A Tale Of Two Cities...And Three DoctorsMY CONSULTATION
Y'all see this building? What do you think it is?
Go ahead, take a guess!
A tenement? An abandoned office building from the 1950s? A crack house in Detroit?
Nope. All wrong. It's a hospital......specifically, an LL hospital.
This is Mangal Anand Hospital in Mumbai, homebase of Dr. Mangal Parihar.
I don't know what you guys would have thought. Maybe that WAS the impression you previously had in your mind, when thinking of medical care in a third-world country like India.....ESPECIALLY if you hadn't seen the glitzy, glossy pictures of Action Medical institute, BLK Super Specialty Hospital, or Paras Hospital on the other doctors websites (or had you just Googled them). In fact, even Dr. Parihar's website presents his place with just a teeeensy bit of Photoshop "primping":
I say this with a bit of surprise because the rest of the site does not have the "come hither" flash, trying to impress, that many docs' employ.
I think, in my mind, the decision of whether I would do my surgery in Mumbai was settled right then and there -- standing outside in the parking lot -- but I had come ALL that way, so I went in for my scheduled consultation.
The inside of the place looked just as old and run-down and scary as the outside. It really looked like they only served Indians of lesser means. For example, if you have seen barely-funded County/public hospitals in the US (like on the show "e.r."), this would be the Third World equivalent.
This is the elevator (notice they discourage its use....sh!t, I wouldn't really need that sign to discourage me):
These oxygen tanks, sitting outside the OR, are presumably the ones that would be used during somebody's surgery:
They seem to do a lot of genetic/IVF treatment:
I had compiled a decent list of questions I planned to ask all three docs and I took copious notes, but when I am in rushed, it usually looks like I was writing with my feet, so some details may suck.
I had been in email contact with Dr. Divya Ahuja, one of Dr. P's staff members, since I had called for an appointment from back home. He came out to meet me a few minutes after my appointment time, and brought me back into his office.
I asked him to explain his take on Reconstructive LL vs Cosmetic:
He said the main difference is that Cosmetic is bilateral and rarely do they have to deal with reconstructive lengthening on both legs. Additionally, reconstructive patients start with muscle and soft tissue of a certain length already and the bone has become short (because of injury, infection etc). The patient has to lengthen his bone to reach the length of those tissues. With Cosmetic, we want to lengthen, but the limiting factors are different. The muscle and tendon tightness adds those factors which are not really as present in Reconstructive. He said the recovery for both is "almost the same". Complications for lengthening are all "correctable, eventually, by surgery". But we want to try to prevent the need for that by hard work through PT.
Dr. Parihar does NOT allow/encourage standing/walking/weight bearing during distraction because, as Dr. Ahuja said, when you stand, you compress. Once the frames come off, gradual weight-bearing is done as the callus develops.
They use Synthes nails. I asked how many rings the frame would have, considering that I am really heavy, and he said 3.
I asked about the pins going the muscle and he said they make a "track through muscle" to place the pins, so as not to catch them as they go through. He said they also "take care not to go close to the nerves"
For the osteotomy, they DO split the patellar tendon with a small incision. He said the knee's recovery from that is not a big deal.
They do not typically do ankle-locking, but now use the sandals strapped to the frame.
In hospital: 5-7 Days
Distraction: after 7-10 Days
There is NO Care Home/Guest House, they have been looking for one, but basically I inferred that we would need to figure it out ourselves.
PTs would be sent from hospital. I asked the difference between an LL physical therapist and a standard one. He said "communication", as the ones they work with will treat within the LL doctor's instructions, rather than going off on their own
X-Rays are done every 10-14 days during lengthening
Dr. Ahuja then did a physical exam, checking my flexibility and my problem ankle and old knee injury. The total time with him was about 35 minutes. After this, he sent me back to the waiting room. I waited there for another 20 minutes or so -- needing to go to the bathroom -- but I opted to wait until after I got back to the hotel....maybe that says something about the place.
I then got in to see Dr. Parihar. He went over the intake Dr. Ahuja did, discussed risk factors, and so on. We talked about him training with Paley in Baltimore (in the early 90s), the tremendous costs of LL in Europe and the US. He expressed that he did not discourage LL patients, but was not actively seeking them, either. It's just not his primary practice/business. All of his lengthening patients have been Indian, and most had no knowledge of the risks and downsides. He talked about the fact that many lengthening docs are doing primarily cosmetic work and deemed it "a paradox" because (in his opinion) the people doing lengthening should be the ones with very solid backgrounds in Ilizarov (which I took to mean Reconstructive/Deformity specialists like himself). An example he gave: if he treats a guy with an infected non-union, heals his bone, gets him to where his functionally is much improved...but still having a 1cm length discrepancy between legs... it's a success, a great positive result from where he was.
