Why it’s important for a doctor to be part of a team whose decisions are constantly questioned, and healthy dialogue is the order of the day.

“Why can’t we have some surgeon-friendly anaesthetists?” I questioned my anaesthetist, who had bellowed back at me for asking her to hurry up amidst her getting my patient ready for surgery. “I need to secure an extra intravenous line, and an arterial line since we are turning him prone,” she started explaining, ending with “…why can’t we have more anaesthetist-friendly surgeons instead!” rolling her eyeballs almost up to the ceiling. I could see condensed air emanating from the sides of her mask, the silent gestural interpretation of having to put up with a surgeon’s low IQ. To infuriate her even more, I retorted, “It’s just a simple cervical laminectomy!”

“There’s no such thing as just a ‘simple’ surgery… you know this better than I do!” she exclaimed, reminding me of my own neurotic obsession to fuss about the tiniest and most frivolous detail in every single operation. “He has a bad heart; you know that, right? We’ve even taken a DOT consent. “What’s DOT?” I asked, not being a fan of abbreviations. “Death. On. Table!” she said, with a short, emphatic pause after each word. This time, my eyes reached the ceiling and came rolling back. “You surgeons don’t see anything apart from the organ you’re operating on, right?” she went on, putting the final taping to secure all her paraphernalia. “Of course we do,” admitting to myself quietly that we often don’t. “We’ve even got fitness for surgery from the cardiologist,” explaining my diligence. “Fitness for surgery is a meaningless term. Anyone who can lie down is fit for surgery. Fitness for anaesthesia is what’s needed,” she retorted, having used that line umpteen times before, borrowing from something she had once read somewhere.

In today’s age, every specialist looks at a patient from their point of view. I have to make sure I can surgically relieve him of his pain. The cardiologist has to ensure that his heart is optimized to withstand the operation. The physician checks that his blood sugars and blood pressure are stable. The anaesthetist has the ultimate responsibility of navigating the ship through the storm if something were to happen, and hence the excruciating emphasis on safety. “The cause for multi-organ failure is single-organ doctors,” one of my teachers used to say, emphasizing the need for being holistically involved in treating a patient.

I remember once operating on a patient’s lower back because he could hardly walk a few steps, having been debilitated by pain for years. He had severe lumbar canal stenosis. The operation relieved his pain completely, and in his newfound freedom and excitement, he started walking several kilometres a day until he had a heart attack. The heart was not conditioned to withstand such a drastic change in such a short span. Luckily, this was not a classic case of ‘the surgery was successful, but the patient died’; this man was okay with one stent placed in time.

After we were given permission to advance with the current case at hand, we flipped the patient nervously on his belly and continued to proceed with the cleaning and draping of the patient in the usual fashion, but this time, the corner of one eye was constantly on the monitor, checking for any fluctuation of heart rate or blood pressure. “If his heart stops, we’re not going to be able to resuscitate him in this position, with him lying on his stomach and his head fixed rigidly on a clamp,” were her soothing words just before I sliced into the back of his neck. To keep up with her wit, I stated mid-way through surgery, “We are losing a lot of blood, hope you’re okay there!” In reality, we were in control; I simply wanted to make sure she was glued to the right screen. We removed the compression meticulously, ensuring the spinal cord was pulsating gently. We were done before the anaesthetist could say anything else to us. But I was wrong; she wasn’t finished.

“Why did you book the case for 6 hours if you could finish it in 2?” she said, smiling behind her mask. “I included the time you would take to get the patient in and out of anaesthesia,” I teased, dismantling my gloves in the heroic fashion surgeons do when they finish a successful operation.

Doctors tend to view patients from different perspectives. Two surgeons viewing the same problem may have a completely different outlook because of context and relativity. A famous spine surgeon once said, “Anyone with a spine problem can be managed without surgery and anyone can be operated; there are very few absolutes.” It is for this reason that the more opinions a patient takes, the more confused they end up being. Medicine is an ambiguous science, leaving those dealing with patients’ lives in a constantly elusive quest of what is the right thing to do.

Two senior physicians may argue on whether a patent is optimized for surgery based on sound reasoning from the information at hand and may yet arrive at varying conclusions. Neither is right or wrong; the knowing is always in the doing, or sometimes, in not doing. On occasion, doing something has a price to pay, but so does not doing it. The best – and worst – part is, we always have a choice. Recently, we were reluctant to operate on someone for a spine issue without optimizing him because we felt the risk from his compromised heart function was too high. The patient was operated immediately elsewhere – successfully.

I’m fortunate to be part of a team where my decisions are constantly questioned. Where patient safety is a prime concern but there is still a willingness to push the envelope. Where we have to perpetually engage in dialogue – sometimes gentle, sometime harsh. Where we have to explain why we want to do what we need to. It’s strange that we are all fighting for a common goal, which is the good of the patient, and yet, everyone has a different perspective of what ‘good’ is.

After all, as the famous saying goes, “No one sees what you see, even if they see it too.”

“These doctors just keeping fleecing patients!” This was said by two middle-aged men walking briskly past me, animatedly talking to each during their evening walk. I was there for a stroll with my kids in the perfectly manicured verdant garden across my home. The warmth of the setting sun made way for a gentle cool breeze that whispered to looming trees lining the walking path.

“…and then there was one complication after another, and he charged them for every visit!” I overheard as they whisked past me in their next round, while I was bending down collecting snails with my children. I tried to analyse in my head what this case could have possibly been about but realized it was pointless; I had no context, no background, and even if I did, it would still be unfair to pass judgment.

“I’m able to get you an authentic Black Label at 50% discount if you order in bulk,” said another walker to his counterpart, where the conversation in each round contained passionate mentions of one banned substance after another. An elderly Jain couple sat on the brass benches that adorned the walk way, listening to soft bhajans. Who are we to decide what gives joy and happiness to others, I thought, as so many familiar faces entered and exited from the park.

“How do people recognize you with your mask on?” one of my girls innocently asked me, as acquaintances made courtesy waves and head nods to me in each round. “His ears are big enough for him to be recognized from anywhere!” said a charming aunty behind us, eavesdropping on the question as she walked hard, no doubt to maintain her yesteryear figure as she’d done over decades of walking.

“I don’t know why they won’t allow navjotes of children where a Parsi girl has an interfaith marriage!” said one of three ladies who had settled onto another bench, eating grapes from a box after their evening jaunt. I slowed down a bit to catch the reply but without appearing to listen in. “Everyone has their own agenda. What is right and wrong is simply a matter of perspective,” reasoned the one in the middle. I guess each one is entitled to their opinion.

On the next bench was a middle-aged couple turned sideways to face each other; the man gently running his fingers over her hand, professing his love for her in a language that I couldn’t understand. But then, as the cliché goes, love has no language. She dropped her gaze and whispered something after making sure I was at a distance; after all, all I was doing while on my walk was collecting fodder for my next article.

“Awakening cannot satisfy you; it frees you from the need to be satisfied,” came a slightly deep voice from behind me. I tried not to turn my head to such profoundness, thereby allowing the speaker, one of two young girls – iPhone strapped onto an arm, hair tied in a bun, running shorts, and a spring in their stride – to energetically zip past me. I wondered if my daughters would resemble these women two decades later; in the present moment, they were busy navigating cobblestones on one leg, tugging at my T-shirt if they felt like they would topple. The generation after us is so much more evolved than what we were at that age; for me, awakening simply meant getting out of bed and making it to school in time.

There is a jovial Sardarji with a huge paunch who walks at breakneck speed every evening in the garden. At 68, he’s trying to learn English, and every time he sees me, he shares a phrase he’s learnt recently, breaking his walk and allowing for his drenched vest to cool off a little. Today, it was “Childhood is real bachpan,” imparting that wisdom as he watched my girls getting wet at the edge of a sprinkler nourishing the grass and then creating art in the wet mud. I agreed completely, not knowing exactly what it meant but admiring his determination to learn. He could have been paraphrasing a famous Picasso quote: “Every child is an artist. The problem is how to remain an artist once we grow up.

“I’m rich but I’m always alone,” lamented an elderly lady in her sixties as she spoke to someone on the cell phone while sauntering through her walk, her only companion her oblique shadow walking tangentially beside her, and that too only when she crossed one of the floodlights that brightened up the park after dark. The weight on her legs seemed infinitely larger than what her physical body was carrying. I wondered what must be transpiring in her life but concluded that wealthy people have just as many problems as the poor do; there is only so much money can do.

As the moon came up, the watchman blew his whistle signalling that it was time for the gates to close. On that pleasant November evening, I realized how enriching eavesdropping could be. I ended up wanting to change the negative opinions people have about doctors and hospitals in our country, I hoped that the guys smoking and drinking would derive their pleasure from fitter sources, I wished the Parsis would find more amicable solutions on the issues that plagued the community, wanted to shout out that no one was ever lonely, even if they were alone.

“Your girls are going to become surgeons like you,” said one of the aunties on our way out, probably once again having listened in on some interesting fact about the brain that I was trying to impart to my daughters.

“What would you like to be when you grow up?” I asked my kids as we made our way home. “I definitely don’t want to become a doctor,” the younger one said. Surprised, I asked why. “I can’t answer so many phone calls, it’s just too exhausting!” she said, lugging her entire body on my arm from the weight of that sentence . “What would you like us to be?” the elder one retorted, tired of reiterating that she wanted to be a dancing chef.

“You need to choose what makes you happy, and this decision might not be the easiest, but it’s definitely the right one,” I told my girls, quoting a line from one of their own story books that I read to them each night.

One of the first senses to develop, smell and the lack of it, has taken on a new meaning in the Coronavirus pandemic; but, its alteration is a diagnostic aid in many medical conditions

A family of four entered and positioned themselves strategically in my consultation room. The middle-aged parents took the two seats in front of me, the teenage daughter plonked herself on the examination bed, and the son chose to stand. This was swift. Often, when there are two chairs and more people, the first 5 minutes are spent deciding who is going to sit where, and most often, one chair remains vacant because people opt to stand out of courtesy. Every culture is different, and every family has a distinct dynamic.

“He can’t smell anything,” the wife started off after pleasantries were exchanged, and then looked at her husband for him to continue. “My head hurts like hell,” he said clasping it with both his palms. He sat there like a stack of circular Russian dolls. His head was a perfectly round. His torso was also thoroughly spherical, albeit a voluminously larger version of his head. And the tumour inside his head was the size and shape of a cricket ball, a glowing third eye. It stood there like a road roller, compacting the nerves responsible for smell into the base of the skull.

The olfactory nerves are microscopic versions of spaghetti that line the insides of one’s nose and then enter the skull through a sieve in the bone, forming a bundle that resembles a thick flat noodle, one on each side. Now, thanks to the tumour, his nerves were thin flat noodles. The complex connections of the nerves with various parts of the brain via sophisticated networks allows smell to become integrated with emotion, memory, and taste.

“He’s also becoming very emotional lately,” the wife interjected. “We’ve been married for two decades, and he’s told me he loves me twice in 20 years. In the past 1 month, he’s said it a dozen times!” she said with the glimmer of a smile, one tinged with surprise and also concern. The teenage daughter had a bit of a twinkle in her eyes, probably drawing parallels to the affection her dad had also been showering on her. I plugged in the MRI films to show them that the downward pressure of the tumour on the olfactory nerves was causing the dysfunction of smell, and that the swelling of the surrounding frontal lobes was responsible for his emotional effusiveness.

They had all the answers but didn’t know what question to ask next. “We have to remove this with an operation,” I helped. “Surgery will relieve the headaches, restore his sentiments, and he will hopefully regain his smell, at least in one nostril,” I elucidated. “We’ll go ahead with surgery,” the son finally spoke as we discussed some more technical nuances related to surgery and its outcome.

A few days later, I walked into the operation theater at 7 AM for his surgery. An early morning OT has a profound and piercing smell you can feel in your bones. It’s ethereal. It is sweet and tangy, zesty and fresh. It has the aroma of mopped floors, buttery walls, sterile packs, warm-pressed linen, and gleaming Keralite nurses – the intense tenderness of whom you can feel even behind the veneer of their tripple-layered masks. And when you’ve operated hard and long enough like I have, the OT also has the smell of joy, grief, gladness, remorse, and hope, with, above all, a fragrance of resilience and compassion.

