Extended Interview: Dr. Steven Fish

SUSAN DENTZER:

Let's talk about what happened to Jay Briseno, to the best that you know, in terms of his injury in Iraq and what happened to him subsequently.

DR. STEVEN FISH:

He was shot just underneath the level of his helmet in the upper part of his neck. This fractured bones in his neck and severely injured his spinal cord in his neck.

DR. STEVEN FISH:

Jay, while he was on active duty in Iraq, was shot in the neck just below the level of his helmet, which has fractured some of the bones in his neck, and also caused severe damage to the spinal cord in the neck. As a result of that, he is paralyzed in the arms and the legs. He is unable to breathe on his own. He is dependent on a ventilator for breathing.

During the period of his evacuation to Germany from Iraq, he had two cardiac arrests which resulted in periods of poor blood flow to the brain without oxygen supply and that has resulted in a type of brain damage that we call hypoxia, which means lack of oxygen.

As a result of that, his abilities to, to, to speak, to think, to reason, to understand, and to see have been affected.

SUSAN DENTZER:

How seriously affected?

DR. STEVEN FISH:

Well, at first it was thought to be very seriously affected and it was thought that he was in fact in a vegetative state where he really did not respond except by reflex.

But he has gradually had some recovery from that and at the present time, it is clear that he understands at least a good part of what is being said to him and a good part of what's going on around him, and he can respond to questions, usually just in a yes/no type of answer and not always accurately but definitely responding.

SUSAN DENTZER:

He can't speak.

DR. STEVEN FISH:

He cannot speak.

SUSAN DENTZER:

So tell me how he responds.

DR. STEVEN FISH:

He responds generally by smiling, meaning yes, and not smiling or frowning, meaning no. We have tried to get other communicative techniques into play with him, using audiovisual technology, where he would look at a, at a certain response on a board and that would indicate what he meant. But the re–the results with that so far have been only partially successful.

SUSAN DENTZER:

To the degree he does response, you were giving me an example earlier, I'd like you to tell it to me again–the anal–or the example of his parents asking him about his favorite show, Friends.

DR. STEVEN FISH:

Yes; yes.

SUSAN DENTZER:

Tell me that whole story.

DR. STEVEN FISH:

Well, his mother would say which character on Friends do you like? And she would say do you like Ross? There would be no response. Do you like Joey? No response. Do you like Rachel? A big smile. So you know that he could understand what, what you're saying. And also when he watches a Redskins game, he is smiling and, and very obvious that he, he is understanding that his team is playing.

SUSAN DENTZER:

He also cries.

DR. STEVEN FISH:

He also cries at times. That is often in response to, to something unpleasant, or something emotionally unpleasant. So, you know, he does have appropriate responses sometimes. Most of the time.

SUSAN DENTZER:

Let's talk about a informal scale of one to ten, one being what his mental and cognitive ability was when you first saw him, ten being perhaps full recovery. Where is he now?

DR. STEVEN FISH:

I'd say he's probably up around a five at this point. Yeah.

SUSAN DENTZER:

How far could he go?

DR. STEVEN FISH:

I don't think we're really sure how far he can go. We initially didn't really think he would get to this point. So I don't think that we can say that he's not going to go farther. I would be very hesitant to say that he'll have a full cognitive recovery because he's, he's now several years out from the injury.

However, we do know that the recovery of the brain can be very prolonged, and that although most of the recovery, we usually say occurs in the first year, we know that that recovery does not end at the end of the first year.

SUSAN DENTZER:

You were saying to me earlier, and I'd like you to say this again, that his age is in his favor here.

DR. STEVEN FISH:

That's true. Young people have a much better chance for recovery than, than older people do. The brain is, has more plasticity, more ability to use alternate pathways and to recruit other parts of the brain that are not functioning, that would be used in–not in their normal function but can be re–recruited for other functions.

This is much easier to do in children and young adults than it is in older people.

SUSAN DENTZER:

We–as I mentioned, we are trying to depict what the totality is of the care–I don't even want to use the word burden, but the care and responsibility that his parents must provide. What do they have to do for him?

DR. STEVEN FISH:

Jay requires 24 hour around-the-clock care. He is of course on a ventilator. T he ventilator has an alarm, if there's a dysfunction, but somebody has to be nearby at all times.

He requires suctioning through his tracheostomy tube. He requires frequent repositioning and turning. He–

SUSAN DENTZER:

Because?

DR. STEVEN FISH:

Becau–to prevent pressure sores and, you know, to give relief from pressure on various parts of the body, repositioning is very important. He requires feeding through the tube that goes into his stomach. That initially was done around the clock, but now we have changed that so that he gets fed regular meals through this tube at mealtimes, although it's not regular meals. It's liquid, it's a liquid feed.

SUSAN DENTZER:

And to state why he must be fed this way.

DR. STEVEN FISH:

He cannot swallow.

SUSAN DENTZER:

He has no–the muscles are paralyzed.

DR. STEVEN FISH:

The muscles in his throat don't, don't function.

SUSAN DENTZER:

Could you say that to me in one package.

DR. STEVEN FISH:

Yes. He requires a feeding tube that goes directly into his stomach through the skin of his abdomen because the, his throat muscles do not function and he cannot swallow. If he tried to swallow, the fluid would go into his lungs rather than into his stomach; would cause pneumonia.

SUSAN DENTZER:

And again, those are parts of his condition from which he's not likely to recover?

DR. STEVEN FISH:

Not very likely to recover. There has not been–there has not been any recovery, that we can determine at this time, in function, muscle function in the arms and the legs, or breathing.

SUSAN DENTZER:

And to talk about a delicate area that people don't always want to talk about. His elimination functions.

DR. STEVEN FISH:

Those are not under his control. He wears a, an external catheter which collects the urine and it goes through a tube to a collect bag. His bowel care, basically he has his bowel movements when he has them, and they're cleaned up; can't control that.

SUSAN DENTZER:

And he wears a diaper of some sort?

DR. STEVEN FISH:

He wears a diaper; yes.

SUSAN DENTZER:

He does have involuntary movements or it looks as if there are involuntary movements of his face.

First of all, if you could say that and then explain what's going on when that happens.

DR. STEVEN FISH:

He does have–he does have both voluntary and involuntary movements of his face. The voluntary movements are expressive, and we discussed these before–the smiling and the frowning and the crying. But he also has some involuntary movements of his mouth and his tongue which are a result of the damage to the brain from the periods of lack of oxygenation.

SUSAN DENTZER:

So what's going on? The brain is just randomly sending signals to the tongue–move?

DR. STEVEN FISH:

This, these probably are coming from a lower part of the brain called the brain stem, which can produce some involuntary movements when damaged.

SUSAN DENTZER:

Give–because, as we were saying, Jay's functions are so compromised and he does require this 24/7 care, what, from your perspective, what kind of emotional burden, again to use that perhaps unfortunate word, has this placed on the family?

DR. STEVEN FISH:

Well, it's a tremendous strain. I can only imagine what it's like for them. I know that they are a very close family and they insisted that he remain at home. They've created an intensive care unit in the basement of their home to care for him. He–the family participates in the care very closely. The father has actually left his full-time job to be the full-time caregiver for, for Jay. The mother also, although she continues to work, she is also a caregiver as well, as, as well as the, Jay's sister who still lives at home.

In addition to this, they do have a staff of, of nurses and aides who do a lot of the care. But the family spends a lot of time with him every day and whenever I call the home, there's always somebody from the family right there.

So I know that this has changed their lives enormously. They, they don't get our very much, they don't do very much. They're, they're there with him all the time.

SUSAN DENTZER:

In your experience as a physician now, here, at the VA for several decades, have you ever seen anything like this?

DR. STEVEN FISH:

We have had other patients who have had very caring and attentive families who wish to care for them at home, and we realize this is an enormous stress on the family, and one of the ways that we help to relieve this is by helping to coordinate and provide the professional care that, that is provi–the VA provides in the home, and we also provide periods of respite care for the caregivers, when the, the, the veteran is brought into the hospital for a stay of one week or two weeks, so that the, the family and the other caregivers can have a break.

SUSAN DENTZER:

And in fact Jay just went through that.

DR. STEVEN FISH:

He did go through that.

SUSAN DENTZER:

During that time he was here, let's just briefly discuss, there was an attempt to wean him off the ventilator.

DR. STEVEN FISH:

Yes.

SUSAN DENTZER:

First of all, if you could say that to me, say why that might be important or desirable, and then tell me what the outcome was.

DR. STEVEN FISH:

The, the family was hoping that they would be able to get Jay off the ventilator, that he would be able to breathe on his own for, perhaps not totally 24 hours a day but at least for some periods.

We attempted to do this by taking him off the ventilator to see how well he could do. Unfortunately, he was able to move very little air because of the paralysis of his chest and his diaphragm, and therefore his blood oxygen level started to drop quite dramatically and it was necessary to put him back on the ventilator to restore the, the breathing.

SUSAN DENTZER:

So the likelihood that he'll be able to be weaned off the ventilator is what, would you say?

DR. STEVEN FISH:

Well, we can try that again when he comes back again. We would prefer to do that while he's here in the hospital, when we have a full staff, right there watching him in case there's a problem.

But since this, several years after his injury, he has very, very little respiratory capacity, I don't really have a great deal of hope that he's going to be able able to be weaned off the ventilator.

SUSAN DENTZER:

How long is Jay likely to live in his current condition?

DR. STEVEN FISH:

With good care, good nursing care, he could have a normal lifespan. However, as we know, patients who are quadriplegic and ventilator-dependent can run into a lot of medical complications, and even with the very best care, bad things can happen. Infections, blood clots, sores, pneumonia. And in the case of Christopher Reeve, for example, who was getting, you know, the best care available, his life was shortened by his, his spinal cord injury.

SUSAN DENTZER:

And he died of an infection–

DR. STEVEN FISH:

Yes; he did.

SUSAN DENTZER:

–followed by cardiac arrest.

DR. STEVEN FISH:

Yes; he did.

SUSAN DENTZER:

So tell me if this is correct. Jay could die tomorrow or he could live to be ninety-five.

DR. STEVEN FISH:

That's right.

SUSAN DENTZER:

Could you say that to me.

DR. STEVEN FISH:

DR. STEVEN FISH:

Jay could, Jay could succumb to an infection or another, another complication in the very near future. Or he could live to be–to old age.

SUSAN DENTZER:

Ninety-five? A hundred?

DR. STEVEN FISH:

Well, if, if that's in the genes of his family, and he would have lived to be that age otherwise, it's possible.

SUSAN DENTZER:

His family is very religious–

DR. STEVEN FISH:

Yes.

SUSAN DENTZER:

–as you know.

DR. STEVEN FISH:

Uh-huh.

SUSAN DENTZER:

And they believe that this is God's–it is God's will that Jay will recover and, and walk again.

First of all, how likely do you think that is, that he will walk again?

DR. STEVEN FISH:

I don't thin it's likely.

SUSAN DENTZER:

If you could say it, I'm sorry, in a full phrase–I don't thin it's likely he'll ever walk again.

DR. STEVEN FISH:

I don't think it's likely that he'll ever walk again with medical technology and science at the current level that we have now.

Improvements or advances in the future may change this, and I would not say that it's never going to happen.

With–but my prediction, you know, at the present time is I do not think so. However, you know, he did have a good deal of cognitive recovery which was not really expected either, so I don't tell the family that it is never going to happen because I know that they feel that they need to have hope.

SUSAN DENTZER:

And they do have hope.

DR. STEVEN FISH:

And they do have hope; yes.

SUSAN DENTZER:

Okay. Let me just glance down at my sheet and see if there was anything else we wanted–oh.

Just the one aspect of his vision, how much vision he has, I think is the only other thing we need to cover.

So you, you've been able to look inside his brain with the MRI technology.

When you do that, what do you see, and what does it tell you about his capacity such a vision, et cetera?

DR. STEVEN FISH:

The MRI can tell us if certain parts of the brain have been damaged and the, the MRI that we have had done shows that there is damage to the part of the brain that has to do with vision to the right side. So we know that he has some decrease in vision to the right side.

However, formal testing of his vision has been very difficult because of his limited ability to respond and to tell us exactly what he's seeing and when he's seeing it.

So we do know that he sees and we do know that he has, you know, at least enough vision to discern faces and to discern what's going on on a television screen.

But we cannot actually put a number on it. We can't say that his vision is 20/20 or 20/50. But we do know that he has enough vision to perceive his surroundings.

SUSAN DENTZER:

So we know he sees, we know he hears. And we know that he can feel–well, let me ask that. Can he feel?

DR. STEVEN FISH:

He can feel in his face but he does not have any sensation below the neck.

SUSAN DENTZER:

So when his mother kisses him he feels that?

DR. STEVEN FISH:

Oh, yes. Yes; he does.