Dr. Larry Zachary sits in front of an operating microscope, looking intently through the eyepiece. Below him is the left hand of a Glencoe woman with Raynaud`s disease, in which blood flow to the fingers is severely restricted.
With a delicate hook in one hand and forceps in the other, Zachary gently pulls a thin layer of tissue away from the artery leading to the fingertips. Chief resident Leonard Tachmes cuts the tissue, which contains nerves connecting the artery to the digital nerve.
For nearly four hours they painstakingly sever connections between the nerves and arteries in the fingers, taking turns cutting the nerves.
The delicate and lengthy surgery, which will allow the arteries to expand and increase the blood flow to the fingers, demands stamina, concentration and acute hand-eye coordination.
Three-and-a-half years ago, Zachary lost all these and more. In a car accident, he sustained brain injuries so severe that he was comatose for eight days.
He had to learn to walk. He had to learn to talk. In occupational therapy, he had trouble putting pegs in holes and playing patty-cake.
The doctor overseeing his rehabilitation predicted that, at best, Zachary would someday be able to live at home, where he would need 24-hour care.
Over the next three years, in an extraordinary triumph of will, Zachary pursued a goal that his doctors and friends had thought beyond contemplation. On April 2, 1992, he won full reinstatement of his faculty appointment and his surgical privileges at the University of Chicago Medical Center-the right to sit in front of a microscope healing a hand.
Waiting and praying
On Jan. 2, 1989, a little boy cut his hand on a piece of glass. Zachary, a plastic and reconstructive surgeon at the medical center, was called in.
At 35, Zachary was smart, warm, emotional and talkative almost to a fault. He had a vivacious and beautiful wife he loved; they had been sweethearts at Von Steuben High School on the North Side, where Zachary had been an All-City baseball and basketball player. They had three children, and a close circle of dear friends.
At the hospital that day, Zachary stitched up the boy`s wound.
”Before he left, he stopped in my office,” recalled Dr. Larry Gottlieb, a close friend of Zachary`s who was then head of the section of plastic and reconstructive surgery.
”We chatted a few minutes. He said he was going to pick up lox and bagels on the way home. Then he left.”
At the intersection of the Midway Plaisance and Ellis Avenue, a few blocks from Zachary`s Hyde Park townhouse, another car ran a stoplight and hit the driver`s side of Zachary`s car with such force that the passenger side door was knocked off its hinges.
Paramedics rushed Zachary to Michael Reese Hospital (the U. of C. is not a trauma center for adults.) When his wife, Julie, arrived, what struck her was how good her husband looked.
”I walked in and he just had a bandage around his head,” she said. ”I said, `God, he`s fine; he`s OK.` ”
But he was not OK. He was in a coma. He had broken his pelvis and three ribs, and punctured one lung. But the most serious injury was to his brain.
The nerve sheaths traversing Zachary`s brain had been twisted in several areas, including the cerebellum, a coordination center governing eye and body movement and speech production; the corticospinal tract, which controls muscle tone in limbs; and the hippocampus, which affects memory and the processing of information.
To prevent further swelling, Dr. John Alverdy, director of trauma and critical care at Michael Reese, placed Zachary on a mechanical ventilator that was set to hyperventilate. This decreased the amount of carbon dioxide in his blood, which decreased the blood flow to the brain.
Beyond that, there was little to do but wait.
”We didn`t kow whether he was going to live or die,” Julie said.
”There was a doctor`s lounge across the hall from the (intensive care)
unit that we literally took over,” said Stewart Dolin, a Chicago lawyer who has known Zachary since college. ”At any time of the day or night, there would be 5 to 20 people there.”
Gottlieb, an Orthodox Jew, visited at 6:30 every morning, and again late at night.
”He came and sat at his bedside with his tallis (prayer shawl) on and his Bible, and sat and prayed for him every day,” Alverdy said. ”He would work a full day, and at 8 o`clock at night, he would be there and pray till midnight. The guy was magnificent.”
On every shift, nurses tried to get Zachary to respond to verbal commands. He did not. Then, eight days after the accident, he did.
”We got there in the morning,” Alverdy recalled. ”We said to him,
`Open your eyes.` And he opened his eyes. We said, `Squeeze our hands.` And he squeezed our hands. And everyone was crying.
”All that time, there was no Larry Zachary. But finally, he was there.” But where exactly was there?
”He could not walk. He could not talk. He was a blob,” Julie said.
”I remember once . . . the nurse ran in and said, `Your husband is sitting in a chair!` I walked into the (intensive-care unit), and there he was, sitting in a chair, with his tongue hanging out the side of his mouth and his whole body hanging off to the side.
”It was an awful sight, like an old person who had had a stroke. At that point I said, `Please, God, just let him die if he`s going to be like this.`
”
They gave him pen and paper. He made chicken scratches. He kept trying. Soon words could be discerned.
”Julie Zachary,” he wrote, several times. ”They do not think I will remember,” he wrote another time.
Ten days after the accident, he whispered his first words: ”Good bye,”
to Gottlieb as he left the hospital.
Daunting task
After three weeks, Zachary was moved to the Rehabilitation Institute of Chicago. He had begun to walk, but the task ahead was daunting.
”He was confused and disoriented,” said Dr. Richard Lazar, Zachary`s physician at the institute. ”His speech was almost impossible to understand. He had severe imbalance and incoordination of his limbs. He had a lot of intellectual processing problems. He had a great deal of trouble remembering what happened from one day to the next, and a very poor memory of what had happened to him.”
”I would have expected that he would have been someone who could have lived at home with his family, but would have required 24-hour care,” said Lazar, now executive vice president of medical affairs and medical director of Schwab Rehabilitation Hospital and Care Network on the Southwest Side.
And yet, some of Zachary`s fine motor skills seemed fairly intact. One day he used a safety pin to remove from his hand a splinter of glass from the accident.
Lazar put Zachary on a regimen of physical and occupational therapy. But after a few weeks, Zachary began refusing to cooperate, a common phenomenon among rehabilitation patients, Lazar said.
”They get to the point where they develop some awareness of the tragic nature of their circumstances, and they rebel,” he said.
”Larry started to reject the idea of psychological testing. He thought the questions on the test were stupid; yet he was having great difficulty answering them.”
”He was having difficulty with balancing activities-things like balancing on one foot, or batting a balloon. And fine motor coordination tasks like transferring objects from one surface to another, or placing a peg in a hole. He was having trouble with simple clapping movements, playing games like patty-cake.
”Rather than acknowledge the difficulty, he said the challenges were beneath him.”
”I had no patience,” Zachary recalled. He didn`t see the point of practicing putting pegs in holes quickly. ”In surgery, speed is not as important as accuracy,” he said.
Lazar thinks there was more to Zachary`s rebellion than that. ”It was terrifying to him, I`m sure,” he said. ”You can imagine if you`re having difficulty putting a 1-inch diameter peg in a hole, how much trouble you would have putting a fine nylon suture in a surgical wound.”
Lazar says he persuaded Zachary to cooperate. Zachary says he realized he had to play the game.
He resumed his rehabilitation. He worked with an oscilloscope to alter the pitch and force of his speech. He went home for weekends.
After six weeks, he was sent home, which was both thrilling and frightening. ”He had this very strange stare about him. His eyes were fixed,” Julie said. ”He was scary.”
He spent the next nine months as a rehabilitation institute outpatient, with Julie driving him downtown and picking him up every day.
Zachary`s dependency strained their marriage. ”He was so needy,” Julie said. ”I felt smothered.” They consulted a marriage counselor. Zachary saw a psychiatrist who specialized in head injuries.
And he made it clear that he intended to return to surgery.
”This is my love,” he explained. ”If you define me, this is part of my definition.
”I knew I could do it. I would never put myself in a position where I could do some harm. Never. If I felt I couldn`t do it, I would never try.”
He never lost his medical license. But he automatically lost his surgical privileges and faculty appointment at the U. of C. when he went on disability pay.
Dr. Thomas Krizek, then chairman of the medical center`s department of surgery, tried to gently dissuade him from trying to return to surgery. He mentioned the possibilities of teaching, research, internal medicine.
”The discussion never proceeded,” he said dryly.
Graded by his peers
In fall 1989, less than a year after the accident, Zachary began operating on rats and pigs, repairing blood vessels or intestines and doing skin grafts.
”The speed with which he used to do microsurgery was not there,” Julie said. ”But that was unimportant. It`s not a race. It upset him a little bit, but he dealt with it.”
Lazar worried about more than Zachary`s physical abilities.
”He was having trouble with some of the fine points of mental flexibility, acquiring new information and using judgment-things that are essential in a plastic surgeon,” he said.
Moreover, he said, in psychological tests Zachary was showing excessive impulsiveness and recklessness, common side effects of head injuries but undesirable qualities in a man wielding a scalpel.
Indeed, so eager was Zachary to return to surgery that he stitched up minor wounds on two patients, one being his wife, before he had won reinstatement of his medical privileges.
But here the line blurs between pathology and personality. Gottlieb contends that Zachary, who before his accident stormed out of his car in a traffic jam once and started directing traffic on Michigan Avenue, was by nature impulsive.
”Recklessness, lack of inhibition-Larry had that before,” he said.
”His ego was so strong that he could get away with it.”
He started showing up at his office, which had been untouched.
”He would come in every day, say hello, and take a nap,” Krizek said.
”He has a couch in there.
”Someone asked, `Larry, why do you bother even coming in?` And he said,
`If I don`t come, it will be easy for everybody to forget me.` ”
”I was a pain,” Zachary said. ”They would say, `What are we going to do with this guy?` ”
His superiors indeed had no idea what to do with him. Standard tests for recovery from disability do not address a person`s ability to perform microsurgery.
”There were no road maps,” said Krizek, who as department chairman was responsible for overseeing Zachary`s return.
Krizek and Gottlieb designed a detailed training and observation program, which the university`s lawyers and other officials approved.
”Of paramount importance to us was the welfare of patients,” said David Rakov, general counsel of the university.
So two years after his accident, Zachary returned in the role of a resident. He performed physical exams. He took medical histories. Under supervision and with patients` permission, he sewed and cut stitches in surgery. At every turn, his performance was analyzed on grading sheets.
Three physicians from other universities observed him, questioned him and wrote reports.
”We graded him on patient acceptance, speech, fatigue, tremor, knowledge, recall, speed-everything,” recalled Dr. George Block, who succeeded Krizek as chairman of the department of surgery.
His greatest difficulties arose from his speech, which was still so slurred that several patients asked nurses whether he was drunk. The problem was solved when Krizek and his wife, a university lawyer, wrote an explanatory script for Zachary to read to patients. ”The patients became overwhelmingly sympathetic to him,” Krizek said.
After about nine months, he was allowed to perform surgery under the direct supervision of other surgeons.
”Initially, his stamina was reduced,” Krizek said. And Gottlieb noticed that his surgical technique was slightly less elegant.
”There were things that I saw he couldn`t do that he wanted to do,” he said. ”After one of those cases, I came back up to the office and cried.”
Zachary persevered and improved. He underwent a rigorous peer review that included personal interviews, reviews of his grades and surgical observations by doctors from other disciplines at the medical center.
”He passed with flying colors,” Block said.
The months stretched on. Zachary`s patience grew thinner than usual. He believed he was being held to a higher standard than any other surgeons-in large part because of his difficulty with speech.
”It`s a kind of discrimination,” he said. ”If my speech were perfect, not one person would have questioned all this.”
`Betty called`
Zachary arranged a code with Block`s secretary: if he was reinstated and she could not reach him by phone, she should leave the message, ”Betty called.”
Last March 27, Zachary returned to his hotel in Vail, Colo., where he had taken his son, Adam, skiing.
There was a message waiting: ”Betty called.”
”My son said, `Dad, why are you crying?` ” Zachary said. ”I said,
`Adam, you won`t understand.` ”
Larry Zachary is now 39. He is a different man than he was before his accident-a little less cocky, a little less exuberant.
”Is he as good as he was? That`s hard to measure,” Krizek said. ”He is not as facile. Is he still among the best and the brightest? Absolutely.
”I think he`s probably in many ways a far more cautious surgeon than he was before. He no longer believes he`s indestructible.”
Zachary says he has learned the pricelessness of the love of his family and friends. During his hiatus, he took his 8-year-old daughter, Jordann, to a dude ranch, and his 6-year-old daughter, Victoria, to Florida, in addition to the skiing trip with Adam, 10. Next month he will take Adam fishing.
”I want my kids to know who I am,” he said.
His speech is still sometimes difficult to understand. If he gives a talk, he prints it out with the syllables separated and dashes inserted where he should breathe. He exercises to improve his equilibrium. He has to concentrate on his balance when he walks.
”Things change,” he said. ”I can live with that.”
