Jordan was nine years old at the time of the devastating accident. He was in the backseat, buckled up, when a dump truck collided with the car his mom was driving. The force of the impact was so severe it literally tore Jordan’s skull from his neck and pitched it forward. The medical term for this type of injury is an atlanto-occipital dislocation, also known as an internal decap-
itation. All of the soft tissues inside the neck that keep the head connected were destroyed and his head was dangling, unattached by anything except his skin and the most superficial neck tissues. His mom later said that when she looked into the backseat after the horrific collision, it looked like Jordan’s head was just dangling in front of him. She didn’t know how right she was.
I was the neurosurgeon (brain surgeon) who was in charge of Jordan’s care. My first question upon his arrival to the hospital and after seeing the X-ray studies was, “Is he still alive?”
As soon as I evaluated him, I knew how severe his injuries were. His MRI test (a special type of imaging study) showed that all of the soft tissues under the skin of his neck were destroyed. Survival from this type of injury is less than 1 percent, and among those very few who survive, paralysis and brain damage are the rule. Although Jordan’s spinal cord was, miraculously, not severed, I didn’t know how badly it may have been traumatized. What I did know was that his head and neck had to be immediately stabilized to prevent his spinal cord from further injury.
I put him into a halo vest, a carbon-fiber ring that is fixed to the skull with sharp pins, and then attached to a vest on his torso with rods to temporarily hold his head in a stable position. A torture device, to be sure, but still the best way to stabilize his neck. We then took him to the operating room where I attached a titanium plate to his skull and titanium rods and screws from the plate to his spinal column to keep his skull attached to his spine. After surgery, in the intensive care unit, we allowed ourselves to believe for the first time that he would likely survive, but we still had no way of knowing whether or not he’d be paralyzed, or have other brain or spinal damage from the injury. In the early hours and days it didn’t look good. The left side of his body was weak, suggesting there had indeed been some stretching or bruising of the spinal nerves. And he wasn’t speaking, raising the concern of brain damage.
But in the weeks following surgery, Jordan shocked all of us with his astounding recovery. With the help of intense physical therapy, he went from a wheelchair to a walker to walking on his own. His speech came back and the weakness on his left side resolved. When he left the hospital, three months after his accident and several days before Christmas, he did so on his own power. Incredibly, he returned to school after winter break. Because of the rods and screws attaching his skull to his spine, his neck movements will always be somewhat restricted, but otherwise he is neurologically back to normal.
This is the first case of internal decapitation I have ever seen survive. It’s an injury that is almost always catastrophic, almost always fatal. Most patients never make it past the accident scene, dead on arrival to the emergency room. Of those who do survive, a nearly full recovery like Jordan’s is virtually unheard of.
In media interviews when her son was discharged from the hospital, Jordan’s mom called this the best Christmas miracle she could ever have imag-ined. I agree and, along with fine teams of caregivers—beginning at the accident scene, on to the emergency room and operating room, in the intensive care and transitional care units, and all the way through rehabilitation and hospital discharge—it was a privilege to have been a part of it.
Date of event: July 1, 1968
When Lightning Struck
James K. Todd, MD
It was July 1, the first day of my first clinical rotations as a third-year medical student, far too early for me to have decided what area of medicine I would ultimately like best. After all, I had never really taken care of a patient of any kind yet, and there was so much I didn’t know.
This was my pediatrics rotation, and I was assigned to a typical county hospital with very limited resources, staffed by a few senior physicians, residents, and medical students like me from the large, state university medical school. It was a Saturday that began bright and sunny, but became cloudy with severe thunderstorms in the afternoon. I had just gotten oriented to the pediatrics ward when a call came from the emergency room that I should come immediately. A six-year-old girl had been playing in her backyard when lightning struck a metal clothesline and sparked down one of the poles, leav-ing little Fern breathless and without a heartbeat.
The firemen responded quickly and found her barely breathing and having violent seizures. As soon as she arrived at the emergency room, staff quickly inserted a breathing tube through her mouth into her trachea. They were using a self-inflating resuscitation bag connected to the tube, pumped by hand, to breathe for her.
“Here,” said the senior resident handing me the bag, “you keep her going while we see to some other emergencies.” The doctors had heavily sedated her to slow her seizures, which had the unfortunate side effect of stopping her breathing altogether. It was all they could do under the circumstances. I sat there for what seemed like hours watching every heartbeat on the monitor. If I slowed down my hand-pumping of the bag, her heart rate would begin to slow as well, indicating she wasn’t getting enough oxygen. This tube and bag were the only things keeping her alive.
By evening, it was obvious we had to make other arrangements for Fern’s care. We didn’t have a pediatric intensive care unit, she couldn’t stay in the emergency room because of lack of space, and we certainly didn’t have the staff to keep breathing for her by hand-pumping the bag.
“Do you know how to run a ventilator (mechanical breathing machine)?” asked the pediatrics resident in charge of the nursery.
I had no idea—this was my first day wearing my white coat as a medical student in a hospital! This hospital had just two newborn baby breathing machines that were used for small premature infants; one was available.
