A missing Thumb, and- God!

One of my main area of interest was reconstructive micro-surgery: putting back severed fingers, repairing nerves and blood vessels under the microscope, taking tissue from one site of the body and inserting it into defects created by trauma or tumour re-section by joining minute blood vessels, etcetera.

This was a branch of Reconstructive Plastic Surgery. Occasional cosmetic surgeries were an interesting diversion. But, as a healer, the reconstructions gave me more pleasure. It was good not to encounter death too often, I reflected.

‘Shall I send the next one in?’ Shobha, the OPD nurse called out. I became aware that I was back in the outpatient department.

‘Yes, please.’ 

A huge shadow appeared on the OPD wall. I looked up at the massive figure framed by the doorway. Six foot two, and dark. He had bulging muscles. Beetle brows and a square jaw made him look like Arnold Schwarzenegger. There was a jagged scar across one cheek that ran over the lip.

He wore tattered jeans and a t-shirt with an image of a demon with horns.  Blood dripped from its fangs. His right hand was thrust into his jeans pocket, as if fiddling with a concealed weapon.

‘Please sit down,’ I said.

‘Er –’ the man mumbled, sinking into the chair. Obviously, he was a man of few words.

 ‘What is your problem?’ I looked interestedly at the jagged scar on the other man’s face. ‘Is it the scar?’
‘Nah. The scar is nothing.’
‘Oh. Then you came for–? I mean, what is your complaint?’
‘Ah, that. See this. There is this thing.’ He slowly took his hand out of his jeans pocket.

There were four fingers on it, but no thumb. It seemed to have been amputated. A small scar marked the spot where it had once been.
‘ Okay.’ I was enlightened. ‘Your right thumb is missing.’
‘I don’t need you to tell me that.’
‘Yes, of course.’ I was mildly taken aback. The man was touchy about the subject. And he didn’t seem to have much patience either. His general demeanour made me suspect something else. ‘How did it happen?’
‘It was an accident.’
‘What sort of accident?’

 ‘What is this, a police interrogation?’
 ‘Nothing like that. Don’t tell me if you don’t want to. But it might help in planning the treatment, you know. Was it crushed by a machine? Or by a sharp instrument?’
‘A hatchet.  It was quite a sharp one.’
‘Oh. You accidentally cut off your thumb with a hatchet?’

 ‘Well, not really accidentally. There was this fight, I mean – an argument. The guy –’ He looked almost embarrassed. ‘You know, it is rather complicated.’
‘I see. What happened to the guy?’

 ‘He is dead.’
‘Oh.’ Before the silence could become noticeable, I considered the options. Then I tried a different tack. ‘What are you professionally?’
‘Er?’
‘I mean, what do you do for a living? Unless I know that, how can I determine what to do with your hand?’

This seemed to cut some ice with the man. The logic penetrated his thick skull. He mellowed down and offered a sheepish smile.

‘Suppose you have a difference of opinion with somebody, and want to settle the issue once and for all, what do you do?’
I thought over this for five seconds before replying. ‘Talk to him? Thrash it out? ‘

 ‘No, no. You just send for me. I settle the issue. I negotiate with him for you. With bare hands. Or a knife. Whatever.’
Oh no, a hired goon, I thought. Nothing was remarkable about this. People who came in with homicidal injuries were not usually saints. But I had to make a show of scruples. I mean, I had some.
‘Then I can’t help you much. You see, I do not exactly … er – approve of your line of work.’

 The man seemed to be prepared for it. ‘But I have given up all that.

That is the point. I am reformed. I am like a saint now, really. I want to work properly, like anybody else. But where is the thumb? Without that, how can I work? ‘ 

‘Hmm.’  
‘You are the plastic surgeon?’
‘Yes, I am.’
‘But I want a micro-surgeon. The doctor who sent me said –’
‘I am a reconstructive micro-surgeon as well.’
‘Both are the same?’
‘In this case, they are.’
‘Then you can easily put a plastic thumb for me and finish off the job. That is nice.’
‘Plastic has nothing to do with plastic surgery.’
‘Really?’
‘Really.’
‘Strange. Then what do you plan to do?’
‘ Well, in your case, it would be ideal to take the second toe from your foot, along with the arteries, veins, nerves, and tendons, and put it in place of the missing thumb.

