“Lorna,” he said, calling his sister. Then again sharply, “Lorna!”
I froze. What was happening? Was he angry? Was he going to do something radical, perhaps call the police?
“Bring me a tissue.”
Lorna came in with the box and dabbed her brother’s eyes. Sam nodded for me to continue.
“I don’t want to pressure you to forgive me if you are not ready,” I said. “This is not about my trying to feel good; it is about your becoming free. If you have resentment, anger, or bitterness toward me, it is not good for you or for your health. I want you to be free from it so that you can heal.”
I waited for his answer while a battle raged inside my head. I was used to helping people get rid of their resentment toward others, but never against myself. I felt exposed and undefended. Then the old doubts about the surgery flooded back with their original force. Had I used the right mixture of glue? Had I been trying to be a hero, to show other doctors what I could do? This patient suffered daily while I continued to enjoy my life. Maybe I was just doing this to assuage my own guilt. I certainly had not come for this purpose, but I stood to benefit emotionally if he would forgive me. Would I be misunderstood? Were my motives pure? Had I ever had a pure motive? As uncomfortable and dangerous as it was, I wanted him to be free from his bitterness. I wanted him to heal in every way possible.
Sam was still crying.
“Maybe we can walk through the steps of forgiveness together,” I said. “Would you like to do that?”
He cleared his throat, nodded, and said, “Yes.”
“Then repeat after me,” I said, beginning with, “I choose to forgive Dr. Levy . . . ,”
“I choose to forgive Dr. Levy . . . ,” he said,
“. . . for the things that he did, . . .”
“. . . for the things that he did, . . .”
“. . . that hurt me.”
“. . . that hurt me.”
“Specifically, I forgive him for . . .”
“Specifically, I forgive him for . . .”
“Now, what do you want to forgive me for?” I said, indicating that he should now say specifically what he was forgiving. He hesitated. God, don’t make me put these words in his mouth, I thought. It’s too much. Yet he said nothing. He would not move forward unless I led him.
After an awkward moment I finally said, “. . . for putting me in this wheelchair.” It hadn’t been my fault, but Sam had been holding it against me, since there was no one else for him to blame for the tragedy, and I needed to humble myself and allow him to release his bitterness.
“. . . for putting me in this wheelchair,” he repeated as the dam burst and he began to cry again.
“I forgive him for what my life has been like since the surgery,” I said. Tears now filled my own eyes as he repeated the words. God, can I do this? I wondered.
“I forgive him,” I said, my voice cracking as I choked back my own tears, “that I can’t walk.” He repeated it as I grabbed a tissue and wiped my eyes.
“I forgive him for all the things that I have not been able to do since the surgery,” I said, and he repeated it. It was taking real effort now for me to get the words out without breaking down.
“I set him free,” I said, but he did not repeat it.
I looked up at him. I realized in that moment that I did want to be free of his anger. But Sam did not repeat those words. Instead he said, “I set myself free.”
I smiled and felt peace fill the room. Though I had offered Sam the opportunity to set me free from his blame, his forgiveness had set himself free from the need to blame at all.
“Yes,” I said, agreeing with him, “I set myself free from all anger, resentment, and bitterness.” He repeated this after me.
“And I am confident that God will treat Dr. Levy,” I said, swallowing hard as I continued leading Sam, “according to his justice . . .”
I said this with great trepidation. He repeated the phrase.
“. . . and mercy,” I concluded.
“. . . and mercy,” he said.
I paused for a moment.
“How do you feel?” I asked.
“Better,” he said, smiling. The tears had stopped, and he was beaming in spite of himself.
“When we forgive others their offenses, God wants to forgive us.16 You have forgiven me, and now God would love to forgive you for anything and everything. He sent Jesus to pay for your sins so that you can go free. Would you like to have your sins forgiven?” I said.
“Yes,” he responded. With my leading he prayed, “God, please forgive me for my resentment and bitterness. Because you want me to forgive people . . . and until today I had not.”
When he had finished, he looked directly at me for the first time since the surgery, no longer angry but appreciative.
“How do you feel now?” I asked.
“Much better,” he said with the biggest smile I had ever seen him wear. He looked like a different person. The minute-by-minute misery he had previously embodied was gone. Now his smile was genuine. He was healing on the inside.
I asked if I could pray for his physical condition again, and he agreed. After I said “Amen,” he looked at me.
“I feel an electrical sensation going down my spine,” he said softly. “And . . . my right leg is moving better.”
In the next few weeks, Sam found a new physical therapy program—and new strength. Within six months he was able to support himself with his arms and walk between parallel bars with the help of a therapist. He called to tell me, his voice exuberant, childlike, full of hope.
Sam and I both hope that someday he will walk again unassisted. Whether or not he does, the day that he forgave me was the day he released himself from his prison.
