Gray Matter

by Kilpatrick, Joel;Levy,David

  The first goal with any endovascular neurosurgery is to get the guide catheter situated properly in the carotid artery in the neck. This becomes the “base camp” from which I enter the brain, or in this case, the face, with an even smaller tube called a micro-catheter. Endovascular surgery is like virtual reality surgery. It is performed with the aid of continual X-rays that show the field of operation. Wires, balloons, and stents all have metal markers so that they show up under X-ray.

  The X-ray machine and contrast dye that are needed to see into the vessels are costly, not just financially but physically. Contrast dye is harmful to the kidneys and must be used sparingly, especially in a child. Every time I step on the machine’s pedal to see inside the body, the patient and parts of the doctor are radiated. Radiation is harmful, and I’ve heard estimates that 2 percent of all cancer cases will soon be caused by radiation given in hospitals for tests and procedures. Therefore, you must balance your need for updated information (gained with contrast and radiation) against doing the best you can with the information you have. In a long case with a high radiation dose, the patient can actually experience hair loss and skin irritation in the area where the X-ray beam passes through the head. Though the hair grows back within six months, radiation has a powerful, damaging effect, and it is not to be unleashed lightly.

  As well as Tina’s surgery had been going, there was still no guarantee of the desired outcome. From the moment you enter the artery in the leg, things can go wrong. The artery is made up of three layers, and it is possible to cause dissections through the vessel layers—tears in the soft, slippery inner lining, laying open the muscular layer underneath. A vessel dissection can allow blood clots to form on the rough muscular layer, which can then break off and cause a stroke. You are always navigating between the dangers of causing bleeding or causing clotting. Both lead to stroke. In addition, you are never sure how the body will respond to the invasiveness of a catheter running half the length of the body through a major artery. The artery can spasm around the catheter, cutting off blood flow to the brain on that side. It is possible for a catheter navigated far out in the circulation to be stuck and unable to be removed after glue injections. The longer you are inside the vessels with your instruments, the higher the chances of something going wrong.

  I guided the micro-catheter using a micro-guidewire, positioning them in a feeding vessel to the tumor in Tina’s face. Once I was certain that I was in the optimal position, I pushed a liquid embolizing agent into the tumor’s blood supply to close it. This took more than six hours of concentration because of the size of the tumor and the generous blood supply it was receiving from the internal carotid artery and the ophthalmic artery. It was slow and tedious work, with many stressful moments when I had to make snap decisions about how aggressively to fill the critical areas with blocking agent—arteries that went directly to Tina’s eye and brain. Finally, I believed that I had accomplished what I had set out to do.

  After the procedure, I waited for Tina to wake up. I was exhausted from the procedure and had just one desire: to know Tina was okay. After thirty minutes or so that felt like hours, Tina awoke. I held up fingers in front of her face, and she counted them perfectly. She had sight in both eyes and was able to move both arms and legs. It appeared that after many hours of painstaking work, she had suffered no neurological deficits.

  Dr. Willard, Tammy, and Richard were in the waiting room, anxious after the seven-hour wait. I told them things had gone well and showed them a picture of the tumor, which was now obviously filled with the agent and cut off from its blood supply. Dr. Willard looked at the scans and seemed pleased. Several days later, Tina had open surgery, which was done by our outstanding skull base team, consisting of another neurosurgeon and a head and neck surgeon. The entire tumor was removed with very little blood loss. The liquid embolizing agent had cut off the blood supply, the open surgery was a success, and Tina went home a few days later. After six weeks her facial incisions were barely visible.

  I received a card from Tammy a month after the surgery. She thanked me again for the special care that Tina had received. Six months later, I was surprised to receive a letter from Dr. Willard:

  Dear Dr. Levy,

  It is hard to find words to express my heartfelt gratitude for you and the team for the exceptionally competent care that you provided my granddaughter, Tina, during her recent bout with a stage 4 tumor. From my first meeting with you in preparation for Tina’s embolization, I was especially impressed with your caring manner and that rare ability to relate to this young child who was about to endure such a horrific and complex set of medical and surgical procedures. You were able to help Tina and her parents clearly understand what treatment was necessary and openly face the serious risks that were involved. After forty years in the medical profession I have rarely experienced such a profound combination of clinical, personable, and spiritual competence in one physician. As a result, your words, manner, and spiritual input put Tina’s frightened parents at ease and left them with a sense of hope. For this our family will ever be grateful.10

  When I read that letter, I remembered the courage it had required for me to pray in front of a physician who had spent his career at some of the best hospitals in the world. I was glad I hadn’t shied away from caring for Tina in the best way I knew how, which was by addressing the whole person.

  As happy as I was with the results of praying with patients, I had still feared praying in front of other medical professionals. It was a fear that took a great deal of courage to overcome—and that finally reached a breaking point.

