When you’re caught in a conundrum and have to take decisions to avoid hurting your patient’s sentiments
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We were lying in bed, fast asleep at night with our backs facing each other,” started Peter, wanting to narrate exactly what happened to his wife. “That is how we usually sleep since we’ve been married for 12 years,” he continued, not wanting to spare any details. “Suddenly, I heard her make a grunting sound that partly woke me up, and I, in my deep sleep, simply thought she was snoring, so I kicked her to keep her quiet. And usually this works!” he explained, giving me an insight into the dynamics of their relationship. “But the sound continued, so I turned around to pinch her nose and found that my hand was wet. I immediately turned the light on and saw her frothing at the mouth. Her eyes had rolled up and she was breathing heavily,” he gestured with animated hands, “and then the breathing stopped!”
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I nodded, listening patiently. “I tried to wake her up, but there was no response. I didn’t know what was happening. I called my kids from the bedroom next to ours and she didn’t wake up to their calls either. She was dead, we thought. The three of us were simply holding hands and crying profusely, saying our final prayer…” he trailed off. I nearly sported a ridiculously goofy smile on my face. I could afford to grin because his wife was sitting right next to him in perfect health, while he was narrating something that happened two weeks ago.
“While we were wiping our tears, we heard a moan from her,” he continued. “It was as if Christ had heard our prayers! She was back to life, but still not conscious,” he heaved, “So, we decided to rush her to the hospital.” Peter went on to narrate how they somehow got her to sit in the car, driving 20 minutes to get to the nearest hospital in the middle of the night. As soon as they reached, she opened the door to get out and asked “Why are we here? What happened?” with no awareness of what had happened to her.
“When the doctor in the ER examined her, he found nothing wrong. He explained that what she had was a seizure,” he looked up at me and saw me nodding in agreement. “For you, it seems ordinary,” he countered, looking at my nonchalant expression, “but for us… we’ve never seen something like this and still don’t know how to deal with it!” he exclaimed, shaking his head. I comforted him and told him that the good news was that his wife was fine and that was all that mattered at the moment.
He handed over the whole bunch of blood reports and MRI films of the tests they had been asked to perform in the city from where they had travelled to come see me. “You do know you have a big brain tumour in your head,” I confirmed with one glance at the scan. “But we were also told that it is not malignant,” they counter-checked with me. I agreed. I explained to them that it was a meningioma, a growth arising from the meninges covering the base of the brain near the temporal bone and extending to the orbit. It measured 5 cm and was stuck to the internal carotid artery, the body’s most important blood vessel that nourishes half the brain. I also explained that these are extremely vascular tumours and bleed profusely, simultaneously instructing my colleague to arrange for three bags of blood instead of the usual practice of reserving only one every time we open a head.
“Doc,” the husband held my hand. “There’s one problem.” I waited for him to continue.
“We can’t give her any blood,” he said, pulling the rug from under my feet.
I allowed for the depth of that statement to seep in before reacting. “Are you a Jehovah’s Witness?” I asked, having seen a few in the United States where I trained, but none so far in India.
Jehovah’s Witnesses are a Christian denomination with beliefs distinct from mainstream Christianity. A staunch conviction of theirs is the refusal of any blood transfusion, considering it to be a violation of God’s law. “We believe that life is blood, and if God wants me to live, he will do so with my own blood,” the wife spoke for the first time in this conversation, calmly and clearly standing her ground. I respected her belief, but couldn’t help but wish she had an easier tumour to remove; this one was sure to need a blood transfusion. “How about we draw your own blood, allow your haemoglobin to build up over a few weeks, and then operate so that we can transfuse it when you need it?” I suggested, coming up with a brilliant plan that I had implemented previously for someone with a very rare blood group. “Not allowed,” they vetoed it instantly.
“You go ahead with the surgery, doc. I’m willing to consent for death on table, but I won’t take the blood,” she said emotionless, while my emotions were playing football in my chest. We are so entrenched in our beliefs that what seems completely logical and straightforward to one person seems outrageous to the other, and yet, surprisingly, neither is wrong. Two surgeons had refused to operate on her, and we could do the same thing. The question was, what did I want to do?
I excused myself for a bit and went out to discuss with the team. “Even if the patient is willing, I don’t want a death on ‘my’ hands,” I justified. “How will she know if we’ve given her blood? Just don’t tell her,” innocently reasoned a colleague. “If she gets the blood of a Parsi, she’ll be cursing for the rest of her life and then she’ll know!” I laughed, trying to make light of the situation.
Trying to make up my mind, I decided to speak a little longer to the courageous woman who was willing to die for what she believed in. A few conversations after, she convinced me to do the operation. The evening before surgery, she held my hands and said, “I have two little kids to go back to.” I nodded and quipped, “Thank you for adding more pressure to an already intricate situation!”
As we wheeled her into the OT the next morning, she was happy to see the pleasant wallpaper view of a scenic beach and mountains that adorned the walls. “If this is the last thing I get to see before I die, it’s worth it,” were her last words before the anaesthetist put her to sleep. “Does this lady want to live or die? I’m very confused,” I said aloud, while everyone got to doing their part.
From the moment we opened her head, it started bleeding. We used all the tricks in the book to stem the blood flow, ably assisted by our anaesthetists, who reduced the blood pressure for us so that we could minimise blood loss. We quickly drilled the bone, and in a set of coordinated moves, cut off the blood supply to the meningioma by buzzing with a bipolar cautery all the vessels feeding it, turning a red ball of fire to its ashen counterpart. Coring out the inside, I kept shrinking it until only a shell remained. I held the shell with an instrument and with the other hand peeled it off the internal carotid artery, removing the tumour completely without needing a single unit of blood. I must have aged a few years in those few hours.
She was fully awake by the time we wheeled her out of the operation room. “I hope you didn’t give any blood?” was the first question both she and her husband asked me in sync. Back to my usual filmy self, I replied, “The only blood I gave her was mine!”
The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals.
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