A legal secretary, an 18-year-old student-athlete, and a U.S. soldier in Iraq: These people had little in common until sudden traumatic brain injuries threw their lives into chaos.
They're not alone. Traumatic brain injury has become the signature injury of the conflicts in Iraq and Afghanistan, and a growing concern for many professional and student sports organizations, which are increasingly aware of the easy-to-overlook but all-too-real cognitive and emotional toll of blows to the head. Incidences of concussion—and examples of the lasting damage they can cause—are so common they're on the verge of becoming an epidemic.
The ASHA Leader spoke with three people who've suffered brain injuries about their lives before and since, and the challenges they've experienced. It's not just brain injuries they have in common, but also the determination required to recover, combined with the commitment and support of rehabilitation clinicians, including audiologists and speech-language pathologists.
His Biggest Win
by Matthew Cutter
Brian Boyle’s journey to recovery began with learning to sit upright and continued to his successfully finishing the Ironman World Championship race in Hawaii.
On July 6, 2004, Brian Boyle left swim practice in Welcome, Maryland, with thoughts of a recent Independence Day cookout fresh in his mind. Under the red glare of fireworks, he'd shared his plans for college and training for the swim team with friends and family. He was 18 years old, a typical student, athlete, and "quiet guy." And all his plans were about to be shattered.
As he drove across an intersection on his way home, a dump truck barreled into the side of Boyle's car and crushed it beyond recognition. The impact was so severe, it shunted his heart to the opposite side of his chest. He suffered a concussion, lacerated liver, collapsed lungs, and shattered pelvis and ribs. His kidneys failed, and he lost 60% of his blood. Emergency medical personnel resuscitated him eight times, and nearly pronounced him dead at the accident scene, before Boyle was taken to intensive care by medevac.
Few expected him to survive. Little did they know he was only beginning a new life—one that would begin with his first spoken word.
"I woke up," Boyle says, "and my parents were on both sides of me, crying. They were explaining to me, 'Brian, you were in a bad car accident. You have a few broken bones, and you'll be out of here in a few days.'" But soon Boyle realized the situation was much worse than his parents let on. "I was paralyzed, I couldn't talk, I couldn't blink, I couldn't move." All around him he could hear medical monitors beeping and chirping, the steady mechanical hiss of a ventilator, and hospital personnel discussing his condition outside his room, using words like "vegetable" and "nursing home."
Boyle had been unconscious—in a medically induced coma—for nearly a month, his mind drifting through states of wakefulness. "I couldn't tell what was dreams, what was reality, what was nightmares," he said. It took nearly a month for him to realize he was in Room 19 of the Intensive Care Unit (ICU), and another month to regain full consciousness. He was awake, but his struggles with locked-in syndrome were only beginning.
"It was one of the darkest moments in my life," Boyle relates. "When I was coming out of the coma, I was still paralyzed from the medication. I was unable to speak, barely able to think." As he began to comprehend the enormity of what had happened, he began succumbing to the possibility that he might never rise from his hospital bed again. "I was giving up," he says. "I just realized my time was up, and lay there saying my final prayers."
Sometimes communication goes far beyond words. When Boyle's parents arrived for their visit that day, they could tell something was different about their son. He couldn't do more than move a single finger or blink his eyes, but they knew something was wrong. "They realized I was giving up," Boyle says. "I don't know how they knew. My dad was begging me to keep going, to stay strong, to keep fighting. He pretty much yelled at me in last-resort desperation. Fire in his eyes, everything."
After they left, Boyle had a change of heart: "It's a selfish thing that I was thinking. I had to do something." But paralyzed, only able to blink or wiggle a finger, what could he do? Boyle says the realization hit him that "Smiling is the best way I can communicate that I'm still here."
He struggled to move his facial muscles, to force them into a smile. But when he finally succeeded, the result was not what he'd hoped for. "I went into seizures for several hours. I had tons of episodes where I was going into seizures. Everyone was just so concerned that I was really slipping into darkness. The brain surgeons, the neurosurgeons, they were all coming in. They weren't sure what was happening." For Boyle's parents, who'd only days before begged their son to keep trying, the process was excruciating.
But Boyle wasn't dying. CT scans revealed that when the nerves in his face reactivated, they triggered the nerves in the rest of his body. "It was just the body coming back to life. I kept pushing," Boyle says, "I went through the seizures. And that night when my parents came in, I was able to smile for them."
Doctors assigned a team of therapists to aid Boyle's recovery. "I had speech therapists, I had respiratory therapists, my nurses, and physical and occupational therapists. I was still paralyzed." Because he still had a tracheostomy tube, team members tried to get Boyle to mouth words. Each day when nurses removed his trach for cleaning, they attempted to spur Boyle's speech. "They would clean out my trach several times a day," he says, "and when they did they would almost always cause this coughing reflex. When that happened, I would have to hurry to sound out a few syllables or words."
Progress was slow. Boyle's nurses wondered—sometimes aloud—if he would ever speak again. Then, the breakthrough.
