Trauma (19 page)

Lifting the folder, Dr. Finley said, “This battery of psychometrics documents Ram
ó
n's impressive progress. In addition to the MMPI, we concentrated mostly on tests of all aspects of memory function, emotional intelligence, and executive functioning. There's an alexithymia scale.”

Carrie was familiar with the Minnesota Multiphasic Personality Inventory, or MMPI, but had not heard of the alexithymia scale and asked Dr. Finley to clarify.

“It's when people have difficulty describing and expressing their own emotions,” Dr. Finley said. “Kind of a measure of how much people are in touch with their feelings. It's a useful addition to other tests of emotional intelligence and frustration tolerance. They're far from perfect, but we get a pretty good picture of someone's personality when we analyze the entire test battery results.”

Adam didn't seem to have that much difficulty there, Carrie thought. He seemed as caring and understanding as ever. But she could not deny his explosiveness, as seen in David's bloodied nose and the damage Adam had inflicted on his Camaro. Adam was a firework of violence, awaiting only a match.

“You thought Don McCall was impressive,” Dr. Finley said. “Wait until you meet Ram
ó
n.”

 

CHAPTER 25

The Department of Neurology and Neurosurgery at the VA occupied an H-shaped section of the second floor in the main building. There was some talk that the department would move if they ever finished construction on the annex, but that was a very big “if.” While it was a bit cramped, there was a certain convenience to having the surgical suites and the neurology exam rooms all in close proximity.

Dr. Finley led Carrie at a brisk pace to exam room five in the neurology unit. The exam room was like most Carrie had been in over the years; not that different from the one where she'd almost died. It had a waist-high counter, a sink, and various instruments for checking vitals.

Seated in the aluminum chair next to the examination table was a clean-cut, neatly but casually dressed and well-groomed Hispanic gentleman, who stood and shook hands with Dr. Finley. He was powerfully built and quite handsome, Carrie noted.

“Hey, Doc. Good to see you.” He spoke with a youthful and vibrant voice, the voice of somebody excited for the future.

Carrie had to look carefully to see the slight asymmetry of the neck where the stimulating wires had been tunneled from the scalp, running down beneath his right clavicle to attach to the battery pack in his upper chest.

“This is Dr. Carrie Bryant, who has taken over for Dr. Rockwell.”

“Yeah, I heard about his accident,” Ram
ó
n said. “Terrible. He was a terrific guy. Nice to meet you, Dr. Bryant. You've got big shoes to fill.” Ram
ó
n's hand, half the size of a baseball mitt, swallowed Carrie's as he gave her a firm but gentle handshake.

“I've heard only great things about Dr. Rockwell,” Carrie said.

“Mind if she examines you, Ram
ó
n?”

“Be my guest,” Ram
ó
n said. “But I can probably examine myself by now.”

Carrie resisted the urge to come right out and ask if he ever heard the same words spoken over and over again. Her old pal Val would say Carrie possessed all the subtlety of a jackhammer.

Carrie proceeded through a series of questions pertaining to Ram
ó
n's current lifestyle. It was clear that he was socially appropriate, concentrated well, and attended to questions with insight and flexibility. He enjoyed his work, and even gave some thought to getting married to his longtime girlfriend.

“Considering she could have charged me with domestic assault not that long ago, I'd say I've come a long way.” Ram
ó
n's smile projected the kind of cocky confidence required for the battlefield.

“Can you elaborate?” Carrie asked.

How far had Ram
ó
n really come, she wanted to know.

“I used to get drunk and jealous. I hit her. More than once. Not something I'm proud of, obviously. Once I got my anger under control with the DBS I could actually listen to what the therapists were trying to tell me.”

“And that is?”

“That I was trying to control her because I was really afraid I was going to lose her.”

The insight impressed Carrie, but she was curious to see how he would react to questions about his war memories. “What happened during that ambush? Do you mind talking about it?”

Ram
ó
n's eyes flashed, but he just shrugged. “Honestly, I don't remember all of it.”

“Share what you can,” Carrie said.

