by Dave Alfvin
Byun: It was very cold the day Teri arrived at the hospital. I got a call to come to examine someone with traumatic injuries. Usually, emergency room doctors see a traumatized patient first. They go through the blood tests and the initial examinations. In this case, we were looking at a thermal injury. After the ER team is finished, the trauma surgeons begin their work. They call a neurosurgeon to examine Teri to determine whether there is any brain damage. If there is any eye or lens damage, they call an eye doctor. Teri had severe frostbite—frostbite and burns fall into the medical area of plastic surgeons, my specialty, so that’s why I got involved.
Plastic surgeons have to fully understand a person’s total “surface area,” but we also must have complete knowledge of a person’s internal structures that may be affected by the external injuries.
Alfvin: What happened next?
Byun: Teri was suffering from hypothermia, a very serious injury that can affect the internal organs.
Alfvin: Was Teri’s life in danger when she reached the hospital?
Byun: Sure, because with hypothermia, the body temperature gets so low that the internal organs, even the brain and heart, deteriorate due to the lack of blood flow. The blood circulation actually slows down. Many hypothermia victims just drift into a coma and die quietly because they’re breaking down the energy sources from muscles. We don’t know how long Teri could have survived in the storage locker, but it was close. So with Teri, we warmed her body by infusing IVs with warm solutions.
Alfvin: Who treated Teri after that?
Byun: After the trauma team stabilizes Teri, they do body scans, and more blood tests; then they call the experts—the orthopedic surgeons and me. I was involved because she had a soft tissue injury of frostbite, quite severe on both feet. Her hand also had frostbite but milder than her feet. I was also involved because I do a lot of work with head trauma. She had a severe baseball-bat-sized injury to her head, and a severely crushed outer surface of her cortex (the top of the head). So with Teri’s injured head, it wasn’t just soft tissue.
We ran a CAT scan to determine whether she had any broken bones near her eye sockets or internally. We determined her eye sockets were intact, though she had scratches and bruises everywhere. There was no bleeding to the brain and no apparent brain injury, so the neurosurgeons eventually were not involved in her treatment. Her swollen face was about 30 percent larger than normal, and her head volume was probably about double. The swelling moves from the top of the head and then downward.
Alfvin: To have a crushed skull, and no internal bleeding…
Byun: Yes…amazing.
Alfvin: What was the original prognosis for Teri’s legs?
Byun: Originally, they wanted to amputate her legs just below the knee, but I said, “No, no, no…you need to give me some time to assess things, because if there are no internal injuries, we can wait a few days to see if things improve; we may have a chance to save some things. She’s getting an IV and antibiotics, so as long as the infections don’t spread (infection can spread from dead tissues to healthy tissues), we can give her body a small amount of time to fight this. Infection was the reason some of the doctors wanted to amputate sooner than me. But when I looked at her, I saw a healthy young woman…if we had amputated her leg at the ankle, basically, you’ll just have a stump…forever. So I insisted, and they gave me the chance to observe and treat Teri. I used special cleaning techniques and applied medications that would increase the blood circulation. The first treatments probably began a few days after she entered the hospital. If you’re looking at a tree branch, you can’t be sure which part is dead…there’s circulation going through the branches. With a human limb you want to make sure the core (of the leg) sends enough blood to the affected area to optimize her condition.
Alfvin: So let’s do a brief summary. You’re giving Teri’s body the best chance to heal itself through IVs and antibiotics, at least for a while. And you’re keeping a close eye on infections and whether they spread.
Byun: Yes, and increase the possibility of sending more nutrients, like blood, to the outer body (hands and feet), because the heart has to pump blood through the little capillaries and deliver oxygen to the damaged tissue, so we try to optimize that. Then, while we’re watching the tissue on Teri’s lower extremities for improvement, I then focused on her face and skull injuries. The crushed area of the skull was about the size of a baseball. The skull bones were exposed because the scalp tissue was dead, due to the extreme force of the bat…crushed cells become necrotic.