After fixing the patient’s circular head on a clamp, we made a semi-circular incision from ear to ear and reflected the scalp down. We then drilled out a 4 x 4 cm piece of bone above the right eyebrow. The brain was extremely tense as we opened the dura, requiring us to do away with a small and inconsequential part of the frontal lobe to get to the tumour, called the frontal pole. “We’re sucking away the ‘I love you’ centre of his brain,” I told my assistant in jest. “He’s now going to say ‘I lobe you’ to her!” he retorted, my wit rubbing off on him after the years we’ve spent chatting under the radiance of the microscope. “Finally, he’ll do justice to his Bengali linage,” I quipped, before we moved to a more critical stage of the surgery.

Once we got to the tumour we cut off its blood supply first and then cored into its centre so that it could fall on itself. Then, I gently peeled it off the right olfactory nerve followed by the left one, hoping it wouldn’t snap at its thinnest point, where it was almost transparent. I often whisper into patients’ brains when I operate: “Hang in there,” I implored to the cranial nerves, and they did so with tenacity. A few days later, he was discharged with a smile on his face that met the incision on his head.

The sense of smell is the first of all our senses to develop. Even before we are born, our sense of smell is fully formed and functional, although unfortunately, some children are born without the ability to smell, a condition called congenital anosmia. An alteration or loss of smell is a diagnostic aid in many medical conditions. It is a harbinger to Parkinson’s in several cases, predicting it several years before the actual onset in some individuals. Often, patients who have seizures report that it started with a disagreeable smell – rotten eggs, pigeon poop, burning rubber, and anything else one can imagine. In some people, strong smells of glue, petrol, or bleach can even trigger a convulsion. The coronavirus has given the loss of smell an elevated status, and many people have experienced what that feels like to not even be able to taste their meals, because it is smell that gives our food its flavour.

Six months later, the entire Das family was back in my consultation room. They positioned themselves in exactly the same fashion, as if it were home. A fresh MRI showed no tumour and pristine-looking frontal lobes. He was delighted that his sense of smell was back. “I’ve had to add more spice in his food, though,” his wife interjected. “And how is he emotionally?” I asked. “Absolutely fine,” she smiled. “In fact, he’s become kinder, softer, and still keeps saying he loves me, but I’m not complaining!” she said as they looked into each other’s eyes, happy faces all around.

“I’ll readily take credit for that, if you don’t mind,” I signed off with an equally happy face.

Diagnosing a patient whose symptoms are as indiscernible as the expressions on their face when masked, throws another kind of a challenge for a doctor

Do you ever wonder what someone looks like behind their mask, someone you’re speaking to but have never met?

As a doctor, I indulge in this amusing activity daily. When we talk to new patients, the brain subconsciously analyses what the rest of their face must look like. Inevitably, at some point in the consultation, every single patient brings down their mask – either because their nose itches, their glasses are fogging, or from an inherent human desire to establish a personal connection – only to confirm to me that reality matches imagination in no way; those you perceive to be clean shaven have a scruffy beard, and those you think might have a sharp jawline have it covered by chubby cheeks instead.

A patient once asked me matter-of-factly, “Doctor, please could you lower your mask? I would like to see the full face of someone who is going to stick a knife into me!” I obliged gingerly, understanding fully well that an honest human connection demands transparency beyond the opacity of a veil that is dividing the entire human race in these times. Often, I am unable to recognize people who acknowledge me, and in a kind gesture, lower their mask to reveal their physiognomy. I am sometimes even more embarrassed when I fail to make the recognition despite this courtesy shown to me.

I was recently examining a hypertensive patient who had come to me after enduring a severe headache over the past few days. In the middle of the assessment, his fluorescent orange mask started to flutter. Given the variations in masks these days, for the first two seconds, I wondered if this was something new in the market – until I realized he was having a seizure. I pulled his visor down and saw his face twitching uncontrollably. Within seconds, his arms and legs started jerking, his mouth was frothing, and his eyes had rolled up. I lay him on the examining bed and put him on his side for the next few minutes until the fit abated, while his relatives stood there aghast at what they were seeing.

I dug my fist into into his sternum, deliberately causing him pain, and realized that he didn’t react by moving his left arm or leg. He was paralysed on that side while the right moved briskly. We immediately transferred him on to a hospital trolley and connected him to some oxygen while a nurse promptly pricked him to get intravenous access and pumped in some drugs, just like we see on every medical drama series on television. Except, over here, as the cliché goes, there are no retakes. Also, in television, the elevator is always ready, but in reality, the sicker the patient, the longer the elevator takes to get to you. Luckily, where I work, we have a system set in place for emergencies.

We rushed him down to the CT scan room and rolled him into the machine, watching it dissect an image of the patient’s head into 256 slices on the computer console. The scan revealed a large bleed in the right half of his brain, which explained why he wasn’t moving his left side. By the time we spiralled him out of the gantry, he was stuporous. We needed to shove a breathing tube down his throat to guard his airway and connected him to a ventilator to keep him breathing. His blood pressure was 220/110 mm Hg.

I explained to the family that he had had a stroke. “80% of strokes happen because of blockage of a blood vessel, which disturbs the brain because of a lack of blood supply to it. In these cases, we can give a clot-busting drug. He falls into the remaining 20%, where a stroke occurs owing to haemorrhage inside the brain,” I elucidated, while the team was already shaving his head, prepping him for surgery, which the family had instantly agreed to. Given its typical location, I told them with authority that the bleed was because of high blood pressure in his case, although sometimes, a large blood clot can ‘mask’ an underlying tumour, arteriovenous malformation, or aneurysm. We did a few more investigations to clear all of the above and swiftly transferred him to the operating room where a team was already spruced up and geared for his arrival.

Within minutes, we made a linear cut over his scalp and secured the bleeding from his thick skin with some plastic clips. We drilled a small hole and swirled around it to make it larger. I nicked into the dura and met the blood clot where it reached the surface of the brain. Blood clots in the brain are like people in a Matt Kahn quote: “They can meet you only as deeply as they have met themselves.” Using an endoscope to visualize it and a sucker to slurp it out, I navigated around to get all of it out until the tense brain regained its supple composure. Within a few days, he was alert enough to have his breathing tube removed, and his paralysis showed signs of reversal. “Quick removal of a clot like this prevents an entire cascade of secondary injury to the brain,” I explained to the family, who was relieved to see him finally being shifted out of the ICU and complaining about the horrible food in the hospital. He had every right to do so; after all, he was a Parsi being served vegetarian food.

