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Ultimate Reality

I showed up at the Student Health ENT Clinic fresh from my second-year lectures about the anatomy and physiology of pain.  Since my undergraduate degree had been in psychology, I also felt that I had an edge in understanding the emotional component to pain.  Though pain was on my mind, the reason for my ENT visit was the aggravating but nearly painless problem of persistent otitis externa–swimmer’s ear.

Interns and residents, bright, knowledgeable young men and women lacking only experience, staffed the Student Health Service.  Being all of twenty-three myself, I was convinced experience was highly overrated, and happy to accept the free and convenient care.

“No problem,” the resident said.  “You just sit here and I’ll curette out that wax and debris.  You’ll feel better in no time.”

I relaxed.  He curetted.  And in ten seconds I experienced the most intense pain of my life.  I jerked away and stifled a scream.

The resident told me to stay still.  I relaxed.  Pain is a state of mind, I told myself.  Mind over matter.  I willed myself into an immobile zen-like state.

He curetted again.  I jerked away again.  We repeated the scenario multiple times.  In the end, I still had otitis externa, and now a whole new understanding of pain.  There is no mind-over-matter.  There is no zen-like state.  Pain is pain.

A few years later I took care of an old man with a compression fracture of his thoracic spine.  His fall had been minor, and osteoporosis had made him susceptible to such fractures.  The important thing, I kept telling him, was that his spinal cord was in no danger and these injures always healed with time and rest.  But it hurts bad, he told me.  So I gave him a generous prescription for narcotics before he went home from the hospital.

A few weeks later I saw him in the office.  “It hurts bad,” he said.  I asked if the pain medicine was working.

“Not taking it,” he said.  “It’s narcotics.  I don’t want to be no dope addict.”

I assured him that he would not get addicted using the medicine only while he was healing.

He looked doubtful.  “How long?” he asked.

“Six to twelve weeks,” I said.  “From the time of injury.  Another month or two.  No more.”

He gave me the same skeptical look, but this time shaded with something darker.  “I don’t know if I can take it,” he said.

“Take the pain medicines,” I told him.  “Rest.  Be patient.  You’ll be fine.”

I wasn’t worried.  In a few weeks he would be back to normal, which for him involved caring for his rural cabin where he spent his life hunting and fishing.  I had no reason to think this would not be his future.

A few weeks later, his wife called to tell me he was now in great distress.  She was afraid for him.  I got him on the phone.  “The pain’s so bad,” he said.  “I don’t think I can take it.”

I asked about the pain medicines.  He wasn’t taking them.  I reassured him and asked if he wanted to come back to the hospital.  He didn’t.  I got his wife back on the phone and told her to bring him in if it got too bad.  She told me that I didn’t know what he was like.

“He will be okay,” I told her.  “The pain is temporary.  He will heal.”

Two hours later Rescue called from the patient’s kitchen.  He had shot himself in the chest with a shotgun, aiming for the painful fracture site which was located immediately behind his heart and aorta.  He was dead within minutes.

He possibly would have been okay if he had taken his narcotics.  He possibly would have been okay if he had come back to the hospital.  He certainly would have been okay if he had been patient, if he would have–could have– given himself the time to heal.  If only he could have stepped outside of time and stepped back in a few weeks later.  But instead he was dead, a victim of the white-hot obliteration of rational thought and panic induced by uncontrolled pain.

Pain is the ultimate reality, psychiatrist Jordan Peterson stated.  None of our philosophies or religions or meditation strategies can completely take us out of our physical state in this time-space-matter continuum, and nothing drives that point home more poignantly than pain.

Often a patient with a concussion experiences something like stepping out of time for a day.  This concussion patient suffers an injury then a quick return to consciousness but with amnesia for the traumatic event and events several hours before.  He then loses the ability to retain any new information for the next twenty-four hours.  He repeatedly asks where he is, what happened to him, how long he’s been there.  After their questions are answered, almost immediately he will repeat the same questions.  It is as if time now stands still in his mind.  He remembers everything up to one moment, then nothing new.  Nearly always he will return to normal the next day.

The curious thing is that patients with this type of concussion rarely complain of pain, even if they have suffered a broken bone or worse during the traumatic event.  But the next day, when memory returns, pain returns.

Pain, therefore, seems to require us to be conscious of our place in time.

Which brings us to Jesus.

If God is God, and created the universe, one hundred billion galaxies with one hundred billion stars each, and God is all-knowing, and He exists in eternity, that is, not simply forever but outside the limits of time, then God knows of pain but does not experience it.  Yet, He made a decision to not let one species on one tiny planet circling one middling star in one middling galaxy, destroy itself, even if it cost Him some mystical transformation into flesh and time, and, yes, pain like that white-hot thought-obliterating, panic-inducing pain that would cause one to blow their heart away with a shotgun.

So this is the miracle of Christmas: the Creator of the Universe chose to experience pain like yours so that you could experience love like His, and someday you, too, can step into eternity, outside of time and outside of pain.  And into great joy.

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Broken

 

The patient had just murdered his wife.  A single shot from his handgun had sent her straight to the morgue.  Then, with a sudden loss of basic marksmanship, he failed to kill himself.  He placed the gun in his mouth, allowed an awkward angle, fired, and the bullet lodged in the right temporal lobe of his brain, narrowly missing the structures that would have led to his immediate death.

Frankly, I lacked enthusiasm for treating him.  He wanted to die.  He deserved to die.  I wanted him judged by the standard of an eye for an eye, a tooth for a tooth, and a life for a life.  But the discipline of medicine allows no such judgements, and I found myself in the operating room removing the bullet, debriding damaged brain, and sealing the cranial cavity from potential contamination from the tract through the mouth and sinuses.  Miraculously, and somewhat to my disappointment, he survived.

And he survived well.  On day one, I changed his bandage.  On day three, he regained consciousness with no loss of vision or paralysis.  On day five, I removed his stitches.  He suffered no complications despite the high risk of infection.  Physical therapy supervised his return to normal balance and ambulation.  For two weeks he wore a patch over his right eye because he saw double, but then that symptom also went away.  By the third week he could read again.

