Brian Rife lay in a pair of burgundy sweat pants in Room 5A-8 at Mount Vernon Hospital. His right eye scanned the room, one of the few ways he could communicate with the people around him.
"Brian, today is January 10th," physical therapist Mary Beth Ireland said. She began all her therapy sessions this way, never sure what Brian remembered from one day to the next. "You were in a car accident last July. You suffered a bad head injury and have been in a coma ever since."
Speaking clearly and in a slightly raised voice, Ireland said, "Now you're coming out of the coma. We're all here to help you get better."
Brian looked at her intently. Then he slowly parted his lips. A nurse quickly placed a pad of gauze over the tracheotomy hole in his throat, blocking the flow of air there to force more air into his mouth.
"Do you understand?" Ireland asked.
Brian nodded. Then three loud noises, barely intelligible, trumpeted from his mouth. Ireland and two other therapists leaned closer. Brian's mother, Janet, came forward.
"Please say that again, Brian," Ireland said.
"I . . . go . . . home."
Silence for several seconds. Then, muffled gasps of joy. It was 11:05 a.m. For the first time in six months, Brian Rife was speaking.
Ireland went right to work. "Right now, you're not strong enough to go home, Brian. You've got a tube in your throat and your mouth doesn't open very well because you haven't used it in a long time. But please keep trying. We want you to talk."
"I . . . unnerstan you," Brian replied, as tears raced down his mother's face.
One hundred and eighty days.
For the first time since he was nearly killed July 14 in a car accident, 20-year-old Brian Francis Rife was using his voice to answer questions. To those gathered around him that day -- his therapists, his mother -- it was a breathtaking sight, one that once seemed unthinkable. His family remembered the long days of summer and fall, when Brian remained in such a deep and seemingly irreversible coma that doctors and his own parents wondered whether his life was worth sustaining.
Even now, with Brian's first words echoing in their minds, they had to remind themselves that he was still in poor shape.
He could not walk or swallow. He breathed through the hole in his throat. He was fed the essential elements of life -- food, water, minerals -- through plastic tubes that snaked through the wall of his stomach. He had a shunt in the back of his head to relieve a periodic buildup of cranial fluids. Because he had no muscle control of his left eye, doctors had sown its lid shut to protect the cornea.
Yet, the therapists had always felt that Brian possessed enough inner strength to fight his way back from the coma. Now, on this cold morning in January, that strength astounded them.
"Do . . . you . . . avv . . . ah . . . nick . . . name?" he asked Ireland, as laughter filled the room.
"Do I have a nickname? Is that what you said, Brian?" Ireland asked, still speaking with her voice raised. "Yes, I do. My family calls me 'Shump.' Do you have a nickname?"
Brian slowly shook his head no.
Suddenly, he began mumbling. Then, an expression of fright came over his face.
"I feel . . . that . . . I see something." He stopped. His right eye opened wider.
"Animal," he blurted. "A dog . . . flying."
Brian appeared confused. Ireland looked around the room. She noticed a collection of stuffed animals on the windowsill. "He's hallucinating," she said, lowering her voice to normal tones. Picking up a floppy-eared dog, she placed it near Brian's hand and asked him to touch it.
"Brian," she said slowly, firmly. "You're seeing things and you're not sure whether they're dreams or not. You've have a very bad injury to your brain. Because of the injury you can mix up what's real and what isn't real."
Brian stared at Ireland's face. Then he slowly surveyed the room, finally focusing on the face of a dark-haired woman who stood at his side.
There was no way to know whether he recognized his mother.
"Hi," Janet said, her eyes still moist.
Brian gently lifted his left hand and wiggled his fingers in greeting. The Arrival
Brian Rife arrived at Mount Vernon Hospital on a cold and gray December morning, 13 days before Christmas. As attendants wheeled his stretcher down the corridor, Janet walked alongside, carrying one of Brian's sweatshirts, a pair of his pants and his running shoes.
