Gray Matter

by Kilpatrick, Joel;Levy,David

  “We pray for peace—for all of us,” I concluded. “In Jesus’ name, Amen.”

  The emotional agony I was feeling made it difficult to say the words. Instinctively I knew that appealing to God was the right thing to do. It wasn’t about me; it was about helping Ken.

  After we prayed, I left them together and went back to my office. It was late afternoon, but I couldn’t bring myself to go home. Leaving the hospital felt like a betrayal of Ken and his family. I stayed late doing paperwork and keeping busy doing nothing of significance as a sort of penance. I checked on Ken several times and applied more topical cream to his face. It was a further act of penance, since this was something the nurses normally do, and I performed it knowing all the while that it probably was having no effect; the vascular damage had been caused from the inside. In spreading the cream on his face, I was just trying to make myself feel better.

  I finally went home that night and entered a weeklong nightmare of regret and self-condemnation. I was unable to eat for days, unable to think of anything else for more than a few minutes. Ken was constantly on my mind. I could not believe that I had injured his face so badly that he would need plastic surgery to reconstruct it and that I had perhaps robbed him of sight in one eye. There was nothing I could do to take it back or fix it. I replayed the tape of the procedure in my mind as if reliving some personal trauma. I had known the risk, but never before had a cosmetic outcome of this scope resulted from a procedure I had done. Fears chased through my mind: fears that I was not a good doctor, that I would lose my job, that Ken and his family would be angry with me and sue me. When I had felt hesitation during the case, I reasoned now that God had been telling me to stop. If he had been, I hadn’t listened, and I had hurt a man who trusted me. I also remembered that Ken initially had not wanted the procedure.

  Along with the fear, irrational anger washed over me—anger at myself, as well as at the other doctor and the technologist for encouraging me to proceed when they knew I was uncomfortable doing so. I realized anew and with awe how thin is the margin between doing great good and doing great harm in my profession. The glue was just one example of that; all the tools of brain surgery must be used within a very narrow range, and with sometimes superhuman precision. Otherwise, those tools become instruments of destruction.

  I woke up the day after the surgery and each subsequent day hoping that it had all been a dream. One night I actually dreamed that it had not happened at all, only to wake up to the reality that when I arrived at the hospital, I would look under Ken’s bandage—and relive the nightmare.

  I checked on him three times a day. The affected area of his face turned white, then gray. They had moved him to ICU, where a nurse kept up with his demand for narcotics. Only a strong sedative kept his pain under control. The pain would subside when the injured tissue actually died.

  With each visit I would talk with his wife and family, give them—and myself—a pep talk, or console them as needed. Once his pain was under control, Ken seemed to appreciate my coming by to pray with him. I was there to be his cheerleader. His wife and parents also looked to me for assurance and guidance. They were trying to support Ken, and this was just the first step. His tumor still had to come out, and the other doctor was already scheduling the next surgery. Ken’s family stayed remarkably steady throughout. We prayed together whenever they were in the room; they told me they greatly appreciated this.

  It took a week before we knew that Ken’s eye had not been damaged. The blurriness had been temporary and perhaps due to swelling around the eye. Unfortunately, his facial skin did not improve. On day three a small central area of the wound began turning black. This black spot spread outward until it encompassed the whole area that had initially been white. Black is a color that does not exist in the human body; it is the color of death.

  Not only would plastic surgery be necessary, but Ken’s face would never look like it had before.

  As Ken went through his own painful recovery, I began to untangle the knot of regret and try to make sense of what I had done. The question I asked God was not, “Why do you allow suffering?” but “Why did you let it come by my hand?”

  As I spun myself into ever-deeper tunnels of remorse, I knew the only path out was to follow the steps I had taught others: confess my sins to God, receive his forgiveness, and then apply his grace to what I had done. This advice seemed inadequate to the offense now that the offense was my own. Forgiveness was easy when I was prescribing it for someone else. Now I had to take my own medicine and believe that receiving God’s forgiveness would help me heal.

  I called a friend, a surgeon and a follower of Jesus, the kind of friend who would be especially helpful at a time like this. Most friends, especially doctors, were telling me things to make me feel better: “It is part of the risk of surgery. The patient knew the risks.” “Everyone has complications.” “You just need a vacation.” “You have done so many great cases; focus on those.” All were common expressions from sympathetic colleagues. Though having people speak to me in this way was comforting, I was in a prison of guilt and couldn’t get free. I told my friend what had happened and that I was so upset I was unable to eat.

  “Guilt is powerful. You’re beating yourself up mentally, and your body is just following along and punishing itself,” he said.

  “I can’t believe I did that injection. I ignored my own reservations,” I said.

  “You feel guilty—and maybe you are; maybe you’re not,” he said. “Confession is what I recommend. There is nothing that God won’t forgive. Even if you confess to something you didn’t do, God knows, and it can’t hurt anything but your pride. Whatever you’ve done, it doesn’t change the way God sees you, and it doesn’t change the way I see you.”