  Chapter 5

  Facing My Colleagues

  Prayer had become a comfortable part of my routine. Patient reactions were overwhelmingly positive, and I even felt prayer was improving the outcomes of the procedures. Still, though, I was confining my prayers to those brief times when I was alone with the patient before and after surgery. I was afraid to pray in the presence of anyone who was not the patient or family. Mostly, this meant the nurses.

  Nurses are powerful and extremely valuable members of the hospital staff; no hospital can be first-rate without good ones. Nurses can make a huge difference in a patient’s stay and in a doctor’s day. Good nurses know their patients well and can often point out things a doctor may miss. They notice what goes on in the operating room and even whose patients have the most complications after surgery. I value and need their opinions, assessments, and care in a hectic environment, so I wondered what they would think of me for potentially violating their sense of decorum in the medical setting.

  If a nurse makes one subtle, negative comment regarding a doctor, within seconds that doctor’s standing, at least among the nurses, can be devastated, rightly or wrongly. Of course they still have to follow his orders; they just don’t respect him. It probably shouldn’t matter to us, but deep inside, every doctor is keenly aware of his reputation and afraid of losing the respect of those around him. The idea that nurses might pass judgment on you and that this opinion might somehow percolate up to your own colleagues is threatening, no matter how you try to ignore or minimize it.

  I was living with fear and double-mindedness. Even though I was praying with patients, I did not want to be known as someone who prayed with patients. I was certain the nurses and other doctors would misunderstand my motivation and would even question my integrity as a surgeon. To make it more challenging, I had been working at the hospital for seven years and had formed long-term relationships there. People had a pretty good sense of who I was. To introduce this radical change in behavior could destabilize these relationships and attract attention and questions I just didn’t want to deal with.

  But praying in secret was proving unbearably frustrating. Waiting for the nurses and the anesthesia personnel to leave the room so I could pray was easily the most miserable part of my day. I was bound up in anxiety each time I was forced to wait. I couldn’t count the number of times I lurked around pre-op, killing time or pretending to read
a chart in a patient’s bay while waiting for nurses to finish their work and head off to other tasks.

  Then I was brought to a point of decision.

  I walked into the busy pre-operative area one day feeling that mixture of hopeful anticipation and frustration. I was looking forward to praying, as usual, but not to waiting for all the nurses and anesthesiologists to clear out. In spite of my best efforts I had found no reliable way to time my entrance to see the patient alone. I had tried arriving early, but the administrative personnel were often there placing the hospital wristband. I had tried arriving late, but the anesthesiologist was often there. During the rest of the time, the nurses were ever present. If I came too late, I would miss my chance because the transportation team would be carting the patient off to the procedure room.

  On this day I stood there, trying to look busy while waiting for the industrious nurse to leave. My level of irritation kept rising. I felt impatient, anxious, out of control. Suddenly, an inner voice—I knew it was God—posed an unexpected and simple question: “Do you believe that what you are doing, praying before surgery, is a good thing?”

  I thought about it a moment, then answered silently, “Yes, I know it is good. I have seen the effects of prayer in calmed nerves and tears of emotional release, and I have heard the patients’ reports.”

  “Then why are you afraid? If you don’t believe in what you are doing, why don’t you stop doing it?”

  That got my attention. Stop praying? I couldn’t do that. I had opened up a whole other avenue of care that was blessing people and blessing me. Praying was now something I enjoyed. I didn’t want to stop; I just wanted to continue in secret.

  “I can’t stop praying,” I answered. “It wouldn’t be right for me or for them.”

  “Then why are you afraid?” the voice persisted.

  I had to answer truthfully: I was afraid because I still valued what people would think or say about me and my reputation.

  Stung, I argued back, “But I don’t want people to think that I’m one of those weirdos who go around praying for people. Good grief, I’ve worked for years to build a reputation in my field and in this hospital.”

  “You don’t want to be known as someone who goes around praying for people?” the voice asked.

  “That’s right,” I answered silently.

  “But you do go around praying for people, don’t you?” the voice asked, and even though no one else could have heard our conversation, I actually turned red with shame.

  “Yes, but I don’t want people thinking that I do!” was all I could respond.

  It was clear to me that God was calling me out for my lack of authenticity.

  I wanted to have it both ways—to pray for people and see the power and comfort that it brought them but not to be thought of as someone who prayed for people or believed that God is relevant to medical care. To stop living that lie would take courage, but it would also provide relief if I could do it—no more waiting around for nurses to leave, no more agonizing or hiding my actions. I saw before me the tantalizing freedom that would come from being bold and single minded. I also saw the risks to my reputation and to my pride.

  I had a choice to make.

  In that moment, with the pre-op activities buzzing around me, I decided to step into authenticity no matter what it cost me—my reputation, my job, or the respect of my coworkers. Swallowing whatever resistance my heart still offered, I walked up to the foot of my patient’s bed.

  “Good morning, Mrs. Greene,” I said.

  “Good morning, Doctor,” she replied. She looked weary and resigned, as if a long journey had brought her to this moment. The nurse patiently swabbed her arm, acknowledging neither of us.

