Spiritual Experiences from the Brain

Walking with Jesus

Jesus said to him, “Rise, take up your pallet and walk.”

And at once the man was healed, and

he took up his pallet and walked.

 

Afterward Jesus found him in the temple, and said to him,

“See you are well! Sin no more, that nothing worse befall you.”

John 5:8-9, 14

 

In my last post I included a passage from Luke’s gospel that told the story about Jesus giving sight to a blind man. The key statement by Jesus was: “Receive your sight; your faith has made you well”. Here, Jesus heals a paralytic but the implication, to me, is not just that the man was able to physically walk, which certainly was a miracle, but that he should also walk in the footsteps of Jesus. And just to be sure the man ‘got it’; Jesus finds him later and clarifies what is really important in his new life by saying, “Sin no more, that nothing worse befall you”.

Recently, my wife’s mother Janice, who had been ill, past way. Because we had been on Cape Cod at the time we had a funeral service there. She was then cremated and when we returned to Florida we had a funeral mass here.

At both services I was asked to deliver a eulogy celebrating her life and the person she was. In contemplating what this was, I kept being reminded that the single most important characteristic of her life was the love she had for her children and later in life, her grandchildren.

A passage from John’s gospel clearly spoke of this to me; It was when Jesus gives his apostles a new commandment that they love one another as He loved them. He then tells them, “by this all men will know you are my disciples, if you have love for one another”.

And this is what Janice tried to become in her life… a true disciple of Jesus Christ.

After we got home to Florida, my wife, Stacy found a journal that her mother had kept. In one particular entry from several years ago, she spoke over and over about walking with Jesus. And how she regretted earlier in life not ‘seeing’ that this is what she should have been doing all along. Yet, she was grateful for finally realizing that this was the path she should be on.

I guess I knew she was close to God; after all He used her to touch and change my heart many years ago when cynicism and selfishness threatened to derail me off my path to help others using the gift God gave me.

But, and I am embarrassed to say so, because she wouldn’t come to church with us on Sunday I merely assumed God was not playing a big role in her life. It is ironic that in our efforts to be ‘good Christians’ we allow the evil one to cause us to be judgmental of others when they do not ‘appear’ to be the same ‘God-fearing’ people we perceive ourselves to be.

Of course she had very real health reasons that kept her homebound but I felt she should have made a better effort to be there. Jesus, I suspect would have been more loving and understanding than I. As it turned out she was walking closer to Christ than I was…

When she was 16, she had a vision while she was hospitalized. She recalled that God appeared to her surrounded by the brightest of lights with a child at His feet. She then heard Him say ‘Do not fear, I am here’. At the time it seemed to me she was more confused rather than inspired by what she had ‘seen’.

Later in life as she looked back on this experience, she regretted not allowing it to influence her decisions in life more. I guess we all have our demons that constantly struggle with the good inside of us. Jan worried a lot and as a result became very anxious. Often she found herself being critical and judging others which led to what she called ‘tears of frustration’.

She realized that often she was not always able to forgive others for what they may have done to her. Quite eloquently she wrote that because of this particular failing she had deprived herself of the gift of God’s love and forgiveness.

The one thing that Jan did excel at all her life though, was her love for all her ‘children’. Very much like Jesus, Jan did cherish the innocence and hope that is embodied in every child.

 

And calling to him a child, he put him in the midst of them

and said, “Truly I say to you, unless you turn and become

like children, you will never enter the kingdom of heaven.

Whoever humbles himself like this child, he is the greatest

in the kingdom of heaven.”

Matthew 18:2-3

 

Later in life though, through much prayer Jan reached out to God in the ‘truest form’ and as result came to truly know Him and as a result was able to not only walk in the footsteps of Christ but ‘with’ Him. Of course she realized her first steps had to begin with forgiveness and in this she found such peace and love.

About 10 years ago, Jan’s husband Don or as he was called by his grandchildren, ‘Pa’ was diagnosed with Alzheimer’s. Throughout this time, Jan devoted every waking moment to him right up until his last day three years ago. She missed him dearly but she continued her journey with Christ. Not that it was always easy…

Two years ago she was diagnosed with lung cancer. Initially it was thought because the tumor was so small it could be successfully treated and perhaps cured with a specialized form of radiation. And for a while she did well and continued to live her life to the fullest traveling to Cape Cod with Stacy and with our family to the cabin in North Carolina.

But earlier this year the cancer recurred and so we all were forced to face the reality that she would die, although the end came more quickly than we had anticipated.

As the summer approached she had wanted to make one more trip back to her home on Cape Cod. A repeat PET scan showed the cancer still had not spread so we felt she would be able to make the trip and we fully expected her to make it back to Florida before the end would come.

In fact she was so happy and gleeful to be heading back to Cape Cod that she seemed to have new-found strength that overcame the weakness of her illness. And as she crossed the Sagamore Bridge she had a sparkle in her eye and a smile ‘ear to ear’.

Sadly, as soon as she got home, she weakened quickly and practically before we could realize what had happened, she passed away on the 4^th of July with her family and friends surrounding her, as a final tear rolled down her cheek.

Watching and helping my wife take care of her in the last several months, as she became more and more dependent on Stacy for her care, it seemed as though she became more and more like the child that Christ wanted her to become that day in the hospital 60 years earlier.

Just this past week, Stacy lay to rest the ashes of Jan (or Mimi as the grandchildren called her) and Pa at home in Sandwich, Massachusetts. Together again, they are surrounded by the love of her Lord, Jesus Christ.

