anonymous

5th November 2018

PHILOSOPHY OF MEDICINE - 2

PHILOSOPHY OF MEDICINE - 2

DR PRAFUL DESAI

Having spent nearly 3 and half decades - the best part of my life - in the diagnosis and management of cancer, one might be led to believe that I must be a die-hard pessimist. Quite the contrary: optimism dominates and pervades my professional life. There have been for sure, many failures; nevertheless, the failures increase one's resolve to overcome or vanquish the foe the next time. Successes have been dramatic at times: not many, perhaps, but enough to stimulate one to carry on the fight against cancer.

It is very tempting to list all success stories; however, I would like to relate some experiences which have a blend of sadness and joy; a lesson to be learnt from those whom I consider to be my great educators: the patients whom I have had the privilege to treat. I have the permission of the families to relate these true case histories; the names have been changed to avoid greater publicity beyond a circle of friends who may easily identify the individual concerned.

Almost every encounter with a patient brings forth a new and enriching experience. It is an education indeed. Each patient comes with stress and anxiety as there is a suspicion of a diagnosis of cancer which needs to be confirmed or disproved. Apart from one's professional expertise one needs to provide strong psychological support to the patient. A good doctor must therefore be an appropriate amalgam of professional competence, ability to listen and relate to the patient's problems and needs-compassion is the word, I think—and above all someone who can generate confidence in the patient. A good doctor also needs to be a good communicator vis-a-vis explaining the clinical problem to the patient in simple terms and the treatment alternatives that could be offered. This is a tall order to ask of every medical professional and yet these attributes need to be practised and cultivated with time.

I have been singularly lucky to have received my initial training at the K.E.M. Hospital and G.S. Medical College, my alma mater, which was further nurtured and groomed at the Tata Memorial Hospital for Call across the street from the alma mater. This, again, was not intentional but quite inadvertent. Keen to learn the nuances of good operative surgery - an absolute imperative for any surgeon - I wended myself to the Tata Memorial one cool evening in December 1956. I accepted the assignment of the junior most medical Resident beginning 1 January 1957. I stayed on ever since-for the simple reason of job satisfaction, extraordinary surgical training and experience, a fabulous environment, inspiring peers to learn from and a challenging field. All these factors outweighed the distressing environment in which only a few could be cured with pain and disappointments a plenty and where death was a frequent companion. And yet, indeed, there were streaks of silver lining which kept us going-all now for 34 years. One of my most memorable experiences was with a bright, alert male child of 10 years who was brought in with much care by his parents. The father carried him as if this was his last hope, his only possession, a symbol of his aspiration too, reluctant to part with. Rahul, I will call him. He had obviously wasted. His eyes were shrunken, yet bright; the breathing belaboured with spasms of pain and cough. The kid was sick and needed urgent help. Most investigations were completed outside as were available in 1970—the X-rays and the blood and the urine. The child obviously had a large tumor in the left upper half of the lung filling the chest and pressing on the nerves and veins and eroding the ribs. By the normal parameters it was most probably a nerve tumor arising within the the chest but not in the lung but obviously pressing and compromising lung function. These tumours are not amenable to drug treatment and radiotherapy and the only recourse was major surgical operation with a severe risk due to the large tumour, poor condition of the child and invasion of the surrounding blood vessels, nerves and bones. Often the relatives do not understand the gravity of the situation. With modern techniques of medicine, success has to be there and is often taken for granted. When we presented the facts to the parents - stark facts of an advanced cancer - poor general condition of the child and surgery as the only method available (and a risky one at that) for the salvage of their dream, the initial reaction was of total disbelief which culminated into a shock-like state after a while. How on earth can this happen to their child and if that was so, how utterly ridiculous that he cannot be restored to quick normal health without any risk, leave alone the high surgical risk to life that we explained. Devoid of any other alternative and clutching almost to the last straw of hope, they gave the permission to go ahead.

