The surgical blow

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There's a 62-year-old woman in the ER," I got a call, just as I was leaving for home, after an exceedingly active day. "She was sitting pillion on a two-wheeler, when she lost her balance and fell backwards. The back of her head slammed the road," the physician in the emergency told me quite casually, in contrast to his gruesome description of the fall.

In the matter of seconds, I had already imagined in my mind a fractured skull with brain tissue splattered all over the road. I cancelled the dinner I was supposed to go out for, and was wondering - for the umpteenth time - why pillions don't wear helmets. "How is she?" I asked to verify if my imagination matched the reality. "She's absolutely okay!" he said, probably wondering why I sounded so edgy. "She's fully alert, quickly obeying commands, moving all limbs well, and her pupils are briskly reacting to light," he said, giving me the low-down on her neurological examination. I promptly uncancelled the dinner in my mind, replacing it with an image of the spare ribs I was so looking forward to.

I lugged my backpack over my shoulder and left my office to swing by the ER before I could call it a day. Apart from a tiny bruise on her occiput (back of the head), she was immaculate. I was intrigued to see that her hands were covered in ornate mehndi from the tips of her fingers, up to her elbows. It was so fresh that I could smell cloves from two feet away. I asked her what the occasion was. "My son is getting married tomorrow afternoon," she said, the longing to be present at the wedding clearly visible in her eyes. "And I need to go home tonight," she requested.

"I would have sent you home, but your CT scan shows a thin sliver of blood in the brain, so it's better you stay the night and go home tomorrow," I reasoned. Her overbearing family started loudly concluding that nothing was wrong and that she would be taken care of at home. Just then, she vomited once. "We should not only keep her overnight but also watch her in the ICU," I cautioned sternly. They found it hard to argue with that and reluctantly agreed.

I am certain most patients are of the opinion that doctors and hospitals only want to fleece patients when they suggest an admission for something that is seemingly harmless and where recovery is possible at home.

As I left to feast on burgers and spare ribs with truffle fries, I promised her family that I'd come see her the first thing in the morning and discharge her soon after. At dinner, I asked my friends if they had ever been advised admission by their doctor that they thought they didn't need, and three of the five raised a finger. They couldn't elaborate because their mouths were stuffed with chunks of meat. We had the kind of meal that induced a food coma the moment I reached home way past midnight.

At 3 am, while I was in the deepest stage of sleep, my phone rang. I picked it up with my eyes still fully closed. "Kamlaben has suddenly become unresponsive and she's not moving her right hand and leg. She's not able to verbalise," the intensivist reported. "What does the scan show?" I slurred. "The blood has massively increased, causing severe pressure on the underlying brain. I've sent it to you," he said, raising his voice slightly to awaken me. I scrolled through the video he had sent me and sat up startled. "Get her to the operating room now," I instructed, putting on my scrubs to go to war. Over a few phone calls, the army was deployed. The OR was prepared, blood was arranged, her head was shaved. She was intubated and shifted for surgery.

Within the hour, I entered the hospital with a heavy heart and an even heavier stomach. I spoke to the son, confirming that we had to operate or else, she would not survive. He wished me luck. I wished him back - in case he decided to get married.

"Thank God I insisted on admitting her," I told my colleague as we made a big skin flap to expose the bone. We drilled a few holes in the bone, the burning dust smelling like the charcoal on the barbeque that was still being digested in my belly. The brain was tense as we lifted the bone off. As I cut open the dura, a large subdural hematoma - brain bleed - delivered itself like an overweight baby way past its due date. There was a large contusion within the lobe that we removed, after which the brain regained some semblance of normalcy.

"Would you get married if your mom was undergoing surgery on the morning of your wedding?" I asked my colleague, as we started closing. "I don't know about my mom, but if my mother-in-law was undergoing surgery, I would," he joked. As we placed the final stitch to close the skin, we placed bets on whether they would go ahead with the wedding; I said they would, my colleague said they wouldn't.

As we wheeled her into the ICU from the OR, we saw the son waiting outside, his mehndi-laden hands folded in prayer. I told him that surgery had gone well and that she should recover, but it would all depend on how soon we'd be able to get her off the ventilator. "How is it possible that she was okay for the first seven to eight hours after the fall, but became unconscious later?" he asked me, clearly having pondered this while waiting outside. "There is something called as a lucid interval in patients with a head injury," I explained. "After a transient unconsciousness from the impact of the injury, patients are fully okay. If a CT scan is done immediately, it may not show too much blood. But if active bleeding continues in the head, the pressure builds up and patients then deteriorate after a few hours."

I wanted to tell him that these patients are often termed "talk and die" in medical parlance, but I didn't want to burden him with negative thoughts. In cases of a mild head injury, it is sometimes a dilemma even for the doctor to determine which patients should be admitted and who can be sent home.

While it is mandatory in most countries for the driver of a motorcycle to wear a helmet, fewer countries have put laws in place for the well-being of the pillion rider, even though statistics show there is no significant difference between the head injuries sustained by motorised two-wheeler drivers and their pillion riders. In fact, before the Motor Vehicle Act of 1988 came into effect, a study found that only 0.6 per cent of all pillion passengers were helmeted. While Delhi made helmets compulsory for even the pillion rider about 30 years ago, Mumbai brought this rule into effect only a year ago. It is for each one of us to recognise how vulnerable the pillion rider is and insist on a helmet whenever we ride pillion. After all, Kamlaben hadn't even been in an accident; she simply fell off the bike.

We saw the son return in the evening, straight from his wedding; I had won the bet. He had his vibrant wedding head gear on. He also wore a nose ring and multiple earrings in both ears. Chains adorned his bare chest, and he wore a piece of golden cloth that looked like a combination of a dhoti and kilt. Without asking, he applied the ritualistic haldi and kumkum on his mother's forehead and left a box of sweets by her bedside, holding her hand for a while.

The next morning, Kamlaben woke up with a smile on her face, surrounded by her loved ones. She heard in great detail about the wedding she'd missed while her new daughter-in-law fussed over her and pressed her feet. A gentle-mannered woman, she thanked me profusely for saving her life and asked when she'd be able to have a bite of the celebratory mithai her visitors had brought her. "One tiny bite, right away. The rest of it, once you're out of here!" I joked, patting her hand.

The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals.