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CHAPTER 1
Divine Intervention — God Giveth, God Taketh Away: Mrs. Ibarra's Gift
Hold off your hands ... and know that I am God.
— Psalm 46:10
In operating room 3, the only audible sounds were the soft wheeze of the anesthesiologist's respirator and the occasional soft click of instruments being passed between rubber-gloved hands. Through the lenses of the operating microscope, I could clearly see the magnified stereoscopic images of Mrs. Ibarra's brain tumor, a large peach-sized outgrowth of the dura (a thin leather-like membrane) that covers the brain. This benign lesion was behind this 72-year-old woman's right eye; total removal would be a cure. For the past four hours I had been slowly, but steadily, removing the growth piecemeal — the hard way — with electric forceps and wire-cutting loops (small circular heated wires on the end of a plastic wand). As the loop sliced through the tumor, smoke and vapor obscured the field. My assistant, Dr. Peterson, sucked the smoke away with his metal suction tip. I longed for the ultrasonic aspirator that I had used in training; it would have made this job much easier.
Four hours had elapsed since Mrs. Ibarra's surgery began and I had one remaining portion of tumor left — a small, scraggly clump of cells at the bottom of the operative field, hardly bigger than a pencil eraser.
"Just one little piece remaining," I told Dr. Peterson. He could see it too; he had an excellent view through his observer's eyepieces. I easily sliced through the remaining tumor with the cutting loops and then suddenly, like an explosion, the field of view turned bright red.
"Suction!" The nurse complied, placing the tool in my hand.
Eventually, through the process of suctioning away the obscuring blood, I came to a startling realization: the last small piece of tumor had invaded the carotid artery, the major artery supplying the right side of the brain. The overlying tumor cells hid this fact from me. Removal of that final portion had taken out a section of the artery's wall; without applying pressure to seal it off, the vessel would bleed profusely. I initiated repair of the vessel.
"Silver clip," I commanded. The nurse handed me long-handled clip-applying forceps.
Because of the invasion by the tumor, the clips would not take a solid grasp; no matter how many times I tried, they didn't work.
Dr. Flower, the anesthesiologist, said, "Are you going to get it? I've given her three units of blood."
"The carotid artery has cut loose; I have to repair the arterial wall," I replied. Dr. Flower returned to his position at the head of the table behind the drapes. "Suture, eight zero," I requested as I continued to peer into the microscope lenses. I began the slow and tedious process of sewing the vessel, but was confronted with another problem: the walls of the artery were softened by the tumor, and the suture would not take a solid grip but merely pull through when tightened, causing further injury to the vessel.
I repeated my efforts with clips and sutures while minutes multiplied. I had spent four hours trying to stop the blood loss. Dr. Flower replaced the woman's entire blood volume with donor blood; she was now a candidate for developing dreaded complications that can result after massive blood transfusion. My patient had been under general anesthesia for more than eight hours and had received 10 pints of blood. I was nowhere close to being finished. It appeared as through I were about to experience my first loss of a patient during surgery, and would be introduced to the feeling of having caused a patient's death. I should have foreseen the possibility that the last remaining piece of tumor was a sticky wicket and just left it alone.
All eyes in the operating room were on me. All ears waited. What was I to do? I had exhausted all of my options ... all but one! I never thought of praying before this day. Although I had been an acolyte in the Episcopal Church as a youth, I had no interest in religion. Having trained in physics, I doubted the significance of prayer and was skeptical about the existence of God. I had been too busy with academics during the past 21 years to allow time for religion. But today I prayed with sincerity. I would have fallen to my knees if I had not been scrubbed in and sterile. I felt incapable of saving the life of this patient. I took a deep breath and exhaled slowly. I needed to connect with that force. As I looked through the scope, I prayed silently: If there is a God, a higher power, then I need your help. It is not Mrs. Ibarra's fault that she may die. I have done all that I can do. I am asking for help. Don't let her die on the table; help me to repair this damaged artery. Please!
I took a second deep breath ... and went back into the breech. "Suture," I said. For what seemed to be the umpteenth time, the scrub nurse obeyed my request. Once more, I carefully tried to approximate the torn vessel's walls.
"Clip," I said. She handed me clip after clip until, after 15 minutes, I had applied several clips and snippets of suture, trying to bring the remaining walls of the artery together without occluding the vessel. To my amazement, the operative field remained as dry as a bone! No bleeding. I was pleasantly stunned. I'd done nothing out of the ordinary during that last 15 minutes except to repeat the previous attempts of the past few hours. But this time, the sutures and clips held firm. The prayer — the silent plea — had worked. The damaged artery showed no sign of bleeding. Everything at the base of the skull looked perfect.
