Pain is part of life and global in nature. Dr Tariq Tramboo, Kashmir’s young inventor doctor has done pioneering work in pain management thus fetching him patents for the procedures he evolved. Shuttling between hospitals and the workshops, and keeping a low profile, he is keen the policy makers foresee the opportunities that Kashmir has once his patented systems become global as FDA approvals are around the corner, reports Saima Bhat
Writhing in pain, Shaheena, 35, rolls over the bed. Incessant tears and wails fill the silence of the room. Married for four years now, the mother of a toddler girl, Shaheena was diagnosed with a malignancy in her pancreas a few months ago.
It all started with pain in her abdomen and other complications which later investigations revealed was the last stage of cancer. Ruling out the possibility of any surgical intervention, the doctors informed the family that “she has very less time left.”
“Please take her to some other place. Don’t keep her in front of me,” Shaheena, having serious pain in her abdomen, yells at her mother.“She should not see me dying.”
Aware of the fate of their daughter, the family has been in pain for days to manage some way-out to bring some relief to Shaheena’s perpetual and unbearable pain. “We are dying every day to see her bearing this unending pain,” the desperate mother said. “Painkiller injections bring no respite to her now. Doctors say they can’t do anything to give her relief. We feel helpless.”
Managing pain in cancer patients is a serious effort. For the last few years, they do have an address, in Srinagar’s Khyber hospital, where the pain is being treated as a disease and not the symptom of an ailment by pain management specialist, Dr Tariq Tramboo.
“Pain brings a patient to a doctor,” Dr Tramboo said. “It requires a serious effort to detect the underlying cause.”Over the years, his expertise has evolved into a super-specialty as a result of which he is getting patients from outside for managing their pain.
“Pain could be a symptom of a disease but chronic pain is a disease in itself like chronic back pain, knee pain,” Dr Tramboo said.“It has to be managed as people manage hypertension or diabetes.”
Now, very well-known for ameliorating the pain to improve patient’s quality of life, Dr Tramboo, is the chairman of Spine LOOP, a California based medical device company that pioneered innovative technologies in the treatment of spinal stenosis and other spinal pathologies.
Credited with more than 30,000 interventional pain management procedures, Dr Tramboo was granted a patent for the invention of a treatment for spinal canal stenosis. This technique is expected to revolutionize the complicated spinal surgery as it reduced a five hours surgery with the cut in lamina-spine, bone, muscles, into a simple 15-minute procedure. The patient does not need a cut. The first human trial will start in Ukraine soon.
The procedure is a huge success and is a novel for spinal canal stenosis. The technique has won many international patents.
The procedure, Dr Tramboo says, envisages going through the epidural space and then surgical instruments like a needle will be inserted without a skin cut. The upper incision won’t be there and the procedure will be inside out,” Dr Tramboo said.
Usually occurring in the lower back and the neck, the spinal stenosis is actually narrowing of the spaces within the spine, which puts pressure on the nerves that pass through it. It happens in the patients above 70 years and in some cases, it is diagnosed early when the disease is congenital. “These patients are medically high-risk patients so the risk has been reduced,” Dr Tramboo said. “Millions of patients, who were unfit for surgeries because of the underlying medical conditions after a certain age, will now opt for this procedure. It is safer.”
Dr Tramboo said the procedure is actually a medical device and the protocol involving goes through the root of epidural space, the lamina is cut from inside out. The first procedure was done on a cadaver at King Abdul Aziz University Jeddah in 2013, after which it was endorsed by world-famous Japanese spine surgeon Dr Katsuro Tomita. Later, the research on the procedure was practiced at Saint Diego in the United States. “This technique was taken from Jeddah to the USA by investors and venture capitalists because of technicalities, developments and the medical technologies which were much advanced in the US,” said the inventor.
Inventor of these percutaneous (literally meaning ‘effected through the skin’) methods, DrTramboo was later joined by two more doctors. Dr Ash Taha, an orthopeadic doctor in the USA, joined him in research and became his co-inventor. He took the responsibility to take this technique to the US where he managed to raise around four to five million dollars for research. All the research on this subject was successfully done and is well documented on animals. The research showed that it was helping in increasing the canal diameter. Later, another doctor Dr Harshavardhan Hegde, a spine surgeon from India and Dr Abdullah Kaki (Canadian trained pain physician) from Jeddah who was heading the department of pain at King Abdul Aziz Hospital, also joined them.
