Saturday, May 10, 2014

The Miracle Continues

Dallin with Peter Nielsen, the EMT who saved his life during those first 8 minutes while waiting for the ambulance to arrive. 

Him and his wife invited Dallin and Amy for a BBQ and volleyball with their cute family. We feel so indebted to this wonderful man and his beautiful family!

It's so funny that it's taken almost a year later to find out this crazy, important detail in those first few critical moments after Dallin was hit! We love this family like our own now!

From Amy's blog:

We have learned some incredible things about Dallin’s accident since corresponding with Charles Sparks, the Clinical Director of the Emergency Department at Logan Regional Hospital.

He asked if he could use Dallin’s story for an annual trauma conference they hold for EMS and when describing the accident he used the words “miraculous” and “amazing”. I asked him if he could describe to me, medically speaking, why he would use those words. Of course I know it was a miracle, but if he was willing I would’ve loved to hear from his point of view why it was a miraculous recovery.

He does such a beautiful job describing Dallin's injury. Here is his whole email:

"The type of injury that Dallin sustained is called “Severe Diffuse Axonal Shearing Injury”.  This type of injury occurs when the head whips side to side or forwards and back.  As the brain tissues slide over each other, brain cell axons tear in half.  The axon is the long part of the brain cell that sends a signal to the surrounding brain cells. The brain cells can no longer create thoughts, memories, feelings and emotions.  Small blood vessels are torn in half, resulting in small hemorrhages that rob brain tissues of needed blood, which increases the injury.  Also, as the brain cells tear, they leak chemicals that are toxic to the brain if they are outside of the cells, again, causing further injury.  Diffuse axonal injury is  the same injury that we see with shaken babies. 

Diffuse axonal injury is seen in a wide variety of head injuries from mild concussion to severe head trauma.  Severe injury means that a large part of the brain is affected and damaged.  Dallin’s injury is classified as  “severe”.  GCS, or Glasgow Coma Score, is a quick assessment tool that we use to determine brain response.  The scale measures three responses; Eye opening, motor response, and verbal response.  Each area has a different scale, then the three scales are combined into the total score.  The total score ranges from 3 to 15.  3 to 8 is considered comatose and requires advanced airway and respiratory support.  Dallin ranged from 3 to 6 in the ambulance and in the ER.

The brain rapidly swells because of the injury, just like any other body part that swells with injury. Like a twisted ankle.  But, inside the skull, the brain does not have space to swell, so it begins to compress its-self. As the brain compresses, it rapidly affects the respiratory drive, and the person stops breathing, which will result in death in just a few minutes.  The brain can continue to swell to the point where the brain stem shears from the brain, which causes immediate death.

In the ER, we can perform some interventions to support the airway, breathing and relieve some of the pressure from the swelling brain.  Dallin was intubated in the Logan ER, meaning that a breathing tube was inserted into his trachea to hold the airway open.  Then breathing was supported with a ventilator.  We closely monitor urine output and increase the kidney functions to pull water out of the patient.  AS water is pulled from the blood stream by the kidneys, the body’s tissues, including brain tissues, move water into the blood stream.  As the brain shifts water into the blood stream, the swelling goes down.

50% of patients with this type of injury die due to the rapid brain swelling and hemorrhaging.  We have seen patients like this many times in the ER.  Often, they do not have any other injuries and look unscathed, but the brain is too damaged to survive.

Of the 50% that survive, 90% of those will never regain consciousness and many of them die due to secondary causes such as pneumonia.  Of the 10% that regain consciousness, nearly all are profoundly disabled physically and mentally, and will remain disabled for the rest of their lives.
Because we know that there is a very, very small margin for recovery from the type of injury that Dallin had, we recognize the profound miracle of his recovery.  Honestly, we sometimes discuss the futility of resuscitating patients with this type of severe injury.  It is understood that if the patient survives, the patient would be vegative at best.  However, because of the very, very slim chance of recovery, we do all we can for the patient. 

The brain cells that are damaged never heal, which is the cause for permanent disability for most people with this injury.  The neuro- pathways that we develop to retrieve information, memories, associations, motor responses, etc. can be permanently lost as a result of torn axons.  Think of it as a  destroyed bridge across a river.  All of the world on the other side of the river is no longer accessible, unless another way across the river can be found.

Some people with a severe axonal injury can build new bridges to retrieve otherwise inaccessible information.  For example, Dallin did not recognize you as his wife at first, until his brain was able to find or build a new bridge into that information.Most people with Dallin’s type of injury never build or find new bridges.

Most people with Dallin’s type of injury never build or find new bridges.  My cousin had the same type of severe diffuse axonal injury.  She also was one of those very few people who make a miraculous recovery,  however, she has a permanent memory loss of eight years of her life.  During those eight years, she served a mission, graduated college, earned a PhD, married and had three children.   The memory loss is permanent and she has struggled to develop a relationship with a husband and children that are essentially strangers to her.  She has no memory of attending school, but can recall all that she learned during that time.

Many who survive, regain consciousness, and are able to make some kind of recovery have profound changes in personality and identity.  People who were once nice and loving are mean and distrustful.  They choose completely different lifestyles than they had before.  Many lack motivation and/or impulse control.  They recognize loved- ones, but are unwilling to continue a relationship with them.    Many lose an ability to cope well with stressors, even minor ones.  I did a case study on a 14 year old boy who was hit by a truck while riding his bike.  His primary injuries were a shattered leg and a punctured lung.  He was also diagnosed with a mild traumatic brain injury.  Though his brain injury was mild, he now struggles with concentration, motivation and impulse control.  Before the accident, he was a straight A student.  Now, he is failing in all classes and refuses to attend physical therapy for his leg injury.

As we flew Dallin to the neuro-surgeon at McKay Dee, there was little hope that he would recover at all, let alone survive.  Any recovery at all would make us say, “Wow!”  To see that he was running and playing football six months later is completely astounding.

As part of my review of Dallin’s case, I read through all of the EMS reports.  The first EMT on scene was off duty and driving home.  He heard the call and responded to the accident.  He noted that Dallin’s airway was closed because of his head position, and that Dallin had agonal respirations, which means that he was breathing, but not effectively enough to survive.  The EMT aligned Dallin’s c spine (neck vertebrae) and opened his airway which immediately improved Dallin’s ability to breath.  Without that initial intervention, there would be no miraculous recovery story because Dallin would not have arrived at the ER in Logan alive.  He probably would have died before the ambulance arrived and any efforts to resuscitate would have been completely futile.

In my eight years as a trauma nurse in the ER, I have witnessed truly awful things that will haunt me for the rest of my life, but stories like Dallin’s are what gives me the motivation to show up every day and work hard on every patient.  Because of stories like Dallin’s we still keep a sliver of hope in the most futile situations.

Though I have witnessed horrible things, I have also seen miracles happen through the power of prayer and the power of the priesthood.  These miracles happen when there is no more that can be done medically for the patient, or in conjunction with the best medical care that we can give."

 Here is a part of another email:

"One thing that I forgot to explain in the last email is that Dallin was exhibiting a behavior known as “decorticate posturing”.  Decorticate posturing is a physical response to pain- the patient pulls his arms in to his chest and the legs and feet become rigid.  As the brain swells and the brain stem is compressed, the physical pain response of the patient changes.  Decorticate posturing is the response to pain that we see when death is imminent."

So incredible!!!

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