Never Give Up Hope

Memories are notorious for fading with time. However, some that are attached to intense emotions remain fresh even after the passage of decades, as if they happened yesterday. One such memory is from my early days of neurosurgery training in India.

I had finished my general surgery training and was selected to join the neurosurgery program. It was a new field for me. I was excited at the prospect of joining this extremely fascinating specialty, but at the same time, I was aware of the tremendous responsibility I was taking on. This would require me to make quick decisions that could determine the life or death of a patient.

My hospital was one of the three main municipal hospitals in Mumbai. It was famous for spine surgery, not only in Mumbai but across India. The outpatient clinic overflowed with patients, and the wards often had twice, or sometimes three times, the number of patients as there were beds. Patients would come from far-off places, traveling from the interiors of India, often bringing their entire families to Mumbai and to our hospital for spine surgery treatment. No one in need of admission was ever refused. It was not unusual to have three beds in a cubicle with three more patients sleeping on the floor.

Along with the patients came their families—husbands, wives, young children, parents, or siblings. Entering a cubicle felt like stepping into a small community, with patients and their relatives all talking to one another. It was like one big family, helping and supporting each other through tough times. By the time patients were ready for discharge, I often knew each member of their family on a personal level. I had had similar experiences during my general surgery training, so this was not unusual for me in neurosurgery.

We had a five-bed neurosurgery special cubicle for patients who required more intense monitoring and management. These patients were more unstable or had just undergone major brain or spine surgery. Family members were not allowed to sit with patients in this cubicle.

As a junior trainee just a few months into the program, I had recently been given the privilege of answering emergency calls and performing emergency surgeries independently. This was my third on-call emergency duty, a 24-hour shift. My senior registrar and I had finished a few cases in the neurosurgery elective operating theatre earlier that day and had just started the 8 p.m. evening rounds in the neurosurgery ward.

The staff in charge of the ward greeted us, and we were in the third cubicle when we received a call from the emergency ward to review a young adult who had sustained a severe head injury. I excused myself from the rounds to attend to this emergency patient.

The emergency ward was located at the entrance of the hospital, diametrically opposite to where the neurosurgery ward was situated. I started walking briskly toward it, slightly anxious to learn more about the patient. I visualized in my mind the scenarios I might encounter in the emergency ward. I expected to see a severely traumatized patient with significant external facial and cranial (head) injuries. I imagined myself surrounded by very anxious relatives, engaging in animated discussions with me and demanding immediate intervention to save their loved one.

Though it took only a few minutes to reach the ward, my mind had already played through countless scenarios.

Surprisingly, the ward was quiet. There were 12 beds in the emergency ward. The doctors on duty had finished their rounds and were seated in the doctors’ corner at the far left end of the ward, where they could monitor all the patients. I could hear the rhythmic sound of ventilators (machines used to provide artificial breathing for unconscious patients). A nurse was performing suction on a tracheostomized patient (a patient with an opening in the neck to the windpipe to allow breathing and ventilation) on my right side.

Seeing me enter, one of the emergency ward doctors walked toward me from the doctors' corner and said, “Thanks for coming, Anant,” before briefing me on the newly admitted patient.

“Unknown male, fell backward from a moving bus at 6 p.m. He hit the back of his head on the pavement. He has been unconscious since. He was brought in by the police and arrived around 6:30 p.m. He was GCS 3 (Glasgow Coma Scale, a parameter to monitor the level of consciousness, with GCS 15 being normal and GCS 3 the worst level of consciousness) when we evaluated him.”

I followed the doctor to a bed on the left side, near the doctors' sitting area.

“His breathing was very shallow, so he was intubated (a breathing tube inserted through the mouth or nose to assist breathing) on arrival,” he continued. Then he looked at me and added, “His pupils are dilated and fixed” (this indicates brainstem dysfunction, which can occur due to brain swelling and pressure on the brainstem, or primary damage to the brainstem. The brainstem, located at the back of the head, is vital for maintaining consciousness and essential body functions. Significant brainstem damage is not compatible with life).

“We’ve done a CT scan, which doesn’t show any bleed or midline shift in the brain. The CT scan of his body hasn’t shown any other injuries or fractures either. I think he has severe brain damage, possibly brain death. We’ll be doing brainstem testing soon to confirm brain death. I’m not sure if there’s anything you can do for him. Let me know if you agree.” I nodded, and he left me alone to examine the patient.

I saw this young man lying in front of me. He must have been in his mid-20s, not much different from my age at the time. There were no visible injuries to his face or head. His eyes were shut. He was clean-shaven, and his disheveled hair suggested he’d had a recent haircut. Apart from the tube inserted into his mouth and taped to the right side of his face, he looked as if he were sleeping.

I looked at the monitor in front of me. It showed a heart rate between 40 to 50 beats per minute. His blood pressure was stable. I could hear the ventilator pumping air in and out of his lungs. He was dressed in a hospital gown, and the lower half of his body was covered with a thin brown blanket. He had intravenous lines in his left arm, with fluids slowly dripping into his veins.

