By A J PHILIP
MY daughter-in-law was admitted to a large private hospital in Kochi for removing a "growth" in the thyroid gland. Early morning, the hospital staff commenced preparations for the surgery, which included tying a wristband. It was then that my son noticed the inscription, "thyroidectomy", on the wristband.
Immediately, he did a Google search on the word and found that it was a surgical operation to remove the thyroid gland, partially or in full.
By then she was already in the operation theatre. He virtually barged into the theatre and asked the doctor, a well-known surgeon, what exactly he was going to do. The doctor told him that he was going to remove the whole thyroid gland.
He knew the consequences of the surgical removal of thyroid which would have left his wife medicine-dependent for life. The thyroid gland is one of the largest (edocrine/hormone secreting) glands in the body. It is found in the neck, below the ‘Adam’s Apple’. It controls the use of energy and produces thyroid hormones and calcium-regulating hormones. Lack of calcium after the complete removal of thyroid gland in many cases leads to Tetany, a grave physical morbidity, where cramps, shivering and convulsions occur.
In other words, the thyroid performs a major role. In a woman, even child birth, menstruation, physical exertion etc are controlled by thyroid. He had to take a quick decision — allow the doctor to perform the operation or take his wife home. He opted for the latter earning the instant displeasure of the doctor who told him a little harshly, "I have done thousands of thyroid operations and I know my job".
He politely told the doctor that he wanted to seek a second opinion before agreeing to the surgical removal of the thyroid. The problem would not have arisen if the doctor had rightly briefed the patient about the procedure he was going to follow. Medical ethics expected him to tell the patient in clear terms what the operation entailed and how it was going to affect her life thereafter. In no case should a patient be left in the dark.
Her problem was a growth in the thyroid and the resultant complications. Many doctors, including relatives, were consulted later and they all suggested that we go in for a partial surgery. That is how we consulted Dr Thomas Varughese, head of the Department of "Surgical Oncology and Reconstructive Surgery", at Lakeshore Hospital, off National Highway-47, at Kochi.
By then a few months had passed and the "growth" in the thyroid had "spread" giving all of us anxious moments. Finally, Dr Varughese surgically removed the potentially dangerous nodule keeping the opposite half of the normal gland intact. Biopsy of the nodule removed all our fears as it was not "malignant". Post-operation, her voice is intact and so is the rest of the thyroid gland which only is required for the normal existence and further child-bearing without any supplementation.
In retrospect, the turn of events confirms that my son’s decision to pull his wife back from the operation theatre was wise. Otherwise, we would have got back our daughter as a thyroid cripple with life-long medications for thyroid hormone, calcium supplementation and possibility of recurrent laryngeal nerve injury for which the doctor/surgeon would have taken anticipatory bail! Most doctors are reluctant to explain to the patients their findings and the procedures they are going to adopt. Lack of time could be one reason. Another, more important, reason could be the doctors’ belief that they are infallible.
The surgical procedure that she underwent is what Dr Varughese calls "Thomas’ Technique". It is a technique he has devised himself. Traditionally, thyroid surgery is done by making an opening across the neck under "Adam’s Apple". Father of this conventional technique, practiced across the globe is Theodore Kocher, a German Surgeon, in an era when the world lacked any imaging modalities or modern concepts about neck anatomy or refined surgical techniques or modern instrumentations to minimise blood loss or skills.
The name of this incision, put 1 inch above the root of the neck, across from one jugular vein to the other is termed Kocher’s collar incision, which ultimately after healing is called Necklace incision! This leaves a mark for life. Who loves to bear the trauma sign of their surgery ever in life? I have seen women who underwent the operation trying to cover it up, most often unsuccessfully.
"This is the conventional method (Kochers’ Collar incision) that surgeons have been following for over a century. I found that there is no need to make the incision in the front region of the neck as everything related to thyroid can be approached through an opening on the neck (laterally) under the ear. I use the natural fold in the area to make the cut.
"The advantage of my technique is that there is no mark in any visible area. Whatever little mark is there merges in the natural fold giving the patient confidence in a matter of weeks! What’s more, the patient is discharged from the hospital within 24 hours of the operation. I may soon be able to start discharging patients within 12 hours of the operation.
"I am a lover of beauty and I do not want to leave my eternal "mark" on my patients. Let them remember me for the mark that I did not leave on them. In breast cancer cases, too, I do not go in for immediate removal of the affected breast. Breasts give a woman both beauty and confidence. If they are removed, she will miss them for life. Mastectomy is always a surgeon’s choice and convenience and never a woman’s choice.
"I have done a pilot study to evaluate the feasibility of ‘Thomas Technique’ in mastectomy too." Dr Varughese is a socially-conscious doctor who finds time to write both letters to the Editor in the ‘New Indian Express’ and research-based articles for scientific journals. A prominent Rotarian, he has also ‘authored’ a booklet on cancer explaining the different types of cancer and how to fight them.
"Cancer is a disease that people fear, though it is responsible for one in eight deaths worldwide. Cancer causes more deaths than AIDS, tuberculosis and malaria combined" says the doctor quoting an American authority on the subject. I found the booklet which I perused on the return flight quite informative and helpful.
