Washington - On November 8, 2012, my son Dylan - two months into his junior year at Tufts University - was struck by a car in a crosswalk.
His head punched a hole through the car's windshield, and he suffered a traumatic brain injury so severe that doctors initially warned he might be permanently disabled. He might never be able to feed himself again.
When I got the call from the ambulance, I was sitting in a cosy chair reading “The Black Swan: The Impact of the Highly Improbable,” in which Nasim Nicholas Taleb argues that we should recognise the disproportionate effects of unexpected events on our lives.
Dylan's accident certainly made that case. An injury suffered in one second overwhelmed our family for months. Instead of studying abroad in Germany as he had planned, Dylan spent the rest of that academic year with doctors and therapists.
Every year, millions of Americans suffer traumatic brain injury, or TBI. When the TBI is as severe as Dylan's, most victims struggle for years to recover, with varying degrees of success.
Dylan has made an extraordinary comeback, one that has surprised and inspired not only his family and friends but also the doctors and nurses who treated him. The neurologist who enrolled my son in a neuroimaging research study said that after examining his initial brain scan, he would have put the odds against Dylan achieving his current capabilities at “10,000 to 1 - I mean, something astronomical.”
This is how it happened.
Dylan was unlucky to have been hit by an inattentive driver, but his luck changed in time to save his life. Because the accident occurred at 8:30pm rather than in the middle of Boston's rush hour, he was brought to a hospital within a half hour - and not just any hospital. It was Massachusetts General, a top-rated trauma centre with a dedicated neurosciences intensive care unit. The immediate insertion into his skull of a drain tube relieved intercranial pressure, meaning Dylan didn't have to have part of his skull removed. He was quickly admitted to the ICU and equipped with a ventilator and feeding tube. Within 24 hours of the accident, he was getting an MRI scan.
The speed of triage was impressive, but the results of that scan were devastating.
Dylan's brain injury was rotational, meaning his head had been slammed around inside his skull. There was extensive damage at the cellular level. The diagnosis was “grade III diffuse axonal injury,” meaning that throughout his brain, axons - nerve fibres that transmit electrical impulses - had been sheared and torn, disrupting the brain's internal communications system. In addition, the MRI showed several dark patches near the brain stem, indicating injury to the areas governing arousal and alertness. Doctors warned us that if Dylan could wake up, he might need assistance with every aspect of life - possibly forever.
Fortunately, Dylan's neocortex, the brain's seat of higher-level processing, was mostly uninjured. And he had one other thing going for him, doctors said: his youth.
Studies have shown that youth is a prominent factor in neuroplasticity, the brain's ability to form new connections to compensate for ones that get blocked or severed, to partially repair injured pathways and even to repurpose parts of the brain.
It is clear, doctors say, that young people have greater potential for co-opting undamaged parts of the brain to take on new functions than older people do. And in general, the systemic health of young patients, such as more blood flow and oxygen, electrolyte balance and overall positive metabolic state, are helpful in healing.
All we could do was wait and hope.
Days went by. Dylan's cranial pressure was being successfully controlled, which was a very good sign, but his comatose state was terrifying. Every four hours doctors repeated a seemingly cruel physical exam: they yelled Dylan's name into his ears, pinched his arms, scraped the bottoms of his feet. They pried open his eyes and shone a bright light into them. There was no response. No sight is more chilling than looking into eyes you know so well and finding an immovable stare.
After a week, however, Dylan's pupils did begin to dilate. On Day 8 he opened his eyes on his own. Then his eyes began tracking voices; next, he wiggled his toes. Each of these baby steps was greeted with great celebration by his audience - an audience that included a lot of friends.
A big factor in Dylan's recovery may have been the strength of his support network.
Certainly his family was always on hand, but his friends volunteered in ways that can be described only as heroic. Scores of them showed up at the hospital on the night of the accident, keeping a concerned vigil for hours. A core group of a dozen 20-year-olds came to the ICU and then the rehab hospital daily for two months. Housemates, fraternity brothers, his friend Nick (who had been hit by a car months before near the same intersection)... they came alone or in groups; they talked, read and sang to Dylan, held his hands and generally provided the lively social atmosphere he was accustomed to. His high school friend Erin took a leave of absence from Smith College so she could be at the hospital every day.
Despite my objections, Dylan's housemate Teighlor cancelled her upcoming semester abroad in Florence. Most incredibly, she and Nick transferred from Tufts to Haverford College for a semester so they could help Dylan during the long months of rehabilitation at home in Pennsylvania.
This kind of emotional support is critical in warding off depression, but it's also important to the plasticity process. Doctors say that in the early weeks and months after injury, when nerve cells are most likely to make new connections, there may be a “use it or lose it” phenomenon: Cells are more likely to reach out and form new synapses and connections if the trauma patient is stimulated than if he is mentally passive or less engaged socially.
