04/01/08

Chapter 5

           Diagnosis and Prognosis

When Babe and Sally arrived at the hospital, they discovered that Libbi was unconscious, and their concern of a possible broken bone swelled to anxiety about the uncertainty of their daughter’s state.

The ER doctor at Sycamore performed the perfunctory evaluation as Elaine stood by helplessly. Watching the doctor evaluate her daughter’s condition, Elaine came to realize that the injury was more serious than she originally had thought. Libbi still did not respond to Elaine’s voice, nor did she react to the sternum rub the doctor performed, where he used the knuckle of his right index finger and pressed hard into her breast bone. She didn’t move.

Elaine watched the doctor lift the lids of her daughter’s eyes and shine a pen light into them, one at a time. In a panic, she asked, “Do her pupils react?”

“They do, but they’re a little slow to constrict right now, and that’s an indication of increased intracranial pressure. But,” he said and then paused, and Elaine waited for the good news.” There’s no papilledema, er—there’s no swelling of the optic nerve in the back of the eye; what we call papilledema. This swelling is an indication of intracranial pressure too. So the fact that she doesn’t have it now is a good sign.” Elaine was grabbing at the hope, gathering it in her arms, stuffing it in her pockets, even swallowing it.

“However,” the doctor continued, “the swelling might take two or three days to develop.” And Elaine released her hold, emptied her pockets, and regurgitated all the hope she had ingested in the last moments.

She asked the doctor, “Do you have any idea when she’ll become conscious?”

“Well, Ms. Evans, what we’re going to do is send your daughter up to Kettering Hospital for further evaluation. The doctor there will be able to tell you more. I can tell you now that her X-rays are negative; her chest is not collapsed and none of the bones in her neck are broken or misaligned. That’s good news.”

It wasn’t much comfort to Elaine, who still had no good idea of the true magnitude of her daughter’s condition, and that not-knowing was scary. Elaine failed to will away her uneasy stomach, but no tears had fallen yet.

The doctor avoided explaining to Elaine the Glasgow Coma Scale, which measures severity of head injuries on a scale from three to fifteen: Four of those points are reserved for evaluation of eye activity, five points for vocalization, and six for motor skills. A score of eight or below indicates severe head injury. Libbi lay lifeless—with a pulse; she scored three. The situation was dire. The doctor had decided to spare Elaine his depressing determination, for she was already aware that the situation was severe.

Hospital orderlies loaded Libbi into an ambulance to take her to Kettering Medical Center, fifteen minutes further north, but Elaine was not permitted to ride with her daughter. Earl had not yet arrived, and she had no money, didn’t have her purse. She was desperate. She’d have to ask her ex and his wife if she could accompany them on to Kettering Hospital.

In the emergency waiting area, she saw the doctor reporting to them what he’d just told her. As the doctor walked away and Babe and Sally stood, Elaine approached and made her request to Sally. Of course, Sally said they’d give her a ride.

Elaine got into the Lincoln on the driver’s side and slid all the way across the black leather seat to sit directly behind her ex-husband’s new wife, for she did not want to eye her ex or him to eye her in the rearview mirror.

Babe and Elaine both were experiencing great stress due to not knowing the true extent of their daughter’s injuries, but now they had to ride fifteen minutes to Kettering together, which only served to thicken the tension. Babe never spoke a word. Sally, playing the peace-keeper, asked Elaine for details of the fall. Elaine was relieved to tell of the event, to have something to diffuse the charged silence.

“We were riding down the east side of Beachler—where it’s all field?—and, um, she turned to ask me if she could run her horse, and I told her, ‘No,’ and she asked, ‘Why not?’ in that tone she’s starting to take with me.”

When her ex veered into the left turn lane to get on to I-75 north, Elaine had to bite her tongue: If she were driving, she would have continued on under the highway to the first intersection and taken State Route 741 north to Dixie Highway. Truth be told, Elaine would have been equally irritated had Babe chosen to go that way; then she would have wondered why he weren’t taking the highway route. She liked to make the decisions, to be the one in control.