I examined him and found that his pupils were dilated, but his doll’s eye movements were not absent (indicating some brainstem function). The CT scan did not show any bleed or midline shift (which would indicate a mass lesion on one side causing a shift of the brain to the opposite side, potentially requiring urgent surgery). However, it did show a very tight brain with early transtentorial herniation. This occurs when the brain sustains a generalized injury and swells. Since it cannot expand outward due to the skull, it begins descending onto the brainstem region, causing pressure and potentially damaging vital bodily functions.

I thought to myself, He is not brain dead… he is on the brink, but not brain dead.

I immediately called my senior lecturer, who was on call from home.

“Hello,” came a sleepy voice on the other end.

“Sorry to disturb you,” I said apologetically. “I need to discuss a case with you, sir. He may have to go to the theatre,” I blurted out. “He’s young,” I added quickly. “There’s transtentorial herniation. I think we should do a bifrontal decompressive craniectomy to reduce intracranial pressure. We may save him.”

He agreed with my plan.

I had assisted in several of these operations and performed a few with the senior registrar scrubbed in alongside me. However, I had never done one independently. I called my senior registrar, who had finished the ward rounds by then, to assist me. I asked the emergency ward to administer another dose of mannitol (to reduce intracranial pressure and buy us some time) as I urgently moved the patient to the operating theatre.

I performed my first independent craniectomy (a procedure in which part of the skull is removed, and the covering over the brain is opened. This releases pressure on the brain and may stop the herniation onto the brainstem). My senior registrar kindly placed the bone flap under the skin in the patient’s abdomen (this keeps the bone alive so it can be reimplanted into the skull defect at a later date when the brain swelling has subsided).

It was 2 a.m. when we finally left the theatre. We hadn’t eaten anything since morning, but this was not unusual. By then, the hospital mess was closed. The only place to get anything to quench our hunger was the ice cream freezer at the 24-hour pharmacy outside the hospital. It had become routine to finish our emergencies at this hour. When we tapped on the closed grilled window of the pharmacy, the shopkeeper would appear with sleepy eyes, hand us the keys to the freezer through the grill, and go back to sleep.

The ice cream freezer stood outside the pharmacy with a small lock. We picked out the ice creams we wanted, sat on the shop’s steps, and ate while looking at the deserted roads and pavements in front of us, with the hospital looming in the background. We made small talk. These quiet moments, accompanied by the treat of the delicious ice cream I loved so much, were something I always looked forward to during such on-call shifts.

Tonight, however, I couldn’t help but think about the young man. Who was he? Did he have family? Did they know he was fighting for his life? Would he survive? If he did, what deficits would he have?

Over the next three days, he remained in the intensive care unit on the ventilator. His pupils began to react, and he started taking spontaneous breaths between those given by the ventilator—signs of very early recovery. The site of the brain surgery remained swollen and full.

By the seventh post-op day, he was weaned off the ventilator and could breathe on his own. However, he remained at GCS 3. There was no response to painful stimuli, no eye-opening.

I saw him regularly as part of my daily tasks. He was one of the few severely head-injured patients in our wards, though he was the youngest among them. Ten days later, he was transferred from the ICU to the special cubicle in the neurosurgery ward. He required feeding through a nasogastric tube (a tube inserted through the nose into the stomach for feeding or aspirating stomach contents). He received regular chest and limb physiotherapy, and his skin was carefully managed. His craniectomy site was now sunken at the front of his skull, and the brain’s pulsations were visible through the skin, indicating that the brain swelling was subsiding.

Around two weeks later, during ward rounds, I noticed his eyes opening spontaneously. By then, he had been moved to the general neurosurgery ward. His gaze was vacant, and he did not respond to commands or painful stimuli. He looked frail, having lost significant weight. He hadn’t been large to begin with, but now his bones protruded, and his cheeks were sunken.

Everyone else in his cubicle had families. He was the only one lying alone, with no one by his side. At times, he would be turned onto his side to help his skin breathe, and he would stare vacantly at the wall. He hadn’t made significant progress in the weeks that followed.

Four weeks later, during my morning ward rounds, I entered his cubicle and was astonished to see a woman sitting next to him. She was holding his hand and speaking to him in Gujarati.

She was young, probably in her late 20s or early 30s, with sharp features. She was dressed elegantly in trousers and a smart half-sleeved shirt. Her short hair was tied in a ponytail. Sitting on a chair with her legs crossed, she looked at me. Her eyes were slightly red, as if she had been crying or hadn’t slept much. She immediately stood, stepped forward, extended her hand, and said, “Good morning, doctor. I am Neena, Ajay’s sister.”

It was the first time I realized the “unknown male” was Ajay Mehta (names changed).

I asked her more about Ajay. She said they belonged to a business family in Gujarat. He had completed his engineering degree and had come to Mumbai to pursue a management course. She was his elder sister, a lawyer in Gujarat. Their father had died during their teenage years, and their mother had continued the family’s wholesale clothing business, raising them with all the luxuries she could provide.

Neena had no interest in the family business and had pursued law, but Ajay had shown a keen interest in continuing it. Ambitious and driven, he wanted to complete an MBA to expand their enterprise.

Her brother called every day, or, on rare occasions, every couple of days if he was busy. When she hadn’t heard from him in ten days, she became worried. This was unusual. She contacted his management college and learned that he hadn’t attended classes for many days.

Fearing the worst, she left everything and rushed to Mumbai to look for him. She visited his residence, but no one there knew him well enough to help. With his photograph in hand, she went to every police station and hospital she could think of. She had come to my hospital twice, but it was only on her second visit that she was directed to the neurosurgery ward, where she finally found him.

Seeing him in this state shocked her, but at the same time, she was relieved he was alive. As she narrated her story, her eyes filled with tears.

It was my turn to tell her about Ajay—how he had presented, what surgery had been done, and that part of his skull was now in the abdominal wall, to be replaced in a month or so. She listened intently, nodding at times to encourage me to continue. When I finished, she asked, "Will Ajay recover to how he was?"

This was a difficult question to answer. He had suffered a severe head injury, to the point where brain death had been considered. Yet there was hope in her eyes.

"Only time will tell," I said. "Youth is on his side, and young brains are resilient and recover much better. We will do everything to support him in achieving his optimal recovery."

Over the next couple of months, Ajay received intensive supportive therapy to stimulate his brain. However, he did not show any improvement in his level of consciousness. His vacant stare persisted. He did not respond to commands or show any sign of recognizing his sister. His craniectomy site was now sunken, indicating that his brain was no longer under high pressure.

Neena never left his bedside during those two months. She continuously spoke to him, held his hand, and gently stroked it. She helped the staff clean him, feed him, and change his clothes. She would leave his side only to freshen up or rest briefly. Sometimes, I would see a small idol of a deity placed near his head or flowers—likely blessings from a temple—kept near him. Despite the difficult times, she continued to smile. She was always polite and supportive to other patients and their families in the cubicle. She distributed flowers or sweets as blessings from God to staff and families alike.

The time came to replace the bone flap from Ajay’s abdomen back into the bony defect created during the craniectomy. This would restore the shape of his skull and protect the brain from further injury. We sought Neena’s consent, as she was his next of kin. Her usual smiling face was visibly tense. She knew the procedure was an essential step toward Ajay’s recovery but was also aware of the associated risks. She had been determined from the beginning to find her brother and make him better—she didn’t want to lose him again.

She had countless questions, which I answered patiently. I also explained the option of not proceeding with the surgery and the potential consequences. After an initial period of uncertainty, she was convinced that the bone flap replacement was the right course of action.

The surgery went uneventfully. Ajay’s head regained its normal shape, as it was before the decompressive surgery. Over the next four weeks, he continued to receive vigorous physiotherapy and other supportive treatments. By now, he had been in the hospital for over four months without showing significant improvement. His vacant stare remained. He did not respond to verbal commands, could not speak, and showed a complete lack of awareness of his surroundings. We began to think he might be heading toward a persistent vegetative state—a condition where a person is awake but unconscious, with no awareness. This suggested extensive and potentially irreversible brain damage.

I was away for a couple of weeks. When I returned to work and began my ward rounds, I was surprised to find someone else in Ajay’s bed.

"Neena took Ajay back home to Gujarat," said the nurse accompanying me. "She felt that familiar home surroundings might help his recovery. His mother also wanted him back home."

They had arranged for all the necessary supportive treatments in Gujarat, similar to what was being done in Mumbai. I felt it was the right decision. Ajay had been part of the ward for almost six months. Though he had been unaware of his surroundings, his presence provided a sense of constancy in the ever-changing landscape of admissions and discharges. It took me a couple of days to adjust to his absence.

One and a half years later, I was a senior resident. As I began my ward rounds with my team, I noticed a familiar figure near the nursing station. At first, I couldn’t place her. Then she walked up to me, extended her hand, and said, "Good morning, doctor. I’m Neena, Ajay Mehta’s sister. Do you remember me?"

I was thrilled to see her. Memories of Ajay had begun to fade, as happens with time. I smiled and said, "Of course, Neena! It’s so nice to see you. How is Ajay doing?" I wasn’t prepared for what I was about to hear—the kind of news every doctor hopes for.

"He’s doing very well," she said, looking straight at me with a smile. "A couple of months after we went home, he started recognizing me and Mum. Soon after, he began saying words and sitting up. But in the last six months, he’s made remarkable progress. He’s almost back to normal. He doesn’t remember this hospital and has sketchy memories of his management college days."

As I listened, my eyes filled with tears. I cannot describe the feeling of intense satisfaction and happiness that overwhelmed me. I could almost hear the emergency doctor’s voice in my mind: "I think he has severe brain damage, with possible brain death. We’ll do brainstem testing to confirm..."

I wanted to hug Neena with joy but instead said, "I’m so delighted to hear that, Neena. I hope he can come to visit us someday."

Many decisions in medicine are guided by statistics—whether it’s appropriate to operate on a severely head-injured patient who might end up in a vegetative state, potentially burdening their family and society. This is a valid and justified argument. Yet I can’t help but wonder: how many Ajays might we lose in the process?