His discharge was delayed, however, because he had no place to go except jail, and he couldn’t go there until he reached sufficient physical and mental capacity to be competent and self-reliant.  For several weeks he lingered in the hospital with a sheriff’s deputy stationed at his door.

Each day I would come to see him.  Always he was courteous and cooperative with myself and the staff, and in my mind I tried to reconcile the gentle person before me with the raging lunatic who had killed his young wife.

I asked what would happen to my patient after he was transferred to jail.  The deputy shrugged.  “It’ll be up to the judge,” he said.  “But I think probably nothing.”

“But he murdered his wife,” I said.

“Yeah, but the judge is going to see that scar on his head and send him to a psychiatrist who will say he’s not competent to stand trial, and maybe he’ll go to a state mental hospital, or maybe he’ll just go home.”

I stared at him.  He shrugged again as if to say What are ya gonna do?

The next day I found the patient reading his Bible.  I wondered if he even remembered what he had done.  So I asked.

A cloud passed over his face.  “I killed my wife,” he said.

“Do you remember why?” I asked.

“I was angry.”

His memory was intact, but sometimes patients with temporal and frontal lobe damage will be incapable of remorse.  “How do you feel about that now?” I asked.

The cloud came back.  “I feel bad,” he said.  “I loved her.”  He paused for a moment,  then continued, “I’m not that person anymore.”

In his last statement, he was entirely correct.  Due to his self-inflicted wound, his temporal lobe and frontal lobe were significantly damaged, and changes to his emotional responses and intellectual capabilities were undeniable.  He may be incapable of anger.  In a way, he was broken.  Yet the changes left no outward signs.  Even the scar became hidden as his hair grew back.

I once watched a man in Wyoming break a horse.  The horse was dangerous and useless, but expensive with good breeding and therefore worth saving if at all possible.  As a last resort the horse had been sent to the trainer from New Mexico.  Unless the horse could become trainable and safe, it would be euthanized.

The horse bucked and snorted in his stall before being released to a circular corral about forty feet in diameter.  The man stood in the middle of the corral with only a light six-foot flexible rod and let the horse run around him, seemingly oblivious to the threat of crashing hooves and sharp teeth.  He then described his own life, full of passion and rage and despair, and stated he and the horse were alike until, on the eve of his own self-destruction, he was broken and began a redeemed life.  Over the next hour he talked to us about redemption as he let the horse run, made himself vulnerable to the horse, thereby building trust, and then gave the horse the opportunity to submit.  He never touched the horse with his rod or his hand until near the end of the hour when he faced the now calm animal, stroked his muzzle, and placed a halter on his head.  Then he mounted and rode around the ring.  The horse was no longer the dangerous bucking bronco that had entered the ring.  The changes left no outward sign, but the horse was “broken.”

I know that within myself is a streak that is wild and self-serving and ultimately destructive.  It is the voice that tells me that only I know what is best for myself, that life is short and I need to get what I want now, that I need to free myself from the people and the rules that restrain me.  This voice echoes the wild spirit of the stallion, the spirit that would have led to its destruction, and I expect that it echoes the demon voices that drove my patient to murder.

We all needed that spirit to be broken before we could become whole–at least whole in the sense of fulfilling our best destiny.  In other words, we needed to be broken to be healed.

But I don’t think we can break ourselves.  My patient may have come close by trying to destroy himself.  But the horse needed a gentle trainer.  And I also have a gentle trainer; His name is Jesus.

When we are broken, we can be redeemed from the wild and self-serving spirit that leads to rage and lust and alcohol and drugs and despair, the things that hold us in back from our best selves.  The best of us are broken.

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Sorry

Christina throws a piece of debris far over her head into the already overloaded, over-sized dumpster then screams in pain, clutching at her right shoulder.  Even from twenty yards away I know the shoulder is dislocated.

She is a young woman from Michigan, an EMT and firefighter–an angel really–who had volunteered to come to Middleburg, Florida and coordinate relief efforts for flood victims.  Earlier that day, we met Christina when our motley crew from Crossroad Church arrived at the Middleburg United Methodist Church, and before we divided into teams to go muck out homes.  Strong and beautiful, and she gave us our safety lecture.  She reminded me of my wife and daughter and daughters-in-law: mostly kind but a little fierce.  I wanted to adopt her.

Now I run toward her with no plan.  It has been over forty years since I graduated from medical school, nearly seven since I practiced neurosurgery, and I have never treated a dislocated shoulder.  I could only support her and immobilize the arm.  Between her cries I learned that she had suffered the dislocations before but she had no clue how to fix it.  We both collapse into the mud, kneeling face-to-face, both clutching her right arm.

I suggest the emergency room, but she cries No!  She tells me the longer it stays out, the worse it will be.  I need somebody to put it back it, she says.  Tears streak her cheeks and fall between us.

She doesn’t know me.  To her I am an old man kneeling in the mud with her.  Vague memories of shoulder anatomy float to consciousness as I see her arm where it shouldn’t be, forward with her biceps pointed at a bizarre angle across her chest.  I take her forearm and press down, then rotate her wrist toward me.  She utters another short gasp.  I feel a little click; I hope it is a tendon sliding into place.  Then the arm audibly thunks back into the joint and it is over.

For a few moments neither of us moves.  Greg lays hands on Christina’s shoulder and prays.  Her tears still fall into the mud.  Then she says what I don’t expect: I’m sorry.  I’m so sorry.

And I want to hug her and tell her a thousand things–but only one important thing–because I know exactly what she means.

I am like her.  As she runs toward fires, I ran to ERs.  As she resuscitates as an EMT, I operated as a surgeon.  As she volunteers to serve in disaster areas, I volunteered for medical missions.  We want to serve; we want to be heroic.

