Trauma

CHAPTER 14

It felt like divine intervention to be going on rounds again. Carrie thrummed with excitement. A few days ago she had been listless on the couch, trolling Facebook and doing what her mother always advised against, comparing her insides to everybody’s outsides. But today she was back in a hospital, about to visit with patients, and feeling both curiosity and confidence return.

Carrie had dressed professionally in a blue blouse and dark slacks, but felt a bit naked without a white coat. She reminded herself that she was here to observe, nothing more. So far.

Patience — first things first. Let’s see what this DBS is all about.

Carrie introduced herself to the receptionist. A few minutes later, a nurse took her into the neurology clinic. The aromas and sounds were instantly familiar, and she felt like a shipwreck survivor spotting dry land.

Inside exam room eight, Carrie found Dr. Finley and an obviously married couple who appeared to be in their late sixties. The man seated on the examination table was heavyset, with a horseshoe head of hair, a weather-beaten face, and loose skin all around. Petite and well put together in a dress suitable for church, the woman kept her hands interlocked in front of her. Concern for her companion was etched on her face.

Dr. Finley’s expression brightened on Carrie’s arrival.

“Dr. Bryant,” he said. “Let me introduce you. Donald and Nancy McCall, this is Dr. Carrie Bryant. She’s an accomplished neurosurgeon, visiting today to learn more about DBS.”

The compliment boosted Carrie’s morale considerably. She was an accomplished neurosurgeon. Giving up on her career would do nothing to erase the damage she had accidently inflicted on poor Leon. Every day she would try and make penance. Surgery was and always would be her true calling. In the same way Howard Bryant double-checked each injection of phenobarbital, Carrie would take special care with presurgery preparations.

Dr. Finley provided a brief patient history. Donald McCall had well-established Parkinson’s disease (PD), and had undergone a deep brain stimulation treatment twelve weeks earlier. Carrie observed the parallel scars on Donald’s scalp where cuts had been made to implant wires in his brain. A horizontal scar ran along the base of Donald’s neck, and a vertical one on his chest marked the pulse generator’s location. Those scars were harder to see. In time, they’d be nearly invisible. Carrie was amazed that so much technology could be so effectively concealed. Even a keen observer would have no idea Don McCall was one of the walking wired.

“This is Mr. McCall’s eighth visit to us,” said Dr. Finley. “We’re just fine-tuning the electrical settings.” He turned to Nancy. “Mrs. McCall, would you mind telling Dr. Bryant a little about the changes you’ve observed, before and after the implant?”

Nancy sparked to life. “At first I thought Don was just depressed,” she said. “He stopped talking much, and when he spoke it was like there was no feeling, and his voice got soft.” Her own voice softened, as if in sympathy. “I can’t say he looked sad — more like he wasn’t there. And he started to stare at me for long periods, which was odd and made me uncomfortable. He slowed down, too. It was all very gradual, at first.

“But then he started falling, and my Don had always been so balanced. He used to play ice hockey in an adult league, and now he was stooping when he walked. Then his hand started shaking. A doctor put him on some sort of antidepressant, but that didn’t do anything. Don was only fifty-five, but he acted like a man in his eighties.”

Carrie nodded. Nancy had her complete and undivided attention.

“It was no surprise when he lost his job at Home Depot,” Nancy went on. “I saw that coming miles away. Finally, what — ten years ago now? — we started seeing another doctor, and he knew it was Parkinson’s just like that.” Nancy snapped her fingers. “He started Don on Sinemet and he got a lot better. But I’m sure you know the story. He started to get worse again, even after increasing his medication. He was taking it almost every hour, it seemed, trying a bunch of new stuff. It got very frustrating.” Nancy reached out and caressed Don’s shoulder, reminding Carrie of her parents. “Then he started developing these wild movements all over, his arms, legs, neck, and torso.”

“Peak dose dyskinesia,” Dr. Finley said.

Nancy said, “At other times he seemed almost frozen solid, and it got so you couldn’t tell when one state would change to another. It was like a switch.”

“On-off effect,” Dr. Finley elaborated.

“We saw a bunch of neurologists, but no one could do anything new or different. Then Dr. Sawyer learned about Dr. Finley’s program, and since Don is a vet — two tours in Vietnam — he thought Don might be a good candidate for the deep brain stimulation.” Nancy exhaled a protracted sigh. “I felt like I was Don’s nurse for thirty hours a day.”

