Gray Matter

by Kilpatrick, Joel;Levy,David

  The aneurysm was located on the basilar artery in front of the brain stem, and it had grown so large—more than an inch in diameter—that it was compressing the brain stem, causing him trouble when he walked. Most aneurysms are less than 7 millimeters in diameter, about a quarter inch. Jerry’s aneurysm was more than 25 millimeters (an inch), which boosted it into the giant category. All parts of the brain are surprisingly forgiving; they tend to accommodate an aneurysm or a tumor as long as it grows slowly. However, the brain stem, like the spinal cord with its tightly packed nerves, is affected earlier than other parts of the brain, and this aneurysm was now encroaching on the brain’s territory. It was a situation that could soon prove fatal.

  My first questions when confronting any case, even one this dangerous, are always, “Should we do something or should we do nothing? Is the best option to leave this alone? It has lasted this many years—what are the chances of its harming him now? Can we treat his symptoms without doing anything to the aneurysm?” I pondered these questions as I drove to the hospital that morning, but only after I arrived and saw more-detailed scans was I able to settle on a recommendation. The scans showed that the problem was even more serious than I had thought. The risk of stroke during or after surgery would be 25 percent or higher, but if we did nothing, he was likely to progress into debilitation and eventually death.

  I went into the exam room and met Jerry, the “owner” of this aneurysm, for the first time. He was a short man of about sixty-five who looked as if he could survive in the jungle with nothing but a knife. I knew from talking to the neurosurgery resident that he was strongly independent and had waited as long as he could before considering treatment. Realizing that his symptoms were only getting worse and that he would soon be wheelchair-bound, he grudgingly agreed to look at his medical options.

  I began interviewing him before the procedure.

  “What do you do for a living?” I asked, trying to learn about him and the context in which he was coming in for surgery.

  “Retired,” he said.

  “What was your career?” I asked. He looked unwilling to answer.

  “Odd jobs here and there,” he said, and gave no further explanation.

  “Tell me about your symptoms,” I said. He began to explain in clipped sentences that he had been getting slowly weaker on his right side. He was still able to get around town on the bus system, but he had started walking with a limp.

  “Do you have anyone who can drive you where you need to go?” I asked.

  “I live alone,” he said.

  “No friends or neighbors?”

  “Not really,” he said.

  Either he was a true loner or he was just bluffing because he was scared. In any case, I was learning that he wasn’t the kind of man who liked divulging information or depending on others.

  “Well, it looks as though the problem is getting worse,” I said. “This procedure is risky, but if we do nothing, your symptoms will probably continue and you will eventually become incapacitated.”

  “I get that, Doc,” he said. “It’s why I’m here.”

  Something about his manner struck me as odd. He was treating our time together as if it were a routine visit to the dentist, and he was about to get a filling. I wondered whether he was taking the risks of the procedure seriously. I decided to change direction with my questions.

  “Did anyone come with you today?” I asked.

  “No,” he said.

  “Any family in town that you could call?”

  “No.”

  “The reason I ask is that this is a high-risk procedure.”

  “How high risk?”

  “Very high,” I responded. “You have a giant aneurysm next to the most important part of your brain. The vessel has taken on an unusual shape and will be difficult to repair, if it can be repaired at all. It could be fatal. I think you have at least a one in four chance of having a major stroke or dying.”

  A startled look passed over his face.

  “Are you serious?” he asked.

  “I am,” I said.

  He did not seem emotionally prepared to hear this, and I wondered why he thought the risk would be low. After all, it was a giant aneurysm and he was already becoming paralyzed.

  “I haven’t heard anything about dying,” he said.

  I was sorry that this was the first time he was hearing it, and I said so. “This is a very risky procedure,” I repeated.

  Jerry looked down at the ground and grimaced. It was painfully apparent that this was new information to him and that he had never really thought about dying. He began to breathe heavily and make small gestures of frustration and distress, as if being rushed into a situation he hadn’t expected.

  His sentences got longer, too.

  “I need to call my wife,” he said. “Actually, she’s my ex-wife, but she’s the most important person in my life besides my son.”

  “Sure, go ahead. You can call her from here,” I said, and he took out his cell phone and dialed.

  In the space of time this afforded me, I thought about what else I might do to fill in the gaps for Jerry, now that I realized he had not been made fully aware of the risks involved with such a procedure. He should have had time to consider the implications, and ideally he should have had a group of supportive people with him to comfort and encourage him before and after the surgery. Instead, here he was—alone, in clear emotional distress, and completely unready for something of this magnitude.

  He reached his ex-wife’s voice mail. As soon as he heard the recording of her voice, this previously impassive man began weeping and was unable to stop. Finally, when it was time to leave a message, he squeaked out the words, “This is Jerry. They’re going to do a procedure, and I might not survive.”

  He hung up, tried to compose himself, then dialed his son but failed to reach him as well. He put down the phone and choked back tears. He looked anguished. In the meantime I handed him a tissue and began studying another bit of information in his chart that must have been seen as inconsequential in light of his aneurysm. His blood work from the morning had just returned and the numbers were noticeably low.

  “Your blood count came back low this morning. Do you have any idea where you might be losing blood?” I asked.

