Category: Dean’s Stories

“The one who has dipped his hand into the bowl with me will betray me. The Son of Man will go just as it is written about him. But woe to that man who betrays the Son of Man! It would be better for him if he had not been born.” Matt. 26:23 (NIV)

In the early 1980’s I cared for a forty-eight year-old man with an acute subarachnoid hemorrhage from aneurysm. In those days delaying surgery for seven days after the initial bleed was thought to allow time for the brain swelling to go down making the surgery safer. The decreased surgical mortality made up for the small number of people who would re-bleed during the waiting period. One of the trickiest parameters to manage during that week was blood pressure. If the pressure went too high, the aneurysm would rupture; if the pressure went too low, the patient would suffer a stroke.

This man’s high blood pressure was difficult to control on several medicines. Fearing a rupture any moment, I ordered a seldom-used IV alpha-blocker at a low test dosage of 0.5mg, not wanting to over-treat. Normal doses would be 1 to 2 mg. An hour after the phone call, I got a call from the nurse that the patient had gone into shock and the ICU staff had already begun resuscitation. I arrived at the hospital a few minutes later to help with the unsuccessful code.

The fatal blood pressure drop had occurred shortly after the “test” dose. The nurse held out the empty 5.0 mg. glass vial. She had given ten times the ordered dose, a lethal mistake.

They don’t make that drug anymore, and pharmaceutical companies now take care to avoid packaging medicines in ways that make such mistakes easy. But the changes came too late for that patient, too late for that nurse.

She was inconsolable.

We make mistakes. She read a drug label wrong. Judas Iscariot read the Messiah wrong, and no one has ever forgotten the betrayal with a kiss. I know I’ve made big mistakes. A drill plunging into the all-important speech and language areas as I tried to drain a subdural hematoma. An injury to the carotid artery leading to a fatal stroke while I tried to get control of the blood flow to a giant aneurysm. A wrong-sided scalp incision. A bruised spinal cord.

The consequences of the big mistake are not limited to the victim. Yes, the nurse’s patient died. But what happened to the nurse? She was a good nurse–smart, hard-working, and compassionate. When we lost the patient, did we lose the nurse too? What happened to me?

Yes, Jesus died. But what happened to Judas?

When Judas, who had betrayed him, saw that Jesus was condemned, he was seized with remorse and returned the thirty silver coins to the chief priests and elders. “I have sinned,” he said, “for I have betrayed innocent blood.”

“What is that to us?” they replied. “That’s your responsibility.”

So Judas threw the money into the temple and left. Then he went away and hanged himself. Matt. 27:3-5 (NIV)

Remorse leads to despair. Returning the money was not enough. Despair led to suicide.

The nurse underwent a review and received a cautionary letter in her permanent file. She took a course in error prevention. The drug company changed the way they packaged the medicine and the hospital changed risky methods of ordering and dispensing medicines. She could have returned to working in the ICU, but she did not. Because she needed one more thing to be fully restored.

I know. There are times when the word Sorry is too small. I’ve paid for the consequences of my own mistakes, struggled with my own self-confidence, wondered if I should go back the next day to take care of the next sick person.

The passion story of Jesus carries a parallel story of betrayal. Judas wasn’t the only one to lose hope. Peter, in spite of his bluster of faithfulness on the night of the arrest (quote: “Even if I have to die with you I will never disown you”) by morning had indeed publicly denied knowing Jesus three times. When the cock crowed at the break of dawn, Peter remember his vow and wept.

Matthew doesn’t mention Peter again in his Gospel. Neither does Mark. Luke and John both tell us Peter ran to the tomb after two women had found it empty. Then we don’t hear anything about Peter until another episode recounted in the Gospel of John that occurred a few weeks later.

Peter had given up Jerusalem, returned to his home and his old job. I imagine him severely depressed. He had stood at the threshold of the Kingdom of Heaven, looked in, saw the endless beauty, and met the king. Then someone asked if he knew Him, and Peter said No, no, no. Not me! Then, three days later, his own eyes told him that he was wrong. Jesus was who he said he was, and Peter had failed his very first trial.