All these things have to be joined with the corresponding structures in your hand, under the operating microscope, using micro-surgical techniques.

Of course, it is a delicate surgery, and could take about eight or ten hours. The missing toe won’t be noticed, and should give no trouble as far as routine activities are concerned.’

The man listened carefully. It was for the first time in a long while that he was listening to someone without interrupting. The fact was he was too astonished to speak. Finally, he opened his mouth.
‘You don’t really mean that?’
‘Yes, I do.’
‘But one doctor – a well-known expert in tribal medicine – gave me an oil that would grow the thumb slowly over many years.’
‘That is nice. You could use that.’
‘I tried it for some months.’
‘I can’t see any growth, if you will excuse me.’
‘He said that is because I didn’t adhere to the instructions.’
‘Such as?’
‘No drinking, no smoking, and no thinking. I mean, thinking about women. Sex.’
‘No sex either?’
‘No, not even thinking about it.’
‘All that is not practical?’
‘No.’
‘Well then, what about toe transfer? We could try that.’
‘How much will it cost?’
‘ Hmm. It is a ten hour micro-surgical procedure. It will be around fifty thousand rupees. Maybe more.’
‘I don’t have that much money! There is no way I can pay that much.’
‘How much can you afford?’
‘I can arrange, at the most, fifteen thousand rupees.’
I looked at the huge muscular man. After many years of practicing surgery in India, this was hardly a new experience.

Money is, was and in the foreseeable future, will be the chief issue, especially in procedures that are not life saving.
‘Look here.’ I broke the silence. ‘What is your name?’
‘Kudiyirikkal Sunil.’
‘See here, Mr. Sunil, I will send you to Mr. Satheesh Raghuram, the senior administrator of the hospital. He is the son-in-law of the owner. Please go and meet him. Explain the situation to him. I will give you a note.’

After the man was sent off, I was busy with the rest of the patients. I was relatively free after about an hour, and was just going to the canteen to have lunch, when the OPD-in-charge called. ‘Mr Satheesh wants to speak to you. Shall I connect him?’
‘Sure. You can’t say no to the boss.’ I sighed.

‘Hello, Dr. James. Good morning. How are you?’  The familiar enthusiastic voice reached him.

 ‘Hello, Satheesh. It is about that Kudiyirikkal Sunil, isn’t it? ‘
‘Why, doctor, can’t I call you otherwise? Give you a social, friendly call?’ Satheesh chuckled.
‘ Sure, sure.’ I smiled. After two minutes, he returned to the subject. I asked him, ‘Can we subsidise his treatment or not? It is an interesting case. Toe transfer is one of the most challenging procedures in micro-surgery.’
‘I understand that,’ Satheesh said thoughtfully. ‘I talked to him. He is a goonda! Did you see the picture on his t-shirt?’
‘He says he is reformed.’
‘And you believed him?’
‘That is not the point, Satheesh. It is not our job to judge. We offer him whatever treatment he needs.’
‘Even when he can’t pay for the services?’

I knew this would not get us anywhere. Modern hospital management works on mysterious ways for their wonders to perform. Sometimes it is all about money.

Sometimes it is only about patient satisfaction. Rarely is it about the correct treatment and long term vision. But then, it was a difficult branch of commerce. I decided on a different approach.
‘This would be a sensational surgery, Satheesh. It will get people’s eyeballs. Imagine the headline in the local newspaper: Toe for missing thumb! Rare miracle surgery at RR Hospital. How does that sound?’

Satheesh was silent for a moment. One could hear his business brain whirring.
‘Oh, I did not think about it that way. Mmm. Maybe we could do something. But you will have to forgo your entire professional fee in this case.’

‘Why not reduce the professional fee as well as the hospital charges equally?’
‘But, doctor, surely you realise that the hospital has expenses – colossal investments?’
‘Very well, then.’

The surgery went off smoothly. I dissected the minute vessels and nerves, arduously and meticulously, taking the toe out in under two hours – by itself a remarkable achievement. Preparation of the site for the thumb took another two hours. Two stainless steel wires were used to fix the toe to the carpal bone in the hand. Repair of the tendons followed.

