Trauma

CHAPTER 18

Steve Abington was breathing comfortably, twelve times each minute, heavily sedated, his oxygen delivered via an endotracheal tube. Just hours ago he had been rabid, but now he looked peaceful thanks to the combo of propofol and fentanyl, which the anesthesiologist, Dr. William Kauffman, titrated expertly. The patient was hooked to a ventilator as well as the usual monitors for ECG, blood pressure, and pulse oximetry. Abington’s labs came back within normal limits. Still, he almost hadn’t gotten to this operating table.

The whole team had met for a lengthy discussion in the conference room down the hall from where Carrie had been attacked. For the first several minutes Dr. Finley apologized profusely to Carrie for not having been clearer about security and safety measures. He promised a thorough review of all practices and standards, and said he would have new protocols in place by the end of the week.

In the meantime, there was the matter of Abington. This was a medical meeting, but Cal Trent from DARPA was present, along with Dr. Finley, Dr. Kauffman, and Carrie. Trent was dressed nattily in a tailored blue suit that showed off his muscular frame. At the grand rounds, she’d thought him cold and distant, but here he acted warm and conciliatory.

“I’m really sorry for what happened to you,” Trent said in his low, gravelly voice. “You must still be very shaken.”

“I’m doing all right,” Carrie replied, which was only a half-truth. She was shaken, but perfectly functional. She’d had a brief medical exam, and despite some bruising on her neck, she was unharmed and experiencing no shock. She had recovered her composure rapidly.

“Timing here is everything,” Dr. Finley said. “Abington is active right now.”

“Active?” Carrie asked.

“He’s been subjected to the VR simulation program. This is the time when those re-created memories are being enhanced emotionally by connections through the amygdala. The DBS has to block those emotional connections, and we’ll lose our chance if the memory evaporates. It’s not like PD, where we have the luxury of making subtle adjustments over weeks and months.”

“There’s no telling if the virtual reality would be effective again,” Trent added. “We don’t have any data on this. Essentially it could be a one-shot deal for him. If we don’t get a DBS system installed and working, Abington might miss his only opportunity to lead a normal life.”

“Carrie, I want you to know that it is up to you,” Dr. Finley said. “Medically speaking, I see no reason not to proceed. But obviously we need our head surgeon to be at the top of her game.”

All eyes fell on Carrie. She was starting to develop a conference room complex; the last time she’d been in one with all eyes on her like this, the conversation went horribly.

And again, Carrie had an important decision to make. Should she go ahead with the procedure? Though the decision was hers, there was no mistaking what Dr. Finley and the rest of the team wanted her to choose. As for Abington, it was clear that the hyper-realistic virtual reality simulation had triggered his rage. Carrie felt deep empathy for her attacker, and would not hold him accountable for his actions. But she wondered what he had seen during the simulation. Was Smokes there? Roach? What had happened to them over there?

While Carrie had come to the VA to recover from a devastating professional setback of her own, this procedure might be a way to truly help people like Adam and Steve, whose minds and lives had been turned into a daily nightmare. Right now, Carrie was the only surgeon here. It was her job, and the window was fast closing. If DBS could ease Abington’s grievous memories, in a Don McCall miracle way, Carrie owed it to him to try.

“I’m fine to proceed. Let’s do it.”

Carrie could not believe how natural it felt to be back in the OR. This was an environment where she could feel herself in control. The old adage of riding a bike was not lost on her. Unlike the vets whose PTSD she hoped to cure, Carrie had no trouble blocking out the memory of Abington’s assault. She was focused on the task, summoning not only her recent training, but her years of residency work as well.

As she prepared to drill the burr holes, Carrie thought back to the time, not long ago, when Beth Stillwell’s life had rested in her hands. Today’s procedure was technically a breeze by comparison.

Acting as the team’s neurophysiologist, Dr. Finley was in the operating room to record the electrical discharge patterns from nerve cells when Carrie worked the electrode, ever so slowly, toward the basolateral nucleus of the amygdala.

Intraoperative neurophysiological monitoring was a demanding discipline, and obtaining certification required years of additional study. Carrie was impressed by Dr. Finley’s dedication to his calling. There was no question that the doctor brought world-class medical skill to the VA.

In addition to Dr. Finley and Dr. Kauffman, the team included Dr. R. T. Patel, a first-year neurosurgical resident. Though Patel was primarily there to observe, he was also scrubbed, should Carrie require any unforeseen assistance. Intracranial hemorrhaging remained Carrie’s chief concern during the operation, and post-op she would be vigilant about monitoring for signs of infection.

