It was just a tumble down a couple of steps. But the bump on her head nearly killed Samarah Morrison, a Madison toddler now recovering from the same kind of brain injury that led to the recent death of actress Natasha Richardson after a fall on a beginner's ski slope in Canada. Most of us have had similar accidents and walked away with little more than our pride wounded. We've comforted bawling kids with hugs and ice and told them they'll be fine - and usually they are. So how do these commonplace and trivial accidents become so deadly?
When they fell and hit their heads, both the actress (who was not wearing a helmet) and the Madison 2-year-old sustained a sneaky brain injury called an epidural hematoma, which is a blood clot between the skull and the dura, the tough tissue covering the brain. Hallmarks of this silent killer are stealth and speed. Many victims experience a lucid interval and appear fine before rapidly deteriorating. Doctors term this the "talk and die" syndrome. After her fall in the snow, Richardson, 45, reportedly got up, made a joke or two, and refused help. Samarah's mom, Nichole Jelinek, picked up her wailing daughter and rocked her to sleep, initially unconcerned.
Neither baby nor actress had obvious signs or physical marks of injury. But inside their skulls, a pool of blood from a torn artery was starting to compress and shut down their brains. "It's the great masquerader," said Lee Faucher, the director of trauma at UW Hospital and Clinics. "Someone might be talking and doing just fine and the next thing you know they're unconscious."
These two classic cases, with such similar beginnings but such different endings, offer valuable lessons about a brain injury that, while relatively rare, is still more common than many people realize. "People were shocked by Richardson's death, but the stark reality is that even an everyday fall can kill you," said Wendy Leedy of the Brain Injury Association of America. There are many other similar tragedies - a couple of months ago, John Philip Keillor Jr., an experienced skater and Garrison Keillor's brother, died after hitting his head on the ice while skating with a grandchild at Vilas Park.
Every year around 1.4 million Americans incur a traumatic brain injury, according to the Centers for Disease Control. That's about 4,000 individuals a day, or one person every 22 seconds. According to studies published in medical journals, roughly 40,000 people suffer from the kind of epidural hematoma sustained by Richardson and Samarah. (Fatality estimates in the medical literature range from 15 percent to 50 percent.) Surgeons at UW Hospital, Dane County's top trauma center, calculate that Samarah was just one of several such cases they operate on each month. The outcome depends on how quickly the clot has been identified and treated. While there have been a few cases reported with a lag of up to eight hours before symptoms appear, normally there's far, far less time to intervene. Surgeons call it "the golden hour" and that is what ticked away for Richardson. Not only did she reportedly spend precious minutes after her injury alone and unobserved in her hotel suite, but when she finally did complain of a crushing headache it took hours to get her from the remote mountain resort to a major hospital. On the way, she slipped into an irreversible coma.
Samarah was luckier. After she woke up screaming and vomiting from her nap an hour or so after her fall, her mother rushed her to UW Hospital. It was a race against death. "The doctors told us that if she had arrived five minutes later, she would not have made it," said her dad, Michael Morrison.
Just going about their lives
What shocks so many people about these cases is just how innocently they begin. Most are the result of falls, not always obviously nasty ones, either. A study published in the journal Annals of Emergency Medicine found that nearly half of 53 children treated at Boston Children's Hospital between 1980 and 1990 developed an epidural hematoma after a fall of less than 5 feet.
What seems to be key isn't necessarily the force or the velocity of the injury, experts say, but where contact occurs. "You've got to hit your head in just the right place," said John Kuo, director of UW's comprehensive brain tumor program and the neurosurgeon who operated on Samarah. That spot is at the temple right over the ear, where the shell of the skull is especially fragile. When the skull fractures or cracks, nicking or tearing a key artery, there is no place for the leaking blood to go. "The skull doesn't get any bigger, so if you introduce anything in there like a blood clot, the brain will get squashed. That's what happened to Samarah and also Natasha Richardson," Kuo explained.
While these accidents may strike most of us as freak occurrences, neurologists and brain surgeons, keenly aware of just how vulnerable and mysterious the brain can be, said they are surprised there aren't more of them. "The brain is really rather fragile. In some ways it's amazing to us how well the body does with all the bumps and bruises that we go through life with," said Robert Dempsey, professor and chairman of neurological surgery at UW Madison's School of Medicine and Public Health.
