…the start of the book I’m never going to finish…
— — — — — — — — — — — — — — -
At eighty miles per hour, something bad was bound to happen. Had the road been straight and dry, perhaps, it would have just been another exhilarating ride. But the road twisted and curved, in a consistent ‘s’ pattern, at least right up until the last curve which was a little different than the others.
He knew he was in trouble before he lost control of the motorcycle. This curve was a little sharper and wound just a little tighter than the last few twists in the road. The confidence which had been building as Jack threw the motorcycle back then forth, right then left over the last 3 miles suddenly became his enemy. It evaporated quickly as Jack saw the front tire of his Suzuki GS1100 drift inexorably toward the white line separating safe macadam from deadly gravel.
Time slowed. Doubt crept in, like a cancer, long enough to prevent recovery. Mechanically, Jack reacted flawlessly. He eased the throttle, and leaned the bike over as far to the left as he possibly could, his attention riveted on the narrowing gap between that front wheel and the edge of the road.
As often happens, danger struck from somewhere. unexpected. Just as Jack leaned the bike oh so little more to the left, thinking for a moment that HE HAD IT, the case guard — a set of aluminum tubes designed to protect the engine from scratches in a fall — made contact with the road. And as some of the weight of the bike was assumed by the case guard, the bike’s front wheel came off the road. The bike resumed its deadly drift toward the shoulder. Jack, puzzled, leaned left more, shifting more weight from the tire to the case guard, and sealed his fate.
Years later, when asked what he recalled from the spectacular crash, Jack would describe a sensation of being pushed from behind by an unseen force. He felt that, had he turned around at that moment, he would have seen Death itself thrusting him off the road. The screech of aluminum on pavement added to this affect, seeming to be the grim reaper’s triumphant roar as it claimed another soul. Even after reading the accident report, which explained the damage to the case guard and its role in the accident, Jack could never shake the image of Death hurtling him toward the wooded roadside.
Jack’s first memories after the accident were spotty. He remembered noises, primarily; the various beeps, hums and hisses of medical technology’s latest monitoring devices. Vague sensations of pressure, more than discomfort but not quite pain, arrived at his brain, but he could not associate these sensations with their source. He did not remember seeing anything, at first, although his doctors assured him that his eyesight was never affected. Visitors later told him that, in the first few days after the accident, he had kept his eyes screwed tightly closed, as if afraid to confront the reality of his condition.
Gradually, the doctors choreographing his recovery throttled back on the pain killers which dulled Jack’s senses. Jack was able to answer simple questions and demonstrate that he was not paralyzed.
“Do you know where you are?”
“In the hospital”.
“I had an accident, right?”
“How many fingers am I holding up?”
“Eleven? I’m just kidding, three.”
“Good, a sense of humor… …can you wiggle your toes for me?”
“Uh, I think so… But they feel so distant.”
“No, that’s good, that’s very good, they’re moving fine. Both feet.”
It was the questions that Karen asked that gave Jack trouble.
— — — — — — — — — — — — — —
— — — — — — — — — — — — — —
Karen worried something was wrong when Jack did not return for dinner. Jack had said he was going for a ride for a couple of hours, and that he would return by 4:30 or. 5:00 PM. They talked about going out to dinner with the kids.
Karen loved Jack deeply, and considered him the perfect husband except for his occasional, inexplicable bouts of self-destructiveness. These moods overtook him like a surprise summer thunderstorm, and usually lasted for a day, maybe two. They were characterized by Jack’s brooding silence, combined with some act of recklessness — heavy drinking, or an angry confrontation with some stranger who had committed some minor offense. At first, Karen tried to help Jack deal with what she jokingly referred to as his other personality. At other times, she had worried that they were the result of some deep and fatal flaw in his psyche, and that she would have to either help Jack resolve them or move on; before she ever decided to leave, though, the mood would pass and everything would be fine again.
She worried then, when he talked about buying a motorcycle, that the combination of the dangerous toy with his periodic forays deep inside himself would be disastrous. However, the motorcycle seemed to give him peace, and significantly reduced the frequency of his mood funks, so she came to accept the motorcycle.
But 5:00 PM came and went, and she began to worry as she threw some burgers on the grill for Lisa and Kelly.
