The Paragon of Courage (My Worst Night As a Doctor)

The Paragon of Courage
(My Worst Night As a Doctor)
© Dr. Rajas Deshpande

“She is sinking. Unlikely to survive” said a doctor who had come for second opinion. The parents broke down. The father, a gentleman, held his speech as tears ran down his face, but the mother, like all mothers, could not hold her pain.
“Why Us? Is this all really happening? Why did we even do this procedure? I don’t know anything, doctor. I want my little girl back” she said, crying.

That was the worst night of my career as a Neurologist.
It was 2 AM. Dr. Anand Alurkar and myself waited on the road outside Ruby hall Clinic, Pune. We both felt extremely low, tearful. The loss of a life as a complication of treatment is the worst nightmare of a doctor. To save lives, a doctor must take courageous decisions, do the best thing for the patient. Every doctor, especially a surgeon, has to face this cruel dilemma: to not treat, let things be and leave the patient to nature’s rules and agonies, or try to save a life with the two inherent risks: a medical complication and the reality that such a complication may make the doctor an instant villain.

Three days prior, Tanushree, a 17 year old student from Manipur had gone to Pune airport to see off a friend. She suddenly fainted there and had a convulsion. Her friend brought her to my OPD. Her examination was normal, but she seemed quite aloof and had mild headache. An urgent MRI showed a bleeding in her brain. She had a bunch of abnormal blood vessels in the brain, which form a tangle. Some such blood vessels may bleed as they have thin wall, or when the pressure inside the bunch increases. In such cases the abnormal blood vessels are usually closed with a glue injected inside them. It is a standard, but very complicated procedure that requires skill and experience of years. I had called in Dr. Anand Alurkar, he had treated many such cases successfully. He opined that the girl would need such glue injection / embolization.

The procedure is risky (one must enter the brain’s blood vessels with a thin tube / catheter inserted from the leg), and other than the usual minor risks of any hospital procedure, the major risk here was a possibility of fresh bleeding in the brain, which happens in 1 percent of cases even if the procedure is correctly done. Such bleeding can even be life threatening.

Tanushree’s parents, Mr. Khuraijam RatanKumar Singh and Mrs. E. Meghabati Rani ji, were in Manipur. They arrived immediately. Mr. Khuraijam is a highly placed officer, and wanted to give her the best treatment options, they didn’t care about expenses.

We could understand that we were quite new as doctors for the family, and far away from their home, in a strange land. In view of recent bleeding in the brain, it would be risky for Tanushree to fly. We had all the necessary facilities. We explained the situation to them, including the risks. Her parents told us that they had complete faith in us. They signed the papers, consenting for the procedure. Tanushree was fully conscious, and had no complaints.

A brave teen, she went into the cathlab smiling, at 3 PM.

The procedure took over three hours, at @ 6 PM Dr. Anand confirmed that everything was done well, she was stable. She was shifted out to the ICU for observation. I saw her after the procedure, she smiled back. We went home for dinner. I planned to return to see her late night.

The nightmare began.
Just before I reached home, I got a call from the ICU team. “Tanushree complained of a severe headache, and then has become unconscious” said the panicked ICU doc.
“Get an urgent CT scan” I said as I took a U-turn. It was 9 PM.
The CT scan showed fresh bleeding.

That one major complication, known to happen in extremely rare cases despite all precautions, had happened in this 17 year old teen. The bleeding was substantial. Dr. Anand came rushing back too. We started all the emergency treatments for reducing the swelling on her brain. The parents, lost and broken, supported each other. Her mother was upset with the whole thing, and felt guilty that they had consented for the procedure. I understood her feelings, but was helpless. I knew how my mother would have reacted, and this was not different. We now prayed that Tanushree improved, and desperately hoped that her brain swelling reduced. But things went worse.

At @ 4 AM her brain swelling started to cause pressure effect on the brainstem: the area that controls heart, breathing and blood pressure. Once that area fails, the patient is unlikely to survive. She became almost comatose. In an unfortunate twist, a doctor called in for a second opinion told that parents that there were no chances of survival. The parents lost it.

I discussed with Dr. Anand. We were not willing to give up. There was a very small chance of her survival, if her skull was opened to relieve the pressure effect of the bleeding on the brainstem. But this is a major surgery, and has more risk than the earlier procedure. We explained the situation to the parents. Her mother was disturbed beyond decision making. Her father told me: “Do what you think is the best. I will leave it upto you”.

Once again, I had to risk her life in an attempt to save it. Only a doctor would understand the full implication of these words.
I called our senior neurosurgery expert, Dr. Ashok Bhanage. He arranged for an emergency surgery within a few minutes. He spoke to the parents, explained that there is risk of death even during surgery, and took her in. I waited with the parents in the waiting room.

“Save her, I beg of you” I kept telling my God.

After three hours, she was wheeled out to the recovery room, on a ventilator. In two days, the ventilator was taken off. She had developed paralysis of the right half of her body, and lost speech. In a week, she started speaking a few words. In a month, she started walking and regained almost complete speech, but her memory was still not well. She was stable. I thanked Dr. Bhanage for his timely response. Accepting the risks, he had turned the game over.

Every doctor has to play every day with these fears: of mistakes, of complications, which will ruin his / her career within moments. It is a stress beyond description, and amplified in case of surgeons. The more aggressive and distrustful the relatives or the patient, the more difficult the decision making, the higher the risk of a decision in favour of avoiding risk, even if life saving.

On the day of her discharge, Tanushree’s father and mother became emotional, and thanked our team with beautiful, heartfelt words. Her father also gifted me a Reid and Taylor suit fabric, which I will pass on to my son as my precious treasure.

In a year, Tanushree recovered nearly completely, and joined back her college. She went to London to explore possibilities of further education, and now has chosen to pursue law. In spite of some mild effects that the event has left upon her, she continues to be brave and bold, and takes on any challenge with the grit of one who has already defeated death.

When she followed up yesterday, she was smiling as brightly as she ever does! “Sir, I am sure I can defeat any problem in my life now, after what I have overcome” she told me.

Her father told me: “You are God for us”. As much as I love and respect those undeserved words, I am keenly aware that there is only one God that looks after both: the patient and the doctor.

I cringed at the thought: “What if, out of fear that night, I had decided not to advise her that second surgery?” I will never forget that being a doctor I am also assigned this extra responsibility: to take the best decisions fearlessly for my patients, to explain them well to the family, and to hope for the best.

I was lucky that my prayers were answered, and I learnt that my God also meets me in the life of my patients.
© Dr. Rajas Deshpande

PS:
Thank you, Ms. Tanushree Khuraijam, Mr. Khuraijam RatanKumar Singh, and Mrs. E. Meghabati Devi Ji, for the permission to share this story.

There must be far better doctors and teams in India and abroad, I am sure. This article is to highlight the plight of what a doctor feels when things go wrong, and to tell the world about the exemplary courage of a teen.

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