Gray Matter

by Kilpatrick, Joel;Levy,David

  I threaded the catheter up the left internal carotid artery to the base of Dave’s brain. Through the main catheter I inserted a micro-catheter that had a guidewire with a curved tip. From three feet away I could rotate the wire and move it right or left, depending on where I wanted to go. Getting in was tricky, and I held my breath as I often do at this point, carefully advancing the micro-catheter over the wire and into the aneurysm.

  Because in this procedure you are pushing from three feet away, the curvature of the vessels can absorb a lot of energy and mask what is really happening at the tip of the wire or catheter. If it builds up too much energy, it can jump forward. The last thing I wanted was the catheter jumping into the aneurysm and rupturing it. A significant number of people die or sustain permanent injury when an aneurysm ruptures during a procedure. Poke through a vessel or an aneurysm in the brain, and the brain cavity will fill with blood—a dire emergency. It is one of the ever-present possibilities of every procedure I do.

  With careful movements I avoided that outcome, and within an hour, I was safely in position and ready for the detail work. Into the back of the catheter I loaded my first coil, a 20-centimeter length of platinum wire that, when extruded from a catheter, would form a 7-millimeter, three-dimensional sphere. This would serve as the scaffolding. Slowly, with the gentle force of my fingers, the first coil reached the aneurysm and began to form its spherical shape. I saw it enter the aneurysm correctly and was pleased with the little “construction project” so far. Although magnified on the screen, the entire aneurysm was only about a quarter of an inch in diameter.

  “Let’s do a run,” I said to my tech, and she changed the working view on the machine to capture new images. I stepped on the pedal to begin the digital subtraction angiography. The computer captured a picture of the skull and brain with no contrast dye, then it signaled me to inject the dye. As the dye coursed through the arteries, the computer captured images at three frames per second and subtracted out everything that was on the first picture of brain and bone. That left a view of only the dye flowing through the sharply delineated arteries and veins, without all the bones to distort the view. It then played like a movie while I looked for anything that didn’t appear as it should. Was the coil bulging into the main vessel? That could cause a clot and a stroke. Was the coil poking through the back wall? That could cause a bleed. Was there good flow into all the normal vessels? I didn’t want to damage one of them while trying to fix the aneurysm.

  I love watching angiograms. I never get tired of seeing blood flow through the brain. The best is an angiogram of an aneurysm that bled but is no longer filling because the repair is perfect. That was the movie I wanted to see here, but I was only at the beginning. The moving picture of Dave’s brain arteries popped up on the screen showing the aneurysm containing its new piece of “furniture”—the 7-millimeter coiled ball. It was perfectly placed.

  “There we go,” I said, as I slowed the movie down to watch it frame by frame.

  The platinum ball was rather loose, and inside it I inserted another sphere, this one made of shorter wire and only five millimeters in width. The idea was to put progressively smaller coils inside one another, like Russian nesting dolls, creating a dense, hard ball that could resist the blood’s pressure.

  I inserted several more coils, checking each time to see what had moved in the process and whether the scaffolding was still in the correct place. Soon, I had a mass of metal coils filling one side of the aneurysm. Then I went to work on the other side, using a pair of smaller scaffolding coils and filling them with other coils until there was enough density to withstand the blood flow.

  There was a time early in my career when I would have joked with the technologists about Dave’s moral predicament, but not now. They didn’t need to know any of his personal details to do their jobs. Dave was a person to me, not a mannequin. I wanted the best for everyone I worked on, and that meant leaving this man’s private life as private as possible. During breaks in the surgery I occasionally prayed silently that God would give him another opportunity to live well.

  Meanwhile, I was also performing the ever-present balancing act between using blood thinner and not doing so. Clots form on foreign bodies, such as the catheters and coils I was putting inside Dave’s vessels. If a clot formed on the coils and was carried up the arteries into the brain, it could cause a stroke, making his debilitated condition even worse. The situation was complicated further by the fact that Dave’s aneurysm had hemorrhaged—twice—putting his body on high alert for further bleeding. Injuries tend to make blood hypercoagulable (tending to coagulate more quickly than normal) to stop any further bleeding. This heightens the danger of a clot forming.

  That was a strong argument for adding blood thinner early rather than later.

  But how early? If I added it before the aneurysm was blocked off and, say, one of the coils poked through the wall, Dave would start bleeding and it would not stop easily.

  I gave Dave blood thinner early because, in my experience, clotting is a more common problem than bleeding, but this made my task much more delicate. I didn’t want to cause bleeding or clotting; each could result in Dave’s not making it out of that room alive.

  We were in surgery for two hours, filling Dave’s aneurysm with coils. As usual, I wanted the patient off the table as soon as possible, but I also had to be extremely diligent and not rush through a single step. The last coils were the riskiest and most difficult. It is like filling the last bit of a bottle with water: it’s easy to let it overflow. If the coil did not remain in the aneurysm, it would hang out into the artery and potentially cause another problem. If not enough coil was placed, the barrier would not be complete, allowing compaction of the coils and reopening of the aneurysm. It was tiring, focused work, but finally I had constructed a barrier I believed could withstand the relentless pulsing of blood.

