Big Enough

I had my pediatric rotation during the third year of medical school. My first assignment was in the Newborn Intensive Care Unit of St. Paul-Ramsey County Hospital.  The NICU in those days was a new idea, and our unit was modest–a mere eight incubators with monitors and respirators.  My first patient: a premature baby boy weighing 500 grams (about 17 ounces).

The NICU director taught me how to intubate a premie struggling to breath, how to take advantage of the umbilical artery and veins during the first day of life, how to start an IV in a scalp vein. I learned to calculate fluids and nutrition within very narrow margins of error by the barest of guidance from limited labs, weight and physical examination. I learned about respirator settings for tiny human beings, the perils of too little and too much oxygen. I worked hard and learned a lot. The NICU director gave me great autonomy and an experienced nurse gave me lots of help. And I believed my little patient would live.

Then, forty-eight hours later, the baby died.

I was shocked. I had done everything right, done everything I could, and he died anyway. My knowledge and skill and willingness to work were not enough. The baby was too fragile.

The NICU staff was not surprised. Because the one thing I didn’t know, and everybody else did, was that a 500 gram baby had never survived. They had worked with me treating the baby because they hoped he would survive. I didn’t know any better; I believed he would.

Though we failed with that child, there now are a few babies who have survived, even thrived, from sub-500 gram birth weights because another generation of doctors not only hoped, but believed, the most fragile could survive.

I learned three things: babies are fragile, hope is good, belief is better.

This Christmas season I’ve found myself wondering about the baby Jesus and remembering that baby in the NICU.

History tell us that about two thousand years ago, the creator of the universe gave up being God and chose to become the frailest of human creatures, a baby. A very fragile baby. We know what happened next: The baby survived, grew in wisdom and strength, sacrificed himself thirty years later for the salvation of mankind.

But babies are frail. Did God risk the salvation of mankind by coming as a baby? Did He have an alternative plan if the baby Jesus had not survived? I don’t know. I feel that with the alignment of the stars, the signs in the heavens, the specific prophecies about Jesus going back several centuries, Jesus’ birth and life were planned since the beginning of time.

Maybe part of God’s message is about fragility. The nation of Israel had been hoping for a Messiah for hundreds of years, expecting some kind of celestial Superman who could save them from their enemies and restore their political and religious dominance.

Then Jesus arrived as a fragile baby, someone who needed constant care simply to survive, and a message from angels to keep him from being slaughtered with the other infants in Bethlehem by the evil King Herod. I mean, really, if you were there–say, a shepherd who had heard about this miracle from angels in the field–and you had to change a diaper, would you really believe this little guy was the Son of God?

I don’t know why God does things the way He does. The story we have about Jesus is so much more beautiful than the stories we have about the great political and military saviors in the Bible–Moses, Joshua, David, for example. But though the Jesus story is beautiful, it remains puzzling.

This Christmas season, I am thinking of Jesus as a metaphor. A baby Jesus is born into my heart. He represents all those beliefs that are beautiful and true: that I am a beloved child God, that my current experience only touches a true and deeper reality, that my life is not limited by time and space, that order reigns over chaos, that good triumphs over evil, that mercy is better than justice, that true wealth is in the heart, and love is real and stronger than fear and hate.

But He is small and frail.

I have moments, maybe many moments, when I can believe that reality is limited to the cold facts demonstrable by science, that life is limited to a short time on this small planet, that human law is the best we can expect out of justice, that mercy is weakness, fear is self-preservation, forgiveness is foolish, success is getting more, and that love is an illusion based on hormones and reproductive drive.

These are easy beliefs in our secular age. As a flinty-eyed realist, I should be able accept them and dismiss my hope for Jesus as sentimental foolishness.

But I can’t.

When Jesus was born in the stable at Bethlehem, He was small, fragile. Maybe He only weighed 500 grams. But by the grace and love of His Father, our Father, He survived.

He was big enough.

My baby Jesus, born in my heart, has been small sometimes, maybe only 500 grams. Who can measure these things? Sometimes He seems frail. But, by the grace and love of our Father, He survives.

He is big enough.

