The surgical snake

Tom arrived with his mother and brother from Malawi a small country with a big heart in the eastern part of Africa Unfortunately it is also one of the poorest countries in the world ranked 174 out of 193 on the Human Development Index India is at 134 Switzerland is at the topldquoThey do not know what to do with him back homerdquo Tomrsquos mother said telling me of the occasional sudden jerks in his left hand and leg ldquoHe starts shaking like a machine gun out of nowhere and the last time this happened he spat out bloodrdquoI explained to her that her 18yearold son was having seizures or epileptic fits and that the blood was probably from a tongue bite ldquoI also have headachesrdquo he interjected pointing to the right side of his head from which tiny curly hair sprouted The CT scan they had brought with them showed ldquosomethingrdquo in the right frontal lobe but it was too grainy to decipher it was like a bad screenshot from a monochrome movie in the 1950s ldquoWersquoll get an MRI done to ascertain what the exact problem is and take it from thererdquo I announced as we started medication to control the jerksI am amazed how we still live in a world where people have to travel across continents for advanced medical aid Patients who come to South Bombay for treatment from Goregaon may be able to relate to thisThe MRI revealed a 5cm arteriovenous malformation ldquoThere is an abnormal tangle of blood vessels between the arteries and veins disrupting his blood flow and oxygen circulation which is why hersquos having headaches and seizuresrdquo I explained to his mother ldquoBecause these blood vessels do not form properly they can even rupture to cause a brain haemorrhagerdquo I cautioned as she sat down with a thump while the younger brother was playing video games on his phone least affected by the drama in the room I added that often times people donrsquot know that they are harbouring such a malformation until it starts bleeding inside He was lucky that catastrophe hadnrsquot struck him yetldquoWhy do these things happen doctorrdquo she asked after adequately composing herself I resorted to my standard template for most questions in medicinemdashldquoNobody knowsrdquomdashbut went on to explain that it could have a genetic predilection Maybe I should have said it comes from too much screen time the other brother might have then paid some attention ldquoWe have to remove thisrdquo I suggested after studying the angiogram we got done subsequently Despite her fragile state I went on to enlist all the possible complications that this surgery could entail albeit lovingly ldquoSurgeries such as these are long and difficultrdquo I added ldquobut wersquove done many with good resultsrdquo I reassured her She gave me the big famous Malawi smile ldquoDo your best doctorrdquo Africans are kind and trusting In my opinion it is the most soulful continent on the planetThe next day we made a large Cshaped incision over half his skull and removed the bone the size of a saucer We opened the covering of the brain the dura along the edge of the bone and saw the arteriovenous malformation staring at usmdashalmost like aggressive convoluted magenta and fuchsia snakes hissing angrily at us once their bamboo basket had been opened The surgical challenge was to extricate this serpentine leash without being bitten This was a complex task because some of the arteries that feed the malformation also supply normal brain tissue and oftentimes it is hard to differentiate between an artery and a vein since their blood mixes In these malformations the normal capillary network is missing and hence the pressure in the system is very high You buzz the wrong vessel and the malformation will blow up in your face akin to being walloped by a pythonWe meticulously meandered around the periphery terminating all the baby snakes first and then gently went into the depths without waking up the mother snake Often times there were angry spurts of blood that needed to be controlled with equal aggression I was the predator disguised as the snake charmer but my pungi was not mesmerising them with music but violating them with vehemence One by one we decimated over two dozen ldquosnakesrdquo until the last one gloated with pride I held it between the tips of my forceps and charred it to death disconnecting it from normal circulationA great ball of fire was now a scalded birdrsquos nest The crimson African sun was doused before the sunset We removed it completely and waited for a while to ensure there was no further bleeding before we closed ldquoThese malformations are notorious for bleeding even after surgeryrdquo I told my team suggesting they keep close vigil as I left the operating room allowing them to closeTomrsquos mother was thrilled to see him in the ICU fully alert and talking well with no neurological dysfunction But just when I was about to leave for the day the ICU called saying he had had a seizure Not only was he shaking he was also not responding Luckily he regained consciousness in seven minutes A CT scan came out clean with no snakes spitting venom We hiked his antiseizure medication Two hours later he had another seizure Something in my gut told me to repeat a CT scan This time it showed a significant amount of blood at the edge of our resection cavity Luckily it didnrsquot need going back to the operation theatre because an angiogram confirmed we had removed the entire nidus We ventilated him overnight while his mother played Bible music close to his ears The next morning the African sun rose again Bright and cheerful In all its glory We were able to shift him out of the ICU and got him to eat walk and be free again in a few days ldquoNow we know why no one in the entire country wanted to do this operationrdquo the mother told me I told her how challenging these cases could be and gave her the snake analogy ldquoDid you know there are 66 different kinds of snakes in Malawi 24 potentially deadlyrdquo the zoology teacher in her surfaced ldquoThere are no venomous snakes left in Malawirdquo I stopped her ldquoWe killed all 24rdquoPS No animals were harmed in this surgical strikeThe writer is practising neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals mazdaturelmiddaycom