The super highs and the extreme lows

A complicated eight-hour surgery to remove a spinal tumour against advice from colleagues in the OT, led me to the darkness of doubt. Before the sun came out again 

He cautiously walked into my clinic with his brother. Rajesh was just 27 years old and wondered why his legs kept ‘giving way’ while walking. “I’ve had four falls in the past one month,” he moaned, perplexed about why this was happening to him in the so-called ‘pink of his health’. I reminded him that he was over 100 kilos and should refrain from using such a ‘rosy’ description of his well-being.“My legs feel heavy and tight and I’ve stopped driving cause I sometimes have no control over the accelerator – my foot just does its own thing,” he lamented.

I made him lie down on the examining table to confirm my suspicion. I intertwined my hands behind his knees to check for spasticity. His legs were like logs – stiff and unwieldy. Then, when I bent the knee and pressed against the ball of his foot, the ankle went into a rhythmic jerky contraction that wouldn’t stop until I released the stretch. “This is what happens when you drive, right?” I demonstrated, and he acknowledged it. “It’s called clonus – Latin for turmoil,” I said clarifying his confusion. I completed the examination to note that he had lost a substantial sense of touch below the torso, and when I made him stand with his eyes closed, he instantly buckled and fell to the ground.

 

 

I pressed the MRI against the fluorescence of the viewing box to corroborate the diagnosis I had made in my head. And there it was. A four-inch sausage-shaped tumour inside his spinal cord, T2-T6. A sliver of normal spinal cord circumferentially wrapped the tumour, like the silver foil that encircles an Indian mithai roll. The surgical task was to eat the sweet completely while preserving the foil entirely. Any deviation from that goal could result in paraplegia, loss of bladder or bowel control, and sexual function. We endlessly discussed all the options open to him along with all their macabre outcomes. And then they left, probably more dazed than when they arrived.

I was told that the family, after comprehending the risks of surgery, had opted for alternative medicine, but Rajesh returned 3 weeks later with worsening gait and recurrent falls. My stance did not change. Surgery was the only option. He was admitted a few days later, but as I later understood, his family was still not ready for surgery. They opted for a discharge the same evening. I was a bit irritated, as extensive coordination and preparation is required for a surgery this intense, but at the same time, I was in some sense relieved that he would not be on my list of ‘complications’.

A week later, when he was finally admitted and in the operating room, we flipped him prone and made a one-foot incision down the middle of his back. This operation is performed with intra-operative electrophysiological neuro-monitoring of the leg muscles. If there is an undue stretch or distortion of spinal cord tissue during surgery, the physiologist fastidiously watching the computer informs us instantly and we subvert any potential harm by temporarily stopping the dissection or by moving to another area until the signals recover.

Here, however, they were unable to record any normal signal right from the start. We gave time for the muscle relaxant to wear off as we continued our exposure, cutting through bulky tissue and then sawing the bone to lift off ten spinal segments in one piece to fix back later. An hour later, the dura, which covered the spinal cord, was exposed. “Now try,” I said hoping for some response. Physiologists usually bellow since they always think they are providing extremely crucial feedback. Her silence made me turn around and look at her – she nodded her head sideways, to signal a no. They rechecked all their connections following the universal rule of hardware malfunction – almost everything works if you unplug it for a few minutes and plug it back. This didn’t.

I was left to make an epochal decision. Either proceed without signal feedback or re-attach his spine hinged at one end and close. I always involve my team in decision making even if subconsciously I already know what I’m going to do. “He’s 27, you can’t do this to him; he’ll be paraplegic for life,” said my compassionate anaesthetist, vetoing my plan to go ahead. “What if this is not a technical problem and he’s too spastic for the muscles to send normal signals? It’s going to be the same the second time around,” I tried to rationalize. “Or let’s wait for a few months till the tumour causes the paraplegia instead of you causing it today!’” the assistant interjected cheekily, clearly trying to wriggle his way out of a 12-hour operation if we decided to go ahead, something we’ve all done as ‘juniors.’

“Knife, please,” I announced, with my hand outstretched, and opened the dura exposing the ballooned spinal cord. All the fibres of the brain converge into this bundle, thick as the width of a thumb, to form the spinal cord, which was pushed to its edges by the tumour – much like a younger brother’s face tightly pressed against a wall by a bullying elder sibling. We zoomed the microscope for maximum magnification and incised the entire length of the spinal cord to identify the tumour. Painstakingly, we dissected tiny strands off it, buzzing the small arterial feeders supplying it. Over the next 8 hours,we laboriously isolated the entire tumour from the spinal cord and removed the ‘hot dog’ in a single piece – the silver foil seemingly intact. We closed in the normal fashion, restoring the anatomy laboriously, which we had defiled on the way in.

