Spiritual Experiences from the Brain

The Price of Friendship

“Every one who comes to me and hears my words and does them, I will show you what he is like: he is like a man building a house, who dug down deep, and laid the foundation upon rock; and when the flood arose, the stream broke against that house, and could not shake it, because it had been well built. But he who hears and does not do them is like a man who built a house on the ground without a foundation; against which the stream broke, and immediately it fell, and the ruin of that house was great.”

                     Luke 6:47-49

 

Just the other day I was thinking about the friendships I have had. There have been some rock solid ones that have stood the test of time, although these are few indeed. Many of them have been built on shifting sand as it were, rarely surviving the first storm that served to wash it away. Then it occurred to me that I have not always been the friend I should have been, standing behind the very people who had stood by me in times of trouble.

Unfortunately over the years I have encountered people who seem to have an ulterior motive in being my friend. In most cases it was when they desired a friendship in order to establish a business relationship, and in these situations, this has made me feel at the very least uncomfortable and many times, sad.

When I order CT and MRI scans and other x-ray tests I can choose from many different facilities to perform these studies, and I usually do so depending upon where the patient lives. Predictably the physicians and other ‘health care providers’ affiliated with these free standing businesses do whatever they can to entice me to refer my patients to their ‘center’.

I have, for the most part, refused these inducements on principle and utilize the facilities based on the quality of the services they provide.

However, many years ago I became friends with the owner of one of these MRI centers. His name was Steven Wright (No, not the comedian). But he was a funny guy and he was an enjoyable person to be around; and I had many interesting and intellectually stimulating conversations with him. I would even admit at the time, if all things are equal, you might as well do business with a ‘good guy’ (and as it turned out the quality of the scans his center produced was just what I needed to make my clinical decisions).

In many ways we were very good friends and I probably bought dinner and drinks as much for him, if not more, than he did for me! We even spent holidays and vacationed together a few times. But I always had this feeling in the back of my mind; if I stopped referring patients to his scanner would we still be friends...?

Over the years I have been in practice I would see patients referred to me from chiropractors. Generally, these patients were no longer benefiting from chiropractic care. In many cases they had a ruptured disc in their neck that was compressing their spinal cord and so chiropractic would not help and even could be dangerous.

Although more often than not they were accident cases and the motor vehicle insurance was exhausted so then they would refer me the patient. The difficult and often uncomfortable issue with this was, while I was grateful for their referrals, I was often made to feel that I had to send them patients, less they ‘lose confidence’ in my skills as a surgeon.

The reality of my practice is that by the time patients are referred to me for possible surgery they have already treated with a physical therapist or chiropractor or both and so there was little need for me to prescribe such care.

Nevertheless, I would, on occasion have reason to refer a patient for conservative treatment. Sal Marino was one of the chiropractors I would send patients from time to time. Interestingly, as long as I continued to send patients to Sal he would send patients that required surgery to me, and we were great friends. But as soon as the referrals to Sal’s practice dropped off, seemingly his confidence in my ability and our friendship dropped out of sight as well….

Then there was Tim Perry. Tim worked for a company that sold spinal hardware - surgical screws, rods and plates that I would use to correct spinal deformities which were caused by trauma, cancer or degenerative disease. Since the company was on the leading edge of technology and the fact that Tim provided outstanding service I worked with him exclusively for many years. Understandably we became friends, although to be honest I kept that friendship at ‘arm’s length’ because I doubted his sincerity.

I often wondered how Tim would (re)act if I started to use another company to provide the surgical instrumentation that I used frequently. And for a period of time I did just that. Not to test the friendship, but I thought that just from a business standpoint it would encourage him to continue to provide a high level of service, and that the hospital might benefit from better pricing.

Tim actually handled it very well and in the end I came to respect him more for his maturity. Actually, distributing the cases fairly equally between the companies became a nightmare logistically and most of the time I felt uncomfortable being around Tim if that particular day I was using the instrumentation from the competing company. So, one day I just shifted all the business back to Tim. And I allowed myself to become better friends with him as well….

Somewhat ironically I recently found myself assessing a friendship based upon how it benefited me from a business standpoint. Although it would be more accurate to say I turned my back on that friendship because of the feeling, ‘there was nothing in it for me’.

For several years Lance Durso and I have worked closely together and over that period of time had become good friends. Not too long ago because the strategic plan for the hospital had changed, Lance found himself making critical decisions that could possibly affect me professionally, and from my perspective, negatively.

Instead of understanding those decisions had nothing to do with our friendship, I lashed out. Not only did I disrespect Lance, I as much insinuated that he was no friend of mine for taking that action. Unfortunately I am not always the most diplomatic when my feelings are strong and I said things I didn’t mean.

The reality of the situation was that there was no way Lance could avoid taking this course of action since it was for the greater good of the hospital and if he refused, his job would be in jeopardy; but I was too immature to accept it.

And so here I was attaching a price to my friendship with Lance, in the same way I that I thought others had done with me. Why? Because the way I had practiced medicine for almost twenty years was about to change and this frightened me. Of course fear is not what I felt; it was anger! I even convinced myself Lance was making these decisions without even considering how it would affect me.

But as I thought more and more about how I allowed my feelings to get out of control I realized that not only was it totally un-Christian of me, I was allowing  Satan to take advantage of my insecurities and harness that anger to blacken my soul and to inflict pain on someone else. Sad to say it was not first time I’ve committed this sin of jealousy and mistrust.

Ultimately, I realized that this new direction could actually benefit me which of course made me feel even more guilty for doubting Lance’s honest intentions.

I guess I have often had a hard time embracing change but this will have to be a topic for another story. Suffice it to say that acceptance is the key to happiness and a good friendship.

A Patient Who Became 'My Brother'

Most patients in my surgical practice I know for only a short period of time.

Some patients I take care of for a longer duration. Perhaps they did not get well following surgery and so I feel a sense of responsibility to oversee their care, referring them to, say a pain management physician hoping to get them some relief of their persisting symptoms. Occasionally, a patient will develop a surgical complication and I take care of them until the issue at hand is corrected or resolves.

Other patients actually over the course of time develop more than one problem for which they will return to see me.

Of those patients I take care of for an extended period of time I naturally develop a closer relationship with. Rarely, however do I develop a bond with a patient that transcends the usual doctor – patient relationship.

Robert Cross, however, was one of those patients with whom I developed a unique friendship.

Robert turned out to be one of those patients that failed to get better after the initial surgery I performed, requiring additional surgery. But he also developed a surgical complication requiring even more surgery; and then developed an unrelated problem requiring another (sixth) operation. Yet in spite of it all he was always grateful for what I tried to do to help him.

I first met Robert in December of 2002. He was 69 years old. He had previously undergone lower back surgery in April of that year by another surgeon and though his condition had improved he re-injured his back causing one of the discs in his lower back to re-herniate

So, on the 31^st of December I re-operated on Robert to remove the herniated disc that was pressing on his ‘sciatic nerve’ causing unrelenting pain in his left leg.

Following surgery he was certainly better, ‘but not 100%’. I then referred him to a pain management physician who performed periodic injections of cortisone in his lower spine to help alleviate his continued lower back pain.

Robert did reasonably well with this form a treatment for about two years. Ultimately the cortisone injections became less and less effective and then he developed recurring pain in both of his legs. Further tests revealed progressive degenerative changes and arthritis in his lumbar spine.

After reviewing the new MRI scan with Robert, I discussed with him the possibility of fusing his spine as I felt it might give him a degree of stability which I believed he was lacking with the advancing degeneration in his discs. He agreed and so on the 7^th of March 2006 I performed a spinal fusion on Robert Cross.

After he recovered from this surgery he was transferred to a rehabilitation facility but was readmitted one week later with severe left leg pain. Tests revealed it was only inflammation in the sciatic nerve and so I was able to treat it with medication.

Robert did well for about a year until the pain once again reoccurred, for which I performed two more surgeries. Unfortunately his continued complaints of pain finally led me to tell him, ‘Truthfully, there isn’t anything further I can do to help your back pain’. He nodded in agreement and thanked me for my honesty.

Later that year, 2007, Robert began having some difficulty walking but this problem appeared to be unrelated to his lower back. A CT scan of his head revealed that he had hydrocephalus so I inserted a ventricular shunt which improved his ability to walk somewhat. Unfortunately Robert also developed a severe peripheral neuropathy which caused his legs to feel constantly numb. As a result he was unable to appreciate where his legs were, particularly in a dark room, and this would cause him to fall frequently.

One day, not too long after I inserted Robert’s shunt I began to think of him more as a friend, and not a patient. I was in church and was returning from communion when I saw Robert sitting in a pew by the aisle. Without even thinking, I was drawn to him and I reached out my hand to him and extended a greeting of peace.

He was alone and I’m not sure he needed me to acknowledge him but I crossed the aisle shake his hand nonetheless. Actually, that meant a great deal more to him than I could have imagined. Several times after that day when I would see him he would remark about the event prominently, almost with a sense of gratitude, as if I lifted him from a moment of despair.

Actually, Robert had very good reason to be depressed. He was a very sick man, having multiple medical problems which over the ensuing three years caused him to be admitted to the hospital over 15 times; and during those hospital admissions he would undergo six more operations by two other surgeons! In addition, it was becoming increasingly difficult for his wife Joann to take care of him at home.

He wasn’t always admitted to Mease Dunedin, but when he was I would either find out he was there from Francy, my nurse or I would happen to stumble upon him making rounds on my surgical patients. Always I would stop by to at least say hello and to see how he was doing. And always he would turn to the other patient in the room if there was one and say, ‘This guy is a good man’. Slightly embarrassed I would say, ‘You are too kind’ and then reach out my hand to shake his, saying ‘It was good to see you brother’. ‘You too, brother’, he would reply.

Each time I saw him in the hospital he appeared to be getting weaker and weaker. Ultimately, because of his frequent illnesses, the amount of nursing care he required grew exponentially and so he had to move into a nursing home. The last time I saw Robert Cross in the hospital was in December of last year, 2010.

He had developed a pulmonary embolus or blood clots in his lungs. His spirits appeared good although he just seemed tired. I stopped by briefly to say hello, thinking I would stop back later in the week.

I never did see him again. He was discharged only to be readmitted on Christmas day at another hospital with pneumonia. Less than a month later he had a cardiac arrest and died, at 77 years of age.

A week or so later, his wife Joann called the office to let us know, and to ‘especially thank us for taking care of Robert over the years’.

Shortly after I felt compelled to write this story about him because, ‘He was a really good man’ and I wanted to ‘especially thank him for being my friend and ‘brother’ all those years.

Charity and the Price of Eternal Salvation

‘And Jesus looking upon him loved him, and said to him,

“You lack one thing; go, sell what you have, and give to the

poor, and you will have treasure in heaven; and come, follow me.”

At that saying his countenance fell, and he went away

sorrowful; for he had great possessions.’

Mark 10:21-22

How difficult is this request for us to follow?  I suspect for most of us, myself included, if we are to be honest, it is practically impossible! And not only does Jesus want us to give up our material possessions, he also wants us to follow Him, relying not on the life that allowed us to accumulate those things in the first place. And I believe, in these words also is the inference that Jesus wants us to be happy with the choice.

This command not only pertains to material possessions, but our time and talent as well. And it is with these gifts that I am not always such a ‘cheerful giver’.

In the course of my practice I am on call for emergencies and not every patient that is brought to the emergency room has insurance. And for many of these patients this is the reason they stay away from the doctor in the first place.

Granted, many of these patients are there because of self-destructive behaviors, such as abuse of alcohol and drugs. But, there are some who find themselves incapacitated, frightened and without a choice. It is these patients that remind me that God has given me a gift that I must give freely to others.

Darnell Benjamin is a patient that reminded me of this recently.

In April, Darnell decided he would get back in shape since he was about to begin a construction job he was lucky enough to have landed. During one of his workouts he felt a pop in his neck followed by some pain but he figured it was a muscle strain so he just took some Tylenol and ignored it.

Over the next few months he developed some weakness in his hands and actually noticed some of the muscles had atrophied but since he could still lift and haul the lumbar that his construction job required he quietly went about his work. His daughter tried to convince him he should see a doctor but since he did not have health insurance he told her ‘no’. In late October, Darnell began to notice his legs were a bit sore and weak but he just figured it was due to all the hard work he had been doing.

About 3 weeks ago he awoke one morning and his legs were so weak could barely get out of bed. And when he tried to stand up his legs gave out from under him and he fell to his bedroom floor. It was at this moment he also noticed he could barely pull himself back up because his hands and arms had gotten much weaker as well.

Unable to ignore his problem any longer he allowed his daughter to call 911. Shortly after he was brought to the Emergency Room by the EMTs, he was examined by the ER physician on duty who then ordered an MRI scan of his neck and lower back. As soon as the radiologist interpreted the scans and informed the ER doc of the results, I was called.

Darnell was actually in a hospital 20 miles to the north of Mease Hospital where I practice and because the emergency room doctor there believed a neurosurgical emergency existed, she wanted Darnell transferred because they did not have a neurosurgeon to take care of the problem there. After reviewing the MRI scan I agreed Darnell would need surgery.

Darnell had ruptured a disk in his neck and because there also was injury to the ligaments of his spine it created additional weakness that resulted in damage to his spinal cord. Not only would I have to operate on his cervical spine through an incision in the front of his neck and remove the disc and fuse the vertebra together; I would also have to operate on his spine a second time through an incision in the back of his neck and insert screws and rods into his spine to prevent further damage.

(When I meet patients I try not to be judgmental, but unfortunately since I make assessments and deductions based upon the patients’ history, examination and MRI scans all the time, I too often make conclusions why they have come to see me. Often it is obvious; they are in pain and want to know what their options are to alleviate or eliminate the pain. In other cases it is not so clear; the person may have been in a car accident or had an injury at work and they may only want to collect a monetary settlement or obtain a medical disability so they do not have to return to work.

In some respects it is up to me to try to make this determination so I can decide whether the patient truly is injured and may need surgery or whether they are malingering.

But sometimes I find myself making superficial judgments as to the patient’s appearance. When patients’ such as Darnell are brought in to the Emergency Room and are poorly dressed and without impeccable hygiene, the thought, ‘do they have insurance and will I be paid for the surgery I might have to perform?’ may cross my mind. In those cases I say a prayer to myself and refuse to look at the patient’s face sheet which indicates this information before I have decided what needs to be done and I have done it.)

By the time Darnell arrived at Mease Dunedin it was the following morning. He was then prepped for surgery and brought to the preoperative holding area. As I walked in he looked frightened, which was understandable since he could barely move his legs and could not move his arms much more. I introduced myself, took his hand to shake it and told him what I would be doing. He nodded and thanked me.

The surgery went well and by the next morning he could move his arms and legs quite a bit better. As I walked in to the preoperative holding area this time Darnell was actually smiling. I asked him, ‘Are you ready for round two?’ He said, ‘Yes’.  This operation was more difficult than the first but everything proceeded as planned and there were no complications.

When I rounded on Darnell the following morning he was sitting up in bed eating his breakfast, feeding himself which he was unable to do the previous day. I asked him how he was doing and he said, ‘Very well’. He went on to say, ‘Thank you so much for what you have done. I was so afraid because I could not walk and my hands were so weak. And now I am so much better. Thank you’. I smiled and said, ‘You are very welcome’. As I left his room and walked to my office I felt grateful for being able to help him.

By the end of the week Darnell was walking without any assistance and was discharged home. I figured I would not see him again until his six-week postoperative check in my office. Unfortunately that would not be the case.

Thanksgiving morning, though I was not on the schedule for emergencies, I received a call at 5 am from the ER of another hospital to the north. Apparently something happened to Darnell at home and he became unconscious. When the EMTs arrived his blood pressure was more than fifty points lower than it should have been. By the time he arrived at that hospital he was awake but the ER physician examined him and found him to be almost completely paralyzed in his arms and legs once again. I told the ER physician to transfer Darnell back to Mease Dunedin Hospital.

At this point I thought, ‘Boy, God is really testing me now. Not only did He want to see if I would be cheerful operating on Darnell, gratis, He wanted to see if I would still be smiling now that my Thanksgiving plans might be completely disrupted!’

By the time Darnell arrived in the ICU at Mease Hospital the movement of his arms and legs was almost back to where it had been when he was discharged. After reviewing the scans that were done at the other hospital I concluded Darnell became weak because the blood flow to that damaged area of his spinal cord was compromised when his blood pressure had dropped so low. Fortunately, he would recover completely.

When I returned to see him the following morning, Darnell’s weakness had continued to improve and as we talked about his condition he told me that everyone in the ICU had been great except one nurse who had taken care of him the night before. In fact he told me that nurse was actually mean to him. He then proceeded to tell me in a very articulate way that he had said to the nurse, ‘I want to apologize to you if I had said or did anything that had upset you (‘which I did not’, he said as an aside to me) because I really need your help and I don’t want you to be mad at me and ignore those needs’.

I told him I was sorry that he had that experience and that I would look into it. Darnell then looked at me and said, ‘and I’m sorry if I have inconvenienced you in any way over this Thanksgiving holiday’. I told him not to worry about that and with lump in my throat and a slight feeling of guilt myself I said, ‘that is why I am here, to take care of you’ as I grasped his hand tightly and looked deep into his eyes. Darnell merely said, ‘thank you’ as I turned to leave his room.

Lately, collections have been off a bit and yet the bills continue to pile up and it is hard to ignore when I spend no less than 15 hours operating and taking care of a patient without physical payment. What Darnell reminded me however, was that my time spent was hardly in vain and that God will truly pay me back a hundred fold if I am a ‘cheerful giver’.

 ‘The point is this: he who sows sparingly will also reap sparingly,

and he who sows bountifully will also reap bountifully. Each one

must do as he has made up his mind, not reluctantly

or under compulsion, for God loves a cheerful giver.

And God is able to provide you with every blessing in abundance,

so that you may always have enough of everything

and may provide in abundance for every good work.

2 Corinthians 9:6-8

A Colleague, a Friend and a Missed Opportunity

 

Today, a colleague of mine died. We were not close friends but I had known him for almost 20 years. He had been struggling a long time with cancer.

He was a neurologist so I had frequent interaction with him when I began my private practice in neurosurgery. He was an extremely bright man, in fact my former partner, Kevin and I used to say that he was so intelligent that he probably had little room for common sense. Nonetheless, we respected him greatly and always knew that if we had a difficult and puzzling case Bryce was one of only two guys we would go to.

Jack was the other neurologist I knew. He was more of a philosopher. Perhaps not as intelligent as Bryce (although I think we would be splitting hairs here!) but he had a ‘sixth sense’ about patients. He would tell me you had to have a gestalt about the brain and neurological problems. He would say ‘if a clinical finding didn’t make sense in the grand scheme of things you had to at least temporarily disregard it, if not throw it out altogether to see if a diagnosis could be made based on the remaining information’. Otherwise you could be ‘stuck in the weeds’ for a long time, so to speak.

When I was in medical school contemplating what area of medicine I would pursue, I gravitated to neurosurgery because it made sense logically (I was fascinated with neuroanatomy and I loved surgery), but probably more importantly I felt ‘at home’ being among other neurosurgeons. For neurologists, I am certain it is the same; it’s just that the cerebral aspects of the brain captivate them more than wanting to be ‘merely a technician who cuts out what we (the neurologist) have already diagnosed’.

In a way it’s a funny thing that our personalities influence our choice of hobbies as much as the medical specialty we are ‘drawn’ to. Many of the neurologists I have met over the years have been avid gardeners, which in a way is ironic. In neurosurgical residency the patients we would operate on who either had a major stroke or brain hemorrhage postoperatively often became unable to communicate or care for themselves. These patients, or the so-called ‘vegetables’ would then be passed on to the neurologists, who would take care of these chronic patients. We would joke that they essentially would ‘water the garden’ since there wasn’t much else they could do.

Of the two, Jack was the gardener although I’m pretty sure he would have turned up his nose at the notion anyone would have considered him an ‘amateur’ at it. In fact his depth of knowledge was so great it would have more appropriate to consider him a botanist. Bryce on the other hand was an avid photographer. So while Jack seemed to revel in the evolving colors of the plants and flowers that he nurtured, Bryce found immense satisfaction in capturing those brilliant moments of nature with his camera.

(By contrast, Jack was also a serious fisherman while I, the neurosurgeon would rather scuba-dive and spear the fish.)

Jack, too, had been sick. He had chronic neck pain and despite several surgeries he required frequent pain medication and occasionally oral prednisone. He also had an aortic valve problem for which he underwent open heart surgery, but apparently his heart had become weak from years of being overworked. And one day about a year ago his heart began failing and despite the heroic efforts of his doctors, he died. When Lora, his wife called me to tell me, I was shocked, saddened and I think, a bit upset. I had just seen and spoken with him on Halloween, several weeks earlier. While not the picture of health he sure didn’t seem like someone whose heart might fail him at any time.

Bryce, fought his disease courageously and at one point it appeared he had won. As of late, however he did not appear well; though because he was a private person and less vocal than Jack I could only make the assumption his cancer was no longer in remission, based on my impression of him. So when I heard he had been hospitalized and was not doing well I was not taken by surprise. Several days later when I heard he had died I almost felt a sense of relief for him.

At first this feeling did not seem strange. For I knew Bryce was finally well and at peace himself; just like he looked in those radiant, healthy, younger photographs of himself. But then I began to wonder why I felt one way with Jack and another with Bryce. I really didn’t socialize with either of them very much outside of work, but I felt more of a kinship to Jack than Bryce. I guess because Jack had ‘taken me under his wing’ when I was starting out, he was more friend than colleague. In a way I sort of had a feeling that he should have been a neurosurgeon rather than a neurologist.

Then I began to think about all the funerals I attended growing up. I came from a large Italian family with many aunts, uncles and cousins. And it seemed like someone was always getting married or dying. So I probably attended as many funerals as I did weddings.

Funerals seemed a bit odd to me. First of all the funeral homes were either Italian (Maiorana) or Irish (Murphy), and depending on your nationality of origin that is who you would call to ‘make the arrangements’. On the night of the wake in the front of the funeral parlor was the family of course but also older matriarchs of the family, usually of distant relation, that held their handkerchiefs in one hand and cried all night. Most of the people sat quietly in the center of the parlor after paying their respects to the family and remarked to one another how good the deceased looked. In the back the men milled around talking to one another as if they were at their favorite bar. The only thing missing was the beer… or was it Dewar’s!

Had I finally become so numb to the dying of patients and family that I was no longer capable of feeling sorrow?

No, that wasn’t it. I knew in the depths of my being that I when I died I would become united with Jesus Christ, my God and for whatever reason I felt that was where Bryce was. I really did not have first-hand knowledge of either Bryce or Jack’s spirituality or faith but I had a strong sense that Jack lacked this in his life.

Sure, I was saddened by his sudden death but I think more so I was upset with myself for not at least speaking with him about my faith and telling him how important it was to me personally and professionally.

Jack was a good, honest and kind person despite his seemingly abrasive exterior so I’m sure eventually he will be in heaven. But for my part I felt should pray for him and his soul that he would get there sooner than later. And so this is what I did for months afterward whenever I would pray the rosary… “O my Jesus, forgive us our sins, save us from the fires of hell, lead all souls to Heaven, especially those most in need of Thy mercy”.

And so, two men, both brilliant and talented neurologists had their lives snuffed out in the apparent prime of their lives. I have to believe there is a reason for this but I firmly believe one day they both will be united together with our Lord in Heaven.

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’.

 

For Love of Family (Epilogue)

 

Michael Dubois died the other day, less than one month after I performed surgery on him. Only his name was not Michael Dubois, it was Richard M. Swist and his wife’s name is Virginia.

I was shocked to hear he was gone and that it happened so quickly, and very likely because of the inspiration from the Holy Spirit, I felt compelled to share his passing with you. In fact I had Francy, my nurse contact his wife, Virginia and to let her know that I had written about him in my blog and that I would also like to write some more about him and would she be kind enough to share with me their memories of him.

I am changing to his actual name at the request of his wife, Virginia and their daughter Carol.

These are their thoughts about a wonderful man, and a loving husband, father and grandfather…

 

‘My father and mother were married for 41 years; they had a love like nothing anyone has seen before’

‘Dad was a DISNEY man; he had brought his family there since it opened. That was our getaway place to go. He loved to eat at Cosmic Ray’s Starlight Café in Tomorrowland at Walt Disney World and listen to his children and later in life his grandchildren sing with Sonny Eclipse. He also loved to watch the fireworks behind Cinderella’s Castle at the Magic Kingdom’

‘He was a father to three children and a grandfather to five’

‘He worked many hours to make sure his family had everything they needed’

‘He was a man of his word, had a kind spirit and a man who you instantly fell in love with’

‘He was a FAMILY man; family always came first. He would take his last dollar and give it to you if you truly needed it’

 

And so this was the man, Richard M. Swist that touched my heart immediately the first  day I met him, like he had to all those that loved him dearly and knew him better than I.

‘The point is this: he who sows sparingly will also reap

sparingly, and he who sows bountifully will reap bountifully.

Each one must do as he has made up his mind, not

reluctantly or under compulsion, for

God loves a cheerful giver’

2 Corinthians 9:6-7

For Love of Family

 

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 4^th ventricle (which was connected to the 1^st, 2^nd and 3^rd 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.

A Confession

 

I have a confession to make.

In my last post, “Decision, Direction and the Holy Spirit”, I made the following statement: “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’”.

The fact of the matter is that for many years I not only believed I this, I considered myself god-like. That all my talents and my skill came from within, and that the illnesses I cured and the lives I saved were entirely because of me. Ironically, as neurosurgical residents we would say, ‘as soon as you would think you were the best, a complication would occur or a patient would die to remind you that you weren’t as good as you thought you were!’ But my memory of these ‘minor setbacks’ was short and in no time I would be convinced they had nothing to do with anything I did or failed to do.

During my training in Atlanta an article appeared  in a magazine pullout of the Sunday paper which referred to neurosurgeons as the ‘High Priests of Medicine’. To me at the time it seemed an accurate portrayal of our supernatural powers.

All this may seem at the very least arrogant, although sacrilegious is probably closer to the truth. Unfortunately I held tight to this view of the world around me for many years.

It would only be years later with the help of my wife that I would place Jesus Christ in the center of my life. Only then would I realize that my talents and skill were gifts from God. Thus becoming more grateful, I also realized my patients deserved not only the work of my hands but to know my ability to treat and heal them was from God not me. That, I no longer ‘walked on water’ as so many of them had said in past.

I am compelled to share this with you because of a CD I was listening to in my truck on Wednesday as I was driving to meet up with the rest of my family for my daughter’s wedding this weekend. It is a talk by a well know theologian, Dr. Scott Hahn who was speaking on Understanding the Lord’s Prayer.

He was speaking about the petition, ‘Lead us not into temptation’, only Dr. Hahn said that the actual meaning of the word ‘temptation’ was a trial or test. He then went on to say that God tests us not to see how much we know, because he already knows that, but to show us how much we don’t know. Dr. Hahn says, ‘He allows us to enter these tests because we tend to overestimate our own strength and that we underestimate how much we need God’s strength; and how often we find ourselves in over our head and yet God is only a prayer away.’

It was at that point a light bulb went on over my head. I certainly had come to appreciate that my abilities were gifts from God, and as I have pointed out previously prayer during surgery has become very important to me as well. But, all those times I found myself in over my head and got out ‘without a scratch’ had falsely convinced me of my own superiority. It was only now that I truly realized God was testing me all along and then delivering me from my trial in the hopes I would come to give glory and thanks to Him. It just took me a while to shift the praise from myself to Him.

