Head Injuries: Jason Joyner

There was that time when the editor saved the medical professional.

As a physician assistant, I enjoy having medical aspects in my story. But even medical folks can slip up and have errors in our fiction.

I have a scene where my heroine gets head trauma and wakes up later in the clutches of the villain. The freelance editor, Ben Wolf, wondered about that. He had read that if there was significant time of loss of consciousness (LOC), then it suggested a serious injury that would be hard for the victim to bounce right back from to be active.

One of my pet peeves is when characters are injured and recover too fast, so I had to look into this again.

Basically, my heroine suffered a concussion, also known as a Traumatic Brain Injury (TBI). Symptoms of a concussion can include headache, confusion, dizziness, visual changes, a blunted affect, and may or may not include LOC. (People always flash lights in pupils to check for concussion. If the pupils are affected, it is a serious sign and they won't be up and active soon.)

LOC usually is only for a few minutes, and as my editor noted, will mean a much more severe injury if it lasts for hours.

Blast. Foiled by the editor.

Except, you can use the amnesia angle.

A concussion with LOC may have retrograde (before the incident) or antegrade (after the incident) amnesia. According to one research article, the antegrade amnesia can last for a few hours after the incident. I can attest – I had a concussion in 5th grade and couldn’t remember a couple hours afterwards.

So if you need your protagonist to be out of it for a while, keep the actual LOC on the short side and use the amnesia angle to get you where you need to be. The victim may be incoherent, unsteady, with a blank expression during this time. Use these symptoms to add drama to the situation.

When your protagonist comes to, it is actually the end of antegrade amnesia. I remember with my concussion it was like I "woke up" after lunch during our quiet reading time at school. I was confused, unsure of what happened. I could remember part of the morning, but about two hours was blank. I even found a goose egg on my head later, but I didn't know how it got there.

So that was my work around. My heroine didn't have LOC the whole time. But there was enough injury to cause confusion and amnesia, keeping her from attempting escape. There you go Ben. A few minor tweaks, and all is well. Except for my heroine, who's tied up and threatened. But that's another story.

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Jason loves good stories and wants to use words to make a difference. When he's not writing, playing soccer, or losing in fantasy football, he works as a physician assistant in southeast Idaho. He also tries to keep up with his awesome wife, three high-energy boys, and his little princess. He writes suspense and YA supernatural, and likes to use his medical experience to punch up the stories. You can find him on Twitter @JasonCJoyner or his blog at www.jasoncjoyner.com/blog.

Author Question: Brain Bleeding 1/2

I'll be handling Christy's question in two parts. Part one today.

Christy Asks:

A bullet grazes my hero's brain. He's taken to the hospital where he has an intracranial hematoma.Would he be in a medically induced coma after this? If so, for how long? When do doctors decide to take someone out of a medically induced coma? What would a victim be like after the fact? Sedated? When would they know the extent of the injuries?

Jordyn Says:

It depends. Let’s start from the top.

A bullet grazing someone’s brain. Okay—well in order for it to even hit the brain it has to come through the skull. So, it’s not going to be a minor injury considering that. Not like a bullet grazing your arm.

An intracranial hematoma means you have bleeding on the brain but you haven’t really specified the area. For instance, epidural hematomas occur between the dura (which is a tough membranous covering) and the skull. These are almost always taken to surgery.

In a subdural hematoma the bleeding occurs between the dura and the arachnoid layer. These are not always evacuated by surgery. It depends on their size. Intracranial bleeding can mean a lot of things—that the bleeding is just within skull (which includes the two things I’ve mentioned) or in the brain tissue itself. Bleeding within the brain tissue itself is much harder to deal with.

Would he be in a medically induced coma? It depends. The decision to put someone in a medically induced coma is more based on whether or not the doctors think the brain will swell as a result of the injury and not necessarily because there was a bleed. For instance—epidural hematomas are generally taken to surgery and evacuated without the patient needing to be put into a coma.

