27 April 2017

A true story. Not for the faint-hearted!

I’m sitting here alone in my consulting suite. My back is aching as well as my hands, after a grueling ten hour surgical list. On my screen is the MRI scan of a patient whose brain tumor was successfully removed five years ago. It was a patient that I also coached. Her case study was described in a buzz which I recently uploaded . And now … a small recurrence of the tumor! And once again her re-growth has been preceded by another significant life crisis. And as I sit here pondering how we’re going to manage this new problem, another dangerous craniotomy (brain surgery) or Gamma-Knife (a specialized form of irradiation) a troubling feeling is descending upon me – am I really making a difference? Yes it’s a fact that I have successfully treated many and believe that a not insignificant amount of people have experienced alleviation of pain and suffering over my thirty years of private practice, however it’s in the patients that I’ve failed to effect a lasting cure or in the ones that have been left with some unavoidable post-operative neurological deficit, that have had the greater emotional effect upon me. Strange, but true. The successes are mostly vaguely recalled, but the failures – permanently etched in my mind until eternity! And this is what I recall and feel every time I experience a case that I haven’t managed to effectively treat and cure.

But it doesn’t end there. Twenty two years ago I developed and implemented a coaching program. This was designed to enhance wellness and performance based on the integration of the neurosciences and psychoneuro-immunology, PNI (the scientific study of the mind-immune connection). Initially it was only applied in the clinical environment but evolved, in addition, to a corporate wellness, performance and leadership program. As a result, many of my patients with medical diagnoses as well as many without medical diagnoses were coached by me (You can divide the world’s population into those with a medical diagnosis and those yet to get a medical diagnosis!) And so my successes and failures don’t just reflect the neurosurgical domain but also the coaching environment, especially since many of the neurosurgical patients have received coaching as part of their treatment plans. And therefore the medical successes incorporate often the successes of coaching as do the failures reflect that modality of treatment.

Since I’m now drifting into ‘am I making a difference’ mode, I can’t help conjuring up my failures. I remember so vividly a patient ten years ago, in his late forties who presented with the most malignant of brain tumors, a glioblastoma multiforme – the dreaded GBM. I have never had anyone survive more than two years with this tumor. In this particular patient’s case, his diagnosis had been preceded by a major life crisis (nine months before diagnosis). His closest friend, who was a business partner as well, defrauded him of a substantial amount of money. It was not just the fraud but the fact that it was a close friend, that resulted in uncontrollable reactive anger and hostility. I have noted through the years that it is often chronically harbored hostility that is associated with the development of subsequent ‘organic’ illness. And so I removed the tumor, arranged for post-operative radiation to be directed to the tumor site and then began working intensely at a coaching level to facilitate some dissipation of the anger and hostility. I even encouraged the patient to attend a workshop that I facilitate for coaches. Nine months later the patient presented with a recurrence of severe headaches and a grand mal seizure. I re-scanned him immediately and there was a massive re-growth of the tumor. Two months later my patient died. His last words to me on his deathbed were 'Sorry doc. Just couldn’t let go of the anger!’.

And in the pure coaching environment there are two specific archetypes that I have found to be the most intractable to any amount of intervention and the least amenable to change. The first is the individual with a low self-esteem who is often the product of significant nurture deprivation. They are pessimistic and generally see and expect the most negative aspects in everything. They genuinely believe that they are not deserving of personal gratification. As a result of their low self-esteem, they are unable to assume responsibility for their own wretchedness and generally find someone or something to apportion blame for their situation. To make matters worse, they have often suppressed their emotions due to the associated pain. But the suppression is applied also to their cognitive function – they fail to acknowledge or even perceive many aspects of their environment which are painful or inconvenient. It is in this archetype that one discovers the ‘schadenfreude complex’ – This is the individual that derives gratification from other people’s suffering possibly related to an early component which crept into their life narrative which goes something like ‘Why should I be the only one that’s suffering?’ The prevailing low self-esteem, the inability to take responsibility for themselves and their general hopeless-helpless outlook on life, makes coaching for change a very frustrating exercise. My success rate has been very low with these individuals over the years which is regrettable since these individuals are the most prone to chronic inflammatory disorders.

The second archetype which is really a hard nut to crack is the ‘Snarly’. These people are usually the products of moderate deprivation. They live in a space characterized by an obsession with self-interest. They need to be recognized, respected and adored. They suffer criticism badly, usually hitting back with a not so subtle reaction. They are typically judgmental (disparagingly so) of others. This archetype is too preoccupied with their own self-importance to the point that they are invariably insensitive to others and their subjective spaces. The Snarly is highly controlled and controlling and derives gratification from outsmarting others (providing a great source of personal gratification). They can be very warm and accommodating, which is the lure for gathering more adoring fans and holding on to existing ones. But deep at the core the Snarly is insecure and driven by the fear of failure, loss and abandonment. The Snarly will only consider accepting information that is authentic, validated and conforming to their subjective limiting beliefs. They will delete, distort or discredit any information which is inconvenient in regard to their subjective beliefs or threatens their existing world view. As a result, it is very difficult and tedious to attempt to bring about change in a Snarly. The only times that I was able to access a Snarly and make some headway towards change was when either they or their spouse was diagnosed with a serious illness – but then it was invariably too late to follow the coaching route for change.

