Section Editor: Michael Reznik, MD
Contributor: Aleksandra Yakhkind, MD, Neurology Resident Alpert Medical School, Brown University/Rhode Island Hospital
It is late morning on New Year’s Day, and Kathi has just left her home to go to the local supermarket, where she works as a cashier. She had just spent the previous evening together with her family celebrating New Year’s, reminiscing about 2017 and looking forward to 2018. Kathi is 19, works two jobs and eventually hopes to go to nursing school — a big deal for her family, who are from Guatemala. Despite her commitments, Kathi’s family praises her devotedness as a daughter, sister, cousin and friend, and they have been ever-supportive of her hopes and dreams. The coming year was to have been another stepping stone to Kathi reaching her goals and ambitions — no one had any idea that it would instead bring tragedy and heartbreak.
A Physician-Bystander and First Responder
I first met Kathi on that fateful New Year’s Day, in a way I could not have expected but now cannot forget. Around the same time late that morning, my boyfriend and I were driving in our car, having just gotten on the highway to visit my family. Suddenly, I hear my boyfriend shout at something on the road, and I look up as a white sedan wildly cuts across three lanes not far ahead of us. It crashes right into the concrete median, and the force of the impact bounces the car back into the middle lane before it finally stops. A black SUV jolts out of the way; luckily, no other cars are hit. I look over at my boyfriend as the same thought crosses both our minds, and we pull over behind the tan, now severely dented, sedan. We run out of our car and over to the other vehicle, where I see a girl with dark curls and a green sweatshirt slumped over unconscious in the driver’s seat. As a neurology resident, it is also apparent to me that the girl is in the midst of a seizure. We try to open her car door, but all the doors are locked. My boyfriend retrieves a tire wrench from his car, breaks the sedan’s back window, and quickly crawls through to open the drivers-side door.
By this point the girl has stopped shaking and is slumped over to the passenger side. I sit her up and try to wake her. I check her pupils, her airway, try to move her limbs around. Her pupils are briskly reactive and she is adequately protecting her airway, breathing on her own, but her arms are fixed in position and I can see foam coming out of the side of her mouth. Three other people have gathered. My boyfriend and another man move her car to the breakdown lane while another bystander directs traffic around us. A second bystander walks up to us and hands us Narcan, an emergency treatment for suspected opioid overdose that has become both more accessible and essential in the face of a growing opioid epidemic. My boyfriend, a clinical pharmacist, administers the Narcan, but the girl does not wake up. I hold her head up and hold her hand while we wait for an ambulance to arrive.
Her Name is Kathi
There are sirens — an ambulance, police cars — and the next hour seems like a whirlwind. The ambulance takes the girl to Rhode Island Hospital, and I call the residents in the Emergency Department to alert them, filling them in on the details. As police gather around, we recount the same details and story to them, too. Afterwards, we resume our drive up north to Boston and replay the events of the morning all over again. When I see my family, I hug my parents earnestly and meaningfully.
Meanwhile, back in Providence, the girl is shuttled through tests and procedures in the Emergency Department, and our worst fears are realized. As my resident colleagues later inform me, the girl’s head CT reveals a large left-sided intracerebral hemorrhage, which likely precipitated the trauma rather than the other way around. A CT angiogram confirms the cause as a ruptured arteriovenous malformation. As the girl’s neurological status continues to deteriorate, she is immediately taken to the operating room to take off part of her skull to relieve the mounting pressure in her head and save her life. In the midst of this chaos, the girl’s identity is confirmed — her name is Kathi, she’s 19 years old and has a family — and her family is called to tell them about what happened, that there had been a terrible accident.
“When we received the news, we were devastated. We were thinking the worst,” Kathi’s father Byron says now, almost two months later. “They called me and told me it was an accident, but we didn’t know [the full extent of what happened]. When we got to the hospital, we were looking for her, but there was no information about Kathi. We didn’t know what was going on, we didn’t know if she was in surgery, we didn’t know a specific location … she wasn’t in the system [yet], because she wasn’t registered.”
When the medical team was finally able to sit down with Kathi’s family, they informed them how grave the situation was, and that Kathi might die because of swelling in the brain caused by her hemorrhage. “One of the most difficult moments was when we went into that first meeting,” Kathi’s cousin Jackie says. “Knowing that she was in crisis was very difficult … it brought us all to tears. That moment killed the little bit of hope that we had [at the time].” She grows tearful here, and adds: “Right after [they] said that, we all grabbed [each other’s] hands and asked if we could stay in the room for a few moments and pray.” It’s worth noting that Jackie, along with Kathi’s aunt Yohana, have helped Kathi’s parents translate each time I’ve stopped by to talk to them, and have also exchanged shifts day and night to be by her side in support.
Something Like a Rollercoaster
When I saw her in the ICU the next day, she was intubated and in a coma, with a post-surgical scar clearly visible on her head and an external ventricular drain in place to measure the pressures in her head while draining excess fluid. It was also the first time I met Kathi’s family, and they immediately asked me details about the accident and what I saw, while thanking me for having been there. They asked my opinion on her prognosis, but all I could say was that we needed more time to have a better idea. It was clear that they had spent the whole night awake, and the tears were still fresh in their eyes. Her family emphasized to me then how happy she always was, that she was always smiling, and that she was the light of their family. The connection between us has only grown since then.
