion was the better part of valour.

A celebratory start to the month turned out to be yet another ordinary day in the life of this surgeon

On the 1^st of July, I woke up to a barrage of messages. WhatsApp was buzzing with Happy Doctors’ Day wishes. Doctor groups encouragingly wished each other, family groups said loving things to the physicians in their families, patients’ groups hailed them as superheroes, and medical representatives gestured how we were the backbone of our society albeit with a gentle reminder for prescribing drugs that would make our society even stronger.

I had a perfectly organized day ahead of me. Yoga in the morning, two standard spine operations, a regular list of patients in the clinic between the two surgeries, and then an early dinner with family and some friends who were visiting.

8 AM: “Good morning, Mrs. Jones!” I greeted the feisty lady with a firm handshake as we wheeled her in, the coldness of the operating room making way for the warmth of our smiles. She had a critical compression of her nerves in her lumbar spine at three levels. There was fluid in her joints and her spinal ligaments were lax, resulting in her vertebrae slipping over each other. After 5 hours, we had meticulously relieved her compression by biting away at all the overgrown ligament, replaced 3 of her discs with metal cages, and realigned her spine with 8 screws and 2 rods, making it look picture perfect. When you have sweat trickling down your back in a room that’s 16°C, you know you’ve worked for your lunch. She woke up feeling great. “I feel like I have new legs!” she exclaimed. I showed her an X-ray of her resurrected spine. “There so much metal in there,” she gasped. “I could audition of the next Iron Man movie!” she said, still groggy from the anaesthesia but with all her spirits intact. “I’m going to the OPD,” I told my colleague, as he prepped to get the next case in.

2 PM: I saw a bunch of patients in the OPD after I finished my first case. Some bought along a box of chocolates, some gave pretty flowers, and others drew up a card or two. Some didn’t have an appointment but just showed up to wish. I was overwhelmed. A few years ago, even doctors didn’t know it was Doctors’ Day, and now, thanks to social media, every day is a Day. The nurses had also arranged a small celebration with high tea, cake cutting, and games, which we briefly partook in.

4 PM: Our second case for the day was a 55-year-old man with neck and arm pain that was bothering him relentlessly. He had a C5-6 disc prolapse. We had to artistically open up his neck, retracting his carotid artery to one side and his food pipe to the other, and remove the disc cramping his nerve. We inserted a cute titanium cage in the place of that disc as a souvenir for him to remember us whenever he sees an X-ray of his neck, which I usually ask my patients to frame and hang in their room as a reminder to take care of themselves. “My pain is completely gone!” he said looking at this arm in disbelief after the operation. “I’m going to do rounds of all our patients and then head out,” I told my colleague, adding cockily, “I have dinner plans.” “I’m going to the ER to see someone,” he replied.

7 PM: We were operating on the third case of the day. A 72-year-old man with a large haemorrhage in his brain from uncontrolled hypertension had come in for emergency surgery. I’m never annoyed when plans are cancelled and got right to it. We swiftly opened up one half of his head. The brain ballooned out with each heartbeat threatening to make it burst. I nicked into a safe part of the surface to slurp out the blood clot, expeditiously deflating the balloon and restoring calm. “Will you close?” I requested my assistant, still hoping I could make it for dinner. “We will keep him on a ventilator tonight and see how he fares,” I told the family. “Thank you,” they said, sensing my hurry.

10 PM: I made it to dinner while everyone was having dessert. We sat in a restaurant overlooking the harbour and I devoured crispy fried prawns while bragging about how hard I worked. “One thing COVID has taught me is never to complain about work,” one of them said and we all agreed. We spoke about what it means to be a doctor in our country in these times. We spoke about how doctors were revered generations ago, while today, we are simply service providers who are expected to do their job well and pay the price if the customer wasn’t happy. “Touch wood, Indian patients are far more understanding about things than those in the West,” I muttered, as I walloped some ice-cream and got ready to call it a day.

11:30 PM: “Sir, the brain tumour we were to operate on 2 days later has come to the ER now. The patient is unconscious. We’ve intubated him. His CT shows a massive increase in the size of the cyst behind the tumour, which is probably why he’s in a coma.” Never alarmed by an emergency, I signalled all my people to cram into one car while I took off alone in mine. “Take him in but talk to the family; it’s a high-grade cancer,” I ordered.

1 AM: We were opening up another head. The tumour occupied the entire frontal lobe, almost a quarter of his brain. The ghoulish monster reared its ugly head, but we attacked it on all fours. My assistant and I performed a synchronized symphony in the middle of the night, miraculously converting an angry brain into a composed one. His frontal lobe now sat in a jar on the nurse’s table. When I took the specimen and showed it to his wife, she collapsed. A few sprinkles later, she woke up to the realization that a quarter of her husband’s identity was now on a table in the operating room. Despite that, he was going to live a normal – and hopefully healthier – life.

8 AM: I drove home, feeling the exhaustion of the past 24 hours, but was revitalized by the onset of the monsoon. The rain and smell of the wet earth energized me, making me look forward to the day to come.

Each year, the 1^st of July is celebrated as National Doctors’ Day in honour of Dr. Bidhan Chandra Roy, who was instrumental in setting up the Medical Council of India of which he was the founder president. He was a renowned physician, freedom fighter, educationist, and philanthropist, and served as the Chief Minister of West Bengal for 14 years. July 1 happens to be his birth (1882) and also his death (1962) anniversary. Had he died on any other date, he is likely to have had two days celebrated in his honour, in homage of his legendary contribution to medicine in India.

The 1^st of July is also National Chartered Accountant Day, to celebrate the formation of the Institute of Charted Accountants of India in 1949. I would have wished them with all my heart, but I’ll wish with only two-thirds of it – because they always deduct a third from everything I do.

