The Sunday Beacon News
By Marie-Anne Hogarth
STAFF WRITER

Last year, as a national debate raged over the fate of Terry Schiavo, the Florida woman who has existed in a vegetative coma for more than 13 years, a Fox Valley family faced a similar dilemma: To save their loved one's life irrespective of condition, or watch him die within a matter of hours or days.

They were lucky to have had the choice.

In the early morning hours of Palm Sunday a year ago, as he slept peacefully next to his wife in the bedroom of the log home he built with his own sweat and determination, Dennis Ryan's brain began to die.

Unbeknownst to him, three days earlier the 55-year-old swim coach from North Central College had torn a major artery in his neck as he strained to start an old piece of machinery.

But as he lay sleeping that Sunday morning, this injury to the carotid artery finally stopped the flow of blood and oxygen to the brain enough to cause a massive stroke. It would destroy almost half of Ryan's brain and leave him heading toward certain death.

But Dennis Ryan caught a break. From his home in Lee County, he was taken to Rush-Copley Medical Center in Aurora, one of a diminishing number of community hospitals in an era of skyrocketing malpractice rates where a neurosurgeon still operates on brains.

And Dr. Ramsis Ghaly believes in aggressive intervention, even when hope is slim.

He suggested a surgery rarely attempted so late in the game for a patient with so massive a stroke. In the tree of arteries and vessels that feeds to the brain, Ryan's stroke amputated a major branch, destroying almost 90 percent of the right hemisphere, compared to 5 percent in an average stroke.

Within 24 hours of the stroke, the brain had started swelling uncontrollably, the natural reaction of billions of cells and nerve fibers dying together. The brain became like an animal unable to escape the cage of Ryan's skull. Inside the cavity, the pressure increased. Cells collided, releasing toxic substances, further angering the swelling brain.

Two days after the stroke, Ghaly wanted to open the skull to give the brain more room.

It was not the most radical solution. A handful of physicians might have removed parts of the dying brain, but that would have hurt chances of eventual healing. Other doctors might have done nothing because the prognosis for intervention was so poor.

After years of under-utilizing this surgery, doctors are turning to it again for patients with massive strokes accompanied by swelling, says Dr. Jeffrey Frank, a stroke specialist with the University of Chicago. And preliminary findings from a study he's directing for the National Institute of Health, indicate the procedure might modestly increase chances of survival.

Still, there is the risk patients can fall into a lifelong coma.

Ghaly believed it was a chance worth taking.

"I have learned over the years that you cannot predict, only do your best," the surgeon told Ryan's family. "And if God has meant for him to go, we can always withdraw support measures later."

During those hours, as Ryan's brain boiled and doctors used drugs to keep him from death, the family debated what course would be best.

His daughter, Amy Ryan, flown in from her home in the Czech Republic, feared the worst. Ryan's sisters, including one who said God cured her cancer, wanted to give their brother every chance. Meanwhile, Ryan's wife, Venna ("Vee") Raye considered something her husband once said: He didn't want to live unless he could walk in the fields with his dogs.

"What do I do if he ends up paralyzed?" she worried. "Is he going to hate me, be mad at me?"

As morning broke on the third day, Vee Ryan made the final decision — opting for surgery.

'Angry brain'

As dozens of relatives, student swimmers and coaches gathered in a waiting room, Ghaly went into battle against his patient's dying brain. Assisting in the operation was Dr. Jaweed Sayeed, a personal friend who Ryan was teaching to swim.

During the five-hour ordeal, they removed almost half of the coach's skull and placed it for preservation into a pouch in the fat of his abdomen. This is the same surgery that would be used six months later to save the life of entertainer Roy Horn after he was mauled by a white tiger in Las Vegas.

Outside, Ryan's supporters talked and prayed.

"It was so weird," recalls Stephanie Fameree, a North Central junior and one of Ryan's athletes. "It felt like we were at a funeral or a memorial service."

In the first hours after the surgery, all seemed in vain as doctors watched the pressure inside Ryan's head climb — a sign the operation had failed. When Ryan's pupils no longer reacted to light, the only reason to keep pushing was because the heart and lungs had not stopped.