Some Kind of Miracle


Denise was nineteen and had been married for two weeks.  Her husband said they had been together that afternoon when she suddenly complained of a headache and lost consciousness.  He called rescue who resuscitated and intubated her at the scene and transported her to the hospital.  A CT scan demonstrated hemorrhage in an area of the brain that was both critical and inoperable, the brainstem.  She was placed on a respirator sent to the ICU.

I saw her there, a tiny black woman, not more than five feet tall, weighing no more than a hundred pounds, beautiful still in spite of the distortion from the endotracheal tube and other lines and monitors.  An EEG had just finished, and the technician was leaving.  An official reading would take a few hours, but I saw the flat lines consistent with no brain activity.  Her neurological exam was also consistent with brain death.

She met all the criteria for a diagnosis of brain death except a repeat confirmatory examination to be performed eight to twenty-four hours later.  Once the diagnosis was confirmed she could be removed from the respirator without any further ethical concerns, either before or after her organs were harvested to be donated.

The family entered as I finished my exam.  Denise lay between us like a sarcophagus.  I replaced the gauze pads that covered her eyes.  The cardiac monitor beat out a steady string of slow beeps.  Every five seconds the respirator made a clunk-wheeze sound and Denise’s chest rises and falls beneath the thin, white sheet.

Her husband, not much older than she, is so diminished by shock that he stands like a mute child with large, fearful eyes.  Her mother, a formidable looking woman flanked by a small army of family and friends, takes charge.

Color separates us: my white coat and white skin, her dark dress and dark skin.  Language separates us: my Midwest accent, her Southern drawl.  I see in her eyes the sins of  generations of white men and know that trust would not be earned easily, and my authority would be recognized only grudgingly.

“Doctor?” she says.

I ask what happened, although I already knew.  I ask about her prior health, though it mattered little now.  I ask because I want to listen to their voices and I need to earn their trust.

And I don’t want to talk.  I don’t want to tell her that her daughter is dead in every sense except that her heart beats on.  I listen to the story of her short life, her childhood illnesses, her graduation from high school, her recent marriage.  I hear, as she describes Denise’s plans for the future, the hopes and dreams of her whole family.

Finally there is silence, and they look at me.  I tell them that she likely had been born with something that now caused bleeding in her head.  This is nobody’s fault; it could not have been prevented.  An act of God.

“She’s in a coma,” I say.

Mother’s face steels.  “She going to get better?”

The monitor beeps, the respirator wheezes, and Denise’s chest rises and fells.  I shake my head.

Mother’s face almost crumbles before it steels again.  “We a praying people, Doctor,” she says.  Soft voices behind her murmur assent.

“I pray, too,” I say.  I pray for forgiveness, I pray for comfort for Denise’s family, I pray I can leave this tragedy and go home to my wife and children.

I tell Mother about coma and brain death, how brain death is not only a diagnosis; it is the end of hope.  I speak about transplantation, how life and hope can be salvaged from death and despair.  I am met with stony looks.

“We be praying for a miracle, Doctor.”

I nod and look down at Denise, small enough to be a child, then explained about repeating her EEG and exam the following day.  We set a time to review the results.

The following day her exam is unchanged.  The EEG is still flat.  Her vitals signs are normal and her labs are normal.  She is brain dead, I tell her family.

“What now?” Mother asks.

I explain how transplantation works, how she can remain on the respirator until her organs are harvested then the body is released to the undertaker.

“No,” she says, “No transplants.”

I want to explain again but the steel has returned to her face, and I am forced to agree.  Denise is my patient; I am responsible only to her, and by extension, her family, not the unknown recipient of a transplant.  I nod.  “Then we can remove the respirator.”

“My son is a preacher up in Georgia.  We need him to lay on hands and pray over Denise.”

Technically, Denise is dead.  A death certificate could legally be filled out now, but I am in no hurry. Death and grief are hard enough without inflicting more wounds with technicalities.  “When?” I ask.

“Tomorrow morning.  Ten o’clock.”


I wonder what happens when you pray with such certainty for something that is so impossible.  Do you give up God?  Do you give up prayer?

And I wonder what happens if you pray for the impossible, and your prayer is answered.  Do you give up your faith in the expected?   Is the science of medicine so frail?  Does reality and experience know no boundary?