"We're out of here," I told the scrub nurse and my assistant. All that remained was to close the operative site. This took 45 minutes, but it was a walk in the park compared to the ordeal I had faced over the past nine hours. Now, believing that my prayers had produced the miracle, I put forth another silent request: I have one more favor to ask. Please do not let her be comatose. Let her wake up and heal quickly. Do not let her become stroked out and paralyzed, but instead let her speech and strength be normal.Let her come out of this in the best possible way. If you do this, I'll be as good a person as I can possibly be.
When helping to move her from the operating table for the trip to the Intensive Care Unit, Dr. Flower said, "You know, you have to learn that you can't make 'good enough' better."
This case taught me that there is a higher power. It had seemed to flow through me when called upon. Was this the God who created us in His image? Alternatively, was it a force, an energy that is available when summoned to supercharge our meager human efforts? At the time, I was unsure just what to call it. It was there waiting for my call, and when asked, it came to my assistance. Although signs pointed to God, a nagging question bothered me. Was it something within me that required the slow, deep breathing and mental refocusing for its activation? Whatever the mechanism, it was now a moot point — Mrs. Ibarra was going to at least make it to the ICU and I would be forever thankful. Now if she could just pull through intact, I would be the second-happiest person on the island.
Mrs. Ibarra not only survived the surgery, but she healed quickly with little neurological sequelae. She was discharged in seemingly normal condition one week later. Besides ptosis (a slight droop) of her right eyelid, she had a second problem. I found out about it three months after surgery when she came to my office for a final post-operative checkup.
"How is your eye?" I asked.
"Oh about the same, doc," she replied, "I've learned to live with it, and it's not bad at all. But I have a problem. My husband will not give me enough sex!" She smiled at me, and I smiled back. That was a great complaint for a woman in her seventh decade of life.
"I don't think I can help you with that," I replied. "Are there any other physical problems?"
"Not really. Say, I have something for you, doctor." She pulled a large piece of lacquered wood from her shopping bag. On it were two engraved Japanese kanji. The patient, however, was from the Philippines. I was confused. The Japanese characters must be of special importance.
"What is this?" I asked. "What does it say?"
"Oh, I don't really know, I'm not Japanese. But when I found it, I had the feeling that somehow, in some way, doctor, it was for you. This is what you need."
"Well, thank you very much. I will treasure it and think of you often."
She smiled again, and I returned her smile in kind.
"This is your last visit with me, Mrs. Ibarra. You have done well; the scan we did last week reveals no further tumor growth; in fact, the scan was normal. I will recommend to your doctor that he perform a follow-up scan in six months to confirm that everything is still okay. If you have a question or would like to see me, please call anytime."
Later on, I asked a few of my surgical colleagues if they had experienced a case where they could not stop the bleeding. The response was uniformly, "Yes, why?"
"What did you do?" And again, the reply was always the same: "What can you do?"
At the end of the year, I hosted a Christmas party at my office. During the festivities, I pulled my friend Dr. Nagashima aside and showed him the calligraphy that Mrs. Ibarra had given me. "What does that mean?" I asked.
He peered at it for a moment through his thick eyeglasses. "Heiwa," he said. "Roughly translated, it means peace."
And indeed, as a result of my intraoperative prayer, Mrs. Ibarra survived. Now that I knew a higher power was with me, I was at peace, confident that I could overcome any difficulties either on my own or with help, on those rare occasions when good enough truly needs to be made better.
Sara's Sudden Demise
Every life has dark tracts and long stretches of somber tint, and no representation is true to fact which dips its pencil only in light, and flings no shadows on the canvas.
— Alexander MacLaren
I continued to bask in the blissful feeling of serenity that resulted from the prayerful experience that ostensibly saved the life of Mrs. Ibarra. I augmented my budding conviction in the unseen spiritual world (and a higher power) when I became "born again" at a local Pentecostal church. I'd connected with the universal force (that I now called God), and felt as if I could ask it to aid me at any time. I became filled with the Holy Spirit. Time passed, until an otherwise routine day changed dramatically into one of the saddest days of my life. It was an experience that caused me to rethink my recent religious conversion and to search for another answer to the mysteries of life and death.
Sara DeAngelo came with her parents for a consultation. Nine years old, she radiated great beauty and spirit. Her smile was adorable and by her appearance and manner, I could tell that one day she could potentially be a fashion model. She had been blessed with great looks. I was struck by her natural charm and her soft-spoken, friendly nature, seemingly years beyond her age. Her parents worked in the sugar industry and had recently moved to Hawaii. The girl had a ventriculoperitoneal shunt — a bypass tube with a valve that drains cerebrospinal fluid (CSF) from the brain to the abdomen to treat hydrocephalus (enlargement of the fluid spaces of the brain). The shunt was performed in the first days of her life. There had been no problems with the device since its insertion, but in time, she would outgrow the length of tubing in her abdomen and it would have to be replaced. Shunts also can become obstructed.
