Three weeks ago, Kaufman operated on Neary in a South Jersey hospital, expecting to perform a delicate and rare procedure with about a 50-50 chance of success. He was going to salvage one of Neary's healthy nerves, the one that allows him to shrug his shoulders, and transplant it to replace the phrenic nerve. If that worked, it would have taken six to 10 months before Neary could try using a pacemaker to fire up his diaphragm and breathe without the ventilator for minutes, perhaps hours, maybe even 24/7, if they were very, very lucky.
But once the surgery was under way, Kaufman discovered that Neary didn't need a transplant after all. His phrenic nerve was intact and functioning. It had been merely caught in a clutch of scar tissue and shoved out of place. Kaufman cleaned out the biological muck, both freeing the nerve and giving Neary more mobility in his neck, then sent him home to heal.
Kaufman also was able to extract the bullet from Neary's neck and gave it to him to take home. (The bullet, about 3/4 of an inch long and weighing less than an ounce, will be handed over to the Philadelphia District Attorney's Office this week.)
As soon as the scars healed to pink and brown dashes above his collarbone and along his rib cage, Neary was anxious to try out his new equipment.
He, his father, and one of his nurses had been up before dawn Wednesday, preparing for the 90-minute drive from Upper Chichester.
"Not many health-care professionals are comfortable with this pacemaker," said Kaufman, an elegant man in a dove-gray suit. He is 39, tall and thin, with the poise and posture of a ballet dancer.
"The only thing we want to do is turn it on and see if he's getting responses. We don't expect miracles today. This is like Week One of a four-week training for a marathon."
Neary laughed. "I do a lot of walking and running in my spare time!"
Neary's father reached into the backpack for a 9-volt battery to plug into the gray box, which would emit signals to the internal transmitters. Then he tore off strips of athletic tape to attach the antennae - two rubbery-looking circles - to his son's chest.
Then Kaufman's assistant called Kenneth Aron, the vice president of sales and marketing for Avery Biomedical Devices, the company that manufacturers the phrenic nerve stimulator.
The device was first approved by the FDA in 1986, Aron said. In 2003, actor Christopher Reeve, who had been paralyzed in a horse-riding accident, was part of a trial testing a system similar to the one Neary received.
A few dozen patients have been breathing with these pacemakers for 20 years, Aron said. Fewer than 100 a year are implanted.
From his office in Long Island, Aron would be guiding Kaufman through the test run. He had planned to monitor, by telephone, how well the device was working, but the connection was not clear enough. Kaufman, instead, would report Neary's oxygen levels and heart rate and adjust the power of the electrical impulse accordingly.
"You're going to have to walk me through this," said Kaufman. Normally, the test run is handled by a pulmonologist or respiratory therapist, but there had been scheduling difficulties and Neary was impatient, so Kaufman agreed to get him started. There was no risk, he said, because if the device didn't work, he would immediately put Neary back on the ventilator.
"How do we want the settings?" Kaufman asked Aron.
"My starting point would be 1.8 to 2.4 . . . look for maximum diaphragm contraction."
"OK," Kaufman said, talking over static on the phone line. "Are we on Mars yet? On the transmitter, the lever is switched to B. . . . Is that correct?"
Neary listened carefully, trying to follow.
"Hello?" Kaufman asked. The telephone connection was lost.
While the assistant redialed, Neary complimented Kaufman. "I like your shirt and tie," he said, offering to send him something from his own collection. Before the shooting, he had started his own business, recruiting health-care staff, and had been an impeccable dresser. Now his injuries made sweatpants and hoodies more practical.
With Aron back on the line, Kaufman flipped a few switches.
"OK. Take the vent off," he told the nurse.
"Nice!" said Neary. "I hate the vent."
The room fell silent. Everyone stared at Neary's chest. The machine beeped. His rib cage jerked suddenly. Then again. "He's getting some movement," Kaufman said.
For the first time since he was shot, Neary was breathing independently.
His dad began to cry and left the room to regain composure.
"Apollo has landed!" said Kaufman. "He's cranking."
"It feels weird," Neary said, mouthing the words. It will take months for him to learn how to speak with the reversed flow of air. And over time, as his breathing muscles regain strength, the contractions will grow smoother.
After 14 minutes, Neary's oxygen levels were still at 98 percent, but Kaufman didn't want to push him too fast, too far. "Why don't we switch him back to the vent?"
Neary shook his head, "No!"
"All right. We'll go to 15."
Reattached to the ventilator a minute later, Neary thanked Kaufman. "Good job, doc."
"You're on your way, my friend."
Contact Melissa Dribben
at 215-854-2590 or firstname.lastname@example.org.