Category Archives: Medical Story

Not like it’s ‘brain surgery’!

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An extradural haematoma is a condition which happens after a head injury. It is a collection of blood that builds up in the space between the skull and the outer covering of the brain, the dura mater.

The brain is protected by several layers. First is the scalp, which is the tough skin covering the head. Under that is the skull, a hard bone that protects the brain. Beneath the skull are three layers called the meninges: the dura mater, arachnoid mater, and pia mater.

Layers covering the brain

The brain continues downward as the spinal cord, which passes through an opening at the base of the skull called the foramen magnum and into the spinal canal, which is made up of bones stacked on each other but interlinked called vertebrae. There are a total 33 vertebrae out of 5 are fused as the sacrum and 4 are fused as the coccyx. The stacked arrangement gives the spine flexibility, due the multiple joints. The meninges also cover the spinal cord.

The brain and the spinal cord float in a special fluid called cerebrospinal fluid (CSF), which helps cushion and protect them from injury.

After a head injury, a small fracture in the skull can sometimes tear a blood vessel on the surface of the dura mater—usually an artery called the middle meningeal artery. This causes bleeding in the space between the skull and the dura mater. The resultant expanding clot presses on the brain. The brain has the consistency of ‘Jello’ and can get easily compressed. At first, this pressure may compress the brain to the opposite side of the clot, and then downwards and out through the foramen magnum.

In essence the clot occupies the space previously occupied by the brain, by squeezing it out through the path of least resistance, the foramen magnum.

This wrecks havoc and initially causes headache, nausea and vomiting, followed by confusion and drowsiness progressing into a deepening coma.

There will be weakness of the body on the opposite side of the haematoma, because the right and left hemispheres of the brain control opposite sides of the body.

There will be a dilation of the pupil on the same side of the haematoma because as the brain is pushed to the opposite side, there’s traction on the 3rd cranial nerve as it emerges from the base of the brain and exits via another opening in the skull, the cavernous sinus to supply the eye. As the brain is pushed to the opposite side it gets stretched.

The good thing about extradural haematoma is that there is no injury to the substance of the brain, the symptoms are caused by the compression, hence timely evacuation of the haematoma would result in a complete recovery.

There is what is called the ‘lucid interval’ which occurs in 20%-50% of the cases. This is characterised by a period of lucidity between an initial brief period of loss of consciousness followed by a prolonged period of deepening coma.

Initially following the trauma to the head there’s a loss of consciousness due to ‘concussion’, which is a temporary loss of consciousness, following a head injury, with complete recovery and no neurological deficits.

The patient recovers from the concussion but due to the expanding clot in the extradural space, the patient again loses consciousness and progresses into a deepening coma.

‘Lucid interval’ though not present in all cases of extradural haematoma, if presents is highly indicative of an extra dural haematoma.

I did my surgical residency in Punjab, in the late 80s and 90s, when the secessionist movement was at it’s peak. Trauma a plenty with bombs exploding regularly in front of the police station near the hospital, terrorists opening gunfire in market places and on social gatherings. Once we treated a film crew who were shot at during the shooting of a Punjabi film, ‘Jatt te zameen’. The reigning superstar of the Punjabi film industry Veerendra Singh, who was starring was brought dead to the casualty. He was a cousin of Bollywood film star Dharmendra.

Then there were penetrating head injuries. Among the cases I can recollect there was a young man, who was shot in the head by a 12 bore gun. The cartridges of a 12 bore contain multiple pellets which didn’t penetrate the skull but were embedded all over the scalp. A 14 year old boy shot point blank with the muzzle of the 12 bore kept below his chin. One entire half of his face was blown away. His tongue hanging free and his epiglottis was visible opening and closing with each breath revealing the glottis.

The miraculous thing was both of them survived, the young boy underwent extensive surgery, lost one eye and ear and half of his face but lived to tell the tale.

Another case where a husband attacked his wife with an axe. He opened a good portion of the forehead exposing the frontal lobe of the brain. She too survived to put a case against her husband, for which I had to go to the court as a witness.

Then there were the blunt traumas to the head secondary to road traffic accidents and violence, the victims were invariably under the influence of alcohol and were extremely restless and sometimes violent. One was a boxer who had fallen off the back of a motorcycle, while riding pillion and sustained injury to the back of his head. He was disoriented and restless and almost impossible to restrain. He would easily lift off from the ground two orderlies trying to tie down each arm, like doing a pectoral fly but using two men instead of dumbbells in each hand.

In those days chlorpromazine, an anti psychotic drug was injected to calm down the patient.

Once sedated they could be taken for a Computed Tomography Scan (CT Scan) to assess for brain injuries. The reports could vary from brain contusions, subdural haematomas and of course extradural haematomas.

I was posted as surgery residents in Neurosurgery and as there was no post graduation program in the department of Neurosurgery, I had to fill that role. The pecking order was the Chief, the lecturer and then us. I got exposed to a variety of surgeries.

In neurosurgery like in any surgery the first step is the exposure of the area of interest. In abdominal surgeries the abdomen has to be opened in order to operate, similarly in neurosurgery the skull has to be opened or craniotomy over the required area for the surgical procedure to be performed.

Surgeries had to be performed with the patient in various positions depending on the location of the lesion in the brain. Once we were operating on a portion of the brain called the cerebellum, which is located over the back of the head, just above the neck. The patient had to be seated with his head flexed forwards. Luck followed Murphy’s Law, which decrees, “What can go wrong will go wrong and at the worst possible moment”. In the midst of the surgery, the endotracheal tube or the tube which is inserted via the mouth into the trachea or windpipe, to ventilate the patient and deliver anaesthetic gases got dislodged and came out of the mouth. Because the patient was seated with a flexed neck and covered by surgical drapes, it was not immediately detected, until the brain started swelling and protruding out of the opening in the skull. Immediately the anaesthetist did the impossible of intubating or inserting a endotracheal tube in the seated position. Mind you that’s not an easy task and quoting Shakespeare, “All’s well that ends well”, the patient had an uneventful recovery.

The swelling of the brain was due to the buildup of carbon dioxide and lack of oxygen. Seeing an actual demonstration of this phenomenon made me realise the importance of oxygen in a head injury patient. The brain being already swollen due to trauma gets further swollen due to hypoxia or a lack of oxygen.

I learnt how to do craniotomies which unlike what is commonly believed about ‘brain surgery’ is fairly easy. First is to plan craniotomy according to the location of the lesion, then if possible to avoid crossing the midline as there’s the saggital sinus in the midline. The saggital sinus is a channel carrying venous blood enclosed by the dura mater. Also avoid going too posteriorly as the transverse sinus crosses there.

The logic being if you drill into the sinus you will encounter torrential bleeding which will be very difficult to control.

After planning the location of your craniotomy an incision has to be made on the scalp. This is in the form of a flap with a wide pedicle to prevent devascularisation or loss of blood supply to the scalp the flap preferably should be within the hairline as to be cosmetic.

A very popular question which is asked to residents in neurosurgery is ” What is the most important covering of the brain?” The answer is the scalp and not the skull as most people believe!

I encountered so many craniotomies done in other hospitals where there’s a defect in the skull covered by only scalp. Rather than cutting a flap of bone, a hole was nibbled in the skull and the scalp was sutured back over the defect. The patient is otherwise perfectly alright except for having a concavity on the head.

We treated this by sending the patient to the dental department where they take an impression of the defect and make a prosthesis, made out of the same material dentures are made of, to fit the defect.

The scalp again had to be opened and the prosthesis always fitted perfectly, sometimes it required some minor adjustments. The prosthesis was then anchored over the defect and the scalp closed. The patient had satisfactory contour of his head.

These days thanks to 3D printing a perfect prosthesis can be made to fit in the defect, like a hand in a glove.

Our plastic surgeon once used the flat bone from the ileum, which is the large bone deep to the buttocks. He only took just the outer layer of the bone along with it’s supplying blood vessel and placed it to cover a defect in the skull. The bone had a natural convexity matching that of the skull and the blood vessel was anastomosed or joined to the blood vessel in neighbourhood and voila! The patient had a living bone covering the defect.

Returning to the subject of crainotomies, once the location is planned and an incision is made in the scalp, holes called ‘burr holes’ are drilled on the skull in a polygonal pattern, either pentagonal, hexagonal, octagonal or nonagonal pattern depending on the size of the opening required. While drilling the holes the dura mater is not punctured.

A. Scalp incision B. Burr holes
C. Surface of dura exposed D. Surface of brain exposed

Then a Gigli saw wire is passed between adjacent holes and the intervening bone is cut. When all adjacent holes are connected a bony flap is raised having a polygonal shape. The advantage of having this bone flap was it could be replaced over the defect once the surgery was completed, avoiding the concave defect in the skull.

The Gigli saw is a very simple but versatile instrument. It consists of a thin, twisted stainless steel wire with serrated edges. Like a piano wire. It has detachable handles at each end for gripping. Designed to cut through bone with a back-and-forth sawing motion. It can easily threaded through two adjacent holes and the intervening bone cut.

Ironically it was originally designed by a Obstetrician and was used to divide the symphysis pubis in cases of obstructed labour, when Cesarean section was not safe.

Once the skull is opened, depending on the pathology, either on the dura mater or on or within the brain, an opening can be made in the dura mater to expose the surface of the brain.

I was gradually initiated, first I was allowed to make an incision on the scalp. The scalp being very vascular, the bleeding had to be controlled by holding the inner layer and everting the scalp.

Next I was allowed to make the burr holes, this was done using what is called the’Hudson brace’ which essentially is like a carpenter’s drill. It had two tips, one is called the perforator which we use to penetrate the skull and the other is called the burr, which is used to widen the hole.

Initially the perforator is used till the thickness of the skull is penetrated and a small opening is seen at the base of hole. Next it is widened with the burr. It blunt tip but has bevels around it’s circumference and widens the hole.

Once burr holes made in a polygonal pattern over the skull we next got to join them with a Gigli saw. The wire of the Gigli saw is threaded through one burr hole and brought through an adjacent burr hole. Then the handles are attached and the wire is moved in a to and fro motion. The wire cuts the bone smoothly and once all the holes are connected, we have a bone flap which can be lifted off.

The skull because of it’s dome shaped design is very tough and does not fracture easily but the portion of the between the ear and forehead, behind the eye and above the zygoma or cheek bone is the weakest portion. This portion is called temporal region also colloquially known as the temple.

This area includes parts of several bones—primarily the temporal bone—and it’s a sensitive region because it has relatively thin bone and several important blood vessels and nerves running through it. That’s why a blow to the temple can be particularly dangerous.

In most martial arts the blows are aimed at this region as this can result in a KO or knockout. In Karate, Kung Fu and Muay Thai there is the round house kick which aims at hitting the temporal region with the side of foot or shin.

The protective gear worn is designed to protect the temporal region. Trauma to this region can result in fracture or in children who have an elastic bone just bending without breaking. On the surface of the underlying dura mater lyes the middle meningeal artery, the anterior branch of this artery is prone to injury and bleeding and an expanding haematoma collects in this region.

Before the advent of CT Scan diagnosis of an extradural haematoma was not very easy. A plain x-ray of the skull could show the calcified pineal body being pushed to one side. A cerebral angiography could be done which is injecting a dye which is radio-opaque into the internal carotid artery. An x-ray taken would outline the brain and demonstrate compression and deviation.

When there’s adequate suspicion an exploratory burr hole can be made on the side of the trauma. This is normally made just above the zygoma or cheek bone, midway between the eye and ear. You will encounter blood clots which will confirm your diagnosis. Then the same burr hole can be enlarged using a bone nibbler and the clot evacuated or burr holes made around it which are joined and a bone flap is raised. The advantage of creating a flap is there’s no defect and concavity in the skull.

With the advent of CT Scan things have become easy, a convex opacity is seen in the scan and the degree of compression and deviation of the brain from the midline can be assessed.