 

 

We flipped him over and the anaesthetist was quick to extubate him knowing we were all anxious to see if he moved his legs. And…he didn’t. Not even a flicker to deep pain. Even after he was fully awake a few hours later. This happens occasionally owing to the swelling of already compromised nervous tissue, but when there was no improvement even a week later, when it was time to be discharged, I had the realization that I’d made the worst decision of my life to proceed with surgery. As I saw him leave on a wheelchair (he had come in walking), I dug my palms deep into eyes, cursing myself for being so frivolous with someone’s future. I gave detailed instructions to the family on physiotherapy and other assistive devices.

 

 

These are moments when you question your craft. Your skill. Your ability to deliver in times of a complex crisis. You ask yourself if you are worthy of being in a position where someone’s life is in your hands. “It takes hundreds of good golf shots to gain confidence, but only one bad one to lose it,” said the golfing legend Jack Nicklaus. I was devastated. People assume that doctors are inured to complications and often annealed by them. I was heartbroken. I lost my sleep, hair, and appetite. Ars longa, vita brevis: “The art of medicine is long,” Hippocrates tells us, “and life is short; opportunity fleeting; the experiment perilous; judgment flawed.”

I operated on easy cases the next few days before venturing again into dangerous territory. I thought of Rajesh everyday and spoke to the family patiently every time they needed advice, tracking his seemingly imperceptible progress. A book by Cheryl Strayed was lying on my desk; I flipped to a random page and read a random line “Most things will be okay eventually, but not everything. Sometimes you’ll put up a good fight and lose. Sometimes you’ll hold on really hard and realise that there is no choice but to let go. Acceptance is a small quiet room.”

 

 

Six months later, on a sunny Tuesday evening, I got a video on my phone from an unknown number. It was of a man running and then climbing 22 stories. After the initial 30 seconds, I scrolled to the end. It was Rajesh. He had taken his own time to recover. Alone in my consulting room, I stood up, clenched my teeth, and pumped my fist in the air six times. I had hit a Roger Federer backhand winner, realizing its brilliance about half a year later.

Every ‘cord’ clearly has a silver lining.

 

 

 

27 Comments on “The super highs and the extreme lows
  • Cashmira S says:

    Dr Mazda you were God sent to Rajesh. You have the ability to change a humans life . . . as I said before . . . a true gift to mankind.

    Reply
  • Neepa V says:

    Well written…and excellent surgery done…
    Kudos to you….
    Keep doing the good work mazda…

    Reply
  • Mahashweta Biswas says:

    What an innumerating experience. Whilst reading too I was getting anxious by the min, I can imagine what you & your team were going thru during the surgery. But as they say All’s well that ends well. You did your best, & it showed results

    Super Mazda 👍👌

    Reply
  • Dr V Z Belani says:

    Dr Turel, I empathize with you for the periodbof uncertainty intra- and post- operatives and also appreciate being so candid about your inner feelings in social media. At the end, today, I admire you more than yesterday, everytime I read about your achievements. Well done. Keep it up…best wishes. Dr Belani

    Reply
  • Clera Menezes says:

    Beautifully narrated a live experience of an Surgeon.
    As usual you are a super Heroe in your surgery and as a surgeon , You are simply great in your kindness and respect for other team members.God bless your good work and sincere care and consern for your patients .

    Reply
  • Priyadarshan Pradhan says:

    Congratulations doctor Saheb. How are you able to stand and do surgery for 8 hours at a time?

    Reply
  • Farhad says:

    Super Doc…..

    Reply
  • Rita singh says:

    Wonderful ur a wizard of surgery is all I can say.Hands n brain seem to b designed when God was really free from all his engagements.Go ahead with ur blessed service.

    Reply
  • Dr. Feroza Unwala says:

    What can I say? I cried, first at your dejection and disappointment and then with joy at the outcome!
    Written from the heart, with head and hands in the right place!
    Well done as always.

    Reply
  • Asit Ray says:

    Dr Mazda !
    I’m not competent to congratulate you for what you have to Rajesh coz I do not congratulate God for whatever he has done or given us.I can only admire and wonder ! You are the closest definition of Godliness .
    I’m happy now I know you !

    Reply
  • Asit Ray says:

    Dr Mazda !
    I’m not competent to congratulate you for what you have done to Rajesh coz I do not congratulate God for whatever he has done or given us.I can only admire and wonder ! You are the closest definition of Godliness .
    I’m happy now I know you !

