Trauma

CHAPTER 15

On Wednesday afternoon, a week after her coffee with Dr. Finley, Carrie followed a crowd of doctors into the cramped VA hospital auditorium for the monthly grand rounds conference, which was usually a welcome break from the grind. This gathering hummed with extra excitement because Dr. Finley was expected to make a big announcement regarding the deep brain stimulation program. The room was packed with neurosurgery, neurology, and psychiatry attending and resident physicians, as well as a number of other parties who were interested in hearing what Dr. Alistair Finley had to say about DBS. Dr. Finley, who’d been working at this VA for years, was considered a pioneer in applying the technique to a variety of brain and mental disorders. Perhaps that was why this GR was so well attended.

Or maybe it was the free pizza.

Carrie settled into one of the cushioned seats in the second row, where she had a good view of the rather small screen used for the PowerPoint projection. Most everyone was dressed in scrubs and white coats, except for two men Carrie had noticed in the back of the hall. One was bald, with close-set eyes and a round face. The other had a square head, broad shoulders, and a football player’s neck. His stone-hard gaze held all the joy of a funeral, and Carrie got a shiver when they briefly locked eyes.

For the past week Carrie had been obsessively studying the software that did most of the heavy lifting in the OR. When it came to DBS procedures, precision, surgical skill, and patience were the chief operational skills required, and she would have to work as part of a team. It was painstaking, complicated work; a typical procedure could last five to six hours. That explained why nobody was available to assume Sam Rockwell’s responsibilities.

The entire Department of Neurology and Neurosurgery at the VA consisted of only three full-time physicians. Three! It was microscopic even by BCH standards. Dr. Finley was the staff neurologist, and Dr. Sandra Goodwin and Dr. Evan Navarro comprised the surgical team. Dr. Goodwin, a severe-looking woman in her late fifties with a broad forehead and aquiline nose, was the head of the neurosurgery department and therefore perpetually bogged down with administrative work. As a result, most of the actual surgical responsibilities fell to the staff attending, Dr. Navarro.

Dr. Navarro, a thin man with a small face, dark hair, and ferret eyes, was also in charge of the residents who rotated through the VA from satellite hospitals, much as Carrie had done at Community. Carrie and Navarro had not quite hit it off. She found him cold and disinterested — a typical ego on legs. Goodwin was more affable, but harried by the constant demands on her time. The good news was that Carrie’s involvement with Navarro would be limited. For the DBS program to flourish, Finley needed the dedication of one committed, exclusive neurosurgeon. That role would be Carrie’s, her sole responsibility.

At five minutes past the hour Dr. Finley strode to the lectern and slipped on his half-moon reading glasses. His hair was tousled as usual, but with his starched long white lab coat, crisply pressed white shirt, and classic repp tie, he shone with authority. The attendees, largely sleep-deprived residents, made the effort to stop eating and pay attention.

“Show the video first, please,” Dr. Finley called.

Carrie noticed a resident to her right spontaneously close his eyes with the dimming of the lights. The rigors of a residency program were universally brutal, and Carrie understood his fatigue. She hoped none of the VA residents would ever have to endure the nightmare she and, more importantly, Leon Dixon had suffered because of her own exhaustion.

“This gentleman, we’ll call him Patient X…” With the start of Dr. Finley’s lecture, Carrie cleared her troubled thoughts and focused on her new boss’s narration.

“Patient X developed signs of Parkinson’s disease in his early forties. He had been exposed to Agent Orange while in Vietnam in his late teens.”

The video was a series of home movies. A life well lived, but as the film soon revealed, one quickly diminished by the ravages of disease. The symptoms were a mirror of Don McCall’s ailment. The footage went on to show the crippling nature of PD — frozen movement, violent tremors, spastic limbs. Dr. Finley reviewed the anatomy of the basal ganglia and its interconnections, structures deep in the brain that were affected in Parkinson’s disease. Then he began to discuss the DBS treatments.

“We first stimulated the right ventral lateral nucleus of the thalamus. That benefitted his left arm tremor, but not much more. That electrode has been removed, and six months ago we placed electrodes bilaterally in the globus pallidus interna. This next video shows his current status.”

The audience, impartial before, was captivated by Patient X’s freedom of movement. Had Carrie not witnessed Don McCall’s dramatic improvement for herself, she would have had a hard time believing the footage.

