Pieces Missing

Larry C. Kerpelman, PhD, Two Harbors Press
Pieces Missing

A family's journey of recovery from traumatic brain injury

Chapter 2

Our walks back from the Boston Bean coffee house in Maynard always finish the same way, with Joanie pulling way ahead of me and then jogging around the corner and down the last few hundred yards to our house. But not today.

When I turn the corner, about three minutes behind her, I see my wife lying on her back on a neighbor’s lawn. The street is strangely silent and still — no wind, no traffic, no sound of birds.

It is unseasonably warm for early December, so I assume Joanie is relaxing and cooling off on the grass while she waits for me to catch up. She waves her arm languorously as if to call me over, confirming my assumption — or so it seems. Then:

“Larry, I’m hurt!”

I run full speed toward her, and as I close the distance between us, I see the blood. When I get to her, my heart is racing as much from the anxiety of seeing her lying there as from the exertion of running the fifty yards to get to her. I kneel beside her. Blood is dripping from a cut near her right eye and from heavy abrasions on her lower lip, the red seeping into her hair as she lies there, face up. The sleeve of her grey sweatshirt is red, too — from where she had used it to wipe her face and hair. My first thought is that she has been struck by a car and thrown onto the lawn as she jogged down Robert Road — that’s how torn and battered she appears to be. I ask her what happened.

The pain slowing her words, she answers: “My feet got caught in the laces of my sneakers, and I fell on my face onto the road. I crawled over here to get out of the road. I felt such a whack when I hit.” She adds, “This can’t be good.”

I take out my handkerchief, wipe more of the blood away from her lip and eye, and assess the situation. She has some bad cuts and bruises on her face, but having dealt with the occasional wounds our children acquired as they were growing up, I think that these, too, will pass eventually with the application of ice and a rest.

Suspecting nothing worse, I tell her, “Wait here. I’ll get the car and we’ll get you home.”

I run to our garage, get into my car, and reverse the two hundred yards down the street to where she is lying. Gently, gingerly, I help her into the car.

Once home, I clean her cuts and bruises. I put ice in a couple of Ziploc bags and hand them to her to put on her lip and eye, both of which are now beginning to swell. She sits at our kitchen desk as she tries to calm down.

“I’m going to look awful for Christmas,” she says.

Trying hard to work out a sensible plan of action, I suggest, “Well, we can wait and see what happens— see how you feel in a little while. Or we can call Acton Medical now and see what they have to say. If you feel really bad, we can go to the Emergency Room.”

Acton Medical Associates, our physicians’ office, is only a short ride away, but this being the weekend, there’s likely to be only a skeleton staff there. We kick around possible courses of action as she sits there, but before we reach a decision, she announces, “I’m going to take a shower first, Lar. If we’re going to go to Acton Medical or the ER, I’ll at least wash the blood out of my hair and get into some clean clothes. Let’s see how I feel after that.” A hopeful sign, I think, caring about her appearance. After a shower and a short rest, she returns to the kitchen.

“Larry, you better phone Acton Medical. My head feels much worse.”

The nurse on weekend duty there listens to my description of Joanie and her fall then tells me, “You should get her over to the Emergency Room at Emerson Hospital. They have equipment there we don’t have at our office that would be able to tell if there’s any hidden damage.”

I think that is possibly an over-reaction to what appears to me to be just cuts and abrasions on her face — bad cuts and abrasions, sure, but not anything that won’t heal with time. After all, as painful as her wounds are, Joanie is conscious, able to talk and walk, and does not seem to have any other grave injuries that I can see. We have had a few experiences in our family where a visit to the Emergency Room was called for — when our son, as a toddler, fell against a table and opened up a gash in his forehead, and when our daughter, as a teenager, injured her finger playing soccer — and the thought of spending hours waiting in the Emergency Room for my wife to be attended to doesn’t appeal to either me or her. But taking to heart the nurse’s comment about hidden damage, we conclude that the prudent thing to do is to go to the ER at Emerson Hospital in nearby Concord, Massachusetts. As the hospital closest to where Joanie and I live, it is the logical place for us to go in an emergency.

* * *

Joan sits in the dim, cramped office of the triage nurse in the Emergency Room as the nurse asks her to describe what happened so she can determine what to do with her next. I wait a few yards away in one of two chairs in the hallway outside the office while the nurse questions her and records the information she gives her. I manage to catch snippets of sentences as Joanie describes her symptoms: “achy all over from the fall,” “sore wrists,” “chest hurts,” and “my head aches badly.” The nurse records Joanie’s recitation and then directs us to wait in the hospital’s Urgent Care Unit across the hall.

