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It didn’t look like we were going to be able to convince anyone in the group of neurosurgeons we had emailed to bring Janel to one of their hospitals for surgery. But Michelle didn’t let them off so easily. She wrote them an email to, as she put it, “help them understand why their answer was the wrong answer.”
This is not the first nor the last time we will come across these kinds of heartbreaking patients, and continue to try to find a way where there is no way, because we know that we can help. True, this is not a “sustainable” approach, but when the patients arrive in front of us, it is hard to not do everything possible to help that one patient. Sustainable health care in Haiti will take decades . . . I understand wanting to stay in the scope, but do also know that with this work, we have to be flexible . . . I can’t predict what cases are coming our way, but do appreciate our ongoing conversations about these really tough ethical challenges . . . I do also think that as we find these patients, we should do the best we can. We have been successful in getting some patients to the US for surgery, and I think it’s worth a serious try for this patient.
The neurosurgeons didn’t reply.
Disappointed but determined, we decided to try our own hospital, Brigham and Women’s. Although I had spent the previous four years training there, I had just undergone the humbling transition from being one of the most senior trainees in neurology to being the most junior staff physician. As a new faculty member in my first months of practice, I wasn’t sure what the neurosurgeons would make of an email query from me, or if they would even read it among the backup of emails they must have after spending the entire day—and sometimes the entire night—operating. To get our neurosurgeon colleagues and the hospital on board with offering free care to Janel, I needed some higher-level backing. I decided to present the case at morning report.
Morning report in the Brigham neurology department takes place at 7:30 a.m. every weekday. Neurology residents, students, and faculty cram around a big conference table in a small room to discuss patients who had been seen the night before in the emergency room or who were being cared for on the ward. At the head of the table sits Dr. Martin A. Samuels, the chair of the department for nearly thirty years. A young seventy, tall and slender, with thin-rimmed spectacles and an impressive collection of bow ties, Dr. Samuels fits the visual description of most people’s stereotype of a Harvard professor. And so does his CV. He has quite literally written the book on neurology, coauthoring the encyclopedic 1,600-page textbook that is considered the go-to reference in our field. The awards and honorary degrees he has accumulated over his illustrious career fill every inch of wall space in his office and spill out into the hallways beyond it. But he is humble, humorous, unassuming, and down-to-earth. His office has a piano, a tissue dispenser that dispenses tissues out of the nostrils of a large nose, and several framed photographs of Freddy, his feisty Norfolk terrier. Not one for hierarchy, he goes by Marty. It was Marty who offered me a job at Brigham and provided me with the flexibility, freedom, mentorship, and support to work part of the year in Haiti. My hope was that if I could get him interested in Janel’s case at morning report, he might help me approach the neurosurgeons and the hospital administration.
When the residents finished presenting the cases they had seen over the prior night, I asked if I could get the group’s advice on a case from Haiti. I gave the brief story and described the physical examination from Martineau’s video. Then we turned out the lights to look at the CT scan on a large monitor that hung on the wall of the conference room. As the enormous tumor came into view, faculty members, residents, and students gasped and whispered in the darkness. Nobody had seen anything like it.
“Can anything be done for him in Haiti?” one of my faculty colleagues asked me.
“Unfortunately . . .” I began.
“You have to bring him here for neurosurgery!” Marty interrupted enthusiastically. Others around the table nodded slowly in agreement, their faces palely illuminated by the digital light from the projected images of Janel’s tumor.
Success! I thought excitedly. But I suppressed a smile and soberly said, “I’m going to try.”
Having Marty’s support would go a long way. He is a legendary figure at Brigham due to his long tenure as a charismatic chairman, renowned clinician and educator, and admired colleague. I decided to see if he could help me get a Brigham neurosurgeon interested in Janel’s case. Approaching him after morning report as he opened the door from the conference room to his adjoining office, I asked him which Brigham neurosurgeon he thought I should contact.
“Ian Dunn,” he replied. “He’s one of our top brain tumor surgeons. He does all the most complex cases with impressive results. Good guy too. Tell him I suggested you write to him. Keep up the great work you’re doing in Haiti.” He smiled and disappeared into his office, and I ran to my office and wrote an email to Ian Dunn about Janel with a well-placed reference to Marty Samuels in the opening line.
It worked. Just twenty minutes after I’d sent my email, Ian replied:
It’s an impressive scan. I think it is definitely worth trying to get him here for a definitive MRI and likely attempt at resection. While large and deep, it does seem to be readily distinguishable from the thalamus. Obviously we are happy to help in any way.
Success again! was my first thought. But my second thought was about the thalamus. Situated centrally and deep within the brain, the thalamus is a crucial structure for consciousness. All modalities of perception—visual, auditory, tactile—are processed there en route to the cortex on the outer surface of the brain, where they rise to the level of conscious awareness. Important circuits for movement and coordination make critical connections in this vital structure. Even small strokes or hemorrhages in the thalamus can leave patients comatose or severely disabled.
Suddenly it hit me. In my eagerness to go for a big save and in my knee-jerk reaction against arguments of cost-effectiveness and sustainability when a person’s life was on the line, I had neglected to consider the final point of trepidation raised by the neurosurgeons Michelle and I had emailed: the high risk of surgery. I was asking a neurosurgeon to remove a tumor dangerously close to a structure essential for conscious existence. And I had never even met the patient.
I realized queasily that I was entering the type of situation that caused doctors to be accused of “playing God.” I would be making decisions for Janel that could have life-or-death consequences. At first, bringing him to the US had seemed like a no-brainer: a twenty-three-year-old healthy student with a brain tumor who could be treated should be treated. But this same treatment that could prevent him from getting worse—or at best make him better if we weren’t several years too late—also held the risk of severe or even fatal complications.
As a neurologist, I had never had the “playing God” feeling I imagined some doctors experience. When I was a medical student, I saw cardiac surgeons stop a patient’s heart and then start it beating again. I watched neurosurgeons saw open the skull to reveal the brain, pulsating and bloody and glistening under the bright lights of the operating room. I imagined that even the most humble surgeons must find it hard not to feel as though they’re playing God when they shake hands with patients before and after they cut them open, handle their internal organs, and sew them back together with those same hands. Thinking through Janel’s case, I began to have a sense of what a weighty feeling that must be.