Trauma

CHAPTER 23

Carrie spent fifteen minutes in her cramped, windowless office trying to decompress. Her blood pressure had settled, but she was having enormous trouble concentrating on her DBS research. She was halfway through a difficult paper on dysarthria in Parkinson’s disease, but the words jumbled on the page.

She was ruminating on that contentious conversation — ambush was more like it — with Drs. Goodwin and Navarro. The insinuations were absolutely infuriating. Carrie had not taken the job just to be a surgical tool. A hammer for a nail, so to speak. Dr. Finley had told her she’d be part of the team, and that was how she’d envisioned her role.

I would have preferred we bring in somebody who had gone through a formal residency program successfully. Dr. Goodwin’s words bit hard.

Out of frustration, Carrie balled up the printout she’d been reading and threw it against the wall. That woman had been cutting, disparaging, and downright offensive. Something odd had happened with Steve Abington, something potentially related to his DBS treatment. It was more than the agitated state the duty nurse had described. This was something — but what? She was focused mostly on his strange response. In her mind, she could still hear him muttering the same phrase over again, repeating what she had said.

Follow my light … follow my light …

Abington seemed to experience some form of auditory hallucination. It was unusual, not the type she had seen in schizophrenics where disturbing voices outside the head seemed to speak directly to victims. She was keen to try and understand. Even if she were prohibited from seeing Abington, her time was her own, and Carrie could still work his case.

Take that, Dr. Goodwin!

Carrie squeezed into the crowded elevator. Her finger hovered over the button to the medical ICU floor before she resisted the temptation. It was one thing to do some research in the library on a “turfed” patient, but she couldn’t flagrantly ignore Dr. Goodwin’s instructions minutes after they had been issued. It was best for now to keep her investigation academic.

The library at the VA was located on the first floor, just off the lobby, and it did not look like it got much use. The floor was covered with a threadbare carpet, and though it had a few wooden carrels, none had a chair. Unlike the gift shop, which was staffed by volunteers dressed in brightly colored smocks adorned with patriotic pins, the library reception desk was unattended. In place of a human, a sign in an acrylic holder provided instructions on how to obtain a password to access the computer and navigate to the home page. Some of the more recent medical journals — what limited print supply was on hand — were stuffed haphazardly into a standing magazine rack, but the library’s shelves were notably barren.

Carrie located a plastic chair and set it facing a terminal. A thought of her dad flashed across her mind. How would he go about this? Her father loved doing research. To him, it was a major part of the challenge of medicine. He and Carrie could not have been more different in this regard. As a surgeon, Carrie preferred her puzzle pieces manifested not as words, but rather lab results, machine readouts, and whatever visual cues she could derive from inside the human body.

She was typical of the field; few surgeons loved doing research. Carrie recalled her third year in medical school, during her clinical clerkship, when she was on hospital rounds with the attending physician and a host of medical interns and residents. The resident would summarize the previous day’s events, what the blood work or imaging studies revealed, while the rest hovered over the patient’s bedside like spectators at a sporting event.

While these bedside rounds may have been a bit intrusive, they were always interesting and instructive. Until, that is, some suck-up student or resident would inevitably blurt out something like, “Thompson et al. in last week’s Lancet…” Then they’d go into detail about some study that was published and how it might relate to the patient before them.

Inwardly, Carrie would groan her displeasure. To Carrie, rounds on surgical services were about practical information and hands-on study. The book learning, though important, was no longer the focus. Instead, her attention was on the ins and outs of active treatment. She held nothing but respect for internal medicine docs, or “fleas,” as the surgeons called them. Her dad was one, for goodness’ sake, and he would always be her idol. But from day one Carrie felt more comfortable in her skin as a surgeon.

An old joke came to mind: an internal medicine doc, a pathologist, and a surgeon are out duck hunting. Suddenly a flock of birds goes by. The internist says, “They quack like ducks, they fly like ducks, they’ve got the coloring of ducks. They’re probably ducks.” The surgeon glances over at his friend, raises his shotgun, and shoots the birds out of the sky. Then he says to the pathologist, “Go see if they’re ducks.”

Carrie was a surgeon.

After about a minute of aimless clicking and browsing, Carrie called her dad.

“Hi, sweetie,” Howard Bryant said.

Carrie smiled at the sound of his voice. “Hi, Dad. I could use some help.”

After she’d explained what she was after, Carrie’s father pinpointed the problem: She was at the wrong library. It felt liberating to walk out the front doors of the VA, leaving the building Dr. Goodwin occupied, for the Orange Line T stop. Carrie could have driven to the Harvard Medical Library, but parking at this time of day would be a hassle. Thirty minutes later, Carrie traded the warm spring day for the cool interior of the Francis A. Countway Library of Medicine.

The Harvard library was a sprawling, multifloor building, with a winding marble staircase and a spacious courtyard gloriously situated beneath a massive atrium ceiling. It took Carrie some time to find the Index Medicus, which had stopped publication in 2004, toppled by medical search engines, but respecting her dad’s library research attack plan, she’d start with the tried and true.

