Read an Excerpt

GRAY MATTER

Tyndale House Publishers, Inc.

Chapter One

Maria, the well-dressed businesswoman sitting in my office, had a brain aneurysm. One of the blood vessels in her brain had weakened, causing the vessel wall to balloon out in one place like a snake that has swallowed an egg. From the size and irregular shape of the aneurysm I had concluded that if not dealt with relatively quickly it might burst and kill her.

She was employed in high-level management and looked the part: she wore a black suit and heels, and an attaché case that appeared to be full of paperwork, presentations, and binders rested on the chair next to her. It looked as if she might be here on a lunch break between important meetings. I half expected her to say something like, "I've got ten minutes until my face-to-face with clients, Doc. Make it snappy." But I could see that this sudden and unexpected diagnosis was causing her concern—a brain aneurysm isn't exactly one of those things you put on your calendar and schedule into your life.

It was our first meeting. She had been referred to me a week earlier by the neurologist who had picked up on the aneurysm, an unexpected "catch" that might very well save Maria's life. Many brain problems don't announce themselves. Aneurysms, notoriously, give no warning; they hide in the brain until one day, when the blood pressure proves too great for the strength of the artery wall, they rupture and bleed, causing a tremendous headache, loss of consciousness—and eventual death. Sometimes, in the fortunate cases, the aneurysm will push against a nerve or brain structure and prompt some odd symptoms that might alert someone before a catastrophic rupture. In Maria's case, there hadn't even been a suspicion of an aneurysm. The MRI scan had been ordered for a completely different, minor concern. But like a video security system that happens to catch images of a wanted killer lurking in the background, the scan had detected this menace inside her skull.

My job was to fix it before it could do any real damage.

If you have a brain aneurysm less than seven millimeters in size, a quarter inch in diameter, the chance of it bleeding is relatively low, less than 2 percent per year. That means the chance of it not bleeding is greater than 98 percent every year, which is not a large risk. However, if it does bleed, the risk of death is high—30 percent of those whose aneurysms burst don't even reach the hospital alive. They die from the trauma of blood flooding the skull and having nowhere to exit. Of those who make it to the hospital, 30 percent end up with a major cognitive deficit of some sort, losing their ability to talk or walk or recall information or even recognize loved ones. They are not able to resume their previous lifestyles. These are the kinds of facts I have to lay out for patients when discussing whether or not to treat them. I have to tell them whether I think that aneurysm or other malformation we see on the scan has a good chance of bursting or harming them and, if so, how to fix it before it does.

As for Maria, I felt she had no choice. The nine-millimeter aneurysm had multiple weak spots, or "daughter sacks," and was large, unstable, and unpredictable. It had to be treated.

We sat across from each other in my exam room at the San Diego hospital where I practice. The room is nothing special, your typical ten-by-ten medical box with a sink, cabinet, and window looking out on the trees in the parking lot. Nothing about it bespeaks comfort. Only my own nature photography hanging on the walls sets it apart from any other room in any other medical facility in America. Lining one wall are seats for the patient and family, though there was nobody here today but Maria and me. Just off to one side is a rolling computer stand into which I enter data and can review a patient's scans. Now I turned the computer screen around and showed Maria a 3-D rotational picture of the aneurysm from the CT angiogram. The multilobed, balloon-shaped aneurysm arose from her smooth brain artery like a phantom from a drainpipe.

"Let me lay out how I would approach this technically," I said. On the wall behind me was a whiteboard on which I drew a picture of her aneurysm and then detailed the treatment plan, to help her understand what would be taking place inside her skull while she was asleep. After a moment, I swiveled gently away from the board to face her. This was an important moment for both of us. In spite of her professional demeanor, Maria was now giving all the visible signals of agitation: arms and legs held uncomfortably tight against her body, eyes and facial muscles tense and alert. She kept making quick motions with her head and unconscious repetitive movements with her fingers. If she was trying to hold the anxiety in, it wasn't working; the tension was spilling out. Maria seemed to be wondering if her life, so full of the things she had hoped and planned for, was coming to an end. It was as if someone had slammed on the brakes and turned sharply into a blind alley called brain surgery.

As the neurosurgeon walking her through this difficult news, I had a complex set of tasks to perform. I had to ease her mind about the upcoming procedure, giving her the confidence that it could be successful and that she could come out of it without any loss of function. I also had to be honest with her about the level of risk it involved—of blindness, coma, paralysis, or death—so that she could properly set her own expectations and those of her family. We could not avoid the possibility that, as with any surgery in so delicate an area, things could go terribly wrong. I had to convey all this in a calm, honest, and straightforward way—to someone who really didn't want to hear it.