"My doctor came in the room that day, and they did the reflex with me—just testing it out—and I just said, 'hello.' That was my first word. I got the first word out, and that was my comeback." Boyle's doctor, nurses, and therapists were thunderstruck, then overjoyed. "It was kind of creepy," Boyle says, "because it wasn't my natural voice. It was high-pitched, but it came out, it was coherent, and I tried to keep going." But with his weak lungs, still functioning with the help of a respirator, he couldn't go far. And producing speech by means of a coughing reflex was unreliable.
Boyle's speech-language pathologists next installed a speaking valve on his trach, and the result was nothing short of miraculous. "They blocked up the hole in my neck, and they said, 'Brian, try to slowly sound out the words. We're going to take our time. Do what you're most comfortable with.'
"I just started talking," says Boyle. "It was the most amazing thing for my whole recovery. It was my step back into life all over again." As doctors and nurses rushed into his room to see for themselves, Brian tried to thank every one of them despite his weakened lungs. "They all broke out in tears," he says, "like they were seeing a ghost. A man risen from the dead and talking all over again." Says Boyle with characteristic understatement, "It was a great day."
Over the next few weeks, Boyle learned to talk again. "I'm a very fast talker, and a lazy talker…so I'm a mumbler," he says with a laugh. "I was trying to be coherent, very slow, very soft-spoken. It took a lot of time to get back into my normal rhythm, my normal speech pattern."
After regaining his speech, Boyle's recovery advanced by leaps and no-less-miraculous bounds. In 2007, only three years after leaving the ICU, Boyle crossed the finish line to complete the Ironman World Championship race in Hawaii—a grueling triathlon consisting of a 2.4-mile swim, a 112-mile bike ride, and a 26.2-mile run. Embodying his nickname— "Ironheart"—he went on to run several triathlons and marathons over the next five years. Now he's training to run the Ironman New York City triathlon in August.
But for a self-described "shy and bashful person," Boyle's biggest change came as a spokesman for the American Red Cross. "When I left ICU, I wanted to help others with my experiences," he explains. "I tried to focus on improving my voice—not just to make it back to the way it used to be, but to have it make an impact on others. I felt like I had been given a gift, and I had to share that with people who were going through a similar situation, and give them hope." The American Red Cross has named Boyle its Spokesperson of the Year twice, in 2009 and 2010.
Now, what Boyle feels most is gratitude. "Ever since that day," he says, "it's been about making the most of life and being grateful, especially for having the ability to talk. To have a voice.
"My biggest comeback in life—bigger than the Ironman, bigger than all my races combined—was talking again."
A Miracle Recovery
by Kellie Rowden-Racette
Danalee Ariel Casey maintained her positive attitude during her recovery from a near-fatal accident.
It happened in a flash. On Oct. 13, 2011, the day before her 31st birthday, Danalee Ariel Casey (or "Ariel," as she prefers to be called) was commuting to her job as a legal secretary when she stepped out onto a busy, rain-slicked Maryland street and was struck by a car. After being rushed to the hospital and treated for a badly broken leg, doctors began to look for other injuries.
Minutes after her husband, Michael, arrived at the hospital, Casey became less responsive and couldn't hold a conversation. Ten minutes later a neurologist was called in and immediately took Casey to the operating room. There was fluid on her brain and mounting pressure. To allow the brain to swell and alleviate pressure, doctors performed a bilateral cranioectomy, taking out two pieces of her skull and placing the pieces under the skin near her abdomen to keep them viable. After her surgery, Casey went into a coma that lasted for three weeks.
Her first memory after the accident was in mid-November. She recalls knowing she was in a hospital and knowing something horrible had happened to her. Rohini Rao, her speech-language pathologist at the National Rehabilitation Hospital in Washington, D.C., tried to assess her condition, but Casey was so lethargic that she couldn't stay awake long enough to complete the tests. Ultimately she was diagnosed with moderate to severe cognitive communication disorder and dysphagia. She was able to mouth only a few words, follow very simple one-step directions, and pay attention only for very short periods of time. But when the doctors at Suburban Hospital in Bethesda, Maryland, replaced the pieces of her skull in early December, things changed quickly. She began to have memories and describes it as her brain "rebooting."
"It's almost as if all the memories I had started reappearing and I was coming back," she said. "But I still don't remember the accident or what happened up until that point. And I'm glad."
Now that Casey was out of immediate medical danger, Rao reassessed her and found she was already making progress. Previously unable to verbalize any words beyond "yes" and "no," now she was saying more words and able follow multiple-step directions. An avid reader before the accident, Casey always had a knack with words, but needed help getting them out. She and Rao worked on reading and auditory comprehension exercises as well as exercises to improve her executive function. She progressed quickly.
Casey had already begun to think of returning to work, so Rao incorporated the development of Microsoft Excel worksheets into her exercises. She quickly regained the communication and organizational skills and continued her miraculous recovery. Her progress was fast and within a month, much of her cognitive function had returned.
