Dr. John L. Turner Blog

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Chapter 1

Divine Intervention-

God Giveth, God Taketh

Away: Mrs. Ibarra's Gift

Hold off your hands... and know that I am God.

-Psalm 46:10

In operating room 3, the only audible sounds were the soft wheeze of the anesthesiologist's respirator and the occasional soft click of instruments being passed between rubber-gloved

hands. Through the lenses of the operating microscope, I could clearly see the magnified stereoscopic images of Mrs. Ibarra's brain tumor, a large peach-sized outgrowth of the dura (a thin leather- like membrane) that covers the brain. This benign lesion was behind this 72-year-old woman's right eye; total removal would be a cure. For the past four hours I had been slowly, but steadily, removing the growth piecemeal-the hard way-with electric forceps and wire-cutting loops (small circular heated wires on the end of a plastic wand). As the loop sliced through the tumor, smoke and vapor obscured the field. My assistant, Dr. Peterson,sucked the smoke away with his metal suction tip. I longed for the ultrasonic aspirator that I had used in training; it would have made this job much easier.

Four hours had elapsed since Mrs. Ibarra's surgery began and I had one remaining portion of tumor left-a small, scraggly clump of cells at the bottom of the operative field hardly bigger than a pencil eraser.

"Just one little piece remaining," I told Dr. Peterson. He could see it too; he had an excellent view through his observer's eye­pieces. I easily sliced through the remaining tumor with the cut­ting loops and then suddenly, like an explosion, the field of view turned bright red.

"Suction!"

Eventually, through the process of suctioning away the ob­scuring blood, I came to a startling realization: the last small piece of tumor had invaded the carotid artery, the major artery supplying the right side of the brain. The overlying tumor cells hid this fact from me. Removal of that final portion had taken out a section of the artery's wall; without applying pressure to seal it off, the vessel would bleed profusely. I initiated repair of the vessel.

"Silver clip," I commanded. The nurse handed me long- handled clip-applying forceps.

Because of the invasion by the tumor, the clips would not take a solid grasp; no matter how many times I tried, they didn't work.

Dr. Flower, the anesthesiologist, said, "Are you going to get it? I've given her three units of blood.

Divine Intervention-God Giveth, God Taketh

The carotid artery has cut loose; I have to repair the arterial wall," I replied. Dr. Flower returned to his position at the head of the table behind the drapes.

"Suture, eight zero," I requested as I continued to peer into the microscope lenses. I began the slow and tedious process of sewing the vessel, but was confronted with another problem: the walls of the artery were softened by the tumor, and the suture would not take a solid grip but merely pull through when tightened, causing further injury to the vessel.

I repeated my efforts with clips and sutures while minutes multiplied. I had spent four hours trying to stop the blood loss. Dr. Flower replaced the woman's entire blood volume with do­nor blood; she was now a candidate for developing dreaded com­plications that can result after massive blood transfusion. My patient had been under general anesthesia for more than eight hours and had received 10 pints of blood. I was nowhere close to being finished. It appeared as through I were about to experience my first loss of a patient during surgery, and would be intro­duced to the feeling of having caused a patient's death. I should have foreseen the possibility that the last remaining piece of tu­mor was a sticky wicket and just left it alone.

All eyes in the operating room were on me. All ears waited. What was I to do? I had exhausted all of my options... all but one! I never thought of praying before this day. Although I had been an acolyte in the Episcopal Church as a youth, I had no interest in religion. Having trained in physics, I doubted the sig­nificance of prayer and was skeptical about the existence of God. I had been too busy with academics during the past 21 years to allow time for religion. But today I prayed with sincerity. I would have fallen to my knees if I had not been scrubbed in and sterile.

I felt incapable of saving the life of this patient. I took a deep breath and exhaled slowly. I needed to connect with that force. As I looked through the scope, I prayed silently: If there is a God, a higher power, then I need your help. It is not Mrs. Ibarra's fault that she may die. I have done all that I can do. I am asking for help. Don't let her die on the table; help me to repair this damaged artery. Please!

I took a second deep breath... and went back into the breech.

"Suture," I said. For what seemed to be the umpteenth time, the scrub nurse obeyed my request. Once more, I carefully tried to approximate the torn vessel's walls.

"Clip," I said. She handed me clip after clip until, after 15 minutes, I had applied several clips and snippets of suture, trying to bring the remaining walls of the artery together without oc­cluding the vessel. To my amazement, the operative field remained as dry as a bone! No bleeding. I was pleasantly stunned. I'd done nothing out of the ordinary during that last 15 minutes except to repeat the previous attempts of the past few hours. But this time, the sutures and clips held firm. The prayer-the silent plea-had worked. The damaged artery showed no sign of bleed­ing. Everything at the base of the skull looked perfect.

