Spiritual Experiences from the Brain

A Physician Greater than I

I had just finished operating for the day and I had a meeting to attend but I told my wife before the meeting, I would join her and the children for a quick picnic, and if I didn’t leave soon I would be late. To say I was rushed was a bit of an understatement, but first I had to run up to the ICU and quickly see Nora Horace who I was scheduled to operate on the next day for metastatic breast cancer to the brain.

Nora had been diagnosed with breast cancer several years ago and had undergone treatment, including chemotherapy, but a recent PET scan was clear. So it was quite a shock when the emergency room physician told her she might have a brain tumor.

Nora had been having some imbalance and unsteadiness walking but she thought it might have been side effects from the chemo, but when it got worse, she and her close friend Diane felt it best to have it checked out further.

She actually had been admitted the evening before and I had been called during the afternoon and was told of her case. So when I reviewed the CT scan, I ordered an MRI to be done the following morning and told the nurse I would be by to see Nora the next day after I finished operating.

The MRI indeed revealed a large tumor in her left cerebellum which is the area of the brain responsible for coordination; in addition the pressure it exerted on the brain around it, caused compression and partial obstruction of the flow of cerebrospinal fluid within the brain. This was even more critical because if the flow became completely blocked off, the pressure within the brain would reach a life threatening level.

So it was clear I had to operate to remove this tumor. Unfortunately, Nora also had three ‘pea-sized’ tumors elsewhere in her brain which indicated her metastatic disease was more widespread.

As I walked into her room, she greeted me in a warm way similar to what I had experienced at a resort in the Bahamas many years before. This was her nature because she, in fact, was from one of the islands in the Caribbean.

I brought up the images of her MRI on the portable computer to show her and her friend the nature of the problem. After I finished describing the findings on the MRI and explaining the surgery I had planned, I fully expected her to be like most patients, a bit shocked, a bit depressed but resigned to what needs to be done. At that point most patients say ‘ok, whatever you say doc’. My reply is often a bit curt as I nod and tell them I will see them in the morning, as I turn to leave.

And this day I had planned on it playing out that way, so I could be on my way to where I had to be.

But what she said, stopped me… dead… in my tracks.

Nora then replied, ‘I am not afraid doctor… I know the Great Physician… do you know Him?  I said ‘Yes I do…very well.’ She said ‘that is good because sometimes when I ask people, do you know Jesus Christ? They tell me he was just some guy.’ I continued, ‘No, He is way more than just a guy’.

She then asked if I prayed to Him to guide me before I operate and I replied, ‘all the time’. Nora then asked, ‘Well tomorrow before you operate on me’, as she pointed to the sky, ‘I want you to call Him… collect!’ Practically with tears in my eyes, I promised I would.

I shook her hand with both of mine and told her I would see her in the morning, as I slowly turned, to walk out of her room.

Going into the surgery I anticipated that removing the tumor would be fairly easy, since most tumors of this type are not adherent to the surrounding brain. As it turned out removing the tumor was extremely difficult and I spent no less than six hours micro-surgically teasing the tumor out.

The amazing thing to me was that throughout the procedure, ‘ideas’ would pop into my head on how to proceed, which were not necessarily techniques that I usually employ. As a result I was able to completely remove the tumor without any complication whatsoever.

As I was finishing up, I thought about this, realizing that God had been with me and by my side guiding me every step of the way.

The following morning, I examined Nora and found her to be completely normal neurologically. Though the pain of the incision caused her to wince, she said ‘I am grateful to God, grateful that you are a Christian, and grateful that He worked through your hands to help me’.

for she said to herself, “If I only touch his garment,

I shall be made well.” Jesus turned, and seeing her he said,

“Take heart daughter; your faith has made you well.”

And instantly the woman was made well.

Matthew 9:21-22

Blind Faith and Praying For a Cure

As humans we are slaves to our senses. If we can not see it, or touch it, it doesn’t exist. And that is why faith is so hard for many. It requires believing without seeing. But when we are able to believe at the very depths of our soul, our faith can change lives.

Quite a few years ago, shortly after I had finished my active duty service as a neurosurgeon in the US Navy I began my private practice of neurosurgery in Palm Harbor, Florida. One of the first patients I took care of was Shelly Birch. Shelly had a brain tumor and one that I told her would have to be removed surgically. After I explained this to her as well as the details of the surgical procedure and its associated risks, she politely thanked me and got up to leave. When I asked her if she was going to schedule her surgery, she proceeded to informed me she would be having the members of her church pray over her so God could perform the miracle of removing her tumor without surgery.

I was shocked at her suggestion. With an incredulous tone, I told her, ‘that wouldn’t be a good idea’. I continued, ‘if the tumor got even the slightest bit larger it would put you in a coma and you could die’. She smiled and told me resolutely she would be fine.

