Good Medicine - October 2009
Michael Jackson has a story to tell. At 57, he’s tall and handsome, a rugged character with a history of robust health. Three years ago, Jackson ran a thriving commercial construction company and spent his free time fishing and hunting. Though recently divorced, he adored his two sons, now 23 and 19. Life was good.
He looks back at that time and shakes his head. "You think you have everything, but you can lose it all in the blink of an eye," he says. "Life can blindside you."
On Aug. 30, 2006, Jackson was in the middle of telling a funny story to a bunch of buddies at his favorite local tavern. In mid-joke, he felt a sudden, sharp pain in his head. He sat down, but something was strange. He couldn’t feel his right side.
"I told my friends that I didn’t feel right," he recalls. "I didn’t know what was happening."
Luckily for Jackson, his friends knew what to do. They called 911 and, minutes later, the paramedics arrived. Today, Jackson says, he remembers everything up to the point when he was loaded into the ambulance. "Then it all went blank," he says.
His life remained blank for nearly six weeks—the time Jackson spent in a coma, battling his way back to consciousness. Jackson didn’t know it at the time, but his neurosurgeon, Dr. Andrew Fine, and a team of dedicated professionals in Sarasota Memorial Hospital’s ICU department were fighting alongside him.
What had happened to Jackson had felt like a stroke. It wasn’t, although the symptoms were the same. Fine and his team eventually discovered, through advanced neurological testing, that the culprit was a relatively rare condition: a cavernous malformation.
Fine explains that cavernous malformations aren’t caused by "anything you do, consume or have happen to you." These malformations occur developmentally in the brain, he says, "when the number of veins draining a normal area of brain is too few, and the capacity is overloaded and the veins dilate. If they stretch beyond their elasticity, they’ll rupture."
And there’s often no advance warning of this problem. "The condition is usually asymptomatic," Fine says. "Cavernous malformations can be detected in an MRI scan, but typically, patients don’t go in for a scan if symptoms don’t present." When symptoms do appear, it’s usually bad news.
"Cavernous malformations can produce hemorrhaging in brain tissue," Fine says. "In Mr. Jackson’s case, blood filled the ventricles of his brain, which are normally filled with cerebral spinal fluid." As Jackson’s condition worsened, Fine explains, the blood blocked the flow of Jackson’s cerebral spinal fluid, which in turn created a second problem called hydrocephalus, an abnormal accumulation of cerebral spinal fluid in the brain’s ventricles. If untreated, the increased intracranial pressure inside the skull results in death.
While Jackson remained in a coma, Fine performed a ventriculostomy, inserting a small tube into Jackson’s skull to remove and divert excess blood and spinal fluid. Even so, Fine knew irreversible damage had already occurred.
Simply put, the hemorrhage had destroyed parts of Jackson’s brain—and his body. When specialized brain cells are damaged or die, the body parts they control can’t function. The loss of function can be slight or devastating; the damage can be temporary—or forever. It all depends on how much brain damage there is, and how fast blood returns to the impacted cells.
As long as Jackson remained in a coma, there was no way to determine just how much damage he had suffered. Still, Fine hung on to the hope that Jackson would make a meaningful recovery.
"In cases like this, we study the brain scans to determine what areas have been irreversibly affected," he says. "Then we counsel the family on the patient’s chances of making a reasonable recovery. My thinking, from the very beginning, was that we needed to do all we could to get him through this. The part of the brain the hemorrhage destroyed was going to cause a disability for certain—but I felt it wouldn’t interfere with leading a fulfilling life. Mr. Jackson and his family weren’t willing to give up, and neither was I."
Jackson spent the first two weeks of his coma in Sarasota Memorial Hospital’s intensive care unit. Fine has the highest praise for its team. "In my estimation, the ICU staff are the real heroes in Mr. Jackson’s case," he says. "A patient in a coma faces all sorts of risks. Sarasota Memorial’s ICU has a highly focused team approach and delivers care on a minute-to-minute basis. His recovery is the result of that expert care."
Indeed, Sarasota Memorial’s ICU department has received its share of national attention. For six years in a row, SMH has been rated as one of America’s best hospitals by US News & World Report. Part of what influenced that rating was the specialist care provided in ICU. Its highly trained staff includes registered nurses, critical care pulmonary specialists, health care coordinators, personal care attendants, a critical care pharmacy staff and case managers. Many of its more than 50 registered nurses have advanced nursing degrees and critical care certification.
Registered nurse Sue Shkrab, the director of SMH’s ICU department, credits the unit’s high success rate with the ongoing, rigorous critical training her staff undergoes under the leadership of Dr. Kenneth Hurwitz, medical director of Critical Care Services. "We have an incredible interdisciplinary team that meets three times a week and visits each patient to review their current status," she says. "Our staff balances high technology with the care and compassion necessary to care for critically ill patients."
The ICU continuously monitors the brain function of people like Jackson who come to the ICU after suffering a stroke, aneurysm or cerebral hemorrhage, Shkrab explains, working side by side with interventional radiologists and neurosurgeons. Thanks to that constant monitoring, Jackson’s medical team was able to stabilize him during the two weeks he was there.
Throughout his coma, Jackson had other angels by his side, including his brother, Tom, and his older son. "I have no memory of it," Jackson says. "I found out later, and it means the world to me."
When Jackson first emerged from his coma, he didn’t know how much time had gone by. He couldn’t move his arms or legs or talk.
"I was dazed and confused," he says. Tests concluded that the right side of his body was paralyzed. Dr. Fine and the rest of his team thought he might never walk again.
But a few days after awakening, Jackson moved his left leg. Days later, he was attempting to walk.
"Dr. Fine called me a miracle man," says Jackson.
Of course, medical miracles usually come with a lot of hard work—and no guarantees.
After his awakening, Jackson underwent months of physical, speech and occupational therapy at HealthSouth Rehabilitation Hospital of Sarasota, an acute-care specialty hospital. There he learned to walk, talk and even think again. With his right side paralyzed, he had to learn how to feed himself, dress, and write without a right arm or hand.
As Jackson puts it, "I gradually got my mind and body back. I was starting to feel normal on the inside. Talk about taking baby steps. This was it." Every step of the way, his brother and sons were there, he says. "I can’t thank them enough." As for Dr. Fine, Jackson heralds him as his savior.
In the three years since the incident, Jackson has regained some function on his body’s right side, although it remains more than 90 percent paralyzed. He has almost completely recovered the use of his left side. Determined to regain his mobility, he taught himself to walk longer distances, thanks to a cutting-edge device called the NESS L300. Worn just below the knee, it sends an electrical impulse to the nerves, causing the muscles to contract. A computer program adjusts the rhythm of the contractions to Jackson’s natural gait. Using the same principles as voice recognition software, the device "learns" and adjusts to the user’s walking patterns, constantly fine-tuning itself. The more Jackson walks, the more natural his gait becomes.
He’s also driving again. July 3, 2007, was Jackson’s personal independence day. "That’s the day I got my license—and my freedom—back," he says. Now he drives with a left-foot accelerator and a knob on the steering wheel.
"Mr. Jackson’s recovery is nothing short of amazing," says Dr. Fine. "He’s still dealing with limitations, but I’m confident he’ll get better and better. Hopefully, he’ll continue to make gains."
Jackson also feels confident. But he expresses himself in less guarded terms.
"The worst is over," he says. "I’m healing every day. It’s a process—and it's
Today, Jackson is a little on the thin side and walks slowly. He enjoys showing photographs of himself before the incident—photos that show a rugged, solidly built man who beams with life and a devil-may-care attitude. In one shot, he’s wrestling an alligator. But he he says he doesn’t look back.
"I’m grateful to be alive—period," he says. "Crap happens and you deal with it. You move on, and you keep moving on. That’s the lesson I learned from this."
Cavernous malformations are relatively uncommon
as is the likelihood that they’ll bleed seriously. These vascular malformations typically do not cause any symptoms, but instead are detected on a brain magnetic resonance imaging (MRI) scan done for unrelated reasons.
In some cases, the cavernous malformation may lead to significant bleeding or hemorrhage into the brain tissue, causing weakness, numbness, difficulty in speaking, difficulty in seeing, gait unsteadiness or incoordination. Even the small amount of blood surrounding the cavernoma can cause irritation of the surrounding brain tissue, sometimes causing seizures. Source: www.mayoclinic.org
The annual incidence of aneurismal subarachnoid hemorrhage in the U.S. exceeds 30,000 people. Ten to 15 percent of these patients will die before reaching the hospital and over 50 percent will die within the first 30 days after rupture. Of those who survive, about half suffer some permanent neurological deficit. Source: www.brainaneurysm.com
Dr. Fine of Neurosurgery and Spine Specialists,
5831 Bee Ridge Road, Suite. 100, Sarasota; (941) 308-5700.
Sarasota Memorial Hospital
1700 S. Tamiami Trail; (941) 917-9000
Sarasota Memorial Health Care System earned Magnet Nursing Services Recognition, the nation’s highest honor for excellence in nursing, in 2003. The quality designation is awarded sparingly to hospitals around the world by the American Nurses’ Credentialing Center (ANCC). Only five percent of hospitals in the United States have received the award.
Sarasota Memorial Hospital is the only state-certified Comprehensive Stroke Center in this region. With services that extend beyond those offered in a Primary Stroke Center, SMH’s stroke program has been nationally recognized "with distinction" by the Joint Commission and given its "Gold Seal of Approval" for providing the greatest breadth and depth of specialists and advanced services for stroke patients.
0.2 to 3 percent of people with brain aneurysms may suffer from bleeding in any year.,