Case of the Missing Limb

anonymous

7th December 2019

Dr N.S.Savant

After specialising in Anaesthesiology at Baroda, my home town, I decided to come to Bombay in the fond hope of further advancing my knowledge in this specialist. Bombay was considered the seat of learning and, moreover, it boasted of such eminent anaesthesiologist as Dr. G.S. Ambardekar and Dr. Sarcar. It was my good fortune to be selected an assistant to Dr Faria at the prestigious Tata Memorial Hospital. The thirty to thirty five years that I have spent in this great institution benefited me not only academically but I could also see at very close quarters a splendid drama unfold before my eyes—a rich saga of courage in the face of impending death; instances of faith that give meaning to life; pathos and occasionally humour too. Yes, humorous incidents do occur even in the otherwise drab and gloomy premises of a cancer hospital.

Some time in the early sixties, when I was a relatively junior anaesthetist. a very beautiful lady, perhaps in her late forties, and of royal descent, was wheeled into the minor operation theatre for a procedure called Oesophagoscopy--that is, to have a look into the oesophagus or food pipe with the help of an instrument called oesophagoscope.

She was breathtakingly beautiful and came from a famous Nawab family of Lucknow. She was suspected to be suffering from cancer of the foodpipe and hence the investigation. Her beauty was not marred by the other physical ailment that she had-bronchial asthma. She was a long-standing asthmatic and was being treated with bronchodilators and other drugs.

Oesophagoscopy, to confirm the diagnosis of malignancy, is a very routine procedure and performed even by the juniormost surgeon. However the surgeon in this particular case was an eminent one. During endoscopy, to her misfortune, the oesophagus was inadvertently perforated resulting in a grave situation. Errors occur in the best of hands which only shows that doctors too are human. Radiologically, it was already proved that she had a malignancy and it was now decided to carry out the procedure of resection and anastomosis of the oesophagus (removal of the diseased part of the oesophagus and resuturing of the two ends).

The surgery necessarily had to be of an emergency nature and it lasted for about 3-31/2, hours without any problems. At the end of the surgery, I was looking forward to a relaxed evening listening to some Indian classical music, the day's hectic activity being over. It had indeed been a very tiring day but the job had been done and all was well. I went ahead and injected the antidote to the muscle relaxants that I had given the patient during surgery, so that she could now start breathing spontaneously. Her smile was very infectious and all of us were eager to see her smile after she emerged from the anaesthetic. But what do we find instead? A blank, expressionless face, pupils of her beautiful eyes widely dilated and fixed and no sign whatsoever of her making any attempt to breathe. I looked at her in disbelief, made every possible attempt to get the expressions back on her face by calling out to her, but to no avail. Even on that winter evening, with a well-functioning air conditioner in the Operating theatre, I was sweating profusely.

All the Consultants involved in her management introspected on the surgical procedure so as to find out what had gone wrong. There was no apparent reason for her to have developed such a serious complication. I had myself conducted the entire anaesthetic proceedings and to the best of my knowledge, nothing untoward had happened during surgery. Being an asthmatic, I had injected the broncho-dilators and given enough oxygen so as not to cause any hypoxia (lack of oxygen) during the artificial respiration that we provide during surgery, when the patient is paralysed with muscle relaxants. Besides, there was no indication to suggest that she had suffered from a stroke or a heart attack during surgery since all her vital parameters were normal during the entire procedure. Then where did I err? After ascertaining once again her inadequate breathing, we put her on a respirator (a life support machine) and despite a two-hour vigilant watch when her sensorium did not improve, we sent for a very eminent neurologist. In the meantime, the surgeon informed her relatives about the gravity of the situation and, to their credit, they were extremely dignified. Not once did they doubt our credentials. Soon came the very eminent neurophysician who after a detailed examination gave his verdict: Brain Damage, Cause Unknown.

There was a general despondency and the verdict was conveyed as gently as possible to her composed relatives who again accepted this news in a very serene manner. But not I. something inside me refused to believe that she had suffered an irreversible brain damage. Her asthma had posed no problem, the anaesthesia machine which delivers oxygen and other gases was in perfect order, she had not shown any evidence of cyanosis blue discolouration of tissues due to lack of oxygen), her pulse was regular, she had not sustained a prolonged fall in her blood pressure—then how could she get a brain damage?

