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Logan's miracle

The story of a young boy's amazing recovery from severe brain trauma - and the estimated 150 emergency first responders and caregivers who helped him along the way

Logan Quatember in therapy
Logan Quatember relearns standing balance with occupational therapist Paige McCullough (foreground) and physiotherapist Kim Hamilton.
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Pediatric Intensive Care Unit

Working to support Children's Hospital

BY GERALD FLOOD
Winnipeg Health Region
Wave, May / June 2016

As usual on a Saturday morning, all three levels of the sun-drenched atrium at the Royal Winnipeg Ballet School were packed with hundreds of kids, all stripping down to the essentials for dance class - black leotards and white hose for girls; white T-shirts and tight black shorts for boys; white ankle socks and ballet slippers for all.

As usual, too, Logan Quatember was among them, hopping from one foot to the other as he shucked off his street clothes. What emerged seemed unremarkable - a typical 12-year-old boy, a bit of a puppy, gawky and gangly, as if growth was spurting unevenly in his transition from late childhood to early adolescence.

He seemed self-conscious, at once eager but unfocused, distracted by the hubbub one second, attentive to his mother the next.

However, as Shakespeare long ago warned, it is best to ignore first impressions - to "know not seems."

Sure enough, within minutes, a different Logan stood with a hand resting on the barre in a bright, mirror-lined dance studio along with 20 other children - 16 girls, four boys. He posed, posture-perfect - elegant, in fact - no trace of awkwardness or distraction, his attention riveted, his eyes focused always on an imaginary arch beyond the tip of his nose.

He arranged his feet, legs, arms, hands, and spine just-so as he dipped and stepped, turned and jumped to the instructor's metronomic counts and a pianist's supporting classical melodies.

The transformation was nothing short of astonishing.

Even more astonishing, however, was that Logan was dancing at all. A little more than a year earlier, he was lying in a hospital bed, comatose for 12 days with severe brain trauma suffered in a car crash.

It was touch and go whether he would survive, let alone walk or perform as he so loves to do.

Many people who were closely involved call Logan's recovery a "miracle." And without a doubt, chance and the inexplicable played roles in his journey from the dark night of the crash to this brilliantly sunny morning on Graham Avenue in downtown Winnipeg.

But it would be wrong to give too much credit to fate, the supernatural or whatever mysterious force might produce what is described as miraculous. More concrete and creditable were the efforts of a remarkable array of professional caregivers and support workers - from firefighters and paramedics to brain surgeons and physiotherapists. It has been conservatively estimated that at least 150 people were involved in making Logan's "miracle.'' In other words, to rephrase a familiar aphorism, it takes a village of miracle makers to save a child.

The first of these became involved at 7:35 p.m. on Thursday, Feb. 19, 2015, when a two-tone alarm sounded at Station 27 on Sage Creek Boulevard, not far from the Royal Canadian Mint in southeast Winnipeg.

The alarm was followed by the buzz of a printer spitting out a message from the Emergency Control Centre, where a staff of 10 directs fire, ambulance and police responses to emergencies 24/7. It is universally agreed that the work of these dispatchers in coordinating the right response at the right time is under-appreciated by the public - out of sight, out of mind, as it were.

The message was that a vehicle with two occupants had been T-boned by a semi-trailer truck in an 80 km/h zone on Lagimodiere Boulevard at Sage Creek Boulevard, fortuitously, less than 200 metres from Station 27.

A pumper truck and a team of four emergency first responders, one of which must be a paramedic, were on the scene in minutes. Team member Dave Szyszkowski says it was quickly confirmed that Nik Quatember and his son, Logan, were trapped inside the Jeep, the passenger side of which was punched in as if by a giant fist.

Father and son had been returning from a dance class . . . and were almost home.

Nik was conscious but not Logan, who was showing tell-tale signs of brain trauma that emergency first responders are trained to recognize. "He already was snoring, his arms were flexed up toward his chest and he was grinding his teeth,'' explains Szyszkowski.

Over the next 12 minutes, two ambulances arrived at the scene, along with a second pumper truck in case of fire, a rescue vehicle with a jaws-of-life crew to cut away the fused passenger door, two police cruisers to direct traffic, a safety officer, two medical supervisors, and the district fire chief.

In all, more than 20 emergency workers scrambled to make best use of the "10 platinum minutes" of the first "golden hour" after the alarm sounds - the crucial window for intervention following a life-threatening trauma.

Their efforts were not simply coordinated, they were shared electronically in real time on computer tablets and pagers across the emergency response system and at the Children's Hospital emergency department at Health Sciences Centre Winnipeg, which immediately began mustering a team of medical specialists to receive the injured. 

Szyszkowski and partner Ken Laramee managed to open the Jeep's rear hatch. Szyszkowski crawled inside and, according to "C-spine" protocols, grasped Logan's head between his hands to prevent neck movement that could cause or exacerbate spinal cord damage.

Szyszkowski has no memory of how long he crouched there, only that "it seemed like forever" in the bitter cold and dark.

Laramee, meanwhile, managed to remove Nik from the Jeep through its sunroof.

Members of the Winnipeg Fire Paramedic Service team: Front, Kevin Graham. Second row, from left: André Lacroix, Barry Rochon, Gary Wiebe. Third row, from left: Gary Loewen, Eric Buscha. Fourth row, from left: Darren Kowalchuk, Ross Takenaka, Ken Laramee, Jason Schmidt, Dave Szyszkowski.

Members of the Winnipeg Fire Paramedic Service team: Front, Kevin Graham. Second row, from left: André Lacroix, Barry Rochon, Gary Wiebe. Third row, from left: Gary Loewen, Eric Buscha. Fourth row, from left: Darren Kowalchuk, Ross Takenaka, Ken Laramee, Jason Schmidt, Dave Szyszkowski.

Paramedics André Lacroix and Garry Wiebe, were in the first ambulance on the scene.

Wiebe confirmed the signs of brain trauma but there was little else he could do. "If there's a hole, we can plug it. If it's internal, all we can do is watch and listen," he explains.

Watching and listening continued as Lacroix drove the ambulance through blessedly light traffic to Children's Hospital, but there was intense activity in the back, where Wiebe had been joined by the two medical supervisors, at least one of which is required at the scene of any emergency involving children. They administered an electrocardiogram (EKG) and inserted intravenous therapy tubes (IVs).

Twenty years earlier, when many ambulance services were still voluntary, attendants might have been expected to do little more than drag a crash victim from a wreck, secure them to a stretcher and perhaps administer CPR.

Today's attendants, who respond to about 65,000 emergency calls a year in Winnipeg, are trained medical workers who, in addition to doing EKGs and setting up IVs, can also insert breathing tubes and administer life-saving drugs, 20 of which are available in their ambulances.

Logan would benefit from these advances. Studies have repeatedly confirmed that transforming ambulances from stretcher carriers into mobile emergency rooms has saved countless lives, not just through better medical training but by reducing the need for emergency doctors to rig IVs and conduct EKGs themselves, thus speeding more specialized intervention.

Dr. Rami Ableman was on duty the night Logan was brought to the trauma bay at Children's emergency department. He recalls that it had been a "steady" night prior to the Sage Creek alert, at which point activity ramped up as a team of about 10 emergency experts began to muster and prepare for what they already knew would be a critical case involving brain trauma.

The team included the emergency doctor in charge, an emergency resident, Ableman, who is a pediatric resident, a pharmacist, a respiratory therapist, and several emergency nurses.

Ableman, who has a special interest in emergency pediatric medicine, abandoned basketball when it interfered with his medical studies. He has a gentle demeanor, which softens his imposing six-foot-seven frame.

Logan, he says, was unconscious when he arrived at the hospital, and did not have the functional brain capacity to regulate his posture and brain reflexes, which meant that his breathing and circulation could be compromised at any time.

The primary function of the trauma bay is to prevent that from happening by following a deceptively simple sounding ABC protocol (airway, breathing, circulation).

No matter the severity of injuries, the ABCs are paramount because without an airway through which to breathe and pass oxygen to the blood to be circulated to vital organs, such other interventions as splinting a broken bone would be pointless.

Task A was addressed by inserting a breathing tube. B required the use of a manual bag-pump to force air into Logan's lungs. C was stabilized by introducing fluids to ensure blood flow.

With the ABCs out of the way, attention turned to task D, or disability, a determination of how much trauma the brain has experienced by measuring dilation of the pupils, for example.

The final task is, E, exposure, examining the body head to toe for such things as internal bleeding or broken bones.

Logan had contusions on both sides of his head, the most severe in visible terms on the right side. But more importantly, there were signs of dangerous swelling of the brain on the left.

Over the next few hours a CT scan located the areas of swelling. A hole was drilled in Logan's skull and a needle-like probe was surgically implanted in his brain to monitor pressure. He was moved to the pediatric intensive care unit (PICU), where he would remain, comatose, in critical condition, for the next 12 days.

More than 100 nurses and support staff are employed in the PICU, along with a whole range of specialists. Nurses were dedicated to Logan's exclusive care on 12-hour shifts throughout his stay in a room equipped with the full range of monitors, devices and drugs needed to support life, ready at hand so that they are available instantly as needed.

There are 10 such rooms in the PICU, which treats about 500 children a year.

Nurse Kelly Minski, a 32-year veteran on Winnipeg pediatric wards, remembers that first night when Logan arrived bruised, bloody and unconscious. "I don't want to say there was not a lot of hope . . . but he was in such a bad place. The (readings on the) monitors were just devastating."

Dr. Greg Hansen, a youthful-looking 43-year-old, called the "brain guy" by PICU nurses, is one of a very few pediatric neural critical-care physicians in Canada. In short, he's an expert in brain trauma and its treatment.

Hansen, who saw Logan the morning after the crash and led a team of five specialists, including neurosurgeons who managed his care in PICU, says that what happened in the crash is unknown, but can be reconstructed from Logan's injuries.

In any collision, the energy of the moving vehicle, a function of its speed and mass, is transferred in milliseconds to the struck vehicle. One measure of how hard and fast the impact was might be that the soles of Logan's feet were bruised black.

The mechanical energy of the truck would have transferred to the Jeep, likely causing Logan to fly to his left and strike his head on the driver's seat, and then to bounce back to the right where his head hit the window hard enough to embed pieces of shattered glass in his flesh. He had severe contusions on both sides of his head, the bloodiest on the window side.

Because bodies are fluid in nature, and because organs are of different masses, the shock of a crash sends everything in motion. "The body literally vibrates as it goes from first impact to static state," Hansen says.

All that torque, exerted in seconds, caused tearing in Logan's spleen and liver, bleeding of the adrenal glands and rib fractures.

While severe in themselves, those injuries were not life-threatening and were nothing compared to what had happened to Logan's brain, which would be "a little harder than a sponge." Encased by bone and floating in brain fluid, it "banged from one side of the skull to the other."

Worse, the brain has many parts and, like Logan's other organs, they all have different masses so they all accelerate and decelerate at different speeds. His brain at impact might be compared to a pinball game in which a dozen different sized balls instantly are in play, banging and bouncing at tremendous speed.

All these parts in motion cause "shearing" - stretching and tearing of tissue - so that neurons "disconnect," cutting the flow of signals from the grey matter - the wrinkly outer brain - through the underlying white matter to the spinal cord.

These disconnections - called diffuse axonal injury - can result in unconsciousness. In severe cases, this can be fatal.

Meanwhile, all the banging and shearing caused pin-point bleeding and swelling inside his brain. Logan was bleeding all along his frontal lobe and on the right side of the brain. The left frontal lobe and left temporal lobe (above the ear) were swelling.

As with any bruising, blood rushes to the injured tissue. But when an arm is bruised, for example, the swelling is of no great concern because the arm can expand. The brain, however, encased in a rigid skull, has nowhere to expand to. Instead, expansion causes internal pressure to rise. Bleeding only exacerbates the problem because it starts to take up some of the very limited space.

As pressure increases, it pushes back against the pressure of blood pumping from the heart, restricting its flow, which, if not relieved, will cause brain cells to die in a domino effect where one dying cell weakens the next and so on.

The needle inserted into Logan's brain was reading over 20 on a brain pressure scale - more than twice the normal pressure.

Hansen says it was decided that Logan be put into a chemically induced coma, to "reduce brain activity to a very low energy mode."

The reason? Brain activity requires oxygen and glucose - in short, blood. More blood would only mean more pressure in Logan's skull. So brain activity - dreams, reactions to sound or touch, etc. - was stopped.

Pentobarbitol, the coma-inducing drug, however, also suppresses blood pressure throughout the entire body, endangering other organs and processes.

Other drugs are introduced to mitigate the side-effects, causing more side-effects. In all, Hansen says, as many as eight "infusions" and at least 15 different therapies were required to control the swelling in Logan's brain.

The effects of the chemical cocktail were followed and adjusted constantly according to the ups and downs of 15 readings and a dozen wave forms measured by bedside monitors.

This process of gradually helping the brain to "heal itself" is part science, part art, Hansen says, and, in this instance, did not include neurosurgery. That was ruled out when it was determined that bleeding had stopped on the first day, allowing the body to absorb the blood and reduce blood-induced swelling naturally.

"It's all a very fine balancing act," Hansen says.

When the swelling finally began to abate, and then fell to normal range, Logan was moved again, this time to a general pediatric medical ward.

