Herseverance

How We Survived My Wife’s Traumatic Brain Injury

Herseverance

Or

How We Survived My Wife’s Traumatic Brain Injury

Introduction

“There is a time in life when you expect the world to be always full of new things. And then comes a day when you realise that is not how it will be at all. You see that life will become a thing made of holes. Absences. Losses. Things that were there and are no longer. And you realise, too, that you have to grow around and between the gaps, though you can put your hand out to where things were and feel that tense, shining dullness of the space where the memories are.”

H is for Hawk, Helen Macdonald

“DON’T LEAVE THE PATH!”

The Hobbit, J.R.R. Tolkien

This is a self-help book, written specifically to help only two selves. And yet it will likely help you and your loved one, somewhere along the interminable—and for us, interminably rewarding—path to recovering your selves, after your partner is devastated by a life-threatening illness or injury.

It would be nice if there were a path such as Tolkien describes. But there is none—at least that I’ve been able to find. You can read all the books on the subject, if you have time. I didn’t have or didn’t take the time. Another excuse I gave for not reading those books is that they were about strangers helping other strangers. I needed something about my wife’s specific injury (a traumatic brain injury or TBI) and how to cope with it. Finally, I decided to write my own.

In fiction, there might be a safe and reliable path on which to take a dangerous journey, but in real life, how can there be a path when the ground suddenly falls away, like the first stage of a rocket launch? From the moment I learned of my wife’s traumatic brain injury, my feet were no longer firmly planted on the ground. I was at sea. And not the “master of my fate, captain of my soul” at sea. I suddenly found myself taken hostage by invisible pirates—alone, held against my will, plying unfamiliar and perilous waters, on a storm-tossed ship of unknown seaworthiness.

The boat had no pilot to steer her, no navigator, no rudder. The engines were dead, the sails shredded. I quickly apprehended that this vessel was no match for the ocean and its unexpected perils. As wave after wave crashed over the side, I was nearly swept overboard. I somehow managed to hang on, but I had to keep on bailing, just to stay afloat. I did not know the destination, if there was one. All I could do was bail, like the hapless four of Stephen Crane’s The Open Boat, hoping to remain afloat until I could reach a beach or someplace “populated with men with blankets, clothes, and flasks, and women with coffee-pots and all the remedies sacred to [my mind]. [A] welcome . . . warm and generous.” But, again, what happened, and is happening to me, is not a work of fiction. I am lost at sea, perhaps indefinitely. 

It will soon become clear why I’ve stretched the “at sea” metaphor much too far. You see, our troubles started with a boat I did not take, on the night of May 6, 2014.

Chapter 1

Post Hoc Ergo Propter Hoc

Post hoc ergo propter hoc: A fallacy in logic occurring when one assumes that if A happened after B, then B caused A.

Andrea Opalenik lay on her back—helpless, motionless, unconscious. Blood poured out of her. She was having a Class IV hemorrhage, and people rarely survive past Class III. The paramedics lifted up her hips and slid medical antishock trousers (MAST) over her legs. One of the paramedics then rapidly foot-pumped, inflating the trousers to keep her blood pressure from falling critically low. The MAST was invented during the Vietnam War to save gravely wounded soldiers as they were medevaced to field hospitals.

Paramedics are taught, “Keep calm. All bleeding stops eventually.” Yeah, even if the person bleeds out. After Andrea recovered, she recounted that as she was being rushed to the hospital, she floated up from the gurney, turned over and looked down at her pale, motionless body. And right then and there, she decided she wasn’t going to die. Even though she needed six or seven pints of blood to replace what she’d lost, she did survive that day—September 6, 1982, the day she gave birth to our son at home.

But this book tells the tale of an exponentially-more serious trip to the hospital – via emergency medical helicopter – after a high-speed bus struck her bike, knocking her to the ground, where she sustained a life-threatening, and life-changing, severe traumatic brain injury.  After watching her fight to get her life back both times, I chalk up her remarkable ability to survive, and eventually thrive, to Andrea’s ability to triumph over mortal adversity.  That quality  I call herseverance.

May 6, 2014

A Boat Not Taken

I looked down on the massive, white, ovoid candelabra, its hundreds of lights doubling crazily off the black nighttime waters of Seattle’s Elliot Bay. I was in a taxi, heading north on the Alaskan Way Viaduct, the ferry below me to my left, tethered in Slip 1 at Colman Dock. I wondered if I should take it. Even at ten p.m., the late spring twilight in the northern latitudes let me look into the future at its likely path—thirty-five minutes west to Bainbridge Island, where my love lay sleeping.

She was in the comfy upstairs bedroom of our home, in a Tempur-Pedic slumber under a puffy, brown down quilt. (May nights are not “spring” nights on Bainbridge Island, at least as far as Andrea defines the season). The house was surrounded by Douglas firs, Western red cedars, and the occasional Western hemlock—Andrea’s favorite tree. If she was still awake, (I dared not call her to see) she could have looked out the picture window, beyond the thousands of “Port Blakely toothpicks”—the hundred-foot tall, ramrod straight Doug firs—to the Rich Passage, which snakes around the southern end of the island. Perhaps, in the fading twilight of a late spring night, she could have even made out pink-hued Mt. Rainier in the distance. There was still time. I could have told the driver to divert, and I’d be on that ferry and in my sleep-happy wife’s arms by midnight. She wouldn’t be upset. In fact, she’d be overjoyed, even though she had to rise six hours later to minister to twenty-five largely indigent patients—most with serious comorbidities—at Peninsula Community Health Clinic in nearby Poulsbo. But that wasn’t the plan tonight. The plan was for me to sleep at our daughter Nadine’s house on Queen Anne Hill in Seattle, where I needed to go in the morning anyway. I was already in Seattle, so why go back to Bainbridge?

I went to Seattle every morning because I was an addict. I’d failed at convincing Andrea to find a different job in Seattle so we could move there to feed my addiction. Every day, I absolutely needed Emma and Hudson, my two adoring and adored grandchildren; but Andrea wasn’t going to give up her job in rural community medicine to move. And so, I’d worked it out that I went to Seattle every weekday. Once there, I’d prepare them a nutritious breakfast (fresh fruit, whole grains, protein) and bring Nadine a Grande. Then I’d take them to school, laughing at their innocent jibes all the way, and return with a smile on my face to Nadine’s, where I’d write in the little office behind her house. By three, I was back in the car. I’d pick them up from school, and was once again regaled for the twenty-minute drive home.  Back on Queen Anne Hill, it was sugar time. Would it be a Slurpee at 7-11 (generally a cocktail of Mountain Dew, Coke, 7-Up, and Dr. Pepper), frozen “yogurt” from Menchie’s, silky, hand-crafted ice cream from Molly Moon? Two out of three? Anything was possible from this grandfather. The grandfather who at sunrise—like the most dedicated commuter—rode his bike twenty-five minutes from home on Bainbridge Island to the ferry terminal, caught the 7:10 ferry across the Sound, then stowed his bike on the back of his car parked downtown, and drove to Queen Anne to buy the aforementioned Grande and prepare the aforementioned nutritious breakfast.

Once afternoon treats were consumed, I reversed the commute, traveling back to Bainbridge on the 5:30 with many of the same, now-bedraggled or supine commuters who looked so fresh that morning. By 6:30 I was pedaling up the 14-percent, three-hundred-foot grade to the top of Baker Hill Road. I was on the clock, as I had been all day. Hadda get home—pant, pant—and make a quick, nutritious dinner (fresh vegetables, whole grains, protein) for my beloved—pant, pant—who would return from the clinic by seven, exhausted but exhilarated. She’d be hungry, she’d be tired. She’d be in bed by ten because she had to get up by six the next morning for her own car-bike commute. Rinse and repeat. Rinse and repeat. Rinse and repeat. Rinse and repeat. Four days a week. She worked four ten-hour days (which were actually fourteens, but she didn’t care.)  She was dedicated and as happy and fulfilled as she’d ever been.

Four fourteens, or sixteens if that’s what her patients needed. Andrea Opalenik, a thirty- one-year old house cleaner with little more than a high school education when I met her, became a doctor at age fifty-five. Loved by her patients, respected by her coworkers, I’d adored her the past thirty-three years.

If I had taken that ferry the night of May 6, 2014, what happened on May 7, 2014, wouldn’t have happened. But I made the wrong decision. What’s that they say about trusting your gut? Never changing an answer on a standardized test? In fact, studies have shown that changing your answer in multiple-choice examinations generally helps your score. Yet the common belief persists that changing your answer drags your score down because you switch from the memorized or intuition-derived right answers to the wrong ones.

And what was my original choice? Stay in the cab and go to Nadine’s. But I had a doubt. I could have erased my choice of C (for cab) and marked F (for ferry). If I had, none of what follows would have happened. If, on the morning of May 7, Andrea and I had been together, she would have gotten up at a different time, showered at a different time, brushed her teeth at a different time, gargled with mouthwash at a different time, dressed at a different time, and headed out the door at a different time than she actually did. And, instead of driving toward her clinic in Poulsbo, she would have first driven me to the ferry terminal. (It was rainy that morning, and on rainy mornings, I don’t ride my bike to the ferry). We would have kissed good-bye at the ferry terminal and gone our separate ways. It’s a kiss that never happened.

I try to assuage my guilt by going back even further. It was Andrea’s choice to attend medical school. And her choice to work at this clinic, when I wanted her to work at nearby Virginia Mason Clinic, a ten-minute bike ride from home. So maybe I’m not guilty after all. Maybe Andrea has to take responsibility. But it was I who pushed for the move from Los Angeles in 1991. She never would have been sideswiped by that bus if we’d stayed in California. So it really is my fault, you see? But in the final analysis, ascribing blame changes nothing. What matters now is Andrea’s life. And it’s on the line.

It was on the line in 1982 as well, when she almost bled out after the birth of our son. But she, or something in her, chose not to die. She later told me she didn’t want me to have to raise our son alone. So why did the bike accident happen? Andrea believes everything is a matter of luck. So perhaps we should leave it at that. Bad luck put her in the path of that bus. Andrea has certainly had her share of good luck too. In 1982, when the LA Fire Department paramedics asked me where I wanted them to take Andrea to treat her life-threatening hemorrhage, I replied, “Beverly Hills Hospital.” Despite its name, Beverly Hills Hospital was not ranked as highly as world-class Cedars-Sinai. In fact, it no longer exists. But it was at the corner of Pico and Beverwil, only one mile away, while Cedars-Sinai was near the top of sluggish Robertson Boulevard, nearly twice as far away. There was literally no time to spare. As the ambulance sped west on Pico, I was in the back, cradling my fifteen-minute old son in my arms, looking down at my wife of sixteen months, whose life was slipping away. The OB at Beverly Hills Hospital simply reached in, removed her placenta, and sewed her up. After one night in the hospital and many units of blood, we were discharged.

Andrea’s primary care physician later chastised me for not instructing the paramedics to take her to Cedars-Sinai. Had I made that choice, would Andrea have received AIDS-infected blood in her transfusions there, as did Elizabeth Glaser who, like Andrea, was rushed to the hospital after birth complications? She, like Andrea, needed seven pints of blood to survive. Donor blood wasn’t being routinely tested for the AIDS virus at that time. And tragically, Elizabeth and her newborn daughter Ariel succumbed to the AIDS virus. I guess luck was on Andrea’s side this time.

So leaving aside guilt, luck, and blame, the facts remain and are not subject to conjecture: On the morning of May 7, 2014, Andrea got up alone, showered, brushed her teeth, gargled with mouthwash, dressed, and headed out the door. She drove north on Fletcher Bay Road from our house, instead of taking State Highway 305 from the ferry terminal. At about 6:10, she got to the Park and Ride across from the Suquamish Tribe’s gaudy Clearwater Casino, just beyond of the Agate Pass Bridge—the only land link between Bainbridge Island and the rest of the state. She parked our shiny, white, all-electric Ford Focus, put on her black-and-white P.O.C. bike helmet (purchased from R.E.I. and utilizing MIPS technology, the most protective money could buy), and lowered her bike from the sturdy Thule bike rack on the back of our car. She slipped on her bike shoes and gloves, attached her paniers, turned on her lights, mounted the bike, and rode up the Highway toward her destiny: permanent brain damage resulting from her head slamming against the pavement just twenty minutes later.

“Don’t blame yourself,” you protest, as you put a sympathetic arm around my trembling shoulder. “What if your going to Bainbridge Island the night of May 6 would have caused her to be killed by that bus the morning of May 7? You would have thrown off her schedule by critical seconds that could have cost Andrea her life.”

While your argument is irrefutable and your logic airtight, the fact remains that I did not go home the night of May 6. And on May 7, by 7:30 a.m., while I was washing raspberries for my grandchildren’s breakfast, my gravely-injured wife—unconscious, blood flowing out of her brain and filling her cranial cavity—was in a red and white Airlift Northwest EC-135 Eurocopter crossing the same Puget Sound I’d declined to eight hours earlier. She was bound for the helipad at Harborview Medical Center. As I placed their red, yellow, and orange gummy vitamins on their plates, here’s what was happening to my wife.

From the Harborview Medical Center report:

“Andrea Opalenik . . . was found to have a hyperacute right-sided subdural hematoma with evidence of brain herniation syndrome. She arrived intubated and unable to provide a history. She was intubated on the scene due to reported decreasing levels of mental status. She was noted en route to Harborview Medical Center to have decorticate posturing in her upper extremities. On arrival, she was quickly surveyed and found to have an occipital laceration, but no other obvious injuries. She was quickly rushed to the head CT scanner, where a 1.4 cm hyperacute right subdural hematoma was found with 1.4 cm of midline shift. While in CT her right pupil became fixed and dilated. She was then rushed to the OR for an emergent right craniectomy prior to completing trauma series. She was found to have a right side hyperacute subdural hematoma associated with frontal and temporal contusions with progressive cerebral herniation syndrome, had right frontotemporoparietal craniotomy (craniectomy) for evacuation of hyperacute subdural hematoma, debridement/hemostasis of superficial frontal and temporal cortical contusions and placement of left frontal intraparenchymal intracranial pressure and tissue oxygen tension monitors via twist drill.”

            In 2014, Andrea was one of the 1.7 million who sustained a TBI in the United States. Of those, 52,000 died; 275,000 (Andrea among them) were hospitalized; and 1.365 million were treated and released from an emergency department. The number of people with TBI who were not seen in an emergency department or who received no care is unknown.[i]  

What was Andrea thinking, experiencing at this time? No one knows. She doesn’t even remember getting up that morning and driving, then riding her bike to work, as she did every morning in spring and summer. Ahead for her that day—as on most days—were twenty-five or so appointments. Her adoring patients—most of them low-income, many of them uninsured—looked forward to their visits with “Dr. O,” whether they saw her for a chronic condition, an upper respiratory tract infection, or a well woman exam. To say Andrea was a rock star to her patients and her fellow providers would not be an overstatement. She’d become a doctor at age fifty-five, defying the odds, overcoming seeming insurmountable internal and external obstacles that would have derailed most of us who aspire to become self-actualized, but only end up dreaming about it.

What I know now, nearly three years after the accident, is that her haphazard brain injuries remind me of the damage a tornado does when it touches down here and there, utterly destroying some buildings while leaving others entirely intact. Andrea lost about a third of her right frontal lobe (the part of the brain that controls executive function) to a blood clot. But even more serious were her diffuse axonal injuries (DAI), which occurred when her skull bone stopped moving, but her brain didn’t—until it slammed into her stationary skull, that is. According to the website Brain and Spinal Cord, (an organization that provides resources and legal help for brain and spinal cord injury survivors), “Diffuse axonal injury isn’t the result of a blow to the head. Instead, it results from the brain moving back and forth in the skull as a result of acceleration or deceleration. . . .

“A diffuse axonal injury. . . causes brain cells to die . . . [and] swelling in the brain. This increased pressure in the brain can cause decreased blood flow . . . as well as additional injury.”

The results of Andrea’s DAI were manifoldly destructive. Loss of the use of the right side of her body. Inability to hold her head, swallow, or speak. Crushing fatigue. Urinary and fecal incontinence. Do you really want to hear more?

On the morning of May 7, 2014, at 6:30 a.m., Andrea pedaled northbound, up the slight grade on the generous shoulder of two-lane State Highway 305. Like a grey poncho, fog draped the tops of the innumerable firs and cedars bordering the road. After we moved from essentially barren Los Angeles in 1991 to the luxuriant Northwest, I often felt as though I was driving through a national park whenever I drove home.

In spite of the fog there was good visibility, and cars were moving at normal highway speed, about fifty miles per hour. Andrea was bound for the turnoff 1.6 miles ahead, onto scenic Lemolo Shores Drive, just a few deer bounds to the east of heavily-trafficked 305. Lemolo Shores Drive and its seamless extension, Fjord Drive, hug quiet, lake-like Liberty Bay, a cul-de-sac inlet of the Puget Sound whose shores are dotted with modest homes that are nestled among the evergreens. From the air, Liberty Bay resembles nothing so much as a drawing of a leaping Orca—fins, tail, and all. When you bike it, you’re sure you’ve never rolled down a lovelier lane. I often worried about her biking up 305 to get to Lemolo and suggested she drive to the turnoff (instead of to the Park and Ride), park her car somewhere near the intersection, and bike from there to work. No highway required. But she felt she wouldn’t be getting enough of a workout. “What about biking up and down some side roads off Lemolo to replace the lost highway mileage?” I suggested.

“Yes, I guess.”

But nothing ever came of it. Andrea was a hardcore biker for over thirty years, and that meant she rode a bike built for speed with no equipment that might add weight and slow her down. When she wanted to see if it was safe to change lanes or turn, she looked over her left shoulder to see if anything was behind her. And she never so much as got a hangnail riding thousands of miles.

But from the time she got me into biking to today, I’ve always been a bike-gadget freak. Helmet mirror? Check. Kickstand? Check. Lights? Blinding bright stroboscopic helmet light, handlebar light, and two flashing taillights mounted on my helmet and my seat post. Check. Turn indicator? Wait. Turn indicator? Yes, I found one and installed it on my bike—and used it. Not caring whether I’d be laughed off the road by the daring bikers in Seattle who blithely weave in and out of traffic, screaming indignantly at inattentive drivers, I installed and used it nonetheless. And in spite of all this equipment, I’ve gone over the handlebars twice, breaking the same wrist each time.

Andrea had agreed to my installing front and rear lights on her bike, and she used them. But as she approached her turnoff, happy the climb was nearly over and the noisome, noisy highway would soon be but a memory, the helmet mirror—which likely would have spotted the five-ton bus bearing down on her—sat in the junk drawer in our laundry room.

At the same time, I was just getting up in Nadine’s house in Seattle. I’d spent the night there, having come back late the previous night from San Francisco. I’d flown down to wish my nephew, Nathan, good luck with his upcoming surgery to remove a nonmalignant tumor from his brain. Andrea had cautioned him he’d end up looking a bit like Frankenstein’s monster after the surgery, and I think Nathan kind of enjoyed that mental image.

As I decoratively arranged the raspberries into smiley faces on my grandchildren’s plates, my cell phone rang. It was Peter Lucas—a family friend, psychiatrist, and a colleague of Andrea’s at work.

Peter asked me if I’d heard from Andrea. Starting to get a sinking feeling, I told him no. He said, “She’s not at work yet either. I don’t want to alarm you, but I’m at an accident scene on Highway 305, and there’s a white bicycle down on the side of the road.”

“Can you read me the name on the bike?” I managed to say, already knowing the worst, but unaware of how bad the worst actually was. After some negotiating with the State Patrol, Peter came back to tell me what I already knew. 

“Riedel,” Peter said. It was Andrea’s white, handmade bike, fashioned by Ian Riedel, who’d ridden with Andrea and hundreds of other tree huggers, for ten years in a row on the Save Mono Lake rides. The downed biker was my wife.

While the facts of the accident are in dispute, this is what seems to have happened: The driver of northbound, thirty-five-foot Gillig bus, operated by Kitsap Transit, was running late, deadheading back to Poulsbo, where it would stop to pick up another load of commuters bound for the Bainbridge Island Ferry to Seattle. As it rounded the long, slow downhill curve just south of the intersection of Highway 305 and Lemolo Shores Road, it picked up speed, and was doing 53 (in a 50-mile zone), just as Andrea was beginning to cross the highway, on what she believed was a clear path to Lemolo. The bus came up behind Andrea and passed her on the left, swerving quickly to avoid rear-ending her, sideswiping her. So how did her injuries occur? A paper produced by Australia’s Department of Transport and Main Roads, “Cycling and Heavy Vehicles” provides the answer. In the paper, the author states: “Sideswipe crashes can occur without initial collision between the truck [bus] and the bicycle. Instead, the incident can be due to the ‘blow and suck’ effect as the truck [bus] passes the bicycle rider.” [ii]

As the bus approached Andrea between forty and fifty-five miles per hour from behind and on the left, it first blew her to the right. Then as it passed, it sucked her into the side of the bus. A metal advertising frame on the right side of the bus struck Andrea’s helmet on the rear left with such force that it not only dented the helmet but created a five-inch laceration on her scalp. Then the bus dragged her along its full length, severely bruising the entire left side of her body before throwing her to the ground when it was done with her. Andrea’s helmeted head hit the pavement at approximately 6:30 a.m. By 7:30, the Paramedics had loaded her into the ambulance for transport to the helipad. But Andrea’s “golden hour” had already elapsed. Blood that is toxic to brain tissue was pouring into her brain from the subdural hematoma. Parts of her brain were dying. 

According to the Journal of Emergency Services website, “‘The ‘Golden Hour’ was first described by R Adams Cowley, MD, at the University of Maryland Medical Center in Baltimore. From his personal experiences and observations in post-World War II Europe, and then in Baltimore in the 1960s, Dr. Cowley recognized that the sooner trauma patients reached definitive care—particularly if they arrived within 60 minutes of being injured—the better their chance of survival.”[iii]

For Andrea, the golden hour was gone.  And things were rapidly moving from silver to bronze. The closest helipad was in Poulsbo—three minutes north at highway speed—maybe two since the ambulance was going against the grain of the southbound commuters. But the fog, which had covered only the tops of the trees an hour earlier, had by this time perversely descended to sea level. The helicopter could not land at Poulsbo. Bad luck. Instead it would meet the paramedics at the Bainbridge Island Fire Station’s helipad, normally fifteen minutes to the south. At this hour, it was more like twenty minutes, as the ambulance would have to navigate past hundreds of bumper-to-bumper commuters bound for the ferry. The fog cost her nearly twenty precious minutes, and an untold number of brain cells.

But Andrea was now at Harborview Medical Center, and I had to get to her. In shock, I left my daughter’s house without telling her where I was going. I was out the door and on the road. Nearing Harborview Medical Center, I got a call from an Emergency Department (ED) doc who wanted to inform me of Andrea’s condition. She asked me where I was. “Driving,” I told her. She suggested I pull over, but I told her I was now a block from the hospital. She told me they had to operate immediately to save Andrea’s life, and that I might be able to see her prior to surgery.

In the ED, I was ushered to the entrance of a curtained treatment cubicle filled with medical personnel—all business, hovering over a patient lying motionless, supine, on a gurney. Dr. Ali Ravanpay, a neurosurgeon, broke from the pack and came to me. After I identified myself, he told me they had to operate immediately to save her life. “When she was brought in, her right pupil was dilated. By the time she got back from the CT scan, it was blown.” He saw the puzzlement on my face. “The bleed on her brain is causing so much pressure, we have to cut through her skull to relieve it—or she won’t make it.” He guided me in to see her, just as the orderlies were releasing the brakes on the gurney and wheeling it away. I squeezed her hand, perhaps for the last time.

At some point amid this trauma maelstrom—probably on my way to the hospital—I managed to call Nadine and explain my disappearance, and to let her know what had happened. Nadine took the news very hard. Her emotions have always been as exposed a denim-clad hipster’s knees, but by the time I got to the surgery waiting room, she was there with her decorous husband, Jason. After very long, life-renewing hugs, it dawned on me that I hadn’t notified Cory, our son living in New York. I called him, explained what had happened to his mother. I then called an airline, arranged for his ticket, and called him back. He’d be home tonight. (Except he—blasted by the trauma like the rest of us—somehow missed his flight and came the next morning.)

I sat in the surgery waiting room, looking up at the coded display every few minutes to monitor Andrea’s progress.

“In Surgery.”

“In Surgery.”

“In Surgery.”

Would she ever get out of surgery? As I looked beyond the monitor, at my surroundings, I came to grips with the fact that I was, yet again, in a hospital as my wife fought for her life.

Finally, around 3 pm, after six hours of surgery, the display changed.

            “In Recovery.”

Chapter Two

The Never-Ending Night

Nadine, Cory and I staggered into Andrea’s room in the Intensive Care Unit on the 4th Floor of the Harborview Medical Center.  There was saw how dire was the situation.  Andrea was bald, with a Frankenstein scar running from behind her right ear, around the back of her head, running forward over her skull and then raking across her forehead and back over her ear, rejoining the original incision.    Even though a good portion of her skullbone had been removed, there was so much swelling from blood and edema, that her head was its normal shape.  (It was only after the blood and edema subsided that she would take on on a caved-in head appearance that would be truly scary.) 

There was a probe jutting out from the left side of her skull, inserted to monitor inner-cranial pressure.   She was on a respirator/feeding tube combination and an I.V.  Her arms were stiff and bent inward, her fists clenched and held tightly to her chest.  Her legs were stiff as well, her toes pointed.  This “decorticate” is a sign of severe damage to the nerve pathway between the brain and spinal cord. 

A constant flow of medical professionals monitored every conceivable system, in the hopes that they could keep Andrea alive.   How dire were things?  Dr. Holly Grace Novack, a diminutive, caring young anesthesia resident -- and far and away the most comforting of all the docs caring for Andrea (and her family) -- laid things out pretty clearly in her post-op report.

“63-year old otherwise healthy woman who was a helmeted bike rider involved in a collision against a bus. She was intubated at the scene and was posturing during transfer. At HMC she was found to have a R 1.4 mm-thick hyperacute SDH with frontal and temporal contusions with progressive herniation syndrome (pupils became fixed and dilated during CT scan). She was crushed in the OR for decompressive craniectomy. Subsequently her head CT showed blossoming of her contusions, but resolution of midline shift. Her PbO2 remains low in the 10s which in itself is a poor prognostic indicator. Her clinical exam also remains poor with extension posturing in all extremities and some trace of abnormal flexion in the LUE. Post-operatively she requires pressors and have mild metabolic acidosis both due to lactate production and hyperchloremia which are resulting most likely from neurogenic shock with some contribution from the resuscitation fluids. Spontaneous hyperventilation with
hypocapnia. In addition to the metabolic acidosis and compensatory respiratory Her labs are also notable for acute kidney insufficiency.
DIAGNOSES, ASSESSMENT AND PLAN:
The following conditions contribute to the high probability of acute, clinically significant deterioration.
-Severe TBI with hyperacute SDH, fronto-temporal contusions, compression of the brain
-Intracranial hypertension and brain tissue hypoxia
-Acute post-injury respiratory insufficiency
-Acute kidney insufficiency
-Metabolic acidosis, lactic and hyperchloremic
-Neurogenic shock
-Occipital condyle fracture
This is a very severely brain-injured woman who is undergoing intensive neuroresuscitation to prevent further secondary injury. The therapeutic goals follow the BTF guidelines as follow CPP>50, ICP <20-25, PaCO2 >35, normothermia, normonatremia, HOB elevation, correction of caogulation, maintain in Miami-J collar for the condyle fracture. Continue titration of norepinehrine for CPP goal, stop MIVF and start nutrition, intravascular volume status appears adequate. Adjust vent settings for PaCO2 goal and trend ETCO2 for further vent adjustments. PT/OT for posturing and range of motion. Start DVT prophylaxis with LMWH 24 hours postoperatively.”

About this time, Dr. Novack asked Nadine whether her mother had an advance directive.  Nadine told her that Andrea had a living will, that she would look for.  Until that time, the Attending said that “Ms. Opalenik was to receive aggressive therapy and is full code in agreement with family to allow sufficient time to evaluate for potential recovery. Goals of care might be re-addressed if otherwise directed based on patient stated wishes.
            It was all too much for Cory, who, it seemed, couldn’t bear to see his mother – the mother to whom he turned for advice (medical and otherwise) – now so helpless.  Who was going to help him?  He’d spend his time perched in the ample sill of an Art Deco window, down the hall from the ICU, and when he could handle seeing his mother in this horrible state, he’d come in, hold her hand and grimace.

            Nadine, on the other hand, moved swiftly into take charge mode.  Cory, fresh off the plane, was to move into her “shed” a home office in the back yard of her Queen Anne-Sears kit home from the 1900s.  And I was to occupy son Hudson’s tiny warren, in which he never slept anyway, preferring to cuddle with Dad Jason in the capacious king next door.  But I was nowhere near her home that terrible first night.

            That first night, I couldn’t be anyplace but in the corner of Andrea’s room in a brown vinyl “sleeper” chair.  I needed sleep.  I tried to sleep.  But the woman I’d slept next to nearly every night for the past 33 years was across the room – unavailable and unreachable in every sense of the word.  We were separated by a distance of no more than fifteen feet.  Two or three quick leaps and I’d be in bed with her, pulling her close.  But the distance between us was unbridgeable.  The distance is one of states of consciousness, the very states of being by which one differentiates life from death.  No matter what I did or what I said there was no way – so far as anyone knew -- she could feel my presence or hear me.   If she remained in this vegetative state, if it became persistent, then by our mutual prior agreement, I was to withdraw life support and let her slip away from me forever.  

But that wasn’t where I wanted to be that night.  I wanted to be there with her and somehow hold on to her.   I could do nothing for her, but that didn’t keep me from lying there, watching, wishing, wondering if she’d make it through that endless night.

Every few minutes, it seemed another provider came into the room to adjust, monitor, tweak or observe this very healthy woman who a few hours before had been riding her bike up a gentle grade, her heart pumping on its own at 90-100 beats per minute, whose respiration was increasing to oxygenate the blood that pumped through that heart, to get her up that hill. 

Now heart and breath were controlled mechanically.  Her hold on life was tenuous.  A thousand things could go wrong, and that night enough of them did to nearly end her life.

At around two a.m. as I was just starting to fall back asleep, an alarm jangled.  This was a new one, and it brought four or five nurses and doctors.  I sat up, got up.  What was wrong?  Her hematocrit had dipped dangerously low.  Hematocrit is the ratio of the volume of red blood cells to the total volume of blood.  A low hematocrit with low red blood cell count and low hemoglobin indicates anemia.  Andrea’s low hematocrit could have been brought on by her loss of blood, her severe trauma or both.  The only solution was to transfuse and a bag of blood suddenly and miraculously appeared on the “tree” next to her bed, and plugged into her central line.  The alarm stopped.  The medical staff monitored the blood flow, checked Andrea’s vitals and quietly left.  I slept, somewhat.  I was too worried to sleep.  My mother always said, “don’t worry, it might not happen.”  But it had happened. 

            The sun comes up early in the Northwest in early May, and by 5 a.m., the light from the east started reflecting off the buildings looking west and the Puget Sound.  

But the medical team had been on duty all night and by morning, this was the situation:

“On 5/8 she was started on tube feedings which she has tolerated well. She developed a metabolic acidosis secondary to normal saline with respiratory alkalosis. Pressors were weaned off by 5/9 and she was sedated with propofol to prevent overbreathing on the ventilator to achieve a PaCO2 of 35. She also received a unit of RBCs to maintain her PbrO2. She was started on 10mg of propanolol for storming on 5/11, which was increased to 20mg on 5/13. She was trialed on SBTand transitioned to pressure support on 5/11. MRI demonstrated DAI. Her neurological exam has been stable for brainstem reflexes and extensor posturing. On various occasions she has been witnessed to have what appeared to be voluntary movement of her left toe and left thumb. This has not been consistently reproducible on exam.

Trach and peg placement were discussed with the patient's family on numerous occasions to prevent VAP and allow for long term enteral access as she is unable to protect her airway and is unlikely to have any significant recovery. GOC discussion is ongoing, family understands poor prognosis and would like to allow chance for recovery without violating

patient's wishes to not have trach or peg. Discussed with family there is very minimal chance of significant neurological recovery, which would be on the scales of months or longer and in order to optimize change for significant improvement it would be necessary to move forward with trach/peg placement. Palliative care met with family 5/16 (see note for full

details). As of discussion 5/18, Richard feels that he will likely proceed with trach/peg placement to allow optimal conditions for significant neurological recovery over a period of months. He and his children continue to struggle with this decision and have requested to speak with a neurologist as well as the NICU and NS teams a during upcoming planned

family meeting.”

Chapter Three

My mind drifted back through the thirty-four years that we’d known each other and how hospitals served as mileposts along that journey—which had begun in Southern California in the late seventies.

"In his head, as he slumped and fell, were 50 billion neurons. They held the secrets of turning sugarcane sap into white crystals, they held the memories that made him smile at just such a joke, they held the cunning with which he sought out his lover's desires, they held the names of all the people who stood circled in silence....The dancing electrons in Amar's brain caressed forty-five years of words, pictures, feelings, the village imam with his old book, his mother calling him from the door of a mud-brick house. The memory of a slave ship or maybe more than one, the rumor of Saint-Domingue -- all this was there, was him -- but his cells were cascading into sudden death.”

The Half Has Never Been Told, Edward E. Baptist

“I’m Very Fond of You”

Andrea’s path to becoming a family practice physician was circuitous, to say the least. When I met her in the late seventies, she was a house cleaner with a forgettable, poorly-performed semester of college to her name. Her name was Krishan Kaur Khalsa, and mine was Baba Singh Khalsa. No, we weren’t married—yet. (It’s complicated. I’ll explain.) She had a daughter, Hari, about nine, by her then-husband Krishan Singh Khalsa. We Khalsas were all members of what I now will call an unintentional, intentional community (read: cult). We were followers of Yogi Bhajan, a wise, funny, charismatic sociopath who attracted, then preyed upon thousands of naïve, vulnerable, desperate young people like myself. He promised us a healthier, happier, holier life, then changed our appearance, our names, arranged our marriages, decided how and where our children would be educated, and how we’d make money—a piece of which he skimmed off.

Surprisingly, my life—which had been a disaster when I ran things—improved in every respect when I joined his Healthy, Happy, Holy Organization (3HO). The intense kundalini yoga and strict vegetarian diet helped me lose thirty pounds and get in the best physical and mental shape of my life. My hemorrhoids shrank. So did my depression. I could live with the former, but the later was eating me alive. I finally had the father figure I’d longed for, ever since my dad had walked out on us a dozen years before.

Six months prior I’d been a graduate teaching assistant at the University of Virginia, working on my master’s in Russian language and literature. Now I was broke, aimless, confused—living out the last days of my lease in my cheap Hollywood Boulevard apartment. Dabbling with a vegetarian diet, I’d lunch daily at The Source on the Strip, where I was increasingly drawn because of the blissful wait staff as much as the food. Spending the last money to my name there at lunch one day, I asked if I could get a job.

I wasn’t a spiritual seeker, like so many of my contemporaries in the late sixties. I was just broke. I was told the only way I could get a job at The Source was to start practicing kundalini yoga, as all the other employees did. Almost all of them were spiritual seekers—lost souls with nothing to fight for now that Vietnam was over and the Civil Rights Movement had settled down. All that was left from those two struggles were the perks of the protest movement: drugs and sex. And when those lost their newness and appeal and depression set in, we were the perfect marks for the wave of predatory prophets hitting our shores in numbers seemingly as plentiful as the GIs who poured out of LSTs at Omaha Beach.

Among those promising enlightenment were the Beatles’ and Beach Boys’ Maharishi, of course, and the Hare Krishna founder, A.C. Bhaktivedanta Prabhupada. Later there was Rajneesh, whose followers practically took over rural Oregon. But lesser-known leaders also amassed quite a following: Guru Maharaji, Da Free John, Iyengar, and Swamis Satchidananada, Muktananda, and Vishnudevananda. The last three were the “Huey, Dewey, and Louie” of gurus—all followers of the pioneer Vivekananda, who first “colonized” our shores early in the twentieth century.

Then there were the darker dudes: Jim Jones, Charles Manson. And of course, my very own daddy-guru Yogi Bhajan—FKA Harbhajan Singh Puri, and a former customs agent at Palam International Airport in New Delhi, who’d rolled his study of yoga, Hinduism, and Sikhism up into a brand-new thing, The Healthy, Happy, Holy Organization (3HO). While early adherents were the ladies-who-do-yoga crowd, he soon attracted the patchoulied and cannabis-scented detritus of the now-deactivated social movements of the sixties.

The tall, bearded turban-topped Sikh Yogi Bhajan seemed like he had all the answers. I’d been looking for a father figure since the day my sixty-one-year-old father left us when I was ten and moved to an apartment across Houston’s Brays Bayou. And even though my inspired attempt to lure Dad home a week later on lamb chop night (his favorite) failed, I still had hope. But that was dashed soon after he moved to Beaumont and married a twenty-one-year old with a five-year-old daughter.

Science teachers, psychologists I knew . . . wouldn’t any of them come home and be my new daddy? No, they wouldn’t. Later, there were inspiring professors at college. Father figure material? Not really. Too self-absorbed and often more fucked up than I. But at age twenty-two, when I was as vulnerable, desperate, and alone as I’d ever been, I met Yogi Bhajan, and I felt I’d found my new daddy—even though I was pretty sure he was a charlatan. He spoke in an almost Victorian oratorical style, similar to that of London-born Hyman Judah Schachtel, my first rabbi at Houston’s Beth Israel. But his Punjabi accent only let through every other word.

Five years later, I was Baba Singh Khalsa, a slightly shorter carbon copy of the man himself, right down to the calf-hugging white churidars. Not only had me made me a yogi; he had converted me to the Sikh religion. I was a lean, mean, yoga-teaching machine, driving all over LA and Orange County to teach up to twenty-five classes a week to such diverse students as Peter Sellers (no doubt forced to go by Britt Eklund) and lifers at Terminal Island Federal Penitentiary. Fortunately, gas was twenty-nine cents a gallon back then, and my little European model Karmann Ghia (the better-looking Ghia, by far) sipped the stuff. I even got a class added to UCLA’s undergraduate curriculum in Yoga Philosophy, for which students received three quarter hours’ credit toward graduation. But that was canceled after one quarter when students complained Yogi Bhajan was proselytizing.

But I could not hear–or rather, listen to—any criticism of “The Yogi.” In spite of the fact I was always mortified when he came up with one of his seemingly endless supply of wacky “spiritual” positions. When a caller to Carol Hemingway’s Sunday night KABC radio show, Religion on the Line, called in to ask guest Yogi Bhajan if he was really Professor Irwin Corey (the comic promulgator of reasonable-sounding nonsense), I wanted to crawl into a hole. But then I remembered how miserable I’d been before I met the Yogi, and decided that I was better off with him than without.

Why, you may ask, would a bright, college-educated, middle-class man join a cult? Didn’t I see what I was getting involved in? Dr. Adrian Furnham provides the answer in his Psychology Today article “Why Do People Join Cults?”

“What do all groups (cult and non-cult) offer a potential recruit? Answer: friendship, identity, respect and security. . . . But they offer more. . . . They provide clear answers to difficult and big questions: what it all means; the secret of happiness; life after death; the difference between right and wrong, who is with us and who against us; the saved and the damned.” [iv]

My family couldn’t understand why I’d accepted this way of life so completely, right down to changing my name and appearance. As my mother put it so well: “You never wore a yarmulke, so why wear a turban?” Yes, I faced some discrimination, but I was used to that, as a Jew growing up in Houston in the fifties and sixties. And wearing a beard and turban in the seventies and early eighties had none of the post-Ayatollah or post-9/11 associations that have spawned hate crimes against those devout Sikhs mistaken for radical Muslims.

On the whole, life was good. I’d started to earn some money. I was driving a new baby-blue Olds 88 and was head of LA’s Guru Arjan Dev Ashram, where I was responsible for twenty or so of the Yogi’s followers who were crammed into a suburban four-bedroom house. My vegetarian food-writing career had taken off, with articles in the New York Times, Los Angeles Times, and Food and Wine Magazine. Wolfgang Puck left instructions with his staff to always give me a table “on the windows,” looking out on the restless sea of LA lights at his original Sunset Strip Spago—where we’d sit next to luminaries like Rob Lowe, Johnny Carson, Phyllis Diller, and the like. Wolfgang and then-wife Barbara Lazarov even came over to Guru Arjan Dev Ashram for lunch one day. Over an Indian vegetarian feast, all went along swimmingly until the pistachio kulfi dessert course. Yogi Bhajan—his spies everywhere—showed up unannounced and quickly pissed off Wolfgang by fanning the flames of his marital dispute with Barbara, painting him as the villain. Wolf didn’t speak to me again for months and even changed his mind about writing the preface to my first book (published by Chronicle Books). But then M.F.K. Fisher agreed to step in. So maybe I have the Yogi to thank for that.

I actually have a lot to thank the Yogi for, not least of which is my attitude that any adversity (most of it originally supplied by him) can be overcome. And I met my wife through him. Actually, my wives.

After five years of devotion and celibacy, you could say I was ready to get married. You can transmute only so much semen by the yoga practice known as mul bandh, (kind of a Kegel maneuver) which purports to “pump” the baby batter up the spine, through the chakras, and to the top of the skull, bringing “enlightenment.” Funny thing is, the practice actually seemed to work for me. I experienced within myself, repeatedly, what I believe to be universal understanding. (All well and good during meditation, but try to act universal when some jerk cuts you off in traffic.) Still, now I knew what was out there, or in there, underpinning everything. And though it was nearly impossible for me act in a manner consistent with that experience, it comforted me and saw me through some very challenging times. And occasionally, even under the direst stress, I was able to see that only by nonattachment to the results of my efforts could I find contentment. It was that connection to the universal that I’d need if I was going to make it through what happened to Andrea thirty-plus years later. I just didn’t know it at the time.

I mentioned wives, didn’t I? My first wife, Das, met the Yogi at a yoga intensive in Toronto, in 1974. A free-spirited hippie, looking to be not-so-free, Das thought it was a pretty good idea to agree to marry “his best student” at the Yogi’s behest. So she flew to Los Angeles and we, total strangers, were married as soon as the blood test, license, and ring could be procured.

Seven miserable years later, the Yogi reluctantly agreed to let us have the divorce we badly needed. The marriage had been a disaster—chiefly because I insisted that Das follow every fanatic teaching to the letter. But the teachings were all I had. They’d saved me, rescued me from the train wreck of a life I was living. You didn’t waver from the teachings, even if they were (as one of his students savagely and sagely observed) “made up as the Yogi went along.” So we divorced, as Das charitably and correctly put it, “because we couldn’t live up to each other’s expectations.”

During this denouement, the Yogi bizarrely sent a man named Krishan Singh Khalsa and his wife, Krishan Kaur Khalsa (fka Andrea Opalenik), and their nine-year old daughter, Hari, (who would later change her name to Nadine) to live at Guru Arjan Dev Ashram for “marital counseling.” But serial philanderer Krishan Singh already had one Birkenstock out the door, and it wasn’t long before Krishan Kaur was a single mom.

I don’t remember the first time I’d met Krishan Kaur a year earlier, but she remembers it well. And from that day forward, she had a teensy little crush on me. I’d accompanied Yogi Bhajan from our “world headquarters” in LA to the satellite yoga ashram in Pomona, where Krishan Kaur and Krishan Singh resided with Hari. The move into the ashram had a protective effect on Krishan Kaur. Her husband could no longer blacken her eyes or knock her unconscious with his vicious right hook. They’d moved in because they were broke, ironically mirroring my own decision to start practicing yoga (to fulfill the only hiring prerequisite at The Source).

Now, after nearly eleven years of physical and verbal abuse, her brutal (“I’ll break you in two, you fucking cunt”) husband had finally moved out, hauling his few possessions away in the beat-up blue Honda Civic her parents had given her. In the dead of night, I retrieved the car. That act of gallantry would become a habit, and that’s what ultimately won her heart.

With Krishan Singh gone from her life, Krishan Kaur no longer needed her IUD. The removal procedure was to take place at Cedars-Sinai Hospital, and she was told to have someone drive her. Who better than the guy who’d retrieved her stolen car, the guy who’d given her a foot massage late one night by the fireplace, the guy who gave her money so she could pay for her daughter’s needs?

I drove her there in the baby-blue Olds, and we sat as far apart as a nun and priest might, at the far extremes of the long, front bench seat. I escorted her to the clinic and waited while the MA roomed her. A short time later, the same woman rolled her out in a wheelchair and we helped Krishan back into the Olds.

She was a little pale, a little woozy, and lovely as a faded rose petal. We drove back to the ashram and pulled into the driveway. I asked her how she felt. With great courage, she reached over and took my hand, looked me in the eyes and said, “You know, I’m very fond of you.” Six months later we were married.

***

I looked back up at the display.

“In Surgery.”

Perhaps to escape from the gravity of the moment, perhaps to go back to a time when a trip to the hospital ER turned out all right, I recalled the home birth of our son, Hari Manat (now Cory), on September 6, 1982. It had started out so beautifully. When it was her time, I sat on the futon on the floor of our room at the ashram, my back against the concrete wall. I spread my legs and drew my knees up, making room for Andrea to sit in the little birthing cave thus created. When it was time, she, too, drew her knees up, dug her heels in, and pushed against me with the greatest force ever exerted on me, prior to that time or since. She drove me back into the cinderblock wall with such focused exertion that I literally couldn’t breathe. And then, as our son’s head crowned, she relaxed. I caught my breath, and as I looked over her shoulder at our son emerging from her, she pushed once more. “Pull your baby out,” encouraged the midwife. And out he came.

Her doctor had warned her against having a home birth, since she’d had complications during the birth of Nadine in 1972 in a hospital. But no one tells Andrea what to do, and the OB relented, only because the midwife Andrea chose was also an RN, skilled at starting IVs should the need arise.

And moments after Hari Manat was born, the need arose. The placenta stubbornly refused to follow him out of the birth canal, and Andrea started hemorrhaging. Fifteen minutes later, we were in the back of the ambulance on the way to Beverly Hills Hospital.