Gray Matter

by Kilpatrick, Joel;Levy,David

  “I’d love to hear you say it one more time,” I said, and she smiled as she declared with more conviction, “I am beautiful.”

  As she repeated these words, her countenance began to change. The truth has that kind of power when we choose to engage it. So many people have been treated badly for so long that they begin to act as if they deserve that treatment. Maureen was rediscovering her God-given identity.

  “Is that everything you want to clear up?” I asked after a moment.

  “That’s everything,” she said. She looked up and wiped her eyes with tissue. She seemed fifteen years younger. Her face was no longer drawn. By all outward appearances she seemed transformed.

  “I feel a tremendous peace,” she said. “I feel really free.”

  “Good,” I responded.

  “I—I feel like I need more spiritual connection with God in my life,” she said. “I want to start going back to church. My boyfriend will go if I get him up in the morning.”

  “I think that’s a great idea,” I said. “You have been very courageous and honest today. I am really proud of you, and I know that God is as well. He wants you to get to know him. God is really amazingly good, and he is very patient and kind.”

  “I feel it,” she said. She got up and hugged me, and I walked her out.

  I saw Dave every day for the next week until he left the hospital. His speech remained slow, but the procedure had been a success. The coil barrier in the aneurysm held. Every day he consented when I asked to pray, but there was never any outward sign that he was open to God.

  The police reported that the underage girl admitted that she had lied about having sex with Dave and with his son. Nothing Dave had done had violated the law—his headache had dropped him to the ground before he could go any further. In a strange way, his sudden aneurysm bleed had spared him a prison sentence. The case was dropped.

  I saw Dave six months later. Speech therapy had helped him, but he still spoke slowly and not in complete sentences. His right arm remained weak, and it was clear that he would have a permanent deficit on that side of his body. This upset him because he wanted to go back to work but would be limited in what he could do. On the upside, the scans showed the coil construct was holding beautifully. I would not need to see him again for several years.

  I thought he might be humbled by his recent dramatic experiences and reconsider what he valued in life, including his own lifestyle and spiritual condition. When I asked him during his follow-up visits if anything was happening on his spiritual journey, he said no. He shrugged his shoulders and shook his head; he wanted nothing to do with it. His only concern was getting back to work and back to life as it had been before the hemorrhages.

  I never saw Maureen again, but I felt confident that, unlike Dave, she had allowed the experience to open a new chapter in her life. Life is a continual journey. When people leave my office, I have no idea which direction they will choose to go. All I can do is to give them my best while they are in my care.

  Early on, when I first began to pray with patients, God seemed to answer all my prayers and reward me and my patients with success. I began to think that perhaps I had found the key to perfect surgical outcomes. I even began to think that if I prayed, I could control the outcome and would never have a failed surgery again.

  Boy, was that the wrong prognosis.

  Chapter 8

  Paralyzed

  Sam was a thin man in his mid-forties, with straight black hair and a skeptical, serious personality. He was by most measures poor, having come from another country without a lot of advantages, but he was in the middle of a career change. He had returned to school to become a nursing assistant and had only a few more classes to take. He came to see me because he was having progressive difficulty walking and moving his arms. An MRI revealed the chilling truth: he had an intramedullary arteriovenous malformation—an AVM, which is similar to an AVF—in his spinal cord—that is, a thatch of abnormal and oversize vessels connecting an artery to a vein in the spine. As soon as I saw it, I drew my breath sharply and knew we were in for rough sailing. It was as if his body had created a problem designed to defy treatment.

  Because the spine is part of the nervous system, the same system as the brain, neurosurgeons often work in this area as well. Spinal cord AVMs are the riskiest problems we deal with. Sam’s problem had the additional disadvantage of being high up on the spinal cord, meaning that everything below his neck was at risk of being paralyzed if the surgery failed. To make matters worse—much worse—because the AVM had been forming for probably more than forty years, putting steady pressure on the vein, the wall of the vein had ballooned out and created a huge aneurysm in the middle of one of his vertebra. The aneurysm was one of the largest I had ever seen in the cervical spinal cord—two centimeters in diameter, so large that it had actually changed the shape of and enlarged the bony opening in his spinal canal. This naturally threatened the spinal cord itself, which was pressed against the bone by the aneurysm. The spinal cord was now compromised and was slowly being severed.

