Entangled Realms

Chapter One

I t is odd how events leading up to a crisis seem so ordinary, so innocent. However, through the scope of retrospection, these same happenings may be judged to clearly mark the path to calamity. In this way, the minutiae of everyday life are inextricably tied to our ultimate, unknown fate. In just such an instance, Rachel Lajoie did not see it coming.

The call came at shortly past one in the morning. The sound of the telephone, rather than causing him to awaken instantly, as was usually the case, became incorporated into a dream he would never remember. His wife, Sheila, gave him a poke in the ribs with her elbow, reached across, picked up the phone and handed it to him.

Dr. Lee?

Yes, he mumbled.

Phil Roberts here.

Yes, Phil, fully awake, now.

Sorry to get you out of bed, but we need you here in the ICU, stat.

Okay, what do you have? Just give me the short version for now.

Sure. We’ve got a thirty-two year old woman with a bleed. CT shows an intra-cerebral blood accumulation in the left frontal lobe with a midline shift. She was still breathing when I did the intubation but she’s been unresponsive. Her pupils are sluggish and unequal. I’m afraid she’s on her way to herniation. Don’t have much history to give you but, according to the boyfriend, she must have gotten up to pee and just passed out. No sign of trauma on exam. The guy was awakened by a sound in the bathroom and when he went to check, he found her on the floor. He immediately called 911. We were the closest hospital so they brought her here.

"You are hyperventilating her?’

Yes, we’re keeping her respiratory rate in the mid-twenties. That seems to be working. I’m a little worried about her blood pressure, though. It was 190/110 last check.

Try to get that pressure down and make sure you do a drug screen and run the coagulation studies with her labs. I will be right along.

Will do, and the labs are already in the works.

One other thing, Phil.

Yes?

Alert the MRI crew. I am probably going to want a scan ASAP.

They’ve already been called.

Good man. See you in a few.

In another life, Winston Lee, MD, or Win as he was affectionately known by co-workers, friends and family, was Li Wenlong. Then he was a citizen of Shanghai, a top medical student at Fudan University. Like most Chinese children who come from privileged backgrounds, Win had been taught English since a small boy. Consequently, his language skills were superb. And, like so many, he sought to further his training in the US. That is how he became a neurosurgery resident at Emory University School of Medicine in Atlanta. His original plan was to finish his training in the US and then head back to China where he would become a famous neurosurgeon at Zhongshan Hospital in Shanghai. But, of course, that was before he met Sheila, the OR nurse who couldn’t keep her hands off him, or was it the other way around? It was too much for his Asian sensibilities and before he knew it, Sheila was pregnant. That was eleven years ago. Plans changed. Now he was the father of three adorable daughters and Chief of Neurosurgery, not at Zhongshan, but rather at Piedmont Hospital in Atlanta. Life was good.

Normally, it was only a ten minute drive from his plush home in northwestern Atlanta to the hospital. In the middle of the night, his vintage Porsche could make it in a shade over seven. The police knew him as one of the good guys so there was never a problem of being stopped.

On arrival, he walked quickly into the first-floor ICU. Dr. Phil Roberts, one of the brightest intensive care specialists in Atlanta, was sitting at a computer writing his note.

Winston sat down beside him. "Any change?’

Nope, pretty much as I described. We did get her started on a nicardipine drip and that got her systolic pressure down to 145. I’m happy with that.

Yeah, that’s good. Don’t go any lower. We need to keep the blood pressure in the brain high enough to supply that sketchy zone around the clot but not so high as to promote bleeding.

Speaking of the clot, you haven’t seen the scan yet, said Phil.

Nope, let’s take a look.

Phil pulled the images up on the computer.

Nasty, said Win. I will need that MRI right now. It would be too risky to do an x-ray dye study at this point, but I do need to know what vascular structures are involved. This is probably a big arterio-venous malformation that let go.

I agree. She is in the right age group.

What bed is she in?

Twelve.

Win walked over to where his new patient lay. Standing by the bed, holding her hand, was a man whom Win estimated to be in his mid-thirties. He was thin, medium in height and handsome in that all-American, square-jawed, probably-a—runner sort of way. His dark hair was cut short to minimize the effect of his receding hairline. It was the horn-rimmed glasses and the intelligent eyes that really gave him away, though. He was probably a professor of something-or-other, either at Georgia Tech or Emory. Win guessed Tech.

Hello, I’m Dr. Lee, the neurosurgeon. And you are… ?

Terrence McGuire, Rachel’s fiancé. Call me Terry; everybody does.

Well, Terry, so sorry to be meeting you under these circumstances. I’m sure Dr. Roberts has already told you that this is a very serious situation. Rachel has sustained a hemorrhage into the substance of her brain. Of course, that means that, by definition, there is already some brain damage. How much, we can’t be sure. It could be just a little or it could be a lot. Our more immediate concern, though, is increased pressure inside the skull. If not relieved the pressure is likely to be fatal. Do you understand?

Yes.

What we need to do first is an emergency procedure to decrease the pressure; then we will look to stopping the bleeding and removing the clot.

Where is it coming from, the bleeding?

Well, I will need a little more information to be certain, but the most likely source is what we call an AVM, which stands for arterio-venous malformation. Due to a quirk of nature, on rare occasions high-pressure arteries and low-pressure veins get hooked directly together. Since the veins are not meant for the pressure, they become dilated, stretched out so the walls become very thin. Sometimes they rupture.

Win could see the tears welling in the man’s eyes and could imagine what was going through his mind. Part of him wanted to take him out into the waiting room, sit him down, and offer some comforting words; but that little inner voice was urging him not to waste any time. At this stage, every second counted. We need to get going. Ordinarily in such situations we like to ask the next of kin for permission to do the procedures.

That would probably be me. We are not married but we’ve been together for seven years. Rachel’s parents are both gone and she was an only child. There are some cousins in Maine but she has not had any contact with them for as long as I have known her.

Okay, that’s good enough for me. Do I have your permission to proceed?

Of course.

Good. Then while I’m getting things ready, we’ll have you sign a consent form.

Truthfully, it was only a matter of minutes and Rachel was being whisked into the operating room. The first task at hand was to relieve the pressure that threatened to cause a fatal brain herniation. The brain cavity has very little room for extra fluid or tissue. The blood was taking up too much space. Consequently, brain structures to the left of the midline were being displaced towards the right. If the pressure was not relieved, and soon, parts of the left side of the brain would be squeezed under a membrane that divides left and right sides of the brain cavity. If that were to happen, vital brain tissue would be injured irreparably, major blood supplies disrupted, and that would be that.

The indignity of a surgical prep was never lost on Win, especially when done in haste. In seconds, Rachel was transformed from having beautiful, shoulder-length, red hair to being totally bald. But it was necessary. Ironically, coma saved her from the distress of that particular moment.

Despite the fact of Rachel’s insensible state, Win took the precaution of injecting local anesthesia into the area of scalp he intended to incise. Once done, he retracted the edges of the incision and, via that opening, drilled a burr hole through the skull. This brought into view the membrane covering the brain, called the dura. Due to the pressure, the dura protruded into the window that had been created. Win then opened the dura, exposing the surface of the brain. With very sure hands and at just the right angle, he then passed a small catheter through the brain into the fluid-filled lateral ventricle. When clear fluid began to drip from the end of the catheter, tubing was attached that led to a transducer. This allowed monitoring of the pressure. The catheter system also allowed for draining cerebrospinal fluid as a means of lowering the pressure.

What’s the fluid pressure now? Win asked.

I’m getting about 20 millimeters of mercury, replied Pete Baxley, the anesthesiologist. Pete was smart and, as he would gladly tell you, from Texas. You had to be around him awhile to know how smart he was. But the part about being from Texas was hard to miss. When he was in the OR, he had to use special shoe covers just to go over his pointed cow boy boots.

That’s still a little high. Let’s try to get her down around 10, Pete. You can stop hyperventilating, though.

Okie, dokie, son. I’ll just open up that little valve there and let out some fluid. Then I’ll drop her respiratory rate down a bit, he drawled. That should do it.

Great! Can we move her from here right into radiology? We need to get an MRI.

Don’t see why not, said Pete. I’m going to give her a little Propofol just in case she begins to wake up.

