Contributors: Lindsay Marchetti, RPA-C, Lead APP, NMICU1; Kathryn Zelazny, RPA-C1; Betty Rosabal, LMSW1; Chris Zammit, MD, FACEP, Assistant Professor of Emergency Medicine, Neurology, Neurosurgery, and Medicine1,2
1University of Rochester Medical Center/Strong Memorial Hospital
2University of Rochester School of Medicine & Dentistry
Section Editor: Michael Reznik, MD, Assistant Professor of Neurology & Neurosurgery, Alpert Medical School, Brown University/Rhode Island Hospital
Ayanna was a young woman on a mission, on her way to the gym for a workout in preparation for boot camp with the United States Marine Corps (USMC). She was days away from starting her senior year of high school and had already come up with very specific and carefully considered post-graduation plans. Athletics came naturally to her as an avid and competitive cheerleader, and she knew she wanted to serve in the USMC; she also hoped to attend college at Old Dominion, and eventually planned to become a paramedic.
The Things Nightmares Are Made Of
Ayanna never made it to the gym that day. Instead, her car veered off the road, crossed the right shoulder, and crashed into several trees before finally coming to a standstill. Ayanna was left unconscious behind the steering wheel. A driver not far behind her happened to be a local nurse who stopped and immediately recognized the seriousness of the accident, calling emergency medical services to come to the scene. EMS was rapidly mobilized, and on their initial assessment, Ayanna was indeed unconscious. She was also unable to breathe adequately, so the paramedics placed a breathing tube and emergently brought her to the area’s Level 1 trauma center.
When the medical team at the University of Rochester Medical Center’s Emergency Department assessed Ayanna, they found that she was in a coma, with involuntary reflexes representing her only signs of active brain function. A head CT was done, which showed that she had suffered a small subdural hematoma and some traumatic subarachnoid hemorrhage — that is, some bleeding around her brain but no obvious bleeding in the brain tissue itself — and probably not enough to explain her severe impairments. CT scans of the rest of her body were also done and showed that, although Ayanna had suffered a severe traumatic brain injury, she luckily had not sustained any serious injuries to any other parts of her body. She was subsequently admitted to the Neuromedical Intensive Care Unit (NMICU), where she underwent intense monitoring and management of her intracranial pressure and cerebral oxygen levels.
“Seeing Ayanna was … the things nightmares are made of for Moms,” said Ayanna’s mother, Tanya, as she reflected on seeing her daughter in the hospital. For her first week there, Ayanna remained unconscious, and her prognosis was very much uncertain. When Ayanna eventually did get an MRI of her brain done that week, it brought grim news, showing that she had evidence of grade 3 diffuse axonal injury — the most severe type of shear injury to the nerve fiber connections in her brain — a finding that explained why she remained in a coma.
Then, after one week in the NMICU, Ayanna began to turn a corner. She started to have more than just involuntary reflexive movements of her body, as she began to show signs of using her right arm in a purposeful, voluntary fashion. Slowly, signs of consciousness began to follow, but as she started to become more awake, it became clear that her left arm and leg remained severely weakened. The axonal injury visible on Ayanna’s MRI — the tearing and stretching of nerve tissue caused by the whiplash and shaking her brain endured during the accident — unfortunately corresponded to the parts of her brain that helped move her left arm and leg. It was to be the beginning of a long, and still ongoing, road to recovery.
A Young Woman on a Mission
After Ayanna had a tracheostomy and feeding tube placed, she was able to be liberated from the mechanical ventilator and more easily and safely mobilized out of bed. In short order, Ayanna was off the ventilator and breathing on her own through the tracheostomy. Medications called neurostimulants were initiated to improve her wakefulness. By the end of her NMICU stay, Ayanna’s nurses were gladly painting her fingernails and toenails to help perk her up, and were bringing her outdoors to enjoy some of the afternoon sun.
Like many other survivors of severe brain injuries, Ayanna did not remember any of her stay in the NMICU, and to this day still has no recollection it. Three weeks after her accident, Ayanna transitioned to acute rehab, where she would get full-time physical, occupational and speech therapy. She was still not speaking yet and had just regained the ability to perform simple tasks when instructed; and though she was getting helped out of bed, she was still not able to walk or stand. But her progress was quick, and within one week of being in acute rehab, Ayanna had begun to speak; three days later, she had her tracheostomy removed and began eating soft food. In another eight days she was eating regular food that she could chew on her own, and was able to stand and walk with the support of two people. Thirteen more days — a total of 52 days after her injury — and she found herself being able to move her left leg on her own again. “I fully remember the day I moved my left leg for the first time,” Ayanna now says as she’s able to think back and reflect on the moment. “I remember thinking, ‘I am going to walk. I am going to walk. I can do whatever I put my mind to.’”
Around this time, Ayanna also began reading about recovery from traumatic brain injury, taking a particular interest in the concept of “neuroplasticity.” She asked for a tutor to help her keep up with high school because she was intent on graduating on time, and she made a goal of being able to walk out on the football field with the other senior cheerleaders on her high school’s senior night, which was to take place 75 days after her injury. Keeping true to her plans, Ayanna was discharged from acute rehab on senior day and walked out onto that football field, just as her fellow cheerleaders did, with her mom and dad at her side. And four months after her injury, Ayanna returned to school, eventually finishing the school year as scheduled and graduating from high school together with her class.
Finding Strength, Finding Happiness
While Ayanna and her parents are delighted and grateful for the recovery she’s made, the process hasn’t been without its struggles. The whole ordeal occurred while Ayanna’s mom was in the midst of completing nursing school, and her dad left his job to help care for her after she had been discharged from rehab. This left the family in a period of financial difficulty. To make matters worse, when Ayanna returned to school, she experienced bullying and insensitive comments from other students.
One year after her accident, Ayanna is able to walk unassisted, but she still has lingering weakness and stiffness in her left arm and leg. While she remains deeply committed to her prescribed exercises to improve her strength and tone, they often come at the expense of spending time with her friends, and she finds her social life strained as a result. To her great disappointment, she also learned that regardless of any further recovery she makes, she will never be able to join the USMC because of her disability, and she recognizes that she can’t become a paramedic either until she is able to use her arms and legs fully. Finally, she has had unexpected issues with her voice, having remained hoarse since her accident, and it was discovered that she had sustained an injury to her vocal cords. As a result, she is no longer able to sing, something that had once been a passion for her prior to her injury.
Through all these struggles, Ayanna has had to battle through periods of sadness, disappointment and depression. But despite these challenges, Ayanna has developed profound resiliency. “I was going into the Marines to prove that I was strong,” Ayanna says, speaking of her lost opportunity to serve in the USMC. “I am not weak. I am not weak. I proved it, just not through the Marines.” Even though she says she is proud of herself, she adds: “As a young girl, going from doing anything I wanted to needing pretty much help for everything is quite difficult, but it gets better. Because I went from being in a coma to now being able to talk to you, and walk, and sit in a normal chair — and that in itself makes me happy.”