But how could I, a mere junior in my department, contest the verdict given by the final authority on brain damage? The accusing finger was pointed towards me and I felt dismayed and helpless. Having untiringly tended to my patient during the entire evening, I was advised to retire to my room to calm down my frayed nerves. As I passed her near and dear ones, they gave me a very understanding look a look that was trying to convey: "We understand!”. This compounded my agony and I rushed to my room trying to overcome my emotions.

Around midnight about six to eight hours after the neurophysician's visit, I was sitting in my room dejectedly when who should come to see me? The operating surgeon, none other! He not only rushed in but hugged me with joy and excitement. What he told me was incredible-my intuition after all had proved right! My patient, I was told, had regained consciousness and was wide awake. Both of us rushed to the patient's bedside. There she was beckoning me to remove her endotracheal tube and to switch off the respirator! I willingly obliged her and for that I was rewarded with her bewitching smile. I was in seventh heaven. Her post-op erative stay over the next few days was absolutely uneventful.

To this day I am at a loss to understand the reason for her ‘apparent' neurological deficit which was so convincingly opined as brain damage. Was it a human error? Was it an error on my part or his? I do not know. But the reason I have described this story at some length is because I wish to make a few pertinent observations:

1. In my heart of hearts, I knew she would pull through, for I was guilty of any neglect during the conduct of anaesthesia. Perhaps unknowingly, I had administered an overdose of the anaesthetic agents and the pain-killers or perhaps she was unusually sensitive (hypersensitive) to these drugs and hence the 'deep sleep'. But more importantly, I, a junior anaesthesiologist did not, or perhaps could not contest the elder, respectable physician's judgement. It was futile. Looking back I feel miserable for not lodging my protest against such a terrible verdict!

2. The dignity and serenity displayed by the relatives was exemplary. Not once did they bombard us with unseemly or uncivil questions. Without any hesitation they gave us the permission to carry out all the necessary investigations. Their implicit faith in us did wonders to our morale and without the fear of rebuke or accusation, we worked untiringly for her. How many people in times of adversity can maintain such poise, such a balanced mental equilibrium? Most of us tend to be cantankerous and agitated and it does not take much time to change a "Well Doc, you now see you Are simply fab!” to a "You rascal, you have butchered my wife, I shall see you only in the Court!”

Very often we come across relatives of patients who, after the brief initial enthusiasm, soon lose interest in the patient, especially in a long-drawn out illness like cancer. They often neglect their near and dear ones, leaving them to the mercy of some benevolent hospital staff. But once I Came across a young man who was not yet officially wedded to his lady love but Displayed undiluted devotion.

Pushpa, a young girl, twenty two years of age, was suffering from a malignancy. She was operated upon at the Tata Memorial Hospital. He post-operative stay of about ten days was uneventful. While she was in the hospital, we regularly noticed a young man at her bedside, tending to her needs in the evenings. What struck us was his devotion, concern and affection for Pushpa. Ramesh and she seemed deeply in love. Round about that time, another calamity was to befall poor Ramesh! His father disapproved of his son's infatuation with a girl, who was suffering from an incurable disease like cancer, and whose days were numbered. In an angry outburst he asked Ramesh to forget the girl and to break off the relationship. Ramesh, however, was made of sterner stuff and refused to accede to his father's wishes. Thereupon, his father told him, that Ramesh would have to choose between his father (his family), and his lady love. Ramesh told him that he could not leave Pushpa. This infuriated his father who threw him out of his house.

Pushpa was soon discharged from the hospital as she was slightly better and wished to go home to be with her parents. Two months later Pushpa was re-admitted, due to a recurrence of her very virulent malignancy. Accompanying her again was Ramesh who had now started spending the days with Pushpa as she was rapidly going downhill. When questioned about his presence in the hospital even during day time, he replied that he had requested his employer to give him a night shift so that he could look after Pushpa throughout the day and upto late evenings. His devotion to Pushpa was so phenomenal that the entire hospital staff soon got wind of this unusual pair and one could not but help pray for Pushpa's well-being, although everyone knew that her end was near. His ceaseless devotion amounted to almost no sleep for himself, for during the night he worked in the factory and during daytime he looked after Pushpa. We did not fail to notice that he too was gradually failing in his health.

