When Lightning Strikes
from Practice Update, Fall 2006
Pediatric Inpatient Neurotrauma Rehabilitation Team Treats Lightning Survivor
Janae Montes is an active 14-year-old girl who loved sports. Softball is her passion, and she has played on a competitive team in her hometown of Pueblo , Colorado for seven years. In June 2005, her softball team was playing a scrimmage game to prepare for an upcoming state tournament. It was a hazy day with some clouds in the distance, but no storm was in sight to postpone the practice. Janae was in center field preparing for the next batter when a bolt of lightning came out of nowhere and threw all players on the field to the ground. Janae was struck by the lightning in the back of her head, throwing her forward and knocking her unconscious. While everyone in the vicinity of the field was dazed from the powerful bolt, a nearby walker and a physician in the stands raced over to Janae to immediately begin CPR. Their actions revived Janae and enabled her to breathe on her own before paramedics arrived.
Janae’s mother, Gerlyn Kinser, heard the lightning crash from her office only a few miles away from the ball field. Soon after the crash, she received the horrific call that the same bolt she heard only a few moments earlier had struck her daughter. She raced to the field, arriving around the same time as the paramedics, who immediately took Janae to Parkview Medical Center in Pueblo . The medical staff in the Emergency Department at Parkview intended to send Janae via Flight for Life to The Children’s Hospital in Denver , but storms in the area prevented any air transportation. The trauma team was able to keep Janae stable enough to send her to Denver by ambulance with her mom by her side.
Upon arrival at Children’s Emergency Department in Denver , the trauma team was assembled and ready for her arrival. Janae was awake and stable, but unable to move her left side. A CT scan of her brain revealed that she had bilateral, right greater than left, basal ganglia hemorrhages and a well described sequela of a lightning strike. Janae was admitted to the Pediatric Intensive Care Unit (PICU), and within a day, she was formally evaluated by physicians and therapists from The Children’s Hospital’s Rehabilitation Department.
“Our evaluation focused on identifying the extent of Janae’s impairments,” said Susan Apkon, MD, Director of the Inpatient Neurotrauma Rehabilitation Unit at Children’s. “It was unusual how alert and interactive she was despite the very large hemorrhages she suffered.”
Dr. Apkon also noticed Janae’s lack of movement in her left arm and leg and the obvious asymmetry of her face and mouth. As Janae’s physiatrist (rehabilitation physician), Dr. Apkon immediately began to focus on how the physical changes impacted her daily functions and made recommendations to begin improving those skills. Janae had impairments in speech and language, gross motor skills such as sitting and walking and activities of daily living (ADLs) such as feeding herself and dressing. Dr. Apkon requested the PICU staff to consult The Children’s Hospital’s therapy team, which includes a physical therapist, an occupational therapist and a speech-language pathologist. This team began working with Janae and her family before she even left the PICU in an attempt to prevent complications that can often result from a lengthy intensive care stay.
After spending three days in the PICU, Janae was transferred to the Inpatient Neurotrauma Rehabilitation Unit under the care of Dr. Apkon. Gerlyn felt at ease about transferring her daughter to the Rehabilitation Unit after seeing Janae receive exceptional treatment for her traumatic brain injury and learning that Children’s is the only inpatient pediatric rehabilitation unit throughout Colorado, Wyoming and Montana.
“I was really impressed with the entire staff and the extensive attention and care they gave to Janae the minute she arrived at The Children’s Hospital and throughout the entire rehabilitation process,” Gerlyn said.
The Inpatient Neurotrauma Rehabilitation Unit provides comprehensive treatment on the inpatient unit while still in the acute phase of an illness or injury and onto recovery. Treatment starts as early as the patient’s intensive care stay and continues once they are transferred to the Unit. Earlier intervention improves medical and functional outcomes for many patients.
The most common diagnosis on the Rehabilitation Unit is a traumatic brain injury like Janae’s, which made up 37 percent of total discharges from the Unit in 2005. Other common diagnoses include brain or spinal tumors, head trauma due to child abuse and cerebral vascular accident (CVA). Children with congenital disabilities such as cerebral palsy are also admitted either from home or following an orthopedic or neurosurgical procedure to participate in an intensive interdisciplinary therapy program through the unit.
