As we sat in the post screening clinic conference debating the risks and benefits for each patient before proceeding with surgical procedures, my mind flashed back to a day shortly after we arrived in Nepal. I walked the grounds with Dr. Saswat, the orthopedic resident assigned as our Operation Walk liaison. He pointed to a distant sight. Awkwardly making his way across the pavement, steadied by a set of crutches, was a young man of approximately twenty five. Saswat explained to me that he was a candidate for the Op Walk camp and had travelled from afar in hopes of undergoing bilateral hip replacements.
His hips were fused and he suffered from ankylosing spondylitis--a long term disease that causes inflammation of the joints between the spinal bones and the joints between the spine and pelvis. It eventually causes the bones to join together and mobility becomes progressively compromised, often to the point of complete incapacity. His mobility had steadily diminished over the years and was now at the point that he was unable to independently care for himself.
The team debated his case and discussed the potential for surgical success. From a medical standpoint, anesthesia would be a challenge. A successful spinal anesthesia modality would likely not be successful due to the anatomical challenges posed by his spine and rib cage. Although general anesthesia was a possibility, the anesthesia team lacked the critical equipment that might be necessary to safely manage the airway of a patient with major neck and spine abnormalities. After all, general anesthesia was not in our plan for any of the patients as a primary anesthesia route. From an orthopedic surgical standpoint, the procedures were not elementary, but certainly manageable. Orthopedic score-2 and anesthesia/medicine score-3. Discussion engaging everyone in the room ensued relative to the potential for success and a positive outcome.
After what seemed like an eternity, the team rendered its decision. It was neither wise nor prudent to proceed with these procedures. The inability to manage him from an anesthesia standpoint posed a serious threat and could possibly even result in his death. The team had made its decision and that would then be explained to the patient. Disappointment hung heavily in the room, but the correct and safe decision had been made; or was it?
From the front of the room I heard the quiet and calm voice of the LA surgeon who accompanied us on the trip. His presence on our orientation trip was intended to provide guidance and a means for an experienced resource to our novice team. He acknowledged that our assessment was completely accurate and the risks associated with proceeding with the procedures were high. He continued to engage us. Left untreated, this young man would be doomed to the effects of advancing disease with no way to mitigate the damage and destruction that would be left in it's path. It wasn't a matter of "if" he would become completely immobile, but "when"? He challenged us. Should the patient not be given the opportunity to make the decision if the benefits outweighed the risks for these procedures? Should he not at least have that modicum of control over his own future and destiny? And with that, the momentum changed. Enthusiasm mounted. The dialogue shifted to "how" this could be accomplished rather than "if" it could be accomplished.
Surgery day two dawned with a sense of accomplishment from our initial operative day, and eager enthusiasm to launch into the series of more complex patients that this day promised to bring. The team was buoyed by increasing confidence and the comfortable camaraderie that had begun to develop and solidify. Pramod had not only accepted the risks associated with his procedure, he desired to get in the OR as quickly as possible. His smile was ear to ear. There was no turning back for him. The day flew by quickly for us, but for him it was an eternity until his OR time arrived. We had agreed he should be the last case of the day so that additional team members would be available, as well as limitless surgical time. He finally arrived in the OR. That same dazzling smile greeted the team as the anesthesiologist worked his magic and by some miracle (or exceptional skill), the spinal slipped into place signaling the start of the surgical procedure.
The right hip replacement was completed, hemodynamic stability confirmed, and the anesthesiologist gave the green light to reposition the patient to the other side to commence the left side hip replacement. Everyone was excited about the realization that the second procedure could be initiated and therefore, the true therapeutic effects of the bilateral procedure could be achieved. We carefully began the transition to reposition the patient for the second procedure. This involved a brief stop in the supine (back laying) position prior to propping the patient up on the opposite side. Much to our surprise and delight, Pramod lifted his head, steepled his hands in the traditional Nepalese manner, and with his broad smile intact, greeted us with "Namaste" as we turned him onto his back. He deeply touched the hearts of all present in the room. I recalled how close we were to denying him this life altering surgery and silently thanked the surgeon for nudging us forward appropriately.
Before long the surgery was finished and he was in the recovery room having received two new hips. He was overwhelmed with emotion and joy. He gripped Dr Saswat's hand and searched his eyes for an answer to the question on the tip of his tongue. "I marry now?" he exclaimed. As Saswat answered in the affirmative, the grin broadened and was this time accompanied by dark eyes sparkling with hope for the future.
Early the next morning family, friends, and a group of team members crowded around him as he ventured into the hallway taking his first steps. Filled with exuberance and free from pain, he cruised the hallway, physical therapist at his side. Pramod became an inspiration to others (patients, family, and the Operation Walk team) for the remainder of trip. He touched the hearts of us all and impacted us in a manner that will not soon be forgotten.
We were drawn to him and nourished by the inspiration, hopes, and dreams that he symbolized. I visited him several times each day and never found him to be without that wide grin and unflappable demeanor. As our Operation Walk camp drew to a close, we assembled for the traditional team-patient photograph. He spotted me across the room and motioned to me. He patted the bed next to him and I sat. I remained seated near him for a few moments, both of us silent but aware of the powerful exchange that was in process. Before I realized what was happening, he had draped a vibrantly colored scarf around my neck and shoulders, pressed his palms together and with the smile that was now so familiar to me, nodded his head and exclaimed "Very Happy". Operation Walk Nepal a life altering experience for us? Perhaps. A life altering experience and a promise for a future for Pramod? Without a doubt. We depart Nepal content in the recognition that we made the right decision to proceed with his surgery. Sometimes the message present in your heart must overrule the logic of your head.