When my lecturer became confident in my abilities to do a craniotomy he allowed me to do a craniotomy for a case of extra dural haematoma. After reviewing the CT Scan he instructed me to make a ‘trauma flap’ on the scalp and then do the craniotomy. He drew the trauma flap for me, which started from the forehead on one side without crossing the midline and ran parallel to the midline posteriorly, then took a curve downwards and returns to end just above the ear.

I’m happy to say that the surgery was successful and the patient’s recovery was uneventful.

After completing my surgical residency I joined a hospital in a remote rural area, the population was 70% tribal. I had a lot of training but now was to put it into practice.

One night a young patient was brought unconscious to the casualty. He was a travelling salesman who sold blankets. He had gone to a nearby village to sell his blankets and had some altercation with the villagers who were drunk with the local brew ‘mahua’. One villager hit him on his right temple with a lathi. He lost consciousness momentarily but recovered and then went with his companions to register a complaint in the local police station. After registering a complaint he returned to the dharamshala where he was staying and lost consciousness.

His companions took him to the district hospital but they were unable to do anything for him. He was then brought to our hospital in the night, where the emergency doctors saw him and admitted him.

I saw him in the morning, he was deeply comatosed and both his pupils were dilated.

Going by the history of lucid interval I could come to a diagnosis of extra dural haematoma but since we were in a remote area we didn’t have the facilities for a CT Scan to confirm my diagnosis.

I was faced with a conundrum, if I referred this patient to the major cities which were 200 kms away, by the time he reached he would be unsalvageable. We had the equipment to perform a craniotomy so I explained the situation to the relatives and after taking they’re consent I proceeded on.

The anaesthetist said that he was so deeply comatosed that he would intubate him but not give any anaesthetic gases, only oxygen.

I positioned him to left side with right side of the head up. I first made a vertical incision over the temporal region and made a burr hole, I got got clots from the burr hole, confirming my diagnosis.

Next I thought whether to enlarge the burr hole or raise a bone flap. I opted for the bone flap. I made a trauma flap on the scalp and five burr holes around the first one. I joined the holes using a Gigli’s saw. Once I lifted the bone flap I could see the dark red clot. After evacuating the clot I could see the bleeding vessel which I ligated. Then I took stitches hitching the dura to the craniotomy opening. Then a drain was placed on the dura and the bone flap was replaced and the scalp closed.

By the time I finished the surgery the patient regained consciousness and began to move. The anaesthetist had to now supplement him with anaesthetic gases.

The patient made a dramatic recovery and only had hemipareisis or weakening of the left side of the body. This would also would improve with time.

I consider this one of the most satisfying moments of my career when I could use my knowledge and expertise to save a life. This was the reason why I became a surgeon.

Dr. Jodaram

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One of my Professors made a statement which rings true to this day, “you can teach a ‘monkey’ how to operate and he will do a fairly good job, but what differentiates a monkey from a trained surgeon is, knowing the indications for operating and post operative care!”

Let me illustrate these points by a few examples, before I had joined MS course I worked as a junior doctor in a rural mission hospital. The hospital was well equipped and run by NGOs. One fine day the orthopaedic surgeon asked me out of the blue, “do you want to do an amputation?” Harbouring dreams of becoming a surgeon, I couldn’t wait to get my hands on a scalpel. I replied in the affirmative, to which he said “Gaekwad will teach you how to do an amputation”.

On the face of it Gaekwad did not seem to have the academic qualifications to be a teacher or for that matter, to operate. He had a high school degree and a certificate for rehabilitation of leprosy patients. But years of assisting various orthopaedic surgeons in the operating theatre had taught him the ropes. He was a patient and ‘respectful’ teacher, very unlike normal teachers who show scant respect to their students. It may have been my superior paper qualifications. So this student teacher relationship was on an unequal footing.

Thus began my first foray into a life with a knife. Though I was the one holding the scalpel, it was Gaekwad who was gently directing me, “Cut here, okay there’s a blood vessel here so tie it and a nerve here so cut it high”. Those were sound principles as if you leave the nerve long it could grow to form a neuroma and give rise to neuralgic pain over the stump.

In a limited field he was good. He may not be competent enough to do a complicated surgery but he was good at fractures and nailing bones, perhaps better than some orthopaedic surgeons. He did everything under the guidance and shadow of an orthopaedic surgeon. But the decision regarding the surgery or which patient would benefit with which surgery he would not be able to decide. In case there were complications following the surgery, he would not be able to handle it. What he was good at is to mechanically do the steps of an operation and with practice he had achieved a degree of perfection.

Fast forward 5 years and I returned to the same hospital with a MS general surgery degree against my name. I did all the general surgery operations leaving the orthopaedic work to the specialist. The orthopaedic surgeon was going on leave for 15 days and he asked me to look after orthopaedics during his absence. I confessed that I’m at sea regarding orthopaedics. His reply was “No problem you have Gaekwad and Titus to help you”. Gaekwad was considered the orthopaedic surgeon and Titus the orthopaedic physician. “If any patient comes with a fracture and only requires close reduction and plaster than the duo will do it. If it’s more complex requiring surgery then explain to the patient that we cannot operate immediately, because there is excessive swelling. He will require elevation of the limb and splinting followed by surgery. I should be back by then”. In this fashion I handled an orthopaedic unit, being the mere face of the unit whereas the grunt work was done by the duo. I looked after the general management of the patient. This is not unique as I have seen many orthopaedic surgeons dependent on technicians for placement of implants.

In this hospital there was a single qualified anaesthetist and two male nurse anaesthetists. These male nurses had done nurse anaesthetist course and were extremely efficient. They could give spinal anaesthesia, epidural anaesthesia, intubate the patient and even do single lung intubation. They managed the patients independently but were under the umbrella of the anaesthetist.

I like to give the analogy of an automobile engineer and your friendly neighbourhood car mechanic. The engineer knows all the theory, that the differential produces so much of torque etc. But he would be lost if you brought your car to him to fix. But the mechanic though may not know the physics behind the car engine design or would be unable to design a new car but by experience and trial and error, he fixes the car. He tightens some screws needs and some part needs to be gissoed (grinding) and will fix your car.

This is also true of a fresh MBBS graduate, who is bursting with knowledge but is at sea as far as the practical application of the knowledge goes. He learns the practical once he becomes an intern and is thrown into the management of patients.

When I joined as a surgical resident in Punjab, on my first call day I went to see a patient in the casualty. I met a ward boy (despite being middle aged, he was still known as a boy) in the casualty. He had been working in there since he was 18 years old and had risen from the rank of sweeper to ward boy. He greeted me warmly and told me that if I needed to do any emergency surgical procedures like tracheotomy (making an alternative breathing site in the neck), chest tube insertion (inserting a tube in chest for a collapsed lung) or venesection (inserting a intravenous line), he could assist/teach me.

He claimed to have a diploma in Ayurvedic medicine from Bihar by paying ₹400/-, which I suspect was fake. He always took the night shift which suited him but was unpopular with others, because he could practice ‘daktari’ during the day. I enquired what this ‘daktari’ entailed? To which he replied that he has his regular clients of rich business men or ‘lalas’, who were suffering from the problems of plenty like obesity, heart condition, hypertension and diabetes. He would administer their insulin shots and check their blood pressure. He also worked as a compounder for another doctor in the city, doing dressing, giving injections and dispensing drugs. He had his own clinic in the slum area where he lived and a devoted following of patients. He was Jodaram to us but his patients referred to him reverentially as ‘Dr. Jodaram’!

Once in a while a patient would stray into the casualty and ask for Dr. Jodaram. They would consult with him, show him a prescription given to them by some other doctor, for his opinion. He would then bring the prescription to me or to any other doctor present and say, “Doctor sahab yeh kya likha hai? Aaj meine chashme nahi laya hoon, padhna mushkil ja raha hai” (Doctor can you tell me what’s written, I have not brought my glasses hence having difficulty reading). Then I realized that he was barely literate, he could just about sign his name. He would ask what the drugs were for and whether they were appropriate and then convey the same to his patient. I wonder what he did for prescribing patients!

Another example in the same hospital was our head of plastic surgery’s assistant Rattan or ‘Rattanji’ as we had to reverentially refer to him. On my first days in plastic surgery posting, the Boss told me, “Rattanji and me are your teachers”. Rattanji was again a high school graduate but had the intelligence and aptitude to pick up things. The Boss used to perform specialized microvascular surgeries like reimplanting amputated limbs and fingers. There was one injury which was unique to Punjab. Since a majority had long hair, on Sundays they would wash their hair in the morning and leave it open to dry. Next they would start their agricultural water pumps to irrigate their fields. Very commonly their loose hair would get entangled in the spinning wheel of the pump pulling the hair and along with it avulsing the scalp from the cranium. Literally getting ‘scalped’. Patients would come to the Casualty with a bandaged head and holding a portion of the scalp with the hair still attached to it.

Another agricultural equipment which was a responsible for giving us patients was the ‘toka machine’. This was used for chopping stalks and chaff into small pieces to make fodder for the cattle. It consisted of a wheel whose spokes were sharp blades. The wheel had to be rotated and the bundle of stalk inserted slowly into wheel. The blades would chop the stalk into small pieces. Two scenarios resulting in accidental amputation of finger were, the person holding the stalk and pushing it into the wheel would accidentally push their finger along with the stalk into the wheel. After use if the wheel was not properly locked, to prevent the wheel from rotating, children playing with toka machine would get a finger amputated. The flip side of a toka machine amputation was that it was a clean slice and was amenable to reimplantation.

Toka Machine

Reimplanting scalps is difficult due to the multiple blood vessels, but our boss was very good at it. The only person he trusted to assist him was ‘Rattanji’. He knew the specialised instruments and how to assist. A wise person rightly said “To be a good surgeon you need to be a good assistant”. The assistant should know the steps of the surgery and anticipate what instruments or what retraction the surgeon would require. I sometimes equate it to a waltz where the dancing pair know the steps perfectly, when to sway pirouette and bow. But it should not become a Tango!

Rattanji was the perfect partner in the waltz, anticipating the surgeon’s needs perfectly. When the surgeon extended his hand he would know exactly which instrument he wanted without being told. When we had an exceptionally long list in plastic surgery we used to rope in Rattanji to do some of the minor procedures or suturing. He claimed he could do a cleft lip repair surgery and other plastic surgeries.

I am sure everyone in the medical field may have encountered a version of ‘Dr. Jodarams’ and can recount the case of a paramedical staff who was as good as a doctor in a limited field.

The killer string!

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Nylon ‘Chinese’ manja

Tuesday, 8th February 2022 at 5:30 pm NS, a 25 year old photographer by profession, stepped out of his house in Bhim Chowk, Jaripatka, Nagpur. Little did he know what fate had in store for him. Aptly demonstrating the unpredictability of life.

He was rushing for an assignment at a tony Hotel in the city. He was dressed to the nines with freshly coiffure hair, spiffy clothes and a gold chain around his neck. He got on his two wheeler and because he was running behind time, he drove at a fast pace. The route took him through crowded localities with narrow lanes.

A month had passed from Makar Sankranti when traditionally kites are flown but there were some stray kites still flying from the roofs of houses. Suddenly NS felt a sharp piercing pain in his neck. He had been snared by a stray kite string, suspended across the road between two buildings. The string dragged him off the vehicle and onto the ground. The vehicle drove driverless for some distance before toppling over. He put his hand on his neck only to find his hand covered with blood. He could feel a huge gash across his neck which was bleeding profusely. He immediately took out his handkerchief and tied it around his neck. Meanwhile bystanders gathered around and began clicking pictures and videos of the accident. He tried to appeal to them for help but no sound came out of his mouth, only wind escaping from his neck with gurgling sound. The thread had cut through his neck and severed the trachea or wind pipe below the vocal chords rendering him literally voiceless. He was a victim of the killer string, the infamous Chinese Manja.