  “All done,” I said, calling for the closure device that acted like a stitch in the femoral artery. Moments later I was outside the room reviewing the images from the case.

  The angiogram showed that I had treated the aneurysm successfully, but everything looking good in the vessels doesn’t mean the patient will wake up the same way he went to sleep. Because of the blood clot caused by the second hemorrhage, Dave’s speech was still impaired when he woke up fifteen minutes later. In the recovery room after an hour or so, I checked his speech and the movement of all four extremities. Nothing had changed. I could do no more than let him recover and wonder again what sort of legal trouble he was in.

  The next day while I was checking on Dave, I met Maureen. She had come in to get paperwork signed so he could receive a disability check. She said he was in danger of losing his apartment.

  “How’s he doing?” she asked with somewhat of an edge. She looked in terrible shape.

  “You are his . . . wife?” I clarified before I gave her any information. She explained that although they had been separated for some time, they were legally married.

  “We’ll know more as he recovers, but the procedure went well,” I informed her. “I am glad that you are able to help him with his disability paperwork. There is no way that he could do it.”

  It was painfully obvious that the situation had distressed her deeply. She seemed distraught, lost, casting about for answers.

  “I can see you’re stressed,” I said. “This must be very hard on you.”

  She sighed heavily.

  “It’s a mess. It’s a nightmare my kids have gotten dragged into.”

  “I’m not even sure what the situation is,” I said.

  “Oh, it’s a wonderful situation,” she said sarcastically. “He met a girl on the Internet who wasn’t as old as she said she was.”

  That explains the police visit, I thought. She continued to talk freely, and I learned that Dave had suffered his burst aneurysm while this girl was at his apartment. By this time Dave had suspected that the girl was underage, and fearing that medical personnel would report him t
o the police, he called his son instead of an ambulance, and the son in turn called Maureen. While the son drove Dave to the hospital, Maureen tried to take the girl home, but she was a runaway. The girl began accusing Dave and even his son of rape. Both men were now facing legal charges.

  Maureen was almost shaking with anger as she spoke.

  “How are you dealing with it?” I asked.

  “I’m not sure I am dealing with it,” she said.

  “Do you have family support?”

  “Not enough,” she said. “Our family has blown up. It’s incredibly ugly.”

  “This may sound strange, but I think you’re in danger in this situation too,” I said, my head spinning a bit from the amount of drama involved.

  “Tell me about it,” she said.

  “I don’t mean what’s happening with your family, even though that’s obviously a problem,” I said. “I mean you’re in danger of having a lot of bitterness because of this. This is embarrassing for you and your family. You have every reason to be angry, even bitter—but that is not good for you.”

  She looked at me sideways, incredulous.

  “Bitterness is a word I’m well acquainted with at this point,” she said.

  “In any case, it’s a very powerful thing, and it can do significant damage emotionally and physically.”

  “What are you? A psychologist?” she asked, drawing the line I must walk with utmost care. I am a neurosurgeon, not a psychologist, and counseling is not my field or what my patients (or their families) expect from me. I am careful not to cross the professional bounds, and I offer to send many of my patients to psychological services for ongoing emotional and psychological care. Still, if I can open people’s eyes to the power they have over the wellness of their own bodies simply by reconsidering their thoughts, I consider that part of my job.

  “No,” I said, “but I’ve seen a lot of people in bad situations get worse by holding grudges. It’s not psychology, but I’ve seen a lot of people get better through forgiveness. If you want to talk more about it, you can come by my office at twelve thirty. I will have some time during lunch to chat.”

  Under normal circumstances she might have brushed off the offer, but she was like a drowning woman looking for a helping hand. Like many others I speak with in times of crisis, she was looking for someone who cared, someone who would give her knowledge and wisdom without judgment or ulterior motive.

  Given the fast pace of typical health care, it is all too easy to move through a traumatic, life-or-death situation without having a chance to catch one’s breath or think very far beyond the immediate present. I can fix an aneurysm, which has the benefit of extending life, but adding years to someone’s life does not necessarily make it better. In many cases people’s life choices are not working for them, and they have never considered that they can make different ones. A physician is perfectly positioned to be a healing balm, an advisor who tells people the truth in noncondemning ways, to appropriately help them sort out how they got to their present situation and where they could go from there. We occupy a place of trust in society, and we must honor that trust by sharing the best of our knowledge on how to treat our patients’ problems, doing so with professionalism and respect for the patients’ dignity.

  She showed up to my office at twelve thirty sharp.

  “Thank you for taking the time,” she said as she sat down. She seemed more centered and in control than when we had first met.

