Some lessons I have learned (Sometimes the hard way)
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.190280
Source of Support: None, Conflict of Interest: None
When the editor suggested that senior members of the Society record their early experiences, which would be of interest for the present generation, I readily agreed.
I had two choices. One would be to report on the difficult working conditions that existed when I started neurosurgery 55 years ago, with no catheter angiogram, computed tomographic scan, magnetic resonance imaging, ventilator, intensive care unit facilities, mannitol, bipolar cautery, operating microscope, shunt, endoscopy and chemotherapy. The other would be to write about the lessons that I have learnt during my training period and later on. After weighing the two choices carefully, I chose the latter option. The reason was that the lessons learnt over the years may be of relevance not only for the present generation but also for the future generations.
Respect your 'gut feeling'
In 1956, when I was a fresh resident in the unit of the Professor of Medicine, a case of pyrexia of unknown origin was admitted. Clinically, there was no relevant information to suggest a specific cause for the fever. In particular, there was no altered sensorium, neck stiffness or focal neurological symptoms or signs.
My chief asked me to do a lumbar puncture. The cerebrospinal fluid was frankly purulent. I asked him why he had suspected meningitis. He said, “I don't know. It was a hunch.”
Very often one's long clinical experience makes the subconscious mind 'reason' and reveal a 'gut feeling' regarding a possible diagnosis although there may be no historical, clinical or laboratory evidence to support it. Respect your gut feeling and do further tests to confirm or exclude the suspected diagnosis. More often than not, you may be right.
I have seen a 'classical' cervical spondylosis turning out to be syringomyelia, a 'typical' dissociative reaction proving to be a seizure disorder, and a 'text book appearance' of a glioma dissolving with antituberculous treatment. Only a feeling that 'something did not click' made me ask for a magnetic resonance imaging of the spine, video electroencephalogram and magnetic resonance spectroscopy, respectively, in these three cases.
Big projects can be done by busy clinicians
When I was leaving the Neurosurgical Department at Edinburgh after four years of training, my chief, Professor F.J. Gillingham, President of the Royal College of Surgeons gave me some very practical advice. He said, “When you return to India you will be very busy with an enormous clinical load. You may not have the support of radiologists, nurses, physiotherapists and secretaries as you have in Edinburgh and you may have to do a good part of their work also. Do not neglect your research work because of the work load. Choose one good topic – it may be post- traumatic epilepsy, or tuberculomas, or pathological spinal fracture. Set apart half a day or quarter of a day every week for meticulous documentation of the cases and spend time in taking photographs of the radiology. At the end of ten months, you would have gathered 50-100 cases. Spend the weekends of the next two months searching the literature, doing the statistics, etc. At the end of the year, you would have a good paper for a national or international journal. At the end of 20 years, you would have published 20 to 25 good papers – which in fact would be much more than many neurosurgeons in UK or USA would have done.” I have followed this advice and have succeeded in a great measure.
When in doubt, never fail to check the facts personally
During my first year of training, a young child was admitted after a head injury, fully alert and conscious and with no neurological deficit. Radiographs of the skull and cervical spine showed no abnormality. The epiphyseal line below the odontoid was seen. Two days after admission, while playing, the child stood up in the bed and then suddenly collapsed and died. When I referred to the books, I found that the epiphyseal line fuses much earlier during the age of a child and what we saw was a fracture line. The child probably died from an undiagnosed and untreated, unstable fracture-dislocation at the atlantoaxial level. It was a poor consolation that my seniors had also missed the diagnosis.
Learn the maximum possible in the subjects outside your specialty
In 1957, when I was posted as a house-surgeon, I met Dr. B. Ramamurthi, who asked me which ward I was working in at that time. I replied that I was doing a posting in general medicine. Dr. Ramamurthi asked me to spend the entire period of 24 hours in the medical ward and learn as much as possible. I wondered why I should do so since I was planning to take up a career in surgery. He told me, “Do you realize this is the last posting in your life in which you will examine cases of viral hepatitis, pleural effusion and mitral stenosis in detail? You will never get this chance again in your life. You can always learn surgery later. You will have many years as a postgraduate student or as a surgical registrar. But for medicine, this is your last chance.” It was a very sane advice indeed. The same applied to general surgery (although I was aspiring to became a neurosurgeon later!). I am happy to state that I have diagnosed hypothyroidism, jaundice, ruptured spleen, impacted fracture of the femor neck, etc., when others with more experience in these specialties had missed them – thanks to Dr. Ramamurthi's advice.