Don sat on the table, his expression vacant.

“Don, I’d like Dr. Bryant to examine you briefly, if that’s okay,” Dr. Finley said. “Don’s machine is off, and we asked him to hold his medication this morning.”

Don nodded, his stare still blank. He’d been poked and prodded by plenty of strangers before. Carrie would just be the latest.

Carrie slipped back into the role of caregiver without missing a step. It really was like getting back on a bicycle, even after an ugly fall.

Don had textbook PD, she thought. Pill-rolling rest tremor of right upper limb, dystonic turned-in posturing of the right foot.

Don gazed unblinking out the window and showed little expression. It was easy to empathize with Nancy. The poor woman had to care for a ghost of her husband. Carrie asked Don a few simple questions — his name, birthday, and home address. His voice came out soft and stuttered, barely intelligible.

Carrie helped him down from the exam table and tested his mobility. He followed her movement instructions with all the grace and fluidity of the Tin Man: classic cogwheel rigidity in all limbs. Positive glabellar tap response, classic flexed posture of the trunk. The Parkinsonian shuffle was on full display as he attempted to walk, and it was no surprise when he froze midway while turning to his left.

Carrie recounted all that she had observed, and Dr. Finley looked pleased.

“A lot of neurosurgical residents who rotate through my program don’t seem to know a thing about movement disorders or show that they can conduct a decent neuro exam,” he said. “You’re already two steps ahead.”

From a nearby countertop Dr. Finley retrieved a compact device, approximately the size of a deck of cards. It had a plastic case, several buttons, and a small display screen.

“This programming unit will help us fine-tune Don’s stimulation settings,” Dr. Finley said. “It uses radio communication to adjust the stimulus parameters of the surgically implanted unit. Last time we set the frequency at one hundred and forty cycles per second, and the pulse width at eighty milliseconds. Today, we’re going to increase the voltage amplitude just a bit, to two and a half.”

Dr. Finley peeled away the paper covers over the sticky pads on the back of a plastic dock and adhered the unit over the scar on Don’s chest. He snapped the programming device into place on the dock, then spent some time making sure the programming unit worked properly. When he was satisfied, he said, “I’ll be back in a while to take another look at you, Don, and we’ll see how you’re doing ‘plugged in,’ as they say. And then we’ll put you back on your medication and see how the whole package is working.

“As you know, Nancy, this is going to take some time,” he added. “I’ll be here checking on other folks for a while. Why don’t you get yourself some coffee?” He turned to Carrie. “My job is to make sure the patients receive the proper dosage of medicine and stimulation. It would be up to you to get those wires precisely where they need to be. And believe me, Dr. Bryant, this is no simple feat.”

Up to you. Did he mean it? Could she work here?

The VA’s cafeteria, even down to the food, was about what Carrie had expected. “Institutional” was apparently a flavor, as well as a design aesthetic. Still, so far, she was enjoying every minute of her time with Dr. Finley. They had looked in on several more patients, and Dr. Finley suggested they take a coffee break before concluding with Don McCall.

“So, what did you think?” he asked once they were seated.

“Well, the management of movement disorders is far more nuanced than I appreciated,” Carrie said. “It’s interesting, and really necessary work.”

Dr. Finley looked pleased. “Let me be very candid with you, Carrie,” he said. “I’ve checked your references, and I know even more about the incident we discussed in my office. Believe me, everyone at Community and White is heartsick over what happened. They really like you, and I know you saved a woman’s life the night before. I’ve got to tell you, Metcalf is still pissed — but he’s all massive ego anyway.”

Carrie shrank at the mention of Metcalf’s name. “I hope you didn’t ask him for a reference.”

Dr. Finley laughed. “I don’t think you’ll ever get back into his good graces. But I don’t need his commendation to know talent when I see it.”

“I’m really glad to hear that, but I guess I’m a bit confused,” Carrie said.

“Why is that?”

“When we met in your office you said there were no residency openings available, but you also said my timing was fortuitous. Can you explain that now?”

A shadow crossed Dr. Finley’s face. He spent a moment stirring the cream in his coffee. When he looked up, his eyes showed strain and more than a hint of sadness.

