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.

How a surgeon’s desire of harboring three superpowers was completely vetoed by his daughters who clearly had funkier ideas

“Dada, Dada, Dada!” my six-year-old feisty daughter called me thrice to secure her attention as I lay on the bed nursing a sprained back. The first “dada” was to put my phone away, the second one was to look at her, and the third was to listen to what she was saying.

“I have a question for you,” she asked, beaming, after coming back from watching a Disney movie with her cousins. “If you could have three superpowers, what would they be?”

I peered into her inquisitive eyes, wondering if I should give her answers suitable for an adult or a baby, but then decided to go with what came first to my mind.

“I would want to be able to look inside people’s brains and see if they have a tumour or any other problem. That way, I’ll save all the unnecessary MRIs that I ask my patients to get when someone comes to me with a headache or giddiness.” She gave me a very bored look. “I wouldn’t want to know what people’s thoughts are because that would drive me nuts!” I added and was rewarded with a whiff of a smile from her.

“Okay, what’s the second one,” she jumped, disappointed with me seemingly having wasted my first superpower. “I want to be able to perform complex surgery without ever having a complication,” I ruminated, remembering a few patients whose surgeries did not go off smoothly. She looked back at me, thoroughly unimpressed.

“Okay, dada, last chance!” she said, hoping I would finally come up with something fun. The Mother Teresa in me prevented me from giving her what she wanted. “I think I’d like to eliminate hatred and spread love,” I said, knowing it to be a cliché but genuinely meaning it, hoping she would understand what I meant. I continued, “Wouldn’t it be wonderful if we stopped judging each other and simply loved and appreciated one another instead?” “Whatever!” came the disenchanted reply to my prosaic responses.

I decided to turn the tables and asked her, “Okay, why don’t you tell me what powers you would like to have?” She promptly made a fist and released the index finger from it to denote the first superpower. “I would like to have the power to skip days,” she said instantly. The look on my face made her realize that I didn’t understand, so she began to explain. “I’ll skip days from Monday to Friday, so that we don’t have to do school. Only Saturdays and Sundays are allowed. Then, I’ll skip straight to my birthday, Meme’s (her sister Meher, who she fondly calls by that name) birthday, mamma’s birthday, and yours. Then all our cousins’ birthdays,” she said, nodding her head as if she were already imagining this.

“If I had a superpower,” my elder daughter interjected, “I wouldn’t do any homework. I would just find a way for it to get magically done without me having to do it!” she emphasized. On the few occasions that she hasn’t turned in her homework and the teacher asked for an explanation, she very soulfully replied that her father was in the hospital. The first time the excuse was used, the teacher was empathetic; the second time, she was suspicious; and the third time, she realized that the father was not a patient but a doctor.

“My second super power,” said the little one, “would be to be invisible. I can sneak into granna’s fridge and steal all the Frooti and chocolates and no one will know!” She twirled her wrist with two fingers now up.

The elder one, who is now seven-and-a-half, said, “I want to be able to shapeshift!” and then did a little jig to contour her body. “What the hell is that?” I asked, being out of date with recent trends. “I can become an animal or a plant or anything else I want whenever I want to and you won’t know it’s me,” she said, adding “and then you can’t chase me around to finish my homework!” She cocked her head and raised her eyebrows like teenagers do to tell their parents that they’re smarter than them.

The younger one was not one to stand down without an exciting finish. “My third superpower is to be able to fly!” she triumphantly concluded. “She’s copying my power!” the elder one objected, then continued, “but mine is way cooler than flying, actually, it’s teleporting!” “What on earth is that?” I asked, thoroughly befuddled. “I can go from anywhere to anywhere in a second,” she helpfully explained. “I can walk through the door without opening it or even meet Burgese Kaka in America and come back in a second.” I was very impressed. “Maybe you’re ready to read Autobiography of a Yogi,” I said, trying to outsmart her. “Dada!” she exclaimed, “I’m not doing any such thing!” and twirling her body she disappeared.

A few days later, we all watched Encanto together, the movie that had given rise to the superpower questions. The Madrigals are an extraordinary family who live hidden in the mountains of Columbia in a charmed place called Encanto. Every child in the family is blessed with a unique gift – except Mirable. Isabelle’s gift was to conjure beautiful flowers and plants in a whiff, Antinio could communicate with animals, Dolores could hear into the distance, Brono could see the future, Luisa was so strong that she could carry the mountains, and Juliet’s gift – my favourite – was to be able to heal with a meal. And Mirable, as it turns out, while being the only one not endowed with a gift, was in fact incredibly empathetic and had the ability to unapologetically be herself – a gift that the rest of the family wished they had too.

So, if there’s one amazing thing you could be, let it be the power to be yourself, unabashedly. Apart from that, if you could have one more superpower, what would you like it to be ?