So much of a doctor's job is in not just diagnosis but in demeanor and presentation as well—the way you come across as you speak, the way you comport yourself, the way you relate to patients. Are your eyes steady, or are they shifty? Do you look into their eyes or over their shoulders or around the room? What does this subtly tell them about their prognosis? What can they read into your body language, your hand motions, your almost imperceptible movements of facial muscles, your ease or lack of ease, and your willingness to engage with them as persons, not just medical problems? Pre-surgical consultation is a dance. You have to practice it, becoming light on your feet and making the right moves in sequence, for it to seem graceful to you and to your patients. Fortunately, I have a calm manner that seems to set people at ease. Still, it takes a great deal of experience to make bedside manner seem effortless, and ultimately that is what you want to achieve: a sense of peace and confidence in spite of a bad diagnosis.

I explained the risks and benefits of intervention, and the risks and benefits of doing nothing. She nodded and followed along, taking it all in. As she looked at me, her eyes pleading for good news, I knew she was waiting for me to tell her that there was a pill or an easy treatment—something quick and painless that would solve her problem. Most patients believe, or at least hope, that a doctor can do anything. We are the modern medical high priests, called upon in almost spiritual fashion to rid people of the inconveniences of illness and to heal on demand. At least, that's how people treat us and how, especially in my field of neurosurgery, we often want to be treated. But I had made a decision to give up the role of high priest, even if I still looked like one in my white coat and light blue scrubs—the standard, intimidating outfit that helps to signal the surgeon's separation from and, technically speaking, superiority to the people around us. Yes, I am a highly trained medical professional, but I am not my patients' ultimate healer, and I certainly am not their god. I believe that position is already taken.

I glanced over her scans one more time, knowing full well that, with her, there was only one way to go.

"Maria, I recommend we take care of that aneurysm," I said. "It is the type we call a berry aneurysm because it has a small 'neck' holding it to the parent vessel. The aneurysm itself is round like a berry. Unfortunately, this kind has thin walls, and your thin walls have thinner walls called 'daughter sacks,' which I believe make it more likely to burst."

She didn't even exhale when I said this. It was as though she were holding her breath, waiting for the good part. She wanted me to tell her that she would be fine, but I could not promise that. Looking at this woman in the prime of her life and career, I was struck yet again by the fact that people with nothing outwardly wrong can have a ticking time bomb inside their heads.

I felt compassion and a familiar sense of peace. It would be tricky, but I had the skills to help her, and I loved using those skills; we were going to mend this thing so she could get on with the rest of her life. I wanted nothing more than to help put this incident firmly in her past. Ideally, she wouldn't see the inside of a hospital again until we did follow-up scans several months later to monitor her progress. Unlike other relationships, most surgeon-patient relationships should be temporary. We come together, solve the problem, and then go our separate ways.

"Can it wait?" she finally asked.

Statistically, it could; an aneurysm of that size had been there a long time. But those who have been in the business long enough have seen people bleed before they can get into surgery.

"If your aneurysm were perfectly round or smaller, I would have no problem waiting," I said. "We could wait a month—but I don't feel good about the size and shape."

She nodded slightly. "Then I guess that's what I have to do," she said. "I'm sure I'll have more questions when I've had a chance to digest this and research it a little more, and after I tell my family."

We both sat quietly as she considered again what I had said. After a moment, I leaned forward slightly and did what had become customary for me, something that I had never seen another doctor do, something that in a single moment stripped me of any semblance of godlike status.

"I know that I have given you a lot to think about. Would it be okay if I said a prayer with you?" I asked in a tone that made it safe for her to say no if she wished. I had asked earlier about her spiritual history and learned that her parents were Catholic but that she did not attend services.

She tilted her head to one side and looked at me curiously, as if reading a financial report she didn't understand. She relaxed slightly and nodded.

"Uh, okay," she said, a little confused. "Fine."

I slid my rolling chair over to her and slowly reached out my hand. As surprised as she was, she instinctively reached out with both of her hands and grabbed it as if grabbing a lifeline. I bowed my head to give her privacy. Then I began to pray.

"God, thank you for Maria and for allowing us to find this problem," I said. "This is a surprise to us but no surprise to you. I am asking that this aneurysm not cause her any problems until we can fix it. Please give her peace and good sleep leading up to this surgery. God, we are asking you for success for this surgery. Give her the sense that you are with her. In Jesus' name, Amen."