“I was stationed at Camp Dwyer in the Helmand Province, a place we lovingly referred to as ‘Hell, man.' Luxury there was a sandbag that could double as a couch,” Ram
ó
n said, with the detachment of a newscaster. “We were on a scouting mission, looking for a terrorist named Nasser Umari. He was a big-time anti-Coalition dickhead, pardon my language—hooked up with the Taliban, and other militant groups, too, I suppose. We had just fast-roped from an MH-47 helicopter, did our patrols, and after that, exfiltrated back toward our extraction point. There were about fifteen of us in the fire team.” He paused to remember. “Yeah, about fifteen. It was the usual oven hot that day. A few more degrees and the sand would have turned to glass. We had just vaulted a mud wall in what looked like an abandoned town when machine-gun fire seemed to come out of nowhere. Me and three other guys fell back into an alley where I figured we'd get a better read on the enemy position. But the Taliban had machine-gun positions all around and next thing I knew I got shot in the arm. Hurt like a mother, you know what.”

Ram
ó
n rolled up the sleeve on his white cotton T-shirt to show Carrie a scar on his bulging trapezius a little bigger than a quarter. She was sure his body was riddled with other scars that had nothing to do with DBS surgery.

Ram
ó
n continued. “We were returning fire, but I had crawled into a doorway to try and clot the wound. Next thing I knew, an RPG struck our position and two of the guys in the alley with me couldn't have an open casket at their wakes. It was that fast. But, I guess that's war. The bad guys are after us, and we're after them. Kill or be killed, right?”

Carrie was taken by how calm and controlled Ram
ó
n seemed. She saw no reticence or protectiveness. He remained focused, his mind targeted in the present, the past trauma mitigated by perspective. She was duly impressed. If emotion was a color, Ram
ó
n's ambush had been rendered in simple black and white.

“So, what sort of problems are you having?” Carrie asked.

Ram
ó
n gave this some thoughtful consideration. “Well, sometimes I don't seem to care about things all that much,” he eventually confessed. “I don't get as worked up about a lot of things that used to bother me, either. Mostly that's good, but I wonder if sometimes I'm too relaxed. If I get behind in work, I don't seem to care or worry as much. That's not me. And I don't remember a lot about my time in Afghanistan. I mean I do, but I don't. There's lots of holes. People have to tell me things, and sometimes it doesn't make sense. But I can live with that.”

“What about your hearing? Do you hear voices?” Carrie asked.

“No.”

“How about hearing sounds or voices that you know are real, but they seem to go on and on in your head, like an echo that never stops?”

Dr. Finley looked at Carrie, nonplussed. She knew these questions would produce that kind of reaction. They were way off base for this sort of exam, but Dr. Finley did not intervene.

“No,” Ram
ó
n said.

Carrie went on to complete her examination, standard bedside tests of memory and cognition that she knew he would pass with flying colors. She analyzed his vision and eye movements, his hearing, speech, and swallowing. His motor functioning, gait, sensation, and reflexes were all perfectly normal.

“Thanks,” she said. “It was a real pleasure meeting and talking with you. And thank you for your service.”

“My pleasure. See you again. And good luck with the program.”

She shook hands again and Carrie followed Dr. Finley out of the exam room. Dr. Finley had more to discuss with Ram
ó
n, but he said he wanted to speak with Carrie in private first.

“Amazing, right?”

“I'm truly astounded,” Carrie said.

Dr. Finley's pride and enthusiasm were infectious, but Carrie could not embrace the moment to his degree. Ram
ó
n had reinvigorated her mojo, but her curiosity had not been fully satiated.

“Was Steve Abington ever diagnosed with schizophrenia? Any history of the disease in his family?”

Dr. Finley thought on it and shook his head.

“No, why do you ask?”

“Just curious,” Carrie said.

The answer was expected and did nothing to waylay her concerns. Post-op delirium or some strange side effect to DBS? It was impossible for her to say. Carrie contemplated her next move. She was scheduled to be back in the OR on Friday, for a DBS surgery on a marine named Eric Fasciani. Before she could share Dr. Finley's enthusiasm completely, she had to see whether the condition happened again.