Three years before, when Jesus had sent them out on their own for the first time, in his guidance had said, “Whoever disowns me before others, I will disown before my Father in heaven.”

Peter was disowned before the Father in heaven. Life could offer him nothing more than return to fishing in the obscure province of Galilee. He had turned away from the kingdom of heaven at the critical moment. He had made the big mistake.

Now he worked all night and caught not one fish. He was no longer good at fishing. Total and complete failure. And this time of day was the worst, the graying of the sky before dawn, the time the cock crows. Tired, depressed, and hungry, he felt like throwing himself overboard.

In a few minutes he would do just that. But for a reason he did not expect.

He smelled something. Smoke. And fried fish and warm bread. It tickled his hunger and made him lift his head. A hundred yards away a small fire flickered on shore. Some early riser getting ready to make breakfast. Some early riser who was apparently a better fisherman.

“Friend,” the stranger called out to them, “haven’t you any fish?”

Was their failure that obvious? Even from a hundred yards away?

Peter’s companions shouted back, “No.”

“Throw your net on the right side of the boat and you will find some.”

Just what he needed. A know-it-all. Like the water on one side was different than the water on the other. An idiot bent on making them all look like idiots. Before he could say a word, though, their nets were up and tossed out again over the opposite gunwale.

The net filled quickly and the boat tipped dangerously toward the starboard. They couldn’t pull in the seine of squiggling fish. Peter’s crew kept the ropes tight and started rowing for shore, dragging their catch.

Peter squinted now through the mist and the pre-dawn gray at the flame and the figure on the shore. It sounded like, looked like…but it couldn’t be. Then his cousin John whispered loud enough that Peter heard, “The Lord.”

He looked back into the boat. James and Andrew struggled with the oars, John kept the net tight. Peter should help. The boat barely made headway and Peter was clearly the strongest rower. John lifted his eyes from his struggles long enough to meet his gaze. The Lord, he mouthed.

Peter leapt over the side, the cold water shocking his tired mind bright and clear. He swam hard and fast, keeping his eyes on the small flame. Dripping across the beach he came to the banks of flaming coals, fish already cooking and bread being warmed.

Jesus (it had to be Jesus), said nothing at first, only squatted by the fire and turned the fish. Peter, too, said nothing. What could he say to the the man who had talked with Moses and Elijah, who had walked out of his own tomb?

The words Whoever disowns me echoed again in Peter’s head, as they had for the last three weeks. Why was he here giving them fishing instruction and cooking breakfast? Is this the final farewell? The final I warned you, but you wouldn’t listen. Better luck next time message? He deserved the message, he knew he did. What he didn’t deserve was a record-breaking catch and breakfast.

The boat’s keel crunched into the gravel beach behind him. He heard the bang of the oars on the gunwales and the splash of men struggling with a full net of live fish.

Finally Jesus stood up. Their eyes met, and Peter waited for his dismissal. But he said, “Bring some of the fish you have just caught.”

Peter turned and ran to the boat, scrabbling over the side, grabbing the net from the exhausted crew and dragging it up the beach. Then the four stood before the fire, Jesus on the other side with a griddle and a basket of bread. Had the heavens opened and choirs of angels begun to sing, they would have been less surprised when he simply said, “Come and have breakfast.”

Words failed them. They ate in silent wonder. When they could eat no more, Jesus spoke to Peter. “Do you love me?” he asked.

“Yes, Lord,” Peter answered.

Jesus repeated the question two more times; Peter repeated his answer two more times.

Three times Peter denied knowing Jesus, three times Peter affirmed loving Jesus. The balance was restored. Jesus went on to say a few more things, saving the most important for last: “Follow me.”

After the big mistake, you can throw the coins back into the temple, you can take your letters of reprimand and remedial education courses and pay your fines. You can say you’re sorry.

But if the mistake is big enough, you still live in the cloud of despair.

