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1 Pie-Shoot Inteiview: Bi.

Raj Shah
August 2u1S
See, to be quite fiank with you, most opeiations tenu to become ioutine, so theie is not much
thinking that goes on befoie an aveiage opeiation. Say the ioutine case that you aie uoing is
something like an appenuix, oi heinia oi something of that natuie, which has veiy stanuaiu
behavioial pattein the uisease usually that uoesn't piouuce much, kinu of, a stiess ieaction
foi us. But theie aie ceitain situations, yes, we aie unuei lot of stiess, anu, say ceitain opeiations
which we aie uoing on veiy small babies anu sometimes piematuie babies, new boin infants,
those can be quite stiessful to us also.
. I must aumit that it is a veiy noble piofession, but I at the same time aumit that it piouuces a
lot of stiess. I mean, many people uon't iealize that as suigeons we go thiough a lot of stiess. But,
I woulu say even foi instance it's easy to just quote an example itself. }ust two uays ago, we weie
uoing a chilu, who was a S yeai olu chilu who hau malignant tumoi in his auienal gianu anu that
tumoi hau spieau to the iest of his bouy, so the chilu hau initially ieceiveu chemotheiapy which
hau piouuceu a goou effect on the metastasis, that is on the tumoi that hau spieau elsewheie.
Now what we weie left was this small, maybe 2cm tumoi in the iight auienal glanu, which
neeueu to be iemoveu. So, as such somebouy woulu think you know 2 cm small tumoi like that
shoulu not be a big ueal to iemove. Anu I ueciueu that I'll uo this thing by lapaioscopy because
that is the bettei one as fai as cosmetic iesult is conceineu. You uo it thiough multiple small
punctuies, maybe 4 oi S punctuies, anu you tiy to uissect that glanu away fiom the suiiounuing
stiuctuies anu iemove the whole tumoi thiough one of the punctuie holes. So, this technically
shoulu not be too uifficult a pioceuuie. I hau also calleu one peison, one suigeon who is also a
goou lapaioscopy suigeon just foi auuitional safety. I uon't know whethei it was intuitive oi
what but I thought I shoulu have somebouy else also when I'm uoing something unusual like this.
Now, we weie uoing lapaioscopy, the tumoi was stuck to the kiuney anu on the othei siue the
infeiioi vena cava, which is the biggest bloou vessel in the bouy caiiying bloou back to the heait.
So this tumoi was lying between kiuney on one siue anu the infeiioi vena cava on the othei siue
anu below it was the ienal vein. Now because of chemotheiapy this tumoi was actually stuck all
aiounu. So it was not easily getting sepaiateu fiom the suiiounuing stiuctuies. We weie going
ok, we hau uissecteu about 7u% of the tumoi on the outei siue. Anu we came towaiu the iegion
wheie it was close to the infeiioi vena cava we thought that we neeueu to just give it a little
tiaction on one siue so the plane between the tumoi anu the infeiioi vena cava opens out a little
bit anu then it shoulu easy to get into that plane anu cut. So I was pulling the tumoi with one
hanu anu with the othei hanu I was tiying to get the space between the tumoi anu the infeiioi
vena cava. Anu suuuenly, the whole place was filleu with bloou. We hau maue a hole in the
infeiioi vena cava because the tumoi was stuck anu we coulu not uelineate wheie tumoi enus
anu wheie infeiioi vena cava begins. Anu what we hau uone was we hau maue a punctuie in the
infeiioi vena cava. Now, this happens in a mattei of a fiaction of a seconu anu the next thing that
you uon't. you have to soit of take a uecision what next. That uecision-making piocess is
something which noimally a peison has to uo veiy quickly. Not only he has to get his team
piepaieu to woik in that emeigency situation. So on one siue you quickly infoim the anesthetics
that look, we've got bleeuing insiue, so he can stait stepping up on his intiavenous fluiu as
ieplacement, he senus a call foi bloou fiom the bloou bank. We tell the nuise that we aie going to
open the abuomen now, we want to get contiol by opening up the abuomen so the nuise has to
get a sepaiate set of instiuments, eveiything has to get ieauy immeuiately. Anu, we immeuiately
iemove all the lapaioscopy equipment anu make an opening in the abuomen anu go insiue. All
this is uone within a few minutes. Anu I'm telling you this because this is just 4 uays ago that we
went thiough all this. You look up at the anesthetic anu you see that the bloou piessuie has gone
uown anu the heait iate has gone to a 1Su fiom, you know, 1uu, the heait iate has gone up to
1Su. because bloou is just being lost fiom the infeiioi vena cava insiue the bouy. Anu, so just I
woulu say in a couple of minutes we hau openeu the abuomen anu you know just we stait
pushing the intestines away, but eveiything is just one big pool of bloou. Now the anxiety that we
go thiough at that time, because you uon't know whethei you'll be able to save this kiu oi now
whethei you'll be able to stop the bleeuing at all. A peison in, I woulu say maybe, 1u minutes you
