Saturday, April 25, 2009

The first 48 hours

My name is Fred. Manny and I have been friends for nearly 15 years, since attending medical school together. I am sorry but I can only recount what I know. Many people have done many wonderful things these past few days, and I can’t even begin to know the half of it. I know that it is long, but I am trying to recount to those who are not able to be here the things that I know about, so that you can know. One thing to be certain your prayers are needed and wanted. Your love is appreciated.

For those of you that have children, a pet, or anything in your life that you care about, the following account will hopefully make your cherish what you have more, hug them longer, and realize the fragility of life.

The house that Manny, Traci, Jack, Isa, and Ava Lopez live in is the corner house on the entrance to a small cul de sac. The front of the house faces the street of the cul de sac, but the side of the house is on one of the busiest roads in our subdivision as it is just before one of two entrance/exit gates to the community. As you come in the gate you travel uphill and the side/back of their house on your right. As you leave the community, the hill slopes down and you approach the front/side of their house, across the street on your left. There is a stop sign at the intersection next to their house, but people often disregard it. As the road slopes slightly downhill, toward the gate; consequently cars are often traveling somewhat faster as they are heading to the exit.

On Thursday evening, the 23rd of April, at about 8pm Traci, Isa, and Ava had been in front of their house playing with the Larkin family, who live across the street from the Lopez’s. Manny and Jack had been at baseball practice and were returning home. The Larkins went in for dinner. Traci and the girls wanted to pick up some grass clippings on the side of the house before going in for the evening. Ava in particular wanted to be helpful and put grass in the garbage can herself, but was not tall enough to reach the top of it and wanted Traci to lift her. Traci recounts it as a fun and loving moment, one that makes you smile inside about the perfection of your life, as it is. It was the simple joy of being together and a loving moment of harmony. Traci set Ava down so that she could pick up the last few clippings and noticed a Convertible Mercedes from the periphery of her vision. The car was heading toward the exit and coming down the slope at a high rate of speed. She noticed from her periphery that the car should have been on the other side of the road, but rather was approaching close to her house. She looked up to see the car hit the curb and leap up onto the sidewalk and part of her side yard. The car hit all three of them and a large garbage can, throwing them into the air and against the outside of their wooden privacy fence. Jennifer Wiedenhoefer was approaching their house from the gate at the same moment and saw their three bodies thrown effortlessly before the abrupt halt of the fence line. A scene she describes as, “one of the most horrible things that I have ever seen. It was awful.” The driver of the Mercedes straightened the vehicle, steered around Jennifer, and left the subdivision, despite pleas for help. She had two blown out tires, a broken front headlight and a broken windshield and was only slowed by the bodies she hit.
Traci’s moment of harmony had become one of horror as she saw Isa, conscious but against the base of the fence and looked for 18 month-old Ava. Ava had come to rest several feet away and was lying lifeless, facedown in the grass. Despite her own injuries she went to her and rolled her over to see her non-responsive and with little respiratory effort. She gave Ava a few breaths and then was aided by a physician neighbor, Scott Thomas, who had just moments before avoided the woman in the Mercedes who was driving in the wrong lane, when he heard a loud crash behind him. He helped stabilize Ava initially and tended to the others with Jennifer.
The Larkin family was now aware and came out to help while waiting for the ambulance. Jeff Larkin called Manny, to tell him to get home right away. Manny called him back, “Jeff, what is going on? You’re scaring me.” “Manny, Ava was hit by a car, get home.” Manny arrived minutes after the ambulance and began assisting with Ava’s care in the back of an ambulance. I arrived a few minutes later on the tail of an emergency vehicle.

As I came up, a fire truck, three ambulances, and police cars were all around. Traci was sitting on the curb with Isa and was being tended to by a paramedic. Blood and dirt was smeared across her legs and arm. Her right arm held stiff and straight because of the pain. The tragedy of the situation was apparent on the faces of the neighbors that had gathered. Anxious for news of Ava, I was sent to find out how she was. I looked through the back window of the ambulance to see Manny giving mouth to mouth resuscitation to a lifeless Ava. The pain of that moment was heart wrenching. There was so much despair in the few minutes looking through that window that I can barely describe. A father with the medical knowledge enough to fix most anything, but a lifetime of schooling can’t prepare you for that. How do you cope with wanting to breathe the very life that you have into your child and not being able to do so? You could see the thoughts of desperation, despite the surety of his actions… “Dear God, not her. Not her. Take my own breath from me, but not her.” The recollection of the event makes my tears flow freely.
She was intubated in the ambulance a few minutes later with Manny’s assistance and supported with a breathing bag that you squeeze by hand to push air into her lungs. I saw the tremble in his hand as he continued squeezing air into her lungs, tears flowed.