 

‘When a woman is in labor she has pain, because her hour has come;

but when she is delivered of the child, she no longer remembers

the anguish, for joy that a child is born into the world. So you

have sorrow now, but I will see you again and your hearts will rejoice,

and no one will take your joy from you.’

John 16:21-22

Quality of Life

Quality of life. This seems to be very important to most people when making decisions about a lot of things. Whether it is renovating a kitchen, taking a dream vacation or deciding whether to pursue various therapies for a medical condition that may or may not be curable.

In general, I operate on patients because their quality of life has been impacted negatively. Perhaps they experience pain from a ruptured disc in their neck or lower back. Perhaps they have developed severe weakness due to a brain or spinal cord tumor.

Sometimes, however, instead of improving a patient’s quality of life, surgery itself, may have an adverse impact leaving the patient worse off than before.

In particular, when I am removing a brain tumor, the dilemma I often find myself in is balancing this quality of life issue with my own ego.

You may find such a thought absurd, because of course a patient’s quality of life would always come first. But what you must understand is that it is because of my ego that I am able to do what I do. As such it is my ego that makes it possible for me to be focused and aggressively treat these life threatening tumors which would otherwise destroy the quality of my patient’s life anyway, and in the worst case scenario take it from them.

However if I go too far, the patient’s quality of life can be made worse, not better. Unfortunately, knowing where that cut-off point is… is not always clear.

Recently I took care of two patients where this was apparent in very different ways. Tom Davis had a large benign brain tumor that technically was so difficult it took me all day to remove it; and Paul Kinsey had an equally large but malignant tumor that extended so deep into the brain it took me nearly as long as Tom’s surgery.

After my initial surgical exposure of Tom’s 2 ½ inch diameter tumor, it quickly became apparent that the tumor was literally stuck to the brain. Not only that but it was densely adherent to the blood vessels that were responsible for providing circulation to the motor area that controlled the left side of Tom’s body.

So I knew I would be spending many hours with my eyes glued to the oculars of the surgical microscope tediously removing the tumor from theses vital structures.

It was perhaps half way through Tom’s surgery that I was becoming discouraged as I began to realize I might not be able to completely remove his tumor. This weighed heavily on my heart since he was only 36 and if I was not successful in doing so, the tumor would recur and very likely prevent him from being the father that his young children needed.

I was also becoming fatigued and as I had learned all too well when you become tired it is very easy to make mistakes that could have profound consequences. So, I stopped momentarily, closed my eyes and prayed to God that He would give me the strength and perseverance I would need to remove Tom’s tumor without causing any injury to the critical areas of his brain.

Roughly, ten hours after I began my attempt to remove Tom’s tumor I had successfully removed 98% of it with only a small amount of tumor adherent to two large blood vessels.

In fact when I zoomed out the microscope to get an overall view of the operative field, I was astounded. It appeared as though the tumor had simply rolled off the brain surface without any damage or discoloration of the brain cortex. I smiled as I shook my head, realizing I had just participated in a small miracle.

Tom did great following surgery and was discharged from the hospital four days later feeling better than he had in a while.

Two days later I operated on Paul and the difficulty I had was no less than I encountered with Tom’s surgery. The difference of course was that Paul’s tumor was a malignant astrocytoma and as such I knew there was no possibility that I could remove it completely. In addition, Paul was 66 and not 36.

So, at face value it would appear that the complete removal of Paul’s tumor was neither possible nor imperative. However, I also knew that Paul’s overall survival would be directly related to how much of the tumor I did remove.

In addition, Paul’s wife knew me and she had requested that I be the one to operate on him rather than my partner or the other neurosurgeon on call who was initially consulted to take care of him. So in reality I felt more than the usual amount of pressure to remove as much of the tumor as I could… safely.

And that is the ‘operative’ word here, safely.

In general the appearance of this type of tumor is distinctive compared to the normal surrounding brain tissue. The problem is it is not always easy to determine when ‘enough’ tumor removal is actually, ‘too much’.

So as I was operating three inches deep into Paul’s brain I contemplated how much more of his tumor I should remove. To a great degree my decision is based upon visual and tactile cues I get, but there is also a ‘sixth sense’. And this is when I pray to God to help me ‘know’ when enough is enough.

Postoperatively, I am not always satisfied with the extent of my resection based on the follow-up MRI. Nevertheless, I have to trust that I did my best. Although more importantly, however, I have to trust that I did what was best for the patient and for the quality of the life of that patient that remains.

In Paul’s case his postoperative MRI looked quite good and in fact he was playing a round of golf two weeks after his surgery. That knowledge made me feel good, as I smiled once again, realizing that I was part of another small miracle for the second time in the same week.

A Test of My Feelings, Fortitude and Faith

Hector Gomez fell at home and was found on the floor by his family so he was brought to the hospital and he was admitted for further tests. Because he also complained of numbness and tingling in his arms and legs, an MRI of the cervical and thoracic spine was ordered.

The results of the thoracic spine MRI prompted a call to me for transfer to Mease Dunedin Hospital. The radiologist said Hector had a tear in the tissue layer that enclosed the spinal cord. As a result the spinal cord itself had herniated through this opening and was trapped causing the numbness in Hector’s legs. This report startled the doctors taking care of Hector and so they wanted him transferred ASAP, figuring he would need surgery right away!

Personally, I thought the abnormality was actually a cyst of spinal fluid which surrounded the spinal cord compressing and it pushing forward, but either way it looked like Hector would require surgery. Unfortunately because Hector was obese and had numerous medical problems surgery would be technically difficult and risky. Nonetheless I instructed the transfer center to arrange transport of Hector to Dunedin.

