Beyond the High Blue Air. Lu Spinney
from being disrupted. The emotional impact of Miles’s accident has been traumatic; we must not allow it to damage them practically as well.
Ron is in Innsbruck for the weekend and we talk about it together and with the children. Decisions are made. Claudia will return to London and ask to have her MA exams deferred from May to September, when rewrites are undertaken, so it should be a possibility. I will write to Marina’s tutor at Oxford and explain the situation to him; the pastoral care there is excellent, I know. Will’s situation is more complex, though in some ways easier; his time is not proscribed by terms and exams but by personal deadlines as his future career begins to take off. His business partner is understanding, but undoubtedly combining his work and being here for Miles is going to be a problem.
Traumatic brain injury is by definition sudden and unexpected. Shock and grief follow in its wake, but it is the unknownness, the complete lack of knowledge that compounds the horror. There is no known trajectory to illuminate the terrible blank thing one faces. Somebody you love is there but no longer there. Lack of consciousness is not comprehensible; the person looks the same and that is all. As a family we are adrift together in our ignorance and our craving for knowledge.
I have been talking to the athletic young neurosurgeon on the ward who is the same age as Miles and who, it transpires, is also a keen snowboarder. He is the one who tells me that he never wears a crash helmet when he snowboards. They may protect the skull, he says, the helmet will take the impact, but the sudden acceleration and deceleration can cause the brain to rotate within the skull. I don’t want to hear this. Rotate—Miles’s brain rotated? He continues, The medical term is diffuse axonal injury, or DAI for short. If that happens we do not yet know any way of reversing it.
I research DAI. Please let Miles not have suffered DAI. If he has, his brain will have sheared when he fell, or more precisely, the axons will have sheared. I learn that each of the billions of neurons, the nerve cells in the brain, has an axon, a long fiber that acts like a fiber-optic cable transmitting electrical impulses away from it, allowing one neuron to communicate with another. If the axons are broken, the messaging system is broken. Apparently the brain is made up of tissues that vary in density and during that dreadful rotation the different tissues slide over one another, stretching and shearing the axons that connect them; they cascade. The words are surreal, beautiful: rotate, shear, cascade; it is a betrayal of language. The particular cruelty of DAI is that the areas of the brain stem involved with basic life functions, the cardiac and respiratory systems, may remain unaffected; the victim does not die but is left suspended between life and death. I read that 90 percent of people with DAI remain in a persistent vegetative state. Very few of the 10 percent who regain consciousness will return to near-normal neurological function, and of those who do, the improvement will have to take place within the first twelve months after injury. If there has been no progress by then the prognosis is bleak. It is only after a year from the time of the accident that a neurologist will be able to make a prognosis and even then it will be approximate; the brain does not yield its secrets easily.
Miles, do you remember my last words to you as you were leaving the house? Please don’t do any dangerous jumps, my darling! It was my foolish, ritual request, a kind of game we played. I loved your daring and you enjoyed my mock protectiveness (although it wasn’t really mock, I meant it but I had to say it lightly). I remember you hugged me with that crushing bear hug I love so much and you said, Don’t worry, Ma, I’m older now. I promise I’ll be responsible.
Miles bought his crash helmet that morning just before the jump. He would have died instantly without it. But perhaps without it he wouldn’t have gone as fast, perhaps he would have been more cautious, perhaps it disoriented him.
Is it my fault he bought the helmet?
***
I come across Dr. Stizer on the ward one day. He is in his scrubs, seeing his patients in a break from surgery. It’s strange, he says, but I have connected with your son in a way I haven’t done with a patient before. He could be my son. My greatest hope is that he will return here one day to speak to me himself.
I am profoundly touched by his words and we are both quiet for a moment. Then he says, May I give you some advice? Of course, I say. You saved my son’s life! He looks at me quizzically. The first thing, he says, is that you must never reprimand him for doing that jump. It was a brave and wonderful thing to do. He is a young man and young men should all go out and grab life in the way he did. The second thing is that you should never feel guilty. It concerns me, he says, to see that you and your children come every day to visit Miles. I think it may be too much for you. You must not feel guilty if you go away and enjoy yourselves.
This is a surprise. Neither thing has occurred to me; certainly I would not reprimand Miles for doing that jump. As for feeling guilty, what I do feel is more complicated, not guilt but something stranger, whereby all physical and sensual enjoyment—eating, drinking, long hot baths, music, shopping, reading, making love, laughing—is shot through with a new awareness. It can no longer be simple untainted pleasure. Everywhere I go, everything I do, is suffused with, contaminated by, the image of Miles lying unconscious in his hospital room. The incomprehension at his plight has destabilized me; nothing makes its usual sense, nothing at all. Drinking a cup of tea reminds me he can’t drink; seeing the sun set over the pale mountain peaks reminds me he can’t see it.
Dr. Stizer is an unusual man and I am moved by his evident concern for Miles, on a personal level. Miles would like him, they would get on very well—I can imagine their mutual respect and the laughter their shared rumbustious humor would generate. A fifty-year-old neurosurgeon who snowboards and plays in an amateur rock band in his spare time—they could have a great time together.
For the first two weeks Miles remained in an induced coma; with a controlled dose of barbiturates, his brain had been artificially shut down to the baseline of function. By the time he had arrived at the hospital the right side of his face and neck were grotesquely swollen as the cerebral fluid found its only escape route out of the confines of the skull. When a brain is injured it swells and there is no space for it to swell to; the skull protects the brain but now the protector has become the instrument of destruction. As the swollen brain is compressed against the hard, bony helmet of the head, delicate brain tissue is being damaged in the process. If appropriate, the neurosurgeon will perform a craniotomy as they did on Miles, in which a “flap” of bone rather like a trapdoor is removed to make room for the swollen brain. Then, by inducing a coma, barbiturates will slow down the cerebral blood flow and the metabolic rate of brain tissue and so the blood vessels begin to narrow, allowing the swelling to decrease. The outcome for each person sustaining a brain injury will vary depending on the extent of the original trauma to the brain and, crucially, the time taken to reach a neurosurgeon and therefore the time the brain has to swell unattended. In Miles’s case he had to get from where he had fallen, 2,000 meters high up on an Alpine mountainside, to a neurosurgery clinic 100 kilometers away. That journey took three hours and even the best efforts of a helicopter rescue team could not prevent secondary cerebral damage. There had been nowhere else his brain could swell to except against the skull or down into his brain stem. I have Miles’s case history on admission to Innsbruck University Hospital in front of me. In a crude translation from the German it states the bald facts, as reported by the paramedics who attended to him on the ski slope and accompanied him in the rescue helicopter to the hospital:
State of conscious: unconscious
Breathing was still spontaneous, but he had an apnea soon
Ventilation with a mask was started immediately
Motor reaction: no reaction
Eye opening: no reaction
Verbal reasoning: no reaction
Pupil reaction: left, no reaction, wide
right, no reaction, wide
During transport they got unequal
Intubation was necessary immediately
Grade of injury: life-threatening
GCS: 3
GCS, the Glasgow Coma Scale. It would become our cruel