Miracles We Have Seen

by Harley Rotbart

  John was then transferred to our pediatric intensive care unit. Upon arrival nearly three hours after the accident, profound circulatory shock (inadequate blood circulation and blood pressure) and multisystem organ failure persisted. He remained comatose with no brain activity or neurological activity present. We expected the worst. Despite his miraculous rescue and resuscitation, prospects for John’s survival were discouragingly slim.

  As is typical after a prolonged period without adequate blood and oxygen circulation, acid builds up in the body’s tissues and threatens to keep vital organs shut down. Damage to John’s organs and tissues was so severe his muscle cells were literally breaking open and dumping their contents into his bloodstream. After monitoring him carefully, treating his acid buildup, continuing a state of induced hypothermia (keeping his body temperature low), working hard to prevent kidney failure, providing supplemental oxygen with maximum settings on a ventilator (breathing machine), and supporting circulation for the next sixteen hours, a glimmer of hope began to return. We became confident his body would survive. But even with his heart re-

  started and his vital organs now finally being supplied with blood, little hope remained that he could recover his brain function after such prolonged submersion requiring such protracted CPR.

  Although there are many stories of cold water drowning with surprisingly good outcomes, those require a special combination of factors—none of which were present for John except the cold water—and even that wasn’t optimal. Ideally, to preserve brain function, the water must be cold enough to chill the brain before the blood circulation to the brain stops. In this case, the lake temperature was not low enough, and John’s body size much larger than the typical survival case, so blood flow to his brain would have almost certainly stopped before his brain chilled to a temperature that might be protective. While his body temperature on arrival in the emergency room was a life-threateningly low 88 degrees Fahrenheit, we had no reason to believe it got that low in the proper sequence needed to preserve brain function.

  But I was wrong—and I was never so glad about it.

  Within forty-eight hours of arrival to our unit, John began opening his eyes. Shortly after that, with the breathing tube still in his throat, he began answering complex questions I asked about his two favorite professional basketball players. Using his hands, John gave the answers—left hand for LeBron James, right hand for Michael Jordan. When he answered all the questions correctly, I knew he would recover his brain function.

  I had never seen anything this astonishing in over twenty-five years of doing intensive care medicine.

  After a week on the ventilator and sixteen days of hospital care, John went home, continuing to receive physical therapy to regain fine motor movements in his hands. His brain function was otherwise entirely normal. When the media interviewed his parents and the doctors and nurses in the emergency room where John was first taken, with one voice they all declared that John’s heartbeat starting right after his mother’s prayer was a miracle. Because I’d cared for him at our facility for many days afterward, the news media also interviewed me. I called his brain recovery a bona fide miracle. This is not hyperbole—there were really no other words to describe it.

  Nothing has happened to change my mind since. After his release from the hospital, John eventually went back to school after missing many weeks, caught up with his studies, graduated middle school with his friends, returned to playing basketball and, incredibly, is fully back to being an active teenager.

  Date of event: September 2014

  She Pointed Up to Heaven

  Michael Fleischer, MD

  In residency training, young doctors speak of “white clouds” and “black clouds.” Residents with “black clouds” are the ones with tough, sleepless nights on call, their patients “crashing” with complications and bad outcomes. Doctors with “white clouds” rarely have things go wrong on their watch. I had the reputation among my fellow residents of having a “white cloud.” I’ll leave it to you to decide whether, on this September morning, long past my residency days, I had a white cloud or a black cloud over my head. I know what I would call it.

  I was on my way to the hospital to do a routine repeat caesarean section on Ruby at thirty-nine weeks (full term) of pregnancy. I had delivered her previous baby seven years earlier, also by C-section due to Ruby’s high blood pressure. Ruby remained on blood pressure medicine throughout this current pregnancy, with stable pressures throughout an otherwise uncomplicated pregnancy.

  I was in a good mood because it was my half day on call, and I knew I could go home after the procedure and rest. I had been under the weather all weekend and was finally starting to feel better and no longer contagious, but a short day would help a lot. I greeted Ruby and her family in the pre-op area. They were very excited to see me since they knew that I had been ill, and they thought I might not be able to do her surgery. Ruby and her sister spoke English; however, the rest of the family spoke only Portuguese.

  After checking her vital signs, labs, and the fetal heart tracing, I helped the nurses take Ruby to the operating room. Her spinal anesthesia injection went in easily, and we began the surgery. A few minutes later I delivered a healthy baby boy and everybody was very happy and excited. Her husband hurried over to cut the cord. Within fifteen minutes, the surgery was over, the incision closed, and Ruby was taken to the recovery room.

  I returned to the family in the waiting area to tell them the good news that everything went well and the baby was healthy. They would be allowed in to see Ruby in a little while. I left the area to round on my other patients before heading home.

  That’s when everything went downhill fast. My beeper sounded simultaneously to hearing my name being called urgently overhead on the hospital loudspeaker—always a bad sign. I found my patient back on the operating room table with a breathing tube inserted in her windpipe. The anesthesiologist informed me that Ruby had stopped breathing in the recovery room. Thankfully, he was right there at the time and quickly inserted the tube. Her blood pressure was now unstable, dangerously low. I carefully assessed Ruby. She was not bleeding from her incision or from her vagina. Her urine output was adequate. I used an ultrasound test to see if there was blood in her abdomen; there was not. Everything from the surgery was intact. I knew her sudden respiratory (breathing) arrest was either due to a pulmonary embolism or an amniotic fluid embolism; neither would be good news, but the first one is much more treatable than the second one. A pulmonary embolism is a blood clot that has spread from the lower part of the body to the lungs, where it can cause chest pain, difficulty breathing, and even a total respiratory or cardiac arrest. An amniotic fluid embolism is a much more rare condition where the fluid that surrounds the baby in the womb enters the mother’s bloodstream. This is a highly lethal condition, killing as many as 60 to 80 percent of women who develop it, and it often causes brain damage in survivors. Typically, hospital stays of weeks or even months are required following amniotic fluid embolism.

  The anesthesiologist continued to assist Ruby’s breathing as well as give her strong medicines to keep her blood pressure from falling. Doctors specializing in intensive care arrived to help as well. At this point, I knew I had to discuss the situation with the family. We had been working to stabilize Ruby’s blood pressures for at least thirty minutes. I spoke with her sister, who translated everything for Ruby’s husband and family. I explained that Ruby had difficulty breathing, and we were struggling to get her vital signs under control so that we could take her to the radiology suite for special X-ray testing to determine the problem. If testing found a pulmonary embolism was threatening her life, we may be able to retrieve the clot from the lungs using a special catheter (tube) and she would be fine. On the other hand, if we determine it was an amniotic fluid embolism . . . well, that might be a very different story. They understood and would wait patiently.

  I returned to Ruby’s side as we m
onitored her vital signs and electrocardiogram (EKG). Despite the strong medicines we were giving her, we still could not maintain an adequate blood pressure, now two hours into her crisis. That’s when we saw it on the monitor—she no longer had a regular heartbeat. In fact, she no longer had a heartbeat at all! Ruby was in cardiac arrest! We immediately started cardiopulmonary resuscitation (CPR). The intensive care specialist was the first to begin pumping on Ruby’s chest, counting one, two, three, four, five, six, seven, eight, nine, ten. Oxygen was flowing into her lungs from the breathing tube, but heart compressions were essential to circulate the oxygen to the brain and other vital organs. He continued the exhausting pumping, then asked for someone else to help. The anesthesiologist took over. A little while later, it was my turn to pump her chest. I couldn’t believe what I was witnessing. My routine C-section had turned into a tragedy. She was going to die. My patient—this mom, wife, sister, and daughter—was about to die on my watch. All we could do was continue CPR and desperately try to maintain her blood pressure.

  I spoke to the family again. I explained the catastrophic turn of events and how the likelihood of survival was very low. I told them that we would do everything we could, and I then returned to the OR. We continued CPR for another thirty minutes. Nothing changed. We shocked her with the defibrillator paddles hoping to jump-start her heart, medicated her with drugs intended to stimulate the heart, and continued compressions. And then we repeated the steps over and over again.

  Ultimately, it became obvious to all of us that the time had come for the family to say good-bye. We wanted them to be able to talk to her, hug her, and kiss her before she was officially pronounced “dead,” although after forty-five minutes without a pulse and nearly three hours without adequate blood pressure, she was already, for all intents and purposes, gone. We also wanted the family to see the many people working so hard to resuscitate Ruby so they would know we were doing everything humanly possible to save her.

  As Ruby’s family filed into the OR where we were still working feverishly, they screamed out her name in anguish. They shouted their love for her. They cried out that it was not her time. They pleaded with God not to take her. Her mother asked God to take her instead. It was beyond emotional, it was heart-wrenching. I continued chest compressions while the family hugged and kissed her. Once they each had a chance to say tearful good-byes, they gathered in the waiting room. I joined them as we huddled closely and said a prayer. Then I returned to Ruby.

  We had performed CPR for well over forty-five minutes with no response. We had shocked her five times and given her multiple rounds of medicines. There was nothing left to do. We stopped our compressions and just watched the heart monitor. We kept the tube in her windpipe because her EKG showed some type of vague background electrical activity, although no true beats. We waited for it to stop completely before pulling the tube out. We waited for the flat line.

  Then the impossible happened. A blip of a beat on the monitor. Then another. Then another. Somehow, Ruby’s heart started to pump on its own, now with a normal rhythm. And just as impossibly, her blood pressure was suddenly normal. It seemed she would be okay. Would she, actually? After no heartbeat for more than forty-five minutes and without a normal blood pressure for nearly three hours, how would her brain function? What other organ damage might she have sustained? Kidneys? Heart? What type of life would she have if she survived? At this point, we couldn’t answer those questions or be distracted by them. For now, she was alive! We told the family. In unison they screamed for joy and rushed back into the OR. They proclaimed their faith that God exists and began praying out loud.

