Coma

“Little is understood about the injured brain,” notes a title at the start of Coma. This even as someone’s brain is injured every 15 seconds in the United States. Thus the mystery and trauma are compounded by the fact that they’re so common and strange, so unpredictable and, too often, devastating. While one frequent effect of brain injury is coma, this is not precisely the focus of Liz Garbus’ documentary. Instead, it considers a variety of experiences that begin after patients emerge from coma.

The film looks at four cases at the Center for Head Injures at the JFK Medical Center in Edison, New Jersey. Gently and intelligently, Coma follows the effects of brain injury on patients and, even more acutely, family members, rather than focusing on specifics of damage, diagnosis, technology or medical science (or how such extensive treatment is financed). The first patient on screen is 19-year-old Roxanne, whose mother encourages her to open her eyes, propping open her lids so that she might glimpse light. “Wake up,” says her mother, Miriam, “So everybody can see your eyes.” And with that, you’re made aware that the film is not only about loss, hope, and all-consuming love, but also about the limits of filmmaking and making painfully personal experiences public.

Brain injuries surely do garner occasional flare-ups of publicity: consider Terri Schiavo, the reawakening of Polish railwayman Jan Grzebski following 19 years in a coma, and the fact that some 1,800 US troops have suffered traumatic brain injuries in Iraq and Afghanistan. Still, the film exposes usually unseen diurnal dealing with consequences and possible treatments, impossible and inevitable decisions that need to be made.

These decisions are typically faced after patients wake from comas, entering into one of two conditions — the minimally conscious state, from which Terry Wallis awoke after 19 years (he’s the subject of a short documentary available on HBO’s on-demand), and the persistent vegetative state, in which Schiavo lived for 15 years. (A permanent vegetative state, like Schiavo’s, offers no chance of recovery.) A couple of patients in Coma, Sean Reilly and Al’Khan Edwards — appear to slip between these states during the first year following their injuries (Sean was “assaulted and thrown off a bridge while studying in Europe,” 26-year-old Al’Khan was in a car accident). Their mothers visit frequently, hoping to bring their sons back to consciousness.

Both doctors who provide the film’s primary commentary on consequences and therapies — neurologist Joseph Giacino and Caroline McCagg, Medical Director at the JFK Center — say the first year after injury is critical, that the “the window of improvement begins to close” afterwards. Roxy and 36-year-old Tom show different symptoms, more consistently in minimally conscious states. All the stories are heartbreaking, though they come to different sorts of conclusions. None of the relatives can be prepared for the challenges they face. As Tom’s mother Veronica puts it early in the process (he has just awakened from a three-week coma), “On TV, they wake up from a coma like that [she snaps her fingers], and everybody’s fine. So it’s quite an experience.”

This experience is demanding and difficult, a point underlined by visitors like Sean’s brother or Roxy’s friend Joan, who don’t see them daily. Where Miriam is emphatically engaged in Roxy’s every gesture and sound, Joan serves as something of a surrogate for Coma‘s viewers, her reactions, captured in close-up, revealing sympathy, compassion, and brief signs of discomfort. The ups and downs of the recovery process wreak havoc on caretakers. As Giacino observes, “The hallmark sign of a minimally conscious state is inconsistency.” He seeks “intentional behavior,” responses to stimuli, efforts to speak or connect.

Yet even this sort of behavior doesn’t always mean what loved ones want it to mean. Roxy misidentifies a hammer as a screwdriver, her mother holding tight to her chair in the background of the shot. Giacino is encouraged by the fact that Roxy grasps the category, while Miriam sighs, “Nobody wants to watch their child suffer.” Sean’s mother Susan says, “‘I don’t know’ is the worst thing you want to hear your doctor say,” and yet, this may be the most frequent response that doctors treating brain injuries have to make. Each case is different, no result is guaranteed, and no one makes progress without relapsing.

The sheer complexity of these stories makes Coma a daunting project. To mark shifts in time, it uses a four-way split screen, then selects one story to tell for the next few minutes, suggesting both a 24-ish simultaneity and sense of urgency. Where one patient seems to be improving, another falls back, inexplicably unable to open his eyes where just days before he was watching Dr. McCagg as she moved to test his ability to “follow.” Occasional montages suggest comparisons among the four cases (one montage is set rather excruciatingly to Simon and Garfunkel’s “For Emily”), but for the most part, the film keeps the stories separate, underlining that none is predictable or like the others.

Some patients show frustration (when Tom and Roxy begin cursing at their therapists, one sighs, “You got to have a little bit of a thick skin”), while others seem to fade away, increasingly withdrawn from the world. “This is just an unacceptable state for someone to be,” says Susan. “This is stuck in between.” And looking at her son, Susan is also feeling stuck. “The better they get,” observes one doctor, “The harder it is on the families, because they want more.” One step forward increases hope, which makes a step back seem unbearable. Weary and sad, Susan describes her need to keep on, to seek solutions to Sean’s suffering while enduring her own “very private and independent trauma.”

That she does so for Coma‘s cameras is variously harrowing. When, at one point, the filmmaker’s voice can be heard off-screen asking whether she might follow one mother and father after they’ve received bad news from the doctor, it’d briefly jarring. Informed that they want to be ‘alone,” the camera operator remains behind as the couple makes their slow, sad way to the elevator, the door closing on their unknowable grief. You’re reminded at this moment that the families agreed to be filmed during this most agonizing period of their lives, without any inkling of how their stories might evolve. Fascinating as it is, the film can’t show all.