Trauma (10 page)

“I usually only have coffee with rocket scientists,” he said. “I guess I could slum with a brain surgeon.”

Adam never came back to make amends, leaving Howard and Irene to do the apologizing.

“Don't even mention it,” David had said with a wave of his hand. His battered nose would heal just fine. “If it's okay with Adam, maybe we can try again sometime. People need to know what's happened to our servicemen and -women. They need to see the war after the war.”

For the rest of that night, Carrie thought only of her father's suggestion and David's persistence. She
had
come too far to quit. She called Dr. Finley's office at the VA the next morning.

To Carrie's surprise, Dr. Finley answered his own phone.

“My name is Carrie Bryant,” she said. “My father, Howard, suggested I give you a call.”

For whatever reason, Carrie felt at ease with Dr. Finley. His voice was intimate, with no discernable accent, and he spoke to her as a colleague. He remembered her father, and was interested in her background and experience.

“Can you come by the hospital this afternoon?” he asked.

Carrie hadn't expected that. It felt fast, but that was good. No chance to get cold feet. A few hours later, she was sitting in Dr. Finley's office anteroom, flipping through an issue of
People
magazine. Five minutes later, she was in front of Dr. Finley himself.

Unlike his fancy headshot on the VA Web site, Dr. Finley looked every bit the harried professor. His long hours showed in the silver that streaked his mop of wavy, light hair, and in his pale cheeks and burrowed eyes. He might have been intimidating, except for his cheerful expression and a slightly disheveled appearance.

Dr. Finley shook Carrie's hand firmly. “Please, come into my office. The executive suite,” he said with a smile.

She wouldn't have called the attendings' offices at Community comfortable, but they seemed luxurious compared to the d
é
cor here. Two metal folding chairs faced an L-shaped desk that looked like a Walmart special. An overhead fluorescent light fixture gave off a persistent hum. The walls were bare, except for a couple of diplomas and the requisite pictures of the president and the secretary of Veterans Affairs. The VA reeked of institutionalism, like body odor. Still, the man seated at the desk had a warm and inviting smile.

Carrie gazed out a square window that overlooked the parking lot, focusing on an adjacent multistory brick building under construction. The building was covered in rusted scaffolding and tattered blue tarps, but Carrie could still see signage over the front entrance:
VA HOSPITAL ANNEX
. Most of the windows on the annex were boarded up, but some remained intact.

Dr. Finley noticed her looking. “That was supposed to be our gleaming new facilities,” he said, a bit wistful. “But we've been caught up in a bit of a funding crunch, I'm sorry to say. Work stopped almost two years ago.”

“The building has been vacant this whole time?”

“Unfortunately, yes,” Dr. Finley said. “There were ambitious plans for hospital expansion, but most everything has been put on hold because of ongoing budget constraints. Perhaps one day the fortunes will change. But we're not here to discuss the fiscal woes of the VA.”

“No, we're not,” Carrie said, taking a seat on one of Dr. Finley's metal chairs. “My father sends his regards.”

“He's a good man,” Dr. Finley said of Carrie's father. “That was a great time. Great. Internship was without a doubt the hardest year of my life, but it was probably the best, too. I want you to know he's not the reason I invited you down here. Your call may have come at a fortuitous time for us both, and I'd like to know more about you.”

For the next thirty minutes Carrie shared her experience, career plans, and ultimately the incident that had derailed her. Dr. Finley listened with rapt attention. His avuncular interest let Carrie tell him all the whys and wherefores without embarrassment.

“And so I resigned,” she concluded. “I couldn't see how I could continue a surgical residency. But now that I've had a few weeks to think about it, I realize that doesn't mean I need to be finished with medicine.”

Dr. Finley added some final notes to those he'd been keeping during Carrie's story.

“Well, let me tell you a little bit about our work here.”

For several minutes, Dr. Finley detailed what sounded to Carrie like a typical neurological practice. The hospital had a fully staffed neurosurgical department with an accredited residency program. Together with Dr. Finley's neurology practice, they treated everything from brain tumors to migraines. But of all the work being done by the Department of Neurology and Neurosurgery at the VA, Dr. Finley was most excited about his deep brain stimulation program.

He talked at length and with great enthusiasm about how DBS uses a neurostimulator placed in the brain to deliver electrical impulses to targeted regions, and the great potential it has for treating a wide range of neurological conditions. Mostly he focused its application for treating movement disorders, and he made several references to the patient Carrie's father met during that sponsored dinner on Parkinson's disease. He hinted at other applications for DBS, but kept those allusions intentionally vague, she believed.

“Look, Carrie,” Dr. Finley said after his impromptu lecture on DBS, “I can't offer you an actual residency position here. Our program is fully staffed—and besides, it's mid-year.”

Carrie tried not to look deflated. In their brief conversation, her expectations had gone from zero to high.

“But I do think I may be in a position to help,” Dr. Finley continued. “And I suspect what I have to offer would help renew your confidence.”

“I'm interested,” Carrie said.

“A stint with the VA would, in my opinion, increase your chances of getting back into a formal neurosurgery residency program next year, while teaching you an awful lot about brain diseases one normally doesn't deal with in the usual neurosurgery program.”

If the residency positions were filled, what could he have in mind? “I could certainly do some research on depth electrode stimulation treatment for Parkinson's disease,” Carrie said, anticipating what she assumed Dr. Finley would be able to offer, some sort of research position, nothing that involved actual patients. “It sounds like fascinating medicine.”

Again Dr. Finley checked his notes. “I tell you what. Better than that, I've got clinic on Thursday morning, and some follow-up patients will be there. Could you come?”

“You want me to come on rounds with you?”

“If you'd be so inclined.”

“I'm just curious,” she said. “If there's no residency positions, why was the timing of my call fortuitous for us both? How are you in a position to help me?”

“Come to rounds on Thursday,” Dr. Finley said. “I'll explain everything then.”

 

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.”