“The truth is, Mitch,” he said, “once you learn how to die, you learn how to live.”

-Tuesdays with Morrie

In India we revere our stoic archetypes. Rajinikanth riddled by half a dozen bullets who swears, “Aw heck, Doc, it’s only a scratch,” gets our appreciation. It rarely, if ever, reflects true life situations. This is particularly true in cancer pain, where stoicism is inferior, and comes a poor second, to seeking out for help. When people feel they no longer have the resources to cope with pain, despair sets in. The feeling is heightened by the knowledge that they have to cope. There seem to be no alternatives, no possibilities…nothing. It is a time of despair.

“Thank you,” I acknowledged “would you like a drink?” Just wanted to put him at ease; all these hospital visits would have made him feel like walking through a wolf infested forest with a lamb shank around his neck. Sipping water, he mentioned that stronger painkillers like morphine had not helped his pain. He wanted his final months to be lived the same way as he has always done – with dignity, with courage, with humour, with composure. He was informed that a celiac plexus block might help him.

“What is celiac plexus?” he asked.

“Well, the celiac plexus is also known as the solar plexus. It is the main junction for autonomic nerves supplying the upper abdominal organs (liver, gall bladder, spleen, stomach, pancreas, kidneys, and small bowel). It is a cluster of nerves that lies in front and on the side of the aorta, the largest blood vessel in our body, in the upper abdomen. We could block it to control pain, particularly cancer pain, in the upper abdomen” I answered.

“The benefits?” I continued “Well, it improves pain control and reduces the need for pain medication compared with standard treatment, and allows many to resume their normal daily activities.”

“Solar Chakra? Thought you might come up with better things with your western medicine” he joked.

Now, according to traditional Indian belief, solar chakra is the area which defines “self-esteem”. This intuitive chakra is where we get our “gut instincts” that signal us to do or not to do something.

“My gut instinct would be gone if you block it. Mind you, I am an army person” he continued.

Behind the subtleties of such cultural inventions, there throbs always and everywhere the rhythm of biological life, which needs no external justification. The body knows that life is worth living. It is programmed to seek outcomes that promise to maximize the probability of its survival. He agreed to get it done. Good.

“How long does this celiac plexus block take?” he inquired

“About 30 minutes. Not that long, but patience is a must” I answered.

“Thirty minutes is all right. I have very little patience, particularly for the Nietzschean cliché – that which does not kill us makes us stronger.” He was philosophical. Pain does that to people.

“Will it hurt? Will he go to sleep for the injection? What do you actually inject?” this was Mrs. Rao who was hitherto a silent spectator.

For Mrs. Rao, standing alongside her husband was important. She had always stood by him. Now, it was the most important thing for her, perhaps the only important thing. I did not want to exaggerate the possibilities for hope. Just wanted to open the door a tiny bit and suggest that celiac plexus block might be helpful, to reflect upon its potential.

“The procedure involves inserting a needle through skin and deeper tissues. So, there is some pain involved. However, we will numb the skin and deeper tissues with local anesthetic using a very fine needle before the procedure. We could also give him a bit of sedation to make it easier to tolerate, but it’s not general anaesthetic.” I answered.

I continued to explain to her that the initial injection would be a local anesthetic, and if he does get a good response then we could inject alcohol to permanently destroy the nerves in the same sitting.

“What happens after the celiac plexus block?” More questions from Mrs. Rao

In her book On Death and Dying, Elisabeth Kübler-Ross broke down the process of death into five stages: denial, anger, bargaining, depression, and acceptance. Denial: This isn’t happening. Anger: It’s not fair. Bargaining: What can I do to get out of this? Depression: I can’t, it’s hopeless. Acceptance: What do I do now?

Facing their final months together, the elderly couple were verging on depression. They needed something to hang on to.

“Immediately after the injection, he might feel his abdomen getting warm or feeling a bit different. In addition, he might notice that his abdominal pain may be gone or quite less. He might have diarrhoea & lower blood pressure temporarily, which needs monitoring for at least 1 hour after the injection. Temporary back pain from the needle is common. You should have a ride home. We advise people to take it easy for a day or so after the procedure, and only perform the activities that they can tolerate. The doses of painkillers could then be adjusted. We will give you written instructions on do’s and don’ts.” I parroted the knowledge gained during my training years ago.

“Any complications?” It was Mr. Rao’s turn.

It is not enough for someone simply to be human. To be a person one needs to be able to have particular capacities and to carry out specific functions without which the label ‘person’ cannot be ascribed. Mr. Rao was concerned, and rightly so.

“It’s fairly safe. Fortunately, the serious side effects and complications are rare. Just letting a doctor near you means – risks, side effects and possibility of complications. Quite a few things could be damaged if we aren’t careful. Lungs, kidneys, blood vessel, nerves. If the cancer spread is extensive, it might not work.” I replied.

Content that a decent explanation has been given, I felt like everyone’s favorite long haired genius.

“You should get changed, and we will get on with it.” I showed him the way to the changing area.

Celiac plexus neurolysis

A plastic tube was placed in a vein in his wrist to give sedation and fluids. Intravenous access in medical speak. Mr. Rao was lying face down on his abdomen, and we had the monitors connected. His back was cleaned with anti-septic solution and skin numbed with local anesthetic. X-ray was used to guide the needles into the proper position along the outside of the spine. Once in place, a test dose of dye was used to confirm that the injected medication will spread in an appropriate area. Since this was okay, the injection was given gradually over several minutes. Profound pain relief. Good. Now it was time for injecting alcohol. We did it after warning him that there might be some discomfort or burning sensation. The needles were removed and Band Aid was applied. 30 minutes from start to finish.

He spent an hour in the recovery. The initial drowsiness due to the sedation wore off and he perked up.

“How do you feel?”

“Top of the world”

“Like?”

“Being on the London Eye.” He was well travelled.

“See the Millennium Dome?”

“Fortunately no White Elephant to worry about in my life.”

No White Elephants. Just as joy and sorrow are inextricably linked, the one helping to define and illuminate the other, so there can be a relationship between despair and hope.

He got changed to his clothes and was getting ready to leave.

“Hope it works for a while” he looked at me with anticipation.

“Yes, 3 months if not more. Happy?”

He nodded in affirmation.

Deepest pain holds no meaning. It does not make us a better human being. It is not purifying. It is also ironic that the experience of pain can be, at one and the same time, a time of chaos and a time of discovery. A follow-up phone call from me two weeks later confirmed it. Mr. Rao was about to be joined by his children in a week. He was excited. Excited to see them. Excited that he could spend quality time with grandkids. Pain had reduced him to his primal animal. Short-circuited his sense of self. With adequate pain relief, he was no longer a bundle of biological reflexes.

2 months later, I had a call from Mrs. Rao. He had passed away. Was peaceful in his final days and hours. Being pain free helped him sort out his priorities. He had his quality time with grandchildren.

Medicine, to practice it, is a privilege. It is an art and science they say. There is philosophy too. Philosophy demands reasons for the moral choices made and to subject these reasons to careful critical analysis. Much emphasis during my medical training was on the importance of using scientific evidence in clinical decision-making. Concern for pain relief, however, reflects human instincts for fairness and empathy in the face of suffering. Caring for a person in pain is intertwined with morals, attitudes and ethics to a degree nearly unique among biomedical fields.

It was a solemn funeral ceremony. I was invited. Final good bye. As I was about to leave, Mrs. Rao’s 3 year old grandson came to me with his friends. “Boob Boom Robo-da, Robo-da” he sang. You can escape cancer. In India, you cannot escape Rajinikanth.

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