Cut with the open trachea

Makar Sankranti, Uttarayan, Maghi or Pongal as it’s called in various parts of India, marks the entry of the sun into the ‘Makar Rashi’ or Capricorn. This normally occurs on 14th of January on non leap years and the 15th on leap years. It’s celebrated in various ways, from bonfires, sweets to flying kites.

The cotton string of these kites were traditionally treated with a mixture of rice paste and tree gum as binders, mixed with powdered glass got from crushing tubelights or bulbs, dye and other secret exotic ingredients like the contents of a torch battery. To coat the string with the mixture it is strung between two convenient poles, a lump of the mixture was rubbed along the length of the thread allowing the thread to get coated. To avoid the applicator’s fingers getting cut he wears small tubes on each finger or taped his fingers. This sharp string is called ‘manja’.

All these preparations were for the traditional kite fights. The kites are maneuvered so that the threads of two kites would get entangled in an embrace and rub against each other or ‘pech ladaana’ as it’s known in local parlance. One of the kite’s string would get abraded due to the friction and the kite would float loose. In Nagpur this is followed by a shout in unison by the people flying the victorious kite, “O paar” or “O kaat” depending on which part of the city they’re from, which means the kite is cut. In Gujarat the shout is “kai po che”.

Then there are the kite runners, consisting of children and even adults, scanning the skies and waiting for a kite to go adrift. They chase the kite armed with long bamboo poles having a dry thorn bush tied to the end, to snag the kite thread and claim the kite as a prize. This is called ‘patang lootna’ or looting a kite. The kite itself has hardly any value but the looting was part of the fun and tradition. Then there are the Sharayati, people who place bets or sharayat on which kite will be victorious. Huge sums of money exchange hands.

Behind this seemingly innocuous sport there is a sinister undertone. In a quest to have stronger and sharper manjas, in last 10 years the traditional cotton string was substituted with nylon string, the so called ‘Chinese manja’. Despite it’s name the Chinese manja is not necessarily from China. It is a desi spun product but given that moniker because it was cheap. The fibres, maybe imported from China. This manja is coated with glass and metal filing and is extremely sharp and unbreakable. This manja is capable of slicing through flesh like a hot knife through butter. Unlike the cotton string it is not bio-degradable.

The kite strings get strewn around trees, between buildings, lamp and electric poles. If it crosses a road and an unsuspecting person on a two wheeler gets snared by it, it’s capable of inflicting deep wounds. Invariably it slides over the body but gets hooked at the neck and cuts through the neck. The traditional cotton manjas were sharp but had a low snapping point. They caused damage but not usually deep. The Chinese manja has a very high snapping point enabling it to cut deep and inflict damages.

The kite runners while chasing kites grab on to kite strings which may cross the road and injury an unsuspecting two wheeler rider. The kite runners are so intent on looting a kite that their are oblivious of the traffic and can get hit by a passing vehicle. They also position themselves on rooftops to have an advantage of height to grab onto the string. Fall from buildings are very common. I have treated a small boy who fell from the roof of a house and his thigh got impaled on the spikes of a gate.

Then there’s the betting by the Sharayatis. Betting is illegal but the authorities turn a blind or Nelsonian eye to it. Because winning involves not getting your kite string cut, the demand for the stronger Chinese manja shot up. Now no one can survive a kite fight without using the Chinese manja because cotton manja stands no chance against it.

The manja being non degradable poses an environmental hazard and to birds who also get entangled in it. The National Green Tribunal declared a ban on this manja. But despite the ban, it’s observed more in it’s breach. The Chinese manja can be easily brought in the black market or it is sold in the guise of industrial use.

There were a sequence of events which saved NS’s life. You can call it fate or an act of God or as the Hindi saying goes ‘jako rakhe saiya, mar sake na koi’ (A person blessed by God, cannot be harmed) .

The first was a friend of NS happened to be passing by the accident site and when he saw NS he immediately rushed to his aid. He hailed a passing e-rickshaw and took him to the nearest hospital, which was Janta Maternity Home and Hospital.

The second event was I normally have my consultation in Janta Hospital at 7 pm but that day I had to attend a meeting at 8 pm. I decided to go to Janta early and see my in-patients and miss my evening consultation. I parked my car near the hospital and walked to the gate. I saw an e-rickshaw coming at speed to the gate and attendants lifting a young man off the rickshaw and on to a waiting gurney. The clothes of the attendant were blood stained and the patient’s clothes were soaked with blood. I was told he is a victim of the infamous Chinese Manja. I immediately went along with the patient to the casualty and shifted him onto the examination table. On removing the handkerchief covering his neck, I was greeted by a gush of blood and a spray of blood mixed secretions from the transected trachea or wind pipe, as the patient coughed.

I thought for a moment, “this is way beyond my league!” and the thought of referring the patient to a higher centre briefly flitted through my mind. But then I saw a young man just beginning life, pale as paper, pulseless and a barely recordable blood pressure due to exsanguination . If I referred him in this condition then death was a foregone conclusion.

I recalled an incident during my surgical residency days, an ECG technician stabbed a Microbiology technician in the hospital campus due to personal disputes. The ECG technician knew the anatomy of the heart and stabbed him just below the left nipple, directly in the left ventricle of the heart. What saved him was he was immediately taken to the casualty and a cardio thoracic surgeon was available. The cardio thoracic surgeon took the bold decision of immediately opening his chest, between the ribs, at the site of the knife wound and controlling the bleeding with a stitch on the left ventricle. Once the bleeding was controlled he could be transferred to the operation theatre for a formal surgery. All done sans anaesthesia but the patient was knocking on heaven’s door and was oblivious of pain. This bold action saved a young life!

In Advanced trauma life support (ATLS) training in trauma medicine, there is the ‘Golden Hour’ concept, it is the period of time immediately after a traumatic injury during which there is the highest likelihood that prompt medical and surgical treatment will prevent death and reduce morbidity. I definitely didn’t have an hour to act so no time should be wasted. I went through the ABC of ATLS, which is airway, breathing and circulation. I asked the junior doctors and nurses to start an intravenous line and rush in fluids, administer oxygen and send a sample for immediate cross matching for blood.

I explored the wound to find the source of bleeding, the external jugular vein which was severed on the left side and was pouring blood. I managed to clamp and tie it. There were other smaller bleeders which could be tied off, luckily other major vessels like the carotids or internal jugulars were intact. Now I had a relatively bloodless field and could assess the damage. The trachea had been almost completely transected and was acting like a tracheostomy through which the patient was breathing. I covered the wound lightly with sterile pads and shifted him to the operation theatre. An urgent call for the anaesthetist was sent. I went out and spoke to the relatives, I told them he has a fifty-fifty chance of survival and I will give it my best shot and the rest is in the hands of the Almighty.

In the operation theatre I injected local anaesthesia into the wound and began suturing without waiting for the anaesthetist. The trachea does not have any sensation, I first sucked out the clots and blood in the trachea with a suction, the patient coughed reflexively. Then I began suturing the trachea, with 3 stitches the transected ends came together. There was no air leak and the patient began speaking. Now he was able to inhale the oxygen which was being delivered to him via a face mask. The first thing he said was that no one came to his aid at the accident site. Next I began suturing close the strap muscles of the neck and followed by the platysma which is a muscle just below the skin and finally the skin. His vital parameters like blood pressure and oxygen saturation improved. We finally felt that he was out of the woods.

Immediately after suturing
The next day
Two subsequent days

The patient made a miraculous recovery, he was up about and talking by the next day. He kept in intensive care unit (ICU) and monitored for possible complications like aspiration pneumonia from blood entering the trachea. But luckily his recovery was very smooth.

To quote Shakespeare “All’s Well That Ends Well”. I was lauded for my timely efforts which saved a life. But suppose things went bad? The same people would have criticized me for ‘biting more than I could chew’. The same relatives who touched my feet declaring me a God could have become violent. A patient living or dying is not in our hands, we can do our best but ‘there’s many a slip twixt the cup and the lip’. But ‘fortune favours the bold’ and I got a once in a lifetime chance to save a person’s life. As a doctor and a surgeon that’s what I was trained for. We should never shy away from being the good Samaritan.

News report

One of my classmates sent me this message, “Wow, impressive! Tell us more:

  1. How did you manage the airway to prevent aspiration without an ET tube? I see only an O2 mask
  2. Why under local? Was there no anaesthesia help available?
  3. If you had intubated through the mouth and got the end of the ET tube into the distal trachea and inflated the cuff, could it have prevented aspiration and served as a tracheal stent as well?
  4. Could he have been transferred to a higher centre where specialist anaesthesia help was available? Why the decision to repair immediately under LA?”

My reply was : “I work in a depressed area which has mainly a slum population. Luckily I was in the hospital when the patient was brought to the casualty. His external jugular were severed on the left side and he was in shock. Initially I planned only to resuscitate him. I caught the bleeders and started iv fluids. The trachea was lying open and already blood had gone in which I aspirated. The anaesthetist meanwhile had not yet arrived so I thought I’d close the trachea to avoid further aspiration. Once I had done that then I sutured the strap muscles and closed the wound. He was not in a condition to be immediately transferred and he would not have been able to afford a corporate hospital. The government medical colleges are in shambles, so I took the decision of managing him myself after taking the relatives in confidence.”

The wound today

Facing our own mortality in the pandemic panic

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Are we living or are we dying?
Both are true! Same as a glass of water can be half full or half empty.
In an increasingly uncertain life, two things are certain, first is that we are born and second is that we will die. Events in between are uncertain.

We all have an expiry date written somewhere but luckily we don’t know where and we cannot decipher it!
Suppose we could decipher it and know our date with fate, everything would become pointless. Our attitude would change completely from the enthusiasm of living and planning for the future to a feeling of futility because the future does not exist post expiry date!

In Tamil Nadu and Kerala there is a form of astrology called Nadi. It is based on the belief that the past, present and future lives of all humans were foreseen by Dharma sages in ancient times. The first sage being Agastya. This was written on palm leaves and stored for reference in the Vaitheeswara Temple in Sirkazhi, Tamil Nadu. A person’s leaf could be retrieved by the astrologer based on the date and time of birth and it could accurately tell you the day of your demise. One of my friends recalls that his brother went to a Nadi astrologer, who accurately told him his parent’s name and other details then was just about to reveal his date of demise when he silenced the astrologer mid sentence. He wisely didn’t want to know! If he was told the date, that knowledge would hang over his head like the sword of Damocles. He would count the days, the hours, the minutes and finally the seconds to the day and then it may turn out to be a damp squib! An example is of the Mayan Calendar which experts said predicted the end of the world in December 2012, because the calendar ended on that date. Considering the world is still around in 2020, it was a total wrong presumption! However a lot of people spent anxious moments anticipating the end of the world.

Scientist say “whether the earth will end” is not the question, the question is when the earth will end?”. The end may come as a meteor hitting the earth or a large solar flare destroying the ionosphere and exposing us to cosmic radiation or eruption of a supervolcanoe causing an ash cloud to block sunlight or even the Halydron collider which is trying to recreate the ‘Big Bang’ in miniature exploding.

Quoting the Bard of Avon, William Shakespeare, “A coward dies a thousand times before his death, but the valiant taste of death but once. It seems to me most strange that men should fear, seeing that death, a necessary end, will come when it will come.”

As I gradually creep toward senior citizen status many of my contemporaries have abandoned me. Some due to disease and others due to accidents. The incident which really shook me to the core was the passing away of a MBBS classmate, room mate, friend, philosopher guide and teacher, Sunil Agarwal. He died in an unfortunate car accident, this February 2020 and just before embarking on the fatal last journey, he messaged me good morning and that he was going to a mission hospital for a camp and that he was looking forwards to the cool weather there. Little did I know that by evening I would hear about his demise.


An analogy of life is a train journey. You boarded when you were born and on the way lots of passengers boarded and shared a part of the journey with you, only to disembark at some point for a different destination or sometimes permanently like Sunil.