  We gave them some time with Ruby and then took her to the radiology suite. We still had to determine if she had a pulmonary embolism as the cause of all of this and whether we could remove it. Unfortunately, the scan did not reveal a pulmonary embolism, meaning she definitely had an amniotic fluid embolism. We took her to the intensive care unit to monitor her for the dread complications of this condition, anticipating a long and difficult stay there. For now, at least, she was stable. I couldn’t do anything more at this point so I went home, exhausted and numb, leaving her in the good hands of the intensive care doctors.

  I was not even halfway home when the nurse called me with unimaginably wonderful news. Ruby opened her eyes! She responded to questions by nodding her head. She pointed up to heaven. She knew she was okay. I couldn’t believe it. Ruby’s only bump in the road from there was an episode of bleeding from the incision site, which I was able to stop with a couple of stitches. The next day I sat with Ruby and explained everything that had happened, barely believing my own words. Later that day, we were able to safely remove the breathing tube, confident she was out of the woods. No brain damage, no other organ damage, no broken ribs despite all the pounding on her chest—she didn’t even have bruising.

  Defying all the statistics and all the textbooks, three days later Ruby went home with her healthy baby and entire family. I think about this day very often. Was it God? The prayers of her family? Was it luck? Was it the skill of the medical team? Was all of this evidence of a black cloud or a white cloud over my head? I choose white.

  4

  Extraordinary Awakenings

  Severe impairment of brain function leaves patients and their families in medical and emotional limbo. Coma can result from many causes, but the longer it lasts, the worse the prognosis.

  These essays describe patients in prolonged coma following severe brain injuries from infections, shock, stroke, medication error, and drowning. As the days and weeks wore on, their families were told there was little to no hope for improvement. Brain death and a vegetative state seemed certain.

  Yet, right before our eyes, these patients opened theirs.

  Date of event: October 1984

  A Miraculous Smile

  Rodney E. Willoughby, MD

  I was in training as a pediatrician in a busy children’s hospital with far too many patients to care for. My responsibilities included a ward where children were rehabilitated after serious injuries. Most did not recover fully. Many were connected to breathing machines through tubes inserted directly through the skin in their necks. It was a sad place.

  Heather was a thirteen-year-old with severe asthma who had been at summer camp in July. She developed walking pneumonia and was prescribed an antibiotic to treat her infection. Unfortunately, the camp doctor didn’t realize that particular antibiotic interacted with her asthma medication, increasing her blood levels of the asthma medicine to toxic levels. As a result, Heather had a seizure, vomited, choked on her vomit, and stopped breathing. She was found unresponsive and was airlifted to our hospital. She did not recover meaningful activity. She had been in a coma for four months. She was fed through a tube into her stomach. Her mother visited every day and made sure she was always clean and well-groomed.

  Heather developed a fever and I was called to look her over for a possible infection. In medical school, we are taught to treat patients with respect. We are supposed to inform patients what we are doing to them and why. This lesson is emphasized even in the extreme, such as when patients are unconscious. We are regaled in school with stories of patients (usually doctors themselves, who at one time were under treatment and recovered) recalling what was said about them by others at bedside when they were thought to be unconscious. Patients who couldn’t move after trauma or stroke but who were fully con-scious, in pain, and hearing every word, retold their agonizing experiences to us. But, when you are very busy and very tired, it is easy to take the shortcut and not bother with such niceties as fully informing and showing respect to a girl in coma for many months. After all, there is almost no hope after so long.

  Dutifully, but with some internal skepticism about how necessary it was, I warned Heather about my cold stethoscope and warned her again when I was about to push on her belly as part of my exam. I next told her that I would look in her ears. I had j
ust heard a great joke from the head nurse on another ward—one of those that make you smile for the rest of the day. I decided to tell Heather the joke while at her ear; the joke would just be between the two of us.

  To my amazement, she smiled! I know because I was going to examine her mouth next, and the smile was still there as I got my tongue blade ready. So now I didn’t know what to do. Was it just a random grimace? I am terrible at jokes because I can never remember them. I had no other jokes ready. I resolved to get another joke from my friendly nurse and try again the next day.

  Heather’s mother was there when I next came by. I was embarrassed to try out my new joke in front of such a large audience (two, one of them comatose), and I was worried about creating false hope in her mother. I decided to try my joke, but only after procrastinating through my entire examination. Again, on cue, Heather smiled. Her mother saw it immediately and was so overjoyed that she started crying. I told her mother about the previous day and suggested she buy a book of jokes as my reserves were spent.

  Over the next week, the positive signs kept coming, leaving no doubt that Heather was, indeed, making significant progress. She smiled at some but not all jokes (probably a good sign), opened her eyes, and began to nod yes or no when I asked her questions. She seemed to have a crush on one of the male doctors. She was discharged home a few weeks later—now walking and talking on the way to a full recovery.

  Since that experience early in my career, I always talk to my sedated or unresponsive patients, without questioning its necessity or value. I even tell a joke or two.