Most of the funding for research was done by spine surgeons from the United States, and then finally Prof Dr Walter Bini, head of the department Neurosurgery from Germany saw the research and realised it will revolutionise the entire spinal surgery in the world. Finally, he joined in and decided to start the trails on humans in Europe.
“We are just waiting to enter FDA-deal so that the instruments and technique are sold out to all over the world and not just only in America,” Dr Tramboo said. “Currently we are having seven granted patents and 54 are applied for, which is huge and we might not be having any competition around the world because the technique is well protected in almost all the countries, and it has reviews and testimonies from all the famous doctors all over the world. The only thing which is stopping us further is the massive funding needed for FD.”
Since the technique is protected, patented, and published, the investors are pouring in, finally. But he says they are choosing only professionals to invest.
This technique may not replace all the surgeries but will revolutionise some of the difficult ones. “This technology is expected to stay best than the most advanced in vogue, for the next 30 years,” insists Dr Tramboo.
What is interesting is that in Kashmir, Dr Tramboo has maintained a very low profile. Routinely busy in treating patients and his academic pursuits, he talks less, interacts much less and lives within a tight schedule.
Pain management, now a super specialty, is an offshoot of anesthesiology. Dr Tramboo, after completing his post graduation in medicine from SKIMS, Soura, did a research fellowship in the USA for which he had to pass the interventional pain practices examination. He says he was the first Indian to cross this barrier.
“It was supposed to be the toughest examination in the world for pain at that time, literally painful,” Dr Tramboo said. “I did all my research in the USA but then I never chose to be there. I came back and started as a visiting consultant for Fortis Hospital in Delhi.” Then, at that time there were two or three pain specialists in India.
Since 2005 he is working at Khyber Hospital and at his Relief Pain Clinic Dalgate, where he gets his patients for treatment and invites colleagues to train them. He is choosy in picking the doctors for imparting the technique he has evolved. Partly, it is because he does not want to upset his routine.
Patients can go for interventions in managing three kinds of pain – head and neck, spine and cancer. No interventions are required in neuropathic pain (caused by damage or disease to the sensory nervous system)or myofascial pain (a sort of muscular pain). Since 2007, Dr Tramboo works on spinal cord stimulator and other advanced interventions that are rare and specialised procedures. “We are almost World leaders in doing such advancements,” Dr Tramboo said. “The patients and doctors are coming here to observe the procedures so that they can apply the same in their own countries.” His visiting colleagues are from pain management fields with specialisations in anesthesia, neurology, or orthopeadic. “They come so easily as Kashmir is easily accessible and serves as a touristic destination for them,” Dr Tramboo said.
But what does Dr Tramboo do? For head and neck pain, for instance, there are types like a patient has a cluster headache or a migraine, so they go for sapheno palatine (ganglion placed on the lateral part of the nose) block. It involves a nerve centre block that controls the pain of head and neck, where the pain signal is intercepted by use of medicine. It blocks the pain gate channels. If the pain comes again then they go for radio frequency lesion where ganglion is ablated by giving heat which is a safe procedure under image guidance he says.
“We have done so many cases which probably must be highest in the world and we have a huge rush of patients to the extent that we don’t get time to publish our work,” Dr Tramboo said.
They also do Gasserian Ganglion Block (radio frequency procedure) for a severe facial pain. Percutaneous endoscopic procedures for the disc, and leg pains.
In cancer pain, they go for neuro ablations, spinal cord neurostimulators, and morphine pumps. In patients who have undergone spine surgery and have not recovered, they are offered spinal cord stimulation (neuromodulation). It is like placing a neuro pacemaker, they get leads in epidural space near the spinal cord and then due to neurostimulation patient’s pain using electric modulations gets converted into a pleasant sensation.
“We are good at it and we will be doing more,” Dr Tramboo said. “We have more patient rush so we have to choose between the patients. If we feel the underlying cause of pain is something else then we refer them. And if a patient is in pain and doesn’t want to go for surgery, we treat those patients mostly.”
Every month Dr Tramboo receives at least five to six international doctors who watch him working and pick up the art of various procedures for pain management. “I have more requests than I can accommodate but I cannot tell everybody to just land here because I have to look for their accommodations as well,” Dr Tramboo said, as a matter-of-factly. However, he doesn’t show them the spineloop technique as it is yet to get FDA approval, which comes after going through stringent trails. The trails done on animal and cadavers were all successful because all the doctors who were in their board like Dr Vikram Patel, Dr Abdullah MKaki (Canadian physician), Dr Ash Taha, Dr Gabor B Racz, all internationally famous doctors, have already approved it and are waiting for its formal launch.
