Spiritual Experiences from the Brain

Hearing a Voice in the Wind

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

John 3:8

Walking on Water

'but whoever denies me before men, I also will

deny before my Father who is in heaven.

Matthew 10:33

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Patient Who Became 'My Brother'

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

An Unusual Way to Die

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

‘he will cover you with his pinions,

and under his wings you will find refuge;’

 

‘For he will give his angels charge of you

to guard you in all your ways.’

Psalms 91:4, 11

Dying with Acceptance and Dignity

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

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

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

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

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

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

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

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

Fortunately, surgery wasn’t immediately necessary.

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

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

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

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

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

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

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

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

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

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

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

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

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

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’.

 

A Malignant Tumor, and Support for the Caregiver

Carol Edwards was 67 years old. When I first met her she appeared socially proper and refined, and she was dressed impeccably. Her husband, Thomas had been diagnosed with a brain tumor a year previously, and had undergone surgery at the Henry Ford Hospital in Detroit, Michigan. The surgeon was able to remove most of the tumor visible on the MRI scan and not surprisingly, Thomas recovered without any neurologic deficits. Unfortunately the diagnosis was that of a glioblastoma multiforme, which is the most malignant form of brain cancers. He received radiation and was started on chemotherapy and because he had done well and his follow up MRI did not show any tumor recurrence, he and Carol decided to come to Florida for the winter.

Shortly after arriving in Dunedin however, he began experiencing some neck pain. His doctor figured that he probably had some arthritis in his neck since he was 69 and suggested he see a chiropractor. Within a few weeks he also began experiencing some numbness and tingling in his arms and legs and began having difficulty walking. His doctor then ordered an MRI scan of his cervical spine and this revealed the presence of a tumor within the center of his spinal cord extending from just below his brainstem to the level of the sixth cervical vertebra. This most certainly represented a rare but not unheard of spread of the glioblastoma from his brain. He was sent immediately to my hospital for neurosurgical evaluation.

After I finished operating for the day I went to the emergency room that evening to evaluate Thomas and it was there I met his wife Carol and their daughter Audrey. I explained the location of this tumor was perhaps too risky for surgery and that most  neurosurgeons in private practice, myself included only rarely see patients with tumors in this location let alone one that had spread from a glioblastoma in the brain. I prescribed a steroid medication to control the swelling in the spinal cord that likely would occur as a result of the tumor.  I then offered to call his neuro-oncologist in Detroit first thing in the morning to inform him of the latest developments in Thomas’ condition and ask what he would recommend, since they were contemplating returning to Michigan for any additional surgery or treatment.

After speaking with the neuro-oncologist and explaining the location of the tumor he merely said palliative radiation would be the only course of action which Thomas could just as easily receive in Dunedin, Florida as he could in Detroit, Michigan. He thanked me and told me he would communicate that to Carol by email right away.

I stopped by Thomas’ room that evening and Carol told me they had decided to remain in Florida for the radiation treatment. I assumed that Thomas would be discharged the following day to carry out the radiation as an outpatient, so I was surprised to see he was still in the hospital two days later. I learned that the radiation oncologist was reluctant to begin radiation without a biopsy and so was arranging to have him seen by another neurosurgeon at the university teaching hospital in Tampa for the biopsy.

Two days later I printed up my patient rounding list and was surprised once again to see that Thomas was still in the hospital. I figured a course of treatment was in place and my assistance was no longer needed so I deleted his name of my list. I went about my rounds seeing my post-op patients and then proceeded to leave the hospital. As I was getting ready to walk out the door, I heard a voice in my head saying, “go back and see him”. I thought to myself, “why?” “Perhaps” I thought, “no one would do the biopsy so if it needed to be done I certainly could do it”. So I turned around and went back to the hospital ward on the second floor.

I arrived at Thomas’ room to see Carol sitting by his bed. She appeared a bit flustered and was hurriedly straightening out folder full of papers that undoubtedly she accumulated during this recent hospitalization. Thomas was sound asleep as he had been most of the other times I had stopped by. When she saw me, she relaxed. I asked her what was happening and she told me the doctors had performed a spinal tap and because cancer cells were identified, the radiation oncologist decided a biopsy would not be necessary and that Thomas had received his first chemotherapy infusion that day and would begin his radiation tomorrow.

I said, “OK, I just wanted to stop by and check in, to make sure everything was progressing, as far as Thomas’ care”. I merely expected her to say, “oh yes, thank you”, but instead she reached out for my hand, with tears in her eyes and said, “thank you so much for stopping by”. Taking care of a loved one who is terminally ill is such an enormous task and can be completely draining emotionally even for a normally strong-willed individual, such as Carol. It is at times like these that caregivers need as much care and support as the patients they look after.