  “You and I have talked about the surgery you’re about to undergo. You understand the risks involved,” I said.

  “Yes, I do,” Mrs. Greene said.

  “This morning I will be going in to fix the aneurysm in the back of your brain. If it goes well, you’ll be out and recovering in a couple of hours. Are there any other questions you have for me at this time?”

  “No, I don’t think so,” she said.

  Without allowing myself to pause, for fear that I might stop altogether, I continued, “Then is it okay if I say a prayer for you?”

  I knew the reaction was coming.

  I saw the nurse sitting with her back to me, bent over Mrs. Greene’s left arm so that I couldn’t see it, preparing her for an IV. The nurse stopped what she was doing, glanced at me quickly, and sat up straight. She said nothing. Mrs. Greene looked at me askance, too, then nodded.

  “Okay,” she said, seeming a bit distracted.

  Without hesitation, I grabbed her toes through the blanket and began to pray.

  “God, I thank you for Mrs. Greene. She is precious to you, and I ask for wisdom and skill to fix her vessels. We ask you for success. Give her peace now. Amen.”

  When I opened my eyes, I expected to see a peaceful expression gracing Mrs. Greene’s face, as I had seen on dozens of other faces. Instead she looked uncomfortable and was trying to smile through obvious pain. Looking in the direction of the nurse and Mrs. Greene’s arm, I realized that in my determination to pray I had not paid attention to what was happening procedurally. The nurse had put the IV needle into Mrs. Greene’s arm and was searching for a vein as I had made my offer to pray. She had stopped her work out of reverence and automatically bowed her head when I began praying, leaving the needle hanging out of the patient’s arm the whole time. No wonder Mrs. Greene was having trouble concentrating.

  Fumbling with my words, I apologized that I had interrupted this delicate routine. The nurse resumed her hunt for the vein, found it, and taped the needle to Mrs. Greene’s arm.

  “Thank you,” Mrs. Greene said to both of us with evident relief.

  Though I had bungled the timing, I had also crossed a threshold of courage and was determined not to turn back. I still preferred to pray with the patient and family alone, because it was simpler. I considered it a sacred and beautiful moment, and I did not want to have it lessened for my patients by having others present who might not value the moment the same way. Neither did I want to worry about offending or inconveniencing the nurses or other health care professionals, but from that point on I was able to pray in front of nurses if necessary. Over the next few months I steeled myself many times and prayed in their presence. I earned a number of shocked looks. What is this doctor doing? they seemed to be thinking. This is something new. Wait till the others hear about this. Many of them would stop working long enough to let the prayer pass, like a gust of wind. Some bowed their heads and seemed to participate silently. Others kept working as if nothing were happening.

  Their reactions still mattered to me, but it mattered more that I was being authentic and doing what I thought was best for my patients, even if others thought it foolish. Courage had taken me further down the path of authenticity.

  * * *

  A few months later I was in the room of a particular patient who was about to undergo surgery to repair a massive tangle of vessels that had improperly formed in his brain. I did my normal pre-op talk. The nurse was heading out to get something, but when I asked the patient if I could pray, the nurse made a U-turn and came back quietly. Her shoulder-length black hair hung partially over her face as she bowed her head. The two family members and I held hands with the patient. The nurse stood behind us and listened during the short prayer.

  When we had finished and I turned to leave the pre-op area, the nurse stepped into my path and pulled me aside.

  “Dr. Levy?”

  “Yes?” I responded, thinking, Probably a curbside consult—a doctors’ term for when a nurse or anyone else approaches you in the hallway or elevator to ask advice about a loved one with a medical issue. This is almost the only time nurses approach doctors outside a professional context. I did not know this nurse by name, and she was clearly nervous. She avoided my eyes and wrung her hands. It gave me a chance to see �
��Cheryl” on her name badge.

  “The other nurses and I have noticed that you pray for people,” Cheryl said. This wasn’t what I was expecting, and I felt my stomach do a quick flip.

  “Yes,” I said, bracing myself for whatever was next. Cheryl shifted from one foot to another, hesitant to come to her purpose.

  “I want to join you next time. Would you call me when you are about to pray?” she said, then continued in a hushed voice. “There are other nurses who want to be in on that too. Would you include us?”

  I was amazed. Yet again, the thing that I feared would bring division and mockery had instead drawn people in. The nurses had indeed talked about what I was doing—but not in the way I had expected. Perhaps my actions had offered another care option to some who had not considered it before. Clearly, some of them wanted to be part of something more than just fixing people’s bodies—like me, they wanted to bless patients, body and soul.

  “Sure,” I said. “I’ll look for you.”

  “Thank you,” Cheryl said and had the courage to look me in the eye briefly before walking back to the desk.

  After that, I began to invite some of the nurses who expressed interest to join the prayers. Often they had to take off their latex gloves or stop what they were doing (especially if they had been about to place an IV), but many seemed eager to join in.