Peter Mineros was pulling in his driveway when he spotted what looked like a fire in the woods a few hundred feet off the road. Peter was an attorney for the US Justice Department. Since moving to the far reaches of the Washington, DC suburbs, he rarely got home before 7 or 8 o’clock at night. Tonight was his daughter’s third birthday, though, and he had promised to be home early to help with the festivities.
Peter and his wife Kay had built their dream house just after Rachel was born. They had lived for the first few years of their married life in townhouses in Bethesda and Silver Spring, but had grown disenchanted with the crowds and noise; just getting the basic errands of life done consumed far too much time and energy for both of them, and they often got home after a busy Saturday of trips to the dry cleaner, the Jiffy Lube, the grocery store as exhausted as they were after 12 hour workdays. Both Peter and Kay had grown up in small towns and had loved it, and they had resolved to provide their kids — when they arrived — a similar experience. So they had searched for an out-of-the way location in Loudoun County, Virginia. In just a few short weeks, they had found exactly what they wanted, and built a two story Cape Cod about ten miles east of Middleburg, on Snickersville Turnpike. The isolation it provided was a welcome change from their hectic jobs in the city.
Parking his car halfway up his 500 foot driveway, Peter grabbed his cell phone and started through the woods to see about the fire. In a few minutes, he was on the phone to the local police reporting what appeared to be a serious motorcycle accident.
He found the bike first, lodged up against a big pin oak tree. It was the source of the smoke he had seen. The radiator was cracked, and steam was pouring off the twisted ruins of the motorcycle. With a sickening feeling, he began looking for the rider.
He found Jack almost 30 feet away nearly five minutes later. Peter had started his search between the road and where he found the bike, thinking that the rider would have had to have fallen off before the bike careened into the oak tree. Instead, it appeared that the driver had stayed with the bike to the end, because he found Jack almost in a direct line from the road beyond the wreck. He must have fought to stay on, Peter thought, bailing out at the last second before the impact.
Peter reported his location to the police, and tried to see if there was anything he could do for the lifeless form he found sprawled on the ground. The way the victim’s arms and legs were twisted gave him the appearance of a rag doll, and after the realization of what he was seeing sank in, Peter lurched a few steps away and vomited violently. Deciding to walk back to his house to wait, Peter nearly missed the rider’s weak grown.
Amazed that the man was still alive, Peter went to him and said, “I don’t know if you can understand me, but help is on the way. Hang in there.” Afraid to move him because of a fear of doing something wrong, but needing to do something, Peter dared to check the man’s pulse at the carotid artery. All of his medical training came from “ER” reruns, so he wasn’t sure what he was going to do with whatever he found, but he did so nonetheless.
Jack neither understood what Peter said nor felt the fingers on his neck, but deep within his subconscious, the vague notion that another person was there with him was acknowledged. This awareness triggered enough of a chemical reaction in Jack’s endocrine system that he began to fight to stay alive. A few minutes earlier, Jack’s body had been letting go of life. Hope, however slight, was an incredible antidote, and it made all the difference.
The sound of sirens was infrequent enough in the area that Karen’s anxiety level leapt when she first heard them. A sickening feeling settled in her stomach when the sirens approached but did not fade away. Whatever had happened, it was nearby. Karen felt paralyzed with fear.
The ambulance attendants knew they had little choice but to risk further injury by moving Jack quickly.
“Goddamn motorcycles! Maybe we can save enough of this guy to donate some of his organs to some fucker with more sense. On my count — 1, 2, 3!”
They lifted Jack’s rag-doll form onto the stretcher and retreated through the woods as quickly as they felt they could without risking falling.
Upon reaching the ambulance, they loaded Jack quickly into the bay. Tom, the senior attendant, jumped in with Jack and started an IV. Terry jumped into the driver’s seat and called the dispatcher.
Terry filled the dispatcher in. “We’ve got a male motorcycle accident victim, approximately 30–40 years, old, with severe trauma injuries. The victim appears to have lost control of his bike at high speed and crashed into a tree. We have a faint pulse. Tom, can you talk yet?”
Tom grunted, then connected his headset, and began itemizing Jack’s condition. “Blood pressure 80 over 40 and erratic, pulse 60 and erratic, I’ve got a broken left leg with bone exposed, bleeding heavily from the femoral artery, I’m just getting the blood flow stopped now.”
“I’ve got an IV going with one liter saline, ready with 50 cc of epi if he fibs. Which he probably will any sec, because this guy’s a mess. I’ve got severe trauma to the torso, I haven’t cleared it all up yet, but I suspect extensive internal damage, and bleeding. His helmet’s still on, I’ve been worried about risking any further neck or spinal cord injuries by getting it off, but I can’t fit an oxygen mask until I do. Terry, this guy’s not going to survive all the way to Deaconess. Shit! He just went into vfib!”
The dispatcher, who was a medical doctor, took note of. the severity of the case and made a quick decision. “Tom, give him the paddles and epi. Terry, proceed to Highway 50 and Route 626. There’s an old airstrip there with a beat-up plane right off 50, you can cut right off the highway without even making the turn onto 626. The trauma unit helicopter will meet you there in about 8 minutes. We’re going to move this guy downtown to the Lincoln Medical Center. Get me an id on the victim ASAP, so we can notify the family and get permissions.”
Tom jabbed the syringe filled with epinephrine into the IV collar, and quickly plunged one amp into the line. Next, he placed the defibrillator paddles on Jack’s chest, shouted “Clear” out of habit to no one in particular, and pressed the switch. Jack’s body tensed with the shock. Within 20 seconds, Jack responded favorably. “I’ve got sinus rhythm, blood pressure steady at 90/40, color returning. I’ve got the femoral artery wrapped pretty good, it’s soaking pretty fast, but he’s not hemorrhaging like he was when we first found him. Need permission to give this guy two units of O-, though, or we’re gonna lose him!”
The dispatcher immediately authorized the blood. “Go for it, Tom. Great work! Do you have the helmet off yet? Any id?”
“Helmet’s off, oxygen’s going. Let me check on the id after I give him the blood.”
Meanwhile, Terry had made it to Route 50 and was about three miles from the airstrip. He could see the trauma unit helicopter flying right towards him, following Rte. 50 to the airstrip.
“I’ve got an id! Jack Shannon, birthdate 1963, so he’s 37 or 38. Address listed as 621 Century Drive, Aldie, Virginia. Guy’s relatively stable but unresponsive. Pupils fixed and dilated. BP 80/40 and holding, pulse 50 and still erratic.”
“Oh, and he’s signed the donor card on the back of his license.”
Just as Karen had steadied her nerves, rationalizing that it was extremely unlikely that Jack had been associated with the sirens, the telephone rang.
A tinny voice on the other end of the line asked, “Is this the home of Jack Shannon?”
Karen felt as if she had been hit with a baseball bat. “Yes, who is this?!”
“Ma’am, can I ask your relationship with Mr. Shannon?”
“I’m his wife, dammit! Who the hell are you?!?”
“Ma’am, my name is Dr. David Neersham. I’m a physician in the emergency room at Deaconess Hospital. Your husband has been involved in an accident, and he is on his way to the Lincoln Trauma Unit on downtown D.C by helicopter as we speak. He’s in pretty bad shape, but he’s alive, and we’re going to do everything we can to save him.”
Karen’s legs went weak, and she dropped to the floor. Her vision shrunk until all she could see was the telephone cord. She couldn’t speak.
“Ma’am? Are you there? I need to ask you a few questions, and you’re going to need to get to the hospital to make some decisions for your husband.”
Karen quickly regained her senses. “What happened? That damn motorcycle! How am I going to get to the hospital? You don’t need to have my permission in writing to operate or whatever, do you?! Go ahead and do whatever it takes!”
“OK, ma’am, slow down. We’ll get him stabilized, but we’ll need you there quickly anyway because there may be different options for how to move forward, and you’ll have to ultimately decide. Here’s what I need you to do.”
Karen interrupted. “I’ve got two little kids here, what am I going to do with them?!”
David replied, “Find a neighbor to come stay with them. Do you have a cellular phone? Please give me the number, and write this number down — it’s my direct line here. Six-three-four, one-one-seven-two. Do you have that? And can I ask your name?
“Yes.” Karen repeated the number just to be sure. “And I do have a cell phone.” She gave him the number. “And my name is Karen, and I apologize for being so angry. It’s just…”
David said he understood, then asked Karen some questions about Jack’s medical history.
“Does he have any drug allergies?”
“No, none that we’re aware of.”
Does he have any significant health problems — high blood pressure, diabetes, AIDS…”
“No, Jack’s in great shape.” The irony of this comment given Jack’s current state was missed.
“Do you know if your husband is currently taking any medication?”
“No, unless you count Tylenol. He had a couple last night for a headache.”
“OK, Karen, get someone to watch the kids, grab your cell phone and my number and get to the hospital. If you can find someone to drive you, that would be the best. I won’t be there, though. You’ll be working with Dr. Graham and the trauma unit medical staff, and they’re among the best in the country.”
Karen was finally able to stand up and think. “Wait, Doctor, how bad is my husband. I mean, I know he’s in serious condition, but is he… ..is he conscious?”
“Ma’am, I spoke with the EMTs — excuse me, the emergency medical technicians — who picked your husband up just before I called you. Your husband wasn’t conscious, but he had a pretty steady blood pressure and they had stopped the major blood loss. His pulse was erratic, but pretty good considering. We’ve given him some blood and hooked up an IV, so he’s stabilizing now. I’m going to get back in touch with the EMT on board the helicopter now, so I’ll know more in a few minutes. But, I need you to get going to the hospital. I’ll call you as soon as I can.”
Karen felt herself getting dizzy again. “OK, thanks, Doctor. I can’t believe this. I…” Karen felt herself getting sick.
“Karen, I’ll be honest with you. Motorcycle accident victims don’t generally have luck on their side. There are often internal injuries we cannot detect early on. But the fact your husband is still alive is a positive sign, probably the best indication that he’s got a good chance to survive. Please, though, get moving!”
Karen acknowledged she understood. She called three neighbors before she got something other than an answering machine. Both Kevin and Patty were home, fortunately, and after hearing Karen’s abridged version of Jack’s accident, Kevin agreed to drive her into DC while Patty stayed with Lisa and Kelly. They agreed to drive right over.
While Karen waited for Kevin and Patty to arrive, she packed some clothes and a toothbrush, and shampoo and a brush, and the cell phone, and some other things in a bag. It felt so weird to be doing something so normal when her whole world was collapsing. She couldn’t even begin to think about telling the girls. They would have no idea what it meant. Fortunately, they knew Patty well enough that she could escape without having to explain too much.
The doorbell rang. After a quick, tearful hug from Patty, she got in Kevin’s car and headed for DC.
Dr. Ewen Graham reviewed the results of Jack’s MRI. Dr. Graham had been a neurosurgeon for 15 years, not including his 6 years of medical school studies at Harvard Medical School, his internship of four years at Massachusetts General Hospital in Boston, and a three year residency at the UCLA Medical Center.
Ewen had gone to California for a single reason. Because of the high incidence of motorcycle accidents involving young, otherwise healthy male patients, California was considered “the place” to be for neurosurgeons and transplant physicians. Neurosurgeons thrived on the supply of ‘severe closed head injuries’, incidents where significant trauma to the brain occurred without penetration of the brain from, for example, a gunshot wound. These types of injuries occurred with an unfortunate high frequency because of the high number of young, reckless and inexperienced motorcyclists in California, many of whom did not see the need to wear a helmet. Neurosurgeons were thus presented the opportunity to study many similar brain injuries and draw inferences from their similarities and differences in response to various treatments.
Transplant surgeons liked the state for the same reason. California and Texas shared the dubious nickname of ‘donor states’. Again, someone’s carelessness on a motorcycle and subsequent misfortune often yielded many healthy organs for other desperate patients in need of livers, kidneys, hearts and lungs.
Ewen recorded his observations into a portable recorder, so his staff could later transcribe the details into Jack’s medical record. “Patient is a 38 year old Caucasian male, name Jack Shannon, presented with severe injuries from a motorcycle accident approximately 17:30 PM, or three hours and, um… 15 minutes ago. Computed tomographic scan taken at 19:53 shows neither intracerebral or extracerebral lesions of more than 3 cubic centimeters apparent, however diffuse brain swelling with an estimated midline shift of approximately 2–4 mm. Patient is comatose, so no pupillary response or GOAT score is available. GCS is E2 Vintubated M5. Spinal cord injury appears negative at this time, Babinsky normal. Still categorizing patient’s internal and superficial injuries, confirmed collapsed lung, 4 broken ribs, damaged spleen in evidence. Patient is intubated but is expected to resume breathing on his own. Blood chemistry relatively normal. Standard phenytoin sodium drip is being administered, along with morphine.”
Translating Ewen’s recording into English: Jack had a serious head injury. A CT scan showed no lesions, or bruises, to the brain larger than 3 mm, which was about as small as they could be detected from the resolution of the CT scan. Diffuse brain swelling meant that there appeared to be brain injury, but across many brain cells rather than in one specific location. This was expected with a head injury where the head was protected by a full helmet.
The midline shift referred to the apparent movement of Jack’s brain inside his skull. From Ewen’s view of the CT scan results, it looked like Jack’s brain may have moved leftward a small amount as a result of the impact. Significant shifting of the brain, large lesions, or extreme swelling are indicators of potential permanent brain damage. While Jack had some of these symptoms, there were none so serious that it meant he did not have a chance to recover.
GCS stands for the Glasgow Coma Scale test, which is administered to accident victims with serious brain injuries. The test has been found to be a remarkably consistent means of evaluating and communicating the patient’s condition, and is easily taught to hospital staff. The first part of the scale (E) describes whether the patient’s eyes are opening or not. A ‘4’ indiates that the patient opens his or her eyes spontaneously, without stimulus. A ‘3’ would indicate eyes opening in response to a person’s voice. A ‘2’, as Jack exhibited, indicated that the patient would open his eyes in response to painful stimulus, in this case Ewen pinching Jack on the upper arm. A ‘1’ indicates no eye opening, not a good sign.
The ‘V’ part of the GCS scale refers to verbal responsiveness. If the patient is able to carry on a normal conversation, he earns 5 points; disjointed conversation, 4 points; incoherent words, 3 points; no words, but some sounds, 2 points. No verbal response earned a single point. Because Jack had an endotracheal tube inserted in his mouth to help him breath, the tube passed through Jack’s vocal chords and prevented him from speaking.
The ‘M’, or motor response part of the GCS test, refers to a patient’s muscular responsiveness. If motor response is normal, the patient earns 6 points. If the patient localizes to pain, that is, if he tries to reach the part of his body where the pain is being applied, as Jack did with his left hand when Ewen squeezed his right hand, he earns 5 points. If the patient withdraws to applied pain, 4 points; if the patient exhibits ‘decorticate posture’, an abnormal position where the arms are bent inward to the body, the wrists and fingers also bent and leaning on the chest, and the legs are rigidly extended straight out, with the toes pointed in and down, he earns 3 points. 2 points are credited for decerebrate posture, similar to decorticate posture but even more exaggerated in its rigidity and extremity bending. 1 point is awarded for no motor response at all.
The primary reason to record a GCS score is to be able to project the likelihood of recovery. Patients with a total GCS score (adding the three components together) of greater than 12 were considered to have suffered a mild trauma and were expected to recover fully. Patients with a score of less than 9 were considered to have suffered serious brain injury and were considered unlikely to recover fully, and likely to have significant lifestyle impact, up to and including extended coma and permanent paralysis.
All things considered, Ewen thought, Jack was squarely in the ‘grey’, uncertain range of the GCS scale, and lucky to be there. Assuming at least a 3 or 4 on the verbal response scale, Jack was probably a 10 or 11. He had a fighting chance, which was more than any of the medical staff who had treated him that day would have expected. Another 2 miles per hour on the motorcycle, or a different motorcycle helmet manufacturer, and he might be in a vegetative state.
Ewen left the radiology department with Jack’s charts and went to find Jack’s family. He wasn’t certain what he could tell them, but he knew they were certainly anxious to hear from someone.
Karen saw Ewen approach the nurse’s station and ask a question. She somehow knew he was working with Jack, and started toward him just as the nurse pointed her and out mouthed “Karen”.
“My name is Karen Cardoza. I’m Jack’s wife. I haven’t changed my name yet, we taked about me finally doing it just a week ago, and I finally agreed. You know how it is, you don’t easily give up on the name you had for 25 years..”
Ewen let Karen go on for a minute, accustomed to the nervous energy which relatives of injured patients invariably exhibited. “Karen, let’s sit down so I can tell you how Jack is doing.”
“Is he going to die?” The words came out sounding like someone else had asked the question, and Karen was startled to hear herself ask it.
Ewen gripped Karen’s hands in his own. “Karen, I can’t guarantee that Jack will certainly pull through this, but I can tell you he is showing every indication of possibly recovering from this to lead a full life. He is still on a respirator, but we’ll be taking him off that in just a few minutes to let him breathe on his own. He isn’t paralyzed; he can move his arms, legs, fingers and toes. He is still in a light coma, and he is on some pretty serious painkillers, so you can’t talk to him yet. We won’t know for sure how he is going to recover until we get him stabilized, get him breathing on his own, and can ask him questions about how he is feeling.”
“Oh, my God, thank God. The other doctor was much less optimistic than what you’re telling me. I was prepared for the worst,” Karen exclaimed.
“Well, I am still very concerned, and we don’t know the full extend of your husband’s internal injuries. As soon as we get him further stabilized, we’ll be running some x-rays and scans to see if there is any organ damage. We already know he has several broken ribs, one collapsed lung, and some of his blood chemistry results indicate probable spleen damage. I’m afraid he’s not out of the woods yet.”
“So I don’t know what to think”, Karen sighed, holding her head in her hands. “I know you’re trying to help, but I need to know what to expect from this. I can deal with almost anything, it’s just not knowing that is stressful.”
Ewen paused, and said, “Karen, you’re going to know everything we know just as soon as we know it. We’ll give you the truth in English so that you can understand it, and we’ll be honest about the range of possibilities. Brain injuries are very unpredictable, so it isn’t going to be easy unless you can prepare yourself to deal with what could be a very long recovery period.
Karen focused entirely on the word ‘recovery’. She made a decision that, no matter the outcome, Jack would have every chance — no, the best chance — to recover fully. The thought of such a goal, when just a few minutes earlier she had been wrestling with an absolute lack of control over the situation, motivated Karen. She straightened about and began interrogating Ewen about treatment regimens, alternative therapies, and where to read up on the latest approaches to rehabilitation of brain trauma victims. Ewen shared every possible resource with Karen until his pager went off.
“Karen, I’m afraid I have to go see another patient. We’ll talk more in the morning.” As he ran off, he thought to himself, Jack is a lucky man. With a woman like Karen by his side, his chances for successful recovery were dramatically improved. Despite all the advances in modern medicine, there was nothing comparable to the human will as a source of curative power.
Jack strained to shift his weight onto his legs. He was holding onto the parallel bars, his arms locked, learning to walk again. Six weeks confined to a hospital bed, except for an occasional nurse-aided shower, had left his legs atrophied. And while there appeared to be no permanent spinal damage, it felt to Jack as if his leg muscles took bloody forever responding to his orders. Kevin, the physical therapist, was not an especially apt motivator; technically, he seemed to know what he was doing, but he displayed little emotion or enthusiasm for his patients. Whatever Jack acccomplished, whatever emotional progress forward, he did on his own.
Karen still visited, though not every day. Jack still did not remember her, or the girls. Their visits began with hope and anticipation and ended with long bouts of silence and averted eyes. The time necessary to recharge before trying again was obviously getting longer.
Six weeks is a long time in the workplace, as well. Jack worked as a technical sales representative for a large computer manufacturer. Most of his clients were government agencies, and even at their snail-like pace, his customers eventually needed to move to other suppliers. Jack’s boss, Theresa, had been extremely supportive, assuring Jack his job was there for him as soon as he was well, and assuring him to take his time, but sales were beginning to slip. As Theresa contacted each of Jack’s customers, she found them sympathetic, but they were beginning to move their business elsewhere. Other companies’ sales representatives had leapt to fill the vacuum created by Jack’s sudden absence, filling it with golf outings and expensive lunches, and after all, weren’t these computers just a commodity now, anyway? Theresa found herself in the cafeteria one day in casual conversation with a Human Resources manager, learning the nuances of the Family Medical Leave Act. Her managing director refused to give Theresa permission to hire another sales representative, citing budget pressures and shrinking margins. In fact, during one of her appeal visits, he actually managed to break the bad news that her sales goals were now re-stated in profitability terms rather than revenues, and with that one master stroke she found herself another 25% below target. She popped a few fruit-flavored rolaids and silently cursed Jack for his untimely absence; then she called her husband and hinted that they should find a way to back out of the contract they just signed on that $500,000 house in Potomac.