Alfvin: David Larsen hit Teri so hard on her head, he probably thought he killed her.
Byun: Right. There were multiple events that could have killed her. Someone above must have been looking after her. First, the hypothermia should have killed her and then the blow to her head also should have killed her, too.
Alfvin: So then you operated on Teri’s skull…
Byun: Yes. There are two layers of the skull, kind of like two layers of drywall. Teri’s outer cortex was crushed like an eggshell, but not the inner part. When I operated, I pulled up the crushed part and put things in the correct configuration. At that point, we’re looking at nothing but shattered bone, so now we have to cover that. A skin graft doesn’t stick to bone, so you have to borrow live tissue from a neighbor and make what’s called a rotational flap. I have to cut normal neighboring tissues into triangular shapes, almost the shape of pizza slices. Then I move and stretch the tissue up from the bottom and down from the top of the open area.
Alfvin: That’s amazing.
Byun: After I took care of the skull injury, I worked on her face. That took about two hours. After that, I joined the orthopedic surgeons to treat and make decisions on her legs and feet. Now, it appeared we may have to amputate at the ankles instead of below the knee, but her tissues continued to improve and were becoming healthy…up to the top of the foot. So my treatment to increase the viability of the cells indeed saved her ankles and the base of her foot.
Alfvin: Does tissue improve in a direction downward, in an orderly fashion?
Byun: You’ve got it. It’s like the tree branch…the blood is coming from the heart and works its way to the tissue. That way we were able to save her ankles and the top of her foot…they’re closer to the heart. Then about a month later, we decided which parts weren’t going to live…the toes and some little parts near that area. The orthopedic surgeons performed the operation to remove Teri’s toes and some other small bones.
Alfvin: So what you have left is…
Byun: A large stump at the base of the toes, but the area needs to be closed before we’re done, so that’s the plastic surgeon’s job. After the amputation by the orthopedic surgeons, I went in to do another “flap” surgery over Teri’s two “stumps” at the base of her toes where everything is opened up. You need to close it, but because the surrounding tissues are weak, I couldn’t “borrow” tissue from the bottom of her foot. So I closed the opening as much as I could and began applying skin grafts. We did that surgery about three times.
Alfvin: When were Teri’s arms out of harm’s way?”
Byun: Her arms and fingers improved after a few weeks.
Alfvin: Teri described the skin grafts as very painful.
Byun: Normally, they are not too painful. If you had an area on your thigh that needed a skin graft, and I borrowed skin from your other thigh, your grafted skin would heal in about two weeks. The reason Teri’s pain was sustained was because the recipient site for the skin grafts (her feet) was 80 percent damaged. Her feet were living off a restricted level of blood circulation, and this meant the grafted area healed slower than normal and was the reason she was in the hospital an extra month. There is also the obvious pain from the donor site, where we have to “fillet” a thin layer of skin off the top so we can apply it to the recipient site. For Teri, the skin grafts were donated from her buttock region. After that, Teri went through rehabilitation at the hospital and then closer to her home. If we had her meta
tarsal (the ball of her foot), removed, she could have stood up, but she wouldn’t have been able to walk.
Alfvin: Without the balls of your feet, you would fall forward, right?
Byun: That’s right. So I was able to save her ankle and heel and her metatarsal. After losing her toes, she can still stand up. The ankle/heel and metatarsal are the major weight-bearing structures in your foot. When you consider she survived the hypothermia injury and the skull fracture, which didn’t kill her or cause hemorrhaging to the brain…that was amazing. And she was able to keep both legs except for her toes…from either a plastic surgeon’s or a physician’s point of view, each of these recoveries is miraculous.
Alfvin: It’s quite a story, Dr. Byun. Thank you for sharing this information.
Today, Teri Jendusa-Nicolai is a spokeswoman for Byun’s foundation: the Michael Byun Plastic Surgery Foundation, an organization that provides monetary assistance for individuals’ plastic surgery when health companies refuse to cover procedures that are (unfairly) deemed “cosmetic.”
In this next interview, Teri Jendusa-Nicolai and I discuss her tough road back to recovery at the hospital and beyond, with Teri’s unique perspective on the experience.
http://www.michaelbyunfoundation.org/stories/featured-patients/patient-1/
Alfvin: Teri, at the hospital they thought they were going to have to amputate your legs somewhere around the knees.
Teri: Right, and my arms. At least my right arm, up to the elbow. They actually had a pen line…I have a picture of my arm being totally red and scraped up, with a pen line right by my elbow.
Alfvin: How is your right arm now?
Teri: It works fine. But if you look really close, you can faintly see scarring on my arm and fingers, but everything is okay.
Alfvin: Was there gangrene in your feet?
Teri: I think the toes were heading that way, and that’s what they worried about. Seriously, my legs were black. Actually, Chris (one of the police officers who rescued Teri) told me when they were putting me in the gurney, he kept thinking “she has black socks on.” He thought I had black socks on and then realized, “Oh my gosh, those are her feet!”
Alfvin: So, after a week or so, they started deciding what to do with you?
Teri: I know I was in ICU for two weeks. And in that time, I think the initial thing was “make sure she’s not going into renal failure.” At that time, too, they told me that I’d miscarried. I know that they were doing some things with my feet, trying to salvage as much tissue as they could, and I think a lot of that was just pain control, too.
Alfvin: As far as being told about the miscarriage, that was probably during the first two weeks?
Teri: Within the first couple of weeks. It was obviously after the first week, because in the first week I was hardly cognizant at all.
Alfvin: About how long was it before they operated on your feet?
Teri: There were many operations…I think my head was actually the first operation.
Alfvin: What did they do?
Teri: There was literally a giant hole…the officer said there was a 2x2 hole in the back of my head where he had hit me. And oddly, the skull was not damaged, the brain was not damaged; it was just all the skin over that and everything. So I do remember the first hole, which I think was basically just stitched up. And then my head was totally wrapped up. There were a couple of things on my head—my plastic surgeon gave me a long explanation about a type of butterfly closure, as he called it. He applied this to the back of my scalp to save me from having this big bald spot on the back of my head. He was very proud of his butterfly closure thing. I just remember that. So, fixing my head was the first major thing. The doctor said everyone was so concerned about my feet, which was true, but he also said, “Do you realize what we had to do to your head?”
Alfvin: So the first thing they had to do was repair your skull? And then came the skin?
Teri: Right.
Alfvin: Ugh! So that’s two operations. That must have been no fun at all. So you’re recovering from that—hopefully that wasn’t too bad.
Teri: No, it wasn’t. Then I remember they were performing what was called “debriding,” getting rid of infectious material on my feet…I went under (the knife) thirteen times for my feet. There were thirteen surgeries in all, and a lot of it was just putting me out and debriding. I think they were just getting rid of the dead material and saving as much good material as they possibly could. I also remember them coming in and talking to me, saying, “Because of your age, because of your general health, because of all these things, we want to save as much as possible so you can remain active.”
Alfvin: What were they removing?
Teri: Infected skin…tissue. And at that time too, they also put me on this thing called…something Vac. They got these big black sponges, and it was actually kind of like a vacuum thing, and it was slowly getting rid of the bad tissue and helping grow new tissue, using this big thing I was hooked up to with tubes.
Alfvin: Maybe it wasn’t allowing the bad tissue to grow.
Teri: Something like that.
Alfvin: So they had sponges with suction on them?
Teri: Yes. They were doing that in between my surgeries. And then they would go back in again and look and see how much tissue was saved and get rid of the yucky tissue. The first few surgeries…I never had surgery in my life before this…so I was paranoid. I was like, “Oh my gosh, I’m gonna die when I go under!” and I remember this orthopedic surgeon saying, “Don’t worry, I’ve got you under my wing. I’m not going to let anything happen to you.” By the fourth surgery, I was like, “Whatever. I’ll be fine.” But the first three hours I was very nervous.
