The Perfect Storm

Often we end up striving for perfection where excellence will do. Neurosurgeons learn this eventually on the operating table.

We were operating on a ruptured intracranial aneurysm in the middle of the night. In such an operation, the intention is to place a clip on a 9 mm aneurysm, which, in effect, secures it from re-bleeding. While doing so, one has to ensure that the parent vessel from which the aneurysm arises is not compromised. To witness the astounding anatomy of the brain under a microscope at anytime of the day is special, but at 1 AM, there is something rivetingly enchanting about it. The obstreperous buzz of the operating room is doused at night. There are fewer people. Exits and entrances are less dramatic. You talk softer, you communicate less, and you can even hear your assistant breathe.

We neatly dissected silvery strands off the blood vessel and identified our target. I took a slightly curved titanium clip, and in a gentle, nimble move, opened its fangs and placed it gingerly along the entire length of the neck. This is the operation. That’s it. We were done. I then carefully inspected the anatomy with an endoscope to get a 360-degree view, to ensure there was no remnant hiding opaquely out of sight. Unfortunately, about 2 mm of the neck still lay unclipped.

“We have to advance the clip a little,” I decreed. “Leave it, sir, it’ll thrombose eventually ,”proposed my assistant, who usually believes in my sagacity more than I do. After all, everyone desires a good night’s sleep. When I was a resident in training, I remember coaxing my boss that the operation was “superbly performed” so that he would leave and allow me to close quickly, such that I could catch a few winks of much-needed slumber before the brightness of the next day loomed over us.

“Neurosurgery is a precision sport. It demands exactness,” I lectured now, succinctly, at 2 AM, as I advanced the clip to be perfect. As I withdrew my hand, the clip applicator failed to disengage from the clip and I ripped the parent artery in the bargain. In 3 seconds, the brain was full of blood. From cruising on an empty highway, we were suddenly in the middle of a massive pile-up. Alarms jarred, the ECG on the monitor convulsed, and we got in an extra suction to clear the blood and another nurse to scrub.

William Halstead once said, ‘the only weapon an unconscious patient has against an incompetent surgeon is haemorrhage.’ But we had a capable team.

After a few minutes of the catastrophe, I was able to locate the bleeding point and stop it by suturing the wall, but I had narrowed its calibre in the bargain. We had to perform a rescue bypass to augment the flow to the normal brain to ensure that he didn’t have a stroke later. I finally removed my gloves at 7 AM, when just a few hours earlier, I had visualised myself lying peacefully in bed long before then.

After every single surgery, no matter the time and how effortless or torturous it may have been, I sit in solitude for a few minutes to carry out an in-depth analysis in my mind of every step of the operation from opening to closure. I close my eyes and play out every move, lingering over the manoeuvres that are more frangible. If there is a complication, I always debate between having pushed the envelope too much and erring on the side of safety. As surgeons, we strive for this perplexing balance every day. In this case, did I do what was best for this patient in my hands? Was it really necessary to adjust the clip, or in the wise words of John Lennon, should I simply have “let it be”? If the applicator hadn’t gotten stuck to the clip, we would have been done in a few extra seconds, but it did and it ruined our night. Luckily, the patient recovered swiftly and was discharged after a slightly prolonged hospital stay.

A few months later, we were removing a tumour from the insula, a small region of the brain buried between the frontal and temporal lobes. The deepest portion of the tumour was abutting the area that controls the movement of the left arm and leg. After having removed most of it, we kept resecting the tumour at the depth guided by the neuro-monitoring signals that alert us if we are causing any potential harm. My intuition signalled me to stop but the normal signal feedback we got was cushioning my gut. The more of the tumour that you remove, the better is patient survival, and so we removed it to the extent dictated. But the patient woke up paralysed on the left side. In those moments of solitude after every surgery, cloistered in the confines of an operating room corner, you sometimes need to ask for forgiveness (from the patient and their family) and hope that what makes your heart ache now will ache a little less later. However, as one of my favourite writers Cheryl Strayed says, “Forgiveness doesn’t sit there like a pretty boy in a bar. Forgiveness is the old fat guy you have to haul up a hill.” And every surgeon has a mountain to climb after every major error, no matter how inadvertent.

