When I first met Michael Dubois, I found him to be a truly gregarious man, which was surprising given his diagnosis. He was 63. Our paths crossed because he had fallen at home. He didn’t injure himself but went to his doctor anyway. In reality it was his wife, Anna who insisted he go to get checked out. It wasn’t that he disliked going to the doctor but he just always figured whatever problem he had was nothing serious and that it would resolve on its own. On most every other occasion he was right…but not this time.
As it turned out, Michael had been having some difficulty swallowing his food for the preceding month or two, although he wasn’t one to complain, and he thought this was the reason he had lost 20 pounds over that same period of time. His family noticed he looked a bit thinner but neither they nor he thought much of it. Over the last few weeks however, he had also developed some dizziness and began staggering when he walked but once again he brushed off any suggestions that there was something wrong. That was until he fell at home and almost split his head open on the corner of table in the living room.
Oh, and by the way, Michael smoked 2 ½ packs of cigarettes for the last 43 years.
As soon as his doctor saw him in the office he sent him to the emergency room for further tests; since he had the suspicion (although he didn’t tell Michael this) that he would require admission to the hospital. Initially, a chest x-ray was ordered and this showed that Michael had a mass in his chest which likely was a lung cancer. A CT of the chest was then ordered and this confirmed the x-ray findings. Given these findings and in view of Michael’s neurological symptoms, Dr. Nicker ordered a CT scan of the brain. Unfortunately, but not surprisingly, this scan revealed the lung cancer had already spread to several areas in Michael’s brain.
The largest tumor was located in the cerebellum on the right side. The cerebellum is located at the base of the skull, behind the ear. It has the external appearance and color of a walnut shell but twice as big, and the cut surface looks identical to that of a cauliflower floret. The cerebellum is responsible for coordination and so this explained the reason for Michael’s dizziness and unsteadiness walking.
But, Michael had a second tumor located in between the two halves or hemispheres of the cerebellum. It was this tumor that was causing pressure on the fluid space containing cerebrospinal fluid within the cerebellum called the 4th ventricle (which was connected to the 1st, 2nd and 3rd ventricles located in the brain or cerebral hemispheres above). Because of this pressure, the normal flow of the fluid was impaired causing it to back up leading to enlargement of the other 3 ventricles. This is called hydrocephalus, or what many people know as ‘fluid on the brain’. As a result the hydrocephalus, the increased pressure contributed to Michael’s headache and in reality was potentially more life threatening than the larger tumor.
Looking at his MRI scan I decided to remove the tumors so the pathologist could confirm the diagnosis but also in doing so relieve the pressure that was both causing Michael’s unsteadiness walking and threatening his life. To be sure he would need radiation treatments and probably chemotherapy afterwards but the immediate task at hand was to prevent these cerebellar tumors from taking Michael’s life prematurely.
Armed with all this information I walked into his room in the critical care unit to speak with Michael and Anna. I explained the situation, reviewed the MRI scan findings and then discussed with them my plan.
Anna was tearful as she spoke with me, while Michael could only laugh and joke although his words were a bit slurred because of the tumors’ affect on the coordination of his ability to speak. At first I wasn’t sure whether Michael’s behavior was a coping mechanism but soon it was apparent he was trying to be humorous so Anna wouldn’t cry.
I was wearing my green scrubs at the time and so the cross I wear around my neck was visible through the ‘V’ opening in my scrub top. Anna looked at me and said, ‘I notice you are Catholic’. I nodded my head affirmatively. ‘We are too’ she said as Michael then spoke up…’I go to church and people say I believe in God but I don’t believe in this and I don’t believe in that! I say either you believe or you don’t. I believe so I’m not afraid. If I go to sleep and I wake up, great. But if I don’t, so what…I know where I’m going… So let’s do this thing.’
On Saturday I took Michael to surgery. I removed the large superficial tumor without difficulty. It was when I contemplated removing the second, more deeply placed tumor that I paused. With the distribution of blood vessels on the surface of the cerebellum, there was only a space about 1/3 of an inch that I could operate through and then I would have to go in about an inch and a half just to reach the edge of the tumor.
I thought about the difficulty I might encounter trying to remove this tumor and how I might struggle trying to visualize the tumor well enough to resect it completely. Then there was the bleeding that could occur down in that deep, small hole and if I retracted on the brain tissue too much I might cause more swelling than was already present which would surely obstruct the flow of the cerebrospinal fluid even more. And then of course there was the possibility I could inadvertently go too deep and damage the brain stem which would result in Michael being in a permanent coma.
It was at this point I thought about Michael and his family, and how I would like to spend what time I might have left with my family if I were he. True, Michael was a deeply religious man but I didn’t want my actions to be the reason he wouldn’t wake up. After all I was there to help. No, the length of time Michael would have left would be up to God not me. But I could make sure the quality of his life was something both he and his family could enjoy.
So, I decided not to attempt resection of the smaller deeper situated tumor hoping radiation would shrink it. Instead I decided to remove an additional portion of the right cerebellar hemisphere; knowing I could do so without causing Michael any increased difficulty walking or with his coordination. And in this way, I would provide him additional room for any swelling that might occur during his radiation treatment.
Later, in the recovery room Michael awoke feeling fine and he was walking in the hall two days later and was discharged home five days after surgery. Two weeks after surgery he came in for an incision check with Francy, my nurse and he stopped by my office to say hi and to thank me.
As he stood on the other side of my desk with tears close to welling up in his eyes, I was reminded that every patient I operate on is a person, perhaps a husband or wife, a father or mother, but certainly a son or daughter, and a friend to others. I may not have extended Michael’s life appreciably; but I knew I made the right decision in the operating room that Saturday morning giving back that husband and father to the family that loved him so much. And I thank God for that.
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