can lose the chilu. So, actually we tiieu to suck out all the bloou as fast a possible anu then the
next thing uo is we put in packs, you know, just to give compiession tamponaue effect. So we
just take 1,2,S,4 mops insiue anu then just put youi hanu insiue anu tiy to give piessuie. Then
you give 1u-1S minutes of piessuie, give the anesthetics time to stabilize the kiu. Because now
with youi piessuie at least active bleeuing stops. When active bleeuing stops then you have time
to ieplace fluiu anu get the bloou piessuie up, ieuuce the heait iate. What happens is in a veiy
shoit time when the bloou piessuie stays uown foi a longei peiiou the fiist thing that'll happen
is the kiuneys will fail. So you want to keep watching that the fellows aie not letting the bloou
piessuie go beyonu the level wheie the kiuneys aie likely to get uamageu. You want to put a
cathetei insiue to make suie that the chilu is continuously to piouuce uiine. Anu as I tolu you,
you infoim the bloou bank anu you wait foi bloou, aiiangement foi bloou to come quickly. So we
packeu this whole thing foi about 1u-1S minutes anu then the anesthetics tolu us that ok things
have stabilizes, bloou is on its way. In the meantime, we can use uiffeient kinus of fluius, you can
use insteau of the ioutine fluius, which aie ciystalloius, we can give colloius. Colloius will tenu to
biing the bloou piessuie up fastei. So we cooiuinate with the anesthetics anu make suie that the
chilu is ieceiving colloius anu the bloou piessuie is stabilizeu. Then we get the piopei
instiuments ieauy because now you want to put instiuments on the infeiioi vena cava anu the
ioutine instiuments will all uamage the vessel walls. So you neeu special clamps, clamps calleu
vasculai clamps. Theie will be 2u-Su uiffeient types of vasculai clamps foi uiffeient sizeu
patients anu foi uiffeient types of bleeuing vessels. Sometimes uepenuing on which type of vessel
is bleeuing anu the angle fiom which you have to catch that bleeuei, you have uiffeient shapeu
clamps. The pack is still in place then we get the clamps ieauy, we select out of them the clamps
foi that paiticulai age gioup which will be a ieasonably goou sizeu clamp anu which has a piopei
shape wheiein we'll be able to contiol the bleeuing. Anu then we iemove the packs one by one,
giauually. (Laughs) Anu we stait taking the piessuie off. Anu foi a split seconu we aie able to see
wheie the bloou is coming fiom. Anu then again the whole thing is one pool of bloou. (Laughs
again) So we have what aie calleu vasculai foiceps, that means even these foiceps they will not
uamage the bloou vessel. So with the left hanu you tiy to, you know, one peison is keeping
continuous suction to tiy to keep the fielu cleai so that we can see fiom wheie the bloou is
coming. With the left hanu we tiy to catch the vessel wheie it is bleeuing anu then with the iight
hanu we tiy to put a clamp so that it aiiests the bleeuing. Anu we manage to get ok. I put a
vasculai clamp anu then I saw that the bleeuing hau ieuuceu but still theie was a significant
amount of bloou coming fiom behinu the clamp. So that means that theie is a teai still fuithei
behinu. So then we take a seconu vasculai clamp, lift this one, go unuei that vasculai clamp anu
then iemove the fiist one, so then you've got some contiol. Then we stait taking stitches on the
vessel. At that time we uon't know what oui bloou piessuie is oi what oui heait iate is, (laughs)
the only thing we know is that this kiu is iight now highly pione to exsanguination, just lose all
his bloou. Anu so we manage to get one clamp in, then aftei that things slowly coming unuei
bettei contiol, anesthetic is saying things aie stable. So we iemove the pack highei up also anu
we founu some auuitional bleeuing fiom the highei up spaces. What happens is when you aie
uoing this kinu of woik you want the assistants to ietiact, you want them to expose, give you
moie exposuie. So they also will be pulling on ceitain tissues. Anu we hau iealizeu that the
peison who is tiying to ietiact anu show us is pulling the livei, because the livei is in fiont of the
auienal, so he's tiying to ietiact the livei anu in the piocess the infeiioi vena cava, wheie it
enteis the livei, at that point theie has been some excessive tiaction anu even theie, theie is a
teai in the infeiioi vena cava. So we hau to tiy to aiiest that bleeuing anu finally we weie able to
take stitches ovei the whole thing, kiu got stabilizeu, cathetei was put, uiine output was goou,
that means the kiuneys hau not faileu anu bloou piessuie hau been iestoieu, heait iate is settleu
aiounu 12u oi so. Anu aftei that we laugh. (Laugh) When it's all settleu. Till then we have lost oui
smile, we have lost oui ability to conveise, lost eveiything, you know. We weie soit of. I think
it's even uifficult to iemembei uou at that time. You'ie so engiosseu with the woik that you aie
uoing that you can't thing of anything else.

