“Can we—can we see that first slide again?” someone shouted out.
Mental exertion, Janice saw, was contorting every face, even Dr. Turnbull’s.
“When you say, ‘spontaneously regained…,’ ” someone else asked.
“I mean he stood up from his wheelchair and walked without assistance.”
Murmurs overtook the room while Janice fielded a half-dozen more questions about Cameron’s injury, surgery, and recovery. Frown lines began appearing as the physicians, struggling to navigate through this information, found themselves hitting blind alleys. A few shook their heads in what looked like cognitive surrender or its close cousin, amazement.
“Four-year spinal shock?” someone ventured, weakly enough to pass it off as a joke.
A hand went up. “I realize we’re in unusual territory here,” asked a nurse practitioner who worked in the neurology department, “but are we actually in, you know, uncharted territory? Recovery from SCIs can be awfully variable. I’m just wondering if there’s any precedent here…”
“Great question, and it’s why I consulted with Dr. Price,” Janice replied, referring to the nurse practitioner’s department head. “Let me just put something on the screen here—one sec. Okay, this is data from a two thousand seven ICCP study examining rate of spontaneous recovery after an SCI.” Onto the screen went a bar graph illustrating the percentages of paralyzed patients who’d recovered function, based on the A to E grades established by the American Spinal Injury Association’s Impairment Scale, known as ASIA. “As you can see,” Janice explained, “after one year, using the model systems, about eighty-three percent of ASIA A patients remained ASIA A”—Cameron’s former grade, meaning a complete absence of motor and sensory function below the injury. “Nine percent converted to ASIA B.” (Complete loss of motor function but incomplete sensory loss.) “Seven percent to ASIA C and one percent to ASIA D.” (Both motor and sensory loss incomplete.) “But ASIA A to ASIA E,” Janice went on, which was the leap Cameron had made: “Zero percent.
“So, yeah,” she concluded. “This is way out there.”
“What really astounds me,” said an orthopedic surgeon in the front row, before pausing to laugh: “Well, a lot astounds me here. But one thing—I’m presuming there was significant muscle atrophy in his legs after four years. So, then, the sudden onset of mobility…I mean, even if you exclude neurogenic atrophy, four years of secondary disuse atrophy alone is enough to…” He rubbed the side of his face. “Let’s forget what looks like neuroregeneration for a second. Let’s dial it down. Ambulation on its own seems really—problematic.”
“Yeah, that was my first reaction too,” Janice said. “I will note that his muscular recovery has conformed to a more typical pattern since that initial burst. For the most part he requires crutches now, as we’re starting to rebuild strength in PT. I suppose one possibility is that an adrenal rush in that moment allowed for an unusual degree of muscle contraction—”
“An extraordinary degree,” said the orthopedic surgeon.
“I wasn’t there in the parking lot,” said Janice, “so I can’t say with certainty how long he stood or how many steps he took. This was self-reported.”
“But he was able to walk at your consult, five days later? Unassisted?”
“He was,” she said. “With difficulty, but yes. He walked.”
The audience chewed this for a while.
“Is there any chance we’re looking at a somatoform disorder here? A conversion disorder?” someone asked, raising the possibility that Cameron’s paralysis had been psychological, a type of mental disorder—that he’d converted psychological trauma into physical symptoms, and that the only thing that’d been preventing him from walking since 2010 was his mind.
Janice shook her head. “The etiology of the SCI was organic,” she said. “That’s evident in the imagery. This wasn’t psychogenic.”
“And dermatome tests,” someone else added, “would seem to rule that out.”
“But is it possible—I’m just riffing here—is it possible the physiological damage wasn’t as severe as the initial presentation suggested? If you factor in the overlay of a somatoform? You’ve got penetrative spinal trauma with a patient exhibiting a corresponding lack of motor function. It’s easy to imagine his attending physician at Landstuhl thinking, well, if it quacks like a duck, it’s a duck—”
“Again, I think we can see it clearly on the scans,” Janice said. “It is a duck. Or was.”