Kathi ended up spending two weeks in the Neurocritical Care Unit at Rhode Island Hospital, and it felt like an eternity to her family. “When we were in intensive care, we thought she was in a very critical state,” says her father. “We thought of the worst things that could possibly happen and all the terrible things that were going on. Seeing my daughter [that way], it was very hard for me. My wife was falling apart, she was having a nervous crisis, and I was also falling apart … I didn’t know what to do because I was worrying [so much] about my daughter and my wife.”
Hearing the prognoses also seemed to spell out doom, but as the days went by it became clear that Kathi was going to make it through and survive. They now understand the doctors were being cautious. “I understand why they do it,” Byron says, “because if they give us an exact time, people would be pressuring them [if the timeline didn’t fit their prognoses]. I would always tell my wife [that] … and that we would have to wait.”
Among other things, Kathi had to deal with pneumonia and a urinary tract infection that impeded her progress. “We experienced good and bad days,” her cousin Jackie says, “and this is something one of the doctors said, that [it would be] something like a rollercoaster.”
By the end of the first week, though, Kathi had started moving her limbs around on her own somewhat, even a bit on her right side, though she still wasn’t wakeful. This was enough to make Jackie feel heartened: “Even when she was in the ICU, when you touched her hand she would squish it. She would move her feet, she’d cross them. She’d feel we were there. The nurses weren’t there and didn’t see it, but I [saw it].”
Eventually the swelling in Kathi’s brain started coming down, and as the acute phase of her illness started coming to an end it was time to start planning ahead. After discussion with her family, a tracheostomy and feeding tube were placed to facilitate her transition out of the ICU. After the tracheostomy, Kathi’s family says they “thought more positively … because there were fewer tubes in her, and [they] felt more sure about the outcome of all of this.”
A Glimpse of the Girl They Knew
After several more days, Kathi was able to move from the ICU to the stepdown unit. Her family first started getting a glimpse of the girl they knew as she started to wake up, like “when she yawned for the first time, when she scratched her nose for the first time.” Each of these gestures would carry special meaning.
Only a couple weeks after the tracheostomy was placed, she had already woken up enough to have it downsized and ultimately removed. Finally, in mid-February, she made the transition to acute inpatient rehabilitation, which her family knew was a huge step.
Around the same time Kathi also started speaking for the first time. Her mother Mildred remembers that moment. “She started singing, and then she heard her own voice for the first time and the sound that came out … she got quiet again because she got shocked [by it], and then she started singing again!” She then called Byron. “I was working,” he says, “and my wife called me to tell me that [Kathi] had spoken, and I started crying tears of happiness.” Jackie, meanwhile, remembers “dancing in the car” when she first got the call while she was sitting in a drive-through.
Now, at almost two months after that fateful day, I too can start to see glimpses of that girl. I see Kathi with her helmet off, sitting up in bed, her eyes wide open looking around at me and at her family. The right side of her head has her hair in a braid, while the left side has grown back about half an inch since her surgery. She still doesn’t speak much. But when Jackie asks her to, Kathi waves hello to me with her left hand.
Kathi’s father says that she is doing better at this point than anyone expected. “I thought of her … having difficulty with her right side and speaking, as she is now. But thank God there’s been a lot of progress, and for me it’s a short amount of time, because they were telling us six months. And this has all been happening in just a month and a half.”
Keeping the Faith
When I ask what’s helped them get through this terrible ordeal, Kathi’s family instantly attributes it to their faith. “God and our faith has helped us 100 percent,” they all say. “Our faith in God has guided us and all the doctors that have been working with Kathi [so she could get to the point where] she could recuperate.”
They also realize how many things had to happen in just the right way for her to make it this far. “We’re very faithful, so if God did this for her, if he saved her, we thought of all the possible things that could have happened in that situation, on that highway … it could have been worse, [and] she wouldn’t have been here right now. A lot of things could have been different. We’re thankful for everyone that’s helped her … [everyone] worked together to save her life. And we’re never going to be able to repay everything they’ve done.”
Just as importantly, though, they’ve kept their faith in Kathi. “We thought it was going to be difficult for her … to come here [to rehab],” Jackie says. “Even though there were doctors that didn’t give us a positive outlook, of rehab being an option, we’re here now. [After the first few days], we knew she was going to make it, because she’s strong and has perseverance.”
They also think that, as she continues to recover, she’ll understand and agree with everything that’s been done for her. “We have a huge trust in each other,” her father says. “We know each other very well.”
The Road Ahead
Kathi’s family knows the road ahead is still a long one, but their support for her is unwavering, and they firmly believe that her strength and character will continue to push her onward.
“We’re going to help her go back to school. She [still] wants to be a nurse, and I think she’s going to continue to do it with even more passion,” Jackie says. “We hope she can continue to make her dreams come true. If we stood through this together, we can stand to help her with whatever she wants.”
But Kathi’s mother is hoping for something in the more immediate future. “It would be a huge moment of happiness [just] to have her home,” says Mildred. “We would thank God to have her back home. It would be a really big step … [when] she said goodbye, I never thought I wouldn’t see her at home again [for a long time].”