Next came the most difficult part of all – joining the microscopic arteries and veins, each about one millimetre in diameter. Using suture threads many times thinner than a human hair, I joined them with six to seven circumferential stitches, each done painstakingly with precision.

Similar microscopic repair of the tiny nerves, and the skin closure, completed the surgery. When the defect in the foot was sutured, it was very difficult to spot that one of the toes was missing. There was no gap to be seen. The whole procedure took about eight hours.

It was a deeply satisfying surgery. Completing it without a hitch gave me a thrill akin to having scaled Mount Everest.

The fact that it would benefit the patient was an added bonus. These kinds of surgeries were inspiring. I had spectators comprising junior surgeons and surgeons specialising in other areas.

Even though we did other similar reconstructive micro-surgeries such as transfer of skin, muscle, and bones routinely, replacing a thumb with a toe took the cake. It was something magical.

The next few days, crucial in any micro-vascular transfer, passed uneventfully. The only problem was the patient, Kudiyirikkal Sunil, who was not used to having his freedom curtailed, or adhering to a strict routine.

Friends who visited him often had to be barred from the ward when they started heckling the nurses. He was not used to taking orders either.

I had taken the precaution of confiscating all the cigarettes from his luggage.

The nicotine from even one cigarette was enough to cause a spasm in the tiny repaired arteries and veins. There was a danger of a thrombus, which could have disastrous results.

Within six weeks, the entire wound had healed; the bones had united satisfactorily. The mobility in the new thumb was not much. It was primarily designed to act as a static post, against the other four fingers, providing support for most purposes.

I advised Sunil to resume all his daily chores one by one, so that in a month’s time life would be back to normal.

For a few months, I did not see the man again. I had almost forgotten him, when he suddenly appeared in the OPD one day. His face looked gloomy. A different demon displayed its fangs on the front of his black t-shirt.

Where does he get these T-shirts from, I wondered.

‘Hello, Mr. Sunil,’ I called out, genuinely pleased to see him. ‘I thought you must have had a particularly tricky argument to settle, when I didn’t see you for so long.’
‘ Er.’

I took his huge hand in mine, and examined the toe-thumb. It was perfect. I felt the internal glow of a job well done.

 ‘Brilliant. Totally united. Do you use it regularly?’
‘Er. But –’
‘Yes, what is it?’
‘It looks – doesn’t look good.’
‘Brown and rough?’
‘Yes.’
‘But that is how it is supposed to be. Your entire body is brown, no? You expect this alone to be lily-white like Aishwarya Rai’s thumb. And smooth, like hers?’
I could not resist that crack. I never could, from school days. I was a survivor of many an adolescent fight.

 But fighting with a patient was bad form. But, mercifully, the sarcasm seemed to be lost on Kudiyirikkal Sunil. He was confused. He opened and closed his mouth a couple of times, like a goldfish.
‘ No – er – that is not it.’
‘Oh? Then?’
‘Er, it looks like – looks like a toe.’
‘Obviously. It is a toe.’
‘But it is my thumb now!’
‘Yes, in its present incarnation. But, in its previous life, it was a toe – the material, physical imprint of which remains unalterably in its present karma – as your thumb. You have surely seen Avatar?’

‘I don’t read medical books. I am not a doctor.’
‘You should flip through this one. It’s very interesting, though it does have a medical slant.’

‘Can you explain it so that I can understand?’
The poor man looked hassled.

‘Yes, of course.’ I was always ready for a genuine request like that. ‘Put simply, it means this: your toe, though taken from the foot and joined to your hand, will have the same shape as your toe. It cannot be changed.’

‘Don’t say that!’ There was dismay in his voice.
‘It is unfortunate, I agree, but it is a fact.’

‘That is not fair.’
‘I agree. But there it is.’

‘But plastic surgery, it is all about appearances, isn’t it? ‘
‘That is only in cosmetic surgery. In reconstructive plastic surgery, it is the function that is paramount,’ I explained patiently.