  The spinal cord in a normal body is a rope of densely packed nerves about the width of your index finger, traveling down the neck and back. These nerves connect the brain with the body. Sam’s spinal cord was no longer a thick rope but a thin layer of nerves draped around the aneurysm like a nightgown. All signals from his brain to his body were traveling through this ribbonlike connection. Any wrong move, any swelling, could irreparably damage the layer of nerves and break the connection, leaving him immobilized for the rest of his life.

  Cases this risky showed up only every couple of years, and I soon realized that this would be one of the riskiest cases I had ever treated. There was no way to tackle it in a stepwise fashion, treating one problem and then waiting to fix the other. I couldn’t close the AVM without closing the aneurysm, or vice versa. It was all or nothing. Both had to be treated simultaneously or not at all.

  I explained all this to Sam. He understood that the spine was a dangerous area to be working in, but he stubbornly seemed to think that there was a way to treat it without real risk. Every time I told him what was at stake, he looked at me as if I were exaggerating or simply withholding the perfect treatment for his problem. Like some other patients, he had a hard time accepting that there were limits to modern medicine and that we had now reached the end of the dock, so to speak. What lay ahead were uncharted waters, but I explained that I would navigate them as best I could.

  Unhappy with his options, Sam chose to delay treatment for three months and to continue in school. During that time he kept getting weaker. Walking became more difficult and he was losing dexterity in his hands, making his career goals impractical. All signs pointed to his being in a wheelchair in just a few years. Finally he called my office and told me he had decided to have surgery. No other option was available to him, and he was ready to take his chances.

  I prepare extensively for each one of my cases, but Sam’s consumed me more than any other had up to that point. I started by going through the scans and asking myself the series of critical questions that I ask myself with every patient: What can be done? What should be done? How much can I do? Do I need to do it all? Is there any uncomplicated way to do this? Is there any way to postpone it and do it later? Where is the patient in life, career, and family? Should he or she be taking this risk now?

  In this case the questions all led to the same conclusion: that Sam was better off trying to have this problem fixed now rather than waiting until it was too late. Perhaps we could salvage his mobility and give his body a chance to repair the damage in his spine that this malformation had quietly caused over the decades. Perhaps he would return to normal.

  As I considered my options, I called a colleague to see if he had other ideas. He didn’t. I spent hours thinking about the case and planning for the treatment. To close the aneurysm and the AVM would require that I inject glue to block the vessels comprising the AVM and plug the internal aneurysm—typical treatment for
an AVM. How an aneurysm this large, and in an area this sensitive, would react was unknown. When the flow into the aneurysm was stopped and the pulsating blood was no longer expanding the aneurysm with every heartbeat, the pressure on the spinal cord could decrease. Alternatively, it might expand and put increased pressure on the spinal cord, causing paralysis. I prayed for God’s wisdom and specific direction on this case that included so many variables. Ultimately, I was convinced that I had done everything I could to prepare, medically and spiritually.

  I prayed with Sam in my office on his pre-operative visit the day before surgery. The next morning I entered the procedure room in my scrubs, donned a lead apron, and stood next to Sam, who was asleep from the anesthesia. The techs were busy prepping the instruments and the area on his leg where we would insert the hollow sheath and catheters.

  One of the side benefits of praying with my patients is an increased emphasis on the personhood of the patient—I felt genuine concern for Sam, in addition to professional responsibility. At the same time, I am a specialized surgeon, and as I entered the operating room, I couldn’t help but feel the thrill of taking on a “great case,” the kind that is highly risky and especially difficult. Great cases give us the chance to test our skills against the toughest problems the body can come up with. They provide a challenge to be met.

