-Dr. Anil Aggrawal
W hen I got a telephone call from the Indian High Commission in Timbuktoo, I was relaxing in my bed with a cup of coffee and the morning newspaper. My wife was sitting besides me, and we were gossiping. Nothing irritates me more at such times than a telephone call. With some measure of irritation, I picked up the receiver.
“Is it Dr. Aggrawal, Professor of Forensic Medicine at the Maulana Azad Medical College?”, a faint voice asked from the other side.
“That’s right”, I replied.
“Dr. Aggrawal, I am Abhinav Sinha, High Commissioner of the Indian High Commission in Timbuktoo. We are in a great problem. We have a doctor here, who is being falsely framed in a medical negligence case. I am convinced he is innocent. Could you please come and help us?” and without waiting for my reply, added, “Your tickets are being sent to your house, along with some money to take care of your travel expenses. All the hospitality here will be taken care of by us.”
“Look.. .”, I protested, “I don’t know what your problem is, and I am really not sure I can help you in this case. Moreover I can’t possibly leave my college for any great length of time.”
“Everything has been taken care of sir. Your trip is official. You will be treated as on duty. All expenses paid. Please come as soon as possible”, and he hung up.
I was quite nonplussed, and I was almost sure, it was some practical joker trying to play a fast one on me. But within five minutes, I received a phone call from the Ministry repeating the same thing almost verbatim. Within half an hour, a government official came to my house with some travelers cheques and a club class return air ticket to Timbuktoo. There was an accompanying letter from someone higher up in the Ministry asking me to proceed to Timbuktoo immediately. It also said that I would be treated as on duty.
There was no option now. The flight was at 9 pm. I looked at my watch. It was still 8 am. I had about 13 hours for preparations. I requested my wife to start packing.
For those, who are not aware of Timbuktoo, it is a very tiny principality somewhere in the Middle of Africa - quite near Lake Victoria. It is a hereditary monarchy. Elections have never taken place here. Kings have been ruling this principality since time immemorial from the same family clan. Mostly the eldest son gets the chance to rule, but sometimes court intrigues result in murders, and the younger brother gets the throne. There have been cases, when a still younger brother has in turn killed his second brother and got the throne! In short, the history of this principality is rife with murders, court intrigues, treachery, debauchery and so on. Our country had no diplomatic relations with this country till sometime back, but recently in the wake on the so-called Non Aligned Movement, we had developed diplomatic relations with them. A small mission had been opened there, which was staffed by just six people. One of them was a young Indian doctor, whose main job was to look after the Indian officials and their families, as the medical fraternity in that principality was really in a very nascent stage.
After a relatively comfortable nine hour flight, I landed at the King Hassan Airport in Timbuktoo. The High Commissioner of the mission was there personally to take me to my hotel. Along with him was the young doctor posted in the Mission. His name was Dr. Harish.
While I was being driven to my hotel, I looked out of my window, and was amazed at the clean air and greenery all around in that tiny nation. Coming from New Delhi, it was certainly a very welcome change.
The hotel was comfortable and clean. After I took bath and changed, the duo narrated their story to me, and it was something like this:
Ndubuisi Eke was the king of this nation since about three years. He had a younger brother called Mombutu Eke, who wanted to usurp his throne. On 18 February 2001 - a Sunday - when Ndubuisi was taking his morning stroll, one unidentified man came from somewhere and stabbed him in the neck. The attack was so sudden that Ndubuisi’s two bodyguards couldn’t do anything. However there were rumors that they had been “bought” and did not try to stop the attacker on purpose. There was an immediate commotion all around, and in the mêlée that ensued, the attacker managed to slip away. Again people who had an ear to the ground said that this was also stage managed. The killer was someone hired by Ndubuisi’s younger brother Mombutu, who wanted to usurp his throne.
