To take on a case where death or paralysis is a given, and life, a freak chance, takes confidence in expertise. But also, YouTubing, Whatsapping and faith in music
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No one in the entire continent is willing to operate on him," said Jonathan, on arriving from Africa with his younger brother Jude. I glanced at the MRI films and wasn't surprised. "Gosh," I thought, projecting composed confidence, as the two waited to hear the next words from me.
Jude was a 16-year-old pleasant kid. He had started having headaches a few years ago but had got a brain MRI done only recently, when he began to lose vision. The MRI showed a colossal 10 cm tumour within the ventricles of his brain, occupying 80 per cent of it.
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Ventricles are cave-like cavities filled with cerebrospinal fluid that give buoyancy to the brain. They are the reason why you can carry 1.5 kg of it without feeling the weight, even if you are pig-headed. An obstruction in this normal pathway of fluid by a tumour within the ventricle results in raised intracranial pressure, which manifests as headache, vomiting, and problems with vision.
"This is a very complex and high-risk operation," I explained, after examining Jude and noticing that his right arm and leg were slowly losing mobility. There was a greater-than-usual chance of complications since the tumour was in a precarious location, straddling the centres of consciousness. It was enormous in size, and had voluminous vascularity. We went on to discuss the chances of death, paralysis, and even a vegetative state—all the possibilities that could arise despite the best of doctors taking on the case. "Whatever happens, don't let him die," Jonathan said quietly, pressing my forearm. I wanted to say, we won't but stuck to, "We'll do our best." I left the hospital that day with the image of that beast of a tumour in my head.
For the next two days, I studied Jude's scans from all angles, reading up about his specific kind of tumour, and watching surgical videos. It might be scary for a patient to learn that the surgeon YouTubed the technicalities of the operation the night before surgery, but if one sticks to credible sources, I find this mode of research extremely useful and one that offers clarity.
I also WhatsApped the scans to my seniors to check what approach they'd take. I received replies accompanied by the eye roll emoji, most likely at the monstrosity of the tumour.
The next morning, I was inside Jude's brain. The snowy spotless walls of the ventricle soon disappeared from sight as we saw the tumour rearing its ugly head in the form of a red ball of fire. Some tumours allow you to go around them but this one, we had to get into. From the moment we touched it, it started bleeding. The magnification of the microscope makes trickles of blood seem like roaring rivers. What seemed like a calm start instantly turned into a battlefield; it was like watching an episode of Man vs. Wild. The tumour had pearly lobules, and each of them, burst despite delicate handling, flooding the field of vision.
"Get another suction in here," I ordered to improve visibility. The nurses scrambled, sensing the tension building up. The monitors started beeping, suggesting a drop in blood pressure. The anaesthesiologists muttered in a whisper among themselves on how to tackle the situation. They ordered more blood and administered medication to keep the blood pressure stable.
Just when we thought we were in control, another tumour lobule exploded. The blood pressure shot up this time owing to an autonomic dysfunction. "Control the damn BP!" I barked.
Mature anaesthesiologists never shout back at the surgeon, knowing well the duress s/he is in. They also don't make it known if there is a problem at their end, even when things are out of control, unless they need us to stop. They efficiently go about pressing buttons, turning down the volume of alarms, connecting bottles of blood, and injecting drugs, like clockwork. The communication with the surgeon is constant, brief, and firm. Unfortunately, they don't get enough credit for their competence. Often, lives are saved by them, not us.
A famous surgeon once said, there are four degrees of intraoperative haemorrhage. One: "Why did I get involved with this operation?" Two: "Why did I become a surgeon?" Three: "Why did I study to become a doctor?" Four: "Why was I born?"
In this case, I surged directly from stage one to four.
The only way to control the bleeding from an aggressively vascular tumour is to remove it completely and briskly. This took around six hours and six units of blood. I think I also aged six years in that time.
Once we had removed it, the ventricles finally reappeared in all their glory and the cerebrospinal fluid flowed uninterrupted like an immaculate waterfall. The brain was soft and pulsating tenderly as we closed.
Jude woke up the next morning as we got him off the ventilator. He was paralyzed on the right side but movement improved dramatically over the next few days. By the end of the week, he was prancing, not realising we had almost lost him. His chirpy disposition helped him recover faster.
"Surgery is not an art, it's a personality disorder; that's why we do what we do repeatedly!" I told his brother, quoting a line I had once read.
"How did you pull off such a miracle, doc!" he asked, hugging me.
"We had the Beatles playing in the background," I said.
And we made the lyrics come true: Hey Jude, don't make it bad / Take a sad song and make it better...
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 mazda.turel@mid-day.com
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