In contrast to the old Emergency Department, the Urgent Care Unit is bright and relatively quiet. It is a new addition to Emerson’s facility, having been put in only a year before to afford more space for the hospital’s overall emergency operations. After giving the receptionist there identifying information and data about Joanie’s insurance coverage, we wait on a couch in the Urgent Care waiting room to be called to be seen. I tell Joanie how bad I feel for her, suffering an injury while engaging in something that was meant to contribute to her health and well-being. She expresses the same to me, and we commiserate about the irony of it all. After close to an hour of waiting, we are directed to go to a treatment room. The blood on Joanie’s face has begun to clot, but her lip and eye are still noticeably swollen. As I help her to her feet, she cries out “Larry!” and then crumples. I catch her before she lands on the floor, and, seeing that she is unable to stand on her own, I hold her up and yell, “Somebody get a wheelchair. We need help here!” She seems to be conscious, but she can’t stand. I begin to think this may be getting serious.

A young patient care technician appears and, between the two of us, we maneuver my wife onto a wheelchair and into a room where she transfers, with the help of the technician, to the bed. A nurse wearing a multi-floral tunic top comes in.

“I’m going to take your vital signs — blood pressure, pulse rate, temperature,” she says in a warm, caring tone. “Then one of our doctors will be in to see you.”

She records Joanie’s vital signs and leaves us alone in the room again. We hold hands and, to try to get her mind off her pain, chit-chat idly about inconsequential things we notice about the new Urgent Care center.

Presently, an emergency room physician strides in. He introduces himself as Dr. Gert Walter and asks Joan about the circumstances of her accident.

“I was jogging, my foot got caught up in my shoelaces, and I couldn’t move. I didn’t have any other place to go and fell over and hit my face on the road.” She relates this in a clear, even voice, the quaver of a few hours ago now gone.

On the basis of her description of her fall, her symptoms, the triage nurse’s note, and a brief medical history and examination, Dr. Walter orders a chest X-ray and a computer tomography (CT) scan of her head. She is wheeled to the Radiology Department to have these done and then wheeled back to the room in Urgent Care. While we wait alone in the treatment room for the results of these imaging tests, Dr. Quentin Eliason, a physician from Acton Medical Associates who is covering at the hospital for Joanie’s primary care physician this weekend, comes in and asks about the circumstances of her fall, how she is feeling, and what has happened to her thus far in the hospital. Joan’s answers are much the same as she gave to the previous physician a short time before. Dr. Eliason makes a few notes and then departs, leaving Joan and me to wonder what the CT scan and X-rays are going to show, what the physicians are going to conclude, and what the next steps are going to be. Meanwhile, my mind is pingponging back and forth between wanting to believe that this is just a matter of a few facial cuts and bruises and fearing that it may be something more serious.

“The chest X-ray doesn’t show any obvious damage,” Dr. Walter says when he returns a short while later. “You may have cracked a rib, but small rib fractures may not show up on X-rays. In any event, the treatment would be the same whether or not the rib has a small crack in it, or even if it were just bruised. Right now, let’s just leave it alone; if the pain gets worse, then we’ll decide what to do about that rib.”

He leaves, and Joan and I are both relieved that her chest pain doesn’t seem to be anything grave. We engage in more small talk as we wait for whatever is to happen next. In half an hour, Dr. Walter comes back again and announces, “Well, now I know why you have such a bad headache. Your CT scan shows a subdural hematoma on the left side of your brain. We’ll admit you tonight and keep an eye on you.”

Neither Joanie nor I are well-versed in the implications of the term “subdural hematoma,” neither its consequences nor its cure. We look blankly at each other. I do know that a subdural hematoma involves bleeding in the head, but other than that global picture, I don’t have many details about it at ready recall. Joanie recollected, some time later, that her main familiarity with the term up to that point came from television medical dramas, and its pronouncement always portended something bad. Dr. Walter’s calm demeanor as he delivers the diagnosis doesn’t belie any concern on his part, though, so I return from thinking that blood in the brain sounds terrible to thinking that maybe this isn’t going to be so bad after all.

Dr. Walter then goes on to explain that Joanie fell so hard on the right side of her head that it violently pushed her brain (which lies slightly loose within its cranial chamber) against the left side of her skull, rupturing blood vessels and causing subdural bleeding at the left frontal lobe of her brain. This collection of blood (the hematoma), which he tells us will soon clot, is pressing against her brain tissue, leading to her severe head pain. She has suffered a traumatic brain injury, he goes on, and doubtless some neurons in Joanie’s brain were stretched and torn as a result of her fall in addition to the torn blood vessels. When I hear his description of what has gone on inside her skull, I abandon hope that Joanie has suffered only minor damage.