She silently acquiesced the via-I-75 route and resumed describing the fall: “And I said, “Because then everybody else’s horse will want to run, and five horses galloping in a field that’s not ours is too much.’ About the time I said, ‘field that’s not ours,’ her horse fell.”

Babe got off I-75 at the next exit and waited at the red light at the intersection with 741. When the light changed, he drove past the motel with the horse-and-carriage logo and the marquee advertising hourly rates. He thought of his daughter. That was their joke: what “hourly rates” implied. As dirty as it got between the two. Just earlier this year he’d brought Libbi’s attention to the marquee, and every time they had passed the place since, Libbi always read, “hourly rates,” and laughed. He wished she were in the back seat riding with him and Sally now (instead of her mom), sharing the joke.

Elaine started again: “It happened so slowly. I watched it all happen.” She kept most emotion out of her voice, for she didn’t want to reveal any weakness to her ex. “It was like I could jump off my horse and be there to catch her, but then I thought, ‘The horse is halfway down, you can’t get up there to catch her in time.’ But he fell so slowly.” She paused, picturing the fall. “It all happened so slowly.”

“And I regret…I regret that I didn’t jump off when I’d first thought of it…because I know I could have gotten there in time to catch her. He fell so slowly.”

Elaine lifted her gaze from the back of the seat and blinked out the window at the brick houses zooming by.

After the momentary pause, Elaine continued: “He rolled over her. Just around the base of his neck…” Sally was turned in her seat, and Elaine looked into her face and shook her head. “…not his full weight. And then he rolled back over her and stood up, and then she sat up, straight up, and opened her eyes. And then she collapsed.”

Recalling it all, Elaine was getting light-headed despite the fact that she was sitting. She took a deep breathe and let it out. “Once I got control of my horse, I jumped off. I thought she might have a crushed pelvis or something from the horse rolling over her. But now that I think about it, it was kind of eerie that she sat up and opened her eyes so wide before falling back down.”

Elaine looked into Sally’s eyes and thought back to the scene. “She sat up…she opened her eyes…and then collapsed. She sat up…” Here Elaine hesitated and looked straight ahead, at nothing, her brow furrowing and her jaw dropping further with each passing second. “She opened her eyes. And then she collapsed.”

She recounted the scene again and again, searching her memory for any other details that would quell her feelings off unease. Slowly, she spoke again, to make sure she had it right: “Immediately after she fell,” Elaine’s eyes darted from side to side and all around, searching futilely for some forgotten element. “She sat up,” Elaine herself leaned forward in her seat, eyes still searching. “She opened her eyes,” Elaine’s eyes stopped their movement as she lifted her own brows and widened her eyes. “And then she collapsed.”

“Oh, my God.” Elaine herself collapsed back against the warm, leather seat as she realized her daughter’s involuntary reaction may have been a grave foretelling. “Oh, my God,” she said as she lifted her fingers to her quivering lips. “Oh, my God. Oh, my God.” Tears were on the brinks of overflowing before she took another deep breath to regain her composure. 

She focused her eyes from the past to the present to see how close they were to Kettering Hospital, and she mentally reminded herself that there was no use overreacting; she did not know the true extent of damage yet.

She leaned forward and spoke directly to Sally again: “Earl was the first to her, and he told me she was unconscious.”

Babe’s insides were becoming unsettled at receiving the information his former wife was delivering. His rising emotions were making his face hotter and hotter.  He remembered that Earl didn’t tell Sally and him that Libbi was unconscious, and he couldn’t decide whether to be angry or grateful to be spared the news.

Elaine continued, “We didn’t move her or shake her, of course, but we did call her name and tried to get a reaction, but she didn’t open her eyes, she didn’t move. I yelled to a woman in the front yard of one of the houses there, I asked her to go call an ambulance.”

Sally asked, “What made the horse fall?”

Thoughtfully, Elaine answered, “I don’t know.” Her eyes dropped and her brows tugged nearer to each other as she thought back to the scene, “I don’t remember seeing anything in the road.”

