Spiritual Experiences from the Brain

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.

Margaret Dempsey and Nursing Home Hell

 

Margaret Dempsey found herself in a bad place at a bad time of her life.

She was 82, had undergone several back surgeries as well as two hip operations and one on her right knee. Despite all these surgeries, and perhaps to a degree because of them, she was still in a lot of pain, pretty much all of the time. To make matters worse, her husband had a stroke and was in a nursing home.

Margaret, who could barely take care of herself, certainly was unable to tend to her husband’s needs and so she, somewhat reluctantly, resigned herself to being in the nursing home as well. At least it was the same one as her husband so she could see him every day. But that is where the bright spot ends. Because she had complete control of her mental faculties she could fully appreciate the dismal existence of living there. In fact, she told me that no one at the nursing home believed she had anything wrong with her, and they disliked her because their poor care of her didn’t go unnoticed.

Unfortunately, for most patients and their families, a nursing home is a necessary evil. Patients are generally too ill or weak to go home and families don’t have the facilities or the capabilities of taking care of their loved one in their home. And despite the fact that some nursing homes promote themselves as ‘rehabilitation centers’, it is a thinly veiled guise of their real nature…they are still nursing homes. (Which is kind of ironic, because they often times provide no nursing care whatsoever!)

In fact, it would seem that the lack of ‘nursing care’ the rule rather than the exception.

My wife’s father had Alzheimer’s disease and was confined to a nursing home for the latter part of his life. Were it not for my mother-in-law and my wife, he likely would not have lasted as long as he did. The stories they told me would cause even the meekest person to become irate… ‘But often you would have to bite your lip for fear that some of the nurses or aides would try to teach you a lesson by treating dad, even worse’.

‘They hate the squeaky wheel’, my wife and her mother used to say. Granted there were some good, almost saintly people who worked there; nurses that actually cared and took an interest in the well-being of the residents, making sure they were properly fed and clothed. But it seems, nursing homes attract many health care workers at the tail end of their careers that just got burned out taking care of critically ill patients, or perhaps in some cases were not successful keeping a job within mainstream medicine.

My wife would say, ‘You could always tell when certain nurses were on duty because when you would walk around the facility all the patients were practically comatose in their (wheel) chairs from being over medicated’.

Another time her father wound up with eight long scratch marks on his back from the nurse's aide with incredibly long finger nails which she dug into my father-in law’s skin as she picked him up. It really told a story about a person that was so irritated about having to lift up this poor disabled person from his bed that she could care less if she injured him or not. And she was supposed to be there to take care of him!

Of course this was not an everyday occurrence but what was, was the medication errors. The nurses would frequently dispense the wrong medication to my wife’s dad, almost as often as they would put his clothes on another patient, despite the fact the articles of clothing were clearly marked with his name.

And this was one of the better, more ‘affluent’ nursing homes. I can’t possibly imagine the depravity of care so many thousands of patients receive in poorer and less well equipped facilities. No wonder lawyers can make a living just suing nursing homes.

‘Many of the patients residing in nursing homes are unable to speak up for themselves’, my wife told me, because they have dementia from either advanced age or Alzheimer’s, and ‘unless they have family members that are there to speak for them they will not get the care they deserve’.

And it’s not just the nurses and aides that frequently neglect these patients, the physicians that staff these facilities are guilty as well, either not visiting at all or sending their assistants to tend to medical issues (if any are brought to their attention at all). If they do, it is usually because a family member has intervened on the patient’s behalf.

In fact, Margaret Dempsey told me that because she was unhappy with her physician she wished to switch to another. Finally, after much complaining, the nursing director and social worker gave her the names of several physicians. One of them refused to see her for some unknown reason and the other who said he would take her on as a patient has yet to see her nineteen days later, and counting.

Initially when I reviewed Margaret’s MRI films prior to seeing her I thought she might benefit from additional surgery but that was before I realized she was 82 years of age and had so many other medical problems. And when I sat down with her in my office I realized her biggest worry was that she would not be taken seriously about all the pain she had. I could even sense the extreme level of her anxiety by the way her facial expressions tightened as she talked.

And what distressed her even more was that Margaret understood because she did not have dementia she found herself to be one of those 'squeaky wheels'. Without any doubt, the nurses and the aides at the nursing home resented her for it, and any opportunity that they had to make her life difficult, they did just that.

Margaret Dempsey found herself very lonely indeed. And so all I did was sit down with her, and listen to her tell me about how badly they treated her at the nursing home, speaking up only occasionally and nodding my head in complete agreement, as I only too well understood her condition and situation. And by the end of our time together, helped by an occasional smile, her spirits seemed to be lifted a bit.

As I got up to leave, she asked me if I could write down on the doctors progress notes from the nursing home all of her problems, so they would now believe her. I turned and said, ‘Absolutely’. So, as I handed her the papers with my recitation of her symptoms, all of the operations she had undergone, my interpretation of her MRI scans and my medical conclusion that she had a very good reason to have continued pain, I said to her, ‘Here, you can keep this and show it to them whenever they tell you they don’t know what you are talking about’. She thanked me, took the paper as I sensed a small amount of peace that came across her face.

‘Let brotherly love continue. Do not neglect to show hospitality

to strangers, for thereby some have entertained angels unawares.

Remember those who are in prison, as though in prison with

them; and those who are ill treated, since you are also in the body’

Hebrews 13:1-3

For Love of Family

 

When I first met Michael Dubois, I found him to be a truly gregarious man, which was surprising given his diagnosis. He was 63. Our paths crossed because he had fallen at home. He didn’t injure himself but went to his doctor anyway. In reality it was his wife, Anna who insisted he go to get checked out. It wasn’t that he disliked going to the doctor but he just always figured whatever problem he had was nothing serious and that it would resolve on its own. On most every other occasion he was right…but not this time.

As it turned out, Michael had been having some difficulty swallowing his food for the preceding month or two, although he wasn’t one to complain, and he thought this was the reason he had lost 20 pounds over that same period of time. His family noticed he looked a bit thinner but neither they nor he thought much of it. Over the last few weeks however, he had also developed some dizziness and began staggering when he walked but once again he brushed off any suggestions that there was something wrong. That was until he fell at home and almost split his head open on the corner of table in the living room.

Oh, and by the way, Michael smoked 2 ½ packs of cigarettes for the last 43 years.

As soon as his doctor saw him in the office he sent him to the emergency room for further tests; since he had the suspicion (although he didn’t tell Michael this) that he would require admission to the hospital. Initially, a chest x-ray was ordered and this showed that Michael had a mass in his chest which likely was a lung cancer. A CT of the chest was then ordered and this confirmed the x-ray findings. Given these findings and in view of Michael’s neurological symptoms, Dr. Nicker ordered a CT scan of the brain. Unfortunately, but not surprisingly, this scan revealed the lung cancer had already spread to several areas in Michael’s brain.

The largest tumor was located in the cerebellum on the right side. The cerebellum is located at the base of the skull, behind the ear. It has the external appearance and color of a walnut shell but twice as big, and the cut surface looks identical to that of a cauliflower floret. The cerebellum is responsible for coordination and so this explained the reason for Michael’s dizziness and unsteadiness walking.

But, Michael had a second tumor located in between the two halves or hemispheres of the cerebellum. It was this tumor that was causing pressure on the fluid space containing cerebrospinal fluid within the cerebellum called the 4^th ventricle (which was connected to the 1^st, 2^nd and 3^rd ventricles located in the brain or cerebral hemispheres above). Because of this pressure, the normal flow of the fluid was impaired causing it to back up leading to enlargement of the other 3 ventricles. This is called hydrocephalus, or what many people know as ‘fluid on the brain’. As a result the hydrocephalus, the increased pressure contributed to Michael’s headache and in reality was potentially more life threatening than the larger tumor.

Looking at his MRI scan I decided to remove the tumors so the pathologist could confirm the diagnosis but also in doing so relieve the pressure that was both causing Michael’s unsteadiness walking and threatening his life. To be sure he would need radiation treatments and probably chemotherapy afterwards but the immediate task at hand was to prevent these cerebellar tumors from taking Michael’s life prematurely.

Armed with all this information I walked into his room in the critical care unit to speak with Michael and Anna. I explained the situation, reviewed the MRI scan findings and then discussed with them my plan.

Anna was tearful as she spoke with me, while Michael could only laugh and joke although his words were a bit slurred because of the tumors’ affect on the coordination of his ability to speak. At first I wasn’t sure whether Michael’s behavior was a coping mechanism but soon it was apparent he was trying to be humorous so Anna wouldn’t cry.

I was wearing my green scrubs at the time and so the cross I wear around my neck was visible through the ‘V’ opening in my scrub top. Anna looked at me and said, ‘I notice you are Catholic’. I nodded my head affirmatively. ‘We are too’ she said as Michael then spoke up…’I go to church and people say I believe in God but I don’t believe in this and I don’t believe in that! I say either you believe or you don’t. I believe so I’m not afraid. If I go to sleep and I wake up, great. But if I don’t, so what…I know where I’m going… So let’s do this thing.’

On Saturday I took Michael to surgery. I removed the large superficial tumor without difficulty. It was when I contemplated removing the second, more deeply placed tumor that I paused. With the distribution of blood vessels on the surface of the cerebellum, there was only a space about 1/3 of an inch that I could operate through and then I would have to go in about an inch and a half just to reach the edge of the tumor.

I thought about the difficulty I might encounter trying to remove this tumor and how I might struggle trying to visualize the tumor well enough to resect it completely. Then there was the bleeding that could occur down in that deep, small hole and if I retracted on the brain tissue too much I might cause more swelling than was already present which would surely obstruct the flow of the cerebrospinal fluid even more. And then of course there was the possibility I could inadvertently go too deep and damage the brain stem which would result in Michael being in a permanent coma.

It was at this point I thought about Michael and his family, and how I would like to spend what time I might have left with my family if I were he. True, Michael was a deeply religious man but I didn’t want my actions to be the reason he wouldn’t wake up. After all I was there to help. No, the length of time Michael would have left would be up to God not me. But I could make sure the quality of his life was something both he and his family could enjoy.

So, I decided not to attempt resection of the smaller deeper situated tumor hoping radiation would shrink it. Instead I decided to remove an additional portion of the right cerebellar hemisphere; knowing I could do so without causing Michael any increased difficulty walking or with his coordination. And in this way, I would provide him additional room for any swelling that might occur during his radiation treatment.

Later, in the recovery room Michael awoke feeling fine and he was walking in the hall two days later and was discharged home five days after surgery. Two weeks after surgery he came in for an incision check with Francy, my nurse and he stopped by my office to say hi and to thank me.

As he stood on the other side of my desk with tears close to welling up in his eyes, I was reminded that every patient I operate on is a person, perhaps a husband or wife, a father or mother, but certainly a son or daughter, and a friend to others. I may not have extended Michael’s life appreciably; but I knew I made the right decision in the operating room that Saturday morning giving back that husband and father to the family that loved him so much. And I thank God for that.

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.

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.

The Good Samaritan

 

David Arnold was a sick man. He had every reason to be depressed and perhaps even a bit angry. He had coronary artery disease having had a heart attack a year ago. He had high blood pressure, diabetes and peripheral arterial disease, the combination of which resulted in kidney damage which would soon require dialysis. In addition he also developed blockage in the circulation to his right foot and then his left leg which in turn resulted in gangrene. Because of this he required amputation of the toes of his right foot and amputation of his leg just below the knee on the left. Initially he had a prosthesis made for his left leg but because he had difficulties with this he was unable to walk and was confined to a motorized wheelchair to get around.

And if this wasn’t bad enough, he had fallen transferring from his wheelchair two days prior to his admission to the hospital and upon arrival to the ER, a CT scan revealed he also had a developed a small blood clot on the surface of his brain on the left side. That’s when I was called to see him. When I walked into his room in the ICU for the first time he was lying in bed with his eyes closed. In cases such as this it is critically important for me to be sure the patient is just sleeping and not comatose. If David was in a coma this would be indicative of significantly increased pressure on the brain, which would require emergency surgery to remove the blood clot or hematoma.

Lying there, looking at him, it appeared as though he hadn’t shaved in more than several days, and probably had not bathed either. Immediately, I began to assume he probably was an alcoholic as well. I shook him and called out his name. He promptly opened his eyes, but only half way and shot a piercing glance at me as if to say ‘what the hell do you want?’ I told him who I was and why I was there. He said nothing. I asked him, ‘where do you live’? He muttered, ‘In a house’. Despite several more questions, he said nothing further. I ordered a follow-up CT scan to be sure the hematoma had not enlarged and was causing more pressure on his brain. It was unchanged.

 As it turned out, he was not an alcoholic; he was just ornery by nature, a curmudgeon.

I followed him daily in the hospital for about a week, ordering additional scans to be the sure the hematoma was not enlarging. It did not and so I signed off his case.

About a week later, Chad, my physician’s assistant called me to let me know a repeat CT scan had been obtained on David because he had some increasing headaches. The blood clot had enlarged and now was causing significant pressure on his brain. In fact it caused a slight shifting of the left side of his brain into the space normally occupied by only the right side. He needed surgery. Fortunately David remained alert and displayed no stroke like symptoms, so while surgery needed to be done it was not an emergency. I took him to the operating room the following day and performed a craniotomy to remove the hematoma. The surgery was straightforward and was without complication.

Postoperatively, I called into the recovery room to check on David. The nurse told me he was fine neurologically. He was awake, talking, actually screaming at the nurses, and he was moving his arms and legs well, actually thrashing about and throwing some punches at the nurses, as he yelled for them to leave him alone. I reassured her that was his usual behavior.

The next day, I went to see him in the ICU. As I stood at the entrance to his room, he looked identical to the first day I saw him. Still unshaven and disheveled with that angry look on his face. I asked him how he was. He said, ‘OK’. I figured I would try to inject some levity into the situation so I asked him, ‘Did the surgery change your disposition any?’ He replied bluntly, ‘No’. I told him his post-op CT scan looked good and I turned and walked away.

As a human being, the tendency is to want to walk away from the difficult situations, the difficult patients. And at times I am no different than anyone else. But it is specifically at these times we must force ourselves to face them, not with a stern, confrontational attitude but with both our mind and arms open, even if figuratively, with loving acceptance. Angela, David’s nurse reminded me of this.

On Friday of that week I was on my way to my satellite office in Spring Hill when it occurred to me I really should stop by and see David when I returned from seeing my patients that day. Not just to check on him but to sit down by his bedside and talk to him. Truly I had not treated him the way he deserved, as a patient who was very ill and in need of more than what my surgical hands could deliver.

As I walked into his room that afternoon, there was something distinctly different about him. At first I wasn’t sure what is was, but as I sat down I realized he actually was almost smiling. Angela asked if I noticed anything different about him. Immediately it occurred to me she had helped him shave and she had bathed him. She walked over to the opposite side of his bed and picked up his right hand with both of hers and proceeded to speak aloud, almost rhetorically.  ‘You know he has some trust issues’ she said as David nodded in agreement. ‘But we understand each other now and he knows the importance of being respectful and kind and not being overly demanding’, she continued.

I sat there in silence…and amazement at the transformation that had come over David. All because Angela had been kind to him first. At first she was turned off by his attitude too, but she realized that his apparent anger was probably a manifestation of some emotional hurt or insecurity deep down. She was right.

All it took was for her to set aside her feelings and ‘turn the other cheek’ as it were. As soon as David realized she was not there to confront him but to comfort him, he began to trust her. Thus, she reminded me how much more we can help others by thinking of them first, rather than ourselves. (This of course does not pertain only to patients but our family and friends too).

Luke 6:27-31

Part 2. Life After Death...Life After Life

 

Tom certainly did not want to die, and Marianne definitely did not want God to take him from her either, but they both trusted in God’s plan, no matter what the ‘earthly’ outcome would be. They truly understood the meaning of the words of St. Paul to the Romans, that it is God, not us, who is in control and that “…in everything God works for the good with those who love him, who are called to his purpose.” And perhaps it is not how Tom lived his life that was an inspiration, although I am certain it was, but more importantly it was how he lived it while he was dying that deeply affected mine. You see I truly believe that all things happen for a reason and while we may not understand nor see the purpose behind all that happen to us, we must have faith and trust in God’s plan for us. There is good in everything. This is a bold statement and one that many would scoff at, and perhaps even think is crazy. But that’s the thing about faith, it doesn’t make sense…it doesn’t have to.

