Nothing hurts as much as a patient delaying, denying and deflecting the imminent
Rahul was a biker dude who limped his way into my office one day. He wore a French beard and a tight-fitting Harley Davidson T-shirt. An interlocking brass chain around his neck and steely skull-shaped rings on his fingers sealed the look. He had formidable forearms, but they were wrapped around his puny sister, who helped him into a chair. His robust face wrinkled with pain. “I have very severe back and right leg pain,” he mourned, running his palm along the back of his thigh and calf to show me how it travelled. “I can barely stand, sit, or walk,” he continued. “It’s been going on for over a month and I initially took bed rest for a week but there was no relief. Then, another doctor asked me to start physiotherapy, which didn’t help either, and another gave me an epidural injection, but it’s only getting worse. I saw two other surgeons and they’ve suggested surgery, but I don’t want to have spine surgery because of all the horrible things people say about it. Someone told me I’d get paralyzed, someone else said my pain would only get worse,” he prattled on.
I sat there listening patiently to ‘his story’. That is why this is called taking ‘history’. “I’ve also been feeling numb in my balls since the past 2 days,” he suddenly said, unfiltered. That made me sit up a little. I asked him if he had faced any difficulty in passing urine, to which he shook his head sideways. I had him hobble over to the examining bed to check his motor function, which was good, but he said he was numb all over the back of his leg and around his buttock and groin – a term we call ‘saddle’ anaesthesia. Imagine riding a horse (or in his case, a Royal Enfield). The part of his body that made contact with the saddle or the seat was numb. It was an ominous sign. His sister removed the MRI films that I plugged into the viewing box only to find a very large disc prolapse pressing on the nerves that go down into the leg and also subserve bowel, bladder, and sexual function. I put my fingers briefly on my forehead, much like a doctor in a Hindi movie about to declare bad news.
“You need surgery without a doubt,” I asserted. He asked if he could wait some more before deciding and I shook my head firmly. “I think you should get admitted today and that we should operate on you at the earliest,” I replied, which is something that I say only a couple of times a year. He laughed a little; perhaps he thought I was joking. I wasn’t. Most patients with sizable disc herniations and even severe pain can safely be managed without surgery and recover completely, but when there is a motor weakness or sensory impairment of this nature, immediate action is warranted. If the pressure exerts beyond a critical point where the nerve gets irreversibly damaged, recovery of function is not guaranteed.
Unfortunately, many patients are of the opinion that when doctors suggest immediate or urgent admission, they are out to fleece them or deter them from taking a second opinion. “I’m going to have to discuss this at home and then get back to you in a couple of days,” he concluded, clearly keen on finding other avenues to avoid surgery. I accepted his decision and reminded him of any warning signs to look out. I don’t like to frighten patients, but this is important when they haven’t understood the gravity of your advice.
“Surgery is a big deal for anyone; you can’t just except for someone to instantly agree to going under the knife,” a friend retorted when I told him Rahul’s story. “It’s much easier for them to accept the notion of surgery when it’s an issue with the brain, such as a head injury or stroke and it’s a question of life and death,” he reasoned. “But isn’t leg function equally important? Or bladder function, or erectile function?” I questioned, continuing, “Which 40-year-old would be willing to risk not having sex for the rest of their lives?” “Maybe you didn’t scare him enough!” my friend said and we laughed about it, and the next day I completely forgot about Rahul, although subconsciously he lingered.
Three days later, it was 11 PM on a Saturday evening. I was out dancing at a friend’s wedding and my phone rang. “I’m Rahul’s sister,” she quickly introduced herself. I walked out of the room that was playing my favourite retro music just then at full volume to be able to have a conversation. “He’s been unable to pass urine for the last few hours,” she said in panic. “His bladder is full but urine is not coming out,” she explained, “and he can move his legs but can’t feel the ground he’s standing on!” she said, somewhat ambiguously. “Something is happening to him, but we are unable to figure out what!”
I knew exactly what was wrong. The disc had further compromised his nerves, exactly what I had been worried about, as I reminded her. “Get him to the ER now. We’ll have to operate on him urgently or he’ll be bedridden for life,” I said, oscillating between anger and concern. “Can we try and see if he passes urine through the night and then come tomorrow morning if he doesn’t?” she asked. I felt like smacking her with a gong on her head but instead hung up in frustration, uttering a few profanities as I did so. She must have heard them because 5 minutes later, she sent me a message saying they were arranging for an ambulance to pick him up. I informed the hospital to keep everything ready and they arrived at the ER at 3 AM. On examining him, we realised that his bladder had reached his nipples. The ER doctor stuck in a catheter and drained 2 litres of urine, indicating that his bladder had distended way beyond its physiological capacity, which had certainly damaged its walls.
Once we did the needed investigations, we took him to the OR and flipped him on his back after the anesthesiologist put him to sleep – something that we should also have been doing at 5 AM, but we were dealing with one man’s nitwittery instead. “Why are you getting so irritated with him?” my colleague asked as we painted and draped him in the usual fashion. “Because a perfectly healthy 40-year-old may have to live his life on a catheter when it was completely avoidable,” I countered, making a tiny incision into his skin and docking a 20 mm tube onto the bone through which we would operate. We drilled a bit of the bone and found the extruded fragment of the disc waiting to be pulled out. It was like a chunk of macerated flesh, and once I removed the disc fragment, the swollen and inflamed nerve which was stretched to its limit once again came back into position. “You know what Albert Einstein said once?” I asked my colleague as we closed. “What?” he said, exhausted from a night of being awake. “Two things are infinite: the universe and human stupidity.” There was a silence at the other end. “And he wasn’t sure of the former,” I finished, taking the last stitch and then removing my gloves with a flourish, much like Dr. Derek “McDreamy” Shepard does in Grey’s Anatomy.
Rahul was pain-free a few hours after surgery. He walked again with the panache of a biker dude. Days later, we removed his catheter after a trial of clamping it and he was able to pass urine normally. He must have accrued some karma from a previous life, I reckoned. Three months later, he came back smiling because his numbness had also been resolved.
When he walked into my office, my desk was strewn with the paraphernalia of a science experiment; I was in the midst of a discussion with a college student who had come to get insights from me on a brilliant idea he had. Intrigued by the mess, Rahul asked what I was working on. Not having forgotten his behaviour, I gave him a bright, cheeky smile and said, “A possible vaccine for stupidity!”