On the 29^th of October, we celebrated World Stroke Day. It’s frightening to know that 1 in every 4 adults above the age of 25 will suffer a stroke at some point in their life. It’s heart-breaking to learn that a stroke occurs every 5 seconds across the world, and gut-wrenching to fathom that out of every 10 strokes that happen worldwide, 1 of them happens in India. Mumbai itself sees about 50 strokes a day. Time is of essence in the diagnosis and treatment of strokes, and, very often, minutes can save lives.

Three months later, my patient came back to the clinic having completely regained function and resuming work. This time, his mask was fluorescent green with a big smiley on it. He removed it for me in a flourish so that I could check the symmetry of his face, the intonation of his voice, and the fluency of his speech, all of which had taken a beating from the stroke but were back in perfect harmony. I asked him to put his mask back on, lest he catch COVID from somewhere, which, I told him, also has an increased propensity to cause a stroke.

“Don’t worry, doctor! I have already taken the booster,” he winked. Now that’s a face I’ll always remember.

Be it an octogenarian or school-going teen, spinal problems don’t spare anyone, which is why your back needs constant TLC

“The outcome of any successful spine surgery depends on choosing the correct patient, operating for the right indication, at the correct level, and on the correct side,” I said, attempting to alleviate the furrowed brow of a 50-year-old daughter who had brought her ailing dad to see me for severe back and leg pain. “Of course, the surgeon also matters, but that’s the least important piece in the puzzle,” I went on to add, remembering my mentor, who used to say that any monkey could operate.

Rusi uncle was 84 and walked with his torso bent at right angles to his waist, almost parallel to the floor. This position allowed a pinched nerve in his spine to move away from a bony spur that was irritating it. The moment he tried to straighten up, he had lancinating pain. “Dikra, you do whatever you want without any operation to get me ok. Spine surgery is very risky, and I don’t want to be dependent on anyone,” he said with the loving authority of having lived life on his own terms.

I showed him his MRI and emphasized that while there were multiple levels of degeneration in the spine, the sinister element was only one and could be easily addressed. “We can do a big operation and put in a bag full of screws to treat all the issues I’m seeing in this MRI, but we are operating on you and not the image,” I comforted. “I can say with certainty that your problem is coming from one point, and with a minimally invasive approach, we’ll fix you. You’ll be the tallest person in the house once again!” I said, assuring him of an upright posture. He reluctantly agreed with a half-smile.

A couple of days later, we made a 2-cm incision into his back and drilled off an overgrowth of bone that was jamming the nerve every time he tried to stand straight. I passed a smooth ball tip probe all around the nerve to make sure it was free of any compression. Within the hour, Rusi uncle was awake and walking as straight as a pole. He couldn’t believe it, neither could his daughter, and, frankly speaking, even I was pleasantly surprised. Ever since I have been at the receiving end of delicious organic fruits from his farmhouse.

At our hospital, we follow an ‘enhanced recovery after surgery’ pathway, commonly called ERAS, which is a multidisciplinary approach to improving the quality of patient care in the immediate postoperative period. Most of our patients are out of bed within a few hours of surgery and discharged home sooner than they expect. A combination of efficient pain management by highly trained anaesthesiologists, aggressive postoperative physical therapy, and skilled nursing allow for even the elderly to go home the next day after surgery.

A 37-year-old woman was a little miffed with me because she was made to walk 4 hours after spine surgery as opposed to the promised 2. “All the others who you have operated upon started walking way before I did,” she threw a fit. “Everyone’s a little different,” I tried to reason, “and everyone heals at their own pace. But a month from now, those two extra hours in bed won’t make a difference.”

In today’s pampered existence, patients want a boutique experience to surgery. We are desirous of scar-less incisions, painless injections, gourmet food, and scented rooms. And why not? Anyone who is distressed needs a little mollycoddling, yes, even the doctors.

“I have an upper back pain that does not seem to want to go away,” said a 13-year-old boy. He had come in with his stern-faced mother who was convinced that this was a ploy to stay away from online school. “Studying from home has definitely increased the number of spinal problems we’ve been seeing,” I explained to his mother. “Most often it’s only muscular and gets better by correcting one’s posture, but look, he’s wincing to pain,” I demonstrated, pressing on his fourth thoracic vertebrae. I insisted on getting an MRI done and the mother raised her hands in a huff. I think she was hoping I would chide him to get back to work and there I was, ordering tests worth thousands.

Her irritation was instantly transformed into deep concern when she returned with the results. There was a collapse of the fourth thoracic vertebrae, but luckily no compression of the spinal cord. I could have rolled my eyes at her but refrained. “This looks like tuberculosis of the spine,” I said, recognizing the pattern, “but we need to biopsy it to be sure.” We were lucky it wasn’t a tumour, which is the other possibility when children complain of pain of this nature.

The next day, we stuck a needle into his spine and took out a piece of tissue for testing, the results expectantly revealing tuberculosis. With 6 months of medication he was pain free, probably avoiding major surgery by not letting the diagnosis pass him by.

Most of the time, pain originating in the spine is because of weak muscles, and hence, strengthening the core and improving posture remain key elements to spine care. Even so, attention must be paid to identify what is remedial and reversible, so that spinal tumours, compression fractures, tuberculosis, and other infections – which can be treated if caught in time – aren’t missed. Patients who are undergoing dialysis and complain of back pain should get an MRI to ensure there isn’t a bacterial infection of the spine, as is commonly seen with these patients and which can eat up the bone swiftly if not treated in time. Intravenous drug abuse is another common source of spinal infections. Any patient who has a known malignancy, even if it is under remission, and begins to complain of back pain should be investigated with an MRI to rule out a metastatic spread to the spine.

“What’s the best thing you can do for your spine?” an interviewer asked me recently on World Spine Day, commemorated on October 16 every year to bring awareness to an estimated 1 billion people in the world who suffer from spinal pain at any one point. “Keep moving and be kind to your spine,” I replied. It really is all you need to do.