Alarmed, the doctors performed a CAT scan and talked briefly with the family. Without taking time to alert the O.R. staff or even scrub in the normal fashion, they pushed the patient back into surgery, fully aware that lost time means lost brain power.

They removed more skull to make room for the swelling brain. But each time they suctioned out blood from the hemorrhaging brain and fed Ryan fresh frozen plasma, more blood ran out.

"I remember Dr. Sayeed came out into the waiting room and he was crying," says Vee Ryan. "He sat on the window ledge and said, 'I held the coach's brain in my hands and it was bleeding so much it wouldn't stop. I don't think he is going to make it.' "

When Ghaly could do no more, he induced a deep coma with barbiturates, cooling fluids and blankets to bring down Ryan's temperature to 33 degrees Celsius, the point at which the body loses consciousness.

Then the doctors called off their efforts.

'Like an infant'

Inside the Copley Intensive Care Unit, a team of nurses and therapists pushed past the limits of the health-care system, into the deep recesses of the human brain and to the edges of the human spirit.

Often it would have been easier to call it quits.

For five days they pushed fresh blood plasma into him. Ryan required sometimes as many as two nurses devoted exclusively to his care. He was hooked up to so many heart monitors, IVs and feeding tubes that it took three people at once to move him.

Managing the coma was a constant juggling act. Too much of one drug could help the brain but hurt the heart; too much of another could help the heart but hurt the brain.

"We were watching him on the ventilator, doing the breathing for him. We were drawing labs every hour, titrating different therapies," recalls Robyn Hansen, an intensive care nurse. "He required more care than an infant."

Vee Ryan stayed at her husband's bedside throughout the long days, ignoring her own body's need for food and sleep.

Ghaly knew how vital her role was. Even in this most dedicated of environments there could never be enough eyes watching over this neediest of patients. For a patient this vulnerable, the slightest mistake could mean disastrous consequences.

Over and over, Vee Ryan touched her husband, kissed him, spoke to him. She recounted their dating days, their first camping trip and how they ate potato pancakes and thick-slab bacon on Sundays. Sometimes she played her husband's recorded message on his cellular phone, hoping the sound of his own voice would awaken him.

Often, as the weeks went by, nurse Hansen sat by her side, playing "spirit fingers" over the patient in a giddy attempt at bringing the coach out of his coma and his wife out of the doldrums. Vee Ryan told the nurse how she missed her husband, who used to call her Honey Bunny.

"One of these days, you will hear him say Honey Bunny," Hansen told her.

Hunting for consciousness

Then Vee Ryan got the discouraging news that two EEG tests showed low amounts of activity inside the coach's brain.

She can't remember the doctor's exact words — just that he shook his head a lot.

But she refused to believe her husband would not wake up. She had read that EEG tests are not always conclusive since sweat can disturb sensors. She trusted that somewhere inside her husband's swollen bandaged head there existed some consciousness.

That hope, as tenuous as it was, became significant at crossroads in Ryan's care.

When the drugs that had been used to induce the coma wore off and he did not awaken, for instance, the family did not lose hope. They could have removed the breathing tube then, allowing the coach to die peacefully.

It was appropriate then to question the worth of keeping Ryan alive since he probably wouldn't ever have a quality of life that he would have wanted.

But Vee Ryan never considered letting her husband go. Encouraged by Ghaly, she chose the aggressive option — for doctors to cut a hole in her husband's trachea so the breathing tube, which would eventually cause permanent damage to the tissue and vocal chords, could be removed.

"As a physician and as a Christian, I strongly believe that life should be preserved ...," Ghaly says. "In the end, God's will will dominate."

"I don't force my opinion," he adds. "I give people options."

Meanwhile, therapists who regularly moved Ryan to prevent pneumonia, skin deterioration and muscle atrophy, were teaching the family to stir Ryan with smell, tastes and sound.

In coma stimulation therapy, the patient's responses are measured on a scale called Rancho Los Amigos. How quickly patients move along this scale, says speech pathologist Elizabeth Miller, is one way of predicting if patients will emerge soon from the coma or remain in a "persistent vegetative condition" like Terry Schiavo.

But it is a gray area at what point a person transitions from one state to the other. Some say it can take several months; others talk in years.

At the therapists' direction, Ryan's sister, Kathleen Dunagan, a pediatric nurse from Florida whose work includes rescuing the life of fetuses after attempted abortions, reminisced with Vee about things that would be most significant to Dennis Ryan — like ginger ale or Necco wafers he enjoyed as a child.

They put these objects up to the patient's nose and lips — sometimes defying nurses' orders by placing them in his mouth where they risked entangling in his ventilator. They watched for changes in heart rate and oxygen saturation, twitches in his lips or fluttering of the eyes.

These physiological reactions were meaningful, says Miller, but the therapists wished they were more consistent.

"He was a young guy. He had a lot going in his favor," recalls Miller. "We all wished that he was moving more quickly through the stages."

Vee Ryan wept when she saw her husband's eye roll under its lid after smelling her favorite perfume. "I was very excited," she says. "It gave me hope that he responded to the things that were the most basic or closest to him."

Ghaly considered an even deeper meaning.

He believes in a kind of silent communication between loved ones that sometimes allows them to perceive changes in patients before medical professionals. These inconsistent reactions are like a spiritual vision — hard to quantify but nonetheless important.

"The coma," says Ghaly, "is a beautiful mystery."

Awakening

After a month, Ryan was transferred to a facility for patients on ventilators. But his wife was concerned, because no single nurse would be exclusively devoted to her husband's care.

But here, the patient began showing signs of wakefulness.

When Dunagan came to say goodbye to her brother — she was returning to Florida to care for her husband who had cancer — she saw Ryan open his eyes.

When Dunagan told him he'd suffered a stroke and fallen into a coma, she felt he understood. Tears streamed from his eyes as she explained she was going home. And then her brother closed his eyes again.

Doctors say open eyes during a coma are common and don't necessarily mean a person is awakening. Still, over the following weeks, Ryan showed more signs of awareness. His eyes tracked movement across a room and he demonstrated purposeful movement on the right side.

His wife, noticing now that Ryan puckered up his lips to drink or receive a kiss, grew more hopeful.

Then, two weeks later, on the first evening Vee Ryan returned to work at Home Depot, she got a telephone call.

Her husband had been rushed to the hospital.

Turning Point

To hear Vee and her mother Pat Hoffmann tell it, the coach lay covered in blood on a gurney in the emergency room at Hinsdale Hospital, his eyes open and struck with fear.

As it turned out, the bleeding, likely caused by an irritation to his stomach lining, was not so terrible to require immediate surgery. Still, Ryan was suffering from dehydration, severe anemia, pneumonia and a staph infection called MARSA, common in people with long hospitalizations.

"These are expected complications of longtime coma patients," says Ghaly. "But they are also how people die."

The danger for Ryan had been averted, but the fear had been instilled in his wife, who continued to worry that after coming so far she would lose her spouse again.

As frightening as that trip was, it proved a turning point, for it was during his two-week stay in Hinsdale's ICU that Ryan truly awakened. He spontaneously moved his arms; his eyes remained open for long periods of time; and he tried lifting his head instead of letting it flop over like a rag doll.

Once, while Ryan watched television, his wife saw him mouth the words she thought she would never hear again: "Honey Bunny."

And then, when North Central College Minister Lynn Pries and Ryan's son Steve stopped by, the coach stuck out his hand so they could shake it.

Another time, while a speech therapist was teaching Ryan to speak using a plastic valve placed over the breathing tube in his throat, she pointed to Vee and asked her patient his wife's name.

"Fred," he answered, panicking his beloved.

"I was so worried he had amnesia, or maybe his brain wasn't functioning, or he knew it was me and couldn't verbalize," Vee Ryan recalls. "I freaked out."

Then the coach looked in his wife's eyes and said, "Pizza Hut," an old nickname from their dating days when they used to eat regularly at the restaurant.

"That's when I knew he was back," she says.

04/18/04