When brain aneurysm ruptured, runner defied death

Good health and Sanford neurocritical care team helped beat 10% survival rate

Deb Warner gives two thumbs-up signs as she runs on a gravel road. Her shirt says "gotta run."

At age 57, Deb Warner retired from her beloved teaching career.

At age 58, she ran a half-marathon — although admittedly that was kind of an accident.

At age 59, Deb Warner danced with her son at his wedding.

And this year, she jumped out of a plane to skydive for the first time as she celebrated turning 60.

Deb shouldn’t have been alive to do any of those things.

The odds said her children and siblings would have to wear the funeral clothes they’d hastily packed when they flocked to her side just before her 57th birthday. In a coma with a ruptured brain aneurysm, she had the most severe subarachnoid hemorrhage — or bleeding in the space around the brain — that a person can have.

Learn more: Stroke or seizure? It can be a fine line between the two

Statistically, her husband, Randy, had a 90% or greater chance of burying his wife and going home alone to their scenic Iowa farm.

But two things had happened during the decade or so before her ruptured brain aneurysm that may have made all the difference.

Deb — an “anti-athlete” as a student — had started a new hobby out of the blue: running.

And Sanford USD Medical Center in Sioux Falls, South Dakota, had begun a new unit — neurocritical care — that has gathered the expertise and technological advances to start seeing someone as gravely ill as Deb actually, eventually, walk out of the hospital alive and well.

A phone call cut short

The Warners’ farmstead overlooks a serene area of northwestern Iowa countryside, miles from the closest town. A gravel road and fields lie to the south of their four-season room.

It’s a beautiful place to live. But it’s a terrible place to have a medical emergency. Especially one that requires immediate, specialized care and kills up to half of its victims.

As Deb talked on the phone with her sister in her living room chair one evening during the 2016 Memorial Day weekend, she had no idea she had three aneurysms located in her brain. Or that they might have been there for decades.

The bulging, weak areas in the wall of her blood vessel hadn’t caused any symptoms. The active elementary schoolteacher couldn’t complain of any health problems. In fact, the year before, she had trained for and run a half-marathon.

Earlier that day, Deb had driven her mother 80 miles an hour on the interstate for a trip to decorate her father’s gravesite. That evening, her sister called to see how their mom, who lives in assisted living, was doing.

Soon into that phone conversation, Deb told her sister that her head hurt. Then she stopped speaking. The phone fell to the floor, her sister still listening on the other end.

Randy was around the corner in the sunroom at the time. “It was such a short phone call,” Deb said, “right away a red flag went up because I always talk …”

“Talk to her sister an hour or maybe two hours,” Randy finished.

In the silence, though, he heard a gurgling noise. Wondering if Deb was snoring, he came to check on her. When he found her sitting unconscious in the chair, phone lying on the floor, he called 911.

Help from neighbor, nearby hospital, helicopter

The closest hospital to the Warners’ farm is six miles away. But the call for an ambulance caught the attention of their EMT neighbor, who lives a mile away and recognized their address.

To respond as quickly as possible, the neighbor drove right over in his car, which contained a kit to address aspiration, the source of the gurgling noise. Before the ambulance even arrived, he had placed Deb on the floor and started using a suction unit to clear out her lungs.

The ambulance brought Deb to the nearby Sanford Health emergency department so she could be stabilized for a flight to Sanford USD Medical Center. “My only helicopter ride, and I was asleep for it,” Deb joked.

Dr. Larry Burris, who helped found the hospital’s neurocritical care unit 10 years ago, described the challenges to Deb’s survival before she could even make it into his care.

“If someone has what we call a thunderclap headache — you’re just walking down the street and all of a sudden you’re on your knees or unconscious — up to 25% of people die at that point,” he said.

She survived the rupture, and the gravel road trip to the ER, and the CT scan to evaluate what was going on in her brain, and the helicopter transfer.

“In the meantime, fluid’s building up in your brain,” Dr. Burris said. “You can still be bleeding because the blood pressure’s not controlled.”

But by the time she arrived in the trauma and neurocritical care unit of the hospital, Deb’s journey of survival had only just begun.

Specialized team approach

At one time, a neurosurgeon would have had a single option, clipping, to try to stop the bleeding, and Deb would have stayed in the general ICU, survival extremely unlikely.