By the end of his second week in the ICU, Dylan still couldn't speak, but he was communicating with gestures, including some American Sign Language (which - surprise! - my husband and I hadn't known he knew). He gave a hearty thumbs-down when the hospital TV was turned to Fox News, leading my husband to email friends: “So, no change in his politics.”
The doctors began making subtly more positive remarks. Dylan's prognosis was “less uncertain” than they had originally thought.
On Day 18, I was Dylan's only visitor when he suddenly signalled that he wanted a pen and paper.
“Good Morning,” he scribbled. Then: “Injuries... Nick had an accident!”
“No, you had an accident,” I said. “You were hit by a car at Powderhouse and Packard.”
“No, Nick was hit there!”
“Yes, that was in February. Then in November you got hit and were much more seriously injured.”
“That's very bizarre,” he wrote. “Put my mind at ease: this was not my fault? 2.) this was not my doing.”
“No, this was not your fault. You were in a crosswalk with a blinking yellow light, walking home from the library.”
“Mama I feel like I'm dying. I get to be asleep during the daytime. Is this all real? I'm not dreaming any of this?”
Our conversation continued. I still have his page of scribbles, a remarkable picture of how his mind was processing reality that day in what doctors called the post-traumatic confusional state:
“I've been having dreams that I'm tied down and that monitors are beeping in my ears.
“I can't help feeling like my life's been put on hold. back to school
“I feel like I've been underwater for the past 2ish months . . . my brain should be ringing?
“I feel like my mind's been turned backward. What if I'm living my life backward?
“When's my birthday?
“All these things on my head stitch my head together?
“If I didn't die, I'm just living in my head though, outside my body.
“Should I not be able to speak?
“Help about the shrinking mind...”
It was the first we had heard of his “voice” since the accident.
Two days later, he found his real voice: He began to whisper. Soon he was able to leave Mass General and begin an aggressive rehab programme at the nearby Spaulding Rehabilitation Hospital, where he began relearning such basic skills as how to walk and use eating utensils.
In all, he spent a month in neurological intensive care followed by a month in an in-patient rehab, then home for six months of physical, occupational and language therapies and two rounds of knee surgery. In June of 2013 he completed an internship, and that July he returned to Tufts for a summer course to test his academic fitness. By September, he was back in school full time.
Tests indicate that Dylan may have lost some processing speed, but he is performing at high levels in spite of any residual cognitive deficits.
This summer, Dylan graduated Phi Beta Kappa from Tufts, with an excellence award in history. According to neurologist Brian Edlow, associate director of Mass General's NeuroTechnology Trials Unit, “After seeing Dylan's MRI scan, if you had asked 100 doctors who were experts in TBI if they thought he was going to be Phi Beta Kappa, probably all 100 would have said no.”
When we asked Edlow just how rare Dylan's case was, he stressed how uncertain doctors always are about predicting recovery from brain trauma. In one email he wrote, “I don't think there is any statistic that you could cite from a prior publication that would capture the truly unexpected and incredible nature of Dylan's recovery.”
Every traumatic brain injury is unique. Variables include the biomechanical forces that are exerted on the brain during an accident - their duration, the position the head was in, the speed the object was going that hit the person, the speed the person was travelling when he hit the ground.
In addition, every patient has unique personal characteristics. Generally, the smarter and better educated someone is prior to injury - or, as doctors put it, to what degree he has “good protoplasm” or “cognitive reserve” - the better he may be able to recover. Internal motivation and persistence also play a role, and Dylan, who since babyhood has been very determined in pursuit of his goals, put that discipline to work as he healed. He spent hours at home on brain-training software, played endless word and strategy games with his friends, practiced his viola to improve his bilateral coordination and fine motor skills, and Skyped with his German professor.
The many unanswered questions in Dylan's recovery underscore the need for further research, Edlow says. He has enrolled Dylan in a study focusing on whether functional MRI and other sophisticated imaging tools can help doctors determine if an unresponsive patient has a chance of regaining consciousness and recovering brain functions.
A further goal is to develop medications and therapies that facilitate plasticity and the healing of injured nerve cells. So far, many treatments have been tested, but none have been shown to work in humans.
“Black swan events,” in Taleb's phrase, can be positive or negative: Dylan's accident may have been unexpected and improbable, but so was his recovery. Thanks to the cumulative effects of speedy, top-level medical care, robust emotional support, marvels of brain plasticity, personal determination and some grace, Dylan's story is one of optimism for trauma patients and their families.
Edlow says, “Whenever a team of doctors feels like there is not much hope for a patient, I show them Dylan's scan and say, 'What do you think this kid's chances of recovery were?' Then when I tell them how well he is doing, everyone is just shocked and humbled, and at the very least rethinks their assessment of the patient before them.”
Washington Post
* Williams lives in Haverford, Pennsylvania