'I have to be taller.' - Vidhi Doshi

'I have to be taller' : the unregulated world of India's limb-lengthening industry.

Young Indians are paying for complex,painful procedures despite the absence of medical oversight in the race to improve marriage and career prospects.

Komal never told her friends where she went for six months last year. The 24-year-old, fromt he town of Kota, in western India, went to see Dr Amar Sarin, an orthopaedic surgeon in Dehli, who made her eight centimetres (3in), a procedure which involved breaking the bones in her legs and wearing a brace until she could walk again.

Her parents had to sell the family’s ancestral lands so she could get the surgery, but for Komal, the extra height is worth it. “I have so much confidence now,” she says. “I was just 4’ 6” [137cm]. People used to make fun of me and I couldn’t get a job. Now my younger sister is doing it, too.”

In a country where height is considered attractive, Komal is one of a growing number of young Indians using their increasing prosperity to improve their marriage and career prospects, and fuelling a cosmetic surgery boom.

However, limb lengthening surgery is completely unregulated in India and many of the surgeons performing it lack experience. As it also carries a certain stigma, the Guardian has chosen not to reveal Komal’s real name.

Dr Sarin says: “This is one of the most difficult cosmetic surgeries to perform, and people are doing it after just one or two months’ fellowship, following a doctor who is probably experimenting himself. There are no colleges, no proper training, nothing.”

Patients recover after undergoing limb lengthening surgery. Photograph: Amara Sarin

Prospective patients appear undaunted, including those from abroad. India’s reputation for cheap and well-trained doctors attracts people from around the world, in a medical tourism industry worth an estimated $3bn. Cosmetic surgeries make up a large slice of that figure, drawing increasing numbers from countries in Europe, America and elsewhere where procedures can cost four or five times as much.

Dr Sarin, who started offering the surgery five years ago, has treated 300 patients already, and only a third of them are from India. “It is a growing trend in India,” he says. “I get around 20 calls a day, with people telling me ‘I want to be tall, I have to be taller.’”

One man who had surgery in 2015 says he met at least 20 doctors before deciding to go ahead with the procedure. “Many of the doctors I approached had only done it once or twice before, and one had never ever done it before. I searched for around one year before I found the right person to do it.”

Last month, an ethics committee in the Indian state of Andhra Pradesh summoned orthopaedic surgeons who had operated on a 23-year-old man, after doctors raised concerns about why “unusual, experimental surgery” was performed. The surgery divides orthopaedic specialists in India, many of whom contend that the surgery is extremely difficult to perform and can cripple people for life.

An x-ray showing the progress of limb lengthening surgery in India. Photograph: Amar Sarin

Dr Sudhir Kapoor, the president of the Indian Orthopaedic Association, says: “We don’t recommend for people to do this surgery except for in very rare cases. These surgeries are not done routinely and there’s a high risk of complications.”

Limb lengthening surgery was pioneered in the 1950s, in a small Soviet town called Kurgan in Siberia. Its inventor, a Polish man named Gavriil Ilizarov, once dismissed as a quack, became known as the “magician from Kurgan”, after he performed orthopaedic operations on people including an Olympic high jump champion. Ilizarov never intended for his technique to be used for cosmetic purposes; his work was targeted at people who had had accidents or were born with limbs of different lengths.

Now, the controversial Ilizarov technique is being used by surgeons across India, though with many modern modifications to make it quicker and less painful. Sarin, who has earned an international reputation for his skill in performing the surgery, says he struggled with the ethics of performing it at first. “I used to wonder whether what I’m doing is right, but when I saw how much their self-esteem was improving, I decided to keep going,” he says.

It’s worth it when you see how much their self esteem grows

Amar Sarin, surgeon

The surgery should be used only as a last resort, he adds. “We often turn people away,” he says, explaining many of his patients have suffered acute psychological disorders. “We try counselling first, but we’ve had patients who even threaten to commit suicide if I refuse to do the surgery. Twice I’ve had to call the police in emergency situations like that.”

