Charlotte spoke at his memorial service:
For so long, Alan had a strong body but a hole in his heart. He was consumed by hatred and self-destruction. In the end his heart was made whole but his body was taken. It would have been a shame for him to die unforgiven, and I would be tormented if I had not responded to his plea to come visit him. But every time I think about it now, I feel peace. I did everything I could for him.17
I called her the day after Alan died.
“Thank you, thank you, thank you, Dr. Levy,” was all she could say. “Thank you for being faithful and taking a risk to pray and talk about spiritual things. My path toward healing started when you spoke to me about the spiritual side of health and didn’t just settle for giving me blood thinners. If you hadn’t helped me forgive, I would have been too bitter to see things correctly. I wouldn’t have been there to tell Alan about the forgiveness that he needed from God. Your choice to take a risk changed my life, and it changed Alan’s life before he died.”
Charlotte continues to flourish in her relationship with God, and her children are healthy and happy. She told me recently that she prayed with a patient who had end-stage liver failure—she was able to see him receive forgiveness and peace before he died. She is a living reminder to me of what is at stake every time someone walks through my office door. Life is short, and it is full of need—sometimes desperate need. But it is just as full of opportunities to be used by God in astonishing and eternal ways.
Chapter 11
When Complications Arise
It is one thing to pray for good outcomes or to lead patients through forgiveness for the sake of their health. It is an entirely different thing, and much more difficult, to accept God’s forgiveness when procedures I perform result in injury.
Ken, a thirty-year-old man, came to me with a benign tumor behind his forehead. His operating surgeon wanted me to cut off the blood supply to it so that it would bleed less during the tumor-removal procedure—and he wanted it done the following day. I planned to do this the way I usually do, by gluing shut the vessels that feed the tumor. It promised to be a straightforward procedure, but initially when I met with Ken and his wife, he told me he did not want it done. That surprised me, and I assumed it was typical patient apprehension. I didn’t put any pressure on him but discussed the possible benefits versus risks. With his wife’s encouragement, by the end of the appointment he had come around to the idea and agreed to do it. I added his case to the schedule and was confident that it would go well.
On the day of the procedure I prayed with Ken in pre-op, and before the procedure I prayed with the technologists who would be helping me. Ken was placed under general anesthesia, and I joined him in the procedure room where he was unconscious and draped in blue. My techs were ready. So was I.
I had seen the vascular tumor on the MRI, but as with many other procedures, I wouldn’t know exactly what the vessels feeding the tumor looked like until the procedure began. To see the vessels clearly, I needed an angiogram. I guided the small plastic tube from his femoral artery to the carotid artery in his neck, injected contrast dye, and did an angiogram. The movie, showing dye flowing through the tumor, came up on the screen. The vessels taking blood into the tumor behind his eye were obvious. The tumor was also invading the base of his skull. There was something else, though: the same vessels that supplied blood to the tumor were also supplying blood to the skin of his face. That was troublesome. It immediately elevated the risk from moderate to high. I stopped the procedure.
I often do pre-operative embolization procedures for other surgeons, preparing the tumor for easier removal. Since the other surgeons are the primary ones in these cases, whenever there is a serious question, I want them involved in the decision. It usually comes down to who will take the risk: them or me.
“Get Dr. Miller on the phone,” I said to one of the techs as I headed toward the reading room. Within moments, Ken’s primary surgeon was on the line.
“I just looked at the angiogram, and the same vessels that supply the tumor also supply the skin of the face,” I said. “I’m seeing real danger to his facial skin if we go through with this. I suggest we not do the embolization.”
I heard silence on the other end, and I knew Dr. Miller was going to take the opposite view. He wanted me to plug up the vessels so he would have a cleaner surgery, and I didn’t blame him. Bloody tumor removals are more risky to perform because you often can’t see what you’re cutting out. There are a lot of nerves at the base of the skull, where the tumor was invading.
“I think you can do it,” he said. “That tumor is large. It is a tricky area to operate in and I don’t want it to bleed. I also don’t want to transfuse him. C’mon, Dave, you can do it. You’re a star.”
“Well, I appreciate the confidence,” I said. “But I’m not sure the benefits are worth it.”
“I disagree,” he said. “I have complete confidence in you, and I think it’s the right course of action. I don’t want this thing bleeding all over when I go in to remove it. If you can see any way to do it, I encourage you to give it a try.”
We hung up, and I considered my position. Why was this new wrinkle troubling me but not my colleague? Was I just having an off day? being too skittish? One of the techs came over to sound out what I was thinking.
“I’m not comfortable with it,” I explained. “The risk is going to be higher than I expected, and I have a hard time justifying it compared with the possible benefits.”
“Nah, you could do this, easy,” he said. “You’ve had tougher cases. You can get up there and close those vessels. This could be over in thirty minutes. Why not give it a try?”