Chapter 9
The Girl at the Brink of Death
At two years old, Annette was one of my youngest patients, but I couldn’t have been more impressed with her personality. Though most kids are afraid of doctors, Annette trusted me implicitly and came without fear when I asked to examine her. She was well mannered and remarkably sensitive to those around her. If someone in the room sneezed, she would say, “Bless you.” She seemed tuned in to the needs of others in a way I didn’t know was possible for a child her age. Never aggressive, she was actually a bit cautious. When she approached an unevenness in the pavement or a small downward step, she would turn around and slowly ease herself down backward. She was loving and polite, a joy to be around.
Annette’s parents brought her to me because she had a quarter-sized pulsating bump on the back of her head, behind her right ear. It appeared to be causing her discomfort. She was not sleeping well, and she touched the area as if it bothered her.
In the exam room I felt the pulsating region, and though I had no confirming evidence yet, I was pretty sure that the angiogram would show an aneurysm that was only a small part of a larger DAVF (Dural Arteriovenous Fistula). When I did the angiogram, not only was there a DAVF, but it was surprisingly large for a child her age. It was a massive nest of connections between arteries and veins, and those veins were overloaded from the high arterial pressure: there were many dilated connections between the arteries and veins, and the improper connections were causing the formation of a large arterial aneurysm that we could feel through Annette’s skin, though the largest part of the DAVF was inside the skull.
It was obvious we would have to do something, but all the possible complications of operating on such a young child sprang to mind. The amount of contrast dye you can use in children is limited because it can be toxic to the kidneys; this means you have to be judicious with it and work with images of lesser quality. The blood volume in children is very small, so blood loss is much more serious and could necessitate a transfusion sooner. Also, their body temperature can drop quickly—they don’t have the body fat to keep them warm and intravenous fluids cool the body—so we have to keep children under heating blankets and warm the fluids we use.
More important, closing
off the DAVF would require a long and involved procedure with lots of radiation. I did not want to expose a two-year-old to that much radiation if the DAVF was not posing an immediate danger. Since her only symptoms were apparently being caused by the aneurysm behind her ear, after some consideration I decided to recommend gluing that aneurysm shut and leaving the DAVF in her brain alone until later. The older she was, and the longer we could wait to repair it, the better for Annette. Her parents agreed with this approach.
I performed the procedure. The gluing of the aneurysm went well, and Annette went home the next day. She came back to see me two weeks later, and the mass was no longer pulsating. She was not complaining of any pain. I was pleased, as were her parents, and I happily escorted them out and made an appointment to see Annette again in a year.
Three months later they were back in my office. Once again Annette was not sleeping well, and she was blinking her eyes strangely. The area I had glued behind her ear was still not pulsating, but it had now more than doubled in size and was engorged with blood. DAVFs can grow by recruiting nearby arteries, and this one appeared to be changing. I told the parents that, by the looks of it, the temporary measures had not worked, and it appeared we would need to shut down the DAVF by trying to close the large vein draining the right side of the brain. This would leave only the vein on the left side to drain the brain of blood. Since that vein was large and healthy, it could handle the extra flow. Still, I could not predict how the brain of such a young child would respond to having a large, draining vein closed. This would be a major procedure with higher risks than before, but we did not appear to have any choice. She was getting worse.
Annette’s parents were not particularly religious, although they attended church occasionally. They considered my words carefully. The mother was pregnant with twins, and I thought perhaps this was complicating their decision.
“We can wait until after your delivery to do the procedure,” I suggested. She just smiled.
“I’ll have plenty on my hands after they’re born,” she said. “I’d rather try to take care of Annette’s problem now.”
The father nodded and said, “I agree.” With their decision made, I began planning for the procedure.
I spent much time studying the previous scans and plotting out the potential paths I could take to the DAVF in the back of Annette’s head. Finally, the day arrived, and I walked in to see Annette’s parents and both sets of grandparents in the pre-op area. Annette was in a crib, playing with a few toys. She looked up at me and smiled guilelessly, not knowing that soon we would be together again in an operating room, with her unconscious and me manipulating tools in her skull. I went through my usual recap, reminding the family of the risks and what we wanted to accomplish that day. At the end of the talk I said, “I’d like to pray for Annette.”
Everyone circled up around the crib, surrounding Annette with love. She looked at us curiously.
“Father God, we come to you asking for success in this procedure today,” I said. “I pray for wisdom and skill in my work. Give this family your peace. In Jesus’ name, Amen.”
We squeezed each other’s hands; Annette smiled and continued playing with her toys. I left pre-op, and thirty minutes later joined my crew of techs who were already in the angiography suite. Annette was in the procedure room, asleep on the table. I stood next to her little body. A two-year-old has very small arteries in her legs, and I had already entered her femoral artery once before, for the previous procedure. I wanted this to be the last time I punctured that artery, because small arteries have a greater risk of scarring, which might cause her problems later with leg circulation. The challenge of being minimally invasive is magnified tremendously when the patient’s body weighs less than thirty pounds. It was one of the risks I’d had to consider before deciding not to go after the DAVF in the first procedure. In the case of a child, everywhere you turn there’s a risk.
