the thin line between life and death
MY CHILDREN AND MORE recent friends see me as they do in the here and now. Old friends, especially those I have known for many years, see me in a different light. Not always as the middle-aged man that I have become but me as I was through the time of our friendship, in my early days as the fat child who was always hungry and constantly begging the neighbours for more food; later as the talented young tennis player sliding into a low backhand volley on the grass courts at Wellington’s Central Park or White City in London or as the first XV fullback in his first ever game of serious rugby, fending off the brutes from the Tawa under-nineteen team to score a try in the corner; or maybe as the embarrassed first XI cricketer, distracted by the sight of a pair of ferric-oxide coloured socks worn by Willy Simpson’s father on the terraces at Wellington College and being clean bowled for a duck in the do-or-die annual match with Palmerston North Boys’ High School. Well, that’s what I hope.
These are just a few of the moments in time that have stuck with me. Of course, there are many others, all inexplicable combinations of circumstance, good luck and bad, and perhaps fate where things could have gone either way—that chance meeting in the med school café with a stranger leads to talk about a girl and before you know it, I have been with her for 34 years; the conversation with Jim, the bus driver, and me here now, a doctor of many years; my cousin Denis, a young man, through no fault of his own was in the wrong place at the wrong time and, in an instant, dead forever since 1978. These accidents in life, good and bad, seem as random as can be and fill me with equal quantities of wonder and dread at how they came about, and what might have been if they had not happened at all.
More often though what we get is the result of the choices we make. Why we make those choices is sometimes obvious, sometimes not. As an intensive care doctor, I make hundreds of decisions a day, a good number of which are obvious, rational, and based on a form of explicit knowledge and a strong body of evidence. However, many decisions come from another place, a kind of tacit knowledge gained from experience that may never reach the level of proof to become evidence. Almost always, those decisions are reinforced by an intuitive element, a kind of sixth sense or gut instinct that this is the right thing to do.
When things are most critical and an immediate course of action is called for, usually there’s no explicit knowledge to guide me, and in that unique moment of time, no shared tacit knowledge that I can reliably trust. Instead, there’s a powerful sense of knowing what to do, right there and then. This gut feeling or sixth sense plays out in ways that I can feel and almost taste. When it comes, it is a feeling that I now recognise and trust—and ignore at my peril.
Carlos lived in the eastern suburbs of the city in a house that looked modern and Mediterranean. In the backyard was a terrific swimming pool. There were similar houses all around, separated by good-sized gardens and wide streets, all under a big sky. Even on still days you could smell the sea only a few hundred metres away down the hill.
Carlos was fifty, long married with four kids and a dog. He was born in a far-off land and came here as a single man seeking adventure and good fortune. On all fronts he had succeeded. Soon after arriving he landed a job with a construction firm and, through determination and hard work, he became foreman then manager and, eventually, the owner of the company. Carlos loved to swim and cycle and had always been an extremely fit guy, preferring physical activity to watching television and drinking beer. His kids called him OCD and perhaps he was, choosing to sublimate that potentially destructive tendency into things much more socially acceptable, like his work and his fitness.
Like many cyclists, he had smooth bulging calf muscles, matched only by the smoothness of his head and his manner. He ran his business well, like clockwork, paying attention to detail in the very best of ways. His employees loved him and said that he had a big heart made of gold.
Sandy, his wife, relied on him for all things. She was capable and smart, but it was Carlos that made the decisions, and it was Carlos around whom the activities of the house were largely centred. Don’t take this the wrong way—this was just the way it was; it worked and their house was a happy house. All that changed one sunny Friday evening.
I was the on-call intensive care specialist in my hospital. It had been a slow day. I was thinking about going home and leaving things to the registrars when my phone went off, signalling a trauma call and requesting my presence in the emergency department.
Somewhere out there in the real world, right now, on a road, in a house, something bad is happening. Someone is in real trouble and at risk of dying. An ambulance has been called—there are tears, grief, anxious relatives or bystanders. It might be a crash scene with people already dead—the street littered with broken glass and personal effects. It could be a child run over in a driveway. Whatever the scene, no matter if there’s chaos or outright danger, paramedics will be sent into it willingly. Cool, well-trained and confident, they will make a rapid assessment of what they find, call for help if they need to, and calm the situation. At the same time, they will fall into their practised approach to stabilise the patient as best they can and, depending on the nature of the patient’s condition and the proximity of the nearest hospital, they might do a scoop and run—load the patient and leave immediately. In all cases of serious and life-threatening injury or illness, they will call ahead to forewarn the hospital that they are coming. These calls are then relayed to the appropriate medical staff, who assemble in the emergency department or ambulance bay to meet the crew, hear the story, and get to work on the patient.
