Author: Heather May
On the day doctors were set to drain the dangerous amount of fluid in Jacob Winger’s brain, his mother, Mary Jean Winn, was told he may not make it through surgery. After he passed that hurdle and was stable enough for doctors to assess the damage to his brain with an MRI, they called Winn with the results: The damage after he crashed head-on into a windshield was so extensive, he would likely never regain consciousness.
Winn began to plan her son’s funeral. She knew who would speak and what songs would be sung. But she also had faith. While Winger was unconscious, the family played his favorite songs, especially Tim McGraw’s “Live Like You Were Dying.” They read his favorite book, Because of Winn-Dixie, and brought his dog for a visit. They even persuaded the hospital to take him outside on the balcony to feel the fresh air. “He needed to feel the sun on his face,” Winn says. “He needed to feel alive. ”
His mother sat at his bedside and leaned into the left side of his head, where he was most injured, telling him, “You know we don’t stop fighting. We don’t give up. We never give up.”
It was that attitude that would propel Winger through rehabilitation and the depression that overwhelmed him after.
A Life of New Purpose
It all started with one split decision Winger made at the end of a long ATV ride: He unbuckled his helmet.
The daredevil 21-year-old Army reservist was doing what he loved on June 21, 2018—riding his new four-wheeler in the mountains of rural Utah with friends on a free day before heading to annual Army training in preparation for deployment to Kuwait. After the fun, less than a mile from his truck, he unbuckled his helmet. Moments later, while traveling an estimated 45 mph, Winger hit a minivan on the dirt road. His friends would later say that it appeared as though Winger tried to jump from his vehicle over that Dodge Caravan. Instead, his body broke the van’s windshield, his head slamming into a support bar.
After an ambulance ride down the mountain, Winger was flown by AirMed to University of Utah Hospital, where he would spend two weeks in intensive care followed by 23 days in the hospital’s Inpatient Medical Rehabilitation Unit working with specialists in the Brain Injury Program.
It’s where he was reborn in a sense—learning to eat, talk, and walk again.
Now, Winger has a new life. He must stick to a routine and write down to-do lists to help him remember to take out the trash. When he goes to his appointments, he seeks his mother’s help to explain himself and solve problems. It’s a life of new purpose, with more gratitude and kindness, he says.
“I don’t want to be labeled as a brain injury,” says Winger, whose shaved head and now-muscular body shows little of the trauma he went through. “I find it’s a blessing more than a curse. I know my issues. I can’t change it, so I might as well make the best of it.”
The Impact Aftermath
A traumatic brain injury (TBI) is caused by sudden trauma to the head—think of a blow or penetrating wound—that disrupts the brain’s normal functioning. Every year in the United States, 2.9 million people suffer from a TBI, according to the Centers for Disease Control and Prevention (CDC). Most are mild, commonly called concussions. The severe ones, resulting in an extended period of unconsciousness or amnesia after the injury, can cause lifelong effects for the injured. They can potentially impact their thinking, memory, vision, mood, sleep, coordination, balance, relationships with others, and ability to work—or end in death.
Data from the CDC reveals TBIs contributed to the deaths of nearly 57,000 people in 2014. TBIs are also the leading cause of disability in children and adults up to age 44, according to the Brain Trauma Foundation. On an average day in Utah, 60 people are admitted to the emergency room, seven are hospitalized, and one dies from TBIs, according to the Utah Department of Health (UDOH).
Falls are the top causes of TBIs—accounting for nearly half of the TBI-related hospitalizations and deaths in Utah. Motor-vehicle crashes are the second leading cause, at 16 percent, according to UDOH data. ATV crashes like Winger’s rank third.
But it’s not the initial impact that creates the only damage, says John Speed, MBBS, medical director of the traumatic brain injury rehabilitation program at U of U Health. The primary injury, the wound or fall, for example, ends at impact. It’s the cascade of cellular tissue and blood vessel changes that occurs in the hours and days after the impact that can further destroy brain tissue.