Now, an entire team trained in neurological outcomes assembles for a Sanford Health patient. The roles can vary according to the diagnosis, but they can include neurosurgeons, neurointensivists,  neurologists and neurointerventionalists, along with specially trained advanced practice providers, nurses, respiratory therapists, physical therapists, occupational therapists and speech therapists.

The team might treat strokes, seizures, infections, or intracranial hemorrhages from a variety of causes, including trauma. And they have options for surgery now in aneurysm cases like Deb’s, less-invasive coiling and stenting procedures.

When Deb came in, the team faced a subarachnoid hemorrhage of the most severe type. Her state of coma put her at the highest grade, 5, on the commonly used Hunt and Hess scale, with a 10 percent chance of surviving. A patient ranked as 1 might have little to no headache and a 70 percent chance of surviving.

Dr. Burris worked in New York before he came to Sioux Falls, and fellow neurocritical care team founder Michelle VanDemark worked in Chicago. Neither one ever saw a level 5 patient walk out of the hospital in those places.

“Because of advances … I can’t tell you that we save every 5, but it is no longer a surprise when a 5 comes in and they go through,” Dr. Burris said.

It’s like a series of dominoes

The day Deb arrived at the hospital unconscious after one of her aneurysms ruptured was one of the best days she would have for a while.

Dr. Burris said subarachnoid hemorrhages affect patients the opposite as other diseases in the ICU — pneumonia or a heart attack, for example. With those, he said, “you’re really sick the first day, we do lots of work on you, and then you get better.”

But he likens subarachnoid hemorrhages to a series of dominoes. “You push the first domino when the aneurysm ruptures, and you really have to try to stop it or eliminate it, but you can’t stop all the processes.”

So immediately in these cases, the team addresses the hydrocephalus, or fluid building up in the brain. The patient has a shunt or catheter inserted to drain the fluid off, which is building up pressure in the skull. A surgical procedure stops the bleeding. Then the patient stabilizes for a short time.

After that, though, following the typical cycle Dr. Burris describes, Deb became much, much sicker. Her blood pressure stayed drastically low, she possibly had pneumonia, and fluid built up in her lungs.

“She had pulmonary edema to the point that we could barely ventilate her,” Dr. Burris said. He resorted to an alternative method of ventilation when the standard ventilation proved ineffective.

Pulmonary edema is associated more commonly with heart problems, which also can arise temporarily from subarachnoid hemorrhages — including a heart attack.

‘It would be hard to become sicker than she was’

Deb’s ruptured aneurysm affected multiple vital organs.

“From a cardiac point, she was very, very sick. From a pulmonary standpoint, it would be hard to become sicker than she was. And then she had all this stuff going in her brain,” Dr. Burris said.

She avoided other events that can happen in this catastrophic cascade’s middle phases: spasms in the artery leading to subsequent strokes, seizures and rebleeding of the aneurysm.

But as Deb lay unconscious on life support, doctors struggled to keep oxygen flowing to her lungs, her heart, her brain. Two nurses worked at her bedside 24 hours a day to deliver medications, monitor machines and document everything.

Meanwhile, Randy watched as his vibrant, active wife’s life dimmed day by day. So far, she was surviving. So far, her brother and sister and children hadn’t needed to put on the good clothes they had packed when they expected a funeral.

But surviving and living are two different things.

In this world of extreme coma and extreme uncertainty, families feel an anguish most can’t imagine. Their loved one is not only deathly ill, but chances are good that nothing will get better. If they survive, they could live indefinitely with no physical or mental capability. They could recover enough to sit up in a wheelchair with a feeding tube but never again recognize a loved one, or shape their lips into a smile, or speak a coherent word, or enjoy any moment of the rest of their life.

Families are forced to consider something no one should: whether the most loving choice would be to remove life support. It’s particularly difficult if patients have never discussed their wishes ahead of time or written out a living will or advance health care directives regarding medical decisions made on their behalf.

‘Horrific’ time for families

Dr. Burris tries to imagine the pain of a man who’s suddenly told that his wife of more than three decades has a 10 percent chance of living — if that — because of a ruptured brain aneurysm. He sympathizes with the difficulty of weeks of watching a loved one get worse and worse.

In his work, he also tries to imagine what kind of long-term quality of life his patients might live. An MRI sometimes can help define that quality by showing if and how much of the brain is still working. But there are a lot of unknowns. Are strokes so profound that a patient wouldn’t live? Or will the patient lose crucial abilities? Or will the patient have brain function but for whatever reason just won’t wake up?