God put us on earth to enjoy His creation and for us to be happy. But in reality, even if we live to be 100 years old, and most of us will not, that time is minuscule in relation to eternity. We spend so much time trying to keep ourselves looking young and accumulating possessions and when we die, none of it, is coming with us.

Why is it that so many people try to keep a ‘death grip’ on their life in this world? Perhaps it is reflected in the lyrics to the blues song sung by Coco Montoya, ‘…Ya know I hate to leave this old world, cause I don’t know what the next one is all about’. This phenomenon however is not confined only to nonbelievers, but the faithful as well. I suspect it is because as human beings living everyday in this world we are easily distracted into thinking that our appearance and worldly possessions actually matter. After all we are weak and frail, emotionally and sometimes spiritually, and often need to boost our physical self to feel happy. There is nothing inherently wrong with this as long as we remember what is most important to us long term, and I mean ‘long term’! Personally, I am guilty of this as well. Quite a few years back when I was single and had few responsibilities, I used to work out regularly in the gym, lifting weights. Three or four times a week, for at least 2 - 3 hours at time, I trained intensely. Often, during my work out it would occur to me…I spend so much time and effort focusing on my physical health, that if I spent a fraction of this time on my spiritual life, how much better a person I would be and how much closer to God could I be! But that thought, though it frequently recurred in my mind, would dissipate almost as quickly as I moved on to my next set. It would only be years later when an injury sidelined my weight training that I would finally start doing my ‘spiritual reps’.

But I digress….Assume that through the scientific method and intensive research using our (God-given) intellectual power we discover the fountain of youth. Thus ends all illness and disease. No more cancer, no more lives stripped of their vitality by the ravages of Parkinson's and Alzheimer’s disease, no more tragic deaths of mothers and young children. Our physical beings live forever or at least for a long, long, long time. Then what? I am not saying we should not try to find cures but I believe all life is sacred both from a philosophical and Christian perspective. So do we indirectly or directly promote the death of one being for another? How do you make that choice? How can you? And to what end?

Glioblastoma multiforme is a monster of a brain tumor. For years it has proved to be a stronger and better adversary than anything we have used to kill it. Surgery, radiation, chemotherapy. If we have been able use something successfully to treat it, it mutates into something resistant and more aggressive. I have even ‘completely’ resected this tumor as evidenced by MRI scan, only to see it grow back, twice the size in less than 30 days! Recently, significant strides have been made in chemotherapy that has been hugely successful, even if on a relative scale. (See post of January 16, 2010: Humility and a Malignant Brain Tumor). And one day I pray we find a cure, although I suspect we will always have death to face at some point.

It will be at that point that our true character will finally be revealed. Will we be afraid because we don’t know what the next world is all about or will we embrace it because we trust in Jesus’ promise of an everlasting life with Him.

A while back when my wife and I were in the process of adopting our daughter we met a couple like us, Mark and Karen, also looking forward to becoming united with their adopted daughter from China. He was an ophthalmologist. And it is quite interesting to me how many ophthalmologists I have met that are deeply committed Christians. Perhaps it has something to do with the realization that the ‘eyes’ truly ‘are the window to the soul’. Anyway, he told me of a story of a colleague, a friend of his that had a malignant brain tumor and he had exhausted all forms of treatment, and had death staring him squarely in the eyes. Mark asked him how he felt, was he afraid? And this other physician looked at him and said no. In fact he was excited! He was finally going to meet his creator and spend all eternity with him. “It’s going to be an awesome journey”.

Our life here on earth is far from inconsequential but it is in the way that we live that life that we will be judged by those we leave behind and by God in heaven.

An Unexpected Death

 

I have been in practice more than twenty years and I can count on one hand the number of times a patient of mine has died unexpectedly. Each time it has happened the one thought in the forefront of my mind has been, “I wonder if I’ll get sued!” Sure, I had concern for the patient’s family and the pain they were now experiencing but, immediately I would begin to think about all the things I had done for and to the patient… did I forget anything?, did I do anything wrong? When I perform elective surgery I expect all the patients to do well and leave the hospital within a day or two. So when the unexpected occurs, and everyone is in a state of shock, me included, everybody wants to know, “what happened?” That’s when I would begin to wonder if the patient’s family will ask questions and when the answers are unclear, if they will hire a lawyer because now the feelings of grief turn into anger.