The sound of a helicopter approached. Manny exited the ambulance and it departed to meet with the helicopter so that she could be flown to the nearest trauma center, University Hospital. Some discussion ensued between the ambulance drivers/EMTs as they tended to Traci and Isa, as to which hospital to take them to. Manny insisted, “She is going to University with Ava!!” “You will take her to University.” It seemed like a good deal of time assessing Traci, who was now on a stretcher and a C-collar before being able to leave. Several people offered to take Manny to the hospital to be with Ava, the response, “I am not leaving Traci.” More waiting… “What is taking so long? We have to get to the hospital!!” Not long after, they were on their way to University Hospital.

Eilene Larkin was the first to arrive at the hospital and spent much of her time with Isa, who was evaluated and miraculously released later with only a few minor scrapes to her arm. This allowed Manny to split time between Traci and Ava. Manny came and sat with me, while Eilene was with Isa, and tearfully said, “we’re gonna lose her.” The neurosurgeon had given Manny a very grim prognosis… her pupils are fixed and dilated, she is non-responsive, the gray-white matter differentiation is lost (I’ll explain later). These are all the bad buzz words in head trauma for a potentially unrecoverable head injury. Her list of injuries: skull fracture, subarachnoid hemorrhage, multiple rib fractures, pulmonary contusion, adrenal hemorrhage.

We spent the next several minutes together as Manny talked of Ava’s personality and smile. He spoke of how just the day before everything was so perfect. One day earlier, they had watched American Idol together as a family. After it was over, they all walked hand-in-hand upstairs to go to bed. For those of you with several children, you know how rare that event can be… your children, willfully, lovingly holding hands. The disbelief of the situation is firmly entrenched. “How can this be?” “I can’t go without seeing her smile again.” Several more minutes were then spent with Isa sitting ever so quietly, as is her nature, in Manny’s lap. His face pressed into her hair, gently kissing her head, and offering gratitude in the form of “I love you,” to her over and over.

Eilene then took Isa, and Manny went back to Traci. I went out to the lobby to update several people who had gathered in the ER waiting room, anxiously awaiting news. As they waited the ER televisions played the lead story for the local news: a woman and her two young daughters that were victims of a hit and run. The other people in the waiting room watched in disbelief of such a senseless trajedy, little did they realize that the Lopez family was just down the hall from where they sat.

Jennifer and I went back to the treatment area to see Traci and Manny. Shackled men in orange jumpers with police escorts seemed to be quite normal for this ER. Ava was being admitted to the Pediatric Intensive Care Unit. Traci remained on a stretcher, in a C-collar, with cuts and bruises along her right side. The extent of her injuries was not yet known. More imaging and evaluation needed to be performed, but she was stable. The neurosurgeon returned to talk to Manny and Traci and talked of some of the things that will be happening soon. “We need to find out what the pressure is inside her head. That is very important for us to know whether or not our interventions are working. We do this with an ICP Monitor (Intracranial Pressure Monitor).” This is also called an intracranial bolt. It is a screw that gets tapped through the skull and reads the pressure inside the head like a tire pressure gauge. Traci and Manny almost replied in unison, “Do anything that you have to do to help her.” “We are getting her up to the PICU now. You will need to sign some consent forms.”

“We need to get her music box. She listens to it every night. It plays ‘You Are My Sunshine.’ She loves that . We also need to get her polka-dotted blanket.”