Victims of epidural hematoma are generally just going about their lives. (In fact, most children in a study published in last month's issue of Pediatric Emergency were at home when they got hurt.) Up to twice as many males as females are estimated to get the injury. They aren't engaged in super risky behaviors like car racing, though some get injured in car accidents. They aren't getting injured in combat in Iraq, where there has been a rash of more massive and immediately obvious brain injuries caused when explosions shake up the entire brain like Jello. UW doctors say most epidural hematomas happen when victims are hit on the side of the head by balls. Or when they bonk the car climbing in and out. Or bang against a kitchen cupboard. Or ski or snowboard at a local slope (an activity that local doctors do consider "high risk" when undertaken without helmets.) Or, in Samarah's case, when making Christmas cookies. It was Dec. 13, and Samarah's mom had taken the girl and her baby brother, Daylin, to bake cookies at a friend's house. But Samarah, who loves animals and visiting the zoo, was far more interested in making her way upstairs to see a pet bunny. The towhead had only managed to reach the second step when her mother caught up to her and called out a warning. Samarah turned around, slipped, and smacked her head on the tile floor just above her right ear. "Owie, owie!" she shrieked. But there was no visible blood, no scratch, no mark, no bruise. And she'd had falls that seemed much worse before, like the time she tripped and fell flat on her face, cutting her lip.
Jelinek scooped up Samarah and rocked her back and forth. After about 10 minutes the little girl fell asleep, which was no cause for alarm, either. It was nap time. But about 30 minutes later, she woke up screaming and throwing up. "She just clung to me and wouldn't let go," her mother recalled. Jelinek, an aspiring nurse who works as a nurses aide at Mendota County Health, debated what to do. Her daughter had a doctor's appointment later in the day to check a cold. But some instinct, she later said, told her that she shouldn't wait. Figuring Samarah had a nasty concussion, she called an urgent care clinic and told the nurses she was going to take Samarah straight to the ER. The clinic called UW and warned them a possible brain injury was on the way.
In the car, the little girl started becoming drowsy. She also kept convulsing with what her mother called dry heaves, but nothing came out. Halfway there, Samarah became unconscious. Her desperate mother tried to revive her. "I couldn't get her to wake up for anything," Jelinek recalled. It was 2:20 p.m. when they pulled up to the ER.
"The nurses came running out," Jelinek said. They immediately stuck Samarah with two IVs and, noticing that she did not react or flinch, whisked her into a CT scan, which took an X-ray of her brain. The scan showed a white blob - blood - had already indented the brain. The little girl was dying. A group of four or five ER nurses and doctors, pushing Samarah on a cart, raced through the halls of the hospital to the operating room in another wing. "I could barely keep up with them," Jelinek recalled. As they ran, they kept checking Samarah's wrist for a pulse. "Her pupils are dilating. We've got to go faster!" Jelinek heard one of the nurses yell. She had no time to kiss her baby goodbye. They pushed the girl into surgery right before 2:40 p.m.
It was less than 20 minutes after Jelinek had entered the hospital. The young mother collapsed onto the ground outside the slamming operating room doors. She was in a state of shock when a nearby nurses aide found her crying and led her into a nearby room and covered her with blankets. "I'm like, she just fell down two steps," Nichole said. "That's all I kept saying over and over. It was just two steps!"
An unbearable wait
UW Hospital and Clinics is the only facility in Dane County designated as a Level One trauma center by both the state and the American College of Surgeons. That means that it must have a team of specialists and surgeons on call at all times at the hospital, either sleeping in the small rooms right on site or able to reach the hospital in 10 minutes. Kuo was at home eating when he got the call, and he got to the hospital within minutes.
Every year the emergency department handles about 1,800 traumas or injuries - about 10 percent of them are gunshots and stabbings and the rest are known as "blunt force" injuries, which range from traffic accidents to farm and factory injuries to falls off swings. About 40 percent of these cases involve brain injuries.
Of the 4 percent or so of these 1,800 patients who don't survive, 75 percent of them die due to brain injuries. Some who do survive sustain profound brain damage. "They are not the same people they were before," said Faucher, the UW's trauma director.
Samarah's parents didn't know these statistics, but they knew all too well how close they were to losing their daughter. The waiting was unbearable. Michael, who had left 7-month-old Daylin with his father-in-law before rushing to the hospital with Jelinek's mother, could not stop crying. Nichole had no tears at that point - she was still in shock. "I just couldn't believe it," she said. "I was right there. It was such a freak thing."
Inside the operating room, Dr. Kuo was waiting in his scrubs. He conducted a rapid assessment of his patient. The pupil of her right eye was dilated and fixed, which meant that massive pressure from the blood clot was pushing down on the nerve that controlled the eye. It was an ominous sign. "That is one of the last stages before someone dies," he later said. "There was so much pressure it was squashing her brain stem, which controls her breathing and wakefulness and many other important functions. We got to her just in time."
