An Indian doctor in China learns a universal language
A training in the technique of bypass surgery of the brain became a lesson in the unity behind suffering and healing
I like China. In 2016 BC (Before Corona), I was in Shanghai to learn the technique of bypass surgery of the brain. Healthcare in China is centralised in the form of large hospitals; they don't have nursing homes and private hospitals as we do here. Each hospital has a few thousand beds and centres of excellence for each specialty. Depending on your diagnosis, you will be directed to the most competent team in the field. These centres are nearly always fully occupied, despite the fact that most of life's problems can be dealt with using acupuncture and acupressure; cubbyholes offering them lining nearly every street in the country.
In India, most neurosurgeons operate on the brain and spine. In Europe, those who operate on the brain seldom venture into problems of the spine. In the academic institutes of America, surgeons who remove brain tumours generally refrain from doing vascular brain surgery, and the set of people doing functional brain surgery is entirely different.
In China, if you are a brain tumour surgeon, you will operate in only one compartment of the brain on only one particular kind of tumour all your life (thankfully, they haven't yet decided to specialise based on the right or left side of the brain). This allows for super-specialisation, making a surgeon really, really good at what s/he has been trained to do; it's the simple adage of practise makes perfect. To put things into perspective, here's a stat: a leading vascular neurosurgeon in the US I know has done around 1,000 bypass surgeries in his career spanning three decades. The surgeon I trained with in Shanghai does close to this number annually.
As part of my training, I saw several patients in a speciality moyamoya (vascular disease) outpatient clinic. Due to the language barrier, I didn't understand the intricacies of their symptoms but with intermittent English explanations, some hand gestures, and prior knowledge of this condition, I learned that all these patients had recurring strokes in the brain. The paralysis is often transient, but occasionally long-lasting. There is a high prevalence of the condition in the South-East Asian population, where the main carotid arteries supplying blood to the brain undergo a narrowing owing to several genetic and environmental factors. In order to fuel the deficient blood supply, other collateral vessels hypertrophy (grow larger in size), and the appearance of these new formed arterial branches on an angiogram of the brain looks like a puff of smoke—translated in Japanese to moyamoya. Incidentally, East India also has a sizable population with this condition.
Surgical revascularisation is the mainstay of treatment for patients with moyamoya. Surgery often involves isolating a thick vessel supplying the scalp (the superficial temporal artery) and connecting it to one of the main arteries of the brain (the middle cerebral artery), each of which measures around 2-3 mm in diametre. It's essentially plumbing, but under a microscope on a pulsating brain using a suture that is not visible to the naked eye. Once we identify the recipient vessel, we place two clips on it to transiently stop the blood flow and then nick it, making a small oval to suture the mouth of the donor artery into the opening, end to side. It takes 12 stitches around the circumference, akin to the time on the face of a clock, to connect the two vessels and seal the anastomosis, a process that requires sharp skills, soft hands, and profound precision.
The surgeon's breathing has to be synchronised with every stitch, because an extra heave can tear the vessel. The timing of the words that come out of your mouth have to be calculated and tailored. The nurses breathe in sync with you, literally and metaphorically. They absorb gestures and place instruments in your hand without you having to ask for them or turn your scrutiny away from the magnification of the microscope. The revelation of technical success is bestowed upon you instantly when you release the clips and no blood oozes through the suture line… and then you can take your first deep breath. We further confirm the patency (the condition of being open or unobstructed) by injecting dyes and ultrasonically probing the artery to hear the gratifying woosh-woosh sound it makes when pulsating pleasurably.
We handled around three such cases every day and I learnt this technique efficiently. Scores of patients came to the clinic daily. I still didn't speak the language, but they gradually seemed to become my people. I saw their anguish; I felt their pain, their devastation at suddenly not being able to move parts of their body, an act we take for granted.
Diseases have a tendency to lacerate families and pulverise dreams. Boundaries of race, religion, sex, and culture blur when dealing with serious illness or even death. The current pandemic has made these revelations clear without contention: it has massacred the marrow of every human being, and pictures of misery from Europe, Asia, and America speak the same language. Like suffering, healing too has no language, and doctors across the globe are united in their battle against the same enemy for months. It has you realise what's important in life—health, kindness, love—and that race and religion are perhaps just puffs of smoke.
The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals. You can reach him at firstname.lastname@example.org
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