  “Angiomas,” he said, his tears subsiding a bit. “All over the inside of my gut. They bleed.”

  “How often?”

  “Once a week.”

  “How much blood do you lose?” I asked.

  “About a pint.”

  “You lose a pint of blood each week?”

  “Yeah,” he said.

  Angiomas are small bumps that look like red moles. They are a rare cause of bleeding anywhere along the gastrointestinal tract. Jerry was describing spontaneous hemorrhaging that was causing a significant loss of blood—a fact that had major implications for his surgery.

  “Have you had them taken care of?” I asked.

  He shook his head. “I don’t like hospitals,” he said.

  This was a problem. I would have to use blood thinners during his procedure and throughout his recovery to lessen the risk of clotting and stroke, but if one of those angiomas popped, Jerry might bleed uncontrollably. I calculated the risk for bleeding to death after the surgery at 50 percent if we put him on blood thinners as planned.

  “Jerry, let’s take stock of where we are,” I said. “This aneurysm is pressing on your brain stem. You are losing the use of your right side and can no longer walk without a cane. We were planning to do the surgery today, but your bleeding problem needs to be looked at—perhaps we can help that today. You seem to be learning just now about how risky the surgery is, so I think we should delay it. But I have an idea. Why don’t we do an angiogram today and look at your aneurysm as well as the bleeding sites in your intestines? An angiogram would tell me a lot more about the blood flow in the aneurysm. I will also have a radiologist help me embolize, or plug up, any bleeding sites in your intestines. If we can stop you
from bleeding from the angiomas, the treatment of the aneurysm will be much safer.”

  “Okay,” he said, a bit relieved.

  “I recommend we do that today and not treat the aneurysm yet.”

  He nodded. This seemed to be an acceptable pathway for both of us.

  “Jerry, every procedure, even an angiogram, has a risk. I typically pray with my patients before procedures, and I’d like to do that now,” I said. “Is that all right with you?”

  He looked surprised, but he consented. I placed my hand on his shoulder. He stared straight ahead.

  “God, you know all about Jerry,” I prayed. “I ask you for safety today during this procedure. Amen.”

  I looked up. Jerry was still staring straight ahead as if nothing had happened, as if he were biding his time waiting for me to tie my shoe.

  The anesthesiologist was waiting outside the exam room. Jerry was taken to the procedure room and sedated. Scrubbed and ready, I soon stood at his side and put the catheter up through his femoral artery. I injected dye and took a high-resolution angiogram, which gave me a virtual video of the vessels near his aneurysm. It was big and ugly. There was no easy way to fix it.

  After the angiogram, we spent several hours identifying and trying to plug the arteries that were feeding the angiomas in his intestines. We thought we had achieved a result that would prevent him from bleeding. I went to visit with him in the recovery room.

  “How do you feel?” I asked.

  “Fine,” he said.

  “The procedure went well,” I said as I showed him the images. “I got a good look at your aneurysm.”

  He nodded. “Thank you,” he said. I planned to delay the next procedure two weeks, and I wanted to get him thinking about fundamental things, to be prepared for it emotionally, psychologically, and spiritually.

  “We talked earlier about the risk of death. With your two conditions, death is a significant possibility with or without this procedure,” I said. “Where are you on your spiritual journey? Have you thought about that at all?”

  “Nah,” he said, “I can’t believe in God.”

  “Why?” I asked gently.

  “I’ve seen too much,” he said with contempt.

  My silence invited more explanation.

  “I’ve traveled around and seen too much to believe anything,” he repeated.

  “Okay,” I said. “Some people like to settle their accounts before going into something like this.”

  He nodded unenthusiastically to let me know he’d heard me. It was clear that more probing in this area would be unfruitful and perhaps even harmful.

  “Then I’ll see you in a week or so,” I said. “If you have any questions, feel free to call me. Rest up. You’re doing great.”

  “Thank you,” he said.

  The next week Jerry had another bleeding episode from his GI tract, which earned him a trip to the emergency room. The ER said he had lost a pint of blood and was anemic. He still wanted to move forward with the procedure, to try to preserve his ability to walk independently, and two weeks later he was in the pre-op area again. His son and a couple of neighbors from his apartment complex were in the waiting room. They did not seem to know each other, and an uncomfortable silence engulfed them.

  I went to visit Jerry in pre-op and found him slightly chattier this time. I arrived early, allowing time to talk, in case he’d had a change of heart and wanted to open up. We greeted each other, and I went through my pre-op checklist to make sure he fully understood the high risks of what we were trying to do and what might happen if we failed. Then I again addressed his spiritual life.

  “Jerry, I know you said last time that spiritual things aren’t very important to you, but I make a habit of asking patients if there is anything they need to do to make peace with God before a procedure like this,” I said. “It could be something you feel unsettled about, or need forgiveness for, or something that would give you peace going into surgery.”

  He sighed. “I really don’t believe in that stuff,” he said. He went quiet for a moment, but instead of clamming up completely, he continued talking. “I saw so many starving kids in Africa,” he said. “Dying kids. I never figured out how God could let them suffer that way. They never did anything to deserve it.”