The next morning I enter the ICU and feel like I am in the wrong church.  Twenty souls are gathered in their Sunday best, including Denise’s brother.  Her mother introduces him, and we shake hands over the bed.  I examine her, self-conscious of the audience.  No change, brain dead, I tell them, and step back into a corner, uncertain what to do with my hands.  I cross one over the other and stand with my head slightly bowed but eyes open.  Respectful, but I feel like an alien.

Her brother lays a hand on her forehead.  He begins murmuring a prayer and the room fills with others praying out loud or saying amen.  A babbling hum fills the room and competes with the heart monitor and the respirator.  His prayers become louder with the cadence of a practiced orator.

“We love our sister,” he calls out, one hand on her forehead and one raised to the heavens.  “Now, in the name of Jesus, rise and walk.”

The room falls silent except for the monitor and respirator.  He begins again, the small congregation joining with encouraging words.  Again he cries for his sister to rise and walk, and again she does not.  A third time he cries out in the name of Jesus for his sister to rise.

I find myself praying with him.  I find myself willing to sacrifice all the certainty of the medical science for the life of this young woman.

The monitor beeps, the respirator wheezes, and no one moves, least of all Denise.  A tear streaks down her mother’s cheek.  Her brother’s hand rests still on her forehead.  A minute passes, maybe two, maybe three.

This is the moment, I think.  This is when we admit that God doesn’t answer prayers, at least not this one, at least not now.  And if not now, when?  Surely He must care.  But if He cares, does He not act because the power that raised the only son of the widow of Nain was for that time, those people?  Not now, not us.  Is now the time for bitterness and grief?

Her brother whispers something.  Then repeats himself, now loud enough that I can just make out the words.  I hear, “Thank you, Jesus.”

But why?  For what?

“Thank you, Jesus,” he says again, louder, the words unmistakeable now.  And again, even louder.  Murmurs of assent and soft amens from the family rise like a chorus to his solo as I stand to the side, puzzled and dumb.

“Thank you, Jesus,” he says one more time.  “For we loved our sister.”

I hear the chorus of amens.

“But You loved her more.  Thank you, Jesus.”

He lifts his hand from her head and steps away.  Family members file by, touching Denise, hugging her mother, shaking the brother’s hand, then leaving one by one until only the brother and his mother remain.  He nods to me as he turns to leave, surrendering the ground.

I shook his hand as he passed.  “I’m sorry,” I said.  Sorry your sister died.  Sorry your prayers weren’t answered.  Sorry that I, in spite all my scientific knowledge and skill, am completely helpless.

“Thank you,” he said.

Then I am alone with Denise and the ICU nurse.  We disconnect the lines and turn off the respirator and the clunk-wheeze stops.  The heart monitor beeps on.  I secretly hope that she will breathe and we will call back the family and celebrate a miracle.  But her chest no longer rises.  The beeps slow, then become irregular, then stop.

I sign the death certificate and go to church, joining my wife and children in a quiet Methodist congregation where all the men wear suits, all the women wear dresses, and we all pray for the will of God to be done, but never for the dead to be raised.  We are safe from disappointment that way.

But I wonder if we don’t ask for too little.  Though Denise did not rise from the dead, at least not in this world, I feel that because her family had prayed for something I wouldn’t have risked, we witnessed some kind of miracle.

Before their prayers, her family was lost in grief.  Her family asked God for more time with Denise in this world of suffering and sorrow; God assured them that Denise was living a perfect life now and they would see her again someday.  Because they prayed for a miracle in the hear-and-now, they witnessed a miracle in eternity.

Ray of Hope


I drove home from the emergency room at 4AM feeling tired, frustrated, and depressed.  As I angled off Beach Boulevard onto Hogan Road I passed a low, triangular-shaped black building topped with a cross formed by lighted letters.  Horizontal letters read Jesus Saves; Vertical letters proclaimed Jesus Heals.  Nobody believes that, I thought.  Otherwise the ambulance would have come here instead of the ER.  And I wouldn’t have blood on my shoes.

The victim that night was a twenty-one year-old man named Ray.  He had been in a single-car accident after midnight and looked brain dead on arrival.  He had been intubated in the field, was now on a respirator without motor tone or reflexes, and his pupils were fixed and dilated.  But he was drunk and hypothermic, so an official diagnosis of brain death could not be made.  Resuscitation continued.

