Secondary Impact

by Barbara Ebel

  “Did he fall and hit his head?”

  “Not really. He got hit in the head with a knee first. He was dazed but otherwise fine. Then he suddenly went down.”

  Danny nodded with understanding as a knock came on the door. He opened the door a few inches. “Dr. Tilson, David’s parents are here,” an ER employee said. “Do you want to talk to them?”

  “Send them in. Thanks.”

  “I can leave in a minute,” Annabel said.

  When David’s parents came in, Annabel was still clutching her knees with her hands. “I’ll leave so you can all talk,” she said.

  “If it’s okay with your father, we don’t mind if you stay,” Mrs. Floyd said. “Do you know what happened?”

  After Danny and Mr. Bell positioned themselves on two chairs, letting the women sit on the sofa, Annabel told them what had occurred. After she finished, Tara closed her eyes for a prolonged pause.

  “Dr. Tilson,” she said, “the ER doctor explained some things to us but wanted us to talk to you. Please tell us what’s happened to our son. First of all, I can’t believe he’s in a coma if all he did was get smacked by a knee. This can’t be right.”

  “I don’t understand any of it,” Floyd chimed in. “Is there some kind of precedence in what’s happened?”

  Another knock came at the door and Danny stepped out.

  “Dr. Tilson, CT results are back on David Bell,” the X-ray technician said.

  Danny poked his head back in. “I’ll be back in a few minutes,” he said. “This is the most comfortable place to wait.”

  -----

  It took more time than a few minutes but Danny caught up with David’s condition and called the OR for them to hold up his next case for the time being. In the interim, he’d grabbed a cup of coffee. He needed the hot caffeine to give him a boost on this terrible morning.

  He walked slowly back to the small room. When he stepped in, Tara, Floyd and Annabel looked at him with anticipation, as if they’d held their breath since he had left. At least it appeared that Annabel had stopped crying.

  “Your son is the same,” Danny said, unbuttoning his lab coat. “He’s being transferred to the ICU. You’ll be able to see him there later. In the meantime, I can tell you my theory, my diagnosis, of what’s happened. After our previous discussion about concussions, I think you’ll be able to follow what I’m saying.”

  “Please … do,” Tara stuttered.

  “If this were nineteen-eighty, I would not be able to give you such clear information. After that, we gained insight into David’s type of condition. It began with the death of two football players who received seemingly minor blows to the head after they both received previous first blows. And now our specialty has reported around two dozen cases like those – mostly male adolescents or young adults – who were involved with boxing, football and ice hockey accidents.”

  “But basketball?” Floyd questioned, shrugging his shoulders more than usual.

  “The pathophysiology is the same,” Danny said. “Just like with a concussion. What happened was that David had a blow to the head before recovery from a previous blow to the head. The athlete’s second blow can be minor but it can jerk his or her head and indirectly impart accelerative forces to the brain.”

  “This second-impact syndrome is an uncontrollable increase in intracranial pressure due to diffuse brain swelling,” Danny sadly added.

  Tara’s eyes looked blank as the Bell’s couldn’t ignore Danny’s dire words.

  “The physiology of intracranial pressure is simple, Mrs. Bell,” Danny continued. “Think of the skull as a closed space containing three things: brain tissue, blood in blood vessels, and cerebrospinal fluid. Since it is a closed space, if one component increases too much, it puts pressure on the other components. If the tissues swell, it will compromise the blood flow coming to the brain which in turn can’t give the brain enough oxygen. All three components need to exist with a healthy balance.”

  “It’s making more sense,” Tara said.

  “And in more difficult terms, there is something called autoregulation of the brain’s blood supply. In this secondary impact scenario, it is lost, causing vascular engorgement in the cranium. The increased intracranial pressure is difficult, if not impossible, to control.”

  Danny scanned each of their faces. “This potential condition should be a main concern for coaches and doctors who must make return-to-play decisions in players after a head injury. It’s why I was going to see David this week for re-evaluation.”