A patient’s decision to get operated on his birthday is a timely reminder of why we need to celebrate the little things in life, even the end of an affliction

It was a routine Wednesday and I was on my regular evening rounds to check on all my patients before I left for the day. I knocked and entered the room of a patient I had operated upon the same morning. I saw him sitting in a chair, his sizable single room suddenly appearing cramped because of heavier-than-usual family traffic. His 2-year-old baby (who they must have sneaked in somehow, probably in a spacious IKEA bag) was plonked on his lap. His wife, a few sisters, parents, grandparents, and a bunch of cousins encircled him. Only a few hours after spine surgery, he was in great spirits, rambunctiously guffawing away with his gang. My team and I were greeted by happy and smiling faces. “Come, come, doctor, you’ve come at the right time! Everyone, this is Rawnak’s doctor,” his wife said, introducing me to rest of the extended family, breezing through four generations in a jiffy. I was still a little befuddled as to what was going on until I saw a tall mango cake on the table with ‘Happy Birthday’ artistically engraved on it.

Clapping hands, we sang the quintessential birthday song while the little girl on his lap wisely blew out the candle before the smoke detectors went off. They offered us a big piece that we readily gobbled. Rawnak fed his daughter, his wife fed him, and then she went around the room, unloading a tiny bite into everyone’s mouth in traditional celebratory fashion. “Why would you choose your birthday to get an operation?” I asked aloud, intrigued. Rawnak laughed out loud, his hilarity contained only by the stretch on his stitches. “I was so bothered by this leg pain because of my slip disc, and like you know, I tried everything, but nothing worked. I just wanted a new lease of life and what better a day to do this than on my birthday!” he reasoned. “I didn’t want to spend my birthday in pain,” he said, devouring his cake. It was a strange perspective but an interesting one.

“What if something were to go wrong?” I mused, raising my brow, but before he could answer, I followed it up with something more positive. After some more conversation, the team and I exited. “Good luck, buddy, have a great year,” I said waving goodbye to everyone in the room. As I walked out, I realized I had completely forgotten to check on him and his pain and almost stepped back into the room to ask him when my colleague stopped me, “Let him enjoy his day, he’s obviously okay if he’s smiling so much!” was the justification.

As we walked the corridor toward my next patient, I turned around and asked my team why anyone would get operated on their birthday, still trying to get under the skin of this viewpoint. “It’s the same reason why you make it a point to operate on yours,” my assistant retorted, reminding me of my quirk. Earlier in my career, when I didn’t operate every day, I would make it a point to schedule surgery on my birthday, citing my unavailability a few days before or after stating any reason I could. “That’s completely different,” I argued. “I want to start the year doing something I love. Nothing gives me more joy than operating!” I told them. But I understood what they were trying to say.

“By the way,” my assistant added, “Did you read the article published in the British Medical Journal on ‘Patient mortality after surgery on the surgeon’s birthday’?” “You’ve got to be joking,” was my reaction, and he pulled it up on the phone for me. I scanned the paper quickly. Apparently, patients ‘who received surgery on the surgeon’s birthday experienced higher mortality compared with patients who underwent surgery on other days. These findings suggest that surgeons might be distracted by life events that are not directly related to work’. “Oops,” I thought, recollecting the outcomes of recent surgeries done on my birthday to confirm that I wasn’t contributing to the statistic. “From next year onwards, we’ll keep these birthday cases short and simple,” I announced, unwilling to give up the tradition.

It has been my personal experience that patients put aside surgery for festivities. In the West, almost nobody has elective surgery in the last week of December. In India, hospitals see a drop in routine surgical admissions around Diwali (but injuries related to the festival make up for those). A few weeks ago, on the day of a planned admission, a patient called to cancel scheduled surgery for the next day. I was a little annoyed, as it scrambled a schedule I’d now need to rearrange, and in a slightly irritated fashion, I asked, “Why?” “Sir, there is an emergency wedding in the family tomorrow, so we’ll get admitted the day after that!” Amusement instantly replaced frustration. Their problems were clearly greater than mine.

I’m not a big celebrator but I want to change that about me. I’m inspired after I attended my daughters’ school orientations for their entry into the first and second grades. The principal emphatically spoke about celebrating the little things in your lives. She said, and I paraphrase, “Even if your child comes 5^th in a race, celebrate; if a parent gets a raise or switches a job, celebrate; if a family member excels in a hobby or even participates in something different, celebrate. Don’t only honour and laud the big events, but rejoice in small victories, even if they cannot be measured.”

There is something miraculous about the mundane that we must celebrate. A simple surgery done well, a patient relieved of their affliction, a diagnosis cracked, a colleague’s recruitment, a staff worker’s promotion, the hospital’s accreditation. If we are able to revel in small successes, we might be able to deal with failure more comprehensively. We might be able to treat the spectrum of emotions that traverse the highs and lows in a slightly more equanimous manner. We might be able to acknowledge the many ways in which we are human.

Rawnak got discharged the day after his surgery, completely pain free and thrilled with his decision to get operated on his birthday. New beginnings are beautiful; sometimes terrifying, but beautiful nonetheless. I am now also planning to conduct a study on patient outcomes when they have surgery on their special occasions: birthdays, festivals, promotions, anniversaries, etc. Do I have any volunteers?

The recent killing of health staff in the US is a reminder of what is at stake for doctors for whom workplace violence has become an occupational hazard

“US man blames surgeon for back pain after spine surgery, kills him and three others,” screamed the headline flashing around in the news recently. A patient armed with a gun had shot his doctor at a hospital in Oklahoma in one of the most developed countries of the world, destroying lives that were full of promise. He was allegedly unhappy with unremitting pain following surgery that had been performed only a few weeks prior. He had bought a rifle hours before the rampage of his despicable act and killed the surgeon, his colleague, the receptionist, and a bystander who took a bullet for his wife, robbing four lives of the gift of life. 

Many people have asked me why I returned from the United States after having trained there for a couple of years, and I think I finally have an answer. More than two-thirds of pain specialists surveyed during a violence education session at a 2019 American Academy of Pain Medicine meeting said a patient has threatened them with bodily harm at least once a year. Nearly half said they had been threatened over opioid management.

“If guns were legal in India, we would all be dead by now,” a doctor I know commented when the headlines made our way through WhatsApp circles. Indian doctors have been no strangers to violence either. Over the years, the news has been fraught with reports of brutality against people of the fraternity, but like all scoops, it remains an issue only until something more sensational comes up. 

