Emergency responders found the driver’s-side door of Dylan’s SUV crunched into a telephone pole. Dylan was unconscious. His breathing sounded like the gurgling of a straw in a near-empty cup. He had traveled barely 200 yards before striking the pole, possibly after hitting black ice. He wasn’t wearing a seat belt.
It took responders eight minutes to pull him out. There was so much blood and lacerated flesh that medics could not insert a breathing tube during the 29-minute ambulance ride into Boston. At Massachusetts General Hospital, Dylan had a CT scan and was rushed into surgery, where neurosurgeons removed the left side of his skull and part of the right to stop multiple brain hemorrhages. By the time he was transferred to the neuro intensive-care unit, he was a swollen-faced sphinx—his eyes closed, his head wrapped in bandages, pincushioned with needles, and on a ventilator. His face had been shattered; his left leg was broken. And he was in a deep coma.
To gauge Dylan’s chances of recovery, doctors would rely on standard timelines, and their prognosis would inform treatment. But as neurologists acknowledge, early prognosis is very difficult, diagnosis is often flawed, and the timelines that guide recovery are defied by patients who don’t obey the statistics.
On the same day as Dylan’s first MRI, neuropsychologist Joseph Giacino administered a test known as the Coma Recovery Scale. He pried Dylan’s eyes open to see if there was any sign of visual tracking. There wasn’t. Dylan scored a 1 on the scale, out of 23.
The director of rehabilitation neuropsychology at Spaulding Rehabilitation Hospital and an authority on disorders of consciousness, Giacino had been called in to consult on Dylan’s case. He is among a growing number of experts warning of what he calls a rush to judgment in predicting an outcome for brain-trauma patients. In a study of Canadian trauma centers, researchers reported that one third of the patients who went into the ER with severe traumatic brain injuries died. Half died in the first 72 hours. Nearly two thirds of those early deaths had life support withdrawn, suggesting that the cases were deemed hopeless in the first few days. According to Giacino, it can take much longer than that for a person’s chances of recovery to become clear. Recent literature suggests that if a patient displays any form of conscious awareness within 60 days, his or her chances are considerably better. As a realist, Giacino knows hardly anyone—families, doctors, insurers—can wait that long.
When doctors pored over images from Dylan’s MRI, they were shocked by the damage. In a car accident, the impact sends the brain banging around inside the skull. “It shears or literally tears the axons, the wires that send signals from one part of the brain to the other,” said neurologist Brian Edlow, a member of Dylan’s treatment team. The MRI showed frayed wires everywhere. In his notes, Giacino wrote that “the probability of recovery of functional, vocational, and social independence is low.”…
Dylan’s family members sat in a conference room with doctors, who showed them the scans. Steve recalled, “They kept saying—it was like 90 percent of what we were looking at—‘This [area] will never recover, this will never recover.’”
“They told us they didn’t think he would ever be able to live at home, that he would probably be institutionalized and have moments of clarity where he would recognize us,” Tracy recalled as tears welled up. “But they didn’t think he would even have that.”
About the only factor in Dylan’s favor was his youth. After the doctors left, Dylan’s father ran out and buttonholed one of them. “Lookit,” he said, “we don’t need time to think. You need to do whatever you can do … What would you do if it were your kid?” He got no disagreement from the doctor, who replied, “We want to do everything.”…
Dylan had been storming for several days. Tracy and her mother sat at his side, while Tracy wiped sweat off his forehead. Then something remarkable happened: Tracy went to wipe his head, and Dylan raised his hand. When he did it a second time, she put the cloth in his hand and said, “Dylan, wipe it yourself.” He started to wipe his mouth and nose.
Dylan’s doctors performed a second MRI. Remarkably, the scan suggested that some of his damaged wiring had begun to mend. “To our knowledge,” the doctors noted later, “this type of reversal has not been previously described with serial neuroimaging or in a case with such a widespread extent of axonal injury.” The repair process, referred to as plasticity, is much more robust in a young brain than in an old brain, neurologist Edlow explained. One revelation of recent research is evidence that severe injury can activate mechanisms of neural development that normally deploy during childhood.
Dylan had been tugging at the plastic tubing that connected to his trachea. The family gave him a short rubber tube to distract him. At one point, Steve reached for the other end of the tube and blew into it. The noise sounded like a fart. Dylan laughed. To Tracy, this was a glimmer not only of consciousness but of personality: “We were like, Oh my God! Like, he knew what a fart is, right? He’s still in there!”
At the end of February, Dylan was transferred to Spaulding Rehabilitation Hospital. Still considered minimally conscious, he could sit up in bed with assistance; he could nonverbally answer biographical questions with about 75 percent accuracy; and he could follow one-step commands about 40 percent of the time…
The physical therapy nurses stood Dylan in front of a mirror and wrote “Dylan loves the Yankees” and “Bruins stink” with a marker on the glass. Dylan picked up an eraser and wiped away the insults—“very quick,” his parents reported, “even for Dylan.”
Nurses, patients, doctors, and well-wishers gathered at the reception desk for a send-off party. In a video, Dylan sits in a wheelchair, waving and smiling. His smile has the megawatt quality it had before the accident, but the wave is on a two-second delay, almost slow motion. That day is the first thing he remembers since the day of the accident. “Coming out of it, it was like I was asleep, and I was just back alive,” he said later. “The last day at Spaulding, that’s when I felt alive.”
Before he left Spaulding, he hit another milestone: He said his first word since the accident…
Dylan went rock climbing, working his way up a climbing wall. The Rizzos sent the video to Giacino, who includes the clip when he gives talks about recovery in patients who reached a minimally conscious state within 60 days of their injury. It is a vivid embodiment of his argument for patience. “What this tells us,” Giacino said, “is that the story doesn’t end at 12 months.” Dylan is among a growing number of patients who defy the odds. “We don’t know how many exceptions to the rule there are,” Giacino said. “So I don’t believe in the rule anymore.”…
“He’s still the same person,” Tracy said. “Just neater. He was a slob before the accident.” Dylan smiled.
The most conspicuous reminder of his injury was a slight indentation in his left temple and two shiny lanes of hairless skin that run back from the crown of his forehead. Now 23, he is functionally independent. He volunteers as an assistant track coach at his old high school, helps his father on construction projects, and hopes to attend community college. He continues to need speech and cognitive therapy. “Dylan still has memory issues, organization issues, and time-management issues,” Tracy said. He does not remember a single thing about the six months prior to the accident or the seven months after.
Not only is he functional, but he’s functional in a red-blooded 20-something way. When we went out for lunch, Dylan ordered a sampler of microbrews (“His neurologist says he can have one or two beers,” Tracy said). Back at home, I asked to see his room. Dylan effortlessly climbed the stairs and led me there. Inside was a flat-screen TV, and a lacrosse stick was propped in one corner. The bed was made, and Steve opened the closet to reveal T-shirts, each hung and color-sorted. “There was nothing in here before the accident. Everything was on the floor,” he said, then laughed. “Reprogramming the brain works.”
Courtesy of my daughter