Just the other day, Theresa Marsden, a patient that I had operated on less than a week before had a massive heart attack and died. But this time I felt different…

Theresa was a very pleasant woman, a retired nurse who had already survived one cancer, a melanoma as well as several other ‘brushes with death’. So when I told her she had a brain tumor she was upset and initially cried but she summoned up the strength to look forward, determined to fight it and win as she had in the past. Her husband of thirty years, Ed, was a character. After I had reviewed her brain MRI with them in her hospital room, he looked at me and said, “I’m gonna ask you a question that I have asked her surgeons in the past, and it always seemed to throw them off”, “I ask it because it tells me a lot about your character”… “Are you as good as you think you are?” Most times I get asked how long have I been in practice, or how many times have I done this surgery and most of the times when I get asked the question at all, what is my success rate? But never quite like Ed put it. He did throw me off a bit! So, I looked off a second or two, thought about it and then looked at him the eye and in front of Theresa’s nurse and Chad my physician assistant I said, “I am blessed to have the skill that I do”. As I looked at Ed, his face screwed up, somewhat surprised by my answer, and he nodded and stammered, “Well that’s why I asked it because I wanted to know what kind a person you were”. Now it was Ed’s turn to be thrown off! He then continued, “so when are we doin this?”

I explained to them we would have to transfer her to Morton Plant Mease hospital in Dunedin because that is where we perform all of the neurosurgery and that likely it would be Friday afternoon.

The tumor was located in Theresa’s occipital lobe on the left. She was an avid reader, reading three books a week but recently had suddenly stopped. When Ed asked her what was wrong she told him she couldn’t understand what she was reading anymore. As it turned out not only did the tumor damage her ability to see anything off to her right (the occipital lobes decode the signals from the eyes and creates the image we ‘see’), but the tumor had extended towards her ‘speech area’ (which decodes the words we see into meaningful speech) as well. And by the looks of the tumor on the MRI it was not only large but very likely a highly malignant brain tumor, an astrocytoma.

The surgery went well, though initially when I cut into the tumor, I discovered it had so many abnormal blood vessels I thought for a second it wasn’t a tumor but a congenital abnormality of blood vessels called an arteriovenous malformation. But as soon as the pathologist reported that it was indeed a malignant astrocytoma, I settled in and began the systematic removal of the tumor. After I was satisfied with my resection of the tumor, I inserted the chemotherapy wafers in the brain and then closed.

After surgery, Theresa was unchanged. She still could not see off to the right, and her ability to read still was mildly impaired. She recovered well, was transferred out of the intensive care unit on post-op day number two, and was up and walking in the hall on the second floor feeling quite good. In fact I remember seeing her on Wednesday as she had just finished eating dinner. I asked her how she was feeling and all she could do was remark how hard the broccoli was and that she couldn’t eat it like that. I then remarked “well, I guess if you are able to complain then you must be doing OK”. I promised I would speak with the administrator about the broccoli and walked out figuring she would be ready for discharge in day, or two at the most.

So, when Chad called me Friday morning to tell me Theresa just had a cardiac arrest and the code team was trying to bring her back, I was stunned! I told him I would be right there. As I drove in my thoughts drifted to Ed and how he must be feeling. He was losing his lifelong partner and friend, and not over the course of months as we thought it might be, but, right now. I didn’t think at all about what I might have done wrong.

I stood at the foot of her bed as the nurse performed chest compressions and the intensivist ordered more drugs to be given, and Ed paced back and forth in the hall outside the room. But to no avail. After 30 minutes of this, the intensivist looked at me and shook his head. Ed came in, asked how long we had been ‘coding’ her, and then asked everyone to stop as he said “you’re not going to bring her back”. He went immediately to her side, bent over, put his arms around Theresa and cried.

As he walked away from her bedside, I looked at him and told him I was sorry as he grabbed me, hugged me and thanked me for everything I had done.

I am indeed blessed to have the skill I do, and having asked for God’s guidance before her surgery, I knew I did everything that was in my power to do.

…but to set the mind on the Spirit is life and peace. Romans 8:6

 

 

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.

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.