"We're out of here," I told the scrub nurse and my assistant. All that remained was to close the operative site. This took 45 minutes, but it was a walk in the park compared to the ordeal I had faced over the past nine hours. Now, believing that my prayers had produced the miracle, I put forth another silent request: I have one more favor to ask. Please do not let her be comatose. Let her wake up and heal quickly. Do not let her become stroked out and paralyzed, but instead let her speech and strength be normal.

Divine Intervention-God Giveth, God Taketh

Let her come out of this in the best possible way. If you do this, I'll be as good a person as I can possibly be.

When helping to move her from the operating table for the trip to the Intensive Care Unit, Dr. Flower said, "You know, you have to learn that you can't make ‘good enough' better."

This case taught me that there is a higher power. It had seemed to flow through me when called upon. Was this the God who created us in His image? Alternatively, was it a force, an energy that is available when summoned to supercharge our meager hu­man efforts? At the time, I was unsure just what to call it. It was there waiting for my call, and when asked, it came to my assis­tance. Although signs pointed to God, a nagging question both­ered me. Was it something within me that required the slow, deep breathing and mental refocusing for its activation? What­ever the mechanism, it was now a moot point-Mrs. Ibarra was going to at least make it to the ICU and I would be forever thankful. Now if she could just pull through intact, I would be the second-happiest person on the island.

Mrs. Ibarra not only survived the surgery, but she healed quickly with little neurological sequelae. She was discharged in seemingly normal condition one week later. Besides ptosis (a slight droop) of her right eyelid, she had a second problem. I found out about it three months after surgery when she came to my office for a final post-operative checkup.

"How is your eye?" I asked.

"Oh about the same, doc," she replied, "I've learned to live with it, and it's not bad at all. But I have a problem. My husband will not give me enough sex!" She smiled at me, and I smiled back. That was a great complaint for a woman in her seventh decade of life.

"I don't think I can help you with that," I replied. "Are there any other physical problems?"

"Not really. Say, I have something for you, doctor." She pulled a large piece of lacquered wood from her shopping bag. On it were two engraved Japanese kanji. The patient, however, was from the Philippines. I was confused. The Japanese characters must be of special importance.

"What is this?" I asked. "What does it say?"

"Oh, I don't really know, I'm not Japanese. But when I found it, I had the feeling that somehow, in some way, doctor, it was for you. This is what you need."

"Well, thank you very much. I will treasure it and think of you often."

She smiled again, and I returned her smile in kind.

"This is your last visit with me, Mrs. Ibarra. You have done well; the scan we did last week reveals no further tumor growth; in fact, the scan was normal. I will recommend to your doctor that he perform a follow-up scan in six months to confirm that everything is still okay. If you have a question or would like to see me, please call anytime."

Later on, I asked a few of my surgical colleagues if they had experienced a case where they could not stop the bleeding. The response was uniformly, "Yes, why?"

"What did you do?"

And again, the reply was always the same: "What can you do?"

At the end of the year, I hosted a Christmas party at my office. During the festivities, I pulled my friend Dr. Nagashima aside and showed him the calligraphy that Mrs. Ibarra had given me. "What does that mean?" I asked.

He peered at it for a moment through his thick eyeglasses.

"Heiwa," he said.

"Roughly translated, it means peace."

And indeed, as a result of my intraoperative prayer, Mrs. Ibarra survived. Now that I knew a higher power was with me, I was at peace, confident that I could over-come any difficulties either on my own or with help, on those rare occasions when good enough truly needs to be made better.

Every life has dark tracts and long stretches of somber tint, and no representation is true to fact which dips its pencil only in light, and flings no shadows on the canvas.

-Alexander MacLaren

I continued to bask in the blissful feeling of serenity that resulted from the prayerful experience that ostensibly saved the life of Mrs. Ibarra. I augmented my budding conviction in the unseen spiritual world (and a higher power) when I became "born again" at a local Pentecostal church.

Medicine, Miracles, and Manifestations

I'd connected with the uni­versal force (that I now called God), and felt as if I could ask it to aid me at any time. I became filled with the Holy Spirit. Time passed, until an otherwise routine day changed dramatically into one of the saddest days of my life. It was an experience that caused me to rethink my recent religious conversion and to search for another answer to the mysteries of life and death.

Sara DeAngelo came with her parents for a consultation. Nine years old, she radiated great beauty and spirit. Her smile was adorable and by her appearance and manner, I could tell that one day she could potentially be a fashion model. She had been blessed with great looks. I was struck by her natural charm and her soft- spoken, friendly nature, seemingly years beyond her age. Her parents worked in the sugar industry and had recently moved to Hawaii. The girl had a ventriculoperitoneal shunt-a bypass tube with a valve that drains cerebrospinal fluid (CSF) from the brain to the abdomen to treat hydrocephalus (enlargement of the fluid spaces of the brain). The shunt was performed in the first days of her life. There had been no problems with the device since its insertion, but in time, she would outgrow the length of tubing in her abdomen and it would have to be replaced. Shunts also can become obstructed.

Shunts come in many varieties. The most common type is a flexible silicone catheter that is inserted into the brain. This is done by placing a small hole in the back of the head and inserting the catheter into the ventricular fluid system deep within the brain. A valve mechanism allows one-way flow of CSF from brain to abdomen. Tunneled under the skin, a discharge tube allows drainage into the abdominal cavity. Babies born with "water on the brain" suffer from CSF buildup when egress from the ventricular cavities of the brain is blocked. A pressure-relieving procedure must be performed quickly. Sara had such a shunting procedure after birth and had done well.

Divine Intervention-God Giveth, God Taketh

Sara conversed with me easily and submitted to a neurologi­cal examination without duress. Her parents were pleased as they observed our interaction, and at the end of the consultation they requested that I be available should the shunt require surgical treatment. I agreed and told them how to contact me in case of emergency. I scheduled an X-ray to estimate the remaining length of tubing. As a result, I determined that she could grow a few more inches in height before modification would be necessary. I admired this little girl and mused about someday having a child of my own as sweet as Sara DeAngelo.

Everything stayed quiet for many months. Then one day, the emergency room called. Sara had suddenly become seriously ill with complaints of severe headache and came to the emer­gency department for treatment. A CAT scan showed obstruc­tive hydrocephalus with her ventricular system under high pressure. The shunt was blocked. I arrived at the hospital within minutes to find the mother holding her retching child over a sink in the X-ray department, suffering from the increased pres­sure in her head that, if untreated, would soon lead to brain her­niation as pressure forced brain tissue through the opening at the base of the skull. Coma and death would quickly follow. My evaluation showed the shunt to be occluded at the valve; I planned to insert a new system. I explained the procedure and its risks to the parents and they requested that surgery be done. Within the hour, I was scrubbing for surgery.

Medicine, Miracles, and Manifestations

In the operating room I glanced at the monitor; her respira­tory and heart rates were normal. The anesthesiologist waited for me to begin. I put on gown and gloves and went to the table.

"Knife," I said. The nurse gave me the necessary scalpel and I opened the old incision, disconnected the valve and-suddenly, without warning, the ventricular catheter fractured and disap­peared into the brain.

"Damn it!" I exclaimed, perhaps a little too loud.

It had been old and brittle. To retrieve it could cause injury to the brain and might stir up bleeding that could be difficult or impossible to control. It was better to let it float forever within the ventricular chamber. I inserted a new system without diffi­culty and made sure that it properly drained the fluid drop by drop. I closed both incisions and applied sterile dressings. Sara went to recovery and then to the pediatrics unit, her room di­rectly across from the nursing station. The nurses would keep a close eye on her. Sara's father planned to spend the night in her room. I told him of the difficulty with the old tubing breaking off and disappearing within the brain, and of my decision not to try and recover it. He understood.

I returned home that evening feeling good about the surgery. Before retiring, I called the pediatric floor. Sara was reported to be sleeping comfortably with normal vital signs.

"Remember to check on her routinely as ordered."

"Of course doctor," the nurse replied, "she's doing just fine." I awoke with a start at 6 a.m., rubbed my eyes, and wondered about Sara. I had slept through the night without a phone call, so apparently she was doing well. Showering, I mentally reviewed my schedule for the day: office appointments were the only tasks after morning rounds. I would have preferred surgery, as office evaluations tend to be tedious, although nec­essary, drudgeries.

Suddenly, the phone rang. It was my answering service. "Code Blue Pediatrics, doctor, your patient!"

I could not believe it. I threw on a scrub suit and ran to my car. I lived only a mile or two from the hospital and I arrived within minutes to face a flurry of activity in Sara's room. The on-call anesthesiologist was there with several nurses and a crash cart of medical supplies. The child was intubated; a machine ven­tilated her lungs.

I grabbed a hypodermic needle from the cart and inserted it quickly through the scalp and into the shunt valve. Maybe the new shunt had malfunctioned or the old ventricular catheter had caused an obstruction and buildup of fluid pressure. To my amaze­ment, there was no sign of high pressure. Only a few small drops of fluid came from the needle. The valve has a plastic portion that can be pumped with using thumb pressure-it operated normally. I lifted her eyelids; her pupils were fully dilated and did not respond to light. This was an ominous sign of brain death. Sara was transferred to the intensive care unit. I spoke with her dad, who had just walked into the room.

"What happened?" he cried.

"I'm not sure. Can you tell me how it went during the night? The nurses report that she had a peaceful sleep until just before six this morning when they found her comatose and unresponsive."