Two hours into her effort Carrie still had not found anything useful, but she remained dedicated to the task. It was some relief that Carrie could find no cases of DBS-induced arrhythmia, which quieted the voice in her head that wanted to blame her for that part of Abington’s condition. As for his delirium, the medical search engines offered up a host of unusual types of hallucinations that took her nowhere: hypnogogic hallucinations associated with sleep stage alterations, peduncular hallucinosis associated with brainstem diseases, musical hallucinations that seemed more benign and could even be pleasurable, but nothing that seemed like Abington’s case.

Carrie examined a few old textbooks: Noyes’ Modern Clinical Psychiatry from the ’60s. Useless. She got up to stretch her legs. Another hour slipped by. And then another. Carrie’s stomach was rumbling, but she was not ready to stop. She recalled the pure terror on Abington’s face as she filled out a reference request card for an obscure medical journal. Her hunger for lunch seemed small next to the needs of the patient.

“I’ll be sitting over there,” Carrie said to the delicate and bony eighty-year-old woman working the desk, who hefted enormous tomes with seemingly little effort.

“I’ll get it for you … I’ll get it for you,” the librarian said, repeating her words in what was probably a lifelong habit.

It reminded Carrie of Abington.

Follow my light … follow my light …

That was when it struck her. Carrie had been so focused on calling Abington’s symptoms hallucinations that she had found articles specific only to that condition. But Abington was not exhibiting hallucinations. These were not totally false perceptions. It was more of a misperception of what Carrie had said. She had asked him a question and he had responded multiple times. He only thought she was saying it over and over again, when in fact she had uttered it only once, a simple single phrase.

As a neurosurgeon, Carrie was well aware of the difference between an illusion and a hallucination. She had focused on the wrong issue. A hallucination is a false perception, with no external stimulus involved. Whatever the individual hallucinates is an internal, personal experience. But an illusion is a misperception of reality, and in these cases an external stimulation is always present. With Abington, the external stimulation was Carrie’s voice.

Carrie raced back to her desk and grabbed a standard textbook, Principles of Neurology by Adams and Victor. She had already read up on hallucinations, but this time she aimed elsewhere.

Illusions.

Carrie rifled through the index until she found: illusions, auditory, page 759. There, down toward the bottom of the page, was a reference to auditory illusions associated with lesions of the temporal lobe, where “words may be repeated, a kind of perseveration.” Yes! Perseveration, the uncontrolled repetition of a word or phrase that was associated with brain injury. He was not hearing things, but rather he had a misperception of what was heard. It was a subtle twist, but it made all the difference.

Carrie’s pulse jumped. She was onto something. She read about palinacousis, a condition first described by Bender in 1965, and elaborated by Jacobs with a number of case studies in 1973. Came from the Greek, palin (again) and akouein (to hear). All cases were attributed to lesions in the temporal lobe, where sound was processed in the brain. Some cases were due to a form of seizure, like a type of localized epilepsy. Single words or more extensive phrases would be repeated several times — in other words, perseverated.

The sounds could even be louder and more vivid than the original. Many patients became upset and quite disturbed by the event. Carrie read about several patients who were coherent enough to figure out that the sounds seemed to come from one particular side of their head. As it turned out, doctors were able to determine that instances of palinacousis manifest on the side opposite the brain lesion. If that were true, Abington would have heard Carrie’s words, “Follow my light,” only in one ear — more accurately, the left auditory field, on the opposite side of the lesion.

Palinacousis was extremely rare. Carrie could find only a handful of described cases despite an extensive literature search. She spent some time contemplating possible reasons why Abington had developed the condition. He certainly did not exhibit it prior to his surgery. Then again, he was not in any coherent state during her pre-op exam. Perhaps he was having the illusion then. Maybe that had triggered his rage. Could it have been seizure-related? Or did he have a hemorrhage in the temporal lobe post-op? The amygdala was not in the anatomical area that processed sounds, but could the DBS have done this, in some indirect way?

Carrie’s head was spinning. Was this auditory illusion somehow connected to the arrhythmia, or did the haloperidol bring it on? Perhaps it was a combination of factors. At least Carrie had one possible answer, and a name, palinacousis, to account for Abington’s strange behavior.

Such a bizarre and unusual disorder; she could imagine how anyone would get agitated, believing someone was yelling the same thing over and over again in your ear. And you could not see the person who was doing the yelling or where it was coming from. It was an illusion. The implications were troubling. The condition indicated a localized disturbance in the brain, specifically the part of the temporal lobe that processed auditory information.

Carrie returned to the idea that the condition could be a side effect of DBS. It would mean Abington’s confused agitation was not the commonly encountered post-op delirium, a temporary consequence of anesthesia or other drugs. Carrie needed to see Abington, to examine him further, but obstacles blocked her way, namely Goodwin and Navarro.

She saw another path forward. This one involved a friend, perhaps her only one at the VA.