I hope you haven’t made any big mistakes. Some of us have divorced someone that didn’t deserve it, some of us have abandoned children, some of us have had abortions. Some of us have robbed people legally or illegally. Some of us have killed people for no good reason, and some for a good reason only to discover there are no good reasons.

Remorse, depression, and despair pull us into a deep, dark place, and if you are there right now remember that little light you see a long distance off in the mist is Jesus cooking breakfast for you.

Head for shore. Sorry will be enough. You are forgiven.

A man named James, a recently retired professor of economics, broke his neck. The circumstances seemed like the usual sort of thing: One Tuesday morning he noted a light out in his kitchen ceiling so he got his step ladder, climbed up, changed the bulb, and fell. Could happen to anyone.

Except for one thing. His blood alcohol level on admission was well over the level associated with intoxication. The other lab tests did not show the signs of damage from chronic alcohol, things like liver abnormalities or bone marrow suppression, but the fact that he appeared quite sober with that alcohol level paradoxically demonstrated that his system was quite used to functioning under the influence.

The good news was that his spinal cord had not been injured. Although he was in great pain, he should survive and walk normally as long as he didn’t suffer another compounding injury before the bones of the spine healed solidly.

His neck was braced and a CT scan and MRI defined the specifics of his C2 fracture, one that carries the ominous appellation of Hangman’s Fracture. Because of the alcohol level, he also received some sedative medications designed to prevent delirium tremens. By the next day I had determined that his fracture would likely heal with a brace and he would not need an operation. By the third day, his pain was under good control and he could walk independently and safely. He could go home.

And that’s what usually happens. I go in, tell the patient to wear the brace, not drive or climb on ladders, make an appointment to see me in two weeks, and call if…blah, blah, blah. Sometimes I even add a cautionary note about alcohol, stuff like, “Drink only in moderation,” or, “Just say no.”

This morning, however, before I got to his room, I had a little more imagination–or maybe a vision from God–about what it might be like for a guy who had all the respect in the world at the university to be now sitting home on a Tuesday morning with nothing else to do but change the lightbulb and nothing else to make him feel good other than spiking his orange juice with a tumbler of vodka.

I know what it’s like to be addicted to a substance. My particular addiction is to tobacco, actually much worse for health than alcohol, but fortunately not as destructive to performance or relationships. Although I haven’t had a cigarette for years I remember clearly about a hundred times I “just said no” in the morning and smoked a pack before lights out that night.

“Just say no” was not going to work with Professor Jim. And if he fell again, even with his brace, he could very well be dead long before the ambulance ever arrived. There was a reason they called it Hangman’s Fracture.

After I arrived at his room I got him up and walked him around a little, just to see for myself if he was steady on his feet and not grimacing in pain. Then he sat on his bedside and I sat in a chair facing him. I gave him the good news about going home and the likelihood of healing and the usual instructions. Then I hesitated.

He was my senior by twenty years and a full professor–in more archaic terms, my elder. I had authority by my degrees and training to give him advice about spine fractures. But about lifestyle choices? About addictions? Maybe not. The easy thing to do, the thing I had done a hundred times before, was to tell myself it wasn’t my specialty, it wasn’t my problem, and let him go on and deal with his life as best he could. His problems, his choices.

Another story: About two thousand years ago a guy named Cleopas woke up after a holiday weekend with all hope drained. The person he had believed would usher in a new era of justice and peace and joy had been brutally and publicly executed, and furthermore, under cover of darkness, somebody had stolen the body. Cleopas could have stayed in bed. He could have drained a wineskin on his own. His problems, his choices.

Instead, he got up, took his first step, then another, then found a friend. They decided to go for a walk together, a day trip to a town called Emmaus. 

“I know why you fell down,” I said to the professor.

He nodded, a bit bemused as I seemed to state the obvious. 

“You fell off the ladder because you couldn’t help it.”

His eyes blink in agreement. He would have nodded except for the brace.

“You couldn’t help it because you’d been drinking.”