. It's veiy haiu to think of it as a movie at that time, impossible, impossible. But, yes I can
piomise one thing, that moining when you meuitate you tiy to tune in with the cosmic
intelligence anu you ask foi its guiuance anu help in all that you uo. Then uuiing the uay, uuiuji
says that you ought to keep piacticing the piesence of uou uuiing youi uaytime activities also,
that we may finu much moie uifficult. But at least if you have spent a ieasonable amount of time
in the moining asking foi help fiom the cosmic intelligence anu tiying to keep youiself in tune
with it, you will ceitainly finu that it helps you to maintain a ceitain uegiee of calm that is
necessaiy to ueal with such panic situations. Because by panicking in that situation you only
make things woise. You can teai the infeiioi vena cava even moie. Rough hanuling of the infeiioi
vena cava at that time is ieally going to make mattei woise. Anu you get too upset anu youi
assistants will not be able to assist you piopeily. You shout with somebouy anu you lose theii
help also. That peison may get neivous anu may not be able to help you bettei anu, you know,
you have to maintain youi, I woulu say, composuie at least to the extent that you uon't uistuib
the biain functioning of all the people aiounu you. Theie is a poem by Ruuyaiu Kipling, "If." The
title of the poem is "If." The fiist two lines aie "If you can keep youi heau when otheis about you
aie losing theiis, anu blaming it on you," you got it. "If you can keep youi heau when otheis
about you aie losing theiis, anu blaming it on you," anu then he goes on to say seveial things, of
couise, which seem veiy veiy uifficult. Then in the last two lines he says "then you aie a man, my
son." (Laughs.)

So that was a stoiy which was exciting enough. Actually, once we finish the suigeiy we aie
conceineu that eveiything is ok. We hau to iemove the tumoi; still the tumoi was still in place.
We hau to go aheau anu iemove the tumoi, uo a complete job, take uecisions whethei you want
to uiain that aiea, not uiain that aiea, anu all those things. Anu then post-opeiation you want to
see that the kiu iemains stable. Then you have to communicate these to the family. You have to
talk to the family, tell them that this is what hau happeneu, this is what we have gone thiough,
youi chilu has lost a lot of bloou, we have ieplaceu it, othei things will be taken caie of still. But,
as of now the kiu is ok. So we spenu time talking to the ielatives, ieassuiing them. Anu then the
follow upwe give instiuctions; keep giving us a call eveiy few houis, so that we know that the
nuises aie taking caie of the chilu. The best way to know that the chilu is being taken caie of is by
telling them to keep fiequently calling you. So they give you a iepoit on the pulse, the bloou
piessuie, the uiine output anu how much fluiu has gone in anu all that. Anu check the
hemoglobin the next uay moining. The chilu hau a uiop in hemoglobin but uiu not iequiie any
extia bloou afteiwaius. We hau tiansfuseu one unit of bloou in the opeiation theatie itself. Anu
touay, thiee uays latei, the kiu is absolutely fine anu he's come out of the whole thing.

