Spiritual Experiences from the Brain

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.

Guilt, Gratitude and a Good Laugh

‘Then our mouth was filled with laughter,

and our tongue with shouts of joy;

then they said among the nations,

“The Lord has done great things for them.”

The Lord has done great things for us;

we are glad’

                                 Psalms:126:2-3

 

I pray for many things. The thing of it is that what I pray for isn’t always what I need’s God’s help for. Fortunately He is merciful enough to help me anyways…and my realization of this shows me He has sense of humor too!

 

Quite a while back I operated on a gentleman, Grant Lisset, who had a brain tumor. Unfortunately the surgery did not go as I had planned. At the time of surgery I encountered an unexpected degree of brain swelling which prevented me from removing the tumor completely. Not only that but postoperatively, Grant, my patient, who entrusted his life in my hands developed paralysis on his right side and an inability to speak.

 

After his initial recovery he gained back his ability to speak and a significant amount of strength in his arms and legs to the point where he was able to walk with assistance.

 

Ultimately, a second surgery resulted in removal of the remainder of his tumor, although I had felt guilty…no, remorseful that I wasn’t able to completely remove his tumor the first time without complication. What had transpired during his first surgery likely would have happened to anyone else who might have operated on him but I, still, felt personally responsible.

 

The thing of it is that my approach to a difficult case is directly influenced by my experience with the one that preceded it. So, when Barbara Nelson came to my office with a similar tumor to what Grant had, I hesitated, initially, to even do the case. However, the tumor had increased by 40% over a year and a half period so despite her age of 81 years, it had to be removed.

 

What made the decision somewhat easier was because of her advanced age I knew I didn’t have to achieve a complete resection. This was because radiation could be administered following surgery and would, in all likelihood prevent it from recurring during her remaining lifetime.

 

In addition the tumor was right on the surface of her brain and from a technical standpoint would be (relatively) easy to approach surgically and remove. Nonetheless, I prayed hard for God to guide my mind and hands that I might successfully remove Barbara’s tumor.

 

The tumor was located essentially in the back of her head on the left side, just above the occipital part of her brain which is responsible for her vision. The only difficult part of the surgery would be exposing the tumor because it was right up against the superior sagittal (venous) sinus which runs in between the two hemispheres of the brain.

 

Essentially, the arterial blood which carries oxygen and nutrients is transported to the brain by the carotid arteries. After the arterial blood passes through the brain it becomes venous blood and drains into the superior sagittal sinus on its way back to the heart. Should any damage occur to this venous sinus the build-up of arterial pressure in the brain can cause a major hemorrhage or worse, death.

 

So it was critical for me not damage the superior sagittal sinus as I removed the skull overlying it to expose Barbara’s tumor.

 

As it turned out the surgery was ‘textbook’. I completely removed Barbara’s benign tumor and she was on her way to the recovery room less than four hours after I started the procedure.

 

The irony of my day in the OR, however, lay with my next case, where I would need every bit of God’s answer to my prayers!

 

It was by every indication a routine case. On Wednesday, the week before Deborah Grant had come to my office complaining of severe pain that started in her neck and radiated down her right arm into her hand. She described the pain as ‘a searing type pain that felt as though it was deep within the bones of her arm’ and nothing she did, not the medication, the therapist nor the chiropractor had lessened the pain a bit.

 

In addition her index and middle fingers were completely numb and when I examined her, the muscles of her right arm were severely weak as well. When I looked at her MRI the reason for her signs and symptoms was clear. She had a ruptured disc between the 6^th and 7^th vertebra that was literally squashing the nerve up against the bony opening through which it normally passed easily.

 

Having successfully removed Barbara Nelson’s tumor earlier in the day, I was feeling quite confident (perhaps even a bit prideful) so I figured correcting Deborah’s cervical disc problem would be a ‘walk in the park’ by comparison. In fact what happened couldn’t have been further from the truth!

 

I had just finished removing the majority of Barbara’s disc and with the use of the operating microscope I was closely inspecting the back part of the disc for a small tear in the ligament that separated the disc itself and the nerve root. Ninety-nine percent of the time I would have expected to find a fragment of the disc that had torn and ruptured through this ligament to put such excruciating pressure on the nerve traveling into Barbara’s right arm…but I found nothing.

