Gray Matter

by Kilpatrick, Joel;Levy,David

  Bad outcomes are part of the medical profession. My medical diagnosis and technique will never be perfect every time. I am human, and I make errors. Still, it was painful to make rounds that included a woman who could not move half of her face and who was only two doors down from a man whose facial skin was turning black. Like anyone else, I would rather see my successes than my failures. Some physicians don’t allow injured patients access to their offices. I have always thought that care of the patient and family after a bad outcome says more about a doctor than the plaques on his or her wall.

  Nevertheless, I had caused two injuries in the same week. I was obviously not doing something right.

  * * *

  A few weeks later I was scheduled to do a procedure on Neera, an eight-year-old girl whose left hand and forearm were mildly swollen because of the AVM (Arteriovenous Malformation) located there. She was having only mild symptoms, but I was concerned that the problem might get worse. Because treating AVMs is my specialty, I occasionally treat them in odd places—such as feet, knees, hands, and tongues—and this time I would be operating on the hand. Hand AVMs are rare and difficult, and Dr. Fitzgerald, a specialist in peripheral vascular problems, came to lend his wisdom to the case. He had assisted me several times and I had learned to trust his skill and judgment: he was good.

  I went into the procedure more wary than I had been in a long time. I almost distrusted my own judgment, which is a dangerous thing for someone in my position. With Dr. Fitzgerald present, I prayed with the techs and staff before starting the procedure. When I asked God for wisdom and judgment, I meant it as I had never meant it before.

  I got the catheter into a good position in Neera’s hand and was ready to inject the glue into her vessels and close part of the malformation.

  “We’re in position. What do you think?” I asked Dr. Fitzgerald, who could see from his position behind me the anatomy of her hand on the large TV monitor.

  “Looks good. Glue it,” he said.

  I stood up and went to the back table to mix the glue, but while performing that task, I had a feeling that moving forward was not a good idea. I stopped mixing. I wanted more time to decide.

  I wrestled within myself. Was I simply losing confidence in my abilities? Was this all a mind game? Or was my better judgment speaking to me? Might it even be God giving me wisdom?

  I went back to the table to stare across Neera at the angiogram again.

  “You know, I want to think this through for a minute,” I said to Dr. Fitzgerald. He looked at me without blinking. The techs also looked on. I felt the familiar pressure from everyone in the room. We had a child under anesthesia; this was no time to sit back and contemplate our approach. I was trained to make snap decisions, and it was time to make one.

  But something didn’t feel right, and this time I decided I wasn’t going to ignore it.

  I looked at the scans and saw nothing definitive. I looked at where the catheter was. I thought about the mixture it would require, the amount of blood flow going through those vessels, and where the glue might end up. I could not pinpoint one particular thing that disconcerted me, but I knew deep inside that it would be wrong to go ahead with treatment.

  “I can’t do it. I don’t think it is a good idea,” I finally said.

  Dr. Fitzgerald just stood there blank-faced. The techs paused a moment to see if I was serious. I left the catheter in place, just in case I changed my mind again. Stopping without treating a patient is one of the most frustrating decisions a surgeon can make, for both the doctor and the crew. I got up, pulled off my gloves, and walked into the console room. Dr. Fitzgerald followed me wordlessly.

  Over the next few minutes, Dr. Fitzgerald and I further explored the angiograms. There we discovered something we had not seen before: because of a previous treatment, Neera’s thumb had an unusually poor blood supply. She had only one artery supplying it, instead of the usual two. My injection could have easily blocked the only feeding artery, causing her to lose the thumb.

  We looked at the angiogram in silence for a while. Joy flooded over me. By not treating her, I had likely saved her thumb.

  “Good call,” Dr. Fitzgerald finally said.

  Half an hour later Neera woke up and moved her hand normally, as she had before the procedure. I went home feeling humbled and relieved, mostly for Neera’s sake but also for my own. I had had every excuse to move forward with treatment, including the encouragement of Dr. Fitzgerald, who was more experienced in hand problems than I. But this time I had listened to my gut—or was it God? Given the outcome, I think it was God. The swelling in Neera’s hand and forearm persisted for the next few years but did not increase. It would be three years before Neera would need further treatment of her hand, and her thumb would not be at risk during that time.

  It is never easy making decisions in matters concerning life and limb. Patients rarely know how a doctor suffers when injury happens because of a medical or surgical intervention. Even so, I know that God is always with me, as he is with the patients I serve—even when a procedure goes wrong.

  None of us are beyond his grace.

  Chapter 12

  Memorable Cases

  Blessing patients and addressing their emotional and spiritual health were making a world of difference for them and for me. A few cases stood out from the rest.

  A woman in her late twenties named Claudia came in to see me. This pale young woman seemed unhappy, and her tone was rather whiny. Her MRI scans showed a small feature in her brain that had been labeled an aneurysm but had turned out to be nonthreatening. The reason she had gotten the scan in the first place was because of long-standing and severe headaches, the cause of which nobody could diagnose. When the small bump on her vessel showed up on an MRI, her neurologist sent her to me. Claudia was hoping that fixing the bump would help her headaches. The variation in her vessels was normal, though; there was nothing wrong with them.

