The Moment of Truth - 1



The first case in one's private practice is always exceptional and therefore an unforgettable experience. It is the culmination of a period of training. In the early years of training, being surrounded seniors with greater experience and ability, one is avidly absorbing information and knowledge. Later on, as one reflects, acquires surgical skills and learns to weigh things critically, one's professional skills and judgment become more mature.

When I faced my teenage patient in Bombay after 7 1/2 years of plastic surgery training in United Kingdom, I knew the diagnosis-dentigerous cyst at the angle of the mandible (lower jaw). Such a cyst grows in the substance of the bone and there is always a partly formed tooth in its wall. In this boy, the cyst had become large making the bone as thin as an egg shell in many areas. I knew what was to be done-surgical removal with all its membrane forming the wall as well as the causative molar in the wall. This operation, though not an emergency needed to be done soon, as there was a danger of pathological fracture following minor injury. I knew the dangers and shortcomings of the operation. When I was about to make the cautionary comment, my patient was asked by his father to go out of the room. His emotionally charged speech was highlighted by the tears welling up in his eyes. He said: "You know, he is my only son!" I assured him that to a doctor every patient is a valuable VIP and explained that in this operation there is no inherent danger to life. His son would be less frightened if he heard my cautionary words. After my patient came back, told them that there will be a fine scar below the jaw bone and that there is a small danger that the jaw might break when I remove the cyst. The father's tears were now flowing over his cheeks. I said: "To treat the fracture I will have to fix the teeth together. Your son will not be able to open his mouth for three weeks. I want him to know this so that he will not be frightened and panicky in the half-drowsy state after the operation

The usual questions followed. "How can I talk? Can I talk at all ?

Speaking through my clenched teeth, I convinced the boy that he can.

"How will I eat?”

I told him that with a modified diet he will not remain hungry and that there may even be some increase in his weight! This is usually received with unspoken skepticism. Doubts and anxieties regarding this usually disappear in a week's time. There was, of course, a query about my fees. I found this difficult to answer and still do. It is difficult to place a price on one's surgical skill. During the training period in a public hospital, one does not evaluate one's efforts in terms of money. The visits, dressings, operation and the time given in attending the patient do not carry a price tag. After one is trained and working as an Honorary, as I have been (I was not Honorary at the time of this story) one never considers the pecuniary aspect of the effort and time given to the patient. Putting a price tag on my skills has been—and continues to be a difficult thing for me. Anyway, the patient's father was happy about the fees mentioned.

I had to ask for a week's time before the date of the operation was fixed. I was not worried about the delicate operation I was going to do. I was, however, worried about the unknown nursing home and the equally unknown anesthetist. I visited the nursing home, or rather inspected it without ruffling any feathers. I met my anesthetist, Dr B.S.G for the first time. I talked about the operative procedure I had in mind, asking questions in order to assess the anesthetist’s own understanding. I have not forgotten what he said then. He said: "Dr Mehendale, I will give you operating conditions you were used to in U.K." I trusted him. Dr B.S.G has remained my anesthetist since then.

The operation went on very smoothly. The cavity containing the cyst was opened carefully. The delicate membrane that was the cyst wall and the reluctant, partly-formed molar tooth were delivered out of the bone. Dr V.N.S who had referred this patient to me was watching over my shoulder. He was pleased to say that I had removed the cyst with the ease with which he removes a sebacious cyst. This was high praise indeed! Immediately (and not because it was within hearing of Dr B.S.G) I brought to his attention the praiseworthy contribution of the anesthetist without whose careful control the operation could have become a bloody, messy struggle of a dissection. The anxious father beamed when I told him that his son is cured and that the mandible was not fractured. The postoperative progress was very smooth. The patient came regularly for follow-up. When he came to see me after a long gap of 14 years I almost did not recognise the self-assured, tall young man. The most wondrous aspect was the work of God (or Nature): the bone had beautifully re-modelled! On feeling the involved area on both sides, between two fingers, it was difficult to say which side had the cyst! Only the scar which could be seen only when one looked for it, indicated the site.

Compilation of professional reminiscences of specialists - edited by M.V.Kamath and Dr.Rekha Karmarkar