He didn’t try to nod this time. His expression stiffened, and his eyes fixed on mine.

“And you’d been drinking because you couldn’t help it.”

His expression softened, saddened. His gaze dropped to the floor.

“You couldn’t help it because you can’t fix it alone,” I said. I told him about avenues of help, about Alcoholics Anonymous. I wish I could tell you I prayed with him, but I wasn’t that wise. 

Professor Jim thanked me for the advice and shook my hand meeting my eyes again. I left to sign him out uncertain if I would ever see him again.

About Cleopas: Along the way, he and his friend encountered a stranger, told him of their hopelessness, then listened to what he had to teach them. Then they sat down to share a meal and discovered themselves to be in the presence of the Risen Christ. No longer hopeless and unable to contain themselves, they ran back through the night to tell their friends.

Professor Jim came back to office two weeks later with his wife. He had gotten up from his bed, taken a step, then another, then called a friend. They had started a journey together to to a place called Alcoholics Anonymous. There he discovered himself to be in the presence of the Risen Christ, the One who runs to you when you walk toward Him.

Jim thanked me again, and again when he kept office appointments six weeks and twelve weeks later. His fracture healed. I didn’t see him again, but he had coincidentally joined the church and Sunday School class my parents attended, a fact that allowed me to follow the subsequent ten years of his life, a life lived lived out in peace and joy.

When I find myself slipping toward despair, those times the wrong seems oh-so-strong, and I don’t feel like getting out of bed, certainly not to face reality, then I try to remember Professor Jim, and Cleopas, and I resolve to take a step, then another, and find a friend to go on a journey. I try to listen and learn, even from a complete stranger, and so far I have always encountered the Risen Christ. Then I want to run through the night to tell my friends.

A few weeks into our surgical internship, we invited all the interns to a party at our apartment. About fifteen were able to make it. We were all in our mid-twenties, living on shoestring budgets, bright, and excited about our careers.

            We were also puzzled by many things. For most of us, other than summer jobs, this was our first real career employment, and our first serious responsibility dealing with those who weren’t young, middle class and college educated. We had culture shock. But mostly we were shocked by our close proximity to suffering and death, and the power of our profession to alleviate the same. And how, at other times, we were so powerless, rendered into unwilling front row spectators at pain and the often quick passing of life. None of it looked like what we learned in the classroom.

            That night everybody talked fast and hard, sometimes stepping on each other’s lines, feeling like the emotions of the last few weeks had been bottled up to the point of explosion, and this was the one and only chance each of us had to let it out with a community that just might understand. We should have done it more often, but we only did it that one night.

            Only once did the room become silent. One of my colleagues asked, “When does the patient become real to you again? You know, after the operation? Is it when the last stitch is in, or when the bandage is on, or the drapes are off? Or is it in the recovery room?”

            For thirty seconds, all eyes turned to him, mostly puzzled, considering. We all knew it was a bad assumption, a question that shouldn’t be asked. The patients are always real, we always treat them with humanitarian dignity. Because that is the right answer, that is the classroom answer.

            The responses were interesting. About half the group said that the question was crazy; patients were always human, right? They had the classroom answer, and they were, of course, right. Patients are always human beings with full rights and value.

            But a few were like me. I knew exactly what the other intern meant. After the anesthesia, after the skin prep, after the sterile drape, the patient doesn’t have a face anymore. That makes it seem so much more natural to open their skin with a knife (that we call a scalpel so it doesn’t sound like a weapon). It is then possible to dissect through things that have names like omentum, and duodenum, and gall bladder. Because if we remember their face and call their inner parts by common names attached to them by possessive grammar (Joe’s guts, for example), surgery couldn’t be done–not by anyone who wasn’t a psychopath. At some point all surgeons do an emotional step back, dissociating ourselves temporarily from the humanity in order to deal the anatomy and the pathology.

            But we never talk about it. Except for that one time when one young doctor found the words to ask. Emotional distance goes up when the sterile drape is laid down.

