Author Samantha Lee Schmall on Life Beyond the Shunt

Episode Transcript

Dr. Correa:
From the American Academy of Neurology, I'm Dr. Daniel Correa.

Dr. Peters:
And I am Dr. Katy Peters, and this is the Brain & Life Podcast. Welcome again to the Brain & Life Podcast. You know Daniel, I've been involved with selling my childhood home. It's just been going on recently and when you think back of your childhood home, it's full of memories, good ones, challenging ones, memories where you were growing and changing. And Daniel, when you look back, what are some of your first memories of your childhood that come to mind?

Dr. Correa:
It's always funny. I mean, with early memories, there's this even a question of whether you actually remember the experience or if it's really the stories you were told, the different emotions that ... Remember fragments of your memory and all the photos that the family has, or maybe more recently for videos that people might have. And so, I think that's how I, in a way, I remember my first day of preschool in Puerto Rico, images of me going to the school, but I feel like I've seen more of the pictures than have a lot of clear memory.
More vividly. I think, and clearly, I remember riding my new bike on Christmas Day after my family had moved to Colorado Springs. And just that sense of flying through the air and the smell of Christmas and pine and fireplaces and wet grass after snow had melted after some sunny days there in Colorado. It takes me back and it makes me think actually now, oh, maybe this is the reason why I love those pine scented holiday candles. You can hear my cats welcoming us and joining us on the podcast and the background there.

Dr. Peters:
Well, because of your cat, I have to give a cue of one of my memories. So, one of my favorite memories was a cat, and this is one of the pictures I took of my childhood home, is one of my cats had kittens and insisted that they stay in my closet. My mom would move them downstairs and then my childhood cat would move them upstairs in my closet. So, I raised kittens in my closet as an eight-year-old, and it was a lovely experience. And childhood should be full of new experiences and growth.
But sometimes if you're battling a neurologic condition during your childhood, you have to balance that growing and learning with healing and recovering. And our guest today, Samantha Lee Schmall, reflects on her journey with a condition called hydrocephalus. It started when she was a child, and she had to undergo multiple neurosurgical procedures and other types of procedures and treatments.
And she's recently written a book about that journey called Beyond the Shunt. And she explains what went on with her with hydrocephalus, but also really tells about her resilience dealing with this condition and the inspiration to write the book. We then discuss hydrocephalus with expert pediatric neurosurgeon, Dr. Kristopher Kahle.
Hello, Brain & Life Podcast listeners. Today is another great day because we have another great guest. And we have an author, so I'm just really excited to talk to her today. I want to welcome Samantha Schmall to our podcast. She's an author of a recently published memoir entitled Beyond the Shunt. And she really chronicles her personal journey with a condition known as hydrocephalus, and we'll learn a lot about that from her today. And she's going to tell us about her journey. And also, I think it's just so cool that she wrote a book, what her inspiration was. And I just say, Samantha, welcome to our podcast.

Samantha Schmall:
Thank you so much for having me. I'm so honored to be here.

Dr. Peters:
Great. Thank you so much. And again, where are you joining us from today?

Samantha Schmall:
I'm from Boston, Massachusetts.

Dr. Peters:
Oh, great, great. That's where my husband's from. He's from Sudbury, right outside of Boston. So, tell us a little bit more about yourself and where you live in the Boston area and what you're doing up there.

Samantha Schmall:
I live in Foxborough, home of the Patriots, Gillette Stadium. I'm a full-time infant room teacher in a daycare center, and I own a photography business and a side craft business.

Dr. Peters:
Oh, wow. That's awesome. You do a little bit of everything. That's so great.

Samantha Schmall:
Yeah.

Dr. Peters:
So, Samantha, we're here to talk about your book today Beyond the Shunt. Could you tell us a little bit about the book and what inspired you?

Samantha Schmall:
The book just takes the reader through my journey of living with hydrocephalus. I mean, it started at birth and up and through I was 22 years old, but what I went through in a little spoiler alert, I had a shunt revision and it ended up unfortunately getting infected, but it resulted in them removing the shunt and now I don't have the shunt.
But I was so sick. I was on my deathbed. It was really scary. And my family and friends afterwards were like, "You should really write a book. What you went through was just crazy." And I was like, "Yeah, I mean, I'm not really a book person, but sure." And I sat down one day and I was like, wow, I could write this book. I could inspire so many people with it and put the message out there regardless of what they're going through medical-wise, health-wise, mentally-wise. If they're struggling, there is a light at the end of the tunnel.

