Spiritual Experiences from the Brain

An Unusual Way to Die

I have been practicing neurosurgery for over twenty years and two weeks ago something happened to me that I have never experienced before…

Tracy Schlachter was a 67-year-old gentleman who had undergone two craniotomies in the early 90’s for presumably a benign meningioma. As a result he was left with some right-sided weakness and over time he had to resort to using a walker to help him get around.

In fact within the past few years he had several falls requiring hospitalization.  Each time it was thought he may have had either a stroke or a seizure. Each time, tests failed to reveal the reason for his falls. Nonetheless he was placed on an anti-seizure medicine just in case.

Though these ‘falls’ were often accompanied by periods of confusion, in general he was ‘alert, pleasant and fully oriented’. That was of course, until he fell, for the last time, that Sunday night.

I received a call from Chad, my PA, telling me that Tracy was in the ER at Morton Plant Hospital. He had been told he had an epidural hematoma which, of course, was a neurosurgical emergency.

I logged in to the hospital computer system from home and reviewed Tracy’s CT. There was a hematoma but it was a subdural; still it was causing a great deal of pressure as well as a shift of the brain structures from right to left. I called Matt at the transfer center who then set up a conference call with Dr. Davis in the emergency room.

Apparently Tracy had fallen several hours earlier and when he began to have a seizure at home his wife had called 911. Initially when he was brought to the ER he was conscious but shortly thereafter he had begun to have another seizure and he quickly became comatose. Dr. Davis had spoken to his wife who agreed that Tracy should be placed on the ventilator because of his condition.

As I spoke to both Matt and Dr. Davis I ascertained that Tracy still had brain function and though the appearance of the CT scan indicated to me that his prognosis was poor I decided that emergency surgery should be performed in the hope that Tracy would survive and recover. I directed Matt to arrange emergency transfer and that EMS should bring Tracy directly to the operating room at Mease Dunedin Hospital, where I would be waiting. Dr. Davis then spoke with Tracy’s wife who consented to the emergency transfer.

Now, I must clarify my position regarding treatment of gravely ill patients. In circumstances where the patient has an injury that has caused (likely) irreparable damage from which the patient cannot recover, or if he or she does recover it would result in vegetative state I cannot argue with a family’s decision to withhold extraordinary measures.

However in most cases, the outcome is usually in doubt and so I usually advocate doing what we can. If there is no improvement and the family wants to withdraw ventilator support I honor their wishes.

Of course if the patient is in their 90’s and/or was severely incapacitated either physically or mentally beforehand, I can hardly disagree with providing comfort measures only and allowing the patient to die peacefully and with dignity, if that is what is to happen. However, as far as I could tell Tracy did not fit into any of these categories so I believed we should do what we could.

A soon as Tracy arrived at Mease approximately 1 hour later he was taken immediately back to OR room #2. After the anesthesiologist connected Tracy to the anesthesia machine, I positioned him on the operating room table. I then shaved his head and marked my incision and directed Bill to start prepping his scalp.

It was at this point I received a phone unlike any other I have ever received at this point in a surgical procedure. The ICU nurse told me that he was bringing Tracy’s wife to the surgical department.  She wanted to speak with me immediately… and she meant, ‘right now!’

As I walked through the automatic doors of the operating room out into the hall, there was a woman standing there staring at me as if she had expected me at any moment and yet she was distracted. I said, ‘Mrs. Schlachter?’ She shook her head ‘no’ and with a strange, almost fearful look on her face peered around the corner and motioned toward the other woman whose footsteps I could hear walking quickly and determined in my direction.

She was eating a health food snack and she talked and ate at the same time. ‘What do you think you are doing?’ she demanded. Immediately I was taken aback (and what rarely happens to me), I was put on the defensive! I said, ‘Well I had planned to remove the blood clot that is pressing on your husband’s brain and threatening his life.’

‘Why would you want to do that?’ she stammered.

I felt as though I was a resident again being interrogated by one of my attending surgeons. Before I could answer she began listing the reasons why surgery was not only a bad idea it was the dumbest one she ever heard of!