When Hector arrived, not only did he have numbness and tingling in his legs, they were weak as well, although his right leg was slightly weaker than his left. But before I could consider operating I needed an additional scan. But because of Hector’s size we had to transport him off campus to another facility because he could not fit in the MRI scanner at the hospital.

The additional scan was unremarkable. I spoke with Dr. Lopez, the neuroradiologist who reviewed all of Hector’s studies and agreed the problem causing Hector’s numbness and weakness was a cyst compressing the spinal cord. With this confirmation I took Hector to surgery the following week. Micro-surgically I was able to remove the cyst and take the pressure off of Hector’s spinal cord. Immediately after surgery the strength in his legs was stronger than pre-operatively although it was not yet normal.

Since the hospital was full to capacity, Hector was kept in the Recovery Room instead of being transferred to the ICU following his surgery. This arrangement actually turned out to be a blessing in disguise.

The following day I happened to be performing a spinal fusion and Allen, Hector’s nurse came into my room about 3 pm with some disconcerting news. Suddenly, Hector began complaining of numbness from his chest down and now he was saying he could not move his legs at all.

I was somewhat unsure of whether to believe Hector was truly worse since the numbness he had before surgery had persisted even after the operation; and his strength was still not normal, having examined him earlier that morning. But Allen was insistent that there was a real change, for the worse.

I asked Chad who was scrubbed in with me to go examine Hector while I finished operating and let me know what he thought. He returned to tell me that Hector indeed was worse neurologically. Unfortunately we didn’t have time to get an MRI off campus because if Hector had a post-operative hematoma compressing his spinal cord we needed to act fast.

I instructed Chad to see if there was any way he could be scanned in the MRI scanner at Dunedin. Randy, the MRI technologist seemed to think we could try. Unfortunately, as soon as Hector saw they were going to try to scan him here he became fearful he would get stuck and had a panic attack.

When I arrived, Hector was in a full-fledged panic, screaming to the top of his lungs that he wanted to get out of there, while everyone stood around not knowing what to do.

I went to his side and tried to calm him down and impress upon him the importance of getting the test so we could help him. But nothing I could say seemed to quiet him.

He then began rambling and at first I wasn’t sure what he was saying but then it became clear…he said, ‘If I cannot move my legs, I cannot work, so I want to die’. I told him ‘no’, that I was going to help him walk again, although at the time that was the thing I was least sure about.

‘No, I want to die’, he kept repeating. As I held his hand I closed my eyes and prayed, ‘Dear God give me the wisdom to know what to say’. So I said, ‘Hector, Jesus loves you’ figuring this would get his attention and hopefully focus him on the importance of getting the tests we needed to determine if I had to take him back to surgery.

Instead of quieting him, he said, ‘No, He does not, He has forgotten me!’ I replied ‘No, He has not’, but that did nothing to get Hector off the ledge he had crawled out on to.

He then started saying, ‘I want to be with my mother’, to which I replied, ‘where is your mother?’, although I was certain I didn’t want to know the answer. ‘In heaven’, he replied. ‘I want to be with my mother in heaven’ and he said it over and over.

At this point I did not know what to do. I had failed miserably to calm Hector and I still needed to know what was going on with Hector’s spinal cord. I was very close to giving up but the thought of Hector being permanently paralyzed forced me to do what I had to do to help him, in spite of himself.

So I decided since we could not get an MRI scan I would order a myelogram. For this test the radiologist would inject dye into Hector’s spine. If there was compression of his spinal cord the normal flow of the dye around the spinal cord would be cut off. Fortunately, Dr. Lopez just happened to be at the hospital to see another patient and he was kind enough to agree to perform the procedure, even though he was not on call.

As I walked into the myelogram suite with some paperwork that had to be filled out, Hector looked at me and said, ‘Are you my friend?’ and I replied ‘yes’. He then grabbed my right hand and placed my index finger against his temple and said, ‘then you kill me.’ I took a deep sigh, said ‘No’ and turned to leave as Patrick, the anesthesiologist started the sedative infusion and Hector drifted off to sleep.

The myelogram test indeed revealed Hector had a blood clot pressing on his spinal cord, and at the time of surgery at the bottom of the very large hematoma I found a small artery vigorously pumping blood. With the hematoma removed and the pressure relieved, I coagulated the artery and closed, praying and hoping Hector would recover.

The following day the strength in Hector’s left leg was close to normal but he had no movement in his right leg. Both he and I were somewhat discouraged but I told him to keep trying to move it and I would continue to pray.

The next day, still no improvement but on the third day, when Chad walked into his room, Hector said, ‘I am so happy!’ Chad was slightly confused as he walked toward Hector’s bed with a quizzical look on his face. At that moment Hector lifted his right leg off the bed. When Chad told me, I said ‘man, now that’s a miracle!’

Within a week, Hector was walking with a walker with some assistance and was discharged to a rehab center where he continued to make progress and was then discharged home after about a week of intensive physical therapy.

For me, the most difficult part of taking care of Hector was not the stress of worrying about whether he would ever walk again; it was not knowing what to say to him when he wanted to give up. Granted at the time he was in such a state of high anxiety he probably wasn’t even aware of some of the things that he said. Nevertheless I wasn’t very inspiring either.

What I did do well however was knowing to listen to the angel tapping me on the shoulder telling me ‘Forget about trying to minister to Hector’s soul, and do what you do best. After all, God is depending upon you to take care of the sick for Him.’