Why having intuitive and skilled nurses in the operating room can make surgeons look good

“Micro scissors, please,” I requested, as I meticulously proceeded to split the sylvian fissure, a crevice which, when opened, separates the frontal and temporal lobes, providing a navigable labyrinth to deep targets without violating the substance of the brain itself. We were operating on an aneurysm of the anterior communicating artery that had ruptured. Opening a swollen and angry brain is way more complex than tempering a docile one. A neurosurgeon’s touch must be gentle and precise. Developing the right touch is the biggest challenge.

We performed the operation under the magnification and illumination of the microscope. It’s a big, burly gadget, often draped in a sterile plastic sheet that floats between the surgeon’s and patients’ head empowering us by enhancing sight well beyond the physiologic limits of the unaided eye. Five mm arteries appear like the huge underground pipes that transport water from one part of the city to the other. Even the slightest undue amount of traction or an inadvertent poke can result in the pipe bursting and an overflooding of the brain akin to the Mumbai monsoon.

Dissection in these cases often involves three basic manoeuvres: cutting with a pair of micro scissors, spreading the arachnoid with bipolar forceps, and probing with a slightly curved dissector. These steps are either repeated or alternated as the surgery is displayed on a giant screen for everyone in the room to see what’s going on.

The surgical nurse is supposed to place instruments into your outstretched hand in exactly the same position that they are supposed to go into the brain. We don’t have the luxury of taking our eyes off the microscope as one hand holds onto a suction device that serves the dual role of clearing collected fluid, with its shaft providing gentle retraction when needed. Undue retraction can avulse the dome of the aneurysm causing torrential bleeding. The other hand receives and returns instruments.

If an instrument is not placed precisely and with the right amount of pressure in a surgeon’s hand, it accentuates the stress and strain of an already difficult operation. One needs to look out of the scope or shuffle with the instrument in hand, to get it right, disturbing momentum. “I don’t have eyes on the tips on my fingers,” my boss used to say when nurses didn’t place instruments correctly into his palm. And when I used the same dialogue as I started operating independently a few years later, the nurse would almost smack the instrument into my hand – a silent but stinging way to put me in my place.

Skilled nurses often make ordinary surgeons look good. They can follow an operation and give the surgeon the correct instrument without them even asking for it. In my earlier days (and occasionally in my recent ones) nurses would suggest what next – which instrument to continue the operation with. For an average surgeon like me, “Don’t give me what I ask for, give me what I need,” is a constant plea to my maker and my nurse.

The reality of aneurysm surgery is that technical skill and surgical experience do not eliminate the risk of intraoperative aneurysm rupture. The dangerous combination of aneurysm fragility and surgical manipulation sometimes precipitates rupture and the neurosurgeon must prepare for this catastrophe. This is when the surgical nurse

exemplifies their deftness. A systematic contingency plan has to be discussed before every operation, with both the surgeon and nurse envisioning an intraoperative disaster in every conceivable form and then develop strategies to deal with it.

And that’s exactly what happened in this operation. After an hour of perfectly executed steps, the aneurysm ruptured, flooding the brain with blood. When this happens, there is an intense rush of emotions: surprise, confusion, regret, tension, anger, and even frustration, and every surgeon goes through all or some of these depending on their levels of experience. These moments demand calmness, clarity, and confidence. We must continue to think and operate simultaneously.

The nurse promptly handed over a third suction, allowing me to tamponade the bleeding with a cottonoid. A pre-loaded temporary clip was slieghtfuly transferred, which reduced the flow of blood to the aneurysm and allowed us to visualize the site of rupture so that we could place a permanent clip to secure the aneurysm. The nurse almost guided my hands naturally through the critical steps, transforming an emotional response into an intuitive one, resulting in a successful outcome. “The difference between triumph and disaster isn’t about the willingness to take risks,” says famous writer-surgeon Atul Gawande, “it’s about the mastery of rescue.”

I leaned – metaphorically, not literally – a lot on my nurses as a young doctor. What I gleaned from them in my training couldn’t be learned from textbooks or even other doctors. I started my training in neurosurgery as a registrar in the neuro ICU at the Christian Medical College in Vellore. The nurses taught me little tricks such as how to insert lines, adjust ventilator settings, manoeuvres to reduce intracranial pressure, and even decide on the right time to get a scan done in critical patients. They would even allow me to get a few winks of sleep while they salvaged a critical patient overnight and were happy to hand over the credit to me in front of the chief the next morning.

Even today, there are nurses who offer me suggestions on how to make the operation better and I am indebted to them for those. They pick up nuances from working with other surgeons, find it relatively effortless to enhance the quality of the current case, and don’t hesitate to impart that knowledge. We are fortunate to be surrounded by nurses who are astute, wise, and compassionate. There must be a karmic connection for me to have been born on a day that’s celebrated as International Nurses Day, commemorating the birth of Florence Nightingale, the foundational philosopher of modern nursing, on the 12^th of May in 1820.

There are some surgeons who will not operate on certain cases if their dedicated nurse is not available on that day. Some departments have that luxury, others don’t. “If you’re not in sync with your wife, it’s okay, but make sure you get along with your surgical nurse!” a famous surgeon once said in a conference when he spoke about how to deal with intraoperative aneurysm ruptures. To circumvent this, Prof. Yasargil, now in his 90s and who is hailed as one of the greatest neurosurgeons of the 20^th century, was married to Dianne, the nurse in charge of his operating suite and who assisted him in almost all his surgeries for several decades. Now that gives work from home a whole new meaning.

Nothing in life is foolproof; doctors who have witnessed an otherwise uncomplicated surgery go awry, will tell you why

“Stick your tongue out for me,” I requested 56-year-old Liza as I checked to see if it jutted out straight in the centre or deviated to any one side. It made a sharp swerve to the right, denoting a weak hypoglossal nerve on that side. The hypoglossal is the last of the twelve paired cranial nerves that supply motor control to the tongue, allowing one to speak, swallow, and move stuff around in your mouth. It’s also the nerve that helps Americans roll their Rs and Maharashtrians liven their ळs.Now that you have tried out both accents, we can get back to Liza.

Her nerve was feeble because of a tumour that arose from it after having gradually grown to the size of a Mediterranean lemon, where it compressed her brainstem, making it hard for her to even walk unsupported. “We have to get this thing out,” I told her, assuring her it was not cancer but a benign tumour that we call a schwannoma, receiving its name from the outer covering of Schwann cells that encircle the nerve.

