<div>Dr madhav surya read the e-mail from Abhed Govil, the son of one of his ex-patients Sunetra Govil. Connecting with the family again made Dr Surya, an orthopedic surgeon, happy. </div><div> </div><div>Sunetra’s had been a ‘repair’ case. She had suffered an arm fracture that was treated by several surgeons and finally come to Dr Surya for repair. And now Abhed wrote from Chennai: “It is unusual how life patterns present. I wish to consult you about my friend’s wrist, which he fractured during a rock climbing exercise. The local nursing home checked him and said it was a distal radius fracture. The doctor aligned the bones and put him in a plaster cast. It has been a month now and he has difficulty moving his fingers. I am in Delhi this weekend and would like to show you his X-rays....”</div><div> </div><div>That the friend was yet unable to move his fingers bothered Dr Surya. Usually it was expected that the fingers would be at ease within 24 hours of a surgery or cast. His mind began to raise questions already: Did the patient not go for check-ups or did the doctor not tell him to report within 24 hours and then again weekly for three weeks? Three weeks was a long time. It was usually one or the other...</div><div> </div><div>The X-rays that Abhed showed him, were taken immediately after the accident. It was an intra-articular, non displaced fracture, but the fact that Paritosh (Abhed’s friend) was not moving his fingers pointed to a displaced fracture. Likely the fracture worsened in the week after the accident? “I do think he must go back to the hospital and get examined,” said Dr Surya. “Frequent checkups are crucial to the recovery. Only then the rate of progress can be known. The hospital you mention is good, and did you tell doctor about the painful fingers?”</div><div> </div><div><strong>Abhed: </strong>I stepped in only last week when I found him in pain. I did imagine hospitals were better today than they were 10 years ago when Ma’s fracture took place. Then again, what is good, what is better! The best hospitals have messed my mother’s arm, successfully ruining her life for eight years. So, why did the best hospitals go wrong? </div><div> </div><div>Dr surya did not hold this bitterness against Abhed. After all, the lives of everyone in the Govil family had been thrown off gear for those eight years. Not to mention, poorer by Rs 4 lakh.</div><div> </div><div>Abhed , a PhD student from IIT Madras had come with Paritosh’s X-rays and papers. Paritosh, also a research student, was in plaster cast but Abhed began to grow suspicious when his fingers remained painful three weeks hence. </div><div> </div><div>That was when Abhed recalled his own mother’s tryst with a fracture that was mismanaged. He was 17 then and in the throes of his 12th Boards and IIT entrance exams and the family had protected him and kept him out of all anxiety. It was much later, in fact at his IIT graduation lunch, that she shared with him all that had happened. Abhed who had gotten used to his mother in perpetual pain and frowns, was pleasantly surprised when he saw her, looking good, well dressed and back to being happy about life. She shared with him how she had chanced upon Dr Surya of Dhanwantri Care. “He repaired all my earlier faulty surgeries,” she explained. “Until then we had met, so many doctors; I sensed they were not getting it right. Each time they put a different nail or plate and it was such madness... eight years of trial and error....”</div><div> </div><div>It was this that had alerted him about Paritosh’s condition – that the doctors at Plus Care, were hinting at another surgery without even auditing what went wrong with the first. This was exactly what had happened with his mother too. He now told Dr Surya, “The patient will never know what the doctor does to his insides. He just submits himself, hands his body over to the doctor. Thereafter it is between doctor and your body! Long ago, the doctors at the City Hospital asked my mother what kind of plate she would like put into her arm, without telling her what she needed. How was she supposed to know?”</div><div> </div><div><strong>Surya: </strong>Some doctors wonder if the patient can afford the cost of better quality implants.</div><div><strong>Abhed:</strong> Seriously? Is that how they deliver healthcare? According to affordability? Does my wealth give me a right to life? And my poor resources a duty to die with substandard treatment? Is there not a right to quality healthcare accorded to me under the Constitution? </div><div> </div><div>Dr surya then began to piece together the events surrounding the numerous surgeries that Abhed’s mother Sunetra had gone through, until she finally came to Dhanwantri for repair. </div><div> </div><div>Sunetra Govil had undergone four surgeries in all for her arms, three on her right arm and then a fourth and fifth on her left arm; she had had yet another fall a year after her right had been fully healed by Dr Surya. </div><div> </div><div>When Sunetra fractured her right humerus, she was first taken to a private nursing home by her family, where a 6 hole, locally made, DCP was used to fix the bones. Six months later, she continued to be in pain and it was found the fracture was not uniting. Her family then took her to the prestigious EFG Hospital, where she was operated upon yet again and another local 6 hole DCP was fitted and bone grafting done.</div><div> </div><div><strong>Abhed: </strong>Did the EFG doctors say why the earlier surgery had gone wrong? </div><div><strong>Dr Surya: </strong>The investigating team saw that the plate had come loose, that her bone had not united; so they removed it and put another local made plate. </div><div><strong>Abhed:</strong> How did that help? Without an audit how can a hospital perform a second surgery?</div><div>what could Dr Surya say! But as the story went, the second plate too came loose, the pain got worse and she was put back in plaster cast. And thus she remained in plaster cast for close to a year, yet unusually the fracture would not unite and all the screws and plate were almost out of the bone. </div><div><strong>Abhed: </strong>You said ‘local plate’ twice. Why do you say local? Are there other kinds? For example, if the surgery was done at a super speciality hospital, what is the kind of DCP they would have used? A patient is likely to think that using the best branded implant is the default for any hospital!</div><div><strong>Dr Surya: </strong>Local means either ‘source is unknown’ or unbranded. Save one or two global brands, no implants of any known quality or grade were available in India. It was mostly cottage sector models. Nor were there any filters operating in the implants market. Just about anyone could set up shop and fabricate these, sadly. Only in 2006, the law was enacted that every manufacturer of stents and implants must register the products. Hence it is not necessary that a patient gets fitted with the best, even today. </div><div> </div><div>Your mother came to Dhanwantri on the recommendation of good friends. But she was very cynical and unwilling to be guinea pig again. Her second surgery had failed too, and she was experiencing a lot of neural unrest. I must add, the implant was a fake and her body was rejecting it. Her blood tests recorded high numbers on some parameters, and it seemed to point to the implant. That was when I did a bone graft again but this time I used a titanium Kyosin implant. In two months she was recovering very well, and she was back at work. </div><div> </div><div><strong>Abhed: </strong>And were you able to see why her earlier two surgeries had gone wrong?</div><div><strong>Dr Surya:</strong> A combination of events if we may say that. At 40, her age at the time of the first accident, she may have already been osteoporotic. (For, she was osteoporotic when she came to me the following year in 2005 after her left arm fractured; we had performed a bone density check then.) </div><div> </div><div>Now, see in the case of osteoporotic patients, the bones are very porous, hence the grip of implant is weaker. If the bone quality is strong, the screws and the plate will hold. Think of wood and think of hard foam. This is the difference between a healthy bone and an osteoporotic bone. In an osteoporotic bone, the screw will start to give way. What happens is that the overall construct that is meant to last for a certain period for the bone to unite, starts to become loose. That could be why her first implant came loose with her arm movements and caused her untold pain. I will also say that, that is why after the second surgery they also put her in plaster cast, to reinforce the implant. Usually with implant you don’t need plaster. </div><div> </div><div><img alt="" height="441" src="/image/image_gallery?uuid=ad76b8bb-7258-443d-bf20-23f646d4a72e&groupId=222861&t=1418122892133" width="600" />Maybe there was a suspicion that her bone was osteoporotic and the doctors may have felt it best to add the plaster cast so that her movements will not cause the grip to come loose.</div><div> </div><div><strong>Abhed:</strong> Suspicion? Can a doctor provide a course of treatment based on assumption? Is it not natural for a fracture doctor to first check bone density? If they did not, is it not negligence? The doctors at two big hospitals failed in not having audited why her surgery had failed twice! Nor had they done a bone density check! What is the point going to a big hospital then?</div><div> </div><div>Dr surya then mentioned Sunetra’s second fracture. Her right arm healed after I operated upon it. But a year later, on a family trip to Bharatpur, she fell and broke her left arm.</div><div> </div><div><strong>Abhed:</strong> Yes, I remember, I got a call at IIT... Ma wanted to come to Dhanwantri to be treated, but they thought she was being hysteric and got her treated at some small clinic.