The story of a 90-year-old who arrived with a compression fracture in his vertebrae is a good example of how doctors shouldn’t sell surgery, even if in their favour, but get patients to buy it
My father has not been able to get out of bed for over two months,” lamented Jagdish Sanghvi, as his 90-year-old dad lay helplessly on a stretcher that jutted obliquely into my consulting room. In the tenth decade of life, the old man had a full mop of disheveled silver hair and a perfectly curetted face that wrinkled every time he winced in pain at attempts to adjust his recumbent posture. “He had a fall eight weeks ago and has been unable to walk since then,” continued Jagdish amidst short ragged breadths and heaving sobs. I let him talk, handing him tissue and placing a glass of water on the table.
I have never been uncomfortable watching men cry. I, too, have cried. It’s a natural expression of grief across ages and sexes. Why should stoic men be exempt from expressing? Jagdish must have been in his mid-60s and was unable to comprehend how his completely independent father, while remaining cognitively crisp, was reduced to frail dependency within a few weeks, physically worn out from the pain in his mid-back.
I gently got him on his side and started pressing his back lightly, eventually reaching a point where he unleashed an intense scream. It got a few nurses running into my room. The area I had palpated corresponded to a compression fracture of the tenth thoracic vertebrae that was lit against the luminance of the X-ray box into which I had plugged in the film.
“There it is—that’s the cause of his problems,” I told the son excitedly, pointing to a slightly collapsed triangular vertebra compared to the healthy and nicely squared others. I completed the examination noting the strength in the patient’s legs, which was good. He wasn’t moving only due to the pain. “The family doctor said to just keep him comfortable, that no surgery should be attempted at this age, so we’ve kept him home, but this is getting worse. The medication and physiotherapy is not helping,” he finished in a fresh burst of uncontrollable weeping.
Both, father and son had lost their wives and were each other’s only support. The son bolstered his father physically and the father was his son’s emotional strength; even through his own pain, he had a sympathetic smile on his face, silently conveying to me that it was his son who really needed to be taken care of.
I explained to them that surgery was a very good option in his case. All we needed to do was inject some cement into the collapsed vertebra and fortify it; the heat generated from the cement would then numb the nerve endings in the bone that generated the pain. “We can do this under local anesthesia,” I implored, setting to rest a gnawing concern of theirs. There were apprehensions about his age, him being able to lie awake on his belly for the entire duration of the procedure, management of his high blood pressure and diabetes. I navigated through all their copious questions and got them to finally agree on surgery.
“You must never sell an operation to a patient,” I remember a professor once telling me, “you must get them to buy it.” And, more often than not, this is a philosophy I adopt, simply laying down the pros and cons and allowing the family to decide. But sometimes, when you have a cogent solution that will almost certainly relieve your patient of their malady, the only reasonable thing to do is to be unreasonable about it and goad them into making the right decision. The elderly are an extremely valuable asset to our community. They bring with them grit and grace, courage and compassion that comes with the wisdom of living a long life. There is a lot to learn from them. It is our moral obligation to care for them to the best of our ability.
The next morning, Mr. Sanghvi lay prone on bolsters, shivering in a freezing operating room. We armed him with a warmer that soothed him a little. After cleaning and draping him in the usual fashion, while our anesthetist kept him preoccupied with the latest in the stock market, and after giving him some local anesthesia to numb the area, I directed the needle to our target using intraoperative X-rays and injected 5 ml of toothpaste-like cement into the vertebral body. Live images showed the cement seeping into cracks and crevices augmenting the injured area. Very rarely, the cement can extravasate into the bloodstream and enter the lungs, causing a sudden collapse, but knock on wood—we were okay. I withdrew the needle and sealed the entry point with a stitch.
We flipped him over and asked him to wiggle his toes and bend his legs; the first thing we do after every spine operation to ensure we haven’t caused any harm. He did so effortlessly, without even a wince. A few hours later, I went and saw him in the ward. He lay in bed smiling, chatting with his son. “Would you like to try and walk?” I interjected. They gawked in disbelief. I put the side rails down and extended my hand for him to get a grip as he seated himself at the edge of the bed gingerly for the first time in two months. Then, he reluctantly planted both feet on the ground and stood up, taking his first step. For his son, it was like watching Neil Armstrong take his first step on the moon; he once again wept. Tears are a confused body fluid: they are triggered by diametrically opposite emotions.
The next morning, Mr. Sanghvi had taken a shower on his own, had oiled and neatly partitioned his silver mop, completed a walk around the corridor, and sat upright in bed reading the newspaper. “How do you feel this morning?” I asked. “Younger than my son,” he quipped, and his perfectly curetted face wrinkled again—with a laugh.