Good idea.

The MRI machine at Piedmont was state of the art. It had the triple capacity for doing high-resolution imaging of brain structures, magnetic resonance angiograms for imaging blood vessels and functional MRI for assessing changes in blood flow related to neural activity.

MRI involves placing the patient in a very strong magnetic field which is produced by a superconducting magnet. The spin axes of the hydrogen nuclei in the body’s water molecules align with the magnetic field. A sequence of radio-frequency electromagnetic pulses is then transmitted into the patient and the RF pulses cause perturbations in the spin alignments. When each pulse is over, the spin vectors flip back into alignment, causing the emission of billions of tiny radio signals. Additional 3-D information is obtained by inducing gradients in the magnetic field. The myriad signals thus generated are analyzed by a computer and, over time, an extraordinarily detailed image is formed.

Special MRI-compatible equipment had to be used during the scan. Otherwise, the magnetic field environment would interfere with monitoring devices and the ventilator. With ordinary objects, there was also the potential of metallic things flying around when the magnet was powered-up. There were horror stories about screw drivers being left behind by scanner technicians. Once Pete had made the necessary equipment changes, Rachel was positioned in the scanner and they were ready to go.

Win stood behind the technician, looking over his shoulder as the data accumulated. Pete remained in the scanner room, continually checking Rachel’s heart tracing, blood pressure, intra-cranial pressure, core temperature and oxygen saturation, prepared at a moment’s notice to abort the scan and to perform any resuscitative measures that might be necessary.

What’s the quickest you can do all three exams? Win asked the technician.

The fMRI takes the longest but with this new scanner, I can probably get everything I need in twenty minutes. The computer is wicked fast!

Inside the magnet tube, Rachel was oblivious to the loud clanging which was a consequence of immense, oscillating forces between the gradient coils and the main magnet.

The first images to emerge were the non-contrast views of soft tissue.

Not as bad as I thought it would be, said Win. Looks like a two to three centimeter clot in the left prefrontal lobe and about a centimeter deep to the cortex. I think it is far enough from the motor strip that, if she recovers, motor function won’t be an issue. What do you think?

You know, doctor, I’m not a radiologist, responded the technician, and I’m not supposed to give an opinion…

Oh, go ahead, said Win. I won’t tell anybody.

Well, I agree about size and location. Also, it looks to me like a fair amount of swelling has developed around the clot.

Yes, that’s what I thought, too.

"Just looking at her CT, I would have expected to see more midline shift but it appears that you have stabilized that problem with the, . . . , what do you call it? You know the procedure where you put the catheter in her brain ventricle?

Ventriculostomy.

Yeah, that’s it. Compared to her first MRI, the midline shift is much improved. Good job, doc.

Thanks. Do you think we can see the fMRI images now?

They should be finalized. Yeah, here we go… New images popped up on the screen.

Boy that makes it pretty clear, doesn’t it? said Win. Definitely, there’s a zone of decreased blood flow around the clot, corresponding to the area of swelling. Tissue at risk… What’s the bright spot, though, pointing at the screen, right there, anterior to the bleed?

Damned if I know. Pardon my French. It’s far enough from the clot, that I don’t think it is related. The other thing is the intensity… It’s too bright to be real. Must be a glitch in the software. I’ll check with the Siemen folks to see if they have any ideas.

Okay, on to the MRA. We don’t have time for glitches.

MRA stands for ‘magnetic resonance angiogram. This would tell the tale insofar as the source of the bleeding and what surgery might entail.

You nailed it, guy, said Win. The detail is superb. This is as good as any dye study I’ve seen.

Thanks, boss, replied the tech. It’s this new machine. The resolution is so high, we can almost image micro-structures.

Yes, I can see that. The detail is amazing. I can also see that I have my work cut out for me. No question now. It’s an AVM. These things always look like a medusan tangle of snakes to me and every one poised to bite you. I would put this particular one as moderate-to-high grade by the Spetzler-Martin system. Figuring out which vessels to clip first, pretty pictures aside, will be the challenge of the day. I could screw that up very easily.

That’s why they pay you the big bucks and not me.