            I like to think he was right. If we recognized the emotional distance we put up to operate, it was because these people already meant something personal to us, something very human, very connected, and we needed the separation. And maybe those who didn’t distance themselves, or at least didn’t recognize that they did, was that possible only because patients had never been “real” people to them from the beginning? Patients had always been patients, never people, so dissociation wasn’t necessary? I don’t know.

            Often I have emotionally distanced myself from a patient to do what I believe is good for him or her. But I know my capacity to dissociate is not limited to the operating room, or even the office or the bedside. Sometimes there is a person who is so old, or so intellectually limited, or so drunk or so crazy or so high, or so dirty or so foreign that they could not possibly be like me because I don’t want to be like them. And since I can never be like them, and since I must be a real person, they can’t possibly real. I put up the drape. I take an emotional step back. But now I’m not doing it for them; I’m doing it for me.

            Maybe you’ve done this. When you walked past that homeless guy or drove past that panhandler at the freeway exit. When you visited the nursing home. When the guy in the store speaks Spanish or the woman in the checkout line wears a burka. When the drunk at the next table talks too loud or the crazy guy walking down the street talks to people who aren’t there.

Maybe you put up the drape, take a step back. Then those people aren’t completely real, and somehow we feel safer.

            We come by this “step back” naturally. It’s literally in our DNA. One of the first social tasks of a newborn is to begin the process of distinguishing between the “us” and the “them” of the world. Mom first, then the family, then other caregivers, then the people who look like them–they become the “us.” Everyone else is “them,” which is understandable, but it can limit us. For example, studies have demonstrated that if children are not exposed to persons of another race before the age of four, their initial response to a person of that other race will be negative. The response can be mitigated by education and experience, but it is always there, an unconscious tendency to put up a drape, to step back, to racially profile, and thereby carry a weighty piece of baggage in a poly-cultural world.

            Then there’s another kind of emotional step back, the giant step, the one that says that a person isn’t human anymore, not now, not ever, not as a result of emotional bias but as a result of evilly rationalized doctrine. This is the step taken when a lie becomes imbedded in the mind ignoring the pleas from the heart: They aren’t like us, they can’t help us, they want to destroy us. They aren’t real people. We should separate them, put them in camps, make them work for us, take their stuff, kill them off if they don’t pull their weight. That’s the step back taken by the Nazis, but they are not the only ones who have taken that step in the past, nor will they be the only ones to take that step in the future. From this we should guard our hearts.

            Now I repeat the question that intern asked so many years ago in a slightly different fashion: When does a person become real?

            Is it at the moment of conception?

            The moment the heart beats?

            The moment the brain takes shape?

            Or is it the moment of birth?

            I ask because New York State recently passed a law that allows abortions well past the time (24 weeks) that a newborn could survive independently of the mother. The permissible reasons for late term abortion are: 1.) the life or health of the mother is threatened, or 2) the fetus is deemed non-viable. Furthermore, decisions are to be made by a licensed healthcare provider, not necessarily a physician. Since the health of the mother and the skills of the healthcare provider are not defined, the statute conceivably permits, for vague and possibly trivial reasons, abortion up until the moment of full term birth. In one delivery room a baby, now called a fetus, could be murdered or abandoned, while in the next delivery room a baby of the same gestational age would be treasured and loved.

            Nobody wants this. Nobody wants to kill babies. We can make better laws. For our doctors, for our women, for our children. For our souls.

            So the question returns: When does a person, a baby, become real?

            When you answer, let whatever is imbedded in your mind be guided by the pleas from your heart.

We met by coincidence at Old Faithful, the geyser that is so predictable in a National Park known for unpredictable events like blizzards in August. This particular day was in October, cool with bluebird skies and fluffy clouds, patches of snow in the shadows, a remembrance of summer and a promise of winter.

“It must be great to be a neurosurgeon,” she said to me. “Everybody always knows you’re smart.”