Traci pleaded with Manny to go be with Ava. Minutes later the nurse led us through a back hallway to an elevator that put us at a back entrance of the PICU. Her room is a typical ICU-type room. Large sliding glass doors with easy visibility into all of the rooms from the nurses station. The privacy curtain was partly closed. We stepped around it to see Ava intubated and lifeless on a large hospital bed that was nearly big enough for an adult. She was dwarfed by the size of it. The head of the bed partly elevated so that you could see her face so clearly. A ventilator was at the head of the bed. Oxygen, suction, and monitors were to the right of the head of the bed. A multichannel IV pump was to the left, with colored tape and hand-written labels taped to the different channels, “3% NaCl” “Epi” “NorEpi” etc. The monitors were reading the electrical activity of her heart, pulse, oxygen saturation of her blood, respirations, blood pressure, central venous pressure, urine output, and soon the intracranial pressure. As we walked into the room a pediatric fellow was on Ava’s right side, trying to place an arterial line into her right wrist. Her body was partly covered by sterile green towels as the doctor worked, trying to place the catheter. Manny crossed to the other side of the bed to hover over Ava’s head and whisper inaudible words to his youngest, kissing her intermittently. Work paused as the doctor painfully watched Manny interact with her. After a moment being face to face with Ava he noticed small puffs of air coming out of her mouth and nose as the ventilator blew air into her lungs. “Does she have an air leak(around the endotracheal tube)?” “In babies, we mostly use straight, uncuffed endotracheal tubes. Some air usually leaks around them because there is nothing there to keep some of it from blowing back.” An uncuffed tube is like a drinking straw. It is just a straight tube. If the trachea is just a little bigger than the tube then the air will go to the place of least resistance. Most of the air goes into the lungs, but some of it will leak out as the ventilator pushes in more air and generates more pressure. A cuffed tube has a small balloon on the end of it that gets filled with air to make a seal with the trachea and prevent air from leaking out and allows much greater pressure, and consequently more air to be pushed into the lungs when needed. In babies, uncuffed endotracheal tubes are often used because their endotracheal tissues can be fragile and are small. When the balloon is blown up it can create a sort of pressure ulcer against the inside of the trachea which can ultimately lead to scarring and narrowing of the trachea.

After a few minutes, the Neurosurgeon arrived to put in the intracranial bolt. Here are the consent forms, here are the risks,” blah, blah, blah,” were the words that I am sure that Manny heard. I watched him be respectful, while I could see the agitation… “just where do I sign?” appeared to be the thought in his head. We went to an adjacent, empty ICU bay while they finished placing the arterial line and the intracranial bolt. Desperation still loomed. “Manny, she is gonna be alright. The neurosurgeons mostly deal with adults. She isn’t an adult. Kids her age are like superballs, they bounce back from anything. They recover from the unrecoverable. The same injuries in you or me would like be the end of us, but not her. I know it in the depth of my soul. She is gonna be alright.” This is a true statement. It is amazing how plastic pediatric patients are. It will be an amazing world one day when medicine is finally able to tap in the regenerative and healing abilities that we had in our youth. Manny nervously joked about telling this story on her wedding day, then cried at the thought of it.

Manny called his mother, who was already aware and had left to come here. He called his sister, Tika. They we heading to the airport and would be here in a matter of hours. More tears. While we waited, much of the time in silence, Jennifer called. “You have to get down here and get Traci moved along. She needs to get up to see Ava. Around the same time Jennifer Smith and Kerri Thompson returned from Traci’s house with the things that she wanted for Ava, and other things. I went to the ER for both while Manny stayed with Ava.

When I arrived downstairs more trauma cases were coming in to the ER. Bloodied, shirtless, young men with lots of tattoos get wheeled in on gurneys just feet from where Traci lay confined. They were now consuming the attention of the nurses and doctors. Traci is emotionally beside herself regarding Ava, but is unable to be with her. She is desperate to see her. Tears continue to flow. A few wails of painful desperation echo through the ER, but go unnoticed amid the chaos that surrounds us. It makes me want to cry for her, for them. So helpless they all are right now… Manny waiting for the doctors stabilize his daughter; Traci lying imprisoned on ER gurney with her heart torn from her; Jack and Isa confused; and Ava seemingly lifeless being manipulated and proded. I am prompted by Jennifer to do something to “get Traci out of here,” but feel somewhat helpless myself as I see the battle-hardened veterans deal with the ugliness of life. I approach Traci’s nurse, who is with a group of people attending to a bloodied man who is hand-cuffed to his gurney, wrists and ankles. She looks at me with an expression of someone who has been taken advantage of too many times and will not ever allow it to happen again. She has hardened herself to the heartbreak that is seen in this place routinely. She seemed wholely unmoved by the tragedy of the Lopez’s situation and seemed unwilling to make concessions for them or even offer a sincere expression of sympathy. At nearly the same moment a Trauma surgery resident came up and started disconnecting Traci’s monitor preparing to take her to Radiology himself so as to move her through the ER so that she could be with Ava. The nurse initially protested weakly about moving her. Another male nurse arrived and took Traci’s cause upon himself and assured us that he would push her through the system and get her up to see Ava, and he did, but after her x-rays were completed.