If they think they see a significant amount of swelling of the brain tissue then a medically induced coma is more likely. A patient is generally placed into a coma through the period of peak swelling which is generally 48-72 hours post injury. The patient gets a special monitor (a bolt) that monitors their brain pressure (or ICP—intracranial pressure). 

After that peak period of swelling comes and goes a decision will be made to wean the patient off their sedation. The pressure may stay high. If the pressure stays high the patient may proceed to brain death (caused by herniation or hypoxia related to the pressure), or significant brain injury, or recover. It may not be known for several months what the outcome is though generally if a patient is going to suffer brain death they will do it in that 48-72 hr window. Past that, if they live but the pressures have been high—more a vegetative state or significant neurological impairment. If pressures have stayed lower—the patient may recover okay.

I have seen miracles, though, too so this is not cut and dried.

As far as knowing the extent of injures—they’ll know that pretty quickly based on CT imaging. However, what won’t be known is the affect on the patient. People can have the same exact brain injury—some die—some fully recover so there is a lot of writing leeway here. It may not be known for years how the patient will recover or what their lives post-injury will look like. 

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Christy Barritt is an author, freelance writer and speaker who lives in Virginia. She's married to her

Prince Charming, a man who thinks she's hilarious--but only when she's not trying to be. Christy's a self-proclaimed klutz, an avid music lover who's known for spontaneously bursting into song, and a road trip aficionado. She's only won one contest in her life--and her prize was kissing a pig (okay, okay... actually she did win the Daphne du Maurier Award for Excellence in Suspense and Mystery for her book Suspicious Minds also).

Her current claim to fame is showing off her mother, who looks just like former First Lady Barbara Bush. When she's not working or spending time with her family, she enjoys singing, playing the guitar, and exploring small, unsuspecting towns where people have no idea how accident prone she is. For more information, visit her website at: www.christybarritt.com.

Author Question: Speech Therapy after Traumatic Brain Injury

Karen Asks:

I’m writing a story about a man who is shot in the head in a way that impacts his ability to speak.  Long months of rehab restore his speech but leave him with a stutter.  Is this feasible?  Which part of the head would he need to be shot in?  What else could be impacted by such a wound?  Can you recommend any websites or resources about gunshot wounds or speech therapy?

Jordyn Says:

Karen-- thanks so much for sending me your question.

Generally, the left side of the head is considered to contain the speech centers of the brain--in most cases. It might depend on whether or not your character is right or left handed.

97% of right handed people have their speech centers on the left hemisphere.

19% of left handed people have their speech centers on the right hemisphere-- which may be where the phrase "left-handed people are the only ones in their right mind" come from. I LOVE this phrase speaking as a left-handed person.

68% of people have language abilities in BOTH hemisphere.

To read more on these areas-- check out this link: http://webspace.ship.edu/cgboer/speechbrain.html

A good case to look into would be former Arizona Congresswoman Gabrielle Gifford's. She received a serious gunshot wound to the head and had extensive rehab-- over many many months. It might give you an idea of how long the road to recover is for some of these victims. It can be years.

http://www1.uabhealth.org/BoneandJoint/victims-gunshot-head-daunting-road-ahead

http://www.aans.org/en/Patient%20Information/Conditions%20and%20Treatments/Gunshot%20Wound%20Head%20Trauma.aspx

http://www.everydayhealth.com/blog/dr-black-brain-health/the-outlook-for-recovery-from-a-gunshot-wound-to-the-brain/

I think you have a lot of leeway as an author to decide what you want to do after brain injury because we don't understand as much about the brain as we do other organs. It might be hard to pinpoint sources of "speech therapy after gunshot wound to the head" (which is how I first started to Google your inquiry) but a gunshot wound would be considered a traumatic brain injury so I started to Google that and came up with several other resources as well. Here's a great You Tube Video that demonstrated a speech therapy session that could be great for a fiction novel.

What else could be impacted? Anything really. Again-- you have a lot of leeway here. There could be motor issues as well. Difficulty walking. Difficulty with fine motor skills. To the other extreme which would be coma.