I try to empathize with the cancer survivors who have been operated, received chemotherapy and radiotherapy. Now they can only wait or better live. The disease may raise it’s ugly head again. All it requires is one single cancer cell remaining, which can multiply rapidly and overwhelm their body. They could be in an pessimistic frame of mind or an optimistic frame of mind. In former they are dying a thousand deaths, whereas in the latter they die only once.

Legend has it that the ancient Gauls who inhabited present day France only feared the sky falling on their heads. The SARS COV-2 pandemic, has brought us to a similar predicament. Shoving our own mortality, right into our face. Suddenly we are faced with the real possibility that we may be infected and our infection may be severe enough that we may die!
One question is on everyones mind, “मेरा number कब आएगा?” or “when will my time come” and this is not with hopeful anticipation but with dread.

The virus is highly infective and a zoonotic infection or one which has jumped from animals into man following a crucial mutation which allowed it to infect humans. There is the conspiracy theory that it was genetically engineered to make that jump, blaming our neighbours to the east. But we won’t go into that!
This is not the only virus which is zoonotic, earlier we had swine flu, chicken flu, MERS and SARS which also belong to the same family of Corona viruses, so called because they have a halo or crown or crown surrounding it. These did cause their share of deaths but are not as infective as the latest avatar of corona, SARS COV-2.

Then there is the famous human immunodeficiency virus, which causes the acquired immunodeficiency syndrome or AIDS. The virus belongs to a family of retroviruses and is also a zoonotic infection. It was supposed to have jumped from the African green monkey into humans.
Arthur Ashe, the African American tennis player who is the only black player to have won Wimbledon, American open and Australian open contacted AIDS from blood transfusion following heart surgery. One of his fans wrote him a letter and asked, “Why does God have to select you for such a bad disease?”
His answer was, “The world over — 50 million children start playing tennis, 5 million learn to play tennis,
500,000 learn professional tennis, 50,000 come to the circuit, 5000 reach the grand slam,
50 reach Wimbledon, 4 to semi final, 2 to the finals,
when I was holding a cup I never asked GOD ‘Why me?’.
And today in pain I should not be asking GOD ‘Why me?’ ”
Happiness keeps you Sweet,
Trials keep you Strong,
Sorrow keeps you Human,
Failure keeps you humble and Success keeps you glowing, but only Faith & Attitude Keeps you going.”

Quoting Oscar Wilde, “To live is the rarest thing in the world. Most people exist, that is all.”
I see lot of my colleagues hiding in their homes and avoiding contact with patients in fear that they will contract the disease. However how long can you hide! The virus is going nowhere and our redemption lies in herd immunity or invention of an effective vaccine. Herd immunity will only kick in when at least 60% of the population is infected and as for the vaccine, attempts to create a vaccine for the other corona viruses also yielded zilch. This was thanks to the virus’s penchant for mutations, making it difficult for the antibodies to recognize the mutated virus.
However recently I read that the virus in it’s current mutation causes a less severe disease. This is also a self preservation strategy of the virus. If it killed all it’s host rapidly, it would no longer be able to spread and infect new hosts. Simply put all the people infected with the severe form of the virus succumbed to the infection ending the life cycle of the virus with them. However it is the ones with less virulent strains, who remained asymptomatic or only had mild symptoms, who spread it to others. Therefore the milder versions of the virus get disseminated while the virulent die with their host.

It has been predicted by an epidemiologist that COVID-19 will kill at least 2 million people in India. Though the number sounds large, so is the population of India at 1.3 billion. If you do the simple mathematics, 2 million merely represents 0.15% of the population of India, reducing the probability of you being part of this statistic to lower than the chances of you winning a lottery ticket. Have any of you won a lottery?

Since our knowledge of this virus is merely 6 months old we are daily learning new facts about it. The chances of contacting it while touching inanimate objects or fomites is low. The highest incidence of transmission is through aerosol or tiny droplets of saliva and mucus which are emitted when we cough or sneeze. These droplets when inhaled can enter the respiratory system via the trachea then bronchi, bronchioles which finally end in a tiny sac like unit called the alveolus. The respiratory system brings air into the alveoli, the lining is rich in blood vessels and exchange of gases occur. Oxygen diffuses into the blood and carbon dioxide comes into the alveoli which is exhaled. But now with the air also comes the virus and causes an inflammation in the alveoli, affecting the gas exchange. It also causes what is famously known as the cytokine storm, an over reaction of the body’s immune system to the virus. This causes irreversible destruction to the alveoli giving rise to a reduced lung function. The destruction could be so extensive that no alveoli is left for gas exchange.

The use of ventilators in these patients is push oxygen with pressure into the lungs, inflating all the alveoli and improving gas exchange. However now with no functional lung tissue left, pushing oxygen serves no purpose. Only an Extracorporeal Membrane Oxygenation ECMO, will work. This is similar to the heart lung machine used during cardiac surgeries. The blood is diverted to the machine and it oxgenates it and pumps it back, giving the heart and lung rest. But for a completely destroyed lung only option is a lung transplant.

The strategies which are being used for treatment are transfusing the plasma of patients who have recovered from the infection. Their plasma is rich in antibodies against the virus and help in fighting the virus. Antiviral like Remdesivir show promise in fighting the virus. A steroid like Dexamethasone which suppresses the immune response of the body is helpful in reducing the damage caused by a cytokine storm.
There is a race to make a vaccine for this virus spurred both by concern and commercial considerations. However the vaccine may not be effective because the frequent mutations the virus makes.

The virus is here to stay and we have to learn to co-exist with it like we learnt with other viruses. We cannot hide away forever and have to resume a new normal life which include the necessary precautions.
Finally we have to live and not exist or die a thousand deaths.

Vastraharan

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This incident happened some years ago. I work in a private medical college and on that particular day we had routine surgeries posted. On reaching the hospital, I went straight to the operation theatre. When I reached the operation theatre, I was surprised to find the theatre in-charge nurse tear stained and stripped to her blouse and petticoat, sitting with the female anaesthetist in their room. Her right hand appeared to be scalded which she was dipping in a bowl of ice water.

On enquiry about what had transpired and the reason for her unusual attire, I was told this story.
A case of trauma with fractures had come early morning to the casualty and the Orthopedic Surgeons had posted it for emergency surgery. They had informed the theatre in-charge regarding the instruments they would require and to prepare an emergency tray. Normally except for the routine instruments not all instruments are kept autoclave or sterilized. If a surgery is posted as a routine then the instruments are autoclaved a day before and kept ready. In case of an emergency when the instruments are required at a short notice, the operation theatre nurses resort to ‘flaming’ or flame sterilization for the metallic non sharp instruments.

Flame sterilization is placing the instruments on a stainless steel tray and pouring 100% ethanol or alcohol on them. The ethanol is spread evenly over the tray and then is set alight. The flame is a blue flame, which means complete combustion. But the nurse was not satisfied with the evenness of the conflagration. So to turn up the heat, she poured more ethanol, straight from the bottle onto the burning tray. In a blink of an eye, the flame climbed up the stream of ethanol and set the contents of the bottle alight. The bottle exploded like a molotov cocktail, splattering the burning liquid on her hand and saree. She was wearing a white synthetic saree which immediately caught fire. In her panic she forgot all protocol and began to ran amok down the corridor, towards the exit.
Ideally if your clothes catch fire you should roll on the ground to douse the flame. Running causes fanning of the flames result in a greater conflagration.

Lucky for her some senior female anaesthetist were there and spotted her running aflame. They immediately tackled and caught her. They pulled off her burning saree, stripping her down to her blouse and petticoat. The other people present were mute spectators, not sure what was happening and what to do.

What reaction would you expect from her for the prompt actions of the anaesthetist, who braved the flames and saved her from serious burn injury or even death.
Gratitude! Right? But it was the opposite. Rage against her saviours for having stripped her of her dignity, outraged her modesty in front of male doctors. Drawing parallels to the famous Vastraharan of Draupadi by Dushasan, under instructions of Duryodhan in the Mahabharat. Luckily no males were involved in this Vastraharan.

Later better sense prevailed when she was in a calmer state of mind. She apologized for her outburst and thanked them for saving her life.

Studying for knowledge!

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I know it’s like setting a cat loose amongst pigeons but this has been on my mind for quite some time.

I have taught in a private medical college for close to 25 years and I have noticed this disturbing trend amongst students. It begins in the 10th standard, by then students have either decided or the decision has been taken for them, as to what career they will pursue. It’s a limited choice, either Medicine or Engineering and anything otherwise is considered sacrilegious. Even before the 10th results are declared the students are admitted into coaching classes, which prepare them for the premedical or pre engineering exams. There is a ‘setting’, as known in local parlance or nexus between these coaching classes and some schools and junior colleges. The student admitted in these schools/junior colleges are not expected to attend classes. Instead they spend the whole day in ‘swot’ or coaching classes. The main focus is on the pre-medical or pre-engineering exams. The schools/colleges themselves don’t encourage their pupils to attend classes and their staff moonlight by teaching in these coaching classes. So they are not available to take regular classes. Some students don’t even enroll in coaching classes in their home city, but in famous towns whose names have become synonymous to quality coaching classes, like ‘Kota’. Kota has become a brand name in itself and many wannabe classes in the town have sprung up which have no connection with the original Kota classes but encash on the name. Kota being the name of a town cannot be trademarked. Even for getting admission in the original Kota classes the students have to undergo a pre-pre-entrance exam and only the best are taken. If you are take the best you are guaranteed a good result. The challenge would be to take the average and make them the best.

The students return to write their boards in their home town and as they were enrolled in local schools/colleges that’s no problem. They can now avail of the domicile of the state while applying for admission. Regarding domicile only Delhi is truly all inclusive and anyone can apply in the state medical and engineering colleges. Most other states have quotas for domicile, even for domicile in regions within the state then rural and urban. For clearing the board exams the student has sufficient knowledge to get passing marks and is guaranteed 100% marks for the practicals and of course class attendance. Thanks to the coaching-class-school/college setting.

The students through various permutations of caste, quota and capitation secure admission in a medical college. The students of today are farsighted. They know where their priorities lie. They glimpse the future through their own crystal ball. They realize that a mere MBBS doesn’t amount to much. This is true because the days of a family doctor is over, जिनके पास हर मर्ज की दवा थी, or who had the panacea to all illnesses. The general practitioner field has been taken over by graduates of the alternate-pathies or Ayush. No self respecting MBBS would allow himself to be a general practitioner. So now begins the quest for a post graduation degree. Once again admission is sought into specialised coaching classes for post graduate admission tests. Many of the students miss the morning lectures in college because they are attending the coaching classes. Students posted in surgery sometimes request me that they may be excused on Saturdays. Usually on Saturdays an expert on a topic flies down and delivers a lecture. I ask them what can he teach you which is different from what is taught in regular classes. They have no answer. Possibly ‘घर की मुर्गी, दाल बराबर’, or you don’t value what you have. Since the expert has flown down from a metro and has the aura of a sawant, it is believed that his teaching would be like the revelations of an Oracle.

“To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all” (Sir William Osler) and “The ward is your library, the patients are your teachers”. I must have quoted these adages from the Surgical textbook, Bailey and Love, to students, ad nauseum but with no avail. Unfortunately it is possible to pass MBBS without ever having seen a patient and passing is all that is required. Because admission into post graduation depends on how you fare in the entrance exam and not on your MBBS marks. What is taught in the coaching classes? How to approach the entrance exam and how to score in multiple choice questions. Question banks with questions from previous years is distributed and studied as the questions repeat, sometimes almost upto 20%. The theory taught is related to these multiple choice questions. Internship in hospitals where presence in spirit and not in flesh is required is sought. The flesh can attend the coaching classes while the spirit does the internship. This has resulted in MBBS graduates with zero practical knowledge and selective theoretical knowledge.