Well, we had better get her back in the OR before this thing cuts loose and bleeds again.

Neurosurgeons, somewhat deservedly, have a reputation for being difficult. That is, they tend to be rather high-strung and to lose their temper, especially if things are not going well during an operation. It is, after all, a very stressful profession; the tiniest slip can result in death or permanent disability. Fortunately, however, Win was not the usual sort. The more complex and hairy the situation, the more calm he became. It was as if some outside force took over and guided his mind and his hands in a virtual ballet of harmonious precision. Many, many people were alive because of his skill. Outside the OR, too, he was always polite and respectful and never lorded it over anyone. For most folks who worked in the hospital, he was just Win. In terms of the fusion of humanity and professionalism, that familiarity was the ultimate compliment. Neither bad doctoring nor arrogance was ever rewarded in that way.

Universally, Win’s patients adored him. His quiet confidence, his competence and his compassion were all so evident. How could they not? Rachel, literally, was in the best of hands.

The digital timer on the wall flashed thirty-five minutes. Rachel’s head was positioned in a three-point immobilization device in order to keep it perfectly still. Win had already made a sweeping incision on the left side of Rachel’s head, exposing the outer table of her skull. Using a special saw, called a craniotome, he had then methodically freed up a bone flap, allowing access to the left frontal area of the brain. The room was quiet as he opened the dura, the membrane covering the brain.

Okay, it’s bad, but I’ve seen worse, said Win. Maybe we will be able to salvage some brain cells here.

He pulled an operating microscope into the field.

Pete, I’m going to need for you to really drain that cerebrospinal fluid down, now. That will help me minimize having to retract the brain for exposure. I don’t want to touch anything I don’t have to. Also, with the drop in the CSF pressure, she should be able to tolerate a BP of 100 systolic without compromising her cerebral perfusion. So try to shoot for a pressure in that range. That will lower the risk of an intraoperative bleed. Keep a close eye on the intra-operative EEG for brain wave bursts, too, and if you see any, suppress them with phenobarbital.

Okie, dokie, Win.

The first step was evacuation of the clot. This required Win to dissect down through the brain tissue into the cavity formed by the hemorrhage. Then very carefully, using special suction, he would remove as much of the blood as could be achieved safely.

Here we go guys. Be ready for whatever.

The trick was to minimize disturbance of brain tissue; also, not to stir up any fresh bleeding.

The clot is about a centimeter from the surface. There is a conveniently located convolution. If I can get down into the base of that, I won’t have too far to go.

As with all brain operations, this required very delicate and meticulous execution, but Win performed flawlessly. He was able to get the suction catheter into the cavity and to remove most of the clot. Fortunately, no active bleeding was encountered. Win made it look easy. How are we doing? he asked Pete.

Steady as a rock, buddy.

Great. Next is to find those arterial feeders and clip them. Let me see the MRA images.

A computer screen was suspended over the operating table. One of the OR techs, with the click of a mouse, brought up the images showing the tangle of blood vessels around the bleeding site. The digital timer now showed that ninety minutes had elapsed.

Can I see the three-dimensional simulation?

The scanner computer, by changing the angle of view, had the capacity to show spatial relationships of structures which were unobtainable in a simple, two-dimensional, flat screen projection. True, holographic images were not yet available but it was only a matter of time.

Extraordinary, this new scanner is absolutely amazing! Catheter angiograms will soon be obsolete.

Can you get to all the feeders and the drainers? asked Pete.

Yes, I think so. It is quite a jumble but… Keep that BP down over the next few minutes, will you, Pete? I will try to get everything clipped and then we can gradually bring it back up. Hopefully, she won’t spring any leaks. That will be the test.

Using the three-dimensional MRA as a guide and, looking through the operating microscope, Win carefully identified the arterial vessels that supplied the AVM, double—and triple-checking to make certain that, in each case, the vessel which he intended to obliterate was not supplying normal brain tissue. Once convinced, he systematically choked off the blood supply by applying small, titanium clips around the culprit vessels. This process took the better part of two hours. They were now four hours into the operation.

So far, so good. Let me get the venous side now, said Win. Once we get the whole thing isolated, Pete, I’ll give you the word and you can do a fluid bolus to raise the pressure while I check for leaks.