‘But when he heard it, he said, “Those who are well have no

need of a physician, but those who are sick”’

Matthew 9:12

 

Perspective and What Matters Most

Perspective... ‘The occurrence of such a tragic event put everything in perspective’.

 I think for every one of us there has been one time or another that has put the everyday frustrations, disappointments, and stressful situations of our lives, ‘in perspective’. Maybe it was an encounter with a terminal cancer patient that made you realize that the chronic lower back pain you experience daily really wasn’t that bad. Or maybe when you found out your neighbor just lost his job and the home that protected his family that you realized your ‘dated’ kitchen really didn’t need that remodel you were planning.

Two weeks ago while at Sunday morning Mass, I received a call that would help me ‘put things in perspective’. A hospital in Brooksville, Florida had a patient in their emergency room, Harold Thurman who was brought in by his wife because he was acting strange and he seemed to have some difficulty ‘getting his words out’. A CT scan revealed he had four hemorrhages in his brain, one of which by report, sounded to me like it was big enough that it might cause him some problems without urgent treatment.

Because that hospital did not have a neurosurgeon on call they requested that Harold be transferred to my hospital so I could take care of him. I told them to transfer him right away. Of course I knew with the distance between our two hospitals and the difficulty getting emergency transport from the ‘field’ to make an inter-hospital transport, it would be hours before he arrived.

Later that afternoon, about 4, I called the CCU to check on the status of the transfer. Jackie answered and told me Harold had just arrived but what she said became worrisome to me. Earlier in the day when I spoke to the doctor at the Brooksville hospital, he told me that Harold had been awake when he arrived there and now Jackie was informing me that he was very lethargic. This suggested to me that Harold was lapsing into a coma. Clearly something would have to be done; I told Jackie I would be in immediately to evaluate him myself.

When I arrived I introduced myself to his wife Elaine, their son David and Elaine’s sister.  When I examined Harold I discovered he would open his eyes slightly and move his arms and legs but he could not speak and as soon as I stopped stimulating him, he would then immediately become unresponsive. To be certain his condition had indeed deteriorated, I turned to his wife Elaine, and asked her if his present level of consciousness was different from when she initially brought him to the hospital;  she nodded and said ‘Oh yes, definitely’.

I reviewed the CT scan from the other hospital and decided that because many hours had transpired since that one was done I would repeat it to see if any additional bleeding had occurred. Fortunately there was not, although the four hemorrhages together had increased the pressure within Harold’s brain dramatically.

The largest one was in the center of Harold’s speech area on the left side. I knew if I removed this hematoma it would reduce the pressure by the greatest amount but I also knew it was highly likely I would permanently damage any functioning part of his speech area that surrounded the hemorrhage.   

The best course of action was to let this hemorrhage resolve on its own which it would do if I waited several weeks. The problem of course was that Harold’s condition was such that if I didn’t do something to reduce the pressure within his brain he wouldn’t survive the two or three weeks to allow this hemorrhage to dissolve.

On the other hand there was a second hemorrhage that was located in the right frontal lobe and this was an area I could safely operate in without causing any appreciable damage to Harold’s brain function. This hematoma was moderate in size and was definitely putting pressure on the surrounding brain and causing it to shift from right to left, but I was not certain that removing it would help Harold.

I probably went back and forth from Harold’s bedside to the CT scan display no less than five times, agonizing over the decision I had to make. Logic told me that I should remove the large hemorrhage, but ‘something’ in the back of my mind told me the best thing for Harold’s survival and recovery was to perform a right frontal craniotomy instead.

I sat at the monitor one last time and prayed the Our Father asking for guidance. In an instant, the answer became clear. I told Chad, my physician’s assistant that we would go ahead with the right frontal surgery and at the same time I would place a ventriculostomy or catheter in the ventricle on the left side so we could monitor Harold’s intracranial pressure after the surgery. This would allow the nurses to drain some (cerebrospinal) fluid if his pressure got too high.

I went in to Harold’s CCU room and told Elaine of my decision and that I would be performing surgery immediately. She was hopeful that I would save Harold’s life, but I cautioned her that because we had no idea why the hemorrhages occurred in the first place there was no way to be sure that even if surgery was successful, that it wouldn’t happen again. She nodded affirmatively and thanked me nonetheless.

As I walked towards the elevator, I turned to Chad and said, ‘Man, a case like this certainly puts things in perspective’. What I didn’t say was how stressed out I had been over finances as of late, worrying over how I was going to pay the mounting bills when collections had slowed down to a bare trickle.

But here and now Harold was fighting for his life; and the decision I struggled over was truly a life or death one. This was a situation that truly deserved of a little anxiety; not worrying about something as trivial as bills. After all as long as I had my health and I could work, everything else would take care of itself.

So we walked off to the OR to get ready for surgery.

Initially I drilled a small hole in the skull on the left side and inserted a soft rubber catheter into the ventricle and the cerebrospinal fluid literally shot out. The actual intracranial pressure was near 300, with normal being around 95. When I removed the piece of the skull on the right to remove the hemorrhage, the brain was visibly swollen. I was actually relieved to see this because I wasn’t certain I would encounter much pressure since the large hemorrhage was on the opposite side of the brain.

After I evacuated the hematoma, the brain was relaxed and the pressure was normal.

When the surgery was complete I told the anesthesiologist to keep Harold on the ventilator and deeply sedated. Though the surgery went well I still was not particularly optimistic for Harold’s recovery because of the extent of the other hemorrhages, but we would find out once we allowed the sedation to wear off in a couple of days and allow Harold to, hopefully, wake up.

