Spiritual Experiences from the Brain

A Godly Man Does Not Belittle His Talents

 

Human nature being what it is, we will occasionally compare ourselves to others. To a degree this may be a good thing because we can gauge whether we are being a good Christian, for instance. On the other hand if we use others as a barometer of our own personal worth or wealth we may find ourselves drawn to the darker side of jealousy and envy.

A few of weeks ago a friend sent me an email that contained a video story of a young patient with a brain tumor that had undergone surgery at the Johns Hopkins Hospital in Baltimore, Maryland. It was a wonderful and inspiring story about Carlos who had a grade 2 astrocytoma and his surgeon Dr. Henry Brem, the chairman of Neurosurgery.

 In the story, Carlos is described as an upbeat, positive and fearless man who had braved the jungles of South America. As a result of the treatment he received at the Johns Hopkins Hospital he was deeply grateful for Dr. Brem saving his life and yet because of his diagnosis he had become a bit more cautious not wanting to venture out too far from Baltimore. Dr. Brem is a brilliant man described by Carlos as ‘one of the best in the world at what he does’ and at the same time one who is compassionate and keenly aware of the importance of treating Carlos as a human being and respecting the dignity of his personality and life.

Arthur Grand is a patient of mine. He is a 62 year old man who had fallen several weeks earlier and developed a subdural hematoma, or a blood clot in between the inside of his skull and the surface of his brain. On Wednesday of the week preceding, my partner had removed the blood clot and Arthur was doing so well he was discharged on Friday. In the early morning hours of Saturday, however, Arthur suddenly became aphasic, or unable to speak. His wife, Ellen immediately called 911. Upon arrival to the emergency room, a CT scan was done and revealed there had been another hemorrhage which resulted in the recurrence of the subdural hematoma which was now putting pressure on Arthur’s speech area. And so I was called. After reviewing the CT, I contacted the nursing supervisor to call in the surgical team.

As I drove into the hospital that Saturday morning to operate on Arthur, contemplating Carlos’ story, I began to feel insignificant.  I thought about Dr. Brem and what an incredibly skilled neurosurgeon he was to maneuver through Carlos’ brain removing a tumor that visually, looks very much like his normal brain tissue. And here I was heading into the hospital to perform a surgery that a junior neurosurgical resident could execute flawlessly.

Once I arrived at the hospital, I reviewed Arthur’s scan once again and determined the recurrent blood clot was immediately underneath the previously removed skull flap. So, all I would need to do was to reopen the skin incision, unscrew the bone flap that was secured to the surrounding skull, wash out the blood, control whatever bleeding had caused the recurrent hemorrhage and then replace the skull flap and close.

As I removed the last screw, the bone flap popped off, and indeed there was a blood clot beneath it but there was something wrong. I would have expected that once the blood clot was removed and the pressure released, the brain would become relaxed, but that was not the case. The brain still appeared swollen and under pressure. And if I didn’t do something quickly the brain might continue to swell out through the opening in the skull. Immediately, I realized I would need all 20 years of my experience to figure out what the problem was and what I would need to do to fix it. So much for this ‘simple’ procedure!

First, I had the anesthesiologist raise the head of the bed thereby decreasing somewhat the effect gravity might be having on engorging the brain. Secondly I took a malleable brain blade or ½ inch wide flat metal retractor that I used to gently retract the brain so I could inspect subdural space beyond the limits exposed by my craniotomy. In this way I could determine if there was an additional blood clot beyond what I could immediately see. Indeed there was both clotted blood and fluid that was trapped in this space and upon releasing it the brain began to relax.

However, also located in this space was a membrane or tissue layer that Arthur’s body had formed in response to the presence of the blood clot in an effort to isolate it from the underlying brain. The problem now was there was active bleeding from the edge of this vascularized membrane.  And so with the brain blade in my left hand retracting the brain, I first cut away the membrane with a scissors in my right and then took a bipolar forceps, also in my right hand to coagulate the edge of the membrane to stop the bleeding. I then inserted strips of surgical foam soaked in a substance that would assist in clotting the blood and soon the bleeding had stopped and the brain was completely relaxed. I was now able to replace the skull flap and close.

Before surgery, Arthur had difficulty speaking and appeared confused but was wide awake so to look at him you might not think he had a serious, let alone life threatening problem. But, in the recovery room, he awoke speaking fine and said something that made me realize how bad off he really was. When I asked him how he was he said, ‘where am I? …what happened?’ When I saw him in the office 10 days later he was smiling, looking perfectly normal. I asked him how he was. He said, ‘great’, so I jokingly said to him, ‘good, stay that way’ as he laughed and smiled even wider.