"Poor Rohini—I drove her nuts," Casey said. "She kept having me do all these comprehension exercises and it wasn't a problem by the time we really started working on them. But I know she wanted to make sure I could communicate and verbalize and that's so very important, especially in an office environment like the one I work in."
Today she has returned to her job part time and is happy to be home with her husband and 11-year-old son. Her husband says that even though his wife's recovery appears to be nearly complete (she says she's 91% back; he says 90%), she still has some difficulties with attention and still has some work in front of her. On the physical front she is rehabilitating her legs and is continuing with her physical therapy; on the cognitive and communication front and due to some of her medications, she is still experiencing a shortened attention span and some irritability. To help remind herself to take a deep breath and go with the flow, she has a note on her computer monitor at work—"focus on behavior modification"—that reminds her not to get worked up. They both remain optimistic and are keenly aware of how lucky Casey is to have recovered so quickly.
"When she first had the accident, we were at absolute zero where there was nothing, no response," says Michael Casey. Now, she's "back at work and about 90% recovered. I know from the perspective of her speech-language pathologist and all the other members of her team, she has defeated the odds and her recovery is incredibly fast, but for me just wanting my wife back, it was forever. She's one of the smartest people I know, though, and she made a lot of people at the hospital cry out of happiness."
Cutting Through the Din
by Bridget Murray Law
Kerri Sherred-Pratt linked her husband, Norman, with a local SLP and audiologist. Their daughter, Maddie, is 5.
When the Iraqi insurgents' bomb hit Norman Pratt's armored Humvee in July 2005, the impact threw him against the door, leaving him dizzy and disoriented. The Humvee driver and Pratt—a specialist on convoy security for the U.S. Army—waited for the smoke to clear, then continued on their mission back to home base. Along the way, Pratt noticed he couldn't hear what the driver was saying over the ringing in his ears.
The ringing hasn't stopped since.
Back at base, medical personnel checked him over, treated him for second-degree burns to his arms, and argued over whether the dried buildup in his ears was blood or earwax. They cleared him to return to duty the next day. Then Pratt got hit with two more roadside bombs, one later that month and another in September, which only worsened the ear-ringing.
His wife, speech-language pathologist Kerri Sherred-Pratt, was quick to notice his troubled hearing when he returned stateside in January 2006.
"We had just gotten married and I was in the bathroom off the bedroom with the water running," she says. "Norm was in the bedroom and I asked him to grab something for me. He had no idea what I'd said because of the background noise of the water running."
She noticed the same thing happening when they were out at social gatherings and restaurants. Her husband struggled to block out the din, to focus on the conversation and process information. Sherred-Pratt urged him to seek a hearing screening at the local Veterans Affairs (VA) hospital, which he did, but the hospital lacked the equipment to test his hearing in noise. Undeterred, his wife sent him to the local Meadville Medical Center in Pennsylvania, where audiologist Barb Wentz diagnosed him with tinnitus, hearing loss at high and low frequencies, and short-term memory loss.
"There was one test where I had to repeat a list of words in order, back to back, and I couldn't get past the first six words," says Pratt.
As a result of this diagnosis, Pratt secured 20% disability pay from the VA and went to see a former colleague of his wife's—Meadville SLP Bobbette Trace (now retired)—for treatment.
"Going to see [Trace] really helped," says Pratt, now a sergeant in the Army Reserves and a land manager for the U.S. Fish and Wildlife Service. "She taught me to focus away from the background noise and pay more attention to who I'm talking to. It's hard to do, but it works. She also gave me strategies like avoiding large crowds and restaurants with noise."
And, to keep the tinnitus from interfering with his sleep, Pratt uses Trace's strategies of listening to music or watching television before going to bed. The VA gave him a Transcutaneous Electrical Stimulation machine equipped with white noise to help him relax, but that didn't help.
Looking back, Pratt bemoans not receiving baseline cognitive and hearing testing from the Department of Defense (DoD) before deploying to Iraq. Without it, he has no way of knowing just how much of his difficulties are due to his exposure to bomb blasts. The DoD now administers such baseline testing to service members, due to increased awareness of the link between TBI and roadside bombs.
Pratt also can't be certain that he sustained a TBI in Iraq because he wasn't tested for one immediately after blast exposure—something that the DoD also now does in-theater. But his medical team strongly suspects he suffered a mild TBI, with resulting tinnitus and short-term memory loss. And Pratt largely credits his wife for helping him get properly diagnosed and treated.
"She knew there was something different about me, even though the Army had said everything was fine," he says. "And then she made sure I got good treatment."
Sherred-Pratt is heartened that her efforts paid off.
"I had friends who thought Norm wasn't a nice guy because they'd greet him and he wouldn't respond," she says. "Now he's got strategies like explaining that he has a hard time hearing them, and looking them in the face when he talks to them to make sure he's listening and responding. And when we go out for dinner he can filter out things. His confidence in social situations is so much better. It's just a huge improvement."