</div><div>Dr Surya: Very sad indeed. Often family members discount the feelings of the patient, which is wrong. It appears the doctors there convinced the family that if she was not operated upon she would lose her limb. In my opinion, patient families should not panic and seek to get informed. </div><div> </div><div>Anyway, the team of surgeons at Varsity Public Hospital, put a locally made intramedullary nail into her left humerus. But the nail-implant was not holding the bone in proper position and the limb was just rotating around the nail. This made shoulder movement very painful – the nail was practically sticking out of shoulder joint. </div><div> </div><div><strong>Abhed:</strong> What? What does it mean? </div><div><strong>Dr Surya:</strong> See, the bone is like a pipe with a hollow centre. In the case of load bearing bones, sometimes the doctor may decide not to use a plate, but instead to put a steel rod called the intramedulary nail through the canal. This gives strength as it verily reinforces what the whole bone was doing. So, this is what was done on her. She remained in plaster for six months but the fracture could not unite and also the shoulder became frozen. She was back home and was enduring such a rotten fracture. </div><div><strong>Abhed:</strong> Is not a bone doctor supposed to check the patient several times in between? Did this doctor tell her what could be the reason for the failed union of the bones?</div><div><strong>Dr Surya:</strong> Ideally the damage should have been discovered far earlier. Things need not have come to this pass. See, patients too have very poor discipline. If families discount the pain of the patient, then at the other extreme, patients also discount the doctor’s recommendations for care. Even if I recommend an X-ray, I have seen patients saying ‘the bone will heal sooner or later, why do so many X-rays. Acchha nahi hota hai...’ And then the X-ray is not done. I think your mother was angry over her condition… .</div><div> </div><div>Abhed felt bad suddenly. He recalled one occasion when his mother complained of pain and the family had cajoled her saying, ‘See, it is winter, bones will pain, learn to be patient’; and they had fed her turmeric milk.. “What caused the damage this time round? asked Abhed.</div><div> </div><div><strong>Dr Surya: </strong>What we saw was a poorly done surgery. I shared her X-ray with the technologists at the Kyosin implant manufacturing company. See, you don’t just put a rod and leave it there. You need to lock the nail into position at the top and the bottom so that the two pieces of the bone are no more rotating across the axis. This is the concept of LARD: length, angulations, rotation and displacement. In Sunetra’s case, the rotation was left loose. Actually we learn all this from the implant manufacturers too... they do train surgeons.</div><div><strong>Abhed: </strong>So, then, what did you do differently that mom was healed?</div><div><strong>Dr Surya: </strong>I looked at her bones and based on my work with implants, I felt she would heal perfectly if I fitted her with a titanium plate. It is suited to an osteoporotic bone, which is like sponge... hence any implant we use must grip the bone better.</div><div> </div><div>Dr surya opened a cupboard and brought out a titanium plate in its packaging for Abhed to see. “This is what a philos plate looks like,” he said handing it to him. Abhed examined it a trifle overwhelmed. One side of the pack showed the stages in which it is fixed on a humerus. Below, he read: This description alone does not provide sufficient background for direct use of the product. Instruction in handling this product in accordance with the corresponding technique guide and by a surgeon experienced in handling this product is essential. Abhed was reading it aloud. And Dr Surya commented, “This also means one needs to be informed, trained in what situations various plates and grips can be used. So, you see, it can never be based on affordability! </div><div> </div><div>Abhed’s mind was now a riot. Wow, he thought, four times mom was operated to put in and take out plates of these kinds.</div><div> </div><div><strong>Dr Surya:</strong> There is a huge responsibility that doctors and surgeons have with regard to treatment and solutions. Technology keeps evolving. A doctor has to keep learning. And this occupies a huge part of my professional mind and this is why I spend more time learning than building a brand name. But I also wish to tell you that patients have a duty to know, a duty to ask, a duty to be informed. As in every domain, in medicine too, ignorance is not an option and cannot protect you!” </div><div> </div><div>To be continued... </div><div><br /><strong>Meera Seth</strong></div><div>(This story was published in BW | Businessworld Issue Dated 29-12-2014) </div>
