While Joanne waited upstairs during Chris' and Jenny's appointment with the psychologist, Roy once again found himself trying and failing to read his book. Instead, all he seemed to accomplish was staring at his best friend, hoping and praying.
I don't even know what more I should be expecting for though at this point considering how much he's been improving today, Roy reflected. Dr. Early already pointed out how much his blood pressure has come down. It just seems to be greedy to want or even request for even more improvement when you think of how the intracranial pressure in Johnny's brain has come down to almost normal levels. I still can't believe how well he's doing or the fact that if the ICP stays as it has been, the doctors will further reduce the dexmedetomidine steroid he's on. They weren't even expecting to do that until tomorrow, yet they were felt they could reduce it a bit. I know a .25 mg/kg per hour reduction isn't much, but I'll take whatever I can get.
Excited by that fact and still deep inside his own thoughts, Roy never noticed Johnny's slightly abnormal movements.
I can't wait until Joanne and the kids get here! It'll be a relief to be able to tell them that if things keep going how they have been, Johnny will be able to get off the diazepam sometime tomorrow after they cut down on the dexmedetomidine to a solid .02 mg/kg per hour for a couple days and then cut it in half again for another couple of days. But I really shouldn't get ahead of myself, Roy thought angrily thought to himself. Just because the medications are finally kicking in and working as they should doesn't mean that things will work out as we all hope.
Again, distracted by his random thoughts that seemed to go from excited and positive before crashing abruptly, Roy never noticed the twitches that were beginning to spread throughout Johnny's body. As deeply asleep as the diazepam caused him to be, even the pain that he may normally have felt from these bone deep muscle contracts went on noticed by him. Before Roy could glance back at his partner, his wife and kids knocked softly on the door. Squeezing Johnny's hand briefly, Roy got up and walked out to the door to tell the rest of his family what was taking place.
As soon as they heard the encouraging news, excited squeals came from Jennifer, while Chris let out a loud "Yes!" Joanne just smiled as she had to try hard to contain her own shouts of happiness. The nurses in the ICU just smiled at their reaction, understanding as they too had been glad when the news had been passed around that Johnny was finally starting to rally.
Quickly quieting his family down, Roy began leading his family in, but stopped abruptly at the sight of the slow, seizure like movements coming from Johnny. Unaware why her husband had stopped so quickly, Joanne tried to go around him, but when that failed, chose instead to peer around his side.
Gasping quietly, she hastily spun the kids around and led them out of the doorway.
"Nurse, Johnny needs you now! And Dr. Early needs to be paged quickly!" Joanne informed the nurse who was rushing towards them, alarmed at the atypical behavior being exhibited by the Desoto's.
Nodding, Nurse Mitchell, John's nurse for the day shift, headed back to the desk to page Dr. Early. As the page went over the hospital's speakers, she briskly walked to Johnny's room to see what was taking place.
And to think, he was doing so well these last few hours! she lamented.
Noticing immediately what Roy had spotted, she moved in to take vital signs.
"I already got them," Roy informed her. "Blood pressure is 163/105, pulse is 102, respirations are 24. Temperature is…"
Pulling out the thermometer, he read it off, "100.6 degrees."
"Thanks, Roy," Nurse Mitchell said gratefully.
"No problem Cathy. I'm not sure what's going on. I came back in here and well, at first, I thought he might be having a seizure since his whole body was twitching, but now, I'm not sure. It's calmed down, but…" puzzled, Roy trailed off.
Stepping in, Dr. Early heard what Roy had said. Glancing at the two of them, he reached for the metal clipboard with Johnny's medical information that Sasha Mitchell still held as she had just finished recording the vital signs. Glancing over at the EKG monitor by the bed, the doctor saw that although the heart rate was still a bit fast, it was only when the muscle spasms seemed to be at their worst that John's heart rate increased. To him, that would indicate a sign of pain more than anything.
Moving over to check the surgical incisions on Johnny's scalp, Doctor Early saw that the bandages were clear of any blood or seepage.
"Could you get me some gauze and tape please nurse?" he asked, begin to gently unroll the head wrap.
"Right away," Sasha said.
