Dire prognosis for an injured cyclist

Three years ago, Inquirer reporter Michael Vitez wrote about Matt Miller, an aspiring young triathlete from the Philadelphia area who survived a cycling crash that, but for an extraordinary stroke of luck, would have killed him. Vitez gives a full account of Matt's accident and his struggle to recover in a newly published book, "The Road Back: A Journey of Grace and Grit." All this week, Philly.com will be sharing excerpts from the book. In today's installment, Matt's doctors assess the severity of his injuries.

Jason Sheehan, a neurosurgeon, was at home playing in the yard with his kids when he heard the news. The resident on duty had phoned him, and Sheehan headed into the hospital. When he arrived, Matt Miller was already getting his first scan of the brain.

The early CT scan showed several grave concerns. First, Matt had more than a dozen bruises, black and blue marks, hemorrhages, spread throughout all parts of his brain - the frontal lobes, temporal lobes, and the deeper structures known as internal capsules. The immediate concern was that these would swell. And swelling itself can be fatal, because the brain, encased in a very unforgiving skull, has nowhere to go.

If the swelling can't be controlled quickly, the doctors must literally saw off the top of the skull, the cranium, giving the brain room to mushroom out the top. (This is what would later happen with Arizona congresswoman Gabrielle Giffords, when she was shot in the head at a political rally.)

Then there was the issue of the bruises themselves. They could have damaged Matt's brain even before the swelling, causing permanent damage. It was hard to know at that point if Matt had any cognitive function or how badly he was hurt.

Such broadly dispersed bruising also suggested another big risk to Matt's brain — what is known as diffuse axonal injury. All through the brain, Matt had little nerves, axons, which were encased in a covering for protection, like electrical wire inside a plastic or rubber coating. On impact with the car, from the blunt trauma, these axons got stretched. Pulled. The medical term is shearing. The question was whether the nerves themselves were stretched or sheared to the point of permanent injury, or whether only the casings were damaged, with the nerves inside remaining intact.

Sheehan compared diffuse axonal injury to taking the nerves, or axons, and "putting them in a blender, shaking them up real fast and then expecting them to continue sending normal signals. That doesn't work very well."

J. Forrest Calland, the trauma surgeon who would assume overall responsibility for Matt's care, managing all the various specialists at work, gave two vivid if not entirely compatible analogies to help explain Matt's brain injuries. To understand the diffuse axonal injury, the stretched nerves, he said to imagine the peel of an orange getting twisted away from the pulp. As for how well Matt's brain could be expected to work after the degree of bruising and swelling it was experiencing, Calland compared that to "throwing your laptop out the second-story window."

Clearly, in Sheehan's judgment, controlling the swelling was the first and most important thing needed to be done to try to save Matt's life. And this was why it was important, and extremely fortunate, to get Matt into a world-class trauma center so quickly. Immediately, Sheehan was able to put Matt into a man-made, chemically-induced coma, to ease the work of his brain, to remove all the strain on it.

Literally, they could shut down the brain so it wouldn't think, wouldn't even tell the lungs to breathe. Because having to think, having to work even on a subconscious level, would only tax the brain further, impede its healing, and exacerbate the swelling. The goal was to decrease the metabolism of Matt's brain, to give it a vacation from its duties so it could just rest and heal.

Because of the body's own response, trying to rush blood and hormones to the damaged area to help with healing, "the swelling actually gets worse for the first few days rather than getting better," said Sheehan. "We knew if we were going to preserve his function and prevent any further injury, we had to keep the brain from swelling."

The next 72 hours would be critical. That would be the first test. Could Matt hang on for three days? Could doctors contain the swelling, keep the pressure from soaring to fatal levels?

Sheehan early that afternoon drilled a hole in Matt's head, through the skull and into the brain, and installed a pressure monitor, what is known as a Licox probe. The Licox measured pressure, temperature and oxygenation within the brain. With those measurements, doctors could monitor and regulate all three parameters in his brain.

As Sheehan had looked down at Matt in the trauma bay, at his crushed face with the damaged brain behind it, and prepared to drill and insert the probe, he knew by this point that this was a University of Virginia undergraduate hoping to go to medical school. Sheehan saw himself in this young man, for Sheehan had once been a UVA undergraduate, and had held the same dream, and had seen it blossom into reality, going to UVA medical school, and now working as a neurosurgeon.

Sheehan was going to do his very best for this young man, but at that moment he thought Matt had no chance of fulfilling that dream. After injuries this severe patients almost never recovered enough cognitive function to become doctors. He would do all he could do, but for a moment, to himself, he grieved for the future this boy had just lost.

Coming Friday: A recovery that has the doctors worried

To Read More

Tuesday through Friday, philly.com/roadback will feature a daily excerpt from Michael Vitez's book "The Road Back: A Journey of Grace and Grit."

You can order the book at www.michaelvitez.com, amazon.com (Kindle and hard copy), or BN.com (Nook edition).

Vitez will be selling and signing books at:

The Irish Mile, 350 Haddon Ave., Haddon Township, Tuesday, May 22, from 6 to 8 p.m.

Haddonfield Library, for a discussion and signing, Wednesday, June 13, at 7 p.m.