Fallen: A Trauma, a Marriage, and the Transformative Power of Music (4 page)

Emil Kocher, in 1901, and Harvey Cushing, in 1903, became the first medical men in modern times to describe the use of a craniectomy to relieve the buildup of pressure in the brain. Despite long historical roots, craniectomies remain controversial. Termed a “salvage procedure,” it is not subject to specific guidelines or protocols that state exactly when or in what circumstances the procedure is appropriate, and most research does not support its routine use in adults. The clinical difficulty is in knowing who is and who is not a good candidate for a particular intervention; the ethical difficulty is in employing an intervention that might convert certain death into a lifetime of profound disability. The decision to perform a craniectomy remains an individualized one, depending on the patient and the surgeon, although the most general guidelines indicate that a preoperative score of lower than 8 on the Glasgow Coma Scale and the presence of one or more fixed and dilated pupils significantly increase the risk of an unfavorable outcome—defined as severe disability, persistent vegetative state, or death.

In Simon’s case, by the time the neurological team had cleaned up the large subdural bleed in his left hemisphere, tissue had begun to swell out through the opening of the dura, the relatively inelastic membrane that surrounds the brain. The decision to not replace the skull bone was straightforward, because to do so would have compromised this bruised tissue. There was, simply, no space left.

I AM STILL
waiting as this surgical procedure unfolds. Surrounded by the serious faces of Guido, Jer, Barb, Lou, Dave, and Ryan, I can no longer deny that this is really happening. So I phone Simon’s parents and my mother. I contact Eli’s best friend’s father, a pilot, and arrangements are made to fly Eli in from Vancouver Island. Everyone will arrive tomorrow morning. Tomorrow. In this large generic room with a closed door, too little oxygen, and a terrifying excess of telephones, it is a remote concept, tomorrow. Tomorrow, it seems to me, might never come. At least not in the way the entire rest of my life has taught me to expect it to.

And we wait.

WE ARE STILL
waiting.

As we wait, time narrows to a crystalline point between two opposing tensions: the longer we wait, the more our anxiety grows; the longer we wait, the longer we know Simon is still alive. I count the hours. If he was on his way to surgery at 1:30 when the hospital called me at home, then he has been on the operating table for at least five hours. Six hours. Seven hours. Jer and Barb have left, with promises to return tomorrow, when a nurse comes to tell us that Simon is out of surgery and is in the recovery room. At 9:30, another nurse, who introduces herself as Toni, asks me to come with her. She leads me down a winding hallway, explaining the layout of the floor, how access routes change when the cafeteria, Sassafras, closes at night, details that are so bewildering to me in the moment that she might as well be reciting complicated algebraic formulas. She leads me through the sliding doors of the
ICU
and into a conference room and tells me, once again, to wait.

A voice is shouting Simon’s name. “Simon! Simon! Wake up, Simon!” I walk to the door of the conference room. At the end of the long hallway is a glassed-in room where a group of doctors circle a bed. “SIMON!” There is the sharp snap of a handclap. I move toward the glass room. The doctors turn as I enter, and I get only the briefest glimpse of Simon—his lips, his beautiful lips, so swollen—and the tubes and machines that are everywhere before someone—Toni, I think—is pulling me out of the room and ushering me back to the conference area. This time the door closes behind her.

“SIMON IS VERY
sick,” Dr. Griesdale, the head Intensive Care doctor, explains when he sits down at the conference table with me. It is the second time I am hearing this phrase, and this time it strikes me as profoundly wrong.
Simon is very sick.
It is grossly inaccurate, I think—more a concession to my current decreased mental functioning than a true representation of the situation. Simon doesn’t get sick, I want to say. His twenty-four-hour flus last an hour, two at the most. Simon is strong. Not sick. But the doctor, pale and serious, is still talking. “Simon is very sick” is only the icebreaker. I instruct myself to pay attention. It is important to pay attention. Focus on the details.

“Simon has a serious brain injury,” Dr. Griesdale continues. “It is life-threatening, and it will get much, much worse before there is any chance of it getting better.”

There are three stages of a brain injury, he explains. There is the initial injury—in Simon’s case, the fall—followed by the tissue damage caused by bleeding, and, finally, the damage caused by the subsequent swelling and by potential chemical changes in the traumatized brain. When Simon fell, he hit and damaged the back left side of his head. Inside the skull, the brain catapulted forward so that both the left and right frontal lobes slammed into the bony wall of the inside of his forehead. The initial impact caused several skull bones to fracture. An arterial bleed in his left temporal lobe caused blood to swell between the tissue of his left hemisphere and the dura; during surgery, this large hematoma, or blood clot, in the left hemisphere was removed, a vent inserted into the brain to drain excess cerebrospinal fluid or blood that might pool and cause an increase of pressure, and a craniectomy performed. Because brains, like lips, will swell.

“The skull is stored in a fridge,” Dr. Griesdale says. “If he survives, we’ll replace it sometime in the future. But you need to be prepared. The damage to his brain is global; it is a very serious injury. We are going to keep him in a medically induced coma until some of the swelling comes down, but you need to understand, he might not survive the night. He might never wake up. And if he does wake up, he will never exactly be himself again. He will most likely be severely disabled. He will certainly have profound and long-lasting brain injuries. We will be making treatment decisions based on the potential for his quality of life. Also,” he adds, “because of the area of the head injury and the fact that he could not feel his legs, we are worried about his spine, but at this point a possible spinal cord injury is a completely secondary injury. We will do an
MRI
scan as soon as he is stable.” He takes a deep breath. He’s not done. “There is the possibility of a blood clot forming at the top of the cervical spine.”

I do not understand the exact significance of this, only that, like everything else, it is not good. A news piece I recently heard on the
CBC
floats into my mind: the greatest amount of damage to the spinal cord happens during the immediate post-accident swelling. The quicker the intervention, the greater the chance for recovery. I imagine Simon on a ventilator without the use of his arms or legs.

“The blood clot...,” I say. “Simon wouldn’t want, I mean, if there is a surgical option, he would want to take the risk. For his arms.” I don’t know what I am saying, and a look I identify as pity crosses the doctor’s solemn face. I want to turn away from his firm and unsettling gaze but cannot.

“A blood clot at the top of the cervical spine will not be life-sustaining,” he says. “Let’s just make it through tonight. You need to be prepared.”

A brief and terrible pause. I feel resistant, pig-headed, stubborn. As if he intuits how unwilling I am to understand, the doctor repeats his previous prediction: “This is going to get much worse before there is any chance of it getting better.”

No, I want to say. I want to argue, debate, wrestle, defy this seemingly central point. Nothing can be worse than this. But what do I know? This is a new land. I know nothing.

“YOU CAN SEE
him, but only briefly,” Toni says as she leads me out of the conference room. “There are more tests, the
MRI
...” Her voice trails off as we arrive at the sliding glass door where I stood—what, twenty minutes, an hour, a lifetime ago?—the doctors shouting at Simon to wake up.

Simon. Oh God, Simon.

Wake up.

I cannot take it all in. The machines that breathe and measure and pump and drain. The mad array of tubes—thin, wide, variegated, colored—inserted into his mouth, his skull, his arms, his chest. The bloody yellowish-orange iodine stain that covers the left side of his head, the side where the skull has been removed. His hands. The wide strong fingers that taste, forever, of guitar strings, the chewed-down nails, rimmed slightly with the day’s dirt. His hands, as familiar to me as my own, lying still. So still.

Simon. Oh, Simon.

Wake up, Simon. Please wake up.

“YOU CAN COME
back later,” Toni says, but I am immobile. She places her hands on my shoulders, draws me toward the door, and hands me a cup of ice water with a straw. She suggests I leave and get a hotel. Get some sleep.

But I don’t want to go. I try to pull my thoughts together, the loose questions and images on the peripheries of my mind. I try to compose myself enough to speak to the kind nurse. What I need to do, what is critical, is to be close to Simon. If I sit still enough and quiet enough and wait, surely this whole situation will straighten itself out.

“I want to stay,” I manage to say.

She nods and shows me the smaller, more intimate and empty
ICU
waiting room. “These chairs fold out into a cot.” She demonstrates. “I can bring you some blankets.”

She is about to leave when I call her back and ask her to return me to the main waiting room. I am certain that if I am left to navigate the single hallway on my own, I will become irrevocably, irretrievably lost.

Back in the main waiting room, I find that I can trust my voice only enough to announce that we are changing locations. Lou looks at me questioningly, and all I can do is shake my head. No. No, no, no. But once we are seated in the
ICU
waiting room, I have to make an attempt at explaining. It is impossible to repeat some of the things Dr. Griesdale said. I do not mention the risk of a high spinal cord injury; I do not mention the possible blood clot; I do not mention treatment decisions based on quality of life. I do not say it will get worse before it will get better. I say that the injury is serious and that they have removed a portion of his skull to allow the brain to swell. There is a good chance Simon will have a lasting brain injury. When Dave, Lou, and Ryan leave, I finish the thought to Guido.

“The skull will be replaced,” I say, tears coming now. Tears that are like tight explosions, tears that hurt, tears with no relief. “He said the skull will be replaced if he survives. If.”

GUIDO OFFERS TO
stay the night, but I ask him to go home so that tomorrow at least one of us will be rested. At eleven o’clock I return to the
ICU
, to Simon’s room. The
MRI
has been completed, but the overnight nurse tells me the results will not be available until tomorrow. I don’t believe her, and I consider making a fuss. I consider making a fuss from far, far away. What would a fuss look like? I don’t really know, and, more to the point, there is no fuss or fight in me right now. I sit beside Simon and try to orient myself to the various machines and blinking red numbers. Shortly after, and despite the lack of fuss, I am visited by two young doctors. The first reiterates what Dr. Griesdale said: the brain injury is life-threatening. A spinal cord injury is completely secondary. They can do nothing to address the spinal cord until the brain is more stable. And that might not be for another ten to fourteen days.

“Do you understand?” he asks.

“Yes,” I say. Resistance has transitioned into numbness and despair, and this makes me compliant, willing to agree to almost anything.

He leaves, and shortly after, the second doctor arrives.

“Dr. King,” he says, shaking my hand and then positioning a chair so that he can sit opposite me, so close that our knees almost touch. He again repeats the previous doctors’ message: secondary injury; the brain needs to stabilize first before anything will be done. He goes on to outline the finding of the
MRI
. There is no evidence of a blood clot or high cervical fractures. However, several vertebrae in the lower spine are fractured, and there is a dislocation at the juncture of the thoracic and lumbar spine:
T12/L1
. The dislocation has severed the spinal cord completely. Although it is impossible to do a full assessment because Simon is comatose, the fact is that severed spinal cords do not heal. Simon will have no sensation or movement below his waist. So relieved am I to hear of the lack of a blood clot or high cervical fracture that I barely register this distressing diagnosis. It lands with a muffled thud deep in my consciousness with a strict injunction: new information to be dealt with later.

“How fast,” Dr. King says, “how fast everything can change.”

“Yes.” Had I known, really known this before? This is the central point of
The Year of Magical Thinking,
the exact point of departure for Joan Didion’s exploration of how a mind, her mind, attempts to catch up to that surreal and shattering moment.

I have such a weird feeling. Like everything in my life is about to change. Totally change, like on a molecular level. Like my very atoms are shifting.

I sit beside Simon and I swear I can feel, can almost see, his very atoms shifting.

I sit beside him as long as I can, but when I am too dizzy and sick to remain upright, I return to the
ICU
waiting room. A young guy and girl are there (brother and sister? cousins?), and it is evident they are the night shift of a long family vigil. The young man is kind and helps me to adjust the temperamental recliner into a horizontal plane. I lie in a state of suspended animation and try to breathe. Tears come again, but when they do it is less like crying and more like vomiting, heaving and violent and beyond my control. I don’t want to wake the young man and woman, so I leave the darkened waiting room to huddle under the fluorescent lights of the nearby bathroom. Around three a.m., I return to Simon’s glass room with his Cormac McCarthy novel, and I read out loud so that he will hear my voice and know that he isn’t alone. I read carefully, wary. I know that McCarthy’s simple, clear language can lead a reader into sudden scenes of extreme violence, and I wish I had brought a different book for Simon. I do not want to stumble upon such a scene—no massacres of people or animals, no scalpings or vicious beatings. I scan each paragraph before proceeding, my voice a soft, undistinguished monotone that occasionally fades out when a stray thought overtakes me.