“I’m HIV positive, you do know that,” she reiterated tentatively. “That’s fine,” I said brushing it off in my understanding that HIV is now a well-controlled, easily managed entity in a majority of cases. “There’s just a slightly increased chance of an infection,” I said casually, “but it’s nothing we can’t deal with.” Little did I realize that these words would come back to bite me in the backside.

The next morning, we opened up the back of her head behind the ear in the usual fashion. The cerebellum was tense and became soft after the release of some cerebrospinal fluid. With gentle retraction of the pulsating brain, we saw part of the Mediterranean lemon glistening back at us. It was like a sighting of a yellow moon after waiting for a cloud to pass, except that in this case, we were moving the cloud. We entered the tumour, patiently coring it from its centre until it collapsed on itself, relieving the tension from the stretched hypoglossal nerve. With a set of sharp instruments and soft movements, we teased off the last bit of tumour from the nerve, which appeared weary but intact. Every single time I remove a tumour like this, which obscures most of the anatomy when we begin but brings into view the entire panoramic vista of nerves and arteries once it has been removed completely, I can’t help but marvel at a beauty that one can never quite be bored of. It is simply mesmerising.

The next day, she woke-up crisp with no further worsening of tongue function. She could eat, chew, and swallow, and I was confident that with some oro-facial rehab, she would regain normal function in a few months. As long as the nerve is not damaged completely, it almost always heals over time. “You’ll have to work your tongue in ways you haven’t before,” I said in jest a few days later, when she was discharged.

When she came back a week later to remove her stitches, I noticed some pus seeping out of the wound. This is always an ominous sign. A CT scan showed it was tracking out from deep within. “We have to take you back to surgery and wash this thing out,” I said to her, my head in my hand. “Can I not just take some antibiotics to see if it settles?” she reasoned. I said it was an option but cleaning it up from within would help allow the antibiotics to act better, and we could also send the pus for testing.” She agreed meekly. It pains a surgeon just as much as it hurts the patient to go back to surgery.

We took her back and washed out all the muck that had defiled such a pristine operation. We valiantly attempted to refurbish it to a state where we left it last, akin to restoring the Mona Lisa. Once again, we thought we had done a pretty good job, as she was up and about the next day in mint condition.

The day after when we went on our rounds, we noticed she was talking abnormally, not responding to simple commands, and refusing to get out of bed. All she did was moan in pain. Her neck was stiff. We stuck a needle in her spine to drain some fluid via a lumbar puncture, and as suspected, the results proclaimed meningitis – a life-threatening infection to the central nervous system. We had to step up the antibiotics and pray. “We have to hope she responds to the medication,” I told her daughter, Grace, feeling dejected and confused by the mayhem her mother was being put through but stoically accepting it all the same.

My car key was strung to a keychain that coincidentally had her name, Grace, etched on it, and I pulled it out and gave it to her. The other side had ‘Grit’ inscribed on it; I think seeing it made her feel better. Two days later, Liza was back to her usual self, eating her breakfast, taking walks in the hospital corridor, and making jokes with the hospital staff. My anguish was finally subsiding. She told me she was eager to go home. “Soon,” I said, “very soon.”

She was getting better each day until one morning, I walked into her room smiling to wish her a good morning, but she was still asleep. Grace explained, “She went to sleep with a headache, so I’m just letting her rest it out.” “Wake up, Liza,” I shook her, first gently and then with some vigour. She refused to budge, and all I could hear was heavy breathing. I dug my fist deep into her sternum but there was no response, even to pain. “She’s deteriorated!” I shouted. The crash-cart came in and we thrust a breathing tube down her throat to secure her airway. What had been a tranquil room in a hospital ward suddenly transformed into a battlefield. We connected her to a ventilator and got an urgent CT scan. She had suffered a massive haemorrhage in the cerebellum. It was as if a bomb of blood had burst in her head.

We rushed her back to surgery, excising part of the cerebellum and removing all of the blood clot. She came out alive but never completely woke up. We eventually sent her to rehab, the roller coaster finally at a precipitous stand still. One day, a few months later, Grace messaged me to say, “She’s opening her eyes and moving around.”

It had been one hell of a ride.

Handwritten jottings by doctors can serve as a great primer in the art of medicine. A tenacious few continue to part with their wisdom on paper

“I have come to you because my neurosurgeon retired a few years ago and I’ve been asked to do an MRI every 2 years to make sure my tumour hasn’t come back,” an elderly lady stated as she pulled out a note from amidst a heap of medical records neatly filed and crisply labelled. “He was the most wonderful human being I have met in my life,” she added, handing his note to me. One glance at the off-white paper tastefully inked with a fountain pen in handwriting that would make an artist blush made me realize why she felt the way she did for him.

The note summarized her past records and clinical findings with such finesse that even textbooks would pale in comparison. It meticulously mentioned a pattern of thinking and a plan for how her treatment should proceed in the future. It was written in handwriting that was mesmerizing; I am someone who finds it exacting to read my own handwriting a few days after I have written something, leave aside trying to decipher the handwriting of other doctors of my generation.

The note exuded a deep level of care and concern, of nobility and kindness in treating a patient as a whole, rather than simply focusing on a crevice in her brain through which he had removed her tumour a few decades ago, which had resulted in an unblemished MRI till date. “Can I take a picture of this?” I asked the lady as she gazed at me perplexed by my awe. “We don’t see this kind of beauty in our generation,” I explained, soaking in the equivalent of a Rembrandt or Monet. “We are wrapped in the trappings of technology, which is invaluable, but it ironically takes away from us something that is priceless.” I told her that her scan looked perfect and that I would see her again after a few years, with yet another MRI that I was confident would look unchanged.

Every time I find myself falling short in some way or feeling mediocre, I scroll up to the photograph of that note on my phone, thinking of a generation of doctors with half the resources we have and yet being twice as diligent. Despite being such a stately figure in the field, the esteemed gentleman who had written that note lived his life with a simplicity and an elegance that one could only dream of emulating. He is still a constant feature in most esteemed neurosurgical conferences, reminding the fraternity to continually do the right thing at a time when nearly everything seems flawed.