The key to treating a patient who has a walking problem is to observe their gait carefully and diagnose them accurately

“You’ve got a compression in your thoracic spine,” I proclaimed, as I saw 68-year-old Mr. Shaikh shuffle towards the door of my consulting room that I was holding ajar for him. He wore a white kurta and adorned a long stringy silvery beard to go with it. I usually refrain from making any diagnosis until I listen to a patient’s complete history and perform a detailed examination, but his short stiff steps that seemed a little out of his own control gave it away. His wife held one arm while I firmly gripped the other, as we gently helped him into his chair and allowed him to tell me why he was here.

‘I’ve been diagnosed with Parkinson’s,” Mr. Shaikh said. “I’ve been taking medication for a while but its only getting worse. I was feeling better than James Bond just a few years ago,” he lamented, remembering an earlier, healthier time. He appeared fidgety with his hands, which was probably assumed to be a tremor by his treating doctor. Patients with Parkinson’s have an extremely stoic looking face, often deadpan, and they blink very little, but he seemed pretty animated in expressing his difficulty in walking. “Do you wake up in the middle of the night and shout sometimes?” I asked; some patients with Parkinson’s have a sleep behavioural disorder. “She does that!” he jested, pointing to his wife. “That’s because he gets up and turns the light on every few hours to pass urine,” she said giving me another clue in the puzzle.

I examined him to find his upper limbs devoid of the usual rigidity that we expect in Parkinson’s, but his legs were stiff as logs. While he sat on the examining bed facing me, I tapped on his knees with a neurological hammer and his feet briskly sprung up in the air and back. If you are positioned directedly in front of a patient while doing this, you can injure vital parts of your anatomy, but with experience, you learn where to stand. However, as I remember reading somewhere, experience is something I’d like to have without going through all the trouble of getting it.

“Sometimes, progressive degenerative conditions of the brain and spine have several mimics,” I finally asserted, and to confirm my suspicion, continued with, “It would be best to get an MRI of the spine.”

He returned within a few weeks, this time taking a little longer to position himself than he did the last time he was here.“You’re right, doctor, the report does mention severe compression,” he said, while his wife handed over the MRI films to me. I slid the scan into the groove of the light box and showed them where the ligament over the fourth and fifth thoracic vertebrae had thickened, thinning the spinal cord considerably. This MRI visual is one that most patients seem to intuitively understand, instantly relating it to being responsible for their symptoms. “This will need an operation, Mr. Shaikh. We’ll position you on your belly, make an incision over the upper part of your back, drill off the bone, and bite off the thickened ligament, giving the spinal cord its rightful space. Over the next few months, your gait will improve dramatically,” I said confidently. “Will I go back to being James Bond?” he wondered aloud. “Shaikhen but not stirred,” I punned, but he didn’t smile. I’ll admit it wasn’t a very good joke.

We operated on him a few days later. We cut down from skin to bone, cleanly dissecting the muscle off it. I then drilled a trough on either side of the bone and lifted the back of the vertebra in a single piece. We nibbled all over the thickened ligament as the compressed covering of the spinal cord finally came to the surface, one bite at a time, assuming its normal rounded position, free and breathing easy. “I already feel less tight in my legs,” he muttered in his partly conscious state, as we wheeled him out of the operating room. A few months later, when he came in to see me, he looked several years younger. His walk was swift and smooth, with perfect cadence and in complete control. “Do you feel like James Bond now,” I asked, after seeing him so relieved and happy. “I just bought an Aston Martin!” he quipped.

In any patient who has a problem walking, diagnosing it rightly is the key to successfully treating it. I remember, as a child, standing with my dad on the balcony of our home and identifying gait disorders. We have a garden in front of our house, and as the number one advice given by any doctor to someone who has a walking problem is that the patient should take a walk, we were treated to a spectrum of ailments we had fun identifying. Sometimes, when I disagreed with my dad, I would run down to ask the person walking if what he had was indeed what my father said he did, and was amazed by his clinical acumen when we got an affirmative answer. There was someone who would walk a few quick steps, then freeze, and then repeat the pattern. “That’s the propulsive gait of Parkinson’s,” my dad taught me when I was eight. Then, there was someone who would swerve his leg out with every step. “This guy has had a stroke and residual hemiparesis,” I learnt.

People who have an excess accumulation of fluid within the ventricles tend to walk with a broad-based gait, as if their feet were refusing to leave the ground. The gait is referred to as magnetic and is seen in patients with a condition called normal pressure hydrocephalus. Patients who have a foot drop slap their foot on the ground making a distinct sound;often, just hearing (not seeing) a patient walk can establish the diagnosis. A painful or an antalgic motion could either be because of arthritis of the knee or hip or spinal stenosis, and oftentimes patients can have both; my orthopaedic colleague and I have constantly discussed the overlap. Children with cerebral palsy have a scissoring gait where their feet crisscross while walking.

After thus learning about different kinds of gaits as a medical student, I once took profound responsibility for the knowledge I had and went up to someone in the garden across my house. I told them they walked this way because they had a slipped disc and needed to be urgently evaluated. “I’m sorry, young man,” the elderly gentleman kindly told me, putting his best foot forward, “it’s just a shoe bite from an ill-fitting shoe I’m dealing with!”