Though he has performed the surgery successfully on hundreds of people, Sarin admits: “It’s madness to do it.”

Still, he feels successful limb lengthening can transform a person’s life: “You can barely recognise them. It’s worth it when you see how much their self esteem grows.”

Citation:

Doshi, Vidhi. "'I Have to Be Taller!'" The Guardian. Guardian News and Media, 08 May 2016. Web. 10 May 2016. <http://www.theguardian.com/world/2016/may/09/i-have-to-be-taller-the-unregulated-world-of-indias-limb-lengthening-industry>.

The very concept of "limb-lengthening" sounds absolutely mortifying but the reality of having your legs broken and wearing a cast until you can walk again all to be three inches taller is exactly that: mortifying. As the bulk of our societies push people to fix, improve and change themselves to fit-in better, plastic surgeries are only going to become more popular. Obviously in India, marriage prospects and employment are high stakes and are definitely enough to push people to have this risky limb-lengthening surgery. There are high enough stakes for a family to sell ancestral lands to afford such surgeries that could leave the patient completely crippled for the rest of their life. But the author of this article, Vidhi Doshi, shows the ethical dilemma surgeons who originally set out to improve the lives of those who had had accidents or were suffering are now facing. Now they are meeting the demands of self-improvement because of dissatisfaction. Although Doshi lists the great lengths that people all around the world will go to have such a surgery, he is biased against the surgery because he writes more about the ethical dilemma or the risks of the surgery over statistics of more patients getting jobs post-surgery. He also shows that although there are those that are desperate, many come from all around the world to India for the purpose cheap self-improvement surgeries. Medical tourism is a billion dollar industry in Indian because many patients come from all around the world to have affordable and fast surgeries in India. So, there are a lot of people that such an article can be aimed at, even if just for them to question whether the battle with ethics is worth another celebrity's  nose. If a person wants to change one thing about themselves, they will find another part to be dissatisfied later. It is a vicious cycle of never quite being good enough until after another surgery and then another. But so much of this is linked to a self-improvement cultures that are only growing.  So, after reading the final line of this article of a doctor proclaiming that the improvement in self-esteem is worth it, do you think it is worth it? 

Measure

Measure

When the Patient Won't Ever Get Better - Daniela J. Lamas, M.D.

When the Patient Won’t Ever Get Better

By

Daniela J. Lamas, M.D.

April 28, 2016 12:00 pm April 28, 2016 12:00 pm

Photo

Credit Stuart Bradford

“Tell me,” my patient’s daughter asked at the other end of the phone line. “Is she stable?”

I wasn’t sure how to answer.

My patient hadn’t been home in nearly three months. It had all started to come apart in the fall. Until then, she’d been a healthy 90-year-old who lived alone and cooked all her own meals, played tennis in the summer, binged on movies in the winter. But then there was a strange pain in her back, a visit to an urgent clinic and a harrowing ambulance ride to the emergency room. A tear had developed in the wall of her aorta, one of the main vessels carrying blood from the heart. In a windowless conference room, the doctors told my patient’s family that without emergency surgery, she would most likely die.

To her family’s relief, the surgery went well. But there were complications – first pneumonia, then kidney failure, delirium, profound weakness. After two weeks she hadn’t died, but she hadn’t recovered, either. Because she was still dependent on the ventilator, her doctors took her back down to the operating room for another procedure, a tracheotomy, cutting a small hole in her neck to serve as a more permanent connection for the ventilator. Because patients with tracheotomies can’t eat using their mouths, at least not at first, she returned from the O.R. with another new tube, a feeding tube in her stomach.

Another few weeks passed in the I.C.U. It seemed that as soon as one infection got under control, another developed. From time to time, my patient’s delirium seemed to clear – when she was strong enough to breathe through the tracheotomy without the ventilator, she could speak with her family and offer one-word answers to questions. Her whisper was so soft they could barely hear her. On other days she was scared and wild-eyed, hands bound with soft “mitten” restraints to keep her from pulling out the feeding tube that delivered the thick white liquid slurry pumping from a bag on an IV pole above her head directly into her stomach.