As luck would have it, Ndubuisi did not die immediately thereafter. He did however receive a nasty gash in the neck. As the whole of Timbuktoo did not have a reasonably smart surgeon, he was brought to Dr. Harish in the Indian Embassy. To be sure, he too was young and rather inexperienced, but better than the best Timbuktooan doctor. Dr. Harish tried his best to save Ndubuisi, but he died immediately after arriving at the hospital. No autopsy was ever conducted on the body, and the body was cremated in haste. Mombutu Eke ascended the throne immediately thereafter.
However the public - who loved Ndubuisi no end - was restless. In Mombutu, they saw a killer and usurper. There were hushed voices all around. And perhaps to silence his critics - and perhaps to clear him as well - Mombutu ordered an enquiry against Dr. Harish. It certainly was against diplomatic norms. But as far as Mombutu was concerned, it didn’t matter as his throne was in jeopardy. He wanted to show that the wound received by Ndubuisi was not fatal, and the death occurred instead because of Dr. Harish’s negligence. It was where I came into picture. I was to prove that Dr. Harish had tried his best. There was no negligence on his part and the death occurred prima facie because of the wound.
But how could I do that? Had Ndubuisi’s body been with us, it would have been a relatively simple matter for me. All that I needed to do in that case was to conduct a thorough autopsy on his body to find out the correct cause of death. But the body had already been cremated in haste. Now all I had in my possession were some reports prepared by Dr. Harish, when Ndubuisi first arrived at the hospital.
I interviewed Dr. Harish in great detail. He was young and inexperienced, but certainly a very bright doctor. Obviously he was terrified. He was being prosecuted in an alien land, and if found guilty, they could send him behind bars for a lengthy period of time. Something had to be done very fast.
Fortunately Dr. Harish had prepared a very detailed injury report. I read the injury report over and over again, and found that the most significant part was that his left sternocleidomastoid had received a gash 6x2x4.5 cm in size. It was that wound which appeared fatal to me.
But the volume of blood that Ndubuisi lost was not very much. Dr. Harish had immediately sutured the wound. At a rough guess, he had lost about 500 cc of blood. Now that is not sufficient to cause death by shock. One would require at least 2000 cc for that. Obviously Ndubuisi had died because of some other reason. But what? That was the million dollar question.
I could not sleep that night. I kept thinking the whole night. And I do not know when I fell asleep. But soon I started dreaming. I saw Ndubuisi going down and down in deep water. He was struggling to stay at the surface. But something was taking him down and down. Bubbles of air were streaming through his nostrils. Bubbles of air.. ..
I woke up with a start. It came to my mind in a flash. It had to be air embolism! Perhaps I was thinking about air embolism subconsciously. That is why I dreamed of those air bubbles, perhaps.
For recapitulation, let me state what air embolism is. It was Rudolf Virchow, the famous 19th Century German pathologist who introduced the term embolus and embolism into modern medicine. In 1856 he applied the term embolus to a loose clot in the blood stream. These words are of Greek origin and come from the Greek word “emballe” meaning to throw in, or to lay in or to put in as a stopper, peg or bolt. A loose blood clot in the circulation indeed acts as a stopper or a peg. As long as it travels in vessels bigger than its size, it is alright, but as soon as it encounters a vessel smaller than its own size, it gets stuck there, acting as a stopper or a peg. Many of you would be surprised to know that embolism is used in a general sense too, meaning the adding or “throwing in” of an extra day to the year. In relation to medicine, we usually speak of embolism in relation to blood clots which travel from leg veins upwards and get lodged in pulmonary arteries. This is a serious condition causing almost instantaneous death. Under certain conditions - as when veins are cut - air can get sucked inside the veins. It forms a bubble inside and this bubble travels towards the heart along with the blood stream, and gets lodged in the pulmonary arteries just as a blood clot does. A bubble of air is incompressible, and there is no way the blood stream can negotiate this bubble. Inside the vein this bubble acts just like a blood clot. That is, it blocks the circulation just as effectively as does ordinary blood clots, causing immediate death. It is almost as if someone had put an arterial clamp over that place!