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After creating Christian education curriculum for 25 years and writing over 250 published articles, Karen Wingate has turned her attention toward historical and contemporary fiction.  She lives with her husband and Welsh Corgi in Western Illinois.

Author Question: Death by Trophy

Susan Asks:

I have a woman murdered when she is hit on the back of the head with a metal trophy. The trophy is cup shaped so the largest part of it is a thinner metal. I expect the trophy will dent from the impact, but I'd also expect that there would be blood as a result of the injury. Would this kind of injury cause bleeding and if so can you give me a general idea of how much?

Jordyn Says:

It depends. Blows to the head can go either way. They can just cause internal bleeding (intracranial hemorrhage) and/or an external scalp laceration that would bleed A LOT depending on it's size and depth. Scalp wounds are known for being pretty bloody.

These injuries can be nice for your character as you have some leeway medically to do them in as you please. 

Strangulation: Care of the Victim 3/3

I'm concluding my series on strangulation today. You can find Part I and Part II by clicking the links.

Victims of strangulation/hanging require emergent evaluation due to the structures in the neck that could have obtained injury (trachia, hyoid bone, vocal cords, blood vessels, and brain from lack of blood flow).

image by thetombstonesnake courtesy of Flickr via baratunde.com

If the victim was hanged, it is important to know the height from which they dropped. If if was equal to or greater than their height, there is a high probability of C-spine injury. Therefore, these patients need to be placed in a C-collar until such injury is ruled out.

Remember, there may few external signs of injury. This doesn't rule out significant damage. However, there may be signs of bruising around the neck and petechia above the point of the ligature. There may also be bleeding in the eye, changes to the voice. Symptoms may range from general soreness to difficulty breathing.

Other signs and symptoms include:

1. Difficulty swallowing.
2. Mental Status Changes: may indicate a period where the brain has gone without oxygen.
3. Miscarriage
4. Swelling of the neck
5. Lung Injury: if the patient vomited during strangulation.
6. Chin Abrasions: from the victim trying to protect their neck.
7. Defensive wounds to the neck from the victim tryng to break free.

How do we care for this patient? History of the event will be paramount in helping the physician determine what tests to run. Hopefully the patient will be able to supply pertinant information.

1. Baseline vital signs including continuous monitoring of the patient's oxygen level.

2. Assessment of neurological (did the patient lose consciousness, are they neurologically intact?), respiratory (are they having difficulty breathing) and cardiovascular systems.

3. If the patient was hanged-- they will need X-rays of the spine to rule out fracture as well as soft tissue films of that area. If they were strangled, soft tissue films of the neck are still warranted.

4. Direct Laryngoscopy: Visualizing the vocal cords to look for damage.

5. CT of the brain: if the patient was unconcious at any point.

6. CT/MRI scan of the neck: to look for soft tissue/vascular injury.

7. Chest x-ray: aid in diagnosis of aspiration.

8. Carotid Doppler: Looking at the neck vessels with ultrasound to look for injury and clots as a result of the attack.

This patient, depending on their severity of injury, could be observed in the emergency department for several hours and sent home or intubated out of concern for further airway compromise and admitted into the ICU. There is a lot of lattitude for the writer here.

Resources:

General Overview: http://emedicine.medscape.com/article/826704-overview

Wisconsin Medical Journal: Strangulation Injuries http://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/102/3/41.pdf

Emergency Medicine Reports: Strangulation Injuries. http://www.ahcmedia.com/public/samples/emr.pdf:

How to Improve Your Investigation and Prosecution of Strangulation Cases. http://www.ncdsv.org/images/strangulation_article.pdf:

Strangulation: Facts 2/3

I'm continuing my series on strangulation injuries. Here is Part I.

I once worked with a physician who was having a baby. Her father handmade her a crib. Sadly, his grandchild was strangled in that crib.

Vintage crib where slats are too wide.

I often think about that family-- how he must feel to have constructed the tool of this infant's demise. How was the relationship of that woman with her father after that? Definitely enough conflict in just that scenario to carry a novel.

While researching this series of posts on strangulation for a reader, I came upon a lot of interesting facts I didn't know myself. This is one reason why I'm such a research hound-- I love learning these things to add extra detail for the reader.