  “Why were you in Africa?” I asked curiously.

  “Work,” he answered cryptically.

  “What kind of work?”

  “Just work,” he parried—then he finally relented, looking at the ground. “I was a mercenary, paramilitary. Did for-hire stuff. Various places. Different groups.”

  I nodded and received the information carefully.

  “Sounds like interesting work. Which African countries were you in?”

  “Whichever ones needed a war started,” he said grimly and with a slight chuckle. “These governments—they were so corrupt. You almost didn’t feel bad, taking out these guys. I should probably be dead myself. All my friends died—of bullets and land mines. I’m not sure why I escaped. I haven’t been able to figure that out.”

  I kept listening, giving him the respect of my silence.

  “We trained rebel groups,” he elaborated. “Brought in weapons, got rid of bad guys.”

  “Dangerous?”

  “Real dangerous. But the work wasn’t what bothered me,” he said. “It was the inhumanity of the people I worked with. It sounds stupid, but sometimes when we were on the boats, other guys—mercenaries from other countries—would shoot the crocodiles on the banks. How could they shoot innocent animals like that? They just played target practice with ’em. And the children—everywhere we went, I saw them suffer for nothing.”

  I nodded. “Have any close calls?” I asked. “Plenty,” he said. “We were ambushed on our boat. Ambushed in buildings. Couple of times I thought I would never make it out alive. In fact, one time I was the only one who did make it out alive. Everyone I worked with eventually got killed. I’m the only one left.”

  “So why did you do it?”

  “Good money. Very good money. Exciting work. Camaraderie.”

  “So the reason you can’t believe in God is because of what you saw and what you did?” I asked a little more boldly.

  He exhaled. “A little of both,” he said. “I wouldn’t have done what I did if I didn’t think the governments were unjust. But you can’t justify everything. Some of the guys I served with were heartless. After a while I was afraid I was becoming like them. And I hated seeing the starving kids.”

  “I wonder if you’ve ever told God how unfair it was, all the things you saw.”

  “He doesn’t need me to tell him,” he said.

  “Not for his sake, but for yours,” I said. “It seems that you haven’t made sense of it.”

  He thought a moment.

  “Maybe so,” he replied. “I still feel angry about it.”

  “God is not afraid of your anger,” I said. “He can take whatever you throw at him as long as you are honest. Making peace with God starts by being honest. Are you interested in telling him some of these things?”

  “All right,” he said. “Can’t hurt.”

  I sat in a chair next to his bed. “God,” I said to start him off, “Jerry has seen a lot of suffering in his life. He’d like to talk to you about that today.”

  On cue, after my brief silence, Jerry began to speak.

  “I don’t know why I saw so much suffering and unfairness,” he said. “There were innocent children dying. Inhumane behavior on both sides. Cruelty. Why would you let those things happen? How could you just stand by and watch?”

  He stopped for a moment, then opened his eyes, startled, as if receiving a revelation. Then he continued as if speaking to himself.

  “I guess people did those things to other people,” he said. “Maybe the suffering wasn’t God’s fault. God gives men free will. It was . . . people.”

  I nodded. “One of the things I tell patients is that they don’t have to understand why things happen in order to t
rust God,” I said. “If you want, you can set those things aside and trust him now, even though you don’t have all the answers. It sounds as though you are getting some new insights just by talking to him.”

  He nodded, and I continued.

  “One of the best ways to further the conversation between you and God is to mention some of the things you’re thankful for,” I suggested. “Can you think of anything that falls in that category?”

  “Yeah.”

  “Do you want to take a moment and thank him?”

  “Sure.” He closed his eyes and put his head down. “Thank you for all the times my life was spared,” he said. “You brought me home every time. My friends are all . . . gone. Thank you that the bullets and the land mines and machetes never got me. Somehow I made it. I feel like you deserve credit for that.”

  He was quiet.

  “Jerry, is there anything you need to be forgiven for?” I asked.

  “Yeah,” he said as he nodded slowly. “Lots.”

  He thought a moment, and I gave him time.

  “I know I should do this,” he said after a while. “God, forgive me for . . . the things I’ve done that weren’t right. You know what I did that was wrong. Forgive me so those things don’t weigh on my mind anymore.”

  He was quiet.

  “Feel better?” I asked.

  “Yeah,” he said. He seemed more human than I had ever seen him, less the aged warrior and more a tender man facing the end of life alone. I shook his hand.

  “Any more questions for me?” I asked.

  “No, Doc, I think I’m ready,” he said and smiled. I left to prepare for his procedure.

  The surgery was difficult. I couldn’t use a stent as I had hoped because that would have required Jerry to be on a blood thinner regimen for six weeks. That would risk a fatal bleed from the angiomas in his bowel. Instead, I used a small balloon to hold open the vessel while I placed coil after coil in the mega-aneurysm. The procedure was successful, but the day following the surgery, he suffered a stroke and had difficulty speaking. His son was there to comfort him. His neighbors lingered in the waiting room out of obligation, but none of them seemed to know him well enough to offer any real encouragement. Whatever community he had known in the mercenary trade was gone. His social network was too thin to offer support in his moment of crisis.