Trauma (18 page)

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.

 

CHAPTER 24

The timing could not have been better.

Functioning as Dr. Finley's private DBS surgeon, Carrie had no clinic responsibilities, but he had sent her an e-mail to ask her to join him this morning because of a specific case on the schedule, one of his first patients who had undergone DBS for PTSD. The stars appeared to have aligned just for her.

Carrie had replayed her conversation with Abington dozens of times in her head. She had no doubt that he had repeated the phrase “follow my light” numerous times, and seemed to answer her question each time he thought it was asked, but that was not proof of palinacousis. Since Abington was off-limits, the best way to learn more, Carrie concluded, was to see another patient like him. Dr. Finley's e-mail was like manna from heaven.

At this point, Carrie's investigation into palinacousis was nothing more than an intellectual challenge. She simply wanted to know if the behavior ever manifested in others, or if Abington was truly an outlier. She was not in a position yet to broach the subject with Dr. Finley. Her confidence was nowhere near where it should be, and any claims made had to be based on evidence, not conjecture.

She had found nothing that reported auditory illusions in DBS cases treated for Parkinson's or other movement disorders. But with these PTSD patients, electrodes were being placed in a completely different area of the brain, the amygdala nucleus.

Carrie pondered this. The amygdala was not generally associated with hearing perception. She knew that. But this was an experimental program, and the brain was still an organ of profound mysteries.

Carrie was scheduled to meet with Dr. Finley on Wednesday morning, after the general neurology clinic. Dr. Finley was supposed to supervise the neurology clinic, which was otherwise run largely by the residents who rotated on three-month shifts through the VA. But Finley's increasing commitments to the deep brain stimulation program had gradually displaced his direct teaching and supervisory obligations, and on a typical Wednesday he would hold court from his office, making himself available as needed for residents. For the most part, the residents preferred to leave him alone and solve clinical problems by themselves.

Carrie had attended just one clinical round since she joined the VA's rank and file, but the DBS patients she saw that day were being treated for movement disorders, not PTSD. She had no way to correlate those patients to Steve Abington's condition. Traumatic brain injury patients comprised the majority of cases Carrie observed, with cognitive, perceptual, and language deficits usually accompanied by a hemi- or quadriparesis or seizures. Those patients whose foremost symptoms were post-traumatic stress were often referred to the psychiatry clinic, which was bursting through its seams.

Everyone realized these veterans were suffering from a brain disorder, but treatment was limited to antidepressants, antianxiety medication, or ineffective psychotropics. Acceptance into the DBS program was extremely limited during these early clinical stages, and the pent-up demand dwarfed the number of operations performed to date. Unless humanity put an end to war—likely only if humanity put an end to itself—a cure for PTSD seemed the only palliative measure for the VA's mushrooming resource woes.

Carrie arrived at Dr. Finley's office five minutes after the clinical rounds concluded and gently knocked on his door. She worried about interrupting him, but he threw the door open, as if in anticipation. A reassuring smile eased much of her concern, and he was filled with effervescence.

“Really exciting day, Carrie. I've just been reviewing the neuropsych tests on Ram
ó
n. We are clearly on track. Look at this.”

He handed Carrie a bulging manila folder full of test results and graphics referencing one Ram
ó
n Hernandez, a thirty-two-year-old male, and a veteran of war in Afghanistan. Carrie leafed through the studies.

“He was one of our first DBS cases, because he failed all the usual therapies,” Dr. Finley said. “I remember that Sam Rockwell had some difficulties with his surgery, and actually had to reposition the stimulating electrodes several times before we got adequate signals from the amygdala, but fortunately there were no obvious complications.”

No follow my light,
Carrie thought.
No arrhythmia.

With an expression like a proud papa's, Dr. Finley went on.

“Ram
ó
n Hernandez has gone from living on the streets, or in jail, to holding a respectable job as a logistics analyst for a Target distribution center. He's still on sertraline one hundred and fifty milligrams, but the Oxycontin, benzos, and beta blockers are gone, and he regularly attends the weekly counseling sessions with his clinical social worker. Last I heard, he's even got a girlfriend.”