‘Don’t confuse me. I told you I am not a doctor.’
‘Sorry, I keep forgetting.’
The man stared at me sullenly for some time. Then he rose to go. ‘When shall I come back?’
‘After three months should be fine,’ I replied, sincerely hoping I would never have to see Kudiyirickal Sunil again.

But the hopes were misplaced. Three days later, the man was back, sullen and dissatisfied.
‘Hel-lo. How are you, Sunil ? Everything alright?’
‘Er. The thing is –’
‘Yes ?’
‘My friends don’t like the look of it.’
‘But they have been seeing it for years. It has been there for a long time, hasn’t it?’

I was thinking of his face when I said that. Very uncharitable for a doctor, I know. But one can’t be convicted for a thought-crime.
‘Uh, the thumb –  you know, it looks odd – like a toe.’

I stared at the man, partly exasperated and partly amused. ‘I agree. Philosophically speaking, in spite of its present evolutionary high ground, it bears, in its person, the indelible mark of its lowly origin. You know your Darwin.’

‘I am warning you, doctor, don’t use medical jargon with me. I cannot understand it. I’ve told you that once before.’
‘Sorry. These habits grow on one.’
‘What did you mean anyway?’
‘ I meant that the shape of the toe will remain like that, whether you like it or not. I, too, have told you that already.’
The huge man stared down at me with narrow eyes for several seconds. I stared back, but with a smile that was very forced.

A physical attack was not improbable. One had to be to be cool under provocation or threat. But inside, I felt dispirited.

Everything had gone well. I had meant well, and done the surgery without a single-rupee benefit, and yet –

I pushed the thoughts away. Self-pity was something every physician had to guard against. Part of the blame was mine, of course. A challenging case was enticing. But caution is never wasted. The image of a wise and discerning surgeon, an erstwhile teacher, rose in my mind. He had once said, ‘Never operate on a patient you don’t personally like, unless in an emergency because, even though the surgery may be short, the post-operative period will be infinitely long.’

‘Any other problem?’ I broke my reverie.

 ‘It doesn’t move much. You can see.’

 He wiggled his thumb, which was a toe once, and it moved about an inch in all directions.
‘Mr. Sunil, I warned you before the surgery that it would not move much but would act as a support to your other fingers.’
‘I don’t remember that.’
‘I am really sorry about that.’ I decided, deliberately, not to remind him about the detailed consent he had signed before the surgery. ‘And you did not obey my orders regarding physiotherapy. It was crucial in your case.’
‘I am not used to obeying orders.’
‘That may be so, but this is the result. And it’s not too bad either. The thumb is functioning better than I expected.’
‘But it is not what I expected!’
‘I am sorry about that.’
‘I will sue you.’
‘Go ahead.’
Sunil seemed to be contemplating something.
‘I have some pain in the shoulder as well. Is it related to that?’
‘No, I don’t think so.’
‘Okay. Could I have some medicines for that?’ 
‘Of course.’ Relieved, I hastily prescribed some pain-killers.

A week later, Sunil was back yet again, wiggling his toe-thumb. This time there was a tingling sensation in it.

‘You know,’ he mused, ‘I have been thinking about it.’
‘What have you been thinking, Mr. Sunil?’ I asked absently. I was thinking how to get rid of him.
‘ I want it put back.’
‘What!’ 
‘Yes. I want you to remove it and restore my toe.’
‘Why, for heaven’s sake?’
‘Earlier, I could hide my hand in my pocket. Now, this damn thing is always in the way.’
‘I am afraid it is not possible ‘
‘Why?’
‘I will not do it.’
‘I will complain. I will go to the court.’
‘You are welcome to do either, Mr. Sunil.’

The same scene was repeated five or six times more. Satheesh called me one day.
‘ Hey, doctor, that Sunil has been creating a ruckus in front of the director’s office again. This is the third time. I am sick of it.’
‘What do you want me to do?’
‘You can’t put his damn toe back, by any chance?’
‘ No.’
‘Please don’t operate on such patients again, James, and create a headache for the hospital.’
‘Yes, of course. As you wish. But the news item was sensational, I believe. Good publicity for the hospital.’
‘Er, that is true. But this is too much.’
‘I agree.’