“Somatoform, though…that could potentially explain the sudden ambulation,” said the orthopedic surgeon. “If his leg muscles had stimulation or some movement in his sleep over the years…” He shook his head, grimacing. “Maybe. I don’t know.”
“But aren’t we ignoring what appears to be axonal sprouting?” someone else said. “That seems to be the elephant in the room. Somatoform can’t account for those MRIs, folks.”
“But clerical error can,” someone said.
“An SCI with an overlaying somatoform disorder plus a scan mix-up?” said another. “Isn’t that pushing coincidence to its outer limits?”
“I’m more comfortable with coincidences than with miracles,” the orthopedic surgeon grunted.
“I’ll second that,” Janice said, a moment later realizing she’d unwittingly endorsed the somatoform disorder theory, which she found wholly unconvincing.
“What about infectious discitis?” someone else asked. “This was a penetrating wound.”
“As you can see from the imaging,” Janice replied, clicking the remote, “there’s no indication of any epidural abscess. No indications of effusions.”
“And we evaluated spinal fluid?”
“We did,” Janice said.
“Can we go back to that study for a moment?” someone asked. “What’s the rate of conversion from ASIA B to E? I’m curious. Is there one?”
Janice clicked the remote a few times. “About one percent,” she answered.
“Huh,” came the response. “So if there was some degree of sensory function present, and he was misclassified, maybe we’re not entirely in uncharted waters…”
“Based on the study parameters, yes—possibly. Dermatome test results can be variable, even within individual patients, but we should note that at Landstuhl, Brooke, and here—he never scored above zero. Not once.”
“Have we trended electrolytes?” someone said. “I might be grasping at straws but…but, hell, I guess we all are…”
This went on for another fifteen minutes, with Janice finding herself increasingly isolated onstage as certain theories gained backers and alliances started forming in the audience: somatoform versus abscess versus ASIA misclassification versus clerical error versus what an anesthesiologist deemed “shit happens.”
“I did a residency in pathology before switching to anesthesiology,” he explained. “And in pathology we sometimes had to say—excuse my language—shit happens. By which we meant the precise cause of death just couldn’t be determined, not with precision. Maybe there’s a corollary there…”
The orthopedic surgeon, with a teasing grin, swiveled around to say, “Bill, I can’t think of anything more terrifying for a surgeon than to hear an anesthesiologist uttering the phrase ‘shit happens.’ ”
Above the resultant laughter came Dr. Turnbull’s croaky drawl. “I hate to spoil all this fun here, folks, but I’m afraid I gotta cut this off,” he announced. “I’ll grant this is fascinating stuff but we could hash it out till the cows come home. I think we should all thank Dr. Cuevas here for the excellent and very unusual presentation.” All eyes were pinned on Turnbull now, since custom was for him to have the final word on case presentations—and with anything but cardiac cases, to which he often dispensed granular-level opinions, this final word tended toward coach-like platitudes. He cleared his throat. “The purpose of these lovely confe
rences, as we all know, is to evaluate care quality to determine whether there’s room for improvement. So let’s ride that pony. Anyone got a thought as to how we might’ve achieved better care efficacy here? Or what we can do better for this boy going forward?”
No one said anything.
“If we look at this from an outcome-based perspective,” he went on, “and I think we should—I’d have to say this appears to be a successful damn case. This boy came into our care as a paraplegic and during his care here regained full function in his lower extremities. I’d say he hit bingo. Anyone care to argue that definition of success?”
Again, no one said a word. Scattered shrugs were all.
“Now, Bill,” he said to the anesthesiologist, with a touch of mock-sternness. “There’s another way you could’ve put that, uh, sentiment from pathology. It’s the way my mama used to put it: The Lord does work in mysterious ways.”
“God happens,” came the anesthesiologist’s rejoinder.
This time it was Janice’s voice cutting through the laughter. “With all due respect, sir,” she said to Dr. Turnbull, perhaps more icily than she intended. “The Lord actually works in predictable ways.”