The techs had tremendous faith in my abilities. They had seen me do hundreds of procedures, and we had failed relatively few times together. The others watched me from their posts around the room. I was the only one hesitating. Perhaps I was wrong. Everybody else believed in my skills, why didn’t I? A familiar feeling came over me—the desire to be the hero in this situation, to help this man in a way few people could. After all, this was what I’d been trained for.
I tried to shake off my doubt.
“All right,” I said. “Let’s do it.”
Everyone snapped back to action. The show was on.
I inserted the micro-catheter through the guide catheter positioned in Ken’s neck. I proceeded up the external carotid artery and soon encountered my first problem—a tortuous twist in the vessel. Though I was using the smallest catheters and wires available, the path to get into position proved to be an obstacle course. There were corkscrew turns in the vessel, and when the catheter made its way slowly through the looping area, the vessel spasmed, seizing the catheter and cutting off blood supply.
“Spasm,” I said. “Get the vasodilator.”
The techs went to their tasks.
Spasm of the arteries is common, especially in smaller vessels. When something such as an instrument irritates a vessel wall, a muscular reaction causes it to clamp down on the instrument. It happens in vessels of all sizes, but in the smaller vessels it can actually shut down a procedure for a time. Like a tanker caught in a frozen ocean, you have to wait for the passageway to relax in order to free up your instruments to move forward.
Thankfully, this vessel was not the only one supplying blood to that part of the body, so the lack of blood flow would not harm Ken. I injected a vasodilator to help relieve the spasm, and then we stood by in silent frustration. It was like being asked in the middle of battle to stand around and wait.
Ten minutes later the vessel had relaxed enough to move the catheter again. I proceeded gingerly through the corkscrew, past the junction where vessels branched off to supply the face, and down the vessel that went through the skull to feed the tumor. The nearby presence of the vessels feeding the face still made me uneasy. Whenever you inject glue, there is a chance that it can go the wrong way and cause serious problems. The beauty and the danger of glue is that it permanently blocks any vessels
into which it is injected. Proper placement means the difference between closing diseased vessels and injuring healthy ones.
Ken’s vessels were very small, so small that even with machine magnification it was difficult to see everything I was doing. I had earlier considered using not glue but little plastic particles, which go in and jam up the circulation, blocking the vessel by acting more like a dam. I chose glue in the end because the particles could also jam the small catheter I was using and not reach the target. Glue is also easier to see under X-ray and is therefore more accurate. In a complicated situation such as this, with a “good” facial vessel sitting so close to the “bad” tumor vessels, I had to be as accurate as possible.
The level of complication still bothered me as I readied the injection. I knew it would be hard to control the glue in a space that small. The danger was that I would push too much glue in at once, causing it to flow back up the vessel and into the branch supplying the face. To make it more difficult, the X-ray machine was having trouble seeing down to that level. I could still see what I was doing but was now working at the limits of the machine’s visualization capabilities.
My catheter sat in the vessel supplying the tumor, past the branches supplying the face. I had mixed the glue and put it into the syringe. I did a practice run with contrast dye to watch the flow into the tumor. It went briskly. There was nothing left to do but inject the glue.
With a screw-type motion I attached the glue syringe to the back end of the micro-catheter, which was sitting on the blue drape overlaying Ken’s knee. I said, “Blank road map,” and the tech next to me pressed a button to change the function of the machine. I stepped on the pedal, and the screen went blank—a light gray tone. This screen would register only the movement of the glue as it flowed into the tumor instead of showing all the other background structures.
I began to inject the glue and focused my gaze at the tip of my micro-catheter on the screen . . . and waited. Several seconds passed as the glue traveled the length of the micro-catheter. I expected it to appear as a black substance on the screen. As the breathing machine gave Ken a breath, his head moved slightly, making several areas on the screen turn black. Then I saw something appear on the screen, a darker shade of gray that seemed to be going into the tumor. It was the glue. I injected a little more, focusing on getting it deep into the tumor. Pleased that the glue was flowing as planned, I pushed the plunger more. One second, perhaps two; then in a fraction of a second I saw the glue flash back along the catheter, past the branch point for the vessels leading to the skin. I stopped injecting and quickly pulled the catheter out of the vessel before the glue hardened it permanently in place.
I exhaled forcefully. I had forgotten to breathe again.
The glue had come back a bit, but I was happy with the penetration into the tumor. The blood loss at Dr. Miller’s surgery would be minimal.
Through the guide catheter still in Ken’s neck, we did a final angiogram. The tumor looked like a ghost; the glue had cut off its blood supply. Feeling relieved at the success of the procedure, I left the techs to pull out the catheter and hold pressure on the puncture site until it stopped bleeding. This usually took fifteen minutes and was easier to do with the patient still asleep. A bandage over the entry point in his artery would be the only reminder of the procedure, I hoped.
Half an hour later I was reviewing the scans that showed that the vessels to the tumor had been destroyed. I was pleased with myself for having gone through with it.
“Good job, crew,” I said, and the techs voiced congratulations back to me.
