The card from India

She knocked on the door and came into my office. She looked me in the eye and handed me a letter. This was very unusual as she would normally keep all my letters in my in-tray in my absence. I was blessed with one of the best secretaries. Having a great secretary is half the battle won for a Consultant Neurosurgeon. She managed all my correspondence, was very good with the patients, and understood what needed prioritizing. She was punctual, very cordial, and very organized. I could not have asked for more.

This was, however, very unusual. She was bringing a letter and handing it to me…… I looked at the letter. It was not posted in England but was from India. All letters to my office are from England or the UK, and rarely from Europe. This letter from India was extremely unusual. No doubt I got this special delivery. She looked at me, raised her eyebrows a little, pursed her lips and smiled before leaving. I was sure she was curious about this letter.

When she left, I immediately opened the letter. It was from Sarah (name changed). I had received greetings from her every Christmas for the last four years, but from London. This was from India. There was a thank-you card inside with a photo of the beautiful Jaipur Palace from North India. She had written only two lines: “Remembering you on this visit to India. Thank you for making my dream come true.” I could not help but feel emotional reading these two lines.

Five years earlier, my registrar had called me in the early hours of the morning, stating that a patient was admitted to a local hospital in Lake District, having lost strength in her legs and control of her bowel and bladder function. They had done a lumbar MRI which showed a disc at the L4/5 level, and they suspected it was ‘Cauda Equina Syndrome’.

Cauda Equina Syndrome is a condition where there can be a large disc pressing on lumbar nerves (which have the anatomical appearance of a horse’s tail, hence cauda equina) leading to symptoms of bilateral sciatica, weakness, numbness in legs, saddle anesthesia, and bowel/bladder/sexual dysfunction or a combination of these symptoms. This is a neurosurgical emergency.

I asked her to be blue-lighted across, a term used to get the patient urgently transported by ambulance with blue lights and sirens, to avoid any delay.

When I went to the ward to see her, that was when I saw Sarah for the first time. She was lying in bed in the far right corner of the cubicle, which also housed five more patients. Each had their private space separated by curtains. As my registrar, the in-charge nurse, and I approached her, I pulled the curtains to give us some private space. She was in her late forties, not slim, but not significantly overweight either. She had large blue eyes filled with apprehension and an anxious face ready to ask a hundred questions.

I introduced myself, and we went through her story. She was a single lady, divorced five years prior. She lived in London. She and her friends had come to Lake District for fell walking four days earlier. Two days prior, she had felt heaviness in her legs during her walks and had attributed it to being bit tired. But since 4 pm the previous afternoon, she noticed rapidly worsening weakness in her legs and was also incontinent of urine and feces. She had flicker of movement in her legs with a sensory level in her upper abdomen.

I looked at her. “I have gone through your clinical examination, and your clinical picture cannot be explained by the disc at the L4/5 level in your lumbar spine,” I said. “I am suspecting a mid-thoracic lesion, and we will have to organize another MRI of the rest of your spine.”

That MRI revealed a tumor in her spinal canal in the mid-thoracic region, which had crushed her spinal cord to one side. The spinal cord was thinned out and stretched over the tumor, which was inside the dural sac. The dural sac covers the spinal cord and nerves and also contains spinal fluid. There was a strong suspicion it was a benign lesion called meningioma.

I went back to her with my team. She was anxiously waiting for the results of the MRI. I explained the MRI findings, and offered her urgent surgery to remove the tumour and relieve pressure from the spinal cord. She was very worried that it was a tumor though benign. “I am passionate about walking, Mr. Kamat. My friends and I go for walks regularly. That’s why we have come to Lake District for fell walking,” she said. She looked into my eyes and asked, “Will I be able to walk?”

How anyone will recover from surgery, after an insult on the spinal cord, is difficult to predict. If there is permanent damage, no matter how good the surgery is, there may not be any recovery. “I will do my best,” I said, reassuringly.