Several weeks later she returned without any additional neurological problems, actually feeling better than she had in years. She requested that I order I repeat MRI scan so she could see that prayer had cured her. I almost scoffed at the idea, knowing that the tumor would still be there and perhaps even larger. But I agreed, only to show her that she would need me to cure her.

Indeed the tumor was still there, and Shelly consented to having the surgery which I performed without complication. (Interestingly, when I reviewed the follow-up scan with her she didn’t appear all that disappointed. It was as though God’s will was still at work in her life even if the outcome wasn’t as she or her church had been convinced it would be).

Now flash forward almost twenty years. I am more experienced for sure, certainly more mature but without a doubt more religious than I had been when I first met Shelly Birch.

Praying to God for a cure is something that people who are ill should do, but as I have pointed out previously, praying that God would place before us those who can help and possibly cure us is what I believe God would want us to do first. Quite honestly when I treated Shelly Birch, I did not believe God would cure her but I also did not believe God had anything to do with me successfully removing her brain tumor either. At the time I firmly believed that she was cured of her tumor solely because of me. Today, I know that was not the case.

Granted, her story is different from many of the patients I treat with brain tumors because she had a benign meningioma which I was able to completely remove. Not that it wasn’t difficult to do so, it is just that her prognosis happened to be brighter than patients with, for instance, a malignant astrocytoma.

A colleague of mine once said, in reference to malignant astrocytomas and in particular the glioblastoma, ‘we aren’t even treating these patients’ brain tumors (effectively), it’s more like we’re beating them with a stick’. Perhaps from a medical standpoint this may be true, but I think Shelly Birch had more to teach me than I realized at the time.

Actually my experience with Shelly came to mind the other day because of a conversation that I had with the wife of another patient of mine.

Tom Renner is 47 years of age. He had been experiencing symptoms of sinusitis and so he went to his primary care physician. Since he had also been having a low-grade fever and night sweats, his doctor prescribed an antibiotic. After finishing the prescription, his symptoms persisted and so his doctor prescribed a stronger antibiotic. But this didn’t help either and in fact he began to develop some pretty severe headaches. It was at this point his doctor sent him to the emergency room at Mease Hospital.

An MRI revealed Tom had a tumor in the right frontal part of his brain. Because most of the tumor appeared to made up of a cyst and he had been having a fever at night we thought this could represent an infection or a brain abscess. Although deep down I didn’t feel he would be so fortunate.

Indeed it turned out to be a malignant astrocytoma. Surgery went well enough but because the tumor extended to wall of the cerebrospinal fluid ventricle within the brain I purposely did not attempt a more aggressive resection but instead implanted some chemotherapy wafers on the surface of the tumor that visibly remained.

Tom was discharged within five days, with arrangements made for him to begin his radiation treatments in two weeks. Unbeknownst to me, he and his wife Renee had sought out additional opinions at Moffitt Cancer Center in Tampa and then at Duke University in North Carolina. Because of logistical difficulties starting Tom’s treatment nothing was done and two months passed.

Tom then began to experience some increasing headaches and a repeat MRI was done. Because of the findings I called Renee.

‘The tumor has come back’, I told her. ‘In fact’, I continued, ‘it’s probably bigger than it was when I operated on it two months ago’. She was devastated, although she was not that surprised given Tom’s symptoms. She explained the events of the last two months and how frustrated they both were that they could not get the physicians from the different institutions to co-operate with one another.

I told her that additional surgery would probably not be the answer at this point and they should pursue the aggressive chemotherapy and radiation recommended by the local oncologist Tom had just seen. Not having much more to add medically, I told her I would keep Tom and her in my prayers. She thanked me and I hung up.

The next day I remembered Shelly Birch and how I could not believe she was going to walk out of my clinic to pray that her tumor would disappear and now I was praying that would happen for Tom Renner. If only the depth of my faith could be a fraction of what Shelly had, I thought.

As I take care of more and more patients with malignant brain tumors (on occasion, with God’s help, using a ‘very big stick’), I have become convinced that God has a larger role than I could ever have in trying to cure them. In reality, I only treat these patients and it is only God that can cure them… and He’s probably responsible for most of the long-term survivors, too.

‘And Jesus answered them,

“Go and tell John what you hear and see:

the blind receive their sight and the lame walk,

lepers are cleansed and the deaf hear,

and the dead are raised up,

and the poor have the good news preached to them.

And blessed is he who takes no offense at me”.

Matthew 11:4-6

The Importance of Never Giving Up...or Giving In

Emma Grandsom was a very pleasant woman with a proper English accent, even though she had been living in the United States for quite some time. One afternoon, about three weeks ago, her son, David took her out for lunch. As she sat there with the menu in her hands, the waitress asked her what it was she would like to order. Just at that very moment her mind became a jumble of confused thoughts and she couldn’t figure out what it was she wanted to say, let alone tell the woman what it was she wanted to eat for lunch.