While surgeons subscribe to full disclosure so that their patients are aware of any risks involved post-surgery, it’s not always an easy position to be in.

“You’ll have to sign here,” I instructed a chubby patient of mine, after I had explained to her the risks of undergoing surgery for a brain tumour. She had come in complaining of an unremitting headache, and the MRI revealed a tumour the size of a tennis ball in her right frontal lobe. She was 23 years old. After explaining the need for an operation, I began talking to her about the possibility of death, paralysis, seizures, infection, or a postoperative haemorrhage requiring a redo surgery, wanting to give her a full disclosure of the possible complications any brain surgery can entail. “Will you shave my whole head?” she asked, combing her hands through her pink highlights. I remembered Eliot: Our vanities differ as our noses do.

“We usually don’t, but if you insist, we will!” I teased, and was rewarded with a priceless expression as her fair complexion turned ashen. I hastened to comfort her. “We’ll make a tiny incision behind your hairline,” I pointed to where we would cut, “and a few weeks later, no one will know you’ve even had an operation, which is the beauty of modern medicine,” I said, and watched as her face regained colour.

I later pondered upon what gets patients to agree to have surgery. Are they concerned about the part of their body being operated upon, the probability of a mishap, or the intentions of their doctor? Do they rely on their intuition or who they’ve been recommended by? Do they want to ensure that their expectations match what the surgeon is able to deliver?

When I trained at the Christian Medical College in Vellore, we treated a sizable portion of Bengali patients having large brain tumours, and their primary complaint – obviously unrelated to the tumour – was constipation. It’s the problem of all of East India. It didn’t matter to them if we performed the finest operation to remove the most complex tumour from deep-seated cervices of their cranium; surgery was deemed a complete failure if we were not able to solve their ‘gas problem’. “Aye bodo operation toh theek aache kintu aami paikhana korte paachi na, ki kori?”

On one end of the spectrum are patients who don’t want to know of all that can go wrong; they will stop you in the midst of an explanation of the risks involved. “We have complete faith and trust in you. Please do whatever you deem fit.” These are patients who, in my experience, sail through surgery like a breeze. On the other end of the spectrum are patients who want to know details down to the bone: they want to know numbers, statistics, how our complications match up with what’s published in the literature, and everything else one can possibly ask their surgeon. When I trained in the United States, one such patient who had an issue with her spine and needed a complex procedure, asked my boss how many of these operations he had performed. “I invented this procedure!” he proclaimed. He really did.

The latter set of patients want a minute-to-minute low-down on what’s going to happen, from the time of admission to the time of discharge and then every day thereafter as well. While I treat the entire spectrum without judgement, I (and most surgeons) can almost intuitively predict that something is likely to go wrong in this group, and it does, but thankfully, it’s almost always something minor. But it is also often something you haven’t spoken about while taking consent for surgery – like a fall in the washroom, diarrhoea from outside food sneaked in by a relative, or a rash from a medication they didn’t know they were allergic to.

And then there is the patient who complains about something post-surgery that you don’t know how to respond to. A zesty young patient of mine had come to me for decompressing her trigeminal nerve (responsible for facial sensations) from an artery that was deeply indenting it, causing an electric shock to her jaw every few seconds. “The pain has gone, but I can’t feel sufficient sensation over the left half of my lips,” she complained. “Every time I kiss a guy it feels so strange – and you never mentioned a word about it before surgery!”

The surgical consent form is now a medico-legal document. There are lectures conducted on how consent should be well-informed, the importance of the legibility of what is written down as risks, and the alternate options to surgery. It is signed and sealed by the doctor, the patient, and a witness. It is ceremonial. Even a marriage certificate is not this intense – and surgeons have to do this every day. It may also be heartening for a patient to learn that consenting to every single risk of surgery and signing the paper doesn’t absolve a doctor in the court of law if something does go wrong.

In his book Blink, Malcolm Gladwell analyses why highly skilled doctors get sued much more than those doctors who make a lot of mistakes. Patients file suits not based on shoddy medical care alone but something else that happens alongside that. And that something is how they were treated by their doctor on a personal level when something goes wrong. After a successful operation, most patients thank the surgical team for taking such good care of them. In return, not only do we acknowledge the gratitude, we also thank them back for allowing us to operate on them.

The cumulative risk of any untoward occurrence in most standard brain and spine operations is less than 5%. While we’re explaining the risks of a surgery, patients’ relatives often ask, “What if he is paralyzed or comatose after surgery?” or “What if she doesn’t wake up?” Even though with practice I’ve mastered the art of not letting a reaction show on my face, my response varies every single time. Sometimes I reiterate that it’s an extremely unlikely possibility. Often times I say, “We’ll do whatever it takes to resolve it.” If I’ve had a really long and exhausting day, I simply peer through the concrete ceiling of my office into the sky above and point my finger to the big guy in the sky. And then exhale deeply.