My personal interaction with him had been minimal, as he had retired by the time I started practice in the city, until he wrote me an email a few months ago to say how much he enjoyed reading my articles in the papers. He signed off with ‘more power to your elbow’, followed by his first name. As I reply to a handful of such emails each week, I wrote to acknowledge his email with gratitude but erroneously addressed him by his first name; not registering it was ‘the neurosurgical matriarch’ until after I hit ‘send’. I wrote back immediately, telling him how embarrassed I was at my blunder, but he brushed it away, explaining that such reverence was reserved for teachers and saints and that we were merely colleagues. He invited me over to his home and we spent a lovely afternoon chatting about cabbages and kings.

Recently, a chirpy patient of mine with unremitting back pain sought an opinion from a senior physician who the country unequivocally considers the God of medicine. “Can I write a letter to your doctor?” he asked her, after having analysed her case. “Of course,” she proclaimed. “He’ll end up framing it in gold!” she said confidently. In a few words, this medical luminary detailed what he thought was going on, suggesting a few modifications and advising that she continue treatment under my care. Within a few sentences, decades of wisdom were handed over with no other reason but to enlighten and encourage a complete stranger – me.

A candle loses none of its light by lighting another, I realized, when I thought about what contributes to such magnanimity. I wrote back requesting a personal meeting and he obliged immediately. He autographed for me copies of books written by him, and when he agreed to allow me to take a picture with him, with me reverentially maintaining a safe distance, he instructed, “Come stand a little closer,” and put his arm around me. I felt like how a teenage footballer would after getting snapped with Messi, or a fledgling actor after sharing the frame with Mr. Bachchan. These moments happen in medicine too.

“A letter should be regarded not merely as a medium for the communication of intelligence,” advised an 1876 guide to the art of epistolary etiquette, “but also as a work of art.” Surgical notes are a primer in the art of medicine. The charm of writing and sharing letters can never be replaced by the curtness of the efficiency-obsessed electronic generation. Even so, modern technology is indeed a boon in enhancing patient care. Budding doctors can spiral images to their more seasoned counterparts and seek hypersonic guidance – only because ‘what to do’ is always more pivotal than ‘how to do’. The latter is simply technique, the former, tenacity. “You not only save the lives of patients, you save the lives of other doctors too!” I joked with a senior neurosurgeon friend who had recently advised me on a case I needed an opinion on.

Medicine is fraught with doctors who want to give: give of their time, effort, and insight. That is one indisputable way to carry one’s legacy forward. What they know will go with them, but what they teach will live on forever. These greats live their lives with a sentient generosity of spirit.

To accomplished doctors who look out for the burgeoning counterparts, may you all be blessed with a healthy life that is energized by the insurmountable goodwill of the millions you have healed and even more that you have inspired.

Death like life is mysterious and sometimes, the struggle for a doctor is to accept that the end is near for their patients

“She was absolutely fine a minute before she collapsed in front of my eyes,” an agitated father said to me as he watched the ICU personnel hooking up his 26-year-old daughter to every possible tube and line that a comatose patient is wired to in order to keep her alive. An appalled mother could not fathom the thought that her daughter, who had been pottering around the house just a few hours ago, was now on a ventilator fighting for her life.

“She had a fever for about four days,” the father went on to narrate amidst all the chatter and clatter of a busy ICU past midnight. “She complained of a constant headache,” he continued, “but today there was no headache!” he rationalized in disbelief of how such mild symptoms could result in such a catastrophe. After about two days of the fever, they got a COVID-19 test done, which was negative, and their family physician correctly prescribed a host of other tests the next day, the results of which were still awaited.

“We did our evening meditation, listened to a discourse, had our dinner, and were just winding up for the day when she had a seizure. I saw her violently jerking her hands and legs and she fell suddenly to the ground. Her eyes rolled up and her mouth started frothing. We immediately rushed her to the hospital,” he said, emphasizing the promptness of their actions. I shone a bright torch into her eyes. The pupils, which normally constrict with a certain shyness of being exposed to the light, refused to budge in her case. They gawked back at me sending an unsaid yet stern message: large non-reacting pupils are a harbinger of brain death.

Her CT scan looked ghastly. The brain was terribly swollen. All over. There was thick blood layering the surface and splattered specks within. This could be some sort of an aggressive viral infection, the brain damage made worse by possible trauma to the head from the fall after the seizure, I reasoned with the family. “The only option we have is to take her to surgery, open up both sides of the skull, and allow the brain to expand out rather than keep the vital structures pressurized within. We’ll remove the blood clots on the surface and then see what happens,” I offered. “When the pupils don’t react, we often don’t operate, but since all this has happened within 2 hours and she’s so young, we should give it a shot,” I determined, justifying the plan in my head and in my heart. “Even if there is a 0.001% chance, you do it,” they said, paralyzed from reason, powerless from circumstance.

Within the hour, we cut into the scalp from ear to ear and exposed as much of the skull as was possible. We drilled holes into the cranium and cut out large pieces of skull on both the right and left as the smell of burning bone infused the operation theatre. As expected, the brain was extremely tense, and as we opened the dura – its leathery covering – it gnawed at us angrily. It was as if someone was pumping air into it, and with each inflation, it felt like that brain was distending closer to our faces. Both the temporal lobes appeared terribly inflamed, tiny vessels rupturing from its surface unannounced. We removed the blood clots and closed the scalp back briskly as the brain attempted to cheese out through the suture line.

“We’ve done what we intended to do, but the brain appears badly damaged – like it is being devoured by a flesh-eating organism. It’s extremely rare, but we call this haemorrhagic necrotizing encephalitis,” I concluded with dismay. Any viral infection could have caused this. Initially, we suspected that this could be due to dengue, as her platelet count had kept dropping, but those tests came back negative. The coronavirus – or, as a matter of fact, any influenza virus – has also been reported to cause this. In her case, the entire panel of tests for all tropical diseases came back as normal. We had no answers.

The next day, she lay motionless on the ICU bed. I could feel her brain directly under the scalp as we had removed all the bone. It was like concrete, with no pulsations. The rest of her brainstem reflexes were absent too. Her pupils were much larger, more rebellious, refusing to bow down to the light.

For the next few days, we spoke to the family for long hours to explain to them that we had lost the battle. They sought opinions from other neurologists and surgeons from the city, all of whom concurred. Every day, we spent time asking ourselves just one question: “Is there anything else we can do to reverse this?” The answer, unfortunately, didn’t change.