There are four types of strangulation:

1. Hanging
2. Manual: The use of bare hands.
3. Chokehold: Elbow bend compression
4. Ligature

Strangulation injury is not as uncommon as I thought-- it accounts for 10% of all violent deaths in the US. Perhaps because the hands are such a ready weapon-- the criminal doesn't have to think about bringing them to the crime scene.

Infants are likely to be strangled by falling between something (like slats in a crib that are too wide), or entangling themselves in something (like cords that dangle down from blinds).

Teens and pre-teens can suffer strangulation injury by playing the "choking" game or engaging in autoerotic hanging. These are not so uncommon activities in the pediatric population and we should discuss their danger with our children.

Women are increasingly using hanging as a means of suicide whereas in the past it was more common among men.

Prisoners will often kill themselves by hanging as it is the means of suicide that is most available to them.

When treating the victim of a hanging-- it is important to know the height they dropped from. A height equal to or greater than their height brings forth large concerns for C-spine injury. When a prisoner is hanged, they essentially die from decapitation. The C-spine is fractured between C1-C2 and thus severs the spinal cord(also called a Hangman's Fracture) so the head will free float. If done right, death is instantaneous.

When a person is strangled, there may be no signs of injury to the neck or very minimal signs. There may be only a single bruise present which is caused by the imprint of the thumb.

Resources:

General Overview: http://emedicine.medscape.com/article/826704-overview

Wisconsin Medical Journal: Strangulation Injuries http://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/102/3/41.pdf

Emergency Medicine Reports: Strangulation Injuries. http://www.ahcmedia.com/public/samples/emr.pdf:

How to Improve Your Investigation and Prosecution of Strangulation Cases. http://www.ncdsv.org/images/strangulation_article.pdf:

Strangulation: What Really Kills the Victim 1/3

I got a message from a new blog reader with this comment:

Finding this blog is so timely for me, as my protagonist witnesses a strangulation in the first scene of my WIP, and I haven't been able to find out the precise observable symptoms.  I wanted to ask if you'd done a posting on strangulation.  I've looked back a bit in the blog archives, but haven't seen that topic yet.

Well, let's just fix that for Colleen.

I'm sure many of you, particularly if you're an avid crime show TV watcher, have seen the scene with the medical examiner and the victim splayed open on the table talking about damage to the "hyoid" bone. Though this is true, damage to this bone or the trachea itself is not what ultimately kills a victim who is strangled to death, though it can complicate their care if they live.

For instance, there have been instances of individuals with tracheotomies hanging themselves and the ligatures were above the level of the trach-- which means the person would still be able to breathe.

So the following theories are proposed as explanations for the cause of death related to strangling.

Venous obstruction, leading to cerebral stagnation, hypoxia, and unconsciousness, which, in turn, produces loss of muscle tone and final arterial and airway obstruction.

Arterial spasm due to carotid pressure, leading to low cerebral blood flow and collapse.

Vagal collapse, caused by pressure to the carotid sinuses and increased parasympathetic tone.

Which is a lot of scientific language to say "death ultimately occurs from cerebral hypoxia and ischemic neuronal death".

Which means-- when a person is strangled, they die because their brain is no longer getting blood flow from the carotid arteries, which leads to brain cells dying from lack of oxygen.
As you can see from this photo, the major blood vessels that drain blood from the brain but also, more importantly, feed it with oxygen-- are in very close proximety to the trachea or windpipe.

It is the vital oxygen these vessels carry to the brain that upon slowing or stopping-- is the biggest problem for the victim.

Next post we'll discuss some strangulation facts. Third part of this series will include treatment of the strangulation victim.