So the student cracks the post graduate entrance exam and gets admission in a post graduate seat. The most sought after seats are the ones where ‘practice’ or patient footfall is good. For example orthopedic surgery, trauma is increasing and not decreasing thanks to the fast pace of life, there is always trauma and people are breaking bones. A broken bone is obvious even to the untrained eye of a patient on an x-ray. Not much persuasion is required regarding the need for surgery. In contrast in general surgery a patient with appendicitis, intestinal obstruction or perforation peritonitis would not show much in his x-ray which would be discernable by the untrained eye.

Gynaecology is another all time favourite because every married lady will become pregnant sooner or later, preferably sooner. She will have to deliver and a Nursing Home close to home is preferred. It is convenient for delivering tiffin and accommodating visiting relatives. So there is a ‘friendly neighborhood obstetrician’ in every locality. In our days suction cups, forceps and manipulations were used to ensure a vaginal delivery. These days the Obstetricians take no chances, if there’s even a slightest doubt then it’s safest to do a Cesearian section. What surprises me that these same ladies who have undergone multiple Cesearian sections when told they will require an appendectomy, baulk and say they are scared of operations, can’t it be fixed with medications? When asked how they endured the multiple Cesearian sections, they retort, “that was many years ago”.

Dermatology is another sought after speciality where there are plenty of patients and no emergencies. These days dermatologist are packaging themselves as cosmetologist. Their plethora of services along with consultation includes beauty treatment.

Radiology used to go abegging when I finished my MBBS, because in those days x-rays were the only diagnostic tool in the hands of the radiologist. Now there is a plethora of diagnostic tools like sonography, CT scan, MRI and PET scan. Interventional radiology has also taken in a big way. Now radiology is in the great demand for the same reasons, plenty of patient footfalls, no emergencies. However being a dependent branch it involves schmoozing specialists but once the chain is established it is all hunky dory.

Medicine is another sought after speciality because physicians are the gate keepers. Almost all patients initially land up first to a physician who in turns decides where to send the patient. Somebody describes them as Kings because “जिसके पास प्रजा, वो ही राजा” or the one who has a following is the King. The physician can manage the patient initially till relevant specialist sees the patient. The physicians also always have a gaggle of chronic patients suffering from diabetes, hypertension and heart disorders. These ailments cannot be cured and can be merely controlled, hence the physicians have patients for life. Physicians fitness is mandatory for patients posted for routine surgery. It’s their job to optimize the patients for surgery.

Ophthalmology is another speciality where footfalls are guaranteed. All of us require glasses after 40 and cataract surgery after 60 is all part of the aging process. This speciality has few emergencies and plenty of patients.

Coming to my speciality, surgery, it lies somewhere in between. The surgical field has also been encroached by the superspecialist depleting the field. Now a general surgeon handles purely general surgical problems, leaving the cancers for the surgical oncologist, vascular to the vascular surgeons, endocrine to the surgical endocrinologists, urinary problems to the urologists, head injuries to the neurosurgeons, gastrointestinal problems to the surgical gastroenterologists and lower gastrointestinal problems to the Colo-rectal surgeons. He is left with hernias, hydroceles, abscesses, wounds, lumps and bumps.

Finally the real value of a seat is determined by the market forces, which is most sought after and which attracts the highest capitation. Capitation fee or sometimes euphemistically called donation is uniquely an Indian term, refers to an illegal transaction in which an organisation that provides educational services collects a fee higher than that approved by regulatory norms.

Now once a student gets his speciality of choice or had no choice, just had to take what he gets. If he gets surgery than his goal now is to get a super speciality seat. No one except fools like me would be happy being a plain general surgeon. But I can say because I have worked in all specialities of surgery, I can teach the superspecialists some practical things.

The students we get from premiere institutions are solely lacking in practical knowledge. Some don’t know how to take the blood pressure others don’t know how to start an i.v. line. One student introduced an i.v. cannula into the vein in the wrong direction, pointing distally. After starting the i.v. the patient’s hand got swollen up. But now the focus is studying for the superspeciality pre admission test and the cycle begins again. After that they will be studying for a foreign degree.

Someone said “When I finished my studies I began my education”. The question is when will the studies end and education begin?

Murder of a model!

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The papers few days ago blared the murder of a model in Chandrapur. Her mutilated body was found abandoned on the roadside and police identified her, based on the tattoos on her body. Her boyfriend was the prime suspect for the murder. He is the son of an alleged drug peddler from the Gittikhadan area in Nagpur. When he was picked up by the police, he denied any involvement, as it’s customary but on further interrogation confessed to the murder. His motive was jealousy as the girl was also seeing other men and was procrastinating in typing the knot with him.    A very common story of LSD, love, sex and dhokha (धोखा). Add to it some intoxicants and it adds up to a catastrophic cocktail.
But how do I figure in this story?
You will understand once you read on.
I am in charge of a surgical unit in our hospital and by rotation we are on call for emergencies on Sundays. And that particular Sunday was one such Sunday.
The day began as a relaxed day, getting up late, watching TV and chilling. when I get a call from my resident informing me about two emergencies which presented in the casualty. The first was a case of acutely inflamed appendix or appendicitis.
The appendix is a finger like pouch attached to the beginning of the large intestine. It is believed to be a vestigial organ and was earlier useful for digestion of complex carbohydrates like cellulose. But since we stopped eating grass way down the evolutionary chain it shriveled up. It also believed to harbour the ‘good bacteria’ which help in digestion. But sometimes it’s lumen gets blocked with a faecolith (hard piece of shit) or or an ingested seed or sometimes worms, causing it to swell up and become inflamed. This condition is known as appendicitis and the treatment is surgical removal of the inflamed organ before it swells up so much that it burst discharging the contents of the large intestine into the peritoneal cavity.
The other was a case of torsion testis in an engineering student.
The testis or balls as it’s colloquial known as is suspended in the scrotum like a bell and it’s clapper. The clapper being the testis hence in Hindi it’s also colloquially called ‘ghanta’ (घंटा) or bell. The suspensory cords contains the artery veins, spermatic cord and surrounded by a muscle called the cremasteric muscle, whose function is to pull the testis upwards in response to a stimulus. This stimulus could range from stroking the inner aspect of the thigh, called the cremasteric reflex to straining during defecation or vigorous coitus. If the testis is loosely suspended in scrotum, it could cause a twist on the cord and testis, cutting off the blood circulation to the testis. Imagine if one’s balls get twisted the agonizing pain which would ensue.                                             On a lighter note it reminded me of of our Hostel Days in Christian Medical College, Vellore. We had our own campus terms and one of them was ‘kottais’. In Tamil kottai meant seed, but in campus lingo with the added ‘s’ to indicate it’s plural, it meant ‘balls’. Then it was further abbreviated and you need not say the word, just hold your hand hand up as if you are holding a cricket ball and give it a twist in an anticlockwise direction or a torsion. This would convey a painful message, ‘kottais’ or ‘balls’ to the intended person.               Returning to the present this is a real emergency because if not corrected within 6 hours the testis would become gangrenous and have to be removed and the double whammy is gangrenous testis secrete antibodies against the testicular cells and can destroy the opposite testis too.                                I instructed my residents to inform the anaesthetists and post the patient for surgery ASAP and I would be coming for the surgery.    So I embarked on a medical mission of mercy driving down the 15 kms to the hospital.     Now along the way there was a large gathering of people blocking one lane of the road. It looked like there might have been an accident and the crowd was gathered to display their protest. There was a security guard posted by the under construction Metro project, who directed me to use the other lane. Sensing there was a tense situation brewing but there was also an emergency, I took the risk. As I came close to the crowd there were burning tyres strewed on the road leaving just enough space for me to squeeze between the crowd on one side and the tyres. There was also a two wheeler coming from the opposite end and both of us reached this narrow patch. I stopped to permit him to cross but he rather than crossing, stopped his motorcycle and was peering curiously into the crowd trying to figure out what was happening. I made the mistake of tapping my horn and immediately the crowds attention turned towards me. A visibly emotional and agitated looking youngster separated from the gathering and stood in front of my car and bent down. I braced myself for a rock to smash my windshield to smithereens. Instead he pulled one of the burning tyres and placed it under my car. Luckily there was a sensible elder who came immediately removed the tyre, pacified the youngster while indicating to me to scram! I immediately drove out of the danger zone and reached the hospital. The operations went off successfully the twisted testis of the teen could be salvaged and the inflamed appendix was removed in the nick of time.                   Only the next day did I find out what the gathering was all about. The murdered model lived in that locality and her body had been brought home in preparation for the last rites. The gathering was of the mourners. The former boyfriend and perpetrator belonged to a different community so the gathering was taking communal hues. Definitely what the boy did was wrong and no one has the right to snuff out anyone’s life. But senseless violence would be counterproductive. Quoting Gandhi, “an eye for an eye makes the whole world blind

The rumble in the Bagayam Oval

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In Christian Medical College, Vellore, the Men’s Hostel Union had it’s fair share of fisticuffs. That is only natural in an all male environment with pressure of studies, raging hormones and other factors. Three  incidents which I witnessed were, two over something as innocuous as a game of carroms and the other was when one felt slighted by the other in front of the girls in his class.

Wine did not contribute to much of the violence, though it did contribute to destruction of college property. One such incident was a party on a weekend in D block first floor in MHU. After everyone was suitably charged, the next move was to go to the other side of the road and make our presence felt. On the other side of the road dwelled the fairer sex. What’s the point of partying unless the residents of the other side of the road are not brought into confidence? This completed the trilogy of Wine, Women and Song. The Song was  provided by the blaring tinny music our cassette players and our own raucous singing. Luckily I choose to pass out on a convenient bed rather than join the trip to the other side of the road. I fell into a  peaceful slumber only to be awakened by polite but persistent knocking on the door.  I realized it was morning and got up and opened the door. I was surprised to find Dr.  Dilip Mathai, our Hostel Warden standing there. He smiled and asked me the whereabouts of the host of yesterday’s party.  To which I pleaded ignorance. He muttered something about destruction of a college monument and walked off. Only later did I learn what had transpired last night. There was a Community Health Conference going on in Scudder Auditorium and strung between the necks of the swans at entrance was a banner declaring the Conference motto, “Health for all by 2000 AD. Way back in the 80s, 2000 seemed too far away! Far enough for people to promise the Kingdom of Heaven in 2000 AD. As I later learnt the inebriated gang spotted the banner and coveted it as a decoration for the MHU. Standing under the banner one of them jumped and caught the banner, however the nylon rope stringing it across the swans refused to snap. Immediately the remainder of the gang lent their weight on the banner. The rope didn’t snap but one of the Swan keeled over and collapsed with the combined weight! The guys immediately ran helter skelter but in the general direction of MHU. Just recently I visited Scudder Audi and saw that in order to preempt future such misadventures they have placed poles on either side for stringing banners. 

There was a senior in the third year who was not very popular with his Batch mates. Let’s just describe him as being different. Perhaps because he had spent his earlier years in West Africa.  He was a regular in the MHU gym with an impressive upper body poorly supported by spindly legs. Thus the Mr. Men’s Hostel title eternally evaded him. Another favourite past time of his was playing carroms and he spent  a lot of time in the common room on the  carrom board. He was good at the game and I remember many closely fought Men’s Hostel Tournaments. During a crucial decisive shot in these tournaments the spectors would choose to sneeze explosively, drop a pencil box or laugh loudly to startle him.
One afternoon he was playing carrom with one of his Batch mate who must have weighed close to a 150 kgs. An impressive person, dark, tall, and equally wide. There was a dispute regarding a shot which progressed from a shouting match to shoving and punching. The senior flexed his muscle but was unable to displace 150 kgs.150 kgs merely gave him a hard shove which caused him to lose balance and fall backwards. He then sat on him which immobilized him and compressed the living daylight out of him. It was a real funny sight, seeing him pinned down helplessly.