An article published in a psychiatry journal states that ‘the Indian Medical Association suggests that up to 75% of doctors have faced some kind of violence at work, which is similar to the rates from some other countries on the continent.’ This violence may comprise telephonic threats, intimidation, verbal abuse, physical but non-injurious assault, physical assault causing simple or grievous injury, murder, vandalism, and arson. ‘Medical professionals who faced violence have been known to develop psychological issues such as depression, insomnia, post-traumatic stress, fear, and anxiety, leading to absenteeism,’ quotes the British Journal of General Practice in a 1994 article – almost three decades ago! 

When I trained as a resident doctor, I once walked into the room to complete the paperwork on an elderly gentleman who had passed from a complication not directly linked to surgery. His weeping son held me aggressively by the collar and shook me until my teeth rattled. “You people have killed my father!” he shrieked, in a voice I can still hear echoing through his bloodshot eyes till date. I was momentarily stunned but quickly realised where this uncontrolled hysterical outburst stemmed from.

I remember not long ago when the clergy of a religious sect was brought into the emergency department at another hospital with a flat line on the ECG. The staff did everything they could to resuscitate him, but his heart attack was massive. His followers broke down the ER, destroyed the glass panes, and damaged monitors, causing a colossal loss to the hospital’s overall infrastructure. We’ve all seen CCTV footage of patients’ relatives cornering and lambasting resident doctors in government hospitals. A statement from the popular American journal JAMA written 130 years ago, in 1892, rings true even today: ‘No physician, however conscientious or careful, can tell what day or hour he may not be the object of some undeserved attack, malicious accusation, black mail or suit for damages’. 

Illness, when faced by us or inflicted upon loved ones, conjures up a plethora of emotions. All of us at some point in our lives have cursed a doctor. Within two consecutive days, feelings towards a doctor can change from intense affection to extreme anger. Sometimes you can hear it in their voice, sometimes in their eyes. Of course, patients and families have a right to be angry when things don’t go well. As physicians and surgeons, we understand that. We acknowledge that when patients don’t get better, there is anguish and distress. I’ve also realised that often, good communication alleviates most concerns even though uncertainty may linger. Violence stems from ignorance and hatred, when, instead, we should strive for learning and reason, the much-needed antidote for impulsive behaviour. 

I’ve had patients who’ve been unhappy with my treatment. I’ve had outcomes that have been less than satisfactory (to put it mildly). However, I have always endeavoured to seek a solution that gets my patients to be better than what they were before they came to me. If their issue falls beyond my core expertise, I send them to the right specialist, and if it’s a complication of a previous surgery, I seek a second opinion. It is imperative for a doctor to go beyond their call of duty to attempt to alleviate suffering by being true to themselves and their patients. Most doctors do that, and most patients can see it. 

Pain is multifactorial and remains a complex problem to treat. If the primary problem is not adequately addressed, long-standing pain gets wired into the brain. Neuroscientists are now determining networks that could modulate those circuits through transcranial magnetic stimulation and relieve pain. Soon, we might be able to use this technology to change the minds of those who want to shoot us. 

Egaz Moniz, a neurologist of the 20th century who won the Nobel prize for psychosurgery in 1949, pioneered the now obsolete procedure of the frontal lobotomy for curing mental illness. His belief was that surgically removing white matter fibres from the frontal lobe would improve a patient’s anxiety and depression. He was shot multiple times by a patient with schizophrenia and lived the last 15 odd years of his life in a wheelchair, until he died from an internal haemorrhage in 1955. 

“Love is the only way to rescue humanity of its ills,’ Leo Tolstoy, one of the most prolific writers of his time, wrote in a letter to Mahatma Gandhi, affirming his advocacy of non-violence. Violence in any form, in any field, should be admonished. It is simply not how a civilized society can make any progress. As legendary composer Leonard Bernstein said, when he addressed the country’s most distinguished artists, writers, and other public figures a few days after JFK was assassinated, “This must be the mission of every man of goodwill: to insist, unflaggingly, at risk of becoming a repetitive bore, but to insist on the achievement of a world in which the mind will have triumphed over violence.” 

How do you tell an undefeated patient that there perhaps might never be a road to recovery?

“Will I be able to walk again?” Ronald asked me, peering deeply into my eyes as I stood next to his hospital bed.Three months ago, in another country, he was waiting at a red light on his bike when a truck lost control and thrust into him from behind, transecting his spinal cordand leaving him paralyzed below the waist. He had surgery back home to realign the spine, which they did with some screws and rods to stabilize the broken fragments, but, as expected, with an injury of this nature, there was no gain of function in his lower limbs. He was transferred to our hospital for extensive rehabilitation.

The short answer to his question was ‘No’. The long answer was also ‘No’. But how do you tell that to a 45-year-old father of two sprightly children, an image of whom I could see on the screen saver on his phone. He had left them behind with his parents and had travelled here with his wife, promising them that he would come home walking in two months. “My hands are fine,” he said, raising them up and opening and clenching his fists. He had rounded biceps and chiselled forearms, probably from using them to move his torso around. “But I can’t feel anything below my chest,” he mourned with a listless anguish. “I don’t even get an erection.” He pointed to the urine bag that his catheter drained into.It had flaky sediments that made the urine appear hazy; a consequence of prolonged catheterization.

I gently lifted the blanket off him to examine his legs. He had no power. He couldn’t move at the hip, knee, or ankle, even though the grimace on his face showed that he was trying. He couldn’t even wiggle his toes. He had no sensation from below his chest to the soles of his feet. “And yet, everything below feels so heavy,” he said, miserable.

I helped him onto his side as he wanted to show me his bed sore. Like an asteroid had landed on his planet, he had a crater on his buttock, with dying skin of varying hues sloughing away and tracking down to bone. “This is what we need to fix first,” I told him. “Without this, we can’t do any physiotherapy. We’ll get a plastic surgeon to clean it up and rotate a muscle flap over it.”His melancholic expression told me that he wasn’t interested in the technicality of any of it. “I just want to be able to walk,” was his doleful one-liner. “We’ll get there,” interjected his wife who was standing beside him. She was half his size but was astonishingly able to transfer him off the bed onto a wheelchair all by herself. “What doesn’t kill you makes you stronger,” she reminded him,summarizing the story of their togetherness.

I ordered some investigations and explained to them a plan for what we should do over the course of the next few months, which they agreed to. I walked out of the room and stared at my feet for a full minute. I stood on my toes, on my heels, and did a squat. I thanked God. As neurosurgeons, even though we treat patients with spinal cord injuries all the time, this man’s pain felt unbearable. The heartbreak in his eyeswas as tangible as the dysphoria in his voice. However hard we try, we can never fathom what these patients must be going through. I sometimes wonder what’s worse – to have an active mind in a paralyzed body or a functional form with loss of insight, judgement, and creativity?

About half a million people globally sustain a spinal cord injury, annually. A majority of these are young adults. The social, cultural, and economic burden of this is unconceivable. Its impact on the immediate caregiver is beyond belief. The assault on their emotional and sexual needs is just as devastating as the damage to their sensory and motor function. Physical barriers to basic mobility result in their exclusion from society,ensuing in a plethora of mental health issues. Billions of dollars are pumped into research to enhance recovery of spinal cord function with no promising results that could be universally applied.

“Why am I still not walking?” Ronald questioned me after a month. His bed sore had healed and his rehabilitation was in progress. “We’re building strength in your upper body so that it’s strong enough to support your crutches when you stand,” I deflected. Every time we chatted, he spoke in the same monotone without blinking his eyes. Day after day, I went into his room and we talked for about 20 minutes or more. On some days, I took him down to the cafeteria and we spoke there. I got him a book to read. We cut a cake on his birthday and got all the hospital staff to sing for him, but it barely turned the corners of his mouth upward. “How about we watch a raunchy film?” I tried, willing to sound inappropriate. He didn’t concede.

I recalled lines from a poem by Australian author Erin Hanson. It starts with ‘They say happiness will find you/ But I think sadness will find you too’ and goes on to say, ‘You can’t remember how it started/ And you don’t know when it will end/ But you know that you’d give anything/ To stand up on your feet again/ Sadness is that feeling/ When the falling doesn’t stop/ And it saps your life of meaning/ And of the good things that you’ve got.’

Every day, I would pause before entering his room. I would close my eyes and takea deep breath, then enter sounding loud and chirpy,but he looked at me with those brooding eyes and a tediousness in his voice, as though he could see through the facade. “When will I walk?” his grief questioned me, almost making it seem that I was the one responsible for his infliction. The physiotherapist showed him videos of his improvement, but he refused to acknowledge those. From being unable to sit, he was now standing with calipers and holding onto a monkey bar, but he was nowhere close to walking, even with any kind of support.

On my rounds one morning, I saw all my patients on his floor but didn’t enter his room. As I was heading to the next ward, the nurse reminded me that we hadn’t seen Ronald yet. “I can’t,” I told her, defeated. “It exhausts me completely and I have nothing to offer that makes any kind of difference to him,” I conceded. We had failed him. His wistful eyes and his despondent voice told me so.

It’s been three months and Ronald is still at the hospital. He does his physiotherapy religiously and is making progress. He still cannot walk. Maybe he never will. But he hopes. As do I.

Post-operative behavioural changes are a well-known phenomena—in one such case, a gentle god-fearing soul turned into a violent person

“You need an operation on your neck, Mrs. Smith,” I told the god-fearing 66-year-old lady after conducting a detailed evaluation in her hospital room. The medicine cabinet next to her bed had three different-sized photo frames of Christ, two rosaries, and the Bible. The window sill was lined with a picture of The Last Supper, and next to it were a couple of wooden crosses. There was gentle ‘Praise the Lord’ music playing on her husband’s phone. I felt as though I had just walked into the kingdom of heaven.

Over the past year, Joanne Smith had started to complain of a difficulty in walking on uneven surfaces. She had tripped over and fallen a few times. She found it hard to cook, as vegetables and utensils kept slipping out of her hands. As a well-built lady, she was used to a large amount of physical labour, but most of her activities had been curbed owing to her ailment.

“I feel like I’m walking on fluffy clouds all the time,” she said in a reticent voice, describing the sensory impairment in her feet. I really was in the kingdom of heaven. “Squeeze my fingers tight,” I instructed as I put them on her palm for her to grasp. Her hand slipped off easily, and her husband, who was standing stoically next to me, nodded his head, expecting this outcome.

I prophetically held the MRI films against the light streaming in from the window to show them where her cervical spine was being compressed by her thickened bone and ligaments. “We will remove whatever is pinching on the cord, and over the next few months, you’ll regain most of your function back,” I explained, advising them of the usual complications that could arise with an operation like this. “God has chosen you as an instrument for her healing,” her silver-haired, dark-skinned husband proclaimed. “I will do my best,” I said, with my hand on my heart, albeit a little nervous of their proximity to God.

The next morning, we flipped her on her belly, fixed her head on pins, and sliced down the back of her neck. I went ahead and meticulously drilled off the bone, punching out the thickened ligament to allow for her spinal cord to breathe again. “I don’t want anything to go wrong with this lady,” I said, which is what I assert loudly when my subconscious tinkles that something might. The surgery had gone off well, and I sounded off the postoperative instructions as we closed. We shifted her to the ICU for overnight observation.

I saw her again in the evening before I left for the day. As I placed my hand over her forehead, she softly smiled at me and said, “Thank you,” still groggy from the anaesthesia. She was moving her arms and legs well, which was an excellent sign. “Thank you, Jesus!” I said to myself for a change, a variation from the oft-used “Thank you, Khodaiji,” hoping my Parsi God wouldn’t mind. I drove back recalling the Smiths’ belief in God and I wondered if atheists or agnostics recover just as well as devotees of the divine. It might be a study worth conducting one day, although I am convinced that providence plays a big role in successful outcomes, especially in the kinds of cases I do.