Anxious expressions in the audience alerted her to how insolent this might’ve been received, and when her gaze returned to Dr. Turnbull she could see this was the case. Below his combed-back white hair his face seethed with the redness of a lobster splashing into boiling water. “I realize the cases on y’all’s schedule today might not be as interesting as this one,” he announced, his eyes pegged hard upon Janice, “but neither are your patients as healthy as this boy seems to be. So let’s go give the rest of ’em our best effort, boys and girls. Let’s try to get ’em all to hit bingo.”
As the audience members began standing Dr. Turnbull stood up and announced, “One additional note, folks. Can y’all listen for a second? There’s obviously a great deal of press interest in Dr. Cuevas’s case so let’s make sure that everything that you’ve heard and said in this room stays right here. The usual protocol remains in effect—everything goes through public affairs, everything.” His face still flushing, he shot a quick glare at Janice, who’d briefly (and, she’d thought, benignly) appeared on a Fox News segment after getting ambushed outside the hospital. “Thank y’all for your attendance.”
And with that Dr. Turnbull left—so swiftly that Janice was forced to abandon her laptop onstage in order to pursue him. (She did stash her iPhone, still recording, into her lab coat.) She squeezed her way through hallway discussions of Cameron’s case, one of them intriguingly heated, and trailed Dr. Turnbull’s white coat out the door. A cooling bay breeze was drawing patients and visitors outside, and dozens were lounging and smoking in the circular courtyard that Dr. Turnbull was bisecting, most of them congregated around a fountain in the middle. The courtyard had just been restored after hosting construction equipment for two years for a $304 million expansion of the GCVHCS campus, still ongoing, that Dr. Turnbull had helped shepherd through congressional thickets. The hot drowsy summer had been hard on the newly planted grass; only a few green tufts were struggling upward.
Dr. Turnbull must’ve heard Janice’s heels clicking fast and insistently behind him because he turned to face her, just before the fountain, without her calling his name.
Flatly, he said, “Dr. Cuevas.”
“I didn’t mean any disrespect back there,” she said. For a marathon runner, she was oddly out of breath. “I’m sorry if my comment came across that way. By predictable, I meant, I guess, explicable—that a positive abberation is still an abberation, and warrants further study. It felt like you gave that short shrift, sir. To me. I’m sorry if I’m being too frank”—Janice hates this tendency of hers to over-apologize; she and Nap still laugh about the time he pointed it out to her and she immediately apologized for it—“but I think this case deserves more.”
Dr. Turnbull ran a hand through his hair and scanned the courtyard before he spoke, nodding amiably to a patient rolling by in a wheelchair. “Do you know who called me last week?”
Janice shook her head. “Sir—”
“Secretary McDonald did. And Senator Burr too.” He was referring to Robert A. McDonald, who’d just two months before been confirmed as secretary of veterans affairs, and North Carolina senator Richard Burr, the ranking member of the Senate Committee on Veterans’ Affairs. He lifted his heels to slightly raise himself, as though to emphasize the importance of these calls.
“And do you want to know what both of ’em said to me? ‘Larry, I don’t know what y’all are doing down there, but whatever it is, keep doing it.’ ”
Janice shook her head, opening her mouth to speak—
“Now hold up, let me just tell you what I told ’em both: I got me one helluva fine doctor on my staff, name of Janice Cuevas. C-u-e-v-a-s. I appreciate taking the call, gentlemen, but all the credit goes her way.”
“I’m honored, sir,” Janice said. “Genuinely. But you know that credit isn’t mine. All I did was read the same newspaper they did.”
Pursing his lips, Turnbull vented a long sigh through his nose. “Maybe you need to be looking at this another way,” he told her. “That boy of yours—once he’s out of physical therapy, hell, the next time you see him might be for his flu shot next year. Benchmarks don’t get higher than that. That’s a success, Dr. Cuevas. That’s as good as success gets around here.”
“But it’s not our success.”
“Is that what this is about? Whose success this was, or is?”
“I’m not quite following you, sir.”
“Look, you’ve got a lot of patients, Janice,” he said. “You’re clocking so many goddamn hours that our contract docs are ’bout ready to see your head on a platter. Those patients—all ’em—they’re your focus. You really want to take hours away from them to figure out why this one boy managed to switch his transmission out of park?”