Dr. Peters:
And that hope is just so important. And so, I really appreciate that you took pen to paper to do this. And how long did it take you to do this and to make this process of writing this book?

Samantha Schmall:
From start to finish, it really only took me just over a year.

Dr. Peters:
That's still a very long time.

Samantha Schmall:
Yeah. I mean, I chipped away at it. It was day by day. I did a little bit at a time. I did the good old graphic organizer that I learned how to do in middle school, had some writer's block, but I knew I wanted to get it out there as soon as possible, but I wanted it to be my best work possible for my readers.

Dr. Peters:
Well, that's so great. I mean, I'm having to work on a book right now, so I'm going to write down all these tips because...

Samantha Schmall:
Oh, my god, [inaudible 00:07:01].

Dr. Peters:
... I think just getting started and having that writer's block is some key.

Samantha Schmall:
It's a real thing. It was my life. I'm writing about my life. I lived it, yet I can't get my thoughts straight sometimes.

Dr. Peters:
And you mentioned that you had to have several surgeries. Can you tell us a little bit more about what is hydrocephalus and what did you have to do to treat it?

Samantha Schmall:
Yeah. So, hydrocephalus is an abnormal build-up of cerebral spinal fluid on the brain. Nowadays, doctors can detect it with the amazing technology and science out there. But when I was born, I'm now 28 years old and they didn't detect it until I was born. So, immediately I was just days old and had brain surgery 15 years without having my first revision. I was 15 years old and still had the same shunt in my head that was placed at birth.

Dr. Peters:
Wow. And wouldn't you eventually grow out of the shunt?

Samantha Schmall:
Yeah. I mean, that's what they told me because the tubing, so the valve is on your brain that helps to regulate the fluid and then it drains through a tube in your abdomen. So, realistically, yeah, you would grow in the tubing, I would imagine, would not be long enough to reach your abdomen, but it was unheard of. I went 15 years.

Dr. Peters:
Wow. And then you mentioned that then there were complications. What happened with those complications and were you having symptoms?

Samantha Schmall:
Yes. So, I had that first revision and then I had a second revision. The first revision was just the valve in my head. Second revision was four years later, and it was both the valve and the tubing. The symptoms I was having were just extreme headaches and probably a little bit of nausea, but all I can remember is just extreme headaches.
And that would bring me into the ER because I mean, I would suffer from headaches, but I knew one specific headache. I knew it wasn't right. So, we would go into the ER and my mom would bring me into Children's. They would do immediately a routine MRI ventricle check, and that's when they would see, "Okay, your ventricles are enlarged. We need to do a revision. Your shunt isn't working."

Dr. Peters:
Well, I mean, and how old were you when you were dealing with these changes in having to have these surgeries?

Samantha Schmall:
My first revision, I was 15. I was a freshman in high school. I had just started high school.

Dr. Peters:
Oh, wow.

Samantha Schmall:
And then got that thrown at me.

Dr. Peters:
Yeah. So, it sounds like you're a very resilient person to say the least. And I'm glad your friends and family said, "Hey, you need to share this." Can you tell us what you did to recover after those multiple surgeries?

Samantha Schmall:
Believe it or not, the "brain surgery" for a shunt placement was a very minimal procedure and that probably sounds crazy, but I probably spent two nights tops in the hospital and I would be out of work or school for a week and then I'd be back on my feet.

Dr. Peters:
Okay. How did your family and friends help you heal from having those surgeries and having those procedures in light of having the condition of hydrocephalus?

Samantha Schmall:
They would just support me. They would be there for me, let me know that it's just a condition. It doesn't hold you back. It's not going to hold you back from any daily activities. You can do hard things.

Dr. Peters:
Oh, great. And have you met other people with hydrocephalus since you've written the book? And is there really an advocacy community out there that wants to have more awareness about this?

Samantha Schmall:
I mean, I went through my life with hydrocephalus not knowing anybody else who had it and having to explain it to so many people because they didn't know. In 2021, my fourth-grade teacher reached out to me and was like, "Hey, I'm pregnant. My baby in utero has hydrocephalus."

Dr. Peters:
Oh, my gosh.

Samantha Schmall:
Yeah. So, she reached out. She needed all the support she needed. My mom and I invited her over, reassured her of this condition. And obviously we were trying our best to comfort her because when I was diagnosed, it was years ago. So, the technology and all that, she was diagnosed in utero. It was four months in, I think. But long story short, we connected. Zelda is her name. I was her nanny for five years. I supported her through OT, PT sessions. I was there for her while her parents were at work and couldn't be with her at home to support her and her condition and her development and everything in between.

Dr. Peters:
That is so amazing that you did that. I guess it lends itself for you naturally being a teacher that not only are you a teacher and own right, but now you're teaching somebody to go through what you went through.

Samantha Schmall:
Exactly. And I mean, I could go on and on about this little girl. She is five years old and now she is walking. She's walking, she's talking, she's basically running now. And unfortunately, the doctors did tell her parents that she may unfortunately never walk. And this child has defied all the odds possible and is continuing to. So, we have such a good connection. It warms my heart to be her best friend and be so close to her family, too.

Dr. Peters:
That is such a cool relationship. I love that one that can happen. So, what surprised you the most about writing the book?

Samantha Schmall:
I guess the outpouring of support, one, but also the amount of people in the community that have the condition. Obviously not in my town or anybody close to me I know has it, but I put myself out there. I joined some Facebook groups and I'm learning about so many people around the world that have it and honestly have it a lot worse than I do.
And I have goosebumps right now because yes, I still have hydrocephalus, but you look at someone and you don't know what they're going through or what they might have, but the people that I have met or just observed online, there's so many people out there with the condition, it's crazy. And I'm still learning and meeting people and learning how they are dealing with the condition compared to how I did.

Dr. Peters:
And I will tell you, in full disclosure, Samantha, I'm a neurologist and I have patients that have shunts and it is so important for them to know about their shunts and to understand what's out there. So, I can't wait to share your book with them because I know that all of them have that unique experience. But when you put yourself out there and your story like you have, it makes it so that other people feel more comfortable in the challenges that they're navigating, that they can be resilient just like you have. You've just written this book. What's next for Samantha in terms of writing and advocacy?

Samantha Schmall:
I want to write a children's book, like a picture book so children can have these visuals if they have the condition or maybe even not even hydrocephalus, just another unique disability that they may have that I could publish for them so they could have that. But I also really, really, really want to record an audiobook.

Dr. Peters:
That would be great. Well, hey, you're getting your chops done at doing a podcast, so I think you're doing a great job. So, this is step number one.

Samantha Schmall:
Exactly. I never ever imagined I would be invited to be on a podcast, I will say that.

Dr. Peters:
Well, this is so great for our audience because I'm sure that several of our audience have hydrocephalus, probably have a shunt or have a loved one that has hydrocephalus or has a shunt. So, I just want to say thank you so much, Samantha, for chatting with us today and for sharing the details of your story and your book Beyond the Shunt. And I want everybody to go out and check out her book and read it. And also want to thank our wonderful Brain & Life Podcast listeners.

Samantha Schmall:
Thank you, Katy, for having me.

Dr. Correa:
On the Brain & Life Podcast and online, we share stories from people living with neurologic conditions and the science that helps them navigate everyday life. Behind that progress, are researchers working on ideas that could lead to better treatments, better understanding, and better care.

Dr. Peters:
The AAN Research Program has supported this kind of work for more than 30 years, but each year, far more researchers apply for funding than we're able to support.

Dr. Correa:
So, if you're someone who values neuroscience that makes a real difference for patients and families and all of our communities, we invite you to join this effort. A donation to the AAN Research Program helps more promising research move forward. Learn more about this at aan.com/donate.

Dr. Peters:
Hello, Brain & Life Podcast audience, and we are delighted to have one of our experts again with us today. And this is a neurosurgical expert, Dr. Kristopher Kahle. Dr. Kahle is the director of pediatric neurosurgery at the Massachusetts General Hospital and Harvard Center for Hydrocephalus and Neurodevelopmental Disorders.
He is a board certified pediatric neurosurgeon with experience in a broad range of pediatric neurosurgical disorders, including brain and spinal cord tumors, cysts and all types of hydrocephalus, Chiari malformation, spina bifida, vascular malformations, and other types of spinal cord abnormalities. He also treats these conditions in a transitional age patients and adults, providing continuity of care across the age spectrum. And this is just so important for those patients. And I just want to welcome Dr. Kahle to the Brain & Life Podcast.