The four-year-old rehabilitation center, created largely in response to the growing numbers of survivors of brain and spinal cord injuries, was located on the fifth floor, a large and sunny space comprising 40 beds in two wings. Brian's fellow patients ranged in age from 14 to 63; most were survivors of head injuries that would have proved fatal a decade earlier.
At the door of Brian's room, Janet was met by Dr. Roger Gisolfi, director of the rehabilitation center, a balding, wiry man who was responsible for Brian's coming to Mount Vernon.
In October, when Brian was a patient at Fairfax Hospital, the Rifes' medical insurance company had asked Gisolfi to assess Brian's chances of coming out of the coma and to decide whether he could benefit from the kind of intensive therapy that Gisolfi's program specialized in.
For several months, Janet and her husband Curt had tried to persuade their medical plan, Kaiser Permanente, to pay Brian's expenses at Mount Vernon, estimated at $18,000 a month. But Kaiser's plan did not include such coverage. Their discussions finally led Kaiser officials to ask Gisolfi to consult on the case, which gave the Rifes hope.
Gisolfi told Kaiser that Brian was starting to use physical and sensory skills that had been dormant for months. One morning his right eye tracked the movement of a nurse in his room. Another day Brian tried to hold his head up -- much like an infant does -- when therapists sat him up in bed.
On Nov. 19, Kaiser informed the Rifes that it had reversed its decision. The company would cover up to 60 days of rehabilitation treatment because Gisolfi concluded that significant improvement could be made. (Kaiser has since made this kind of provision part of its standard policy.)
The Rifes were relieved. They had fought off the prospect of placing Brian in a nursing home, at least temporarily. Yet in winning that battle, another loomed. This one pitted them against Virginia's Medicaid agency.
Medicaid was the only other way the Rifes could afford to pay for Brian's rehabilitation. Although Medicaid is intended for the poor, Brian qualified because he had no assets of his own and was older than 18. But Medicaid would pay for long-term rehabilitation only at certain hospitals; Mount Vernon was not one of them, although it was seeking to become one.
If Janet and Curt could not find a way to expedite Mount Vernon's accreditation, Brian might end up in a hospital no closer than Richmond and as far away as Boston. They tried to put that battle out of their minds, however, and concentrate on Brian's fight to recover. "He's Very Fragile"
Gisolfi watched as his new patient was lifted by two orderlies onto the bed in Room 5A-8. "Look at that eye," he said softly, watching as Brian's right eye, its lid flickering open and shut, tracked him as he moved from one side of the bed to the other.
Several minutes later, on two plastic chairs beside a picture window in a day room, Gisolfi sat down with Janet to discuss Brian's case.
"It's a good sign, the way he's able to track with that right eye," he said, picking his words carefully. "But I can't see a lot when I look in it."
Janet sighed, turning briefly to look out the window. Gisolfi went on.
"He's very fragile. He's got 45 things wrong with him medically, and every time you turn around something else goes wrong."
Gisolfi paused and folded his arms. "You know, I can't think about the 60 days Kaiser has given us. All I can do is take what I've got and work with him. We'll deal with the deadline when it comes."
Gisolfi knew 60 days was not nearly enough time, that awakening from a coma is a protracted process in which patients go through various stages of consciousness.
Only in the last decade have researchers devised ways to detect those stages. One of the most common measurements is called the Rancho Los Amigos Scale, developed in 1980 at a head-trauma hospital by the same name in Downey, Calif.
The scale has eight levels of consciousness. During most of Brian's stay at Fairfax Hospital, he was stuck in Level 2, the next to lowest -- "Generalized Response: Patient reacts inconsistently and non-purposefully to stimuli . . . . "
One night, another coma patient on Brian's floor at Fairfax rattled the entire ward when he started screaming and shouting obscenities. Later, his family left his room ecstatic -- because his outburst signified that he was entering Level 4: "Confused-Agitated. Patient's behavior is frequently bizarre. He may cry out or scream, may show aggression, attempt to remove restraints or crawl out of bed."