Again, the extremely exacting procedure was conducted on the thin-walled, venous side of the malformation. This took another hour.

Okay, Pete, let’s bring the pressure back up.

Alrighty, son. We’ll start with a 250-milliliter bolus of saline. She’s currently at a BP of 100/60. I’ll tell you when we get up to 130 or 140 systolic. Is that okay?

Perfect.

Win watched the wound very carefully as Pete gave an infusion of fluids to raise the blood pressure. It was just like leak testing a car radiator. You pressurize the system.

Up to 140 now, said Pete. She’s had the 250. Anything else you want me to do?

No leaks, said Win. I think we are all set. Just give her some Decadron for the swelling. I would hold off on prophylactic anticonvulsants. If she seizes, we will treat then but otherwise best to see what she does. Now if she will just wake up.

I’ll betcha she will. You did good, son, said Pete.

Nine o’clock in the morning of

post-operative day zero:

Win was checking on Rachel in the ICU. Don’t you go home, Phil? he asked.

You are one to talk. You just got done with one hell of a case on practically no sleep and have a full day ahead.

You were here before me.

Yes, well, I get to leave any time now. My partner is taking over.

Is my new patient settling in okay?

Yes, I would have to say that she is doing remarkably well under the circumstances. Her pupils are now equal and reactive and she is moving all four extremities. We’ve kept her on a little Propofol because she was bucking the endotracheal tube. If all goes well, later today, the plan is to take her off the ventilator, give her some humidified oxygen down the ET tube, and let her gradually wake up. Maybe we can extubate her tonight if she tolerates being off the vent for a couple of hours. Does that sound okay to you?

Sounds fine to me. Ask your relief to let me know as soon as she is off drugs and cerebrating. I will want to hear what she has for a neuro exam.

Will do.

The neurologic examination would give good indication of potential for recovery. If the deficits were profound, then the prospects were not so good. However, it the deficits were minimal, that was a very good sign. Win knew that the operation had gone well and he was hopeful. But neurosurgery, perhaps more than any other surgical specialty, can disappoint, like in the saying, the operation was a success but the patient died. It happened that way sometimes.

Chapter Two

Beginning of post-operative day one:

F rom the hidden recesses of her mind emerged a train of vivid dreams, images from the past. With quickening speed, memories pierced the boundary of awareness. Abruptly, she was propagated back across time and space to the old farmhouse in Maine, to the place where she had spent her youth. She could see the house as clearly as if she were there and she could hear the sounds, smell the smells and feel the cold, for, in her mind’s eye, it was winter. Beyond the bare maples that shielded the dwelling, rolling, snow-covered pastures glowed in a pale, suffused light. Around the pastures were stone walls, shoulder high, that stood as testimony to the four generations of Lajoies who had lovingly tended this land.

When Rachel’s great grandfather, Reny Lajoie, first brought his family from Canada, in the early nineteen hundreds, this part of the state was covered with dense forest, nothing but trees for miles in every direction. To make a new life, a better life, Reny applied his skills as a woodsman to cut some of those trees. As he labored, a clearing grew, first just large enough for the house and barn, then a good-sized garden, then a small pasture, then the fields. Every board that went into the buildings, almost every scrap of food that they ate and the fires that cooked their food and warmed their bones, were all, either directly or indirectly, products of the rocky soil.

As the glaciers retreated from Maine at the end of the last ice age, they left a rich deposit of stones, varying from pebbles to the size of a house. To farm this land meant exhuming thousands of stones, one-by-one, and moving them to the edge of the clearing. This was how the stone walls came to be. Each spring brought a formidable harvest of stones, heaved up by the frost and, each spring, the stone walls grew higher and higher, marking the passage of time, as the sands of a giant hourglass.

The immaculate, white clapboard cape stood in stark contrast to the dark rambling barn, its roof saddled by more than a century of winter snows. In dreams, as in reality, home is that place of continuous belonging, a place where family is enjoined with the land, the buildings and the animals… enjoined by years of toil and struggle.