On Wednesday afternoon I went by Harold’s CCU room and ‘amazement’ would describe my feelings. I had discontinued the sedation early that morning, and because Harold became so alert, the pulmonologist had removed the ventilator that had been breathing for Harold while he was on the anesthetic drip. Not only was he sitting up slightly in his bed but when I asked him how he was doing he said ‘OK, how are you?’, and when I asked him what his name was, he told me without hesitation.

What you must realize is that when Harold initially was brought to the emergency room he was globally aphasic which means he could neither understand what was spoken to him nor could he speak himself. This of course was not surprising to me because the large hemorrhage was right in the middle of his speech area. But this was not the hematoma that I removed!

As I finished writing my daily progress note in Harold’s chart I looked up to see Dr. Raja, the pulmonologist walking down the hall. As he walked toward me he remarked, ‘Well, he seemed to be awake enough so I extubated him’ as he gestured in the direction of Harold’s room. ‘Yeah’ I replied, ‘but the fact he is speaking is a miracle!’ He nodded somewhat quizzically and continued walking past me toward his next ventilator patient.

I was somewhat disappointed that he did not appear to acknowledge God’s hand in Harold’s recovery but, as long as I did then at least I could keep things ‘in perspective’.

Blind Faith and Praying For a Cure

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

‘And Jesus answered them,

“Go and tell John what you hear and see:

the blind receive their sight and the lame walk,

lepers are cleansed and the deaf hear,

and the dead are raised up,

and the poor have the good news preached to them.

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

Matthew 11:4-6

Illness, Prayer and My Summer Vacation

 

This past week we had been on vacation. It was to be a road trip of sorts and one of the stops was to visit with my parents who at 88 years of age were celebrating 56 years of marriage.

 

It didn't turn out the way we planned and in fact we had quite a scare.

 

I have been on the other side of medicine a few times in my life. It always gives me an appreciation of what patients feel when they have to give up total control to someone else, who literally has your health and in some cases your life in their hands. Nothing can prepare you, however for what we as parents went through when our little boy became so sick that he wound up being admitted to the hospital for the first time.

 

During my internship in general surgery and my residency in neurosurgery, I never liked pediatrics. It wasn't that I didn't like children but dealing with anxious parents was ten times, no one hundred times worse than dealing with adult patients or even their families Of course at that time in my life, I could care less about the 'feelings' of my patients or their families. I considered it extraneous to becoming 'the most talented neurosurgeon on the planet'! In retrospect, it is ironic that I have come to realize that allaying the fears and anxieties of my patients and their families, often times, from a spiritual perspective is even more important than what my hands can accomplish.

 

So, I was keenly aware of the difficulty of being a pediatrician but it wasn't until this past week that I came to fully appreciate how important the care they provide truly is. Of course without the nurses and physician assistants that surround them, their job would be next to impossible. I say this because not only did they have to get our boy well, they also had to, and this is the hardest part, calm my wife and me down and convince us that they would do just that.

 

Upon arriving to Connecticut, Michael was feeling fine. That night after dinner, however he developed a fever. I didn't have a thermometer at the time but experience told me his temperature was certainly over 101 degrees. I began administering Tylenol every few hours or so but his fever didn't seem to break. The next day he only seemed to get worse and he began to develop severe gastrointestinal symptoms along with nausea and vomiting. Not only could I not get any Tylenol in him but because he would not drink any fluids, he was becoming dehydrated too. When his temperature hit 105, I knew it was time to go to the hospital.

 

On arrival to St. Mary's Hospital, I told the woman at the desk what the problem was and she immediately rushed us back. The nurse took his temperature and fortunately it was down to 103. They immediately got him a bed in the pediatric section of the Emergency Room and within a short period of time a seasoned nurse came back and effortlessly got an IV in his arm and drew blood for the necessary lab tests. I knew he was sick because he hardly put up a fight even when he saw the nurse coming with the IV needle and tubing in her hands.

 

Soon the pediatric ER doctor came back and told us they suspected he might have appendicitis. The thought of our little boy having surgery began to raise our anxieties and my blood pressure. 'That just couldn't be', I thought. 'His abdomen was so soft without any of the signs of an inflamed appendix'. But after all, I was just the dad who happened to be a neurosurgeon, not the pediatric surgeon. So we waited.

 

Soon, the surgeon, Dr Zarif came in and examined him. He impressed me as experienced and his demeanor was calm and comforting. He looked at us and told us he did not believe Michael had appendicitis but that he would need to be admitted for intravenous hydration and continued observation. We were somewhat relieved but still concerned because our boy was still so sick. Fortunately, it just so happened the pediatric floor of the hospital was actually owned and staffed by Connecticut Children’s Hospital.

 

Our worries however were far from over. I spent the next two nights helping to take care of Michael, getting up every one or two hours helping him get to the bathroom as I navigated his IV pole and then washed him afterwards.  It was a though he was an infant all over again completely dependent on my wife and I for his care .

 

By the following morning as a result of the frequent trips to the bathroom along with the occasional episode of vomiting, he began to experience abdominal pain. Dr. Zarif still did not believe he had appendicitis but rather a severe form of gastroenteritis and colitis. So he consulted a pediatrician, Dr. Jennifer Gannon, who was in contact with the pediatric gastroenterologist in Hartford, Connecticut.

 

Soon we were also told that Michael also had blood present in his urine which could represent a complication of the gastroenteritis, called hemolytic uremic syndrome. Quick research on my part revealed this syndrome could result in kidney failure and in worst cases, heart failure, or coma. And because many of the more effective pain medications could increase the likelihood of this potentially life threatening complication, the doctors and nurses were unable to use anything stronger than Tylenol.

