Spiritual Experiences from the Brain

Hearing a Voice in the Wind

I had just finished my second case of the day, a cervical fusion, when Chad, my PA got a consult to see a patient at Countryside Hospital.

Aaron Cook, 81 had been diagnosed with multiple myeloma, which is cancer of cells in the blood that accumulate in and weaken the bones of the body.

Chad had spoken to the nurse and was told, Mr. Cook was paralyzed in his legs.

An MRI of his spine revealed that the cancer had replaced most of the bones of his spine. In his mid back, the cancer had weakened so much of one of the vertebra that it crushed upon itself. As a result the bone and cancer cells were pushed back into Mr. Cook’s spinal cord causing his paralysis.

Given Mr. Cook’s age, his paralysis, and the appearance of his MRI my initial reaction was that there wasn’t much that could be done. I spoke to his physician, Dr. Reynolds, who told me Mr. Cook had initially presented with severe back pain.

But because the cancer was so widespread it was concluded by the oncologist and radiation specialist that any treatment would be palliative, which basically meant the cancer could perhaps be slowed down but not cured.

Dr. Reynolds informed me Mr. Cook had been in the hospital about ten days receiving radiation treatments to his spine. ‘The excruciating back pain that he had on admission had subsided’, he continued, ‘but now he was unable to get out of bed because his legs were paralyzed’.

I told Dr. Reynolds that it was unlikely anything could be done surgically to help Mr. Cook but that I would go by and evaluate him if he wished. He said that would not be necessary. He just wanted me to look at the films and let him know if there was anything that should be done.

As soon as I hung up I was called back to OR room #4 for my next surgical case of the day. I finished up operating at about 6pm, and after I dictated my surgical note and checked on my post-ops I thought about Mr. Cook. I knew I wasn’t expected to see him but I felt compelled to drive over to Countryside Hospital and see him nonetheless.

As it turned out I had performed surgery on Mr. Cook’s wife many years earlier so he knew me, and in fact, he was expecting me. As I talked to him about how he wound up in the hospital he told me that up until about 4 weeks ago he was just fine. He and his wife had gone over to the Florida east coast but because he ‘just didn’t feel right’ he told his wife they needed to cut their trip short and return home.

When I was given his history earlier in the day I just assumed he had been diagnosed with multiple myeloma several years ago and that now his MRI revealed the end stages of the disease. But he had just been diagnosed 10 days ago.

When I examined him, I discovered he was ‘paralyzed’ in his right leg but that the strength in his left leg was only mildly weak. I then discussed with him options and prognosis. ‘In most circumstances such as yours I would remove the crushed vertebra and replace it with a metal or plastic cage filled with bone’, I told him. ‘Then I would place screws and rods in the spine above and below the fractured vertebra to stabilize it’, I continued.

‘But because the cancer had affected so much of your spine, I can’t do any of that. And because of your age, I’m not sure you would survive such an extensive surgery anyway’, I concluded.

‘So, what does that mean’, he asked. ‘Well’, I said hesitantly, ‘I’m not sure you will ever walk again’.

Choked up, Mr. Cook said, ‘Oh my God, my wife is too ill to take care of me…’ Looking down at him lying in his bed, still in pain and unable to get up and walk, I was sorrowful, wishing there was something I could do, yet realizing surgery was too risky.

I told him I was sorry and that perhaps with continued radiation treatments, he still might get better, although I knew this was not likely.

As I stood at the nurse’s station writing my progress note in Mr. Cook’s chart, I felt compelled to look at his MRI scan again. As I flipped through the images I thought to myself, ‘there’s got to be something I could do that might help’.

I called Chris, one of my colleagues to discuss his case. He too, agreed that Mr. Cook at 81 years-of-age would never survive a major surgery. But perhaps if I removed some of the bone from the back part of the spine, he suggested, this would free up enough of the pressure on the spinal cord so that his strength might improve to the point where he could walk again.

I thanked him, hung up the phone and walked back into Mr. Cook’s room.

I told Mr. Cook that I had given his problem more thought and there was something I could do surgically that might help him. ‘However, while I cannot promise you it will be successful, I think it may be worth the risk’. Not surprisingly he was willing to take that chance.

I spoke to Dr. Reynolds and explained my plan who then agreed to have Mr. Cook transferred to the hospital where I would perform surgery in the morning.

Surgery went well and though the cancer had destroyed most of that particular vertebra I was able to relieve the pressure on Mr. Cook’s spinal cord. Over the ensuing weeks following surgery Mr. Cook gradually regained strength in his leg and began to walk using a walker and some assistance.

For me, Mr. Cook’s case reinforced to me the importance of several things. The first is that nothing replaces talking to and examining the patient myself.