‘He’s already had two brain surgeries for brain tumor… he has a seizure disorder… and despite all the tests he has had, the doctors still can’t figure out why he falls all the time.’

I was confused by her reasoning. First of all the brain tumors were benign and the surgeries were 20 years ago; his seizures were controlled by medication and most of the time he walked just fine, albeit with a walker. It wasn’t as if he had terminal cancer or had been confined to a nursing home with Alzheimer’s disease for the last five years.

It seemed to me she was talking about mere inconveniences, not life threatening illnesses. ‘Well, I thought I would perform the surgery to give him the best chance of recovery’ I said.

‘Why, so he can wind up in a nursing home? No, you are not doing anything!’ she said as she stared directly into my eyes with pinpoint accuracy.

To say the least, I found her behavior a bit odd because usually when something sudden and unexpected happens, most family members want everything done. If not just to see if recovery is possible but also partly because they don’t want to feel guilty that they didn’t do everything that they could.

But it was clear that this woman was not going to change her mind so I said, ‘Fine… we will transport your husband to the ICU and when you are ready he can be taken off the ventilator and allowed to pass’. She nodded emphatically and gestured towards me, as if to dismiss a servant, took another bite of her snack and turned to go to the ICU and wait for her ventilated husband to arrive.

As I arrived at Tracy’s ICU room there was an older woman in a wheel chair, to whom Tracy’s wife was almost reprimanding. ‘Do you want him to be in a nursing home for the rest of his life?’

A taller woman with dark hair approached me and asked, ’Doctor, what do you think his chances would have been?’ The answer to this question really didn’t matter, but before I could say anything, Tracy’s wife practically pushed her to the side and said, “I don’t care what his chances would have been.’ To which I replied, ‘Yes mam, you made the perfectly clear’, and I turned to sit and write my progress note.

Tracy’s wife went to his bedside and the other women remained outside his room, the taller one mumbling that this decision would never sit right with her.

I didn’t really know what to think about what had just happened. In reality, Tracy was likely terminal anyway since as soon as the ventilator was removed he died shortly thereafter. But his wife didn’t know that and I couldn’t be 100% certain he wouldn’t have survived either.

In the end I have to respect the family’s wishes even if I don’t agree with them… although most of the time I do.

Dying with Acceptance and Dignity

Chuck Durbin was one of those patients who always was appreciative of the care he received from his doctors.  (Though his warm acceptance of others extended not only to those that he knew, but to strangers as well.) Consequently every encounter with him felt nonthreatening even if all you had to give him was bad news. As a result he made me feel good about myself and confident I was doing the best possible job I could for him.

Chuck was 63 years of age and had been diagnosed with prostate cancer. Unfortunately cancer was not unfamiliar to him as his father had died from lung cancer and his mother, from colon cancer.

Three years ago during the course of a routine blood work, Chuck was found to have an elevated PSA, or prostate specific antigen. This is a very sensitive indicator of prostate cancer. In many cases when prostate cancer is first diagnosed, it is confined to the prostate and men have a number of treatment options available in an effort to eradicate and cure the cancer before it spreads.

Sadly, this was not the case for Chuck. His biopsy indicated extensive infiltration of the cancer and a further workup indicated the cancer had already metastasized to his bones. In fact he had soon developed metastatic cancer to his spine, pelvis and the femur bones in his legs. Yet Chuck kept upbeat and was determined to fight his cancer no matter what the odds.

Because the metastatic cancer in his spine was particularly painful Chuck underwent radiation treatments. He also received chemotherapy but because his cancer seemed to be refractory to the drugs he received he participated in several experimental protocols both here in Florida and in New York. But in spite of the efforts of all of his doctors and Chuck’s dogged perseverance, his cancer never went into remission.

And if that was not enough, as a result of the treatments he received, his bone marrow was damaged to the point that it would not produce the normal amount of blood cells necessary for everyday life. This meant that with a low red blood cell count he would feel tired; with a low white blood cell count he was at risk for infection and with a low platelet count he could spontaneously hemorrhage anywhere in his body.