Always check the theatre nurse's sterilized instrument table before starting surgery
When I planned my first craniotomy in 1973 in a private nursing home after fourteen years of operative experience in government hospitals, the theatre nurse told me that she had assisted in several neurosurgical cases earlier. I made the burrholes and asked for the Gigli saw. Those were the days when power driven instruments had not been introduced. She turned round and asked me, “What is a Gigli saw?” There was no saw available. I slowly and meticulously connected the burrholes by nibbling the bone in between with a fine double-action rongeur. Fortunately, the operation went off well without any further problem. It is always wise to check the instrument table and ensure that spares are available. I have heard of a 'near disaster' happening in a teaching institution when a suitable aneurysm clip applicator was not available during surgery undertaken for aneurysm clipping.
Detailed history taking is the most important aspect while attempting to establish a neurological diagnosis
This has been emphasized again and again by all our teachers and in all our text books but still we let an occasional lapse occur. In many cases of headache, facial pain, transient ischemic attacks, seizures, minor head injury, etc., only a detailed history can guide us properly.
I came across a case of a middle-aged housewife, who had her first attack of generalized seizures in sleep. She was investigated in thorough details to exclude a cause for 'seizures of late onset' in two big corporate hospitals. An electroencephalogram, a detailed analysis of the plain and contrast computed tomographic scan as well as a plain and contrast magnetic resonance imaging scan, an echocardiogram and a whole battery of blood tests were done and all results turned out to be normal.
Talking for fifteen minutes with the husband after all these tests had been done revealed the fact that he had administrated 5ml of eucalyptus oil to her a few hours before the seizures, for her upper respiratory infection – a household remedy that some friend had suggested.
Tell the truth but give them hope
When a patient has a tumor of the brain, the close relatives ask me, “Doctor, is it cancer? How long will he live?” I have a simple method of answering. I tell them, what I have learnt from my teacher, Professor Norman Dott.
“If there are a hundred patients with this type of tumor, half of them may not survive more than a year. However, more than twenty of them are likely to survive even up to three or more years. We can only guess to some extent. Let us hope that he will be in the last category. But let us also be prepared, in case he falls in the first category.”
We have warned them that the patient may die within a year but at the same time, we have given them hope that he may be in the lucky twenty percent who may survive more than three years. The human mind always believes that there is a high probability of getting that one-in-a-ten thousand chance of a lottery prize but does not believe there is a reasonable probability of that one-in-ten chance of a road traffic accident while driving above the speed limit.
Publish any new finding immediately
In the 1960's, Dr. Ramamurthy, Dr. Balasubramaniam and I had quite a few cases of clinically definite lumbar disc protrusion with myelographic block. The laminectomy showed no disc bulge and the wound was closed as a 'negative exploration.' Postoperatively, the patients had very good symptomatic relief. We did not pursue the matter to find out why this had happened. We did not publish our findings. A few years later, Verbiest got international recognition for describing lumbar canal stenosis.
A decade later, one day I got a call from Dr. Ganapathy in the operation theatre. He was doing a laminectomy on one of my patients for a middorsal myelographic block. The bone was very thick and the ligamentem flavum was unduly hypertrophied. There was no tumor. He successfully achieved decompression and the patient recovered from his paraparesis. We did not publish the case. A year later Clinical Neurosurgery published the entity of dorsal canal stenosis.
May be, we did not have enough confidence to announce our findings publicly. May be, we were too busy treating and teaching to publish our findings.
Train your mind to always be confident
Hundred percent psychological fitness for the clinician is as important as hundred percent physical fitness.
It may be through yoga, meditation, prayer or any other suitable method.
I have heard that Dr. Jacob Chandy, the Founder President of Neurological Society of India (NSI) used to pray before and during difficult operations. I have seen Dr. B. Ramamurthi, the Founder Secretary of NSI keep a picture of Goddess Saraswati in his room in the operating theatre and pray to her before starting surgery.
While scrubbing up for any surgery, I have always prayed to my Guru that the outcome of surgery be successful.
To get the best results in the treatment of our patients, we must always have sufficient knowledge, skill and experience as well as supporting staff and infrastructure. There are also many other protocols and precautions that we need to observe. I have outlined some of the important lessons that I have imbibed over the years.