Doctors apart, international patients also come to Kashmir just to get treated by him. In the last three years, Dr Tramboo, while referring to the data available at Khyber Hospital, said around 200 patients from around Gulf have visited him in the hospital.
Dr Amin Athwayee, a pain specialist and an anesthesiologist from Hungary, is in Kashmir for the last ten days now. He has come for the first time along with his father, having chronic knee pain. He has exclusively come for Dr Tramboo, whom he has met five years ago in Dubai. Since then they were in touch.
“It became an added package,” Dr Athwayee said. “My father was treated and then I got a chance to learn the pain treatments of almost all types as his clinic remain crowded with pain patients. We visited a few places as well.” He said he had come across the expertise of Dr Tramboo in a number of workshops.
“He is quite an academic and at the same time he is clinically quite advanced,” Dr Athwayee said. “He gets a number of patients with almost all kinds of pain at his clinic like the neck, shoulder, knee, lower back (which is almost number one this time), and facial pain, which is quite difficult to manage and quite advanced.”
The interesting observation by Dr Athwayeeis that chronic pain stands almost forgotten by modern medicine. “People go to doctors because of pain but over the years it was forgotten by the mother medicine itself,” the foreign doctor said. “In the last 15-20 years, physicians again started paying attention because pain is very crucial and important for patient management.” Pain is quite subjective and approaches to a subjective issue has to be multidisciplinary. There are multiple ways of approaching a patient in pain; from physiotherapy to lifestyle changes to prevention to pharmacology to procedures.
He says they treat patients by intervening the pain-causing nerve or areas by using anti-inflammatory medication. “Presently the big part of this treatment is diagnosis where doctors give numbing medicine to nerve or block to a particular joint which they suspect is the cause of the pain,” Dr Athwayee said. “If the patient gets relief the doctors get the cause and if not, then they focus on other parts for the pain.”
With the FDA approval to the spineloop, now round the corner, there is a possibility that Kashmir could think of giving a boost to medical tourism.
Presently Dr Athwayeesaid all of his travel and then accommodation was looked after by Dr Tramboo. “We enjoyed the hassle-free travel as Dr Tramboo has himself made the arrangements,” Dr Athwayee said. “It was election time and there were a lot of soldiers around which is a part of the situation in Kashmir.”
Dr Tramboo’s expertise is already helping Kashmir in getting a number of International doctors or patients. In the last five months, he received around 50 International doctors who came for a minimum ten days visit to observe the new techniques in pain management.
These doctors were just observing him. In case Dr Tramboo allows all the interested doctors and patients to come, they can challenge any corporate hospital in Delhi as far as medical tourism is concerned. Presently Delhi’s economy is mostly dependent on medical tourism, as the corporate hospitals get patients from Gulf, Africa, Afghanistan and other parts of the globe.
“It is very easy for us to catch that medical tourism but unfortunately most of the Gulf doctors and the patients who want to come to Kashmir are not given visas for Kashmir, I have email statements to prove that,” Dr Tramboo said. “When the doctors and patients from Gulf countries say they are going to Kashmir, a visa is almost denied or they are made afraid of visiting Kashmir. This is the huge problem for gulf tourism and nobody is helping because it may be the policy matter. They are allowed for Delhi and other states though.”
“Medical tourism industry has grown too big and most of the hospitals in Delhi have 80 per cent of their patients coming from outside the country and many of them are from Kashmir as well,” Dr Tramboo, who has worked with various hospitals said. “If we are able to cash on only ten per cent of medical tourism we will forget rest of the tourists, every hotel will remain occupied and most importantly they are foreign tourists who like to spend more.”
The pain management also includes the radio frequency ablation for cancer patients. “We get patients from across India who come for the procedures,” Dr Tramboo said. “We don’t have any competition, but the only problem is we don’t have the infrastructure for the medical tourism.”
“If we have one of the finest doctors than any other in India so why a patient from Gulf should go to Delhi and not come to Kashmir?” said a hospital executive. “It is not like they are coming here just to see the mountains but they are coming for their treatment. We have patients from Iraq, Australia, Singapore, Gulf, Kuwait. And for pain management patients can travel up to Kashmir but when it is emergency related issues like heart stroke, a fracture that time patients can’t come here.”
Presently Dr Tramboo receives two International doctors and a few patients every fortnight but he says he can get at least 50 a month. If that happens, it can trigger a huge difference.
Does somebody in business or policy-making understand what it means?