David immediately realized there was something wrong as his mum had a puzzled look on her face and her lips were writhing as if to mouth some words but nothing came out. He immediately put her in the car and drove her 'straight away' to Mease Hospital. A CT scan, and then an MRI were obtained and they revealed a grape sized tumor very close to the speech area in the left temporal lobe.

She was admitted to the hospital that evening and by the time I saw her the next morning her speech problem had cleared completely. This was no doubt due to the lessening of the extensive cerebral edema or brain swelling (which surrounded the tumor), as she had been receiving intravenous dexamethasone or Decadron through the night.

After I introduced myself to her, I asked her how she was feeling. She told me, ‘I feel fit as a fiddle’. In fact she didn’t understand why she had to be in the hospital at all. I reminded her she had a small tumor in her brain and almost immediately a look of incredulity came across her face. ‘I can’t believe it’ she said, ‘because I feel so well’. I replied, ‘I know’. She then asked what it was and I told her it looked like a cancer and probably one that came from somewhere else in her body.

The look of surprise never left her face, as she muttered, ‘How can that be, I always have been healthy and I’ve never felt better than I do now’. I explained to her that the medication she had been receiving was partly the reason she felt so well. I then told her that more tests would be carried out that day to see if we could find out where the tumor came from. She nodded in agreement but said, ‘Well if it is cancer I’m not going to have any radiation and most definitely no chemotherapy’. At 82, I could hardly disagree with her but I told her, somewhat weakly’, ‘Well, we’ll talk more after the tests’ and I backed out of her room in the Critical Care Unit.

I called David, her son at the request of Emma’s nurse. I explained that I had seen her and spoke to her about the findings on the MRI scan as well as informed him that additional tests would be needed before we could come up with a plan. He agreed. I also told him that she told me she would not want any radiation or chemotherapy, let alone any brain surgery. He acknowledged this and I told him I would speak with him once the additional scans were complete.

Somewhat surprisingly all of the tests were negative. To me this meant the only other possibility was a primary brain tumor or astrocytoma; but ‘darn it that scan still looked like a metastatic cancer’ I thought. ‘Perhaps its site of origin, elsewhere in the body, was so small that the scans did not pick it up. That would not be unheard of, after all’.

And so I returned later that day to speak with Emma and her son, David to discuss the results and possibly a surgical plan. Upon entering the room, Emma was sitting in a chair by the window while it rained incessantly outside. David, who was rather tall at 6 feet, was standing quietly by her side. Both of them had their attention on the door as if I would walk through at any minute.

After I informed them of the results of the scans, I realized they had already been told that they were negative by another physician, who had also told them the mass in her brain could be an infection. While I did not particularly agree with this diagnostic possibility I acknowledged that until the pathologist examined the tissue under the microscope we could not be 100% sure.

And so because David wanted to ‘know’ what it was he convinced his mum to, at least, have the biopsy. Emma looked at me and asked me what I thought it was. I paused as I thought what I would say, but merely told her I believed it was a tumor. ‘Cancer?’ she inquired. ‘Yes’, I replied. Tears came to her eyes as she said ‘He’s all I got’, gesturing toward David. David held back his emotions as he turned to her and said, ‘But we won’t know for sure until the biopsy’. She nodded and said ‘OK’.

There were no complications during surgery but when the pathologist called into the room he told me what I expected. ‘It’s a malignant astrocytoma, and probably a glioblastoma’, his voice echoed through the intercom. Though I had hoped for different news, I was not surprised and yet, my heart sank a bit.

After surgery I went out to the surgical waiting room to speak with David and his wife, and gave them the bad news. I explained to them that without any further treatment his mother might survive a year but probably closer to six months. They shook their heads in disbelief; I said I was sorry and turned to go check on Emma in the recovery room.

The next morning I went to see Emma in the Critical Care Unit and found her sitting up in bed having some coffee. I asked how she was and she told me, ‘I’ve never felt better!’ What was strange to me, however, was that most patients as soon as they see me the morning following surgery want to know how the surgery went and what I found. Not once did she ask any of those questions.

After examining her and reviewing her lab work, I volunteered, ‘Well the surgery went well and it was not an infection’, expecting her to make the conclusion that it was a cancer instead. All she said was, ‘Well that’s great it was not an infection’ and she breathed a visible sigh of relief and said nothing more, as she took another sip of coffee.

Emma recovered quickly and was discharged that weekend, 3 days after her surgery.

The following Monday I received a call from Dr. Diaz, the pathologist who informed me that after studying the permanent microscopic sections of the tumor, he determined that it was not a glioblastoma but a primary CNS (central nervous system) lymphoma. Now that may sound just as bad, but in reality Emma’s prognosis went from a survival of 6 – 12 months to possibly being cured with only some radiation treatments!