I returned to the PICU with Ava’s things. At about the same time the neurosurgeons had finished placing the bolt. We went in to see her again. Two wide pieces of white tape covered the top of her head, securing the very thin pressure catheter from being inadvertently pulled-out. Manny was told prior to the bolt being placed that they want the pressure to stay below 20. Injury to the brain is unlike a sprained ankle. When you sprain your ankle the tissue can swell and expand outward, swelling can rise into the leg or down into the foot. But even in the leg, if there is too much swelling then the pressure within the tissue gets higher than the pressure within the small arteries. When this happens it becomes simple physics. The blood pressure can’t overcome the tissue pressure, then tissue starts to die. In the head this is so much more fragile. When the brain gets injured, it tries to swell also, but as it swells it has no where to expand to because of the skull. As a result the pressure builds up faster. Worse yet, the brain is very sensitive to not getting oxygen. Brain tissue starts to die after only a few minutes without oxygen. If the intracranial pressure rises above 20, then we should be very worried.

The 72 hours following the injury are critical. Just like if you were to break a bone, immediately after it happens the tissue around it is still normal. It has not had time to recruit the cells from the blood stream and tissue that cause the swelling that comes later. The brain is no different, the swelling will likely peak by about 72 hours, then should start to decrease. These three days will be critical, how things are now, is not necessarily how they will stay. We know that the reassuring gains can be lost in a moment. Let us pray that they are not lost.

The initial intracranial pressure measurements were 12, then 5, then even as low as 1 at times that first night. Manny resumed his position at her bedside. I brought him the music box which he continued to wind and play for the remainder of the night.

Then the most reassuring thing happened… she moved. Not just a deliriously looking for any sign of hope movement that was really the result of the nurses moving some tubing or something… She really moved. She tried to raise her arm and moved her feet. This was huge. In order for her to have such a movement, her brain is still getting oxygen and is still working. Hope!!

Traci, Jennifer, and the male nurse that promised to get her to Ava arrived. She was in a wheelchair that was big enough for someone four times Traci’s size. Her fears were confirmed as she saw her daughter for the first time since the moments after the intoxicated driver irrevocably changed their lives. Tears. Traci demanded to stand and kiss Ava. It was emotionally painful to watch her navigate her own pain while wearing a C-collar, keeping her neck straight, and trying to be careful not to move Ava in any way.

The male nurse and Jennifer then went to Traci’s hospital room on the 7th floor, for the first time. Ava appeared to be stable and we sat in her room, as Manny recalled some of the loving times with Ava. Continuing to wind and play the music box.

Traci returned with Jennifer and was in tears. “I am not going back to that hospital room. The woman sharing the room with me told me that I needed to ‘move on and focus on the other children.’”Ugh! Sometimes people can say the most senseless things.

It seemed like just minutes after she returned to the ICU, one of Ava’s alarms started sounding. It was her pulse oximeter. It monitors what percentage of her hemoglobin/red blood cells are carrying oxygen. It is a measure of how well her lungs are working. They put the suction tubing down her endotracheal tube and suctioned out some blood from her lungs. A minor improvement. Then it dropped again… 80’s… 70’s. They would take her off of the ventilator and use a bag ventilator that they squeeze by hand, forcing air into her lungs. Every time they stopped and put her back on the ventilator, her oxygen saturation would drop again, despite 100% oxygen. It seems that the multiple rib fractures and pulmonary contusion (bleeding into the lung tissue or big lung bruise) have begun to cause problems of their own. The damaged lung tissue has begun to swell and fill with some blood. This increases the lung’s resistance and requires more and more pressure to push enough air into it to get the oxygen into her blood. Too much air pressure and it will start to leak out of the lungs, causing a pneumothorax. If this complication were to occur, then this would require another intervention… a chest tube.
The pediatric fellow was on her i-phone talking to her attending, keeping him/her abreast of the situation, and feeling somewhat nervous as Ava’s physician-father watched her anxiously. “Switch her to a cuffed tube,” were the instructions. This is not such a simple feat, like changing a band-aid. The ABC’s of emergency care begins with “A-irway, then B-reathing.” If you lose an airway, then you are in a world of hurt. Everything depends on having a reliable airway… everything!!!

Anesthesia arrived to change out the endotracheal tube. We left the room and went to the adjacent vacant ICU bay. We talked of prayer and hope. We talked of the good indicators, like her low intracranial pressures and her movement. We talked of her young age and that this will help her. In the background we continued to hear the alarms sound. When will it end?

