A PIECE OF MY MIND
Beyond Hope?
THE HEAVENS CONSPIRED TO MAKE IT A GLOOMY DAY. OUTside, as black clouds rolled across angrily, the sky
dumped rain on the earth with a vengeance. Beginning my first term as a medical registrar, I opened the envelope addressed to me, containing a letter equally bleak:
Dear Doctor:
Thank you for accepting this man into palliative care. His
poor outlook has been communicated to his family.
Recently turned 25, Sam had celebrated the milestone by
becoming engaged to his long-time partner. They expressed their commitment by forsaking heroin. Five months
later, the urge to use heroin was overwhelming. One last
time, he promised himself.
By the time his toddler, Lucy, scrambled on to his chest,
Sam had been slumped on the sofa for hours, oblivious to
the world. The screeching sirens of the ambulance announced his arrival into the rural hospital emergency department, where he was immediately intubated. As the helicopter rose from the ground to transfer him to a major
referral center, dusk was beginning to set in. There was much
else to color the night black.
Despite naloxone, Sam’s Glasgow score on arrival was a
dismal 4. Computed tomography of his head was clouded
with global ischemia. The chest film showed ominous shadows of aspiration, his kidneys strained to bear the burden
of rhabdomyolysis, and his liver protested against the ravages first of hepatitis C, and now of profound hypoxia.
For 7 days, world-class technology battled to save him.
But with each shift, the entries grew briefer, until on his last
day there, the notes had volunteered, “No new problems encountered.” But neither were new solutions. The initial enthusiasm borne of a successful extubation diminished. The
startle response or vacant stares that persisted soon quelled
initial expectations. From now on, palliation was Sam’s lot.
He arrived back at the rural hospital to the welcome of
flowers, photographs, and family. To all these, his response remained the same: decorticate. As the physiotherapist grimly noted the contractures creeping over his
disused limbs, destined to abort recovery, and the speech
pathologist pronounced him unfit to swallow, the medical
notes denoted the pessimism that dwelt in our hearts. The
intern noted, “Gripping my hand on request, or simply
primitive reflex?” “Unclear whether eyes following or just
gazing.”
Did Sam know? For we certainly did not.
Despite such painful messages, his family maintained its
bedside vigil, stroking his flushed face, whispering words
of love, deterred by neither the numerous intravenous lines

that assaulted his skin nor the monotonous beeps of the insipid nasogastric feeds. Theirs became a grief intensely private, compounded by shame and the fear of being ostracized by the small community, with Sam’s secret now
discovered.
To the family’s pleading eyes, I responded only with
guarded optimism, ever cautious to subdue any soaring hopes
at first smell. My answers about Sam’s recovery were steeped
in caveats, and I grew weary of my seemingly rehearsed
speeches, delivered daily, only a few words rearranged.
Although I marveled at the impossibility of the task before, my heart yearned for him to recover. Barely a year older
than Sam, I found his vegetative state confronting. My mind
would often replace him with me, or any one of my friends,
and I grew weary of its tricks, which would leave me feeling strangely powerless to combat them. I was also frightened by the sheer magnitude of Sam’s misadventure, recognizing that a personally more plausible event such as
driving to work could well produce a similar outcome.
The demons of every hospital further avenged his broken body, first with pneumonia, then deep vein thrombosis. The odds against him were increasing, when one late
night, I joined his mother, Anna, at the window in Sam’s
room. There was a sepulchral quiet in the room, barely moved
by Sam’s moist breaths. We gazed out into the silky night,
rendered achingly beautiful and mysterious by a sliver of
moonlight. The mountains cast imposing shadows in the
distance, the silence pierced emphatically by the occasional cry of a lost bird. I joined Anna in her tearful remonstration: “Oh, God, he has so much to live for!”
The next morning 3-year-old Lucy arrived to visit her father for the first time. Excited by the new environment, Lucy
bounced in, a sparkle in the room. She danced toward him,
her arms upturned for the familiar embrace. The gesture unmet, she continued on, almost uninterrupted, her peals of
laughter resonating as she frolicked out of the room. I turned
around to see tears streaming down Sam’s cheeks. The fingers of his right hand flickered, pining, it seemed, with a
father’s love; for the first time, impassivity had been replaced by emotion. Our notes rejoiced that day! Like proud
parents we proclaimed, “Displayed emotion upon sighting
his child, fingers flickered.”
Did we dare expect more?
Little Lucy was the impetus that awoke the spirit within.
The weeks ahead were heady times, bringing countless milestones. Sam started by obeying simple commands, folA Piece of My Mind Section Editor: Roxanne K. Young, Associate Editor.
©2002 American Medical Association. All rights reserved. (Reprinted) JAMA, September 11, 2002—Vol 288, No. 10 1203
lowed by sitting in a chair, rewarding us with a smile, and
capping it all with a pert retort to our daily, eager question:
“What did you do today?”
“Bugger all!”
Yet for the times we delighted in this unforeseen progress,
we realized how desperately far away he was from independent living.
Always respectful but seemingly unmindful of our cautious attitude, Anna began to spend hours stimulating her
son, gaining hope from each move, to return it in the form
of renewed faith.
The mother-and-son team was indefatigable. Were Sam
twice his age, I would have discussed his dismal prospects
with Anna with more ease, but although I wished to warn
Anna, my reluctance to remand her young son to a death
sentence continued to overpower me.
Soon my rural rotation had come to an end. I did not say
good-bye to Sam lest his hand fail him when he waved. I
had heard the physiotherapist comment on Sam’s nonfunctional hand. I spoke to Anna with false levity, expounding
the striking capacity of the young brain to regenerate, hiding my fear of the revenge the same, starved of oxygen, might
extract.
Back home, though I wondered often, I avoided inquiring about Sam’s fate. The experience became a chapter, folded
away among others.
A year has passed and I have returned as a medical registrar to the rural hospital. When the flurry of the first week
had subsided, I walk into Sam’s old room, to be struck by
the involuntary emergence of tumultuous thoughts. The
chapter is not so neatly folded away as I thought. My mind
is swarming with questions. What happened to Sam? Did
he succumb to pneumonia, or was he swallowed by a massive pulmonary embolus? Did his contractures cramp his
style, or did a nursing home vanquish his spirit? Did his arms
ever rise to reciprocate little Lucy’s?
Statistically, Sam’s chances of recovery were remote. And
if this were true, I was reluctant to allow the ghosts of the
past to resurface. Confronting my own mortality always turns
into a frustrating, futile exercise, marked in turns by disbelief, sadness, and contempt at my inability to reconcile
with the undeniable.
Several days of indecision culminate in a call to Anna. She
remembers me, and I know immediately from the lilt in her
voice that her son is alive. But is he well? Perhaps sensing
my fear, she asks me to see for myself.
I need more time.
Late one afternoon, on a ward round, a giggling mass of
pink collides with me. It is Lucy! Sam must not be far behind. My heart pounds uncontrollably as I chase after Lucy,
my indecision brought to a dramatic end. I follow Lucy to
a room to find Sam standing there. He is visiting his ill grandfather. Wearing a pale yellow open-collared shirt, he advances smilingly to greet me. With a lump in my throat, the
first things I notice are his unblemished face, the absence
of crutches, and the gold wedding band that catches the sunshine streaming in the windows. As Sam’s family and I walk
to the cafe, I deliberately fall behind. I just want to see him
walk.
Over coffee, I delight in the details I never saw unfold.
Soon after I left, Sam went into rehabilitation, where he continued to make large and rapid gains. He was discharged just
2 months later, walked unaided up the aisle at his wedding, then resumed driving to full-time work.
“How many accidents have you had?” I blurt solicitously, conjuring images of delayed reflexes.
“None,” he rebuts expectantly. “My reflexes are fine.”
It is telling, the memory that haunts each. For the mother,
it is the route past the nominated nursing home where Sam
was destined to go, while the wife is consumed by the guilt
of the co-conspirator who survived. Shadowing Sam’s young
face are recollections of the endless nights when he would
coax his lips in vain to lend voice to the thoughts of his chaotic mind.
Lucy, with heartrending innocence, wants to tell me a
story. It starts, “One day, when my daddy died ….” Sam’s
hand shoots over his daughter’s mouth.
Tears flow freely as we confront the miracle before us.
Together, we had seen much vulnerability mingled with fear,
love linked inextricably with grief. A mother’s faith had
clashed with a doctor’s doubt. And the unimaginable had
occurred, thanks to the tenacity of a young man, the persistence of his determined mother, and, simply, much good
fortune. I wonder silently whether Anna ever truly realized
how profound Sam’s brain injury was and the usual devastating outcome of such an event. It is no longer my place to
ask her.
Suddenly, I am wishing I had been more positive. Looking at him, I want to say, “I knew you would make it”; but
the unforgiving mind flings me reminders of my resolute
pessimism.
I am left to tell him what a great job he did.
As Sam puts away my coffee mug and holds the door ajar,
I am overcome with immeasurable gratitude for the courage I have witnessed. I am awed by the dignity he has maintained through a clearly grueling time. But most of all, I am
humbled by the convincing demonstration that even in the
unlikeliest of places, where faith fuels it, there will be life.
A full year later, I finally find the capacity to extend my
hand to Sam. He meets it firmly. Unlike the day we first met,
the clouds have lifted.
As Sam’s long strides reach the end of the corridor, he
turns to deliver the last word.
“Did I tell you I coach the running team? Come and watch
sometime.”
Ranjana Srivastava, MBBS (Hon)
Melbourne, Australia
A PIECE OF MY MIND
1204 JAMA, September 11, 2002—Vol 288, No. 10 (Reprinted) ©2002 American Medical Association. All rights reserved.