“One of the complications or difficulties in neurocritical care is that you can try to save almost everybody,” Dr. Burris said. “The question is what are they going to be like afterwards.”

For Randy, who went through “a lot of sleepless nights,” the decision became much easier when doctors eventually were able to use an MRI to look at Deb’s brain to try to detect serious damage.

When the MRI revealed just a speck, Randy knew he wouldn’t be ending his wife’s life support.

Improvement after 3 weeks

The subarachnoid hemorrhage cycle ends about 21 days after its onset, Dr. Burris said. If a patient can survive that long, the intensive health issues tend to end.

In that time, Deb went through procedures ranging from insertion of a drainage tube, to surgery to stop the aneurysm’s blood flow, to ventilation, to insertion of a feeding tube, to insertion of a tracheostomy tube.

After three weeks, it doesn’t mean patients are healed. They may face a long journey of treatments for the effects of brain injury, including a variety of rehabilitation therapies, with a goal of regaining as much of their life as they can. But at least they’re moving forward.

In Deb’s case, “she did much better after that point,” Dr. Burris said.

A real awakening is not like TV

When patients awaken from a coma, Dr. Burris said, they do not act like characters on “The Young and the Restless.”

On TV, he said, “they’re in a coma for five years, and then they open their eyes and have this long discussion as they’re having a cup of coffee.”

In reality, he tells patients’ families to expect something much different.

A patient might start with a blink, or a yawn. Maybe just once and then not for a while. But, Dr. Burris said, “it kind of means their brain’s starting to come back online.”

When the doctors get excited about small signs, like a blink even if a patient is far from waking up, families do, too. “We’re all contagiously happy about these things,” Dr. Burris said.

Randy recalls his wife’s first blinks. And he recalls that she first opened her eyes when a doctor spoke to her. The doctor asked Deb if she knew where she was, and, as instructed, she blinked twice for “no.” He told her she was at Sanford hospital with a ruptured brain aneurysm. When he asked if she understood, she blinked once for “yes.”

“That’s how it started,” Randy said. “Just slowly, she started coming back.”

“That’s how you knew I was going to be OK,” Deb said.

Deb’s brain told her a little different story

The brain helps us think and plan our actions. It remembers. It forgets. And it imagines — even in times of distress. Maybe especially in times of distress.

Before she was fully awake, Deb’s brain concocted for her a vivid dream world. In it, she had collapsed and an ambulance had brought her to an unconventional Sanford Health emergency department: the second floor of a convenience store.

When that filled up with patients, she was moved to a place equally unusual: Grand Falls Casino, which is not far from where she lives in Iowa.

Randy and Deb have a theory that alerts on the hospital medical equipment she was hooked up to sounded to Deb like the dinging of slot machines. “Her machines were going off all the time,” Randy recalled.

Deb left her room to eat meals at the buffet and entertain visitors in the lobby. Conversations included people who actually came to visit her in the hospital.

“Afterwards for the longest time, I had to keep asking them, did that really happen?” Deb said. “It was so vivid and so real.”

‘Very fast’ progress

Deb and Randy had been prepared to face at least six months of therapy. Starting out, she had several inpatient therapies, including physical and occupational therapy, and speech therapy for her swallowing issues.

“I was just a ragdoll,” Deb said. “They’d say, ‘Mom, raise your head.’ ” It would drop immediately.

But after Deb began rehab, her progress soared. “She went from being so-so to being great very fast,” Dr. Burris said.

“My dismiss date was constantly being moved up. Constantly,” Deb said.

“I had a walker at first, and they would walk me around, and I really liked that. And I really pushed myself, too, because I just wanted to get better.”

While in the hospital, Deb had stents placed in her two unruptured brain aneurysms as well.

Less than two months after arriving with a condition considered fatal for most of its victims, and after just three and a half weeks of rehab, Deb walked out of the hospital in later July “on my own power.”

“She started off as a very healthy person who got very, very sick, and once the symptoms were gone, she came back to a healthy person,” Dr. Burris said. All of that running had positioned her well to heal.

Deb continued outpatient therapy for about six weeks, working on balance and strength in her legs with a physical therapist. “My ankle is probably still a little sluggish,” she said, “and my toes are sluggish moving, but they’re very functional.”

After the brain aneurysm rupture

Deb passed the cognitive tests fine, but she’s not a multitasker. “I get overwhelmed easily,” she said.