I stepped into a small anteroom to write orders for the nurses to carry out for Ken in the recovery room and ICU. Then the anesthesiologist called me back into the procedure room. He was removing Ken’s breathing tube but had stopped to observe something.
“Look at this facial skin. It doesn’t look right,” he said, pointing to Ken’s cheek. There, an area the size of a silver dollar had become unnaturally white. The skin was blanching. I’d seen this happen before, but never on so big an area.
“Oh God, please, no,” I thought.
A feeling of horror and sickness swept over me as I quickly imagined what must have happened: glue had closed the vessels feeding the skin of his face.
“If there was an embolization of the skin, it’s going to be painful,” I told the anesthesiologist. “Be ready with some morphine.”
A nurse rushed away to get the morphine, and I immediately went out of the room to call the plastic surgeon. Closing the blood supply to the skin is similar to frostbite. With frostbite, the blood vessels in the tips of your fingers or nose freeze, so the skin no longer receives oxygen, and it stings. If the nerves in the skin go without oxygen for more than a few minutes, they begin screaming that something is wrong—that the tissue is not getting oxygen. For the patient, this registers as one continuing cascade of pain.
In the same way, embolizing Ken’s facial vessels cut off blood and oxygen to the skin. Now the nerves were clanging like a four-alarm fire bell to alert the brain that the skin was dying.
The plastic surgeon said she was on her way, and she told me to apply a topical cream to the wound, which would dilate the vessels and perhaps increase the blood supply. I went back to Ken, who was still unconscious, and applied the cream to the whitening area. The anesthesiologist gave him some morphine. Then he was wheeled up to the recovery room.
Fifteen minutes later, Ken awoke in terrible pain and began screaming and writhing in his bed. I arrived with the plastic surgeon, and we tried to observe the damaged area amid Ken’s semiconscious moaning and thrashing. It was tough to get a long look at it, but the plastic surgeon agreed that the skin looked damaged.
“We won’t know how bad it is for a few days,” she said. “There’s nothing we can do except wait and see how large it gets.”
“The white part seems to be growing,” I said dolefully.
“It doesn’t matter what turns white,” she said. “It matters what turns black.”
As we left the room, I realized there might be another complication. Because the vessels were so close to Ken’s eye, if there were connections, the glue may have traveled into these vessels as well. Not only was the skin on his face dying, but if the glue had traveled far enough, he might be facing blindness in that eye.
It is difficult to explain the condition I was in at that point, knowing that my procedure had caused pain and damage of this magnitude. I prayed something like, “God, . . . help,” but I felt totally alone. The unexpected had happened, and there were steep consequences. I had criticized other doctors for exactly this kind of result before, citing their poor training and lack of judgment. How could I have done the same thing? How could I have gone forward, ignoring my gut instinct? How could I have listened to others instead of to myself? Had I lost my skills, my edge, my judgment? As a result of my actions, Ken might never look the same and might have only one working eye.
I can’t believe I did this! I thought. I felt lightheaded, and a wave of nausea swept over me as I tried to grasp what I had done. I had no time to address my own emotions, however. Ken’s family were now facing a medical crisis, and they would look to me for leadership. I tried to pull myself together before I headed to the waiting room to talk with Ken’s wife and parents. They were there, tense and expectant. I took a deep breath.
“I was able to get the tumor’s blood supply, but one of the risks we talked about, harming some of the skin on his face, did happen,” I said. I saw them wince.
“There is going to be some damage,” I continued. “I’m just not sure how much. There also might be some loss of vision. Ken is in pain right now, but I’d like you to come with me to see him.”
As I led them to the recovery room, I heaped judgment on myself. How could I have let this happen? The guilt was overwhelming.
We arrived at Ken’s bay in the recovery room. He was moaning in pain. The nurses had sedated him enough to stop his thrashing, but the normal dose
s of morphine were barely effective. We could not give him higher doses because it might stop his breathing.
His wife rushed to his side and began stroking his head. Ken’s eye was swollen shut and the white cream highlighted the wounded part of his face. With their help I calmed him down and separated his eyelids with my fingers to conduct a brief vision test.
“Ken, can you see my hand?” I asked.
He moaned. “My head hurts. It hurts so bad.”
“Can you see how many fingers I’m holding up?” I asked.
He shook his head. “I can’t.”
The morphine took effect and he lapsed back into a stupor. I looked at his wife and parents.
“I can’t tell. We’ll have to wait and test him later,” I said. “I would like to pray for him.”
They nodded their approval, and I put my hand on his head. This prayer was for Ken but also for me. I needed to talk to God about this awful situation I had caused.
“God, we know that you are here even if we can’t feel you right now,” I prayed. “We know that you love Ken, and we pray for Ken’s skin and eye to heal.”
I paused. I was asking God to undo the damage I had just caused, to fix supernaturally something I had done. He wasn’t under any obligation to help me, and I wasn’t sure it was appropriate to ask. Still, I continued out of sheer faith.
Gray Matter Page 19