Present Tense

By Bruce H. Dobkin|Saturday, August 01, 1992
RELATED TAGS: HEART DISEASE
His heart surgeons and cardiologist had asked me to clear George for coronary bypass surgery. I had reluctantly given the go-ahead. The atherosclerotic plugs in his coronary arteries had already led to a serious heart attack and a life-threatening irregularity in his heartbeat. George was only 52, a working engineer, the father of two boys in high school. Other therapies had failed. Without surgery he would likely die. How could I recommend withholding a treatment, one that could save his life, simply to avoid the real, but small, chance that he’d suffer a stroke during the operation?

The stroke risk had been higher for George than the usual complication rate of 2 percent because atherosclerosis had partially plugged his basilar artery, the major supplier of blood to the vital centers deep in the brain that control breathing and consciousness. Two of the artery’s branches also feed the brain’s occipital lobes, which are essential for vision, and two others nurture the inner temporal lobes, which are crucial for remembering new experiences and acquiring new knowledge. Four times in the previous two years, George had endured frightening symptoms for 30 to 90 minutes that had resulted from the narrowing in this artery. He would feel dizzy, lose his balance along with strength in his left arm and leg, go numb in his cheek, see double, slur his speech, and appear confused. Twice he remembered almost nothing about the spells. These transient ischemic attacks, as they’re called, were evidence that many of the brain structures fed by the basilar artery were, at least briefly, not getting the blood flow needed to nurture them.

What, then, might happen during coronary bypass surgery, when the heart is temporarily quiescent? Although a mechanical pump usually keeps the blood pressure high enough to perfuse the brain and other organs, the pressure is much lower than usual. When atherosclerosis already narrows the basilar artery, there’s a danger that blood flow can become so restricted that some or all of the brain tissue fed by that vessel is destroyed.

George and his wife understood the risk when they agreed to the surgery. That was about a year ago. All had gone well during the operation, until the surgeons took him off the mechanical pump and tried to get his heart beating again. It barely contracted. He was in shock. They put a sausage-shaped balloon into the aorta, the wide artery that leads out from the heart, and rhythmically inflated and collapsed it to mechanically pump blood to his organs. He remained comatose on a respirator. No matter what emergency therapy the team of doctors tried, nothing could get his heart to squeeze powerfully. I stood at the end of his bed in the intensive care unit six hours after the bypass. A dozen flexible tubes penetrated George’s body. Fluids of every sort dripped into and out of natural and man-made orifices. His face, chest, and limbs were pale and puffy under the tape that held the maze of tubes and his life together. It was a disaster, a nightmare for his doctors and family. Despite the balloon’s pulsations, his entire brain might not be getting the blood supply it needed to protect its billions of cells. More likely, we feared, his vacillating blood pressure between pulsations was often too low to push blood through the basilar artery.

By the next morning, more than one doctor wondered aloud whether we should remove him from the life-sustaining fluids, drugs, and balloon. I could only say that he was not yet brain dead. We had to keep him on life support. I tried to comfort his family, but I worried that George would be left in a vegetative state, like another Karen Ann Quinlan.

Then, nearly two days after surgery, his heart muscle miraculously came alive and pumped vigorously on its own. The surgeons pulled out the balloon. But what would we be left with? He was still in a deep coma when I transferred his neurologic care to an associate for the weekend.

On Monday morning I was astonished to find George moving his arms and legs as he lay in bed wide awake. The tube that connected his trachea to the ventilator prevented him from speaking, but he was able to follow my directions to hold up two fingers, salute, and draw a circle within a square in space. He nodded his head to pick the correct choice for the month and year. His strength, feeling, and coordination tested normal. Tears ran down his wife’s face. Somehow, his brain had protected itself. We had not done George in. Two days later, he was out of intensive care.

As I entered his room on my first visit after the last tubes had been removed, he pushed aside the newspaper he was reading, greeted me by name, stood up from his hospital bed, and reached for my hand, as if the ordeal had left no mark. A half-slice of toast and an emptied cereal box lay on his breakfast tray. It was remarkable how good he looked, considering that less than a week had elapsed since the disaster following his surgery. I asked if he had any pain from the chest incision. He said his chest felt sore, but he’d probably lifted something and strained the muscles. It was an odd answer, one that I almost ignored.

I noticed a coat and silk scarf thrown over a nearby chair. Has your wife already been in to see you? I asked.

I think she’ll be here soon, George replied.

You don’t recall seeing her this morning? I reiterated. This was no longer a social call. Did you eat breakfast yet?

He looked at me hesitantly.

Who ate that? I asked, pointing to the tray.

He scratched his head and broke into a smile. Guess I did.