Her surgery went well. I removed the tumor completely, taking all care to protect the spinal cord and nerves while doing so. She withstood the operation well, and when I saw her in the post op ward, she was barely able to open her eyes. When she realized I was next to her, she asked, “Will I walk?”

“Everything has gone very well. The tumor is all out, and the operation was uneventful,” I said without giving her a direct answer. “I will see you tomorrow when you are more awake and the anesthetic drugs are out of your system.” I checked with my anaesthetic colleagues that she was doing well and left.

I usually keep thinking about my patients and what success of an operation means to them. Success of operation for her was not just taking the tumor out safely but recovery in leg strength to normal and being able to walk. That was a tall order when a person had no strength whatsoever in their legs, and with bowel, bladder, and sensory involvement. I was not sure if there would be any recovery.

I came the next day, eager to meet Sarah and see how she was doing. As I entered her own single room, which she had earned following her surgery, I saw a beaming smile on her face. She greeted me with “Good morning, doctor,” and said, “I am able to move my legs a bit and think I can sense my legs a bit better too.”

This was a very good sign. We might have caught her before she sustained significant permanent damage, I thought. “I am so pleased. Let’s see how things progress,” I said cautiously. In such spine surgeries, it is very difficult to predict the extent of improvement, which only reveals with time. I reconfirmed to her that the surgery went very well. Looking at the physiotherapist in the team, I said to Sarah, “We will ask our physiotherapy team to work on you.”

Over the next few days in the hospital, she had further improvement with antigravity strength in her legs, which is not good enough to walk. She failed her trial without urine catheter and needed the catheter re-inserted. During one of my daily visits, she asked me, “Where are you from?”

“Originally from Mumbai, India,” I said.

“I always wanted to go to India. Never been there. It was on our list of places to go. If I start walking, I will go to India and send you a card,” she said.

She was shifted to her local hospital in Lake District for further rehab and recovery. I received her pathology report two weeks later, confirming it was a benign meningioma. I called her to let her know.

“Good morning, Mr. Kamat,” she said. “So nice to talk to you.”

Before I could say anything further, she blurted out, “I am improving every day. They have taken my catheter out, and I have passed urine normally,” she beamed. “They are going to make me walk with support today.” She was very cheerful. She did not know how happy I was for her, at the other end of the line.

“I am very pleased with your progress,” I said. “We will keep working hard with physiotherapy and see how things improve,” I continued my cautious stand. “The report of the tissue sent for pathological examination revealed it was meningioma. This is a benign condition,” I said. “That is good news.”

I said I would see her in a few months in the clinic. I organized a follow-up MRI to check the completeness of the tumor removal. This scan showed complete removal of the tumor, which I let her know with a letter. I arranged for a follow-up MRI in a year’s time. It is always better to keep under radiological surveillance to confirm that there are no residual cells growing back into a tumor.

After this, I did not have any contact with her. She had in the meantime moved back to London. This was a five-hour drive from my hospital. When I realized that, I wrote a letter to give her the option of shifting her care to her local hospital with a neurosurgery center, which she politely declined, saying she preferred to come to my hospital for her surveillance scans and any treatment.

A year later, as I was sitting in my clinic, a lady walked in with a beaming smile. I could not believe it was Sarah. She had recovered almost completely. Her sensation and strength was almost normal. She had no bowel or bladder dysfunction. And she was walking without any aid. I don’t know who was happier, her seeing me or me seeing her. I did not mince any words to express my happiness at seeing her and her improvement. The MRI had shown no tumor recurrence. I said to myself, I can now say the operation was successful.

Since then, she has come every year for the next four years to confirm that the MRIs did not show recurrence. Every time I found her fitter and happy with her life. Every Christmas without fail I receive a card from her, thanking me for the surgery and the new lease of life it has given her. And how she was living life to the full and fulfilling her passion for walking and seeing the world.

This card from India meant more than just a card. It was the successful journey of a fighter who fought her way to achieve her dreams… And for me, a sense of gratification in the job I do…