Before Goodrich would take on the Aguirres, however, he needed to know that he had a realistic chance of successfully separating them. For six months, MRIs and X-rays of their unusual anatomy flowed between Manila and New York. Goodrich, meanwhile, pored over the available medical literature, queried fellow neurosurgeons, and consulted with his plastic-surgery partner David Staffenberg. One factor that might have deterred them, Goodrich says, was if the brothers’ brains were connected, not merely abutting. On the MRIs, everything looked clear.
By the time 31-year-old nurse Arlene Aguirre got off the airplane with her sons at Westchester County Airport in September 2003, Goodrich thought he knew how to proceed. But as Carl and Clarence were carried down the plane’s steps, the two surgeons could tell the boys were “sick puppies,” Goodrich says—in far worse shape than their colleagues in the Philippines had led them to believe.
Arlene had learned of her twins’ condition from an ultrasound, but as a Catholic, she refused to consider abortion. She’d given birth alone in Manila (the boys’ father had long since left the scene) but moved home to her rural village, an overnight boat ride from the country’s capital, so her mother could help care for the boys. At 18 months, both Carl and Clarence were malnourished; Arlene hadn’t been able to feed them much more than milk. Clarence was the tinier of the two, as much from exhaustion as from lack of food. He was the twins’ “engine,” Goodrich soon discovered. His blood pressure was three times the normal level, while Carl’s was just 60 over 40. Somehow, none of this had been mentioned by the Filipino doctors, but what was Goodrich going to do now? Put the boys back on a plane? Return them to their “dirt-floor hut, no running water, no electricity,” as Goodrich likes to describe Arlene’s family home? No, that couldn’t happen.
The overwhelming message Goodrich says he took from his research was that most craniopagus separations had been disastrous. Neurosurgeons had managed to “take two children into an operating room and bring them out alive,” he says, but all the survivors had been “basically devastated” neurologically. The next step was “not to just bring out ‘ga-ga’ survivors” but “two kids that go in and come out the same way.” The secret, Goodrich believed, was to separate Carl and Clarence in several small operations rather than one epic one.
Goodrich was inspired to break up the operation by his friend Jack Walker, a Salt Lake City neurosurgeon who had used the staging approach in three craniopagus separations in the eighties and nineties and lost none of his patients. His innovation—to draw out the surgery, to be patient, essentially—wasn’t exotic, but it challenged brain-surgeon culture. “When I was in training, you went into the operating room and you stayed until the case was completed,” Goodrich says. “That was considered virtuous, that I could stand there for 27 hours and continue to work on a tumor. Absolute bullshit.”
Walker’s patients had suffered some neurological harm, but Walker now believes that may have been because he did the surgeries over a couple of months. There was no textbook to say how far to space the procedures, and the fact is that separations are extremely expensive for hospitals. “I was always getting the nudge: ‘Can you hurry this up?’ ” Walker says. With Montefiore’s blessing, Goodrich decided to conduct the Aguirres’ surgeries over a year.
The theory behind multiple operations is that when you try to split conjoined twins’ byzantinely entwined cranial vessels all at once, the blood can’t find its way out of the brain fast enough—strokes, hemorrhaging, or catastrophic swelling can be the result. Staffenberg compares the circulatory backup in one-shot surgeries to the gridlock that would ensue if a bunch of Manhattan streets were closed all at once. Instead, with the Montefiore plan, “let’s say we block off West End Avenue, what will drivers do?” he asks. “Initially, it’s a problem, but within a few hours, the drivers realize they can go around the block or say, ‘You know, I’m not going downtown today.’ So traffic still flows, even with the roadblocks. That’s what we wanted Carl’s and Clarence’s veins to do.” In other words, the hope was that Carl would begin to drain his own brain, rather than rely on Clarence to do the work. Carl had the venous infrastructure to do it, the doctors believed—he just wasn’t using it.
By the time the fourth and final surgery began on August 4, 2004, Goodrich had worked his way around about 80 percent of the boys’ heads, dividing up their shared blood vessels in what he calls a “rotisserie” approach. The first three procedures had helped control Clarence’s blood pressure, so much so that he was down from four hypertension medications to one. Meanwhile, MRIs showed Carl was pumping much of the blood out of his own brain.