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Alex's Case

The Journey Begins | Dear Film Crew: Help! | On Call | Alex's Case

September 20, 1996
The "Medical Tower" apartments next to New York Hospital
Room 1019

At 6:00 a.m. this morning, Tom (the principal cinematographer), and Peter (the principal sound person) returned to their post at Jamaica Hospital. Jeffrey (the second camera person) and I returned to our post at New York Hospital. We each went about the business of setting up equipment; Dr. Ghajar driving re-introducing ourselves to the paramedics, emergency dispatchers, trauma teams; and directing the production assistant to secure for us the necessary production supplies and food for our locations.

That evening, at 5:53, my beeper went off. Since it was our first day back on call, I assumed that the emergency dispatcher at New York Hospital was testing our system. But the beeper read 111, which was the signal for Team A at Jamaica to race to the emergency room. Just as during our first period on call, the drill was for the team to go ahead and film 1 or 2 camera rolls, no questions asked. Then they would punch one number on their specially programmed cell phone to consult with me. I made sure my cell phone battery was charged and waited for the call.

Some time later, a call came, but it wasn't from Team A. It was from Dr. Ghajar. There was a severe head trauma case in the emergency room at Jamaica. It was a young boy, who had been struck by a car while crossing the street. He was in a coma.

I alerted Jeffrey to prepare to film Dr. Ghajar driving to Jamaica. It was about 6:30 p.m. Shortly thereafter, the crew at Jamaica finally called from the emergency room. Usually, Peter would phone me, while Tom would continue to watch a given case, just to be sure it wasn't a false start. This time, Tom was on the phone, and his voice was shaking. The case was serious. This was no false start. He and Peter had been following the basic resuscitation by the trauma team—the ABC's, for airway, breathing and circulation—and were preparing to follow the patient up to the CT scan.

Jeffrey and I meet Dr. Ghajar at his car. We start rolling when Dr. Ghajar calls Jamaica on his car phone. Part of the conversation is in the final program:

		Dr. Jam Ghajar: Hello, Venu.
		Dr. Venu: Yeah?
		Dr. Jam Ghajar: Yeah. Did you examine him?
		Dr. Venu: Yeah.
		Dr. Jam Ghajar: Does he, does he open his eyes?
		Dr. Venu: No, he's not.
		Dr. Jam Ghajar: He's not opening his eyes.
		Dr. Venu: No.
		Dr. Jam Ghajar: Okay, can you have the ventric set and a cut-down set?

When colleagues watch the film, they assume that we later simulated the car drive and phone call to Jamaica. But it's real.

And so is, of course, what unfolded in the emergency room.

None of the false starts prepared us for what we saw that night. The young boy was clearly in trouble. His body was struggling to breathe—in a very shallow but tortured way—so he was immediately hooked up to a respirator. The trauma team had to keep suctioning blood that repeatedly accumulated in his mouth. All sorts of lines—wires for monitors, tubes for IVs—went into his lifeless body. I just remember standing there with the crew, thinking, 'Oh, my god, this is really happening.'

Even when the popular and well-produced medical drama series get it "right," the real thing is very different. In television dramas, physical movements are rehearsed; in a real-life emergency room, no one has choreographed the action. There are no actors, no scripts. Real trauma team members don't wait for someone else's line to end before they start talking; everyone is talking at the same time, asking concerned questions, Closeup of Ghajar, while performing surgery on Alex, CT scans in background barking tense orders—cursing if something isn't working. Watching actors try to convey tension, fear, and concern is a whole lot different than seeing real people feel these very real emotions, as a child lays critically injured, near death.

Ghajar gets into his scrubs upon arrival and reviews the CT scans. There are definitely signs of brain swelling. The brain could strangulate without more room, and one way to make space is to drain clear fluid that the body makes and replenishes on its own, filling cavities in the brain called ventricles. Ghajar drills a hole through the patient's skull and inserts a catheter. The trauma team gathers to watch the procedure. When the catheter hits the brain cavities, clear fluid immediately drains out, showing the pressure already building in the patient's skull.

His name is Alex, he's nine years old, and he was excitedly racing home from karate class that evening, to tell his mother that he had just gotten his second yellow belt, when he was struck by a car.

At the moment his family sits in a private conference room at Jamaica Hospital, down the hall from the trauma room where all the activity has been unfolding. Now, at what could very well be the lowest point of their lives, I must ask them for permission to follow the case.

When I enter the private conference room, I close the door behind me. I hear the spunky voice of a little girl, peaking out from behind her mother: "Don't close the door on your finger," she cautions. This is Alex's three-year-old sister, Arianna. And for a brief moment, she breaks through the grief in the room, causing everyone to smile or laugh nervously. I start to introduce myself and the project, but I hear my voice shaking and cracking, as if I am listening to someone else. It is at this moment that I look directly at Alex's mother, and see a most amazing, welcoming, and warm look in her eyes. "I know what you want to do," she says.