Our friend however did not learn his lesson, few months later he had another dispute with a final year student again over carroms. And again matters turned ugly, the final yearer was fairly fit himself being a hockey player but didn’t stand much chance against the brawn of the third year so he ran to his room in D block and locked the door. The third yearer was in hot pursuit and then began banging the door challenging him to be a man and come out. We all trailed behind and watched as mute spectators waiting for events to unfold. Then suddenly the door opened and out came the final yearer with an equalizer in his hand, a hockey stick. It is taught in self defense lessons even a stick can tip the balance to your advantage. The hockey stick was already upheld ready to swing and and swing it did in a short arc and connected with the  left parietal region of the head of the third year. And  the door was promptly closed and bolted. The third yearer collapsed and we quickly transported him to CHAD Hospital. He had a lacerated wound on the scalp which required suturing, luckily the skull was intact and no other permanent damages. But he went around swearing vengeance. We did not witness that part of the saga. Perhaps he believed in Don Coleone’s words, “revenge is a dish best served cold.”

But the most memorable was the rumble in the  Bagayam Oval. We had an immediate senior who also spent a lot of time in the Men’s Hostel gym. He loved roaming around the hostel shirtless displaying his torso. He had managed develop a ‘V’ shaped upper body but his muscles lacked definition.

One day we were heading for the SA Hall to study and took the route via the appendix. This senior had a room in appendix ground floor and was standing in front of his room punching a makeshift punching bag. To prevent his knuckles getting abraded with the punching he had got the Men’s Hostel cobbler to make leather straps which would fit around his fingers covering his knuckles. He was pounding the bag shirtless as we passed him. “That____I’m going to thulp him today as soon as he gets off the last bus from college.” He was referring to one of his classmates who was an African national. We asked him what happened? To which he responded “that *%'” :* he insulted me in front of the females” and then he went on to tell us how he got slighted in front of the girls in his class. I felt the provocation was extremely trivial and not something worth  getting ballistic about, but not something you could explain to such an opinionated person. I pondered on staying back and witnessing the action but I decided studying was more important. So I proceeded on to the SA Hall to study.

When I returned at around 10:30pm, curious to know what was the result of altercation I retraced my path via the appendix. His door was open and he was lying on his bed applying an ice pack to his face. I came close to him and saw he had a left black eye and swollen left side of his face. I asked what had happened? To which his reply was, “I gave him as much as I got. And ultimately we declared a truce.” Somehow this explanation didn’t really ring true and I asked around and got this version of the story from eyewitnesses. The last bus reaches Men’s Hostel at 9pm, came around the drive and halted in front of the mess. Our friends was waiting near the mess, shirtless and lightly  punching his left palm with his right strapped fist . As soon as his enemy alighted from the bus he accosted him and said “if you are a man enough come to the Bagayam oval we will settle our differences there in a mano a mano fight.” His opponent was a more mature person. He had escaped civil war in his country and had seen a lot of violence. It was even rumoured that he served in the militia during the Civil War. He reasoned with him that nothing can be settled with violence. He was even willing to apologize for any transgressions he had wittingly or unwittingly committed. But our friend was adamant to settle the score in the Bagayam oval.

I am not much of a gambling man but if I had to put my bet on a side,  then it would definitely be the African.  He was at least half a foot taller and though did not have a bulky frame but he was muscled.

So they trouped down via the gym onto the Bagayam oval along with the spectators in tow. Again the African tried to reason with our friend but instead our friend  swung out without connecting. The African punched him straight on the face and KOed him, draining all the fight in him. He then helped him back on to his feet and helped him stagger back to his room.

On reaching his room friend requested another classmate and neighbour to do a fundoscopy and check for retinal detachment and head injuries. Luckily there were no permanent damages.

Courting Arrest! 

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“I have an arrest warrant in your name.

Imagine if these words are spoken to you despite you being a law abiding citizen. Okay I may have broken some traffic signals unwittingly but no serious misdemeanour.

But these exact words were being spoken to me.

How did this happen? Let me fill you a bit about the history behind it.

I teach in a medical school and devote my evenings to a charitable trust hospital. I have worked there for the past 20 years and I have developed a loyal patient base.

Mondays are normally very busy days in the hospital. There is a tall stack of out patient cards on my table arranged in order of who came first and I examine the patients in that order.

One such busy Monday I was examining a patient and a young man barged into the room. Taking him for a patient trying to cut que, I admonished him for his lack of etiquette and patience. I firmly told him to wait for his turn. He tried to say something in his defense but I was peeved and cut him short. He gave up resisting and meekly retreated and I went back to examining patients completely forgetting the incident.

After I had finished seeing all the patients, he again opened the door and politely asked permission to enter, which I responded to the affirmative. He looked like the garden variety of patients I see regularly, except for being tall and well built. He must have been in his twenties with short hair combed sensibly.

He approached my desk with a piece of paper in his hand and very apologetically proffered the paper to me and said “Sir! I have an arrest warrant in your name!”

Surprisingly it did not alarm me rather it sent me into a state of déjà vu!

I have been through this before!

I had a flashback to my days as an overworked surgery resident in Ludhiana Punjab.

I had the good fortune of being in Punjab during it’s most disturbed period in history. There was a violent separatist movement going on. I will not go into the politics and justification behind these movements, suffice to say ‘today’s terrorist could be tomorrow’s freedom fighters’. Depending on whose side you are on.

It could be considered as mixed fortune because you had to duck bullets whizzing by and bombs exploding all around you. There was the division number 3 Police Station near the hospital which was a favourite place to plant a bomb. There was Fieldganj vegetable market where we did our vegetable shopping where motorcycle borne terrorists opened fire randomly into the crowd. There was the RSS Shakha assembling in a park in Kidwai Nagar and terrorists opening fire on them.

But every cloud has a silver lining and I could help the innocent victims and also gain experience treating trauma patients. I’ve seen bullet injuries of almost every part of the body. I will spare my readers the gory details. Since I left Ludhiana I have not treated a single bullet injury case.

It was bad luck for the innocent victims who was the common man trying to eke out a living.

Not all the trauma could be blamed on terrorist, there were a fair number of personal vendatta cases. Fights between neighbors and familes turning violent, Bride burning and other domestic violence.

Along with the treatment we had to do the paperwork. An FIR (First information report or FIR) to be filled and sent to the neighbouring police station, informing them that such a case has been admitted. The Police would come to take a ‘statement’ from the victim, but before taking a statement they would ask a resident to certify whether the patient was fit or coherent enough to give his or her statement. The resident had to sign on the Police records stating whether the patient was fit or unfit.

After the statement was taken the police would make another visit and ask for an injury report. This again was provided by the residents, certifying that he had examined the patient and the injuries were listed, with the dimensions. The mode of injury were mentioned, i.e. blunt trauma, sharp object or penetrating. Finally the type of injury, whether it was simple, grievous or dangerous to life. All this would be part of the police record.

The consultants studiously avoided getting involved in the paper work though they were active in the treatment. Later the readers will realize why.

Not all cases would reach the courts, they would be settled amicably by the concerned parties. However if it did reach the court then the Judge after sifting through the paperwork done by the police, would issue summons to appear as expert witness to whoever had certified the fitness or issued the injury report or had his signature on any paper in the police records.

These summons had to be personally served to whoever it was intended. The job was given to a constable of the Punjab Police. He would personally roam the entire hospital ferret out the concerned resident and hand him the summon. The residents would warn each other about a summon waiting to be served so hide! Sometimes you could see a resident running with the cop in hot pursuit waving the summon in his outstretched hand and shouting “Haanji Daktar Sahab!” (Loosely translated to Attention Doctor Sir). Sometimes when confronted face to face with the cop, the resident would deny that he was himself. But police being police would establish his true identity and serve the summon. An acknowledgement was taken on a carbon copy of the summon. Surprisingly the cops were very indulgent and took it like a game in good humour. All the straight faced denials of not being yourself was met with a smile and an expression which said “I’ve heard that one before.”

The summon itself is the most ambiguous document. All it said was that you are requested to appear in the court of the honourable Judge so and so in so and so court on so and so date to be witness to State vs so and so and to top it all it will be written in Gurmukhi! We were clueless to which of the scores of patients we have seen did it pertain to.

Why was there so much reluctance to attend court? Because it was the most boring and fruitless thing to do, the whole day was wasted. If it involved a visit to the local court then it would be okay but victims came from all over Punjab. I’ve attended the courts in Ferozepur, Fazilka, Faridkot, Pathankot, Bathinda, Batala, Dhariwal, Kapurthala, Khanna, Moga, Malerkotla and many more. I leave home early in the morning catch a bus either from the bus adda or Samrala Chowk, which was a major intersection. This is when I realized that Punjab is not a very big state, divided by Radcliffe’s arbitrary line during the partition and then Haryana and Himchal were carved out of it during the reorganization of states on linguistic lines. So with a 3 hour bus ride you can reach most major towns in the state.

On reaching the destination, I had to catch a cycle rickshaw and tell him to take me to the ‘kaccheri’.

On reaching the court I had to find the courtroom of the Honorable Judge who had issued the summons. The courts are rabbit warrens with rooms built at random. Originally they were built by the British but after Independence with the rising population came an increase in court cases and a requirement for more space. So courtrooms were built without much prior planning.

Once you find the courtroom and enter the scene is the same in all courts. A bailiff guarding the entrance and hailing out the witnesses to be hazir or present whenever there case comes up for hearing. The Judge sitting on his desk perched up high above everybody else, looking totally bored with the proceedings around him. He is flanked on one side by the clerk who is checking the list of cases to be heard for the day and giving the bailiff instructions on who to hail. And the stenographer typist who is vigorously typing the proceedings of the cross questioning of a witness going on in front of the judge. Behind them are benches and chairs arranged in two rows with a narrow aisle separating them. Lawyers and their clients, police men and undertrials and others whom I presume were relatives occupy the chairs with an expression of disinterest.

I go to the clerk and meekly hand him my summon, he looks at me suspiciously and checks the summon with the list in front of him and then smiles at me. “Tussi Daktar ho?” (Are you a Doctor?) he asks in Punjabi. To which I answer in the affirmative. “Tussi baith jao, twada case chheti ho jayega” (you sit down, your case will be taken up soon) gesturing to the rows behind. I find an empty place and unfold a newspaper and begin to read, immediately the bailiff admonished me and tells me that reading is not allowed in the courtroom, all attention has to be directed to the proceedings. So I watch the proceedings, every lawyer entering the court will turn and face the judge and give a ceremonial nod in a show of respect. I suspect it actually supposed to be a bow but got abbreviated with time. The judge is busy with some paper work while the witness is being cross questioned by the two lawyers. The proceedings are being typed by the stenographer typist. When they finish the paper is first handed to the judge for his okay and then to the witness to sign.

Then I’m called to give witness, they have taken into consideration that I’ve come from a distance and I’m a busy doctor and allowed me to cut que.

The Judge asks me, “do you take an oath to tell the truth?” Not asking me to place my hand on any holy scripture, unlike in the films. Though I suspect this also got abbreviated. I nod to which he says “answer my question!”

I say loudly “I do!” Then he indicates to the lawyer representing the state to take over. The lawyer hands me a stack of documents tied onto a cardboard base with a red tape (the phrase ‘red tape’ originated with this practice). I untie the tape and go through the documents. It consists of photocopies of the hospital in patient records, the injury report and the fitness certificates, the discharge summary. Finally I get to know which case it was. It was when I was posted in neurosurgery and a lady was brought who had been brutally hit on the head with a ‘gandasa’ by her husband. She must have really served him a bad meal! A gandasa is an agricultural implement used in Punjab, it consists of a long stick, often as long as the user with a blade at the end, akin to a long axe. There was a deep gash on the scalp and the underlying skull bone above the left eye was shattered. Obviously she was in no condition to give her statement on arrival so my unfit certificate was in the records. She had to be immediately operated where the shattered pieces of bone were removed along with most of the left frontal lobe of the brain. She survived and recovered. Frontal lobes were removed in the early part of the 20th century as a routine to treat extremely violent mentally ill patients without causing major disabilities except for subtle personality changes, like not understanding relationships, boastful behaviour and urinating in public! I suppose the last disorder would not be considered unusual in India. A famous case was that of Rosemary Kennedy sister of John F. Kennedy or JFK. However the surgery was unsuccessful and the procedure left her with the mental capacity of a 2 year old child and incontinent.

