Trauma (12 page)

Dr. Finley paused until the chuckles died down.

“An operation, I believe, would be far more attractive to those afflicted, and thus would dramatically increase the numbers of those willing to be treated.”

Dr. Finley fell silent to allow the notion to sink in.

“It has been reported that the economic impact of PTSD, limited to just the military, is anywhere between four to six
billion
dollars. And this does not take into account the spouses and children whose lives are further traumatized. I would argue that four billion grossly underestimates the economic toll.”

Of course Carrie thought of Adam: his lost wages and diminished potential, coupled with the burden on her parents emotionally, financially, and in scaled-back career plans for themselves. Her family was just a tiny fraction of that billion-dollar crisis.

Dr. Finley showed a schematic of the limbic system, a complex network of structures ringing the ventricular system deep in the brain. Its functions were many, including regulation of emotion and basic drives and motivation. It also regulated the initial processing and emotional aspects of memories, and the body's response to stress including blood pressure, pulse, and respiratory rate, as well as sleep patterns. Tiny as it was, the almond-shaped amygdala nucleus, located deep and medially in the temporal lobe, was accountable for a whole host of critical functions.

“We believe the basolateral nucleus of the amygdala represents the most promising target for DBS in treating PTSD. Here is where fear and its memory converge.”

Dr. Finley advanced the slide. The amygdala was now circled in red.

“This is the epicenter—where our primitive fight or flight reactions form in response to a threat, where unchecked rage can be unleashed in response to a disturbing memory. Regardless of how much we try to alleviate these terrible memories through therapy or pharmaceuticals, we know that PTSD symptoms are structurally imbedded, literally imprinted, in the brain. And we believe this processing involves the amygdala nucleus significantly.”

Dr. Finley came out from behind the lectern. He made eye contact with Carrie, and she smiled.

“We have realized something that you may find counterintuitive. Traditionally the goal of treatment has been focused on the mitigation of disturbing thoughts and memories, analogous to the way we treat many phobias. Think of the man who is afraid of heights, for example. We may subject him to systematic desensitization by gradually introducing him to higher heights. And indeed, such treatment is often effective, at least partially, for phobias, but war zone trauma is something else entirely.

“We are discovering in controlled laboratory experiments that electroshock therapy administered to animals in close proximity to a traumatic event greatly suppresses those animals' behavioral response when immediately re-exposed to the trauma. In other words, they seem to have forgotten their emotional response to the initial trauma.”

Dr. Finley went on to discuss a group of human test subjects who were involved in a different memory experiment involving electroshock therapy, more commonly known as ECT. These patients were first shown images of terribly unpleasant events and asked to recall them. Surprisingly, the researchers found that the patients were not able to remember any details of the disturbing event the day following their ECT, even though they had been told explicitly to remember the event in as much detail as possible. The shock treatment seemed to interfere with storing a new memory in the brain. The researchers concluded that there was a period of time when stored memories were accessed, in which they could be vulnerable to manipulation. They could be modified, changed in some way, reconfigured or “reconsolidated.”

Dr. Finley continued, “We know the intense connections of memory tied to emotions sends the amygdala into overdrive in PTSD. If we can dampen that hyperactivity in the amygdala, all the social and psychological consequences we see in PTSD—the nightmares, depression and apathy, anxiety and fear, the likely drift into drug and alcohol abuse, the emotional roller coaster, potential flashes of aggression—all this can potentially be negated.”

Dr. Finley went on to present a series of slides referring more specifically to the anatomy of the amygdala and its connections to other limbic structures.

“Our goal is not to erase the memory per se, but to erase the emotion associated with the memory. Let me repeat: The goal of our DBS program is emotional erasure. To do this, we first need to reproduce the soldier's trauma, as vividly as possible. And just then, after the memory has been reproduced, we suppress the amygdala by deep brain stimulation of the amygdala's basolateral nucleus, interrupting its emotional and physiological connections to that memory, and in so doing, reconsolidate the memory without the emotional context.”