 

It was agonizing for us. There was nothing we could do to make him feel better and it seemed that there was nothing the medical staff could do to either. We just had to wait it out.

 

On the second day of our hospitalization, I picked up a publication of the Connecticut Children’s Medical Center, called ‘Pediatric Matters’. It told a story of a 7-year-old boy who survived an illness much more severe than our son’s. As a result he was selected as a ‘Champion Child’ to represent the medical center as part of the ‘Children’s Miracle Network’ program designed to raise awareness of the specialized health care and research supported by the Children’s Miracle Network and its affiliated hospitals, like the Connecticut Children’s Medical Center.

 

I have to admit I was a bit sleep deprived when I read this but the use of the word ‘miracle’ struck me. The story did not mention faith, religion or prayer but to me the implication was clear. What we could do for our boy was to pray. Not that we would have ever considered not praying, but the urgency of our prayer was never more certain to me in that moment.

 

And not that our prayers would be any less important to God than the next person, but I do believe that the more people who pray for you the more meaningful the prayer is. And that is the interesting thing about Facebook. As a social media it allows people to communicate across the world to friends and strangers alike, though much of the information is often pointless. However, in this situation… in this crisis we found ourselves in, instead, it became a network of people who not only passed along their thoughts and concern but also prayed for us. I have to admit, however, this was not my observation but that of my wife, Stacy, once again reminding me that I don’t know everything.

 

We also found it comforting to be near my mother. She has always been a deeply religious and prayerful person. In fact she initially entered the convent before deciding that her true vocation would be to raise a family. Recently I needed her prayers and she was there for me and now she was there to pray for our son.

 

On the fourth day of our hospitalization, the staff was getting prepared to transfer Michael to the main hospital campus in Hartford for a colonoscopy and biopsy as the diagnosis was in doubt. That afternoon the third and final culture returned positive for Salmonella (the first two were negative) so the transfer would not be necessary. And almost as soon as we were told the results Michael became well. His temperature became normal, his abdominal pain subsided and he wanted to eat. The following day he was discharged and by the looks of him you would never know he had ever been so sick.

 

So our thanks go out to our family and friends for their prayers, and to Dr. Zarif and Dr. Gannon and all the nurses and physician assistants for their part in our little miracle.

 

‘And whatever you ask in prayer, you will receive, if you have faith’

Matthew 21:22

If Healthcare is a God-given Right, How Can We Possibly Consider Rationing It?

 

It was Thursday night and I was just getting ready to go to bed. It was 11 pm and I turned my phone on to see if I had missed any messages. I wasn’t on call for emergencies so I had my phone set to vibrate. When I looked at the phone I saw that I missed a message at 9:11. Actually no one was on call for neurosurgical emergencies that particular evening.

So, when David Osgood arrived at the ER with an abnormal brain MRI scan which was done as an outpatient earlier that day, Kelly the ER nursing director sent out a text to see if any of the staff neurosurgeons were available to take care of him. I tried texting her back but got no answer so I called the ER directly and spoke with Dr. Feusner who was on duty. She told me that arrangements had been made to transfer David to another hospital but that he was still there at Mease.

I told her it wasn’t necessary to transfer David and that I would be available to see him first thing in the morning. So she cancelled the transfer and arranged to have him admitted to Mease Hospital.

David was 67 years of age, married with three children, two daughters and a son. He had recently developed a facial droop on the right side of his face and also was having some difficulty speaking. It wasn’t that he couldn’t speak; it was just that he had trouble getting some of his words out. He also had weakness of his right arm which began at the same time as his speech problem. Initially his doctor thought he had a stroke, but when the MRI scan was performed it was clear his symptoms were not due to a lack of blood flow to his brain but a tumor located right in the center of his frontal speech area, on the left side of his brain. Dr. Feusner told me David had a tumor; I just didn’t know the tumor likely was inoperable until I walked into David’s room the next morning.

As I entered his room, David was lying in bed and his wife Marjorie was at his side. They only had a vague idea of what the MRI showed and were certainly hopeful that despite what was in his brain, there would be a treatment for it, even if it required surgery. I picked up the MRI folder and turned to the window as I began pulling out the films one by one, holding them up to the sunlight to see what kind of tumor David had and where it was located. I too, was hopeful that there was something I could do for David, but as I looked at the scans, my heart sank. Because of where the tumor was located, surgery would almost certainly worsen David’s problem speaking, or aphasia. In other words, he would be able to understand what was said and perhaps even know in his mind what he wanted to say but wouldn’t be able to verbalize a single word.

And to make matters worse, this tumor was most likely a malignant astrocytoma. Given this diagnosis and the inability to aggressively remove the tumor made it likely that David would have 6, perhaps 12 months to live.

Knowing all this, I now had to turn away from the window and face David and Marjorie. Times like this are probably the second most difficult conversations I will have with a patient and their family. I have to be honest, yet at the same time I must give the patient hope. And as I stood there, during the first few seconds while I contemplated what I was about to say, I thought how can I possibly project a hopeful outlook?

That’s the thing about these conversations…patients listen to what I say but more than anything they study my facial expressions and how I deliver the message to determine if there is something I am not saying.

I explained to them what kind of tumor I thought it was, and the fact that even with an aggressive surgical resection, tentacles of the tumor would likely be left behind. The problem was, I told them, that because of where the tumor was located, it might not be possible to safely remove any of the tumor. I asked if I could have some more time to study the films further and that I would return later in the day to speak with them again. ‘Of course’, they said in unison. So I took the MRI scan and walked back to my office.