‘I am weak yet unafraid because Jesus is my friend.’

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.

 

Faith, Belief and Doubt, and a Night at the Movies

 

Just the other night my wife and I watched the movie, ‘Angels and Demons’. In one scene Tom Hank’s character, Robert Langdon is asked by the Camerlengo, ‘Do you believe in God sir?’ To which he ultimately replies, ‘I am an academic…my mind tells me I will never understand God’. The Camerlengo then says, ‘and your heart?’ Langdon answers… ‘tells me I’m not meant to…Faith is a gift that I yet to receive.’

And in my mind and heart, that about sums it up… that belief in God is only possible through faith alone.

Even my 8-year-old son who ‘knows’ that Jesus Christ is God because of what he has been taught, can appreciate on a very basic level the difference between a belief and reality. One night a while ago as he went to sleep he expressed his fear of being alone because he was not physically near his mother or me. I tried to reassure him that Jesus was with him in his room but since he could not see or touch Jesus, that thought was no more comforting than knowing his parents were just 20 feet away in another room. 

Unfortunately this conflict between belief and doubt exists in the lives of adults and perhaps to a degree even within the Christian community. Because we are human we have human weaknesses, and fear and doubt are just that, weaknesses. And this is why prayer is so important. Prayer, particularly when it is truly contemplative redirects our thoughts away from our weaknesses and our imperfect world and focuses them on God. And I firmly believe that when our innermost being, our soul, has God at its center, the belief that God exists is no longer a metaphysical concept but a physical reality.

(As an aside, just the other day, my son asked me, ‘Dad, can you transplant the soul?’ I proceeded to explain that you could not; that the soul was not an organ in the body that could be taken out. He asked me what the soul was. So, I told him that it was a gift from God that lives all through our body and allows us to be like Jesus and close to him. Seemingly satisfied with that answer he then asked me what organs could be transplanted and which one was the hardest to do…)

And so if prayer is a daily part of our lives, God will become a part of that life, and then our actions will truly become a reflection of Jesus Christ in the world in which we live.

 ‘Then he said to Thomas, “Put your finger here, and see my hands;  and put out your hand, and place it in my side; do not be faithless,   but believing.” Thomas answered him, “My Lord and my God!”  Jesus said to him, “Have you believed because you have seen me?    Blessed are those who have not seen and yet believe.” ‘  

John 20:27-29

 

A while back I had been performing a spinal surgery in which I had to stabilize an area in the lower back by inserting some rods and screws into the bones of the spine. It is a procedure I had performed hundreds of time before but on this particular occasion I was employing a new technique. Thus, I relied on intraoperative X-rays and electrical neurologic monitoring rather than open visualization to insert the screws into the spinal bones.

For some reason I had difficulty positioning one of the screws despite the fact the X-rays indicated I had selected the exact entry point and trajectory that I should have. After multiple attempts, my frustration was apparent to all in the operating room.

It was at this point, I paused for a moment as I will occasionally do and took a deep breath. This time, however I rested my hands on the patient one over the other, bowed my head slightly, closed my eyes and said silently to myself, ‘God, Please help me’. I then opened my eyes, resumed the case and proceeded to immediately place the screw in the correct location on the very next attempt. I then let out a verbal sigh of relief, lifted my head and said aloud, ‘Thank you God’.

From the corner of the room, Peter, the X-ray technologist spoke out, ‘You just said a prayer there, didn’t you?’ I looked up and said to him, ‘You bet I did’. As I said that something occurred to me… not only did I rely on God to help me, which I often do but I professed it openly, which I don’t do enough! Not only is praying helpful to me in doing what I do but letting others know that I do and that it is important to me changes more lives than just the patients that I treat.

And so this brings me back to my original thought… the importance of faith in resolving the never-ending battle between belief and doubt…good and evil. Even I have doubts that creep into my consciousness:  not that, ‘is there a God?’ but, ‘do my prayers really make a difference?’…  ‘How can I be sure God really hears me?’  The thing of it is we can never be humanly certain, only faith can galvanize certainty in our soul. Faith truly is a gift and those without it should pray that they receive it.