Trauma

CHAPTER 39

At five thirty the next morning Carrie was back at the VA for Gerald Wright’s DBS surgery. Parkinson’s disease had crept into and enveloped the retired lieutenant colonel’s life over the previous fifteen years, and as with all the other PD candidates for DBS, medication management had become unreliable. The surgical team, including Carrie, Dr. Finley, and the anesthesiologist, Dr. Kauffman, met to review Wright’s MRI from the day before and the CT scan from that morning to determine where best to insert the leads.

To Carrie’s surprise, Dr. Evan Navarro showed up for the meeting. The images had just been brought up on the computer when Navarro entered the conference room without knocking, as though he belonged there. He gave Carrie a cool smile as he walked through the door.

“What are you doing here, Evan?” Carrie asked.

“Sandra wanted me to observe this morning,” Navarro said. He fell silent, feeling no compulsion to further elaborate.

Carrie’s heart began to thunder. In the aftermath of yesterday’s tumult in the park, she gave serious consideration to the possibility that the missing vets, the encounter with the jogger, and the ransacking of her room were all somehow connected. Now that Navarro had shown up unexpectedly, this notion took deeper roots.

Navarro looked snappy in his white lab coat, red-and-white-striped tie, and dark trousers. His hair looked extra oily, slicked back as if in homage to Eddie Munster, widow’s peak and all. Carrie bristled at the thought of him joining her. A glance told her that Dr. Finley was equally displeased.

“Why would Dr. Goodwin want that?” Carrie asked.

“Surgery is her department, Carrie,” Navarro answered coolly. “I don’t ask how she runs it. I just do my job.” His tone was condescending, implying Carrie would benefit from doing the same.

Dr. Finley stepped forward. “This is entirely inappropriate, Evan.” His face was a shade of crimson Carrie had never seen on him before. “Nobody cleared this with me.”

Navarro just shrugged. “You’ll have to take that up with Sandra, too, I guess.”

“And I damn well will do just that,” Dr. Finley said. “We both know what this is about, don’t we, Evan? And it’s total bullcrap.”

Navarro’s smarmy expression set Carrie’s blood on fire. “Well, Alistair, last I checked, this is surgery that you’re doing here. And that would be my boss’s area of responsibility. So I can only offer the same reply to you that I just gave to Carrie, which is if you don’t want me here, you’ll need to take that up with Sandra. Otherwise, I’m not interested in pissing her off today — or any day, for that matter.”

Navarro set his beady little eyes on Carrie. She glanced over at Dr. Finley, who glowered at Navarro until he softened. No value in wasting energy, his expression conveyed. He pulled Carrie aside.

“I suspect this is a bit of payback for questioning her AMA orders,” Dr. Finley said in a whispered voice. “I know her style. She’s letting you know you’re on notice. Don’t worry about it, and try to ignore Navarro if you can. I’ll speak to Sandra after and see if I can smooth things over. Nobody wants to work under a microscope.”

Carrie gave a nod. She had her own payback in mind for Goodwin, and after the surgery she would help David make that plan a reality. For now, Carrie would dedicate all her attention to her patient and ignore Navarro as Dr. Finley advised.

The question now was where to place the electrodes.

Wright’s facial inexpressiveness, unblinking vacant stare, and almost inaudible whisper of a voice belied a reasonably intact intellect, but significant personality and behavioral problems had influenced Dr. Finley’s decision. The apathy and depression, for example. Were these behaviors a direct consequence of his disease, or an understandable psychiatric reaction to the devastations of a failing motor system?

Wright had had enough problems for Dr. Finley to decide on the right globus pallidus interna for the stimulating electrode target. This would seem to afford the best opportunity to reduce the left arm tremor and improve Gerald Wright’s overall motor status. Dr. Finley and Carrie considered other target placements, but the risk of psychiatric complications favored the GPi as the better choice.

“He may be a bilateral case,” Dr. Finley told Carrie as she went in to scrub for the surgery, “but let’s see how he does with this side first. He’s pretty intact cognitively, but I’m concerned about his behaviors and the neuropsych testing reports we’ve gotten back.”

Carrie was still schooling herself in the subtleties of Parkinson’s disease and the options of DBS surgeries. Like everything else in medicine, this was a rapidly evolving discipline, meaning patient and doctor alike were on steeply ascending learning curves. Carrie reprimanded herself for not spending more time studying about PD, even though she was still new to the program. She’d had too many distractions.

Like missing vets.

The familiar harsh smell of Betadine scrub and the lather up above her elbows brought her mind back to the problem at hand, retired LTC Gerald Wright. She smiled slightly beneath her mask. Despite all that was going on, she was still a surgeon at heart, and she could focus all her attention on her profession and the task at hand.

Funny how at the most unpredictable of times, she became aware of the transformational effects of training. No one had ever taught her to feel like a competent doctor, a leader. But that was how she felt as she did her second scrub midway up the forearms, and then the third, just the hands.