American author Henry David Thoreau said, “In human intercourse, the tragedy begins not when there is misunderstanding about words, but when silence is not understood.” Surgical consent is like that.

While there’s a certain sanctity in seeing patients at a hospital or a clinic, a doctor must learn to make exceptions for friends who reach out in good faith

“Hey Maaz (which is what my friends affectionately call me), got a minute?” A frizzy-haired school friend had called to ask about her mother. “Mom’s got this back pain going down the leg for the past few days,” she narrated, sprucing up the account with how her mother had had a small operation for a deviated nasal septum a few weeks ago and why her stomach was hurting as well. “It’s probably just sciatica,” I said, disregarding it while in the midst of something else.

A few days later, she called back saying that the pain in her mother’s leg was better but that the leg was slightly swollen. I promptly removed my ‘friend hat’ and put on the ‘doctor topi’. “Why don’t you bring her to the hospital, we’ll take a look,” I advised, switching from dismissive to cautious. She was there within the hour, holding by the arm her mom, who was walking with a limp. I gently lay her down on the examination bed and ran my hands on the back of both her calves. The left one was distinctly taut while the one on the right was soft and flabby, as it usually is for most septuagenarians. This was clearly deep vein thrombosis that I had initially brushed aside. I got a doppler to confirm the diagnosis and directed her to a physician who started her on the right medication.

Before leaving the hospital, they profusely thanked me with a big box of chocolates (which is what most people do when you don’t charge them) for treating them with such care, but as soon as they left, I sank into my chair. “This could be fatal, Maaz,” I said to myself. An untreated clot in the leg can easily travel to the lung and cause sudden death. But thanks to some borrowed grace I have accrued over the years from curing patients, she made a good recovery and came back a month later with another box of chocolates. ‘We are all more than the sum of our sins’ – I remembered Jeaniene Frost.

Is there a difference between treating a friend as opposed to a complete stranger? As much as the official answer should be an emphatic “No!” human beings have a few inherent biases. While advising someone dear, I’m either much too concerned or completely carefree. I wish to be like the Buddha and follow the middle path, but for now, the pendulum swings depending on who the person is, how often they call you, the environment in which the issue is discussed, and whether their problems fall into the spectrum of your specialty.

There are some friends who call me with numerous minor health issues, to which my standard reply is “It’s nothing,” and they echo, “I know it’s nothing but I still wanted to check with you.” There are times when you don’t want them to expend on countless investigations and want to offer them the quickest and least bothersome solution. But sometimes, albeit rarely, in trying to help someone, you may get hurt yourself.

Then there are friends (or rather acquaintances) one bumps into at a wedding or funeral who, when they see me, want to catch me up on their blues. It is not uncommon for me to be checking a neck for tenderness, a back for spasm, or tracking someone’s eyeballs to examine for giddiness amidst a social gathering. “Doesn’t this drive you nuts?” someone asked when a friend’s uncle dragged me to the washroom at a party to show me a testicular swelling. “Not at all; in fact, I enjoy it,” I replied. “Not the toilet part,” I clarified, “but the ability to make someone feel instantly at ease is a privilege.”

Of course, there is a certain sanctity in seeing patients at the clinic or hospital where they receive undivided time and attention, but we must be flexible to make allowances. After all, wouldn’t I unflinchingly discuss my next holiday plan with a professional globetrotter friend or a broken washing machine with my buddy, who’s an expert with appliances?

All through the pandemic and initial lockdowns, I was flooded with calls from friends on how to ‘manage the virus’. It’s not my area of expertise at all, but then, in hindsight, no one knew much about it anyway, so why not help someone out to the best of my abilities? My driver could probably impart the same advice, but my friends would rather hear it from me. My mother directs all her geriatric friends to me; they have problems I know nothing about, but simply talking to them about it alleviates half their pain and all of mine.

“Doesn’t it irk you that so many people are calling you and asking for advice without any consideration for what you might be doing or where you are?” I was asked recently when inundated with calls over dinner one evening. “If it weren’t for them, no one would call me; at least that way we can have a conversation. Who calls anyone nowadays?” I justified. And after the phone call, I usually shoot of a bunch of WhatsApp messages prescribing elixirs, because every phone call to a friend ends with their saying, “Just message the meds, na!” Thankfully, no one has died yet, even with autocorrect prescribing dangerous stuff on its own.

I have often been stopped by the traffic police for violations that I firmly believe I never committed. But every time I tell a cop that I’m a doctor, I’ve ended up prescribing medication instead of paying a fine. They invariably talk about what’s hurting and are happy to receive a roadside fix. Waiters in the restaurant across the hospital, ushers at NCPA, my regular chaiwala, fruitwala, and postman are now all friends whom I recognize from what’s distressing them rather than what they’re doling out. At the end of the day, all we are doing is walking each other home.