But there is a thin line between service and self-affirmation.  We become what we do, and when we can’t do it we are lost.  We are ashamed.  We are sorry.

We are “Marthas.”  Martha is the women who, when Jesus is coming to dinner and everybody (including her sister, for crying-out-loud) sits at his feet and listens, is in the kitchen cooking the meal.  Somebody has to do it, Martha thinks, and she is the one who shoulders the responsibility.  Martha wants to get dinner on the table; Christina and I want to muck out that flood-damaged house.  We are doing it for Jesus.  But when we fail, we forget that we are not loved for what we do but for who we are.

Jesus didn’t exactly criticize Martha for her service, but He did tell her that it was more than okay for her sister not to help.  In his gentle rebuke is a reminder: I can feed five thousand people with food out of thin air and turn water into wine.  Your sister knows she is loved; so are you.  You are a child of God.

A few days later, my ninety-eight-year-old mother complains of “indigestion” and general malaise.  My wife, Mary, sits with her for a few hours and realizes this is more than indigestion and calls me and her doctor.  I arrive and take Mom to the emergency care center.  For ten minutes she gasps for breath and clutches her chest as I drive her to the ER.  I know it is the aortic valve disease that has finally thrown her into congestive heart failure, and I fear this is the beginning of the end for her.  In between gasps, she says, I’m sorry.  I’m so sorry.

I know exactly what she means.

Mom is okay now.  She’s back in her assisted-living facility, taking care of herself and, in many ways, happier than I have ever seen her.  But her words on the way to the hospital reveal to me how persistent is the feeling that the love we receive is conditional.

God has a different message, one about unconditional love. 

We must know that this is true.  But when we cannot be who we want to be, when our shoulder is on fire and we collapse on our knees in the mud with tears streaming down our cheeks, or when our chest hurts and we can’t breathe, we forget.

It’s okay to cry because we hurt.  Jesus wept, too.  But we never have to cry because we have failed.  I try to tell Christina, and I try to tell Mom: Jesus loves you, just like you are, in sickness or health, injured or whole, strong or weak, serving or listening.

Then every day I try to remind myself.

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Forgiving the Innocent

Dean
Adam

 

 

 

 

 

Adam got well.

After a long, hard winter of radiation, infections, a second operation, antibiotics, his hair started growing back–first with wispy strands, finally morphing into a confident mop.  He let it get long; I didn’t object.  He finished his junior year in high school, and we celebrated by going cycling in Europe as a family.  The following year he finished high school and started his first year at a prestigious college in Atlanta.

But I found myself emotionally distanced from him.  A little voice in the back of my mind told me I should be more grateful, more joyful.  I hope I disguised my emotional desert well and did the right things as a father.  It was depression, I told myself, and I’m sure that’s part of it, but the emotional distance from Adam was specific and held a thinly veiled streak of anger.

Many months, perhaps years, passed before I realized my anger was in response to his illness.  He quite unintentionally terrorized me with the specter of grief that came from nearly losing him. And he also held the power to terrorize me again.  I feared to get too close.

But if I were to have an authentic father-son relationship, I had to get over my fear and my anger.  I had to forgive my son for having a brain tumor.  The tumor wasn’t his fault, obviously, and it wasn’t his choice to make me vulnerable or to hurt me.  But emotionally, I somehow held him responsible.

Once I understood that neither Adam, nor his tumor, caused my fear, my anger dissolved easily.  My fear of loss came from something within me, something beyond my ability to give up: the power of love.  And that love is without choice; he was born, I held him, I loved him.

Love is always a risk.  Give your heart away, and it can get weighed down so that it can drag you to the depths and destroy you.  If I were to continue to love him, I had to forgive him–even though he was innocent–and I had to accept the consequences of love.

Forgiving Adam for his tumor is not so much granting absolution as it is granting permission to hurt me again.  It is saying Go ahead, get sick if need be, because I will be there and I will not flinch, I will not distance myself, I will not walk away.  Because fear of loss is the cost of love, the dark side of the coin whose other side is shining joy.  And Adam gives me great joy.

I am awed now by the infinitely better love of our heavenly Father who loves me and forgives me–and I am not innocent.  He gives me permission to get sick, to sin, to live like a prodigal son–not encouragement, but permission–even though what I do may break His heart, cause angels to weep, and the world to become more like hell than heaven.  Yet He promises to be home waiting, ready to get up and run to meet me.  What I now understand in a small way is the cost of that great love, the dark side of the coin He is willing to pay because in some unimaginable way I must give Him great joy.

If this sounds like I am special in the eyes of God, I am.  So is Adam.  But the good news is, so are you.  You give Him great joy.

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Stuff It Down

Dean

One Friday afternoon in August of 1991, Adam, Mary and I sat waiting for his MRI to begin.  I had scheduled the scan myself a week before when his opthalmologist couldn’t explain his double vision and referred him to a neuro-opthalmologist.  I had already become secretly concerned.  Then that morning the neuro-ophthalmologist called me to tell me he had a condition that was nearly always associated with a tumor.  I knew then what the scan would show, yet I hid my anxiety from Adam and Mary and held onto the slim hope that I would be wrong.  Mary was a mere six months from surgery for her breast cancer and had one more chemotherapy session to go.  We weren’t ready for more bad news.

Then my junior partner called from the operation room.  His patient had a rare and life-threatening complication in the middle of an operation, and he asked me to come and help.  No other neurosurgeons were nearby; it was me or nobody.  I left Adam and Mary blithely ignorant of the pending disastrous results of the MRI and went to the operating room.

The next three hours challenged my ability to segregate my feelings from my thoughts and actions, but that was nothing new.  For two decades I had learned that when you’re the one involved in direct patient care, everything else gets stuffed down.  You’re hungry or tired or sick?  You just had a fight with your wife?  Your mother and father are coming to visit?

Nobody cares.  Stuff it down.

Dr. Harvey Cushing, widely considered the father of neurosurgery, once did an appendectomy on one of his own children.  Another time he received the news of his son’s death in a car accident and took fifteen minutes of solitude.  Then he went directly to the operating room and performed the previously scheduled operation.

Stuff it down.  Deal with it later.  Even when your kid is sick.

After the crisis abated I left the OR and received the expected message that the radiologist wanted to review the MRI.  The images had been transferred to the hospital.  All I had to do was walk across the hall to radiology.  The images hung on the view boxes–crisp, clean lines of black and white on film representing the dark, uncertain future of a boy with a brain tumor.  The reality stunned me.  The words “evil incarnate” came unbidden to my mind.

I was particularly overwhelmed because I’d ordered the scan myself.  Now I had to deliver the news myself without the buffer of an outside authority figure, a professional in a white coat.

I felt terror.  I didn’t want to be the doctor; I wanted to be the dad.  But I couldn’t be dad.  Not yet.  I stuffed my feelings down again, and we did our family conference at home.  I remember only a little about that night.  Mary and Adam and I talked.  Then we included my parents and Jay and Brieanna.  Then we prayed.

The next morning I cancelled my appointments and spent the morning on the phone with neurosurgeons across the country searching for the best answer for Adam.  At the time, therapeutic options for his type of tumor were hotly debated.  Which surgical approach was the best?  What was the role of radiation therapy?  How to deal with tumor-associated hydrocephalus?  I had my own opinions, but had at least enough sense to realize my judgement was clouded.  I needed someone else to be his doctor.  Two days later we checked him into Shands Hospital at the University of Florida in Gainesville, and I could be the dad again.  Only then could I cry.

The ability to “stuff it down” is important.  No one wants a surgeon, a policeman, a fireman or an EMT dealing with their own emotions when they are dealing with your needs.  But this ability also has its own consequences, its own scars.  Once you’ve stuffed down your own fear and grief, it doesn’t easily resurface.  Then if I am insensitive to my own emotions, I could be nothing but insensitive to Adam and Mary.

I was a good cheerleader, but a bad listener.  “You have a good prognosis,” I would say.  “A ninety-percent cure rate.  I looked it up.”

They would stare back at me, sometimes blankly (Adam), sometimes with frustration (Mary).  And I would stuff down the fact that ninety-percent now terrified me.  A cure rate that sounded so good to me when I told patients now sounded way too low.  We had a ten-percent chance of repeating the current nightmare, and the next time would hold no chance of salvation this side of eternity.

Over the next few months Adam underwent two operations, one spinal tap, several weeks of radiation therapy, two weeks of antibiotics.  He lost his hair and he lost his strength.  I told him the prognosis was good.

The day after we returned from Gainesville Mary went in for her last chemotherapy treatment.  Her eyelashes fell out and she couldn’t eat.  I told her the prognosis was good.

It was a hard four months.  Then the active medical interventions were over for both of their cancers.  It was time to get better.

Adam tried to resume normal activities.  Chemistry was hard.  Sports were impossible–anything requiring hand-eye coordination was downright dangerous.  Mary tried to find clothes to fit her new shape.  They would tell me it was hard; I would tell them they had a ninety-percent cure rate.

Soon we stopped talking about illness and recovery as each of us drifted into our private world of terror and grief.  On the outside we looked like a normal family going about work, school, and community activities like anyone else.  Scratch the surface, and any one of us could fall apart.

Then, in the Spring of 1991, I bought a self-help book–not for me, you understand; I thought it would help me provide direction to my other son, Jay.  One chapter dealt with the skill of listening.  Some people don’t need instruction in this, but I did.  Don’t think of your response while the other person is talking.  Repeat what they say as a question to 1) make sure you understand, and 2) give them permission to keep talking.  This is instruction so simple it borders on stupid to repeat, but there it was.  I tried it out on Mary the next time she spoke about her cancer treatment, her scars, her fears.  She kept talking; I kept listening.

Her depression started to lift.  (She has an amazing testimony about a dramatic moment of recovery, but that is her story to tell.)  On the other hand, all the fears and grief I had stuffed down now floated up.  I had to start dealing with the fact that I and everyone I loved was going to get sick and die, and that fact terrorized me.  I could no longer be the cheerleader with “the ninety-percent cure rate,” since I was now quite conscious that the cure rate was a temporary illusion, a distraction from the fact that life has a one-hundred-percent mortality.

But I became a much better listener.

Listening, I learned, has a cost.  If you listen to those who have suffered loss and fear for the future, you will mourn.  So I mourned the scars of Adam and Mary, the loss of their hopes, and the fears of what the future would inevitably bring to all of us.  But if I mourned with them, we were no longer alone, and if we were no longer alone, we were comforted, and if comforted, loved.  And if we had love, we had hope.

Jesus knew this.  His first public declaration in his ministry was that the kingdom of God was near.  His second was that the poor in spirit are blessed because they would receive the kingdom of heaven.  But his third was that those who mourn are blessed because they would be comforted.

There are times to stuff it down, those griefs about things lost and the fears of future sufferings and separations.  But do not fear listening, do not fear mourning.  Because we are blessed to mourn.  Then we shall know comfort.  And love.  And hope.

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Probably Nothing

When Nothing Was Something

Adam, Jay and I played ping-pong on the upper deck of an ocean liner cruising on the Alaskan Inside.  The night was spectacular.  Though it was ten PM, the multi-colored twilit sky gave adequate illumination for our game, the sea reflected the sky, and distant hills of pine forest slid by.

Family vacations then were a novelty, a rare period of recovery.  This one was especially precious because our family was recovering from Mary’s diagnosis and treatment of breast cancer just a few months before.

Adam was losing at ping-pong.  “I’m see two balls,” he said.  “I don’t know which one to hit.”

Brain tumor jumped to my consciousness.  I had seen dozens of patients with brain tumors whose initial symptom was double vision.  But then I quieted my alarm.  People get double vision for other reasons, I told myself.  And I’m not his doctor; I’m his father.  Let his pediatrician take care of it.

It’s probably nothing, I thought to myself.