Deb said she already had trouble remembering details before the brain aneurysm ruptured. “But I would say my short-term memory — I need to write everything down. That’s weak. And whether it’s weaker and I got older, you know, a brain bleed didn’t help any.”

Deb had to relearn how to follow steps in a process to complete a task. She had to reestablish routines, and then if she found herself in a new situation, such as a hotel stay, she had to really concentrate on the new routines.

Now she has an MRI each year to check for leakage or new growth in her brain. She takes an aspirin every day. She worries a little more than she used to, and a sharp headache makes her nervous until Tylenol takes away the pain.

But otherwise, Deb isn’t letting a little thing like a ruptured brain aneurysm stop her from — well, anything, it seems.

Retirement, then running

Deb returned to work as a Title I teacher part time in mid-August 2016, when the school year began. She went back to full-time teaching Oct. 1, on track to her planned retirement the following May.

She was grateful to return, because it bothered her that her aneurysm had ruptured before the end of the previous school year. “I missed the last four days of school,” Deb said. “I never got to say goodbye to my kids.”

Deb retired in style that May, leaving school in a limo surrounded by her family. And then she got busy.

One of her first goals: to run the 5K in the Sioux Falls Marathon in September, the year after her aneurysm ruptured and two years after she had trained for and run a half-marathon.

The whole point of her running the 5K was for her husband to take her photo at the finish line so she could give it to Dr. Burris and her physical therapists with a big thank you.

So she trained by running three miles a day on the country roads surrounding the Warners’ farm.

Um, did that marker say 5 miles?

The day of the race, Deb arrived at the venue at 7:15 a.m., which was the time the half-marathoners were scheduled to take off. Encountering a mob-like atmosphere before her 5K was scheduled to start, Deb decided she should use the restroom quick.

Then Deb got in line to start her race. It was too loud and chaotic to hear what the announcer was saying — something to do with the pacers, she thought — but when the gun went off, Deb started running with the mob.

Once she got outside the venue, she could hear her phone ringing as she started off. Figuring it was one of her kids calling to wish her luck, she decided to just pick up later.

“So I’m running, and I’m really doing well,” Deb said. “I think, ‘Man, I’m going to have the best time ever.’”

She sailed by the 1-mile mark and the 2-mile mark. But then instead of heading back toward the starting venue, the mob of runners turned in the opposite direction. That didn’t seem right to her.

“Then at some point, I saw the 5-mile. And I thought, ‘No, no, not 5 mile, 5K,’ ” Deb said.

So she asked the runner next to her if they were running the 5K race. The runner replied no, it was the half-marathon.

This was a dilemma. Deb hadn’t trained for the half-marathon this time — not even close. She had faithfully been running three miles a day. Never 13.1.

But she desperately wanted that finish line photo, to send an important message to her medical team: “Because of you, I can do this.”

‘I just kept running’

At some point, Deb’s husband called. He had been able to hear the announcer from his vantage point above the mob of runners, and he had watched with concern as Deb ran out the door with all of the half-marathoners. He had been the caller she ignored earlier.

“How you doing?” Randy asked while checking whether she knew she was in the wrong race. He offered to pick her up.

As she refused his offer, Deb thought to herself, “I’ve gotta have a picture.”

“So I just kept running,” she said. “You know, 7 miles, 8 miles, 9 miles. I just kept running.” Other than slowing one time to walk over the top of a hill — to save her strength — she ran the entire way.

Her time was only 14 minutes slower than the half-marathon she trained for and run two years earlier — before her ruptured brain aneurysm.

It turned out lightning had delayed all of the races by 15 minutes. That’s why she left at the correct time for her 5K but ended up running instead with the half-marathoners.

“So,” Deb said, “my thought was, when you pray to God to go to the moon, he sends you to the stars.”

Deb still runs regularly when it’s nice out because she enjoys being outside, and at the same time, she picks up litter along the roadside. However, she has crossed half-marathons off her bucket list. She has plenty of other goals to achieve, after all.

The teacher goes back to school

If Deb had died from her ruptured brain aneurysm, she would have had one big regret. She had always wanted to go on for a master’s degree but never did.

Now came the time to seize that chance. Deb enrolled in the Master of Arts degree of Bible and Theology at Sioux Falls Seminary. The program is self-paced, but she hopes to graduate next spring or summer.

“It’s hard. It’s demanding,” Deb said. She went from being the teacher to writing research papers for instructors in less than a year.

