Patients And Their Families Face New, Altered Lives

Chicago Tribune

(KRT)

CHICAGO - There was a story he loved to hear. Sometimes it was the only way to settle him down, telling that story. When Jim Kane was so agitated that he looked as if he might vibrate right out of his wheelchair, his wife would tell him the story.

Jill Kane had told it almost every day of his six-week stay at the Rehabilitation Institute of Chicago. She told him the story again on his final day, as Jim, like research into brain injury medicine itself, headed down an uncharted road.

"Do you remember, Jim, when you worked at the racetrack?" she said. "You were 18 years old, and your job was to take care of two horses. Mr. Brown and Scotch Run. You'd walk them around and around, and Mr. Brown - do you remember this, Jim? Mr. Brown loved Snickers bars." She laughed. "A horse who loved Snickers bars! Isn't that funny, Jim? And you took care of them."

He nodded and listened, his big shoulders settling back in his wheelchair. Whatever else was going on in his brain - a brain catastrophically injured June 23, when his Honda Gold Wing motorcycle crashed into a concrete barricade along Interstate 290 - there was still a part of him that loved this memory, this picture of horses and sunshine and blue sky at Arlington Park Racetrack.

Was he remembering, or just remembering the memory of the memory? And did he know he'd heard the story dozens of times before?

Jill wasn't sure. Neither were the physicians and therapists on the 10th floor of RIC, site of the Brain Injury Medicine and Rehabilitation Unit, a renowned and innovative center for people who have suffered brain traumas.

So much is still unknown about brain injury. So many mysteries. Although brain injury is the No. 1 cause of death and disability for people under 44, striking at least 1.5 million Americans annually, research into injured brains is still unfolding. The brain remains a locked vault in many ways, especially when crushed by terrible wounds.

At places such as RIC, physicians such as Dr. Ricardo G. Senno, the unit's medical director, are learning from the plight of Jim Kane and others like him. Scientists are edging toward a more complete understanding of consciousness and unconsciousness, of the brain's ability to reconstitute itself after injury, of the crucial role the brain's chemical and electrical connections play in emotion and personality.

Dr. Mark Hallett, chief of medical neurology at the National Institutes of Health in Bethesda, Md., said, "Certainly the basic idea used to be that the brain was very complicated. It was hard to put it together and once together, it couldn't be re-wired or reorganized."

Yet research into the rehabilitation of people with brain injury, including stroke - the blockage or rupture of arteries in the brain - has revolutionized scientists' ideas about the brain. "The amount of information pouring in is just enormous," Hallett said. "The notion of creating new neurons by implanting them is actively being investigated. But even more promising in the short term is plasticity" - the brain's ability to repair itself after injury by creating new strategies to handle familiar functions such as walking, talking, swallowing and remembering.

Kane, 48, sat in his wheelchair in Room 1046. Behind him, his wife was getting ready for their departure from RIC, opening cabinets one by one, checking for his belongings.

Jill, 45, had driven here every day from their Rolling Meadows, Ill., home to watch his physical, speech and occupational therapies. Like most of the patients in the 20-room unit, Jim had come here after about two months in an acute-care hospital, where he was medically stabilized after his skull fracture and massive bleeding deep in his brain.

He had made progress. While he was still loud and unruly in many therapy sessions, Jim could now do what he couldn't do when he first arrived: He could stand up and walk. It required two physical therapists to assist him, but he could do it.

Just the day before, he had lurched and wobbled 120 feet down the hall, all the while screaming, "Stop! Stop! I can't do it! Jesus, Mary and Joseph, stop-I can't do this!"

The average stay at RIC is 26 days. Barely a month, during which time people with brain injury had to relearn, in many cases, how to walk, swallow, dress and groom themselves, and grapple with memory loss. How to deal with family members and friends after an injury that may have irrevocably changed their personalities, the very center of their souls.

The people who had come to the 10th floor at roughly the same time as Kane-Sarah Conrad, 24; Nick , 52; John Sanders, 28; and Patrick Welch, 18 - already had concluded their stays here. They were already home, traveling to outpatient rehabilitation centers at least three days a week to continue their work.

Conrad, a high school English teacher, had been hit broadside by another car while she and her husband, Pete, drove to her grandmother's house for a Mother's Day celebration. Contri, a heating and air conditioning technician, tumbled off a ladder as he climbed down from a roof. Sanders, who sold building products, was thrown off his motorcycle during a late-night ride in downtown Chicago. And Welch, a recent high school graduate, was struck by lightning as he stepped out of a college summer-school class in Oglesby, Ill.

Different people. Different tragedies. But the same challenge: to somehow re-inhabit themselves.

Not to be the people they had been - that was impossible - but to become the people they would be next. People with brain injuries were "reborn," according to Dr. Ghada Ahmed, attending physician on the 10th floor. When you saw what happened here, the slowly momentous transformations, a renaissance by inches, her observation did not seem at all hyperbolic.

Two weeks before Jim Kane left RIC, Patrick Welch faced his last day. His parents, Tim and Lori Welch, would drive him back to their home in Streator, Ill., some 77 miles southwest of Chicago. While he was here, Patrick had learned how to sit up, how to walk, how to hold a knife and fork - all things he couldn't do anymore after the lightning bolt tore through his body, stopping his heart and canceling the oxygen supply to his brain for critical minutes.

The week before he left, Patrick, accompanied by occupational therapist Marc Fischer, had found his way from RIC to the Niketown store on Michigan Avenue, then to the post office and back to the hospital. He presented his mother with 200 stamps he had purchased.

It didn't sound like much - a smattering of city blocks, a few left and right turns, a sheet of stamps - but for Patrick, it was remarkable.

Now, though, Patrick's stay here was over. Like more than 80 percent of RIC's patients, he was going home, rather than to another facility, and would keep up with his therapies at an outpatient rehabilitation center.

Patrick's 22-year-old sister, Lana, had driven up from Streator that morning to help her parents pack. They had to take down the get-well cards that blanketed a wall of his room. And they had to pull down the homemade banners, crafted out of construction-paper letters of red and blue and green: THE LORD IS MY STRENGTH AND MY SHIELD and COMMIT YOUR WAY TO THE LORD. They also had to keep an eye on Patrick, because he was up and down and all over the place, restless and fidgety, his wide eyes blinking rapidly.

"Where am I?" he asked his mother, Lori, a question he asked every day, all day long.

"Where do you think you are?"

"I don't know."

"It starts with an `R,'

" Lori said, as she folded and stacked a freshly laundered batch of Patrick's T-shirts.

"R," he said.

"Ree - ,"

"Ree - ," he repeated.

"Rehab."

"Rehab."

`Rehabilitation Institute of Chicago," she said.

Patrick repeated it, although some of the syllables seemed to get stuck in his mouth. It was a lot for him to say, all in one phrase.

At the small round table in a corner of the room, his father, Tim, was looking over a sheet of paper. Tim, a control systems technician for Com Ed, was an organized, methodical man. The paper was one of his ways of dealing with the problem, the problem of keeping Patrick safe in a world that might not understand him. Tim planned to offer copies to friends, family members and anybody else who met Patrick.

The sheet was divided into two columns: One was headed "Deficits" and the other, "How You Can Help." On the line "Short-term memory," Tim had typed, "Answer questions in simple form, i.e., yes and no." For "Walks into the street without looking," he suggested, "Needs supervision."

The family, finished with the packing, began taking loads down to the car, always leaving at least one person with Patrick. Then there was a final walk down the hall to say goodbye to therapists in the therapy gym.

This was the place where Patrick had spent so many hours bending and stretching and finding his balance again, and many hours, too, working with speech therapists on tasks such as reading and understanding pictures and remembering sets of words or numbers just a few minutes after he heard them.

His mother knew these halls, too. Lori had walked through them with Patrick night after night, when her son couldn't sleep. Up and down they would go, then up and down again. One night while they were walking, Patrick had turned to her and said, "I died, didn't I?"

"No, Patrick. You didn't die."

"I died," he insisted.

"No."

"I'm dead."

And he would say it again sometimes, would suddenly announce that he had died. His mother would patiently talk him out of it.

The car was packed and ready, the RIC staff had signed the required paperwork and then, with every detail presumably concluded, every loose end tied, just as the Welches reached the glass double-doors that led to the elevators, Patrick shuffled away.

Mystified, his parents and sister followed him down the hall. He stopped in Room 1046, where Jim Kane sat impassively in his wheelchair.

Patrick leaned over and stuck out his hand. "Good luck."

"Good luck," Kane replied.

"I'll pray for you," Patrick said.

The day after Patrick left, it was Nick Contri's turn.

Nick was restless. He had been ready for hours this morning, but these things take time. His wife, Susan, had paperwork to fill out before he was officially discharged. There always seemed to be more paperwork. Always.

Susan and Nick's daughter, Chris, had gathered his things in Room 1050 and piled them up in his wheelchair. Nick didn't want to use the wheelchair; he'd be walking out of RIC.

Nick was going back to the house in Griffith, Ind., that he shared with Susan. From there, he would be taken each weekday for outpatient therapy at CRS Rehabilitation Specialists in Munster, Ind. A few days earlier, as she was visiting the facility to arrange for Nick's sessions, Susan thought there was something familiar about the address.

She checked. Sure enough: The CRS building at 9200 Calumet Ave. was the building from which Nick had fallen June 18, landing on a concrete parking lot 25 feel below, which caused bleeding deep in his brain.

After emergency surgery, a drug-induced coma and six weeks of therapy at RIC, Nick could seem to be lucid for several minutes-and then he'd do or say something that revealed just how far he was from who he had been. How far he still had to go to get home-home to himself, that is.

Like the day he bit Kara Kozub, his speech therapist. She was asking him questions, gesturing, and Nick grabbed her hand and bit it. Kozub, following hospital rules, had to get a hepatitis shot.

Nick still had trouble finding the right words for what he was trying to say. In about a third of brain-injury cases, people exhibit what is called aphasia, caused by damage to specific areas of the brain that handle language formation and recognition.

So he would need round-the-clock monitoring. Susan, who worked full time as an office assistant in downtown Chicago, had already started interviewing candidates for various shifts.

How far Nick would progress, what he'd be able to do, was a mystery. All Susan knew was that she'd loved her life, the life they had, and now - well, who knew?

The RIC staff helped, Susan thought, by being tough. By not letting her hope get out of hand. Dinh To, one of two social workers on the unit, listened to her talk one day about how thoughtful and kind Nick was, about what a wonderful husband and partner he was, about how he'd go out and pick up a last-minute item for dinner if she forgot it at the store. And did so happily, cheerfully.

Dinh To looked at Susan and said firmly, "It will never be the way it was. Never."

That kind of cruelty, she knew, was a kindness.

John Sanders had made his mother cry. He didn't do it on purpose, Elizabeth Katehos knew; he was just talking. Talking in that whispery way he talked now, so softly that she had to lean in close to hear him. A few sentences a day. That was all.

"How did you handle my death?" he asked her.

The question caused Elizabeth to weep most of the night. He hadn't died, he had lived, and even with severe brain injury, even with his silences and all the things he couldn't do anymore, even with what seemed to be an odd new personality, he was alive. He was her son and he was alive.

Elizabeth and John's fiancee, Cathy, had both returned to work, so they couldn't stay all day with him anymore. They came evenings and weekends, and if they asked John where he thought he was, he would say, "In prison." That was a good sign; his restlessness and agitation, the fact that he didn't want to be in the hospital anymore, meant he was coming back, they believed.

Before the accident, John Sanders had just about everything a young man could want. A lucrative job selling building supplies; two young children, John and Shay, from a previous relationship; and Cathy. They'd met through mutual friends, although she fought hard against falling in love with him. He was such a smart-aleck. Such a kidder.

Somehow, though, everything came together - his kids, her 8-year-old daughter from a previous marriage, a house they had picked out in Wildwood, Ill. Her only qualm was his motorcycle riding. She had tried it once with him and hated it, absolutely loathed the danger and the speed. It was his passion. But it was her nightmare.

Now everything was on hold. The house, the marriage, everything. Their lives were reduced to Room 1008. John was supposed to go home in three days - Saturday, Oct. 4 - and "home" meant home to Grayslake with his mother and her husband, Alex, where there was space for the things he'd need and proximity to a good outpatient rehabilitation center.

His speech therapy that morning had not gone well. "He's just shut down," Elizabeth warned occupational therapist Fischer, who had just arrived in John's room for a session.

Fischer, a rangy, amiable man whose calmness in turn seemed to keep patients on an even keel, pulled up a chair next to John's bed. "What's wrong, John? Not feeling good today?"

No reply.

Fischer said, "John, we better get you up, OK? A guy your age shouldn't be in bed like this." To Elizabeth, Fischer said, "This is going to happen at home, too." Meaning John might withdraw from them for no apparent reason, turning inward.

Elizabeth stood in front of her son, voice stern. "Listen to me, John. We've got to get better." He shook his head no. She said, "Yes. Yes, you do. I'm not going to let you give up. I'm not."

It wasn't a straight line. You wanted it to be, but it wasn't. Recovery from brain injury was slow and tedious and highly idiosyncratic. No one's injury was the same as anyone else's, and no one's rehabilitation was the same, either.

A straight line would've been nice. Just give me clear goals, standards to meet, and I'll do it, Sarah Conrad told her doctors in the short, halting sentences she was able to manage. But brain injury wasn't like that. It wasn't like getting ready for softball season, where, as she explained to the young women she coached at Oswego High School, if you worked hard enough, that you'd get where you wanted to be. If you pushed yourself, you'd succeed.

Brain injury almost seemed like the opposite. No one on the 10th floor worked harder than Sarah, no one had a better attitude or a higher pain threshold, but setbacks multiplied.

Her first departure date from RIC, Sept. 11, had to be postponed when physicians discovered a buildup of scar tissue from the surgery after her accident, which was obstructing her intestine. Sarah underwent another surgery at Northwestern Memorial Hospital, returning to RIC Oct. 5.

Her mother, Kathy Tabor, was there every day, especially after Pete had to go back to work at Hinsdale South High School, where he was a teaching assistant. Sarah worried that she'd have to start all over again at RIC, beginning therapies as if she'd never had them before, but no: Sarah was able to pick up close to where she had left off. Her mother wasn't surprised. That, she said, was Sarah: Give her a task, show her the mark, and she'd hit it.

Sarah would finally leave RIC Oct. 18. A week later, she was admitted to Loyola Hospital for surgery to implant a shunt in her brain to drain excess fluid.

Then at long last, she was back with Pete in their Plainfield, Ill., home. On Oct. 27, she began daily excursions to an outpatient rehab center.

All he had wanted, Pete said, was to be able to hold his wife again at night. Just that. A simple thing. To sleep beside her and then to wake up that way in the morning.

That's all Pete asked for-yet it took more than five months. Five months from the day they got in the car and headed for Sarah's grandmother's house. Five months between leaving the house that Sunday afternoon and coming home again.

There had been a slight detour.

Because physicians didn't believe there was much hope for the rehabilitation of people such as Kane or Sanders or Conrad, traditionally they spent little time and few resources on the problem, said Dr. Michael Pietrzak, executive director of the International Brain Injury Association. "But now," he declared, "the science is moving forward very fast."

Pietrzak sat in the lobby of a Stockholm hotel in late May, where he was attending. He was in the Swedish capital to attend the IBIA's fifth biennial meeting, a gathering of physicians, therapists, academics and researchers from 30 countries.

Amid the pastel edifices and cobblestone streets of this city by the sea, researchers at the four-day conference presented the latest findings in brain injury medicine and rehabilitation. Between formal sessions, many participants alluded to a new optimism in the air, a sense that science soon may have more to offer people with brain injury.

The conference was one of the major places where the long-term futures of Welch and Contri were being decided, where the ultimate fates of Kane and other people with brain injury hung in the balance. Researchers from places such as RIC came together to compare findings, to share insights and techniques, to test theories.

What happened here, that is, some 4,000 miles away from Contri's home in Griffith, Ind., might one day directly affect the life of the man with the gray mustache and the quietly bemused expression.

"At some point," Pietrzak said, "we'll be able to regenerate neurons (in humans). Not in two or three years - more like two or three decades. But that's within our lifetime. And that would have been laughable 10 or 15 years ago."

Researchers have known for more than a century how to transplant the healthy fetal brain tissue of animals such as rats into damaged areas of the brain. In the process known as neurogenesis, fetal tissue is grafted onto the damaged area and the new neurons effectively take over the functions of the non-functioning areas.

Dr. Claudio Perino, an Italian physician and president of the IBIA, believes that neurogenesis will be the next great leap forward in repairing the brain after injury. He acknowledged, though, that the use of stem cells currently is problematic in the United States, because of federally mandated restrictions arising from thorny ethical and religious questions. Stem cells are harvested from fetal tissue; that fact thrusts the process into the center of the abortion debate. And even if those issues are resolved, the knowledge required to transplant brain tissue in humans with brain injury still is years away.

The caution is understandable. Fetal tissue grafts have been employed in several countries, including the United States, with patients suffering from Parkinson's disease, but the results have been troubling. In 2001, an experiment to implant stem cells into the brains of people with Parkinson's was abruptly suspended when some 15 percent of the recipients displayed uncontrollable twitches and spasms. The lesson, researchers say, is that more experiments are needed with brain tissue transplantation with animals - and that treating brain injury in humans remains astonishingly complex.

Because the brain, after all, is astonishingly complex.

In the meantime, plasticity - which Hallett, an NIH stroke researcher, defined as "the brain's continuous adaptation to its environment" - is the new buzzword in neuroscience, one heard over and over again at the Stockholm conference. Hallett, who was also at the IBIA meeting to present his research findings, said, "Plasticity can help in the repair process," Hallett said. "If you learn to do something new or different or even learn a new fact, it means something in your brain has changed."

For many years, he added, scientists believed that after early childhood, the brain was basically finished with its development. "Once put together, it couldn't be rewired or reorganized." Or adapt to changes such as injury. Now, however, "We're trying to apply the basic mechanisms of plasticity to people who have had strokes."

If Kane could no longer pull a T-shirt over his head, if Welch couldn't kick a soccer ball because the parts of the brain normally devoted to those tasks weren't responding, plasticity meant that another part of their brains would pick up the slack. The brain was a creative problem-solver. "Very likely, all parts of the brain are plastic, some parts more than others," Hallett said. "Every part is capable of undergoing change. There are many different cellular mechanisms of change."

Another promising new frontier, many researchers said, was pharmacology - the use of drugs both to lessen brain injury in the trauma phase and to enhance rehabilitation. Physicians already knew that drugs such as Ritalin could help brain-injury patients focus better during their therapies. And anti-depressants such as Effexor and others seemed to reduce some forms of neuropathic pain.

Senno, who also attended the conference in Sweden, finds the possibility of replacing damaged brain cells with new ones exciting. But even if it were routinely applied in humans, neurogenesis would not put an RIC out of business. A new neuron would not hold the memories that existed in the person before her or his injury. The patient's family still would have to learn to deal with a new person with a new brain.

Senno's own hopes for the future of brain injury medicine rest in the development of brain injury markers. He is collaborating with physicians at Northwestern Memorial Hospital to pinpoint specific chemical and electrical changes in an injured brain, just as physicians now can identify enzymes that indicate a heart attack. Misdiagnosis and underdiagnosis are notorious problems with mild brain injury, he noted.

"Mild brain injury is hard to diagnose and easy to treat, while severe brain injury is easy to diagnose and hard to treat," Senno said.

Brain injury markers would not only identify people whose brain injury previously went undiagnosed - the existence of certain chemical changes would indicate a brain injury had occurred - but also enable therapists to tailor the rehabilitation to the type of brain injury, making it more efficient.

"We'll be able to capture a ton of people (with brain injury) who aren't being captured. We'll be able to say, `This is the injury and this is what's going to happen,'" Senno said.

He also longs for the day when medical school administrators and physicians in other fields will pay more heed to brain injury, a development bound to come, Senno believes, as advances in brain injury medicine continue at their swift pace.

Yet the distance between the "Eureka!" moments in research studies and the bleak reality of patients' lives remains vast, concedes Donald G. Stein, neurology professor at the Emory University School of Medicine and co-author of "Brain Repair" (1997). "The stuff (neuroscience) is often so esoteric that the rehab people can't figure out how to translate it into something to help patients. I detect (among neuroscientists) a certain devaluation of work that has direct clinical application. It's like, `Well, that's not pure and basic science.'"

People with brain injury are helping neuroscience, that is, but thus far neuroscience is not returning the favor as much as it should.

"A lot of the problem," Stein said, "is that everybody wants to learn the latest imaging method. The technology is so captivating that people get hooked on that and forget what question they're asking. Often there's not the slightest concern for anything that might have benefit for the patient.

"I'm the only person at Emory studying TBI (traumatic brain injury) and trying to fix it. And we're a major medical center."

Allan Bergman, too, struck a note of caution about advances in brain science, trumpeted in recent cover stories in Scientific American and Forbes.

While trauma surgeons have made impressive gains in saving the lives of severely brain-injured people such as Kane and Conrad, once the patient leaves the ER, "They fall off a cliff," said Bergman, president and chief executive officer of the Brain Injury Association of America, a non-profit advocacy group based in McLean, Va.

"Why," he added, "are we working so hard and spending so much money on saving people who used to die if we're not going to follow up?"

Rehabilitation from brain injury, Bergman believes, just doesn't grab public attention the way trauma medicine does. It isn't exciting. It isn't compelling. There are no sirens, no physicians racing through the halls yelling, "Stat!"

There is, instead, a painstaking and repetitious process of incremental change. There is, from people such as Kane and Contri, Welch and Sanders and Conrad, and the therapists who work with them, a quiet daily heroism.

The biggest shift in attitudes toward recovery from brain injury may be in the expectations. Previously, experts believed that people such as Sanders and Kane generally made gains for only about a year after injury. Then, allegedly, they reached a plateau. Now, however, researchers have demonstrated that people can continue to make gains for as long as five years post-injury and maybe longer.

But before those gains can occur, the brain injury must be diagnosed. David Mulholland, among others, believes that undiagnosed brain injury has disastrous consequences. Mulholland, an administrator at Landmark College in Putney, Vt., who attended the Stockholm conference, studied a group of college students with ADD (attention deficit disorder). Almost 20 percent of them, he reported, said they had suffered untreated brain injuries as children.

Other studies, he noted, claim that more than 80 percent of violent felons may have suffered undiagnosed brain injuries in their youth. A study in Seville, Spain, earlier this year identified a link between criminal behavior among juveniles and undiagnosed brain injuries. In 1988, a report by a psychiatrist at the New York University School of Medicine found that of 14 death row inmates - all of whom had committed their crimes as juveniles - all had suffered significant brain injuries in childhood for which they were never treated.

Mulholland, whose brain was injured in a car accident a decade ago, said his condition was only recently diagnosed. "Everybody was telling me I was OK, so I thought I was OK. If you're having memory loss, you don't remember that you're having memory loss."

For those with more severe, life-threatening brain injuries, this is a historic moment, said Mark Sherry.

Sherry, who suffered a severe traumatic brain injury in 1992 in his native Australia when he was struck by a hit-and-run driver, declared, "We are the first generation of people with brain injuries to have this experience and live," since new emergency-room techniques mean that more people now survive serious brain trauma.

After his injury, Sherry earned a PhD at the University of Queensland and now holds a postdoctoral fellowship at the University of Illinois at Chicago, where he writes and teaches in the relatively new field of disability studies.

Asked what living with a brain injury feels like, Sherry hesitated. "A mixture of profound confusion, emotional pain and isolation," he finally said. "But we're here and we belong in the community."

Of the four others who had come to the 10th floor at roughly the same time as Jim Kane, he was the only one who wasn't going home. Ahmed and the rest of the RIC staff had decided that he needed more therapy, but not at the intense level provided by RIC. The plan was for him to stay at a skilled nursing facility, Alden Poplar Creek Rehabilitation & Health Care Center in Hoffman Estates, Ill., for several weeks and then go home with Jill.

As it turned out, Jim would remain there until Dec. 4, when he finally returned to their house in Rolling Meadows.

On the morning of Oct. 15, Jim's last day at RIC, Jill packed his extra T-shirts and sweat pants, his medications and get-well cards and all the rest of it.

She was weary and frightened and sometimes just plain mad: Why, she asked herself, had God saved her husband if he was going to be a depressed, ranting man stuck in a wheelchair? Why would God do that?

She wanted her old life back. She wanted to be fixing dinner in the kitchen while Jim fussed and puttered in the garage. She knew his recovery would be slow - she had no false hopes - but sometimes, she was just sick of it all.

She was afraid, at bottom, of drowning in bitterness and frustration. Of having lost the companionship of her life partner and gaining, in its place, a lifetime of anxiety about the angry stranger who looked a lot like her husband, Jim Kane.

Earlier that morning, Jill had told Jim they were leaving RIC. Because he seemed restless, she told him the story about the horses again, and then she and Warren Owens, a staff member, helped him into his wheelchair. The driver of the private ambulance, who would take Jim to the next facility, had just arrived.

In the driveway in front of RIC, the driver pushed Jim's wheelchair onto the small platform attached to the van, pressed a button, and the platform slowly rose. The driver slid Jim and his wheelchair into the van and secured it. Jim stared straight ahead.

Jill, who believed the RIC staff had done everything they could for her husband, climbed into the passenger seat. She would miss this place, miss its energy and optimism. Jim, she knew, wouldn't miss it because he wouldn't remember it.

The driver started the engine. The van rolled forward, then turned right onto Superior Street.

Jill waved back at the RIC building.

Jim didn't. He stared straight ahead; there was no telling what he was thinking about or if he was thinking about anything at all.

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ABOUT THIS SERIES

To report this story, Tribune reporter Julia Keller spent three months observing and interviewing patients and staff in the Brain Injury Medicine Unit at the Rehabilitation Institute of Chicago, and interviewed physicians and neuroscientists from around the world.

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(c) 2004, Chicago Tribune. Distributed by Knight Ridder/Tribune News Service.