Kuo and the surgical team sawed open Samarah's skull right above her right ear. "We opened it up sort of like a manhole cover," he said. "When we got in there we immediately found a very large clot. It was about the size of a small plum." As soon as they removed the clot, the girl's vital signs stabilized. Underneath was the torn artery. "We could see blood squirting from the artery just like a little fire hydrant," he said. He took a surgical instrument that looks like a chopstick, he said, and used a little volt of electricity to cauterize or pinch the vessel shut. And then the doctor went another layer deeper, peeling open a portion of the dura, the sheath, or envelope, around the mushy brain, to be sure there wasn't another injury underneath. There wasn't, which was good news.
Kuo put the layers of skin and muscle back in place, closed up the dura with "just a small stitch," and reconnected the piece of skull bone he had removed with titanium hardware clips and screws. Then the surgical team tightly wrapped Samarah's head in bandages. "We closed her up, put a little turban on her head, and sent her to ICU," he said.
The entire surgery took only about two hours. It was a breeze compared to the marathon 12- to 18-hour surgeries to remove brain tumors that Kuo and UW's other neurologists also perform.
"It's a very short surgery," he said. "We joke about it. This kind of surgery is not really brain surgery, it's skull surgery. It's relatively easy, and it saves a life and prevents something deadly." The success of these kinds of brain cases are tremendously rewarding, Kuo said, particularly compared to the more grim prognosis faced by many of his other patients suffering from brain tumors and severe brain damage.
"This is exactly the thing that makes trauma and neurosurgery so gratifying," he said. "If we get to these cases in a timely fashion, they are saved. But if we don't, that's exactly what happened to the actress."
Samarah came out of surgery and entered ICU around 5 p.m. It seemed she would live, but had they removed the clot in time to spare her brain damage?
Her parents could barely see her under the tubes and bandages, but what little they saw was frightening. She looked tiny, frail, pale and still. "She had gone from this playful little girl in the morning to a porcelain doll," her mother recalled. The worst thing, her dad said, was hearing the whooshing sound of the huge ventilator breathing for his daughter. "It was surreal, the most horrible feeling a father could have," he said. "I couldn't even hold her or hug her." He kissed her on her hand where there was some uncovered skin and walked out of the room crying. "I can't do this," he told his wife. But after pulling himself together in the waiting room, he rejoined his wife and waited next to his daughter's crib to see if the girl they knew would return.
Soon there was hope. Samarah flinched when the nurses tested her reflexes and pinched and tickled her toes. As the sedation wore off, she started to flail around. She tried to pull off her bandages and IVs - a natural reflex and a promising sign. And within hours, the nurses noticed she was breathing faster than the machine. Soon after they removed her breathing mask, at around 1 a.m. in the morning, the little girl croaked out one word: "blankie." And then her mother finally cried. "It was her!" she recalled. "I was getting her back."
Over the next couple of days, Samarah made rapid progress. They knew she was back for good the second day of her stay, when a visit from a young friend named Jasmine perked her up. She had been quiet and reserved - scared, her mother suspected, and confused about what she was doing in the hospital. She was refusing to eat. But as Samarah played with her friend, Jelinek said, she started to "glow." Suddenly she was gobbling down her favorite food, cottage cheese, and venturing out to the hospital playroom, where she made a beeline for the doctor's kit. "It was like a switch turned back on," her mother said. Three days after her emergency admission, Samarah was sent home.
Samarah's rapid recovery, local experts said, is typical of epidural hematoma cases that are caught and treated in time. Surgery is necessary in the vast majority of these cases, but when there is a clot but no deterioration of the victim's mental or physical state, the victim is closely monitored in the hospital. In those cases, the hematoma is not causing brain damage and eventually clears up on its own - just as it would if you were to get a bruise, or hematoma, on your knee. "If you have to get a brain injury, this is the best one to have," Faucher said. "Yes, it can kill you. But if you catch it in that golden hour, you can make a complete recovery."
That is why local physicians and surgeons, saddened as they were by Natasha Richardson's tragic death, hope that some good can come out of her story. It was a death, many say privately, that could have been prevented if she had been given a helmet or more timely and skilled medical assessment and treatment. And that is why Samarah's parents are eager to tell their daughter's tale, too. There can be happy endings with this injury - if it is recognized and treated in time (see sidebar).
Samarah can now expect to live a completely normal life, which the other day entailed coloring all over the kitchen chairs and walls. Her curly hair has started to grow back and already hides the 10-inch scar on her scalp - which could make her the envy of the Goth community if she decides to shave her head when she is in high school.
She's pretty much back to herself again, her parents said. But she clings to her blanket more than she used to and is obsessed with playing with her doctor's kit. She also scolds anyone she sees climbing anywhere, whether it is her mother standing on a step-stool to reach something in the kitchen cupboard or her baby brother trying to crawl up the stairs. "Be careful!" she scolds. "You will fall down and get an owie!"
\ See video on www.captimes.com.