The Boy With The Spike In His Head

Xavier Cunningham was having great fun that warm Saturday afternoon in September 2018 with his buddies Silas and Gavon. Bubbly and energetic, the slim, sandy-haired 10-year-old with blue eyes was a big fan of the video game Fortnite, but nothing beat running around outside, playing Nerf gun wars in the yard behind his house in Harrisonville, Missouri, in the US.

It was almost as much fun as playing football; this was his first season on the youth league’s Wildcats. He’d feared being tackled at first but had improved with extra coaching and drills. Coach Jeremy Cornell loved Xavier’s sparkling personality, and the boy was a great team leader, but he needed a little more grit. He told Xavier, “Be strong, always know what your job is and do it. Be the hammer, not the nail.”

For a while, Xavier and his two friends played with a stainless steel meat skewer they’d found, chucking it into the ground like a spear. At 43 centimetres long and more than a half-centimetre thick, the square-edged skewer was used to cook chicken or other meat on a rotisserie; one end had four sharp prongs attached.

They ditched the metal skewer near a neighbour’s tree house, sticking it in the ground with the four prongs anchoring it. After getting the neighbour’s permission, they climbed the three-metre ladder. Up top, a few yellow jacket wasps buzzed around. “If we don’t bother them, they won’t bother us,” said Xavier. They took shelter in the tree house’s small hut.

But the boys hadn’t seen the large wasp nest wrapped around part of the tree house. Soon the yellow jackets were coming at the panicked boys thick and fast, like a dense black cloud. Silas was so scared he knelt in the corner and started praying.

“I’ll get my mom!” Xavier said, but now he stared, frightened, at the tree house ladder, which was covered in a seething mass of angry wasps. This is going to hurt, he thought. His hands crunched on the insects and the stings were painful as he grasped each rung, going as carefully but as quickly as he could.

When he was about halfway down, a wasp painfully stung the thin skin of a knuckle on his left hand, and as he swatted at it with his right, he lost balance and fell, face down. Just before breaking his fall with his arms, he felt a sting just under his left eye. Was that a wasp? Then he realized he’d landed on the metal skewer, and about 15 centimetres of it was buried in his head. Screaming, he got up and ran towards home, 15 metres away.

Gabrielle Miller, 39, was upstairs folding laundry in the two-storey brick home she shared with her husband, Shannon, a teacher and their four children. Shannon had taken two of their kids to a family games centre in nearby Peculiar, while Gabrielle, who manages a local title-insurance business, stayed at home with Xavier and his 14-year-old sister, Chayah. She heard her son screaming and sighed. When will he grow out of this stuff?

Xavier—called “Bear” by his family after a story Shannon told him as a toddler—made a fuss over the smallest scratch. If one of their two dogs jumped up on him, he’d start screaming; he was too scared to walk Max, the coonhound he’d gotten as a puppy, because the dog pulled on the leash. His overreactions were pretty much a daily occurrence.

Gabrielle was almost down the stairs, Chayah right behind her, when Xavier pushed the front door open, shrieking, “Mom, Mom!” Chayah took one look, covered her mouth with her hand and fled back upstairs. Gabrielle was trying to make sense of what she was seeing. “Get them off!” Xavier was yelling, batting at wasps.

She pulled wasps off him, getting stung herself. But she was confused and shocked. “Who shot you?!” It looked like there was an arrow through her son’s face; a single trickle of blood ran down from it. With his stung, swollen hands he touched the tip of the skewer on the back of his neck, a lump that hadn’t pierced the skin.

“Chayah, go find the boys. I’m taking Bear to the hospital!” She guided Xavier out the front door, as a neighbour phoned emergency services to help Silas and Gavon.

Xavier manoeuvered himself into the front of his mom’s Camaro, as Gabrielle ran to the driver’s side. A shocked neighbour, watching as the car backed out into the road, thought, That boy’s not coming home.

Gabrielle swatted at the wasps stinging them in the car—many were still in Xavier’s clothes—as she drove them to Cass Regional Medical Center, a few minutes away. “I’m dying, Mom,” Xavier said quietly. His whole body was on fire from the stings. “I want to see Jesus but not yet,” he said. “I love you, Mom.” He closed his eyes and leaned back on the seat.

Gabrielle panicked. “Stay with me, Xavier, it’s OK, Jesus is here with us now.”

The First Six Hours

Emergency room personnel acted quickly when the mother and son walked into the medical centre, giving Xavier painkillers for the stings and sending him for X-rays. The meat skewer didn’t appear to have hit his spine, but an X-ray can’t show tissue damage. They’d have to send him somewhere with more advanced imaging equipment: Children’s Mercy Hospital in downtown Kansas City, 40 minutes north.