On this occasion the 111 call was from a rural back road that ran between orchards and horse paddocks in the south of the city. It was a relatively orderly scene—a few cars stopped on the side of the road and a big SUV parked at an angle, stopping traffic from going through. Just beyond that, a group of motorists were gathered alongside an unconscious man dressed in Lycra, his broken bicycle in a ditch 40 metres back.
Realising the gravity of the situation, the paramedics quickly put an oxygen mask on the man’s face, stabilised his neck in a stiff collar, and carefully clipped a scoop stretcher underneath him. They loaded him into the ambulance, called ahead and sped for the nearest trauma hospital.
Despite practising for scenarios like this, and becoming slick in managing them, these are always tense times. While waiting for the ambulance to arrive, we assembled in one of the resuscitation rooms to organise ourselves—a critically injured cyclist, unconscious, likely shocked from blood loss and close to death.
I was appointed team leader to oversee the immediate management. An emergency department doc and a senior nurse would assess and manage the patient’s airway and breathing. The surgical doc, another ED doc and a nurse were allocated to assess and manage the patient’s circulation, insert two large bore drips for fluid resuscitation, and be responsible for giving all the medications to the patient as required. Finally, a senior nurse was assigned to be our scribe, to record everything that we did and when we did it.
We heard the ambulance before we could see it, its siren blaring loudly all the way to the ambulance bay. On arrival, the patient was breathing oxygen delivered by a standard mask. As we transferred him onto the resus room trolley, one of the paramedics gave us the handover.
The patient was an as-yet unidentified male of about fifty. A woman on her way home from work had found him sprawled on the road. She rushed to help and called 111. A few minutes later an ambulance arrived. The man was unconscious, with a large gash over his right eye, its pupil appearing dilated and not reacting to light, as it should. He was breathing but had a very fast and thready pulse and a blood pressure so low we couldn’t even measure it. He had multiple abrasions and small cuts everywhere, as well as skin loss in several places where he had skidded along the road.
Later another witness came forward with a more detailed story. The man had been cycling when a truck and trailer unit overtook him at about 80 to 100 kilometres per hour. He saw that the left stabilising arm of the trailer was unsecured and it was this that struck the man from behind, hitting him across his lower back, catapulting him through the air and onto the road. The truck did not stop and was long gone by the time the first passer-by arrived.
It was pretty obvious from the outset that he was as close to dying as it gets, most likely from internal bleeding. He was deeply unconscious and that fixed and dilated right pupil suggested a severe, usually fatal, underlying brain injury. He was barely breathing but despite that had good air entry into both lungs. We could not feel an actual pulse though he had a pulse rate on the monitor of 170 beats per minute and he was ice-cold to touch.
We quickly intubated him to take over his breathing. As we did this, almost imperceptibly, I saw him move his left arm in a way that should not happen if he’d had as serious a brain injury as the pupillary sign suggested. My colleagues inserted a couple more lines to take bloods and give him fluids and we quickly went over him to narrow down his source of blood loss.
There are only a few places blood can go in a scenario like this: on the floor, but there was no torrential external bleeding to cause this degree of shock; into the long bones associated with fractures, but there were none; into the chest, but again there was no sign of that when we listened to his breath sounds and his chest X-ray was clear; into the belly, which was a real possibility here, but at that time, we didn’t have the portable ultrasound technology available to rule that out, so we remained suspicious; the final injury that can cause this degree of exsanguination is from a severely fractured pelvis with blood lost into the tissues of the posterior abdominal wall or retroperitoneum. This had to be the place because it was obvious that his pelvis was completely shattered. Quickly, we wound a sheet around him to stabilise his pelvis, called the interventional radiologist to come in to help us, then we raced up to the operating theatres. My plan was to get the surgeons to open his belly, deal with any haemorrhage there or reassure us that he was not bleeding into the abdomen while waiting for the interventional radiologist to do his magic and stop the pelvic bleeding.