“I don’t know if it will work for someone this big, but it’s all we’ve got,” he said.
Still hand-bagging her, I moved Fern to a room across from the pediatric nursing station. We hooked her up to the newborn breathing machine that was run off a pressurized oxygen line. There were only a few dials that allowed adjustments so we fine-tuned it the same way I had learned how to adjust a sail as I headed the boat close into the wind—pull the tiller in a bit while tightening up on the main sheet. Sailing was all a matter of trial and error, with constant attention to the wind indicators and the speed and direction of the boat. In trying to adjust the dials on this breathing machine, I watched her chest rise and fall with each pressurized burst of the machine, and made sure that her heart rate didn’t drop.
“Good work,” the resident said. “Don’t go anywhere for the rest of the weekend. You are all she’s got. There’s no one else who knows how to run this machine.”
God help us, I thought, we’re in big trouble if I’m the knowledgeable one.
The nurses brought a bed in for me, but I don’t remember having slept a bit the next two days. It was July 4th, and we had tried several times to wean her off the sedation that was controlling her seizures and suppressing her breathing, but every time she would start having seizures again. Her devoted and grieving parents, who had been continuously at the bedside with me, were losing hope and so was I. It seemed like we weren’t making any progress. Fostered by exhaustion and self-doubt, questions raced through my mind. Should we give up? Is this what a career in medicine is going to be like?
The nurses insisted I go home for some much-needed rest. By then, the ward resident and another student had learned how to keep the breathing machine going, but we were all concerned that her brain had been too badly damaged from lack of adequate oxygen and seizures. I was exhausted, both emotionally and physically, even more the former because of the realization that Fern’
s life had been solely in my inexperienced hands for almost three days and yet her condition remained grave.
I slept through Independence Day and have no recollection of any fireworks; they could have exploded right next to me and I doubt that I would have noticed. The next morning, I hurried back to the hospital, my own heart racing with the fear that Fern had not made it. As I walked down the hallway, I saw several of the nurses looking excitedly toward me. They disappeared and then, probably with their coaxing, little Fern came around the corner walking unsteadily toward me. Miraculously, while I had slept, her seizures had stopped and she had been quickly weaned off the ventilator.
“Thank you, Dr. Todd,” she said as I dropped to one knee to hold her with tears of joy in my eyes. I wasn’t even close to being a doctor yet, but at that moment, even though this was only my first clinical experience, I knew I was destined to be a pediatrician. I had witnessed the resiliency of young life, its ability to heal and to adjust to adversity. Fern’s parents later told me the only difference they saw in their little girl after her recovery was that she had previously been right-handed. They presented me with a picture their now perfectly normal daughter had drawn for me, now with her left hand. A few circuits may have been scrambled by the lightning, but not her essential spirit. Having endured for agonizing days the ordeal of helplessly watching their daughter having seizures and unable to breathe for herself, they were so thankful—and so was I.
There would be many times in the years that followed, as I cared for other desperately ill children in the intensive care unit, that I would remember Fern. She had taught me that, beyond the limits of my medical knowledge and skill, there is also always the power of hope.
Date of event: 2005
Shrapnel—I Knew He Had Lost His Eye
Robert J. Buys
Before I ever met Joe, I knew he had lost his eye.
It was all there in the black-and-white X-ray image of his eye sockets—a large piece of metal lodged in the back of the eye. This is called an intraocular foreign body (IOFB), meaning an object within the eye that shouldn’t be there. Joe’s story was a common one for this type of incident—and so typically frustrating. A piece of metal had exploded off an axe during log-splitting. He was not actually using the axe—he was several feet away. As the metal projectile raced through the air it heated up and probably became sterile from the friction. That is where the good news for Joe ended. It is not unusual for flying projectiles to hit the one soft spot on the face—the eye—as it did with Joe. Or maybe when an object hits elsewhere on the bonier parts of the face, victims don’t require medical attention as often. Regardless, when a flying projectile is headed in the direction of the eye, the eye seems to lock in on the incoming missile so, invariably, the vital structures in the center of the eye, the center of visual focus, are hit. Structures crucial for vision, like the optic nerve, which transmits visual images to our brain, or the macula, which is the structure responsible for our main central vision and the source of our greatest visual acuity, are damaged. The bigger the IOFB the greater the chances are that the damage will be catastrophic. And this was a big one.
Joe was just a kid—floppy blond hair, smooth skin, round face, full of the innocence toward life that all twelve-year-olds seem to have. At this age, he’d yet to hit the really big milestones that would mark his passage from childhood to adulthood: getting a driver’s license, senior prom, graduation, attending college. I was certain this accident would affect all those events in ways we couldn’t predict just yet. For now, all I could see was a kid facing the first truly big crisis of his life.
As I met the family I tried to assess his home situation. Would he have the support needed to get through this? The parents were on the verge of tears, very concerned, and full of love and compassion. They were older folks who, as it turned out, were not his parents but his grandparents. There was something in the way the grandfather rubbed his hands, dropped his head, could barely speak. It was not just love and concern—guilt. He had been the one using the axe and he blamed himself.