I immediately called David and told him of the news and how he should convince his mother to have radiation. I explained that other than losing some hair, the course of treatments was generally tolerated very well. He thanked me and hung up. Later in the week, Francy told me that they had made an appointment with the radiation oncologist.

I have to admit I was doubtful from the start that Emma’s prognosis would be anything but dismal; and initially I was willing to let her leave the hospital without any treatment at all, if that was her desire. Quite frankly the only reason I operated in the first place was that one of her doctors made the incorrect conclusion that it could represent an infection.

Many times I draw my own conclusions as to the nature of a patient’s problem and the prognosis and present it to them as ‘gospel truth’. And most of the time I am correct. Emma reminded me however, my knowledge truly is finite and that God is the only one with ‘all the answers’.

Granted my human traits allow me to do what it is that I do. But in the end they are gifts from God and I must always be open to giving up control and allow God to mold me so that my hands truly become His instruments here on earth.

‘Then the word of the Lord came to me:

“O house of Israel, can I not do with you

as this potter has done? says the Lord.

Behold, like the clay in the potter’s hand, so

are you in my hand, O house of Israel.

Jeremiah 18:5-6

Muppets in the Brain

 

Like many of the patients I take care of with malignant brain tumors, Samantha Rice is an affable person, and perhaps even a bit gregarious. It is actually rare that I confront a patient with this type of diagnosis or any type of cancer for that matter that is a mean-spirited person. And in most cases it is not that this diagnosis changes their hearts for the better, it just seems most of them are just nice people to begin with. In fact, my former partner, Kevin and I used to say (years ago), ‘It’s never the a________ that get cancer… the ones that do are the nicest people you will ever meet’. Today, because my faith has become a more prominent part of my life, I no longer say it quite that way, but the apparent reality of it still makes an impression on me.

Samantha had begun to experience the sensation that her head was in a cloud and at times she would feel confused, forgetting what she was about to say or do. She then became unsteady when she walked, but it wasn’t until she noticed her left arm wasn’t working well and that she began to slur her words that she went to the doctor. Immediately he sent her to the emergency room where a CT scan was done which revealed she had a large brain tumor in the frontal lobe on the right, likely a malignant astrocytoma.

In general, if you had to have this kind of a brain tumor, the right frontal lobe is one of the places where you would want it to be. The motor strip is behind you and the speech area is on the left side so surgery is relatively safe and the possibility of removing most of it without causing a neurological deficit is good to excellent. That is unless the MRI shows that the tumor is clearly extending across the corpus callosum, or the pathways which connect the two halves of the brain.

Another exception may be if the tumor extends down to the wall of the ventricle, which I have previously described as the cerebrospinal fluid containing cavities within the brain. In this case there is the possibility that cells could spread to another area of the brain if during the course of removal the ventricle is opened allowing the tumor to enter the cerebrospinal fluid pathway. This was how Samantha’s tumor appeared, growing all the way to the wall of the frontal horn of the lateral ventricle.

When I met Samantha she impressed me as a very positive and upbeat person. Though she didn’t seem to be a religious person, I got the sense she was a good and perhaps somewhat spiritual woman. I proceeded to show her the MRI scan and discuss with her surgery and what it was I would likely be able to accomplish. I saw her on Monday and because of my schedule that week, I told her, it would be Thursday before I could operate. As I saw her over the next couple of days on my hospital rounds, her emotions ran the gamut from happy to fearful to tearful. On one occasion she told me, ‘I decided to call him Ernie!’ Initially I was puzzled and confused but then I got it. ‘Ah, the tumor’ I said, as she smiled and nodded affirmatively. I guess we all have different ways of coping with anxiety and stressful situations and for Samantha it was to refer to her tumor as a loveable character, one that couldn’t possibly hurt her.

Surgery on Thursday went well. I resected a majority of the tumor but I purposely left a small amount right up against the wall of the ventricle. The diagnosis was as I thought, a malignant astrocytoma, so I placed several chemotherapy wafers along the tumor that visibly remained. The following day I spoke with Samantha and told her how surgery went. She appeared a bit solemn and even though I tried to be encouraging she had hoped that I would have gotten the entire tumor out! When I asked if I could pray for her, I think it only served to remind her I had not cured her.

Within a day or two, however, she became upbeat again, determined to fight off this tumor as well as the idea that it could possibly grow back.

When I returned to see her that weekend, I knew her sense of humor returned when I asked her if the radiation oncologist had been by to see her. She said, ‘Yes he did and I asked him (with the treatment) if I was going to lose my mind…he said yes, so I guess I won’t ask any more questions!’ I smiled as she belied a smirk on her own face, nodded and told her I would see her later as I walked out of her room.

A few weeks later, I was walking into the clinic building, somewhat late, to see patients for the day. As I walked through the door with my eyes toward the elevator, I caught the figure of someone in my peripheral vision sitting down to the right of the door apparently waiting for her ride to pick her up. I stopped, turned and looked and to my pleasant surprise it was Samantha. She had just finished seeing Francy for her incision check.