Despite all the odds and the risk, the team went into work on Rahul on a cool January morning in 1970. The chief of anaesthesia, tense but composed, slipped the anaesthesia tube in the trachea with great dexterity and skill. The heart rate was 160_about twice the normal, almost a prohibitive rate for major surgery of any kind, leave alone that within the chest; however, the young heart was beating strongly and we opened his chest; the moment of truth had arrived. There was the tumour, sitting atop who lung and closely adherent to the dome of the lung: large arteries and veins criss-crossing the tumour which was densely stuck to the chest cavity which was slowly siphoned out. The Sister in charge collected the sample quietly and efficiently in a test tube for subsequent laboratory testing. Initial attempts to move the tumour - a test which conveys whether operation should be attempted or abandoned – were unsuccessful. It was as if a rock was deeply welded into the surrounding tissues. This one manoeuvre often sets the scene of surgery; easy, relaxed and devoid of tension when the offending cancerous tissue hours filled with tension, anxiety, concern and rappears fixed into the tissues. There is always an easy way out. To close the chest and pray God and pronounce that this is not removable. Incurable. Fatal. Two, four or six months. The life story is over before it begins. The easy way out. None to question your judgement. Surgeons and their assistants often peer over their masks and talk to each other with their eyes. In proceeding further making an attempt to remove the irremovable cancer-a few moments of deafening silence. How is the child behaving?” I asked of my anaesthetic colleague the head end. "Worrisome, but stable. Are you going ahead?” he asked. A quick mental introspection often seizes you. Young kid. A life ahead. The only hope and aspiration of his parents. A tumor of the nerves. Does not often spread elsewhere but is aggressive locally and destroys the surrounding tissue. A bloody operation. A risky undertaking. A major bleeding catastrophe during surgery can snuff out the life in minutes, literally with blood on your hands. You are directly responsible. Retreat is so easy with no tarnish on your reputation which is so difficult to build and so easy to destroy within minutes, seconds. "Are you going ahead?” This question suddenly jolted me from my thoughts. Yes, I am. Please start blood. I expect a significant blood loss as the tumour is very vascular. Done. Orders went out. The Blood Bank alerted. The Nurse in charge and the surgical team pumping their own adrenaline, set about their work. Three and half bloody and exhausting hours later, after a loss of nearly six bottles of blood, the tumour lay in the kidney tray. The lung which was collapsed due to the tumour sprang and expanded to its filling the whole chest. During the procedure, the tumour with two ribs as excised along with a part of the vertebra which was also eroded. A large raw area which formed the bed of the tumour continued to ooze and the major life sustaining blood vessels were all visible, only millimeters away from the tumour but out of harm’s way.

At completion of surgery, his heartbeat was pounding away registering 180/190 beats, but regular and strong. Surgical and anaesthetic formalities were completed and Rahul returned to the recovery room 5 hours after he was wheeled into the operation room.

In a moment of enlarged ego - all of us are human to a fault - I met the parents and related the story. I remember those faces well. Pale and ashen as if aged more than ten years in those 5 hours with a constant vigil outside the operation room, sending an unending message to the good Lord to spare their own flesh and blood - with hope, worry, anxiety, concern - all rolled into one. Their eyes were glimmering and moist, a moment of grief and happiness combined. It is difficult to describe the innermost feeling on both sides, theirs and ours. I could not manage a long conversation, not because of exhaustion and tension. "Should be okay. We were lucky to be able to remove the difficult tumour" I said shakily. "but he is stable. Let us hope he does well". I mumble imperceptibly. I knew fully well that the initial battle was won, but the war was yet to begin. During his recovery. For any major post-operation complications. Long term result. Recurrence of tumour. Life span ahead. The quality of life. Any further treatment. A myriad questions, concerning the life and/or of a young child. Answers which I knew I cannot give, neither predict.

Time flies. Twenty one years later, in 1991, on my office desk was invitation marked "From Rahul S, M.D; D.G.O". Inauguration of yet another Consulting Room of a young gynaecologist. The name was very familiar and too close to me. After a remarkable recovery, Rahul kept on coming to the hospital for his regular check-ups. Happily, though his tumour was frightening in appearance and took all the patience and skill of the operating team, it was quite benign under the microscope. The type of tumour which generally behaves well - does not spread once totally removed. When Rahul turned 16, five years after his surgery on one of his now annual visits to the hospital, I asked him: "What are you planning to become when you grow up? He replied: "I am already grown up! I am about to join college. I would like to become a doctor. My parents are keen and so am I".

It took me back to my own experience as to how parents can shape our life and make something out of us. Rahul grew into a normal, healthy teenager and adult, completed his post-graduate medical training and education and gives his professional expertise in our very city. These are moments of pride and satisfaction. I still very vividly recollect Rahul, a 10-year-old bundle of sickness and pain 23 years ago, in the lap of his father, looking with bright but sunken eyes. He has achieved what he set out to do in his life that he was destined to lead. For us a moment of Truth, Humility and Pride. How nature can help the professional to fight for a life, despite seemingly hopeless odds!