“A few weeks ago our DBS surgeon, Sam Rockwell, was in a terrible, terrible car accident coming back from his vacation home in Maine. I saw the photos. His car crumpled like a tin can. His condition is too tenuous to MedFlight him to White Memorial, so his family has been keeping vigil at his bedside in a Bangor hospital. He’s in a drug-induced coma with multi-organ failure and sepsis. There’s a good chance he won’t make it. It’s a definite blow to our program.”

“That’s horrible,” Carrie said, feeling a stab of sadness for Dr. Finley and for Rockwell’s family.

“Sam and I were extremely close, and I’m — I’m just devastated. Anyway, there’s no way Sam is coming back here any time soon, and we need someone to take over his responsibilities. I know you would be an excellent replacement. There is some time sensitivity to this offer. I’m afraid we may lose funding for a very special initiative if we don’t get someone into the role posthaste, but I can’t take just anybody. And, as you know, most of the qualified candidates are currently employed. We can’t wait for them to become available to us.”

Carrie nodded grimly. “I see now why you said my call was fortuitous.” Medicine was a Darwinian world. One doc’s misfortune was another doc’s golden opportunity. Still, it felt ugly to profit from tragedy.

“Listen, Carrie, I know this seems wrong, given Sam’s unfortunate circumstance, but a person with your considerable skill and talent would be a huge asset to us. You’d be able to jump right in without missing a beat. I’ve got the funds, and while this would not be a formal residency, it might help you get your groove back, so to speak. The surgical schedule is not too demanding, not at all like what you’re used to. We try to limit the surgeries to one or two per week. There simply isn’t a large staff to conduct proper patient evaluations and handle follow-up care.”

“That’s a wonderful offer,” Carrie began, but Finley stopped her.

“But here are the restrictions,” he said. “You’re my hire. You work for me on this, not the VA. I’d be able to pay you out of the DARPA funds, and that includes benefits. Those funds give me a tremendous degree of clout with the VA’s leadership team, including the acting medical director. You won’t be part of the residency program, but that’s no issue. I know you’re a good surgeon, and your reputation precedes you. I know what you did for Beth Stillwell, and I thought it was remarkable. I truly believe you’d make an incredible addition to our team.”

“How do I get credentialed?” she asked. “It’s going to take so long to get on board here.”

Dr. Finley showed no concern. “Carrie, you have a medical license. You got that when you graduated medical school. Your residency is for training, but legally, if you wanted to go out and start a practice, you could have done that. Some people need five years of residency to get where they need to be, some get it after three, but my inquiries have persuaded me that you got it after one or two. You’ve got enough talent, enough training to do this job. Even though I run the neurology residency at the VA, I’m hiring you under private funding for this program. It’s a very unusual opportunity, and you’ll be able to use this experience to enhance your credentials if you wish to get back to formal residency — though my hope is that you’ll stay with my special initiative for years to come.”

“And what exactly is the special initiative?”

An inscrutable look came to Dr. Finley’s face, then it morphed into a grin.

“Come with me,” he said.

Carrie followed Dr. Finley back to Don McCall’s hospital room, where Nancy McCall greeted them with a bright smile.

“Already much improved,” Nancy said.

“Have a look for yourself,” Dr. Finley said to Carrie.

Right away, Carrie noticed the rest tremor was significantly decreased.

“How are you feeling, Don?” Carrie asked as she checked the mobility of his limbs. It was not enough to get him back on the ice, but the degree of movement made Carrie think somebody had replaced one Don with another.

“I’m feeling much better, Doc,” Don said.

The stutter was gone and his voice was strong and intelligible.

After her brief exam concluded, Carrie followed Dr. Finley back into the hallway.

“Impressive, isn’t it?” Dr. Finley said.

“Yes, very much so,” Carrie said. “But treating Parkinson’s with DBS isn’t all that new, at least not according to my research. So I’m still curious about that special initiative you mentioned.”

“What if I told you that we could use DBS to cure PTSD — not treat it, but cure it?”

Adam came to Carrie’s mind with a flash of wonder. How was it possible? Could it be possible?

“If that were true, Dr. Finley,” Carrie said, “I’d say you had yourself a brand-new DBS surgeon.”