It was because of this last problem that I came to know and become involved with Chuck Durbin’s care.

In receiving his chemotherapy, Chuck would occasionally experience nausea and even vomiting, but usually with some medication these symptoms would pass. This time they did not and because he also had developed a headache, a brain scan was ordered by his oncologist. The CT revealed a subdural hematoma, or a blood clot on the surface of his brain and so he was admitted to Mease Hospital.

Fortunately, surgery wasn’t immediately necessary.

When I walked into Chuck’s room in the ICU for the first time and introduced myself, he made me feel as though I had known him for ten years. In spite of his terminal condition he welcomed me as he would the rest of his family, who surrounded his bed. I reviewed the findings on the CT scan with him and told him that for the time being we would not have to consider surgery. As his headache had subsided with intravenous administration of dexamethasone he was grateful I wouldn’t have to drill any holes in his skull.

I followed Chuck for that week he was hospitalized, stopping by to see him on a daily basis even though there wasn’t much I could do. Despite the numerous transfusions which he received his platelet count remained low, too low to even consider surgery. In addition, because of the persistent low platelet count, there was a constant risk of further hemorrhage.

Although I would later discover surgery wasn’t something Chuck was willing to consider in any event.

Though he fought a long hard battle, he had come to the realization that the end was likely near. Not surprisingly, he did not become depressed… actually quite the opposite. He did however, make his wishes known to his wife Claire and their children. If the ‘time’ came he did not want any extraordinary measures and he definitely did not want to be resuscitated should his heart stop beating.

Over the years of performing neurosurgery, I have not always been successful, but my training has nonetheless conditioned my inherent being to want to save patients from death. I cannot always know what the outcome will be, so in most cases I do what I can and leave the rest in God’s hands. I have to admit this has not always appeared to have been the best approach. Often time’s, patients die anyway and the family rides a roller coaster of emotion having hope, then becoming distraught followed by the inevitable grief of the loss of their loved one.

Sometimes however it does give the family the opportunity to come to accept what has happened because things happened so quickly. Families would tell me, ‘We can’t believe it…just last week mom was fine without any complaints and even had gone bowling like she did every Monday afternoon’ and now, ‘without warning she is lying in a hospital bed in a coma’!

With Chuck, however, he, Claire and all his family were well aware of the terminal nature of his disease and knew this day would eventually come. Though they hoped it wouldn’t be so soon; in a way, they were ready.

So they all sat by Chuck’s side every day, every night, just talking and enjoying his company whenever his headache would permit. And though he had been comfortable for the first few days his headache seemed to be getting worse.

On Saturday I was making rounds in the Intensive Care Unit and Chuck’s nurse, Barbara came up to me and told me that he had become less responsive. One look at him from my seat across the hall told me all I had to know. His breathing had become labored and I knew this likely was the end.

I told Barbara to get a CT of the head, stat, and I asked for Claire’s cell phone number. I called her and told her of Chuck’s condition. She told me that she was on her way.

As soon as she got to the ICU the CT was completed. I reviewed the scan with her and showed her where there had been more bleeding in the brain and that the subdural hematoma had increased significantly in size. ‘Now’ I told her, ‘there was pressure on the vital areas of the brain stem controlling Chuck’s breathing and his heart’. She nodded in agreement… and acceptance.

I told her I would do whatever she wished, although surgery in Chuck’s case would be extremely risky and would probably not alter the events of what were now transpiring. She said, ‘No, he knew this was coming and he was ready’.

I went outside the room to the sitting area where the hospital charts were kept to write my progress note. Claire came out briefly to ask me, ‘Is he in any pain?’ Instinctively my military background took over as I looked up and said, ‘No, Mam’. She looked at me somewhat embarrassingly and said, ‘Please, call me Claire, and thank you for all you have done’ as she turned and walked back in to be at Chuck’s side.