Not long ago, I was operating on a patient with a large lumbar disc herniation, a facile surgery done by me a few times a week. I decompressed the root diligently, but as the disc was calcified and causing compression on the other side, I tried to decompress it a little more so that he wouldn’t face problems in the future with the opposite leg. In the process, it led to a rent in the dural tube from which spinal fluid leaked out and nerve roots started popping out like spaghetti in a clear soup. We spent the rest of the day repairing the rent. The patient healed well but I ended up ageing quite a bit.

Too often, we strive for perfection where excellence will do. Most neurosurgeons obsess about the nitty-gritty’s of everything. The way we do one thing is the way we do everything. While this may seem great on the surface, it has the potential to harm at the depth. With this attitude, it is possible that we might hurt our patients, do a disservice to our personal relationships, and battle with our own peace. Over the years, therefore, I’ve come to soften my stance on perfection by transforming it as Maya Angelou suggests: “Do the best you can until you know better. Then when you know better, do better.”

 

 

29 Comments on “The Perfect Storm
  • Ved Prakash Maurya says:

    It is a great article and the same incident has happened with me. I was operati

    Reply
  • Jyoti Girish Raut says:

    Excellent true life experience. Thank you for sharing.

    Reply
  • Priyadarshan Pradhan says:

    You have tremendous patience doctor saheb

    Reply
  • Avinash Karnik says:

    Dear Dr. Mazda,
    You have superbly told us the difference between a perfection and excellence from the perspective of a neurosurgeon. And the end is just too good.

    Reply
  • Gaurav kesri says:

    I read this as I am about to operate on a Dural avf. And I’m thinking that just how much is mentioned in the blog is true. Almost everything, I concur. Neurosurgery is not a surgical speciality, it’s a life skill. And it entails a lot of sacrifice. Well written Dr Turel.

    Reply
  • Sumit Singh says:

    Do your best Doctor.

    Reply
  • Debashree Turel says:

    🤍🤍

    Reply
  • Gloria Msampha says:

    Well written as usual. It’s nice when a patient recovers and goes home in a better shape after surgery. Keep up the good work.

    Reply
  • T George Koshy says:

    Mazda..a very honest piece of writing where u talk about your successes as well as your errors..loved the analogy “spaghetti in a clear soup”..”forgiveness is the old fat manU have to haul up a hill”..”what makes ur heart ache now will hurt a little less later “..”battle with our own peace “..your descriptions of surgeries are so good it’s almost like us being in the OT with u and witnessing each move..NEVER STOP WRITING Mazda and thanks so much for sharing that with me every Sunday morning..

    Reply
  • Dr Sandeep Iratwar says:

    Too good Mazda, you did hit the nail on Neurosurgeon’s head

    Reply
  • S.Sankhla says:

    Brilliant piece of write up. A very important message. Thanks, Mazda.

    Reply
  • Deepak Dinkar Vadujkar says:

    Neurosurgery in itself is a difficult task always, you are doing it successfully every time,hatsoff to you & salute to your patience & tireless work.

    Reply
  • Vineeta Rao says:

    Wonderful writing as always doctor!
    As long as the intention was to improve outcomes rather than perfect , forgiveness is natural.

    Reply
  • Rita Singhr says:

    Very interesting doctor.Ur surgery descriptions are so interesting its like reading a story u do not want to end.keep writing and sending to us.

    Reply
  • Rita Singh says:

    Ur surgery write ups r like reading a story u don’t want to end.Keep writing and. posting to us.

    Reply
  • Natwar Panchal says:

    Really great experiences..

    Reply
  • Anjali Patki says:

    Beautiful narrative. So true..your observations on difference between excellence and perfection…an intelligent perspective…great work Dr Mazda

    Reply
  • Chandrashekhar says:

    Well written Mazda. Perfection may be the enemy of excellence but ” dil maange more” applies to scientific pursuits as well. And art of surgery vs. Science of surgery is still a battle

    Reply
  • Dr kautuki Mistry says:

    Sir you are excellent.i learn a lot from your article.thx sir

    Reply
  • Muhammad Ahmad Salisu says:

    Edwin C. Bliss is a broadcaster and an internationally recognised expert on time management who lectures extensively and works as a business consultant. He is the author of GETTING THINGS DONE. Regarding the discuss- Perfection vs. Excellence, he maintained thus:
    “The pursuit of Excellence is gratifying and healthy. (However), the pursuit of Perfection is frustrating, neurotic and terrible waste of time”

    Michael J. Fox stressed further that ” He was careful not to confuse Excellence with Perfection. Excellence, he could reach for. (But) Perfection, is God’s business. ”

    Simply put, Dr Mazda has put the round peg in the the round hole. Perfection is therefore, not attainable but, if we chase perfection, we can catch Excellence👍🏽🌷

    Reply
  • Zubin Bhesadia says:

    Dear Mazda,

    Truly a mini-archive of some real-time experiences expressed in a well-articulated manner.

