Jessica Strikes Back
After a brief outing on a warm evening in mid-June, Ronda and Kurt Canning returned to their home in Kitty Hawk, N.C., to find police cars and a rescue vehicle crowding their street. A police officer approached as they pulled in the driveway, and Ronda’s mind raced immediately to their 4-year-old daughter Jessica and their 16-month-old son Nathan who were being babysat by a family friend.
“Something happened to the 4-year-old,” the officer said.
From that moment, the Cannings’ relaxed Outer Banks evening deteriorated into a nightmare with Jessica’s life in the balance.
They discovered that soon after they’d left home, their daughter had been struck on the back of the head by a golf ball that had sailed over dunes and a 60-foot hickory tree from a nearby golf course. The freak shot knocked Jessica down her back stairs.
The sitter had reacted immediately. Paramedics reached Jessica in minutes. When the Cannings arrived, they found Jessica unconscious in an ambulance, waiting to be airlifted to Norfolk.
“I touched her leg and it was as cold as ice,” Ronda said.
At CHKD in Norfolk, neurosurgeon Don Penix received a page and learned that a critically ill 4-year-old girl was being flown up from Kitty Hawk with a traumatic brain injury. Unaware of the extent of the damage, Dr. Penix assembled a surgical team and prepped an operating room.
Though Jessica’s injury by a flying golf ball was unusual, Dr. Penix knows that traumatic brain injuries are far too common.
When Jessica arrived at CHKD that night, Dr. Penix could see she hadn’t sustained any lacerations or broken bones. Her single critical injury could be seen only after they clipped her hair: A small, round, golf-ball sized mark on the back of her head.
A CT scan confirmed a subdural hematoma, essentially a deep bruise on Jessica’s brain that would cause swelling in the next few days. Swelling inside an enclosed skull squeezes oxygen-rich blood from the brain the way compression squeezes liquid from a sponge. Without oxygen, brain cells can survive only a few minutes.
The treatment amounted to medications to keep Jessica paralyzed and life-support while she remained in a coma-like state.
“We try to take care of all this metabolic activity so her body doesn’t have to do the work,” Dr. Penix said. “We need to reduce brain activity and allow her brain time to recover.”
Dr. Penix took the parents aside.
“I explained that Jessica had a severe brain injury and that we needed to do a small surgery to insert an intracranial pressure monitor inside her skull,” Dr. Penix said.
He also explained that the inflammation would increase, much the way a sprained ankle swells for days after an injury. Swelling would probably reach its peak in three to five days.
He made it clear: The gravest danger lay ahead.
“Dr. Penix laid everything on the line,” Ronda said. “But as a parent, you hear all this stuff and it just blurs. It’s just so much that you can’t think straight.”
The CHKD PICU is the region’s only civilian intensive care unit exclusively for children. Even though CHKD’s special care for children is abundantly evident even in intensive care, the sight of their daughter in this environment was almost too much for Ronda and Kurt to bear.
Jessica lay in a hospital bed medically paralyzed, breathing by means of a respirator, fed through a gastrointestinal tube, with wires snaking from her body to monitors recording her heart rate, blood pressure, blood oxygenation, cerebral blood flow and intracranial pressure.
In brain trauma patients, maintaining optimal blood flow to the brain requires intricate medical management. In the first 24 hours after the injury, Dr. Penix had to lower the intracranial pressure even as he increased the blood flow to the brain. With each passing hour, medical requirements changed with Jessica requiring a complex and ever-changing regimen of fluids, medications and nutrients, all aimed at nourishing her damaged brain with life-giving oxygen.
“No parent wants to see their child with all these tubes and monitors, but I knew this sophisticated equipment was keeping her alive,” Ronda said. Over the days that followed, the Cannings learned to read the monitors and found hope in the normal readings they saw.
For three days after the accident, Jessica lay completely immobile. The only “communication” between the child and her parents was in the movement of those colorful lines on the monitors.