One fine morning, Ramesh told me that he wanted to marry Pushpa. I tried my best to dissuade him. I explained to him Pushpa's grave condition, coaxed him, cajoled him to change his mind. He said he was fully aware of her precarious condition. Pushpa was by no means a rich girl, nor did she have any property. What then would Ramesh gain by his insistence, we wondered.

The next day, Pushpa took permission from the hospital authorities to go out for a few hours. When later she returned with Ramesh she was wearing a bridal sari and looked every inch a bride with a large kumkum mark on her forehead and the accompanying mangalsutra. Ramesh distributed some sweets and we, the staff of Tata Memorial Hospital, gretien them with floral offerings. There was absolute bliss on the faces of the couple. Soon enough, as was expected, Pushpa's condition deterioraid and she became critical. Ramesh now stopped attending his night shift too, devoting all his time to his dear wife. Within a few days Pushpa died.

Because of his continued absence from duty, the factory a him and Ramesh was now even more forlorn. But his devotion sincerity and humility had so impressed one and all in the hospital that ties decided to employ him on their staff. To this day he continues to be on the staff!

Mr Gore, a 76-year-old man lived happily in one of the distant, suburbs of Bombay. He was well settled in life having educated two of his sons to become engineers and married off his daughter into a well-to-do family. Both the sons were in the United States and since the elderly couple did not wish to leave India, the sons would visit them, each one coming to India every alternate year. Mr Gore couldn't have asked for anything better. There was bliss, contentment in his home. He led a satisfactory retired life with his wife.

On one of the annual visits of Arun, his elder son, Mr Gore complained about the appearance of an ulcer on the border of his tongue. He had assumed it to be a harmless aphthous ulcer, but not so Arun. Arun told Mr Gore that they should take a medical opinion to which the old man refused. When Arun warned his father that the ulcer could be malignant. (having lived in the United States, he was very much conscious of the symptoms and signs of cancer) the old man still refused to see a doctor, maintaining that he did not wish to have any surgical intervention and had no desire to live longer. Mr Gore was content with his life and wished to spend the remaining years chanting bhajans.

Arun was in a fix. Staying in a distant land, he was naturally worried about his father. To his watchful eye, the ulcer certainly did not seem innocent. What if the ulcer was cancerous, he thought. But his father would not listen to him. Finally, after much coaxing and cajoling, the elderly gentleman agreed to go to the Tata Memorial Hospital for a checkup--much against his wishes, though. The consultant having seen the lesion advised a biopsy to confirm the diagnosis and if positive, Mr Gore would have to undergo a partial glossectomy (partial removal of the tongue to get rid of the cancerous part). Mr Gore was apparently dejected on hearing this. Yet again he told his son to leave him alone. But the Loving son finally convinced the reluctant father about the necessity of the biopsy and the father related and agreed to go to the Tata Memorial Hospital.

As they lived in a distant suburb the father-son duo came fairly earlier than the scheduled time of the biopsy. Since he was a day-care patient he was not admitted the previous day nor was he given any prebiopsy sedation. They were made to sit in a waiting room when exactly opposite my office. Everytime I went out of the office, I saw frightened man and also did not fail to notice the son's gesture of gently putting his father's back in order to reassure him. This sight was an everyday affair to me, and besides, apart from the normal courteous erecting that I extended to them. I did not feel it right to unnecessarily strike a conversation with them, and with the very busy day ahead of me, I soon forgot them. However soon after, during one of my hurried exits from my room, I heard a peculiar sound emanating from somewhere near the patient. The sound was peculiar enough for me to halt in my tracks and give a second glance to the patient. He appeared very pale and was obviously unwell and was frothing at his mouth. After a quick examination it was not too difficult for me to diagnose pulmonary oedema-yes, Mr Gore's lungs were filled with fluid and he was in a potentially dangerous situation. He had developed left ventricular failure. Such a situation if unattended to, soon leads to a fatal outcome. I immediately instituted the basic therapy and summoned a cardiologist. The latter opined that Mr Gore had indeed suffered a heart attack and soon the necessary ICCU admission and drug therapy were rushed through. To his good fortune, Mr Core did survive this episode.

