By Jon Franklin

Copyright  2001 The News and Observer

Used with permission

            Jim Vertucci drove fast, bent over the wheel, peering through the streaks of the wiper blades, trying to stay tucked in behind the ambulance as it whipped in and out of traffic, racing north fromSanford.  Beside him, his daughter cried softly.  He struggled to keep his thoughts in line, his head clear, face the facts, even these facts that threatened to numb his mind and rob him of . . . everything.

For more than two thirds of his life Judith had shared his days and his mind. She had borne his children, prepared his meals, cleaned his house, washed his clothes, arranged the birthday parties and bought the Christmas presents and generally provided the warmth and civilization without which life is only existence.  She had been the entire family’s anchor during those long years in Queens and Long Island when he was aNew York Citycop and often had to be away during nights and holidays.

He had reciprocated, of course — played the role of devoted provider, almost in the old country sense.  Family had come first, for both of them, and it had all worked out, produced strong blood bonds and a productive life for them all. Along the way they’d had their problems, but they were not remembered at this moment.  Trying to follow the wailing ambulance, his daughter’s muffled sobs in the background, it was the joy that mattered.  And joy had been theirs.  The reunions they’d gone to, the parties, the movies.  They’d loved the movies, he and Judy alike — especially theJohnWayne movies, and they’d seen them all. They had laughed a lot. One of the things Judy said was that he could always made her laugh.

Said.  Had said.

Now, just a few days short of their 40^th anniversary . . .

It was one of those moments that compressed life.  Childhood, youth, adulthood, recent past all telescoped into simultaneous awareness in the most disorienting ways.  He could remember Judy as the girl who was elected to the student government, in high school — could remember like it was yesterday how pretty she had looked up there on stage, and how it had awakened an interest in him that had evolved into . . . he could remember her as she held their first child, he could remember . . . well, he could remember it all.  And those memories collided in his mind with the fresher memory of something terrible that had begun to develop, he now knew, over the past year.

It had begun, for him, on January 30.  He’d picked up the telephone at work and she’d been on the line, saying she felt dizzy and disoriented.  He had left work immediately, raced home, and rushed her toCentralCarolinaHospital.  The emergency room team had sent them right on to Rex, where she was admitted.

There were a series of tests, examinations and scans.  Mostly, there had been waiting, but now those events too telescoped into a few vivid scenes.  Sitting in an office while a vascular surgeon show them pictures of the carotid arteries, one on each side of the neck.  He drew a picture showing how they drew blood from the heart and pumped it into a circular arrangement at the base of the brain called the Circle of Willis, from which arose all the arteries that fed blood to the brain.  The circular arrangement was one of nature’s more ingenious fail-safe arrangements.  If one of the carotids failed, the other one could keep the circle pressurized and blood would keep flowing to both sides of the brain.  The brain, and the personality it created, would not know the difference.

In Judy’s case, that was exactly what happened.  The right carotid was totally clogged with atherosclerotic plaque, and probably had been for a long time.  But now the left one was almost clogged too.  As the arteries narrowed, the interior walls became increasingly rough and scarred, which made the rush of blood more turbulent.  When the blood was battered it was more likely to form clots, which would travel up the branching, narrowing arteries that fed the brain.  Eventually the clot was propelled to an artery small enough for it to get stuck in.  Then the brain cells downstream would become ischemic.

“Ischemic,” would fast become a familiar word in the Vertucci household.  It meant “suffocating.”  The brain was the most metabolically active organ in the body.  It took muscle cells as much as an hour to die when their oxygen supply was cut off, but the delicate neurons worked so hard even at rest that they would suffocate in six minutes.

Fortunately, the surgeon said, the clots in Judy’s brain had been small enough to dissolve in less than six minutes, which was why the first symptoms were temporary ischemic attacks, or TIAs.  If the family looked back, they’d probably realize that Judy had been having TIAs for a while, but they were just getting bad enough to be obvious.  Eventually, she would have a real stroke — a clot that lodged and stayed long enough to kill the cells downstream.  Depending on where the clot got stuck, she might be severely disabled or killed.

Fortunately, that hadn’t happened yet.  But the danger was clear and present, and the options nil.  The operation she needed was called an endarterectomy, in which the surgeon would cut open the left artery and carefully scrape out the hard plaque that was clogging it. It was an operation that had to be done with great care to make sure that none of the debris floated downstream, into the brain.  That was always a risk.  There was a laundry list of risks, in fact.  But none of them matched the risk of not doing it.

Judy hated doctors; always had.  But she and Jim were also rational people, especially in a crisis.  A few hours later, Judy was on the operating table while Jim and one of their four children, Patricia Reinhart, sat in the waiting room and worried.  After a while another of the children, Michael, who was a landscaping contractor inRaleigh, arrived to sit with them.

The surgeon had been right.  As the three of them waited they found themselves comparing notes and realizing that, yes, there had been hints all along. Over the last year or two Judy’s handwriting had deteriorated until, at one point, she’d sent her Michael a check he couldn’t decipher.  Jim had bought her a new Cadillac for her birthday, the year before, when she turned 59, and she had recently scraped it getting it into the garage.  That was not like Judy.  She’d also started dropping things.  They’d all shrugged those things off.  Judy, mother, wife, rock-solid citizen, great cook, was reliable as the seasons, dependable as the tick of the clock, and immortal.  Or maybe, they realized soberly as they waited outside the surgical suites . . . maybe she was not so immortal after all.

Finally, though, the surgeon came out, smiling and pleased with himself.  The procedure had gone well, very well indeed, and the prognosis was excellent.  Indeed, two days later she was doing so well they’d sent her home for Jim and Patricia to take care of.

It all seemed so routine.  Patricia and her 10-year-old daughter Kelly stayed in a spare room and the three of them took care of grandma.  In a few days, they seemed to be through the woods.  Patricia started talking about heading back toNew York.

Then early this February morning the world had caved in.

Jim was awakened by the violent shaking of his bed.  Judy was in convulsions, her right arm swinging up and down with unbelievable strength.  He tried to grab her arm, to hold her down and protect her somehow from the awful thing that had taken over her body. He screamed for his daughter, who was sleeping in the next room. A moment later Patricia was on the phone, dialing 911, and young Kelly was trying to help Jim hold Judy on the bed.

Everything happened quickly, by objective measures of time — but terror imposes a measured slow motion on the mind.  The wait seemed endless, but eventually there was the sound of a siren in the distance. Slowly, ever so slowly, it grew louder.  Jim whispered comfort to his wife, though he suspected she could not hear.  Then the room was suddenly full of emergency technicians and their equipment and in minutes Judy was in the ambulance. Jim and his daughter and granddaughter pulled on clothing and were quickly on the road, heading forCentralCarolinaHospital.

It was a day tailor made for anxiety; a somber, gray February day with dark clouds that boiled just a few hundred feet up, shedding drizzle driven by an icy wind.  Jim drove fast.

When they arrived at the hospital Judy was already inside the emergency department.  Their family doctor, Gerald O’Donnell, met them in the waiting room.  He told them that the medical team had managed to get Judy’s original seizure under control, but that a second seizure had then exploded and was now in progress.  Nobody used the specific words, but the look on Dr. O’Donnell’s face and the funereal deference shown by the staff told Jim that Judy was dying.

The doctor said he had called a helicopter.  He was taking Judy to Duke.  It was her only chance.

A few minutes later, a return call from Duke said the weather was too sloppy for the helicopter to fly. Three generations of Vertuccis stood under the canopy of the emergency entrance, watching numbly as the team loaded the sheet-wrapped form into an ambulance. Dr. O’Donnell climbed inside with her.  The doors slammed shut and the ambulance immediately moved forward, out into the cold day, lights flashing, siren growling into life. Jim tucked his car in behind the ambulance, determined to keep up.

Jim Vertucci was a disciplined man, his mind shaped by a stern father, a hitch in the Air Force, and almost two decades as aNew York Citycop. He did what he had to do, went through the motions, stuck close to the tail of the speeding ambulance.  Everybody was doing what they had to do.  If anything could be done, the big, famous hospital inDurhamought to be able to do it.

But what could you do for stroke?  Jim knew the answer all too well.  Everybody knew the answer.  Nothing.  Jim’s father had died young of a brain hemorrhage and Judy’s mother had died of a stroke.  But when it came to stroke, Jim knew, death was often not the worst outcome.  A stroke could kill you, but even worse it could change who you were.

It could make Judy not Judy anymore, into some mockery of Judy, even into some vegetative thing.  Would he have the courage, if that was the trajectory?  To do the right thing, even if the right thing made him the agent of Judy’s death?

The question hung somewhere in his mind, but he suppressed it.  It was not yet time to face that one. The task at hand was simpler, more direct: Drive.

But the ambulance driver was skillful and had the deference of the other traffic, and it slowly moved ahead.  After a while blocky vehicle disappeared around a bend. Jim sought to catch up but he couldn’t, he couldn’t catch up, Judy was slowly pulling away from him, he was helpless. He didn’t know what else to do but drive hard, try to catch up, even in the face of a certain knowledge he couldn’t.  By the time he pulled up at the Duke ER the ambulance was standing open and deserted. Judy was inside, behind closed doors.

Jim, Patricia and Kelly took seats in the waiting room, waiting silently to be told that Judy was dead. A few minutes later, Michael and his wife, Alane, arrived to wait with them.  Jim’s other two children, both inNew York, had been notified as well.

Jim tried to imagine what life would be without her, but he couldn’t conjure up the vision.  The future was as featureless and gray as the cold February sky.

The minutes passed, an hour.

Patricia had never seen her father so helpless.  He had been a distant authority all her life, strong and distant. When Patricia would ask his permission for something, he’d reply not to her but to Judith.  “Tell her no,” he’d say, and his word was law.  But when there was punishment to be meted out, it was Jim who made the decision but Judy who actually did it.  Patricia had resented it, on the one hand — but on the other, he had been a tower of strength.

But now, as he faced the biggest loss of his life, he was clearly devastated.  Now, she realized dimly, the roles were reversed.  HE needed HER help.

Indeed, some great turnover had begun in Jim’s mind:  As one life seemed to drop away, another, different life took its place.  For 30 years he had been a heavy smoker, but sitting there in the waiting room it never occurred him to step out for a smoke.  He just sat there and waited.

Finally an emergency room doctor came through the automatic doors and walked in their direction.  Jim braced himself . . . against a blow that, inexplicably, did not come.

Mrs. Vertucci, the doctor said, was doing quite well given the circumstances.  She was dazed, but was coming out of it.  She responded purposefully to commands to open her eyes, squeeze the doctor’s hand, move her limbs.  She’d had a small stroke, maybe a TIA . . . but the situation didn’t seem all that grim.

The thing to do now, the man said, was for the emergency room doctors to hand her off to the neurological experts.  They had a neurological ICU, where stroke specialists could monitor her and take whatever steps were necessary to prevent more problems, and if some complication developed they’d be right there to treat it.

The Vertucci family stared dully at the doctor, disoriented by the good news, not knowing whether to believe it or not.  They’d heard such reassurances before.

It was as if the whole family had been twice dropped down some terrifying incline on a celestial roller coaster, and if they were now once again crawling up the next ascent, that was little comfort.  Humans were exquisitely mortal and life was brutally unpredictable — eternal truths that the Vertucci family had just lost the capacity to deny. After the doctor left they sat there, stunned, trying to absorb the uncertainty that was the lot of stroke patients and their families.

It was about eight o’clock the following morning when Dr. Carmelo Graffagnino walked through the pneumatic doors and into the into the neurological intensive care unit, signaling the beginning of rounds.  Quickly the unit’s operational team coalesced around him.

The makeup of the group varied from day to day, but it usually included the offgoing attending nurse, a critical care nurse practitioners, a Ph.D. level pharmacologist, a respiratory therapist and an assortment of interns, a dietary technician, a neuro resident, sometimes a chaplain, and anyone else on the floor who was involved in the case or who just wanted the experience of watching Graffagnino work.

Graffagnino (graf-fa-NEEN-o), who was not quite 40 at the time, was heir to centuries of hardscrabble efforts of the mind understand its own wiring, plumbing and metabolic chemistry. As a result, he was a master of complexity.  He was board certified both as an internist and a neurologist specializing in stroke, and when neuro intensive care medicine became an official specialty, which it was expected to do soon, he would be certified in that too.

His most important credential, however, was arguably his membership in an unofficial but elite group of young neurologists who composed a radical new and optimistic movement in the field.

By historical measures the neurological tradition was one of one of deeply rooted pessimism, mired in the enduring experience that brain disease, however difficult it might be to diagnose in the first place, was even more difficult to treat.  Impossible, usually.  Stroke in particular was an essentially untreatable condition.  The doctor provided support for the patient, and the patient either got better or . . . didn’t.  Granted that “support” in the modern teaching hospital often bordered on science fiction, that fact didn’t change the basic equation.

When Dr. Graffagnino had told his mentor in internal medicine that he had decided to switch fields to neurology, the man had looked at him in disbelief.  “Neurologists,” he said disdainfully, “are nothing but a bunch of electricians without screwdrivers.  They may know a lot about the circuitry, but they can’t <ital>DO<end ital> anything about it.”

Graffagnino would never forget the indictment, but he wasn’t dissuaded.  His new mentor, the famous brain scientist Vladimir Hachinski, shrugged off such deprecatory slurs. They were valid enough, if you looked back, he admitted.  Neurologists had been helpless in the past, limited in most cases to diagnosing the problem, reading the omens, and sitting with the patient’s family.  That was one of the things that helped drive the world’s most famous neurologist, Sigmund Freud, down the path that eventually created psychiatry.

But why, Dr. Graffagnino’s mentor asked in rebuttal, should one look only backwards?  The future was what counted, and a whole new world was dawning in neurology. What was once impossible might become possible and, beyond that, even routine.  That had been the story of medicine, hadn’t it, and though it made sense that the field should lag behind the simpler domains of cardiology, say, and kidney disease, there was nothing to indicate that the brain fundamentally different from other organs.  It would yield and, when it did, the first major disease to become treatable would surely be stroke. If helplessness was the condition of neurology, it was the job of Dr. Graffagnino’s generation to change that.

Revolution fit Graffagnino’s temperament. He was a dark-haired, compact man of average height who climbed mountains in his leisure time and had an affection for dapper jackets and colorful ties.  He attributed the mountain climbing to his adrenaline-junky temperament, and he blamed his taste in ties to the mixture of Sicilian and Spanish blood that flowed in his veins.

The revolution in stroke medicine had really first taken hold in the 1970s, with a large-scale public health campaign aimed at controlling blood pressure. This dovetailed with smoking cessation programs and lifestyle changes in diet and exercise.

As a result, brain hemorrhages rapidly became more infrequent; where once they had accounted for half of all strokes, they ultimately dropped to 10 to 20 percent of all strokes.

But the mortality rates didn’t drop that much as people who would have died of hemorrhage lived on to die of a clot in the brain.  Likewise patients who might have had a clot-related stroke in their 50s tended to have it in their 60s instead.  All that was to the good, but there was still not much the doctors could do for a victim already in the throes of stroke.  Like generations of neurologists before them, they could only support the patient with life-sustaining machines while hoping for the best.

