2April's story

January 23, 2005

arrived and it no longer seemed hopeful: "Often with a head injury it doesn't look too bad at the start. But she was in terrible shape."

D'Urso cut across the top of April's head from ear to ear. "Be ready for this," he told anaesthetist James Tomlinson. She was going to bleed so much she might suddenly die. He peeled the skin forward and big pieces of April's skull came with it.

The skull is not a single bone but a collection of them.

The cranium, which accommodates the brain and forms the skeleton of the face, contains more than 27 bones jigsawed together along interlocked joints known as sutures. The forehead is formed by the frontal bone which sits above the orbits of the eyes between the paired parietal and sphenoid bones and is fused in place along the coronal suture.

When the car roof hammered April's skull it exploded, bursting at the seams of the major suture lines. Her frontal bone broke in half and split away completely. The sagittal suture running longitudinally across the top of her cranium breached for half its length like an earthquake fault line.

Directly beneath that crack the sagittal sinus, the main vein from the brain to the heart, had ripped. While the skull pieces were held beneath April's skin, it tamponaded the wound, applying pressure that minimised bleeding. But when D'Urso opened her up it gushed.

It now became a battle to keep her alive. She was losing litres of blood and there was a danger of air sucking into the vein, sending an embolism to her heart. Neurosurgery registrar Greg Matthews packed off the tear with layers of surgicell gauze while Tomlinson transfused her. D'Urso removed pieces of skull, as if peeling shell from a hard-boiled egg, sucked away the blood clot and flushed out pulverised bone fragments and infection.

April's cheek was fractured, the top of her nasal bone broken away, there were fractures to her skull base and she had lost the roof of her eyes. D'Urso put in a layer of collagen-based material to partition the "dirty areas" of her eyeballs and nasal cavity from her brain and to prevent leakage of cerebro-spinal fluid.

The brain was bruised and swollen. When he opened the dura, the membrane enclosing the brain, to relieve the pressure it started ballooning through the incision. Now it was a race to get drains in and pull her scalp back before the brain was so enlarged he couldn't close the skin over it.

But even after he stapled her shut, she looked dreadful. "I thought she'd had it, that she'd die," he confesses. "And probably that night."

GAIL couldn't believe the size of the bandage around April's head when she came out of theatre. In the middle, where her forehead had been, someone had written a warning. It said "No bone".

April's father, Arthur, had arrived while she was in theatre. A taxi driver, he'd learned to read people's faces. He didn't like what he saw in the recovery room: "They'd look down or away." Someone said to prepare for the worst. "But I wasn't taking no for an answer under any circumstances. I felt it was my job to be undeterred."

Janine Spinks was on-call nurse for the Alfred's intensive care unit. She was asleep when the phone rang at 1am and arrived at ICU five minutes before April. Despite years of experience she was shocked. "You never really get used to it," she says. "You do become a bit desensitised, but only to a point. I'll never forget that night . . . I'd never seen a head so swollen. She looked like an alien, not a person."

She thought it was hopeless, and had that familiar feeling of how tragic life could turn. Then she focused and with her team began the desperate job of keeping April alive. "We just got in there and went vroom."

Through the blur of activity she remembers other staff coming by. They'd look at April, then at the numbers on the monitors - "and it only took one look to realise how bad she was doing" - and they'd say: "Oh, my God."

"Even though her frontal bone was out her brain was still swelling and all the measurements of her intracranial pressure were out of control . . . Everything we did, it just went up, up, up."

In major head trauma there are two types of injury. The first is the primary injury, the immediate damage done to skull and brain at impact. Then there is secondary injury, the consequent swelling of the brain and its effects. When a brain is hit hard, it reacts in the same way as a punched eye and swells. But the brain is within the rigid, closed box of the skull and can only swell so far before something must give.

Once the swelling brain starts to fill the cranial vault two things can happen. One is called coning. The stem of the brain pushes through the foramen magnum - the hole at the base of the skull where it joins the spine - and strangles. As the brain stem contains the nerve centres that control breathing and heartbeat, coning always kills.

The other effect is that pressures inside the head rise dramatically. When intracranial pressure exceeds blood pressure the heart cannot pump blood to the brain to oxygenate it. Eventually blood flow stops and the oxygen-starved brain dies.

Even if the swelling recedes and the patient survives, lack of blood and cell damage can have caused severe brain damage.

ICP is measured in millimetres of mercury. Normal range is between eight and 12mm. When April arrived in ICU her pressures were four times that and for much of that morning, no matter what Spinks' team tried, were in the seventies. If her skull had still been there, pressures like that would have killed her.

As a lifesaving last resort in cases of major brain swelling, neurosurgeons sometimes perform decompressive craniectomy: cutting away a football-shaped section of the frontal bone, allowing the brain to swell through the hole and significantly reducing the internal pressure.

Since mid-2003, the Alfred has been part of a three-year trial called the Decra Study. In a randomised trial of 210 patients suffering traumatic brain injury that does not immediately require surgery, half are treated with conventional management, while the others undergo craniectomies in the first 72 hours.

Associate professor Jamie Cooper, head of the study, says only a third of traumatic brain injury victims have "favourable outcomes", meaning they can resume independent lives. The remainder are severely disabled or dead. The study aims to find if early intervention can improve those odds - or if it is just shifting the proportions among the unfavourable outcomes.

Or, as D'Urso puts it: "Are we having an operation that basically saves brain-damaged vegetables? Are we going to keep people alive who'd probably be better off dead?"

For April though, he has no doubt that a sort of spontaneous craniectomy saved her. The impact of the car roof opened the closed box of her skull. "She did her own Decra study. I just finished it off, tidied it up. It's why she survived and wasn't brain-dead by the time she got to us."

How long she survived and what she survived to be were the questions now.

GAIL was a zombie. Six days now and she might as well have been in the coma with April. Barely eating, hardly sleeping, existing in a blur of incomprehension and disbelief.

The first two days she'd haunted ICU, seeing but unfocused in the confusion of activity. Taking in snatches of conversation, unintelligible acronyms: April's numbers were all wrong; her BP unstable; ICP way too high. They were battling her pressures with hydration, salts and ionotropes, ventilating to give 100 per cent oxygen and reduce carbon dioxide levels.

"There was no control," recalls D'Urso, putting it in plain English. "We were struggling, just fighting, resuscitating her and trying to keep her alive."

At the eye of the storm April was unmoving and oblivious. She was hooked to drips and monitors, a tracheostomy in her throat to keep her breathing, sedated and paralysed in a thiopentone-induced coma.

Gail, Tony and Arthur sat at the bedside, holding her hand, whispering encouragement, telling her they were with her and telling themselves that at a subconscious level she knew it. They stuck a montage of photos on the wall: April in a neon-blue gown at her senior ball; in Star Trek costume with her mates; on dinosaur digs; with her pet duck Harry. And laughing in every one.

"Beautiful, beautiful pictures," thought nurse Brionhy Judd. But she'd read the theatre notes, seen the scans and been told that treatment would probably soon be withdrawn. How sad, she thought, that April's family would never see her like that again.

On the Thursday a doctor had taken the family aside. "He was just a young guy and he said 'There's no hope'," remembers Gail. "It was horrible. Just the day before we'd been told 'Don't give up, there's still hope'."

They had reduced her sedation, removing the drugs that induced the coma, but April remained unconscious and unresponsive. Judd would do her neurological observations and get nothing: not even a reflex reaction to pain. On the Glasgow scale she was a three, the lowest possible score.

On Saturday night, six days after the crash, Gail and Tony began discussing organ donation. They thought April would want that.

BRIONHY couldn't stop crying.

It was 7.30 Sunday morning and she'd been doing her observations, going through the routine. April didn't open her eyes to any stimuli, make a sound or move to command. Judd squeezed her thumbnail hard, then rubbed her sternum. Even unconscious a patient would react against that pain, moving to push her hand away, but as usual there was nothing.

She doesn't know why but she took a hand in hers and said "April, can you squeeze my hand?" And she did.

"My mouth fell open. I thought 'Oh my god, oh my god'. I said 'Can you wriggle your toes?' and she did." Judd's heart started pounding. She said "April, can you hear what I'm saying?" and she nodded her head.

She went to tell the other nurses. "Bullshit," they said, so she took them over and told April they didn't believe her. "She got this real look of determination, as if to say 'I'll show them'. I realised I was crying. I felt this massive wave of emotion. I was just awestruck."

When Gail and Tony arrived, Judd was at the head of the bed. She said "April, your mum's here." They were used to that; she chatted to her patients even if they were comatose. Then she said "You understand mum's here, don't you?" and April nodded.

Gail's knees gave way. She grabbed a desk for support as the tears flooded. It was like a wall fell down. "I was almost hysterical, I think. I was laughing, I was crying, I was doing both at the same time." The zombie was exorcised.

When Arthur arrived everyone was crying and for a terrible moment he thought she was gone. They hugged April and each other, holding her hand, talking to her. She squeezed their hands, nodded or shook her head as if making up for lost time. Gail remembers other fragments: nurses in tears; the dazzling smile of a registrar, a Sri Lankan, who kept coming back saying "I don't believe it."

Judd talked all shift, telling April what she was doing and why. "Have you got any pain?" and she'd shake her head, "Do you feel sick?" and she'd nod. She couldn't open her swollen eyes and couldn't talk because of the tracheostomy, but still Judd was amazed: April was not simply following commands, but processing them and pulling out appropriate responses.

"That one day in my career stands out," she says. "Five years caring for cancer patients you know will die, patients who are brain dead, having to withdraw treatment. Every single day that happens, one day like this makes it all worthwhile."

'THERE are days I don't want to go into that hospital. I get scared. You can't help but be scared something new is going to go wrong." It was 10 weeks since April woke up but if Gail had thought the worst was over she was wiser now.

It was wisdom born under punches. Three more times they'd come too close to losing her again.

April lay in ward Three East, cabled into monitors, punctured by catheters, hooked to drips, pipes and her thick blue trachy tube. She was helplessly weak, her eyes dark and deeply sunken, her skin transluscent and stretched tight over protruding bones. She was 60 kilograms the day of her accident, now she was a skeletal 38.

The torn vein over her brain had continued leaking, forming a 60-millimetre haematoma. It wasn't immediately threatening and D'Urso wanted to give April time to stabilise before operating. Sixteen days after the accident he took her back to theatre, cut a cookie of bone out of the left side of her skull and removed the clot. X-rays revealed a nasty fracture of the thoracic spine but there was no way she'd survive spinal surgery.

But her crises had seemingly more pedestrian origins. She was being fed through a tube but had an unusually sensitive gag reflex and, irritated by the intrusion, kept vomiting. She was losing more than she was taking in and visibly wasting away. On Christmas Eve, Mark Baxter, nurse manager of Ivanhoe Manor rehabilitation hospital, had visited April to assess her: "She was malnourished to the point of starvation. I said 'She looks like an Auschwitz victim'."

April's tracheostomy was fitted with an inflatable cuff to block saliva or sputum from slipping back the wrong way. But twice she breathed in enough vomit to trigger near-fatal bouts of pneumonia.

In between she went through a cycle of fevers, her temperature spiking to 40 and her heart rate racing, that sent her back to ICU. Finally, she was struck down by golden staph. She was under an umbrella of antibiotics and drugs, but her immune system was battered and to Gail it seemed that every day something new and cruel would sneak up and mug her.

She and Tony were bruised too. They had fallen into routine: Ring the ward at 6.30 every morning; visit at 10.30; go home at 1; then back to the hospital from 4.30 until 7pm. Gail had taken indefinite leave while Tony, self-employed, would work lunchtimes and nights.

Now, 11 weeks in, April was unusually stable. "But it's almost as if you're waiting for that to change," says Gail. "You have to remain positive - or look like you are - but in the back of your mind it's: 'This can't be. Something else has to go wrong'."

But it didn't. Slowly, in creeping increments, April finally began to get better.

She began gentle physiotherapy with Alice Thom. They would work together once, sometimes twice a day. Neurological changes had increased muscular activity in April's arms and legs and she would be placed on a tilt table to lengthen her calf muscles as well as work her cardiovascular system. Her feet had fallen into a drop position and were put in a series of casts to return their natural range.

Occupational therapist David Price's initial task was to assess April's cognitive functions: orientation, memory, whether she could comprehend instructions and recognise common objects and how to use them. "It was one of the most horrific injuries some here had ever seen, and when I first met her I assumed she wouldn't be responding to me much at all, that she'd be looking at me blankly."

But at the first meeting, two weeks after she woke, she was following commands: sticking out her tongue, touching her nose. Price had her do a thumbs-up for 'yes', but her arm was to weak to turn her thumb down for 'no'. So she improvised, sticking out her little finger instead. Price was stunned: she had found a problem and devised an appropriate solution.

"I walked out of the room that first day with my eyes wide, saying 'I can't believe she can do this'. We have head injuries where people look perfectly normal but when you press in they have all these cognitive defects. She looked awful, she had a terrible injury, but was responding quite amazingly."

She kept improving, persisting through repetitive exercises, trying to impress. "She has this incredible willpower," says Price. "She had one of the worst injuries, but might well have one of the best outcomes."