She entered the OR not feeling as comfortably in the zone as she was accustomed.

The procedure was becoming commonplace, which played in her favor: affix the stereotactic frame with four screws under local anesthesia first thing in the morning, then down to MRI for ultra-thin slices, with the images sent over to the planning station in the OR. Carrie selected the optimum XYZ coordinates to minimize risk of brain injury or hemorrhage as the needle advanced its way to Gerald Wright’s globus pallidus interna.

He was awake for this procedure, kept comfortable with just the right amount of propofol. That way, Dr. Finley could monitor the patient’s motor status directly and also use the electrode recording techniques that signaled their specific placement. They were a team now, Dr. Alistair Finley and Dr. Carrie Bryant. They were able to carry out the extended, time-consuming procedure with little back-and-forth dialogue, as if they were reading each other’s thoughts, despite the fact that they had worked together on only a handful of cases.

Evan Navarro’s presence was as innocuous as the familiar sounds of the operating room machinery. Maybe the choice of music helped Carrie block out the unpleasant distraction. Gerald Wright was also a jazz fan, and he had requested Bill Evans’s Portrait in Jazz for his big day in the OR. The melodies reminded Carrie of her life at BCH, and friends like Valerie, with whom she was no longer in touch. Even in the Facebook era, friendships forged at work faded quickly once that bond was broken. But now she had a new community, a new team she counted on and who counted on her.

“Are you doing all right, Carrie?”

Carrie’s focus had been so total that Dr. Finley repeated himself.

“Yeah, I’m fine. Why?”

“You’re about to go off your line by about three micrometers. Do you need a rest?”

“I’m sorry,” Carrie said. “Maybe just a minute and some water.”

Navarro’s black eyes seemed to be smiling.

Carrie was not 100 percent, and Dr. Finley seemed to know it. A thin film of grit blanketed her eyes, left behind from a bad night’s sleep plagued by nightmares of men chasing her in the dark. Adam had crashed on the couch watching TV, and Carrie woke him by accident getting ready for work.

Yesterday’s fight was in the past. He had smiled warmly at her and wished her a good day without having read the long note of apology Carrie had left on the kitchen table. Seeing Navarro’s wicked look made Carrie more willing to believe her brother. Could Evan Navarro have been in her bedroom? Could Goodwin have put him up to it? And if so, why? Carrie had a gut feeling that bugging Goodwin’s office would get her some answers.

After a short break, Carrie resumed her work. Dr. Finley recorded the electrical discharge patterns as Carrie sank the electrodes on the sweet spot. Navarro did not stay for the entire show. Evidently, he had made his point and was off to other things. Soon enough he, or one of his residents, would be looking in on Gerald Wright, and Carrie would probably never see this patient again. Even if everything that had been happening lately had a logical explanation, Carrie doubted she could continue to work under such rigid constraints.

In total, it took seven hours to drill the holes and close up the skull, and in that time Carrie developed knots in her shoulders the size of walnuts.

“You seemed a little off today,” Dr. Finley said back in the scrub room. “You sure everything is okay?”

“Navarro had me a bit rattled,” Carrie replied.

“Well, leave that to me. I’m going to speak with Sandra right now. That won’t happen again, I assure you.”

Carrie went to the locker room to take a shower and get changed. After that, she stopped by the hospital cafeteria for her second coffee of the day. Next, it was on to the front desk where Carrie would arrange a temporary ID for David Hoffman. They had settled on the ruse that he was a medical student coming to the VA tonight to help with some research. To keep their activities as covert as possible, David asked Carrie to use an alias, and she picked “Michael Stephen,” which were the first two names that had popped into her head.

She texted David her chosen moniker and headed to an on-call room to grab a few hours of shut-eye on the narrow, industrial bed before Mission Possible commenced.

Carrie’s cell phone buzzed in her lab coat pocket, which she assumed was David responding. She checked the number, but did not recognize the caller.

“Hello, Dr. Carrie Bryant speaking.”

“Dr. Bryant, I’m Dr. Abbey Smerling from Seacoast Memorial Hospital in Maine.”

Carrie’s entire body came alive. “Yes, Dr. Smerling. What can I do for you?”

“You placed a call regarding a patient, Dr. Sam Rockwell, and asked to be notified if there were any developments.”

Carrie braced for the news to come. A potential link to the mystery of what might have happened to Abington and Fasciani had probably just died.

“Yes, that’s correct,” Carrie said.

“Well, I have some good news to share.”

This was what Carrie had hoped for. It was common practice for doctors to share patient information with other doctors irrespective of the new privacy laws. Some habits were harder to break than others.

Dr. Smerling said, “The brain swelling had begun to recede, so we lightened up the coma to see if he could come back.”

“And?”

“And we got something,” Dr. Smerling said. “A lot more than we expected.”