 

Immediately I had a sense of dread come over me…I must be at the wrong level! Quickly I looked at the x-ray I had just taken…1, 2, 3, 4, 5… 6 and 7. No, I was at the correct level. But where was the herniated disc! I turned to review the MRI scan. Yes there was the fragment on the scan but why couldn’t I find it surgically?

 

In most cases a cervical disc will herniated more towards the central part of the spinal canal but in Barbara’s case it was far out to the side. Just beyond this was the vertebral artery which is similar to the carotid artery but it travels close to the spinal column to the base of the brain. Once, many years ago while performing a cervical disc surgery I punctured the vertebral artery and I had never witnessed such extensive hemorrhage before or since.

 

And I didn’t want to ever see that kind of bleeding again.

 

But I really had no choice at this point in Barbara’s surgery. I had to make a cut in the ligament to see if the fragment of disc was hiding beyond my surgical view. So I took a deep breath, said a quick prayer and then taking a micro-surgical instrument I separated the fibers of the ligament until I punctured through….

 

Fortunately there was no bleeding but what I did see created a sigh of relief…the fragment of disc I had agonized over not finding for the past 20 minutes! In fact as I probed out along the nerve root I found several large fragments.

 

As I stood there peering through the oculars of the surgical microscope it occurred to me I needed God’s help on this case a whole lot more than I did with Barbara’s brain tumor. And it was that case that I was way more fearful of doing in the first place. I really had to laugh at myself over that one.

 

God really does have a way of getting our attention. And I guess this day He reminded me that even the most ordinary, every-day, run-of the-mill events of our individual lives can be the most important or possibly the most treacherous if we take them for granted.

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’.

Muppets in the Brain

 

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

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

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

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

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

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

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

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

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

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

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

 

Rock and Roll, and a Prayer

 

‘You can’t always get what you want,

But if you try sometime you just might find,

You get what you need’

Mick Jagger, 1968

 

I can’t recall how many times I have heard this song, but these words are forever embedded in my brain, coming to forefront of my thoughts from time to time.

There was the time about 10 years ago, when my neurosurgical practice was in disarray and I was facing many obstacles. I actually had seriously considered quitting practicing altogether. Through the course of many events I found myself at a men’s retreat at my parish church. Early in the morning of the first day I sat, somewhat nervously, at a table with about 7 or 8 others. Joe, our group leader quickly made me feel at ease, as he was the embodiment of love and acceptance, seeing the good in everyone. We started out the morning reading a scripture from the bible, one I should remember but I cannot. Joe asked us what we thought Jesus was saying to us in that particular passage. Almost immediately and without thinking, I said, ‘You can’t always get what you want, you get what you need’.

As it turned out, by the end of the weekend I discovered that what I did for a living was not merely a job it was a vocation.  I had been given the talents to help and heal others and this was truly a gift from God. And even when my hands could not heal my patient’s bodies I was in a unique position to help them emotionally or spiritually. And while I had ‘wanted’ to quit doing it I realized what I ‘needed’ to do was to fight through whatever adversity I had because in relative terms they were minor in comparison to the problems of the patients I was asked to treat.

For many years I thought of neurosurgery as a means to inflate my ego and to monetarily provide me with the lifestyle I wanted. But now, I came to the realization of my true purpose as a brain surgeon; that there were a great many more things I was not only capable of but had a responsibility to integrate into my practice and my life.

Many of us, me included think we know what we want even to the point of praying for it. We certainly don’t want to get sick or get a brain tumor but it happens anyway…

On Wednesday I saw a woman in the office, Kathy Poster who is 62 and is a diabetic. “A brittle diabetic’ she told me. By this she meant that her diabetes was extremely hard to control…that her blood sugar could be over 600 or less than 50, before she would even know it. She told me that she frequently would wind up in the hospital for days on end when her diabetes got out of control which happened regularly. Though she had been diagnosed about 10 years ago she is considered a Type I diabetic.