  With my friend listening, I confessed to God what I had done, and I received God’s forgiveness. Because God had forgiven me for what I had done, to continue to punish myself would mean that my standard was higher than God’s. Only pride had prevented me from believing that I was forgiven. Still, my mind kept rehearsing that fateful decision to proceed, and it took awhile to feel forgiven. It became a daily battle. Each day when I walked into Ken’s room, I had to remind myself that God loved me regardless of my performance.

  Although I conveyed to Ken and his family how sorry I was that this complication had occurred, in this case I did not think it would be helpful to them to ask their forgiveness for the bad outcome. It was, after all, a risk of the procedure. I prayed with Ken for healing and for the upcoming tumor surgery. The only good result of my procedure was that the tumor would bleed little when they took it out.

  It is mandatory to present a report to the chief of neurosurgery about any complication that takes place during surgery, and I did so. Since the complication was cosmetic and had no neurological impact on the patient, he didn’t think it worthy of discussion. To me, though, the outcome was far from acceptable.

  Ken went home on day seven, taking mild pain medicine. The tumor was successfully removed two weeks later, and plastic surgery was performed at the same time to repair the damage to his face. A permanent scar remains.

  A scar also remains on my heart.

  * * *

  The very next patient I treated was Lisa, a fifty-year-old hairstylist who required an embolization on a cigar-shaped tumor that ran along the base of her skull just behind her right ear. It was an uncommon location for a tumor and was threatening the brain stem and ear region and the nerves in that area. It was also an uncommon type of tumor and one that was bound to be bloody if the skull base surgeon tried to remove it without my first blocking the vessels.

  All tumors are parasites, poaching the body’s normal circulation in order to feed themselves. A tumor actually secretes a substance that causes vessels to grow into the tumor to feed it blood. The vessels supplying the tumor become enlarged, and the blood that should be going elsewhere serves to grow the tumor.

  Among tumors there is great variety in the amount of vascularizatio
n, or the extent to which a tumor has taken over the blood vessels. Some tumors are avascular (having few vessels) and grow slowly. Others, like the one this patient had, are highly vascular, with a high density of vessels in and around the tumor.

  On the initial scans I could see a number of normal vessels that had been drawn in to serve the tumor. The mass was so vascularized that it was almost nothing but blood vessels, many of which were very small. It was obvious why skull base team members Dr. Samuels and Dr. Bronson wanted me to cut off the circulation of the tumor before they removed it. Bleeding in that area of the head can be profuse and can complicate surgery and require transfusions. The unusual location of the tumor also meant it sat near cranial nerves going to the ear, tongue, throat, and face. The tumor had grown around some of these nerves, making it easy to injure one of them during a bloody surgery.

  Skull base surgeons know the course of the cranial nerves, carotid arteries, and other important structures that are hidden in the bones of the face, ear, and occipital region, where the skull attaches to the cervical spine. Using a drill, they shave the bone surrounding the nerves to a paper-thin layer in order to carefully separate nerve from tumor. The cases are long and tedious, more so even than typical neurosurgical cases. Removing tumors from between the cranial nerves at the base of the skull requires a level of skill, patience, and dedication that few surgeons possess.

  Lisa was from out of town and had made a fairly long trip to San Diego for a double procedure: the embolization one day, followed by surgery two days later by my colleagues. I put on my hat and mask and headed into the procedure room. She was anesthetized and on the table, and I did a quick angiogram by entering at the femoral artery and navigating to the carotid artery in her neck. I went into the control room, took off my gloves, and sat down to take a look at the movielike angiogram. What I saw made me uncomfortable. As I had suspected, the vessels feeding the tumor were dangerously close to the facial nerve, which runs near the ear canal. I called Dr. Samuels, and he came down in minutes.

  “This tumor is really close to the facial nerve,” I said, watching the angiogram as I spoke. “I don’t want to give her a facial nerve palsy.”

  He was silent for a few moments.

  “I don’t want this thing to bleed,” he said. “The last time you used particles, it bled a lot. Use that new glue, the thick stuff. That works great.”

  He looked at his watch. There was some urgency in his schedule, and he wanted my procedure to be done that day. I looked at the angiogram again, then looked over at Lisa, unconscious and ready for the embolization. I felt immense compassion and wanted the best for her. The techs stood nearby, ready and eager to work. The train was moving down the track. Once again, I was the only one threatening to stop the momentum.

  “Let me make a quick phone call,” I said, and excused myself. Dr. Samuels made a sound of exasperation behind me. The techs held their places quietly.

  At Dr. Samuels’s request I was using a different substance, an agent that is not actually a glue but acts like one and is injected as a liquid. This black mixture has the consistency of thick molasses and is much thicker than the glue I normally use, which is thin and flows with the blood into the tumor. You literally push this substance forward until it fills the whole tumor, vessel by vessel. It contains metal powder, which settles in the vessel and plugs it up. I had used it before, but not in this particular location. I wanted to be completely sure that there was not some history of complications with the facial nerve when using it in this part of the body. I had read a journal article that reported success in treating a large series of tumors using the glue to cut off the blood supply; it reported no major nerve injuries with it, but I could not tell whether the surgeon had been treating a similar tumor in a similar location.