When Brian was admitted at Mount Vernon, he was still at Level 2 but was moving to Level 3, which meant he was more aware of his body and his environment and could respond intentionally to stimuli. On his first day at Mount Vernon, he resisted and pulled at the various tubes connected to his body.
His progress was recorded in a medical chart kept by the dozen or so nurses and therapists who worked daily with Brian. They were the troopers in this protacted struggle, front-line caretakers and sentinels who faithfully documented their every observation.
Four women were primarily in charge of Brian's two daily therapy sessions: Judy Holmes, a speech pathologist, and physical therapist Ireland treated him in the morning; their afternoon counterparts were Emmy Gardner and Adair Villarreal. Collectively, they were known as "The Team." Every two weeks, "The Team" met to trade discoveries about Brian and map out ways to treat him.
December 18: Team Meeting. Patient strengths: Inconsistent responses; Demonstrating head righting in sitting; visual tracking with eye; Well-informed family.
Coma: Rancho Scale 2/3
Deficits: Rigid trunk, no vision in left eye.
Nursing goals: Continue to turn and reposition every two hours. Suction trache one to two times each shift.
Therapy Goals: Observe for responses to stimulation; develop yes/no responses.
Each weekday Holmes trooped into Room 5A-8 to spend an hour talking to and stimulating Brian, all the while looking for the faintest hint of reaction. Wet washcloths, bells, hand-clapping, ice and rock music were among the other tools of her trade.
Just as important was the physical routine. "The Team" helped Brian do the things he could not do on his own. They bent and flexed his stiffened knees and elbows. They turned him onto his stomach and side. They lifted him into a sitting position in a wheelchair, watching his balance, the position of his hands and head, explaining what they were doing in hopes he could understand and remember.
Day after day, no matter who treated him, they repeated the same message: "Brian, you were in a car accident. Now you're getting better. That's why I'm here. To make you move. To get your muscles to do things again."
Gradually, his physical responses improved. He began using his hands and arms, scratching at his stomach tube because it itched and pushing Ireland's hands away when he felt annoyed with her efforts to make him respond.
On Dec. 23, the Monday before Christmas, the family stopped by to sing Christmas carols. Janet later recorded the scene in the diary she began keeping after the accident:
Brian's gestures much more common now: reaching up to people, things, touching his face, his eyes, his ears . . . . I'm feeling it difficult to place a smile on my face. Someone looks at me and says, 'smile.' I try and keep singing, "Noel, Noel . . . . "
. . . Brian is here now at the door, in the wheelchair, holding his head up with dignity. They wheel him in, paraphernalia and all, oxygen and feeding tube hookups. The atmosphere in the hall changes. The singers take it all in and add a bit more soul to "What child is this?"
From that point I make eye contact with no one but Brian. Perhaps it's the first time I've begun to feel acceptance and love of him as he is now without the crowding in of the pain of losing the Brian that was.
. . . Later Eric [Brian's 13-year-old brother] is weeping at the foot of the bed. "I just want him to get better." "The Team" at Work
Each day the work went on in Room 5A-8. Often there was little change. The Team's observations for the last two weeks of January show the difficulty of Brian's struggle.
Ireland: "Patient very confused. Refused to get out of bed . . . . "
Holmes: "Patient cupped hands to ears while therapist was talking. Patient gave his name and asked therapist for hers."
Ireland: "Patient could not identify his own picture."
Brian's ability to remember -- both the immediate and distant past -- came and went. One morning, at Ireland's suggestion, he was able to recite his home address: "Eight, one, one, two, Dabney Avenue." The next day he could not remember who Ireland was.
Brian seemed to shuttle in and out of his own realm, his bearing sluggish and leaden, his moods unpredictable.
"Can we talk about your family, Brian?" Ireland asked during one of her therapy sessions. She held up a family photo album and flipped through its pages.
"Who is this guy? Is this your brother?"
Brian stared hard at the picture. "No."
"Sure it is. That's your brother Scott. He's grown a beard since you saw him last summer."