The experience of Arthur’s case taught me two things. One, I should never underestimate the impact I might have on someone’s life no matter how ‘insignificant’ that act might seem. And two, I must never disrespect the gifts given to me by God by thinking that the actions of someone else, even a neurosurgeon are more important. Everything in life is relative… There will always be someone that is smarter, or more skilled surgically, or more gifted athletically. But everyone has unique talents that are gifts from God and they are just as remarkable as the abilities of others. So, for me to diminish the importance of my intelligence and skill is not only wrong but an insult to God – a sin. And not surprisingly to me God has a way of periodically reminding me of this by placing before me people and situations that hammers that point home.

‘For as in one body we have many members, and all the members do not have the same function, so we,   though many, are one body in Christ, and individually members one of another. Having gifts that differ according to the grace given to us, let us use them: if prophesy, in proportion to our faith;’  Romans 12:4-6

 

 

If Healthcare is a God-given Right, How Can We Possibly Consider Rationing It?

 

It was Thursday night and I was just getting ready to go to bed. It was 11 pm and I turned my phone on to see if I had missed any messages. I wasn’t on call for emergencies so I had my phone set to vibrate. When I looked at the phone I saw that I missed a message at 9:11. Actually no one was on call for neurosurgical emergencies that particular evening.

So, when David Osgood arrived at the ER with an abnormal brain MRI scan which was done as an outpatient earlier that day, Kelly the ER nursing director sent out a text to see if any of the staff neurosurgeons were available to take care of him. I tried texting her back but got no answer so I called the ER directly and spoke with Dr. Feusner who was on duty. She told me that arrangements had been made to transfer David to another hospital but that he was still there at Mease.

I told her it wasn’t necessary to transfer David and that I would be available to see him first thing in the morning. So she cancelled the transfer and arranged to have him admitted to Mease Hospital.

David was 67 years of age, married with three children, two daughters and a son. He had recently developed a facial droop on the right side of his face and also was having some difficulty speaking. It wasn’t that he couldn’t speak; it was just that he had trouble getting some of his words out. He also had weakness of his right arm which began at the same time as his speech problem. Initially his doctor thought he had a stroke, but when the MRI scan was performed it was clear his symptoms were not due to a lack of blood flow to his brain but a tumor located right in the center of his frontal speech area, on the left side of his brain. Dr. Feusner told me David had a tumor; I just didn’t know the tumor likely was inoperable until I walked into David’s room the next morning.

As I entered his room, David was lying in bed and his wife Marjorie was at his side. They only had a vague idea of what the MRI showed and were certainly hopeful that despite what was in his brain, there would be a treatment for it, even if it required surgery. I picked up the MRI folder and turned to the window as I began pulling out the films one by one, holding them up to the sunlight to see what kind of tumor David had and where it was located. I too, was hopeful that there was something I could do for David, but as I looked at the scans, my heart sank. Because of where the tumor was located, surgery would almost certainly worsen David’s problem speaking, or aphasia. In other words, he would be able to understand what was said and perhaps even know in his mind what he wanted to say but wouldn’t be able to verbalize a single word.

And to make matters worse, this tumor was most likely a malignant astrocytoma. Given this diagnosis and the inability to aggressively remove the tumor made it likely that David would have 6, perhaps 12 months to live.

Knowing all this, I now had to turn away from the window and face David and Marjorie. Times like this are probably the second most difficult conversations I will have with a patient and their family. I have to be honest, yet at the same time I must give the patient hope. And as I stood there, during the first few seconds while I contemplated what I was about to say, I thought how can I possibly project a hopeful outlook?

That’s the thing about these conversations…patients listen to what I say but more than anything they study my facial expressions and how I deliver the message to determine if there is something I am not saying.

I explained to them what kind of tumor I thought it was, and the fact that even with an aggressive surgical resection, tentacles of the tumor would likely be left behind. The problem was, I told them, that because of where the tumor was located, it might not be possible to safely remove any of the tumor. I asked if I could have some more time to study the films further and that I would return later in the day to speak with them again. ‘Of course’, they said in unison. So I took the MRI scan and walked back to my office.

I told Chad my PA about David and what his MRI scan showed and asked what he thought I should do. I knew I was the only one that could make that call; he merely shrugged his shoulders and said, ‘well you could debulk it ‘, although he and I knew too well the possible implications of that.

I returned to David’s room later that afternoon to speak with him and Marjorie although at this point I still had not completely decided what I would do. In part, this is because the phrase’ ‘Do no harm’ is more than just a cliché to me. By this time his children had arrived and surrounded his bed. I began by repeating most of what I said earlier in the day since David’s children had not been there. At one point David asked, ‘How much time do I have?’, only because of his aphasia it came out more like, ‘How much light is there?’ Not wanting to take away all hope and yet at that moment realizing what I needed to do, I told him if we did nothing he might have 6 months. If I operated and removed as much of the tumor as I could safely, inserted some chemotherapy wafers in the brain and post-operatively he received radiation and additional chemotherapy, he might have 12 – 18 months or possibly longer. Through the tears he and his daughters were shedding, he said ‘OK, do it’!