A week later his pediatrician examined him.  He said, “It’s probably nothing, but I’d like him to see an ophthalmologist.”

A few days later the ophthalmologist said, “It’s probably nothing, but I’d like him to see a neuro-ophthalmologist.”

At this point, I no longer thought it was nothing.  I scheduled an MRI scan on my own son.  The neuro-ophthalmologist found that Adam had an eye condition that always points to a tumor in the pineal region of the brain.  A few hours later the MRI confirmed his suspicion.

I suppose it’s possible to have a child with cancer and not pray.  Perhaps there are those so convinced of their atheism, or so lost along their way, or so unattached from their child that the impulse doesn’t come.  But I suspect those are the rare exceptions.  Even those with the thinnest belief in an almighty benevolent power are driven to their knees when their child’s life is at risk.

So I prayed.  And Mary prayed, Adam prayed, and the whole family prayed together.  Then I sought out the best medical care possible.

If you’ve followed this website, particularly Adam’s posts, you will know that the subsequent road was hard.  Many things were lost never to be re-gained.  Some dreams folded up and died along the way.

But Adam survived and is cancer free twenty-six years later.  This week Adam and I are hiking together in the Smoky Mountains, one way we have of celebrating life and health.

So here is a question I have kept to myself for a quarter century.  Did Adam survive as an answer to prayer?  Or did Adam survive because of good medical care?  The person of faith in me says that my prayer was answered; the doctor in me says that surgery, radiation, and drug treatment cured him.

Both, I want to answer.  I have faith that God is real and He heard and answered our prayers.  And I have faith that medicine and surgery prolonged Adam’s life.

But is it true?  Before neurosurgery and radiation therapy, parents prayed for their children with brain tumors, and they died.  I have personally treated a teen-ager with a similar tumor who had no family, nor apparent faith, and he lived.  The medical care seems to be the most critical element, at least to my worldly eyes.

Then again, I prayed to the Almighty, the creator of the universe, and He granted my request.  Should I say now that the prayer had nothing to do with the outcome?  That the radiation would have cured him anyway?

When Nothing Was Nothing

A few months ago, my daughter, Brieanna, called.  She had developed a lump in her armpit.

It’s probably nothing, I said.  She was nursing her second baby; maybe the lump had something to do with that.  Small cuts or infections in the arm could cause a swollen lymph node.  Or a viral infection could do the same.

Two weeks went by and the lump increased in size.  She had no symptoms or evidence of breast feeding problems, injuries or infections.  It’s probably nothing, I told myself.  But I wasn’t so sure.  This is how lymphomas start.  A nightmare scenario played itself out in my mind: my grown daughter with cancer, her two little boys needing her, her devastated husband.  Such scenarios are easy to imagine after your wife and another of your children have been diagnosed with cancer.

So Mary and I prayed for healing.  Brieanna scheduled a doctor visit and an ultrasound of the swollen node.  On the morning of the the ultrasound the lump unexpectedly disappeared.

“What do you think?” Mary asked me.  I still have a small amount of credibility when it comes to family medical matters.

The residual doctor part of my brain thought, unrecognized breast infection or cuticle infection or a virus.  Probably nothing.

Then I caught myself.  When I pray for something and get it, I am sometimes quick to forget the prayer and ascribe the good fortune to natural or manmade causes.  Something wonderful had just happened.  I should not be so quick with an explanation; I should be quick with grateful praise.  The appropriate response is Thank you, Jesus.

“It was probably nothing,” I told Mary. “Or a miracle.”

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Scathed

The MRI showed the tumor as a white Rorschach blot in the midst of gray brain.  Two words bubbled to the surface of my mind: evil incarnate.  Evil had become flesh and dwelt among us.

Clinical jargon quickly took over my thoughts: Large pineal area tumor in an adolescent male presenting with visual signs typical for a tumor in this area.  Most likely diagnosis: germinoma.

My mind flips forward to surgical approaches for a tumor like this, the advantages and disadvantages of each, the myriad of complications.  Then I stop.  This time I am sickened by the violence that is surgery, and I am afraid.

This time the tumor, this incarnate evil, is in my son’s brain.

Eight years before, our family went for a Sunday afternoon family walk on the beach.  Although it was Fall, the afternoon turned warm, and the boys (then aged six and eight) started wading in the surf.  Soon they were up to their necks, and I jumped in to join them leaving Mary with baby Brieanna in her stroller.  The boys and I splashed for what seemed a mere moment in the surf before I realized we were treading water.  I looked up and could see the shore only when we bobbed to the top of a wave.  It looked a mile away.

I had heard of riptides but never experienced one.  Somehow I had to keep us together and bring us home.

At my direction Jay slid over my back and wrapped his arms around my neck as I did a slow breaststroke back to the beach.  Adam swam in front of me.  I talked and made a game of bobbing in the waves.  I didn’t want them to be frightened.  If any one of us panicked we were all doomed.

A long time later (thirty minutes? forty-five? an hour?) we made it to shore.  I stood at the waterline, relieved and exhausted, Adam next to me, also tired and probably irritated that he had to swim all the way while his little brother got to ride.  I congratulated myself that I had concealed the danger from the children and they could still feel safe.

Then Jay ran to his mother shouting, “Mommy, Mommy!  Daddy just saved us from a watery grave!”

They knew.

A few months later I saw a newspaper report about a fellow neurosurgeon who had completed his residency in Boston and took his family for a vacation to Florida before starting his career in Atlanta.  He went swimming with his two sons, got caught is a riptide and they all drowned.  A reminder–it could have been us.

But we were unscathed.

We learned that our lives could change in the blink of an eye, that our time together is not a given–it is a gift.  We also felt that regardless of how hopeless our situation, we were under God’s protection.

Eight years later I looked at Adam’s MRI and had the same feeling I had when I bobbed to the top of the wave and saw the shore a mile away.  We had a long swim before us with no guarantee we would ever reach safety.