His wife walked in with a Styrofoam cup of coffee from the hospital cafeteria and cheerily declared, I’m back, dear. George looked at me with almost childlike innocence and said, She’s back. He did not recall her visit 15 minutes before. For a moment, I considered whether to examine George with his wife in the room. But it was best, I decided, to ease her into what I suspected by letting her overhear what was to come. Otherwise, she’d never believe the nature of this silent calamity.

I asked George to remember the words peaches, newspapers, and Chestnut Street and said that I’d ask him to repeat them in a few minutes. In the meantime I gave him a phone number and asked him to repeat it immediately, forward and in reverse. This he did easily. He knew the name of the Vice President and governor, recalled the places he and his wife had visited on a trip to Hawaii several weeks before the heart attack, slowly generated a list of ten words that began with the letter f, and copied a figure of a circle overlapping a rectangle. But when I asked him to recall the three words I had given him, he looked at me blankly.

I tried again with three words that are easy to associate-- school, pencil, and book. He repeated them 15 seconds later but had forgotten them within less than two minutes. Nor could he now remember the simple drawing he had just copied. George’s language and perceptual skills were fine, and his memory for immediate and past events was intact. But he could not learn anything new. He suffered an anterograde amnesia. He drew from his past and registered the present, but his brain could not consolidate a new experience and retain it.

I walked his wife into the corridor and explained what I thought had happened. George had suffered a stroke in each of the temporal lobes, within the two coiled sea horse-shaped hippocampi. These swirls of nerve cells are especially susceptible to a critical fall in cerebral blood flow, and his plugged basilar artery made them even more vulnerable. They are the electrical switches that turn on our memory so we can record what we experience, and then somehow code this new information and send it off to the appropriate brain area to be stored for long-term memory. George had lost this pivotal step; he could not encode and retrieve anything that had just happened. I hoped he would improve.

To look for evidence of a stroke, I ordered a magnetic resonance scan. As soon as I recognized the bright crescents engraved into each of George’s hippocampi on the scan, I felt the thrill of having made the correct diagnosis of a rare condition. But the horror of the problem, and maybe my guilt about okaying the surgery, quickly chilled any self- congratulation.

Pencil and paper tests given by a psychologist confirmed that, despite a normal IQ and intellect, a portion of George’s memory was failing. His declarative memory--the type that we use to acquire and consciously recall facts and events--was letting him down. He would forget after 15 seconds what someone with a normal memory should be able to recall for a day. He held on to what had happened before the heart surgery and lived within the present, starting over perhaps every minute. It was as if the brain’s tape recorder for life’s experiences was set on an ebb and flow of automatic erase after every brief recording.

George and his wife have visited me monthly since the accident. At first, she thought he was sometimes faking the severity of his amnesia. Gradually, she stopped denying what was so difficult to believe. She took him to her office on days when he did not have therapy and sat him on a couch while she worked. We set up a cognitive rehabilitation program that tried to aid him with mnemonic strategies. Nothing helped much, but he did gain more insight into his memory failure.

On a recent late-afternoon visit, George wore his best square- dancing clothes, with polished boots and hair neatly slicked back. Surprised, I asked what he had been up to.

He shrugged and said, Today? I got up and got here. He laughed.

Anything else? I pushed.

You know. I get up, shower, eat breakfast, and go to the office or watch TV. We take our youngest son to school, I guess. Not sure when. I mean, I’m aware of today and so forth, but tomorrow I’ll forget it.

His wife added, He keeps asking for the time or date, again and again all day. He’s even eaten breakfast two or three times in a morning, each time as if it’s the first. And he follows me everywhere. She sounded irritated and frustrated, then suddenly perked up. He keeps saying he wants to live in Hawaii. We went there before the stroke and twice after. He had a good time. Of course, he stayed right by me. Otherwise, he panics if I go where he can’t see me. So he keeps telling me we should move there, but he doesn’t recall our last two vacations in Hawaii.

I like Hawaii, George interjected. I don’t have to see anyone I know there. I get a headache listening to people. They don’t finish their sentences. I feel like I’m in a box, hearing little bits and pieces.

Do you understand why this has happened? I asked.

I had a stroke. I get a headache when I think about it. Do you think I’ll get my memory back?

You’re getting better, I hedged, recalling the tubes, the ventilator, the failing heart, and the coma. You remember some of what happens, especially if it carries emotional weight. Remember the earthquake?

Uh, San Francisco. I always used to go back there. Lived there when I was younger.

You went through a lot in the hospital, and it takes time to get well, I said, as much for his wife, who could hang on to my words, as for my patient, who could not. George looked terribly sad. His wife took his hand. I realized how much more apathetic he had grown over the year. When is my mind coming back? he asked his wife. I get a headache when I think about things.

George had a wisp of memory, like the remnants of a nightmare. But for the rest of us his personal nightmare would never fade away.
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