I asked how she was doing and she said fine. She then told me, ‘Patrick Kelly (Professor of Neurosurgery at NYU) asked to see my films. Apparently, I’m related to him and didn’t even know it’. ‘Well he is nationally known as a brain tumor expert and it’s always great to get a second opinion’, I said. Samantha then replied, ‘Well I told them I have been very blessed to receive the care that I have’. I nodded and thanked her for saying so.

As I said goodbye and turned to walk towards the elevator, she spoke up, ‘You know, he’s not coming back’. For a split second I was confused once again and I’m sure my face appeared a bit bewildered, but then it hit me, ‘Ah, Ernie, right?’, I said. She smiled widely and said, ‘That’s right’.

 

Decision, Direction and the Holy Spirit

 

‘The greater you are, the more you must humble yourself;

so you will find favor in the sight of the Lord.

For great is the might of the Lord; he is glorified by the humble.

Seek not what is too difficult for you,

nor investigate what is beyond your power.

 

   For their hasty judgment has led many astray,

and wrong opinion has caused their thoughts to slip.’

    Sirach 3:18-21, 24 

 

Just yesterday I saw a patient, Susan Curry, in the office who had been recently diagnosed with breast cancer. Following her surgery she began experiencing a number of neurological symptoms which led her doctor to order an MRI of the brain. This scan revealed she had a small tumor on the surface of her right temporal lobe, which had the appearance of a benign meningioma, which was unrelated to her cancer and her ongoing symptoms. But because her surgical oncologist could not be certain of this he sent her to see me.

As it turned out she had an MRI, 7 years earlier which in retrospect showed the tumor, although it was smaller; so my conclusion was that it was indeed a benign tumor and because of its current size I told Susan we could simply follow it with serial or future MRI scans. I did tell her and her husband Jim I wanted to run some additional tests because of her symptoms but for now we would just keep an eye on the tumor to make sure it was not going to continue to grow.

Susan, however looked at me and with an insistent tone asked me, ‘Are you sure you don’t want to take this tumor out? After all, in your blog you said how excited you get when you have a patient with a brain tumor.’ I told her, ‘Well that is true, but only if the tumor needs to be removed.’ Seemingly, she was not completely satisfied with that answer, as if to imply she wanted me to take the tumor out anyway. She went on to say that she was fine with knowing the truth but it was not knowing that upset her so I assumed she just wanted to be absolutely certain it was not cancer, but in the end, said ‘OK’.

In many ways the decision-making of when to operate is more difficult than actually performing the surgery. And in some cases it is not whether surgery should be performed but whether I should be the one doing it. There may be many reasons for this; perhaps I don’t have all the equipment that I may deem necessary to take care of the problem at hand or perhaps it may be that it is a procedure that I don’t perform regularly and so I should refer that patient to a neurosurgeon that is more experienced.

To be a brain surgeon one cannot be short on ego or confidence and so admitting that I may not be the best one for the job can be a difficult pill to swallow!  

Of course no patient wants someone to operate on their brain if that surgeon doesn’t believe he is the ‘best and most talented neurosurgeon in the world’! And so for me it is a delicate balancing act between confidence and honesty. Although there have been many times in my life when in the middle of a surgical procedure I have literally said to myself, ‘What am I doing here?’, only to deftly navigate myself through the procedure without complication.

Once I operated on a patient with a ruptured aneurysm and for reasons beyond my control I went into the surgery not having a complete picture of the surgical anatomy. As it turned out it was an extremely difficult surgery and an aneurysm I had never clipped before but I performed the surgery flawlessly. Had I known going in where that aneurysm was located I might never have agreed to do the case but as it turned out I was indeed the best man for the job.

So in practically all instances my skill, talent and knowledge is more than enough to get the job done. And having operated my way out of seemingly impossible situations many times before it is easy to understand how I would come to believe that I am indeed the ‘most talented neurosurgeon in the world’. But this is exactly why I must always turn to God, and ask for guidance.

Such was the case with Maria Papadakis. Maria, 22 years of age was involved in a car accident. For some unknown reason she became dizzy while driving one day, passed out and drove her car off the road and hit a telephone pole. On arrival to the emergency room she had a headache but otherwise was perfectly fine that is until she had a CT scan done of her brain. In the left frontal lobe was a tumor, just above the speech area and right up against the motor area controlling the right side of her body. Later, the neurologist would conclude she likely had a seizure which caused the accident.

She was admitted to the hospital that evening and I saw her in consultation the following morning. As it turned out I had operated on her mother Helena for a ruptured disc in her cervical spine a couple of years earlier. I then ordered an MRI scan to be done. After reviewing it with the neuroradiologist we concluded that the tumor likely was a low-grade astrocytoma, or perhaps it might even be a relatively benign tumor. Nonetheless, it would have to be biopsied so I could determine what would need to be done surgically.  I discussed this with Maria and her mother and told them I would perform the biopsy the following Monday and depending upon the results I would tentatively plan on the actual craniotomy for Thursday of that week.