Not only does this allow me to get a real sense of the patient’s problem but also helps me to understand the true impact of the illness on the patient and his (or her) life.

In Mr. Cook’s case I initially dismissed ‘out of hand’ that anything could or should be done surgically in someone who had widespread cancer. However after speaking to him I realized he was living a normal life just 2 weeks earlier. Not only that but his wife was very ill herself and there was no way she could take care of him.

So as I stood there leaning up against the counter at the nurse’s station, I felt a change of heart. Was it merely my sense of compassion… or was it an angel, or the Holy Spirit that inspired me, reminding me I was given my gift to help others.

And so, grateful once again for be able to hear that voice in my head, I did what I could to help Mr. Cook, and his wife.

“The wind blows where it will, and you hear the sound

of it, but you do not know whence it comes or whither

it goes; so it is with every one who is born of the Spirit.”

John 3:8

Walking on Water

'but whoever denies me before men, I also will

deny before my Father who is in heaven.

Matthew 10:33

When people are sick they will say most anything if it means getting well, and if I should happen to ‘cure’ them of their affliction, they often heap ‘praise’ upon me that makes me feel at the very least uncomfortable.

They will say things like, ‘you walk on water’ or you’re a miracle worker. Most times when this happens I am caught off guard and I struggle for something polite to say. I have said things like ‘no, last I checked only two people were able to do that and I wasn’t one of them’, or ‘I'm not the one who works the miracles’.

I often pray that the Holy Spirit will inspire me and give me the correct words to say but it doesn’t always seem that my words are said with conviction.

The odd thing about this type of encounter, is that when these patients say these things, they seem visibly upset when I deflect their ‘words of gratitude’. I sort of understand this because I may appear to them as ungrateful. But while I am truly appreciative of their recognition of what I had done for them, I just can’t accept what they are saying as a ‘gospel truth’!

Perhaps they say these things because they are so overcome with emotion they don’t know what to say. But in part it may be because their faith is not strong enough to acknowledge where the true source of healing comes from. The irony, of course, is that many years ago I would have completely agreed with them.

Human emotion being what it is, we like to be complemented on our accomplishments, particularly when it involves saving someone’s life. But I am always mindful of the fact that I am able to do what I do because I have been blessed by God with intelligence, talent and a 'sixth sense'.

On the other hand, there are other patients that have said to me, ‘I thank God for putting you in my life to help me’, and those times I am in complete agreement.

Recently however, I took care of a woman who said something that really startled me.

Theresa Purvis had been diagnosed with and treated for breast and lung cancer, and surprisingly had done well. That is until she developed a headache and became somewhat confused. An MRI of her brain did not reveal a metastatic tumor, per se, but evidence that the tumor may have spread somewhat surreptitiously to cerebrospinal pathway around the brain.

I was asked by her oncologist to perform a simple procedure, a spinal tap, to obtain some fluid which would be analyzed to see if in fact the cancer had spread to the brain.

To be sure that Theresa would be as comfortable as possible and that I wouldn’t encounter any difficulty with the procedure, I arranged to have it done in the operating room instead of at her bedside on the regular ward. This way she could be easily sedated and I would have available all the supplies I might need.

Everything went very smoothly, and I was done in less than 15 minutes. Of course Theresa had been lightly sedated but when I stood up and leaned over her to tell her I was done, she had a surprised look on her face. Amazed, she said, ‘you’re kidding, right?’ I said, ‘no, I’m done’. She then said boldly, ‘you are God’!

‘No’, I replied. ‘I’m just here to give Him a hand’.

Perhaps it was the medication she received or maybe it was the cancer that had infiltrated her brain, but she appeared to dismiss my remark and turned back to lie down on the stretcher.

Nonetheless, afterwards I felt deeply grateful that for the first time I was able to say the right thing at the right time, regardless of whether the patient was inspired by my remark or not. After all there were others nearby, nurses, doctors and perhaps a patient or two that may have overheard what I said.

In the end we never may know the full impact of what we say or do on the lives of others. All we can really do is try to be the best version of ourselves and have faith that others follow our example.

A Chance Encounter with a Patient... or an Angel?

A few weeks ago I was in the mall and I saw by a big, tall man with a cane. He limped slightly as he walked. As I passed by, I looked at him and realized he was somewhat familiar, and old patient of mine I thought. I smiled and mouthed ‘Hi’ as I continued on to my destination, a health/vitamin store.

As I turned from the shelf from which I grabbed a box of fitness bars, I was startled because that big tall man was right there in front of me. He must have walked softly because I didn’t hear him come in. Of course there were two other customers at the counter and the sales girl talking so that must have covered up his footsteps.

He began, ‘Doctor Colbassani?’ I said ‘Yes’. He said, ‘You still doing that brain surgery thing? Feeling slightly uncomfortable with it being put that way, I nodded yes.