It was during Kudiyirickal Sunil’s eighteenth post-operative visit, or perhaps the twenty-first, that it happened.

As usual, the fellow had started his complaints and demands, and the usual replies followed.

After a particularly bitter session, Sunil came out with another complaint.
‘I have a peculiar burning sensation in my stomach. You know, a stomach ache. What do you think I should do?’

‘We could give you a Ranitidine injection – an anti-acid medication.’
‘Okay.’
I wrote a note to the sister-in-charge, and went back to my waiting patients.

Suddenly, I heard a commotion in the injection room. The nurse was shouting. Somebody was running.

I rushed there to find Kudiyirickal Sunil’s body sprawled on the floor. His narrow eyes were staring blankly at the ceiling. A nurse knelt by his side, and wrung her hand nervously.
‘It was just after the injection. Could it be a reaction, sir?’ She sounded frantic.
I kneeled on the floor, and felt for his carotid pulse. There was none.

‘Call Code Blue. Where is Dr. Jerry? It is an arrest.’

I started the cardiopulmonary resuscitation by pressing with both hands on the lower sternum rhythmically. The patient was mine and it was my responsibility.

This was one of those occasions where the adrenaline flows mercilessly and one’s blood pressure goes up permanently by a few degrees. Not good for the coronary arteries.

The Code Blue team arrived, led by the efficient anaesthetist, Dr Jerry. His team took over the resuscitation. Jerry inserted a tube down Sunil’s trachea, with the help of a laryngoscope, and connected a balloon-like contraption, the ambu-bag.

He pressed the balloon rhythmically, to allow the oxygen through the connected cylinder into the lungs, making the chest rise and fall.
‘ Shift him quick,’ he ordered.
The patient was wheeled into the ICU. James Mathias also accompanied him.

In the ICU, he was quickly connected to the defibrillator. The monitor showed irregular squiggles that indicated ventricular fibrillation, but no effective cardiac activity.

Jerry pressed the charger button. When it was fully charged, he put the metal paddles on the patient’s chest after applying jelly.

‘ Everyone, stand back.’
Thwack!  One shock at 200 joules.

Another shock, adrenaline, and few more cycles of compression and ventilation followed. It was by the third shock that regular cardiac activity returned. But the patient was not out of the woods yet. He was still on the ventilator.

Was there any brain damage, I wondered.
After another hour, Sunil opened his eyes.

‘He will be all right,’ Jerry told me. I felt relief wash over, like air from a ceiling fan that was switched on in a stuffy room in summer. ‘But we will keep him on the ventilator overnight.’
‘Thank god. I am entrusting him to you. I am off to Malaysia tomorrow for a week-long workshop.’

By the time I returned, Sunil had been discharged. I expected him to return at any moment, threatening to sue the hospital for trying to kill him. I even feared for my personal safety.

Months passed. There was no further sign of Kudiyirickal Sunil.

Two years later, I was passing by an office in the suburbs. There was a group of people collecting money for the treatment of a local girl who needed a kidney transplant.

My eyes zeroed in on a familiar towering figure. Kudiyirickal Sunil!

He was shaved, and looked well-groomed. His t-shirt had the calm face of a little girl, the mascot of the charity organization he was working with, smiling enigmatically at the world.
‘Hello,’ I called out, in spite of myself.
‘Hello, doctor.’ Sunil smiled at me sincerely. “I am working for this NGO, that helps young sick children in need of money and help.”
‘What is it with you?’ I enquired. My tentative smile grew wider.
‘I died, doctor.’
‘I know. You remember that?’ I was startled.
‘Sure. I left my body, and hovered above it in the air.’

I stared at him in silence. My heart beat a trifle faster. I had heard of similar things.

‘Suddenly, a light appeared. I saw God framed by the light. He had a kind smile. He spoke to me. One more chance, he said. Then I remember waking up.’

‘I see.’

‘I have found peace, Doctor!”

My gaze shifted to Kudiyirickal Sunil’s right hand, and the toe-thumb brandishing the bowl that he used to collect money for the cause. In front of his T-shirt, was a large smiley.

‘“I can see that”,  I said. (Jimmy Mathew)