Source:  http://emedicine.medscape.com/article/826704-overview

Other Resources:

Wisconsin Medical Journal: Strangulation Injuries http://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/102/3/41.pdf

Emergency Medicine Reports: Strangulation Injuries. http://www.ahcmedia.com/public/samples/emr.pdf:

How to Improve Your Investigation and Prosecution of Strangulation Cases. http://www.ncdsv.org/images/strangulation_article.pdf:

Why McDreamy is the Worst Neurosurgeon Ever

First and foremost, let me say that I am a Grey's Anatomy fan-- not for the medical accuracy for sure-- but it is a guilty pleasure of mine. So, considering the known medical inaccuracies I've seen, I don't have to be a neurosurgeon to guess that they are likely a little loose with the surgical details.

But this one I could not ignore.

Neurosurgeons place VP (ventriculostomy-peritoneal) shunts. What is that?

A VP shunt is a tube that is placed in a person's brain, specifically the ventricle, to drain off excess cerebrospinal fluid (CSF). Placing a VP shunt is primary treatment for a condition called hydrocephalus where there is excess accumulation of CSF in the brain. Too much CSF will lead to increased intracranail pressure-- which can be deadly.

A VP shunt helps keep the brain at an even pressure by draining extra fluid into the perotoneal cavity (or your gut.)

Here is a primer on traumatic brain injury. This post covers some important principles of managing traumatic brain injury. For quick review, the skull contains three components: your brain, blood, and CSF.

Back to Grey's.

Derek (aka McDreamy) and his surgeon wife adopt a baby named Zoila. One of the principle reasons for the adoption was that the child (approx 2 y/o) had a VP shunt and Dr. McDreamy would be an expert at managing her condition.

Really?

So, when the child begins to have vomiting and fever-- he makes the statement, "Well, she just has the flu."

The first thought in a neurosurgeon's mind, until ruled otherwise, is that something is wrong with the shunt in her head!

This concept is drilled into emergency medical personnel-- particularly pediatrics, that if a person with a VP shunt presents with headache, vomiting, and fever-- it is an emergency. First assumption is something is wrong with the shunt and if not treated, the person could have elevated intracranial pressure (which is bad) and die (which is super bad!)

Classic symptoms for increased pressure in the brain is headache and vomiting. These could mean that the shunt is obstructed and no longer draining CSF. Fever could indicate the shunt is infected-- which essentially means the patient has a brain infection (meningitis)-- another really bad thing.

So for super surgeon, McDreamy, to blow this off as a viral illness is a big no-no. Off to the ER little Zoila should have gone.

Determining Brain Death: 3/3

Last post, we talked about the use of apnea testing to determine brain death after the patient meets certain criteria.

There is one additional test that may be done to determine brain death and that is a brain perfusion scan.

This procedure is done in radiology which can make it very difficult. Imagine taking a ventilated patient through the halls of the hospital along with several IV pumps giving medication that are keeping the patient alive. That in itself is not a fun excursion.

Once the patient is in radiology, they are given an injection of a radioisotope—something that will trace where the blood is flowing. After the injection, photos are taken of the patient’s brain. If there is no blood flow to the brain, and this must include the brain stem as well, then the patient is said to have “brain death” and is clinically dead at that point.

This You Tube video provides a very good explanation of these concepts.

After brain death is determined, the patient is not immediately withdrawn from life support but a conversation will ensue with the family that the patient has died and they will be encouraged to discontinue life support.

Generally, families are given a lot of time to come to terms with this decision. Anywhere from 1-3 days is reasonable. They may want to fly in additional family members to be present when life support is discontinued. I’ve never been part of a situation where, when the finding of brain death were fully explained, where families chose not to discontinue support.

This is not to say that the patient may not proceed to circulatory death despite receiving life support. Once the brain has died, it does become very difficult to keep the body functioning.

Does this change your mind about how brain death is determined?

Determining Brain Death: 2/3

I’m continuing with a series on how brain death is determined. All hospitals likely have a policy in place with strict guidelines on how brain death is determined. Check last post for the beginning stages.

Now, we’ll move onto actual testing.

Can the patient breathe on their own? This is a relatively simple test. It’s called apnea testing. The ventilator is turned off and we see what the patient will do. Naturally, when we stop breathing, carbon dioxide will build up in the blood stream. Your body has receptors that monitor the level of CO2 and it will initiate a breath when the levels rise.