To all my buddies out there: Whether I’m able to solve your problems or not, whether I give you advice that helps a little or a lot, if you’re in a health quandary, call me, and we’ll do whatever it takes to fix it. In the words of Carole King, ‘You’ve got a friend in me’.

This article first appeared in the Sunday Mid-day on 6^th February 2022

If human suffering can’t be measured, should doctors be differentiating between patients with minor illnesses and those with serious conditions

“What is the prestige of hierarchy in medicine?” a bald friend of mine asked, when I referred him to a general surgeon to remove an annoying sebaceous cyst on his sparkling scalp. “Brain surgeons don’t deal with such paltry problems,” I said with a jolly arrogance, dismissing the puffiness on his head. “I’ve had it removed twice before and it keeps coming back, which is why I want you to do it,” he said, massaging my ego.

“Neurosurgeons are on top of the medical totem pole,” I said to answer his question. “We do the most sophisticated and precise work. Also, our job has the maximum potential to harm and hence the stakes are very high – because the brain and spinal cord controls everything,” I explained. Just then, quite coincidentally, my cardiac surgery colleague peeked his head into my office to see if I was free to discuss a case. “Cardiac surgeons some a close second but their job is essentially plumbing, knowing how to bypass faulty pipes!” I said, to humour him. “But we do the plumbing when the tap is running or while the toilet is being flushed,” he interjected, justifying his position at second, “everyone else languishes at the other end of the spectrum!” My poor friend now looked quite baffled by our banter. “The general surgeons, urologists, and gynaecologists are quite literally furthest away from the top,” we explained.

A physician, overhearing our open-door conversation, levelled the playing field. “Do you know that in some countries like the United Kingdom, surgeons are not even called doctors! They lose their title of ‘doctor’ when they branch out to do surgery; they are simply called ‘mister’ then. In the olden days, they were considered unskilled, like barber surgeons. It’s us who are the thinkers and planners, telling the surgeon what to do,” he finished and quickly exited, leaving no room for debate.

A couple of days later, I got rid of the cyst that got us started talking about this. When my friend complained of unbearable pain, I rebuked him gently, saying, “Do you know what some of the people who come to us are going through?”

That made me think about what someone posed to me recently. “Does suffering have a hierarchy? Does a person who is disabled by injuries and pain deserve more sympathy than one whose life has been crippled by grief brought on by failed or lost love?”

Until recently, I used to placate patients for their so-called minor issues by comparing their ailments with the dreaded ‘C’: “At least you don’t have cancer.” But I now believe that this is the incorrect way to empathize with someone. Who are we to judge if someone’s depression, an unseen illness, is less grave than something we can see, like a tumour biding its time inside someone? How can you justify the loss of a parent being less intense than the loss of a child, even though the anguish of the latter seems to be almost universally greater? Why is heartbreak always looked upon as something that someone will get over in the due course of time?

Just because some people seem okay while they are going through whatever they are doesn’t mean they feel it any less. They have either found a way to channel their hardship into something transformative or make peace with it, accepting what is. According to me, there are two ways to live: one, as if everything is a matter of life and death; the second, as if nothing is.

Each person’s suffering is their own and does not exist in relation to anyone else’s, even though it is human nature to compare suffering: theirs with ours, theirs with someone else’s. Being in the profession, I have come to see with my own eyes that most people live with much more suffering than what is visible to the most sensitive and proximate onlooker. “I’ve had this pain for the past 2 years but I informed my family only a week ago, when it became unbearable” or “I haven’t been able to see clearly for 6 months but I told my husband just a few days ago, when I started bumping into objects,” is something I commonly hear, and unfortunately, it often is an indication of a patient coming to us a little too late in the course of a disease.

Sometime ago, I was operating on a brain tumour through the nose with my ENT colleague, biting away all the nasal debris with hubris. “Be a little gentle with the nose,” she nudged me, as I was showing scant respect for it. “There’s nothing really important in here!” I said, marching on. She responded, “The next time your nose gets blocked, you’ll realize its value.” The sentence clung to me like food that’s stuck in the molars: even after you’ve removed it, it feels like it’s still there; exactly how an unblocked nose still feels blocked.

Even COVID has its own chain of command. Two years ago, the virus was treated with a fearful distance that was more than just social, as we were apprehensive of those who had it; now, we are suspicious of those who don’t. Sometime ago, a fever was a phobia; now, it’s freedom – to take a week off. “It’s just a cold!” is no longer the ubiquitous expression that the higher order allows us to use.

Human needs have a hierarchy, as proposed by Maslow, which range from the basic physiological ones of food, water, and shelter, to safety, love and belonging, esteem, and finally self-actualization – the desire to become the most one can be. Humour also has a hierarchy, with dumb jokes and puns forming the base of the pyramid, practical jokes and irony somewhere in the middle, and self-deprecation and paradox at its apex. Art has its own hierarchy (though it can easily find its place in the hierarchy of humour – especially modern art), as does architecture and science. There is a hierarchy to the functioning of the universe, so why not in medicine.