The next morning, I walked into the ICU with a bounce in my step and a freshness that comes from having slept deeply. After the previous day’s successful operation, I was hoping to see Joanne sitting up in a chair and eating breakfast. But when I walked over to her, I was aghast to see her lying flat with all four limbs restrained to the bed. She was thrashing around violently with a strength I never knew could exist in someone who was so weak before surgery. Her heart was thumping at 200 beats a minute and her blood pressure had the same numerical value. I looked urgently over at the ICU registrar and a couple of nurses who were around, my eyes wide open and arms up in the air, questioningly. “She’s become violent and aggressive over the past hour,” the nurse explained, showing me her own arm that had been clawed into by Joanne. “She almost bit the ward boy who tried to help her,” another continued.

“Everyone here is trying to kill me!” Mrs. Smith yelled at the top of her voice. I thought that looking at me – a familiar face – might ease things a little, but I was wrong; the screams continued. “You are the devil and my murderer,” she growled at me with fiery eyes. The way she was moving her neck while chained to the bed made me worry if she would suffer a whiplash injury. The junior doctor in the ICU came over to confer with me. “We gave her something to calm her down, but it hasn’t worked so far,” he said, pointing to her chart.

“We should shift her out of the ICU now, she’ll be fine,” announcing it with the panache of James Bond, who knew exactly what might be going on. “But her blood pressure and heart rate are uncontrollable; it might not be safe,” the doctor responded, reasoning for the well-being of the patient. I put my arm around him and said, “Please shift her out. Being in the ICU is part of the problem.”

Post-operative psychosis is a rare but known phenomenon. A wide range of behavioural symptoms may occur after any kind of surgery, not necessarily those performed on the brain or spine. Patients have been reported to develop depression, mania, hallucinations, and impulsivity. In an ICU setting, however, listening to the constant beeping of various machines, hushed voices of the nurses, and the wails of some who are gravely ill, patients may experience disturbed sleep and start hearing voices, feel severe anxiety, and see things that aren’t there. This might result in them being severely disoriented, agitated, and even violent. We call this ICU psychosis and it shows up acutely. It is best treated by transferring the patient out of the ICU and into the comfort of their loved ones. If lifesaving treatment is being administered and that might not be possible, appropriate medication is administered instead.

The next morning, Joanne greeted me with a cheery “How are you, Dr. Turel?” exhibiting an effusive warmth that was oblivious of the apocalypse of the previous day. I tested her hand grip and it was as strong as a beast. My operation was a hit, but I wanted to get to the bottom of all the drama. “Do you have any recollection of what happened in the ICU yesterday?” She shook her head sideways, unaware. “You were not a good girl in there!” I reprimanded her in jest, knowing fully well that what she had gone through was beyond her control. “Jesus died for our sins,” she said apologetically. “And it would be a complete waste of his time and effort if you didn’t commit them!” I concluded in agreement.

 

Revisiting scenes from a conference where the mysteries of the mind and body took centre stage

“Can you hear me?” I asked a live audience, testing my mic out. After more than a year, I was delivering a guest lecture in person to a bunch of general physicians. Mechanically, I followed my question with the customary “Can you see me?” – a hangover from the innumerable Zoom talks I’ve delivered in the recent past during the pandemic, which now threatens to behave like an ex-girlfriend: over but not over.

The Indian Medical Association has various branches, and each ward in the city has its own division that organizes activities for its physicians. Doctors from various specialties are invited to impart wisdom on updates in their areas of expertise so that general physicians (who, I believe, are the backbone of our profession) may be empowered to guide their patients in cases beyond their realm of proficiency.

We had specialists come up and talk to us on advances in laparoscopic surgery, robotic knee replacement, precision angioplasty, minimally invasive bypass surgery, artificial intelligence guided endoscopy and in-vitro fertilization along with a few more to cover the entire spectrum of human afflictions. I found it a bit ironic that the talk on premature ejaculation was the last talk of the day – or maybe it was a smart move by the organizers to ensure that everyone ‘stayed till the end’!

My talk was somewhere in the middle. Not wanting to seem left behind in comparison with all the awe-inspiring accomplishments and developments in the other fields, I enlightened the crowd that even neurosurgery has advanced to including keyhole surgery, as minimally invasive surgery is fashionably called. Imagine, if you will, peeping into the keyhole of a door where the entry is pinpoint but the view is panoramic. I explained that by using an endoscope, we can enter the brain through the nose, the eye, and even from behind the ear. I also cautioned them from imagining any other orifice, which, I’m sure, awakened the post-lunch crowd, although technically, one can enter the brain through a puncture in the groin by guiding wires through blood vessels – what is fondly known as endovascular surgery.

As brain and spine surgeons, we have the luxury to take a peek into someone’s brain and spinal cord on a daily basis, and every time it only gets more fascinating. With a pristine picture of the brain, I explained to the gathering that it is mindboggling to fathom that there are 100 billion neurons in the average brain, constituting a complex network of trillions of synapses which we can keep building (even by playing Wordle or Sudoku). These neurons interact with each other and from this activity emerges the whole spectrum of abilities that we call human nature and human consciousness.

When we neurosurgeons meet at conferences, our discussions often revolve around how to best preserve human consciousness in its truest sense, not simply a state of wakefulness. Often, when we remove tumours from certain areas of the brain, patients who outwardly appear to have a seemingly perfect existence may feel like they’ve been rewired. Something shifts within them that we are sometimes unable to decipher and heal. This is akin to patients having neurogenerative conditions such as Alzheimer’s and Parkinson’s, who switch to becoming bleak shadows of themselves within a few months of the onset of their illness.

In the past five years, the progress made in neuroscience equates that made in the past five decades, and yet, it is the simplest questions that sometimes confound us. Like when a patient with a brain tumour asks, “Why me?” I am unable to give a satisfactory answer; indeed, why does anything happen to anyone? I could just as simply ask, “Why not you?” – a question I ask myself when something goes wrong – but it isn’t fair to expect someone to introspect at such a time.