A hand shot up from one of the psychiatric social workers seated directly behind Carrie.

“How would you do that? How do you plan to re-create these memories so vividly?”

Dr. Finley's expression brightened as if this question had been planted and anticipated.

“Glad you asked, Wanda. Today I am officially announcing a very exciting pilot program, initiated with the assistance of DARPA.”

Dr. Finley's gaze traveled to the back of the room, where the two men in suits were seated. Carrie guessed they were from the government.

“By a show of hands, how many of you have heard of DARPA?”

Fewer than half the hands in the room went up. One person felt a need to clarify. “The initials, yes, but I'm not sure what it stands for.”

Dr. Finley gave a slight nod. “It stands for Defense Advanced Research Projects Agency. Their mission is to create breakthrough technologies for national security. They're the folks who gave us the Internet—sorry, Al Gore.”

The reference inspired scattered laughter.

Dr. Finley continued. “PTSD is approaching epidemic levels in the military, so DARPA has been experimenting with exposure therapy using virtual reality simulations.”

Carrie felt a jolt. DARPA was remaking the war in pixels.

“We can re-create that IED event when a soldier's buddies were killed or maimed.” Dr. Finley spoke to a hushed audience. “And while the brain is forcibly agitated, we have an opportunity to treat that individual with deep brain stimulation with the hope that we will actually erase the emotion associated with those terrible memories forever. I'm not talking suppressed. I'm talking
gone,
forever. Ladies and gentlemen, I am pleased to see Calvin Trent from DARPA has joined us today. Cal, could you please stand up?”

Cal, the man with Atlas shoulders and cold eyes, glanced briefly at his companion and stood up slowly. He acknowledged the audience, then sat right back down. Dr. Finley either did not recognize or did not know the other suit that had accompanied Cal Trent. Either way, the bald guy with a round face and beady eyes got no introduction.

Dr. Finley said, “Cal oversees all aspects of the program, including the virtual reality simulation, which is used prior to the DBS surgery to reconsolidate the negative memory. The virtual reality does leave many patients highly agitated, but that's a temporary state. We need the emotion heightened, the negative memory fresh, as close to surgery as possible. Once the electrical stimulation commences, the emotion gets dampened. It's as simple as that. Cal's pulled together an amazing team of people to run this program, and I know you'll extend him your every courtesy.”

Carrie could sense excitement building in the audience. Just about everyone there had had some contact with a returning soldier who was devastated by PTSD, or his or her family. She thought again, always, of Adam.

It had been eye-opening to live with her brother, and see the difficulties he and her parents had been enduring. Sometimes his nightmares were so savage it sounded like he was being murdered. She saw how Adam avoided going out, especially into crowds. Even walks in the woods behind the house were an ordeal. Everywhere he went, he was scouring the ground for IEDs. At least he had started going running with her—well, more like she followed Adam as he sprinted. Poor kid could easily outrun her, but not his demons.

The hope she saw in Dr. Finley's eyes, the enthusiasm in his words, buoyed Carrie's commitment. Dr. Finley had told her about the program after she had accepted the position, but seeing everyone else respond with excitement reinforced her own enthusiasm. She was proud to be on the cutting edge of such critical care. Funny that she'd named her goldfish Limbic, the system the amygdala resided in.

Was fate at work here?

 

CHAPTER 16

The operating room was Carrie's amphitheater, and she was the violinist about to dazzle. She was back in uniform: green scrubs underneath a white lab coat. Soon she would enter the preoperative holding area to visit a patient, her first at the VA. His would be the first burr holes she would drill in almost two months.

Jealousy from the other resident physicians had been an initial worry. Other residents had competed for their positions, while Carrie had been handed what many would perceive as a post-resident fellowship, working directly with one attending on a single project, without the onerous responsibilities of taking call or being responsible for patient care. It was a plum assignment for sure, but Dr. Finley made it clear to everyone that Carrie would not receive credit toward her residency requirements. No, this was a different trial for her. Would she perform to her ability?