‘Why are you cast down, O my soul,

and why are you disquieted within me?

Hope in God; for I shall again praise him,

my help and my God.

Psalm 43:5

Immediately following surgery, David’s ability to speak had worsened somewhat although it slowly improved during his stay in the hospital and when Francy, my nurse saw him for an incision check 10 days later his speech was back to where it was when I first met him.

Only time will tell whether I appreciably lengthened David’s life here on earth. Which brings me to a thought? With all the concern over curbing the rising cost of medical care, if we know that, statistically, a patient’s survival from a malignant astrocytoma will not be long, do we withhold treatment? Personally I think this would be wrong…dangerous…and evil. Because then we would be playing God, essentially determining the worth of a human life. It is one thing for a patient or the family, if the patient is unable to make that decision, to decide enough is enough, but the only other one to make that decision should be God, not us.

As I have pointed out before, extending one’s life even 3 months can be a miracle if allows a human hurt to healed or gives family the opportunity to say goodbye, at least for now.

Unquestioned Trust in God

 

Just the other day, I was in an exceptionally good mood, and found myself whistling at work, as I was running up the stairs heading towards the OR to begin my surgical cases for the day. Immediately I found myself transported back 36 years to Botany class during my freshman year at Fairfield University. My professor at the time, spoke out somewhat rhetorically (as he had a difficult time looking me or anyone else in the eye) that whistling was not allowed. He said ‘whistling did not promote a professional atmosphere in the scientific laboratory and was prohibited’.

I actually had to agree with him at the time. Scientific inquiry had to be precise, rigid, and devoid of all emotion. And whistling was certainly an emotional act of happiness, contentment and glee…and certainly there was no place for these sentiments in a scientific laboratory…right?   

Even at 18 years of age, I guess I was still juvenile and naïve. And so began my official desensitization that would be advanced during medical school and then ramped up into overdrive in my neurosurgical residency.

Children, of course are without any prejudice or barriers, just innocence. They accept without question what they are taught. Their belief in things that are seen and unseen is true and unwavering. As we mature we become responsible and conscientious and as we advance our intellectual curiosity we begin to question and doubt. After all that is the scientific method, is it not? The unfortunate thing is that we also question and doubt the truthfulness and honesty of those around us. And as we become skeptical we may even become cynical. We may even question the very existence of God.

Of course, for me, I must be analytical and critical and there is certainly no place for being childish in the operating room…. I remember a particular case well. It was 1992 and I had just begun my practice of neurosurgery in Palm Harbor, Florida. I was on call for neurosurgical emergencies at Mease Hospital in Dunedin when Alex Goodman was brought in to the emergency room by EMS. Alex was 32 and had been working out in the gym when he had the sensation that a bomb had just gone off in his head as he was bench pressing 225 pounds.

Shortly after his arrival a CT scan of his brain revealed a massive hemorrhage from a ruptured brain aneurysm. I ordered a cerebral angiogram which showed me the location of the aneurysm. I had to operate immediately and place a clip across the aneurysm to prevent it from rupturing a second time which almost certainly would be fatal.

The surgery had been textbook right up until I was getting ready to ‘fire the clip’ across the neck of the aneurysm. As I was reaching for the titanium clip, the most improbable chain of events occurred. The aneurysm ruptured and the light bulb on the operating microscope I was using burnt out at the same time.

At a time like this there is no room for a temper tantrum, and I couldn’t lose my composure simply because Alex’s life was slowly slipping from my hands as arterial blood poured out of the opening I made in his skull. I calmly told Liz, the circulating nurse to pull the microscope away from the operative field and replace the light bulb. I inserted a large-bore suction into the operative field to remove the blood that Alex’s heart was pumping through the tear in the aneurysm wall and I instructed the anesthesiologist to use his finger tips to compress the carotid artery in his neck to slow down the flow of blood. Simultaneously a second anesthesiologist began administering two pints of blood intravenously to replace what blood Alex was losing through the ruptured aneurysm in his brain.

Somewhat surprisingly a light bulb was readily available and I was peering through the oculars of the operating microscope less than five minutes later. The hemorrhage was profuse and I was unable to completely suction the blood from the operative field. Fortunately I had an image of the carotid artery and the aneurysm indelibly burnt in my brain so I inserted the clip through the pool of blood towards the spot where I thought the neck of the aneurysm was and released the clip. Immediately the hemorrhage stopped and as I quickly inspected the carotid artery, its branches and the aneurysm, I discovered the clip was in perfect position. Post-operatively, Alex was fine and completely unaware how close he had been to dying.

During my residency, our mantra was ‘just deal with it’! No excuses, no whining, you just had to be able to take care of the situation at hand, no matter what.

