It’s not the metallic clink of an instrument dropping, or the robust thud of a plastic saline bottle slipping from the IV pole. It’s the unnerving softness of the bone flap hitting the floor. It’s a part of the patient’s skull that is sawed out during a craniotomy—to be replaced once the brainwork is over so that the skull may retain its conventional form. And, if it has fallen to the floor by accident, it’s not something that you can impulsively pick up in a five-second technique similar to what I use with my kids for edible items that land on the floor.

This is akin to a baby slipping out of an obstetrician’s hands soon after delivery. A piece of a patient’s body that is supposed to go home with the patient is suddenly lying on the floor in front of you. The nurse looked at me with her eyes welling up. In this case, I was the python. Life is a cycle, I thought to myself. Sometimes you are the pigeon, and sometimes you are the statue. I pardoned her and asked for the bone to be kept aside, because luckily, our plan in this case was not to replace the bone, but to tuck it into the abdomen until later use. This surgery was being performed for a hypertensive haemorrhage with malignant brain swelling, and the bone was to be replaced only a few weeks later.

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In other cases, however, where the intention is almost always to replace the bone, one either disinfects it with betadine or autoclaves it and then puts it back (albeit with an added risk of a postoperative infection) or otherwise restores the contour of the head with a titanium mesh. “What will you tell the family, sir?” my assistant asked wryly. “If there is one guiding principle when you leave this hospital after finishing your training with me, it should be…?” and I stared at him waiting for him to complete my sentence. “Always speak the truth,” he muttered underneath his mask. It may seem like it’s the most onerous thing to do, but it almost always calls for worthwhile outcomes. After surgery, we went out and spoke to the relatives together, explaining to them what had happened and taking full responsibility, and they were simply happy that he was alive.

Patients often ask me how many such cases I have handled when they see me in my clinic with a brain or spine condition. What my successes and failures are. Am I lying when I say a couple of hundred—because that allows me to play within a span of 900. What should younger surgeons say when they’ve only assisted tons of these cases but never actually performed one independently? If I were to say this is my first time handling that specific medical condition, would any patient show up to the party? Truth and transparency (sometimes with a little tact) with patients, however, goes a long way in building trust.

Occasionally during spinal surgery, we may inadvertently cause a spinal fluid leak. Even if we’ve sealed it well, I make it a point to mention it in the operation notes and tell the patient about it. It can often rear its ugly head a few days or even weeks later, and if the patient is being treated elsewhere later for any reason, the treating physician ought to have a detailed account of what transpired at surgery for optimal management.

I once cemented a fractured vertebra of a 70-year-old man. The needle, positioned accurately, transgressed right through the osteoporotic bone into the chest. This happened because I had to use some additional force to inject the rapidly solidifying cement. I removed it in a flash, but it could have punctured his lung or, even worse, his aorta, and he could have died on the spot. Luckily, nothing happened. He was discharged the next day and several years later remains pain free. Every time I see him, I debate if I should tell him what happened at surgery; I wonder if I’m not honouring my own guiding principle.

Not long ago in January 2021, I was operating on a complex brain tumour at 4 o’clock in the afternoon and the buzz in the operating room went up a few notches. Suddenly, the entrances and exits of people become a little quicker; there was palpable energy in the room. The anaesthetist bumped up the volume on her cell phone and I hear cricket commentary amidst the beating of the monitor. I paused for a moment and turned my gaze outside the microscope, enquiring, “Guys, what’s going on? I’m inside someone’s frontal lobe! Can we have the volume down in the room please?” “India is on the brink of a historic test series win against Australia—six runs to win in three overs, but only three wickets to spare!” came the retort with no regard for my request.

For a change, I didn’t want to be a party pooper, and, as I wasn’t at a critical stage of the operation, I packed the cavity with some cotton patties, stood up, and walked towards the phone while keeping one eye on the huge monitor displaying the surgical field.

“Let’s all watch the last over peacefully,” I said to everyone’s relief. After about eight minutes, a boundary commenced celebrations and everyone’s smile could be seen beyond their masks. “And now, can we get back to some surgery?” I taunted with a grin. We removed the rest of the tumour much faster than we expected and the patient made an excellent recovery, but should I have told him of the little fun we had while his head was open?

When I think back on these incidents, I am reminded of how doctors are, after all, human. They may seem indestructible—but they feel and care just like the others, they are excited by the same passions that drive the rest, and make mistakes and create miracles just like everyone. To be a doctor is to know when to rise above it all and treat someone with singular focus, putting the patient’s dignity and one’s own ethics above all else.

The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals.