Saving Sid

Sidharth Gupta always dazzled people with his intelligence.

“Everybody used to praise my brother’s brain,” says Isha Gupta , two years his junior. “Everybody. Like, ‘Oh Sidharth, he’s very smart. He’s got a very sharp brain.’ That’s something that I’ve heard all my life. And his brain is what gave up on him.”

Two years ago, “Sid” was the picture of exuberance and ambition. Having established his own marketing and event planning business in his native India, he moved to Toronto in 2011 to work as an account executive at Canada’s largest advertising agency, MacLaren McCann.

According to Isha, Sid had big dreams. The event management company in India was just the beginning; he was planning to grow it into a worldwide marketing business.

Thirty years old at the time, Sid was smart, savvy, on the ball — and always up for fun.

He had “insane energy,” says colleague Zain Ali . “He could work all day and then party late and then get back to work the next day.”

“Sid was very happy-go-lucky,” says another work friend, Rishi Gupta (no relation). “He had that same smile on his face all the time. He wanted to be part of the party, to have a good time.”

That was Sid’s frame of mind on Feb. 20, 2014, as he geared up for a marketing launch at the Canadian International Auto Show in Toronto. After he and Zain put in 12 hours setting up an interactive display for the new Camaro Z28, Sid joined a few friends to celebrate Rishi’s birthday.

It started with dinner at a downtown restaurant. The group then headed to The F-Stop, a trendy nightclub in Toronto’s entertainment district.

The F-Stop is known for fine champagne and attracting a good-looking crowd, and that night the room was typically electric, with high-energy dance music blaring. Sid was in his element, recalls Rishi.

Then at one point in the evening, something peculiar happened.

Sid and Rishi were chatting when Sid unexpectedly dropped his glass. “Sid said, ‘I don’t know what happened. I just let go. I couldn’t hold it,’” Rishi recalls.

The moment passed, Sid went to the bar to get another beer and the revelry continued.

Rishi lost track of his friend after that. As the night was coming to a close, he did a quick circuit of the room. He didn’t see Sid and guessed he had already gone home. So Rishi left.

As it turns out, Sid would be the last to leave the bar. When The F-Stop was closing, the bouncer made one final check of the restrooms before locking up. There, he found a man unconscious on the bathroom floor.

Sid.

The bouncer tried to wake Sid up, but when he didn’t come to, he drove him to the nearest hospital.

In the next 36 hours, Sid’s loved ones would try to piece together how Sid came to lie semi-conscious in a downtown club — and would have to confront an agonizing choice.

An unforgettable call

The first friend or family member to hear the news was Shouvik Datta .

He has known Sid since their high school days in New Delhi, India, and has been in Canada since 2001. In 2011, Sid and his wife joined Shouvik in Toronto. (Sid's wife did not want to be named in this article.)

After the couple separated in 2013, Sid rented a bachelor suite in Shouvik’s condominium building and the two old friends got into the habit of talking or texting daily.

On the morning of Feb. 21, 2014, Shouvik got up, went to work and texted Sid around 8:30 a.m. Ordinarily, Sid would reply almost instantly. But that morning, there was no response.

After 9 a.m., Shouvik got a call from Sid’s number. Shouvik quite naturally assumed it would be his friend on the other end. It wasn’t.

“It was a lady, and she started asking who I was,” says Shouvik. “And I said, ‘Well who are you?’”

The woman on the other end was calling from Toronto Western Hospital, and wanted to know if he was related to Sidharth Gupta.

Shouvik said he wasn’t, explaining that Sid’s family was scattered across three different continents: his estranged wife lived just outside Toronto; his mother was in London, England, along with his sister, Isha; and his father was in New Delhi.

Although he wasn’t family, Shouvik managed to persuade the nurse to give the phone to the doctor, who instructed him to come to the hospital immediately.

Shouvik got there at 9:30 a.m. Upon seeing his friend in the hospital bed, Shouvik says, “I had a really bad feeling.”

“Sid couldn’t speak and he just cried when he saw me.”

The emergency room report states Sid had been brought in by a “nightclub worker.” That was around 3 a.m.

The hospital’s ER triage records (PDF) show that at 3:47 a.m., Sid was “unable to stand,” “not answering questions” and had a “hematoma over his right eyebrow,” thought to be from a “fall in the washroom.”

Zain believes that initially, the hospital staff “just assumed he was drunk.” And so Sid sat semi-conscious in the emergency ward for several hours.

At 8:07 a.m., he got a CT scan and a diagnosis: “Acute infarction [swelling] of the majority of the left middle cerebral artery territory.”

In other words, a massive stroke.

It seems quite likely now that the signs were there the day before. On Thursday, Feb. 20, Sid told Shouvik he had experienced a number of unusual physical sensations.

Sid texted Shouvik that morning to say that when he tried to eat breakfast, the food kept falling out of his mouth. Shouvik encouraged his friend to see a doctor, but Sid dismissed the severity of it, saying it must have been the result of a hangover from drinking the previous night.

Sid later told Shouvik that when he got to work and complained about numbness in his right arm, his boss advised him to get it checked out immediately. Sid acceded and went to a nearby walk-in clinic.

After visiting the clinic, Sid told Shouvik the doctor said “it was probably just a muscle strain and it would pass.” So with an apparent clean bill of health, Sid had gone back to work and later carried on to the birthday party.

When Sid’s glass of beer slipped from his grasp that night, Rishi says, “nobody thought anything of it — especially when you’ve gone to medical professionals and they said not to worry.”

The weakening of the grip, the numbness down the arm and in the face — what Sid had experienced were classic symptoms of an ischemic stroke.

After seeing Sid for the first time since his collapse, Shouvik called Sid's wife, who arrived an hour later. Shouvik also called Isha.

She recalls it was late afternoon London time when she heard from one of her brother’s oldest friends, who told her Sid had had a stroke.

At the mention of “stroke,” Isha’s mind immediately went to “Act FAST,” the slogan from a UK public awareness campaign about how to recognize a stroke and when to call an ambulance. The acronym FAST stands for “face” and “arm” (both of which become numb and droopy), “speech” (which slurs) and “time” — a reminder that when it happens, every second counts.

But that mnemonic was useless now; Sid’s stroke had occurred more than 24 hours ago.

The doctors were preparing to operate on Sid’s skull. But they needed family consent first.

Shouvik passed the phone to the doctor, who told Isha they wanted to take aggressive action — a decompression craniectomy, which would hopefully relieve pressure inside Sid’s skull.

Dr. Michael Tymianski , head of neurosurgery at Toronto Western Hospital, says that in this procedure, surgeons remove a piece of bone from the skull. With his hands, Dr. Tymianski approximates something the size of a postcard.

Video: Dr. Tymianski explains a craniectomy

“This allows the swollen brain to actually herniate out,” says Dr. Tymianski, “to come out of the confines of the skull. It sounds quite terrible, but as a result, the remaining brain is not pressed on, so the pressure inside the cranial cavity goes down.”

Isha admits she was shocked to hear that, but quickly went into a “flat zone,” where she was “concentrating on what information the doctor was giving me so that I can understand and correctly pass [it] on to my mother so that she can give her fully informed consent for the operation.”

Isha tried first to locate her mother, Manju, who was nearby in London. Since it was late in the evening in New Delhi, her father, Sushil , would likely be asleep.

When she told Manju, Isha says “all the colour from my mother’s face just faded.” Manju asked her daughter to give the consent, because “she felt she couldn't speak to the doctor.” Isha countered that it had to be her.

By this time, around noon on Feb. 21, a number of Sid’s intimates had gathered by his bedside. There was Sid's wife and Shouvik, a friend named Najah Hussain, as well as Raghu Modi , who had known Sid since they were 10 years old in New Delhi and was now living just outside Toronto.

Eventually, Isha, Manju and Sushil had a conference call with the Toronto Western medical team via Skype. Manju saw her son in a semi-conscious state and tried to reassure him, even as she quietly quaked with fear.

Manju reluctantly spoke to the doctor, asking whether Sid would live. When the doctor answered that he couldn’t say with any certainty, Isha says Manju told him, “do whatever you can do to save him.”

It was decided that Sid should be booked for a “Level A emergency surgery.”

The second surgery

During an emergency meeting at Sid’s bedside after the surgery, a doctor told Sid's wife, Shouvik, Najah and Raghu that unless the swelling subsided, Sid would have to go for a second operation.

That doctor, who was not a neurosurgeon, told the group that a second procedure “is the thing we want to avoid.” But he also explained that “if [we] don’t treat the swelling, it will get to the point where it actually will affect his brain stem. And that’s a concern.”

Audio: The bedside conversation about a second surgery

Raghu held Sid’s hand as the doctor explained that they might have to resort to a lobectomy — that is, removing a part of Sid’s brain.

The group was utterly stunned. Once the proposal had sunk in, they began asking questions they knew Sid’s family members — thousands of kilometres away — would want answered.

“What effects will that have on him later on?” Najah asked. The doctor couldn’t say for sure.

It was with the hope that the swelling would subside on its own that Raghu left the hospital around 9:30 p.m. to drive home to Mississauga. But while still on the highway, Raghu got a call from a nurse who reported that a second surgery would indeed be necessary.

If part of the brain wasn’t removed, Sid could die — at any minute.

Raghu turned the car around, called Isha and returned to the hospital.

Isha remembers the call from Raghu as the point “where things took a turn for the worse.”

By this time, Dr. Tymianski had left for the day. His colleague Dr. Mark Bernstein was on call.

In his report, Dr. Bernstein writes that Sid was falling deeper into a coma, and “eventually started to dilate one pupil, and then around midnight... dilated the other pupil.”

ICU staff hyperventilated him and gave him some mannitol, a diuretic that helps with cranial swelling. A CT scan, however, showed that the swelling was getting worse and shifting the brain off-centre from the spinal column.

On the CT scan, the affected area was “coming out as black,” Isha recalls the doctors telling her.

Dr. Bernstein felt the only option was to actually remove a part of one frontal lobe.

Isha says “they decided that this part is no good to him anyways, so let’s try to take it out and see if that will make him live.”

The proposition seemed ghastly, Raghu admits, but he assumed it was the best course of action. “You seek professional advice and you don’t doubt it, because [the doctors] know much more about it than you do, and you’re in such an emotional state.”

Isha says the nurse told her that Sid was losing consciousness, so time was at a premium — they needed to make a decision.

“It was all happening so quickly,” says Isha. “It was 5 a.m. in the U.K. at that time, and I only managed to ask the nurse, ‘What are my brother’s chances?’ and she was like, ‘Ah, not much,’ so obviously I just didn’t know what to say. So I said, ‘OK.’”

However, as the only next of kin in Canada at the time, it fell to Sid's wife to give the ultimate consent for the second surgery. Though she and Sid had been recently separated, she was still technically his spouse, which is why such a decision would be hers to make. (She shared a few of the details of Sid’s hospitalization with CBC, but says the memory is still too painful to talk about.)

In his report, Dr. Bernstein writes that he spoke to Sid's wife and that she “preferred that we do something for [Sid], in the hopes of saving his life."

“I made it clear to her that he might still die, and that in any event he would never be better than right hemiplegic [paralyzed on the right side of the body] and completely aphasic [severe language impairment].”

Meanwhile, assuming that the first operation had been successful, Sid’s father, Sushil, had caught the next available flight from Delhi to Toronto.

He was unaware that while he was en route from India, Sid's wife was giving consent for a very tricky second operation.

Isha is grateful for all the friends who were physically present during these crucial hours of Sid’s life to deal directly with the doctors and offer emotional support — essentially, “doing [the family’s] jobs when we couldn’t.”

“I feel indebted to each of them,” Isha says.

With his wife and friends at his bedside, his sister and mother on tenterhooks in London and his father on a plane to Canada, Sid was wheeled out to the operating room for a second surgery at 3 a.m. on Feb. 23.

To give a sense of how much pressure was building around Sid’s brain, according to the operation report (PDF), when Dr. Bernstein and his surgical team opened the skull and inserted a large retractor, “the frontal lobe exploded out of the patient's head."

During the approximately two-hour procedure, Dr. Bernstein and his team ended up removing a large amount of superior frontal lobe and some of the temporal lobe, but chose not to go further, “as we certainly were not planning to resect [cut out] the entire hemisphere.”

‘It was almost unthinkable to let him go’

While decompression surgery has become a fairly common treatment for ischemic stroke, the surgery is nonetheless controversial, because many people question the quality of life that patients are left with.

Video: Sid Gupta in hospital, post-surgery

“What decompression does is it generates lots of disabled people as opposed to lots of dead people.” That’s the blunt assessment of Dr. Timothy Jones , a brain surgeon at St. George’s Hospital in South London, England, which is internationally renowned for its neurosurgery and stroke services.

In terms of whether it’s advisable as a life-saving intervention, Dr. Jones says it varies from surgeon to surgeon. He says some are quite positive about it as a way to treat stroke and brain swelling, while others are more dubious, aware that many of “these patients do very badly and they have a very poor quality of life afterwards.”

Looking at the factors that inform such a critical decision when time is running out, Dr. Tymianski says there is one that always stands out for him, and that’s the age of the individual.

“Younger patients recover better, younger patients are able to cope with rehabilitation better, younger patients are able to cope with a disability better,” he says.

Doctors “don’t have a crystal ball, but we do err on the side of caution, and in [Sid’s] case, the decision was easier, because he was so young — it was almost unthinkable to let him go.”

How did such a young guy even come to have a stroke?

While the majority of strokes occur in people over age 65, 10 to 15 per cent affect individuals 45 and younger. Dr. Tymianski says the most common cause of a stroke for someone in Sid’s age group is a torn carotid artery, one of two blood vessels in the neck that feeds blood to the brain.

The tear can be due to genetic abnormalities of the blood vessel walls, chiropractic manipulation or some trauma to the neck incurred during the playing of certain sports.

The fact that strokes are less likely to happen to younger people may be why they’re often misdiagnosed.

A 2009 study by the Department of Neurology and Stroke Program at Wayne State University/Detroit Medical Center found that among 57 young stroke victims, one in seven were given a misdiagnosis of vertigo, migraine, alcohol intoxication, seizure, inner ear disorder or other problems — and sent home without proper treatment.

There’s been no determination of what caused Sid’s stroke. For his family and friends, once it was clear what had happened, their thoughts were purely on how to keep him alive.

Futile or not?

A case such as this captures all the ethical complexities of an existential debate — namely, at which point a person or their family should have the right to choose whether to preserve life or make that excruciating decision to let go.

After the second surgery, Sid was catatonic and unresponsive. When his colleague Zain arrived to visit him, he was aghast. Sid “was completely different after everything was done. He was completely somebody else.”

Zain says, “He had such a personality, and that was the biggest shock in watching him there at the hospital — was him not having that personality anymore.”

There has been impassioned discussion in recent years about euthanasia and the right to die, and in February 2015, the Supreme Court of Canada ruled that people with grievous and irremediable medical conditions should have the right to ask a doctor to help them die.

But what if the patient can’t make that decision? At the point where Sid might have died without the second surgery, he had been incapable of speaking for himself about whether his life was still worth living. Rather, it had been incumbent on his family to determine whether attempts to save him — “heroic measures” in medical parlance — were preferable to letting him go.

In his post-operative report about the removal of part of Sid’s brain, Dr. Bernstein writes that the staff in the hospital’s intensive care unit “strongly suggested that we perform some surgery to help this gentleman, and we knew it was relatively futile, but felt that we could do it.”

Isha says that after she saw the word “futile” in the report, it “was stuck in my head for months.”

“I didn’t even know what the word ‘futile’ meant and I actually Googled it and the meaning was something like ‘useless’ or ‘pointless.’”

In fact, the idea of futility in medicine goes back to ancient Greece and Hippocrates, who wrote that doctors should “refuse to treat those who are overmastered by their disease.”

In cases such as Sid’s, it may not be so black and white, says Dr. Judy Illes , Canada Research Chair in Neuroethics at the University of British Columbia, who has studied the decision-making process for decompressive craniectomies.

“There is a continuum of people who have different beliefs about when and why to save someone’s life,” she says.

In a 2014 research paper, Dr. Illes and her colleagues asked the very question: How do we make decisions about decompressive surgery? All of the neurology professionals surveyed “unanimously supported the procedure for young and healthy patients.”

But 86 per cent of respondents also agreed “that withholding surgery is ethically justified if the outcome is perceived as futile.”

Dr. Illes says that despite all the research, futility — or the expectation of a poor outcome — is ultimately a subjective call.

“The question is, ‘poor outcome' as defined by who? It sounds to me like [Sid] got some quite heroic, if not phenomenal, medical care. He’s a 30-year old man and the family was appropriately consulted every step of the way.”

Dr. Tymianski says doctors are “not in the business of taking people who are destined to die and relegating them to a life of complete dependence or disability or being in a vegetative state. In fact, many people feel that that’s actually an outcome that’s worse than death.”

But for the families, trying to take the limited information at hand in order to make a decision between death and a future of possibly severe disability is almost unimaginable, says Dr. Jones.

When the patient’s pupils are dilating, “you really only have a few minutes to save their life,” he says. “At that point, there is absolutely no time to go through the intricacies of the morals or the ethics of life after this sort of surgery.”

When asked whether he ever thinks a severely traumatized patient would be better off dead, Dr. Tymianski says, “That is not a choice for me. That is not part of my job description.”

Dr. Henry Brem , chairman of the Department of Neurosurgery at Johns Hopkins Hospital in Baltimore, says surgeons cannot concern themselves with such a decision.

“We don't play God. Our obligation is to use the resources we have to help people,” says Dr. Brem, who has performed several craniotomies. “If you start empowering doctors to decide what's a good quality of life and what's not a good quality of life, I think that gets into a very dangerous ethical area.”

Ultimately, Brem says, “A surgeon just intrinsically doesn’t want to lose a patient.”

Dr. Tymianski says surgeons constantly wrestle with this.

“Sometimes we deal with situations that are so devastating that there’s a small chance that we can have a good outcome, but there’s also a chance that we can have a very adverse outcome. So surgeons often have to face these life-and-death decisions, and sometimes we lose,” he says.

“But if we have scientific evidence backing up our actions, then we know ahead of time that if we do the right thing then we will win more times than we lose.”

Is a “win” the saving of a life?

“No,” says Tymianski, somewhat irritably. “A win is to give the patient the kind of outcome so that when they’ve been through everything, they wouldn’t curse us for doing what we did to them. Our goal is to be aligned with the patients and to give them what they wish they could have.”

In the case of Sid Gupta, we’ll never know his wishes, because he wasn’t in a cognitive state to voice his preference. And this is the central dilemma surrounding the ethics of giving patients or their families the option to choose.

And two years later, Sid is no more able to state his opinion than he was while lying on the operating table.

A second life

Sid was in hospital for five months. Despite the expense and the language barrier, his father, Sushil never left his side.

When Isha came to Canada a couple of weeks after Sid’s surgeries, she wasn’t sure the family had made the right decision.

“At that time, he was completely in a different world,” she says. He would only “stare at us — there was no smile, no reaction, no nothing.”

Anyone who visited Sid noticed that his left hand would reflexively go to the left side of his head, which looked like it had caved in. In May 2014, he had a third surgery, to replace the piece of skull that had been removed in the first decompression procedure.

One of Sid’s work colleagues undertook a crowdfunding campaign and clothing drive to ensure Sushil could weather a Canadian winter in order to stay with his son. They raised over $8,000.

But eventually, Sushil could no longer afford to stay in Toronto, and took Sid back to India.

Sid now lives with his father in the family’s home in New Delhi. In order to accommodate Sid, they had to buy a hospital bed — it’s too large to fit through the door of Sid’s old room, so it currently straddles the living room and the hallway.

There is no live-in caregiver other than Sushil, although a nurse does come every weekday to help bathe Sid and change his clothes.

The only other permanent resident of the house is Sid’s beloved Doberman pinscher, Zeus. According to Isha, when Sid arrived at the house in a wheelchair in July 2014, the dog immediately sensed that something had happened. Rather than jump all over Sid as he might have done before, Zeus is now content simply to lie near him.

Sid is visited twice daily by both a physiotherapist and a speech therapist. In a series of texts and videos to CBC News, Sushil reveals that while Sid cannot form sentences or use his right arm, he is able to sit up, stand with the assistance of a brace on his right leg and feed himself.

In many ways, he has exceeded expectations. Sushil writes that while Sid is still in poor shape physically, mentally “he is better.”

On Sept. 1, Sid celebrated his 32nd birthday. Photos show him smiling while surrounded by friends and family in India. His father takes pictures and videos of Sid’s progress in speech therapy and physiotherapy, as well as some of his daily routine. One video shows him shrugging and shaking his arms in rhythm to Indian pop music.

Some of the clips can be difficult to watch. It’s gut-wrenching seeing a once-vibrant, intelligent young man struggling to feed himself and learn to say something as basic as “mama.” There are also moments when Sid can be seen shrieking in pain; anytime this happens, the dog becomes unsettled and starts pacing.

Isha can’t help but compare Sid in his current state to the capable man he used to be. “He just wanted to do everything.”

What makes the situation even harder for her to bear is that Sid has always played an outsize role in the family. When Isha was younger, he was her protector and the breadwinner.

For many years, the Guptas depended on Sid’s guidance and generosity. For example, after their father’s business failed, Sid paid for Isha to go to university in London.

Now, she and her husband, Saeed, send money back to India for Sid’s care.

“I’m not used to being the responsible sibling,” Isha says.

Although she now lives in Wales with Saeed and their two young children, Isha has visited New Delhi on several occasions and stays in close contact with her dad.

“My father was telling me the other day that Sid sometimes starts to laugh and then starts to cry and sometimes sticks his tongue out and winks all at the same time, all one after the other,” Isha says.

“When my father told me this, I wasn’t sure whether to be happy about it or to be sad about it, because it’s something that is messing him up. I started crying after this.”

Raghu talks to Sid on the phone from time to time. Because Sid can’t really speak, Sushil mediates the calls. For Raghu, hearing his friend’s incomprehensible utterances only reinforce how much he misses the old, gregarious Sid.

Shouvik has doubts about whether his best friend would want to live this way.

”I don’t know if he’s happy that he’s alive or sad that he’s alive like this. I mean if I were him, I would rather be dead. And looking at what a free spirit he was… it’s just that he has the rest of his life and he has to spend it like this.”

Dr. Tymianski says that if asked hypothetically, “some people have a perspective that if they can’t be neurologically normal, they wouldn’t want to stick around.”

But others say they “would find it acceptable if they could stick around and be with their families and see their grandchildren and watch television with them.”

All the neurologists interviewed for this story agree it may be too early to tell the full extent of Sid’s recovery. One thing is for sure: his youth may work to his advantage.

The brain’s ability to remake neural connections — what’s known as its plasticity — is still not fully understood, but it is possible for a person missing a large portion of their brain to live a productive life, says Dr. Brem at Johns Hopkins.

He cites the example of epileptic children who undergo radical hemispherectomies in order to stop incapacitating seizures. These patients can “grow up normal, not impaired. They're not paralyzed, they're normal human beings.”

Isha acknowledges that as excruciating as it was to make those decisions back in the winter of 2014, the surgeries saved her brother’s life. She takes solace in the fact that when “I think about my brother, there is someone there for me to think about.”

And despite his limited brain function, Sid’s situation is not the worst-case scenario sketched out by the doctors prior to his first surgery — namely, a “complete vegetative state.”

Recounting Sid’s story brings Raghu to tears, but he is ultimately proud of his friend’s recovery.

“The doctors said he wouldn’t be able to eat, he wouldn’t be able to stand… he wouldn’t be able to do so many things, but he’s doing a lot of things. He eats, he swallows, he tries to write the alphabet with his hand and doctors said he would never be able to do those things.”

While it’s hard to quantify his progress, Isha believes Sid has beaten those dire early expectations.

“Compared to where my brother is now,” she says, the doctors “were about 40 to 50 per cent wrong.”

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