"Yeah, it's Scott."
"Doesn't . . . look like him."
"You have another brother, don't you?"
"What's his name?"
He thought a moment.
"Dann . . . eee." He nodded.
"And a sister."
"Sherr . . . eee."
"Yeah. Who else?"
Silence. He tried, but could not remember Eric.
Ireland then pointed to the foot of the bed, where Janet was sitting. Ireland asked, "Who is that? Can you see her?"
Brian looked. "Lisa," he said.
"No, it's not Lisa. Looks like your mom, doesn't it?"
"Yeah. Mom. That's right."
"What's your mom's name?"
"Jan . . . it."
One morning, Ireland said to him, "Brian, I want you to lay on your side," Brian became alarmed. His right eye widened.
"I don't . . . want to die," he said.
"No, no, Brian. I want you to lay on your side. Side."
"I . . . thought . . . you said . . . I was dead."
Amid the problems of memory and mood, his sense of humor began to return -- delighting his therapists because it implied a growing awareness of his surroundings.
"Brian, do you know you're in a hospital?" he was asked one morning.
Brian looked up a moment and said, "God, I hope so." A Howl of Agony
Chris Wade, a 24-year-old registered nurse, became an expert at detecting the nuances in Brian's progress. A buoyant young woman with pale green eyes and short wavy brown hair, she spent more time with him than anyone else. She bathed him, changed him, fed him, all the while keeping up a constant conversation. In time she became his biggest booster.
She was about his age and shared many of his interests -- playing Frisbee, camping and Bruce Springsteen songs. He typified many of the patients she cared for.
"You look around the ward here and there's a few strokes, but the rest are head injuries," she said one morning outside Brian's room, a stethoscope around her neck. "And in just about every one of these cases, the family was told early on that there was little chance they would survive. Yet here they are.
"I sometimes go home at night feeling sad," she went on. "I ask myself, 'Would you want to live this way?' I don't really have an answer yet. But I do know this: Ten years from now we'll probably be able to do a lot more. That's what keeps me going."
As time progressed she began to glimpse more and more of Brian's character and personality. It wasn't just a body awakening before her eyes, but a person as well. One night, he refused to go to sleep. Wade put him into a wheelchair and tooled him up and down the halls. He smiled and laughed, and waved at the other nurses.
"Chris, you're crazy!" Brian exclaimed as they raced down the hall.
But Wade was most moved by the statements that caught her off guard. One night as Brian sat in a wheelchair, Wade set him before a mirror. He studied his reflection for several moments. "This body," he said. "It's not working."
Then one morning in late January, Wade heard an ungodly sound -- a moan, a howl of agony -- coming from Brian's room. Her first thought was that his tracheotomy hose had gotten stopped up.
She raced into the room and found Brian writhing violently in bed. The hose was clear. He seemed to be having a nightmare. His face was red, his arms waving madly. Amid the moaning and gushing of air that emanated from Brian's hose, Wade recognized a word: "Car."
The time was 9:30 a.m., Jan. 29, more than six months since the accident. It was the first hint that Brian was starting to remember the crash.
Wade grabbed his hand. "Brian, you are in Mount Vernon Hospital. You were in a car accident. You had a bad head injury. You were in a coma but now you're coming out of it. I'm here to help you get better," she said.
The pace of Brian's breathing gradually slowed. The redness slowly drained from his face.
"Tell me that again," he said. The Medicaid Maze
On the same day that Brian began to remember the accident, a flood of letters began arriving at the Richmond offices of newly installed Gov. Gerald L. Baliles and other Virginia officials -- all part of Janet Rife's well-organized campaign to make Mount Vernon's rehabilitation center into a Medicaid-approved facility.
The Rifes had a deadline. Feb. 12 was the last day Kaiser would pay for Brian's rehabilitation care; if Medicaid did not kick in, then the Rifes had two choices: move Brian to another Medicaid facility and disrupt the therapeutic relationships that had been established, or pay the $550-a-day cost themselves, which they could not afford.