So, be it scientifically or surgically there is a necessity for the lack of emotional involvement. Over time however, as my religious faith has deepened and as I have become closer to God, through Jesus Christ, I have come to realize that spiritually, not only it is difficult to separate human feelings from what I do, it is imperative that I remember my patients are human beings not merely surgical cases!

However during a time of crisis I almost have to forget that I am operating on a person. I have to look at it as a problem that must be solved…quickly. But when it is over and I am done I must once again have empathy for my patients and their families, regardless of the outcome. I have to embrace the innocence inside of me and them.

‘And they were bringing children to him, that he might touch them; and the disciples rebuked them. But when Jesus saw it he was indignant, and said to them, “Let the children come to me, do not hinder them; for to such belongs the kingdom of God. Truly I say to you, whoever does not does not receive the kingdom of God like a child shall not enter it”’. Mark 10:13-15

So, as I was whistling, I was on my way to operate on David Osgood who had a malignant brain tumor located in his speech area. It was a risky surgery but I was confident in what I had to do and feeling blessed I was certain that God would guide my mind and hands, to do what was needed.

Gratitude, Faith and a Song

 

Most people in the United States are right-handed, perhaps as many as 93% of the population. In practically all, the ability to understand the spoken and written word and the ability to speak is confined to one side of the brain. Interestingly this ‘speech area’, in most people is located in the left side of the brain.

Gary Robinson, was one of the few people who very likely had his speech are located on the right side of his brain.

Sometime around Thanksgiving of 2008, Gary became a bit confused, although in retrospect his brain was probably developing a difficulty with processing things he heard and saw. The resulting confusion caused him to be involved in a car accident. Fortunately no one was injured but after being brought to the Emergency Room, Gary’s confusion led him to leave the hospital against medical advice. In fact, Gary was now becoming belligerent as well and had also developed some weakness on his left side. As a result, his wife, Barbara was becoming a little distraught. She was however able to get him to come to the hospital at Mease Dunedin by reassuring him that she would be with him the entire time and no one would touch him without her permission. This seemed to calm Gary and so he came.

After being admitted, an MRI scan was obtained which revealed the source of Gary’s ‘confusion’. He had a large cystic tumor in the temporal lobe on the right side, very near the speech area, if it were on the left side in the majority of people. As it turned out, Gary’s speech area was located on the right side. And if this wasn’t bad enough, Gary had a second tumor in the frontal area on the right side but close to the pathway connecting the right and left sides of his brain.

On December 2nd, I performed surgery on Gary and as I suspected the tumor was a glioblastoma multiforme. This meant the second tumor was merely a radiographic visualization of the tumor which actually extended from the temporal area of his brain, where I operated, all the way to the frontal area. With such an extensive tumor, Gary’s prognosis was not good.

Postoperatively, Gary received radiation and chemotherapy but when I saw him back in the office on April 8, a recent MRI had shown the frontal tumor had gotten bigger and was now extending across to the left side of his brain. I told Gary and Barbara there was nothing further that could be done. On April 28, Gary passed away, less than 6months after his confusion began. Shortly after his death, Barbara sent me a letter…

5/20/2009

Dear Dr. Colbassani, Francy, Paul and staff,

I would like to thank you for everything you did for Gary. Obviously, I had forgotten my lessons on how his down fall would be. Probably something that shouldn’t be happening. I had also forgotten the meaning of weak, too. I have learned is has many definitions.

Gary did not lose his humor or wit, or kindness. He could hold on with his right hand until the very end; that was most helpful as I flipped him like a burger, so he could have a different look in the room. He did lose his speech and that was hard for me, but I did find out that he could sing and carry a tune with his ‘ahhs’.

We have a hammered dulcimer; you hit it with mallets, it has a very bell like sound, not loud, unlike the piano and organ which distressed him. It bothered his sensitive hearing, I was told.

So I blew off the dust & tuned it up. Since we couldn’t go to church, perhaps we could “sing” hymns at home. As I was playing “Amazing Grace”, Gary began to sing – I just about fainted! Here is a guy that could hardly move, but could sing along. We kept it up for 40 minutes. He slept well after that! Even on his last day, (April 28) he delighted me and sang along. It was such a special gift.

I want to really thank you for giving him the time to say goodbye to his family and to say things that needed to be said and done. Had he waited, he would never have had the chance.

Your kindness and patience gave us hope that we had a little time and we were so very grateful.

May you continue to do all the good work you can do. Thank you also for your compassion. Without that, I don’t think I could have done what I did.

Your staff is exceptional and you should be very proud of them.

Taking their time, from their busy days, calling me back and calming my fears – Answering my questions, telling me of their experiences with the others that have gone on before, was invaluable. All I have to offer is my humble thanks.

 I hope in our lifetime this hideous disease can be cured – wouldn’t that be such a miracle!

Sincerely,

Barbara Robinson

(& Gary)