Medicine, Miracles, and Manifestations

"I spent the entire night with her," he said slowly, crushed by the rapidity of recent events and the now critical condition of his daughter. "She whimpered occasionally and complained of mild pain where you made the incisions, but all in all, I was quite pleased with her progress. I thought it would be okay to run down for a cup of coffee. When I returned, the room was filled with doctors and nurses. They said her heart stopped."

As we walked to the ICU, I told Sara's distraught father that I wanted to do a brain scan to see if the shunt was decompressing the ventricles and if the old tube had somehow caused damage, bleeding, or obstruction. He consented, and we went from the ICU to the CT scan with Sara. The scan was normal. Sara re­mained comatose with fixed and dilated pupils. She had no his­tory of cardiac or any disease other than the aforementioned hydrocephalus at birth.

I sat by the bedside holding her hand, thinking and rethink­ing this case. Would I have done anything differently? Should I have sent her to the ICU after surgery with a special monitor in case her breathing stopped? No, the pediatric nurses were always on top of things, and her room was directly across from their station. There was really no need for special monitoring. Should I have tried to recover the lost tubing from the ventricle? No, that may have caused more problems.

"Doctor, may I begin?" said Thomas Bearden, the brain-wave technician, as he prepared to wheel his electroencephalograph (EEG) into the room. This test would confirm brain death.

"Of course," I said. As he attached the scalp electrodes using conductive paste, I turned to look out the window. The parking lot was slowly filling up as doctors arrived to begin their daily ritual of morning rounds. It was quiet in the room except for the occasional hiss of the ventilator as it kept Sara's lungs and blood well oxygenated.

Divine Intervention-God Giveth, God Taketh

After Thomas finished, I saw that the recording was flat line (no electrical activity) at the highest sensitivity setting of the ma­chine. There could be no question about brain death, an irrevers­ible condition in spite of the continued beating of her heart and mechanical inflation of her lungs.

I gave the parents the sad news. I told them I had no idea how or why their daughter died suddenly. I requested an au­topsy. Maybe it would reveal if the catheter was the cause of her death. In addition, it might have disclosed an unknown heart condition that could have led to cardiac arrest. I needed to know the etiology of her demise.

"Doctor," the father said, "we understand your concern and your pain. It may be that we will never know what happened. Although an autopsy may help you to understand, we have care­fully thought this out. We would prefer, as would Sara, that she be an organ donor. Her heart, liver, kidneys, and eyes may give someone else a better life. My wife and I sincerely believe this would be her wish."

"Are you sure? There is a chance the old tubing may have-"

"Please doctor," he interrupted. "I really do understand your concern, and we empathize with you, but we feel the most ben­efit will be to donate her organs."

I wiped a tear away. It was indeed a sad day to see this beautiful child gone from the world. Yesterday, she had been her normal cheerful self, dressing for school, when she began to com­plain of a headache. By the afternoon she had started to vomit, a result of the pressure developing within her brain. Now it was over. I was dumbfounded and unable to understand this fatal series of events.

The organ harvest team took Sara to the operating room. Her heart, lungs, liver, and kidneys were deemed suitable for donation, as were the corneas of her eyes. As she was wheeled from the room, I sighed in grief, lowered my head and gave Sara a silent farewell.

A few days later, the parents called to invite me to a funeral event for Sara, which they called a "Celebration of Life." As I drove the 50 miles to the small church, I again pondered the case. If I had to do it over I would do the same thing: leave the old tube, nurse the patient on the pediatrics floor, and leave the same routine orders for post-op nursing assessment. I would feel comfortable, even if it were my child. Would this ever happen a second time? It could, as medicine is an art as well as a practice. But I sincerely hoped that I would not have to face such a tragic situation again. I arrived at the church in time for the celebration of life.

"We thank all of our family and friends for coming today," the mother said. About 50 or more friends and relatives had gathered for the event. "We want to say how fortunate we feel to have had Sara in our lives for the past nine years. She was truly a gift from God and provided us with untold joy and happiness." Her remarks were followed by a message from the father and brief remarks from a few friends of the family. The service ended with a meal of local-style food and drink. I offered my condo­lences to the family and left.

Divine Intervention-God Giveth, God Taketh

The universal force, the higher power that came through with Mrs. Ibarra, was unaccountably absent in Sara's case. I was more than disappointed. I felt deeply saddened and baffled. I decided to continue my investigation of a spiritual world to determine if there was such a thing as a universal force. It is of note that years later, when I observe my 3-year-old son laughing and playing, and when seeing how he fondly looks at me, I can't help but wonder, could this be Sara?

NB: I hope this sample chapter had stimulated your interest in this book. I might add, that after publication in March 2009, by a strange series of events, I was drawn to a second volume which I plan to title:

Beyond Medicine, Miracles and Manifestaions :Beyond A Reasonable Doubt

It will go deeper into the explanation of "The Afterlife."