Widespread damage is called diffuse axonal injury, which describes injuries to the long threadlike part of the nerve fibers (axons) that communicate between cells. When the brain, with a consistency of gelatin, hits the skull upon impact, the axons tear and leak out their contents, Speed explains. That leads to further swelling in the closed space of the skull, which can then block the blood supply to the brain, resulting in further disability or death.
That’s what happened to Winger—he was diagnosed with diffuse axonal injury and spent 15 days in a coma. Winn says it was described to her in terms that strike fear in any parent of a newborn: “It’s basically shaken baby syndrome in an adult.”
A Focus on Function
Speed took over Winger’s care after he regained consciousness in intensive care and was eventually moved to the rehabilitation unit. Therapy usually starts in acute care—unconscious patients’ legs and arms are moved to maintain blood flow. Once doctors determine patients can tolerate and benefit from therapy, they are moved to the Inpatient Medical Rehabilitation Unit, where they work for about three to four hours a day in therapy, relearning skills and adopting new ones to achieve the highest possible level of function and independence. While damaged or destroyed brain cells are unlikely to regenerate, sometimes the brain can learn to function around the damage, or other parts of the brain can take over for the injuries.
“There’s the possibility of some very dramatic recovery,” says Speed, who has worked in the Brain Injury Program since 1989. “You take somebody who’s incontinent of bladder and bowel, who can’t communication with you, has no idea where they are and what’s going on, and three weeks later, they’re walking and talking and ready to go home. Three months later, they’re ready to go back to work. That’s incredibly gratifying.”
Over his 31 years at U of U Health, Speed says treatment for TBIs has improved dramatically.
About 160 brain injury patients a year receive treatment at the Craig H. Neilsen Rehabilitation Hospital, which opened in the summer of 2020. On average, a patient stays 15 days in rehab; the only U of U Health department where patients stay longer is on the burn unit. Throughout the patients’ stay, the rehabilitation team—made up of doctors, nurses, psychologists, a social worker, educators, and physical, occupational, and speech therapists—work together to devise the best methods to help their patients. They learn the patients’ interests to use that to motivate them. They brainstorm ways to break though barriers and coordinate their care so that, for example, patients practice memory tricks while also taking steps. They set goals for the patients and meet to discuss their progress. The team works to accelerate brain recovery.
Medication has improved over the past three decades to help speed recovery, Speed says. In particular, the drug amantadine, used to treat symptoms of Parkinson’s disease, boosts levels of the neurotransmitter dopamine, which is linked to arousal. Patients become more alert more quickly, Speed says.
Equipment used in therapy has also improved, especially with the opening of the Craig H. Neilsen Rehabilitation Hospital, which features a new physical therapy gym, along with rooms for speech therapy, occupational therapy, and psychology services. “This is a very positive and beneficial environment for people to pursue rehabilitation in,” Speed says.
Benjamin Ingraham, DO, who also specializes in brain injury recovery and has taken over inpatient rotation, agrees, noting that the new building allows more collaboration between doctors and researchers to advance outcomes for patients.
“Large private rooms make providing nursing care and assistance with completing activities of daily living easier,” Ingraham says. “More treatment spaces give therapists more options of where to treat patients who need low stimulation environments to succeed. The building also fosters more collaboration across disciplines and allows for the continued transfer of knowledge not only between team members but to patients and families as well.”
Unlike in other medical specialties, Speed says, the rehab team doesn’t address the function of just one body part (like a cardiologist focuses on the heart). “Rehab doesn’t have a particular organ or body system. Our focus is on function—people’s ability to do stuff. You need to look at the person as an individual, in a family setting and community setting.”
Inside a Kaleidoscope
A typical morning of rounds to visit patients can reveal how precarious brain health really is—one patient was hit by a car while jogging, another was injured when a semi-truck hit her vehicle, one fell more than 20 feet, and another was hit while riding a motorcycle.
Caring for such patients has changed Speed, he says, giving him a “sense that you just need to appreciate every single day. You just never know what’s going to happen.”
