Crash Course

When the Cataloochee Ski Patrol got to fifteen-year-old Thomas Sowell, who had fallen headfirst while snowboarding, it was clear that he was in trouble.

The call to his parents, Virginia and Jim, was minutes away. The MRI at Mission Hospital in Asheville, which would show severe brain trauma, was hours away. The transfer to Grady Memorial Hospital's Marcus Stroke and Neuroscience Center, where Thomas would be treated by Emory doctors who specialize in severe brain injuries, was days away.

And the pivotal night that determined whether Thomas would live or die was nearly a week away.

Sunday, January 30, 2011, was the last day of an annual winter sports trip Decatur's Scout Troop 77 takes, this year to the Cataloochee Ski Resort in Maggie Valley, North Carolina. Thomas and the other troop members decided to get an early start—they wanted to be the first ones on the slopes.

The weather had been unseasonably warm that weekend, in the sixties, but the mostly machine-made snow at the ski area had refrozen overnight and glittered in the early morning sun.

Thomas had on his rental helmet as well as ski goggles he had borrowed from a friend. He snapped one of his boots into the snowboard's binding and got in line for the lift. A snowboarding novice, he was sticking to the run called Short 'n' Sweet.

Monday meant heading back to classes at Lakeside High, including a challenging trigonometry precalculus course he had been placed in because of his strength in math, but today was all about making the most of his remaining time on the mountain.

Like a 'serious car crash'

Thomas doesn't have any memory of the accident, but volunteer Ski Patroller Eric Hutchinson vividly remembers getting the call around 9:30 a.m.

"I was on Upper Turkey Trot, which comes downhill into Short 'n' Sweet. I heard on my radio there was a person hurt and not responding," Hutchinson says. "A bunch of us got there together and started tending to Thomas according to the medical protocol we've been trained in."

Thomas had experienced what the patrols call a toe-side edge catch, which means that the board stops but the body keeps going. "Basically, the snowboard becomes a fulcrum," says Hutchinson. Thomas catapulted forward, landing directly on his head and upper face, with enough force to flatten his goggles.

Once Thomas was transported to Mission Hospital, he was sedated and placed on a ventilator. He had lost the ability to breathe on his own, which is often the case with severe brain injuries. After a CT scan and an MRI, an intracranial bolt was placed in Thomas's brain to monitor increased pressure from the swelling.

His parents—Virginia, a freelance graphic designer, and Jim, an astronomer at Georgia Tech—were contacted at church on Sunday around 10 a.m., went by home to grab a change of clothes, and left for Asheville.

"On the drive up, we thought it was a concussion," Virginia Sowell says. "He'd sent us a text on Saturday saying that everyone had been falling all day. But after meeting with the doctors, we learned that this was much more serious. They likened his brain injury to one caused by a serious car crash."

Thomas's diagnosis was "diffuse axonal shearing"—damage to individual neurons and connections among nerve cells—in both hemispheres of his brain.

Diffuse axonal injury (DAI) results from the brain violently hitting the wall of the skull, and is one of the most devastating diagnoses a parent can hear; Google DAI and terms jump out like "coma," "significant impairment," and "persistent vegetative state."

"We knew zero about traumatic brain injury," says Virginia Sowell, "but we were about to learn."

The 'secondary cascade'

Through a mutual friend, the Sowells got in touch with David Wright, associate professor of emergency medicine, director of Emory's Division of Emergency Neurosciences, and an expert on traumatic brain injuries (TBI).

For the past decade, Wright has focused most of his research on TBI. He is the coinventor of DETECT, a portable device for assessing concussions, and is primary investigator for a national clinical trial, based at Grady, testing a promising progesterone treatment discovered by Asa Candler Professor of Emergency Medicine Donald Stein.

"Really, the impetus behind me doing research in TBI came from my clinical work at Grady. It came from seeing so many patients with traumatic brain injury coming in and not having any tools to treat them with," Wright says. "Most patients with TBI are disabled for life. It's horrific when you start looking at the statistics. And it occurs mostly in young people who are in the prime of their lives."