Twenty-five minutes after arriving in the ED, we were in the operating room. The on-call surgeon was not terribly enthusiastic, citing the fixed and dilated pupil, the degree of shock, and the rate of ongoing haemorrhage as reasons why this man wouldn’t survive. He suggested instead that we make him comfortable and wait for what he believed would be his inevitable death. I quickly countered his arguments—the abnormal pupil was most likely the result of a direct injury to the eye, not the brain. He was a young and fit-looking man. And I had a strong gut feeling we should press on!
In emergencies like this, doctors follow a set guideline to rapidly assess and manage life-threatening situations. It’s called the ABCD approach—airway, breathing, circulation and disability or level of consciousness. In the trauma setting, we call this the primary survey and it is designed to deal with immediate threats to a person’s life. Once completed, we then begin the secondary survey—a comprehensive head-to-toe examination of the patient followed by appropriate investigations: blood tests, X-rays and CT scans. In this case we were stuck at C—we needed to stop the bleeding as soon as possible.
As soon as the surgeon opened his belly it became clear that there was no intra-abdominal bleeding but, instead, ongoing torrential haemorrhage into the retroperitoneum, as we suspected. We could actually see it, the tissues there bulging and blistering before our eyes—it was a sight I will never forget. If anything looked ‘fatal’, this was it. Pelvic bleeding can be like a rupture in a reservoir: blood pours out like water down a waterfall. Damaged by the sideways shearing of the pelvic bones, the big arteries and veins—the ones that ferry blood to and from the lower half of the body—shear and empty their contents into the tissues as fast as the flow of blood to them.
There are only a few effective treatments for this kind of injury. Certainly stabilising the pelvis with a sheet can help as a first-aid measure, but once in hospital, torrential bleeding of this sort is best stopped by our radiology colleagues, sometimes helped by external fixation of the pelvis by the orthopaedic surgeons. The radiologists use X-ray technology to guide small catheters into the distal vessels deep inside the body and inject a radio-opaque dye into them to identify the bleeding points. Once identified, they then inject small amounts of Gelfoam and coils of wire into those vessels to effectively stop the bleeding. It sounds crude and it is. It sounds easy but it isn’t. Who said a childhood spent on the Xbox is wasted? It’s exactly those skills that are needed to twist and guide these fine catheters along the vessels and round tight corners to places that surgeons’ hands will never reach without causing more harm than good.
It was clear that our mystery man was losing blood faster than we could replace it and his blood pressure was still dangerously low. The combined effect of prolonged hypotension, and the torrential and ongoing bleeding into his retroperitoneum, effectively obliterated the normal pressure gradients in the kidney necessary to make urine, causing his kidneys to fail. This was no surprise, but it meant more than ever that time was of the essence. The more he bled, the more blood we needed to give him. If only it was as simple as replacing what is lost, but it’s not. This kind of loss and replacement has consequences of its own.
As all of this was swirling through my mind, I told the surgeon to clamp the patient’s aorta, just above where it divides to become the left and right common iliac arteries. By doing this for a short period, I hoped we might be able to stem the blood loss while we waited for the radiologist. It seemed like an age, all this waiting, but in real time it was no more than twenty minutes. We were pouring in blood, platelets, clotting factors, giving calcium, running noradrenaline through a long line in the neck, sending bloods to the lab; receiving the results, all looking increasingly ugly, so in our minds we were preparing for the worst.
I was so relieved to see the radiologist arrive and thrilled that it was Rowshan. He grew up in Iran and had lived through extraordinary times—he was my friend and he was an absolute master of his trade.
As he got to work, I kept my eye on the monitors, especially the cardiac trace (ECG). All patients will die if you cannot stop this kind of bleeding; continually replacing blood in an ongoing fashion is never enough. Massive blood loss like this causes a raft of metabolic problems as a result of poor tissue perfusion, and the need for ongoing transfusion compounds that, especially because of an increasing potassium and acid load that cannot be excreted because of the renal failure. As the potassium rises, muscles lose their ability to effectively contract, and the muscle that matters most here is the heart. High potassium changes the normal narrow complex of the ECG trace making it increasingly broad so, like a drunk, slowing and slurring, it too will eventually stop.
Rowshan did well, stopping the bleeding one vessel at a time, and my crew were replacing what we could, all the while treating the complications of all of that. Despite all of that good work, time was passing and his bloods were becoming increasingly abnormal but unusually, this man’s ECG trace stayed resolute as it articulately and reliably made its way across screen after screen, beep after beep.
