Performing a complicated surgery on a nonagenarian is usually avoidable, but should you give up without giving them a fighting chance?
Representational Image/ Courtesy iStock
I was clipping a ruptured aneurysm in the angry brain of a 35-year-old girl at 9 pm on a Thursday evening, when a nurse walked into the operating theatre with a message from the ER that she’d been asked to deliver: “There is a 95-year-old man with a large hematoma [blood clot] in the brain. He’s drowsy and paralysed in the right arm and leg.” Without seeing the scan or asking for any more details, deeply engrossed in the critical part of my ongoing surgery as I peered through the microscope, I responded crassly, “He’s 95; let him go in peace.” I could see the nurse nod her head through the corner of my eye, saying, “Okay, sir” as she exited. I dissected around the aneurysm and placed a clip perfectly on its neck, securing it from further rupture. I was ready to call it a day.
The nurse returned a few minutes later. “The family too doesn’t want surgery or any form of aggressive treatment, but wants to admit him under you for comfort care till he passes,” she ended. “Sure,” I replied briefly, while inspecting the precision of my clip placement and ensuring that no arteries were incorrectly stuck within. I sprinkled the now soft and peaceful-looking brain with saline, sutured the dura, and put back the bone. While we closed the head, I asked my colleague, the surgeon assisting me, “If that was your grandfather, would you operate on him?” “I wouldn’t do anything even if he was 75,” he replied, confident in his knowledge and experience that the elderly don’t recover well after surgery for a massive blood clot. “You finish closing, and I’ll go see the old man in the ICU and talk to the family,” I told him, removing my gloves, feeling the exhaustion of two four-hour operations in the day.
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Mr Gupta lay on the first bed as I entered the ICU. My first impression was that he didn’t look 95. His son-in-law stood next to him as the nurse placed a blanket over him to keep him warm. His eyes were closed, but he opened them after my third try of calling out his name and shaking him a little. “Show me your tongue,” I said, raising my voice after learning that he didn’t have his hearing aids on. He gently pulled out his parched tongue. “He’s a bit dehydrated,” I told the nurse and asked them to run some intravenous fluid. “He’s not had anything for the past 12 hours,” his son-in-law mentioned. He raised his left arm and leg on my command, but couldn’t move his right side. On further questioning, he seemed confused about where he was and even which century we were in. He could barely utter a few words.
I plugged the CT scan films into the viewing box, and as I was informed, there was a large subdural hematoma compressing the left half of his brain responsible for his right-sided weakness. But this was a chronic subdural hematoma, which has a very different prognosis from an acute one. The former entity often occurs in the elderly with or without minor trauma, and a simple small hole made in the skull to drain the waterlike blood, results in good recovery. When the clot is acute, the blood is thicker and it requires a bigger operation and has a poorer outcome. My stance changed in an instant. I explained my intention to do an operation and to do it now. The son-in-law was befuddled; he had just conveyed to the rest of the family, who was out of the country that they were going to let him pass in peace.
They put me on a conference call with his two sons, one in Dubai and the other in the United States, and I explained why I had changed my mind. “If he was completely independent prior to this recent affliction and as has no other medical comorbidities, I would operate on him,” I explained. “He’s so old and he’s lived a full life. He’s just recovered from throat cancer and we don’t want him to suffer. Have you operated on a 95-year-old before?” they asked me. “No,” I said, “But I’ve operated on quite a few in their late 80s, and most of them have done well—but the final decision is yours.” I concluded by explaining all the risks and benefits of performing brain surgery on someone this old. They had a quick internal discussion and then said, “Go ahead.”
My colleague from the previous surgery walked up to me. “The aneurysm is extubated, she’s absolutely fine. I’m going home; it’s midnight.” I shook my head. “No, you’re not; we’re operating on this 95-year-old uncle right now.” I could almost hear his jaw drop. “We’ll do it under local anaesthesia,” I added. Within a few minutes, we had him in the operating theatre. We numbed his scalp and sliced into it, drilling a hole in the skull. I incised the dura and dark altered fluid gushed out under pressure. At that very instant, he started moving his right hand and leg under the drapes, and by the time we finished, he had even started talking coherently. We shifted him back into the ICU within the hour, and his son-in-law was shocked to see the transformation. His children, who had steeled themselves for his demise, cancelled their tickets.
The next morning, Mr Gupta was as fresh as a daisy sprinkled with morning dew. He told me the story of how he had been diagnosed with throat cancer eight months ago and that the oncologist had told him that they couldn’t treat a 95-year-old. He then sourced out immune therapy medication after seeking a second opinion and was now in complete remission.
In medicine, we often generalise, and more often than not, it is correct not to be aggressive when the patient is at such an age. But we must make room for the exception that will defy all odds and we must have the courage to follow one’s gut instinct. It is said that there is an exception to every rule. The exception was in front of me: I watched an old man chatting away, seeming young again.
“I have a four-bedroom apartment on Altamount Road, but I live all alone. Both my children are abroad. I bought the house for Rs 4 lakh in 1975, and now it is over Rs 15 crore,” he beamed with pride. “Uncle, don’t forget to write my name in your will!” I said in jest, and everyone in the ICU along with a nearby patient burst out in a laugh.
The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals
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