Jerry was understandably angry about his loss of function. The surgery had extended his life, but at the expense of his independence. With rehabilitation he recovered some of his ability to talk, but he was as terse after surgery as he had been before. When I asked if he was making any progress on his spiritual journey, he said, “No.” We never again spoke at length about spiritual things. My prayer and hope was that he continued talking to God about the pain from his past and the frustrations he had as he fought this new battle—but for me, that’s where the story ended.
* * *
Then there was Betty, a thin, eighty-seven-year-old woman with a lively manner. I met her as she was waiting nervously for me in the exam room. She had been referred to me after tripping over a curb and falling while carrying her bridge club newsletter to the post office. The resulting bump on her head prompted her doctor to request a CT scan. It showed a brain aneurysm that had nothing to do with her fall and that was not very serious.
My conversation with Betty was quick and conclusive: the aneurysm had never bled or caused her a problem. She was already in her late eighties. To fix it surgically risked causing a stroke, and that was, in my opinion, riskier than doing nothing. I recommended leaving it alone. She agreed, and we found ourselves finished with the substance of her appointment. Because it had gone so fast, I felt obligated to give her a little more value for her time. She was still wringing her hands and didn’t seem in a hurry to leave.
“You seem anxious,” I offered. “When people are in their eighties, I always recommend that they consider end-of-life issues before there are any surprises. Were you raised with a faith or religion?”
She had been listening pleasantly, but when I mentioned religion she gave me a sideways look.
“Methodist,” she said, “but I don’t believe in anything now. Why did you ask me that?”
“I like to know where people are coming from and what is important to them,” I said. “Some people say faith helps them cope with the challenges that can arise in later life. At eighty-seven, even though I’m sure you have many years left, it’s good to make sure you are at peace with dying.”
She shrugged her shoulders. “I’m at peace. When you die, then you’re dead. That’s all there is to it.”
I didn’t say anything immediately, but just nodded. She went on.
“At my age I go to a lot of funerals and hate it when they talk about religious themes or an afterlife,” she said. “They should keep the discussion strictly to the person’s life. I don’t like being preached to.”
“So nothing worries you about the end of life?” I asked.
“The only thing that worries me is that people will find my house in a mess after I’m gone and think I was an untidy, disorganized person who did not finish the projects she started,” she said.
She gave a firm nod to punctuate the sentence.
“It sounds like you’ve thought this through,” I said.
“Of course I have,” she responded. “My ex-husband and my husband died the same week, one year apart. A dozen people close to me have died in the last five years. I’m well acquainted with death.”
“I’ll just ask, then, is there anything unresolved in your life you’d like to take care of?” I asked.
“Aside from my messy house? No,” she said.
“Once you’re dead, will you really care what people think about you or your housekeeping?” I asked. “You can probably keep your house as messy as you want.”
“True,” she said, reflecting for a moment. “I guess you’re right about that.”
“Is there anything else bothering you?” I asked.
She fell quiet.
Finally, she opened up. “I haven’t spoken of this to anyone, but there is a painful family situation,” she said. After hesitating, she continued. “My son wanted to marry a woman, but I wasn’t for it and put pressure on him to leave her. She told him that she was pregnant, and he committed suicide. Now she is suing our family for his money. She says it’s for the child. Most of the money has already gone to lawyers.”
“I am sorry to hear that,” I said. “That sounds very difficult.”
“I haven’t told anyone about my son, even when I hear my friends sharing stories about their family problems,” she said. “I’m just too embarrassed. If they found out, they would know that my life isn’t what it seems to be. The worst of it is, I can’t see my two-year-old grandchild because of the lawsuit.”
“Are you angry at your son for killing himself?” I asked.
“Not really,” she said. This surprised me.
“Are you angry at God for allowing it to happen?” I asked.
“No,” she said.
It was curious to me that her opinions were so firm, even in the face of such pain and trouble. My spiritual questions were not resonating with her. Can she not see God wanting to help her with her grief over these losses? I wondered. Then something unusual happened: I felt a strange prompting to compliment her. I prayed, God, show me the beauty you see in her. Immediately I began to see the things God saw when he looked at Betty. Not her faults, but her strengths. Not her failures, but her successes. Not her timidity, but her courage. Not her lack of faith, but the fact that she simply had not yet recognized God’s goodness in her life.
“You know, I am really impressed with you; you are an amazing woman,” I said. “You were carrying your bridge club newsletter to the post office when you fell and hit your head. You invested a lot of time and effort to put that together to bless your friends. You obviously want good communication and good relationships with your loved ones. I find that really commendable. You didn’t have to do it, and nobody paid you to do it. You did it because you have a big and beautiful heart.”
She stared at me. Then her eyes welled up and she started crying. Her face turned red with emotion. I handed her a tissue.