One day, her family learned that she had a bed at another facility, called a long-term acute care hospital. This was good news, her doctors told the family. It meant that this weak, intermittently delirious woman who looked nothing like the spry 90-year-old who’d come to urgent clinic some months before didn’t need the I.C.U. any longer. They were cautiously optimistic.

In this new hospital, she did get better. Some days she managed to stay off the ventilator for eight hours, then 12, then a day, then two. Her tracheotomy was removed and the hole in her neck started to heal. Her delirium lifted, replaced by a dull, lifeless gaze. Her kidneys improved. And then, things stopped getting better. Time slowed. There she was – neither dead nor truly alive – stuck, it seemed, in limbo.

One Saturday, she spiked a fever. Her breathing grew ragged. Back in the E.D. she was intubated once again, then sent up to the I.C.U., where her daughter called us to ask, “Is she stable?”

I debated about how to respond. The ventilator was delivering sufficient oxygen. Intravenous med drips were acting directly on her heart to keep her blood pressure at an acceptable level. Her kidneys were functioning to make urine.

But behind the façade of stability was a more dire truth: she might never get better. With her constellation of ventilation dependence, infections and delirium, she had what doctors call “chronic critical illness.”

Her story isn’t unique; there are about 100,000 chronically critically ill patients in the United States at any one time, and with an aging population and improving medical technologies, this number is only expected to grow. The outcomes of these patients are staggeringly poor. Half of the chronically critically ill will die within a year, and only around 10 percent will ever return to independent life at home.

Chronic critical illness is not something I learned about in medical school, or something that many doctors even talk about. One reason might be that the care for the chronically critically ill quite literally takes these patients out of our view – they move, as my patient did, from hospital to long-term care and back again, accompanied by a growing stack of medical records as things slowly fall apart.

In the early moments of critical illness, the choices seem relatively simple, the stakes high – you live or you die. But the chronically critically ill inhabit a kind of in-between purgatory state, all uncertainty and lingering. How do we explain this to families just as they breathe a sigh of relief that their loved one hasn’t died? Should we use the words “chronic critical illness”? Would it change any decisions if we were to do so? Here, I find that I am often at a loss.

I was quiet on the other end of the phone line that night. Was my patient stable? For the moment, she was. But with each event like this one, and there would be more, my patient would move further from the hope of ever reclaiming that life she had had in the fall: living in her own home, watching movies, cooking. I felt that I could see the weeks and months spooling out, a moment of calm, a new emergency. But this wasn’t the time to tell her daughter, not on the phone, not tonight.

And so I told her the truth – one truth, at least. Her mother was critically ill, but stable for the night.

Citation: 

Lamas, Daniela J. "When the Patient Won't Ever Get Better." New York Times. New York Times, 28 Apr. 2016. Web. 03 May 2016. <http://well.blogs.nytimes.com/2016/04/28/when-the-patient-wont-ever-get-better/?ref=health>.

This article is very different than the articles I focused my response on in the past. To start the author is a doctor rather than a journalist which gives us a very different viewpoint. I know that I often think of the suffering patients or the anxious family waiting for the next phone call (which is good) but not as often the doctor or caregivers.  Even though my mother is a doctor and  I often heard phone calls much like the ones the author Daniela Lamas makes,  I never really thought as much about the responsibility that is placed on doctors to give the life or death answers even if there are none. Daniela Lamas talks about her training that never really prepared her for these situations that will only become more common for in a world with improving technology and a growing elderly population. She has a bias against that aspect of her training and the fact that it is not spoken about enough among medical professionals more. Maybe she is warning  medical students about the difficult decisions that are inevitably coming their way that can only be taught through experience. Or she is subtly telling families that to be patient when such questions cannot be answered.