Because, the first hole is most magnificent

September 13 2007 2 AM NeuroICU Department of Neurological Sciences Christian Medical College Vellore It was the second month of my residency programme in neurosurgery and I was struggling to stay afloat after being thrown into the deep end I had barely returned to my hostel after 24 hours of rigour and the fleeting joy of changing into airy boxers was robbed by a phone callGo ahead and put two burr holes into his head drain the blood clot for Muthu the chief resident ordered Call me if you face any difficulty Santhosh will help you He has done plenty of themThis signalled his exit to Chaikada a holeinthewall stall across the entrance of the hospital that served a delicious combination of tea and cigarettes keeping resident doctors awake for 36 hours at a stretchMuthu was a 55yearold potbellied South Indian who was brought to the emergency department drowsy He had slipped into a coma within a few minutes of arriving Imaging revealed chronic subdural hematoma a blood clot that forms right beneath the outer covering of the brain the resultant pressure leaving him unconsciousnessWe rushed him to the OT shaved his head cleaned and draped him in the usual fashion After administering local anesthesia and making an incision in the scalp the senior resident handed me the power drill I would be boring a hole into the skull for the first time I felt like Kajol in the DDLJ climax while Amrish Puri relinquished control with Ja Simran ja jee le apni zindagiWith hope in my heart and pressure on my palms I drilled as the bone swivelled into dust on the way to reaching the dura the outer covering of the brain Normally this layer is glistening white But due to the underlying blood it had taken a bluish hue This brought a sense of relief since it confirmed that we were operating on the correct patient and the right side of his head had been opened An important double check at 3 amI coagulated the tiny blood vessels on the dura and with a knife made a cruciate nick A dark jet of altered blood spurted out under profuse pressure as we used a large suction to drain as much of it as possible to prevent it from splaterring onto my maskAnd then came one of the most ethereal sights I had seen The surface of the brain gently rose close to the bone as if to say thank you for taking the load off my back I was hypnotised seeing in reality what I had until then only read in text booksJust then Muthu mouthed the choicest Tamil profanity for having been woken up from deep slumber While we sutured the skin he was fully awake and talked coherently although he was still abusing usmdasha sign of good health and prosperity in many cultures including my ownAs we wheeled him out of the operating theatre his family acknowledged our effort their hands joined Their bread winner was back to lifeI thanked Santhosh the senior resident as we walked out to grab filter coffee the bluish grey walls of the hospital engulfed in a purple haze just before the crack of dawnTraining is neurosurgery in India means working 20 even 24 hours a day in suboptimal conditions sacrificing family friends and foodAt work we follow a coma scale to assess patients whose consciousness is not intact It has a maximum score of 15 Decreasing scores suggest confusion delirium and unresponsiveness to verbal commands or various forms of pain stimuli Normal individuals have a score of 15 which is suggestive of alertness and appropriate understanding of surroundings Traditionally neurosurgery residents fluctuate between a score of 12 and 14 which is consistent with moderate to severe disorientation It was for these reasons that the Americans mandated the 80hour work week for residentsBut its these years of hardship that build a surgeons character refine his judgment allow intuition perception and awareness to guide decision makingEvery day I ask myself Am I doing the right thing for my patient Because at the end of the day all each of us wants to do is get better Better is possible It does not take genius It takes diligence It takes moral clarity It takes ingenuity And above all it takes a willingness to try says bestselling author American surgeon and public health researcher Atul GawandeThe writer is a practising neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of HospitalsCatch up on all the latest Crime National International and Hatke news here Also download the new midday Android and iOS apps to get latest updates