If she were careful, Carrie could go see that patient post-op, and Goodwin would never be the wiser.

 

CHAPTER 26

Carrie had never acquired much of a taste for alcohol. She seldom drank, but on Friday night, two days after meeting Ram
ó
n Hernandez, she sat alone in a booth at Bertucci's and sipped from her glass of Sauvignon Blanc. Her thoughts were dim from fatigue. She had spent seven grueling hours on her feet performing another successful DBS surgery on Eric Fasciani.

The operation had gone smoothly enough, and it was easy to see how her job could become routine. Two Parkinson's cases were already on the schedule for next week, and they would be virtually identical procedures. Today it had been Eric Fasciani's turn on the table, and depending on what Carrie found out, it could change everything.

A middle-aged waitress with a kind face and friendly smile scuttled past Carrie's table, but backtracked when she noticed the empty wineglass.

“Do you want another?” She cleared the glass along with the remains of Carrie's salad meal. “Maybe some dessert? The chocolate mousse is amazing.”

“Sounds tempting,” Carrie said, “but I'll just get a coffee. Black.”

The waitress departed and Carrie checked the hour on her smartphone, then frowned. She was eager to get to Fasciani on the neuro recovery floor, but it was too early to see him. Her latest DBS patient represented a possible answer to the Steve Abington mystery, but he would be too heavily sedated for Carrie to properly evaluate. She needed him more alert.

Fasciani's operation had been long, but without incident. At the advice of Dr. Finley, Carrie had skipped pre-op consultation altogether. Better for her nerves, it was thought. Instead of greeting a troubled and nervous patient, Carrie saw only a shaved, bald-headed young man, deeply sedated and intubated with his endotracheal tube tied to a ventilator, and an IV drip open to KVO. It was probably better this way, and it fit right in with Dr. Goodwin's view of her role as hired help. Carrie was a technician, not a doctor. At least Dr. Finley had briefed her on the poor fellow's history.

“Three tours in Afghanistan, but it was the last one that did him in,” Dr. Finley had said. “Apparently, the attack was highly organized. A hundred fifty Taliban came running down the hillsides from four directions and riddled his base with gunfire and RPGs.”

Carrie wondered if anybody came back from the war unchanged.

“The outpost went up in flames,” Dr. Finley continued. “After this, he was a quivering wreck. He couldn't sleep without his dead buddies waking him in a sweat. They MedFlighted him out of there and eventually got him back home to Worcester. But he failed reentry miserably. He suffers from horrible flashbacks and daily panic attacks. We actually found him on the street, living out of an old shopping cart. We've got him in a shelter now, but he's made little progress.”

Carrie felt a fleeting sense of gratitude. Adam had a home, loving and helpful parents, and her. She looked over at Fasciani and saw the scars and needle tracks in his arms and neck, and the dozens of skin-raising scars on his limbs and trunk. One of his demons was heroin.

“He hasn't done too well with talk therapy,” Dr. Finley added. “And most of the time, his blood work comes back with no evidence that he's even taking the antidepressants we've prescribed. Just Valium, alcohol, Oxycontin, and other opiates. So in this case, Carrie, DBS is not just a treatment, it's his only hope, a prayer.”

The surgery was Abington redux. The small burr holes for fixing the stereotactic frame, the CT scan and superimposed computerized mapping with his earlier MRI images. The 14mm burr hole placed just where the images told her to drill, the cannula driven through to the basolateral nucleus of the amygdala, finally the electrodes, only to await Dr. Finley's confident voice coming up from the monitor on the other side of the table: “Great, Carrie. Precise and perfect signals. Lock 'em in.”

After, Dr. Finley and Carrie had met outside the OR. Her boss was beaming with pride, overjoyed.

“This is your second case this week, and you are, in a word, terrific,” Dr. Finley said. “Trust me, Carrie, you have what it takes to do this. You're a machine. I mean despite all those computerized gizmos, a lot of times Dr. Rockwell had to reposition the cannula, three or more passes at times, and I always worried about an increased risk of infection or hemorrhage. But with you, I'm sure we've got those electrodes placed where they need to be, and I'm just that much more confident in the results.”