So then the State lawyer asks me which documents bear my signature? I point out to the injury report, the fitness certificate and the discharge card. The lawyer begins to dictate ‘my statement to the typist’, “It is true that the documents numbered so and so bear my signature and have been prepared by me then he asks me to dictate out the injury report and at the end adds “the contents are true and prepared by me.” Then my typed statement is handed to me and I’m asked to sign. I try reading it but he tells me “don’t bother reading just sign it!” I protest saying they are a lot of spelling errors in the statements. He says “doesn’t matter just sign it!” rolling his eyes skywards in exasperation.

Now is the turn of the defense lawyer to cross question me, he starts off with “Doctor are injuries like these possible with a fall from a staircase?” I say “technically it’s possible but she would have to land on her head over a sharp object.” The defense lawyer cut me short and said “just answer yes or no!” To which I meekly said “yes!” and typewriter clattered almost in unison with my response. Then he asked “Doctor can you give me the definition of coup and countrecoup injury?” Now though I understood the mechanism of coup and countrecoup injuries when suddenly asked to give the definition I began to fumble with the answer, to which he cut me short and said “that’s enough!” And another typed statement was placed in front of me to sign without reading.

Coup and countrecoup injuries are as a result of the brain floating in cerebrospinal fluid, coup injury is at the site of impact and countrecoup injury is on the other side due to the brain moving within the skull and hitting the inside. This apparently was a favourite question lawyers would ask especially in head injuries cases to demonstrate the inadequacy of the doctor.

After the signing was over the judge said “you are now excused Doctor.”

To which I said “what about the travel allowance which the court is supposed to pay me?”

To this the Judge said “do you really need the money Doctor?” A rhetorical question, but then playing by the earlier rule laid down by the State, I said “yes!” After all that money has been set aside for this purpose and if I don’t claim it someone else would. So the Judge hands me an attendance certificate and another letter for the amount and tells me “go collect the money from the Naazar.” My next job is to hunt out the Naazar’s office in that rabbit warren. When I finally reach the Naazar’s office I’m told he has gone out to an unspecified destination for an unspecified length of time. I’m welcome to wait for his return. I decide to head back home because if I wait for too long I would not get a bus back. Because of the disturbed situation in Punjab, buses did not ply after sunset and it was risky to travel in the night.

So having gone through this fruitless exercise and also having to pay for the excursion obviously I was not too enthusiastic about accepting another summon.

So after a couple of more visits to the courts I also became a seasoned summon dodger avoiding the constable if possible but more often than not he was successful in serving me the summons.

Then came next stage when despite being served the summon I would not appear in court, either due to work load or due to lethargy or just that it slipped out of my mind.

So then what happened?

I would be served another summon for the same case and yet another. Sometimes after the first non attended summon the matter would get settled either amicably by both parties or another resident whose signature is also on the records would attend court and identify my signature and certify that the documents are true.

However there were the cases in which the differences were irreconcilable and there were no other signatures on the records except mine and I did a hat-trick in non appearance. Then again a constable would hunt me down in whichever corner of the hospital I am in. He would approach me beaming from ear to ear and greet me “Sat Sri Akal Ji Doctor Sahab!” To which I would respond in a similar manner. Then the constable would say, “Assi arrest warrant le ke aye si, twade naa da.” (I have brought an arrest warrant in your name).

This jolted me for a moment.

“Tussi court aye nahi teen vele iss liye” he added. (You didn’t appear in court 3 times that’s why).

So then I imagined I would be handcuffed and maybe read the Miranda Rights like in Hollywood movies

1.You have the right to remain silent and refuse to answer questions.

2. Anything you say may be used against you in a court of law.

3. You have the right to consult an attorney before speaking to the police and to have an attorney present during questioning now or in the future.

4. If you cannot afford an attorney, one will be appointed for you before any questioning if you wish.

5. If you decide to answer questions now without an attorney present, you will still have the right to stop answering at any time until you talk to an attorney.

6. Knowing and understanding your rights as I have explained them to you, are you willing to answer my questions without an attorney present?

However this is India and the main difference is that in India any statement or confession made to the Police is inadmissible in a court of law.

Anyway it was only me dramatising my situation using my fertile imagination.

Going back to reality I asked now what am I supposed to do? To this he replied “this is a bailable warrant and you just sign here and I will post your bail. But if you don’t appear in court subsequently a non bailable warrant will be issued.”

That was a relief for me and I quickly signed wherever he told me to and since I couldn’t read Gurmukhi I didn’t have the faintest idea on what I had signed on. By the way Punjabi has two scripts Gurumukhi which literally means the words of the Guru which was developed Guru Angad Devji the second Guru of the Sikhs. All the Holy literature of the Sikhs is written in Gurmukhi. Then there is the Shahmukhi script which is in the Arabic-Persian script and used by the Punjabi Muslims mainly across the border.

On asking around I discovered this form of arrest was fairly routine. Almost every resident has had an arrest warrant in their name. I asked another senior what would happen if I still didn’t go? He replied “Nothing! You’ll just get another and another ad infinitum, until you attend.”

So I realized I was in good company of jail birds though none of us had seen the inside of a jail or that matter the inside of a police station.

Then I began to wonder about the legal implications of this ‘arrest warrant’. As I understood if you are served an actual arrest warrant you would have to go to the police station and obtain bail for which a surety amount is posted. This warrant was more like a threat to frighten you into attending court. It would look bad for the police and the judiciary to arrest an innocent doctor for just not appearing in court!

But I took no chances and avoided any further ‘arrest warrants’ being served.

Mr. K. P. S. Gill was the Director General of the Punjab Police, he is credited in bringing the terrorism in Punjab under control but he was also accused of human rights violations. The Police were in total control and even having a pillion rider on your two wheeler was not permitted after sunset. If you were caught having a pillion rider and did not stop when the police stopped you, they had full right to open fire. Because motorcycle borne terrorists with the pillion rider shooting was the modus operandi of the terrorist.

We once had to attend a party in the other side of town. Only one of us had a motorcycle and 9 had to attend. So the solitary motorcycle made multiple trips ‘triple seated’ trying to avoid the police barricades. I was lucky to make it to the party and back. But the last trip got caught and the driver was slapped so hard he had a swollen face. So it was better to remain in the good books of the police.

After finishing my MS I returned to my home town Nagpur but my past life or more specifically my signatures continued to haunt me. One day I was resting at home when the domestic help told me that someone has come to meet me. I go downstairs and there is seated a familiar sight, a constable of the Punjab Police. He jumps to his feet and salutes me then greets me in a very familiar manner “Sat Sri Akal Ji Doctor Sahab!” I return the niceties and then comes another familiar statement “Twade vaste assi arrest warrant leke aye si!” (I have brought an arrest warrant for you). I inwardly groan and ask him to show me the papers. Looking at the papers I realise how much the Police have to work. Warrants have been issued for 3 ex residents. One lives in Pitthoragarh Uttarakhand, the other lives in Allahabad but now shifted to USA. The warrant is for an assault case in Malerkotla for which I have already been twice. I accept the warrant and get bail and promise insincerely to attend the court in Malerkotla. And before leaving he gave me a veiled threat, “if you dont come this time we will return with a fauj and arrest you!”

Malerkotla formerly a princely state was incorporated into the state of Punjab. It is in the heart of Punjab and has a Muslim majority but is an island of communal harmony.

The roots of communal harmony date back to 1705, when Sahibzada Fateh Singh and Sahibzada Zorawar Singh, 9 and 7 year old sons of 10th Sikh Guru, Guru Gobind Singh, were ordered to be bricked alive by the governor of Sirhind, Wazir Khan. His close relative, Sher Mohammed Khan, Nawab of Malerkotla, who was present in the court, lodged vehement protest against this inhuman act and said it is against the glorious tenets of Quran and Islam. Wazir Khan nevertheless had the Sahibzadas tortured and bricked into a section of wall while still alive. At this the noble Nawab of Malerkotla walked out of the court in protest. Guru Gobind Singh on learning this kind and humanitarian approach and blessed the Nawab of Malerkotla with his Hukanama and kripan. In recognition of this act, the State of Malerkotla did not witness a single incident of violence during partition.

But it’s a long journey from Nagpur to Malerkotla so I decided to take the risk of a fauj descending on me and arresting me. It’s been 17 years now and the fauj hasn’t turned up!

Back in Nagpur I treat quite a few cases of violence especially in the charitable hospital where I work and of issue injury reports.

And returning to the present, the arrest warrant which was being served to me pertained to a unique case of domestic violence with reversal of roles.

Now being much older and wiser I told the plain clothes cop to go ahead and arrest me. He was very apologetic and said “how can I do that?” So again I sign wherever required to prove I was arrested and received bail on the spot and with assurance I would attend the case the next day.

The case was that of a young couple who had an intercaste marriage against the wishes of their parents. But very soon there was a falling out between the two. Now allegedly the wife hired goondas to bump the husband off. They attacked him one evening in a lonely spot and stabbed him on his back. Luckily it was not fatal and the knife had not penetrated deep enough to cause serious damage. I sutured the wounds and discharged him within a day. The police came for the injury report which I issued. Then the matter went to the ‘fast track’ court and I was issued a summon. I attended the summon in the fast track court. This court is housed in what used to be the MLA Hostel. On reaching the court I found it empty except for the clerk and stenotypist. They informed me that the judge has gone to attend a workshop so they will be no hearings today.

Some months later I got another summon for the same case. Again I went to the fast track court and again was greeted by an empty court and this time the judge was on leave.

Subsequent summons I ignored and now comes the arrest warrant which is being served to me!

So I attend the hearing the next day, this time the judge is present and asks the defense lawyer to cross question. To this the accused lady stands up and says “I have done law so I am going to defend my own case!” The accused is an attractive slim young lady, stylishly dressed in black pants and a white shirt. Not looking at all like a seasoned criminal capable of giving out supari.

The judge asks her if she has a bar council registration to which she replies no. Then the judge says she cannot represent herself. He requests her former lawyer who is sitting in the benches to take her case and he refuses. So again the court is adjourned till she finds a lawyer to represent herself.

Few months later I get another summons for the same case. This time both the judge and a lawyer representing her are present. During my cross examination the defense lawyer finds a discrepancy in the discharge card. The date he was operated and the date he was assaulted don’t match. This card was filled by a junior doctor who made an error in the dates. Due to this discrepancy she is granted bail.

The judiciary system is famous for being notoriously slow. They say justice delayed is justice denied. Because of this comes the rise of the vigilante form of justice.

A famous case is that of a 2004 incident which occurred in Nagpur which created national headlines known popularly as the ‘Akku Yadav’ case. In August 2004, Bharat Kalicharan aka Akku Yadav a murder and rape accused was being led to the courtroom by the police for a hearing when a group of women attacked him in the court premises with knives, sticks and stones. The police were mere spectators, not anticipating such a vicious attack by women. The women killed Akku Yadav and the attack was so vicious they even emasculated him.

What drove ordinary women to such extent you have to know the history of Akku Yadav. He was a local goon terrorizing the Kasturba Nagar slums in Nagpur. He felt every young girl was fair game and no one dare raise any objections due to fear. The Police in their wisdom preferred to turn a Nelsonian eye towards his activities.

He was arrested couple of times for charges ranging from rape, murder or intimidation however was released due to lack of evidence. No one dared to come forward to give witness against him.

So finally the women of the locality, totally disgusted with his activities took the law in their own hands.