On Saturday as I operated on Michael Dubois who had spread of his lung cancer to his brain, I thought of Maria and the difficulty I might encounter operating on her brain tumor. It was fairly large and although it’s location was above her speech area it extended right up to the motor area controlling the right side of her brain. Since it was likely to be a low-grade tumor the visual and tactile difference between it and the surrounding brain might not be that great. Thus, I could have trouble knowing if I had adequately removed the entire tumor; conversely I might not realize if I had also removed normal brain tissue in my attempt to resect the tumor.  

So my dilemma was should I be the one to remove her tumor as I knew I could, probably doing a better job than most neurosurgeons. Or refer her to be treated at the University of South Florida where they had an intra-operative MRI and more experience performing an awake surgery where they could accurately map out the speech and motor areas of her brain.

On Sunday making my rounds at the hospital I stopped by Maria’s room first and sat down to talk to her. I explained to her my concerns and that I decided she would receive better care if I referred her to Dr. van Loveren. As I spoke with her she finally comprehended the seriousness of her condition, as her face changed from her usual bright and carefree look to one of apprehension, although she thanked me for doing what I believed was best for her.

 

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

 

 

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)

 

 

Is it Necessary to find a Cure for every Illness and Disease? (Part 1)

“We know that in everything God works for the good with those who love him, who are called according to his purpose.” Romans 8:28

Tom and Marianne Tremain immediately impressed me as wonderful people. Despite his diagnosis of a glioblastoma multiforme, or the most malignant form of brain cancer, they were at peace. While they both believed steadfastly in the power of prayer, they also believed that God bestowed intelligence and skill to Tom’s doctors, and that it was God’s will that they make use of these God-given talents. It truly was their belief that how else would God work His miracles but through the hands of these many men and women.

I had my first contact with Tom and Marianne in May of 2007. He had presented to the emergency room with some difficulty getting his words out when he tried to speak. His MRI scan revealed a large tumor in the frontal area of the left side of his brain. I performed surgery within a few days of his admission and all went well. Following surgery, his speech was actually improved and the post-op MRI revealed I had resected the majority of the visible tumor, although there was a suggestion the tumor may have had the early beginnings of growth towards the right across a pathway of fibers that connected left and right halves of the brain.

Nonetheless, Tom and Marianne were certain that God would take care of them. Mind you, they did not necessarily believe that Tom would be miraculously cured but that had not given up hope, either.

Tom begun his radiation treatments and chemotherapy and was tolerating them well. In October, he had a routine follow-up MRI which revealed a mass in the area of his surgery which the neuro-oncologist thought could represent either excessive cell death from the radiation (radiation necrosis) or recurrence of the tumor. I saw them back in my office one month later with another follow-up MRI, and as I reviewed the images with Tom and Marianne, it was clear the tumor had come back as this mass had increased an additional 30% in size, in that one month’s time. And for sure, the tumor had begun to spread towards the right half of his brain.

I discussed with them the options, including a second operation. Somewhat apologetically, I told them that if they opted for surgery that I knew I would not be able to remove the entire tumor. Marianne quickly brushed my caveat aside, telling me, “Well, that still does not mean that you are not doing God’s work”. I nodded affirmatively, and told her that I would pray for myself that God would guide my mind and hands to do the best job that was possible. She then said, “I know you will, and we will be praying for you too”.

Surgery went well, and Tom was without any speech difficulty or weakness afterwards and left the hospital within five days. When I saw them back in the office for a postoperative check in January of 2008, Tom had resumed chemotherapy and was doing fine. Marianne told me they had contacted the MD Anderson Cancer Center at the University of Texas and were hopeful Tom might be enrolled in an experimental chemotherapy protocol there. Unfortunately, Tom never did make it to Houston, as he died in July of that year.

Facing the possibility of dying terrifies most people I treat. It is certainly understandable, particularly when the patient is a 32 year old woman with two small children. But even patients that I have treated that are elderly, and have lived a full life don’t want to die.

In fact many people don’t even want to get old let alone die. Annual expenditures in the United States for plastic surgery procedures exceed $8 billion dollars, and the amount that is spent on all anti-aging products and services exceeds $70 billion dollars.

Stem cell research and nanotechnology which is being supported publically and privately has become a leading area of biotechnology that initially was hailed as the only field of research that could find cures for Parkinson’s disease, diabetes and heart disease among others. In reality, the goal of this research has become an attempt to treat what is thought to be the basis of all these diseases, aging itself! It is not science fiction to think we could ultimately bypass the idea that we could ever get sick, at least as we know it.