I told Chad my PA about David and what his MRI scan showed and asked what he thought I should do. I knew I was the only one that could make that call; he merely shrugged his shoulders and said, ‘well you could debulk it ‘, although he and I knew too well the possible implications of that.

I returned to David’s room later that afternoon to speak with him and Marjorie although at this point I still had not completely decided what I would do. In part, this is because the phrase’ ‘Do no harm’ is more than just a cliché to me. By this time his children had arrived and surrounded his bed. I began by repeating most of what I said earlier in the day since David’s children had not been there. At one point David asked, ‘How much time do I have?’, only because of his aphasia it came out more like, ‘How much light is there?’ Not wanting to take away all hope and yet at that moment realizing what I needed to do, I told him if we did nothing he might have 6 months. If I operated and removed as much of the tumor as I could safely, inserted some chemotherapy wafers in the brain and post-operatively he received radiation and additional chemotherapy, he might have 12 – 18 months or possibly longer. Through the tears he and his daughters were shedding, he said ‘OK, do it’!

‘Why are you cast down, O my soul,

and why are you disquieted within me?

Hope in God; for I shall again praise him,

my help and my God.

Psalm 43:5

Immediately following surgery, David’s ability to speak had worsened somewhat although it slowly improved during his stay in the hospital and when Francy, my nurse saw him for an incision check 10 days later his speech was back to where it was when I first met him.

Only time will tell whether I appreciably lengthened David’s life here on earth. Which brings me to a thought? With all the concern over curbing the rising cost of medical care, if we know that, statistically, a patient’s survival from a malignant astrocytoma will not be long, do we withhold treatment? Personally I think this would be wrong…dangerous…and evil. Because then we would be playing God, essentially determining the worth of a human life. It is one thing for a patient or the family, if the patient is unable to make that decision, to decide enough is enough, but the only other one to make that decision should be God, not us.

As I have pointed out before, extending one’s life even 3 months can be a miracle if allows a human hurt to healed or gives family the opportunity to say goodbye, at least for now.

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)

 

 

Mental Telepathy and a Miracle in OR #4, continued

 

As I moved the tumor away from the spinal cord I saw what appeared to be nerves within the wall of the tumor… and they were cut. ‘That’s impossible…it couldn’t be’, I thought. ‘It just didn’t make sense’. Immediately I thought the pathologist’s interpretation had to have been wrong. It must be a tumor that arose from the nerves themselves and not a meningioma. So I took a biopsy from another area of the tumor and sent it to him for reexamination. Several moments later the pathologist called back into the room and said it was indeed a meningioma.

So I inspected the area between the tumor and the spinal cord again. Perhaps, I thought, the tumor arose from the dura laterally and as it grew slowly toward the spinal cord it displaced not only the spinal cord but the sensory and motors nerves along with it. The thing of it was, I couldn’t trace these ‘nerves’ back to the spinal cord where the motor nerves exit en route to the biceps muscle in Annie’s right arm.

Perhaps these ‘nerves’ were actually sensory nerves that were pushed down by the growing tumor toward the motor nerves and then looped backed on themselves to join the other sensory nerves. Regardless, I thought, because they were so adherent to the tumor wall, they were very likely permanently damaged anyway and not functional.

To be sure, I stimulated them with a nerve stimulator but there was no response.

It is at times like this during a case that I stop what I am doing and reassess the goal of my surgery…the purpose for subjecting this lovely elderly woman to a major operation. Sure it would have been nice to be able to completely remove the tumor, but to do so would have been, at least in part, to gratify my ego as the ‘best neurosurgeon on the planet’! No, my reason for operating in the first place was to decompress the spinal cord or to remove that pressure that was threatening to permanently damage Annie’s spinal cord and paralyze her from the neck down. And I had already accomplished that.

Besides this was a slow-growing tumor and Annie was 84-years-old, so the likelihood this tumor would grow back and cause any significant problems in the time that Annie had left was remote. Not to mention to extend the length of time Annie was under general anesthesia at her age would only increase the risk of post-operative complications.

And so it was at this point I decided that ‘the enemy of good is better’!

This is a truism that I have learned pertains not only to surgery but life as well. Often times we attain an acceptable outcome in whatever we may have set out to do and any attempt to attain ‘perfection’ only serves to undo all the good we have already accomplished. And so at times like this we should be happy with the ‘good’ we have done and we must bury our pride when our ego wants to be ‘better’.

As a safety measure, instead of merely suturing the dural tube closed, I inserted and sutured in place a tissue graft to enlarge the diameter of the dura. In this way, if the tumor did grow it would have twice as much space and thereby lessen the likelihood it would ever cause undue pressure on Annie’s spinal cord.

Immediately after the surgery, when Annie awoke from the effects of general anesthesia, I went into the Recovery Room to examine her. To my grateful surprise, the strength in her right arm and hand was completely normal! There was no abnormality or deficit of sensation or motor function. It actually was not the first time I have expected a neurologic problem post-operatively only to discover there was none.

Perhaps, those nerves were not working to begin with or that they were redundant and not needed, or perhaps it was just miraculous. Regardless, the way in which the events of Annie’s surgical procedure transpired certainly affected what I did surgically. And I am convinced that was the true miracle…that Annie came through the surgery fine, without any complications.

Soon after I checked on Annie, I went out to the surgical waiting room to speak with Jill. I sat down and began to describe to her the events of surgery. Half way through she interrupted me and said ‘you know, it seemed to me that the surgery was taking a long time so I said to myself, I wish he would just remove the part of the tumor that was compressing the spinal cord and not worry about trying to get the entire tumor out’. To which I replied, ‘well, that is exactly what I did’. Jill promptly smiled and thanked me for everything I had done. I reassured her that her mom was resting comfortably in the recovery room and was doing fine, her strength was normal and that she would be up and about in no time.