Helping Dr. Early lift Johnny's head, Roy winced at the ugly marks covering his best friend's head. Knowing that someone he cared about had gone through a dangerous surgery was one thing, but to see the ugly, red, harsh marks still zig-zagging across the hastily shaved scalp was another.
"You okay Roy?" Doctor Early asked, noticing Roy's slightly paler expression.
"Yea, doc. It's just, well…"
Smiling gently, he nodded that he understood and went back to examining the surgical incisions for signs of infection. Finding none, he wrapped up his patient's head again, sighing slightly.
It's amazing how much trauma one body can survive and how often we as doctors are challenged, he thought. I just wish that it hadn't been you my friend pushing the level of our skills as doctors and our level of knowledge. As often as I've had to treat you, it's never gotten easier and this time, it's so much worse knowing that there is so little that I can do for you or do for those who care about you. I wish I had more answers, but I just don't and for that, I am so sorry.
Pushing aside what he believed his own selfishness, Doctor Early continued with his exam of Johnny with the help of Nurse Mitchell and Roy. He took his time examining each of the small cuts and abrasions, than applying more of the antibacterial cream to them. As he unwrapped the second degree burn near John's tailbone, he sighed internally, fearing that this might be infected. Thankfully, he was proven wrong and so he quickly reapply the antibacterial cream before helping the nurse place gauze back over the sight. Dr. Early than did the same after peeling off each gauze that covered cuts that had required stitches on his back, arms, or legs…in total, there were about 15 sites. Through the entire time, the muscles never let up twitch and at times, it seemed as though Johnny was seizing. However, Dr. Early was beginning to suspect based on his observation of his friend and patient just what was occurring.
After listening to Johnny's lungs and checking his reflexes, Dr. Early looked over the last vital signs, x-ray results, and the EKG monitor.
"So, what is going on, doc?" Roy asked impatiently, as it had been around thirty minutes since the doctor had arrived and begun his seemingly endless exam.
Motioning Roy outside as he didn't want Johnny to overhear any bad news, just in case it was possible even in his drugged state, Doctor Early led him to the ICU lounge where Joanne and his two kids were waiting anxiously. Sitting down next to them, Roy grabbed a hold of Chris and Joanne's hand, while Joanne grabbed a hold to Jenny's.
"First, Joanne, did you explain to Chris and Jennifer what was going on?" the doctor asked. Seeing her nod, he sat down in front of them and began to explain what he believed was taking place.
"Considering all his vital signs are about where they were a few hours ago when we felt the pressure on his brain had gone down enough to reduce the steroid medication a bit, I believe we are seeing a side effect of the swelling that began after his surgery. I believe he is experiencing what is called myoclonus, which is a possible complication after a brain injury. Basically, what happens is that the muscles of the body twitch without warning and it is involuntary. If they twitches, or spasms, are severe, it can be painful, but thankfully, there are ways of treating this," Doctor Early assured them. "There are medications that can be used to help control this condition if it continues. However, at this point in time, I'd rather not use them since I don't know if this condition will improve as Johnny improves. It may be even possible that it goes away completely after a while, I just don't know. It's unfortunately another wait and see deal."
The DeSoto family looked at one another, their emotions showing clearly in their eyes. All of them hated the fact that yet another hurdle was presented that Johnny would have to face and once again, no answers about how long it would be before it would get better, or even if it would get better, was available to them.
"So, how do we deal with this right now," Joanne asked, speaking up for everyone.
"As of tomorrow, if his ICP, or intracranial pressure continues decreasing, it would be at a level considered normal. If that is the case, we'll reduce the steroid in half to see if the ICP continues to stay within the normal range. If it does for 24 hours, then we'll begin waking Johnny up. That would mean that the day after tomorrow, he should start waking up and well, honestly, we would have to take things one day at a time," Dr. Early told them. "I do know that if his ICP holds within the normal range for 24 hours, after two days, we'll again cut the medication in half. If things stay the same or improve, the medication will likely be discontinued after another two days.