While the DBS procedure she would perform would be relatively simple and straightforward, it was by no means free of complications. Opening the brain involved significant, life-threatening risks, every time. Still, implanting wires was not like sucking out blood clots deep in an already swollen brain where the surgeon had to be both swift and meticulous. DBS required a tremendous amount of patience and an OCD-like attention to detail. Carrie took a few calming breaths. She ought to wait for Dr. Kauffman, the anesthesiologist, but felt she could handle the preoperative consultation just fine.

Five minutes later Carrie entered the preoperative holding area, where she was struck by the sight of a man who could have been her brother's twin. Seated on a beige armchair, reclined ever so slightly, the man looked like Adam not before the war, but after. He had Adam's strong jaw and sharp-featured face, but his shaved head called attention to his concave cheeks, and he appeared frail and skeletal. His arms were spotted with ugly purple bruises that spiraled outward like mini nebulas. But it was the eyes that truly alarmed her. They looked hollow, a stare that seemed to stretch out into space.

Carrie was not sure what to expect from patients after they'd been subjected to the virtual reality therapy, but it certainly was not this. Her patient had the dazed look of a car accident victim. She knew he would be sedated, but it was tough to see his suffering. Carrie usually treated the sorts of injuries and ailments that appeared on an MRI. This man's wounds were just as significant, even if they couldn't be imaged.

She checked her chart. She knew the soldier's name, but wanted to double-check to make sure she got it right. Her father's lesson on the importance of details had taken root.

Abington. Staff Sergeant Steve Abington.

Carrie helped Abington out of the chair and onto the exam table, positioned kitty-corner in one end of the room near a counter with a built-in sink. Above the sink was a steel medical supply cabinet affixed to the wall. At first Carrie thought Abington was too thin, but once he was standing she could see he was rippled with muscle. He had the minimal body fat of an athlete.

“How are you doing today, Steve?”

No response.

Abington had fixed his gaze on the framed print of the Boston Common on the wall before him, but he seemed to be looking through it, not at it. Carrie was close enough to smell detergent and cleanser; he smelled institutionally clean. She checked her chart again. No address listed. No emergency contacts. He could have been homeless, and now in the care of the VA system. What did they use for soap where he lived?

“I'm the surgeon who is going to perform your DBS procedure today. I wanted to meet you before the operation in case you had any questions for me. Do you have any questions, Steve?”

Abington turned his head slowly, dreamlike, as through pushing through molasses. His mouth began to twitch, perhaps to form a word. But all that came out was a guttural noise like the clearing of a throat.

Carrie knew that the DBS had to be done within a window of opportunity immediately following the virtual reality simulation, when the negative memory was most fresh in the mind. She did not know exactly where DARPA conducted the simulations, or who had escorted Abington to the exam room, or where that person had gone. Those questions were well outside her area of responsibility.

“There are lots of bruises on your arms, Steve. Can you tell me how you got them?”

Abington shifted his gaze to one of his battered arms. He lifted the limb slowly, like a marionette whose string was pulled, and studied the arm with detached, vague curiosity. Then his face slipped back into that dead-eyed gaze.

Carrie moved to check his vitals, and he did not resist. Blood pressure: 90/60. Perfectly normal. His temperature was 98.6 degrees, and his reflexes were normal. Heart rate was also in normal range for a resting adult. She put a penlight up to his eyes—five-millimeter pupils, a bit dilated but equal, and briskly reactive to the flashlight.
Good
. All the consent forms had been signed. There was no reason not to proceed with the surgery.

“Steve, do you understand what's going to happen? You're scheduled for a very important operation.”

Once again, Abington's mouth began to twitch with words he could not quite form. Then, surprisingly, he started to move his body, bouncing where he sat like an anxious child, and massaging the bruises on his arms. To Carrie it looked as though his drained battery had somehow sparked back to life.