Another popular question I get asked is, “Is this a small operation?” My response to that is always, “Even though I’ve done this several times over, I don’t consider any surgery as minor.” There is a reason for this; in fact, I have just finished attending a symposium with surgeons across the world on Major Complications from Minor Surgeries. Considering the complexity of the human body, it is unbelievable how many things can go awry. It is even more perplexing when they don’t.

At a conference several years ago, a surgeon put up a case scenario and asked his colleagues if they would recommend the proposed simple surgery to a patient who had come to them. All of us raised our hands in agreement. Then he asked a follow-up question. “If this was you, would you have this operation?” Unsurprisingly, most of us kept our hands down. The conflict of dichotomy comes from knowing what can go wrong, even though most often it doesn’t. As the famous saying goes, “No one sees what you see, even if they see it too.”

I demonstrated the fact of that statement during my talk by putting up an optical illusion of a picture of a shoe. Half the crowd perceived it to be pink and white in colour, while the other half imagined the exact same shoe to be green and grey – and both halves refused to accept that any other colour could be present. The science behind this was that the colour visualized by someone was dependent on the area of the brain being used to process it.

I finished my talk to thunderous applause and then like you rightly guessed  stayed back for the last talk of the day, the one on premature ejaculation by a urologist. Most men in the audience were relieved to note that the latest definition has abolished the time criteria of 2 minutes (which had subsequently also been reduced to 1 minute) and now only takes into consideration one’s partner’s satisfaction, which, for the ‘longest time’ did not feature in the treatment of this condition. Like always, it required a female doctor to change the course of mankind. It is not without reason that the famous British writer Virginia Woolf once said, “For most of history, anonymous was a woman.”

Surgical conferences, much like the field of academia, form the bedrock of knowledge in our profession. They foster an atmosphere of learning and wisdom, a place where we may announce the latest breakthroughs in the field, share our experiences, and ruminate on the mysteries we have yet to solve. Most of all, they strengthen what we all know and must never forget: that we are here to serve mankind, and to that, there can be no greater purpose.

How a young Parsi boy’s passion for nature is enthralling all age groups by offering travel experiences that are life altering.

“What made you leave your corporate job and focus on eco-travel in the North East?” I asked Piran, whom I huddled with in a tent at 10,000 feet above sea level with 10 other fellow trekkers and 2 bottles of rum to keep us warm. We were somewhere in the eastern Himalayas, ensconced in a pink and white (and every shade in between) rhododendron forest freezing our asses off.

“I found my job very dissatisfying,” he lamented over our candlelight dinner prepared by Firdos, a Nepali cook we had taken along. “The company had no leadership or vision, and going to work every day was drudgery,” he continued, adding a few endearing Parsi profanities. Eventually, he relinquished his fancy position as an IT executive and jumped at the opportunity to work for an NGO in the pristine climes of North Sikkim.

We were on the third day of our week-long adventure. A few days ago, we landed in Bagdogra, had hopped into three Innovas, and were driven 6 straight hours by budding Schumachers on serpentine roads along the edge of a cliff we were almost certain we were going to fall off. After having camped the night at a Sherpa Lodge, the next misty morning, we set off walking through woods whose beauty was reminiscent of those in Lord of the Rings.

We walked through dense foliage of bamboo and oak, breathing in the crispy air of the mountains until we reached our first campsite, pitched our tents, and set up a state-of-the-art toilet by digging a deep hole in the ground.

After having sipped on steaming hot thukpa (their famous noodle soup) and some more rum, it was time for dinner.

Piri, as we fondly call him, continued his story over dinner. “It was a community-based tourism project where I would work with the locals and help them develop alternate sources of livelihood,” he said with exuberant glee that brightened up our dining tent even more. “And then I got to work with the Bodo community in Assam. This community is prejudiced against as being violent and hostile but I haven’t seen kinder and nicer people,” he confessed giving us a previously unheard-of perspective of the place and its people. “That’s when I decided I want to show the North East to the world,” he said, munching on freshly cut jungle fruit for dessert. We went to sleep to the not-so-sonorous sounds of bells hung over the necks of grazing yaks and cows and some other animals that seemed like a mix of the two.

We woke up the next morning at 5 AM to streams of sunlight peering into our chamber and a full bloom of rhododendrons outside. We had been warned that we weren’t going to bathe for a week, but the rest of our morning ablutions were permitted. After sipping hot chai and gorging on a filling breakfast, we packed our bags and started our trek along a route encrusted with silver firs, whose branches nestled beautiful birds we could hear but not see. We swatted all kinds of unnamed bugs and insects that kept getting into our clothes, and reached our next campsite late into the day. We were on top of a ridge where we were supposed to get breath-taking views of the Khangchendzonga range, but couldn’t because of the thick mist. It was cold enough for us to simply imagine being surrounded by prodigious snow-capped mountains.

Over another freshly prepared hot meal, Piran told us more about his venture. “After travelling around most of the North East over two years, I started Kipepeo in 2010. Kipepeo is the Swahili word for butterfly. I just loved the name,” he said with joy. “The venture promotes responsible tourism and provides so many sustainable livelihood options for the people here,” he affirmed.

“Didn’t anyone deter you from leaving your comfort zone, a sizable income, and all the perks of city life to set up shop in the middle of nowhere?” I asked. “Your calling is your calling, it’s not a conference call,” he said, quoting Emmanuel Acho. “Only you know that pure passion that burns inside you. But I was blessed to have received the support I did from my family,” he concluded. We warmed our hands and other delicate parts of our anatomy over a campfire the Sherpas lit for us that was to burn through the night.

After a day of walking through slushy fields, we camped in a nearby valley the next night. It’s always colder down in the valleys than it is on the mountain tops, but the enthralling views of the sprawling landscape make up for it. Due to the altitude, some of us had headaches, some had body pain, others had blocked noses. I had diarrhea (but that was probably from drinking water from the wrong end of the stream), so I called it an early night – but not before following a rigorous schedule of zipping myself into the tent, putting on my gloves and woollen cap, and then zipping into my sleeping bag. All was well until I heard a rumble from deep within, signalling that I needed to unzip my sleeping bag, get a hold of my torch, and expeditiously walk to our hole in the ground, on the hour. Every hour. It was as if I was playing the ‘diarrhea song’ on loop – “When you’re climbing up the mountain and your butt becomes a fountain – Diarrhea! When you’re climbing up a tree and it trickles down your knee – Diarrhea! The temperature dropped closer to zero with each hour that passed by.