Up close his size was more readily apparent. He was over six feet tall (although he was bent slightly forward leaning on his cane) and weighed at least 260 pounds. When he reached out to greet me I felt dwarfed by the size of his hand.  Face to face he reminded me of my father’s cousin who used to play for the New York (football) Giants.

‘You may not remember me’ he said; to which I interrupted, ‘yes, you are familiar, but it has been a long time’. ‘1996’, he said. He then continued, recounting his recollection of when he first met me…

‘I remember lying in my bed in the ICU when you came in and said’, ‘You are lucky to be here’. And I said ‘What do you mean?’; Then you said, ‘You should be downstairs’. ‘Downstairs, what’s downstairs?’ I asked you. Then you told me, ‘the morgue!’

At this point I felt a bit embarrassed, because I didn’t think I would ever say such a thing, at least not in that manner. But, given my arrogance at that time of my life, I might have said just about anything.

 ‘Then you told me you were going to have to operate but that I probably would not survive the operation anyway, but that I had no choice. And I remember my wife standing outside my room with our pastor and they came in and he prayed over me.’ ‘It’s hard to take the knee but sometimes you have to’. To which I replied, ‘Well sometimes being on your knees is the best place to be’.

The interesting thing about this encounter was, here was this big tall grizzly-like man speaking to me and not quietly, but no one else in the store turned around to look. You would think the words ‘brain surgery’ or ‘morgue’ would pique someone’s attention to look over.

As he continued to speak of his problem and my treatment of him I gathered he had a severe problem in his spine, and at this point I vaguely began to recall his illness. He mentioned something about having a high fever and an elevated white blood cell count, so I remembered he had an abscess pressing on his spinal cord.

‘So you did the surgery’, he continued, ‘and I did survive and my temperature became normal and my white blood cell count dropped to normal as well. But when you came in to my room the next day you said, ‘OK you made it through but you will never walk again’. ‘Well here I am and I guess not doing too bad.’

Usually when I encounter patients that I have treated, if they come up to speak to me, it is usually to say thank you. But this gentleman never said that, and yet it didn’t seem like he wasn’t being critical of me either.

I have been to that mall hundreds of times since 1996 and never once saw that gentleman before so I’m still not certain why I had this chance meeting with him. In fact I had just finished in the office and it was late, and I was going to forgo going to the mall but my wife told me, ‘no you should go and check out that bed we were thinking of buying’. As I was leaving that particular store, I saw the GNC store out of the corner of my eye and figured I would go and buy those protein bars I had been meaning to get.

At one point he asked me how my family was which I found curious, because in 1996 I was not married and though I did have a daughter and a son, I had not yet starting dating my wife seriously at that time.

When he finished his story, I still felt a bit uncomfortable, perhaps even a bit guilty, so I shook his big hand and told him ‘Well it was good to see you and I’m glad to see you are doing well’, to which he lifted up his cane and shrugged his shoulders. Struggling for something else to say I blurted out ‘Well, it is still a good day when you’re upright and able to walk’ (And I’m glad I was wrong about that too, I thought).

That night when I got home I searched my records for this gentleman’s name. I had my notebooks of my surgical cases from 1988 through 1998 but for some reason I had misplaced the one that had the list for 1996. At the office the next day I asked about the medical charts for patients that year and was told after 10 years the charts were destroyed.

So here I was at a loss to find out what was this man’s name, and why our paths had crossed the night before.

Although as I think about it, I’m not sure any of that matters. Of course we always want to know the reasons why things happen but sometimes it is just best to trust in God that there is a reason and leave it at that. I do realize that is not enough nor is it possible especially when tragedy strikes our lives. We feel despair, we are confused, and angry all at once.

And at those times it may be difficult to believe God truly loves us but it is precisely at these times when He wants us to turn to him for comfort and peace.

Now I am not certain how it is that my story which began with a chance encounter with an old patient of mine turned into comments about loss and grief, but it did. I am not sure of the reason anymore than I know why I met that man on that night at that particular time. Maybe it was to keep me from being somewhere else had I just gone into the store, bought my protein bars and left.

Or maybe while he was grateful for what I had done for him, he really needed remind me that I didn’t have all the answers and I wasn’t the one with power over life and death.

It is likely I will never know, at least here on earth. I just trust God sent him as an angel to be there for me.

 

‘he will cover you with his pinions,

and under his wings you will find refuge;’

 

‘For he will give his angels charge of you

to guard you in all your ways.’

Psalms 91:4, 11

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.

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

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

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.

 

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)

 

 

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.