After this event, I called the frightened son to my office and it was here that Arun, now filled with remorse for having brought his father to the hospital against his wishes, recounted the background. Arun said that Mr Gore was a mild hypertensive and had had a history of coronary (a heart attack) in the past. So we had on our hands a frightened, anxious and more importantly a very reluctant and unwilling patient whose sole aim in life after retirement was to sing bhajans and offer prayers to God. His fear and anxiety were of such a magnitude as to precipitate a heart attack. The son had ultimately to bow to the father's wishes and they left the hospital premises without confirming the nature of Mr Gore's lesion. Though not all fears are necessarily sound, some people have an uncanny knack of sensing trouble; they get a premonition of things to come. Moreover, fear being a negative emotion plays havoc with a patient's general well-being and needs to be allayed as much as possible before subjecting a frightened patient to any surgical procedure.

As we are on the topic of intuition and premonition, let me share with my readers another story of a young girl, Shreelata, a nurse by profession. From her episode I have learnt to respect a patient's intuitive power without, however, falling prey to superstitions. But I never ridicule the patients for their naive beliefs or age-old traditions-even if their intuitions may turn out to be mere coincidences. One should learn to respect a patient's genuine wishes and reassure them that everything would turn on well.

Shreelata was twenty two years of age and was struck by a very rare malignant bone tumour for which she was to be subjected to a major surgical procedure disarticulation of hip joint. In this operation, the entire lower limb is removed from the hip joint and entails a fair amount of blood loss. Her pre-operative check did not reveal any abnormality in the heart, lungs, blood etc. Despite her malignancy, she was otherwise a perfect specimen of good health. Surprisingly, the nature of her disease and the magnitude of the surgical procedure did not upset her mental equilibrium. Any other young person would have become distraught on hearing that he or she would lose an entire limb. Otherwise a bubbly girl, she was rather calm and collected the day prior to surgery. Her usual babble was missing and this surprised her parents. Early morning, on the day of her surgery, which was scheduled to take place at 9.30 a.m., as she sat gazing out of the window in her room, watching a glorious sunrise, she made a chance remark to her mother that she doubted if she would ever see a similar sunrise again. Being a late riser, yes, she hated to be awakened early in the morning, her mother ignored her remark. Moreover, Shreelata often made humorous remarks maintaining a straight face and her mother was used to them. When, however, Shreelata repeated what she had said earlier about not likely to see the sunrise again, her mother admonished her and told her that if she would not get up early she would always miss out on sunrises.

The major surgery and anaesthesia were uneventful albeit we had to transfuse a fairly large amount of blood to her during the difficult procedure. After a couple of hours in the recovery room during which time she had fully regained her consciousness, she was shifted to her room. She requested her mother to fetch her some coffee as she could smell the rich aroma of a coffee decoction from an adjacent room. The mother turned down her request as it was too early after surgery.

After some time, Shreelata again requested her mother to hold a cup of coffee near her lips, saying she would never again ask the mother to repeat this act. Yet again the mother did not oblige as there were strict medical orders not to give the patient anything orally for at least six hours after the surgery. Exactly an hour after the unusual request, we received a Call from her room saying that Shreelata had suddenly taken very ill and that her blood pressure was not recordable. When the resident doctors rushed to her bedside they found she was pulseless. No amount of resuscitation could save her post mortem did not reveal any significant causative factor. Was she hypersensitive to the pain-killer that had been given to her? One still does not know.

After the nurse's tragic death her grief-stricken mother rushed to my room and related Shreelata's unusual remarks and request. I still fail to understand such strong intuitive powers. Or was it that her chance remarks and subsequent death a rank coincidence? God alone knows.

Finally there is also the humorous side to this cancer hospital scenario. There was this huge. hefty house surgeon (junior doctor) who was just a few days old in his house post at the Tata Memorial Hospital. After a procedure of disarticulation of the hip joint in a young man of about years performed by his senior, this young doctor deposited the excised Timb in a bucket in the operation theatre. The next day the discarded limb found its way into the municipality kachra van. Very soon one could hear undue commotion in the hospital premises due to the presence of a large number of police constables and a Sub-Inspector who had arrived to investigate what they suspected to be a case of murder. Only after showing them the 'live' patient and a detailed explanation of the young house surgeon's foolhardy and ignorant behaviour did the police relent and leave the 'mystery' unsolved. Normally when such parts of the body are surgically excised, there is a protocol to be followed and the happy-go lucky surgeon, who was totally unaware of it, promptly dumped the limb into the operation theatre waste bucket. Needless to say that we all had a hearty laugh after the departure of the police. The patient, too, in his misery managed to give a faint smile!

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