The next morning, I was drained. “I wonder why we put ourselves through these expeditions when we could have simply had a luxury holiday,” I groaned at Mr. Elavia over breakfast. He laughed and said, “I don’t only do hikes and treks. We conduct all kinds of experiences: cultural, wild-life, festival oriented. I can design a boutique experience for you if you’d like me to, but there’s something marvellous about roughing it out in the wilderness.” I couldn’t help but agree, but ever the ham, I loudly pronounced, “If I die here, I want rhododendron flowers at my funeral!” But I was okay soon after I had popped a few pills along with some coffee powder and sugar, and was even well enough the next day to walk up to the Indo-Nepal border, a treacherous plod upwards and a hard climb on boulders and rocks that seemed to get larger as we climbed higher.

Through the trek, we spent our evenings telling stories about each other’s lives. Six of the group were lawyers, and we also had a French teacher, an engineer, and someone who specialized in natural substances – I’ll leave that to your imagination. We invented indigenous card games and played Dumb Charades. It’s amazing how no matter which group you play the game with, through all ages or religions, someone will always suggest enacting the title How to Make Love to a Negro Without Getting Tired.

After spending the last night amidst thunder, lightning, and a heavy downpour from the Gods above, we made a steep descent down to civilization, and finally – finally! – had a hot water shower. I returned home exhausted but renewed. “How is walking for days in the wild like this any fun?” my aging mother asked me, perplexed by my mid-life pleasures. I lagoaed a dialogue I read somewhere to her: “These mountains that we are all carrying, we are only supposed to climb.”

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If you want to explore the north east, you can reach Piran Elavia on +91 993 000 2412 or visit his website www.kipepeo.in

Performing a complicated surgery on a nonagenarian is usually avoidable, but should you give up without giving them a fighting chance?

I was clipping a ruptured aneurysm in the angry brain of a 35-year-old girl at 9 PM on a Thursday evening, when a nurse walked into the operating theatre with a message from the ER that she’d been asked to deliver: “There is a 95-year-old man with a large hematoma (blood clot) in the brain. He’s drowsy and paralysed in the right arm and leg.” Without seeing the scan or asking for any more details, deeply engrossed in the critical part of my ongoing surgery as I peered through the microscope, I responded crassly, “He’s 95; let him go in peace.” I could see the nurse nod her head through the corner of my eye, saying, “Okay, sir” as she exited. I dissected around the aneurysm and placed a clip perfectly on its neck, securing it from further rupture. I was ready to call it a day.

The nurse returned a few minutes later. “The family too doesn’t want surgery or any form of aggressive treatment but wants to admit him under you for comfort care till he passes,” she ended. “Sure,” I replied briefly, while inspecting the precision of my clip placement and ensuring that no arteries were incorrectly stuck within. I sprinkled the now soft and peaceful-looking brain with saline, sutured the dura, and put back the bone. While we closed the head, I asked my colleague, the surgeon assisting me, “If that was your grandfather, would you operate on him?” “I wouldn’t do anything even if he was 75,” he replied, confident in his knowledge and experience that the elderly don’t recover well after surgery for a massive blood clot. “You finish closing, and I’ll go see the old man in the ICU and talk to the family,” I told him, removing my gloves, feeling the exhaustion of two 4-hour operations in the day.

Mr. Gupta lay on the first bed as I entered the ICU. My first impression was that he didn’t look 95. His son-in-law stood next to him as the nurse placed a blanket over him to keep him warm. His eyes were closed but he opened them after my third try of calling out his name and shaking him a little. “Show me your tongue,” I said, raising my voice after learning that he didn’t have his hearing aids on. He gently pulled out his parched tongue. “He’s a bit dehydrated,” I told the nurse and asked them to run some intravenous fluid. “He’s not had anything for the past 12 hours,” his son-in-law mentioned. He raised his left arm and leg on my command but couldn’t move his right. On further questioning, he seemed confused about where he was and even which century we were in. He could barely utter a few words.

I plugged the CT scan films into the viewing box and, as informed to me, there was a large subdural hematoma compressing the left half of his brain responsible for his right-sided weakness. But this was a chronic subdural hematoma, which has a very different prognosis from an acute one. The former entity often occurs in the elderly with or without minor trauma, and a simple small hole made in the skull to drain the waterlike blood results in good recovery. When the clot is acute, the blood is thicker and it requires a bigger operation and has a poorer outcome. My stance changed in an instant. I explained my intention to do an operation and to do it now. The son-in-law was befuddled; he had just conveyed to the rest of the family who was out of the country that they were going to let him pass in peace.

They put me on a conference call with his two sons, one in Dubai and the other in the United States, and I explained why I had changed my mind. “If he was completely independent prior to this recent affliction and as he has no other medical co-morbidities, I would operate on him,” I explained. “He’s so old and he’s lived a full life. He’s just recovered from throat cancer and we don’t want him to suffer. Have you operated on a 95-year-old before?” they asked me. “No,” I said, “but I’ve operated on quite a few in their late eighties, and most of them have done well – but the final decision is yours.” I concluded by explaining all the risks and benefits of performing brain surgery on someone this old. They had a quick internal discussion and then said, “Go ahead.”

My colleague from the previous surgery walked up to me. “The aneurysm is extubated, she’s absolutely fine. I’m going home; it’s midnight.” I shook my head. “No, you’re not; we’re operating on this 95-year-old uncle right now.” I could almost hear his jaw drop. “We’ll do it under local anaesthesia,” I added. Within a few minutes, we had him in the operating theatre. We numbed his scalp and sliced into it, drilling a hole in the skull. I incised the dura and dark altered fluid gushed out under pressure. At that very instant, he started moving his right hand and leg under the drapes, and by the time we finished, he had even started talking coherently. We shifted him back into the ICU within the hour, and his son-in-law was shocked to see the transformation. His children, who had steeled themselves for his demise, cancelled their tickets.