Friday, September 20, 1996, near midnight
In a transfer ambulance, on FDR, driving south towards New York Hospital

Jamaica Hospital does not have a pediatric intensive care unit, so Alex must be transferred to one at New York Hospital. The paramedics who come Loading Alex's gurney into a transfer ambulance to pick him up know Jeffrey and me from the many hours we've spent at our post, so they offer to let us come along in the ambulance.

From this point on, every time that Alex must be moved, it will be a labor-intensive ordeal. Because Alex must be unhooked from the respirator, a doctor must sit by his side in the ambulance and push air into his lungs with an ambu-bag. A paramedic immobilizes Alex's head with rolled towels on either side—and he too sits by Alex for the entire ride, simply holding the patient's head in place, trying to absorb the shock from New York city's potholes. In an age of high-tech medicine, this whole scene is at once poignant and alarming.

Ghajar arrives at New York Hospital as the pediatric team settles Alex into an ICU bed and hooks him up again to a respirator and various monitors. The main task over the next several days is to help keep a constant vigil on the pressure inside Alex's head. It's called ICP, for intracranial pressure, and it's hovering around 20 mm of mercury. Ten is average for a healthy person, so the medical team continues to drain fluid from Alex's brain.

I've read that "death" is the one word you'll never hear from a doctor, but Ghajar is different. In a conference at New York Hospital to update Alex's mother, around 1 in the morning, he says, "The question is, 'What'll he be like ultimately?' Right now, we don't address those kind of questions. Right now, it's kind of life and death. We're trying to prevent the brain from swelling further. That's why he's here in the intensive care unit."

Saturday, September 21, 1996, 11 a.m.
Alex's ICU room, New York Hospital

"Sorry, Alex, we'll be done in a second, big guy. I'm just going to take a picture of your head." Jean Marie Cannon, a nurse in the pediatric intensive care, is carefully helping to position Alex for his second CT scan. Watching her gently explain what's Moving Alex onto bed for CT scan happening to a patient in a deep coma is reassuring. For a second, I forget the dire circumstances.

Ms. Cannon's bedside manner is also comforting to Alex's parents. She's sees this as a critical part of her job. "In Alex's case, you've got a child who one minute is running around and is healthy and happy and the next minute is laying in a hospital bed, critically ill. And the parents have no chance to, to adjust to that. They're usually in shock, and coming into the ICU such as this, they're just overwhelmed by the technology and the buzzers and the monitors—and all of the things that we're doing to keep their son alive and to keep him healthy."

Cannon and the rest of the intensive care team must perform a number of tasks to keep other parts of a head-injured patient's body from deteriorating. For example, "We take blinking for granted, but comatose patients often don't close their eyes all the way. We need to keep the eyes lubricated, or they can get corneal abrasions or little scratches on his cornea."

Also, for patients who have been intubated—that is, who have a breathing tube inserted into their trachea—the team must take over the bodily function of swallowing by periodically suctioning the patient's mouth. "With that tube in, a patient can't swallow, and therefore they will pool mucous and secretions in their mouth, and we'll need to clean."

The feet of a coma patient are put into cuffs to prevent the patient's Achilles tendon from shortening, a condition called "foot drop," that can severely hamper learning how to walk again.

But the most important job for the entire team in the first week after injury is to constantly monitor the pressure inside the patient's skull.

And on this day, beginning about 48 hours after the injury, Alex's pressure climbs into the 30s, well above a safe level. The average for a healthy person is 10; around 20 would be acceptable in a head-injured patient. 30 is worrisome and requires intervention if draining alone cannot bring it under control.

Because swelling can choke off the supply of oxygen-carrying blood, Alex's team raises his blood pressure, to force more blood into his brain, during this period of high ICP.

Ghajar also counsels the parents not to stimulate Alex, advising them to try not to talk to him. Earlier in the day, when a lot off family members were visiting and talking around Alex's bed, his ICP rose, and he became agitated. There's a misconception, Ghajar believes, on the part of the public, that the earlier you can stimulate a coma patient to "wake up," the better off the outcome. But in fact, during this critical period right Alex's parents at his bedside, watching monitor as ICP rises after the accident, it is important to keep the intracranial pressure down, in order to maintain a steady flow of oxygen to the brain. That's what will improve outcome. And sometimes that means not talking to the patient for a period of days.

While there are physical signs, such as a rise in ICP, that the comatose patient may be aware of the presence of family members, patients do not remember the experience when they emerge from the coma. The brain is too injured to lay down memories, Ghajar explains.

It occurs to me that this is related to why head-injured patients suffer retro-amnesia; the parts of the brain needed to convert a short-term memory to a long-term memory are shut down. This is probably why I can't remember the days leading up to my childhood concussion.

Alex's mother did not sleep last night. Her expressive face shows grief and fear. I now understand why my own parents rushed me to the hospital when I fell off the swing. Even though I did not lose consciousness, I suddenly ceased recognizing familiar people. I had lost my association with the past, and therefore part of my sense of self.