A recent study published by the British Medical Journal found (not to my surprise at all) that neurosurgeons are no smarter than the general population. Maybe it is time to ditch the phrase “It’s not exactly brain surgery!” and give another specialty a chance to be on that pedestal. Any takers?

P.S.: Dermatologists, you are not allowed to apply.

This article first appeared in the Sunday Mid-day on 23rd January 2022

On the 31^st of December, at 11 minutes to midnight, an indistinctive man in a black Parsi prayer cap opened the main door to the Udwada atash behram. He ceremoniously rolled out a red carpet on the intricately inlaid white marble of the magnificently restored fire temple.

Just before midnight, over a hundred Parsis of all ages arrived and waited patiently at the fire to honour the darkness and welcome the light. It was an ethereal experience to be in a space with one’s brethren, none of whom you could see but whose energies you could feel. The hall has no artificial lighting. During the day, natural light through ventilated windows helps you see. But at night, you see nothing except for the red radiance being emitted from the embers of sandalwood. We wait patiently for the priest to stoke the fire and were treated to the crackling whiff of sandalwood and a sudden burst of effulgence until the flame ebbed again slightly.

There were so many familiar faces around, none of whom I could actually identify, and, as it turns out, not many who could see clearly themselves. A gentleman praying fervently with his arms outstretched on a glass façade,assuming it to be the cabinet that housed the holy books, was startled with the gong striking one from within and realized he’d been mistakenly praying to the grandfather clock in the corner instead. An elderly lady standing next to me was struggling to maintain her balance in the dark and intuitively reached out for my hand. I held her and strengthened my grip a little to ensure she didn’t fall. “Homi, your hand is feeling very soft!” she gently whispered to me. “Aunty, Homi Uncle is probably standing on your right,” I whispered back, a smile beneath my mask. “Thank you,dikra… sorry,dikra,” she shuffled and held on to the right man.

Mobiles are to be switched off when one is on the sacred premises. But an elderly gentleman trying to find his footing turned on the flashlight on his phone and suddenly, in the midst of that intense calm, ‘torchbearers’ of the community started hustling him to turn the ‘torch’ off. Just as quickly, people silenced themselves as the head priest started praying.

The Udwada fire temple is the first atashbehram in India and hence its immense importance. After the Arab invasion of Iran, a group of Zoroastrians fled by sea and landed on the island of Dui in India. On the journey, they encountered a fierce storm and prayed to God for their safe arrival, pledging to build an atashbehram if they survived. In 721 CE, the sacred fire was consecrated in Sanjaan and remained there for 672 years. Seeking refuge from attacks on Sanjaan, it was hidden by priests in the Barot caves for 12 years and then moved to the Bansda forest, followed by Navsari, Surat and Valsad,until it arrived in Udwada in 1742. The sacred fire was installed at its current location in 1761 and has been kept burning ceaselessly since its consecration in Sanjaan.

There is something magical about this fire that rests on a 5-foot tall silver base. The priest took six logs, each the size of an arm,and placed them crisscrossed over each other.He then placed their baby versions amidst them, what we call sukhar. Everytime my daughter sees a sandalwood stick placed into the fire, she’ll say, “The sukhar is getting killed!” And then I point out to her, “Look! It is also becoming something else.”

As the priest stoked the fire, what started off as a tiny flame progressively erupted into a giant fire several meters high, its incandescence lighting up the souls of each person in the hall, their faces finally luminous with the vitality of life. The smell of such effervescence can be felt in one’s bones.

People fervently held on to their loved ones, wishes were made, thanks was offered – all of it without voicing a word. The sonorous chanting of the priests’ prayers sent everyone into a trance. Each of us gently rocked within ourselves with our hands folded and were yet standing completely still. Then came a loud gong from the big bell within – the sound of which was amplified by the stillness of the night, sending a chill down the spine, signalling a transition: It asked us what we were willing to hold on to. With each of the nine bells that rang, hands were clasped tighter, and only when they came to an end did everyone breathe, releasing whatever they were willing to let go of. Once the prayer was over, most people started moving gingerly towards the exit, walking backwards to ensure they keep facing the fire until they left. Some zealously held onto the iron bars that barricaded the fire and continued their prayers. Some wouldn’t move from the marble threshold they were bowing down on while paying homage. All of us spoke to Godin our own way.

The New Year gives us a chance to glance over time’s figurative shoulder and introspect on how the past year has been,all the while possessing a conscious, constant desire to make the next one better. We look back on what has irradiated or perturbed our hearts and make changes that we think may help us. But whatever amends we seem to want to make, and however refreshing the start appears to be on the first day of the year, from the second day onwards, everything appears to be exactly how it’s always been. So much for choosing an arbitrary day in the year to mark the beginning of a new one!We’re lucky that in India, the number of religions we have offers us a New Year every few months or so; it gives us a chance to renew ourselves on a regular basis.

