Part III: Doctor moves quickly to remove little girl's massive brain tumor

Third in a five-part series

The series so far:: In the first surgery of what will become a grueling week, Dr. David Donahue, head of neurosurgery at Cook Children's Medical Center in Fort Worth, implants electrodes on the brain of 6-year-old Roberto, hoping to pinpoint the source of his increasingly dangerous epileptic seizures. Roberto's mother, Leticia, holds vigil at the hospital, going back and forth between the chapel and the waiting room.

Wednesday, April 28

One day about eight years ago, Dr. David Donahue, his wife, Angela, and the youngest of their three sons, Wyatt, made an hourlong drive into the country to visit Camp John Marc, a picturesque enclave for children with chronic illnesses and physical disabilities. Donahue is the head of neurosurgery at Cook Children's Medical Center in Fort Worth, and some of the children were his patients. One of them asked the surgeon whether they could row together onto the lake.

Angela and Wyatt watched as the doctor and the teenager pushed off in a small boat and rowed away. In the middle of the lake, Angela saw the oars come out of the water. For a long time, the boy and his surgeon sat there talking."I'm dying, aren't I?" the boy asked Donahue. "My parents are acting funny, but they won't tell me. I want you to tell me."

Some months before, Donahue had removed a brain tumor, but the cancer had returned. Out on the lake, the doctor was momentarily speechless, but Donahue was close to the boy's parents. He felt he could speak honestly.

"I just want to know what it's going to be like," the boy said.

"We'll never let you be in pain," Donahue said. "But, yeah, you're going to die. You need to go to your parents and say, 'Mom and Dad, I know, and it's OK.'"

That evening at home, Donahue described the conversation to his wife.

"That was the hardest thing I've ever had to do," he said.

But for the 59-year-old surgeon, talks like those, and the associated heartbreak, are ongoing occupational hazards. Unlike some physicians who build up emotional walls to shield themselves, Donahue's boundaries remain permeable. For a brain surgeon, professional detachment and emotional poise are essential to the job. But that doesn't stop Donahue from rejoicing with families when medical news is good and sending Christmas cards to patients. The doctor receives graduation announcements and wedding invitations in return.

Conversely, Donahue always grieves when the medical news isn't good, or when a young patient dies. On particularly tough days, the surgeon calls his wife to say that before he comes home, he needs to stop by the Trinity River for a long walk.

"It eats at him when he has a child that dies," Angela Donahue says. "It's not easier each time it happens, whether it's a child he's known for a very long time, or he's just met the family."

Back to surgery

On this Wednesday, the fate of two children gnaws at Donahue's insides the most. One is 6-year-old Roberto, whose epileptic seizures increasingly threaten his life. In the intensive care unit at Cook Children's, Roberto thrusts his arms in the air, his skin pales, his brown eyes roll back into his head and his breathing becomes more rapid until, after a few minutes, the latest seizure passes.

But doctors actually welcome these epileptic events. Ten white wires protrude from Roberto's heavily bandaged scalp, connected to electrodes that Donahue placed against the boy's brain in a surgery the day before. The electrodes will generate data to pinpoint the source of the seizures: a large growth called a tuber on the left side of Roberto's brain that had irritated the surrounding tissue.

Donahue plans to cut out, or resect, that portion of Roberto's brain and the offending growth beneath it. But the boy's doctors are concerned. Virtually all of the brain area monitored by electrodes shows to be abnormal. How far back in the brain did the diseased areas extend?

"You'd like to be able to say, 'OK, we're past the bad stuff,'" Donahue says. "But we don't really know where it [the bad tissue] ends if all of the electrodes are showing abnormalities. It looked like it would be better to cover the brain back there with more electrodes."

So Donahue and Roberto's longtime neurologist, Dr. Angel Hernandez, decide to repeat the previous day's surgery.

Donahue and his surgical team remove the same piece of the boy's skull and place additional electrodes against Roberto's brain.

Another difficult case

The second child is Zoe Austin, a 5-year-old Denton girl with curly blond hair, chubby cheeks and huge blue eyes. She continues to fight for her life in another visit to the Cook Children's oncology ward, undergoing more radiation and chemotherapy.

Zoe started getting headaches in late winter. Before her mother, Kirsten, could get her in to see a doctor, the girl's left eye started to cross.

"Mommy, this is killing me," Zoe told her mother, who called and pleaded to get a doctor's appointment moved up from early April to March 23.

A pediatric ophthalmologist took one look into the child's eyes and said Zoe needed an emergency MRI. After an imaging test a few hours later, a doctor in Denton told Kirsten that Zoe had a massive brain tumor and needed to get to Cook Children's in Fort Worth right away. In the afternoon rush hour, Zoe's father, John, skirted stalled traffic on Interstate 35W, driving on the shoulder at high speeds with his warning lights flashing.

The parents didn't remember much about their first night at the hospital, where John's large Greek family began to congregate in the waiting room. Zoe got another MRI that confirmed a tumor had taken over nearly a quarter of her brain cavity. At one point in the night, Kirsten was put on the telephone with Donahue, who was calling from his home in Fort Worth.

"I know this is hard, but try to get some rest," Donahue said. "I'll take a look at the scans and see you first thing in the morning."

He gave the mother his home telephone number.

"Call anytime," he said. "Don't worry. My wife's a nurse. She won't mind."

Later, Kirsten didn't remember a word of the conversation.