"The goals we as his doctors have is getting Johnny used to the four of you after he is awake and knows where he is enough that he realizes he is in a hospital and had an accident. We also want him to talk things over with Dr. Druthers in hopes that Johnny will be able to express any fears, worries or concerns he has to someone. We also want to have family meetings with the five of you to make sure we find the right place for Johnny," Dr. Early held up a hand to stop any protests he knew would come at that. "I know all of you want him home with you, but until we know how Johnny is going to react to things, no one can say that it is a for sure thing. There are too many possible problems that could come up considering the level of injury Johnny has sustained. I believe you will learn about those tomorrow. Do you guys have any questions?"
Once again looking at each other, each of the DeSoto's slowly shook their heads no.
Standing up with the doctor, Roy shook his hand and said, "I probably should call upstairs and see when the crew is coming to see Druthers."
"Actually, Nurse Mitchell informed me that they have already come and left. I guess that they came a few minutes after Joanne left and well, with everything going on, they left a message in the ICU informing you that they'll let you know what took place tomorrow after the visit to New Horizons."
"Oh," Roy said, eye brows raised in surprise. "I didn't even notice her saying anything."
"It's okay," Early told him. "She actually just passed on a note, so you wouldn't have noticed anything. Besides, you were busy anyway, so don't be so hard on yourselves. Now, why don't you take the rest of your family home, eat and get some sleep. From what I hear, it's going to be a busy day tomorrow."
"Can we at least peek in on Johnny, Doctor Early?" Jenny asked.
"Please?" Chris asked, with a note of pleading in his voice.
Smiling, the doctor relented, "Okay, you four can go in for five minutes, but no more. And remember, you might see Johnny moving around a bit, but right now, its normal. It's okay to be scared by it, but you don't need to worry, alright? He is doing very well today."
Giggling, Jenny told him, "Johnny always moves!"
"True," Dr. Early said as he escorted them to Johnny's section of the ICU wing. "I guess his body just found a new way."
"Yep," Jenny said as she looked in.
Grabbing onto his sister's hand, just in case, Chris and Jenny led the way in, followed by their parents. The two siblings told Johnny that they were glad he was getting better and to continue getting better, before bending down to give him a gentle hug.
Surprised at his sons action, who was 'now too old for hugs' according to him, Roy just smiled before telling Johnny to behave and that they would stop in sometime tomorrow. Joanne leaned in, brushed what little hair remained from off his forehead and gave him a kiss on the cheek.
"Bye, sweetie, if you need anything, just let the nurses know and we'll be here," she told him as she tucked the blankets around him snugly.
Satisfied for the moment that things were as good as they could hope for, the DeSoto clan, headed out the ICU cubicle, past the smiling Dr. Early.
I so hope he has no major problems from this injury. That family is his best chance to recover or if not recover, at least live as normal of a life as possible, Doctor Early thought as he took exited with one last glance at his friend. I'm just so glad you have so many friends who are willing to be your family as long as you need them. You are truly one of a kind, Johnny. I just wish that this had never happened to you.
AN: Myoclonus may develop in response to infection, head or spinal cord injury, stroke, brain tumors, kidney or liver failure, lipid storage disease, chemical or drug poisoning, or other disorders.
Myoclonus describes a symptom and not a diagnosis of a disease. It refers to sudden, involuntary jerking of a muscle or group of muscles. Myoclonic jerks may occur alone or in sequence, in a pattern or without pattern. They may occur infrequently or many times each minute. Myoclonus sometimes occurs in response to an external event or when a person attempts to make a movement. The twitching cannot be controlled by the person experiencing it. In its simplest form, myoclonus consists of a muscle twitch followed by relaxation. When more widespread, myoclonus may involve persistent, shock-like contractions in a group of muscles. In some cases, myoclonus begins in one region of the body and spreads to muscles in other areas. More severe cases of myoclonus can distort movement and severely limit a person's ability to eat, talk, or walk. These types of myoclonus may indicate an underlying disorder in the brain or nerves.
Examples in Healthy Individuals: A hiccup is an example of this type of myoclonus. Other familiar examples of myoclonus are the jerks or "sleep starts" that some people experience while drifting off to sleep. These simple forms of myoclonus occur in normal, healthy persons and cause no difficulties.
-NINDS (Nations Institute of Neurological Disorders and Stroke ( . /disorders/myoclonus/detail_ )