The next morning, Mr. Gupta was as fresh as a daisy sprinkled with morning dew. He told me the story of how he had been diagnosed with throat cancer 8 months ago and that the oncologist had told him that they couldn’t treat a 95-year-old. He then sourced out immune therapy medication after seeking a second opinion and was now in complete remission.

In medicine, we often generalise, and more often than not, it is correct not to be aggressive when the patient is at such an age. But we must make room for the exception that will defy all odds and we must have the courage to follow one’s gut instinct. It is said that there is an exception to every rule. The exception was in front of me: I watched an old man chatting away, seeming young again.

“I have a four-bedroom apartment on Altamount Road, but I live all alone. Both my children are abroad. I bought the house for Rs. 4 lakh in 1975, and now it is over 15 crore,” he beamed with pride. “Uncle, don’t forget to write my name in your will!” I said in jest, and everyone in the ICU along with a nearby patient burst out in a laugh.

 

 

While the tiny rodent can seem like a nuisance when it accosts you inside a car or in your home, its role in advancing medicine can’t be ignored

(No) animals were harmed in the writing of this piece.

Every fortnight, I travel to Kalyan and Ulhasnagar to see patients at the charitable Red Cross Society and a few neighbouring clinics, so that people afflicted with brain and spine problems don’t have to travel to Mumbai to consult with me. The reason for sharing this information is not to boast of my benevolence but my courage in braving a two-hour car ride fraught with a plethora of potholes and tormenting traffic. As I have the luxury of being driven down in a rented car hired by the hospital, like the average human, I spend most of my time on my phone instead of doing what I tell my kids to – look out of the window (and identify the next pothole that we are about to plunge into).

During one of those routine, tailbone-torturing rides on my last visit, I was sitting on the back seat diagonally behind the driver and replying to my email when, from the corner of my right eye, I chanced upon an Unidentified Moving Object (an UMO, if you may) that whooshed under the driver’s seat. I think I saw a tail. It was very early on in the journey, and as I was running late, I decided to remain silent until I could confirm what it was. Maybe it was a cockroach or a lizard – or just my imagination.

I put my phone aside and looked around, scanning the bottom of the car. As I bent down to check under the seat, it whizzed out from under the front seat to the back, two inches away from my face. It was not a cockroach or lizard or some random bug but a full-blown, overfed brown mouse. I jolted back and crossed my legs on the seat, trying to compose myself. It was so big it could classify as a rat. There are some people who find the sight of rodents repulsive, but I’m pretty nonchalant about this species. So, after googling ‘Do mice bite’, I put my feet back on the ground and decided to reveal all to the driver.

“Boss,” I called out, not knowing his name, “apni gaadi mein chuha hai (there is a rat in the car)!” He reacted to the news as if someone had held him at gunpoint; a stream of sweat trickled down his temple. Within a few minutes, he managed to move out of the stream of busy traffic and found a safe spot to park. I thought he was getting out to open the doors and let the murine out, but he headed into the bushes instead to take a leak. Once he returned, we opened all the doors, hoping that the UMO (now identified) would let itself out to be free. But we had no such luck. We had to drive on.

I leaned my head against the window and reminisced about my thesis while at the Christian Medical College in Vellore, where I had trained in neurosurgery. I had designed a unique head injury model in mice to test the efficacy of a novel drug and ascertain if it reduced brain swelling. We were using angelic-looking Swiss albino mice that I would hold in the palms of my hands and anesthetize myself. I would then fix them on a clamp and make an incision over the head, drill a tiny hole into the skull, and then injure the brain with a dry ice probe via a robotic arm I had designed with the bioengineering team. We administered the drug to one group while giving a placebo to another. A few days later, we would remove the brain and weigh it to see if the drug had worked, carrying out a few more technical steps. Once the experiment was done, I preserved the brains in tiny formalin bottles in the fridge I had in my 100-sq. ft hostel room. My ‘residency’ fridge contained protein bars, Nutella jars, and mouse brains. I volunteered to make brain cutlets for those who visited but everyone declined. It’s a Parsi delicacy everyone should try at some point, but not of mouse brains, I concede.

The car came to a gentle halt, bringing me back to the present, and the driver turned back, signalling that we’d reached our destination. While I saw patients at the clinic, my driver inspected the car, looking for the mouse, but without any luck. When I returned, as we drove to our next stop 10 minutes away, he tried to convince me that I must have been mistaken, when suddenly, he felt something wiggle over his feet. He jumped and slammed his feet on the break and accelerator simultaneously, bringing us to a screeching halt, as cars all around us honked in protest. Luckily, my next stop was around the corner, which gave the driver a few hours to regain his composure.

I got out to see the next set of patients lined up and couldn’t help but think about the role mice have played in medicine. A staggering 25 million mice are used daily worldwide for research on diseases of the heart and brain, cancer, HIV, and diabetes. The reproductive, endocrine, cardiovascular, and central nervous systems of mice and men bear very similar structure and function, and by examining the physiology, anatomy, and metabolism of a mouse, scientists can gain valuable insight into how humans function. Unlike humans, mice are easy to look after, and like humans, they multiply quickly. Hence, it comes as no surprise that we share over 90% of our genes with mice.

When I finished with my day and got into the car to head home on another two-hour journey back, the car didn’t start. The doomed sound of the ignition thwarting just when I wanted to get home after an exhausting day loomed over me. The driver tried once again, and the sound got scratchier. And then the unthinkable happened. The mangled mouse flew from somewhere out of the dashboard, splattering blood on the back seat. It limped out of the door (which I had reflexively opened) with an amputated leg and scuffled into the bushes, disappearing into the setting sun. Another mouse sacrificed in the name of medicine.

“Try starting the car now,” I told the driver in Hindi, after he cleaned up the crime scene. It started in an instant. The ride back was far from a smooth operation.