“Everywhere I go, I take a book with me and study.”

But she’s enjoying it. And she’s anticipating her achievement. “I want to put it on Facebook and get a hundred likes,” Deb said. “Hang my degree on the wall.”

She’s also anticipating what comes after the degree, even though she doesn’t know what that is yet. “I lightheartedly say that God has me on a need-to-know basis. When I need to know why I’m doing this, he will tell me.”

Living a life of celebration

Deb doesn’t miss a chance now to celebrate her life, or anyone else’s.

“Birthdays come with a different meaning now, when you weren’t supposed to have this birthday,” she said. “I wasn’t supposed to have this anniversary. And I got to see my son get married. While I was in the coma, he said, ‘Mom, Mom, you gotta wake up. You’ve got to dance with me at my wedding.’ So at his wedding, promise fulfilled, we danced.”

For her 60th birthday this year, Deb celebrated by doing something that had always been in the back of her mind. With a skydiving instructor strapped to her back, and without a bit of fear, she stepped out of an airplane at 7,000 feet into a 150 mph freefall. She loved it.

“Every day, everything is just such a gift,” she said. “Not everybody gets a miracle healing.”

She encourages families facing a similar situation as hers to hold onto their faith. “Just keep your hope. Keep going,” she said.

“Talk to (loved ones) when they’re out because there were things that were coming in that were part of my dream world. They say that people in a coma can hear you, and I believe that. Talk to them. Touch them.”

Expressions of gratitude

Patients like Deb, who recover from severe illness, help reinforce the actions of the entire neurocritical team, Dr. Burris said. “We did everything possible to fix her. And I think without the group, things would be much different.”

“It’s this group of people that have really come together to dedicate themselves or focus their energies on one sort of thing, which makes a huge difference.”

Deb overflows with gratitude when she talks about all of the people who had a hand in helping her survive.

When Dr. Burris came later to visit Deb in the rehab unit, she was more aware of his and his team’s efforts. “Thank you for saving my life and not letting me go,” she told him.

Before leaving the hospital, Deb also paid a visit to the trauma and neurocritical care unit.

“I walked up because I wanted to say thank you to everybody,” Deb said. “So I went up and I shook hands, and the one nurse just had tears. She said, ‘I can’t believe it’s you. I can’t believe it’s you.’ ”

When a recovered patient comes back to visit, it means a lot to the team’s nurses, Dr. Burris said. “The nurses work a lot on these patients. They became very close to this family.  … When they see someone come back like that, they realize that, ‘I did a great thing.’ ”

The Warners are grateful, but beyond that, they also have a tip for the team.

“If Sanford ever runs out of room,” Randy said, “they can just …”

Deb finished the thought: “They can just put them at the casino.”

FAQ about brain aneurysms

What is a brain, or cerebral, aneurysm?

A weak area on the wall of an artery in the brain that bulges out and fills with blood.

What are the possible symptoms of an aneurysm?

Unless an aneurysm grows very large or ruptures, there typically are no symptoms. Pressure from a large aneurysm might result in pain around the eye or other eye problems, numbness, weakness or paralysis on one side of the face.

Who has brain aneurysms?

Statistically, 5% of Americans could have an aneurysm — anyone at any age. They are more common, however, in adults age 30 to 60, and in women. Risk factors for having them can include certain inherited conditions, including a first-degree family history of brain aneurysm; untreated high blood pressure; cigarette smoking; drug abuse; and being older than 40. Her age was Deb Warner’s only risk factor.

What happens when an aneurysm ruptures?

The blood flows out into surrounding tissue, called a hemorrhage. Effects of this can cause stroke, seizures, brain damage, heart attack, coma or death. About 25% of people with a ruptured aneurysm die within the first 24 hours; another 25% die within six months from complications. About 30,000 Americans have a brain aneurysm rupture each year.

What are the possible symptoms of a ruptured aneurysm?

A sudden and severe headache; double vision; nausea; vomiting; stiff neck; sensitivity to light; seizures; loss of consciousness; cardiac arrest.

What causes brain aneurysms to rupture?

Possible risk factors include smoking, high blood pressure, a larger size of aneurysm, its location in the brain, if an aneurysm is actively growing, family history, and personal history of a previous rupture.

Source: The National Institutes of Health

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Posted In Brain & Spine, Emergency Medicine, Network:Rock Rapids, Neurology, Rehabilitation & Therapy, Rural Health

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