My connect with this incident was the main accused and leader a young girl in her twenties was my patient. She was a student of Hotel Management and had an attack of acute appendicitis. I had operated on her and she had recovered. She hardly appeared to be the type of person who would commit such a crime. Dressed like all students do with tee shirt and jeans. Never found her behaviour to be particularly aggressive. Happy with my treatment she brought other members of her family to me with various problems. Her brother was being treated for severe depression and ultimately committed suicide and her father was no more. She had declared to me that she was interested in serving society and did not want to get married. A few months before the incident she came to me saying after the surgery she has gained weight around the abdomen due to which she is getting rejected for jobs in Hotels and felt the surgery had something to do with it. I reassured her that surgery had nothing to do with the weight gain. Possibly because she was now pain free she was eating more. Then couple of months later the incident occurred which caught national headlines and reported on national TV. Initially I was not aware about her involvement but few days later the papers reported that this lady was arrested for being the leader along with her photograph. Later on she was acquitted for lack of evidence. Same story no one came forwards to bear witness against her. If you ask the any of the people in the locality she is a heroine who managed to rid the locality of a menace. The property values in the locality shot up within a year with the end of the Akku Yadav reign. People felt safe.

She is still my patient and I operated on her mother barely two months ago. She has done well for herself establishing a computer training school and a charitable trust as well as having a job in the airport. I have asked her details about the events but obviously she is not forthcoming with it. She claims a biopic is being made on her life and she is under contract not to reveal the details to anyone.

One of my friends told me his father gave him sound advice. “Never get into a legal dispute with anyone and drag him to court, because that’s a Chakravuha, you know how to get in but you don’t know how to get out. Instead haat paar jod lo aur maafi maang lo” (Apologize with folded hands). And further advice his father gave him was, “Kaale coat aur saffed coat se hamesha dur raho” (keep a wide berth from the black coats and white coats, i.e Lawyers and Doctors. Jesus Christ when he was crucified, along side him were crucified a thief and a murder. Someone wrote, “if he were to come down again this time it would be a lawyer and a doctor!”

The theory and philosophy of cancer 

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The disease was first called cancer by Greek physician Hippocrates (460-370 BC). He is considered the “Father of Medicine.” Hippocrates used the terms carcinos and carcinoma to describe tumours. In Greek this means a crab. The description was named after the crab because the pincer-like spreading projections from a cancer called to mind the shape of a crab.

A tumour is defined as an abnormal growth of cells serving no useful function. These tumours maybe benign or malignant.

Benign tumours do not display any invasion into the surrounding normal tissue nor demonstrate spread via blood or lymphatic. In contrast malignant tumours demonstrate an infiltration into the surrounding normal tissue and can spread to distant sites either via the blood or lymphatics or both.

In normal cells there is a limit to the number of times it can replicate itself. This is supposed to be controlled by a gene which prevents uncontrolled replication. In cancer a mutation occurs and this gene is turned off, resulting in uncontrolled replication. Mutations can occur due to exposure to radiations, carcinogenic  toxins or cancer causing compounds and chronic irritation of an area.

To give you some examples of cancer caused by irritation, in India we have the Kangri Cancer seen in Kashmir where they hang an earthen pot in a wicker basket containing  glowing coal embers around their neck and under a  Phiran, a poncho like coat the Kashmiris wear. The constant exposure to heat on the abdomen where the Kangri is in contact causes irritation and cancer on the abdominal wall. Then there is the Saree Cancer and Dhoti  Cancer also known as waistline cancer. This occurs around the waist where the saree or dhoti is tied exactly at the same spot. The constant irritation causes cancer.

There is the cancer seen on the palate of the mouth seen in ‘chutta smokers’. This practice is seen in coastal parts of Andhra Pradesh where the homemade bidi called a chutta is smoked with the lighted end in the mouth. The lighted end comes in contact with the palate and the heat causes irritation and cancerous changes.

And of course too much exposure to the sun or ultraviolet rays could cause skin cancer.

Oral tobacco and slaked lime which is kept in the mouth for gradual continous absorption is another example of an irritant.

The constant irritation of the skin causes cell destruction and regeneration. During these cycles of destruction and regeneration a mutation in a single cell may occur causing unregulated growth. Incidence of cancer are higher in the parts of the body where there is  rapid turnover of cells because where there is a rapid turnover with replication there is a higher chance of mutation.

There is also a genetic basis for malignancy and the most famous being the BRCA 1 gene in breast cancer and RB1 gene implicated in Retinoblastoma. However possessing these genes don’t necessarily guarantee you will develop the malignancy, it just increases the probability. In order to act these genes need to get switched on and the mechanism on how they get switched on is poorly understood.

The cancer cells as mentioned before consist of rapidly replicating cells and originate from a parent cell which has undergone mutation. How closely they resemble the cells of the organ of origin is an indicator of how malignant or aggressive they will behave. This is called differentiation and the tumour could consist of well differentiated, moderately differentiated or poorly differentiated cells. A poorly differentiated malignancy will grow more rapidly because the cells have a very faint resemblance to their parents and are simple in structure and hence take a shorter time to replicate therefore grow rapidly. However a well differentiated malignancy would have a closer resemblance to it’s parent and would take a longer time to replicate.

The surgical principle behind cancer treatment depends on the degree of it’s spread or stage. If it’s localized to one area then removing the tumour along with a safe margin of surrounding tissue and if it spreads via lymphatics then removal of the lymphatics draining that area would offer a cure. The best example is in a cancer of the breast, removal of the entire breast and the draining lymph nodes of the axilla.

However if it has spread beyond it’s parent organ then it’s impossible to detect and remove all of the cancerous cells.

An anecdote to illustrate the point is that of Steve Jobs, the founder of Apple, rated the most valuable company in the USA. He had a form of pancreatic cancer,  a neuroendocrine tumour of the pancreas which are well differentiated and very amenable to treatment. As a matter of fact 30% of them are so well differentiated that they’re not strictly cancers.

All it required a removal of the tumour with a surrounding margin of the pancreas and it would have cured the disease. However Jobs was famous for his intractability, this was so often his greatest asset but may have been his undoing.

He eschewed any modern or practical treatment instead opted alternative therapies, specifically a Buddhist vegetarian approach and only when the water had risen above the nose did he seek the help of modern medicine. The pancreas was removed but then the tumour had spread to the liver. So he got a liver transplant managing to jump the que for a donor liver. This was classically the case of ‘too little too late’. He finally succumbed to his disease on the 5th of October 2011.

His famous commencement speech delivered in 2005 to the graduating batch of Stanford University, after having the second surgery.  He talked about death and guided the students by these words “Your time on this planet is limited, so stop wasting it living someone else’s life. Stop believing in other’s opinions because it destroys your mental confidence completely. The most important things in life are to follow your heart and intuition. Once you find it out, everything else in your life will become secondary.”

Angelina Jolie famously had a double mastectomy or removal of both breasts because a blood test revealed she had the BRCA 1 gene which gave her an 87% chance of developing breast cancer. She had lost her mother, grandmother and aunt to cancer so did not want to take a chance.

So how do you avoid getting cancer? Well the reason why cancer is featuring more commonly as a leading cause of death is because people are living longer. A longer life means a longer exposure to toxins, radiation and pollution, wittingly or unwittingly!

And regarding the treatment of cancer I firmly believe in the dictum, “Don’t add years to life but add life to years”. To illustrate this point I had a friend who was hale and hearty. During a routine health check up a tumour was detected in the adrenal gland and another suspicious lesion was detected in the liver which was thought to be metastases or spread from the main tumour. Since both lesions were deeply placed in the body and not amenable to biopsy, needle biopsies or introduction of a long needle into the tumour under guidance of CT scan or sonography and aspirating the lesion and examining the aspirate for presence of malignant cells. Despite repeated attempts nothing conclusive could be found. But there was a high degree of suspicion and his doctors advised that the test to be repeated.

My friend by then was tired of being treated like a pin cushion and deferred any further investigations.

He lived a normal life for three more years and then had the tests repeated, which showed the lesions had spread to the lungs. Now this was followed by a flurry consultations with various cancer specialists. A famous cancer specialist of Tata Cancer Hospital, Mumbai commented “You look very healthy for a person suffering from disseminated cancer”.

Now the tumour had already spread from the adrenal gland to the liver and the lungs. So if he had to be cured, the adrenal gland along with the liver and lungs would have to be removed and of course transplant a donor lungs and liver. Despite this you cannot guarantee that all the seedlings of the tumour have been removed.

As you can understand that would be a mammoth undertaking and would have stretched an ordinary man both financially and logistically. And I’m not sure whether such operations are  routinely done.

So he was left with the other option of chemotherapy or cancer medication.

One fact which few Oncologists explain about chemotherapy is that the drugs are extremely toxic. They are poisons delivered in controlled doses. They cause a lot of collateral damage along with the damage to the cancer cells. Just to give you an example, Mustard gas was used by the Nazis as a chemical weapon  in the second world war. It caused a lot of death and long term effects in their victims and the environment. Studies done on the victims showed that it had a destructive effect on the bone marrow. This lead to it’s use in Acute lymphoblastic leukemia, or blood cancers which originate from the bone marrow.

Now if you are are giving chemotherapy to achieve a cure then the toxic side effects are worth the reward but if you are only giving it to prolong his life by maybe 6 months to a year then is it worth it? Those additional 6 months he will be sick, nauseous, emaciated and hairless. But alive!

You have succeeded in adding years to life but failed to add life to years.

This I explained to his wife but her contention was “if we don’t give him chemotherapy he will feel that all hope is lost and will get depressed but with chemotherapy he will feel there is some hope”.

How could I argue with logic like that!

So he received chemotherapy which made him sick, fluid accumulated in his lungs and abdomen which made it difficult for him to breathe.

Imagine a previously healthy individual who was eating, drinking and enjoying now being periodically confined to hospitals. I talked to him frankly and he himself stopped the chemotherapy. But it was too late, he spent his last days in and out of hospitals with a bloated abdomen and shortness of breath. When he could have lived at least a year normally doing the things he enjoyed.

I guess we all come stamped with an ‘expiry date’ by our Maker. However this stamp is not visible and thankfully so. Our lives would be converted from ‘living’ to ‘dying’ if we knew our date with fate was so many years from hence. We would stop planning for the future.

If you meet anyone with a terminal illness who knows their journey is ending soon. They will tell you that all they chased so far, name, fame and fortune doesn’t matter anymore.

Recently I attended the funeral of a known person in the cremation ground. Simultaneously a lot of cremations were taking place, side by side. Of millionaires and of paupers. One my friends commented, “Doesn’t matter if you are rich or a pauper, in the end you will end up here”!

There was a final year medical student when I was doing MS, who complained of a backache. She was investigated and the CT Scan showed cancerous deposits in the spine. She was subject to further investigations and on passing a scope via the mouth into the stomach revealed a malignant growth in the stomach. The diagnosis was clear, cancer of the stomach with spread to the spine and on it’s journey to the spine it would have traversed the liver and lungs and left seedlings there. Luckily they followed a more pragmatic approach and were not swayed by emotions. The backache would be relieved by radiations and the primary growth left alone. Her symptoms of backache were relieved and she was able to function normally and pain free.

Despite not knowing her I decided to visit her in her hospital room. Though I have handled many terminally ill patients professionally, I have never handled a terminally ill patient socially. So I didn’t know what to expect.

I tried to put myself in her position and imagine what my mood would be like.

I would be definitely depressed and not very social.

I was very surprised to find her very cheerful and we chatted for half an hour discussing everything except her illness.

She passed away a month later but definitely she had a peaceful end.

For the physicians I would quote the ‘Medical Litany’ of Sir Robert Hutchinson,

‘From the inability to leave well alone;

From too much zeal for what is new and contempt for what is old;

From putting knowledge before wisdom,

science  before art, cleverness before

common sense;

From treating patients as cases; and

From making the cure of a disease more

grievous than its endurance, 

Good Lord, deliver us. ‘

Amen 🙏