I inserted the guidewire and catheter into the port I had placed in Annette’s femoral artery and delicately worked it upward through the aortic arch and into her neck. The distances were so short that I felt as if I were working on a doll. The first part of the journey went smoothly, but soon it became obvious that, despite the shorter distance, reaching the DAVF itself would not be easy. I tried to guide the wire into her skull via the jugular vein on the right side, but the vein could not be accessed from below because of an obstruction. I backed the wire out and tried going up the left jugular and around the back of her head, but Annette’s anatomy would not allow my catheters and wires to cross the midline of the brain. With increasing concern, I redirected my wire down another vessel and tried going through the feeding arteries in the brain, but again I could not reach the DAVF.
Four hours had gone by and I wasn’t where I needed to be inside Annette’s head. I was frustrated and tired of trying unsuccessfully to find a path to the DAVF. If I couldn’t get my catheter near it, I couldn’t treat it. I cringed every time I stepped on the pedal to beam radiation into Annette so I could see what I was doing. I didn’t want this procedure to fail—another procedure would mean another puncture of her artery, more anesthetic, more wires and tubes traveling through her young vessels, more radiation. There is a limit to what surgery can do without accumulating harmful effects.
I pulled out my wire and catheter and set them on the table. I stepped back, took off my protective lead apron, and left the room for a few minutes. Except for a small port in Annette’s leg, there was no evidence that I had been working for four hours on her body. Since no incision is made on the head in these procedures, taking a few minutes does not endanger the patient; in fact, to continue the procedure while frustrated or angry can often cause errors in judgment. It had become my practice, when surgery wasn’t going well and I had been working for a long time without success, to step out, clear my head, drink some water, and pray. A few minutes’ reprieve from the tension allows me to return to the operating table with fresh perspective and sometimes even new ideas.
I stood in the small side room drinking my water and praying, God, what haven’t I tried? After that brief but refreshing break, I returned to Annette’s side with an idea. The assistants and techs looked at me, ready, eyes alert above their masks. I decided to try my original route through the right jugular, using a stiffer wire that might push past the obstruction. I inserted the new wire, threaded it up into the right side of the neck, and after some manipulation, felt it pass farther than the other wire had. The attempt had worked. I gently pushed the wire into the back of Annette’s head and into the DAVF, and I slid the micro-catheter over the wire and into the specific vein where the problem resided. It had taken me five hours, but I had reached my destination. Now came the hard part.
I took a digital subtraction angiography (DSA) of Annette’s blood flow to see how quickly it was moving through the vessels. Then I stepped to the back table and mixed the glue with contrast agent and metal powder. There was a sober feeling in the room because everyone knew that this was the critical moment. It was unlikely that I could get into this position again, so I had one chance to close off the DAVF. With one swing, I had to hit a hole in one.
I stood next to Annette and got the catheter ready for the injection. Then I took the syringe and fitted the needle into the micro-catheter, then began injecting the glue. Because I was in a vein, I was injecting against the flow of blood, which made things more challenging and unpredictable. I watched as the glue began to fill the large vein on the right side of her head. The glue flowed smoothly and began to adhere to the vein. When should I stop? I thought. I held the syringe in my hands, pressing ever so slightly on the plunger, my eyes riveted to the screen as I watched the glue harden in the young girl’s vein.
There, I thought—that was enough. I stopped, pulled suction back on the syringe, and pulled out the micro-catheter. I had made the crucial decision and there was no going back. The glue continued to harden. There was nothing to do now but see what the angiogram would show. The
techs put the camera in the right place over Annette’s head while I injected contrast dye and made another DSA “video.” The video came up on the screen, and what I saw made my heart jump with joy. The vein had been successfully blocked, and the DAVF was almost completely eradicated. I sighed beneath my mask. Perfect. Six hours after we had begun, we had made the hole in one.
It takes time to put a child to sleep and to wake her up. Annette had been asleep for nearly eight hours and was slow to wake up. I was so fatigued, mentally and physically, that I was moving slowly myself. I caught up with her and her mother in the recovery room, where Annette was now awake and moving her arms and legs.
“Move your fingers for me,” I said. She moved them beautifully.
“Now your toes,” I said. She wriggled her toes. I stood up and turned to her mother, feeling elated.
“She appears to be fine,” I said. Her mother just nodded, and I noticed that she was crying. It had been a long day for all of us. To my surprise, tears began to fall from my eyes as well.
“Thank you, God, for helping me in there,” I prayed aloud. “Please heal this child. Amen.”
It had been one of the most taxing procedures I had ever done. Exhausted, I went home and collapsed into bed early, my thoughts full of the day’s events. I was sleeping deeply when my pager went off two hours later. I fumbled for it and called the number: it was the pediatrician on duty at the hospital. Annette had suddenly stopped breathing. She was placed on a breathing machine, which kept her alive, but she was nonresponsive. I leaped out of bed, pulled on some scrubs, and headed out the door.
The first CT scan showed bleeding on the right side in the cerebellum, the hindbrain. Her ventricles, the fluid-filled spaces in the brain, were enlarged and exerting pressure on the rest of her brain. Something had gone wrong, and Annette’s life was now in grave danger.
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