Finally the ET (endotracheal) tube was replaced. She was placed back on the ventilator and her oxygen saturations were 100%. A sense of relief returned. Everything seemed to calm itself. No more alarms or scares, other than the reality of being in the PICU with Ava. The next few hours passed with small conversation and tears. The music box continued to play.

Jeff Larkin called and was on his way from the airport to the hospital with Manny’s mother, sister, and brother, Tony. It was about 420am. They arrived shortly before 5am. We went to the security doors outside the PICU to meet them. Manny and his mother had a long embrace the moment the door opened. A mother tries to comfort her child. Tears. I could see the helpless and loving expressions on the faces of Manny’s sister, Teka, and brother, Tony, and friend, Jeff Larkin.

Jeff, Jennifer, and I left shortly after the family arrived. I learned the following morning that Ava’s head CT was maybe somewhat improved and that she had a normal EEG (Electroencephalogram). This is like and ECG (electrocardiogram) of the brain. Doctors can put monitors on the head and record the electrical activity of the brain. Just like an ECG can show signs of a heart attack or other heart problem, an EEG can show brain abnormalities. A normal EEG in this circumstance is very reassuring… more hope. The neurosurgeon expressed cautious optimism… more hope. Still the “72 hours” continues to loom.

Traci’s mom arrived in the mid morning on Friday. A group of the neighborhood women took her to the hospital. Traci is staying in a two patient room. I was told that as she entered the room she glanced at a young woman who was in a cervical spine collar and thought to herself, that poor girl. A moment later her legs weakened, and she stumbled to one side, being braced by the women accompanying her, as she realized that the “poor young woman” was her daughter, Traci. Yet another mother is heartbroken by the injury of their child.

Friday, during the day, a good friend of Manny’s and fellow Iraq War Veteran, Colonel Joe Brennan brought Manny home to shower and change clothes and spend some time with Isa and Jack. The hope was that he would also sleep, but Manny refused and insisted on returning to the hospital to be with Ava. Much of the day was status quo. Ava had still not regained consciousness, but her vital signs remained stable and the intracranial pressure remained low. She was started on hydrocortisone for steroid support given concern regarding her adrenal gland injury. The adrenal glands are a pair of glands, one positioned just above each kidney, in the back, next to the spine. They make steroids for your body for a variety of important functions.
Yesterday, Traci was to be discharged from the hospital, but was kept as an in-patient to speed up an MRI evaluation of her neck to exclude a cervical spine injury and hopefully get her out of the C-collar. The MRI was not done until the late evening and the results would not be available until today. She was in a fair amount of pain as the soreness from the trauma the day before took hold. After the MRI was completed, she was finally discharged, between 11pm and midnight.

Manny and Traci spoke at Ava’s bedside after being told that she will be discharged, and she agreed to go back to their house to sleep and spend some time with Jack and Isa. A decision that was very difficult for her. She continued to insist that she be called if there was any change and stated that if anything were to happen, and she were not at the hospital to be with Ava, then should would never be able to forgive herself.

Eilene Larkin and I packed up her things and drove her home. She was very upset about leaving but needed to get some rest. As we were driving back to the house Traci fell asleep. After she had been asleep for a several minutes she suddenly threw both of her arms forward and kicked her legs forward as if she was trying to block something. Nothing was said, and she quickly settled back down, but I had to wonder whether or not this event was replaying through her dreams.

She refused to drive in the back entrance, by her house, and expressed anxiety about even going back in her house. She didn’t want to stay there. She closed her eyes as we approached the area where they were hit and didn’t open them until it was out of view.

Teka and Tony helped get her settled in her bed. She was is a lot of pain. We gave her some pain medications and Benadryl, to help her sleep. Teka told me that she slept for about 5 hours or so, then got up and went back to the hospital. As for Manny he stayed at her side, with the expectation that he would come home today to get some sleep.

During the night Ava’s intracranial pressures had gotten as high as 16, and reminds us that “72 hours” has not passed. The intracranial pressures are now lower, at around 12, and will intermittently fluctuate, but I can only imagine the anxiety that they were experiencing as the number gradually increased from its prior low. Seeing it drop again brings hope.

Despite these small glimmers of hope, Ava remains unconscious. Manny and Traci, and their families have maintained a constant vigil at Ava’s side. One or both of them have been with her constantly.

The vigil continues, and the music box continues to play.

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