“How long did it take for the ambulance to get there?” questioned Sally, needing to know more. For the entire ride, she had not taken her eyes off Elaine, so enthralled in the story she was. Though Libbi had been in her life for less than three years, to Sally, she was like one of her own.

As the car turned left, Kettering Hospital not a half mile away, Elaine answered, “Oh, not very long at all really. We passed them on Park—right along the railroad tracks across from Beachler? They were organizing for the parade so they knew right where we were.”

Finally at Kettering, Babe dropped Elaine at the entrance and parked the car. In the emergency department, Elaine was directed immediately to the large, open treatment area, where Libbi had arrived minutes earlier. She watched as this new doctor tried the sternum rub and then pinched her daughter’s belly, inside the groin. Anything, anything to get a response. The doctor wanted Elaine present so Libbi wouldn’t be scared in case she did become conscious.

Elaine witnessed the doctor sticking a safety pin in the bottom of Libbi’s feet. Normally, she would have protested anyone doing something so blatant to cause her daughter pain, but right now Elaine so badly wanted her daughter to feel that stick, that pinch. Please, just feel the pain, Libbi. Wake up and ask them what the hell they think they’re doing to you. Feel the pain. Feel it! Please! Wake up. Please! Just wake up!

Nothing the hospital staff did affected Libbi. Not the repeated pinches to the groin that bought the purple-blue blood to the surface of her creamy skin. Not the pin prick through the soft arch of her foot. They could slice her open, a bomb could go off, Austin Carr, her new celebrity crush, could visit, say he was here just to see her, and still, Elaine knew, she would not wake.

A male nurse pulled Elaine away from watching her daughter’s evaluation so that he could collect the patient’s medical history.

Elaine told of Libbi’s previous injuries and reported that she had no known allergies, and then, on the verge of tears, she related what had recently struck her as the most portentous omen: “When the horse got off her, she sat up for about a second and a half and opened her eyes real wide and fell right back down. She wasn’t reacting at all. She wasn’t moaning, she wasn’t trying to get up, she didn’t respond…” The nurse nodded understandingly while writing it all down.

The ER doctor at Kettering recorded in Libbi’s record:

Respiration shallow but spontaneous.

Doll’s eyes present.

Flexes both upper extremities to pain. 

"What do you think, doctor? What did you write down?” Elaine asked. She was powerless to do anything to help her daughter. She wanted some control over the situation, and knowledge would help her gain it.

“She’s breathing on her own, but it’s shallow. We’re going to give her some oxygen initially. Also, did you see her move her arm when I pinched her biceps? So she is responding to deep pain stimulus. The most positive thing is that she has doll’s eyes.”

“What are doll’s eyes?”

“To test for doll’s eyes, we lift her head a little and turn it from side to side quickly. Her eyes didn’t turn with her head, they seemed like they were fixed on a target as we turned her head, like a doll’s eyes—just staring straight no matter which way you turn the head.”

“And that’s good?”

“Yes. That means that some of the nuclei in her brain stem are still interconnected and functioning. It is a sign of unconsciousness, but it is less ominous than when the eyes turn with the head. That means there’s some kind of disconnect in the brainstem.”

“Oh,” was all Elaine could manage. She still didn’t know the true extent of her daughter’s condition, but she knew it was critical.

Because the doctor elicited a response from deep pain, though Elaine missed seeing it, Libbi had advanced from three, where she was at Sycamore, to five on the Glasgow Coma Scale.

“She looks like a big, limp, rag doll,” Elaine said out loud as she helplessly watched the nurses and doctors insert needles and tubes and hook her daughter up to equipment to monitor her vital signs.

Elaine felt physically numb. As her emotions rose, the last spot they vacated became vacuous, deadening sensation. She was aware only of her upper chest, her throat, and her head now, like she was floating, yet she was still grounded and in the moment, ready to respond or do anything to help her daughter.

She wanted to hold Libbi, to feel her warmth, to know for sure her warmth was there, yet she could only watch from a distance because she had nothing to offer right now that was more important than what the medical staff was giving her. To most help her daughter, Elaine had to refuse to overreact.