And so I left to make rounds feeling blessed that I listened to my conscience and the angels that always whisper in my ear, hoping I will listen.

“Do nothing from selfishness or conceit, but in humility count others better than yourselves. Let each of you look not only to his own interests, but also to the interests of others” Philippians 2:3-4

Mental Telepathy and a Miracle in OR #4

Annie Carter is a very pleasant, spry 84-year-old woman who had been quite healthy all her life. So she was a little surprised when her doctor, Dr. Thomas sent her to the Emergency Room because she thought Annie was having a heart attack. For several days she had been experiencing some pain in her upper back, across her shoulder blades. She didn’t have chest pain or left arm pain radiating up into her jaw, the typical signs of a heart attack. And she certainly didn’t have the sensation that an elephant was sitting on her chest! If anything it felt like a horse kicked her in the back. She had an EKG performed, blood drawn for tests and was admitted to the intensive care unit. The cardiologist examined her and reviewed the results of all her tests and concluded she did not have a heart attack. In fact her heart was healthier than someone half her age! Of course none of that surprised Annie. She was then discharged home.

Nevertheless, she continued to have these pains and in fact they worsened in severity becoming burning in quality as well. She also developed some tingling in her right arm, oh and by the way she had been experiencing some numbness in her right foot as well, which she had forgotten to tell her doctor initially. Because of this Dr. Thomas ordered an MRI of her cervical spine, thinking Annie had to have a pinched nerve or two in her neck. Well she had more than a pinched nerve. When Dr. Thomas called with the results of her scan, Annie was more than a bit surprised when she was told she would need to see a neurosurgeon…she had a spinal cord tumor that could paralyze her at any time!

When I saw Annie in my office she was accompanied by her daughter Jill, who was a carbon copy of Annie, just younger. They both appeared young and vibrant, and Annie certainly seemed much younger than her 84 years. When I examined her it was clear to me she had something compressing her spinal cord, as there were early signs of spinal cord damage.

I then brought up the images of her cervical spine MRI on the computer in the examination room and began to review the findings with Annie and Jill.

The cervical spine is made up of 7 roughly block shaped bones (or vertebrae) that sit on top of one another. (The first and second vertebra, however, have a slightly different shape, but nonetheless sit in line with the others.) Separating these blocks are the discs, or spongy-like shock absorbers that also allow the spine to bend forward, backward, side to side and also twist or rotate. Each spinal block has two small bones that protrude backward from each side, kind of like the walls of a house. Every house, of course needs a roof, so on the back side of these small bones is a gable-like roof that encloses the space called the spinal canal. It is here that the spinal cord is protected, enclosed within a sheath of tissue called the dura, which is shaped like a tube. Within this tube is also the cerebro-spinal fluid which bathes and cushions the spinal cord. Within this spinal canal the spinal cord travels from the brain down to the rest of the body.

The bony spinal canal in Annie’s neck was approximately 1 inch in its widest diameter. The spinal cord occupied about half of this space. The tumor was located at the level between the fifth and sixth vertebrae within the dural tube, on the right side, and was twice the size of the spinal cord. Because of it size it deformed her spinal cord and pushed it to the left. In spite of her age I had to do something to lessen this pressure before the tumor caused significant paralysis of her arms and legs.

Fortunately, based on its appearance on the MRI scan the tumor was benign and not cancer.

I spoke with Annie and Jill about the surgical procedure and the risks involved, and though I told them the risk of paralysis was small, it was always a possibility. They understood and wished to proceed with the operation.

At the time of surgery, I cut away the roof of the house of the spinal canal at the fifth and sixth level. Having peeled away the tissue layer enclosing Annie’s spinal cord, the spinal fluid flooded my surgical field. After I suctioned this fluid away, I could easily see the tumor squashing Annie’s spinal cord. At this point I moved the operating microscope into position in order to be as precise as I could be removing the tumor. Protecting the spinal cord with tiny cotton sponges, I biopsied the tumor. Shortly afterward, the pathologist confirmed the diagnosis; it was a benign tumor, a meningioma.

On the surface of the tumor were the small nerves coming from the spinal cord, which supplied sensation to Annie’s right arm. On the bottom side of the tumor, I knew had to be the nerves supplying the electrical signal to the muscles in Annie’s right arm that would allow her to grasp her coffee cup in the morning and bring it to her mouth so she could drink it.  Damage to these nerves would have devastating consequences, especially since Annie was right-handed.

I then proceeded to remove the tumor using an ultrasonic probe, similar to what a dentist uses to clean your teeth, but this one not only disrupts the tumor tissue, it sucks up the tumor cells essentially shrinking the tumor from the inside. In this way the walls of the tumor can be collapsed and thereby dissected, or moved away, from the spinal cord and its nerves.

Some spinal tumors which arise from the nerves of the spinal cord invade and encompass these nerves, which prevents removal of the tumor without cutting or sacrificing them. Meningiomas, in general push away the spinal cord and its nerves and while it may be difficult to dissect those nerves away, using the surgical microscope, it is possible.

When I had removed a majority of the tumor and could push the wall of the tumor away from the spinal cord I was able to see on the other side of the tumor, expecting to see the motor or muscle nerves passing along the back side of the tumor and out through their opening in the spinal canal traveling to Annie’s right arm. When I did so, however, I was quite literally shocked at what I saw….