As I left Thomas’ room and walked down the hall on Hospital 2, I realized how important those few minutes that I spent with Carol were. And once again I became convinced that voice inside my head was one of my ‘angels’ keeping me on the path that God put me on.

Remembering what is best for the patient.

I was in the office seeing patients the other day and as I looked at my patient list for the day I saw one of my patients was listed as having a brain tumor. As a private practicing neurosurgeon most of what I do in the operating room is treating patients with either disc problems or bone spurs in the cervical and lumbar spine. I enjoy helping these people, but the reason I became a neurosurgeon was to operate on the brain.

So when I saw the David Albright had a brain tumor, I was actually excited. What David reminded me of however, was that I must always temper my surgical judgment with what is truly best for the patient.

In my eagerness to see David, I only glanced at his chart and failed to review the attached documents from his doctor. So, as I asked how long David had the symptoms of headache and dizziness, he began by telling me since shortly after he the IV port placed for his chemotherapy. Immediately I realized his problem was far more serious than I had initially thought.

As it turned out David was diagnosed with a cancer of his kidney, several years before. After surgery and chemotherapy, it appeared his cancer was in remission. Within the last year, however he was found to have metastatic disease or spread of his cancer to his bones and his lung, and the oncologist told him it probably wouldn't be long before it went to his liver and brain. So he was placed on another regimen of chemotherapy in the hopes it would shrink the tumors that had already spread and prevent the possibility of further metastasis. That was when he developed the headaches and dizziness which was causing him to stumble a bit to his left when he walked.

So, David had a brain MRI which revealed an abnormality in his brain on the right side. Initially looking at the scan the radiologist believed this represented a relatively benign, abnormal collection of blood vessels, but looking at it myself, I was not so sure. Given David's history and the fact that there was some swelling in the brain I believed this represented a tumor, and not a benign one, but one that spread from his original cancer.

So I sat down with David and his wife Christine to discuss options about what to do. Surgery, I told them would be risky given the tumor's location, which was close to the area of the brain that controlled the left side of his body. Also, I told them with the presence of some abnormal blood vessels in the area, the risk of a brain hemorrhage would be fairly high. That is when David interrupted me. He told me, 'Doc, at this point I am more interested in the quality of life I have left, not to see how many operations I can survive'. I could hardly agree with him more. So, I stopped talking and merely sat there, looking at he and Christine and listened as they recounted the events of the last several months. After they were done he looked at me and said, 'Doc what would you do if I were your father?' Immediately, and without hesitation I said, 'I wouldn't operate on you, Dad'.

As they got up to leave, I apologized, saying I was sorry there wasn't anything I could do, but then I said, 'if it is OK with you, I would like to keep you in my prayers'. David immediately turned around, looked me in the eyes, as he grasped my hand and said, 'Absolutely, thank you'. 

We cannot hear if we don't listen.

How well do we listen?

I speak for many reasons. Sometimes I have an idea to share, often because I have command to delegate, occasionally I’ll speak up so as to not be the only person in that meeting who hasn’t said anything, and perhaps not infrequently because I like to hear myself talk.

To be sure, speaking is an essential part of communication but listening is probably more important. Listening allows us to fully appreciate another’s point of view and it allows us time to formulate our ideas more carefully. But, in some cases if we don’t listen closely enough, we may miss an important message.

It was September of 2004. Darius Hall had just returned home from evening church service and was opening the door to his home when someone called out to him from the house next door. A man on the porch asked Darius if he could come over and help him move a piece of furniture. Being the kind and considerate person that he was, Darius said ‘of course’. As Darius walked through the front door, the other young man directed him towards a room at the end of a long hall. Little did Darius know there was another man in that room with a metal pipe ready to beat Darius so the two strangers could rob him of his possessions.

I wasn’t on call that night, but as I sat at my computer, something prompted me to go online and check the CT scans that had been that evening. I reviewed Darius’ brain CT and saw a large blood clot pressing on the left side of his brain. I called the ER and told them I would take care of him. The ER doc was extremely grateful because he was having a difficult time finding another hospital to transfer Darius to, for emergency neurosurgery.

As I was operating on Darius that night I became conscious of the thought that I was supposed to be there that night saving his life. That Darius had some important purpose to fulfill in his life which would have been impossible if I had not checked the brain CTs earlier, ‘for the heck of it’. A few days later I felt compelled to share this with him. Though he seemed to have a look of doubt on his face, I knew in my heart this was true, that it was not just a coincidence.