The surgical boundary

Representation Pic

There is some fleshy stuff coming out of his nose," Vicky's doctor called to say, backing it up with a very tentative,

"I think it's a tumour, but I'm not sure." Probably because no one would expect something so freaky, I thought.

"Send him over, I'll take a look," I said instantly, because almost nothing surprises me anymore. Vicky was 30. He came from an unheard-of town in Uttar Pradesh. He had some on-off bleeding from the nose, for which the village doctor kept prescribing medication until it started to get out of hand. "My nose is blocked," he told me, dabbing his scarlet handkerchief. "And the headache is driving me mad," he said in Hindi, breathing from his mouth. "His left eye seems to be bulging out more than normal too," his sister, sitting next to me, pointed out. I shone a torch into his nostril and saw that his nose was full of "stuff". He could not smell and had very poor vision in his left eye. I immediately shunted him off to the radiology department to image his entire head, and, like I said, I wasn't surprised.

There was an 8 cm ghoulish tumour occupying the nose; it had eroded the wall of the left orbit and gone into the eye. Like a rodent, it had corroded the base of the skull and got into the brain, opening up into both frontal lobes like an umbrella. It had no respect for boundaries.

The normal protective layers of the brain - the dura and the bone - had been breached by this monstrosity. "We'll have to remove this," I told the doctor who had sent him to us, confirming his diagnosis with, "You were right, it is tumour."

"Is this cancer?" his sister asked; it's the most common follow-up question. "We'll know for sure once we send it for testing, but it does look like it," I said to their disbelief. A few days later, my ENT colleague and I decided to excise this together, as the tumour had destroyed all boundaries of where the nose ends and brain begins. While she went from below, emptying the nose, I went from above, opening up the head simultaneously. While she gobbled up the tumour with a debrider, I meticulously separated it from the overlying frontal lobe and all the important arteries it was attached to and then removed it completely, until both our instruments shook hands with each other from inside the head.

There was a three cm hole from where I could see into the nose and she could see up into the brain. We spent the next hour repairing the defect from both, above and below to ensure that the brain fluid didn't leak out from the nose - a nightmare for both the patient and surgeon.

Over the next few days, Vicky made great progress. He could breathe comfortably from the nose after we removed his nasal pack, although he didn't regain his sense of smell; the tumour was a carcinoma arising from the nerves that control olfaction.

His vision had been restored and his eye regained its normal position. The postoperative scan showed a large black hole, the size of a cricket ball, instead of the previously seen white tumour. He was discharged a week later, having healed beautifully. I gave the family detailed instructions on after-care until they were to return to remove the stitches on the head.

And yet, once home, the relatives would call a few times every day. If he had a slight headache, I would get a call.

If the nose was a little dry, they'd buzz.

They checked with me daily on whether the medication they were administering was correct. They messaged pictures of secretions to ask if it was of significance. I thought to myself that not only had the tumour not respected any boundaries, even the relatives weren't. Thankfully, my patience keeps irritability away. When they returned a week later, the wound was dry and clean. "You can have a head bath now, and shampoo your head daily," I instructed and gave them a spray to keep the nose moist.

Doctors constantly discuss among themselves if they should share their personal number with patients. While most patients are discerning enough to use it sparingly, there are some who will call even if a pimple erupts on the forehead. My daughter doesn't want to become a doctor because her father gets too many phone calls. My wife is irritated because every time we're having a deep meaningful conversation, a patient calls to ask weeks after surgery if s/he can eat meat on Thursdays. I must, of course, answer every call, unknown number or not. Until I take the call, I don't know if someone is dying or just in the mood for a non-veg lunch.

A surgeon friend from the US, who was visiting me for a week to learn the nuances of endoscopic brain surgery, was aghast to see me talking to patients at odd hours of the day and night. He was stunned to see me reply to queries on WhatsApp. "In America, we don't give our number to patients. If there is an emergency, they come to the ER, or if it can wait, they take an appointment with the office and come in the next available slot. There must be a balance, or else patients will walk all over you," he told me.

"Don't you have boundaries?" he sternly questioned. I understood what he meant. As one of my favourite authors, Cheryl Strayed, says, "Boundaries teach people how to treat you and they teach you how to respect yourself."

"But Indians are emotional people," I explained. "We have to deal with the heart even if we are operating inside the head. They simply need to know that someone is there for them, that's all," I put my arm around his shoulder. "And plus, when you love what you do, your focus is never on boundaries, it's only on the sixer," I told him, hitting the ball out of the park.

The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals