James Brady is going home.
After eight months of operations, fevers, infections, pneumonia and step after tiring step in arduous physical therapy, the White House press secretary who was shot in the head in the assassination attempt on President Reagan last March, is scheduled to leave George Washington University Hospital today.
"Mentally, he is good," his surgeon, Dr. Arthur Kobrine, reported last week in his fullest public account of this remarkable case.
He is to return only for daily physical therapy, which will continue for months. Brady, the amiable "Bear" whom reporters and the president love and respect for his wit and his skill, is still not whole.
He goes home a permanently disabled victim of the president's would-be assassin. His left hand and arm still are mostly paralyzed and may remain so. His left leg is weak and hard to control. He needs help in many routine activities.
That is the negative side.
On the positive side, he is alive and recovering to a degree no one would have predicted. His doctors for a while thought his wound might be fatal.
He eventually should be able to return to an intellectually demanding career. Whether this can be his job as presidential press secretary with its physical and emotional stresses, only time can tell.
But March 30, the day he was shot, "I expected him to die," Kobrine said. Instead: "His intelligence, his wit, insight, humor, judgment, all are there. There are some lesser problems -- a little trouble at times with short-term memory, a show of emotion or break or high pitch in his voice sometimes.
"But these have improved tremendously just in the last month. He is still in the process of brain recovery. I don't think he will wind up with any significant deficits." He walks, with a little help, and "I think before long he'll be entirely on his own," Kobrine says. A few weeks ago he was able to discard a left leg brace. He does hold a short "elbow crutch" in his right hand, and someone must support his left side to steady him.
Finally, his friends report, he is still "the old Jim Brady" despite having a considerable part of his brain shot away.
That this is true, that there will be a walking, thinking, fun-loving Brady is due to such factors as the latest medical methods and the hospital staff's high skills, providing what the White House physician, Dr. Daniel Ruge calls "supercare."
There is also the human brain's resilience. And luck. And a presidential aide's insistence that the first ambulance rush Brady to G.W. hospital, the nearest trauma center, just minutes away.
James Brady still is not home free. Though it becomes less likely daily, he could still suffer seizures, a brain abscess, an infection or a leakage of brain fluid that would require more surgery.
But if he had reached doctors' hands just three to 10 minutes later than he did, he would either be dead or be alive with far less of a functioning brain.
"I think we got him," says Kobrine, "when his brain was just at the edge."
Monday, March 30. 2:25 p.m. Gunfire. The president is hustled into a car. Brady lies face down across a sidewalk grating, blood streaming from his head.
White House advance man Rick Ahearn fiercely demands that Brady be put into the first ambulance and that it head straight for G.W., not another hospital farther away.
In the G.W. emergency room, a white phone installed in 1971 by White House Dr. William Lukash rings. The hospital sounds its Code Orange, summoning a trauma team.
It is midday, which is one bit of luck -- every department, every lab, every support service is fully staffed.
Brady is wheeled into the emergency room, at 2:40 p.m., three minutes after Reagan. His forehead is grotesquely discolored and swollen, his eyelids puffed shut. The bullet has left a bleeding gap above his left eyebrow. Brain tissue protrudes.
In seconds, Drs. Jeff Jacobson and Judy Johnson, a neurosurgeon and an anesthesia resident respectively, are at work. The immediate perils are swelling and pressure. Because the skull is an unyielding container, Brady's brain, untended, would swell and soon be forced down, crushing the brain stem, which controls breathing and awareness.
Blood pressure is already a frightening 240 over 160. Jacobson and Johnson thrust a tube down his windpipe, force-feeding oxygen to expel carbon dioxide and to decrease cranial pressure. They give him massive doses of dexamethasone and Mannitol, a steroid and a dehydrator to reduce inflammation and pressure.
"All this was done within one or two minutes, and within 10 minutes of his being shot!" Kobrine marvels. "That made the difference."
Kobrine was viewing X-rays when his beeper went off. He quickly joined his residents. X-rays showed the bullet's course -- starting just above the left eyebrow, then through the fragile sinuses, the airy caverns behind the nose. Then obliquely through the brain, tearing through the tip of the left frontal lobe and crossing into the right hemisphere, with bone and bullet fragments splaying out almost to the right ear.
Ruge told Kobrine, his old neurosurgery student at Northwestern University, that the patient was the president's press secretary.
"I don't think he's going to make it," Kobrine said.
The brain was still swelling. The only way to get the pressure down was to operate. Kobrine found Brady's wife, Sarah.
"How's my husband?" she said. "You've got to keep him alive. Scott needs a father."
"I had to look away," Kobrine remembers.
3:30 p.m. Operating Room 4. Brady is readied.
Kobrine opens his skull and lifts away the whole forehead. The bullet's terrible hole becomes plainly visible. It has damaged the forepart of the left brain and devastated the right side.
Still, this is more luck. In a right-handed person, the left brain controls judgment, sense of humor, personality, what a person is all about. If the left side of the brain had taken the main damage, Brady might have lived, but not functioned.
Wearing a headlight and glasses with magnifying lenses, Kobrine wields a hissing aspirator to suck up damaged and dead brain tissue and bullet and bone fragments. Eye surgeon Mansour Armaly simultaneously repairs Brady's left eyelid.
After removing clotted blood between the torn dura, or brain covering, and brain surface in the right hemisphere, Kobrine pauses to ponder what to do about the bullet's principal mass.
Pressure deep in the brain solves the issue. The right forebrain spontaneously hemorrhages, erupting like a volcano to spew out a huge blood clot.
Again, luck. The eruption reduces blood pressure, thrusting through one of the least vital areas, the frontal lobe.
Kobrine enlarges the opening, sucks out more blood with the aspirator and puts silver clips on two torn arteries to halt bleeding. Moving along the bullet track, he sucks out more bone and bullet and, unavoidably, some 20 percent of the precious but now devitalized brain cells on the right side. With a probing finger, he finds the main bullet mass and removes it.
Someone enters. The TV networks have pronounced Brady dead.
"No one has told me and the patient," Kobrine snaps.
He moves to the forehead and the thin, shattered bones of the frontal sinuses. He stuffs them with muscle from Brady's temple to try to prevent leaks of brain fluid through this new wasteland.
His goal, however, is not to remove every shred of damaged brain or completely repair the sinuses. Even at some risk of future problems, he limits the repairs and removes as little brain as possible so Brady will remain a functioning human. He feels the operation has now gone on long enough, nearly five and a half hours.
9 p.m. Brady is wheeled to the recovery room, still unconscious.
"Mr. Brady's condition is critical. . . . He is fighting for his life," Dr. Dennis O'Leary, G.W. spokesman, tells reporters. But in the recovery room Kobrine holds Brady's swollen eyelids open and shines a light in his eyes. His pupils react. He is breathing on his own.
"I think we have a chance," Kobrine tells Ruge.
Late that night Sarah Brady visited her husband. She said he recognized her voice and squeezed her hand.
By morning he could indeed squeeze a hand on command and move his right side, Kobrine found, though he wasn't really conscious.
Over the next days he became clearly awake. He sat up in bed and began talking and even joked. Kobrine knew "his computer had not crashed. . . . We had been able to preserve the critical mass of his being."
The patient also began to show anger and depression as he became increasingly aware of his state. Kobrine called that, too, a good sign, for any aware patient must soon ask, "What's going to happen to me?"
But Brady also said, "Not a bad job, Doc."
With no complications of any consequence, the hospital staff began to feel that they -- and their patient -- might have lucked out.
A postoperative course often has both ups and downs, however, and a patient with a serious condition often gets caught in a pattern where one complication follows another in a seemingly inexorable series.
This, too, would now happen.
April 18. Brady develops a 104 degree fever and rash, the first of three adverse reactions he will have to the antiseizure drugs routinely given after a penetrating brain injury.
April 22. He becomes less responsive and dozes off. This means air has been reaching the brain. Where air enters, infection may follow. Kobrine operates for five hours to repair holes -- dangerous pathways from the brain to the nose -- in the dura and sinuses.
April 27. Brady nonetheless leaks spinal fluid from his nose. This means there is still an unhealed passage. He is restricted to bed, and his bed is tilted head-up to help keep drainage one-way.
May 4. His chest hurts. Several small emboli, or blood clots, the result of protracted inactivity, have formed in his legs and reached his right lung. Any larger emboli might be fatal, so Hugh Trout, a vascular surgeon, places a metal sieve, a clot trap, in the main vein carrying blood from the legs to the heart and lungs.
May 26. Brady has pneumonia. Antibiotics control it.
More than two months pass, two good months. There is now daily physical therapy. At first it is largely "passive" movement, induced by the therapist, but gradually Brady participates and response in at least some muscles on his stricken left side increases.
But Aug. 3, he loses consciousness and goes into convulsions. He is suffering a grand mal brain seizure like those in severe epilepsy. Anesthesia and drugs bring it under control.
The convulsions start more spinal fluid leaking. Aug. 20, Kobrine and Dr. Norman Barr again operate and for nearly three hours explore, make more repairs and seal off still another leaking sinus.
They hope this operation will do the trick.
Neurosurgeons say "things can happen" for a year after a grave brain injury. Some say a year and a half.
These are fears. Against them, Korbine says, Brady has plenty of hopes and determination.
In several hours of physical, occupational and speech therapy daily, he has been learning to walk by using his damaged left thigh muscles to swing his paralyzed foot and ankle. He steadies himself with the elbow-stick in his right hand.
Much of his therapy involves "ADL": "activities of daily living." Standing. Getting into and out of a chair. Bathing himself. Dressing.
He functions mentally with both candor and optimism, Kobrine reports, but he has problems "knowing" where his damaged arm and leg muscles are, so he can use them to keep his balance. "This, too, is improving almost daily," according to Kobrine.
As for morale, the week before last Brady went so far as to invent his own occupational therapy: making his famous and fiery Goat Gap chili for the doctors and staff.
This is not the end of the story. "We are only halfway," Kobrine says.
The "real speedy improvement" in almost every such patient, says the White House doctor and brain surgeon of three decades, Dan Ruge, comes once he is really out of the hospital and back in his own surroundings.
In short, once there is Thanksgiving.