The surgical travel

Representational image. Pic/iStock

I had operated on a brain tumour exactly a week before I was scheduled to travel for work to Uzbekistan. This 66-year-old lady had a tumour growing from her pituitary gland that was compressing her optic nerves and rapidly diminishing her vision. We removed it with finesse using an endoscope through the nose. The family was delighted that her vision had dramatically improved after surgery. The day before I was to leave the country, I saw her in the morning and asked the floor doctor to process her discharge. She was chatty and chirpy, and happy to be home soon. "I'm going to be travelling for four days, so I'll see her after a week, as planned," I told her daughter while conveying all the necessary post-operative care instructions.

A few hours before she left the hospital, she collapsed in the washroom. Luckily, a nurse accompanying her prevented her from falling to the ground. When we rushed to examine her, her speech was slurred and she was facing weakness in the right arm and leg. She was having a stroke. Innumerable thoughts crossed my mind as to what could have caused it, as she was wheeled in for a CT scan after the medics ensured that her vital parameters were stable. In contrast, my heart rate and blood pressure were through the roof. It always happens… something always happens before I travel, I told myself. It is the experience of countless surgeons: Something goes wrong when you least expect it to. Or want it to. It's nature's way of keeping you grounded every time you plan on "flying high".

Luckily, the CT scan didn't show any major bleeding in the region of the tumour, neither was there any evidence of reduced blood supply to the left half of the brain, which would have explained the speech disturbance and paralysis of the right half of the body. "There's nothing that needs to be corrected surgically," I assured the family. "But doctor, you're not going to be here," the daughter lamented. "If you want me to cancel my travel, I can, but we need to investigate this further medically, and our neurologist will take care of it," I tried to alleviate their anguish. "We have an entire team here looking after patients and no doctor is indispensable. Also, I'm always available on the phone," I reassured them.

She steadfastly improved under the care of our specialist, although we could never identify the cause of her stroke. Oftentimes, patients with hypertension and uncontrolled diabetes are prone to such occurrences when their system is stressed beyond measure, which any kind of surgery contributes to. Thankfully, with timely intervention and medication, she made a complete recovery.

Two weeks later, I was scheduled to climb Mount Kilimanjaro, a trip that a bunch of us had planned (but not prepared for) over the past few months. In the days leading up to my trip, I promised myself I'd operate only on spine cases, as they are relatively free of any worry or post-operative complications. But as luck may have it, in addition to my scheduled list for surgery, three massive brain tumours showed up. "I'm not in town from Friday onwards and I'd suggest you get operated elsewhere, because this can't wait beyond a week," I told all three patients on the Monday they showed up in my OPD.

The first patient was known to the principal of the nursery my children used to go to. She was a 29-year-old girl with a big tumour in the back of the head causing pressure symptoms - headache and vomiting. They insisted I do it. We slotted her for Tuesday and removed it with ease. The second patient had a haemorrhage inside his tumour and simply couldn't wait, and he was therefore operated on Wednesday. That chap too made an excellent recovery.

The third patient was scheduled for Thursday but was told that I'd be travelling the day after surgery. This was a large tumour arising from the hearing nerve but pressing against the cerebellum, causing balance issues. They understood the risks of my not being around from the second day of surgery but insisted I do it anyway, as I was referred to them from multiple sources. Nothing fans a surgeon's ego more than that, and it's a web most of us succumb to, almost unfailingly.

The morning of surgery, I was informed that her platelet count was below the acceptable range to perform surgery. This was God sending me a signal, I thought. "It's best to wait until we get the platelets up, because there could be a risk of torrential bleeding with a low platelet count," I explained. "Once the platelets are normalised, I will get one of my colleagues to perform the surgery." They were convinced with my explanation, but just before I was about the cancel the surgery, the pathology lab called up to say that some people have large platelets that don't get counted appropriately with the machine, and by manually counting them, this girl's platelets appeared adequate. I went back to the family to tell them, and they requested I go ahead with surgery.

I didn't know whose side the "higher force" was on. We went ahead and opened her up. We fashioned the bone removal behind the ear to get access to the tumour. The brain was tense and swollen, and even on gently retracting the cerebellum, tributaries of blood started filling up my field of vision, which, under the magnification of the microscope, seemed torrential. I shouldn't have agreed to do this operation… This patient is going to land up with a complication… I saw all the red flags and yet I didn't play heed to them… I lamented to myself silently, all the while trying to control the bleeding. Through a narrow corridor, I found access to the tumour, which I quickly shrunk to the size of a raisin from that of a lemon, preserving the facial nerve it was stuck to. Throughout surgery, her blood pressure had surges and drops, probably from pressure on the brainstem. We ventilated her overnight and removed the tube the next morning, and thankfully, she was perfect. "Anything can happen over the next few days," I cautioned the family, "but my team will take care of it, as I won't have any network."

Are surgeons allowed to take a break? Is it ethical to operate on a patient and travel the very next day? Where do we draw the line? Although patients understand that you might be away, if something goes wrong, they might not be so forgiving. Even when we are away, we are thinking more about our patients than the ones we are away with. That's exactly what I did while climbing that mountain. I played on loop every single step of my last operation in my head, whilst in the biting cold, even when it seemed impossible to put one foot ahead of the next - even when it was hard to breathe, even when it transiently felt as though my soul had left my body.

When I returned to civilisation a week later, after successfully summitting the highest free-standing mountain in the world and the tallest peak in Africa (yes, I am showing off a little!), my phone downloaded a barrage of messages. The first one I went to was my colleague's: "All patients are doing great. Nothing to worry about. I hope you reached the peak."
It was a different kind of high.

The writer is practising 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