Hansen's relief, however, was coloured by a new concern. Logan's life had been saved, but what about his brain functions? Would he be the same boy with the same personality and abilities?

Those were the same questions that plagued Logan's mother, Kathryn McBurney.

She was at home the night of the crash, wondering why her husband and youngest son had not yet returned from dance class, when she received a phone call.

It was Nik. He was calling from the crash site on a cell phone borrowed from a paramedic. Nik was injured - whiplash, a vertebra fracture and broken ribs. He could barely talk, but what he said was chilling, Kathryn recalls. "We were in an accident. Logan is breathing."

Kathryn called on a neighbour, a nurse, to drive her to hospital, the route taking them - horrifyingly - past the crash site, where she could see that the destruction of the Jeep was concentrated right where Logan would have been sitting.

"I had a panic moment there," she says. The neighbour explained the situation to police, who provided an escort through the scene of the accident so they could get to hospital in good time.

Very quickly thereafter, other family members arrived, including Kathryn's teenage son Mal. She and Mal were allowed to see Logan. He was bruised, cut, bloody, pale, clammy and unconscious. It was terrible, but better than not seeing him and imagining his condition, says Kathryn.

In the middle of the night she was allowed to join Logan in his room in the PICU. She remained there for the next several days, sleeping in fits while sitting in a chair with her head on Logan's bed, holding his hand when allowed and whispering to him that he was safe, loved and warm. He was lying under a cooling blanket to reduce swelling, she says, "and Logan hates being cold."

In the PICU, and then later when Logan was moved to medical ward CH5, the numbers and diversity of medical staff interacting with Logan ballooned - nurses, constantly, but also a bewildering array of specialists - brain surgeons, residents, respiratory therapists, dietitians, pharmacists, physiotherapists, occupational therapists, speech therapists, child life specialists, social workers, even teachers in a classroom at the hospital operated by the Winnipeg School Division. Extended family members rallied, as did friends.

The constant throughout was Kathryn, who had taken a room in the hotel at Health Sciences Centre, where Nik in a wheelchair joined her for much of Logan's recovery.

Kathryn focused on the positive and began writing a blog. The first positive, obviously, was that Logan survived the crash, and then that the swelling was in retreat and he could be weaned from the coma-inducing drugs.

Now came the big test. All the countless neurons that had been disconnected by shearing had to reconnect or find new routes from Logan's grey matter to his spinal cord. Fortunately, we are born with billions more neurons than we need. Logan's brain started finding new pathways to carry messages to muscles, beginning with basic functions.

On Day 11, for example, Logan opened an eye - "just a slit" - and not long thereafter started moving his eyes.

Kathryn was torn between elation and fear. "I was concerned. Will he be able to function? The doctor told me, 'No one of us can tell you how much he will function. But one thing I'm certain of; you will see your son's personality again.' That was a huge relief. The next day he was smiling."

 On March 2, Mal's 17th birthday, Logan was moving his left hand and arm. On his own birthday, March 18, Logan celebrated by gradually and softly speaking single words to visitors throughout the day.

Kathryn says Logan's first full sentence to her later that day was: "Did I almost die?"

"It was very quick after that," she says. "He was progressing almost hourly."

After five weeks, Logan was walking, talking and cracking jokes. He was allowed a two-hour home visit, and then a single overnight visit that Kathryn asked to be extended to two. "Actually," she recalls being told by the brain injury team, "Pack up his stuff. If he's OK after two days, he can stay at home."

"I was in tears."

Speech-language pathologist Christine Massinon works with Logan during sessions at his home.

Speech-language pathologist Christine Massinon works with Logan during sessions at his home.

Being released from hospital, however, was not the end of Logan's recovery, but the beginning of rehabilitation, with a whole new set of therapists whose treatment continues to this day.

From Logan's perspective, returning to dance class was foremost. In April - two months after the crash - he was back at ballet school, taking part in classes with expert help from his therapists and support from instructors who modified their programs to suit his needs, even creating a unique but limited role for him in a recital in May.

Dance was great physical therapy and especially helpful in regaining movement and balance, says Kathryn. Musical theatre and jazz classes were quickly added. Today he takes five classes a week, and swims once a week with the  Manta swim club, where Kathryn is an instructor.

One of Logan's current ballet instructors, Kristina Washchyshyn, had not known him prior to the accident and could not make a before-and-after comparison.

"But I would never have suspected," she says. "He surprised me."

"He surprised all of us," adds acting RWB principal Nicole Kepp.