Since Libbi could not speak or communicate in any way, she could not say if she were experiencing pain. Therefore, she received a full-body X-ray to check for broken bones the fall from Flash might have caused. The X-rays showed no injuries, a huge relief for the family. Yet the CAT scan revealed something different entirely: blood on her brain and swelling. “Left cerebral occipital contusion” is how it was recorded on her chart. Until the bleeding stopped and the swelling receded, the doctors could not guess at the extent of damage. She was admitted to the Intensive Care Unit.

Elaine walked the halls of the first floor from Emergency Admittance to ICU. She saw her ex-husband and his wife holding hands in the waiting room just past the elevators. Babe’s face was puffy and red, and he gripped a handkerchief in his right hand. Elaine would not—she refused—to let his reaction affect hers. Luckily another waiting room was adjacent, and Elaine entered. Libbi’s parents waiting in the same area would have made a stressful situation even more uncomfortable.

After reviewing the CAT scan of Libbi’s head, Dr. Robinson, the neurosurgeon on duty, stepped into each waiting area and gave the anxious parents the second-worst possible news they could receive: “Your daughter has a severe brain injury.” Better than “Your daughter is dead,” but still pretty bad news.

The doctor further reported, “The first week will determine if she survives. In the event that she does, she may not regain consciousness because the generalized swelling can affect the area of her brain that controls the sleep and wake cycles. It’s a waiting game at this point.”

Sally cried at the news and tried comforting her sobbing husband without effect. Babe felt so helpless.

Earl, who had arrived at Kettering Hospital by that time, held Elaine while she sobbed for several seconds. Pressing the collar of Earl’s shirt into her closed eyes to dry them, Elaine regained control of herself for she knew Libbi was in for the fight of her life, the fight for her life, and she was going to be in her daughter’s corner, supporting her through the struggle, coaching her along the way. This was no time for crying; she needed to start devising their strategy right away.

The hospital allowed Babe and Sally use of a private room with free phone service to call anyone they wanted to report the news. Elaine received like facilities and called her parents, Libbi’s Grandma Vic and Grandpa Harp.

No one answered at her parents’ place until after the fourth ring, and it was Elaine’s nephew.

“Lance? This is your Aunt Lanie. Let me speak to your grandma.”

After a time Victoria got on the line: “Yes?”

“Mom, Libbi’s been in an accident.”

“We heard that her horse fell,” Victoria responded.

“How’d you hear?”

“Well, it came down through the crowd. I don’t know who started it. What? She break an arm?”

“No, Mom. She’s in critical condition.”

“Oh, my God! What happened?!”

“Her horse fell, Mom!” Elaine saw her mother most every day of the week, and they spoke on the phone several times a day. They were close, yet each had little patience for the other.

Curtly, Victoria replied, “Oh, well, I know.” Then she continued: “Um. Okay. Um. What hospital is she at?”

“We’re at Kettering. I think you should come up here. Is Luke there? Can you let him know?” Luke was the nickname Elaine had given to her younger brother Larry when they were children. Since Lance answered the phone, Elaine thought he might have been there.

“Yeah, he’s here. We met back here after the parade. We’ll all come up to the hospital right now.”

“Yeah, I think that’s best. I need all the support I can get right now.”

Victoria broke the shocking news to her husband, son, and grandchildren. They were all out on the side patio eating the homemade ice cream that they had all taken turns cranking to make. That’s why no one answered the phone right away. It seemed a pity to let the ice cream melt after all that work, but that’s what they did. They all left immediately for the hospital.

After speaking to her mom, Elaine called her boyfriend’s home to tell his son the news and her home to leave a message for her son Chris to hear when he got home from work. She also called her son Mike, who had recently moved to Maine after finishing graduate school that spring.

He answered the telephone, “Hello?”

The first words out of Elaine’s mouth were “Michael, are you sitting down?”

E-mail the author at libbi@elizabethevansfryer.com.