Here is the procedure for performing an apnea test.

1. The patient will be on an ECG and pulse ox monitor.

2. Give the patient 100% oxygen for five minutes.

3. After five minutes, disconnect the patient from the vent, but give oxygen via T-piece. The breathing tube will still be in place. At this point, the patient is off the vent and no longer being assisted but will have needed oxygen if they do initiate a breath.

4. Watch the patient for breathing. If any attempt is made to breathe, it is inconsistent with brain death and the test is stopped and the patient is placed back on the ventilator.

5. If the patient has any cardiac arrhythmias, low blood pressure or oxygen level that falls to less than 80% (normal level is 90-100%) then the test is discontinued. These finding will lead more to a conclusion that brain death has occurred.

6. If the carbon dioxide level increases above 60 (normal level is 35-45)—the apnea test is consistent with brain death. The brain is very sensitive to rising levels of carbon dioxide and the absence of a response is consistent with brain death.

Next post, we’ll talk about brain perfusion studies.

Determining Brain Death: 1/3

Several months ago, I skewered a Hallmark movie for its unrealistic portrayal of discontinuing life support. In light of that, I thought I'd do a special series on determining brain death.


How do medical personnel determine a patient has suffered brain death?

Brain death means that your brain as an organ has died. It is no longer receiving blood flow. Without blood flow, no oxygen is being delivered. Without oxygen, an organ dies. Your brain is your body's main control. If it has died, you have died.

If you have a character that is brain dead, they should be on life support. Again, if the brain isn't working, it's not telling your lungs to inhale. However, we can do this medically with a ventilator. This is why families sometimes have trouble understanding brain death means ultimate death. If we provide oxygen to the lungs, the heart will continue to beat and bodily functions can be maintained for a limited amount of time. A family sees the rise and fall of the patient's chest and assume the patient is initiating those breaths when in fact it is the machine doing all the work.

There are several ways to determine brain death. Some are not as precise as others. I'll try to cover least precise to most precise.

Before testing, there is generally an observation period. My hospital uses the following guidelines:

Less than 7 days: Not applicable
Age 7 days-2 months: 2 exams 48 hours apart
Age 2-12 months: 2 exams 24 hours apart
Over 12 months: 2 exams 12 hours apart
Adults (18 years and older): 2 exams 6-12 hours apart.

Also, prior to the exam to determine brain death, the patient must also meet the following criteria:

1. Absence of a reversible condition. The cause of the coma must be documented.

2. Absence of hypothermia. The patient must have normal body temperature.

3. Absence of hypotension. The patient must have normal blood pressure.

4. Absence of drugs or toxins in significant amounts as to interfere with the diagnosis of brain death.

5. Absence of a metabolic cause of the coma.

6. Normal levels of carbon dioxide.

Once these are met, the patient should be observed for the following:

1. No cranial nerve reflexes. Here is an extensive list of what those are: http://www.clinicalexam.com/pda/n_cranial_nerves_exam.htm

2. Flaccid tone in all extremities.

3. No response to deep pain.

Once these are met, the patient proceeds to apnea testing. That’s where we’ll pick up next post.

Every Day’s a Good Day when You’re Not in a Coma!

James Pence concludes the miraculous story of Nate Lytle. Hope you'll check out his novel, More God.

Welcome back, James!

Part 2

The doctors called Nate Lytle’s injury “non-survivable”.

Nate Lytle, a 24-year-old surfer from Victoria, Texas sustained a severe head injury in a fall from a ten-foot ladder. When the doctors did a CAT scan, they discovered the extent of his injuries:

·        He had a softball-sized hole in the left side of his skull.

·        The impact of falling off a ten-foot ladder drove skull fragments deep into his brain.

·        In emergency surgery, the neurosurgeon removed three massive hematomas. When he removed the third, the left side of Nate’s brain collapsed.

·        The CAT scan showed early herniation of the brain stem, a potentially life-threatening complication.

·        The scan also showed a midline shift (the impact caused the brain to shift off-center). The ER physician said that a shift of one or two millimeters was considered “grave.” Nate’s brain shifted 1.7 centimeters off center.