“Deep brain stimulation is a form of stereotactic neurosurgery,” Dr. Finley continued. “We insert electrodes guided by a stereotactic frame, as well as CT and MRI imaging, deep into brain nuclear complexes that are involved in complex movement patterns. Lights, please.”

As the lights came on, some in the audience began rubbing their eyes. Dr. Finley removed his glasses. “The value of DBS has been proven in Parkinson’s disease. But what’s particularly exciting for us at the VA is that we’re exploring the use of DBS as a new chapter in psychosurgery. We believe we are at the vanguard of hope in treating conditions that have defied the most comprehensive drug and counseling programs.”

Dr. Finley smiled. Everyone was there to find out about the planned DBS program expansion. Sam Rockwell had done a number of procedures, but the pilot program had been operating in stealth mode.

Dr. Finley said, “As many of you are well aware, here at the VA, both outpatient and inpatient psychiatry have become overwhelmed by the number of PTSD cases.”

For several minutes Dr. Finley presented a sobering array of statistics. “One-third of veterans from the wars in Iraq and Afghanistan have contemplated suicide.” When he compared this to the 3.7 percent of the general adult population who had serious thoughts of suicide, the military stat looked stark. He coupled these statistics with the numbers of actual military suicides: “Twenty-two per day by current estimates, which also far outpaces the rate from fifteen years ago,” Finley said.

“Long-term mental health care is perceived by many to be detrimental to military career advancement. Misguided as that is, it remains a fact. Close to fifty percent of servicemen and — women suffering from PTSD will not seek treatment because of this stigma or — and I say this knowing who pays my salary — the challenges of navigating the VA’s antiquated bureaucracy.”

Dr. Finley paused until the chuckles died down.

“An operation, I believe, would be far more attractive to those afflicted, and thus would dramatically increase the numbers of those willing to be treated.”

Dr. Finley fell silent to allow the notion to sink in.

“It has been reported that the economic impact of PTSD, limited to just the military, is anywhere between four to six billion dollars. And this does not take into account the spouses and children whose lives are further traumatized. I would argue that four billion grossly underestimates the economic toll.”

Of course Carrie thought of Adam: his lost wages and diminished potential, coupled with the burden on her parents emotionally, financially, and in scaled-back career plans for themselves. Her family was just a tiny fraction of that billion-dollar crisis.

Dr. Finley showed a schematic of the limbic system, a complex network of structures ringing the ventricular system deep in the brain. Its functions were many, including regulation of emotion and basic drives and motivation. It also regulated the initial processing and emotional aspects of memories, and the body’s response to stress including blood pressure, pulse, and respiratory rate, as well as sleep patterns. Tiny as it was, the almond-shaped amygdala nucleus, located deep and medially in the temporal lobe, was accountable for a whole host of critical functions.

“We believe the basolateral nucleus of the amygdala represents the most promising target for DBS in treating PTSD. Here is where fear and its memory converge.”

Dr. Finley advanced the slide. The amygdala was now circled in red.

“This is the epicenter — where our primitive fight or flight reactions form in response to a threat, where unchecked rage can be unleashed in response to a disturbing memory. Regardless of how much we try to alleviate these terrible memories through therapy or pharmaceuticals, we know that PTSD symptoms are structurally imbedded, literally imprinted, in the brain. And we believe this processing involves the amygdala nucleus significantly.”

Dr. Finley came out from behind the lectern. He made eye contact with Carrie, and she smiled.

“We have realized something that you may find counterintuitive. Traditionally the goal of treatment has been focused on the mitigation of disturbing thoughts and memories, analogous to the way we treat many phobias. Think of the man who is afraid of heights, for example. We may subject him to systematic desensitization by gradually introducing him to higher heights. And indeed, such treatment is often effective, at least partially, for phobias, but war zone trauma is something else entirely.

“We are discovering in controlled laboratory experiments that electroshock therapy administered to animals in close proximity to a traumatic event greatly suppresses those animals’ behavioral response when immediately re-exposed to the trauma. In other words, they seem to have forgotten their emotional response to the initial trauma.”

Dr. Finley went on to discuss a group of human test subjects who were involved in a different memory experiment involving electroshock therapy, more commonly known as ECT. These patients were first shown images of terribly unpleasant events and asked to recall them. Surprisingly, the researchers found that the patients were not able to remember any details of the disturbing event the day following their ECT, even though they had been told explicitly to remember the event in as much detail as possible. The shock treatment seemed to interfere with storing a new memory in the brain. The researchers concluded that there was a period of time when stored memories were accessed, in which they could be vulnerable to manipulation. They could be modified, changed in some way, reconfigured or “reconsolidated.”