Something unusual was going on here. It had started in the emergency department with that flick of his hand and continued in the operating theatre. I had been here before—in situations with much less bleeding than this, with bloods not half as bad as these were—and in each case it had ended badly. No sign of that here. This man, whoever he was, was made of tough stuff.
Over the next few hours, we did all we could to control his increasingly abnormal metabolism using infusions of bicarbonate to balance the accumulating acids in his blood, boluses of intravenous calcium, glucose and insulin to lower his potassium level and before I knew it our evening had turned into night and suddenly it was 1 a.m. on Saturday morning.
With most of the bleeding now controlled, we prepared to move our patient across the corridor to the ICU. By then, we had given him 65 units of blood products and over 30 litres of other fluids—over ten times the normal volume of blood in his body. This was a huge transfusion, but most of that came out into the tissues of the retroperitoneum. Miraculously, he was still alive.
Our mystery man was still on a ventilator, I hoped asleep as a result of the sedation we were giving him rather than unconscious due to a massive head injury. What I did know was that he was far too unstable for us to move him to be scanned in order to find out one way or the other. As it was, we were still only partway through our guideline for the assessment and management of severe trauma and still stuck at C!
Just keeping him alive had been our focus. He had multiple lines in now—big intravenous catheters in his right and left internal jugular veins for fluids, drugs and dialysis; an arterial line in the radial artery of his wrist; the large bore sheath in the right femoral artery through which Rowshan had so skilfully directed his catheters; a nasogastric tube to drain his stomach; his breathing tube of course attached to a $65,000 ventilator; and a urinary catheter, its drainage bag sadly empty of urine.
Although some of his bloods tests were better, because his kidneys had failed his blood desperately needed cleaning up. Gingerly, we got him onto dialysis with small boluses of adrenaline to keep his blood pressure up.
It had been a weird evening and I was sure something unusual and mysterious was afoot. I was exhausted but energised and strangely elated too! I walked around the ICU, checked on the other patients and then took a stroll outside. It was a beautiful night. In days past, I would have jumped the fence and gone for a swim in the hospital pool, but that was now long gone. I was hungry but all that was available was crap from an array of vending machines better trained to take your money than give you sustenance. A comfortable chair and my feet up on a verandah rail looking out across the night sky would have done but there was nowhere for that. Sitting in an office looking out the window wasn’t even possible because there were no offices with windows available to me. How weird, I thought, this place is supposed to make people better but it is so awful on so many counts.
There was one saving grace though: hospitals at night, stranger places than they are during the day, are ripe for the imagination to flourish. Like the southern motorway at the same dead time of night, they too have one long, empty corridor after another. The only signs of life are an occasional cleaner in a cowboy hat riding a big floor polisher, our equivalent of a growling road-working machine lit up like a Christmas tree. Like the odd car, an occasional house surgeon will run a red between well-lit pods that could be gas stations but instead are the nursing stations on the wards. I want to breathalyse them all.
‘Life can only be understood backwards, but it must be lived forwards,’ said the great Danish philosopher Søren Kierkegaard. Ghosts and memories flood back to you in those dark hours before the dawn. Did Mama, the thirteen-year-old girl from Aitutaki, really need to die? Couldn’t we have done more? Dr Ken Mayo, his photo on the wall at the entrance to the radiology department, dead at fifty. His weathered face above his Viyella shirt and neatly knotted tie etched in my brain forever. I never want to end like that, all alone, dropping dead at work. I used to worry that one day I too would be remembered by a photo on a wall in the ICU but as time has passed so too has my anxiety about ending that way, certainly at that age.
I carried on past the entrance to the closed cafeteria and remembered the time I organised a concert by Tim Finn, who played to a crowd of kids and adults, all with burn injuries. The venue was grungy, the ceiling suitably low and pockmarked, much like the one at Ronnie Scott’s club in Soho. It was 25 June, Tim’s birthday and, at the end, all the patients and staff returned the favour and sang him a rousing version of ‘Happy Birthday’. He said it was the best present he’d ever had, and both he and I almost cried.
Down towards the coronary care unit I drifted. This place was a good run from the ICU on the first floor of the Galbraith block, opposite the Middlemore railway station. I’ve lost count of the number of long sprints I’ve done from one end of the hospital to the other to rescue patients from their hearts stopping prematurely, at the same time always anxious they might restart long after damage to the brain is certain. Arriving there, gasping, I would wonder whether I was next in line for a coronary. Catching my breath, I would follow the ACLS guidelines to shock and thump that dumb organ back into sinus rhythm.