By 1997, when Mrs. Vertucci’s stroke occurred, the first breakthrough was on the horizon.  The clot-busters used in heart attack patients were being tried in stroke patients as well, and within narrow circumstances initial reports were optimistic.  Every neurologist hoped that, within a very few years, they would have in their hands the first clinically tested drug for acute stroke.

That was still problematic, though, because there was reason to believe that it could only help within 3 hours of the stroke’s onset . . . and, unfortunately, few stroke patients rarely got to the hospital that soon.  So the promise was modest, at least without a public health campaign on the order of that launched in the 1970s by cardiologists.

But, despite those limitations, progress seemed at hand — and progress, in neurology, was a rare and seductive thing.  Optimism bred more optimism, and more doctors were trying new things. Dr. Graffagnino and an international clique of activist neurologists, for example, had begun to take on the central problem of acute stroke, which was brain swelling.  Trapped inside the unyielding skull, the injured brain literally crushed itself to oblivion.

Some of the more aggressive neurologists like were dabbling in experimental therapies which, at least when compared to traditional medical practice, seemed downright bizarre.  A group atHeidelberg, for example, had treated a number of patients with massive strokes by removing half of their skulls.  The bone went into a refrigerator so it could be replaced later; meanwhile, the patient’ brain could swell outward without building up pressure in the skull.  The hemicraniectomy, as it was called, had been disastrous at first, but now the Germans seemed to be producing positive results.  The numbers weren’t large, but still . . .

Dr. Graffagnino, for his part, had another tactic in mind: hypothermia.  If the body was cooled, the brain would swell less — at least in theory, and in animal experiments.  Several neurologists had tried it on humans, though since they did it different ways it was difficult to compare results. Graffagnino himself had used it on one patient who was near death.  The patient had recovered, and Graffagnino had grown a notch more confidence in the process.  Now he was ready to try a second.

It had to be someone clearly on a trajectory toward death . . . but not so far along that the dice were completely loaded.  It had to be someone in the first 24 hours of a stroke, before the brain had really begun to swell.  And, finally, it had to be someone whose family was willing to roll the dice.

As the rounds team assembled in the Neurological Intensive Care Unit on the morning of February 6, however, this was all in the back of Dr. Graffagnino’s mind.  Rounds occupied his full attention.

Dr. Graffagnino counted noses and a nurse found a cart to serve as a portable table for medical records and the pharmacologist’s computer. After a brief exchange of pleasantries the cart, surrounded by people in white coats or scrubs, rolled toward the rim of the NICU.

The unit was laid out in patient bays extending from a central hallway.  Each bay contained one patient, feet out — sheet-covered human forms who were usually still and silent.  In the back of the bays were banks of monitors and other equipment.  Bright dots traced their way across cathode ray tubes.  Some patients had EEG sensors glued semipermanently to their heads.  Many had tubes in their brains to enable continuous pressure readings.  Respirators sighed quietly in the background.

All over the hospital, on pediatrics wards and internal medicine wards, in ICUs and trauma units, rounds were being conducted.  There was a formality about them, rooted in medical history going back centuries.  Neurology, like other specialties, had adapted the traditions to its own needs.

By the time Dr. Graffagnino appeared to start formal rounds, the patients had already been examined by all the principals, from the resident to the respiratory therapist.  Now the cart stopped in front of the first bay and the caregivers provided detailed verbal reports, often mentioning relevant scientific papers and even research in progress at other institutions. Then the group began working its way through the most important systems in the body — beginning, on the neurological floor, with the most confounding organ of all.

Rounds focused everyone’s mind on the physical reality of the brain — on the function and vulnerabilities of the mysterious gray cell that was the basic mechanism of thought. Neurons were gossamer things, almost transparent, and together they seemed like nothing more than three pounds of runny goo held in shape by membranes almost as delicate as that which surrounded the yolk of an egg.  So delicate it was that the slightest touch of a neurosurgeon’s gloved fingertip could produce a deepening purple bruise.

For all of that, the neuron was an electro-chemical workhorse, by far the most metabolically productive of all cells.  In the process it consumed glucose and oxygen at prodigious rates and produced equally prodigious amounts of dangerous chemical wastes to be carted away by the veins.

The raw materials for the neural engine were fed up in the bloodstream, through the carotids, up into the Circle of Willis and then beyond to the narrowing, out-branching tree of arteries.  That arterial tree was pumped up like a fire hose; it was so stiff with pressurized blood that when a blow on the head caused the neuronal gel to slosh, the brain could actually tear itself apart against the unyielding arteries.  That was a common cause of death in trauma units.

However vulnerable the neurons might be to physical damage, they were even more susceptible to chemical disruptions. If a blood clot flowed into the branching arterial tree and clogged one branch, the downstream neurons would be instantly deprived of oxygen and glucose; in as little as six minutes they would use up their reserves, die, and be chewed up by their own metabolic machinery running amok. In the process the cells would spew powerful brain chemicals into the surrounding tissues.

In minutes this secondary trauma would take its toll and those cells would die too, poisoning another layer of cells.  As the damaged area grew, swelling began.

As the brain swelled inside the skull, the pressure built, and the brain deformed.  If the process was not somehow halted somehow by the body’s own defense mechanisms the pressure would mount until there was something had to give.  At that point the delicate membranes would rupture and the brain stem, which controlled breathing, heartbeat, consciousness and other critical functions, would herniate out through the foramen magnum — a nickel-sized hole at the bottom of the skull through which the spinal cord entered the brain.  On the NICU, “herniation” was a polite word for death.

So as the rounds group stopped outside each cubical, the first item to be taken up was usually brain swelling.  If the patient had a catheter in her brain, the pressures could be read directly.  The pressure readings were compared to earlier ones to ascertain whether the swelling was increasing or decreasing.  In the NICU, the doctors often used a dial gauge that produced readings in millimeters of mercury.  Twenty was a threshold of concern, and anything above that would trigger grave discussions at rounds. Nurses, interns and residents flipped through charts and records while the pharmacologist typed into the laptop, refreshing himself on the current drug cocktail.

Was swelling increasing and, if so, how fast?  And was there anything the doctors could do, no matter how marginal, that might shave the odds in favor of the patient? In then end, though, there was usually very little that could be done, beyond spotting the omens, classifying them, and entering them into the record while the patient lay dying a few feet away.

There was, of course, Graffagnino’s hypothermia experiment, but he had to find exactly the right patient . . . and to identify that patient within 24 hours of the stroke.  Such patients did not come his way every day.  Meanwhile, there was the daily routine of the NICU, a routine that commenced with morning rounds.

The rounds team, having discussed the brain and deciding what to do during the next 24 hours, then proceeded to other body systems.  Respiration was usually topic number two, because comatose patients were exquisitely susceptible to pneumonia.  Then came the heart, which included issues of blood volume, salts and electrolytes. The gastrointestinal system came next.

Psychosocial issues came last on the list . . . and, as often as not, was the conclusion of all the previous discussion. Graffagnino’s dreams notwithstanding, the neurological ICU remained largely a place for dying.  On any given day, half of his patients might be what was euphemistically as “ethics cases,” in which attempts to save the patient had degenerated, finally, to one last set of questions: When should the respirator be turned off, and how could the hospital help the family see the inevitability and necessity of that act?

The discussions complete, Dr. Graffagnino stepped into the cubical and addressed the patient.

Mrs. Smith!  Mrs. Smith!  I’m Dr. Graffagnino and I need to ask you a few questions.  Do you know where you are?  Do you know what year it is? Can you open your eyes? Move your legs?  Mrs. Smith!

As was traditional in neurology, Dr. Graffagnino always assumed the patient could hear him . . . even if he couldn’t imagine how.  The legend was that hearing was the last sense to go, and doctors, nurses and technicians shared a common horror that the last semi-conscious flicker of a patient’s life might involve some disrespect on their part.

The clinician, at rounds, was obliged to decide why comatose patients were unconscious. Deep in the brain there was a set of circuits called the “reticular-activating system,” which switched between wakefulness and sleep.  To be comatose, a patient either had to lose both of the upper hemispheres of the brain or the reticular-activating system — the “God center,” as some called it, because of its life or death importance.

The penlight, along with the reflex hammer, was the neurologist’s badge of office, and if the patient didn’t respond to voice contact it came out of the pocket in the white jacket.  Expertly, Graffagnino held one eye open and shined the light into the pupil, and then did the same in the other.

An enlarged pupil was a bad omen for that side of the brain. Beyond that, the neurologist needed to check the circuits, one by one.  If a tongue depressor elicited a gag reflex, that was a good thing.

If both eyes were held open and the head turned back and forth, the eyes of a comatose patient might stay fixed with respect to the head or might move in such a way as to focused on a single spot.  The latter was a good omen — the oculo-cephalic reflex, as the texts called it, was functioning.  Clinicians just called it “doll’s eyes.”  If there were no doll’s eyes, the physician might squirt iced water into an ear.  If the eyeballs rolled to that side of the head, then that was a good thing because it meant that some level of central control, no matter how primitive, remained.  If the eyeballs remained fixed, well . . . the bad news was accumulating.

Of all the brutal realities of the NICU, one of the worst was the fact that, long after happiness and joy had evaporated, discomfort and pain were still there. As a result, one of the neurologist’s most reliable tools were, as another euphemism phrased it, “noxious stimuli.”  Ice water in the ear was a noxious stimuli.  So was a tongue depressor, inserted into the throat.  Did it elicit a gag reflex, or was that gone too?

More directly, Dr. Graffagnino might reach under the patient’s armpit, grab a tender fold of skin, and pinch . . . hard.  Most of the patients on the floor had deep purple bruises in their armpits, but it produced the necessary results.  If the arm drew up and the hand tried to pull Graffagnino’s hand away, the cortical motor areas were still functioning.  If the hand just drew up, like a chicken wing, then only the deep structures of the brain could respond. Other, similarly noxious stimuli would make an eye blink or a leg draw up.  Pulling the butt of a reflex hammer across the bottom of the foot would activate a Babinski response:  The toes spread and the big toe either went up or down.  Down was a good omen, insofar as any news about a comatose patient could be good. If the toe went up, that was not so good.

So it was that morning rounds was an extended and complex affair, often proceeding at no more than four bays an hour.  It was not unusual for complicated a patient to take a half an hour or more, the doctors and medical students leaning over records, checking chemical pathways, and discussing relevant scientific papers..

But eventually then the cart moved on, to the next cubicle . . . routine, step by step, hiding a life and death drama behind a curtain of procedure, technical jargon and euphemism.

And so went the morning.  At a half hour per patient the afternoon might have gone the same way but for the occasional patient like Mrs. Vertucci.

As the cart came to a rest in front of her cubicle, her husband ducked out.  Dr. Graffagnino noticed that, and it told him that the man was no trouble.  Otherwise the nurses wouldn’t have let him stay. In that case Graffagnino certainly didn’t mind.  In his experience a close relative on hand was good, especially if the relative was not prone to panic or hysteria.

Not that it mattered much, in this case.  Dr. Graffagnino looked at the chart, and all the omens were positive.  Mrs. Vertucci was very groggy but she responded to his voice, her eyes blinked, she seemed to know where she was, her gag reflex was quite good.  A picture of health, on this unit.

He scanned her records, put together the story.  When she came into the ER last night she’d had convulsions and they’d hooked up a respirator.  But as the day and evening wore on she’d stabilized and was able to breath on her own.  So the night crew had taken her off.  Graffagnino figured he could move her to the step-down unit; she didn’t need half a nurse’s time, and someone else probably needed the NICU bed. Then again, he thought . . . why not move her all the way down to the regular neuro ward and save the expensive beds for someone who needed them.

In any event, she was certainly no candidate for desperate experiments.

The process didn’t take long.  The rounds team discussed the case and Graffagnino articulated his decision.  The nurses wrote it down, and the cart moved on. Behind it, Jim Vertucci quietly slipped back into the cubicle.

The few hours he had spent on the neurological intensive care unit had added greatly to Jim Vertucci’s unease.  The doctors were very optimistic and Judy was definitely improved. It was true that there was a pronounced weakness in her right hand and that she seemed to be having some trouble articulating her thoughts, but her state of consciousness was more than the term “rouseable,” which the doctors had written in her record, implied.  They didn’t know her but he did, and despite her grogginess and the speech problem he could tell there were thoughts going on in her head, and that those thoughts were identifiably Judy’s.

All the same, the NICU served to heighten his sense of mortality.  It was obvious that many of the other patients on the unit — maybe even most of them — were inexorably slipping down toward brain death. It was a thing he had never seen before, even as a cop.  This time he was personally involved, of course, and that might be warping his perceptions, but . . . he was frightened.

Even as he followed her to the regular neuro ward, he was plagued by some deep uneasiness. After all, they’d told him she was out of the woods once before — and look what had happened.  He was supposed to believe it, this time?  He wished he could.

The ambiance of the regular ward was better than that of the NICU, but it wasn’t all that great. The place was filled with patients, mostly old, who didn’t seem quite conscious; many of them lay awkwardly in their beds and some had their hands tied to the railing. Weeping relatives came and went. Occasionally something critical and urgent happened up or down the hall, and all the people in medical uniforms went rushing down that way.

He tried to ignore these things, mind his own business, focus on his wife.

There were stated visiting hours, of course, but Jim’s experience in the military, the New York City police department and finally in the bureaucracy of the IRS, where he now worked, understood that rules were there to be enforced, or not, according to the circumstances of the moment.  In this case, visiting hours were to keep out the patients who might get hysterical, or cause trouble in some other way.

Jim had immediately set about convincing the gatekeepers that he was no trouble.  He could be a charmer, when he wanted to be, and he lathered it on the nurses.  He was careful not to get in the way. When the doctors came in to examine Judy, he vanished, But he never went very far.

When visiting hours came, the children joined him in the room.  The children.  Well, they were grown up now.  Crisis had a way of crystallizing things like that. Judy knew who they were, though, and if she couldn’t carry on much of a conversation she was clearly cheered by their visits.

He went home late on the 6^th, exhausted — and once he was home he realized he hadn’t eaten.  He forgot eating, was forgetting lots of things.  He had forgotten to smoke, and then . . . well, he just hadn’t, so he’d quite carrying the pack around.  But he shouldn’t quit eating, even if he wasn’t hungry.

He opened cabinet doors, exploring. He didn’t have the energy left to cook anything.  Even the thought of heating something up made him tired. Numbly, he pulled out a box of corn flakes and poured some in a bowl.  Milk. Sugar. Spoon. He ate without thinking, went to bed.  Then it was morning, early, and he was back on the road the old day blurring into the new.  It was a good hour’s drive to Duke, under the best of circumstance, and already the route was getting familiar.  He understood he was not in the best psychological shape, and tried compensate by being extra careful with his driving.

On the 7^th it seemed to Jim that Judy had gotten a little worse, a little groggier, and the doctors in and out more often.  He had already learned that was a bad omen, when the doctors got too interested.  One by one, they examined her neck, gently feeling the carotid that had been cleared out.  An ultrasound crew came up and ran their little transducers over her neck, making soundings of the artery’s interior.  Later, the docs stood outside the door and went over what they’d found.  Then they came in and looked at her neck again, taking her right hand and demanding that she squeeze it.

She did, but it was a weak squeeze.  That night he went home late again, to corn flakes.

On the eighth he arrived to find her wrists tied to the bed railings; she had become confused overnight, the nurses said, and had tried to pull out her IV tubes.  Occasionally groups of people in white coats showed up to hover for a while, worried looks on their faces.

Mrs. Vertucci!  This is Dr. Graffagnino!  Can you tell me your name?  Squeeze my hand!  Open your eyes!

She knew her name, but didn’t follow commands. They scraped the butt of their reflex hammers across the soles of her feet, and the big toe went up/down.  They stood outside the door and scrutinized her medical records.  They sent her down for an MRI image.  A surgeon was scheduled to come by and examine her.  Jim understood they were worried that something might have gone wrong with the carotid — a flap tearing loose from the incision or something, causing turbulence that led to blood clots that were being carried into the brain.  They might have to operate again.

Jim was terrified, but he didn’t complain.  If he made a scene, they’d make him wait in the waiting room.  He sat by his bed wife’s, outwardly accepting, silently trying to work through the permutations of his circumstance, to identify some options, think of something he could do.  But the conclusion always came back around to the same thing.  He could sit beside her bed and worry, and that was the limit of it.

The next morning, the 9^th, the doctors huddled and decided that the carotid wasn’t the immediate problem.  The stroke — and it was clear now she’d had a stroke, not just a TIA — might followed any minute by a second one.

Dr. Graffagnino wanted to give her heparin, a heavy-duty anti-clotting agent, but he had to make sure the stroke hadn’t turned into a bleed into the injured tissue. That happened sometimes, when the tissue downstream of the clot died, arteries and all, and the goo turned to syrupy garbage . . . if the original clot opened up then, a torrent of blood could pour into the goo and make things all the worse.

Fortunately, bleeding was easy to diagnose because blood showed up white on a CATscan.  So again Judy went down to radiology, and a few hours later came back up.  The scan was clear.  There was no blob of white on the left side of her brain, no bleed. With that reassurance, Dr. Graffagnino started her on heparin.

That night Jim drove home in shock, ate something — he almost didn’t notice what — and collapsed in bed.  The next morning he woke a little later than usual, as the sun was coming up. He got into the car, still exhausted, the adrenaline rush long gone, life coming down to endurance in the face of the grinding, glacial movement of the days, never knowing what was going to happen next.

What happened next, happened sometime during the early morning of February 10.  Despite the anti-clotting medication Mrs. Vertucci was receiving, a clot had formed on one of the roughened arteries in her neck.  The clot had grown, and then broken off and been carried along by the river of blood. It had floated into the Circle of Willis at the base of the brain, and from there was quickly vacuumed up by the big ascending artery that fed the left side of the brain.  In the next instant it was swept into one of the narrower branch arteries and lodged there, cutting off blood flow.

From the outside, there was no change.  Mrs. Vertucci appeared to be sleeping.  It was not until the morning that a nurse discovered that hers was no longer a normal sleep. A few minutes later, the house neurologist was on the scene.  Eventually there was a whole bevy of white-coated doctors milling around in the hallway outside her room.

It was an emergency, in any human sense of the word, but the only outward sign of the fact was the thoughtful look on the doctors’ faces. There was no red cart being pushed down the hall by a young doctor on the run, no frantic crash-team experts with the neurological equivalent of defibrillating paddles, snatching a patient back from the clutches of death.

But the treatment of stroke just wasn’t like that. The organ in question was too complicated and the science still too young.  There just wasn’t anything dramatic available to do.

Cardiology, for that matter, hadn’t always been so dramatic either. As late as the early 1970s a heart attack patient often didn’t come into the hospital until three or four days after the pain struck.  There was no point, really; the hospital couldn’t offer much but painkillers and comfort.  You died, or you didn’t.  In an emergency, the cardiologists stood around and tried to figure out to do, just like neurologists did today.  When the heart stopped, they covered the patient with a sheet.

Once scientists managed to develop a few tools for the cardiologists, such as defibrilation, the cardiologists found those therapies difficult to apply in time to help. Because the public perceived heart attacks as untreatable, they didn’t bring the patients in fast enough. Nobody, including ambulance crews, much thought it mattered. As a result, people showed up too late for the doctors to do anything, and public ignorance became a common killer.

In the late 1970s cardiologists launched a massive public awareness campaign that eventually led to the dramatic emergency procedures now so familiar on television medical dramas.  As a result, patients were treated earlier, responded better, and new treatments like today’s clot-busters could be devised.  Now, because patients had learned to take heart attacks seriously, cardiology had become a huge specialty with spectacular tools that could and did preserve and extend life.

Neurologists, comparatively, still back in the ’70s.  Yet most strokes were identical, in most respects to a heart attack. They just lodged in different arteries.  In fact, as PR consultants worked to tool up a useful phrase for public education, they were toying with changing all references to stroke to “brain attack,” instead.

The heart specialists still had some advantages, of course — mainly the fact that the heart was a strong and resilient organ.  A heart was a muscle that never quit exercising. A part of the heart could be deprived of oxygen for hours and still, with luck and the proper care, recover.  But when a clot lodged in a brain artery, the delicate neurons downstream were dead within four to six minutes.

The incipient good news in neurology was that TPA, the drug used to break up clots in heart attack victims, seemed to be turning out in early trials to be able to clear the occluded artery of a stroke as well.  Well . . . sometimes it did.  The problem was that it had to be administered even more quickly than with a heart attack.  If more than three hours passed between the onset of a stroke and the treatment, it was too late. So even once the FDA approved the drug, which it had not yet done, very few patients would benefit.

Clearly, neurologists were about to face the same problem that pioneering cardiologists had faced in the 1970s.  The public, emergency medical personnel — even many physicians — were so fatalistic about stroke that almost nobody would get to the emergency room in time for the TPA.  There would have to be a massive public education program designed to teach people to think of stroke as a “brain attack” and respond with the same urgency they would respond to someone with chest pain.

But it was going to be even tougher, this time.  The heart, when injured, hurt — badly.  But ironically the brain, the seat of all pain, itself had no nerve endings.  Thus, strokes didn’t heart, and was easier to ignore. Surveys had shown that, among aging patients in particular, stroke was the single most terrifying health problem . . . and the fear led to denial.  It was a pinched nerve, maybe.  Or just exhaustion.

And the fatalism was so utter, so black, so hopeless, that it took the fight out of families that, with any other disease, might refuse to give up.

But even if TPA was in use, Dr. Graffagnino could not have administered it to Judy on that fateful morning.  Even though her stroke had occurred right in the hospital, it had happened sometime in the night.  How many hours had passed?  As was so often the case, no one knew.

Dr. Graffagnino’s helplessness was made all the more frustrating because he knew exactly what was going to happen now.  He studied it, written scientific papers on it, knew it in all its ugliness. The neurons downstream of Mrs. Vertucci’s clot were already dead, and the chemical chain reaction of death was in progress.

The dynamic little neurons were, in essence, chemical plants — and the chemicals were powerful drugs, brain hormones that modulated the firing rates of cells.  There were many of them, from natural forms of morphine, valium and nicotine to the broader spectrum chemicals like the one called GABA, which slowed down firing rates and kept the brain from running away with itself, and glutamate, which increased firing rates.  After a stroke, some of these chemicals turned killer.

Glutamate was a particular problem; leaking out of dying cells, it caused other cells nearby to fire faster.  To do that they had to work harder, which translated into a greater demand for oxygen and glucose which was already in short supply. So a ring of cells around the first dead cells would literally work themselves to death and, in dying, add their poisons to the mix, which would in turn start the process over again in the next ring of cells. In that way even a small stroke became increasingly deadly with each passing hour.  Already, swelling was setting in.

Dr. Graffagnino had helplessly watched this happen time and time again. North Carolina, for some unknown condition, was the buckle of the stroke belt, and the patients poured in . . . and died.  It made him a fanatic about prevention.  Quit smoking!  Exercise!  Eat more healthily!  Treat your high blood pressure!

But it was difficult for people to change lifestyles, and there was also a genetic component that couldn’t be changed — at least, not yet. What’s more,North Carolinawas, for some unknown reason, the buckle of the stroke belt.

He examined her again.

Mrs. Vertucci!  Can you hear me, Mrs. Vertucci?  Are you awake? Mrs. Vertucci, squeeze my hand!

Given his knowledge of the brain’s wiring and plumbing, he could tell by his physical examination that Mrs. Vertucci’s clot was in the left middle cerebral artery.  Much of the left side of her brain was fed by the middle cerebral artery.  Critical elements of speech were processed there, in a part of the brain known as Wernike’s area.  Wernike’s area was just downstream of the clot, and it contained the brain’s dictionary.  The speech output motor, Brocca’s area, was on the other side of the brain and had been spared.  He could logic this out by observing that Judy was able to talk, but all she could produce was a babble — a string of words that didn’t make sense.

The middle cerebral artery was so very important, fed so much of the brain, not just on the surface but also deep underneath, where one horn of the hypocampus rose toward the surface.  The hypocampus was critical to memory.

Everyone was different, of course, and that particularly applied to the exact position of the arteries of the brain.  To make it more complicated, people with narrowed brain arteries also often tended to grow collateral arteries, just as happened in heart diserase.  Enough collaterals would minimize the impact of a stroke.  But still, the middle cerebral artery fed a lot of brain, and a blockage there was bad news, very bad news indeed.

The stroke seemed to be evolving almost before Graffagnino’s eyes, the familiar progression from weakness to total paralysis, the loss of language, the increasing drowsiness.  With the passage of hours her responses were dimming and her brain was beginning to swell, crushing the gossamer circuitry of the unique personality known as Judith Vertucci.

Dr. Graffagnino was standing outside her room with several of his colleagues when Jim Vertucci entered the far end of the hallway and stopped, staring.  Graffagnino could tell by his body language that he knew something was wrong.

Jim walked directly up to Graffagnino, and asked what was wrong.  Graffagnino told him Judy had had a massive stroke.

Wild-eyed, Jim stared first at Dr. Graffagnino and then at the others.

Then why are you all just standing here? he demanded angrily. She had a stroke? Why aren’t you doing something about it?

Dr. Graffagnino’s wished he had something to do.  He’d put Mrs. Vertucci on a respirator and connected her to a full bank of monitors.  He had administered manatol, which shocked the kidneys into excreting more fluid; some people thought that lessened swelling. Then she was off to CATscan.  By the time she got back her situation would probably be worse, but there was nothing else he could do except order an EEG, or brain wave reading, to rule out seizures. Seizures were sometimes “silent,” depressing the victim’s consciousness and affecting her ability to move.

The doctor faced another, all too common problem as well:  Mrs. Vertucci needed desperately to be in an ICU but the neurological unit was full.  By the patient’s angry husband  was standing in front of him he was already engaged in negotiations for a bed on the medical ICU on the eighth floor.

Now the patient’s husband was standing in front of him, furious that something visible wasn’t being done.

The two men were about the same height, and they looked one another right in the eye. Graffagnino red the outrage and desperation in the man’s face.  He had seen that many times.  But in this case he registered something else there as well — some hard, stubborn, persistent rock of personality that would not give up, not ever.  Graffagnino recognized it instantly for what it was, vibrated to it, and respected it.

A few minutes later Graffagnino was back in the NICU, tending other emergencies, but the image of Jim Vertucci hung in the back of his mind.

There was a shared belief in the NICU, from doctors down through the technicians, that scrappiness, the will to fight, whatever it was, the never-quit . . . that it meant something. Though it was the sheerest supposition, and almost in opposition to scientific thought, stubborn resistance was somehow exalted in the minds of those who, over and over again, had to stand by helplessly while their patients died. It was a spiritual thing, and Dr. Graffagnino considered that he was a spiritual man.  He accepted that there were forces and processes he did not understand, and that sometimes those things mattered.  And in the desperation of his own routine, he was not above using anything that worked.

As the day wore on, he got Mrs. Vertucci moved to the medical ICU and went up, frequently, to watch the classic deterioration of her clinical signs, a textbook case, pressure building, brain function waning . . . her husband was there, watching his wife slip away, understanding perfectly well what was happening and what it meant.

If it went by the book, it would take three days.  The dead cells would spew out the chemicals that injured other cells, and those cells would be hampered in their recovery by the relentlessly increasing pressure, the swelling now causing swelling, a vicious cycle that would continue until it finally ended abruptly with the herniation of the brain stem out the foramen magnum.  Then the heart would go on beating and the respirator would take over from the flaccid diaphragm, but it would be forever over except for the ethics issue.

It was ironic, in a way.  The organ of personality was perhaps the most complexly ordered piece of matter in the universe.  It understood its own existence, it dreamed, it built great civilizations that knitted together the world and provided hospitals like this one, where science produced what in other times would have been recognized only as magic.

But in the end, and amidst the technology, it was such a simple thing that killed you.  The brain was ultimately just another tissue, and injured tissue swelled.  In this case, the tissue was in a box of bone, and the only opening to the bone was at the bottom, where the most vital functions were modulated.  So swelling led to herniation, and on the neuro ward herniation was another word for death.

If it was an ankle, you’d put ice on it.

And that, of course, was the simple logic that had led Graffagnino and a handful of other neurologists to use cooling, or hypothermia, to control brain swelling in stroke patients.

Hypothermia was not a new thing, exactly.  It had been used for decades in heart surgery, where it served to slow down metabolism and buy a few more minutes for the surgery team.  It had its drawbacks, in that it seemed to also injure the patient’s immune system and, a more immediate problem, cause dangerously changed rhythms in the heart.  Those things weren’t problems in heart surgery, of course, because the heart was on bypass, a whole heart surgery team was there to deal with any emergency, and the whole thing didn’t last long enough for the immune system to matter much.

But what would happen if you continued the cooling for maybe three days or more?

While science hesitated, life itself threw up some clues.  Once intensive care units were common, there were increasing reports of cases in which people were revived and nursed back to health after prolonged immersion in icy water.  Bench scientists used cooling to prevent swelling in the brains of animals, and it seemed to work . . . though you could never tell, of course, with an animal.  People weren’t animals, in that sense, most especially where their brains were concerned.

As the day passed Dr. Graffagnino watched the clinical progression and thought about Mr. Vertucci.  Jim clearly wasn’t the kind of man to give up.

But was he the kind of man to roll the dice?

Back on the ward, Jim Vertucci spent as much time as he could sitting by his wife.  He didn’t think she was aware of him, now, but he wasn’t sure of that and, besides, he was gripped by a powerful need to remain by her side. It was a confused feeling, because it was very lonely in that visitor’s chair, more or less ignored by the medical staff and, of course, his comatose wife.  When they rolled her down to CATscan, or took her for some other tests, he had time to go down to the cafeteria and eat, and maybe talk with whichever of his children were on hand . . . but he was always antsy to get back upstairs, so he could be in the room when she arrived.  He kept silent, stayed out of the way, did nothing that might cause someone to ask him to leave.

That day, the 10^th of February, was a confusion of hurrying up and waiting.  People rushed in and out to check equipment, take blood or administer drugs.  A nurse was assigned almost full-time to Judy.  At one point a middle aged woman wheeled in a computer table, nodded at him, and addressed Judy directly.

Good morning, Mrs. Vertucci.  I’m Carolyn Bolles and I’m an EEG technician.  I’m going to put some tiny electrodes on your head so that the doctors can see your brain waves, but it won’t hurt . . .

Like most of the rest of the neuro team, Bolles was convinced that hearing was the last to go, and so she always explained to the patient who she was and what she was doing, but on this occasion the mind that responded instantly was Jim’s.  Because Bolles’ accent was so familiar as, in this mortal crisis, to twist his heart. Queens,New York!  Where he and Judy had both been born and raised.

He spoke and she recognized his accent too, and so they talked about home for a bit while she was setting up her equipment.  She told Jim that she and her husband had come south for a complex of reasons, most particularly for her husband to study.  He was a cardiac catheterization technician who worked a few floors down.  They had lovedNorth Carolinaand had stayed to raise their family.

Then she turned her attention to her job.  It was a finicky, tricky operation, putting the electrodes on a patient’s head.  Most stroke patients were older, and gray hair matted worse than that of younger people.  She had to comb it out, part it, use a tape measure, calipers and felt tipped pen to find and mark the exact spots.  It took maybe fifteen minutes to precisely place the five lines of black Xs from the crease between Judy’s eyes to the bump at the rear of her skull.  One line of Xs went around the head, horizontally, one went across the top.  The technician scrubbed each spot with an abrasive soap and then shook out a rainbow hank of wires that led to the computer.  Each wire was tipped by a tiny gold cup, which the technician placed over the Xs and secured with glue.

Eventually the computer monitor came to life, 16 jagged lines proceeding quickly across superimposed on a grid that marked the seconds. Bolles could easily read the basic rhythm, eight waves a minute, the eight-hertz alpha wave, the clock speed of the human computer, beat out by an ancient generator deep in the brain.  That wave was then modified by the harmonic firing of the working circuitry of the upper brain.  It took an expert for the fine reading of an EEG, and that wasn’t Bolles’ field; her expertise was in taking readings.  But it didn’t take an expert to recognize the slow, sweeping waves being generated by the left side of Mrs. Vertucci’s cortex.  Initial damage from the stroke was affecting a huge area of the left hemisphere.  The injured cells were running slowly and aimlessly, damping down the 9 hertz beat of the deep brain into big, slow, four-hertz waves.  Delta waves, they were called.  A bad omen, indeed.

Bolles glanced at the man on the other side of the bed. She knew exactly how he must feel.  Less than two months ago she had lost her own mother under all-too-similar similar circumstances on this very same floor, and her heart went out to Mr. Vertucci.

By law, an EEG had to last 20 minutes, and with 20 minutes to set up and take down, that provided them with an hour of intermittent conversation — the light conversation of two Queens Yankees meeting by chance in a faraway land, telling each other what had brought them there, sharing memories of places and faces and times gone by.

By the time she left, Bolles had Jim figured out.  It wasn’t hard.  He was a knight in shining armor, the kind of man that every little girl wanted to marry.  Now there he was, sitting alone with his dying wife.

Bolles left the cart in the room, hooked up to Mrs. Vertucci’s head, and walked briskly away, down the hallway, around the corner. It was always best to walk away, to think about the next job.  But she couldn’t get the image of the forlorn man out of her mind.  She remembered her mother.

There were moments on this floor, in this job, when she just wanted to bawl.

Jim there in the room, waiting for he didn’t know what, watching the EEG squiggles trace across the screen, listening to the quiet sighing of the respirator, watching the nurses use a vacuum tube to suck the phlegm from his wife’s lungs.  The hands on the wall clock moved at a glacial pace, minute by minute, one of them not noticeably different from the other.

There was much to think of.  She was gravely ill; he knew that.  She was slipping away; he knew that too.  He wanted her to live, yet . . . he wanted her to live in a worthwhile way.  To want her to live as a damaged, barely functional human being . . . that would be selfishness.  What would happen, and what might he have to do?

They were hard thoughts to think.  They made him both frantic and numb at the same time.  The thoughts themselves turned on “what ifs” and “maybes,” and invariably came back around in a circle, to where they had started.  She was dying.  But he forced himself to think them.  It was all he could do.

Eventually a businesslike group of people in pink, green and white clothes came to take Judith to the 8^th floor ICU.  Someone told him how to find the waiting room outside the ICU.  He should wait there.  A nurse would let him know as soon as he could visit.

Upstairs, the waiting room located just outside the pneumatic doors of the ICU was crowded with relatives, many with rumpled clothes and bags under their eyes.  Inside the waiting room there was a small desk with a phone and a sign for new arrivals to check in with the nurse’s station.  Above the phone a bulletin board was instructions for newcomers to call the desk nurse, who would call back when appropriate.  Around that were other notes instructing waiting relatives to call parents, sons, daughters, aunts and uncles. Many of the numbers had unfamiliar area codes; some of them were international.  The Duke ICU was a sad gathering ground for people from all over the world.

Outside the waiting room, the hall was lined with people in small clumps, leaning against the wall or one another, talking in hushed voices, some crying, some stoic, some in shocked disbelief.  Jim was only there a few minutes when people began introducing themselves.  In this pressure cooker everyone was an instant old friend.  They were all in the same boat, waiting together, in fear, for the phone to ring for them.

Several hours later, Jim was out in the hallway talking to his son, Michael, when he was summoned to the telephone.  Then they were briskly escorted through the pneumatic doors and into a small conference room.  Dr. Graffagnino joined them a few moments later.

The physician drew a picture on a board, showing how the big artery rose from the Circle of Willis and how it then branched into three smaller vessels.  Judy’s clot was in the middle one, he said, and he explained what parts of the brain that fed and which functions, therefore, one would be damaged in the unlikely event she survived.  But it wasn’t the clot itself that would likely kill her.

He explained about swelling, how the injured tissue released highly metabolic chemicals that damaged the cells around them, and that those cells, as they swelled, damaged the cells around them, and the ensuing rise in swelling and brain pressure.  He snapped some CATscan images up on a light board and pointed out the ventricles.  They stood out clearly, two white lakes of spinal fluid. (art: we need pix of this)

Normally, Dr. Graffagnino explained, the ventricles would be symmetrically positioned in the center, one on each side of the centerline. But notice how, in Judy’s scan, they were clearly pushed to the right.  That indicated that swelling had begun, on the left.

The words were as familiar to Dr. Graffagnino as the Miranda warning was to a police officer.  Nothing was ever certain of course, especially not in neurology, but the omens were not good.  The surgeons had placed a shunt in one ventricle, in part so they could monitor intracranial pressure, and that pressure was steadily increasing.  Given standard treatment, which was mainly support, chances were as much as 90 percent that the pressures would continue to increase for two days, maybe three, and then the brain stem would quietly herniate though the foramen magnum, and . .

“No,” Jim said.  “No way!  We’ve got to do something.  My wife is NOT going to die!

Then Jim was listening to the neurologist telling him that there were experimental procedures — unproven, to be sure, even exploratory. Just . . . a few things had been tried in a few patients. There was a place inGermanywhere stroke patients with such massive swelling as Judy was likely to develop were treated by removing half the skull.  The skull was put in a freezer while the brain swelled outward, so that pressure didn’t build.  Then, if the patient lived, the bone was wired back in place.  It seemed to increase the chances of survival, but again it had only been tried a few times . . .

The other option was cooling.  It was like putting a swollen ankle on ice.  If you put cold compresses on a swollen ankle right away, the swelling will stop and then go down.

Graffagnino explained that heart surgeons had used hypothermia for years, but but only for a few hours with each patient. As a treatment for brain swelling, though, it had to be maintained for days . . . and nobody knew much about how that would work. It wasn’t FDA approved. It was so irregular, in fact, that he couldn’t do it without the hospital’s case-by-case approval under the “compassionate use” clause of the federal ethics rules.

In the last couple of years, the neurologist went on, stroke had been treated with hypothermia at a number of medical schools, and though the numbers were small the results seemed positive.  He himself had done it, but just once.  The recovery had been . . . well, better than expected.  The man could live at home and care for himself. All the same, one case, two cases, fifteen cases . . . that didn’t mean much. They weren’t statistically significant. They weren’t even statistical, they were anecdotal.  The patient might have lived anyway. It was known to happen, in neurology — patients who were supposed to die, according to all experience, but didn’t, and patients he’d have thought would live, but didn’t.

Still.

The known risks of hypothermia included cardiac arrest induced by the low temperature, though the neurologist thought he could avoid that by only taking her down to 33 degrees centigrade, or about 91 1/2 degrees Fahrenheit.  That sounded warm but to a warm blooded animal it was, metabolically, quite cool — significantly lower than the normal 98.5.  It would certainly knock down her immune system and probably immobilize her phagocytes — phagocytes were the scavenger cells that normally crawled throughout the body eating foreign lifeforms like bacteria and viruses. So infection was definitely a risk.

But the worst worry concerned all the many things nobody knew about, and you couldn’t predict and might not even be able to recognize quickly enough to respond. So Dr. Graffagnino couldn’t even vouch for the procedure’s safety or even his own readiness to deal with crises.  He didn’t know, he simply didn’t know, and he didn’t want to obscure that fact.  This was new territory.

The end of the conversation was that Judith would probably die anyway, no matter what they did.  But hypothermia changed the odds by, well, who could know . . . maybe 20 percent.  A guess.  To Dr. Graffagnino’s mind, that made it better than doing nothing.  Then again, it was not his decision.

Jim sat there for a moment, but only a moment.  Then he looked the neurologist in the eye.

“Okay,” he said. “Try it. I want you to do it.”

Afterwards, Jim and his son went back out into the hallway. They talked a little about it, but there wasn’t much to say.  Finally, numbed and exhausted by the events of the day, Jim left forSanford.  At home, he hunted around the house until he found a steno pad and a pen.  Methodically, he began reconstructing a diary of what had happened since Judy’s initial operation.  Each entry was terse, unembroidered and cast in the voice of a police officer . . . except that the diary was addressed to his wife.

In a page and a half he came to this day, February 10.

While in regular room had stroke and seizures, he wrote.  Back in ICU.  Your condition was assessed as a stroke to left side and you were swelling.  Doc Graffagnino said with regular treatment there was a 80-90 percent chance you would die. They wanted to try a radical procedure for the swelling and I approved.  You were cooled down 3 degrees . . .

He read the entry over, closed the notepad, and went to bed.

The last half of the 20^th century had produced a powerful armamentarium of specialized tools and machines to support and treat critically ill patients.  Sophisticated ventilators could breathe for someone who couldn’t.  Blood could be shunted out of the body and oxygenated or dialyzed, as needed.  Tiny wire-like instruments could be snaked into the heart and brain to open arteries or dissolve clots. Robotic surgical instruments could penetrate body cavities, allowing surgeons to remove or repair organs with little damage to surrounding tissue.

But the technoscientific explosion had not anticipated that someone like Dr. Graffagnino’s might want one day to lower a patient’s body temperature and keep it at a precise chill for several days.  As a result, there were no sophisticated ways of doing that.  The neurologist’s only choice was distinctly low-tech:  old-fashioned, blue plastic cooling blankets that were normally used to lower fever when it climbed high enough to threaten the brain.

The blankets were basically two sheets of blue plastic sheeting fused together so as to form one long, continuous channel through which cold water could be forced.  The blanket attached to a refrigeration unit.  Dr. Graffagnino and the attending nurse put one underneath the comatose Mrs. Vertucci and another on top of her.  Jim Vertucci watched in horrified fascination as the machine was turned and his wife’s temperature slowly began to drop out of the normal range . . . 96 1/2 . . . 96 . . . 95 1/2.  She went down faster than he wanted, at times; at other times the thermometer seemed to resist of its own accord.  Those cooling blankets were awful, for something like this.  But they were all he had.

No body function was so fundamental to warm-blooded animals as temperature regulation. The ability to set and maintain a stable temperature let mammalian cells operate within a narrower margin of error, which translated into biological power: A pound of warm-blooded flesh was dramatically more dynamic than a pound of reptilian flesh. That was mammals had taken over the planet after the dinosaurs had vanished, and how they had pushed reptiles into marginal habitats like swamps and deserts.  Mrs. Vertucci’s long-term trip into hypothermia was fundamentally opposed to Nature’s way; she was entering alien medical territory.

As the neurologist cooled her down, her body fought back against the clammy chill.  Goosebumps appeared on her skin and she began to shiver. Shivering of course was muscle work, and one side effect of muscle metabolism was to add heat to the body — precisely what her body wanted and what Dr. Graffagnino was trying prevent.

He countered with a powerful drug related to curare, the poison Amazonian hunters used on the tips of their poisoned darts.  Curare disconnected the nerves from the muscles and paralyzed the victim; In the Amazon forest, death came because the diaphragm could no longer power breathing.  In a human patient breathing was taken over by the respirator but other muscle function, like shivering, became impossible. Mrs. Vertucci’s body lay paralyzed and still as death.

The downside of hypothermia, for Dr. Graffagnino, was that overriding the biological thermostats would sap the normal mammalian vigor, exposing Mrs. Vertucci to unknown but possibly substantial risks. The fact that he had been done before was little comfort; a handful of cases told scientists nothing.  They had to have hundreds, or even before, before confident conclusions could be drawn.  Meantime, clinical scientists’ worst nightmare was the experiment that succeeded, but in which the patient died.

For openers, he would monitor her as extensively as he could.  White patches securing heart monitor leads were stuck all over the front of her body.  Blood gasses, heart rhythms, kidney output — all this was standard ICU procedure.  The EEG leads were gone now . . . keeping THAT score didn’t matter much now. But what bore the most watching was the brain pressure.

Earlier the doctor had sent her over to neurosurgery, where a plastic tube was inserted into one of her ventricles. There were reasons to hope that by draining off some spinal fluid the intracranial pressure would drop — or, at least, not rise so fast —  but it was also the best way to monitor pressures pressure changes.  For this purpose the tube was attached to a machine with a dial that indicated pressures in millimeters of mercury. Brain specialists were generally comfortable as long as the readings stayed below about 20, although the equipment sometimes provided a false reassurance.

This was all scary territory.  Dr. Graffagnino had personally had patients herniate with readings below 20, and he wasn’t sure why.  Perhaps pressures weren’t uniform throughout the brain — maybe, depending on where the swelling was, the various membranes tended to force the pressure downward. But with Mrs. Vertucci there was no reassurance of any sort.  The dial already read well over 20.  If it hit 30 . . . well, at thirty you panicked.  Not that there was anything you could do.

He was cooling her down as fast as he could, but what was left of Mrs. Vertucci fought back against the clammy chill. Goose bumps raised on her skin and shivering set in.  Shivering was muscle work, and so it added heat to the body — heat that Dr. Graffagnino was trying to dissipate.  He countered with a powerful drug that chemically disconnected her muscles from her nerves, producing total paralysis.  Now the body lay still as death, except of course for the respirator.

The battle was fought in the eighth floor ICU, in a bay packed with instruments and, on many occasions, people.  ICU nurses usually tended two patients each, but in this case it was one-on-one.  Technicians were in and out as they checking the equipment and downloaded readings.  Respiratory therapists, pharmacologists, neurosurgeons . . . there was a constant parade of experts in and out of the bay.  Dr. Graffagnino was there as often as his other duties would allow.  But no one was there more than Jim.

The constant presence of a husband in the ICU was unusual; family access was usually restricted because bystanders could be a distraction.  Often they couldn’t comprehend or tolerate procedures involving pain and bodily fluid — certainly the standard neurological exam was a brutal sight to see, even for experienced medical personnel.  Such moments could produce emotional outbursts from family members — outbursts that were understandable enough, given the gravity of the illnesses treated in an ICU, but the doctors and nurses had finite quantities of time and attention, and it all needed to be focused on the patient.

Jim, though . . . Dr. Graffagnino had taken a liking to the guy.  They were both of Italian extraction, though the inflections in Graffagnino’s speech still followed the romantic traditions, while whatever Italian might have remained in Jim’s mind were submerged in generations spent inNew YorkandQueens. Dr. Graffagnino’s impression of Jim was that he was a scrappy, nervy, charge-into-the-guns, never-say-die kind of guy — doggedly rational in the pursuit of his passions.  The physician identified with that.  And he had the feeling, not exactly scientific but not irrational either, that in Mrs. Vertucci’s case, he was the best thing she had going for her.  So, yeah, he could stay.

Jim, meanwhile, was learning about life in this alien world where patients and medical personnel labored around the clock in the shadow of death.  He was basically an intruder, and as he learned to stay out of the way, he became a fly on the wall, not really noticed by the busy ICU workers while he noticed everything — noticed it, and struggled to make sense out of it.

It was especially difficult for him to absorb the neurological exams of his wife. He knew that Judith was not actually feeling anything.  It was just her basic nervous system reacting.  Her brain didn’t notice.  His brain, however, did, and watching her body curl up in agony sent sympathy pains exploding through his own mind and he had to suppress the urge to leap to her aid.

He kept reminding himself that, in the neurological world, pain was a tool.  And in these struggles of perception he found himself remembering an oldJohnWayne movie. Wayne’s legs were paralyzed and the neurologist kept battering him, psychologically, to do whatWaynethought he could not do.  <ital>You’re gonna move that toe!<end ital> the doctor had kept saying.  After a while that impossible demand had seemed like a horrible kind of psychic assault and battery, andWaynehated the doctor.  Who played the doctor . . . oh, yes.  Dan Daley.

He and Judith had seen that movie together, and afterwards somehow it had become a family joke.  At appropriate (or sometimes hilariously inappropriate) times Jim would say, “You’re going to move that toe!” and she would dissolve in laughter.  That was one of the things she said she’d liked about him — that he could make her laugh.  And oh, but her laughter was beautiful! If only he could hear it now.

Meanwhile, though, the memory of the movie was comforting.  Because, precisely because the neurologist had provokedWayne’s anger,Waynefound the will to live and eventually learned to walk again.

But then again . . . it was only a movie, and Jim well understood thatHollywood’s commitment to happy endings was not shared by Mother Nature.

Existence in the ICU was strange and alien.  ICU designers had heeded studies on patient psychology, and so the noise level was less than what it would have been ten or fifteen years ago . . . fewer crashes of metal against metal, fewer loud alarms, softer lights with periodic dimming periods.  But this was all cosmetic.  The medical end game didn’t move any more slowly than it ever had, rushing doctors, nurses and technicians, adjusting things, testing reactions, sending blood downstairs . . .

The place had its own culture, built of tradition and necessity.  Rounds happened at a certain times, and the experts spoke in formalized way and a specific order.  Medicine had long ago deviated from the common language, and was now was almost indecipherable to outsiders.

But Jim was a bright guy, and as observant as a one-time police officer would be expected to be.  When there was a “code”, as cardiac arrests were called at Duke, and a red light started blinking over the dying patient’s door, nobody had to explain to him why doctors and nurses went rushing down the hallway.  He understood what a “no resuscitation” order was, appreciated the gravity of the occasional quiet glide of a sheet-covered mortuary gurney down the aisle outside the bays.  He listened to the rhythmic click and sigh of Judy’s respirator, watched the bouncing course of her heartbeat across the screen and the lazy movement of her EEG.  He especially watched the brain pressure dial, which now hovered around 30.

Even in times of great crisis like this, the human body could run only so long on adrenaline.  Even at the crisis point of his life, there was no way to charge the enemy, no dragon to slay, nothing tangible he could do except live life minute-to-minute basis, being there.  He was sure that, somehow, she knew she was not alone.  Or might know.  He had to be there, for that reason, to her.

But the ICU cubicle was built for the most primitive of bodily functions, to monitor the heartbeat, to allow the nurse to run her suction tube down Judy’s windpipe and to the accompaniment of that obscene slurping sound.  There was nothing for a healthy mind to exercise itself against, no problems he could solve, nothing he could do.  So boredom set in. Boredom and . . . well, he wouldn’t have called it loneliness, because after all his wife was there, and his children often came and sat with him beside the motionless gray form of their mother.  The nurse was always there.  Yet . . .

He could have gone to the cafeteria or for a walk.  In the old days he would have had a cigarette, but cigarettes weren’t part of his life anymore.  There was nothing preventing him from leaving, but even if Judy wouldn’t have noticed HE would have known, and wondered, and felt out of place.  His place was by her side.  He had no idea anything could so immensely powerful.

It was a almost a relief sometimes, such as during rounds, when he was forced to retreat outside.  The waiting room, and the halls around it, were about as far as any of the friends and relatives of the patients felt comfortable going.  What if a patient died, while they were gone, or woke up for a moment . . . and they weren’t there?  But right outside the pneumatic doors they were handy in case a nurse called.

Crisis dissolves differences between people, and out in the halls they were all alike, all terrified, grief-stricken, anxiety-ridden people suspended in life or death crisis.  They all wanted to talk about the same things, to share memories that suddenly seemed precious, and so they formed strong bonds the way people did in small military units or in refugee camps.  Jim, for example, quickly became a confidant to a small-town mayor and his wife fromColorado.  Their daughter was inside, in a deep coma.

If Jim would not have called himself lonely, the staff new better. Family members of patients were almost all lonely, many of them acutely so — utterly divorced, in many cases, from what a few days earlier had been “reality.”  Theirs was simply a lonely business, watching helplessly while a spouse, parent or child lay posed on the edge of oblivion. There was something about it that forced the mind to withdraw, locked the world away, extracted all content from life and left a hard vacuum.

The nurses kept their eyes on Jim; precisely because of his closeness to his wife, and the protective attention that came with it, he was particularly vulnerable.  Occasionally someone would pause in the rush of duty to tell him he ought to go home, get some sleep.  They had a phrase they used.  <ital>How are you going to take care of your wife if you don’t take care of yourself<end ital>?

They also communicated that to Dr. Graffagnino, who had already been watching Jim.  He certainly seemed more haggard every day.  The neurologist told Jim he could easily sleep in the waiting room, as others did.  A nurse offered to make him up a cot.  That was he could avoid the long commute.

He tossed aside their offers. He had to sleep in his own bed in his own house; it was the only place he could really rest, somehow.  And as for spending less time in the hospital . . . that was simply not an option. What if she woke up or . . . well, all right, she wasn’t going to wake up, of course, not now, but perhaps in some dim part of her hibernating mind she was aware that he was there.  Whatever part it was that felt his presence might draw strength from the fact, from knowing that she was not alone, and that might make the difference.

It might not, too, of course . . . but he didn’t know that.  So he’d stay as late as he could at night and get up as early as he could and get there as early as he could in the morning.

Carolyn Bolles, the EEG technician, felt a special empathy for him.  Perhaps it was because they both were raised inQueens, or that recently she herself had watched her mother die here at Duke under circumstances that were all too similar.  But when she entered Mrs. Vertucci’s bay to check on the EEG or download a bolus of information, she set aside a few minutes to talk with Jim.

Bolles was the kind of woman who could make someone talk.  Everyone else in the EEG crew had undergraduate degrees in the sciences, but hers was in the humanities.  She knew plenty about her machines, of course, but she was also knew how to listen.  And Jim needed to talk.

In a vague way, this was part of Bolles’ job — one of the unwritten parts of the job of anyone who works in a hospital, whether they are clinicians or not: Be a human being, be a presence, notice the part of the biosystem that produced pain, despair, hope. So it was duty.  But beyond that, Bolles genuinely liked the man, the knight in white armor, the sweet American cliché of aJohnWayne crust over a heart of gold.

She told him her story, about how she had brought her mother down here fromNew Englandbecause she knew Duke was the best there was.  But her mother had died, of course, even so.

The medical world was full of what seemed like miracles, and in a place like this you sometimes saw unexplainable things happen that, if they were happy, some people might well describe as miracles. But the medical assumption was the scientific one, that things happened for concrete physical reasons.  That was what had gotten medicine to where it was.  And yet Bolles mother . . . Bolles had had access to one of the best hospitals in the world, had stood by her all the way, and still she had died.  The miracles, if miracles they were, were rationed out in some way that made them all too scarce.

But she was using her own experience to help Jim absorb and articulate his own.  It was mostly he who talked and she who listened.  And so she learned about his childhood inQueens; they compared places, names and experiences. He told her about his father, and about Judith — Judith still and gray in the bay down the hall, whose name now brought tides of hope alternating with tides of fear.  His children, his family . . . they all knew the story.  But his head was full of the memories, and they needed expressing.

Bolles listened, Jim talked, told her how she had first seen Judith in high school, when she had just been elected to a student council office (which one).  They were in the auditorium, she on the stage and he in his seat.  He had seen her around before, of course, but this was the first time he really saw her.  A cute brunette.  No, a cute brunette with brains.  He liked that.

He’d leaned over to ask the guy next to him if he knew who she was.  The guy chuckled quietly and whispered back that Jim had better lower his sights; the girl he was talking about was the sweetheart of one of the schools hot football players.

Jim had shifted his attention back to the girl on stage, dismissing his neighbor’s advice.  He, Jim Vertucci, was not in the habit of lowering his sights.

Now, more than 40 years later, he shared these experiences with Bolles and . . . it helped.

Sometimes, he confessed to her that he worried he’d not done the right thing by allowing the experiment. Maybe he should have just let her go, quietly.  Maybe his motivation hadn’t been to help her, but to assuage his own terror of the loneliness that would loom if she died.  And what if his motivation had been selfish and she came back, but only part way — what if she just had enough brain cells left to know she was there, sort of, but couldn’t move or talk or do anything that allowed Judith to be . . . Judith.

His growing knowledge of neurology brought this fear out.  He now knew the truth about the end of life, and the bitterness that often attended it, in a depth that only comes from being a fly on the wall in a place like this.  Pain, always and absolutely, was the last thing to go.

Had he done the right thing?  Or just increased her pain?

Bolles understood that while Jim addressed such questions to her, they were really directed at himself.  She used such opportunities to generally support him, help him feel his way through the anxieties, find a way to accept that these things were ultimately beyond anyone’s control.  People did the best they could, and that was the most they could rightfully expect from themselves.

So it was that the hours passed, sitting in the cubicle, watching and waiting, being there.  The respirator sighed, the lines squiggled across the monitor, nurse’s shoes squeaked on the polished floor.  Frequently the nurse opened the respirator fitting that extended from Judith’s mouth and ran a vacuum tube down into her lungs to pull out fluid that, normally, would be coughed up.  The suction make an obscene sound.  Frequently, samples of sputum from her lungs and blood from her veins and arteries were sent out for tests.

Sometimes Jim went downstairs to the cafeteria, but usually not; he didn’t like to be away from her.  He left late in the evening, when he figured he just had enough energy to drive.  Sometimes he’d stop at McDonald’s on the way home, and other times he’d wait until he got home and eat better.  It stood to reason that corn flakes were made of corn, which was a vegetable, and he figured a guy could live a long time on corn flakes.

The phone message light was always blinking when he got home, people calling to inquire about Judith and wish him well.  He dealt with them, methodically, but his exhaustion was extreme and he sometimes could hardly focus on the conversation.  After a few evenings, he had all the calls forwarded to Patricia, inNew York.  After that he could come in, have his corn flakes, make his entry in the diary, and collapse into bed.

He was just stumbling through life now, and his routines were an efficiency of rote.  He’d park the car, get the mail, eat . . . none of it registered, really, or would be remembered.  But he would always remember the evening he got home and found a letter from Duke in his mailbox. He opened it.

It was a bill.  A whopper

Jim was stunned.  He had insurance.  Why didn’t Duke just deal with the insurance company?  What did this mean?  He read through it until he came to the bottom where there was a deadbeat statement:  If the bill wasn’t paid in full in 30 days, Duke lawyers would take him to court.

His mind filled with panic.  As a child, after his father had died, Jim had lived in poverty.  He knew what it meant, and how it made you feel about yourself, and he had worked all his life to rise above that, to work hard and smart, to pay his bills ahead of time, to amass a perfect credit record . . . and now . . . now . . .

He stared at the bill.  Right now, at this moment in his life, he was supposed to think about money?

He could not afford that. Oh, he’d take care of the bill somehow, sell the house if he had to, but what he couldn’t afford right now was the panic, the worry.  He could call him, but he suspected he’d just end up on endless hold.  He couldn’t let his mind engage in bookkeeping, or he’d fail Judith. He shoved the bill (where) and went on with his increasingly zombie-like existence.  When the next bill arrived a few days later, he did the same.

            Dr. Graffagnino, meanwhile, kept a close watch on Mrs. Vertucci. He wanted her in the neurological ICU where he could watch her more closely, so as soon as a bay was empty he moved her down there. He fretted over her temperature, her brain pressure, her vital signs.

The neurologist’s head was full of information about the brain.  He might not have much in the way of screwdrivers, but he knew the wiring diagram as well as he knew anything in the world.  He knew the intricacies of the motor neurons, and which channels handled such separate functions as the sense of touch, the movement of limbs, and proprioception — the network of nerves that allowed the brain to keep track of exactly where the various parts of the body were located.

He knew which parts of the brain handled conversation: How the ears had to hear, how the Werneke’s area dictionary had to decode, how the forebrain had to make sense of what had been heard and then decide how to respond, and then how the dictionary had to supply the words again and finally Brocca’s area, on the other side of the brain, had to coordinate the larynx, the diaphragm and the lips.  As a neurologist Graffagino had not seen it all . . . but he had seen a significant part of it.

He wished that would help him now.  He understood all too well the sense of helplessness that infected Jim’s mind.  Jim, and by turns his children, kept constant watch on Mrs. Vertucci’s.  Dr. Graffagnino saw them almost every time he went into the bay . . . saw their eyes fixed on the pressure gauge that had become the symbol of life and death.

It wasn’t the doctor’s wife on the bed, of course, but she was a human being.  He had sent her into the mysterious cold oblivion of hypothermia, and in doing so he had assumed an extraordinary responsibility.  So he watched the pressure gauge with no less anxiousness and frustration than her husband did, tensing when it went crept higher, relaxing when it subsided.  But they were bystanders now, all of them.  The course had been chosen and the acts performed; now there was nothing left to do but watch and hope.

As long as she was under hypothermia, she could only become weaker by the day.  The low temperature made the digestive system stop working so there was no point putting nutrients in her stomach through the feeding tube.  And if they did try to feed her that way, hypothermia also kept the bowels from moving and the food would stay in the stomach.  So on top of everything else all the cells in her body now had to make do on short rations . . . this, in a body that was gravely ill to start with.

So he watched and worried.  Each morning the rounds cart paused long in front of her bay as the group of experts gave a thorough update of Mrs. Vertucci’s circumstances; in light of that, they discussed the function of each bodily organ and studied the drug cocktail being fed to her through the IV tube.

Her intracranial pressures hovered breathtakingly close to the number 30 but then, by the end of the second day, began to drop.  Then it climbed again, then dropped.  Deep in her brain, the thin membranes that gave shape to the circuitry of existence bulged against the foramen magnum, stretching, approaching the breaking point.

On the third day sputum cultures taken from her lungs alerted Dr. Graffagnino that a yeast infection had taken hold in her lungs. It was the kind of infection that wouldn’t have happened to the healthy person, but it happened all to frequently on in ICUs, where the patients were weak and their immune systems suppressed.  This was compounded by the fact that the ICU situation required the use of heavy-duty antibiotics, which, in the turn of the biological screw, then developed resistance to those antibiotics. On the ICU common microbes slowly changed into vicious, drug-resistant, killers.

Graffagnino waited and watched for a few hours. She had been in hypothermia for three days, her cranial pressures were finally running below 20, and he’d like to keep her down for a while longer.  But he was pushing the limits. A comatose patient couldn’t cough to clear her lungs and while the nurse could vacuum out much of the liquid, what remained was a wonderful culture medium.  An explosive pneumonia in a comatose patient was every bit as deadly as a heart arrhythmia.

Within a few hours it was obvious that Judy’s infection was getting steadily worse.  He put her on a stiff dose of the anticonvulsant Tegretol, to keep her from going back into seizures, and then disconnected one of the cooling blankets to slowly let her start warming herself up.

In a few days, or a week, or even two weeks, she might wake up.  And then again, she might never wake up.

The night of February 13, Jim Vertucci wrote in his diary that Judith was being warmed up.  It was a brief entry, written in an exhausted hand, but it was not as terse as the others:

They are going to bring you back to normal temperature today, in hopes that you responded good to the treatment, he wrote.  My prayers are with you and I’m by your side every day.  May God be with you!

On Valentine’s day they brought Judith Vertucci up from the cold.  The process was passive, which is to say they simply let her own body’s metabolism bring the temperature up.  Other neurologists had tried active rewarming, but found there was a serious risk of overshooting the mark, and producing a fever.  Fevers are very hard on the brain, especially brains that are not well to start with.

As she warmed, degree by degree, Dr. Graffagnino hovered over her.  Her cranial pressures edged up with her temperature, and he fought it with what few drugs he had.  Her blood volume was low, but he didn’t think she was bleeding — it was probably the cumulative effect of all the blood samples she’d been given.  So he transfused her with two pints of B positive.

The pneumonia grew worse, and he responded with the kinds of powerful (and dangerous) antibiotics used only in places like the neurological ICU. Respiratory therapists came in to pound on her chest, helping fluid to drain down to where it could be siphoned out by the nurse.  X-ray technicians followed with their portable equipment and made images of her lungs.  Dr. Graffagnino fiddled with the respirator settings, sent her down for another CT scan, worried over blood chemistry reports.

All day that day her body temperature went up at the rate of about one-half degree centigrade each hour — plenty slow, he thought, but would later wish he had done it even more slowly.  As the temperatures rose, the intracranial pressure climbed as well . . .  23 . . . 25 . . . . 27.  The doctor fervently wished he could have kept her cold longer; or chill her again now.  But no, if he did that the pneumonia would kill her.

The end of the first day saw her with a normal temperature . . . and then she tried to overshoot.  Pneumonia causes fever.  The pressure hung near 30 and he hooked up the cooling blankets again.

The next day was much the same, temperature fluctuating, the pressure gauge hovering just below death.  The nurse was in constant activity, the pharmacist worried, typing thoughtfully into his laptop, tweaking his database, looking for some metabolic leverage.

Graffagnino hovered around her.  “Mrs. Vertucci!  Mrs. Vertucci!  This is Dr. Graffagnino, do you hear me?  Move your toes!  Open your eyes!  Squeeze my hand!”  The neurologist was beginning to look as haggard as Jim Verticci.

But that evening, or maybe it was early the next day — time had begun to blur for both men — Graffagnino’s attempts to arouse some reaction with pain met with success.  First, severe pain began to make her right side curl up.  Later her right side responded as well.

There was no sign, however, of consciousness.  The neurologist listed her, cryptically, as in “guarded” condition.  He thought, now, she might survive, but he did not yet know whether that would be a good thing or not.  Nor was he enlighten the following day, or the day after, or the day after that.

Jim Vertucci would forever remember those days as the long wait.  If the day of warming was also Valentine’s day, the fact did not register in his mind.  He had never made a big deal out of Valentine’s day, because he liked to buy her presents all the time, not just when the calendar reminded him. Then, on the other hand, he did not like to be to consistent, either, so the previous Valentine’s Day he had taken her into the local Cadillac dealer and told her to pick out any car she wanted.  She’d bought a (color, type).

She had loved that car, and he had loved that she loved it . . . but it was the one she’d scraped, getting into the garage, a few months back.  He had thought it was carelessness, at the time, but now he knew better.  One of the warning signs of stroke, he knew now, was uncharacteristic and inexplicable errors in coordination or judgment.  If only he had known then that . . .

But he hadn’t.  Most people didn’t.  So he and Judy were here, now, she in a deep coma and he . . . waiting.  Sitting by her bed.  Standing outside, in the hallway, talking to the friends he’d made among the other terrified relatives of other comatose patients.  He talked to Boles, the EEG technician, a lot, and talking to her helped but he was repeating himself now, suspended in a stretch of time that did not seem to proceed, waiting, waiting, waiting.

Would she wake, or would she not?  And if she did, when?  And would the moment be blessed? Or cursed?

Bolles observed that Jim was rapidly deteriorating, physically.  His clothes were getting visibly looser on him, day by day.  As everyone who worked in an ICU knew, people under high stress often plain forgot to eat.  They wouldn’t even go to the cafeteria, often, because they didn’t want to be away from their loved one.  Heck, she herself had forgotten to eat when her mother was in the NICU.  So she increased her nagging:   You can’t be strong for somebody else if you don’t take care of yourself.  How are you going to take care of your sick wife if you let yourself get sick?

Jim heard her, and admitted to the logic behind her admonition. But it didn’t apply to him.  His thoughts were on Judy; how could it be otherwise.  Eat more?

But he wasn’t hungry.  What he needed wasn’t food.  What he needed was to DO something!

As a cultural Catholic Jim always wore a crucifix, and he was a spiritual man . . . Bolles had spotted that right away.  But as so often in the modern world that spirituality didn’t manifest itself by overt religious activity.  He hadn’t been to church for many years.  Prayer was not among his habits.

Now, though, he found himself lying in bed at night, silently pleading with God.

God, you’ve got to help me out.  You gotta help my wife out.  My wife is sick, I need some help.

He also prayed to the spirits of people who had died.  <ital>Dad, You gotta help me out.  You’re with the big guy now, and you’ve gotta help . . .<end ital>

The days of waiting passed slowly.  Jim’s daughter Patricia would always remember this time in bittersweet terms.  The bitter stemmed from her mother’s plight, and the sweet from her father’s sudden change in behavior.

When she was a child, Jim had always been distant — so distant that, for example, if they were all at the dinner table and she asked if she could go to a party, he’d answer by turning to her mother and saying, “Judy, tell her she can’t do that.”  Even when she was a grown woman with children, he seemed to treat her as a child. When she called home and he picked up the phone, his most frequent words were, “I’ll go get your mother.”  He seemed distant, unapproachable, needing nothing.

Now the shock and exhaustion had somehow freed them both from the father-daughter roles.  They sat together in Judy’s room and talked as one adult to another.  Sometimes he even confided in her, sharing his fear that he might have done the wrong thing in not letting Judith die quietly, or his worry about the medical bills piling up at home.  Even given the circumstances, Patricia found herself touched and deeply pleased at her father’s new openness.

Jim noted the change as well, but only dimly, and he did not examine it.  After five weeks of alternating terror and hope, fast food and corn flakes, it was all he could do to make it in each day and home again at night.

One evening, arriving home in the dark, he was accosted by a neighbor.  The man told him that the whole neighborhood knew what was going on, and were praying for him and Judith.  And he wanted Jim to know that he, personally, admired him — his unwavering loyalty, his long but unfailing commute, his willingness to reject the certainty and closure of death over weeks of anguish and fear.  Personally, the neighbor added, if it had happened to him . . . he didn’t think he could do it.

Jim looked at him with blank incomprehension. Not do it?  There was a choice?  No, there was no choice.

And so he drove, long trips fromSanfordand back, with only himself for company.  By now he knew 15-501 so well he could almost drive it in his sleep.  He’d get home, park, check his mail box.  Often, there was another bill from Duke.  He threw it on the pile, with the others, and resolved yet again not to worry about it.  Then he ate his corn flakes and went to bed to, as usual, worry about it.

What would be left to him, when this was over?  Would his wife be gone?  And perhaps even his home?

By day he sat by Judith’s side.  Often, when he arrived in the morning he had to hunt for her.  As the brain pressures had begun falling she’d been checked into the step-down unit, but as her pneumonia spiked they’d move her back up to the ICU, and then back to the step-down unit again.

Dr. Graffagnino said her brain seemed to be improving, and though Jim couldn’t see much improvement, he told himself he wasn’t the doctor, after all.  Meanwhile, Dr. Graffagnino seemed to examine her with increasing aggressiveness. There were probably technical terms for what he was doing, but Jim didn’t know those terms; to him, the only words that applied were the colloquial words of combat.  He punched her.  He slapped her.  He hit her feet, hit her face.

“Come on, Judy!” the doctor demanded.  “Get outta this, get outta this!”

Nothing changed.

Jim tried it his own way.  As he sat by her side hour after hour he’d sing softly in her ear, tell her about his day or what was going on around him, cracking jokes. “You’re gonna move that toe!” he’d demand.

But there was no responding laughter, just the soft sound of the respirator.

Then one wet cold morning, heading north on 15-501, windshield wipers sweeping rhythmically back and forth, all that had happened to him seemed to gather like some fog bank in his head, and he was tired, so tired . . .

A loud bang woke him up, the steering wheel spinning out of control under his lax grip.

He reacted automatically, the emergency handling procedures exploding from deep in his memory even before he was fully aware, fighting whatever it was that was happening, mind groping for reasons, putting his biceps into the rebellious steering wheel.  <ital>Blowout!<end ital>.  He did not make the mistake of hitting the brakes.

It all happened in slow motion, a waking nightmare, the vehicle suddenly possessed of a mind of its own, swerving, bucking, finally slowing to the thump-thump-thump of a ruined tire.

He got the car off the road and sat there while the adrenaline subsided.  He had dozed off.  He couldn’t believe it, he had actually dozed off!  He must have hit a pothole and blew the tire.  His comatose wife was far away to the north, his home with the stack of bills far to the south.  The cold rain drummed on the roof of the car.  If it was not the lowest point of his life, it was a close contender.

Jim judged himself incapable at the moment of changing a tire, so he called a wrecker.   Eventually, a tow truck showed up.  The mechanic was a friendly man, and while he took off the shredded tire and put on the donut in its place, Jim found himself telling his story.  When it was over, Jim reached for his wallet.

“What do I owe you?”

The man looked at Jim and shook his head.  You don’t owe me anything.  You’ve got enough troubles.  Get out of here, and try not to kill yourself.

Shaken, Jim drove the rest of the way to duke with Bolles’ words reverberating in his mind.  How are you going to take care of your wife if you don’t take care of yourself?

What would have happened to Judy if he had just killed himself by falling asleep at the wheel?  What if she woke up, needing him, and found he was dead?

Jim had learned his lesson.  That night he went home early, ate a decent meal, and got the first full night of sleep he’d had since Judith had been admitted to Duke.

Slowly, the fluctuations of pressure in Mrs. Vertucci’s head began do dampen down, and the pointer of the dial moved left, to 20 and below, and did not rise.  Dr. Graffagnino was pleased. They had avoided death and, if theory held, they had also avoided massive damage to the brain.  But in the world of neurology there was a vast chasm between being alive and being whole . . . and he was now so far into unknown territory he didn’t know anything for sure.

So he, like Jim, had a certain anxiety about whether he had done the right thing. In neurology there was always the distinct possibility that a patient would be snatched back from the abyss only to spend the rest of her natural life, if that was the correct phrase, as some semi-vegetable in a nursing home until, eventually, some antibiotic-resistant germ put an end to it.

So the question was how much damage she would prove to have? Much would depend on whether the tissue had developed collateral arteries as the main ones became narrowed.  Collaterals might have kept some tissue alive that otherwise would be dead.

Which circuits would be wiped out forever? Which would slowly come back as damaged but not dead neurons fought their way back to functionality.  Given the location of the stroke, there was a high chance that she would never be able to shape words again, and the mobility of her right side was very much in question.  She could also suffer terrible memory loss.  But if she could still recognize loved ones, feel the warmth of the springtime sun, remember her youth . . . that could still serve as a foundation to a worthwhile existence.

Whatever she was left with, and even being optimistic, Mrs. Vertucci would have to re-learn her way around her own brain, wire around the damaged areas to make her body and mind function again as a unit.  She might have to learn to talk again . . . or to live without the ability.  After laying in bed for what could be months, she would be so atrophied that every movement would bring agony.

That was another.  Rehabilitation took an incredible strength of will.  It was a brutal process, painful mentally as well as physically.  Studies had shown that the physical changes in damaged brains caused depression, which was a form of mental pain . . . and that depression was often exacerbated when patients who had been fully functional human beings suddenly found it necessary to relearn the most basic movements and skills, usually in painful baby steps.  Depression made one give up.

And if that wasn’t enough, someone who’d been so sick as Mrs. Vertucci would have a limited amount of courage and energy.  Yet if she would survive as a human being she would have to reach way down into herself, to the uncharted keep of the mind, to the circuitry where psychological strength was stored . . . and, somehow, she would have to find enough to go on.

Jim was her hole card. Every time Graffagnino dealt with Mr. Vertucci, his admiration for him went up another notch.  He was a straightforward, sometimes painfully honest man with the guts to survive and prosper in a world that all too often seemed bent on beating that particular trait out of its citizens.

Early on Mr. Vertucci had planted himself in front of the doctor and said, by way of clarification, that he, Jim Vertucci, spoke what he thought and intended to continue to do so, and the neurologist would just have to get used to that.  A bold man, even a warrior of a sort, hard as rock, sometimes abrasive as gravel. Yet he hovered around his mortally ill wife with the loyalty of a lovebird.

Mrs. Vertucci was in good hands.  If Jim couldn’t help her muster up her courage, nobody could..

In any event, Dr. Graffagnino had his own problems.  The pneumonia continued to rage with a vengence, and could still carry her away. He pushed antibiotics into her veins, kept an eagle eye on the respiratory therapists, worried over her chest X-rays.

Slowly, all too slowly, she improved; like an overloaded freighter her metabolism was slow respond to the helm . . . yet, day by day, it did.  Time and again the pneumonia threatened to carry away but it didn’t, and finally Dr. Graffagnino felt confident to move her to the step-down unit.

Then she relapsed, the bacteria growing hot and virulent in her lungs, and he moved her back to the ICU.

Jim, meanwhile, thought he sensed some flicker of awareness in his wife’s still form. In response, he intensified his efforts to communicate.  He talked to her, sang to her, told her she was Gonna move that toe!  But if she was aware of any of that, he couldn’t tell it.

He knew about the pneumonia, but it was difficult to comprehend the danger it posed.  A mere bacteria?  After all that Judy had been through?  It didn’t bear thinking about, and in any event his job lay elsewhere.

He had had plenty of time to think of these issues.  The nearness of death didn’t distract him any more; he, like the clinical staff, had grown accustomed to it.  Nor did he flinch when her body curled with a neurologist’s pinch. Pain was life, now, and that was just the doctor’s way of trying to reach down into her mind and get her attention.  That was how science dealt with the coma, and he understood now that it was not only acceptable but necessary.  Besides, he no longer had the strength to respond to such outrages to the sensibilities.

His own efforts were to the same end as Graffagnino’s, but since he knew her psychologically, he could use a complementary route.  As pain was their leverage, emotion was his. He sang to her, talked to her, tried to reach down deep into what he thought of as her soul . . . trying to grab her with his mind and shake her into wakefulness, and maybe even help lead her to out into life again.  It was the one thing he could do better than the doctors could, because he knew her and they didn’t.

You’re gonna move that toe!

There was no laughter, no response at all.  Yet he had thought it over carefully, and it was clear to him that the ability to know was not necessarily the ability to acknowledge.  She might well be hearing him, and unable to respond.

Once, in response to nothing he could put his finger on, she opened her eyes.  They didn’t focus, or anything like that, but it was a watershed.

If you opened your eyes, Jim had learned from being around neurologists, it meant you were aware enough to know that you <ital>had<end ital> eyes.

It wasn’t long, though, before it seemed to him that she was having trouble breathing.  He went for the nurse; the nurse examined her, but found her normal.  At Jim’s insistence, a specialist was called in.  Jim waited outside, with the other families, and in a bit the nurse came and got him.

He’d been right, she said.  Mrs. Vertucci had suffered a collapsed lung.  She was being reconnected to the ventilator and taken back to the ICU.

Jim of course followed her there to continue his efforts . . . to whisper and sing, to remind her of times past, to pronounce that she was <ital>going to move that toe<end ital>.  A day later he followed her back again to the step-down unit — and then, when the pneumonia flared up again, back to the ICU.

After that it was back to the step-down unit, back to the ICU, back to the step-down unit, back to the ICU.

On February 23, almost a week since rewarming began, Dr. Graffagnino finally felt confident enough to remove the respirator tube.  She tolerated that okay, and after two more days of close observation he judged her stable and infection free.  It was with a profound sense of relief that he wrote the orders for her to be moved over to the step-down unit for what he sensed was the final time — the first, tentative step to a resumption of her life.

But the neurologist was careful to qualify every thing he said with caution and even a little pessimism.  He didn’t want to give Jim false hope.  At the same time, hope was the whole underpinning of his professional life, and he couldn’t help but feel a quickening himself.

But Jim was far ahead of him.  He knew his wife and her personality, and he could see if flickering in her slightest movements days before the doctor could.  Sometimes she moved on the bed . . . . writhed might be a better word.  And while she didn’t respond directly to him, her level of consciousness seemed higher every day.  When they removed the breathing tube, it was a big deal.

Dr. Graffagnino’s priority now was nutrition.  Mrs. Vertucci had not eaten since she had her stroke.  She’d been fed through a tube, of course, but during hypothermia her gut couldn’t digest. A patient so sick for so long, with unknown but possibly extensive brain damage, was exceedingly fragile in the first place.  Now every cell in her body had suffered the additional trauma of malnutrition.  They needed food, or at least the digested molecular components of food, proteins and vitamins and minerals, to rebuild themselves.

In the days since she’d come up to her normal temperature they had tried to feed her through a tube that went through her nose and into her stomach.  The tube, rubbing against the delicate membranes, could be painful but, of course, a comatose patient didn’t notice.  But as her state of awareness improved she pulled the tube out, again and again.  The nurses had responded by tying her hands to the bed railings, but she struggled . . . and the struggle drove her husband crazy.  He wanted the tube out and her hands freed.  As the days passed that request evolved into a demand.  “Not tomorrow,” Jim had said, drawing himself up to his full height.  “Not tomorrow!  Right now!”

Right now was not possible, but the neurologist clearly had to do something.

In recent days Dr. Graffagnino’s optimism had begun to wane a bit.  Beaten down by his constant struggles with Mrs. Vertucci’s pneumonia and a horde of other, smaller complications, he had come to suspect that she would ultimately have to go to a nursing home, at least for a while.  In that case, she’d need a stomach peg — a fitting that went through the wall of the belly and directly into the stomach, allowing tube feeding without pain.  In rare cases feeding tubes got infected, but the odds were heavily against it.

He ordered the peg put in, and it was done.  Not long afterward, it became infected.

Oftentimes Jim hardly paid attention any more.  He knew that a desperate battle had been waged by Dr. Graffagnino and the pneumonia, and now over nutrition.  But he, Jim, had his own work to do.

As the mind reasserts itself, it does so by stages.  Each time he examined her, Dr. Graffagnino loudly demanded that she open her eyes, but she never would.  She responded to other simple orders, as well; she squeezed the neurologist’s hand, and when he touched her eyes with a cotton swab, she blinked.  So why didn’t she open her eyes?  It was almost as if she was trying to keep reality at bay.

And that, he decided, was exactly the case.  He’d written a paper on depression in stroke patients, and while it was true they had cause to be depressed, the actual culprit was often the neurochemical battles that had raged across the brain.  So he prescribed an antidepressant and sure enough, a few days later, when he said, “Mrs. Vertucci, open your eyes!” . . . she did!

It was a blank stare, a blind stare almost . . . but it was progress.

Jim, like Graffagnino, knew the risk that she would never really recover.  But he dismissed the thought because he thought he saw her <ital>in there somewhere<end ital>.  He was certain of it, in fact. It was something he sense, though he couldn’t have explained it.  It was just a feeling that she was now aware of his presence in a way she hadn’t been before, and was trying to respond. As the days wore on she began, sometimes, to look directly at him.  He couldn’t tell if she knew who he was or not, but even if not something was stirring in there, trying to figure out who he was and what he meant to her.

In this fashion February disappeared, March began.  Graffagnino struggled to keep her body alive and Jim struggled to bring her mind to life.  Carolyn Bolles, the EEG technician, was full of joy for Jim.  He was taking better care of himself now, and there was often enthusiasm in his voice as he talked of this or that tiny, and maybe even imagined, improvement.  Whatever Dr. Graffagnino’s misgivings, it seemed to Jim like a miracle was taking place.

Sometimes it seemed that way for Bolles, as well, and she loved it.  The neurological floor was not a place where one saw many happy endings, and she enjoyed them every one . . . and if ever a man deserved a happy ending, it was this one.

Then Jim grew glum again.  Judy had gotten better and but now she seemed to have hit some kind of barrier and could come no farther.  Her connection with her body seemed to proceed without the active participation of her mind.  She lay on the bed and writhed.  The nurses tied her up again, and he demanded that she be freed.  He simply could not stand to see her tied down.

The nurses granted his request, but then when he’d come to her room in the morning she’d find her tangled in her covers and halfway out of the bed.  He wrestled her back, and she’d wriggle off.  He wrestled her back.  Again and again this happened.

Worse, she had ceased to make psychological progress.

Jim studied the situation as no doctor could: Sitting beside her 12 hours a day, knowing her as he knew himself, watching every thing that was done to and for her.  Eventually he made a connection.  Her frantic writhing consistently began immediately after she was given a dose of the anti-convulsant Tegritol.

He talked to Dr. Graffagnino about it, and the doctor explained that the drug was needed to keep the convulsions from returning.  That was no minor issue, he said; the way she’d been, the convulsions could in and of themselves cause massive brain damage.

Jim, understanding that he was no neurologist, backed off.  Judith continued to writhe, and he continued to watch.

As he sat and watched her struggle against some unknown enemy, he was increasingly torn.  He just couldn’t escape the conviction that it was the Tegritol.  He voiced his concerns to Bolles, who was no neurologist either, but who seemed to have the ability to help him clarify his thoughts simply by murmuring “mmmmmm” at the right time.

On the one hand, he had no business telling an expert like Dr. Graffagnino how to manage a patient.  On the other hand, this particular patient was Jim’s own wife, and he knew her better than anyone did — and he was also sitting there all day every day, focusing entirely on what was happening to her.  He was right, and the more he thought about it, the surer it was.

Finally, he called Dr. Graffagnino’s pager, and when the doctor called back Jim demanded that his Judy be taken off the Tegritol.

The neurologist restated his concerns about seizures, but this time Jim wouldn’t hear any of it.

“Take her off the Tegritol,” he said.

Perhaps, Dr. Graffagnino equivocated, they could lower the dose incrementally . . .

No, said Jim.  That wouldn’t do.  Absolutely not.  He wanted it stopped.

But it was a high dose, and there were risks in withdrawing it abruptly . . .

“I want her off of it,” Jim said firmly.  “Completely.  Right now.”

Dr. Graffagnino thought about it, weighed the differences between the human body and the human spirit, the fallibility of experts against the certainty of a husband.

Jim stood, the phone pressed to his ear, listening to a very long silence.

And then, reluctance in his voice, the doctor spoke.  Against his own better judgment, he would do as Jim said.

By the next morning (March 18), Judith had ceased her writhing and seemed, at least to Jim, to be psychologically regrouping.  Later in the day, Dr. Graffagnino came in the room, examined her, chatted for a bit with Jim, and then turned to leave.

On impulse, Jim whispered in Judith’s ear.  <ital>You’re gonna move that toe<end ital>!

The noise that emanated from Judith’s mouth was froggy and weak, a sort of combination hiccough, belch and rattling cough.  Yet there was no mistaking it.  It was . . . a laugh.

Dr. Graffagnino spun around in the doorway.

Whatever you did, he said, KEEP DOING IT!

Her improvement after that was rapid, and as her level of consciousness rose the damage caused by the stroke became apparent.  She could move her right hand, but when she wasn’t paying attention to it, it curled up in a claw beside her body.  A therapist explained to Jim that a center on the left side of the brain kept track of where all the body parts were located in space . . . and the part that accounted for that hand had been damaged.  The hand wasn’t paralyzed; Judy just didn’t know it was there.

But as her stupor receded the thing that worried Jim most was her speech.  She might be able to laugh, a little, but other than that she made no sound.  Graffagnino had seen this many times before, and it was an ugly omen. A speech therapist was assigned, but after a while he told Jim he didn’t think that Judy would ever speak again.

Jim did not accept that.  Something else was wrong.  He could tell by the way she looked at him that she wanted to communicate.  So why didn’t she at least try? He studied the situation thoughtfully, seeking to project his mind into hers, to imagine how it must feel to be Judy.

She hadn’t spoken for a very long time.  Not for almost eight weeks, in fact. She was unconscious most of that time but still, it was a long time; her body knew that.  It was atrophied, injured by inaction.  The respirator tube had been in her windpipe for a very long time.

Eventually it dawned on him that she didn’t understand that she <ital>could<end ital> speak.  If he could make her make noise, she would hear herself and understand that she still had that capacity.  He told the therapist his theory, but the man was skeptical but not dismissive. “But go ahead,” he said to Jim.  “Do what you have to do.”

While the therapist stood and watched Jim put the butt of his hand just below her diaphragm and pressed.  Nothing happened.  He tried again, the pressing more a blow now, sharper and harder.  Again, and then again.  Finally Judy responded with an “Uh!”

He did it again.  “Uh,” she said, staring at him quizzically.

He pushed again.  “Uh!”  Again. “Uh!  Uh!”

She was figuring out that she was making the “Uhs,”  Jim knew.  He could almost see her mind putting it together, connecting the dots. He pushed again, and again. “Uh!  Uh!”

Within five hours, she was talking.

But now there was another problem:  Her words made no sense. They were babble, pure babble, “bubba-buha-eeh-oobo . . .”  Baby sounds, heavy with vowels and rhythm but devoid of anything approaching human language.

Graffagnio explained to him that Wiernike’s area had been damaged.  Wiernike’s, was the brain’s dictionary.  It was sending nothing but static.  Brocca’s area, on the opposite side of the head, was picking up that static and translating it unto motor instructions for the voice box, lips, tongue, throat and diaphragm.  Words translated into speech.  But static translated into babble.

The neurologist didn’t hold out much hope, but Jim ignored him.  Judith was going to talk again.  He knew it.  It had to be.  She needed time and attention . . . which happened to be exactly what he had to give.  So he stepped in, in place of the speech therapist, and began helping her, pushing her, to exercise better control over the sounds she made.  Within a week she was talking.

“You know what,” the speech therapist mused to Jim, “I think we’re going to hire you.”

Finally, a few days later, she took her first steps.  A day or two after that,  Graffagnino happened to see her walking down the hall away from him, a fragile sprite of a figure, less than 80 percent of her normal weight, leaning on her husband’s arm, moving in stiff spastic jerks, the IV pole swaying overhead.

The doctor stood there for a moment, flooded with awe not just for the power of medicine but also the rawer, more stubborn force it struggled to engage:  the thing called “life.”

A few days later he signed the papers that released Judy Vertucci to the Southeast Regional Rehabilitation Facility, which was attached to the Cape Fear Valley Hospital.

Judith Vertucci would remember bits and snatches of those days — walking down that hospital hallway, riding in an ambulance to the rehab center, laying in a nice room with a television set, struggling back to consciousness through fog and confusion.  Her mind drifted almost uncontrollably.  Bits of memory appeared and disappeared again, like great slow whales broaching and then disappearing.  The weakness of mind was matched by feebleness of body:  She weighed less than 100 pounds, down from a normal of 125 to 130.  Every act of living pitted herself against a body that no longer responded to her mind and a mind that couldn’t ever quite focus on what mattered and what didn’t, what was logic and what was feeling, what was <ital>right now<end ital> and what was yesterday or a decade ago.

But she had will.  That, at least, was uncompromised.  If it was a Herculean effort to get herself out of bed and into her chair, she could nevertheless accomplish the act.  She did it slowly, slowly, moving one muscle at a time, pausing to rest and regroup, willing her right leg to go <ital>there<end ital> and her left foot <ital>there<end ital>.  Her right hand was no help at all, and her tendency was to ignore it.

She absorbed her surroundings.  There were lots of therapists and their helpers, mostly dressed in pastel hospital clothes.  Every morning they came and got her, helped her into a wheel chair and slipped her schedule into a pouch in the back.

The moments came and went, were sometimes transcribed into memory and some not.  She sat at a table, locked in intense combat with a great puzzle of some sort, a pile of colored blocks that fit together to make something.  A puzzle sold as an educational toy for toddlers, but now it was no toy it was the enemy.  She strained mind and body to figure out how the blocks fit together.  With the concentration of a shuttle astronaut piloting a robot arm in space she willed her left arm out and the hand to close around one of the blocks and shove it against the other.  They didn’t fit.  She tried to stack them and they fell.  She sat for an eternity before the puzzle before her body ceased to obey her and her will fizzled into frustrated anguish.  Then someone came, took the schedule out of the pouch on the back of her chair, and wheeled her on to the next class.  The big spoked wheels of the chair made almost noise against the hard-polished floor.

A time came when she could stand on her own, an accomplishment of infinite difficulty. The floor seemed a long ways down, and she sensed her unsteady body was as fragile as a Christmas ornament.  It was clear to her that if she fell she would shatter, yet . . . . they made her walk.

There was a hallway, infinitely long, institutional, tile and fluorescent light.  She fought for balance, terrified and stubborn at the same time.  One leg went in front of the other, her body shifted its weight, the hallway trembled, her heart leaped.  There was someone behind her, holding her by some kind of belt.  Move the other foot, shift the weight . . .

She failed at everything, could do nothing, was helpless.  Yet each time her optimism was crushed and her will destroyed, it returned.  As time passed it returned more quickly.  Unlike others, she was never tempted to crawl back into the warm womb of her disabilities and go to sleep.

Eventually, the effort began to pay off.  The colored blocks were infinitely complicated.  She struggled to see how they might fit together, willed her left hand to somehow fit one block to the other, failed, failed, failed, failed . . . succeeded.

Success felt wonderful, but it didn’t last long.  Someone came for her, checked the schedule in the pocket of the chair, and wheeled her off for some other test of strength, will and courage.

With each day she became more who she was, filling out the old familiar forms of her personality.  Jim was there, to help, and she was grateful, but as she looked across the dinner tray at him she began to read new lines on his face, lines of concern, the tracks of strain and worry and too little rest.

Why was he here?  She would be all right.  Go home, she demanded with newfound authority.  Get some rest, skip tomorrow.  He refused to skip days, of course, but as she became stronger he consented to come in later every day, have dinner with her, go home early.

Home.

Her memory groped with the past, trying to find a way to reinsert herself into its narrative.  She wrestled with things she knew she knew but couldn’t quite haul up into her conscious mind.  Names, dates, events, her own wedding.

But she knew what home was.  The concept bloomed in her mind, took finer form, beckoned like some dazzling, faraway castle.

Stroke.  She had had a stroke, had almost died, but was alive now.

She could walk now without the person behind her, so they sent her off down the hallways on her own.  She walked carefully, oh so carefully, balancing on quaking legs that felt like stilts, terrified of the hard-polished, distant floor.

Brain damage from stroke, trauma or brain surgery often produced a physically rooted depression, sometimes so powerful that it paralyzed patients.  Judy didn’t know it, but her own drug cocktail included an antidepressant, prescribed by Dr. Graffagnino to help prop up her optimism and courage.  It helped for some people; for others, nothing helped.

Some time after Judith arrived she slowly became aware that someone, in the background, was sobbing. It was an awful sound, and forlorn, a limbic despair that proclaimed itself so forcefully that it echoed in all the deep, battle-scared hollows of Judith’s mind.

Later she identified the source of the sobbing — woman in a turban of bandages.  She couldn’t seem to stop.  The patients near her complained, and the therapists tried to help her stop.  But she couldn’t.  Despair was not a thing that could be ordered away.

Judith went on.

The days blended into one another, a mixture of stubbornness and frustration, punctuated with occasional victory.  There was a gym, and they wanted her to get down on mats, roll around, get back up.  Getting down was terrifying:  It was such a long way to the floor.  Another time they gave her a huge, waist-high ball and told her to move it to various places around the gym.  She kept losing the ball.  It would roll away from her, and she had to force her body to go get it, and try again. She learned to lean on it, from the top, so it wouldn’t skitter away.

She learned to feed herself, go to the bathroom herself, shower with the assistance of a nurse.  Dinner with Jim.  Walk down the hallway.  Do this puzzle, do that puzzle.  The turbaned woman sobbed

Then, finally, came the day of her discharge.  An aide wanted her to ride downstairs in a wheelchair.  She refused.  He insisted. There was a back and forth.  Jim intervened, gentled her, told her to let them have their way, it was procedure. Finally she acquiesced.

But when she got outside, and Jim offered to help her out of the wheel chair, she balked. She would do it herself, she insisted, pushing him away.  Slowly, wobbly but in control, she lifted herself from the chair and moved haltingly to the car.  He was right there, but didn’t touch her.  He opened the door and when she was settled inside and her seat belt fastened, he closed it with a solid ka-chunk, separating the world of medicine from the world of hime.

Then they were on the road, toward home, and life . . . not the old life; she knew that by now.  She was realistic.  She would never fully recover, but . . . a new life, then.

And so it was.  For a time, nurses and therapists came to the house several times a week, helping, teaching, encouraging.  She worked now to regain control over her domain — to cook, to do laundry, to handle the phone.  A speech therapist helped her regain her ability to articulate.  She was still frustrated by the thoughts that wouldn’t quite come, the knowledge she couldn’t quite put into words, but with each day she got better.

And that, in the end, would be enough.  She had to learn, but as she thought about it . . . so what?  Wasn’t that life?  Learning?

Jim, assured that she could finally care for herself, went back to work.

In that way a slow year passed, then another.

But life in the Neurological Intensive Care Unit was never slow.  Patients were admitted daily, as others died or were released to rehabilitation units.  Dr. Graffagnino tracked Mrs. Vertucci’s progress for a while, then lost track.

As Mrs. Vertucci was recovering at her home inSanfordthe drug tPA, which was commonly used to dissolve clots in heart attack patients, was approved for stroke victims as well. But as so often in medicine, the new therapy demanded changes in perceptions — changes not just in hospital practice but in the attitudes of patients and emergency medical technicians as well.

The crunch was brought on by the fact that the drug had to be administered within three hours of the onset of the stroke.  Any later than that, and the brain downstream of the clot would have turned to goo and tPA would convert the stroke to an even more dangerous bleed.

On top of that, the drug could only be given after the patient had gotten a catscan to make sure the problem wasn’t a hemorrhage to start with.  In that case, of course, tPA given at any point would probably kill the patient.

So the patient had to come to the hospital as soon as symptoms appeared . . . and that was not a simple matter.  Strokes often happened at night, and those patients were automatically ineligible for tPA because no one new when the symptoms had begun.  And all too commonly patients spent hours or even days denying their symptoms; they blamed a numb arm on a pinched nerve, laid a suddenly difficulty talking or thinking on anything from exhaustion to diet.  Even if the patient or the patient’s family called 911 instantly, the ambulance crews were not accustomed to rushing with a stroke patient.  Rural doctors who would call for a helicopter immediately as soon as a heart attack patient entered the door would have to program the same response for stroke patients.

In other words, stroke experts suddenly found themselves confronting the same set of community perceptions that cardiologists had struggled with back in the 1970s.  Citizens needed to learn the symptoms of stroke at least as well as they had once learned the symptoms of a heart attack.  By 1999 this effort had begun to get underway, and neurologists were trying to teach themselves to say “brain attack” instead of “stroke.”

These were small steps, of course; even when the timing was right, tPA didn’t cure everyone.  Of the five percent of patients who got into the hospital on time, statistics showed that one would be restored to normal.  Others would be benefited, but most would continue to get worse. For them, neurologists had little to offer beyond the watchful waiting that had been the mainstay of neurology for a century and more.

But doctors like Dr. Graffagnino were determined that this, too would change.  Graffagnino himself, considering the results of hypothermia in Mrs. Vertucci’s case, was emboldened to try another patient, and then another.  His results, combined with the results of other hypothermia treatments in theUnited States, Europe andAustralia, were beginning to look significant. In 2000 Duke also began using hemicraniectomy on some patients, and that looked promising as well.  As patients began to arrive earlier and earlier at hospitals, it was becoming possible to try new things very early in the course of events.  That could be significant in itself, as it was in heart attacks.  Perhaps, as in cardiology, there would evolve a whole new armamentarium of useful if dramatic therapies against stroke and, perhaps, all brain trauma.

But nothing was ever simple or easy.  A doctor inAustraliatried hypothermy trauma patients inAustralia, the patients didn’t seem to be better for it.  They might even be a little worse.

This didn’t dampen the spirits of activist neurologists.  The brain was a touchy organ, and there were probably procedures, as yet undiscovered, that would make such therapies much more effective.

The problem, as Dr. Graffagnino saw it, was a problem in clinical science: It was difficult to compare one stroke or injury to another.  The clot varied in its location.  The number of collateral arteries varied from patient to patient.  And it was not unreasonable to suppose that damage to some parts of the brain might be more treatable than damage to other parts.

On top of that, the technology was primitive.  The whole business of sandwiching the patients between cooling blankets made Graffagnino nervous.  For one thing, the doctor had very little fine control over the patient’s temperature.  It might go down or up too fast, or overshoot the mark at either end.  In fact, a year after Mrs. Vertucci left the hospital Dr. Graffagnino had come to regret that he’d brought her out of the chill so quickly.  At the time it had all been such unknown territory, the situation so desperate, that no one thought about such things.

Ultimately they had to have some sophisticated cooling device and some sort of experimental design that would allow them to match up patients with equivalent injuries.  Graffagnino and his fellow stroke experts began to lobby manufacturing companies to produce such a machine.

Meanwhile, Dr. Graffagnino’s group cast about for a patient group that was uniform enough, clinically, to build a preliminary scientific trial around.  Dr. Graffagnino became especially interested patients whose hearts had stopped but who had been revived.

Cardiac arrest patients often suffered brain damage that was similar to what he saw in stroke.  Deprived of oxygen, the brain cells suffocated; later, the brain swelled inside the unyielding compartment of bone and, if the swelling was sufficient, the patient herniated.  But there was one big difference between these patients and stroke patients.  Stroke patients’ damage was focal, and could occur at many locations.  Cardiac arrest patients’ brain injuries, having been caused by a general cessation of blood flow, were more diffuse . . . and more comparable one with another.

The whole thing was a house of cards, probabilities propped up with wishes and anecdotal experiences.  But optimism, however unscientific it might be, was nonetheless a force to be reckoned with — and one measure of the optimism surrounding hypothermia was the formation of three venture capital companies to develop better cooling equipment.  One of them, Alsis, furnished Dr. Graffagnino with a prototype device that would allow doctors to insert a tiny refrigeration unit directly into one of the patient’s veins. The blood that flowed past the probe was be cooled, and as it fed back into the lungs and was pumped throughout the body, it cooled the tissue evenly. The probe could be much more finely calibrated than the cooling blankets, so that patients temperatures could be lowered and raised very slowly.

All of this was in ferment as Judith Vertucci slowly worked through her recovery and sought to build a new life — a life that was admittedly not as good as the old in some ways.  Her attention tended to wander, so she was no longer allowed to drive.  Having been fiercely and independently mobile all of her life, she sometimes fumed over being at the mercy of others to take her here and there.  Her right hand was only marginally useful, and sometimes there were ideas in her mind that she could not quite put the right words to.  There were certain details of life that seemed not only gone but, inexplicably, irreplaceable:  She could not remember her oldest daughter’s birthday, no matter how many times she was told.  Yet she could remember those of the other children.

Still, there was no doubt of her intelligence, or that she was in fact still Judith Vertucci.  She could still cook and clean, do the laundry, hold up her end of the routine she and Jim had worked out over the decades.  Life was still sweet — all the more so, perhaps, because she saw it as a bonus.  A different roll of the dice, and she would be dead.

In late 2000, more than three years after her stroke, she and Jim were invited to visit the new Neurological Intensive Care Unit.  Dr. Graffagnino met them in the unit.  He pumped Jim’s hand and beamed at Judith who, of course, remembered nothing of the weeks in question.  Now she walked the polished halls with evident curiosity.

Jim, though, noticed the changes.  The place had been refurbished.  The bays were larger and less cluttered.

Dr.  Graffagnino proudly showed him the new cooling equipment he had just received.  He held the small refrigerating wand in his hand, explaining how it would be inserted through the femoral vein on the inside of the patient’s leg and pushed up into the inferior vena cava. It hadn’t been used yet to prevent brain swelling, he said, but it soon would be:  Duke had been chosen to test the device — and would begin to use it, soon, on cardiac arrest patients with brain damage.

They wandered down the hall and around the corner, where the EEG office was.  Jim asked if Carolyn Bolles was in, and someone went to fetch her.  Presently she came out of the office, looking confused.  Her eyes swept the hallway, across Jim’s face and to Judy’s.  She had only seen Judy’s face in a coma, so she didn’t recognize it, but her eyes quickly came back to Jim.  Suddenly, comprehension lit her face.

“Jim! Jim Vertucci!” she squealed, leaping across the hallway and wrapping her arms around him.  “And you,” she turned to Judith, tears running down her cheeks “. . . must be . . . ”

A few minutes later, daubing at her eyes, she apologized for the show of emotion.

“We get so involved with our patients here,” she says, “and then, you know they . . . ” she hesitated, then leaped ahead “. . . or they go to nursing homes or rehab centers and we never see them again.  How marvelous it was for you to come back to see us.”

Later, near the visitor’s room, Jim hesitated.  He had spent agonizing hours here, so many days.  It too had been refurbished, but it wasn’t any different.  Not really.  The faces were the same.  Different people, of course, but all with that worn-down anxiety he remembered all too well.

It ended, finally, with a ritual of two men who had been together, once, in battle, and who were now lives apart.  Judith stood slightly back.

Jim thanked Graffagnino for saving his wife’s life.  Graffagnino, a pleased, aw-shucks look on his face, said that Jim had as much to do with it as medicine had.

The important thing, the doctor said, “Is that she’s still with us.”

“For now,” Judith said softly.  “For now.  None of us is here forever.”

Dr. Graffagnino stood outside the NICU, hands in the pockets of his lab coat, watching with a boyish grin as Mr. and Mrs. Vertucci disappeared toward the patient elevators.

“You know,” he said, “it’s really going to happen.  It’s started already.  We’re going to do for stroke what cardiologists did for heart attacks.

 

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