Perspective... ‘The occurrence of such a tragic event put everything in perspective’.
I think for every one of us there has been one time or another that has put the everyday frustrations, disappointments, and stressful situations of our lives, ‘in perspective’. Maybe it was an encounter with a terminal cancer patient that made you realize that the chronic lower back pain you experience daily really wasn’t that bad. Or maybe when you found out your neighbor just lost his job and the home that protected his family that you realized your ‘dated’ kitchen really didn’t need that remodel you were planning.
Two weeks ago while at Sunday morning Mass, I received a call that would help me ‘put things in perspective’. A hospital in Brooksville, Florida had a patient in their emergency room, Harold Thurman who was brought in by his wife because he was acting strange and he seemed to have some difficulty ‘getting his words out’. A CT scan revealed he had four hemorrhages in his brain, one of which by report, sounded to me like it was big enough that it might cause him some problems without urgent treatment.
Because that hospital did not have a neurosurgeon on call they requested that Harold be transferred to my hospital so I could take care of him. I told them to transfer him right away. Of course I knew with the distance between our two hospitals and the difficulty getting emergency transport from the ‘field’ to make an inter-hospital transport, it would be hours before he arrived.
Later that afternoon, about 4, I called the CCU to check on the status of the transfer. Jackie answered and told me Harold had just arrived but what she said became worrisome to me. Earlier in the day when I spoke to the doctor at the Brooksville hospital, he told me that Harold had been awake when he arrived there and now Jackie was informing me that he was very lethargic. This suggested to me that Harold was lapsing into a coma. Clearly something would have to be done; I told Jackie I would be in immediately to evaluate him myself.
When I arrived I introduced myself to his wife Elaine, their son David and Elaine’s sister. When I examined Harold I discovered he would open his eyes slightly and move his arms and legs but he could not speak and as soon as I stopped stimulating him, he would then immediately become unresponsive. To be certain his condition had indeed deteriorated, I turned to his wife Elaine, and asked her if his present level of consciousness was different from when she initially brought him to the hospital; she nodded and said ‘Oh yes, definitely’.
I reviewed the CT scan from the other hospital and decided that because many hours had transpired since that one was done I would repeat it to see if any additional bleeding had occurred. Fortunately there was not, although the four hemorrhages together had increased the pressure within Harold’s brain dramatically.
The largest one was in the center of Harold’s speech area on the left side. I knew if I removed this hematoma it would reduce the pressure by the greatest amount but I also knew it was highly likely I would permanently damage any functioning part of his speech area that surrounded the hemorrhage.
The best course of action was to let this hemorrhage resolve on its own which it would do if I waited several weeks. The problem of course was that Harold’s condition was such that if I didn’t do something to reduce the pressure within his brain he wouldn’t survive the two or three weeks to allow this hemorrhage to dissolve.
On the other hand there was a second hemorrhage that was located in the right frontal lobe and this was an area I could safely operate in without causing any appreciable damage to Harold’s brain function. This hematoma was moderate in size and was definitely putting pressure on the surrounding brain and causing it to shift from right to left, but I was not certain that removing it would help Harold.
I probably went back and forth from Harold’s bedside to the CT scan display no less than five times, agonizing over the decision I had to make. Logic told me that I should remove the large hemorrhage, but ‘something’ in the back of my mind told me the best thing for Harold’s survival and recovery was to perform a right frontal craniotomy instead.
I sat at the monitor one last time and prayed the Our Father asking for guidance. In an instant, the answer became clear. I told Chad, my physician’s assistant that we would go ahead with the right frontal surgery and at the same time I would place a ventriculostomy or catheter in the ventricle on the left side so we could monitor Harold’s intracranial pressure after the surgery. This would allow the nurses to drain some (cerebrospinal) fluid if his pressure got too high.
I went in to Harold’s CCU room and told Elaine of my decision and that I would be performing surgery immediately. She was hopeful that I would save Harold’s life, but I cautioned her that because we had no idea why the hemorrhages occurred in the first place there was no way to be sure that even if surgery was successful, that it wouldn’t happen again. She nodded affirmatively and thanked me nonetheless.
As I walked towards the elevator, I turned to Chad and said, ‘Man, a case like this certainly puts things in perspective’. What I didn’t say was how stressed out I had been over finances as of late, worrying over how I was going to pay the mounting bills when collections had slowed down to a bare trickle.
But here and now Harold was fighting for his life; and the decision I struggled over was truly a life or death one. This was a situation that truly deserved of a little anxiety; not worrying about something as trivial as bills. After all as long as I had my health and I could work, everything else would take care of itself.
So we walked off to the OR to get ready for surgery.
Initially I drilled a small hole in the skull on the left side and inserted a soft rubber catheter into the ventricle and the cerebrospinal fluid literally shot out. The actual intracranial pressure was near 300, with normal being around 95. When I removed the piece of the skull on the right to remove the hemorrhage, the brain was visibly swollen. I was actually relieved to see this because I wasn’t certain I would encounter much pressure since the large hemorrhage was on the opposite side of the brain.
After I evacuated the hematoma, the brain was relaxed and the pressure was normal.
When the surgery was complete I told the anesthesiologist to keep Harold on the ventilator and deeply sedated. Though the surgery went well I still was not particularly optimistic for Harold’s recovery because of the extent of the other hemorrhages, but we would find out once we allowed the sedation to wear off in a couple of days and allow Harold to, hopefully, wake up.
On Wednesday afternoon I went by Harold’s CCU room and ‘amazement’ would describe my feelings. I had discontinued the sedation early that morning, and because Harold became so alert, the pulmonologist had removed the ventilator that had been breathing for Harold while he was on the anesthetic drip. Not only was he sitting up slightly in his bed but when I asked him how he was doing he said ‘OK, how are you?’, and when I asked him what his name was, he told me without hesitation.
What you must realize is that when Harold initially was brought to the emergency room he was globally aphasic which means he could neither understand what was spoken to him nor could he speak himself. This of course was not surprising to me because the large hemorrhage was right in the middle of his speech area. But this was not the hematoma that I removed!
As I finished writing my daily progress note in Harold’s chart I looked up to see Dr. Raja, the pulmonologist walking down the hall. As he walked toward me he remarked, ‘Well, he seemed to be awake enough so I extubated him’ as he gestured in the direction of Harold’s room. ‘Yeah’ I replied, ‘but the fact he is speaking is a miracle!’ He nodded somewhat quizzically and continued walking past me toward his next ventilator patient.
I was somewhat disappointed that he did not appear to acknowledge God’s hand in Harold’s recovery but, as long as I did then at least I could keep things ‘in perspective’.