Detecting ordinary blood clots in pulmonary arteries, or for that matter anywhere else in the body, is relatively easy, but detecting air embolism is a different game altogether. It remains one of the most challenging tasks faced by a forensic pathologist. The reason is that the moment you open pulmonary arteries, the bubble is going to disappear in the air. For this reason, forensic pathologists usually dissect the heart under water in suspected cases of air embolism, but believe me it is a very difficult and challenging procedure. Nobody loves it. There is a silver lining though. If you are suspecting air embolism in a case, before you start the autopsy, one of the best things you can do is to X-ray the body. If an air bubble is present in the heart or pulmonary arteries, it will show up in the X-rays. So you conduct this difficult procedure only in the cases in which you see the bubble in the X-rays, and leave out the rest. In fact, the X-ray plate itself is proof that the person died of air embolism and many forensic pathologists don’t take the trouble to dissect the heart under water after that.
But we all know, no post mortem was ever conducted on Ndubuisi. Even if it had been conducted, I am doubtful, if anyone would have been able to detect the cause of death as air embolism, as there was no forensic pathologist in the whole of Timbuktoo. I was now in a very unenvious position. I did not have the dead body of Ndubuisi, and I had to prove that he had died of air embolism. That was the only way to save Dr. Harish. Only then we could prove conclusively that it was the initial stab wound which caused the death (by air embolism), and not negligence on the part of Dr. Harish. But how could I do it? That was the million dollar question.
In the evening, I was sitting by the lakeside looking at the beautiful lake and the birds leisurely floating in it. I was recalling my younger days, when we had to send almost all bodies for X-rays, in which we suspected air embolism. Then for many months, our X-ray unit was out of order, and we had to start the autopsy without the benefit of the initial X-ray plates. This meant that effectively we had to open all hearts under water and nobody liked that. You have to make a sac in the pericardial cavity by making appropriate cuts in the pericardium; then you fill that pericardial sac up with water with an assistant holding up both the flaps of pericardium with forceps; and then finally you inserted the blade in the pulmonary artery and under various heart cavities, twisting and turning it expecting a bubble to rise through water. Not many forensic pathologists love this. And many complained. To solve the problem, I came up with an interesting formula. I had for long observed that more people tend to die of embolism if the cut was longer and deeper. Similarly if the muscle involved was more voluminous, chances of air embolism were higher than if the muscle were less voluminous. Thus if someone got a 5 cm cut in gluteus maximus, he would stand much greater chances of getting air embolism than if he got a cut of the same size in, say, temporalis muscle. It was because temporalis muscle is less massive than gluteus maximus. Could I turn this observation into a strict mathematical formula, I had asked myself at that time. And quite interestingly I did come up with an interesting formula. It was:
Now if you think you are already familiar with the formula, probably you are wrong. E in our formula stands for Embolism (rate of), m for muscle mass (in grams) and c was a somewhat complicated parameter, which I called the “Cut factor”. I had observed that air embolism tended to depend both on the length and the depth of the cut, but depth had a greater effect on producing air embolism than the length. Thus if the length of the cut was twice, the chances of air embolism in a person would be doubled, but if the depth was twice, the chances would be four times. To take this observation into account, I put the Cut factor equal to [(cut depth)2 x (cut length)].
The interesting thing about this formula was that this stands true across all animal species. Once this formula was in place, we applied it in some experimental animals too, namely rats, guinea pigs, hamsters and pigs. To my satisfaction the formula proved true in all cases.
Now as you can see, this formula actually gives the rate of embolism. To put it in other words, it would give you the probability that the person might have suffered air embolism. What we did with this formula was to look at the muscle which was cut and the size of the cut, and put the numbers in the formula (we had to put the decimal back by four digits, i.e. we had to effectively divide the figure by 10,000 to arrive at the correct rate of probability). If we got a figure, say, 50, it effectively meant that the person had a 50% chance of getting air embolism. If we got a figure of, say, just 2, there was just a two percent chance of getting air embolism and the forensic pathologist could perhaps look the other way and forget about dissecting the heart under water. Gradually all forensic pathologists in our institution got round to opening the heart under water if the figure was greater than 50. This made sense too, because if the probability of getting an air embolism is greater than 50%, you must take enough trouble to find it out.