    We’ve surely heard of the book – “In Pursuit of Happiness”…but if one were to be authored by you on the experiences you’ve had a tryst with in Neurosciences, I’m sure that book would be titled – “OT Chronicles – the Quest for the Best”.

    Its easy to use the word ‘Excellence’ in a speech or the fly-by-wire lingo. But, what happens when the rubber meets the road?? Talking the talk & walking the walk are two different things. And believe you me…many talk but few do the walk.

    In your narrations via blogs & print articles that you regularly publish, a couple of learnings come out very sharply, viz.:

    1. Excellence is a journey…not a destination.

    2. Your experience in radical changes is what defines you…& not the constant.

    3. Understand the pain & frustration of the one suffering, just as it were yours; as you are a human…not a robot.

    4. When you operate, be a like sniper…be accurate, use pin-point precision & take the shot, irrespective of the distractions.

    5. Introspect, simulate, play the Lord’s & the Devil’s Advocate & then prepare for Judgement Day.

    6. We all fall sometime or the other…but its how we rise & how soon we rise that is more important…and Luck at times goes with Labour…but then at times, doesn’t favour Labour…so you need not blame Labour when Luck downplays it at some point in time.

    7. Reflect on your past glory…for that is the fuel to your Happy Hormones reactor…& if you are happy, you can do almost anything.

    8. Many factors define Excellence…the first being your own self-confidence & the confidence in your crew.

    9. If your mind tells you to stop at a point but your heart tells you to go further, re-check, re-calculate, introspect & push forward to a resolution…its but obvious, follow the heart…coz that’s your conscience having a deep conversation with you.

    10. Achieve that Happy Smile…its not only a patient that suffers, but the family with him/her is a part of that experience day in & day out…be the sunshine, even though there may be damn moments for a while…but it does not always rain in the plain.

    The quest for Excellence will always remain a quest…there is no destination whatsoever…for Excellence itself seeks more. Its just like the Black Hole…but the earthly journey is more gratifying as opposed to the lonely one in outer-space.

    More power to you & your team. God speed!

    Reply
  • J says:

    Excellent write up.. can correlate. Keep up the good work Doc. Would love to read more

    Reply
  • Herois Kambata says:

    Doctor, if you ever retire from surgery, you will have an equally excellent career in writing. As for your above article, we pursue excellence, we do our best, and leave the rest to God and Nature.

    Reply
  • Mathew Chandy says:

    Well written Mazda .We are proud of you being forthright .Excellence is indeed enough but will the degree of excellence wane with ‘wisdom’??

    Reply
  • Di says:

    Perfection and excellence… well explained using ur experience as a neurosurgeon… always interesting to read about ur surgeries: ur thoughts, emotions, errors, successes and what u learn from it… liked both quotes by cheryl and maya Angelou in the article 🙂

    Reply
  • Rustam says:

    Dr. Mazda You are a brilliant surgeon. I enjoy reading all of your articles and reading about your experiences. When somebody is as dedicated to their craft as you are then their devotion and absolute resolve to succeed is absolute. I wish you the very best always.

    Reply
  • Rekha Murty says:

    You are an amazingly honest and a humble being.
    The Gita is in your pulse. I doff my hat ( easy to do, since I don’t wear one:)! Jokes aside….. you are admirable!

    Reply
  • Vrushali Telang says:

    This read like a beautiful short story brought to life with vivid description. You transported me into the OT .It was as if I was there with you and your team in the darkest hour of the night. Peppered with quotes and brilliant metaphors like ‘nerve roots started popping like spaghetti in clear soup’ – this makes for one brilliant read.

    Reply
  • Dr Shivkumar V Dalvi says:

    Excellent n brilliant expressions of the human side of a sincere n expert neurosurgeon.The freshness n honest writeups are a treat.creating atmosphere is just too good.

    Reply

Leave a reply

Your email address will not be published. Required fields are marked *