Initially, the patients can look wide-eyed, revealing the difficulty of processing what is going on around them. Patients will also ask to go home. By the time they stop asking, it means they’re probably ready to leave, Speed says, because they’ve regained the insight to understand their situation.
Patients also become agitated and combative with unexplained mood swings—actually a sign of progress, Speed says. It’s an improvement from lying unresponsive or only being able to blink at a strong light or turn away from a loud noise.
Speed likens the aggression to a fight or flight response. “You can’t plan out or make sense of what’s going on, so you randomly, purposelessly thrash around, bite, kick, run away if you can. It’s a physiologic response to sensory input you can’t make sense of. It’s like living inside a kaleidoscope. You just can’t make sense of your world.”
Enter the therapists, who help patients find clarity.
An Unpredictable World
On a spring day in 2020, Jeffrey Parris is wheeled into a breakroom kitchen at the rehab department for his cooking class. But the group that has gathered isn’t there to test the flavor of his battered catfish. The goal is to see if Parris, who spent nearly two and a half months at U of U Health after a motorcycle accident in Idaho, can use the skills he’s been working on with his therapists. Can he remember where the ingredients are in the cupboard and fridge? Can he remember the recipe? Will he use the list of instructions as a guide? Can he stick with a task, or will he get distracted? Will he keep his weight off his injured leg while standing? Will he tell the team that he wants to stand so they can help? Can he cook the fish without burning it? Will he wash his hands after touching the fish?
“Everything we’ve been working on we can put in context here,” says Tyler Christensen, a speech-language pathologist. “We’re trying to prepare him for what it will be like to go home.”
Therapists like to test a patient’s skills in a real-world setting. One patient who loved soccer started out kicking a soccer ball while sitting, then named favorite teams while walking and eventually toured Rio Tinto Stadium in Sandy, which is home to the Real Salt Lake soccer club. Beyond providing a respite from the hospital and some fun, the community outings are a way to gauge how patients function in an unpredictable world—and for family and therapists to discover breakdowns in cognition and mobility. Jacob Winger got to a point where he could easily walk the hospital halls and find his room, but once he went outside, he didn’t register a red light and had to be physically stopped from walking into traffic.
The Propulsion of Hope
Back in the kitchen, Devyn Langille, an occupational therapist, gives Parris cues. “Before we start, should we make a list of all the steps?” She and Christensen continue to nudge Parris on what to do, reminding him of memory strategies like checking his list and getting out the ingredients before starting.
Their roles in therapy can overlap. Occupational therapists work on the activities of daily living such as getting dressed, using the bathroom, and showering. “For some people, if you give them a bundled-up shirt, they have a hard time figuring out how to orient it and where to start,” Langille says. Occupational therapists also work on any activity that is necessary or meaningful to the patient, including cooking, managing medications, and participating in leisure activities.
Langille provides training and adaptations for resuming activities like feeding pets and caring for children; she also develops techniques for patients and their families to deal with confusion, frustration, and impaired memory, like lists and routines.
On another day, Langille, along with physical therapist Shannon Wells, observes and guides Parris as he screws and unscrews an old compressor and later takes steps down the hall. Parris is a mechanic, so Langille and Wells want to find a meaningful skill for him to practice that also tests his memory and allows them to observe how he solves problems and follows directions. One of the therapists asks if he remembers their names. At this point in his recovery, Parris occasionally gives one-word answers and often doesn’t respond to questions.
Wells, who helps patients regain balance, coordination, and strength, notes that Parris doesn’t initially have the attention or insight to remember his leg is broken and he can’t stand on it. That, and patients’ struggles to be able to express what they’re feeling, can make the job challenging.
But it’s the most rewarding work she could do, Wells says. Helping patients regain function and a sense of themselves after a catastrophic accident is an honor.
“There’s an element of brain healing that’s pretty amazing to be a part of,” Wells says. “There’s a little bit of magic in rehab—the rapid increases in function and awareness, or the first time a patient smiles or laughs or engages with their family. The little glimmers of hope that keep propelling us all forward.”