  “Dad, what did you call it again?”

  “A secondary impact,” Danny said.

  “You can’t operate?” Annabel asked.

  “No, I would do that if it were something like the hematomas we discussed a few days ago. Surgical evacuation in those scenarios would relieve the pressure and be therapeutic.”

  “You can’t do anything?” Tara asked.

  “There are measures we can take. They are being implemented as we speak.”

  “I don’t know if I should ask,” Floyd said. “I don’t know if I want to hear the answer. What are David’s chances of getting better?”s

  Danny flinched. “Not good.”

  “Tell us,” Tara said. “We are parents who can handle the blunt truth. We would rather hear it and expect the true possibilities than be given scenarios meant to camouflage what will most likely occur.”

  “Morbidity is nearly one-hundred percent and mortality under the circumstances is a fifty-percent chance.”

  -----

  Danny glanced at his watch as he walked down the hallway. The OR had sent for his next patient but it would take a while before he could see him in the pre-op area so he still had a few minutes. Pausing his hand on the doctor’s lounge doorknob, he knew he had to grab lunch. But perhaps what he needed more was sustenance of a different kind.

  He turned around and went far down the hallway past the nurse’s lounge, waiting rooms, and offices to the room at the very end. Staring at the brass sign for ‘Chapel’ on the wall, he realized he had never gone in. Interestingly enough, he thought, the door was a lighter wood color than any he’d seen in the hospital. Was it meant to be a subtlety? As if for enlightenment upon opening the door?

  It may be a stupid thought, he realized, but that was okay. If this partitioned part of the entire hospital building renders comfort and strength, then they can color it in sunshine.

  Inside, the space was no bigger than a patient’s room. The ten rows had an aisle in the middle to a step-up with a podium and a clothed, elongated table. He slid into the front row and knelt down. The isolated, sparse chapel was a far cry from his regular church where he brought Julia … or any church for that matter. What a treasure.

  Yesterday and today, he thought, have been harsh on Casey and David; Annabel as well. He couldn’t think of a reason why they deserved what happened to them. But bad things don’t need a reason, he knew. It’s how to deal with life’s blows that is important.

  He prayed: God, please allow Casey to heal and make use of his hands like always. They are needed to heal others. And David … his fate is in your hands and my medical care. Please don’t allow him to die. The young man and I can’t see to his recovery all alone. We need your help. I’d be indebted.

  Danny sat on the pew, rested his forehead on his fingers, and closed his eyes. He sighed to think that bad luck comes in waves. What was it about airplane crashes? They come in threes as well as many other disasters. He shuddered.

  The Tilsons had just had two nasty events. That’s all, he prayed again … please let no more bad events strike this family.

  Chapter 7

  Ever since Sara learned about her pregnancy, she’d been more cautious about eating a nutritious diet and avoiding over-the-counter drugs that could be harmful to her baby. She also took a long walk with Dakota every day after arriving home from work. Getting lots of fresh air and vitamin D from sunlight was good for her and her unborn child, she thought, and this pre
gnancy was not like the three she’d had years ago. Being wiser in her ways, and more appreciative of this surprise child, she was doing everything possible to deliver a normal and healthy baby.

  Dakota waited in anticipation for Sara to get home every afternoon and, after hearing her car pull in, he’d tug his leash off the door handle to present it to her. He knew this was a tethered walk versus a free run in the Tilson’s large yard.

  However, Sara always used the bathroom first because the urge to pee had increased, just like the morning sickness had reared its ugly head and given her queasy hours in the classroom before noon. She also had to be careful about certain smells. The coffee in the teacher’s lounge had an overwhelming aroma that she now despised but had found wonderful before. Despite the inconveniences of the pregnancy, she walked around most times with a big grin as if she knew the ultimate answer to the fountain of youth.

