Balance Due had been the black section of Itta Bena. I had been a small child the last time I'd visited there, but I still remembered the smell of raw sewage, which raised sulfurous bubbles in the stagnant, scum-carpeted ditches alongside muddy, unpaved roads lined with weathered wood shacks, rusted corrugated metal roofs, and wood-fire smoke coming out of battered tin stovepipes.
"Killed my uncle and aunt," Tyrone said. "Left me with this souvenir." He swept his index finger casually across the scar. "Made me want to be a trauma surgeon." "I thought drive-bys were a big-city thing."
He shook his head and returned to the keyboard and display, talking as he worked.
"Every small town in the Delta has got its Crips and Bloods, or a bunch of drug-thug wannabes who are half as smart and twice as dangerous." He paused. "That's why I live way out in the country, at the end of a dirt road." He nodded to himself.
"What happened to the people who shot you?"
"Dead," Tyrone said without emotion. "They crossed somebody. Somebody zeroed them out. End of story."
An instant later the EEG appeared on the screen.
"Okay, that's the new one," I said. "Can you display the reference file for comparison?"
An instant later, we had the two files on-screen.
"The reference EEG's been consistent for almost six years, consistent with a persistent vegetative state in this subject, a forty-four-year-old female suffering from profound brain damage resulting from a motor vehicle accident." It felt odd to describe
Camilla in the dry, impersonal language of grand rounds, but it focused my objectivity and made me reach deeper for details than I might otherwise have.
"Okay, you can see the new EEG from yesterday differs significantly, indicating a substantial increase in higher brain function."
"How do you know it's higher brain function from looking at this and not brain stem or something else?"
"Good question." I traced the jagged-line patterns with the cursor. "Notice the P15 peak absent on one side and markedly prolonged in latency on the other." He nodded.
"And here, BAEPs show neither wave IV nor V on either side."
"Meaning?"
"I have an idea, but let's see what the scans tell us," I said uneasily. An increase in higher brain might mean an end to her coma.
"Why would things be the same for six years, then suddenly change?" Tyrone asked. "I thought once you got this far into PVS, nothing ever improved." I recalled my last conversation with Flowers.
"Well, the patient recently suffered from a severe, antibiotic-resistant bacterial infection resulting in temperature spikes over one hundred and five degrees. Sustained high fever can dramatically affect the brain."
Tyrone nodded. "PET or MRI now?"
"MRI."
I grew increasingly uncomfortable as we went through the MRI and, later, PET scans.
"It looks familiar, the pattern here," I told Freedman when we had gone over the scans for the third time.
When I finally recognized the pattern, the significance hit me like a hammer. "Oh, Jesus," I whispered. Freedman turned in his chair, his face full of startled concern. I grabbed the back of the chair for support.
CHAPTER 38
"Dr.-uh, Brad? You okay?"
I shook my head. Freedman got up quickly and helped me sag into his chair. We remained like that as I struggled to calm my breathing. Finally, I regained control, took a deep breath, and let it out slowly.
"Can you pull up the recent EEG and PET?"
"Sure." Freedman leaned over the keyboard and brought the scans on-screen. "Here." I tapped at the monitor. "And here… while higher brain functions are increasing, there's no change in the activity of the lower brain and brain stem. Remember that MRI of the ventral part of the rostral pons?" As my horror grew, I struggled to keep my focus on presenting Camilla like a grand rounds patient. "Uh-huh."
"Okay, now look over here, and there's clear evidence of recovery of higher brain function, especially in areas associated with awareness and consciousness."
"So this patient is coming out of the coma?"
"It appears so."
"Induced by the fever or the bacterial infection?"
I nodded dully at the implications.
"That's good."
"Maybe," I said.
Tyrone started to ask another question, I stopped him with a raised index finger as I grabbed my cell phone and hit Jeff Flowers's speed dial. I turned to Tyrone as the phone rang.
"The scan patterns are a variation on what is known as locked-in syndrome."
"Locked in?"
"Usually from auto accident trauma and strokes, sometimes by pontine lesions, which damage specific portions of the lower brain and brain stem while leaving little or no damage to the upper brain."
Flowers answered.
"Jeff, it's Brad Stone," I said urgently. "We may have a situation."
"Let me get to a place where I can talk," he replied.
As I waited, I pointed at the MRI image on the monitor display. "Look closely at this area and the pattern of hypodensity where the tissue has been destroyed. The pattern of damage leads to quadriplegia and, depending on the extent of damage, easily leads to death without artificial ventilation. This patient's death-ah, case, I mean-did not require ventilation, but all voluntary muscle function was lost as well as higher brain functions- until yesterday."
Flowers's voice came hack on the line. "Sorry, Brad, I was in a staff meeting.
"Thanks for taking the call. Look, Jeff, I think we have a case of locked-in syndrome developing."
"Dear God."
"Yeah. Can you do some tests to make sure."
"Anything you need."
"Thanks. As you may remember, a lot, if not most, people with locked-in syndrome retain some small degree of voluntary control over eye movement or eyelid function. We know Camilla has had neither of those. We need to determine if that's changed. Additionally, we need a functional PET to determine if she's experiencing sensory perceptions-vision, hearing, touch-the whole gamut."
Any specific tests or protocol?"
"You pick it. We need to know whether she is aware and conscious even if she is unable to communicate."
Flowers's breath caught, echoing my own of a few minutes ago. "I never imagined in my worst nightmare it could come to this."
"I know the feeling."
"Okay. I'm on it now. Should I call you back on your cell?"
"Uh-huh. And could you upload the new scans as soon as you can." I explained my ability to retrieve them. "If for some reason you can't get hold of me, you can call Dr. Tyrone Freedman here at Greenwood Hospital." I read the number and extension off the phone. Tyrone also offered his cell number, which I passed along before ringing off.
"This is really deep," Freedman said.
I turned slowly and looked up at Freedman. "People with locked-in syndrome usually retain their ability to see, hear, feel emotions, understand spoken language, analyze complex thoughts-everything cognitively and emotionally, but all the wiring to their muscles that allows them to interact with their environment doesn't work. I'm terrified this patient's consciousness has awakened inside a black void without sight, sound, or other senses, perhaps feeling pain without any ability to express the feeling or do anything to decrease it. Something like being buried alive, but without the compassion of death to look forward to."
"Oh, man." Freedman's voice was dull, flat, and low as the implications played across his face. "I imagine hell would be a lot like that."
He opened his mouth, but before he spoke, his pager went off. He plucked it off his belt.
"Oh, great," he said as he read the text message. "All hands on deck. We've got all our ambulances filled with incoming gunshot wounds, but we don't usually staff up until after it's dark."