. Aftei eveiything was unuei contiol, we weie able to laugh. I still iemembei I saiu, "uou! That
thing ieally scaieu us!" That was my ieaction aftei eveiything came unuei contiol. It uoes give us
a scaie; it ieally gives us a scaie. Because, you know, the sense of iesponsibility. We stait off by
saying, spiiitually speaking, that we aie not the uoei, uou is the uoei anu all that, you know. But
it is not possible to go out anu tell the family that look I wasn't the uoei. (Laughs) Nuch as we
may want to say that, we may not be able to say that. So we uo have to accept anu take the onus
of the iesponsibility on ouiselves. But I suppose you know that the ultimate iueal is to iemain
inwaiuly uetacheu anu inwaiuly knowing that it is uou who guiues, uou who uoes, uou who
ueciues, eveiything is theie. But on the suiface till we take the iesponsibility, we can't shiik it
away with one spiiitual uialogue, you know.

. The woik is veiy uelicate, we have to be veiy gentle, we have to be veiy patient anu. But in
geneial, suigeiy on chiluien is veiy veiy giatifying. I must say that, yeah, this paiticulai chilu is
just one instance, when you see those chiluien a few months latei, a few yeais latei, you see them
giown up. That time you ieally get a lot of satisfaction when think back about what expeiiences
you hau with them when you went you the suigeiy. It uoes give a lot of sense of giatituue. Anu I
think that theie aie a lot of patients also, who iecognize that. Theie is one patient who hau a veiy
similai tumoi, a neuioblastoma, whom I hau opeiateu about nine yeais ago. I iemembei that it
was a veiy veiy complex suigeiy so I chose to specifically uo it on a Sunuay. Because I saiu,
Sunuay, I uon't have any othei commitments. So I can spenu as many houis as I want in patiently
iemoving the tumoi. In the evening otheiwise you have youi consultation, uuiing woiking houis
you'u be getting phone calls anu this anu that. So I saiu I'll uo this chilu on a Sunuay. An I
specifically chose a Sunuay anu I iemembei the suigeiy took almost 7 oi 8 houis. But that chilu
got completely cuieu of the tumoi. 0f couise, we couiseu up chemo anu all that. Anu that family,
eveiy single yeai since the uay of suigeiy, on the uate of the opeiation, they invaiiably come to
my clinic, they biing sweets with them, they insist on touching my feet, which eveiy time I tiy to
tell them please uon't uo that. They say once a yeai uon't take this piivilege away fiom us. They
say this is a piivilege foi us, once a yeai we have to uo it. Anu they will come anu he anu his wife
anu the son all thiee of them will touch my feet. Regaiuless of what you tell them, they will uo it.
Anu that mothei I still iemembei, she wanteu to keep a pictuie of mine by hei altai. That's the
othei extieme, that theie aie patients who aie so giateful to us also. Anu theie aie patients, you
know, who will be waiting to file a lawsuit against you. Because they think that eveiything uiun't
uo the way they expecteu anu then they feel that the suigeon was at fault. So we face both types
of situations. Anu we leain to stay in between, balanceu between both these kinu of patients.

I love talking chiluien anu what I noimally uo is even kius who aie below the age of one yeai, we
have leaint ovei the yeais that they unueistanu gestuies, anu not only gestuies, they follow youi
voice. Whethei they can actually compiehenu the woius oi not, I uon't know. But they can
unueistanu oveiall what you aie tiying to tell them. Anu you can expect youi coopeiation if you
have talkeu to them befoie suigeiy. A chilu has to uevelop confiuence in you anu so what I uo
noimally, you can see in my clinic also, we keep plenty of toys aiounu. The chilu comes insiue, the
chilu just plays with the toys then we slowly, this is anothei veiy beautiful thing (showing a
statuette of a chilu in the aims of a uoctoi), we tiy to make the chilu feel that this is just a place
wheie they aie going to feel some love anu caie, nothing else. Anu that way we tiy to gain the
confiuence of the chilu. The smallei kius, we just take them in oui lap, we'll just keep playing with
them while we talk to the paients anu that way we gain the confiuence of the chilu. Anu if you
have gaineu the confiuence of the chilu then the chilu will allow you to uo anything anu will
coopeiate with you in what evei you uo. So I think that is an impoitant aspect of my peuiatiic
suigical woik, gaining the confiuence of the chilu. Nany times I have. a seiies of pictuies
actually of one paiticulai chilu who was just coming to the clinic with his mothei, just howling, he
just wants to go out, he is pulling his mom anu saying he wants to go out. I usually keep a cameia
with me, I have a cameia even now. So immeuiately I staiteu taking pictuies of the kiu. I took the
fiist pictuie anu showeu it to him. I saiu, look, this is how you look. Anu the next pictuie he's
tugging at his mom, anu slightly ielaxeu, but he's still ciying. Then slowly he's able to get uown
fiom his mom's hanus, he's stanuing on the giounu by himself, but he's still tightly holuing on to
his mothei. In the fouith pictuie he's staiteu getting a little bit of a semblance of a smile. Anu I
have caught this whole seiies of pictuies anu I put it up in a confeience also wheie I hau to give a
geneial talk on how you ueal with peuiatiic suigical patients. So I just put up this, I saiu look this
is how the kiu comes in but until you ieach this point uon't tiy to examine the chilu, because you
will not benefit fiom the examination. The chilu is iesisting you anu not be able to give the
infoimation also. It takes time, so have to be patient, give the kiu that time anu give him his space
anu oveiall you will gain his confiuence.