Alfvin: And so you had these thirteen mini-surgeries on your feet to remove bad tissue?
Teri: Well, they were removing the bad tissue and…I think it was the ninth surgery where they removed the toes?
Alfvin: Obviously, that came after the thirteenth.
Teri: Right.
Alfvin: And how long did you have to mentally prepare for that?
Teri: I remember that they said, “We’re going to have to remove your toes, but we’re trying to save the whole rest of the foot so you can still have…blah blah blah…” And it was a big shock, but I could see my toes. Because my feet were all bandaged up, I could see my toes, and they were black. They looked like when my dad would burn Italian sausages on the grill. Not to be gross, but I remember saying that they looked like burnt Italian sausages. I remember my dad being in the room with me when the orthopedic surgeon came in and said, “We’re going to have to remove your toes,” and my dad was so upset. He said, “Can’t you save them? Are you sure you have to do that?” And I looked at my dad, and I said, “Dad, look at my toes.” I mean, it had been two weeks, and they were just black. They were dead. There was no refuting it.
Alfvin: Your problem was obvious.
Teri: Right.
Alfvin: Isn’t it amazing that ice and cold…
Teri: …makes burns like that, yeah. It’s really weird.
Alfvin: So when they did tell you that the toes had to go… It wasn’t the greatest shock in the world, was it? You knew you were probably going to lose something, right?
Teri: Yes. And when it got to that point, I was glad it wasn’t my leg, and I was glad it wasn’t my whole foot. A few days after that, my sisters came to see me. I remember, we were always making jokes about stuff, and one of the doctors was like, “Oh my gosh, I can’t believe you’re sitting there joking about this stuff!” But sometimes that’s the only way you can get through things. And I remember my sister saying, “I wish somebody would take my toes off. My toes are so ugly! They’re long and they curl!” And that’s when we made up something like “David Letterman’s Top Ten Good Reasons for Not Having Toes.”
Alfvin: Okay, so it wasn’t a big deal to be prepped for your big operation. When you woke up, obviously you knew your toes were gone. How much pain were you in?
Teri
: Terrible pain, especially right after my surgery was complete. The goal for the top of my foot was try to grow tissue, and then I had some skin grafts from my buttocks to my feet to try and close that up. The most painful part was that they had to…they had this black thing that fit really tight on the top of my foot, and they had that Vac again, and then when they had to come in and change that, it was like they peeled that off the foot. So the first time they gave me pain medication, I don’t think they gave it to me long enough ahead of time, and I just about went through the roof. It was extremely painful. After that, a nurse told me to “take your pain meds half an hour to forty-five minutes before they get here; that’s perfect timing.” Once they started doing that, it was okay.
Alfvin: How much flesh would they put on at a time?
Teri: I don’t know, but every Monday, Wednesday, and Friday, they would come to change that thing…and I just dreaded it. Even when I had pain meds, it was just horrible.
Alfvin: So you’re really not sure what they were doing?
Teri: Right. I just know that they were trying to grow the tissue back.
Alfvin: How many grafts did they put on?
Teri: I think there was one on each foot.
Alfvin: So you had two procedures?
Teri: I know that they took one big rectangle off my butt, and they put them both on…there was one procedure, I mean, one for each foot, and…I think so. I mean, I’d have to look at the papers to know exactly.
Alfvin: Was that also by the plastic surgeon?
Teri: Yes. Dr. Byun was the plastic surgeon. My feet were worked on by Byun, and also by the orthopedic surgeon, Dr. (Matthew) Jimenez. Dr. Byun was the head, and Dr. Jimenez and Dr. Byun were the feet, together. And it’s funny because both of them are, like, the top of their field…both of them had very good bedside manner. But both of them had very big egos, and I heard from the nurses that this was a very good thing for them, because they had clashing ideas of what to do and they had to work together, and they had the whole media watching them. So for the first time, they had to swallow their pride and work together to make something good happen…and they did.