If you’re Parsi and you know it, try the midnight fire at the end of this year at Udwada. If you cannot, try again at the end of 2023, and then again at the end of the year after that,until after COVID restrictions on partying elsewhere have finally been lifted. Till then Happy Omicron to you.

While doctors are told to detach from their patients, they are never really trained or prepared for it. 

“It’s a really huge tumour encasing the major arteries of the brain and circling both optic nerves,” I said to the family sitting in front of me. This is after I’ve been intently and repeatedly scrolling back and forth through the MRI images loaded on the computer in front of me. The growth was arising from the pituitary gland but had invaded into the nose below and brain above, chewing up the bone at the base of the skull. 

Betty, who had come in with her mother, was 48 and rapidly losing vision. She was finding it difficult to look after her five-year-old daughter not only because of her deteriorating vision but also her decision making and executive functioning. “It’s probably due to the tumour pressing on the frontal lobe, which is responsible for these functions,” I said. “We’ll have to operate on this through the nose and by opening up the head simultaneously. It’s going to be a major deal.”

“Will she be okay?” her mother asked. “Of course,” I said, following it up with a laundry list of possible complications. Our interpretation of how any operation will shape up is often filtered through the lens of our own experience. 

A few days later, two teams operated on her synchronously. The ENT surgeon put in an endoscope from below and then prepared the passage through the nose. The tumour looked right back at us – quite pale and deceptively well-behaved. But the moment we bit at it, it bled like a pig. The only way to control the bleeding in such cases is to briskly remove the tumour and we proceeded to do just that. We then opened up the head and removed the monstrosity from above, gently separating it from the arteries it was encasing and freeing up the optic nerves till we encountered the cavity in the nose. 

Once we removed it completely, we could see right through from the brain into the nose and right up the nose into the brain, and with the radiant light of the endoscope shining directly onto the brain through the nose in a dark lit room, the skull looked like an art installation. The ENT surgeons then repaired the defect in the base of the skull to isolate the two compartments. This closure is the most crucial part of the operation. 

The next day, Betty was alert and awake, could see better, and looked really happy despite being connected to tubes and pipes in the ICU, which we got rid of over time. Her mother was thrilled that she was ready for discharge within a week, but just the day prior to that, I noticed two drops of water trickling down the nose. It was no ordinary water leaking out but cerebrospinal fluid or CSF from the brain. My heart sank into that elusive pit in the stomach where it makes knots when disaster is around the corner. 

“We have to repair this urgently by sealing the leak,” I said with certainness. “Another operation?” her mother questioned. I nodded; the longer we take, the higher a chance of getting an infection, and I wasn’t about to waste any time. We went back in and redid the closure, tracing a gentle stream of CSF meandering from the brain into the nose. But she developed an infection with fever – no ordinary infection but full-blown meningitis. She became drowsy, irritable, and almost comatose, but with the appropriate antibiotics over 3 weeks, we got her back in shape and she was discharged in pristine condition. Every day of those three weeks, we fought for her survival even when her family was convinced she wasn’t going to make it. She went home with a new vision – literally and philosophically. She was back to taking care of her daughter with gusto. 

A month later, she landed up in the emergency department with severe headache and vomiting. The CT scan showed that her ventricles had blown up – a condition we call hydrocephalus – and worse, they were full of air, air that was seeping in from the nose into the head. More sophisticated testing confirmed it. The year 2021 was bad for nearly everyone, but for this family, it was just getting worse. 

“We have to go back in and fix the problem,” I proclaimed, albeit a little helplessly. Why this had happened after such a meticulous closure was hard to fathom. Was there another area of the bone destroyed by the tumour that was sucking in the air? Was it the pressure of the hydrocephalus that was not allowing the seal to heal? Whatever needed to be done had to be done now, before it became too late. We took her back to the OT and put in an emergency tube to drain the fluid, re-repairing the leak even though we didn’t find the spot it was leaking from. But she wasn’t improving. 

I was razed to the bone of my resilience; yet, I told them I wasn’t going to give up. “We’ll fight this thing together,” I told her forlorn family. I saw her four times a day, checked on her an additional eight times. After doing a few small operations to change the external tube, we did another operation to internalize the shunt tube and then another to set its pressure right. 

After another month, the CT scans looked perfect and so did she. She started talking, eating alone, and walking with support. She asked about her child and gave instructions on how she should be managed at home. We cut a cake for her a day prior to discharge. The family was effused with affection. For our grit and her grace. 

And the next day, she had a seizure; her head was full of air again. She was unconscious. We got another senior ENT surgeon to repair it but that closure didn’t work either. We tried once more a few days later. Three months and ten operations later, she was gone. And I still can’t get over it. It’s like the laceration of a heart that barely feels bearable. 

Often in medicine, we are told to detach. But no one teaches you how. She was an appendage of my mind and body and it is impossible to forget her. The popular mode of thinking is, if you work hard enough and follow certain steps, we’re able to get over our losses. That might be true for most, but some losses don’t follow such models, and it was famous psychologist Pauline Boss who cautioned us on the nature of such loss: “Its ending is never perfect, even in the best of times.” 