“If this was a mystery illness,” Janice said coolly, “I imagine you’d have a different take.”
“Damn straight I would. But it ain’t. It’s a mystery recovery and I’ll take ten, twenty, a hundred more of ’em today. Look at these men out yonder.” She steeled herself as Dr. Turnbull placed a hand on her shoulder to pivot her toward the fountain. “I’d like nothing more than to see every one ’em jump out of those chairs and walk off this campus. Hallelujah and pass the peas. Every one ’em.”
“But don’t you see?” she said. “If we can pinpoint what happened then maybe we can determine if it’s reproducible. We didn’t even get to potential drug reactions back in there, or whether axonal regrowth could’ve been—”
“We’re not a research institute, Janice. And writing papers—that ain’t your job.”
“I’m sorry, sir”—there she went again—“but—”
“Did you forward his case file up to Washington?”
“Just like you said. And I also sent it up to the CfNN in Providence,” she said, referring to the VA’s Center of Excellence for Neurorestoration and Neurotechnology, a research laboratory.
“Then let’s let ’em work their magic.”
“Sir, this is my patient and I feel an extraordinary obligation to him, and to my other patients like him, to—”
“Now hold right there,” Dr. Turnbull said, and Janice did, waiting while he sighed and glanced about the courtyard with a distressed, even pained expression, his face reddening once again. When finally he spoke it was in a lowered voice, a muted baritone hiss: “Let’s just get to the nub of this, okay? Has it crossed your mind that you might’ve missed something along the way?”
“Absolutely,” she said, though without much confidence. “I thought—I thought that was the point of me presenting the case this morning. I thought we were making progress until you cut it off.”
“And therefore it’s possible,” he continued, as though she hadn�
�t answered, “that this boy spent four years suffering in a wheelchair when maybe he didn’t need to?”
He raised his head and tightened his eyes as though assessing a suture he’d just made. Realizing she was out of breath again, and gasping lightly, Janice said nothing.
“What if it turns out a two-week course of Clindamycin could’ve had him up and out of his chair four years ago?”
“Sir,” she protested, “there’s been nothing to suggest infection—”
“Tell me which headlines you prefer,” he said. His face was back close to hers now, his voice tuned to a growl. “The ones we got now, or ones that says ‘VA miracle turns out to be VA mistake’?”
Now it was Janice’s turn to tighten her eyes. “You don’t actually think this is a success, do you?”
“What I think, Dr. Cuevas, is that the deeper you look into this, the greater the risk that you’re gonna find something you wish you hadn’t.”
She tilted her back. “Then that will be on my shoulders, won’t it?”
“Yeah,” he muttered. “Don’t I wish.” He took a step back from her so that his face was no longer in hers and she could no longer smell the coffee on his breath. The smoke from a newly lit cigarette came drifting over from the fountain, and, still short on breath, Janice suppressed a cough. “What I think, Dr. Cuevas, is that the status quo is the very best-case scenario for everyone involved, you and your patient included.”
seven
Call it prophecy, coincidence, or the routine exuberance of a mother’s love: Cameron Harris’s mother, Debbie Ann Harris née Cruthirds, sometimes referred to her son as her “miracle baby.” This was because his entrance into the world, the raw fact of his existence, defied obstetric opinion, or at least the opinion of one obstetrician, hers, who following Tanya’s birth told Debbie she was unlikely to bear more children. No one recalls precisely what the medical hindrance was—“something about her uterus, her tubes,” according to her sister Bylinda—but Debbie’s “miracle” tag for the infant Cameron is a memory set in concrete. “I reckon every mama thinks her baby is a gift from God,” says Bylinda. “But Deb, she was sure of it. Cameron was like a fortune cookie from on high. He spun her life around a hundred eighty degrees. She wasn’t big on church and all that until he come along. Fact, she was pretty wild in her younger days. She and ol’ Snead used to throw down pretty hard.”
Anatomy of a Miracle Page 10