I was now into my second day of the scientific papers I’d gotten waylaid by in Refuge Cove, trying to make sense of the shunting hardware my father had installed in Billy. I had to finish them, here in Burial Cove, because they furnished the technical argument he was counting on to clear his name. Then I could pick up the second act of Billy’s story, where everything went wrong.
Unfortunately, what I had expected to be an easy breeze-through of the science had turned into a time-trip that visited every one of the medical issues in Billy’s case. There was no excitement here, just the dry language of clinical science stuttering slowly forward. Important, yes, but maybe a tiny bit boring.
I turned to the Perinatal Anoxia folder. In English, this means “lack of oxygen around the time of birth.” Billy was very slow to take his first breath, and after he did, he remained in “acute respiratory distress,” tubed and incubated, for weeks. A 1976 chapter on pediatric neurology told me anoxia was the single most important neurological problem for a newborn, causing “mental retardation” (now termed intellectual disability), seizures, and cerebral palsy. Premature infants seemed to be most at risk, and the consequences were often insidious. Intellectual disability was one, along with various dyslexic syndromes and “perceptual disturbances” that surfaced at school age. I already knew that lack of oxygen fries your brain. But it was still a shock to see so many of Billy’s problems (especially his cerebral palsy) explainable by lack of oxygen immediately after birth. Anyway, that was enough on anoxia; I got the point.
On to meningitis, always bad news for any infant, and especially so for a hydrocephalic baby that had been shunted. I found several articles. Mortality from bacterial meningitis in infants was in the 30 to 40 percent range. If you had a feverish, vomiting, shunted infant on your hands, you had to check for meningitis, and there was only one way to do that in 1976: withdraw and examine some cerebrospinal fluid. How did you do this?
With a lumbar puncture.
When I saw those words, I knew the 1970s-era science was critical to my father’s case. It would be another week at least before I could start to piece together the blow-by-blow drama of what happened to Billy after the shunt had first been put in, but I already knew “lumbar puncture” was the reason the case was settled before my father could take the stand.
What did I know about lumbar punctures? I knew that doctors abbreviated the name to LP (I will too), that most people knew their more gruesome and descriptive name spinal tap, and that they hurt. How you did one, and especially the dos and don’ts that seemed such a big issue with Billy’s case, were mysteries to me. But there was a folder here, labelled “Lumbar Puncture,” so I opened it up.
In the mid-’70s, the use of an LP in diagnosing neurological disorders — especially meningitis — was still high, even given the knowledge that an LP itself could actually cause meningitis! But the big problem occurs when pressure inside the brain is already high — major causes are injuries to the brain, tumours, and untreated hydrocephalus — because a lumbar puncture can make things worse. Elevated pressure does some gruesome things to the brain, especially where it joins the spinal cord; it’s called herniation or “coning.” I learned that, yes, an LP can reduce pressure on the brain, but if it was performed when pressure was too high you risked eliminating the back-pressure normally provided by the presence of spinal fluid. Top-down pressure from the brain would win out, and down would bulge the base of the brain.
My head was spinning. Lumbar puncture, on which the lawyers had caved in and settled the lawsuit, looked to me like the Devil’s Pool in Dent Rapids: you can get close to it, but stay away when the current is really running. I needed more up-to-date information, and that meant the Internet. In Burial Cove? I did a quick check on my phone. There was a weak telephone signal, enough to patch my phone to my computer and use it as a router. I would have to be fast because the data charge would be astronomical. But I really needed to know what doctors were thinking today about the risk of doing an LP when intracranial pressure was already high. Did the LP cause herniation (the dangerous bulging of the brain) or didn’t it? Could we even say? If the LP that was eventually done on Billy was so crucial, I had to understand why.
But the Internet, usually so eager to throw information at me, was stingy on this one (and spectacularly slow). There didn’t seem to be much solid evidence that an LP could actually cause herniation, but what if you had elevated pressure to begin with? It began to look as though I wouldn’t get a clear answer about lumbar punctures and herniation. Back and forth the opinions went. Don’t do an LP. Go ahead, but do a CT scan first. Depends on the kind of hydrocephalus the patient has. Finally, I gave up. It was like asking three boaters about the best paint to use on your hull, or how to fix a leaking hose, or what to do if your engine started smoking. Three different answers, guaranteed.
But I did turn up something interesting: the Lumbar Puncture Simulator Mark II, made by the Australian company Limbs & Things. For around $3,600, novice puncturers got the ultimate pin-the-tail-on-the-donkey game: a “lifelike lower torso” with a removable skin flap that hid the “puncture block,” a plastic chunk of lower spine plumbed with fluid from an external reservoir. You filled the reservoir and poked away through the skin flap, trying to get in between the vertebrae and puncture the cerebrospinal space.
“That’s the stupidest thing I’ve ever seen,” my father said.
“Yeah, but look.” I angled the laptop and pointed. “You can even buy different kinds of puncture block. See, they’ve got ‘normal,’ but you can order ‘obese,’ and ‘elderly,’ even ‘elderly obese.’”
“I hated doing back operations on obese people,” he said. “Like cutting into a whale.”
“Well, then, can I ask you about lumbar punctures in general? Risks and all that?”
“I’m not in the mood,” said my father
“Are you finished with the computer?” called Hatsumi. “And Charley wants to go ashore.”
I said good night to the lumbar simulator and handed Hatsumi the computer; she handed me a small dog with a bursting bladder. It seemed like a good exchange.