  The room was electric with anticipation and optimism. My heart was pounding. I was also keenly aware that it was Sam under that blue cloth, a man whose future was in my hands. The surgery was about him, not me, and I felt an overwhelming sense of responsibility to get it right.

  The guide catheter went in quickly, up through the aortic arch and through a vertebral artery. Sam’s vessels were surprisingly straight and flexible, probably due to his relatively young age and the fact that he was so thin. The micro-catheter also went into the feeding artery easily. Within thirty minutes I had the micro-catheter in place in his spinal cord and was ready to do the injection.

  Injecting glue into an AVM is tricky business. The glue that neurosurgeons use, a cyanoacrylate, is similar to superglue, except that it costs $2,500 instead of $2.59. It even smells the same. When it comes in contact with blood, it hardens, sticking to itself and to the vessel wall and forming a blockage. The neuroendovascular surgeon mixes the glue in the operating room and makes the critical decisions about how thick it should be and how quickly to inject it. The thickness of the glue determines how quickly it will harden. If the mix is too thin, it will harden slowly and the glue can flow right through the desired area and into the veins, hardening there and causing the malformation to rupture. If the veins are large, the glue can travel to an unwanted place in the body, such as the lungs. If the glue is too thick, it will harden too quickly and block the feeding artery without going into the actual AVM. As a result, the AVM will continue to feed from smaller branches and you will have lost your access to it, making it harder to repair than before.

  Before mixing the glue, I did an injection of contrast agent into Sam’s AVM to measure how quickly blood flowed through it. The digital subtraction angiography, running at 4 frames per second, showed me how long it took for the blood to travel from the tip of the catheter in the feeding artery to the draining vein. This told me how much time the glue would spend inside the AVM before passing through and, therefore, how thick my glue mixture should be. His blood was moving quickly through the AVM.

  Convinced now about what type of mixture I needed, I went to the back table and mixed the glue with metal powder and with the contrast agent to make the glue visible on the X-ray. I didn’t dilute it much because Sam’s blood was flowing so rapidly. I needed it to harden fairly quickly. I stirred the mixture in a small glass, then drew it into a syringe. I walked back to the operating table and handed the syringe to one of the techs, Lydia, who rocked it back and forth to keep the metal powder suspended until I was ready. I made a final practice run with contrast, and when I was ready, she handed the syringe to me.

  Injecting glue is stressful. My technologists often have to remind me to breathe during those moments, because my whole being is focused on the shades of gray on the TV monitor that indicate where the glue is going. It is over in seconds and requires split-second decision making.

  With a twist of my wrist, I attached the syringe to the clear hub of the micro-catheter, which was essentially now a three-foot-long flexible needle. I began to push the syringe plunger carefully, at just the speed I thought necessary. On the screen I saw the glue come out of the tip of the micro-catheter and enter the vessel. My adrenaline was flowing as I watched to see how the glue was going to respond once it hit the blood. Would it fly through the AVM and into the vein on the other side? Would it stop short of the AVM?

  “Breathe,” Lydia reminded me, and I exhaled.

  I saw the glue flow, as expected, into the AVM and the aneurysm. Within seconds I could see it hardening.

  “Come on,” I said under my breath. “Stick in there.”

  The hardening glue began to close off the unwanted vessels and the aneurysm. The flow of blood narrowed and decreased. Soon, the flow was choked off entirely. I had put solid walls in the passageways of the rogue vessels. In a few brief moments, it was over, and I had done just what I wanted to do. Ninety percent of the problem had been closed in a single injection: the AVM had filled with glue and been almost completely shut down and the aneurysm was no longer filling. I felt as if I had just hit a triple in the World Series.