“I can tell that you love to laugh and that you enjoy making others happy,” I continued. “You are an intelligent woman who has kept herself in good mental and physical health for eighty-seven years. I see such strong character in you.”
She sat crying for a moment.
“Well, thank you. I don’t know what to say to all that,” she said, blowing her nose.
“When you’ve lived life like you have, you could really use your experiences and wisdom to encourage others,” I said. “You have made it through some tough times, and now you have the opportunity to help others who are on the same journey. I don’t think you need to be ashamed about your family situation. You might share your son’s story and allow others to gain strength from your experience and to support you. I think what you’ve been through has added to your character.”
She smiled at me through glistening eyes. I was speaking the truth as I saw it from God’s perspective, and her response told me that nobody had told her such things in a long time—if ever.
“I think I might just do that,” she said.
I was hesitant to ask to pray for her, but decided to test the waters. I did not want to miss an opportunity to bless this beautiful woman.
“I have another patient to see, but I would love to pray a blessing over you before you go,” I said. “Would that be okay?”
“Oh, yes,” she said enthusiastically and grabbed both of my hands, holding them tightly while bowing her head.
“God, thank you for Betty,” I said. “I know you are proud of her. You love the way she cares for her family and friends. You love it when she laughs. You love her mind and how well she has taken care of herself all these years. I ask you to bless her relationships and her health. In Jesus’ name, Amen.”
She stood.
“I have to hug you,” she said and flung her arms around me. I was surprised, given how seemingly self-sufficient and resistant to faith she had been. As we entered the hallway and walked to the nurses’ station, she put her arm through mine and clung to me as if I were her date to the prom. At the desk I offered her one of my cards.
&n
bsp; “I enjoyed talking with you,” I said. “Have a great day.”
But she just stood there with me and the nurses. She didn’t want to leave. For a few moments she basked in something that she perhaps hadn’t felt in a long time—love and appreciation for all that she was. When she finally left, I was expecting not to see her again.
Six months later she appeared on my schedule again, but I did not recognize who it was until I went into the exam room. Then I recalled her face and our earlier visit.
“Betty, how are you?” I asked, shaking her hand.
She beamed. “Just fine,” she said. “I wanted to discuss my aneurysm again.” I think we both knew she didn’t need a visit for such a nonthreatening aneurysm, but I sat down and reviewed the old scan to see if my opinion was still the same. It was, and I confirmed that her aneurysm was just the same as I remembered it. Nothing needed to be done.
“We talked about fixing it last time, but because of your age, the risks were higher than the benefits,” I said.
She nodded and then started talking.
“When I called to make an appointment awhile ago, I was told you were on a medical trip helping the poor,” she said. “I have some friends who spend their time doing things for the poor and homeless downtown. I’m not as good as those people—I spend most of my time playing bridge, which is selfish, I guess. But I was thinking that maybe I should help them sometime. I have time to do good things for the poor, too.”
“That sounds like something you would enjoy,” I said.
“I think I would,” she agreed. “You know, I just wanted to tell you that I’m exploring new things in my life.”
Her eyes met mine and conveyed the importance of these words.
“That’s very encouraging,” I said. “I am really pleased that you want to help the poor. I think you are moving in the right direction.”
She beamed, receiving the compliment. With that, having accomplished her purpose for the visit, she stood and I walked her to the nurses’ station. She hugged me and went out happily.
As a doctor or health-care provider, it can be easy to focus only on people’s problems. Obviously that is why they are in the office. But there is more to medicine than fixing problems—there are healing words. By telling Betty what I saw in her, I helped her to realize that there was a purpose to her life beyond playing cards. There is great power in affirming people’s good qualities—their inner beauty, kindness, strength, and love. My interaction with Betty taught me that affirmation may be God’s favorite way to move people toward their destinies. After all, it is God’s kindness that draws us to himself.
In his kindness he drew me. With the particular set of skills he gave me, he allows me the profound privilege of having a hand in physical healing—and sometimes, even more incredibly, of helping my patients find their way to emotional or spiritual health. It is a privilege that humbles me and for which I am grateful to God with every new patient I meet.
Epilogue
Annette, the little girl who had narrowly survived the surgery to block off her large DAVF a year earlier, was back on the operating table—and about to die. I watched helplessly as her vital signs plummeted. Dr. Thompson and I looked at each other in powerless frustration—what had gone wrong? Why was her body suddenly shutting down after what had been a successful surgery?
I wondered what I would tell Annette’s parents now, after all we had been through together. How could I let them know that their long journey was ending this way, with a lifeless girl on an operating table? How could I even face them?
As I watched her numbers drop on the monitor, there was nothing I could do but prepare to perform CPR when her heart stopped. Maybe we could keep her circulation going long enough to figure out what had gone wrong.
* * *
Annette had made dramatic improvements after her previous surgery. She had learned to walk using a walker and had even taken twenty steps on her own. Her speech had come back much better than expected.