At the end of each case, no matter the result, we always had an informal debrief over a cup of tea and a gingernut—biscuits that were always present in the jar at the nurses’ station. Looking back, these were special times: our performance was reviewed, new relationships were formed, and old ones reaffirmed.
As I wandered, I remembered the day in the early 1990s when—after a long and unsuccessful attempt to resuscitate a youngish man—we found the cookie jar empty and the tea no longer available. There was no debrief that day and we all trudged disconsolate back to our home wards. Soon after, the crackers, cheese and jam disappeared from the theatre tearoom, and with that stopped the unspoken, easy and relaxed conviviality that resulted from those of us attracted to it.
A face seen is a problem solved but there seemed little time or place for that kind of simple interaction between members of the specialist staff so soon after the mother of all budgets. More from less was the philosophy of the day. The buildings became meaner, the spaces smaller, access to the outdoors and natural light were not valued then nor are they much now. These are not environments conducive to learning, building and sustaining working relationships. They are places that I do my best to avoid and, when at all possible, leave.
Not long after that calamity, the hospital swimming pool—the closest world away from the turmoil and drama of the ICU and the wards you could ever imagine—was closed. Within a week it was covered with concrete. They certainly can be efficient when they want to!
Eventually, I went back to the ICU; it was close to 4 a.m. There I met Sandy and some of her family. She had become anxious when her husband of thirty years had not returned home from his bike ride so began looking for him, eventually phoning Middlemore. She was distraught when they told her that someone fitting his description was a patient in our hospital. Not knowing whether this was her husband, she told me things about him that I recognised. She then burst into tears when I gave her the medallion he had been wearing around his neck. A short while later, we went in to see him and then returned to the privacy of another room to talk.
Over the next little while I learned more about this man who was refusing to die. He was a family man with four children, and he ran a small successful business. When he was young he was a member of the Parachute Regiment of the British Army and had been a fitness fanatic ever since. Yesterday, he had been out training in preparation for a triathlon later in the year. Sandy described him as a dynamo, determined, committed and when he needed to be, totally focused on the task ahead. As she was speaking I could feel myself nodding in agreement as though I knew him almost as well as her.
Back in the ICU, the man I now knew to be Carlos had been remarkably stable but at five in the morning, his pulse rate steadily climbed and his blood pressure began to sag. He was bleeding again. Back came Rowshan and this time, with the help of a portable radiology machine, he slid his catheter back into that sheath in the femoral artery, painstakingly sought out the bleeding vessels and once again dealt with them one at a time. By the time he had finished, the sun was up and we had burned through another 30 units of blood products.
Carlos needed more dialysis before things calmed down, and then at 10 a.m. on Saturday, we finally took him to the CT suite to finish our assessment of his injuries. Just as I thought—no brain injury; chest clear; no damage to internal organs in the abdomen; several fractures of his lumbar spine without much displacement of the bones; a totally destroyed pelvis; and massive soft-tissue swelling, extending from the lower back to his thighs.
By this stage too, both his calves had become tense and swollen, and his feet cool and pulseless. We call this the ‘compartment syndrome’ and it is the result of a number of factors that effectively stop the blood flow to the muscles and tissues of a limb. Here in Carlos that was most likely a result of all the fiddling with the vessels in his pelvis, the massive transfusion needed to keep him alive, and the pressure of blood in the tissues of his back and thighs. Once recognised, our surgeons quickly opened the skin and the fascia of his lower legs, dropping the pressure in those muscle compartments, and thereby restoring their blood supply. Once that had been done, I finally went home to bed.
Carlos spent three months in the ICU. During that time, he had a series of complications and setbacks that almost took his life. After multiple bouts of infection, he was finally discharged to the ward, a skeleton of a man, his face badly scarred and blind in one eye. Most of the muscle in his buttocks was gone, a side-effect of the intervention to stop the bleeding on that first night. The same shearing forces in his pelvis that ruptured his arteries and veins, together with the enormous pressure in the soft tissues around those shattered bones, also crushed many of the important nerves to his legs so Carlos could not stand or walk. These devastating physical injuries kept him in hospital for many weeks, followed by months in the spinal unit before he finally went home.