The damage results not only from the initial trauma, but through a domino effect of potential consequences—continued swelling and increased pressure in the brain, toxic changes in brain and blood chemistry, infection in the lungs. "The secondary cascade starts immediately after the injury," says Wright.

Instead of improving once they get to the hospital, nearly half of people with severe brain injuries deteriorate in the hours or days following. Providing care for TBI patients is a complex matter, requiring specially trained medical staff, constant vigilance, and an almost intuitive ability to predict what might go wrong next.

When Wright got the call about Thomas, his immediate response was that the teen should be transferred to Grady's Marcus Stroke and Neuroscience Center, where the nursing staff and Emory neurointensivists (doctors who specialize in neurocritical care) know the danger zones in aftercare for brain injuries.

Largely funded through a $20 million donation from Home Depot cofounder Bernie Marcus's foundation, the center had been open for less than a year. Thomas would be the youngest patient treated at the center, one of a handful around the country that is specifically designed to treat acute, time-dependent emergencies of the brain, such as strokes and TBI.

"This," says Wright, "is where he needed to be."

'Pray for Thomas'

The Sowells are active members of the 175-year-old Oak Grove United Methodist Church, a cornerstone of their historic Atlanta neighborhood. Scout Troop 77 is based there, and many of their neighbors and friends are members.

After Thomas's accident, the church and community went into full support mode. Friends brought food to the Sowells' home, held a "ridiculously well attended" prayer service at Oak Grove, and filled their home phone message box. Daniel, Thomas's older brother, received a flood of cards and notes at his college, Young Harris. And a Scout leader set up a blog, "Pray for Thomas," that became a live news feed for family and friends—and a lifeline for Virginia and Jim.

The entry from January 31 reads:

As you may be aware, Thomas S. (Jim and Virginia's youngest son) had an accident while snowboarding with the Scouts on Sunday morning. He is currently at Mission Hospital near the Biltmore in Asheville, North Carolina. The family is in the process of preparing to have him transported to Grady today. Since the accident he has not been conscious though he responds to stimulation. The physicians have implanted a monitoring device to track brain activity.

Virginia rode in the ambulance with Thomas to Grady, and the paramedics gave her small tasks to keep her busy. ("It was very kind of them," Virginia says.) They arrived in downtown Atlanta around 8:30 Monday night, and Thomas—unresponsive, heavily medicated, and breathing through a tube—was taken directly to the eighth floor.

The Marcus Center is a hub of futuristic-looking technology, dedicated staff, and common-sense accommodations. Modeled after top neuro-ICUs around the country, it has a CT scanner and neuroangiography suite with equipment that appears to have been beamed straight out of a Star Trek medical bay. The floor has large windows to let in light, video cameras in each room with centralized monitors so nurses can keep an eye on several patients at once, and "family rooms" where relatives can sleep, shower, even do laundry.

"Thomas's parents, understandably, wanted to stay with him," says Professor of Neurology Michael Frankel, director of the center. "In fact, his mom didn't really want to be more than a few feet away."

The lowest low

One of the first doctors to see Thomas at Grady was Sanjay Dhall MR09, chief of neurosurgery. Traumatic brain injuries, Dhall says, are classified as mild, moderate, or severe. "Mild is like a concussion, moderate is awake but confused. Thomas's was severe. He was comatose, he would only respond to painful stimulation, he wouldn't open his eyes, follow commands, or speak."

Many patients with Thomas's level of brain trauma never regain consciousness and, if they live, are permanently disabled. "We see a lot of TBI in teens and young adults who survive, but then need around-the-clock care," says Dhall, who had several difficult conversations with Thomas's parents.

"We were being prepared, all along, for the worst case scenario," says Virginia Sowell.

Thomas's CT scan showed multiple areas of bleeding into his brain. "His scan was pretty scary," Frankel says.