The letters came from Brian's relatives, neighbors, therapists. Chris Wade wrote one. So did Eric Rife's entire eighth-grade class. Gisolfi wrote, too, in his role as head of the Mount Vernon center. He told one state official that moving Brian "would be detrimental" to his progress.
The problem with Gisolfi's center was both simple and, to the Rifes, absurd. It was a department within a hospital, not a separate facility, and Virginia Medicaid regulations had no provisions for approving such a center. There was no question about the quality of Gisolfi's center; everyone agreed that it was as good as any Medicaid-approved facility where Brian might go.
Medicaid officials were sympathetic but told the Rifes that changing laws is not a quick or easy process. They said nothing could be done before Feb. 12 -- and probably not until the fall. Meanwhile, Ray T. Sorrell, the head of the state's Medicaid program, offered to send Brian to a facility in Richmond until Mount Vernon got its approval.
Then, unexpectedly, things began to turn around. Janet was not sure why. Perhaps it was Sorrell's initiative or Gisolfi's medical opinion or the questions from The Washington Post in preparation for these articles.
Sorrell asked Baliles to sign emergency regulations, citing Brian's progress and the high cost of sending Northern Virginia patients to facilities in other states: $715,000 since 1982. He said he decided to move more quickly for "humanistic reasons" and to save the state some money.
On Feb. 25, Baliles approved Sorrell's request. The Rifes' six-month battle with their medical insurance company and the state of Virginia was suddenly over. Brian could stay at Mount Vernon.
At the Rife house in Springfield, there was joy and relief. But those feelings soon gave way to a deeper realization that the insurance issue had, at times, helped keep their minds off the accident and its lingering effect on the family.
In many ways, their lives were unchanged. Janet and Curt tried to keep the household routine intact. The list of chores on the kitchen wall was maintained. Danny and Eric continued to play soccer. Sheri continued to date her boyfriend. Scott went back to college at Virginia Polytechnic Institute and State University.
But the accident's reverberations were everywhere, ranging from the obvious to the intangible.
Curt became a proponent of automobile safety, closely following newspaper accounts of legislative battles over mandatory seat belt laws and air bags. He will not shift the family car into gear unless every passenger has fastened a seat belt.
Janet found it difficult to handle tension within the family. At times, she said, everyone seemed almost too ready to go back to their normal routines. At one point, she wrote in her diary:
Felt very fragmented in the evening. Unable to make much contact with the other kids, TV, telephone, felt agitated at them all. Went to the hospital at 9. Talked quietly to him . . . . Needed to let some tears flow after visit.
Aware later that I went to see Brian because he was the only one who wouldn't talk back. The Family Takes Stock
It was Scott, 22, who seemed to have the most trouble coping. On the day of the crash, he accompanied Janet to the hospital in Baltimore. But in the weeks that followed, he seemed to avoid getting involved. As Janet put it: "Scott started running away for it. He went to the beach, he partied, he just ran away."
By the time he left for school in September, his relationship with Janet was fraught with tension. She was angry that he appeared to be emotionally divorcing himself from the crisis; he was put off by her attempts to dominate it.
Separated by just two years in age, Scott and Brian had perhaps the strongest relationship in the family. As children, they roomed and played together. As adults, they were just beginning to develop the kind of close relationship that many brothers dream about.
Then, the accident happened. Ever since, Scott has been trying to cope with the fact that Brian will never be the same. "I have to take some time to get to know him again," he said. "I'm sure there will be memories that will connect us, but it's going to be different."
Janet and Curt had been told to expect these kinds of reactions. In dealing with them, they began to confront problems about their own relationship. At the time of the crash, Curt said, he and Janet just were not talking "about anything very much. The distance between us was pretty great."
Some of that distance was a result of their personalities. "I'm always the pressure person," Janet said. "Curt's the sweet, affable guy."