Learning to Cook, Re-learning to Live
Before Parris could cook, Christensen, the speech therapist, had to teach him how to swallow again. Many TBI patients are impulsive and can’t pay attention to the sensations in their mouths, so they end up choking and don’t realize they should stop, Christensen says. They get a modified diet of pureed food and thickened liquid so they can’t eat too quickly. They are taught to reposition their chin for swallowing and strategies like counting to three before they swallow.
Another common side effect of a TBI is changes in memory—and not just forgetting the accident. Trauma often damages the brain’s ability to take in, recall, and use new information. The problems can improve with time, but therapists help patients develop new strategies to compensate for their impaired abilities. Christensen says those strategies include repeating information, writing down reminders, asking questions, and sticking to a routine.
The cooking class was also for Parris’ family, who would be taking him home later that week. His wife and mother could see he would need supervision while cooking and help in planning out the steps.
While Parris cooked his fish, his family talked about his life before the motorcycle accident. The father of six was hit while returning to work as a mechanic after lunch, injuring the left side of his body from his head to his leg. His mother, Beth Klitgaard, and wife, Charlee, describe him as a hard worker and man of many trades who could design and make furniture and fix just about anything. “He doesn’t call the repairman—he is the repairman,” Klitgaard says.
His family wasn’t sure he would survive the crash; then they were warned that he could have the mental abilities of a toddler. Seeing him recite the steps of his recipe, find the ingredients, and cook the fish—albeit with help and some improv—feels like a miracle from where he started.
“A month ago, he was asking me, ‘Are you my wife?’” Charlee recalls. As Parris hungrily eats the first real meal he’s had since his accident, she sums up the difference therapy has made: “This is huge.”
Meet the New Jake
Inpatient rehabilitation gave Winger a job: Walk down this hallway. Match these cards. Recall the days of the week. When he left University Hospital to live with his mother, he fixated on what he had lost from the accident. He stayed in bed all day and watched TV, smoked, and drank too much. He told his mother he didn’t care if he lived or died.
The change has been hard for his family, too. “Nobody warned me what a brain injury would be like—not that that would have stopped me pleading for my son’s life,” says Winn, who sits with Winger as they tell their story together. “Caring for him in the beginning, it was exhausting. I had to physically teach him how to eat, how to talk, how to go to the bathroom, all those things that I did as a mom to my child. The only difference now is that I have a 21-year-old child.”
While his body healed quickly, his mind has taken longer. A neuropsychological evaluation showed Winger has executive function disorder, making problem solving and carrying out a sequence of steps more difficult.
Winger found his way out of depression through a job. About a month after he was released from the hospital, the Army Reserve asked him to return to help load trucks and organize tools—light work that matched his abilities. “It’s like the clouds are lifting,” he told his mother.
It started Winger on a journey to where he is today. He lives alone, drives, weight lifts, runs, and works at Hill Air Force Base supplying equipment to combat aircraft. He says he’s in better shape than before the accident. He’s also kinder, more confident, and appreciates his family more.
Winger and his mother want to start a nonprofit that would help TBI patients find purpose and confidence in work, particularly outdoors, since that is where they love to be. They also want to create fundraisers to help other patients who didn’t have the military insurance Winger had, which paid for all of his nearly $1 million in care. “I want to be able to help people who don’t have that,” he says.
He wants to become a motivational speaker to help others like him. “I just want to be happy and make people around me happy.”
Winn says she’s wondered if it would have been easier to have a child who was born with a brain injury than to see her son go through one and change. “It’s really hard as a mom to see the before and after and go, ‘But why?’ We’ve all had to learn to embrace the new Jake.”
“You have two choices,” Winger adds. “Make it a positive, or let it kill ya.” He smiles and adds, as his mother agrees, “I like the new Jake.”
Healing the Brain and a Life
The rehabilitation of patients with traumatic brain injuries takes therapy, education, and hope.