With a cosmetic patient, if a doctor gives him 6cm gain, but reduces the dorsiflexion of the knee to just neutral, he has "made that patient abnormal". The margin for error in cosmetic lengthening is much less. Furthermore, he said, cosmetic patients are "probably the most demanding subgroup of patients". But they will be aware of the potential risks and complications. I think the most memorable thing he said is that any of the complications (non-union, neurological injuries) that can come up in cosmetic are "part-and parcel of the Ilizarov techniques", so he would give the edge to a doc who has done 1000 reconstructive Ilizarovs over one who had 50 cosmetic. I WISH I had thought to ask about (touching on what Dr. Ahuja had mention earlier) how (or whether) a strictly reconstructive doc would have the knowledge and experience with the soft tissue stretching issues. Cr*p. Sorry, Peeps. That would have been a good one.
We discussed the frames and he also said the nail is much more significant factor than the frame. He said he is only a proponent of standing and walking in terms of reducing Ballerina.
Dr. Parihar said he was aware of the "LL community", but claimed he had never been on any of the "bulletin boards" and I really believed him. He's very much an Old School, no-nonsense, conservative doctor. Also evidenced by the fact that he then talked about the lack of peer-reviewed studies out there (and yes, you may sense a drastic difference between this consultation and the one I had with Sarin two days later). Dr. Parihar said he usually favors "function over length". 6cm is the general limit he practices, but if he sees a patient with equinus at 5cm, he would advise the patient "to call it a day". The amount of complications goes up "exponentially" after 6cm. I was pretty shocked though, that he said a patient can come back for a second round
of tibia lengthening! I had never heard of this, aside from Jungle.
I asked (because of what I had read here, in one of the Sringari diaries) of where he would do a re-break, in the case of preconsolidation. He would do the 2nd osteotomy "slightly higher or lower".
Lastly, Dr. Parihar was pretty humble, as opposed to some other doc (to be named later). The total time with him was around 30 minutes as well. So I did not in any way feel rushed through there.
They had told me previously (over email), that there was a fee for the LL consultation. I had seen the $350 - €400 listed under those doc interviews and took a big gulp...until I kept reading and it said 800INR. That's like 12 bucks! I emailed them back to make sure it wasn't a typo (but didn't get a reply). Anyway, when I went to pay, they said it was 1500 INR. Not thrilled at the bait-and-switch (possibly once they realized I was American?), but still, only about 1/20th the cost of a consultation with Paley or Betz.
But anyway, if you hadn't guessed by now:
The discouragement of weight-bearing is a debatable subject and goes against so much of what I had been learning. I know how much SysOp
encourages it and how Sweden
seems to have had a rougher recovery for lack of it. Still, that was not the factor that ruled this doctor out. The hassle and work of having to find my own place to stay and arranging basic domestic care (in Mumbai no less) would have been hard enough to accomplish....but having to pay for that on top of the surgery and (possibly) the daily PT made this doctor an no-go. Anyway, if you hadn't gleaned from the beginning, I knew I could never have surgery at Mangal Anand from the moment I caught sight of it from the taxi.
Mind you, this removal from consideration as my LL surgeon has NOTHING to do with Dr. Parihar as a doctor, nor with him personally. He has a very impressive resumé:http://ilizarov.in/about-us/dr-mangal-parihar.html
...and is clearly well-respected. I think because he trained extensively in the West (2 stints in the UK, as well as 2 in the US -- including a postdoc fellowship with Paley), we communicated very easily.
And, though he came off as somewhat cold/distant (or maybe just all-business) at first, he turned out to be a pretty cool guy. After the bulk of the consultation, we chatted a bit and somehow got onto the subjects of music, Vocal Live and Garage Band, and then audio/video production. He edits and narrates those surgery videos himself. Interesting, multi-talented man. Undoubtedly a good doctor. If, God forbid, a loved one or I were in a serious accident next time in Mumbai, I would have no qualms with Dr. P being my doctor.......just hope it would be at a different hospital.