'This thing is huge'

That night in late March, when he learned about Zoe, Donahue's stomach tumbled. In his home study, he pulled up the girl's brain scans on his laptop and saw the tumor, fluorescent white against the grayish brain matter surrounding it. The mass was one of the largest he had ever seen. He went to find his wife.

"This thing is huge," Donahue told her.

Angela Donahue, who has worked as a nurse in pediatric oncology, was horrified when she saw the scan. She pleaded with her husband to drive to the hospital and console Zoe's parents. But Zoe was his second brain tumor case that week. He was physically and emotionally exhausted and knew from experience that he needed rest.

"Honey, what would I do?" Donahue asked his wife. "The family needs to try and get some sleep. I need to sleep. I haven't looked at everything yet. I haven't studied everything."

Donahue called the hospital and talked to Kirsten, and he spent much of the next several hours staring at the tumor that lit up his computer screen. He held out hope that despite its size, the mass would turn out to be benign. He looked over a model of the human skull that he keeps in his study, knowing he would not be able to sleep until he came up with a plan. That's what Zoe's parents needed more than anything, a plan.

Grave risks

Donahue hurried into Zoe's room just after 8 a.m. the next morning, and for the first time, her parents felt some hope. The surgeon shook hands with John and Kirsten and moved to the bed, telling Zoe how pretty she looked. Donahue touched her cheek, studied her eyes with a light, and looked around the room for a piece of paper. Not finding one, he drew circles on the girl's bedsheets for an impromptu vision test.

"Don't tell Mrs. Donahue I'm drawing on the sheets," the surgeon whispered to his young patient.

Donahue and Zoe's parents studied the scans together. The tumor took up two-thirds of the right cerebral hemisphere, Donahue said, but given its position, the surgeon was confident he could get it all out. There were grave risks. Because the tumor was on the right side of the brain, the surgery to remove it might permanently damage motor functions on her left side -- movement of her arm, leg and face. The tumor was crisscrossed with vessels, which meant there would be extensive bleeding during surgery.

As a result, Zoe might not wake up.

"Whenever I see kids with these kinds of tumors, I always tell [the parents] what I'm thinking," Donahue said later. "They're entitled to that. Plus, when you say things out loud, it gives you a good chance to think about it. It clarifies. It's not just to be nice. It's a discipline."

That day at Cook Children's, in his first meeting with Zoe's parents, he had one more suggestion.

"I'm going to do everything I possibly can for your daughter," Donahue said. "Go pray."

The surgeon returned to Zoe's room three times that day. Donahue planned to delay the brain surgery until an attempt could be made to cut off the blood supply to the tumor. But when he came back the next morning, he learned that Zoe's brain had swollen even more overnight and that she was in excruciating pain despite high doses of morphine. Donahue looked at her parents.

"She wants it out now," he said.

Grim diagnosis

In the operating room, Donahue removed a large section of the girl's skull. When he made a small incision in the brain itself, the tumor spilled out at him "like Mount Vesuvius." It had the consistency of oatmeal, as was often the case with pediatric brain tumors.

"S---," Donahue said.

A sample of the tumor was collected and rushed to the pathology lab. Within an hour the preliminary results came back and the news could scarcely have been worse. It was malignant, a round blue cell tumor indicating one of a handful of deadly cancers. Standing at the operating table, Donahue's shoulders slumped and he swore again.

"It was devastating to him. That's what I remember," said nurse Rosa Leos, Donahue's longtime surgical assistant. "He hates it. You can tell. It's almost like he takes it personally, like he says to himself, 'Why does this have to happen?'"

After the grim report, Donahue and his team went back to work. He labored carefully through clouds of blood, using a sucking instrument to slowly reduce the size of the pastelike mass from the inside out. Bleeding was significant, but not as bad as Donahue had feared.

"Is the blood pressure OK?" Donahue asked every few minutes.

Twice during the eight-hour surgery, the surgical team paused and an intraoperative MRI machine was slid into the operating room, allowing Donahue to precisely gauge his progress. When the middle of the tumor had been sucked out, he went to work on its edges, the places where the mass had attached itself to healthy brain.

He used a small paddlelike instrument, sweeping the tumor apart from the brain. Once there was space between brain and tumor, Donahue was always amazed by how fast the surgery moved along.

One hour led to the next, but Donahue wouldn't feel the weariness until much later. The surgeon had been swept into the spirit of his young patient's family. There was a complicated, potentially lethal problem, and all these people on his side who wanted Donahue to succeed. The statistics were in his favor. His concern was to measure up to all of that, to do everything properly, the very best he could. How could any doctor be more fulfilled?

In late evening, Donahue made his way to the crowded waiting room. Zoe's parents remember how tired he looked.

"The good thing is that I think I got every bit of it," he told them. "I think I did my job."

For the next half hour, Donahue went around the room, accepting hugs and answering questions from the Austin family's relatives and friends who had kept vigil all day.

"He's one of the people who you genuinely feel went into medicine for the right reasons," John Austin said. "It wasn't for the Mercedes or the big house. I hope and pray he has everything he has ever wanted, but you can just tell that's not the reason he's there. The reason is that he cares."

It was after 10 p.m. when the surgeon drove home. He talked to his wife about the surgery, ate an omelet, and collapsed into bed. The next day, Zoe was kicking at her nurses with both legs, seemingly none the worse for wear.

Tim Madigan, 817-390-7544

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