It is true that God has given us the ability to discover treatments to diseases and even cures but the implications of our knowledge raises many ethical questions. Just because we can, should we? And I have to wonder, in our attempt to play God ourselves, are we just trying to prove scientifically we have (an illusion of) control over aging, disease and death.

…to be continued.

Faith, Medicine and Miracles

 

Michael Santini was first diagnosed with a malignant astrocytoma in 2004. His surgery was successful and a post-op brain scan revealed that the surgeon had removed all of the visible tumor seen on the pre-op MRI. Of course, as physicians and surgeons we presume that ‘invisible’ tentacles of this kind of tumor extend out into the surrounding brain. In virtually all of the patients I have treated with this diagnosis, that turns out to be the case and at some point the tumor reappears. So Michael underwent radiation treatments to his brain and had chemotherapy. Perhaps because of his relatively young age at diagnosis (58) and the fact that the tumor was initially small in size (about 1 inch in diameter), he remained in remission for five years. However, in September of 2009 the tumor recurred. Unfortunately this time the tumor came back closer to the motor area of the brain, which was responsible for the movement of Michael’s left arm and leg. The surgeon that operated this time was more limited in his ability to aggressively remove the tumor, and since Michael had already received radiation once before this could not be repeated. Chemotherapy was suggested but this time Michael was less eager than he was the first time. And so three months later, the tumor grew back and Michael developed significant weakness of his left arm and leg, causing him to be bedridden for the first time. This is when I first met him.

Upon initial review of his MRI I was reluctant to operate because I knew any attempts to remove the tumor would in all likelihood completely paralyze Michael’s left side. As I discussed this with Michael he said, “Listen doc, you just can leave me in this bed to die!” I was deeply moved by his pleading, but knew I had to carefully weigh the risks before agreeing to re-operate. Studying his scan I decided it was possible to enter the tumor through the same path that the previous surgeon took and thus minimize the risk of any further paralysis.

As I sat by Michael’s bed and discussed the surgery with him, Michael asked me what the likelihood was that the tumor would come back again. Not wanting to take away any hope but at the same time needing to be honest, I told him that the chances were high although, “you never know when a miracle might happen”. He looked at me and said, “Well I guess it’s a miracle that I’ve lived this long!” I nodded and agreed.

Often we define miracles in human terms. That, unless the cancer was cured, it could not be called a miracle. But Michael’s statement is probably closer to the truth. Every doctor and nurse probably knows of a patient whose outcome of their disease or illness was inexplicable. Many of them would claim it was a miracle while others would decry that to say so was traitorous to laws of nature and the science of modern medicine. But don’t miracles happen every day through the hands of physicians, surgeons and nurses. After all, if life and the universe were initially set in motion by God, the intelligence and skill of those taking care of the sick are truly gifts from God. And even if those patients cannot be cured in the ‘physical sense’ are they not capable of being cured in a ‘spiritual sense’. Which brings me to my thought about faith and medicine. Some people would believe that faith and religion should trump medicine and medical care, but for me I see them as co-existing on the same playing field. Certainly, being spiritual or religious helps patients cope with a life threatening or terminal illness and personally it helps me be that more compassionate. But if your faith is strong enough and your belief in prayer steadfast, I believe one’s spirituality and religious faith can transcend the natural laws of the universe. Matthew 17:20.

On the morning of Michael’s surgery I went to see him in the pre-op holding area. I asked him how he was doing and he said, “OK” and then he went on to say, “I’ve been praying for you”. I thanked him and told him, “I am glad you are”. His surgery went well enough but as I had feared his paralysis had worsened.

Somewhat surprisingly to me when I went to see Michael the day after his surgery he was grateful and said to me, “I want to thank you doc for all that you did for me”. Even the next day he was more blunt with me…”Doc I want to thank you for not making me a quadriplegic and a retard”! Though the latter term made me wince a bit, I certainly appreciated his gratitude. As time went on, however, and Michael realized he wasn’t getting any stronger on his left side, particularly his arm, he became less animated. Perhaps it was the decadron taper or more likely he began to realize he wasn’t going to leave that bed after all. Because of the severity of his weakness he remained in the hospital longer than most. This gave me the opportunity, however to visit with him more than I might have with other patients.

It is difficult to encourage most patients when they are in the condition that Michael was, so most times I just sat by his bedside and talked with him. Always, when I got up to leave he would extend out his strong right arm, look me in the eye, and shake my hand with such force as if to say ‘thanks for spending time with me’. The last day he was there, Michael was despondent. He asked me “Doc, do I really only have less than a year to live?” Before I could answer he said, “I hope so, I really can’t live like this”. Even I could understand why he would say that. All I could say was, “Well, this world we live in is not the be all and end all”. I asked him if I could pray for him. He glanced at me and then motioned with his head towards his left arm and said, ‘for this, yeah, OK”.

Taking care of Michael left me unfulfilled both as a neurosurgeon and a Christian. I still believe it is important to pray for miracles, but it also important to realize that God’s answer to our prayers just may not be what we expect.