"The message that should go out is that cancer is curable if it is diagnosed in time. So one should be aware of its symptoms". He is the president of Kerala cancer care society. He has organised several functions under the aegis of the Rotary Club, with this end in view. Among his collaborators in this noble mission are film stars like Mammootti, Mohanlal and Dileep.
It is not always that patients leave hospital in a happy mood and the doctor asks for a "treat" as in our case. Often, they have many complaints and doubts. One of my colleagues in Delhi recently underwent an operation. The removed "gland" was sent for biopsy. He took the report to the doctor. Instead of explaining to the patient what the report contained, he just said "okay, you can go".
He did not have the confidence to ask the doctor for an explanation. He turned moody. That is when I asked him what his problem was. He told me the whole story and I asked him to show me the report. The report, though brief, contained medical terms I could not understand. I checked the Internet and I got more confused.
Finally, I SMSed the report to my relative, who is practicing in a rural hospital in Kerala. Then I called her. She explained to me that there was nothing to worry and the patient was perfectly all right. When I conveyed her observations to him, he became cheerful once again. A thought that occurred to me was, why could not such reports be written in a layman’s language?
Prakash T. John has in an interesting article in ‘The Hindu’ (July 4) quotes a medical report which says, "CT study reveals that dilated loops with slow transmit of oral contrast suggestive of hypokinetic loops to be co-related for subacute intestinal obstruction". I could not make head |{r tail of this report.
"What does one make of a "kidney showing symmetrical uptake of contrast and a gall bladder unremarkable"? Is the kidney ok? What about the gall bladder? Are they both functioning all right? Hundred and one questions can arise in the patient’s mind causing sleeplessness and other forms of anxiety.
"Swelling becomes distention in reports; intestine gets renamed bowel, over-active intestine become hyperkinetic bowel and less active gets reworded as hypo. Urinary bladder is shown as "attenuated" in some reports and the spleen as "enhanced" in yet another one".
Assuming that the reports are written for the doctor concerned and not for the patient and use of scientific words are unavoidable, the question still needs to be asked, why can’t simple English be used in prescriptions and reports? I was recently a victim of a prescription. I consulted a doctor at the famous Parumala hospital in Kerala. He prescribed some tablets. As is the practice, he wrote it in the case file and did not give it to me.
I had to go to the medical store in the hospital to buy the prescribed medicine. While giving the medicines, the compounder wrote clearly for my benefit that they should be taken after the meals. I had a little doubt about it but the writing was clear. Two days later when I consulted the doctor again, I told him that I had been taking the medicines after the meals, not before. He got irritated and told me that all such medicines are taken before the meals and not after.
So, who is responsible, the doctor or the compounder who misunderstood the prescription? Prescriptions are written in great hurry. "Ornilox 1 � 1 means one tablet of Ornilox to be taken in the morning and evening. Is it before or after meals? Not sure. Can we do 1A — 1A for After Meal and 1B — 1B for Before Meal?� If the Parumala doctor had written like this I would not have faced any problem.
On the subject of prescription, I am compelled to narrate another incident, a very recent one. My grandson was taken to a doctor, who prescribed a particular medicine. I am good at deciphering, having handled handwritten manuscripts in the form of letters to the editor and articles during my 36 years of journalism. But however hard I tried, I could not decipher this particular prescription. My wife, daughter-in-law and my sister, who is familiar with medical names, too, could not decipher it.
Finally, it was left to Saji of Saji Medicals, Kayamkulam, who could easily decipher it because he was familiar with his handwriting. He told me about a particular doctor whose handwriting was so horrible that few could read it. In fact, the more famous a doctor becomes, the more infamous his handwriting becomes. Does this lead to complications?
"Yes" admits Saji. Ultimately, it is the salesman at the counter who dispenses the medicines. Usually, a doctor prescribes only a certain number of medicines and the salesman can easily make out. But when he prescribes a new medicine or when the prescription of a new doctor is brought to him, he fumbles. That is when he can give the wrong medicine.
The patient may not die but he will not get cured. Over a period of time, his condition can get worse. Why does a doctor write in an illegible way? My surmise is, first, to show superiority. Another — more probable — reason is that they are not sure of the spelling. If they write in a very legible manner, the patient will discover their inadequacy in terms of spelling.
Whatever be the case, the Delhi High Court recently ordered that in medico-legal cases, all reports should either be typewritten or computer-written. This followed the difficulty the judge encountered in understanding a doctor’s report. The Delhi Government has already implemented the order. Why can’t the order be extended to prescriptions also?
As I conclude, let me mention a prescription I have been preserving for the last nearly half a century. In my childhood, I developed swelling all over the body due, perhaps, to the malfunctioning of kidney. After I was cured of the disease, my father took me to Dr Narayana Pai, who was then Principal of Government Medical College, Thiruvananthapuram. It was said that his touch had a healing effect on the patient.
I still remember the gentle manner in which he treated me. He was tall and handsome and his face had angelic beauty. I consider him as one of the holiest persons I have ever met. I still keep his prescription, though the paper on which he had written it has turned yellowish and brittle. If such a great doctor could write legibly, why do others resort to "Greek" and "Latin" when they write prescriptions? (Courtesy: Indian Currents)