A CT scan showed a diffusely swollen brain and multiple facial fractures.  He was placed on a respirator, given heating blankets, IV fluids, anticonvulsants, steroids, antibiotics, a room in the ICU, and little hope.  Blood dripped onto my shoes when I drilled a small hole through his skull to place a tube to monitor the pressure inside his head (the ICP).

I left him in the ICU after giving his nurse instruction on his care then looked for family or friends.  No one.

Driving home I felt like I’d performed a great exercise in futility.  Ray’s prognosis was dismal.  If he survived (an unlikely event in my estimation), he would likely be left with severe brain injuries and exist (at best) for a few years institutionalized in a neuro-vegative state.  I wished the ambulance had taken him to the faith healers; the outcome was likely to have been the same.

After a few hours of sleep I returned.  Ray’s temperature had been restored to normal and his alcohol level had fallen below the legally drunk range.  His ICP was controlled with minimal intervention, but his pupils were fixed and he still had no muscle tone or reflexes.

Again, he looked brain dead.  But since he was sedated for the respirator, an official diagnosis could not yet be made.  I felt as if I was not so much treating Ray as I was keeping his organs viable as a possible transplant donor.

This morning Ray’s parents were in the ICU waiting room.  I went to meet them and steeled myself to deliver bad news.

The first thing I noticed was they were surprisingly well dressed–he in a coat and tie, she in stockings and heels.  The second thing I noticed were the little gold crosses–one on his lapel, another on her necklace.

I told them what I must while their eyes searched me, listening carefully for the words I knew they wanted to hear–okay, recovery, rehabilitation–words I did not speak.  I said coma, paralysis, brain damage, blindness and, yes, even death.

Then we faced each other, silent for a moment.  Her face begged for better news; tears welled up and overflowed, creating fall lines in her makeup.  He studied me and asked about chances, searching for the thin comfort of statistics.  “I know you can’t say for certain,” he said.

“Less than fifty-fifty,” I replied.  It was worse than that, but I was unwilling to lie but didn’t want to hurt them more than necessary.  It was the best I could do.

“When will you know?” he asked.

“A day, a week, a month,” I said.  “I don’t know.  Everyday he lives, he’s beaten the odds.”

“There’s hope?”

I pause.  I am careful dispensing hope.  Too much is a lie called false hope.  Too little is another kind of lie.

“His response to the treatments we started last night gives us some hope,” I said cautiously.  Some hope.

His shoulders dropped a fraction, perhaps shrugging off the worst, but his eyes narrowed as he continued to fix his gaze on me.  She breathed now without sobbing.

“If he continues to get better there will be room for more hope,” I say, dispensing the possibility of more hope.  “But if he gets worse…”


“If there is no hope, I will tell you.”  The possibility of no hope.

He nodded.  She sniffed.  “We will pray for him,” she said.

“And for you, too, Doctor,” he said.

“Thank you,” I said.  I wished without much faith that the prayers would help.

I’d like to report that I went back to the ICU and witnessed a miracle healing.  But it was not so simple.  Ray had a rocky course, fighting for his life for the next month.  His ICPs gradually came under control and he was weaned from the respirator and sedative medications.  He woke from his coma and, although his vision was impaired from bruised optic nerves caused by the skull base fractures, he was otherwise neurologically intact.  Then, a few days later, he had an attack of meningitis–a complication from his basilar skull fracture.  After a course of antibiotics, he required an operation to seal the cerebrospinal fluid spaces and prevent another bout of meningitis.

But he exceeded my expectations.  He recovered and was discharged home walking and talking.  Eventually, he made a near complete recovery and has led a normal life, left with only a moderate visual impairment and a well-controlled seizure disorder.

As I look back, this was when I started to wonder if the prayers helped.  At the time, I thought he got better because of good neurosurgical care.  But he looked dead, I thought his care was futile, and, in spite of my expectations, he lived.

Later, when he came in for office appointments, Ray always wore a little gold cross somewhere, usually a pin on the collar of his shirt.  It made me remember the night I had no hope and the lighted cross I saw.  Jesus Saves, Jesus Heals

Could the faith healers at that little black triangular-shaped building have done better?  Almost certainly not.  But I know now that there is room for both kinds of healers.  Some are called to don latex gloves and get blood on their shoes; others are called to fold their hands and fall on their knees.  Ray needed both.