We have both since come to be more familiar with what a subdural hematoma is — much more than we ever expected to be. It is an accumulation of blood from a break in a blood vessel or vessels, often leading to the collection of blood and other fluids around the brain, exerting pressure on the brain tissue and causing it to deform. The bleeding of a subdural hematoma occurs below the outermost lining of the brain, the dura mater (thus “subdural”), but external to the brain tissue itself. It is a traumatic brain injury for sure.

The National Institute of Neurological Disorders and Stroke defines a traumatic brain injury (TBI) as one where damage to the brain results from a sudden physical assault on the head. That attack to the head may result in either a closed head injury (such as occurred with actress Natasha Richardson in her fatal skiing accident in 2009) or a penetrating head injury (such as occurred from the gunshot wound sustained in 2011 by Congresswoman Gabrielle Giffords). The NINDS further refines the damage to the brain as being either focal, that is, confined to one area of the brain, or diffuse, that is, involving more than one area of the brain. Joanie’s injury is a focal, closed head TBI.

An injury such as hers can cause all kinds of problems — some temporary, some permanent — due to not only the broken blood vessels but also the damage to the brain’s neurons. Among these problems are head pain, confusion, lethargy, nausea, sleep disturbances, impaired attention, memory loss, speech and hearing deficits, emotional and behavioral problems, and seizures. Injuries on the left side of the brain, specifically, can impair a person’s understanding of language, speaking, verbal memory, logic, sequencing of activities and thought, and control over right-sided body movements. Over the next several weeks we will see almost all of these problems play themselves out in Joanie.

* * *

She is admitted to Emerson Hospital at eight o’clock in the evening with the diagnosis of subdural hematoma. The hospital is an acute care medical center of about 175 inpatient beds serving a twenty-five-town area in the outer suburbs of Boston, Massachusetts. Wheeler 4, where my wife’s semi-private room is located, is a busy place, with nursing and medical staff, patient care technicians, food service aides, and volunteers going up and down the long corridor to their assigned tasks in the patient rooms running off either side of it. Her room itself can best be described as neither bright nor cheerless. It has a utilitarian cast to it, probably typical of most hospital rooms of its age in most hospitals of its age. The wall behind each of the two hospital beds in the room contains inlets and outlets for various tubes and cables, along with a small closet in each corner for the patients’ belongings. A thin curtain can be drawn around each bed for privacy — mostly just visual privacy, as we would soon find out. A television set is mounted high on the wall above the foot of each bed. In one corner of the room is a small bathroom for the patients if they are able to get out of their beds to use it.

Almost immediately, a young nurse comes in, introduces herself, asks Joanie the same questions about her accident, and takes a medical history, as Drs. Walter and Eliason had just done. I wonder to myself why the history and answers that these two physicians elicited from Joanie a short time before didn’t make their way to this nurse on Wheeler 4. It is a question I would repeat to myself over the next few days as nearly every new health care provider who sees her asks the same questions and dutifully records her answers. The young nurse places an intravenous needle into the back of her new patient’s hand for use in the event that they will need to put medications or other fluids through it.

I am glad that, even though she is in such deep pain, Joanie is conscious, talking, and able to tell the nurse what happened to her and to answer questions about her medical history. I am hopeful that the subdural hematoma will just resolve itself after a few days and we can return to our normal lives. At the same time, though, the implication of the words “traumatic brain injury” begins to play on me.

“Do you think we should call Janna and Todd tonight to tell them about this?” I ask Joan regarding our children. By this time, it is late into the evening. Both our children are in their thirties and living independent lives away from us. Janna, younger than her brother by a couple of years, is clever, winsome, and utterly devoted to her mother. Todd, recently married and living in California, is bright, personable, and level-headed.

“Let’s at least wait until tomorrow,” she answers. “It’s getting kind of late, and I’m really tired, so even if Janna gets out here soon, there’s not much she can do for the rest of the night. And as for Todd, let’s wait and see what they tell us tomorrow about this thing before we go getting him upset 3,000 miles away from here in California.”

I stay with Joanie until she settles in for the night, and then I return home.

Excerpted from Pieces Missing by Larry C. Kerpelman, PhD. Copyright © 2011 by Larry C. Kerpelman, PhD. Excerpted by permission from Two Harbors Press. All rights reserved. For more information about the book, go to Two Harbors Press and about the author, go to www.lckerpelman.com.

Posted on BrainLine October 25, 2011.