For those, who are able to follow me only vaguely, I would illustrate with an example. Gluteus maximus’ weight on the average is 493 g. Now if it sustains a cut which is 5 cm long and 3 cm deep, what are the chances that the person would die of air embolism? We would calculate it as follows:
The cut is 5 cm long and 3cm deep.
Since the cut factor is equal to [(cut depth)2 x (cut length)], simple mathematics would show that it would be 45.
Now putting this figure in our earlier formula E=mc2
We get 493 x 452 or 998325
We put four decimals behind and we get 99.8325. This means that a person getting a 5 cm long and a 3 cm deep cut would stand a 99.8325% chances of getting an air embolism. This is well near hundred percent, and I would certainly like to take all trouble to dissect the heart under water.
Over the years this formula had gained International acceptance, and almost every forensic pathologist was using it in his day-to-day practice.
Could I use this formula in Ndubuisi’s case? Then suddenly I remembered that Dr. Harish had been careful enough to record the dimensions of the cut quite accurately. I jumped and ran back to my hotel room. Once inside the hotel room I phoned Dr. Harish immediately and in a most excited voice asked him to give me the dimensions of the cut. He was a little surprised at my strange request but gave the figures to me. The dimensions were 6x2x4.5 cm.
Now my only problem was to find out the weight of the sternocleidomastoid muscle. I am no anatomist and did not know its weight at all. But fortunately I have many good anatomists as friends. One of them is Dr. R.K.Suri, Professor of Anatomy at our own medical college. I immediately made an overseas call, forgetting the time difference completely. It was 2 am in India, and he picked up the phone with some measure of irritation.
“Dr. Suri, what is the weight of Sternocleidomastoid muscle?”
“Is it Dr. Aggrawal?” he asked in great irritation.
“Never mind. The weight?” I insisted.
“Why! it is 153 grams. But why do you ask this question in the thick of the night?” He was obviously quite nonplussed.
“Thanks” I said, ignoring his question completely, banged the receiver back and got back to crunching numbers.
The cut factor in this case would be 121.5 as the length of the wound was 6 cm and its depth 4.5 cm. Now putting all the figures in our good old formula E=mc2, we get:
153x(121.5)2 =153 x 14762.25
Putting the decimal back by four points, we arrive at the figure 225.862425
I jumped on my feet in glee. The probability of getting air embolism was even greater than 100! To a mathematician it may look silly, but we had encountered such figures before. It meant that the person was sure to get air embolism. Everything was clear now. With such a deep cut on his Sternocleidomastoid muscle, Ndubuisi stood a 225% chance of getting air embolism. In other words, he died of air embolism. That was for sure.
We immediately filed our answer in the Law Ministry of Timbuktoo. I am given to believe that the Ministry was going to dismiss that answer too, but before doing that they took the advice of some international forensic experts, and all of them advised that my reasoning was watertight and there was no scope of rebutting it. In fact if they did it, they would go down in the eyes of the International Community as an utterly unjust nation, and would stand the risk of getting completely isolated. Mombutu obviously did not want to take this risk. Dr. Harish was immediately cleared of all charges.
I returned back to India, and the very next day went to Dr. Suri and thanked him for the help he rendered us. He was still very very angry with me, especially because I had banged the phone on him, but when he heard the great service he had rendered for our nation, he forgot all anger and is once again a very great friend of mine.
***IMPORTANT NOTE: THIS MATERIAL IS COPYRIGHTED BY THE AUTHOR AND MAY NOT BE REPOSTED, REPRINTED OR OTHERWISE USED IN ANY MANNER WITHOUT THE WRITTEN PERMISSION OF THE AUTHOR
Sign My Guestbook View My Guestbook
You are Visitor No: