Introduction
The first thing I tell her is that I cannot help. Her son Jake is thirty-four, my age. His gray, bruise-flecked limbs are splayed out on a bed before me; his mouth is dry and agape. I know I cannot help him. I cannot file a lawsuit against the insurance company, I cannot conjure a way out of this dead-end nursing home, and I cannot sucker punch the aloof neurologist or throttle the ignorant psychiatrist. I hold no sway over the waiting list in my own hospital. I explain to her that I can do nothing at all, and she sighs. She is desperate to see Jake in a program where there is a sense of progress and direction. She knows that the rehabs and specialty hospitals are as inaccessible as the moon. She has called them herself, and she knows that nobody can help. She knows I cannot help, but she asks me anyway. She asks, in all earnestness, to do the impossible and find her son a bed, and in my weakness, I agree. It's my job to agree.
Jake turns his head toward me and I suspect he can hear me. If he can respond, no matter how minimally, then he meets the most important criteria. He closes and opens his mouth arbitrarily, but not a sound comes out. I ask him to lift his head and I wait. Nothing. His mother is quiet and nearly in tears. I ask her to turn off the fluorescent lights and shut the door, and when she does Jake exhales faintly. It sounds like relief, like the hint of a response. I ask Jake once more to lift his head. A good fifteen seconds later, his head slowly raises an inch off the pillow, and then drops back down. That's criteria enough for me. His mother grins at me proudly, as though her son just won a marathon. In a sense, he has.
The next two hours find me thumbing through a thick notebook of Jake's medical records, trying to decipher the scribbled progress notes and lab reports, then interviewing nurses and aides and doctors. I spend the last half hour of my evaluation explaining to Jake's mother that this will take months at a minimum, but most likely a year or two—if anything happens at all. She will be my best resource through all of this, I tell her, as I hand her a list of administrators to call and a few forms to fill out. She tells me she will do this and anything else I ask, but she doesn't need to say a word. If she's been through this much already, paperwork and phone calls aren't going to stop her.
Before I leave, she asks for my business card, not because she doesn't already have my number, but because she wants to know my title, she wants to know what kind of person drops everything to go to look at a bedridden man four hundred miles away. I hand her my card and tell her I am a brain injury case manager, and there is the hint of a smirk because we both know that brain injuries cannot be managed any more than a thunderstorm can be managed. They can be endured, accepted, and integrated, but not managed. She clasps her hands around mine, and I say goodbye, and I get back in my car. I am forever back in my car. I turn the ignition and hope for home, so I can lie down next to my wife and rest my hand on the warm crest below her navel.
The hope is false; a singular voice mail from my director asks me if I can drive two hours north to Sioux Falls to assess a woman with brain damage due to a viral infection. Either I drive the two hours today, or I drive back home to Tulsa and drive ten hours up to South Dakota on Monday. I head north and can already hear the disappointment in Christy's voice. When I call her from a filling station outside of Omaha, she doesn't answer and I leave her a message. My marriage unfolds in messages.
On my way up to Sioux Falls, I think about Jake still lying there in the nursing home, and how he has been lying there throughout the past year while I was buying a house and mowing the lawn and attending parties and traveling. He has been lying there long enough for his wife to have given up hope and file for divorce, and he hasn't seen his son in months. Jake is trapped in an awful sense of nowhere, and yet he is still present, still responding, still human. I may not be able to help, but I can act. I can act for Jake, which, right now, is more than he can do for himself.
I don't look for cases; the cases find me. They catch me in airport terminals and waiting rooms, they crowd my inbox and voice mail. A single phone call can send me to Wyoming one day and Indiana the next. During a tough week, I might wind up in a dozen different cities. When I first started traveling, I would forget what city I was in when I woke up, so I would leave a phone book by the nightstand to orient me in the morning. I still forget the city I'm in, but now I leave the phone book in the drawer. The city comes to me sooner or later. Where I am at doesn't matter so much; it's the catastrophe that sets me in motion.
Medicine reserves the term catastrophic for a handful of conditions, and the term fits. Spinal cord injuries sever and parse a person's ability to move and control their limbs and basic body functions. Amputations disintegrate any hope of feeling and sensation. Full-body burns inflict a fierce pain only pharmaceutical amnesiacs can forgive. But chief among the catastrophic conditions is the traumatic brain injury, commonly called TBI. It is an upheaval of physical, psychological, social, and spiritual proportions.
The wry eighteenth-century haikuist Issa wrote, "In this world / We walk on the roof of hell / Gazing at the flowers." Those familiar with brain injury are familiar with Issa, if not by name, then in sentiment. Spend an hour in a room with someone who struggles to maintain eye contact with you and whose limbs are flailing as a result of a simple fall from a ladder, and soon enough a sense of your own vulnerability finds your legs less steady, your mouth a little dry, and your hand slow and cautious. Traumatic brain injury strikes with the concussive ferocity of a bomb; woe to those near its epicenter.
A tap on the head, and anything can go wrong. Anything usually does go wrong. You may not remember how to swallow. Or you may look at food and perspire instead of salivate and salivate when you hear your favorite song. You may not know your name, or you may think you're someone different every hour. Everyone you know and will ever know could become a stranger, including the face in the mirror. When you tell someone you're sad, you may shriek; your entire vocabulary may consist only of groans or hiccups. A brain injury can shatter your notions of the future, splinter your past, and send your sense of time whirling in any number of directions. And that's just the beginning.
A brain injury is never an isolated incident; it affects nearly everything associated with the survivor. It can collapse a family and flatten a business, evaporate friendships and allegiances, overburden a community, and buckle a state's healthcare system. Thanks to antiquated legislation and massive cutbacks, few states are capable of providing even the most minimal level of specialized care for brain injury patients, forcing most survivors to find treatment hundreds of miles from home, if they can find it at all.
Brain injury is a quiet crisis; the numbers are almost too large to make sense. As many as 5.3 million Americans are living with a permanent disability resulting from a brain injury, a full 2 percent of the population. The Centers for Disease Control and Prevention reports that 1.4 million Americans sustain a brain injury each year, and that fifty thousand people die from that injury. Almost a quarter-million people are hospitalized; the remaining number are treated and released from the emergency room. Some of the released go home comforted, only to discover that they no longer have a sense of smell or taste, or that their sleeping habits have changed, or that they can't seem to do their job anymore. There are more undiscovered head injuries in this world than are dreamt of in our medical journals. Only now are we beginning to understand something about the number of known brain injuries.
Reframed, the numbers nauseate. In America alone, so many people become permanently disabled from a brain injury that each decade they could fill a city the size of Detroit. Seven of these cities are filled already. A third of their citizens are under fourteen years of age. Currently, there are at least ninety thousand Americans with a brain injury so severe that it requires an extended stay in a post-acute brain injury rehab, but there are only a few thousand specialty beds, and upwards of 90 percent of them are already occupied. The severely brain injured are not getting the treatment they need—they're getting mistreated through neglect, misplacement, and isolation.
Numbers, however, are not lying in hospital beds, nor are they languishing in mental health asylums and prisons. A brain injury has a way of exposing humanity at its most vulnerable, fragile, and determined. Because the brain is composed of a million billion synaptic connections, each injury to the brain is as unique and complex as the life it affects. No matter how much detail a person's medical records indicate about their injury, the record is only a shadow, a small hint, at the human behind the injury. In the leveling world of TBIs, soccer moms grow heroic as soldiers, drug addicts transcend to the holy, the holy lose hope, and great egos give way.
The sequence of events goes something like this: the brain gets damaged, and two months later, the million-dollar insurance policy is depleted and the patient is shuffled out the door with a shrug of shoulders. A course of treatment that should have lasted years is cut short before it even starts. Bereft, the family starts mining libraries and websites and social service agencies for anything and anyone who can make sense, who can act. Meanwhile, the TBI survivor gets bumped from nursing home to psychiatric ward to emergency room to homeless shelter to group home and elsewhere. They subsist in a medical purgatory. For all their determination and perseverance, the caretakers and the patient wind up shortchanged with me. I show up as embarrassed as a fireman late for a fire.
Case managers number in the tens of thousands, brain injury case managers number in the tens of dozens. According to the Case Management Society of America, case management is a "collaborative process of assessment, planning, facilitation and advocacy," but the definition is genteel. Case managers are troublemakers and vigilantes. I became a brain injury case manager through a series of career miscalculations; I had accrued an uneven set of skills that included writing and mental health work, and found myself a misfit in most clinical settings. The job not only required a familiarity with medical facilities, but also demanded an exacting level of observation, one that could be translated into a comprehensive evaluation of a complex injury and eventually used as a powerful advocacy tool. My ears remain mine, but my voice belongs to the patient.
Of all the medically challenged injuries, traumatic brain injuries require the most involvement and cost over time. A hospital finance director in Boston once told me that he had never met a family that was financially prepared for the cost of a brain injury. It takes, on average, four million dollars over the course of a lifetime to treat a TBI. One person may require two medical caretakers around the clock, indefinitely. Another may benefit from a simple standard treatment lasting three months. But at a cost averaging a thousand dollars a day, most people can hardly endure the financial burden of one week's worth of rehabilitation, much less a stay that should last months or years.
. . .
The goal is to get a survivor unstuck, to move them from a stagnant setting into a life of greater independence. If the severity of their injury warrants it, their best chances for recovery lie in brain injury rehabilitation, a specialized form of care usually available only to the affluent or the tenacious. My job is to assess a person's needs, explore their available resources, and create a means for them to obtain the resource. The biggest obstacle I face is that there are usually no resources and no means available. Sometimes the only choice I have left is to pick a fight. A proper, legal, diplomatic fight, but a fight nevertheless.
After an initial contact—usually a phone call—I accumulate medical records and I review the case for validity. If a person doesn't have a documented brain injury, then the first step is to get it documented, usually through the help of lab reports and a neuropsychologist. Once the extent of the injury is measured, I review the records in detail, trying to enter the person's life as intimately as possible. Through further conversations with their family members or social worker, the rent images of the injured person collect and intensify in my mind. Within the course of days, I become an involved companion, though the survivor may not even know I exist. Once I feel familiar enough with the case, I start in with the phone calls to facility directors, admission coordinators, doctors, state officials, and attorneys.
The phone calls turn into e-mails, the e-mails into faxes, the faxes into plane tickets and gas pumps. The cycle from initial call to in-person evaluation can take two years or two hours, and still the evaluation is only a preliminary step. It occurs, mainly, to reconcile the survivor with their paperwork. I see for myself whether the person seeks help or has succumbed to hopelessness. I find out if their guardian or caretaker wants them better, or just wants them gone. Most important, I am there to listen. Much of what I am told in confidence never appears in a medical chart.
Over the years, I've found myself moving in the background of certain stories that challenge the very assumptions we make about being human. By going deeper into the aftermath of brain injury, we eventually reach an earnest sense of awe about the brain and its mysteries. The survivor's life emerges as an ongoing pull between the changes that occur within an altered brain and the outward repercussions that follow. It is this tension between being and becoming that begs the intimate, soulful questions posed by every brain injury. What are we other than our brains? Is there a part of me that can't be changed by a brain injury?
My boss, a veteran of the brain injury rehabilitation industry, warned me that most of the people I meet won't be able to find help. Even though it is one of the few brain injury rehabs within hundreds of miles, Brookhaven Hospital has only nineteen rehab beds. Waiting lists are the standard in every brain injury program. If I can't get a patient into Brookhaven, I'm determined to get them somewhere. Somewhere, in my experience, is better than the nowhere they inhabit.
Because of the bureaucratic tangles and the inconsistency of insurance companies, my schedule is a peculiar mix of the arbitrary and urgent. I know that six months from now I will probably be in Dubuque, Iowa, but I don't know if tomorrow morning I will have breakfast at home or next to a truck driver in San Antonio. My schedule is urgent because brain injuries are a matter of life and death. On occasion, the worst happens, and the patient dies before we ever have a chance to meet. Cases close silently, and new ones arrive in their place.
Excerpted from Head Cases by Michael Paul Mason. Copyright © 2008 by Michael Paul Mason. Published in April 2008 by Farrar, Straus and Giroux, LLC. All rights reserved.