On the third day, “everything went haywire,” Ronda said. “At 5 o’clock, exactly 72 hours after the accident, everything spiked at once. Jessica’s blood pressure, the intracranial pressure, everything, went up like a rocket, hitting new highs and new lows.”
Dr. Penix and the treatment team knew that Jessica was experiencing a condition called neurological “storming.” Her traumatized brain had begun to misfire, causing wild gyrations in unpredictable waves.
If Jessica received too much medication, she could die. If she received too little, the swelling of the brain would kill her.
The staff tried to comfort the Cannings by explaining that storming is a relatively common complication, and that Jessica’s pressure numbers were actually within acceptable parameters. By then, though, the Cannings had gone beyond mere exhaustion.
“Parents come here in a crisis state,” said Kari Lewis, a PICU social worker who spent time with the Cannings. “Their adrenaline kicks in, but that can only sustain them for so long before they themselves begin to crumble. I tell parents to force themselves to take breaks to help them withstand the strain.”
As the storming continued, the swelling had spread from the golf-ball sized bruise to encompass most of the left hemisphere of Jessica’s brain. By this time, Ronda and Kurt had learned enough to know that this swelling could kill swathes of brain cells as it spread.
“All I’m thinking is, ‘My daughter could die,’” Ronda said.
Gradually, over several days, the neurological chaos came less frequently. Dr. Penix began discussing weaning Jessica from the drugs that kept her in an artificial coma.
Desperate for good news, Ronda and Kurt entertained a fantasy that Jessica would wake up and leave this nightmare behind.
As the meds were withdrawn, Jessica did awaken, but she remained unresponsive, unable to communicate, still breathing with the aid of a respirator. The swelling in the left side of her brain had not gone down and her right side was largely paralyzed.
But as Jessica became aware of her surroundings, her familiar blue eyes communicated something that made her mother’s heart ache. “She was looking at us in terror,” Ronda said.
After 14 days, Jessica was moved to the CHKD inpatient rehabilitation unit for continued recuperation and rehabilitation. It meant she was no longer in medical danger. But Kurt and Ronda couldn’t help feeling empty, wondering if their charming, precocious daughter would ever emerge again.
“The first issue with any patient coming to rehab is that parents feel disappointment,” said Jean Shelton, a CHKD pediatric rehabilitation physician. “They’re glad that their children are out of danger, but they can see that they’re far from normal.”
Dr. Shelton explained that Jessica would remain in rehab for weeks. Nobody could be certain precisely how long it would take or how much Jessica would recover.
In rehab, two occupational therapists, two physical therapists and two speech therapists painstakingly worked to encourage Jessica to speak and increase her motor skills. Ronda, who kept a journal, began to note signs of progress.
Wednesday, June 27: Half a smile! Eyes follow. Giving hugs.
Saturday, June 30: Said “No.” Scribbled with pen. Played with Play-Doh.
Sunday, July 1: Said “Daddy.” Gave kisses.
One day, two physical therapists propped Jessica on her shaky legs. “She could barely hold her own weight,” Ronda said. “But a couple of days later, they tried it again and she walked!”
For Ronda, it was like watching Jessica take her very first steps all over again. She ran for the video camera. Later that same day, Ronda grabbed the camera again when she found Jessica tooling around on one of the rehab unit’s tricycles.
On July 27, six weeks after Jessica came to CHKD, Ronda and Kurt tearfully thanked the team that had saved their daughter’s life. It was time to go home, and the delighted 4-year-old was giving hugs and kisses to her nurses and therapists.
Though no one can know for sure if the changes in Jessica’s brain will affect her future, her progress has been remarkable. As the Cannings left the hospital, Jessica was totally free of any signs of paralysis – a very good sign. The active, coy and spunky child was once again unmistakably Jessica.
Dr. Penix practices with CHKD Health System’s neurosurgery practice. Dr. Shelton practices with the EVMS division of rehabilitation at CHKD.
This story was featured in the fourth quarter 2007 issue of KidStuff, a publication of Children's Hospital of The King's Daughters.