  “Let’s take Dave’s problems and set them aside for a moment so we can talk about you,” I said. “The challenge you’re facing right now is what to do with the pain and justifiable anger you have toward Dave. If you continue to rehearse all the offenses he has committed against you and your kids, the resentment will keep you awake at night.”

  She nodded.

  “You have two choices: to hold onto it or to let it go,” I said. “Forgiveness is a process, not a once-and-for-all transaction. Just as you probably made a habit of reviewing his offenses in the past, you will need to make a new habit of forgiving him from here forward.”

  She considered.

  “I understand that. I guess I’m willing to try,” she said.

  “Do you think you can forgive Dave for this situation?” I asked.

  “It would be pretty hard,” she answered.

  “That’s fair,” I said. “There is a lot to forgive, and you are in the middle of it now. Often people cannot forgive until things have settled down for a while. Even then, I think it may be the hardest thing that you will ever do. It is your Mount Everest. It will take courage and humility. If you aren’t ready, I don’t want to push you. You can take your time and come back when you are ready.”

  “I am willing to try. I still want the best for him. At least for my kids’ sake,” she said.

  “Forgiveness is a process that we can start today,” I said. “Again, it is not a once-and-for-all proposition. If you want to start letting go of the bitterness and becoming free, we can go through some declarations of forgiveness. I’ve seen this work for many others, and I’m sure it can work for you.”

  “All right,” she said. “I’ll give it a go.”

  One by one, with my leading, she named each of Dave’s offenses and handed them over to God. It took about ten minutes and included things I often hear from divorced women: neglect, rudeness, lack of care and affection, outright verbal abuse, abandonment, unfaithfulness.

  “I cancel his debts,” she concluded, repeating after me. “He owes me nothing.”

  When we were done, she looked up at me. “I feel better after that,” she said. “I’m surprised.”

  “Let me mention something else,” I said. “I’m going to guess that the problems in your marriage went both ways. It’s pretty rare for one partner to be perfect. Usually there’s some shared responsibility.”

  She nodded slowly.

  “Yeah, I wasn’t perfect,” she said. “When I finally walked out, I left him with a lot of debt. I just hung it around his neck. That wasn’t right.”

  “I bet you want to get rid of that guilt.”

  “I do, actually.”

  “Why don’t you tell God and receive his forgiveness,” I said.

  “Now?” she asked. “Right here?”

  “No pressure, but God promises that if we confess our sins he will forgive us and cleanse us.14 I am thinking that you would like to get rid of that guilt and feel cleansed. You can do it privately if you like, but when you confess to someone else, there is more power to it, and people usually feel better.15 Being honest about what you have done requires humility and courage, and God loves it when we demonstrate them by confessing. You can confess to someone you know and trust, or I would be happy to help you now,” I said.

  She nodded. “I’d like that.”

  “Tell God. I promise you, he is listening.”

  “Forgive me for what I did to Dave, knowing I was going to leave him,” she said, and grabbed another tissue from the box on my desk to dab her eyes.

  “When you said your marriage vows, did you promise to protect him and care for him?” I asked.

  “Yeah, I think we said that,” she sniffled.

  “I understand the circumstances and Dave’s behavior, but it sounds like you broke your promise,” I said. “Did you make those vows before God and other witnesses?”

  “Yes.”

  “God would love to forgive you for not keeping your marriage vows,” I said without condemnation.

  “Please forgive me for betraying Dave in what I did,” she said, then turned to me. “But he betrayed me first.”

  “Then you can forgive Dave for betraying the vow that he made to you,” I assured her, and she went on to do so.

  Maureen paused for a moment before speaking again—and then it was as if the floodgates had been opened, and she was ready to deal with much more than just Dave’s mistreatment of her. She talked about things that she had buried from her past but that had made her feel as if she didn’t dese
rve anything good, anything beautiful.

  When people share such things with me, it is a privilege to be part of the process, but it is God who does the work. After hearing her story, I asked, “Would you like to forgive those people and let it go?”

  She closed her eyes and began to cry, silently at first, then with great heaves of her shoulders. After a while I encouraged her to express forgiveness in her own words.

  “God, I forgive the person who made me feel like garbage for all these years,” she said. “I’m done blaming you for not protecting me. I don’t know why it happened to me or why this is happening to me now, but I’ll take the chance that you’re good. What else can I do?”

  “You know, God sees you as precious and beautiful,” I said. “I know you haven’t felt that way, but it’s good to speak the truth about yourself to replace the lies you’ve believed. Why don’t you say, ‘I am precious and beautiful’—that is what God says about you.”

  “I don’t know if I can,” she said. “I’ve never believed that.”

  I have suggested this a few times when it seemed to be what people needed to hear, because it is true—we are all precious to God—but they always balk at this suggestion. It is often so contrary to what they have believed for so long.

  “You don’t have to feel it, but when you say it, you’re agreeing with what God says about you,” I said. “It’s not about giving you a good feeling, it’s about agreeing with God.”

  “Then I am precious and beautiful,” she said and broke down again.