  But this Monday proved to be different from the others. Dakota would have to wait until after her obstetrician’s appointment. Her last student left the classroom, she packed up her things, and started for the door.

  “Good luck,” one of the other teachers said.

  “Thanks,” she said, beaming.

  “Are you going to let us know tomorrow if it’s a boy or a girl?”

  Sara stopped. “I sure will. But it doesn’t matter at all. I have lots of experience with girls but a boy would be nice. I’ll have a new learning curve,” she said.

  -----

  Sara glanced around the waiting room in the obstetrician’s office after she filled out more paperwork than during her last visit. The lounge was full of working women further along in their pregnancies than she was. One of them moaned to get past her belly trying to tie a shoe and another sprawled on a two-seater couch; Sara had not seen this many pregnant women in years.

  Finally the door to the back opened. “Mrs. Tilson?”

  Sara got up and followed the nurse.

  “You can undress and slip into this gown,” the assistant said once they stepped into an exam room.

  Sara changed and soon the doctor rapped on the door and entered. Dr. Carr was a big brunette with a small smile. “How are you feeling, Mrs. Tilson?”

  “I’m feeling like I’m pregnant,” Sara replied. “Actually, I’ve probably had less nausea in the last two days than the previous week.”

  The doctor skimmed her chart. “Well, I see you decided against having an amniocentesis. We won’t have to set that up then. But let’s go ahead today and get your first ultrasound. You are over six weeks so your baby’s vital organs are in place and will continue to develop, and he or she already has a four-chambered heart.”

  Sara smiled. “My husband said the heart rate of an infant is very fast. Not like ours.”

  “That’s true. About 160 beats a minute. Ask your husband all about the difference between an adult heart and an infant’s heart. The anatomy and physiology of it is fascinating.” She grabbed her stethoscope and listened to Sara’s lungs and heart, then asked more questions.

  “Okay,” the doctor said when she was satisfied. “I’m sending you across the hallway to our ultrasound tech. She’ll do your scan. Off you go.”

  Sara scooted off the table, held her gown tight and went to the other room.

  “Ma’am, come on over and lie down,” the tech said. “I’m Susan and I’ll be doing your ultrasound.”

  Sara stepped over and, with extra pillows, got comfortable on the hard table. The tech adjusted the machine, dimmed the lights and then squeezed ultrasound gel on her lower abdomen. Sara flinched.

  “Sorry,” said the tech. “I know it’s a bit cold but we do need a conductive medium.”

  “It’s worth it. Will I see arms and legs and eyes yet?”

  “Appendages won’t be fully formed, just small. But you’ll love seeing the dark spots of the eyes and nostrils and the tiny depressions of the ears.”

  Susan dabbed the transducer into the gel and began moving it around. She looked back at the screen and continued making circles on Sara’s stomach.

  Sara watched the black and white image on the monitor. She could make out a sac and what she believed was the baby’s head and curled body but that was her unskilled assessment. Her pulse sped up. “That’s my baby there, isn’t it?” she asked.

  “Mmm-hmmm.”

  The tech continued fiddling with some knobs and looked back and forth between the transducer and the machine. Sara hoped she was taking pictures.

  Susan placed the transducer on a little shelf alongside the screen. “I’ll be right back,” she said.

  Sara watched her leave with dismay as she didn’t think Susan behaved very professionally to leave a patient on the table in the middle of the procedure. The seconds stretched into minutes and the room took on an eerie quality: cold, still and silent. Finally, the door opened and Susan and Dr. Carr walked in.

  They didn’t say a word as Susan again began moving the transducer around on Sara’s belly and they both stared at the image on the screen. Sara felt a growing concern and her heart ticked louder, the sound reverberating against her eardrums.

  Dr. Carr took off her glasses and leaned alongside the table. She switched her gaze directly to Sara.

  “I’m sorry, Mrs. Tilson, but your baby has no movement. And there’s no heartbeat.”