Now, Alex's parents stand watch, waiting for their son to emerge. "The hardest part of dealing with patients [in coma] is that we don't have any answers for these parents," Cannon says. "We can't say, 100 percent, 'Your son is going to be fine, or your son is not going to be fine.' The hardest part is the uncertainty—and not knowing what the outcome is going to be six months down the road."

Wednesday, September 25, 1996, 9:30 a.m.
Alex's ICU room, New York Hospital

When a patient is in a coma, there are few things the doctor can do to examine him. One common approach is to pinch the patient just below the Ghajar pinch-testing Alex collarbone, to see how the patient responds. Two days ago, when Ghajar pinched Alex, he reached toward the noxious stimuli with his hand, a good sign that he was establishing a new level of consciousness.

Today, Ghajar walks into Alex's ICU room and pinches him again. This time, Alex opens his eyes for the first time! Alex cannot yet interact with his environment. He does not recognize family members. He has no idea what's going on. But eye-opening means that Alex's brain is re-establishing cycles of sleeping and waking. Technically, he's no longer in a coma, and Ghajar is no longer concerned about the pressure inside his brain.

I had gathered the crew to film today. Alex's eyes had been fluttering yesterday, and we all hoped he might just open them. When he did, I gasped. It was as magic a moment as I suspect I'll ever experience.

Most coma patients open their eyes within a week, so Alex, thus far, is on an expected course. We can't wait for him to emerge more fully. And we assume, because his pressure is down and his eyes are opening and closing that it's a straight shot to recovery now.

Little do we know that the emotional roller coaster is about to enter and long and tortuous dip.

Wednesday, October 2, 1996
Alex's ICU room, New York Hospital

Vegetative state. These are two words that you never want to hear in connection to a loved one, Alex's mother says. But her son is in one. Since Day Five when he first opened his eyes, he has not shown any conscious behavior. He does not respond to any simple commands, such as, "Raise your right thumb." He can't track moving objects. He is not aware of his environment.

Regardless of how good the care after a head injury, about 10 to 20 percent of all patients remain in a vegetative state forever. This is perhaps because Closeup of one of Alex's MRI scans the initial brain injury was too extensive, or the patient suffered a period of time without oxygen after the accident.

Indeed, Alex's brain injuries from the accident are more extensive than originally realized. He's off the respirator now, so it's easier to get an MRI, a more detailed image than a CT scan. Ghajar and a radiology technician review the scan.

"This MRI shows much more extensive abnormalities than the CT scan showed," the technician says, "including bifrontal areas of hemorrhagic contusion and several deep white matter shear injuries in the left posterior frontal lobe, as well as in the right frontal temporal lobe—as well as additional area of shear injury in the high left posterior frontal lobe. There's a large area of shear injury, which is a common sight of shear injury, in the splenium of the corpus callosum.

"The hemorraghic contusions in the inferior frontal and temporal lobes—that's a common location of hemorraghic contusions, because you have a dense bone separating those two lobes, and as the brain is moving forward, for instance, in a motor vehicle accident, the brain sort of slaps against the bone—the bone doesn't move—and therefore the brain sort of has to come to an abrupt stop at the bone," the technician explains.

"We also call this gliding injury, Ghajar says. "You see here, here is the base of the frontal fossa, the frontal lobe sits on, and you can see if the head moves forward, the brain moves in a different speed and glides across the surface here, and this surface here is not smooth. It's very—it has ridges in it. And what happens is the brain hits those ridges and it causes little bleeding, little tears, and all that. To what extent they heal and Alex's hand in his mother's hand what his eventual outcome is going to be, really you have to wait and see. But he has significant injuries. This is not, you know, minor injuries."

We will continue to follow Alex's case, filming about once a month. But this is our last day "on call." We all had hoped that Alex would respond. We end the filming day by packing and preparing to leave our posts. Usually, wrapping a location is an occasion for celebration, but everyone is quiet and depressed.

Among the crew members, there is a vast range of spiritual and religious beliefs. So I expect that everyone will have a unique way of dealing with what tragically seems to be unfolding.

But I would later find out that after we disbanded and went to our respective homes that night, every single team member, without exception, said a prayer for Alex.

The NOVA team followed Alex's case for 126 days. On Day 15, he showed signs of recognizing his mother for the first time, smiling at her. This was the first sign that he would emerge from a vegetative state. By Day 20, he was responding to simple commands, such as, "Show me two fingers." On Day 32, no longer in need of intensive medical care, Alex was transferred to St. Mary's Hospital for Children, a rehabilitation center. There, a team of physical, occupational and speech therapists, as well as a psychologist, took over Alex's care. Shortly before Christmas, he went home. Then, on January 23, 1997, the NOVA team assembled once more. At Twin Towers Karate, near his nome, Alex received his second yellow belt again. (He had just received his second yellow belt, and was running to tell his mother, when he was truck by a car in September.)

Alex returned to his elementary school three months after the accident. He is slower to learn, and the right side of his body is weak. But he has been returned to his family.

Photos: (1-8) NOVA/WGBH Educational Foundation

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