Carlos’ life was changed forever, but he says he is grateful to me for saving his life. We see each other from time to time, at least once a year for lunch. There have been many lunches now and, during that time, he and his family have been through so much. At the beginning, there was anguish and despair about whether he would survive. Then came the fear that he might survive but be left hopelessly disabled. In circumstances like this it is not uncommon for family members to wonder whether their loved one would be better off dead. With those thoughts can come a terrible sense of disbelief and guilt that continues to gnaw especially when survival is associated with an ongoing gratitude for life irrespective of its challenges.
Carlos had been the man, the family leader, a powerful presence, and, of course, the breadwinner. After the accident, he needed to rediscover and redefine himself—as did all the members of his family as they dealt with the continuous fallout from what had happened. For him, the loss was physical and psychological—obviously his eye, but thankfully we have two, and his mobility. Carlos was in a wheelchair for months. Many said he would never walk again but walk he did. First with the help of a frame, the kind my 83-year-old mother used before she died, then perched on two crutches as he dragged his floppy feet. Months later, with the help of two sticks, he was up on those feet walking with a high-stepping gait and then, a long time later, with just one stick for balance. Now, a decade and a half later, he is walking unaided.
Unlike true paraplegics, who lose continuity of their spinal cord and for whom there is no readily available treatment to restore their ability to walk, Carlos’ paralysis was caused by crush injuries to both his sciatic nerves. The injuries occurred as a result of the pressure effect of all that blood along with the shearing movement of the pelvic bones crushing the nerve roots that form both the right and left sciatic nerves. Those nerve roots emerge from the spinal cord on both sides, then travel through windows in the bony pelvis to join up, forming the left and right sciatic nerves. Like the Amazon River, the sciatic is the longest and widest single nerve in the human body, running from the top of the leg to the back of the foot. It is responsible for the feeling we sense on most of the back of our thigh, the front of the lower leg, and the entire foot. Without it, the muscles of the back of the thigh and those of the leg and foot simply won’t work.
Carlos says I saved his life. I certainly played my part, but he is here today because of the efforts of many, not least himself and his family. In the time he was with us there were many more close calls, occasions when he seemed to be making good progress only to be set back by a complication. In the beginning, these individual battles were fought for every single advance—being able to breathe for himself; sustain his own blood pressure without help from drugs; absorbing the liquid diet we delivered down his nasogastric tube; swallowing food while he was still breathing through a tracheostomy tube. Everything was a challenge; every moment of every day there was always another hill to climb. Two steps forward some days, three steps back on others. Every inch gained came with effort and a fight. Despite our attempts to smooth the ride for Carlos, Sandy rode this rollercoaster from hell with him too—the ups and the downs and the twists and the turns. Wisely, she kept a diary of those times.
Intensive care patients like Carlos are exposed to a series of terrifying near-death experiences, caused by their accident or illness and also by what it takes to get them better. Almost all of them will have recurring nightmares and dreams, and many will have symptoms of a classic post-traumatic stress disorder—unexplained and recurrent panic attacks, depression, fear, anger, sadness, pain, as well as a range of flashbacks in which unreal memories can come back in very real ways.
In more recent times, patient diaries have proved to be a simple, no cost, and powerful means to explain and prevent the progression of many of these symptoms. Most importantly perhaps, they allow confused and scrambled patients to better understand their feelings by connecting them to the reality of what actually happened while they were so ill. Some studies show that patients may even be able to distinguish between reality and imagination, and determine whether some of those memories are misinterpretations of what actually happened. Sandy was way ahead of her time.
During Carlos’ stay with us, I asked several times whether I could read her diary. I thought that it would help us better understand what she and her children were going through, thus helping us to help her and others in the future. However, she always said no. I don’t ask people this anymore because I know that these diaries remain a deeply personal and private record of a harrowing time and, as such, are none of my business. I think it served her well whatever was in it.
It’s hard to believe that anyone can survive the physical trauma that Carlos suffered. That he did speaks volumes about him as a person. Recently, on a fine sunny afternoon, Carlos, Sandy and I met for lunch at a Grey Lynn restaurant. It had been well over a year since our last date so we had lots to catch up on. It was a terrific afternoon of reflection and ongoing reconciliation. At one point, Carlos said that despite his difficulties—and there have been many—he would never wish to turn the clock back. He said he is now more at ease with himself and a better man than he would ever have become without the accident. Carlos is a glass half-full kind of guy, but that means more than him just being blindly optimistic. He is content by design, not by luck. I came away feeling happy—happy to see them so together and in that moment of their lives—and privileged to have been part of this inspirational journey.