An Unexpected Death

 

I have been in practice more than twenty years and I can count on one hand the number of times a patient of mine has died unexpectedly. Each time it has happened the one thought in the forefront of my mind has been, “I wonder if I’ll get sued!” Sure, I had concern for the patient’s family and the pain they were now experiencing but, immediately I would begin to think about all the things I had done for and to the patient… did I forget anything?, did I do anything wrong? When I perform elective surgery I expect all the patients to do well and leave the hospital within a day or two. So when the unexpected occurs, and everyone is in a state of shock, me included, everybody wants to know, “what happened?” That’s when I would begin to wonder if the patient’s family will ask questions and when the answers are unclear, if they will hire a lawyer because now the feelings of grief turn into anger.

Just the other day, Theresa Marsden, a patient that I had operated on less than a week before had a massive heart attack and died. But this time I felt different…

Theresa was a very pleasant woman, a retired nurse who had already survived one cancer, a melanoma as well as several other ‘brushes with death’. So when I told her she had a brain tumor she was upset and initially cried but she summoned up the strength to look forward, determined to fight it and win as she had in the past. Her husband of thirty years, Ed, was a character. After I had reviewed her brain MRI with them in her hospital room, he looked at me and said, “I’m gonna ask you a question that I have asked her surgeons in the past, and it always seemed to throw them off”, “I ask it because it tells me a lot about your character”… “Are you as good as you think you are?” Most times I get asked how long have I been in practice, or how many times have I done this surgery and most of the times when I get asked the question at all, what is my success rate? But never quite like Ed put it. He did throw me off a bit! So, I looked off a second or two, thought about it and then looked at him the eye and in front of Theresa’s nurse and Chad my physician assistant I said, “I am blessed to have the skill that I do”. As I looked at Ed, his face screwed up, somewhat surprised by my answer, and he nodded and stammered, “Well that’s why I asked it because I wanted to know what kind a person you were”. Now it was Ed’s turn to be thrown off! He then continued, “so when are we doin this?”

I explained to them we would have to transfer her to Morton Plant Mease hospital in Dunedin because that is where we perform all of the neurosurgery and that likely it would be Friday afternoon.

The tumor was located in Theresa’s occipital lobe on the left. She was an avid reader, reading three books a week but recently had suddenly stopped. When Ed asked her what was wrong she told him she couldn’t understand what she was reading anymore. As it turned out not only did the tumor damage her ability to see anything off to her right (the occipital lobes decode the signals from the eyes and creates the image we ‘see’), but the tumor had extended towards her ‘speech area’ (which decodes the words we see into meaningful speech) as well. And by the looks of the tumor on the MRI it was not only large but very likely a highly malignant brain tumor, an astrocytoma.

The surgery went well, though initially when I cut into the tumor, I discovered it had so many abnormal blood vessels I thought for a second it wasn’t a tumor but a congenital abnormality of blood vessels called an arteriovenous malformation. But as soon as the pathologist reported that it was indeed a malignant astrocytoma, I settled in and began the systematic removal of the tumor. After I was satisfied with my resection of the tumor, I inserted the chemotherapy wafers in the brain and then closed.

After surgery, Theresa was unchanged. She still could not see off to the right, and her ability to read still was mildly impaired. She recovered well, was transferred out of the intensive care unit on post-op day number two, and was up and walking in the hall on the second floor feeling quite good. In fact I remember seeing her on Wednesday as she had just finished eating dinner. I asked her how she was feeling and all she could do was remark how hard the broccoli was and that she couldn’t eat it like that. I then remarked “well, I guess if you are able to complain then you must be doing OK”. I promised I would speak with the administrator about the broccoli and walked out figuring she would be ready for discharge in day, or two at the most.

So, when Chad called me Friday morning to tell me Theresa just had a cardiac arrest and the code team was trying to bring her back, I was stunned! I told him I would be right there. As I drove in my thoughts drifted to Ed and how he must be feeling. He was losing his lifelong partner and friend, and not over the course of months as we thought it might be, but, right now. I didn’t think at all about what I might have done wrong.

I stood at the foot of her bed as the nurse performed chest compressions and the intensivist ordered more drugs to be given, and Ed paced back and forth in the hall outside the room. But to no avail. After 30 minutes of this, the intensivist looked at me and shook his head. Ed came in, asked how long we had been ‘coding’ her, and then asked everyone to stop as he said “you’re not going to bring her back”. He went immediately to her side, bent over, put his arms around Theresa and cried.

As he walked away from her bedside, I looked at him and told him I was sorry as he grabbed me, hugged me and thanked me for everything I had done.

I am indeed blessed to have the skill I do, and having asked for God’s guidance before her surgery, I knew I did everything that was in my power to do.

…but to set the mind on the Spirit is life and peace. Romans 8:6