Dr. Kahle:
Thank you, Dr. Peters. It's a pleasure to be here.

Dr. Peters:
Now, I mentioned that you're a pediatric neurosurgeon. Can you tell us a little bit more about that and what you do?

Dr. Kahle:
Yeah. I'm a fellowship trained pediatric neurosurgeon. It's definitely my passion. I was trained in residency at Mass General Hospital, but did my pediatric neurosurgery fellowship at Boston Children's Hospital. So, that experience was formative for me. And being a pediatric neurosurgeon in a general hospital, especially in a very large one like Mass General, provides the opportunity for what I call to have a pediatrics plus practice, which I find very gratifying and very busy.
In fact, where we're just not restricting care of patients up to 18 years old like a standalone pediatric hospital would, but really taking care of patients of any age that have what I would call fundamentally pediatric problems. Or I guess another way to look at it would be developmental anomalies, whether structural and/or functional.
And I think that's important because I think a lot of our transitional age patients and adult patients get underserved and there's multiple reasons for that. But I think that from an expertise standpoint, a lot of the adult neurosurgeons, or I should say, all neurosurgeons are adults, I should say, neurosurgeons who treat adults, they may not be experienced or rarely are experienced with these pediatric problems. The anatomy is complex. A lot of these patients, by the time that they're a transitional or adult patient have had multiple surgeries, so the surgeries are risky, the anatomy gets increasingly complex.
And then there's also a lot of socioeconomic, neuropsychiatric, a lot of issues that for whatever reason tends to make people feel maybe a little less comfortable treating that patient population, which obviously is just not fair. So, yeah, I think the commonality is just treating pediatric or developmental issues across the age spectrum. That's a passion of mine.

Dr. Peters:
Yeah, I agree. I have some adult patients that have peds tumors and I always say there is a continuum across that area. And we're going to delve into hydrocephalus, which is one of your areas of expertise. For our audience, can you just tell us in general, what is hydrocephalus?

Dr. Kahle:
Yeah. I mean, maybe a bit of a crude analogy here, but I would just think of the inside of your skull, the brain milieu as like your bathtub in the bathroom where astonishingly, our brain makes about a half a liter, a half a liter of cerebral spinal fluid each day. That's like the faucet in the bathtub. And then there's multiple different reabsorption mechanisms, but like the plumbing underneath the drain, you need to have a working reabsorption system. Any offset in either increased production or decreased reabsorption engenders accumulation.
And when that fluid accumulation occurs in a fixed volume of the cranial vault, the skull, it's going to result in an increase in pressure. And that increase in pressure, depending on important anatomical factors and other factors, it can be dangerous, even fatal. And so, hydrocephalus is not one thing. I would say it's the final endpoint of multiple different etiologies. I think of it like ice cream where there's a billion different flavors, some radically different from one another, but they all get dumped into the same category.
And unfortunately, for folks that may not have a lot of experience treating it or may not know it, one size does not fit all in terms of treatment. And I think neurosurgery has a lot going for it, but I do think that our toolbox is relatively limited and we tend to employ this one size fits all treatments for conditions that in fact are disease subsets and, in some instances, should be treated radically differently.
And so, half of my brain ... Well, I shouldn't say half of my brain is dedicated to patient care. I feel like I have two entire jobs. I've got parts of the day are dedicated completely to patient care and other parts of the day, my lab and I are trying to figure out what those disease subsets are and then what are the causes of those different subsets, whether they be genetic or otherwise.

Dr. Peters:
And that was really my next question. What is the cause of hydrocephalus? I know that there's some mechanical conditions, but maybe there's something underlying genetically. What are some of the common causes?

Dr. Kahle:
Yeah. I think the most useful breakdown or classification would be thinking about it in terms of primary and secondary causes or intrinsic and acquired causes. That would be another way to think about it. So, primary or intrinsic or developmental synonymous terms for that type of so-called congenital hydrocephalus that we and others have found is at least in a very significant subset of patients driven by genetics.
And these are gene mutations that don't necessarily have to be inherited. In fact, the majority of them are not, but they occur so-called de novo in either the sperm or the egg or very, very early in embryogenesis. And so, that's why, for example, someone can have a genetically caused form of congenital hydrocephalus, but have a seemingly normal mother or father, or at least, I don't know if anybody's normal, but no history of hydrocephalus or other obvious syndromic condition. So, that would be one type.
And that's actually in the grand scheme, not the most common type. Far more common is the secondary or acquired causes. These are due to things that in some way disrupt that production system, the amount of cerebrospinal fluid that's produced by this organ called the choroid plexus in the brain and/or impact the reabsorption aspect.
And so, the most common causes of acquired hydrocephalus depend on where you are in the world, and then that of course links with socioeconomic conditions as well. But in a place in the US, for example, and it depends on age group, but hemorrhage would be one of the biggest drivers of acquired hydrocephalus infection, maybe being the second. But that's because in the United States, there's a lot of premature babies because we've got a very good medical system and terrific neonatal ICUs and there's access to care.
So, these patients that may be born at 26 weeks live, but their brains at that gestational age are prone to bleeding because the vessels in the brain were really not designed to be outside of the womb and with these different pressure gradients, et cetera, and so they're pretty friable. And that blood, when it leaks into the system where the fluid is produced called the brain ventricles, it can cause acutely an increase in CSF production through inflammation, and then over time can cause chronic inflammation and scarring of those pathways that are responsible for fluid reabsorption. And so, it's a double whammy.
And so, a major part of our practice as pediatric neurosurgeons is helping out these little infants. And of course, their blood volume is low, so the risks at surgery are higher, their immune systems don't work as well, so they're more susceptible to infection and associated shunt malfunction. We can maybe talk about the different forms of treatment later.
And then of course, in the older age group, you have hemorrhage arising from different reasons. Hemorrhagic strokes, whether it be from high blood pressure would be a common cause, different forms of aging associated changes in the brain make vessels more susceptible to rupture, aneurysmal rupture. People have heard about brain aneurysms. So, in the United States, other developed countries, hemorrhage is the biggest one.
In other poor countries, maybe a lot of the studies done in Sub-Saharan Africa where you might not have access to resources, maybe you only have one neurosurgeon per one million people, which is really how it is. You can imagine that a lot of those children who are born premature don't survive and don't develop hydrocephalus for that reason. But the term babies that are born in conditions impacted by different climate stresses and availability of medical resources, infection is a huge driver of hydrocephalus, a problem that is ubiquitous, but the etiology is different depending on where you live.

Dr. Peters:
Okay. That's fascinating. I didn't really think about it in that context, so I appreciate that you described that for us. So, if you think someone has this condition, what are some of the symptoms that you worry about, and then how do you detect the condition?

Dr. Kahle:
Yeah. I mean, again, it's so different depending on the age of the patient, the type of hydrocephalus. So, for example, we'll go from what I would call womb to tomb. Let's go from across the age spectrum. And I literally have this practice at Mass General where if someone is born with congenital hydrocephalus with an aqueduct that's narrowed, maybe due to genetic mutation, L1CAM gene is the most common genetic form of hydrocephalus. It's an autosomal recessive condition only in boys, essentially, at least the hydrocephalus manifestation. This can be something that comes on very acutely.
There's an increase in head circumference. Maybe the fontanel is bulging because of the fluid build-up, because of the pressure in the brain and its impact on cranial nerves, the eyes start to do something, what we call sundowning, where they're not able to look upward. In fact, you just can see the whites of the eyes above the pupils. That's usually associated with irritability, vomiting projectile or otherwise, lethargy, sleepiness.
And that would be a neonatal presentation. In the pediatric or school age kid, maybe they're complaining about headaches, maybe complaining about double vision. You have a patient who can begin to articulate with language.
Fast forward up to normal pressure hydrocephalus. In the elderly, median age of presentation around 72 years old, this might be someone who exhibits the classic so-called Hakim triad of gait instability, urinary incontinence, and cognitive impairment. And that leads to imaging showing enlarged fluid spaces, et cetera. So, the presentation can vary depending on age and etiology of the hydrocephalus.

Dr. Peters:
And so, your job as a neurosurgeon is to now fix this and to treat it. You mentioned shunting. Can you elaborate more on the treatments, including shunting?

Dr. Kahle:
The toolbox for neurosurgeons, I talked about one size fits all. It may not be one size fits all, but it's not much more than that. Our toolbox admittedly is pretty sparse. And I think that does engender so-called every time you see a nail, you hit it with the hammer approach. Shunting is a bit like that.
I think the two biggest approaches or the two differentiators of the main treatments for hydrocephalus, including placement of a CSF, cerebral spinal fluid shunt. Usually, these are catheter-based treatments in which you cannulate or put a catheter. It's almost like a flexible straw into the brain fluid space called the ventricle.
And then that straw or that catheter, usually made out of silicone, is snaked underneath the skin subcutaneously from the brain, usually behind the ear, over the collarbone, medial to the pectoral muscle or breast of the patient, and down to the belly. Not the stomach, but the peritoneum, which is just a large potential space that's actually very good at reabsorbing fluid.
And so, what the shunt does is it provides an alternative conduit or passageway for that fluid to flow. And these days, there have been some innovations technologically that allow that drainage to be both regulated depending on whether you're standing or sitting. There's a different gravitational force that drives that reabsorption. And also, modulated by a valve setting.
So, the components to the shunt include the catheter that goes into the brain, the part that goes down to the belly, and then intervening in between, usually at the back of your head is a valve. And you can think of that as, at least the ones that I use, it's a bit of a thermostat and everybody has a sweet spot or Goldilocks point or whatever you want to call it. And sometimes that takes some time to figure out, but you can non-invasively modulate the settings of these shunts to achieve a desired effect.
The other type of treatment, which I love and patients love is endoscopy, usually via something that is clumsily termed an endoscopic third ventriculostomy. We can just call it ETV going forward. But what that treatment does is it creates an alternative passageway in the brain by fenestrating or literally Latin for making a window through a very translucent membrane that is at the bottom of the third ventricle.
And so, the fluid can get diverted internally and then reabsorbed on its own without the placement of hardware. And of course, hardware, like any manmade invention, albeit lifesaving, can run into problems. It can malfunction, it can get infected, it can get blocked, it can get disconnected. The distal catheter can migrate to places that you would never think are even possible that I've seen.
So, needless to say, this endoscopic route I love to employ, but it's only relevant for a subset of patients that have something usually called aqueductal stenosis. That's a blockage or a narrowing in this very critical passageway in the brain through which the majority of fluid flows.
And so, when I see that, when neurosurgeons see that on an MRI, we're licking our chops because we say, "Okay, I can use this endoscopic approach that literally takes about 15 minutes," although it takes our anesthesiologist a couple hours to get into the room to do this procedure and the patient can be cured.
As you know, in neurology and neurosurgery, we rarely say cured of anything, but this is something cured in the sense of giving something that reversed the medical condition for which you need no further treatment. And so, that's why we get so excited about it, but it's not always amenable to all of our patients.

Dr. Peters:
Well, at least they're doing it and patients can have an opportunity to have a better quality of life.

Dr. Kahle:
100%.

Dr. Peters:
And Dr. Kahle, thank you so much. I hope we get a chance to chat with you again if we can. We will probably next time we'll talk more about your research and explore that other half of your brain, even though we did mostly clinical. We do want to visit the other side, too. But thank you again, Dr. Kahle, for being our expert today.

Dr. Kahle:
Yeah. My pleasure. And thank you for the opportunity.

Dr. Correa:
Thank you again for joining us today on the Brain & Life Podcast. Follow and subscribe to this podcast so you don't miss our weekly episodes. You can also sign up to receive the Brain & Life Magazine for free at brainandlife.org.

Dr. Peters:
Also, for each episode, you can find out how to connect with our team and our guests along with great resources in our show notes. We love it when we hear your ideas or questions. You can send these in an email to blpodcast@brainandlife.org and leave us a message at 612-928-6206.

Dr. Correa:
You can also find that information in our show notes and you can follow Katy and me and the Brain & Life Magazine on many of your preferred social media channels. We're your hosts, Dr. Daniel Correa, connecting with you from New York City and online @neurodrcorrea.

Dr. Peters:
And Dr. Katy Peters joining you from Durham, North Carolina and online @katypetersMDPhD.

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Most importantly, thank you and all of our community members that trust us with their health and everyone living with neurologic conditions.

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We hope together we can take steps to better brain health and each thrive with our own abilities every day.

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Author Samantha Lee Schmall on Life Beyond the Shunt

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