  The case wasn’t over yet, though. A small, peripheral area of the AVM was still filling with blood. I maneuvered a second micro-catheter into another artery that was supplying the AVM and did a second injection. The scan showed that this closed off an additional 5 percent of the malformation. Ninety-five percent of Sam’s problem had been filled with glue in a matter of a few crucial seconds. It would be many years before the AVM would return and was unlikely ever to need treatment. Now it wasn’t a triple, it was a game-winning home run.

  I backed out the catheters before they became glued into the vessel, and I smiled beneath my mask, extremely pleased with the technical aspects of the case. I had judged the blood flow correctly, mixed the glue correctly, injected it at just the right rate. No normal vessels had been harmed, and the unwanted formations were cut off from blood flow. I was cautiously exultant.

  Sam was wheeled into post-op, where we waited for him to wake up. It took longer than usual because the anesthesiologist had planned for a lengthier procedure than it turned out to be. I waited anxiously, exhausted by the preparation and by the adrenaline still circulating in my system. Half an hour later, in the recovery room, Sam stirred and I saw him moving his arms and legs. I came immediately to his bedside.

  “Give my hand a squeeze with your right hand,” I said. He did.

  “Now your left hand,” I said. He did that, too.

  “Wiggle your toes for me,” I said. He wiggled all ten of them. I had seldom seen anything more welcome or beautiful. Tears of gratitude and relief began to course down my cheeks. It was one of the few cases in my career that made me weep. The almost unbearable stress of the procedure drained away in an outflow of emotion. I grabbed his hand and said, “Thank you, God. We celebrate that you did what we asked of you. Now bless his recovery. In the name of Jesus, Amen.”

  I left the room and headed downstairs to prepare for the other case I had that day. I felt completely satisfied. Whatever doubts or fears I’d had were gone. We had passed through the fire and survived.

  Then, in the midst of my preparations, I got a call from post-op recovery. Sam had stopped moving on his right side, and he was panicking. I rushed up as soon as I could. Sam’s dark eyes were full of fear.

  “What’s happening to me?” he asked.

  “Let’s find out,” I said. “Go ahead and move the fingers on your right hand for me.” Nothing happened. A look of frustration and fear passed over his face.

  “I’m trying,” he said.

  “That’s fine,” I responded. “Try the toe
s on your right foot.”

  Again, there was nothing.

  “I can’t make them work,” he said. “Dr. Levy, I’m scared. What’s happening? Why can’t I move them?”

  He was weak on his left side but flaccid on his right side. I turned to the nurse and ordered more steroids and other medications to decrease swelling, which I thought might be causing the aneurysm or veins to press against the tissue-thin spinal cord.

  “I was fine,” Sam said, his voice trembling with sadness and an undercurrent of anger. “When will I recover? What’s going on with me?”

  “I don’t know, Sam,” I said. “I’m doing what I can. Let’s wait and see.”

  Our celebration had turned to uncertainty bordering on despair. I was watching someone who had emerged intact from a procedure slowly lose function, limb by limb. There was nothing I could do. In the next few hours I considered the different surgeries or options we might try to salvage our initial good result. I talked with my colleagues, searching for an answer I had yet to find, but they agreed that there was no solution that would not put him at more risk. We had done as much as we could to bring down the swelling. Now Sam would have to recover on his own.

  I kept visiting him throughout the day, hoping and even expecting him to recover any time. Instead I watched all his limbs gradually lose their mobility as he grew more desperate and emotionally shell shocked. Paralysis was creeping over his body, stilling every movement, as the swelling pushed against the spinal cord and cut off the signals from his brain.

  Within twenty-four hours, Sam was quadriplegic. He could move nothing below his neck. The worst outcome aside from death—some would say worse than death—had been realized.

  Numbness came over me and I began to function automatically, my conscious mind unable to process the grief. I rarely suffered such an emotional blow from a failed procedure, but I did not have the luxury of taking time away to recover. I had a terrified patient and his angry, frightened family to deal with. My emotions had to be set aside so that I could make important decisions and walk them through this tragedy. I also had another case to do that day and could not be distracted by thoughts about Sam.