Since the injury was diffuse, there was not one spot where neurosurgeons could operate to relieve the pressure. "We placed a drainage tube into the fluid spaces in his brain, the ventricles, that also functioned as a pressure monitor," says Dhall. "And we inserted another device, relatively new, that's a fiber optic that goes into the brain tissue and measures pressure and the amount of oxygen in the brain. One of the things we know about TBI is that lack of oxygen causes very severe secondary injury to the brain."

And then, Thomas's lungs started to fail. The doctors are unsure whether this was triggered by aspiration or was a consequence of his brain injury.

"Thomas developed some very complicated lung problems and went into full-on lung failure," Dhall says. "His lungs stopped working, we had to force high concentrations of oxygen into them, his blood pressure was dropping, and he was going into multi-organ failure. We had to use drugs that artificially elevated his blood pressure to keep him alive."

"When the brain is failing, and the patient is on a ventilator, the body just doesn't react well," says Frankel. "Other organs start to fail when the brain fails."

"When they told us he might not make it, I just collapsed on the floor, crying, vomiting, ready to pass out," Virginia Sowell says. "It was the lowest low I've ever experienced. And then came the highest high."

'So remarkable as to be miraculous'

Lots of factors, both tangible and intangible, can make a difference with traumatic brain injury outcomes. Immediate and constant care by top doctors and nurses using cutting-edge medical technology, certainly.

Age, genetics, gender, and even hormones play a role.

Women tend to survive brain injuries more often and heal better than men, which led researcher Don Stein to his studies of the hormone progesterone as a neuroprotective agent and possible treatment for TBI (see sidebar).

Research also shows that brain injury patients do better when they are exposed to natural light and when loved ones can stay close by.

And the helmet and goggles Thomas wore while snowboarding almost certainly saved his life, Dhall says.

But no one can explain how, just two weeks after his doctors at Grady had to tell his parents he might not live through the night, Thomas is sitting on the edge of his hospital bed at Shepherd Center's rehabilitation unit—surrounded by balloons and stuffed tigers, eating Girl Scout cookies, sneakered feet dangling, eager to go home.

"When he first woke up [on February 8], Thomas thought he'd been in the hospital for a day. He asked his dad for his chemistry book, because he had a report due," Virginia says.

"The turning point," Dhall says, "was about two days before we took his breathing tube out. It was very rapid. Thomas shocked us all. The rates of recovery have been so poor in the past. But he gives all of us hope that even in the most dire circumstances, our patients can get better."

His doctors say Thomas is on track to make a full recovery, and shows none of the serious impairments they expected he would have. He is walking, talking, and thinking at near-normal levels already. "It's so remarkable as to be miraculous," Frankel says.

On February 17, Thomas stood beside his parents, smiling shyly, at a press conference at which the Cataloochee Ski Patrol presented him with a ski patrol cap and told him "it's good to see you upright."

Virginia and Jim Sowell credit the patrol and paramedics and doctors and the Grady Marcus Center staff. They credit the prayers of so many friends, and friends of friends, and community members. They credit Thomas's inner strength.

But they do not take Thomas's recovery lightly or believe that they are somehow deserving of this miracle while others are not.

"We decided to share Thomas's story not because we got lucky," said Jim Sowell. "We know that there are parents who are having to build wheelchair ramps up to their front door. We thought we wouldn't get to this point for months, or even years. We are telling it so that maybe there can be hope."

A reporter asked Thomas to share the first thing he wanted to do when he got back to his house. "Just to be there," he said. "To be home."

Epilogue

Thomas continues outpatient therapy at Shepherd Pathways. "He's enjoying the variety of things they're having him do, but is anxious to get back to school," says Virginia Sowell. Another head trauma, even a minor one, could have dire consequences for Thomas. So while he is eager to play sports again, like Ultimate Frisbee with his Lakeside team, for now he is cheering them on from the sidelines, enjoying the first sunny days of spring.