Brain death and spiritual inspiration

Diana Baxter was a 76 year old woman who one day developed weakness in her left arm and leg. Her family took her to the nearby emergency room where she was diagnosed as having a stroke. Since it had been a very short time since the onset of her symptoms (weakness) the Emergency Room doctors decided she was a candidate for a specialized form of treatment, called intravenous tPA, which is short for tissue plasminogen activator. Essentially, this medication is injected into the blood stream and it dissolves the blood clot occluding or blocking off the blood vessel in her brain that caused the stroke in the first place. Within minutes of receiving the drug, Diana's paralysis reversed. She no longer was weak on her left side. A 'miracle'. Unfortunately, this medication is so effective it often thins a patient's blood too much. Shortly after her weakness disappeared, she began to complain of a headache. The nurses taking care of her became concerned and asked Diana how bad was her headache. She told them it was getting bad and before she could say anything further, she became comatose. The doctor was notified and he immediately intubated her or put a tube down her mouth and into her trachea, hooking her up to a ventilator since she could no longer breathe for herself. A emergent CAT scan was obtained and this clearly revealed the reason for her coma. In the area of her stroke on the right side of her brain Diana had developed a hemorrhage or blood clot within the brain. Because of the effects of the tPA it had ruptured out from the brain and into the space surrounding the brain called the subdural space. Since the bleeding would not stop, it began to accumulate and put pressure on the brain and the vital areas of her brain stem. By the time I was called to evaluate her, there was already damage to her brain. Nevertheless, in attempt to save her life and in the hope this damage could be reversed I took her emergently to the operating room to remove the blood clot. Although Diana could feel no pain, the anesthesiologist administered general anesthesia and I quickly positioned her on the operating room table. I shaved the entire right side of her head and scored a giant reverse question mark in her scalp with the back of a scalpel to indicate where I would make my incision for real. The scalp was then then prepped as I scrubbed my hands in the sink just outside operating room #4. After the operative field was draped out, I made my incision in Diana's scalp and as I did so I applied bright blue plastic semicircular cylindrical (Raney) clips to the edge of the scalp to control bleeding. Prior to the surgery, Diana had been given numerous medications as well as plasma to reverse the effects of the tPA and help thicken her blood so it would clot normally. At this point in the procedure there was very little excessive bleeding so I was somewhat encouraged. This reassurance would be short lived, however. As soon as I drilled a hole in Diana's skull, the underlying dural layer between the skull and the brain beneath was penetrated, and dark venous blood burst forth as if I had cut into the carotid artery. I quickly took the bone saw and cut out an 8 inch piece of Diana's skull. Normally when I perform surgery such as this to remove a blood clot pressing on a patient's brain the source or site of bleeding is easily identified. Once the bleeding is stopped which usually can be achieved very quickly using a cautery forceps the remainder of the surgical procedure is no longer like a 'Chinese fire drill' but a calm, systematic process of irrigating or washing out of the rest of the blood, reapplying the bone and suturing the scalp. On this particular evening I was afforded no such respite. In fact no matter what I did, the bleeding continued unabated; not only that but the bleeding came from everywhere. I inspected every area around the brain, gently retracting it to visualize all of the major blood vessels that I thought could be responsible for this torrential pouring of blood from Diana's brain. I even resected a portion of the temporal lobe where the bleeding began but still the bleeding persisted. Despite calling upon my 20 years of experience I could not stop the hemorrhage. At one point, I gently packed a soft spongy material called gelfoam which was soaked with thrombin (which helps promote the clotting of blood) peripherally around the brain and this seemed to control the bleeding but then the brain began to swell uncontrollably and the surface of the brain began to spontaneously bleed itself. I finally had to concede there was nothing further I could do. After years of mending and saving lives I was confronted, head on, by the realization that I was no longer in control, Despite thinking I could save Diana's life, I had to accept that I could not and that it was not in God's plan to do so. This did not however, assuage the feeling in my gut that I had failed. I replaced the bone flap, securing it with plates and screws and sutured the scalp, knowing that Diana already was brain dead.
The walk to the waiting room that night was a long one, knowing I had to give the worst news possible to her family. What happened however was not only unexpected but even given the circumstances, somewhat uplifting. I finished explaining to her son and daughter what had transpired and how I had done all I could but I still could not save their mother's life. As I was getting up to leave her daughter turned to me and said "thank you for helping people and God bless you".
How do you respond to kindness like that? Despite being exhausted and feeling utterly dejected at that point I immediately felt comforted. I turned to her, thanked her and gave her a hug.
This experience has taught me that God is always there to comfort us, no matter how bad the situation is and that he will often use others to extend that comfort and so we too must be ready to be instruments of that comfort ourselves.

"who comforts us in all our affliction, so that we may be able to comfort those who are in any affliction, with the comfort with which we ourselves are comforted by God. For as we share abundantly in Christ's sufferings, so through Christ we share abundantly in comfort too." 2 Corinthians 1:4-5