I spoke to the parents and told them that it might be best to accept that the end had come. I proposed that they allow her to undergo an apnea test, to certify and declare her to be brain dead. They shook their heads. “How will you understand what we are going through, doctor?” they asked me, refusing my suggestion. “This is our only daughter, the love of our life.”

I narrated the story to them of how my mother lost her sister, aged21, in the infelicitous Handloom House fire of 1982. She was working in the building when the fire broke out on a higher storey. She had been evacuated from the building when she realized she had forgotten something valuable and rushed backup in a quick attempt to retrieve it. A burning beam collapsed right onto her and she was bereft of life instantly. My grandparents dealt with this until they were bereft of their long lives.

Death is mysterious. There is no right time for a young person to go. No circumstance can justify their exit, and yet, more often than not, we need to accept it without having any answers. How they choose to go is equally mysterious, or whether there really is a choice. These are all esoteric questions. We have to survive these with an understanding that their purpose on earth has been fulfilled for this lifetime and that they have moved on to a different realm for a different reason. That unfolding, if it ever comes, will reveal itself to us only when we are ready.

These were my parting words to her parents as I hugged them.

One man’s recurrent pain taught a surgeon how even the best intentions may sometimes not be enough.

A 70-year-old man was escorted into my clinic with his daughter-in-law. Her lean frame was barely able to support his log-like stiffness. Any attempt to move led to lancinating pain shooting down his lower back and into his leg. “I’ve been in excruciating pain for 6 months. I’ve tried everything and nothing has worked. I’ve been told surgery is the only option, and I’ve come to you as you operated on a relative of mine who is now absolutely fine.”

I explained to him that owing to severe degeneration of his spine, one vertebral body had slipped over another, pinching the nerve badly. The surgical intention would be to put in an interbody cage and realign the spine, fixing it with some screws so that the bones didn’t move and there was no compression on the nerve, leaving him pain free. Not able to comprehend much of the medical jargon I was giving him, he finally said, “You do whatever you think is best for me.”

A few days later, we made two small incisions corresponding to his L45 disc space on either side of his spine and used a series of tubular dilators to position ourselves over the target area. We removed the hypertrophied bone and ligament compressing the nerve, removed the bulging disc, and impacted a nice cage packed with bone graft that snugly fit. “This feels really good,” I told my colleague, referring to the proprioceptive feedback I was getting as I gave one last knock with the hammer. We put in screws to complete the job, and the X-rays we took before we closed looked not only perfect but sublime: impeccable symmetry, incredible alignment. I must confess, I sometimes silently marvel at my own artistry. My colleagues would argue that more often than not, it is not silent.

He was discharged a few days later, feeling “as if my car has been fully serviced!” The family was extremely grateful that months of agony had been reversed in a few days. Until two weeks later, when I got a call from the daughter-in-law. “He can’t get out of bed, the pain in his leg is much worse than what it was even before surgery,” she said. Feeling glum but composing myself, I mentally ran through a checklist of possibilities that could be responsible for this. When patients recover from a surgery of this nature, the post-surgery pain gradually subsides over time, but in his case, he had been completely pain free and was now experiencing a fierce recurrence.

I got a plain X-ray done to see if the hardware was in place, and to my dismay, the cage had backed out into the spinal canal and was pressing on the nerve. Luckily, his motor function was not affected. I explained with empathy the need for a second operation, the intention of which was to reposition the cage. “Try and do something to avoid the operation,” he urged me nervously. “If you want, I’ll stay on bed rest, take some injections, but I don’t want another operation. I won’t be able to tolerate it with my age and diabetes.”

I explained to him in all honesty that I had done several hundreds of these cases, that this was the first time I’d seen this happen with one of my patients, and that according to me, this was the only solution. It was in his best interest to opt for a second surgery, and I would never intend for him to be anything but fully pain free. He joined his hands in front of my face and I held them in mine and pressed them against my chest – to tell him that he was going to be okay.

The next day, we opened up the incision and spotted the cage torturing the nerve. We removed it and put in a larger one to ensure an even snugger fit, reinforcing it with some more screws, knowing that this time we were foolproof. The next day saw him relieved and smiling that this was behind him.

Why do good intentions not always end in good outcomes, I thought. I had done what needed to be done even during the first surgery, and an outcome like this should not have happened. I could blame his bone strength and quality or the shape of the cage. I could condemn him for not following proper postoperative instructions and chide him for not taking care of his posture as I’d advised. I could fault his karma, my karma, and the hospital’s karma. I could bring in the universe, talk about the laws of attraction, and allege the misalignment of frequencies. But the bottom line was that this was my responsibility, even if it was not my fault. And sometimes, outcomes are not within your control, even if your intention was good– especially in medicine.

Three weeks later, an X-ray image popped up on my phone from an unknown number. It was the image of a backed-out cage that gave me a sense of déjà vu because it looked so similar. I assumed this to be someone else with the same problem who was seeking my opinion, but when I zoomed in on the name, it was my own patient. The cage had slipped a second time. I dug my palms deep into my eyes. Before I could dive deeper into my anguish, my phone rang. “He is in terrible pain once again, the same kind of pain he had the last time.”

“He will need another operation,” I said, gutted. The family said that there’s no way he would be willing for that. “This time we’ll just remove the cage,” I tried to rationalize, “and put in some bone graft.” I was pretty sure they were not able to understand why this was happening. I wasn’t sure myself, so how could I expect them to be? I suggested that they could go to someone else for the surgery if they wanted to, but it needed to be done, and urgently. I could sense a helpless reverberation at the other end. They came in the next day, we removed the cage, and he was pain free once again. I got the cage cleaned and sterilized and handed it over to him, telling him to put it in a place of pride at home once he was discharged. I’m a little concerned about how the future will unfold for him.

“Tamhari neeyat ekdum saaf che, nai toh I would never have had three operations,” he told me when he came for a follow up. “And I want some royalty for all the experience you have gained from me!” he laughed. “Happy Parsi New Year to you and your family,” he wished me, handing me over a big box of ‘Meher Pinto’ chocolates as he left my office.

This New Year let us at least start with the right intention; the outcome will be what it will be. Que Sera, Sera.