Trauma (11 page)

Dr. Finley peeled away the paper covers over the sticky pads on the back of a plastic dock and adhered the unit over the scar on Don's chest. He snapped the programming device into place on the dock, then spent some time making sure the programming unit worked properly. When he was satisfied, he said, “I'll be back in a while to take another look at you, Don, and we'll see how you're doing ‘plugged in,' as they say. And then we'll put you back on your medication and see how the whole package is working.

“As you know, Nancy, this is going to take some time,” he added. “I'll be here checking on other folks for a while. Why don't you get yourself some coffee?” He turned to Carrie. “My job is to make sure the patients receive the proper dosage of medicine and stimulation. It would be up to you to get those wires precisely where they need to be. And believe me, Dr. Bryant, this is no simple feat.”

Up to you.
Did he mean it? Could she work here?

*   *   *

THE VA'S
cafeteria, even down to the food, was about what Carrie had expected. “Institutional” was apparently a flavor, as well as a design aesthetic. Still, so far, she was enjoying every minute of her time with Dr. Finley. They had looked in on several more patients, and Dr. Finley suggested they take a coffee break before concluding with Don McCall.

“So, what did you think?” he asked once they were seated.

“Well, the management of movement disorders is far more nuanced than I appreciated,” Carrie said. “It's interesting, and really necessary work.”

Dr. Finley looked pleased. “Let me be very candid with you, Carrie,” he said. “I've checked your references, and I know even more about the incident we discussed in my office. Believe me, everyone at Community and White is heartsick over what happened. They really like you, and I know you saved a woman's life the night before. I've got to tell you, Metcalf is still pissed—but he's all massive ego anyway.”

Carrie shrank at the mention of Metcalf's name. “I hope you didn't ask him for a reference.”

Dr. Finley laughed. “I don't think you'll ever get back into his good graces. But I don't need his commendation to know talent when I see it.”

“I'm really glad to hear that, but I guess I'm a bit confused,” Carrie said.

“Why is that?”

“When we met in your office you said there were no residency openings available, but you also said my timing was fortuitous. Can you explain that now?”

A shadow crossed Dr. Finley's face. He spent a moment stirring the cream in his coffee. When he looked up, his eyes showed strain and more than a hint of sadness.

“A few weeks ago our DBS surgeon, Sam Rockwell, was in a terrible, terrible car accident coming back from his vacation home in Maine. I saw the photos. His car crumpled like a tin can. His condition is too tenuous to MedFlight him to White Memorial, so his family has been keeping vigil at his bedside in a Bangor hospital. He's in a drug-induced coma with multi-organ failure and sepsis. There's a good chance he won't make it. It's a definite blow to our program.”

“That's horrible,” Carrie said, feeling a stab of sadness for Dr. Finley and for Rockwell's family.

“Sam and I were extremely close, and I'm—I'm just devastated. Anyway, there's no way Sam is coming back here any time soon, and we need someone to take over his responsibilities. I know you would be an excellent replacement. There is some time sensitivity to this offer. I'm afraid we may lose funding for a very special initiative if we don't get someone into the role posthaste, but I can't take just anybody. And, as you know, most of the qualified candidates are currently employed. We can't wait for them to become available to us.”

Carrie nodded grimly. “I see now why you said my call was fortuitous.” Medicine was a Darwinian world. One doc's misfortune was another doc's golden opportunity. Still, it felt ugly to profit from tragedy.

“Listen, Carrie, I know this seems wrong, given Sam's unfortunate circumstance, but a person with your considerable skill and talent would be a huge asset to us. You'd be able to jump right in without missing a beat. I've got the funds, and while this would not be a formal residency, it might help you get your groove back, so to speak. The surgical schedule is not too demanding, not at all like what you're used to. We try to limit the surgeries to one or two per week. There simply isn't a large staff to conduct proper patient evaluations and handle follow-up care.”

“That's a wonderful offer,” Carrie began, but Finley stopped her.

“But here are the restrictions,” he said. “You're my hire. You work for me on this, not the VA. I'd be able to pay you out of the DARPA funds, and that includes benefits. Those funds give me a tremendous degree of clout with the VA's leadership team, including the acting medical director. You won't be part of the residency program, but that's no issue. I know you're a good surgeon, and your reputation precedes you. I know what you did for Beth Stillwell, and I thought it was remarkable. I truly believe you'd make an incredible addition to our team.”

“How do I get credentialed?” she asked. “It's going to take so long to get on board here.”

Dr. Finley showed no concern. “Carrie, you have a medical license. You got that when you graduated medical school. Your residency is for training, but legally, if you wanted to go out and start a practice, you could have done that. Some people need five years of residency to get where they need to be, some get it after three, but my inquiries have persuaded me that you got it after one or two. You've got enough talent, enough training to do this job. Even though I run the neurology residency at the VA, I'm hiring you under private funding for this program. It's a very unusual opportunity, and you'll be able to use this experience to enhance your credentials if you wish to get back to formal residency—though my hope is that you'll stay with my special initiative for years to come.”

“And what exactly is the special initiative?”

An inscrutable look came to Dr. Finley's face, then it morphed into a grin.

“Come with me,” he said.

Carrie followed Dr. Finley back to Don McCall's hospital room, where Nancy McCall greeted them with a bright smile.

“Already much improved,” Nancy said.

“Have a look for yourself,” Dr. Finley said to Carrie.

Right away, Carrie noticed the rest tremor was significantly decreased.

“How are you feeling, Don?” Carrie asked as she checked the mobility of his limbs. It was not enough to get him back on the ice, but the degree of movement made Carrie think somebody had replaced one Don with another.

“I'm feeling much better, Doc,” Don said.

The stutter was gone and his voice was strong and intelligible.

After her brief exam concluded, Carrie followed Dr. Finley back into the hallway.

“Impressive, isn't it?” Dr. Finley said.

“Yes, very much so,” Carrie said. “But treating Parkinson's with DBS isn't all that new, at least not according to my research. So I'm still curious about that special initiative you mentioned.”

“What if I told you that we could use DBS to cure PTSD—not treat it, but cure it?”

Adam came to Carrie's mind with a flash of wonder. How was it possible? Could it be possible?

“If that were true, Dr. Finley,” Carrie said, “I'd say you had yourself a brand-new DBS surgeon.”

 

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.”