Dr. Finley continued, “We know the intense connections of memory tied to emotions sends the amygdala into overdrive in PTSD. If we can dampen that hyperactivity in the amygdala, all the social and psychological consequences we see in PTSD — the nightmares, depression and apathy, anxiety and fear, the likely drift into drug and alcohol abuse, the emotional roller coaster, potential flashes of aggression — all this can potentially be negated.”

Dr. Finley went on to present a series of slides referring more specifically to the anatomy of the amygdala and its connections to other limbic structures.

“Our goal is not to erase the memory per se, but to erase the emotion associated with the memory. Let me repeat: The goal of our DBS program is emotional erasure. To do this, we first need to reproduce the soldier’s trauma, as vividly as possible. And just then, after the memory has been reproduced, we suppress the amygdala by deep brain stimulation of the amygdala’s basolateral nucleus, interrupting its emotional and physiological connections to that memory, and in so doing, reconsolidate the memory without the emotional context.”

A hand shot up from one of the psychiatric social workers seated directly behind Carrie.

“How would you do that? How do you plan to re-create these memories so vividly?”

Dr. Finley’s expression brightened as if this question had been planted and anticipated.

“Glad you asked, Wanda. Today I am officially announcing a very exciting pilot program, initiated with the assistance of DARPA.”

Dr. Finley’s gaze traveled to the back of the room, where the two men in suits were seated. Carrie guessed they were from the government.

“By a show of hands, how many of you have heard of DARPA?”

Fewer than half the hands in the room went up. One person felt a need to clarify. “The initials, yes, but I’m not sure what it stands for.”

Dr. Finley gave a slight nod. “It stands for Defense Advanced Research Projects Agency. Their mission is to create breakthrough technologies for national security. They’re the folks who gave us the Internet — sorry, Al Gore.”

The reference inspired scattered laughter.

Dr. Finley continued. “PTSD is approaching epidemic levels in the military, so DARPA has been experimenting with exposure therapy using virtual reality simulations.”

Carrie felt a jolt. DARPA was remaking the war in pixels.

“We can re-create that IED event when a soldier’s buddies were killed or maimed.” Dr. Finley spoke to a hushed audience. “And while the brain is forcibly agitated, we have an opportunity to treat that individual with deep brain stimulation with the hope that we will actually erase the emotion associated with those terrible memories forever. I’m not talking suppressed. I’m talking gone, forever. Ladies and gentlemen, I am pleased to see Calvin Trent from DARPA has joined us today. Cal, could you please stand up?”

Cal, the man with Atlas shoulders and cold eyes, glanced briefly at his companion and stood up slowly. He acknowledged the audience, then sat right back down. Dr. Finley either did not recognize or did not know the other suit that had accompanied Cal Trent. Either way, the bald guy with a round face and beady eyes got no introduction.

Dr. Finley said, “Cal oversees all aspects of the program, including the virtual reality simulation, which is used prior to the DBS surgery to reconsolidate the negative memory. The virtual reality does leave many patients highly agitated, but that’s a temporary state. We need the emotion heightened, the negative memory fresh, as close to surgery as possible. Once the electrical stimulation commences, the emotion gets dampened. It’s as simple as that. Cal’s pulled together an amazing team of people to run this program, and I know you’ll extend him your every courtesy.”

Carrie could sense excitement building in the audience. Just about everyone there had had some contact with a returning soldier who was devastated by PTSD, or his or her family. She thought again, always, of Adam.

It had been eye-opening to live with her brother, and see the difficulties he and her parents had been enduring. Sometimes his nightmares were so savage it sounded like he was being murdered. She saw how Adam avoided going out, especially into crowds. Even walks in the woods behind the house were an ordeal. Everywhere he went, he was scouring the ground for IEDs. At least he had started going running with her — well, more like she followed Adam as he sprinted. Poor kid could easily outrun her, but not his demons.

The hope she saw in Dr. Finley’s eyes, the enthusiasm in his words, buoyed Carrie’s commitment. Dr. Finley had told her about the program after she had accepted the position, but seeing everyone else respond with excitement reinforced her own enthusiasm. She was proud to be on the cutting edge of such critical care. Funny that she’d named her goldfish Limbic, the system the amygdala resided in.

Was fate at work here?