Dr. Rick Hodes was used to hearing "no" when he opened his laptop to show brain surgeons pictures of the young Ethiopian woman. An extraordinary case, they would always agree, but there was nothing they could do.
Although he lives and works in Ethiopia, last October Hodes was in town for a fundraiser and stopped at a St. Louis Park synagogue to pray. He started chatting with Dr. Eric Nussbaum, who was there studying with the rabbi.
"Let me show you some of my cases," Hodes said, as he always does when he meets someone who might be able to help the young Muslim woman with the carefully arranged headscarf pictured on his laptop screen. Those around them who weren't doctors recoiled at the photo. But Nussbaum was fascinated.
By chance, Hodes had bumped into one of the few people on Earth who could the do the brain surgery this young woman needed.
In a way, Nussbaum had worked his whole life toward this moment. It was why he left the University of Minnesota to set up shop in little St. Joseph's Hospital in St. Paul, which was on the brink of closing.
It was why he established a super-sub-medical specialty center for complex brain surgeries that is now gaining a national reputation. It is why he wears a beeper and rarely takes a vacation.
When he saw the photographs in the dim light of Bais Yisroel synagogue, he was ready.
"We could take care of this," he told Hodes.
A rare specialty
Nussbaum, 40, is a rare neurosurgeon, an expert in the brain's blood vessels and benign tumors that originate below the brain in the skull.
"Ninety percent of neurosurgeons do spines," he said. "I don't."
His uncle is the same kind of surgeon. As a child growing up in Maryland and New York, he always wanted to be like that uncle.
Nussbaum came to the University of Minnesota hoping to do the work he loves -- repairing gossamer-thin blood vessels and delicately dissecting out tumors. But he was expected to do all kinds of neurosurgery there.
Seven years ago, he made the leap to St. Joseph's. The little hospital on the fringe of downtown St. Paul was struggling, even with its expertise in stroke and radiology of the nervous system. It needed something more, something that would set it apart. He brought it a unique focus.
Other neurosurgeons told Nussbaum that he was crazy, that there would never be enough work for him to survive if he focused so narrowly. He worked seven days a week, rarely taking time off, so he would always be there when the right cases came through. Gradually, physicians began to recognize "that this super-sub-specialty was a good thing," he said.
Now he gets referrals from across the country, and St. Joseph's has added more specializing neurosurgeons, including Nussbaum's wife, Dr. Leslie Nussbaum.
Last year Nussbaum made headlines when he repaired 13 dangerously weakened blood vessels, or aneurysms, in the brain of one woman. He is among a handful of surgeons in the country who can surgically bypass blocked brain arteries in a technique that uses sutures smaller than a human hair. The surgery is so unusual that Medicare won't pay for it. He does 40 or 50 a year.
"He's an unbelievable machine," said Dr. Martin Lacey, a plastic surgeon at Regions Hospital in St. Paul who often teams up with Nussbaum on surgeries.
A growing tumor
On that day in the synagogue, Hodes was stunned by his sudden luck.
After nearly two decades in Ethiopia caring for poor and destitute people, he has become an expert in finding charity care in the industrialized world. His laptop is full of pictures of kids and young adults who need complex surgeries, but the ones of Merdya Abdisa had been in there longer than any of them.
Abdisa grew up an orphan in a northern Ethiopian village. She worked as a servant, had no education and didn't know her age. She was about 20, Hodes estimated.
A year ago, she walked across much of Ethiopia to reach a Catholic hospital, where nuns examined her and concluded they couldn't help. But they sent her on to yet another Catholic hospital, where Hodes works for the Jewish Joint Distribution Committee relief agency as a volunteer.
The tumor had been growing for about 10 years, he said. First it made her eye itch and her nose bleed. Then it destroyed her sense of smell, and the optic nerve to her right eye. When it distorted her face, she stopped going out in public. Without an operation, eventually "it will crush everything else around it," Hodes said. Already it had taken the path of least resistance, emerging in a cone-shaped tumor from her eye socket.
Nussbaum couldn't tell much about the tumor from the medical images Hodes sent by e-mail a few months later. Yes, it was enormous. Twice as big as anything he had encountered.
As Abdisa matured, so had the tumor, gently pushing aside her brain lobes and right eye. Nussbaum knew it wasn't malignant because she was still alive. That also told him it was most likely the kind of skull-based tumor that was his specialty. But he didn't know if it was solid or fluid. If he could get it out, her face and eye would have to be rebuilt, and that was beyond his skill.
So he asked two other surgeons to help. Lacey, the plastic surgeon from Regions, and Dr. Andrew Harrison of the University of Minnesota Medical Center-Fairview, who specializes in plastic surgeries of the eye.
Tumor as large as an orange
The night before the surgery, they checked in by phone. Tests taken earlier that day showed the monster tumor had grown larger in just months, and that tiny vessels were keeping it well-supplied with blood. That was worrisome. It meant she would bleed a lot.
On May 8, the three surgeons clustered around Abdisa's head at one end of the operating table, talking animatedly over rock music on the speakers. Overhead monitors displayed three-dimensional images of her skull, the tumor large as an orange where her eye should have been.
Nussbaum's first incision was across the top of her head from ear to ear. As he gently pulled her flesh away, he saw the tumor for the first time. He had seen hundreds, but nothing to compare. "It's always so dramatic," he said.
If they were lucky, the tumor would be outside the brain's covering and he could remove it from the front. If they were unlucky and it had penetrated the brain's covering, it was going to be far more complicated.
Nussbaum started cutting away from the front side. As always, he worked from the outer edge of the tumor toward its center. "You start from normal and work toward abnormal," he said later. "You can be quick and aggressive if you know you are dealing with abnormal."
In the end it was remarkably easy. The suction machine pulled up fluid, blood and even some of the soft tissue. He was done in just under three hours.
Then came the hard part. The tumor had left a gaping hole on the front of her skull -- like a self-inflicted gun shot wound to the face, Lacey said. He had to put things back to normal. Or as close to normal as he could manage.
He cut out a curved, rectangular piece of her skull to use as his building block, replacing it with a piece of hard plastic shaped to match the missing piece. He cut the skull bone into tiny pieces, fitting them together with tiny screws and plates like a three-dimensional puzzle. He crafted a round, shallow socket for her eye, a bony ridge alongside her nose and a cheekbone.
"If you left that bone just hanging in space, it would probably die," he said. Lacey cut one of her chewing muscles on the right side of her head, wrapping it around the new bone to provide a blood supply. He cut away extra skin that had grown over the tumor. He and Harrison placed her blind eye into its new home, reconnecting the muscles, and stitching her face back together.
Eight hours after they started, they were done.
A face emerges
On the day of her surgery, Abdisa had arrived at St. Joseph's terrified and alone, a scarf clutched across her face. Two weeks later she was sitting up in bed, bare-headed, laughing with Fowzi Hassan, an interpreter whom she said was her new brother.
"She's become a favorite here," Hassan said when a nurse came in to give her a big hug. New friends from the local Ethiopian community were waiting to come in for a visit.
The tumor turned out to be a fibrous displasia, a benign growth that destroys bone as it grows. Nussbaum said he was able to remove all of it. But now she has no sinuses and her brain will never resume its normal shape.
Still, that could be a good thing, he added. Sometimes these tumors come back, but it could do little harm if it did. "It would have a huge space to fill," he said.
Her face was swollen and lopsided, her blind eye covered by a velvet brown eyelid. But it was a face, not a deformity.
"I never thought I would have my face back. My nose," she said, lightly tracing it with her finger. "This is God's work."
Josephine Marcotty • 612-673-7394