I opened my eyes after the short prayer. Maria's chin was on her chest and she was crying softly. Tears had made water marks on her skirt. Peace seemed to blanket her, and she was tranquil and centered, like a visitor in a church or other sacred place. Gone were the extraneous movements born of high stress. She breathed deeply and seemed to exhale the concerns that had nearly overtaken her. This sudden change might have surprised me if I hadn't seen it happen so many times with so many other people.

After a few moments she looked up at me. Tears were blending with her mascara and running down her cheeks in gray streaks. She nodded her affirmation of the prayer and dabbed her nose with a tissue that I handed her from the box I keep on my computer stand.

"Thank you, Dr. Levy," she said with a sparkle in her eyes that spoke of calm and hope. "I've never prayed with a doctor before."

I smiled. I'd heard that many times. This simple act had done what no conversation, no psychological analysis, no recitation of the medical facts had ever done, in my experience. She had received something no insurance company, medical provider, surgeon, or drug could offer: confidence and peace from a simple prayer. And even, I believe, a welcome touch from God.

Maria's surgery went flawlessly—until the very end. Then a tear in the aneurysm caused blood to flow into the spaces of her brain with every heartbeat. I feared the worst; we might not be able to save her.

With my crew waiting for instructions, I called for the specific tools I would need to repair the breach. Everything seemed to happen in slow motion, and I felt my frustration rise. There is nothing surgeons hate more than surprises, especially the kind that could rob this family of a wife and mother.

I guided my instruments up the carotid artery just below the bleeding aneurysm and tried another method to stop the bleeding from the potentially fatal tear in the vessel wall. After five minutes of intensely focused work, I injected dye to see if I had succeeded. My heart sank as I watched the screen and saw the dye leak from the top of the aneurysm as she continued to bleed. She had been bleeding into the brain for more than five minutes. Would she survive? And if she did, what would she be like?

It took several more minutes of delicate, painstaking work and periods of agonizing waiting, but finally the bleeding stopped. It took another hour to determine that Maria would survive the bleed and had not suffered a major stroke; she was moving her arms and legs and was talking. As she went into the intensive care unit and continued to improve over the next few days, I thanked God for answering the prayer that Maria and I had prayed together in my exam room. I believe it made the difference for Maria—and for me.

Because in neurosurgery, you never know what might happen.

* * *

I have no way of knowing exactly how many nurses, doctors, surgeons, or even other neurosurgeons take the spiritual lives of their patients seriously or pray with their patients as I do. It's certainly not a subject that comes up at medical conferences or with coworkers in the elevator or hospital cafeteria. In fact, if spirituality is not introduced in a way that honors the patient and his or her faith, it can lead to ostracism by the medical community or worse—discipline of some kind. The role of prayer in health care is itself a gray matter.

Yet both doctors and patients seem to recognize that some crucial component of patient care is often missing. Though spirituality is almost completely absent from medical interactions, a large majority (75 percent) of more than a thousand physicians surveyed agree that religion and spirituality are important in helping patients cope and in giving them a positive state of mind.

Patients, too, place a high value on religion and spirituality, particularly in the midst of an illness. In one study, 82 percent of 124 consecutive ophthalmology patients at Johns Hopkins University said prayer was important to their sense of well-being.

As I have addressed patients' spirituality and made prayer a regular part of my patient interactions, the response has been impressive. I have seen lives brought to a level of spiritual, emotional, and physical health that my patients had never enjoyed before. In the process, I have learned two important things: that there is a limit to what I can do as a highly trained and experienced surgeon and that there is no limit to what God can do to touch a person emotionally and spiritually, not just physically.

My goal as a professional is to use my skills and knowledge to help people have the best lives possible, for as long as possible. This includes emotional as well as physical health, because the two are interrelated. Emotions can create health or cause disease, and spiritual health affects emotional health. Laughter and joy are known to restore and encourage health, while bitterness and resentment promote disease. Forgiveness has well-documented health benefits. One's concept of God can cause ongoing joy or ongoing anxiety. These issues are not incidental but are central to health.

(Continues...)

---

Excerpted from GRAY MATTER by DAVID LEVY JOEL KILPATRICK Copyright © 2011 by David Levy and Joel Kilpatrick. Excerpted by permission of Tyndale House Publishers, Inc.. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

---