However, her DAVF was one of the largest and most aggressive that I had ever seen. Within a year it had re-formed both above and below the glue injection, building new connections around the blocked vessels. I had never dealt with anything quite like this. I felt as if I were playing a game of chess with Annette’s body: for every move I made, it made a countermove.
Dural AVFs in children are especially difficult to shut down because children’s bodies are full of growth hormones, which cause the DAVF to regrow quickly by recruiting nearby arteries. The new growth of the DAVF necessitated another surgery to try to block it off again, but this time I couldn’t go up through the affected vessel because I had blocked it off with glue the previous time. I would have to go through the skull.
My plan was to close off the entire network of veins in that part of the brain in two stages: First, I would block the jugular vein in the neck, depriving the DAVF of any outflow. Then, in an open procedure, I would expose the problem vein in the brain, put a clamp on it upstream from the DAVF connections, and inject glue to close off the whole area down to the jugular. The only way to stop the rogue arteries from making connections to that vein would be to seal off the outflow, forcing the blood to go elsewhere. It was such a complex pediatric procedure that I needed to work in conjunction with a specialized neurosurgeon, Dr. Thompson.
The risks were manifold. I would be permanently blocking one of Annette’s two jugular veins, which are responsible for draining blood from the head. You never know what might happen when you close a jugular, though I was rather certain that the other side could handle the extra outflow. Jugular veins are like kidneys: you’d rather have two, but you can live with just one. Nevertheless, it was a testament to how serious her DAVF problem was that we would perform such drastic destructive procedures to stop its progression.
After that, we would drill open a section of skull right over the troubled vein. Opening the skull invites all sorts of problems, from infection to problems involving the spinal fluid. I would inject glue directly into the vein, but because we were in a neurosurgical operating room, it would be much more difficult to see what was happening. The quality of the mobile X-ray machines we use in operating rooms is nowhere near as high as those in the radiology department, where most endovascular brain procedures are performed. There was no way to bring the better machine into the operating room because it was fixed in position in its procedure room. Furthermore, there was no way to do the surgery in the radiology department because it was not designed to handle open surgery.
All this meant that Annette’s procedure would be anything but routine.
* * *
On the day of surgery I prayed with Annette’s parents as they held her. By that time I had no inhibitions about inviting God into the medical process. In the operating room, the first step of the procedure went well. I closed the jugular with a device that is basically a high-tech metal cork. It stuck firmly in the vessel, immediately shutting off the flow in the jugular vein. Annette’s body responded perfectly: the blood from her head simply flowed down the other jugular, but did not overwhelm it.
Then we began the open surgery, removing the bone behind Annette’s ear with a burr drill. In some cases we might have cut out a section of skull, kept it in a sterile towel during the procedure, then replaced it when we were finished. However, in this case we essentially sanded the bone away with a motorized hand drill to create a hole one inch by two inches right over the vein. Once this was accomplished, a clip was placed across the vein. Now this vein was sealed shut between the clip in the head and the cork farther down the jugular in the neck, creating a closed area. It had no outflow or inflow, except where the AVM vessels had connected to it.
Standing near Annette’s head, I could not see her face, just the opening in the skull behind her ear. I was looking at the dura mater, the brain’s cover. The large vein that I was looking for coursed just underneath. I felt the stress of the moment. We were at the most significant point in the surgery, and it had
taken us four hours to get there.
Through the hole in the skull I threaded an intravenous catheter into the vein. Blood spurted out, indicating that the vessels had not yet clotted off but were still patent, or open. I injected glue with a syringe. One second . . . two seconds . . . three seconds. I wanted to block all possible connections and fill the entire vein. When I finished the injection and pulled out the needle, no blood came back, which meant that the flow was cut off.
Before backing away and letting Dr. Thompson and the neurosurgery resident close up, I noticed that there was a second venous pouch behind Annette’s ear, separate from this vein and just under the skin. I injected this pouch with glue and let it harden. Then I stepped away from the table to allow them to close up the skull. At the back table I put the needles in the sharps container and removed my gloves. My part of the procedure was over.
Then, suddenly, Annette’s condition began to deteriorate. Rapidly.
The first one to notice was the anesthesiologist. He was sitting next to his cart, which had flat-panel monitors showing indicators such as blood pressure, heart rate, and oxygen saturation.
“Any reason her blood pressure is dropping?” asked the anesthesiologist loudly from his position on the other side of Annette. “You guys doing something up there?”
“No,” said Dr. Thompson.
“Heart rate’s dropping too,” said the anesthesiologist.
Suddenly the alarms on his monitors began going off. Annette’s blood pressure, which had been at 130, was now at 100—and falling fast. Her heart rate was also dropping. And her temperature was rising. Something very serious was happening but none of us knew what.
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