The doctors did not hold out much hope for Nate’s survival. If he did manage to survive, they gave even less hope for his potential quality of life. The areas of Nate's brain that had been damaged were the parts that control movement, speech and communication. The neurosurgeon said even if Nate were to survive, he would never walk or talk or even communicate again.

Surrounded by family and friends from their church, the only thing Billy and Tammy knew to do was pray. And pray they did.

Tammy knew that Nate could cope with living in a wheelchair, but it would absolutely kill him if he couldn't communicate. Nate was a strong Christian with a passion for sharing his faith, and she knew that he would rather die than be unable to communicate. So she asked her pastor to pray that Nate would recover, and if he couldn’t recover, that God would take him home.

Nate survived the first night.

Then another.

And another.

The ICU team had its hands full, trying to manage Nate's fever. And there were some scares when it appeared that he had a blood infection. But day by day, Nate slowly stabilized. He was in a full coma for two weeks and semi-comatose for four weeks after that.

When it appeared that Nate was going to survive, the neurosurgeon suggested that Tammy and Billy tried to get him into rehab. He still didn't expect Nate to ever be able to communicate, but suggested that rehab might at least help him have some quality of life.

When Tammy asked the neurosurgeon what would be the best facility for Nate to do rehab, he told her TIRR Memorial Hermann in Houston, Texas (The same place where Gabrielle Giffords would do her rehab a few years later). But because Nate had no health insurance and lived out of county, it was very unlikely that he would be able to go there.

Tammy, Billy and the Church began to pray again and within a few short weeks. Nate was admitted to TIRR Memorial Hermann.

Two weeks after he arrived at TIRR Nate woke up from his coma. He was able to walk and, although he stuttered badly, he could talk.

Nate's road to recovery was long and challenging. After he was discharged from TIRR, he went on to do three months of inpatient rehab at TLC (Transitional Learning Center) in Galveston, Texas. Then more outpatient rehab and speech therapy once he was back home in Victoria.

Although his recovery was nearly total, Nate still bears some after-effects of his TBI. He has problems with short-term memory. At times—particularly when he’s tired—he struggles with aphasia and apraxia (speech disabilities where he knows what he wants to say but has difficulty finding the words and saying them), and he has to stay on seizure medicine.

Amazingly, though, Nate has no physical disabilities other than his shattered his left wrist. (Because of the severity of his head injury, the doctors weren’t able to repair his wrist right away and it healed incorrectly.) But despite massive trauma to the left side of his brain, Nate has no paralysis whatever on the right side of his body. In fact, one year to the day after his injury, Nate began surfing again. It was challenging at first, mostly because of the restricted movement in his left wrist, but before long he was surfing as if nothing had ever happened.

Nate now conducts surf camps for blind, disabled, and autistic children and adults. He also speaks to TBI survivors and their families. His amazing story is told in full in the book I co-wrote with him: More God: Seeing the Blessings through the Pain.

Nate’s infectious, optimistic personality is often reflected in his unique quotes, called “Nateisms” by his friends. My favorite, which inspired the title for this post, is: “Every day’s a good day when you’re not in a coma.”

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James H. (Jim) Pence is a man of many talents. He’s a performance chalk artist, singer, speaker, published author, editor, collaborator, and in his spare time he teaches karate to homeschoolers. Jim has been called a “Renaissance man,” but he prefers to be known simply as a follower of Jesus Christ and a storyteller. Jim has been published in both fiction and nonfiction. Recently, Thomas Nelson published "The Encounter," a novella that Jim wrote in collaboration with bestselling author Stephen Arterburn. Jim's newest book, More God: Seeing the Blessings through the Pain, is available in hardcover, softcover, and e-book format.

Links:

James’ Web site: http://www.jamespence.com/

YouTube Video about Nate Lytle: http://www.youtube.com/watch?v=l_oyX4rA07s

Nate’s Web Site: http://www.natelytle.com/

Photos courtesy of Alan Lindholm, G. Scott Imaging, and Danny Vivian