    Reply
  • Kainaz Turel says:

    I think the ability to keep connected with all ur patients despite the hits and seemingly immediate misses sets u apart from the rest Dr. Mazda ! Super proud of u for being the compassionate, humorous yet focused par excellence doctor that u are !

    Reply
  • Megan Correa says:

    Congrats Dr Turel on a brilliant backhand a la Roger Federer . What relief you must have felt.

    Reply
  • Zubin Bhesadia says:

    Dear Mazda,

    Another brilliant chapter written by you in your experiential diary of surgical cases. And, I’m sure that its the ending that would be most prized by you in this memoir.

    To err is human – but that which affects someone who has trusted you & has come to you with confidence that you will create that beark-through miracle through your skill, informed decisions & medicology & then at the end of a long, pains-taking & high-effort journey during which you have taken a crucial call, such an adverse result ambushes you at the end, is surely going to take a toll.

    It is during these trying times that one ponders upon decisions taken & may cast a doubt on one’s skill & confidence may take a hit. During such distraught times, however experienced one is, one fails to factor-in the element of “time”. The body after any major surgery or injury requires its own time to heal…no fixed healing period which is a one-fit for all. But then, we being humans, focus on what the result beholds in front of our eyes & completely skip out on the recovery opportunities that the healing period could bring about!!!

    The miracles witnessed in the history of medicology are innumerable…some take days & weeks, some take months & some even years. And that my dear, are the ones nobody can predict or measure through any instruments known to mankind. I’m sure that’s why even the most experienced doctors across the globe would say – We’ve done our best…the rest is upto God & the healing period.

    Nonetheless, your well-timed decision, skill & confidence brought out the desired results albeit the initial set-back & I can say this hand on my heart, that you & your team made a successful recovery, brought joy & blossomed the life of a young man & his family. Kudos…take a bow!!!

    More power to you & your team. Keep making lives pain-free & full of glee. Best wishes.

    Reply
  • Lois Juma says:

    Another beautiful peace. Your honesty is commendable. Thank God for wisdom to take the right decision. Keep on the good work 👍🏽

    Reply
  • Anjali says:

    Nice read and even nicer job…kudos…keep up the Fab work…both writing and clinical practice 👍🎉🎊

    Reply
  • Arun Pushkarna says:

    Words cannot describe the roller coaster ride my feelings experienced just reading this article. I can only imagine what it feels like to you. The only thing I feel like doing right now is hugging you and holding you close because that’s probably the closest I’ll get to divinity!
    May God bless you Dr. Mazda Turel. You don’t just provide physical succour to patients, you provide warmth and genuine compassion to those who need it most.
    Truly this noble profession is privileged that you are it’s flag bearer!

    Reply
  • Supriya says:

    Brilliant. Brilliant. Brilliant.

    Reply
  • Supriya says:

    Glad we saw the before and after…what a cool video…amazing to feel so close to the patient and the hero of this piece…the other being you of course!! Great job Mazda!!

    Reply
  • Avinash Karnik says:

    Superbly described keeping the suspense till the end. You seem to be a doctor with a heart of gold besides great skill at opening and closing not only the incision but the cases with success thereby giving the patients healthy lives for rest of their lives. Keep up the good work and all the very best for future in the OTs.

    Reply
  • Altaf says:

    Breathtakingly beautiful.. written as laboriously as the surgery performed. You’re a master craftsman with both the pen and the scalpel!

    Reply
  • Dr Shivkumar V Dalvi, Cons.Surgeon says:

    I congratulate u on the successful outcome of this very complex, dangerous case.When it is only u vs all others n particularly there is tendency not to spoil ur reputation by playing safe the outcome certainly vindicates ur judgment.All important claims have been documented with Rajesh running clip being icing on the cake.The period till his final recovery must be a tremendous stress for u.Good u stood it well.Wishing u many such successes in future!

    Reply
  • Yasmin Ghaswala says:

    Next time I see you. Please prevent me from giving you a hug. At the moment a virtual one will have to do. Mr. Neurodynamic. More for your prose, than your brilliant engineering. That was pre-ordained.

    Reply
  • Dara mehta says:

    When the hand of God aided by the brilliant knowledgeably effective hand of Dr. Mazda, the results are never negative !
    God bless you !

    Reply
  • Dr. Siddharth Kharkar says:

    Nice job Mazda! As always, your hands and heart were in the right place.

    Reply
  • A Kumarswamy says:

    You are a rockstar as I said before. God bless.

    Reply
  • A Kumarswamy says:

    You are a rockstar . God bless.

    Reply

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