She is easily three decades younger than me, beautiful, brilliant, charming, with a great job, a handsome husband and an adorable toddler. The question surprises me. I know it is more about her than me. I hear years of frustration at not being heard, not being appreciated, her voice, probably the smartest in the room, frequently being drowned out by “man talk.”

I don’t really know how to answer her so I laugh it off. I tell her that’s it so much worse these days. Now when I do something dumb, people shake their heads and say, “He used to be a neurosurgeon. So sad.”

She laughed, I laughed. But it made me wonder about what being smart had to do with being a neurosurgeon.

To be honest, being seen as smart was something that was important to me back when I was a teen-ager. But what I really wanted was what Holden Caulfield wanted: to be the catcher in the rye, the one who caught children playing in the fields before they fell off the cliff.  A meaningful life meant saving lives.

But saving lives is an illusion. By medical school I realized what should have been obvious from the first: Lives are never saved; only prolonged.

I learned to imagine death as a large predatory cat–a lion, a tiger, a jaguar, or a black panther–something sinister and lurking somewhere behind my left shoulder, and everyone has his own big cat lurking behind his own left shoulder. He (and it always is a he) waits for a chance to pounce, and my job became to recognize when this creature is about to leap, then run between him and his prey, shoo him off, make him wait.

Because he only waits. He never goes away. In the end, he will have his prey. A complete win sends the big cat into the bushes for years. A small win sends him away for only a few days. An attack leaves pain, disability, scars, fears, until the inevitable end. He is relentless.

What is it to run between the big cat and his prey? What’s it like to be the neurosurgeon?

It’s standing there when the beautiful young woman with the winning smile and the great mind who can write poetry and play music and draw pictures and run with the wind comes into the ER because she has bled in her brain and can no longer smile, can no longer think, can no longer use her right hand and can no longer run or even walk. And she will die in a few minutes unless just the right things are done in just the right order and done right now. It’s standing in the OR an hour later carefully sucking blood clots out of a damaged brain wondering about the smile, the hand, the leg, and even the piano lessons, and wondering if they will be okay, but not worrying too much about that now because something caused the bleed, something like an AVM or an aneurysm, something that I know is there but don’t know what or where because there was no time to find out if she was to have more time in this life, and any moment whatever it is can explode and bleed again and maybe this time it won’t stop. It’s looking through an operating microscope for the next three hours dissecting arteries, ligating bad ones and saving good ones–they all look so much alike even under the microscope. And one mistake will lead to a lost smile, a lost hand, a lost leg, a lost mind, or even the end of time for her if I, or the cadre of techs and nurses and doctors that hold me up, make that one mistake. Then the big cat does not run back into the jungle, and her time is up.

And when it is over and all the blood is gone and all the arteries are open and there is no more aneurysm or AVM, I do not fist pump like Tiger Woods or knee slide like Mia Hamm or flip my bat while jogging around the bases like Babe Ruth. When it is over, I say Thank you Jesus and feel not triumph but only a cautious relief because the big cat has slunk off for now but I know he is still nearby, still waiting to pounce; the game is not over. The game is never over.

But, yes. Everyone thinks I’m smart.

I’m tempted to lapse into a Ecclesiastes theme: Vanity, vanity, all is vanity. It doesn’t matter if people think you’re smart. There is nothing new under the sun. People have always gotten sick, healers have always fought the losing battle against disability and death. From ashes we come, to ashes we return. All of which is true, of course, but a thin and obvious truth. It’s where Solomon started his book, not where he finished.

There is a time, he said, for all seasons–to be born and die, to kill and heal, to weep and laugh, to make war and to make peace. And this is the profound truth: Time is our gift. We have time for all the moments of our lives that gives us windows into eternity–birth and death, weeping and laughter, war and peace–because there is One who is even older and more faithful than the geyser by the same name, and He cares about the days of our lives.

She returned to her husband and son; they are expecting another child soon. I returned to my wife; we are expecting another grandchild soon. There is a time to be born. Together we all walked to the geyser basin to see it erupt again. Right on time.