It was much the same at Ecole Henri-Bergéron in St. Boniface, where Logan is a French immersion student.

Principal Florence LaPointe says students and staff had been following Logan's progress from the beginning. In the days after the crash, a psychologist and social worker had been available to counsel students - Logan was a popular boy.

Very quickly news of the crash spread to the homes of students and soon fundraising campaigns were underway with a broad network of families contributing money for restaurant meals and prepared foods for Logan's family.

Logan's occupational therapist, Gail McMillan-Law, sent a power-point presentation to the school to help everyone understand Logan's condition, possible consequences, what to expect and how to adjust to it.

A meeting was held with the school support team, division therapists and those actually treating Logan to establish a plan for his return to class.

On Logan's first day back in May, a recital took place that involved the choir in which Logan sang. He had learned the songs before the crash. To everyone's surprise, he remembered all the French lyrics and sang them in tune.

Logan has struggled with writing and math, says LaPointe. "Still, even with the accident, he's (academically) at par in most other areas."

From the moment emergency first responder Dave Szyszkowski braced Logan's head in hands at the crash site, to the day he returned to school just two months later, the care of myriad experts, the loving support of family and friends, and the goodwill of strangers all contributed to his recovery.

At most points along the way, miracle versus medicine was raised and debated in one way or another. Without doubt, Logan would not have survived were it not for the village of miracle makers. But they eschew taking all the credit, especially after the initial crisis had passed, pointing to undefinable "spiritual" dimensions of recovery.

Ableman, the emergency doctor on that first night, followed Logan's progress out of a sense of personal concern but also professional curiosity. "It allowed me to learn from a patient," he says.

In medical school and residency training, he says, emphasis is increasingly placed on family-centred care, especially in pediatrics.

"I would say there's a special aspect of pediatric care which (intersects) a child's environment. We know that children are vulnerable and require support to be nurtured and protected. With Logan, you saw the people around him rise up to give that compassion and support, to give Logan the best chance."

Brain specialist Hansen says the idea that one's "consciousness" plays an important part in recovery has long intrigued "neurological geeks" as a branch of research.

"There is a psychological and physiological aspect of consciousness," he says, "but for some there is also a spiritual aspect, something that science will never put its finger on, something we'll never be able to test."

In Logan's case, inducing a coma - for all intents and purposes - wiped out his brain function, which some might associate with his soul.

"We turned his brain off and on, but in essence, he's the same boy he was earlier - that thread that stays true to him. It's fascinating."

There are other intangibles, like why his recovery seemed to speed up over time, and what parts willpower and family support and the inexplicable might have played in the changing pace.

"Did I think he would do as well as he did?" Hansen asks. "No I didn't. From an ICU perspective, he was not a kid who recovered quickly by any means. But from a ward perspective, he really took off. It was beautiful to see that."

Hansen, who decided to pursue a career in medicine while playing professional volleyball in Europe, says he believes that Logan's background in dance and athletics helped in his recovery.

"I'm one from an athletic background, where pain is part of gain. I think Logan understood that. He pushed through."

Logan was six years old when he started pestering his parents about taking dance lessons, having caught the bug watching a family favourite TV show - So You Think You Can Dance.

In many ways that proved a better desire than could have been imagined. His desire to dance - to perform - he says, helped motivate him to work hard at therapy.

"At certain times I felt I had to push and try things. A couple of times I felt I wanted to scream at the top of my lungs but only a little peep would come out. Or I would want to talk and all I could do was move my arm. It was very frustrating at times.

"But I love dance and I just wanted to get back to pursuing dance and to see my family members and my dog at home," he says.

Logan is not 100 per cent recovered. He has difficulty writing, for example. He gets headaches and mild dizzy spells. His left arm functions better than his right. But his brain is still in the process of healing and there is time for more improvement.

Physiotherapist Mary Eaton says his feet will "slap" when he is pushed hard on a treadmill, signs of lingering weakness that she continues to work on with him. "But no one would look at this little guy and guess what he's been through," she says.

Perhaps the final word should go to nurse Minski, who says she cried when Logan and his mother returned to the pediatric intensive care ward to say thanks. Then she cried again when she remembered the moment.

"Oh my goodness. I told myself I wouldn't cry, but . . . it just makes you so happy, so really happy for them," she says. "You know then that you've done a good job.

"It can be incredibly sad sometimes, but the joy of watching a child walk again after such devastation . . . It's a miracle."

Gerald Flood is a Winnipeg writer and former editorial page editor of the Winnipeg Free Press.

Wave: November / December 2015

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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