Also present was Donna Robinson, the scrub nurse, who looked of an age to have treated vets from Vietnam, and Louise Phillips, who, as a circulating nurse, was not scrubbed. Carrie doubted she’d find anybody quite like Valerie on the VA staff, but she was optimistic about the skill and diligence of these women, and hoped over time to develop a rapport with her new colleagues.

The real art of DBS work was developing leadership and communication skills in order to bring the team along with her during each operation. Fortunately, though everyone made it clear he was loved and missed, she sensed no lingering resentment over her replacing Sam Rockwell.

For what it was worth, during scrub, Donna expressed her admiration for Carrie’s toughness and grit. Hours ago Carrie had been afraid for her life, but instead of retreating, she had brushed off the experience like a kid after a playground tumble. Having spent most of her career working for the VA, Donna measured a person by their ability to endure.

Carrie attached the stereotactic frame to Steve Abington’s shaved head with four screws using a local anesthetic, just to be sure, even though he had already been sedated. Then, he was wheeled next door where an MRI dedicated exclusively to OR protocols had been waiting, and a series of ultra-thin-cut T1 and T2 weighted images of his brain were acquired. Abington was wheeled back to the OR while the scans were loaded onto the planning station. Computer images provided exact XYZ coordinates of Abington’s amygdala, giving Carrie all the information she would need to guide the stimulating electrodes to her target by the least invasive path. This sort of equipment would have prevented the Leon Dixon disaster, Carrie thought ruefully. It was a supremely expensive setup, and she wondered how much of the bill DARPA was covering. Probably most of it.

Dr. Kauffman kept Abington unconscious with propofol and fentanyl. He would add isoflurane if deeper sedation became required. With Parkinson’s and dystonia patients, who had to be awakened intermittently in order to assess their motor function, agents like propofol were ideal. But the last thing anyone needed was another violent outburst during surgery, so it was best to keep this patient insensate.

Carrie made a curvilinear, right precoronal scalp incision and penetrated the underlying skull with the Midas Rex, making a standard fourteen-millimeter burr hole. A Stimloc was screwed in. The electronic drive system was attached to the frame and Carrie sliced open the dura. Next, the long metal cannula, guided by the drive platform, was ever so slowly introduced through the brain. Carrie took her time. She made certain the drive plane avoided any sulcus where some juicy artery or vein might be lurking.

Carrie inched the cannula another millimeter forward. She checked her computer and inched it some more. Long minutes passed as Carrie meticulously worked the cannula toward the target area. By now, Carrie’s legs ached, and a glossy sweat coated her brow and had to be dabbed away. The pull on her back left an unpleasant and persistent dull ache. As the hours passed, Carrie began to feel every stitch of Abington’s assault. She blocked out the throbbing of her throat and the hurt in her shoulder from when she hit the floor. Her concentration had to be total, and it was.

While this was still neurosurgery, it exercised a different set of muscles, which compounded Carrie’s fatigue. She pushed, persevered, and tapped into the kind of mental toughness she’d taken up triathlons to build.

At the start of the operation, Dr. Finley and others did frequent welfare checks with Carrie. Her two-word answer, “I’m fine,” never varied, so the last check had come more than an hour ago.

Three hours into the surgery Carrie announced softly, “I’m pretty sure we’re at ground zero.” She removed the stylus and replaced it with three micro recording electrodes.

“Wow, I’m getting an excellent signal,” said Dr. Finley. “I’m getting a typical pattern of neuronal firing from the basolateral amygdaloid nucleus. Great job, Carrie! You’re right on target with the first pass. The anatomical and physiological coordinates could not be more perfect.”

The microelectrodes were replaced by the stimulating electrode, and its surrounding stylet was removed. Carrie placed on the locking clip. All that was left would be to tunnel the exposed lead component into the chest. Four hours had ticked off the clock. Abington was shifted onto his left side. The right side of his neck and chest were bathed in Betadine. Carrie made an incision in the scalp and another five-centimeter cut in the right side of his chest, just under the collarbone.

Carrie inserted her fingers to enlarge a pocket where the subcutaneous pulse stimulator would fit. Then she inserted a t-tunneler and pushed it under the scalp and through the neck to reach the chest wound. The exposed lead was next introduced through the tunneler and connected to the generator in the chest. The scalp and chest were closed. The system was now in place, and potentially operational.

Five hours of surgery were complete.

Abington would spend the night in neuro recovery. Then it was home, wherever that was, and back in three weeks to follow up with Dr. Finley, who would assume responsibility for adjustments of the stimulus generator signal.

Dr. Finley checked the signal readings once more. “Dr. Bryant, you’ve just hit a grain of rice in a three-pound mass of Jell-O. Congratulations!”

Carrie removed her mask and grinned.