(Pushing) The surgical envelope

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Babulal Ji was gradually losing vision. Everything was a fuzzier version of what it used to be. The entire day appeared to him as if it were always late evening. An MRI of the brain showed a pear-shaped tumour arising from the pituitary gland and pressing against the optic nerves. The only option available to restore his sight was surgery. The only caveat was that he was 96 years old; 96-and-a-half, to be precise.

He sat in my office with his granddaughter who was an anaesthetist. Thankfully. Because she comprehensively understood the complications of "putting someone under" at this age. His round head and pointed nose with cavernous nostrils were offset by a Dalai Lama smile that made him seem oblivious to the implications of life and death I was discussing with her. "The entire family has been dissuading him to have surgery at this age and the two doctors we consulted prior refused to operate on him. But, he is hell-bent on getting his vision back," she told me, adding that he has two stents in his heart. "But apart from that, he is quite fit, walks with a stick and is mostly independent," she added pulling out the list of medication he was on. When I examined him, he could barely count fingers close to his face.

"Why do you want to have surgery?" I asked Babulal Ji. He couldn't hear very well till he adjusted his hearing aid and gestured to me to repeat the question. "Why do you want to have surgery?" I bellowed. He paused briefly and then answered in Gujarati, "Majha nathi aavati [I'm not having fun]."

It was the most succinct explanation of how he wanted to live his life - choosing for himself, joy over everything else. He was the patriarch of a 65-member extended family, several of whom were doctors in India and the United States, all of them wary of surgery. "I have only one request," he tightly grasped my forearm and pulled me closer. "Either you make me well or send me up, vachhma na rakhta [don't keep me hanging if something untoward were to happen]." I thanked him for the added pressure as the family broke into a smile.

While they were finalising logistics for the family to arrive from abroad, I was contemplating on whether it was the correct decision to offer surgery. "He can't hear very well, what's the problem if he can't see?" someone reasoned. Friends who I spoke to about this suggested that "he might have chosen you to help him with his exit strategy." This worried me even more. Senior colleagues made a point that "even if he dies from an anaesthetic complication, the buck will eventually stop with you." All I was interested in was to give him back his vision but I also understood that it came with a ginormous flipside.

A couple of weeks later, the entire family assembled for a final discussion. "He is our everything," said his doctor nephew who flew down from America with his wife. "But we also accept with folded hands any outcome that this decision bears." It was an extremely gracious statement to make coming from someone who had practised medicine in the US for 40 years, a country that is fraught with litigation. "I left India with $10 in my pocket and today by the grace of god, our entire family is very comfortable," he said. He lovingly invited me over to visit him.

It amazes me how every Gujarati who left for America in the '70s did so with exactly $10 in their pocket. Every rags-to-riches story I've heard has this definite amount. Nothing more, nothing less. I'm sure there would be at least a few who left with a couple of hundred bucks? If you did so and happen to read this, please give me a shout out. Isn't $10 too much of a gamble?

Unless you were heading straight to Vegas.

After meticulous planning with our anaesthesia and ICU team, we took him into the operating theatre on a day when all the planets aligned. His nephew, who was an ER physician, requested to watch the surgery and I willingly obliged. With the help of my ENT colleague, we entered his gigantic nose, nibbling away at the bony ridges that resembled the mountains of Leh. The tumour had eroded the bony saucer-shaped floor on which the pituitary gland straddled itself. I made some room around to expose it adequately and cut into it, allowing for the cheesy-oozy tumour to emanate itself. We curetted the walls to ensure nothing was left behind and the optic nerves were completely decompressed. It was a smooth in-and-out operation. "I've never seen something so meticulously and coolly done before," his nephew doctor commented at the end of the procedure. I was thrilled that we managed this uneventfully.

But just after surgery, his blood pressure crashed. Luckily, our vigil anaesthesia team was able to revive it without resulting in any permanent damage. As expected, he took a little while to wake up after we removed his breathing tube. But when he woke up, he said he said he couldn't see anything. And the right eyelid drooped, complicating it further. I was devastated. Instead of restoring his vision, I had made it worse. All my joy of pulling off what seemed impossible vanished.

An urgent scan of the brain showed that it was clean. There was no bleeding or pressure on the nerve from residual tumour. That meant there was no need for any re-operation. We reviewed the operation video to see if we had inadvertently damaged something. At no point did the family say anything. "Acceptance is a small quiet room," I remembered the American author Cheryl Strayed.

We waited a few hours. I prayed a little. Then a lot. After I finished seeing patients in the OPD, I went back to check on him. He could now see clearly with his left eye. The next day, the vision in the right eye also returned. However, the lid was still droopy. There must have been some swelling around the nerve that caused this to happen.

It was his wife's birthday that day. She was there by his side each day, dressed immaculately in a saree, just a year younger to him. "We've been married more than 75 years," she told me as she fed us cake. "What's the secret to a long and happy marriage?" I asked. "Patience and faith," she replied promptly. "I wasn't worried yesterday when all of you were running around wondering what'll happen with his vision," she sounded me stoically. "Everything good takes time," she told me in Gujarati.

With each passing day, his vision got better, counting fingers at a distance of 10 feet easily. He regained strength to walk on his own. His family was delighted with the outcome. I told him them it was team effort, especially the anaesthetists who were able to pull this off. His granddaughter agreed. On the day he got discharged, I asked him how he was feeling. He insisted I run my hand over his head a few times. He clenched both his fits, thumped them in the air and shouted, "I'm the happiest man in the world!"

The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals mazda.turel@mid-day.com