Rachel’s parents had wanted a passel of children but were blessed, as they always said, with only one. Be that as it may, Rachel was a very special child. Enveloped by the love of her parents, she grew to be a confident and cheerful and tenderhearted young woman. And according to the teachers in the little rural school, she seemed extraordinarily bright. They acknowledged that she was beyond them and that she was learning a lot on her own. Her parents, unable to understand fully, just loved her all the more for her special gifts.

The dream, as it turns out, was a vehicle, transporting Rachel to a particular night on the farm, a happy occasion, perhaps the happiest in her bank of memories. The shadows lengthened and the sun set across the fields. From her vantage, she could see the lights of the Christmas tree shining through the living room window, reflecting a rainbow of colors off the crust of the snow. She could see her mother hovering over the wood range in the kitchen, face flushed, stirring this, tasting that, wiping her hands on her apron, smiling as she went about the last minute preparations for Christmas dinner.

The barn door was open, dimly lit by a string of bare bulbs that hung from the hand-hewn posts. Her father was just out of sight but she could hear him speaking gently to the cows as he cleaned their teats and hooked them up to the milking machine. Hello, dearie, relief is on the way. For you, too, sweetie… He always said, Be kind to them and they will return the favor. He was right.

She stood for a few minutes at the gate leading out into the pasture, turning her attention to the rapidly darkening sky. The sliver of a moon was just making its way over the western horizon, pulling behind it a cloak of blue-black on which were sewn countless jewels of light. It was a cold night but beautiful. And on that night, despite the cold, enveloped by the love of her parents and the simple life they embraced, she felt warm.

The warmth was not to last, however. Within a year of the Christmas night of her dreams, reality dealt a dreadful blow. Both of Rachel’s parents were gone. Her mother, first, from an insidious breast cancer that seemed to take her overnight, though, according to the doctor, it had been doing its evil deed for years. Then her father from a tractor accident. Some questioned whether his was truly an accident. A broken heart can lead to many things.

Rachel, at age seventeen, was taken in by her mother’s older sister, a widow who had no children of her own. This meant moving to Boston, leaving friends behind and changing schools. But her aunt did love her and, in Boston, they discovered how smart she really was.

There was a math teacher at Belmont High School who enjoyed challenging his students. Rachel, having taken a battery of placement exams, was steered into his advanced algebra and analytical geometry class. One day, he put up a theorem on the board. He called it Fermat’s Last Theorem. It looked pretty simple but, according to the teacher, it had taken 358 years for someone to come up with a proof and, to do so, whole new branches of mathematics had to be developed. As it turns out, Fermat had scribbled this little theorem in the margin of some notes with the comment that he had a nice proof but there wasn’t sufficient room to write it. That proof was never found.

Rachel was intrigued. She took that theorem home and began working on it. Then, one night, the pieces fell into place. She had found a solution using classical number theory, perhaps the very one that Fermat had stumbled upon over three hundred years before.

The teacher was incredulous. There was no way that a high school kid could come up with that proof. He sent it over to a friend in the math department at MIT who shared it with his colleagues. They all agreed that it was a valid proof. They wanted to talk to this girl.

Rachel bravely presented her proof at a math department seminar at MIT. When she was done, the room was totally silent. They were stunned. After a full minute, they began to applaud and whistle and carry-on. Some of this normally austere group had probably never done such in their entire lives. They called her the new Ramanujan. Rachel, of course, was mortified.

A voice was calling her name. It seemed at first to come from a great distance. Then, suddenly, it was very close and she awakened.

Terry studied Rachel’s face as she transitioned into consciousness. Her eyelids fluttered then opened. She looked about, confused, trying to focus. Her eyes met his.

Terry, is that you?

Yes, it’s me. Who did you expect? he asked, smiling.

Thinking she was still in Maine, What are you doing here? You are not supposed to be here.

It’s okay. You are in the hospital.

In the hospital?

Yes, you’ve been quite ill.

I have?

Yes, you had an operation. Do you remember?

No.

You had a hemorrhage… a hemorrhage in your brain.

How long have I been asleep?

Not that long. You came in last night, just a bit more than twenty-four hours ago.

What time is it now?

Oh, about one o’clock in the morning.

Have you been with me all this time?

Of course.

"I’m so