My physical examination of Joe’s eye revealed the path the piece of metal had taken—an entry site in the cornea, the clear surface structure of the eye. From there it traversed the fluid-filled front chamber without causing any bleeding, and then into the iris (the pupil). His lens was clear, but that can be falsely reassuring—often cataracts will form and cloud the lens sometime after the trauma. The pressure within the eye was low, as would be expected with an open wound. My view to the back of the eye was blocked by blood within the vitreous, the jelly-like substance that fills the back chamber of the eye. His visual acuity was extremely poor—he could only see my hand moving in front of his face.
It was close to midnight when the surgery began. What would be required would be a three-stage procedure. First, I would have to repair the wound to the cornea. Then, an operation called a pars plana vitrectomy. The pars plana is a structure in the eye that provides access to the back chamber of the eye; vitrectomy means the removal of the gelatinous fluid in that chamber. In this case, the procedure would remove the blood that had accumulated in that back chamber. Finally, I would have to make a large incision to get the IOFB out of the eye. In young patients the vitreous is well formed and sticks to the retina at the back of the eye. This presents a challenge to the surgeon, particularly in the early stages of trauma. The retina is the vital structure in our eyes that processes light—without the retina, or with a severely damaged retina, a patient will be blind.
I cleared the blood and looked around for the piece of metal. I carefully examined where it had hit the retina—on the nasal side, causing no damage to the optic nerve or macula that I could see. Remarkable. But I could not find the metal! Often the IOFB bounces off the retina and can lodge away from the impact site. I returned to the impact site and carefully examined it. I could feel the tip of the metal beneath the retina. The IOFB had travelled from the cornea, clear through the vitreous and the retina, and was now lodged in the sclera behind the eye—a through-and-through wound called a double perforation. I could not budge it from its final resting spot, despite trying with magnets and probes. I had no choice but to leave it there and live to fight another day. I closed the incision in the eye and removed the surgical drapes on the patient’s face, revealing, to my horror, the most unusual post-operative situation I have ever seen.
Incredibly, the eyeball was bulging out of the socket as far as humanly possible. He looked like a something from a sci-fi movie. I could not relieve the massive swelling, could not even close the lids over the eye. The operating room went silent and my worst nightmare was literally staring me in the face. It was late at night, I was exhausted, and the fate of Joe’s eye was hanging in the balance. And I had no idea what to do. I covered the eye with ointment, put a patch on, and wondered what had happened. Had he bled into the eye socket as I probed for the IOFB? I faced the grandparents and wondered how I was going to possibly take the patch off the next day.
I knew then he had lost his eye.
The next morning, only five hours after the surgery, I removed the patch, prepared for what I thought would be an ugly sight. I could not believe what I saw—the eye was back to normal and his vision was actually pretty good! I could see to the very back of the eye, and the retina was attached. My only explanation was that as I cleared the gelatinous fluid from the impact site, or perhaps during my attempts to get at the piece of metal, the exit wound became open and the fluid I was infusing during the procedure left the eye and went to the eye socket. This had created the bulging and now that excess fluid had been reabsorbed. I was counting my lucky stars—a miracle had saved the eye—and Joe’s vision was improving!
But it was not to be.
Within a week everything had changed; the retina had now completely detached from the back of eye. Stiff folds of the retina emanated from the impact site. Joe’s vision was back to hand motions only. Again my heart sank;
I had been down this road many times before. In children, even if you can get the retina attached initially, there is a high probability that it will detach again due to a scarring process known as proliferative vitreoretinopathy. And if the detached retina wasn’t bad enough, with the severe trauma and two operations, I considered cataract formation inevitable.
I knew then he had lost his eye.
Back to the operating room. I removed any stickiness left from the gelatinous vitreous fluid, freed the delicate retina from the impact site, and removed the blood that had accumulated under the retina. I then drained the rest of the fluid under the retina and filled the eye with air. Next, I exchanged the air with a longer-lasting gas that would hold the retina in place while it healed. Joe would have to keep his head down for weeks. A great excuse to play video games all day long.
That great family support I had seen that first night played a key role. When I first met Joe he seemed terrified—but as I got to know him I realized he was composed, determined, and confident of success. Miraculously, the eye healed, the retina never detached again, the lens remained clear without cataracts, and his vision became a near-perfect 20/25.
Somehow a large metal shard tore through his eye, completely missing the vital and irreplaceable optic nerve and macula. The shard eventually detached the retina, but Joe dodged every expected complication and ended up with a completely unexpected and fantastic result.
Joe grew up to be great young man, went to high school, and attended leadership camps with my enthusiastic letters of recommendation. The metal remains lodged behind his eye to this day.
I know now I had been wrong all along.
Editor’s note: The miracles didn’t stop with this boy’s recovery. The grateful family became committed to helping save others’ vision, as well; their generosity is evidenced in another essay in this book, “The Thin Line Between Miracle and Tragedy.”
Date of Event: Labor Day 2011
Miracles We Have Seen Page 19