The next several days were filled with a trip to Shands Hospital in Gainesville, a brain biopsy and shunt, a spinal tap, and an appointment for radiation therapy–all this before Mary’s last chemotherapy appointment (a whole story unto itself).  And prayer.

We prayed for healing.  And because we knew that each of our lives and each of our children’s lives are a gift, not a given, we prayed for peace and the Lord’s will to be done.  But along with these prayers, we also had a sense of vulnerability.  Evil had become flesh and dwelt among us.  We were scathed.

Adam lost his hair and he lost his strength.  The tumor shrank, but a shunt infection caused pain and high fevers requiring another operation and weeks of antibiotics.  By Christmas, all he could do was lie on the couch, dozing, warmed by Fluffy the dog.

We continued to pray.  Adam regained some of his strength, but never returned to being a gymnast.  A few wisps of hair returned to replace the dense blond mop he had before.  He kept up with his classes and finished his junior year on time.  He could walk and drive and a few months later he could jump enough that his feet actually left the ground.  The tumor remained absent on follow-up scans.

But we all lived in fear.  A headache could precede disaster, cold symptoms might be the beginning of the end, a phone call could bring tragic news.  We felt vulnerable.

So we prayed more.

Recently our adopted son, Peter Ter, was in Jacksonville to introduce his bride to his Florida families, and he reminded me of what vulnerability brings.  He spent his childhood separated from his family, wandering through south Sudan and Ethiopia seeking refuge from the violence of civil war.  Eventually, he landed in a Kenyan refugee camp where he lived through most of his teen years.  He came to this country in 2001, just before response to the 9-11 tragedy closed the borders.  Since then, he has worked hard, studied hard, graduated from UF, and obtained two Master’s degrees and has served overseas in the Peace Corps in Azerbaijan, China, and the Republic of Georgia.  A year ago he returned to the U.S., moved to D.C., got a full-time job at Peace Corps headquarters, fell in love, got married, and is expecting his first child.

He recounted some of the hardships of the refugee camp, the hunger, the physical punishments, the pain, and the loneliness.  His hope came from only one thing: a Bible that a Catholic priest had given him.  Each day he would read and pray that he would be respected, useful, and not alone, and each day he would feel God’s presence.

Now he has respect, an admirable mission, and he is loved.  But now he says that what he misses is the nearness to God that he felt in the refugee camp.  He does not miss the suffering, but he does miss the complete dependence on God that is so easy to lose when all your prayers are answered.  To be near God now, he must learn a new discipline.

Like Peter, I don’t miss the riptide.  And we don’t miss the dark days of our cancer year.  Mary and Adam carry physical scars; all of us carry emotional scars.   Those experiences forced me to cry out to God in pain and fear.

In response, He gave me a vision.  I saw the universe as one part of the mind of God.  The universe was so vast, incomprehensible, yet God was bigger than even that.  And me?  I was just a tiny part of God’s mind–just one of His ideas.  But an idea, a thought, in the mind of God!  I think my ideas are important.  I don’t give them up, I treasure them, use them, sometimes modify them.  They are what I am.  I might be tiny in the mind of God, but tiny does not mean I am unimportant.  I am His idea and part of His mind.

We have been frightened.  We have been scathed and will be scathed again.  But for now, we have been saved from evil incarnate.  And when evil comes again, I know we will never be alone.  In the mind of God we will each rest in the peace that comes from being His special idea.

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A Funny Thing About the Cat

I’ve had messages from God–a sign I asked for, a voice when I cried out in desperation, an answer to a prayer, a vision to bring me out of the deep depression, an unexpected visit from someone with a word of encouragement.  But I’m hesitant to claim that God speaks to me in special ways.  To believers, I sound prideful; to people without faith, I sound quite insane.

But really, what good is a God who doesn’t speak to you?

On a Sunday afternoon in August a few years ago, the temperature was brutally hot, the drive across the Buckman bridge was aggravating, and the call was urgent.  A fifty-year-old woman had arrived by ambulance at the Orange Park emergency room unconscious and hypertensive.  A CT scan showed hemorrhage deep in her brain.

A shadow of hopelessness started with the first call and hung over all subsequent events.

A bleed like that normally causes death or severe disability, and rarely does surgical intervention do anything to alter the dismal course of events.  But the first task is to decide if the problem is indeed hopeless, and this requires urgency.  If anything beneficial can be done, it must be done quickly.

I finally arrived and walked across the frypan hot surface of the parking lot in back of the hospital, the shortcut to the radiology department.  I wanted to see the scan before I saw the patient.  I wanted to know how bad the bleed before the family asked.

Blood filled the deep areas of the brain called the basal ganglia and dissected into the upper reaches of the brainstem, the part of the brain that allowed for consciousness.  With a bleed like that, one could survive, but one would never wake up.

The problem is that it is always hard to stop saving a life.  Families have difficulty giving up.  Doctors are trained to keep people alive at all costs.  Liability lies with doing too little, never doing too much–even if the cost is prolonged suffering for both the family and the patient.  I headed to the ER for what I expected would be a difficult discussion with the family.

The emergency room doctor intercepted me.  “There’s something you should see before you talk to the husband,” he said.

“I’ve already seen the scan,” I replied.

He nodded.  “Yes.  But we got a chest x-ray after she was intubated and put on the respirator.”

  I had only a moment to wonder why he wanted me to see it.  He led me to a view-box upon which hung a chest x-ray that showed lungs riddled with tumors of various sizes.  “Metastases?” I asked.

“Yes.  Breast cancer,” the ER doctor said.  “I went back after the x-ray.  She’s got a big mass in her left breast.”

We went together to the patient.  Her depth of coma was expected from the findings on the scan.  A tube protruded from her mouth, connected to a respirator that filled her lungs every five seconds.  Cardiac monitors beeped in the background.  I untaped her eyes for a brief exam of her pupils and reflex eye movements, then re-taped them and confirmed a three-inch mass in her left breast.