  -----

  Before Danny left the hospital for the day, he made late rounds on his group’s patients. It was already 6:00 p.m. and he had saved David for last. Perhaps he’d find that the CT and other tests had all been wrong and he’d see the young man signaling to unhook him from the ventilator.

  But that’s not what he found.

  Annabel sat on a chair, her head and arms resting on David’s mattress; some of the therapeutic treatments that Danny had ordered for his brain edema pulsed through the IV attached to his limp arm.

  “Annabel,” he said softly.

  Like a rag doll, she raised her head up and looked sideways at her father. Her dry eyes looked as if they’d expended all the tears she was capable of and her complexion had turned sallow.

  “I couldn’t go to any classes this afternoon, Dad. I had to come back.”

  “I can imagine … it would have been difficult to concentrate.”

  “I really can’t believe this. I keep thinking that none of this happened and it’s all a figment of my imagination.”

  Danny stood next to her and touched her shoulder.

  “I mean, it wasn’t as if he got tackled by a swarm of big football players.”

  As he thought of how to console her, the IV pump made a tiny bleep every few seconds. David lay motionless with no change in his condition so Danny knew he shouldn’t offer her any hope right now.

  Annabel slowly got up and pushed the chair back to the wall. “You didn’t make it clear enough,” she said curtly.

  “What are you talking about?”

  “You weren’t emphatic enough! You should have told him not to lift a finger. You should have told him he was grounded to do anything, even hold a basketball.”

  Danny reeled from the accusation … from his daughter, no less. He opened his mouth, ready to start defending himself. But as Annabel made her way to the doorway, he realized it would be pointless. She would believe the way she construed it, especially now during the denial and anger phases of what happened and also when there was someone to lay blame on.

  But her own father? This was hard to take.

  And now that she had planted the seed into his thoughts, had he really been strict enough? Had he done his best to make David realize the importance of his post-concussion orders after his first fall on the basketball court?

  -----

  Getting out of his Lexus at home, Danny wondered which entrance to go into first. Sara could be with Casey and Mary upstairs; he could check on his friend and his finger if he went in the main entrance. Most importantly, however, he wanted to see the ultrasound pictures that Sara would have from her appointment.

  He
gambled that the babysitter would have left and that Sara, Nancy, Julia and Dakota were downstairs. He opened the door as his rambunctious dog trotted towards him.

  Danny jostled with Dakota down the hallway until he found Nancy and Julia hunched over in the big room eating ice cream.

  “Hi, girls. That sure looks good.”

  “Hi, Dad,” Nancy said.

  He sat on the coffee table and rubbed Julia’s head.

  “How was your day?” he asked Nancy.

  “Good. Do you want to put Julia to bed soon? I still have homework to do.”

  “Sure. Is your Mom around? She went to the doctor today.”

  “She’s in the bedroom. She’s kind of quiet and didn’t even take Dakota for a long walk when she came home.”

  “I’ll go say hello and then I’ll put Julia down and see how your Uncle Casey is doing with his finger.”

  “That’s really terrible what happened. He’s acting like it’s no big deal.”

  “He’s a trouper.” Danny frowned as he felt he was somewhat responsible for Casey’s accident, too.

  “Did you talk to your sister today?” Danny asked.

  “No, should I have?”

  “David is in the hospital. He had another head injury this morning and it’s serious.”

  Nancy held her spoon in midair and then lowered it back into her bowl. “I’ll call her. She doesn’t have to talk to me if she doesn’t want to. That’s pretty terrible.”

  “It is. And she’s taking it hard.” Danny looked towards the bedroom door. “I better go see your Mom and see how things went for her this afternoon. But first …” He smiled at Julia, picked her up and twirled her in the air. She giggled as he put her back down. “You’re almost getting too big for that, pretty girl.”

  Danny walked away towards the bedroom and, with each step, he broadened his smile. He had to greet Sara and her news with enthusiasm as her pregnancy was a beacon of light during a string of misfortune.