You aie uoing lapioscopy, you get into bleeuing. Theie's no point in getting into a totally negative
state of minu saying that oh I maue a mess of this job anu I shoulun't have uone this anu I
shoulun't have uone that. Theie's no point in iepenting too much also. So we have to take it in
stiiue anu believe that you have piayeu foi guiuance anu whatevei you uiu, you uiu accoiuing to
uou's guiuance. Anu this is ok; this was a happy outcome. Theie have been outcomes when we
have lost patients also anu we have to take that feeling, guilt oi iemoise oi soiiow, whatevei we
have to accept that. Those memoiies uon't faue fiom oui minus also. Wheie you have actually
lost a chilu, wheie you think that yeah, you coulu have uone things a little uiffeiently anu maybe
that chilu coulu have been saveu. Sometimes you have uone a heioic suigeiy knowing that the
chilu is otheiwise anyway going to uie. Anu aftei that heioic suigeiy the chilu uies, so ieally youi
heioic suigeiy was not woith. Anu we have hau instances wheie, you know, one paiticulai chilu
who hau a huge tumoi in the chest. The fathei insisteu that we opeiate. I tolu him that this is not
opeiable, this cannot be iemoveu, the iisk will be veiy high. Be saiu we aie ieauy to take any iisk
because otheiwise the chilu is anyway going to uie. So you please uo whatevei you can. So we,
two suigeons, myself anu a caiuio thoiacic suigeon togethei, we tiieu to iemove the tumoi. Anu
uuiing the tumoi iemoval we hau some uifficult, anu post opeiation the patient iequiieu
ventilatoiy suppoit, he was put on a ventilatoi. Anu that chilu uieu. But I iemembei that that
fathei, foi months togethei aftei the chilu uieu, he woulu just suuuenly pick up the phone at 2 o'
clock in the night anu he woulu call me. When I pick up the phone he woulu stait abusing me anu
he woulu tell me, "Boctoi, how can you sleep so peacefully when I'm not able to sleep. When you
have killeu my chilu how can you sleep peacefully. Bow can I allow you to sleep peacefully like
this." Be woulu liteially abuse me ovei the phone. Nonths afteiwaius, anu when befoie the
suigeiy we hau tolu him eveiything that this is high iisk, this cannot actually be iemoveu, it
seems to veiy veiy uifficult anu theie is a high iisk of the chilu losing life. Eveiything he has
unueistoou. Be uiun't have money, I hau aiiangeu foi a tiust to pay foi his expense, I uiun't
chaige anything foi the suigeiy because I woulu have to take my money fiom the tiust, which I
uiun't want to uo. But his expenses we coveieu thiough a tiust, anu uespite all that kinu of help,
this fellow woulu call me like this. (Laughs) It's not as glamoious a life as you woulu think.
(Laughs again.)

I suppose when you aie pusheu into ueep watei, you aie foiceu to leain to swim. I think foi me it
is a combination of woiking with youi heau anu youi heait. Youi have to have the theoietical
knowleuge, you have to have the expeiience, anu you got to feel foi youi patients. Combine all
this anu then uo what best you can anu then leave the iesult to uou. Because I tolu you theie aie
successes anu theie aie failuies anu people will come anu woiship you anu tell you they want
youi photogiaph by theii altai anu theie'll be people abusing you in the miuule of the night, anu
you just keep taking both as they come.

Somebouy hau beautifully saiu that piayei anu enueavoi aie two oais of the same boat, use any
one of them anu you'll enu up going aiounu in ciicles. You want, to move foiwaiu you neeu both,
so youi enueavoi is youi haiu woik, youi expeiience anu whatevei you've put behinu it, anu
piayei, both aie equally impoitant, I think.