  Having a diagnosis of “brain aneurysm” and a visit to a neurosurgeon sometimes serves to validate a patient’s mysterious headaches and to justify ongoing health concerns with family and friends. Even the words brain surgery can give an odd sense of comfort to someone who feels overlooked and undervalued, but I hoped to offer her something more substantial.

  I began interviewing Claudia as she sat in my exam room.

  “How long have you had these headaches?” I asked.

  “A long time. As long as I can remember,” she said.

  “How would you rate the pain, on a scale of one to ten?”

  “Sometimes an eight. Sometimes a five.”

  “What is it now?”

  “Eight.”

  “Does it ever go away?”

  “Not entirely.”

  In our brief exchange she had already struck me as being one of the occasional patients who bounces around the medical system but never finds a real solution for her problems. It seemed to me that medicine had nothing to offer her, and yet I also felt great compassion for her. She seemed frustrated with her life, lost somehow. I wanted to try to help her identify the real source of her trouble, whatever it might be.

  We looked at the MRI together, and I told her that there was nothing of significance to the bump on her artery. It was not a true aneurysm, and there was nothing more to be done for it.

  “However, you are much more complex than your MRI scan shows. There is more to you than what we can see on these studies. How are your relationships?” I asked. “Anything giving you stress?”

  She exhaled slowly. “What do you mean? Like, at work or home?” she asked.

  “Anywhere,” I said. “Are there any people in your life making you angry?”

  “Yes, I guess so,” she said. “I have a terrible relationship with my mother. She drives me crazy. We haven’t spoken in six months. Then my father just moved out of the country with another woman. He is worse than my mother. I don’t speak to him, either.”

  She looked at me curiously, wondering what this had to do w
ith her brain problem.

  “I ask because negative emotions can have physical consequences, not just emotional ones,” I said. “Were you raised with a faith or religion?”

  “I was raised Catholic,” she said, then with an air of defiance added, “but I don’t believe there is a God.”

  I took a deep breath. This might be like trying to take a thorn out of a lion’s paw. I needed to proceed very carefully. I raised my eyebrows and nodded to indicate that I had noted her anti-God sentiments and that I made no judgment of her.

  “When did you decide there wasn’t a God?”

  “When I was nine.”

  “Did something happen when you were nine?”

  She paused momentarily. “I was molested.” She shrugged her shoulders and said it casually, as if trying to convey that it no longer affected her. But everything about her posture and expression let me know that it still hurt and that she had been living with this bitterness. Like many other people who are hurt, she had made certain choices to protect herself from further injury. If God won’t protect me, I will not believe in him, many people think. If God won’t answer my prayers, I will do what I want with whomever I want. These decisions feel justified at the time, but lead people to a prison of loneliness, fear, shame—and often physical illness. There is no lasting peace apart from our Creator. Sure, we can have some great highs, but none of us were designed to live apart from God.

  In that moment I had hope for Claudia, and it appeared to me that this might be a divine appointment. I did not know how much she was willing to confront. Telling her the truth in a way that she could hear it was a delicate job. I had no sense that Claudia wanted to return to her faith, and I was not going to push her. One thing was clear, though: bitterness was stealing the joy from her life, and she needed help removing it.

  “I’m very sorry about what happened when you were nine,” I said. “A lot of people would be angry with God and would be asking why he allowed that to happen.”

  “Yeah,” she agreed.

  I noted to myself that she had just agreed that there was a God and that she was indeed angry with him. That was progress.

  “Claudia, being angry or offended when God doesn’t do what we expect is natural, especially when we are in pain. The problem is that when you need him most, you have no access to him because you have pushed him away.”

  She opened her eyes wide with surprise at my statement, then softened and tilted her head to the side.

  “If you are willing, I would like to help you release your anger toward God. I know that God really wants to hear how you feel,” I said.

  “He knows how I feel!” she snapped.

  “Yes, he does,” I said. “God can read your mind. He knows all your thoughts, but eavesdropping does not constitute a relationship.”

  She smiled at this.

  I continued, “The basis of any good relationship is honesty. God wants to hear how you feel—and how you felt. Abandoned, fearful, whatever you felt, tell him. He has big shoulders; he can take it. If you pretend nothing is wrong and give him the silent treatment, you are the one missing out.”

  “What good could possibly come from it?” she said.

  “Claudia, if I had kept you waiting for two hours in the waiting room, you would probably be offended. You would be expecting an explanation. If I didn’t apologize and explain myself, you might even assume that I didn’t care, right?”

  “Yeah.” She gave me a skeptical look, but allowed me to go on.

  “Well, when God doesn’t meet our expectations, we are offended and want an explanation. He doesn’t usually answer the why questions. God expects us to set aside our offenses and trust him based on his character—not blind faith, but faith based on the things that he has already done for us and shown us about himself.”

  “Like what?” she asked.

  “I bet you have some things that you know came from God that you didn’t deserve. You do live in San Diego, with the best weather on the planet,” I suggested.