And so my failures wash over me and I feel a subtle drift towards a mini-existential crisis. Am I making a difference? I decide to take a walk to the pharmacy to pick up some supplies for the practice. And it is here that the universe provides the answer – a cathartic moment occurs. To provide the dramatic context for what happens at the pharmacy, I need to take you, the reader, back twenty eight years, to my second year of private practice.

I arrived at work one Monday morning. Parked the car, feeling generally fired up for the week, and walked up to my consulting suite. And then all hell broke loose. A referring neurologist was sprinting towards me and shouting my name (a very unusual occurrence, since neurologists generally don’t sprint anywhere!). Breathlessly he screeched to a halt next to me and shouted ‘ Get to the scanner (MRI scanner) urgently, we’re in big trouble!’. And so I hurried with him to the scanner. The situation was dire, even by neurosurgical standards. A young girl, ten years of age, was lying deeply comatose on the scanner table and was being resuscitated. On the screen I could see a massive brain hemorrhage. Knowing that there must be a vascular cause for this (there had been no head trauma) I insisted on an urgent angiogram (injecting of dye to outline the blood vessels in the brain). And there it was. One of the ugliest AVM’s I had ever seen (arterio-venous malformation). Literally a massive collection of primitive, thin walled blood vessels, a bag of worms, on and in the brain. One of the vessels had bled, which they tend to do in young people.

We were now in a desperate emergency situation. The child was dying. Got the OR (operating theatre) ready, anesthesiologist waiting and urgent blood for transfusion ordered. Patient on the table, head clamped into position, shaved, cleaned draped. Scrubbed, incision marked. Skin cut, flap turned. Pneumatic drill and saw, bone window made and removed (craniotomy). Anesthesiologist yelling ‘BP dropping! What more can I do? I’m going as fast as I can. Dura mater exposed (the membrane covering the brain). It’s a horrible blue color, bulging out the head with the pressure of the hemorrhage. Incise the dura, blood explodes out. There’s congealed blood and active hemorrhaging. I start suctioning and there comes into view the ugliest bag of slithering blood vessels. They’re everywhere. Swing the operating microscope into place. One real fat bugger of a blood vessel is actively hemorrhaging. Zap it immediately with the coagulator and the bleeding stops. Now begins the real problem. I have to identify which are the feeding vessels, the arteries, and which are the draining vessels, the veins. They all look the same. The problem is that if you clamp off the draining veins before the feeding vessels, the whole thing will swell with pressurized blood and explode on the table (I saw this happen once before). That would be the end of the patient. We would never be able to control that kind of a hemorrhage. And so I systematically test each vessel, identify the feeders, clip them and cut them. And then to the next, and the next. Slowly I test, clip and cut and dissect the entire bag of worms out of the brain. Finally the last and deepest draining vein is identified, clipped and cut. The whole bag of worms is then rolled out of the brain. Now I explore the brain. Some superficial damage, but not too serious. Child is now stable. Swing the microscope out. Close dura with a graft, replace bone window and wire it in place. Insert drain, suture skin, apply dressing . Take the head out of the clamps, bandage. Transfer to Intensive Care for ventilation for a further twenty four hours.

Twenty four hours later we start waking the child up. She has a severe weakness over the left side of her body. Over a week there is some improvement. She is now cognitively almost back to normal. Once she is stable and the head wound healed, she is referred to a neuro-rehabilitation facility for intensive rehab. At the three month follow up she has made excellent progress, still weak but now walking with the aid of a supportive walker.

Fast forward back to the present. I’m standing at the counter chatting with the pharmacist. I’m aware that standing next to me is a beautiful woman in her late thirties with two children. She turns to me and asks ‘Are you Doctor Weinberg?’. ‘Yes’, I reply. ‘I don’t think you’ll remember my name, but I was that ten year old little girl that had the brain hemorrhage and nearly died!’. I look at her totally transfixed. She continues, ‘I’m thirty eight now, I have no neurological deficits. I graduated as a lawyer and these are my two children!’ I am not able to articulate the emotion that I felt at that moment. Let’s just say that it’s the closest I came to a gush of tears in my own clinic ……

I’m back in my consulting suite. I feel completely discombobulated. Something profound has just happened. I’m trying to make sense of it. There’s a message in here somewhere. And then it comes to me. It’s not about being driven to changing other people. It’s about applying those changes to yourself. To ensure that you try and be the best that you can be. To apply all those coaching interventions to yourself so that you ‘walk your talk’. And then contribute the best that you are to all that share your environment , leading by example. We need to continue to enhance ourselves in terms of knowledge, understanding, skills, sensitivity and awareness and then contributing value to our environments. We can’t hope to change people. This is something they need to do for themselves. And we can't control everything and fix things to conform with our own expectations. But one thing we can always do …. we can aspire to inspire!


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