To look at her you wouldn’t think she had diabetes. She is thin and without any other medical problems. In fact when her doctor in Massachusetts sat down with her to tell her she had diabetes, she said, ‘you’re full of s___, no one in my family has diabetes so how could I have it.’ I told her while I had Type II diabetes I had the same reaction, only I didn’t use the ‘s’ word.

But with being repeatedly sick and in the hospital with diabetes Kathy had become angry and depressed. ‘Why couldn’t this one or that one (in my family) have gotten it instead of me’, pointing her finger back and forth as if those family members were sitting in front of her.

But as of late, with help, she had learned to let go of her anger and in fact she had me smiling and laughing the entire time she sat in my office.

So how is it that any good can come from Kathy Post having diabetes or Tom Tremain (March 8, 2010) (or any of the other patients I take care of)  having a malignant brain tumor and how is it that any of this can be can possibly be what we need. I guess it just depends upon our perspective. As I have mentioned before, we often hang on to our life here on earth with clenched fists and anything that diverts us from our ‘wants’, be it sickness or family turmoil often times causes us to become angry and to grip tighter.

‘We know that in everything God works for

good with those who love him, who are

called according to his purpose’

(The letter of Saint Paul to the) Romans 8:28

 

Yesterday I had a talk with my son because he had disobeyed his mother. I explained to him that his mother and I were placed here on earth by God to take care of him and to guide him until he was able to take care of himself (or until our guidance was no longer needed, though I did not tell him this). I went on to tell him that when he disrespected his parents he was also making Jesus unhappy too, because God was the one who picked his mother and I to take care of him. He seemed to understand and appreciate what I had said and then went about swimming in the pool.

I know that when God’s use of me as a neurosurgeon is done then something likely will happen that will prevent me from continuing to practice. And I know that when God’s use of me here on earth is done He will take me. When that time comes it may be a sad time for those I leave behind or it may be a time that was anticipated and embraced by those that remain. Either way I have to believe that it will be for the ‘good’ and ‘according to his purpose’  

I’m not certain if Mick Jagger and Keith Richards were trying to be philosophical or even spiritual, or whether the verse just sounded right but I don’t think many rock lyrics have ever been as close to something Jesus might have said than these.

In fact, He did… '"And in praying do not heap up empty phrases as the Gentiles do; for they think that they will be heard for their many words. Do not be like them, for your Father in heaven knows what you need before you ask him. Pray then like this:

Our Father who art in heaven

Hallowed be thy name.

Thy kingdom come,

Thy will be done, On earth as it is in heaven.

Give us our daily bread;

And forgive us our trespasses, as we have forgiven those who trespass against us;

And lead us not into temptation,

But deliver us from evil"'

Matthew 6: 7-13

A Confession

 

I have a confession to make.

In my last post, “Decision, Direction and the Holy Spirit”, I made the following statement: “And having operated my way out of seemingly impossible situations many times before it is easy to understand how I would come to believe that I am indeed the ‘most talented neurosurgeon in the world’”.

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

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

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

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

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

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

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

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

Decision, Direction and the Holy Spirit

 

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

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

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

Seek not what is too difficult for you,

nor investigate what is beyond your power.

 

   For their hasty judgment has led many astray,

and wrong opinion has caused their thoughts to slip.’

    Sirach 3:18-21, 24 

 

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

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

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

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

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

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

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

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

John 20:27-29

 

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

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

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

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

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

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.

Unquestioned Trust in God

 

Just the other day, I was in an exceptionally good mood, and found myself whistling at work, as I was running up the stairs heading towards the OR to begin my surgical cases for the day. Immediately I found myself transported back 36 years to Botany class during my freshman year at Fairfield University. My professor at the time, spoke out somewhat rhetorically (as he had a difficult time looking me or anyone else in the eye) that whistling was not allowed. He said ‘whistling did not promote a professional atmosphere in the scientific laboratory and was prohibited’.

I actually had to agree with him at the time. Scientific inquiry had to be precise, rigid, and devoid of all emotion. And whistling was certainly an emotional act of happiness, contentment and glee…and certainly there was no place for these sentiments in a scientific laboratory…right?   