Shunts come in many varieties. The most common type is a flexible silicone catheter that is inserted into the brain. This is done by placing a small hole in the back of the head and inserting the catheter into the ventricular fluid system deep within the brain. A valve mechanism allows one-way flow of CSF from brain to abdomen. Tunneled under the skin, a discharge tube allows drainage into the abdominal cavity. Babies born with "water on the brain" suffer from CSF buildup when egress from the ventricular cavities of the brain is blocked. A pressure-relieving procedure must be performed quickly. Sara had such a shunting procedure after birth and had done well.
Sara conversed with me easily and submitted to a neurological examination without duress. Her parents were pleased as they observed our interaction, and at the end of the consultation they requested that I be available should the shunt require surgical treatment. I agreed and told them how to contact me in case of emergency. I scheduled an X-ray to estimate the remaining length of tubing. As a result, I determined that she could grow a few more inches in height before modification would be necessary. I admired this little girl and mused about someday having a child of my own as sweet as Sara DeAngelo.
Everything stayed quiet for many months. Then one day, the emergency room called. Sara had suddenly become seriously ill with complaints of severe headache and came to the emergency department for treatment. A CAT scan showed obstructive hydrocephalus with her ventricular system under high pressure. The shunt was blocked. I arrived at the hospital within minutes to find the mother holding her retching child over a sink in the X-ray department, suffering from the increased pressure in her head that, if untreated, would soon lead to brain herniation as pressure forced brain tissue through the opening at the base of the skull. Coma and death would quickly follow. My evaluation showed the shunt to be occluded at the valve; I planned to insert a new system. I explained the procedure and its risks to the parents and they requested that surgery be done. Within the hour, I was scrubbing for surgery.
In the operating room I glanced at the monitor; her respiratory and heart rates were normal. The anesthesiologist waited for me to begin. I put on gown and gloves and went to the table.
"Knife," I said. The nurse gave me the necessary scalpel and I opened the old incision, disconnected the valve and — suddenly, without warning, the ventricular catheter fractured and disappeared into the brain.
"Damn it!" I exclaimed, perhaps a little too loud.
It had been old and brittle. To retrieve it could cause injury to the brain and might stir up bleeding that could be difficult or impossible to control. It was better to let it float forever within the ventricular chamber. I inserted a new system without difficulty and made sure that it properly drained the fluid drop by drop. I closed both incisions and applied sterile dressings. Sara went to recovery and then to the pediatrics unit, her room directly across from the nursing station. The nurses would keep a close eye on her. Sara's father planned to spend the night in her room. I told him of the difficulty with the old tubing breaking off and disappearing within the brain, and of my decision not to try and recover it. He understood.
I returned home that evening feeling good about the surgery. Before retiring, I called the pediatric floor. Sara was reported to be sleeping comfortably with normal vital signs.
"Remember to check on her routinely as ordered."
"Of course doctor," the nurse replied, "she's doing just fine."
I awoke with a start at 6 a.m., rubbed my eyes, and wondered about Sara. I had slept through the night without a phone call, so apparently she was doing well. Showering, I mentally reviewed my schedule for the day: office appointments were the only tasks after morning rounds. I would have preferred surgery, as office evaluations tend to be tedious, although necessary, drudgeries.
Suddenly, the phone rang. It was my answering service. "Code Blue Pediatrics, doctor, your patient!"
I could not believe it. I threw on a scrub suit and ran to my car. I lived only a mile or two from the hospital and I arrived within minutes to face a flurry of activity in Sara's room. The on-call anesthesiologist was there with several nurses and a crash cart of medical supplies. The child was intubated; a machine ventilated her lungs.
I grabbed a hypodermic needle from the cart and inserted it quickly through the scalp and into the shunt valve. Maybe the new shunt had malfunctioned or the old ventricular catheter had caused an obstruction and buildup of fluid pressure. To my amazement, there was no sign of high pressure. Only a few small drops of fluid came from the needle. The valve has a plastic portion that can be pumped with using thumb pressure — it operated normally. I lifted her eyelids; her pupils were fully dilated and did not respond to light. This was an ominous sign of brain death. Sara was transferred to the intensive care unit. I spoke with her dad, who had just walked into the room.
"What happened?" he cried.
"I'm not sure. Can you tell me how it went during the night? The nurses report that she had a peaceful sleep until just before six this morning when they found her comatose and unresponsive."
(Continues…)
Excerpted from "Medicine, Miracles, and Manifestations"
by .
Copyright © 2009 John L. Turner.
Excerpted by permission of Red Wheel/Weiser, LLC.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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