Patients sometimes leave, but how they leave always stays. And often, the illusion of closure is exactly what it is – simply a myth.

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This article first appeared in the Sunday Mid-Day on 9th January 2022

https://www.mid-day.com/author-detail/Dr-Mazda-Turel-88

Each of us is guided by an outer force that teaches us to think, and makes us the people we become

“How do I continue to improve upon my craft?” I asked my professor and mentor Dr. Ari Chacko over dinner. He was retiring from the Department of Neurological Sciences at the Christian Medical College in Vellore after having served it assiduously for over three decades. “You have to repeatedly watch your surgical videos,” interjected his teacher, Dr. Mathew Chandy, who had helmed the same department for several years and whose home we were at for the feast. I used to do that with my father, himself a neurosurgeon, I reminisced. Ari, as everyone fondly calls him, continued the conversation: “You have to go back to every surgery and analyse every movement, and you’ll decipher for yourself how many of those steps were unnecessary. I’ve realized that with this approach, over the years, my movements, which might appear to be slow, have, in fact, become very purposeful.”

Revisiting him after several years of leaving his nest was a separate education in itself. When I first joined my training as a surgical toddler, it was he who taught me how to pee in the proverbial neurosurgical pot. Wetting one’s feet was equivalent to burning one’s fingers. Precision was key. Rigor in examining a patient, exactness in studying the scan, definiteness in preforming the operation, and meticulousness in postoperative care and preparing a patient’s discharge summary were constantly imbibed every single day for every single patient. “Any time you try and cut corners, you’ll land up in a mess,” he used to say. And if ever he got away with it, he was reminded of what his witty mother used to tell him: “You have more luck than sense!”

When you train under someone, whether it be for a few months or several years, you tend to absorb more than the craft. Ari taught us to be kind and caring. He was strict when he needed to be but had mastered the balance of treating residents with a perfect mix of firmness and gentility. He also inculcated the habit of listening to the right music and exercising daily. He was universally loved and admired, and with the demands of our work environment, that’s not an easy feat to achieve. When I finished my training with him, people began to notice that I spoke like him, my hand gestures were like his, and I even incorporated his swag. “And all I wish for is to be able to operate like him,” I told all the people who pointed out these similarities to me. Emulating him became such an integral part of my DNA that a few days ago, while talking a stroll in the garden, I noticed that even my daughter walks like he does.

In recent years, after having moved back home, my father has taken the responsibility of mentoring me. Even though we don’t work in the same hospital, whenever I’m lost inside someone’s brain or spinal cord and need to be bailed out, he’s just a phone call away. I tell him where I’m stuck, he provides the unfolding. I discuss the complication, he dispenses the clarification. I go to him with the arrogance and brashness of youth, he receives me with the wisdom and grace of experience. He has taught me what textbooks cannot – about neurosurgery, living, and knowing.

“I still find it very hard to deal with complications, they just drain me physically, mentally and emotionally,” I spoke over dinner. “It just means that you are concerned about the patient and that is exactly how it should be,” he said as we dug into some roast chicken prepared by Mrs. Chandy. I was being continuously badgered with phone calls from a colleague who was finding it exhausting to deal with issues being faced by our patients. “Despite so much experience, I continue to tremble with a staggering degree of doubt and confusion,” I confessed. “You just have to move intuitively and do the next right thing with conviction – and with the technology available today, we can seek help and guidance from anywhere,” he finished, dropping pearls of wisdom over a meal.

Borrowing from what Atul Gawande, a famous surgeon-writer, once said, we spoke about how it would be useful to get a teacher into the operating room to silently observe the surgeon; over a cup of coffee, the surgeon and his observer could then dissect how one could do the same operation better the next time around. All professionals at the highest level have someone to coach then, then why not a coach in the operating room?

It was an ethereal experience to dine with my teacher, Ari, and his teacher, Dr. Mathew Chandy. Beautifully enough, his teacher was his father, Dr. Jacob Chandy, who started the first department of neurosurgery in the country at the Christian Medical College, Vellore, in 1947. Time has a funny way of collapsing when you go back to a place you once loved and so deeply cherish until the present day.

I returned home on my first flight since the lockdown. Isn’t it strange that at every checkpoint at the airport, one is requested to lower their mask rather than keep it up?

When I returned, I messaged Ari that all the patients who had niggles while I was away had recovered completely, and just as I was hoping for an easy week, I mentioned to him that another patient had returned with a collection of fluid in his head 2 months after surgery. He wrote back, “My mother used to say, ‘The wicked are never at peace!’” Did I mention he had a devilish sense of humour?

This New Year, may we all be guided by an inner light and outer force. May we remember those who taught us and continue to do. Each of us has a mentor we revere, who has made us a little bit or a whole lot of who we have become. And like a friend of mine recently told me, “May we always pay it forward.”