Even at 18 years of age, I guess I was still juvenile and naïve. And so began my official desensitization that would be advanced during medical school and then ramped up into overdrive in my neurosurgical residency.

Children, of course are without any prejudice or barriers, just innocence. They accept without question what they are taught. Their belief in things that are seen and unseen is true and unwavering. As we mature we become responsible and conscientious and as we advance our intellectual curiosity we begin to question and doubt. After all that is the scientific method, is it not? The unfortunate thing is that we also question and doubt the truthfulness and honesty of those around us. And as we become skeptical we may even become cynical. We may even question the very existence of God.

Of course, for me, I must be analytical and critical and there is certainly no place for being childish in the operating room…. I remember a particular case well. It was 1992 and I had just begun my practice of neurosurgery in Palm Harbor, Florida. I was on call for neurosurgical emergencies at Mease Hospital in Dunedin when Alex Goodman was brought in to the emergency room by EMS. Alex was 32 and had been working out in the gym when he had the sensation that a bomb had just gone off in his head as he was bench pressing 225 pounds.

Shortly after his arrival a CT scan of his brain revealed a massive hemorrhage from a ruptured brain aneurysm. I ordered a cerebral angiogram which showed me the location of the aneurysm. I had to operate immediately and place a clip across the aneurysm to prevent it from rupturing a second time which almost certainly would be fatal.

The surgery had been textbook right up until I was getting ready to ‘fire the clip’ across the neck of the aneurysm. As I was reaching for the titanium clip, the most improbable chain of events occurred. The aneurysm ruptured and the light bulb on the operating microscope I was using burnt out at the same time.

At a time like this there is no room for a temper tantrum, and I couldn’t lose my composure simply because Alex’s life was slowly slipping from my hands as arterial blood poured out of the opening I made in his skull. I calmly told Liz, the circulating nurse to pull the microscope away from the operative field and replace the light bulb. I inserted a large-bore suction into the operative field to remove the blood that Alex’s heart was pumping through the tear in the aneurysm wall and I instructed the anesthesiologist to use his finger tips to compress the carotid artery in his neck to slow down the flow of blood. Simultaneously a second anesthesiologist began administering two pints of blood intravenously to replace what blood Alex was losing through the ruptured aneurysm in his brain.

Somewhat surprisingly a light bulb was readily available and I was peering through the oculars of the operating microscope less than five minutes later. The hemorrhage was profuse and I was unable to completely suction the blood from the operative field. Fortunately I had an image of the carotid artery and the aneurysm indelibly burnt in my brain so I inserted the clip through the pool of blood towards the spot where I thought the neck of the aneurysm was and released the clip. Immediately the hemorrhage stopped and as I quickly inspected the carotid artery, its branches and the aneurysm, I discovered the clip was in perfect position. Post-operatively, Alex was fine and completely unaware how close he had been to dying.

During my residency, our mantra was ‘just deal with it’! No excuses, no whining, you just had to be able to take care of the situation at hand, no matter what.

So, be it scientifically or surgically there is a necessity for the lack of emotional involvement. Over time however, as my religious faith has deepened and as I have become closer to God, through Jesus Christ, I have come to realize that spiritually, not only it is difficult to separate human feelings from what I do, it is imperative that I remember my patients are human beings not merely surgical cases!

However during a time of crisis I almost have to forget that I am operating on a person. I have to look at it as a problem that must be solved…quickly. But when it is over and I am done I must once again have empathy for my patients and their families, regardless of the outcome. I have to embrace the innocence inside of me and them.

‘And they were bringing children to him, that he might touch them; and the disciples rebuked them. But when Jesus saw it he was indignant, and said to them, “Let the children come to me, do not hinder them; for to such belongs the kingdom of God. Truly I say to you, whoever does not does not receive the kingdom of God like a child shall not enter it”’. Mark 10:13-15

So, as I was whistling, I was on my way to operate on David Osgood who had a malignant brain tumor located in his speech area. It was a risky surgery but I was confident in what I had to do and feeling blessed I was certain that God would guide my mind and hands, to do what was needed.