You can’t die twice, but two things can kill you.  If I had any doubt about the advisability of recommending aggressive intervention, that doubt was now dispelled.  If, against all odds, we could save her life with an operation and a long, difficult hospital and rehab course, the likely result would be to leave her in a vegetative state.  Now her exam and the chest x-ray told us that if we intervened, she would also die a prolonged painful death from disseminated breast cancer.

I went to talk to the husband, uncertain how approach this double tragedy.  But I had time.  The urgency was gone.  Only the cloud of hopelessness remained, now darker than ever.  So I asked him what happened.

He started her story a few months back.  They were simple people, living in a small house on a rural lot.  She had lost her job and her health insurance, and didn’t have the energy to find another.  She stopped taking her blood pressure medications.  Although public assistance was available, she didn’t want to be beholding to the government.  Then today she had a headache and collapsed.

I told him about the bleed in her head, and that the prognosis was very poor.  Even if she lived, she would never be able to live independently again.  Then I told him that she also had breast cancer, a large tumor that had already spread to her lungs.

He told me she’d discovered the lump a few months before, but didn’t want to see the doctor about it–possibly for the same reasons she didn’t get the blood pressure medicines.  She didn’t want to be beholding.  But she seemed to have another reason.  I don’t want to know, she told her husband.

I understood.  Every day she didn’t go was one more day no one could give her bad news.  But inwardly she must have been preparing for the end.

I recommended that we treat her with comfort measures only.

He nodded as he stood looking somber and alone.

I murmured something in the line of sympathy and started to move away to begin the process of reversing the well-oiled medical system that prolonged lives and change it into a system that provided comfort.

Then he said, “It’s a funny thing about the cat, though.”

For a moment, I thought I misunderstood.  “The cat?”

He kept his gaze fixed on the curtain around his wife’s gurney.  “Yep.  About two months ago a stray cat showed up on our porch.  Never had a stray before.  She started feeding it and it stuck around.  Since he looked like he was going to stay, she took him to the vet.  She asked the vet about a lump on the cat’s side.”

“Uh-huh,” I said.  People had many different responses to sudden loss.  He was the first I had heard talk about their cat.  I didn’t want to discourage him.  “Go on.”

“The vet said the cat had cancer.  We should put it down.”  He continued to stare at the curtain.  “But she said no.  As long as the cat was comfortable, we would take care of it.  The lump is bigger, but the cat is still there.”

He turned his eyes from the curtain and met my questioning look.  “So I’m just saying.  It’s a funny thing about the cat.”

The patient died thirty-six hours later, comfortable with her family at her side.  I don’t know about the cat.  But I had to agree with the husband: it was a funny thing.

I am convinced of God’s personal love, and that He will use any means to to bring us a message that we need to hear.  One day we will face our death or the death of a loved one.  Often we face difficult decisions at the end.  He tells us in His Word to prepare, and to not be afraid.

But sometimes we need a very personal message that He is with us always, that even in the shadow of death there will be time and space for love.  I am confident that He will find a way to give us that message, and comfort to those left behind.  Sometimes He even sends a cat.

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Random Acts of Violence

A three-year-old boy is brought to the ER by Rescue, CPR already initiated at wherever they found him, bruises all over his body, left arm askew, certainly broken, not only unconscious but with the floppy motor tone and fixed pupils that signal brain death.

A thirty-something year-old woman is brought by Rescue at nine AM, her face a mass of bruises and lacerations, both fresh and old.  Her nose is broken, her eyes are blackened, her lip is cut.  She is alert and angry and hostile and still drunk.

A twenty-three year-old man is brought by Rescue from a convenience store after a robbery.  He has a red hole in his face, almost indistinguishable from his nostril.  Unlike the first two, he articulates what happened.  “I told him, ‘Don’t shoot, you can have the money.  Here’s the cash register.  Just don’t shoot.’  He shot me anyway.”  This he kept repeating, convincing himself that this actually happened, as he adjusted to a new reality. Traces of anger dawned as the repetition continued with the awareness that he had been shot anyway by a stranger who already had the money.

This is my introduction to the Emergency Room in New Haven, Connecticut; I am in shock.  In my world children were never beaten, women were never struck, and no one I knew would shoot anybody unless the other drew first.

Up until this point I had been willing to believe that all people were good at heart but were sometimes misunderstood or misled or emotionally distressed, and at moments made mistakes, things for which they were sorry and would repent and ask forgiveness, if only given the chance.  I am an idiot in my innocence–not innocence as in the absence of guilt, but innocence is the sense of naivety–and I am now confronted by random acts of violence that must change my understanding of my fellow man.

The world is not filled with the innocent until proven guilty, but with the guilty, only some of whom are convicted.  Maybe the motivations that move society are not generosity and enlightened self-interest, but self-interest alone, and the rough calculation that all actions are permissible as long as the negative consequences can be avoided.  Thus, it is okay to silence that whinny kid with a swift kick or two, to slap that drunk wench into submission, to shoot that kid who might someday identify you in a line-up.

And if that is the way the world works, I have been playing by the wrong rules.  The choice is not whether to do good or to do evil, but whether to be a victim or not.  I need to look to my own interests first, then my family, then my friendships–although I shouldn’t think of them as friendships anymore, but as alliances.

I blame my father for my idiotic innocence.  He was not only a gentleman but a gentle man.  I remember only one time that he raised his hand to spank me, and this ironically for fighting with my brother.  I don’t remember the blow, but I remember what he said afterward.

“Don’t you know,” he said, “how little time we have together?  What few chances to love each other?”

I didn’t know what he was talking about.  My life was a continual competition with my brother.  We fought out our differences.  Sometimes I won, sometimes I lost, and always I prepared for the next battle.  What was Dad thinking?  He’d been an officer in an armored division in Europe during World War II; certainly he must understand the need for conflict.  Dad’s words puzzled me then and still puzzled me again as I stood on the bloodied floor of the ER.

A choice needed to be made: innocence or preparation for battle; allow mercy or demand justice?