  I ducked into the reading room and dialed a few colleagues to run the situation by them and get their professional opinions. No one was available. The only person available was a sales representative who couldn’t get company consultants on the line. Nobody knew if it was safe to use around the facial nerve.

  I was going to have to make this decision on my own.

  Because blood vessels supplying the facial nerve are very small and the substance is relatively thick, I reasoned that the danger of damage to the nerve was small. There was a risk, but I wasn’t sure if the risk was high enough to stop the case. Maybe I was being overly cautious because of what had happened with Ken. Maybe this procedure would even offer me redemption. I had done riskier procedures before with success.

  In fact, I had made a career of tackling risky problems, and the vast majority of the time it paid off. If I didn’t take on this problem, Dr. Samuels would have a much more difficult surgery. The risk was his or mine to deal with.

  I walked back into the procedure room.

  “Okay,” I said. “Let’s go.”

  Dr. Samuels smiled and went back to his office.

  I stood next to Lisa and carefully guided a catheter up her femoral artery and into her ear region. I identified three separate vessels that were feeding the tumor, selected them for embolization, and began filling them with the tarlike glue. For five hours I pushed it through the vessels and watched my progress on the twenty-four-inch screen. The images were regularly refreshed and showed the glue oozing into different parts of the tumor. The screen did not depict any body structures, including the tumor or the brain; I had to imagine where important structures were by watching the glue so I could stop the injection before it blocked important vessels.

  There was one main danger I was trying to avoid. I didn’t want the glue oozing down a wrong vessel, where it could get into general circulation and cause a stroke. I was constantly trying to stay within what I considered to be the boundaries of the tumor. This required me to visualize in my own mind the shape of the tumor and where it ended. If I saw the glue approaching what looked like a “normal” vessel, I stopped injecting.

  Some procedures are long but fulfilling. This one was just long. In the back of my mind I was constantly thinking about the higher-than-normal risk. I knew I could cut off the tumor from its blood supply, but I was not at all sure that I could do it without causing harm, and that put me on edge.

  When I finished, I was pleased with what I had done. The glue hadn’t gone into the brain and didn’t appear to have gone anywhere I hadn’t expected it to. The scans showed that I had blocked the tumor’s feeding vessels. My team of techs felt confident and happy. So did I.

  It took awhile for Lisa to wake up, which was normal for a procedure that long, and when she did, I went into the procedure room to visit her. She was still groggy as I performed the usual post-operative checks.

  But when I asked her to smile, only the left side of her mouth went up.

  “Try again,” I said. Again, she half smiled.

  “Close your eyes,” I said.

  Her right eye would not close.

  My heart sank. The facial nerve was not working. Not another complication in the same week! I thought. This can’t be happening.

  Since she was groggy, she did not realize that there was a problem, so I just smiled back and told her I would see her in the recovery room when she was more awake to discuss the procedure.

  As I entered the case in the computer, a task required by hospital protocol for every surgery, I went over in my mind what might have caused part of her mouth not to move and an eye not to close. There had been no topical anesthesia to immobilize the face. It might have been merely the solvent in the glue that had stunned the facial nerve, meaning that it should recover. But clearly, the most obvious reason was that my injection into the vessels of the tumor had somehow traveled into the tiny nerve-feeding vessels and cut off the blood supply to the facial nerve.

  Before accepting this possibility, I went to the recovery room to visit Lisa again. She was much more awake now. She perked up when I walked into her bay.

  “You seem to be doing well,” I said.

  “I feel pretty good
,” she said.

  “Can you smile for me?” I asked casually. She did. The same side of her mouth did not move. I noticed, too, that when she blinked, her right eye did not close completely. The injury was still there, which meant that it was more likely to be permanent.

  Calmly, I said, “Lisa, there is some weakness in your face, but I don’t know if it is temporary or permanent. For now, just rest. We’ll talk about it later.”

  “Okay, Doctor,” she said, seeming unconcerned. She was already looking ahead to her next surgery to remove the tumor, and for now my news was lost amid her other concerns.

  I knew it was no minor concern. Back in my office, I sat alone and faced the devastating facts: a procedure of mine had injured another patient the same week in which Ken had been injured. Technically Lisa’s procedure had been a success, but it also had harmed her face. Having half of your face paralyzed is significant. I had proceeded when I had reservations—again.

  I leaned forward and put my head in my hands. Two complications in one week were more than I was used to having, and it stung my ego. I struggled again with self-condemnation. Would I do more harm?

  Lisa went to surgery two days later and her tumor was successfully removed. The skull base team was very pleased with the lack of bleeding during the long and difficult surgery. Dr. Samuels told me that he had found the new glue in the small vessels around the facial nerve, confirming that my procedure had caused the facial nerve injury. Lisa went on to recover partial function of her face, including the ability to close her eye. Unfortunately, the right corner of her mouth didn’t go up; the procedure had permanently altered her smile. Dr. Samuels also noted that if I had not done such aggressive work, the bleeding would have prevented him from seeing the facial nerve and he might easily have cut it during the surgery. Here was the blessing of teamwork; celebrating our successes and supporting one another when complications arise.