Janet has always played that role, even within the family. About 10 years ago she began to worry that Curt was drinking too much. They were living in Belgium, where Curt was on assignment for the Army. When the Rifes returned to Springfield in 1972, she said, Curt's drinking became a lonelier, more solitary pursuit. "He'd come home and be asleep in his chair by 10 o'clock," she said.
Curt realized that his drinking had become a regular part of his life, he said a few months ago, but he thought he had it under control. The drinking was a way to "put things out of your mind. Things at home. Things at work."
Finally, Janet forced the issue. In 1983, she joined Alcoholics Anonymous and signed the children up for Al-A-Teen. She tried to involve Curt in the effort, but he resisted. Eventually, though, he enrolled in a four-month counseling and treatment program, which was paid for by Kaiser.
Curt said he has not had a drink in more than two years. At the same time, he said, Janet doesn't understand the origins of his drinking. She grew up "cloistered in the hills of Pennsylvania. In my background, the thing to do was get together and have a six-pack."
Brian, too, liked to get together with friends and share a beer. The night of his accident, Brian and several friends had been drinking for several hours when Brian and a friend decided on a lark to go to Ocean City at 2 a.m. Brian fell asleep at the wheel at 5:30 a.m.; the police report cited fatigue as the cause of the accident. There is no way of knowing whether alcohol played any role in Brian's fatigue.
Janet believes that Curt, on some level, felt some guilt -- that perhaps his attitude toward drinking created an environment at home where drinking was viewed as an acceptable pastime.
Curt insisted that was not true. "Brian just liked to party," he said. He recalled the time two years ago when he went to pick Brian up at college. "There were all these fellas sitting around talking about all the great parties they had. I never went to college myself. I don't know what that kind of life is like.
"But there's one thing I've always made my children aware of. You pay for your own mistakes. Whether it's a flat tire or a blown engine or falling asleep at the wheel . . . .
"The other night Danny said to me, 'If I just had one wish, I'd wish that I could have been home that night to stop Brian from going out,' " Curt said, his eyes glistening. "That time has passed." The Odyssey Goes On
Today, 332 days since the accident, Brian Rife is still considered to be in a coma. His level of consciousness has advanced to Level 6 on the Rancho Los Amigos Scale. At times, he understands -- without being told -- how and why he ended up in a hospital. But his memory comes and goes, and he is still prone to severe swings in mood.
A month ago, doctors removed his tracheotomy tube. Now that the tube is gone, his voice is louder, clearer and stronger. He cannot stand up or walk and still needs help to get from his bed to a wheelchair, which he is beginning to learn how to propel on his own. His hearing is permanently damaged and his eyesight is impaired, both the result of fractures incurred in the accident.
Three weeks ago, Brian began to eat soft food -- vanilla ice cream, orange sherbet -- for the first time since the accident. Two days ago, he ate an entire meal in the form of pureed meats, fruits and vegetables. If all goes well, Gisolfi said, doctors can remove the stomach tubes that have sustained him for the last seven months.
The long-term prognosis is unknown. Gisolfi said Brian will have to stay at Mount Vernon for several more months. At some point, Brian will return home to Springfield where, Gisolfi said, "Brian will have some meaningful life. He will not be a vegetable." But his chances of being self-sufficient -- of holding a job, of taking care of himself fully or walking on his own -- are not good.
Meanwhile, his family is making plans to take a month-long vacation, the first time they have thought about being away from Brian.
A few months ago, when it came time to decide whether to switch their medical insurance, Curt explored the various options and decided to go with Kaiser again. "All in all, I don't think there's another plan out there that's any better," he said.
As for Janet, her feelings can best be summed up by what she told a friend recently.
"What this has done," she said, "is bring me back to some basic values. If I knew I were to give birth to a retarded son, would I? I don't know. I feel a handicapped child does bring a great deal to his environment. But you come to these views gradually. It doesn't come to you overnight.
"At this point I'm very accepting of Brian as he is," she went on, her voice sounding surer than it had in months. "You make peace with what you've got. When I hug him and kiss him it sure is better than visiting his grave."