  “I have a great husband,” she said. “I don’t deserve him. All I do is make his life miserable.”

  “There you go. What else?”

  “My job: I have a job, at a time when I know a lot of people are out of work. My daughter. I love my daughter,” she said, almost smiling now.

  “Let me tell you what I have seen,” I said. “Many people suffer physical problems because of something that happened in their past, such as what happened to you. They are unable or unwilling to forgive someone who hurt them, and a couple of things happen. It drives them away from God, and it becomes a poison in their physical bodies that crops up as all sorts of problems.”

  She was listening intently now.

  “Sometimes they have headaches, sometimes they can’t sleep, and sometimes their immune systems get so compromised that diseases get the upper hand on them,” I said.

  “What do you do with people like that?” she asked.

  “I recommend that they forgive anyone who hurt them, and I help them talk to God if they choose,” I said. “Some people need to admit that they are angry with God. I would never push you into it, but I think telling God how badly these things hurt would do you good. Honesty is the basis of relationship. I recommend that you do it respectfully, but whatever you say, he can take it. He’d like you to tell him directly.”

  She waited a moment.

  “I’m willing to try,” she said.

  “Okay. Why don’t you start by telling God how you feel about what happened?” I said.

  She paused long enough that I thought I’d lost her and that she would cut the appointment short. Then she said, “God, where were you when I was molested? Why did you let that happen?”

  “Did you feel abandoned?” I prompted.

  “I felt like you abandoned me, like you didn’t care.”

  The sentiments hung in the air for a moment.

  “Think about what else you are angry or frustrated about, and tell him that,” I said.

  “I’m angry with my mother,” she said. “She has been so vindictive and controlling toward me. And my father has made such terrible choices. I hate to think that I’m even related to those people.”

  There was more silence.

  “There are a number of things that have happened in your life that you don’t understand,” I said. “You are stuck waiting for an explanation before you trust God. You have already acknowledged that good things have happened to you that you didn’t deserve. So you have questions about your past, but you seem to have evidence that God has been good to you.”

  “I guess so,” she admitted with a half smile.

  “If you are ready to move forward in your relationship with God, you will need to give up your demand to have an explanation for what happened to you. I am sure that you will get one someday, just not now.”

  Claudia thought carefully about what I was saying.

  “I would like you to say something to God if you feel that it is the direction you want to move. Say, ‘All these things that I don’t understand I’m moving to the side, and God, you can explain them to me later. We have all eternity to talk about them. You don’t need to explain them now, but I choose to believe that you are good and that you work all things for my good. You have my best interests in mind.’”18

  By the time I finished saying this, she was weeping.

  “God, I don’t get it,” she said, speaking now from the heart. “I don’t know why this happened, but I will set my questions aside. You can explain them to me later. I choose to believe that you are good and that you have my best interests in mind, even if it doesn’t feel like it.”

  She seemed to brighten and sit up straighter after she said this. Now that she was moving toward God, I asked if she was ready to forgive her mother and father. She said she was, and I helped her release that bitterness. She wept silently again, and my heart was gripped with sympathy to the point of pain. Then she became quiet and still, with a peace she probably hadn’t
felt in years. I glanced at my office computer, which told me I was late. The next patient was waiting. Claudia looked up at me, then sat there for a moment taking her own measure.

  “I feel very strange right now,” she said. “Lighter, like a lot of stuff just left me.”

  “That’s not unusual,” I said. “You’re on your way to a different, healthier life. I’m very impressed with what you’ve done today.”

  Late for my next appointment, I had to send her off with only my best wishes. I knew that bitterness was going to try to get back in, and I hadn’t been able to offer Claudia anything positive to replace the bitterness that had resided in her heart. It would be easy for her to fall back into anger and bitterness the next time she spoke to her mother or father. Fortunately, I didn’t have to wait long before I had the opportunity to follow up with her via phone.

  “How are you doing?” I asked.

  Her voice sounded cheerful and bubbly, no longer whiny.

  “I’m doing so much better,” she gushed. “Something happened to me in your office. I also found out that my mother-in-law has been praying for me. My husband has been telling me the same stuff you did, but I didn’t believe it. Now people at work are asking me, ‘What happened to you? Why are you so happy?’”

  I had seen this many times before. People who wouldn’t listen to relatives or religious leaders were open to reconnecting with God when encouraged by their doctors.

  I gave her the name of a woman professional who could help her spiritually if she desired, and Claudia called her within the hour. She was moving toward spiritual restoration unusually quickly, from open disbelief to embracing God in the space of one visit. Her marriage began to improve, and she now looks at herself and her life with hope. It was as if the component parts of her faith had been lying around waiting for someone to help her put them together again.

  * * *

  Another patient, Jerry, had an enormous aneurysm pressing against his brain stem—a very dangerous situation. I had been called early one morning by the neurosurgical resident who had put him on the schedule for an emergency procedure. After seeing the CT scan remotely from my home computer, I agreed that it looked dangerous and should be fixed as soon as possible.