But the practice of medicine demands mercy.  Sooner or later, the one who killed the child, the one who beat the woman, the one who shot the store clerk, all come in injured themselves.  And they are cared for with all the same resources that their victims received, perhaps with more reluctance on the part of the caregivers, but with the same skill.  Even knowing better, we act as innocents; our only battle is with the disease or the injury.   Justice is invisible, but vengeance is never an option.

Still, I wonder if I am a sucker, never ready for battle.  Mercy is my discipline, but a small ticking clock in the back of my mind waits for justice to show herself.

Years later I testify at a murder trial.  The victim had suffered a severe head injury resulting in an acute subdural hematoma and multiple areas of bruised and swollen brain.  Acute and chronic alcohol abuse complicated her care by liver and bone marrow damage.  In short, her body did not have the reserves to heal her wounds or stop her bleeding.  Despite a major operation and a week in intensive care she succumbed to her injuries.

At the trial, the woman’s boyfriend was accused of beating her to death.  My testimony is limited to answering questions from the prosecutor about the mechanisms of her head injury; the defense attorney asked no questions.  The boyfriend is convicted.

Justice finally appears; I should be satisfied.  But I am not.

What I know is that the woman died as the result of her alcohol addiction.  And whether or not her injury was the result of a fall or an assault, her boyfriend was convicted as a result of his alcohol addiction.  The blame lay less in the blow to the victim’s head than to that obscure first drink given to a person emotionally and physically susceptible to addiction, and the lack of opportunities for redemption along the way–and this is true for both the victim and the perpetrator.  They fell like two lost children clinging to each other in the dark and stumbling together.

Justice appears and is served, but she is a blind and cruel lady.  I am happy to turn away from the courtroom and back to the hospital where mercy reigns.

Sometimes I worry about my adult children.  They are never prepared for battle.  I have watched my them treat others with mercy more than justice.  They have committed random acts of kindness: befriending refugees, paying for a dangerous tree to be removed from the yard of a stranger who couldn’t afford it, sticking with a friend who was not only sick but crazy.  They acted unconcerned about how these others got into their situations.  They acted like suckers.

Dad would have been proud.

Random acts of violence can rob me of my innocence and drive me to seek justice instead of mercy.  But innocence is not a possession to be lost; it is a quality to be chosen.  And if innocence is chosen, random acts of kindness prevail.

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Troubles and Worries

The “troubles” that one patient experienced was not a “worry” to the staff at the Department of Corrections until the inmate showed up late for meals and roll call.  Months later, he wended his way through the medical system and got a neurosurgery referral to Jacksonville.

As this white-haired, stoop-shouldered African-American shuffled along in leg irons, his shuffle looked little different from other men in leg irons.  But when the guard removed the shackles, the inmate clearly had the spastic gait of a man with spinal cord compression.  Further testing confirmed a narrowed spinal canal and degenerative disk disease in his neck as the cause.

This patient, whom I will call Daniel, needed a decompressive cervical laminectomy.  But in truth, few operations worry me more.  The operation is necessary–without surgery he would be wheelchair confined within several weeks, and lose hand function shortly thereafter.  And though the results of surgery are usually good–90% of patients improve, and another 9% will stabilize–another 1% will be paralyzed as a complication of the surgery.

It’s that remaining 1% that worries me.  If Daniel gets worse, the fact that ninety-nine strangers got better after the same operation will give him, and me, little comfort.

We talked for a long time about the costs of surgery–not the financial costs, but the costs in terms of pain, suffering, recovery time and, especially, risk.  Daniel had vague fears about why he couldn’t walk easily anymore and what the future held.  I needed to share my medically-based fear about his future without surgery.  Then I needed to share the hope that surgery would make him better, and my fear that it could make him worse.  This is a melding of purpose: his hopes become my hopes, his fears become my fears.  His troubles become my worries.

I scheduled the surgery.

Then we waited.  The Department of Corrections, due to security concerns, budgetary constraints, and logistics, decides when the surgery will take place.  Literally months passed. Calls to the D.O.C. went unheeded.  I became increasingly worried that by the time the surgery was done, it would be too late; the spinal cord would already have been permanently damaged.

Finally, the surgery was scheduled and Daniel showed up at the hospital with barely enough time to complete his pre-op checklist.  He looked inexplicably content, shackled to a stretcher, a complacent guard at his side.  It had been so long since we talked that I wasn’t sure he remembered anything about his condition or the surgery.

I wanted to give him the whole pre-op talk again with time for questions and answers, give him a day to think about it, and return for more questions if necessary; it was that serious.

But I didn’t really have that option.  If I cancelled this operation, I didn’t know if the surgery could be re-scheduled before he was wheelchair bound.  I had only a few minutes.

“The operation could kill you or paralyze you,” I said.  “But it’s your only chance to walk normal again.”  I skipped all the information about expected recovery times, percentage chances, pain, or even where the incision was going to be.

Daniel smiled.  He still did not appear to be nearly as concerned as I thought he should, and it worried me.  I wondered if he was intellectually impaired.

I started again. “You understand the risks–”

“I heard you, Doctor,” he interrupted, still with that inexplicable smile.  “And I remember what you tol’ me before.”

I must have looked unconvinced because then he reached out with a shackled arm and patted my hand.  “I got troubles,” he said.  He reached over and touched the crucifix tattoo on his forearm.  “But I ain’t got no worries.”

Worries filled me, but by comparison to Daniel, I had no troubles.  I didn’t have decades to serve a prison sentence, a crippling illness, nor did I face a painful and life-threatening operation.  At the end of the day I was going home to a comfortable house and a loving family; if things went well, he would go back to prison.

The operation did go well, and Daniel walked again, normally now, able to get to meals and roll call on time.  He still had troubles, of course.  But spinal cord damage wasn’t one of them.

Days of trouble have come to me before, and they will come again.  But when they come again, I remind myself:  like, Daniel, I ain’t got no worries.