Janae’s experience with Neurotrauma Rehabilitation was a typical one for a patient with a brain injury. As soon as she was admitted to the Unit, an intensive program began, including twice daily sessions by the therapy team as well as regular interactions with a social worker, rehabilitation psychologist, case manager and the nursing staff. The team met on a weekly basis to review the medical status of Janae, review the short- and long-term goals and discuss discharge plans. Her primary care physician (PCP) was also notified when she arrived to the Unit and fax communication was consistent throughout her rehabilitation in order to keep her physician informed.
Dr. Apkon indicated the importance of another aspect of the program, family teachings, which kept Janae’s family updated on her condition and how to cope with a traumatic brain injury in the family. “Family teaching is a large part of the team’s efforts, especially when the child has had a severe injury and will require a lot of care upon their return home,” explained Dr. Apkon. Therapists work on activities such as how to transfer a child into a wheelchair, how to dress an older child who is unable to assist, help with the position and range of motion for comfort and maintain the range of motion. Families may also need to learn medical treatments such as tracheostomy care, ventilator management, use of a gastrostomy tube and medication administration. Another important role for the team is to identify community resources that will allow the child to eventually transition home but continue to receive the services that they require, including how to successfully transition back to school.
“The family meetings helped us understand Janae’s progression throughout her treatment,” said Gerlyn. “We were able to ask plenty of questions, and they kept us informed on a regular basis.”
The Neurotrauma Rehabilitation Program sets individual goals for each child depending on the type and extent of their injury, age and prior developmental status and family expectations. As opposed to an adult rehabilitation unit where maximum independence is the goal, a pediatric unit must consider a child’s previous level of functioning.
Short- and long-term goals were set for Janae by the rehabilitation team shortly after her arrival to the Inpatient Rehabilitation Unit. She stayed on the Unit for almost seven weeks, making progress toward all goals each week. “Given her new hemiparesis, it was expected that she would become independent again with walking, dressing, toileting and feeding,” said Dr. Apkon when addressing Janae’s short-term goals. “At the time of discharge, she met her short-term goals and was walking and independently performing ADLs typical for her age.” For Janae and her family, the long-term goal was to return to the softball field and once again participate at the level at which she had been playing. She was using a cane at discharge and required the use of an ankle foot orthosis on her left leg. Janae’s speech improved and she was able to communicate her wants and needs as well as joke with her rehabilitation team.
During Janae’s final discharge family meeting, plans were established for her to continue receiving physical, occupational and speech therapy with Joyce Oleszek, MD, pediatric physiatrist at Children’s Therapy Center in Pueblo . This regional clinic allowed Janae to receive follow-up rehabilitation care in her community without traveling to Denver on a regular basis. A few times a year, she also visited The Children’s Hospital downtown campus in Denver for follow-up appointments with Dr. Apkon. Ongoing medical follow-up also included regular visits to Janae’s PCP to follow her progression and a community ophthalmologist to ensure she wasn’t developing cataracts, a potential shortand long-term complication from a lightning strike.
One year later, Janae is a delightful teenager, entering her first year of high school. She continues to be successful in her constant progression and remains independent. She receives some outpatient therapy in Pueblo to work on increasing the use of her left hand and arm. She recently returned to Denver for Dr. Apkon to inject Botulinum toxin, a powerful muscle relaxant, into her arm to decrease the spasticity which has become problematic over the last few months. Janae still keeps in touch with her entire team of doctors, nurses and therapists, and she praises each of them for sticking with her throughout her rehabilitation and helping her get back to playing softball.
“My team at The Children’s Hospital was amazing and made my experience fun even though they made me work really hard,” said Janae. “They helped me through a lot, and without them, I wouldn’t be where I am today.”
Although Janae hasn’t returned to playing at the competitive level of softball yet, she is once again practicing with her team. She plans get back out in the field and try out for her high school team next year.