To prevent Xavier from moving his head, staff put a plastic cervical collar on his neck and wrapped his entire head in white gauze to help stabilize the skewer. The only thing left exposed besides it and its four sharp prongs—caked with mud from where they’d been stuck in the ground—was his mouth. Ambulance personnel also tied the boy’s hands down so he wouldn’t be tempted to grab at the skewer. But they needn’t have worried; something told Xavier that was a bad idea.

Dr Jeong Hyun, the paediatric surgeon working the emergency room at Children’s Mercy that Saturday afternoon, couldn’t believe his eyes when Xavier was rolled in about 4 p.m. That thing is huge, he thought.

In the trauma bay, he introduced himself to Xavier and told him, “We’re going to see what we can do about this.” Through the hole in the gauze at his mouth, Xavier said quietly, “OK.”

Dr Hyun had him wiggle his toes and fingers. He was relieved Xavier was so responsive physically and mentally; it meant it was likely neither his spine nor brain had been hit. Dr Hyun ordered a tetanus shot and painkillers. He also ordered antibiotics; it was likely some of that mud was inside the boy’s head.

Now Dr Hyun wanted to quickly understand whether the skewer had pierced one of his vital blood vessels. If an artery, such as the carotid or the vertebral, which carries blood to the brain, had been hit and was leaking out internally, it meant his brain would be starved of that blood, which could cause a stroke. To find out, the team performed a computed tomography (CT) angiogram.

Dr Hyun was amazed to see that not only was nothing leaking, but that the skewer had narrowly missed every vital artery. They looked to be millimetres, if that, away. That’s spectacular, thought Dr Hyun. But now what?

Emergency room staff quickly treated Xavier's pain and stabilized the skewer. (Photo courtesy Gabrielle Miller)

Metal shows up on CT scans as vivid white without defined edges. If the skewer had any kind of bend, a sharp edge or a gap, then pulling it out now would be rolling the dice, as it could catch on an artery and rip it open.

The only way to get a clear picture of the skewer was with biplane angiography—a set of equipment that gives doctors a crystal clear three-dimensional view inside the vascular system, allowing them to see what was happening in those crucial vessels. It was highly specialized equipment that only some adult hospitals had; Children’s Mercy did not have it, since vascular problems are so rare in kids. But The University of Kansas (KU) Hospital, just five kilometres away, had a biplane angiography suite, and Dr Hyun got on the phone to them to describe the case they were about to transfer.

It was now 7:30 p.m. Xavier had been impaled for six hours.

“The Boy Is On Board”

Dr Koji Ebersole, an endovascular neurosurgeon at the University of Kansas Medical Center, was playing tennis with a friend when his mobile phone rang. The slim 43-year-old took the call at the side of the floodlit courts from a doctor on duty at KU Hospital.

Dr Ebersole looked at the photograph the doctor sent. Whoa, he thought. He’d never seen anything like it. The poor boy was lying on a gurney with a huge spike sticking more than 20 centimetres out of his face. How deep is that thing? And how is this kid even alive?

Dr Ebersole knew they’d need to get him into the angiography suite as soon as they could—but first he needed a plan. He was the best-trained neurosurgeon for more than 200 kilometres, but there was nothing in the medical textbooks that could help with this one. He headed home to make some phone calls.

Meanwhile, his colleague at KU Hospital, Dr Kiran Kakarala, 39, an otolaryngologist (or ENT—ear, nose and throat—specialist), was at home with his family when he took a call from Dr Valerie Wood, an ENT he had trained. “You’re not going to believe this,” she said. “I’m sending you an X-ray right now.”

Dr Kakarala, a tall, soft-spoken man with kind eyes, sucked in his breath when he saw the image from Cass Regional Medical Center showing the side view of Xavier’s head with the skewer angled downward in it. His first thought was that the odds were against the boy. How can someone live through an impalement like that?

Yet he was alive—which told Dr Kakarala they had a chance of removing it. But how? If it hadn’t damaged any key vessels yet, it could easily uncork something on its way out. That could mean death or a stroke, which could cause permanent mental and physical damage.

For the next couple of hours, Drs Ebersole and Kakarala consulted with various specialists by phone. They knew they needed to see exactly what the skewer had damaged, or still could damage, and then remove it while carefully monitoring its exit. Using the angiography suite required a team of 15 to 20 medical staff. It would be tough to get the right people together so late on a Saturday evening. Plus, they’d have a better chance of saving the boy if they were well rested.

But could the boy wait until morning? For now he was stable physically, but what about mentally? What if he panicked, grabbing at the skewer? That would force their hand before they were prepared. Everything depended on his state of mind.

Dr Ebersole asked the doctors in paediatric ICU, where Xavier and his family waited, to talk to them and gauge whether he was brave enough to hold on. When Dr Ebersole heard back from the hospital at about 11:30, he made his final call of the evening. “We can wait until tomorrow morning,” he told a relieved Dr Kakarala. “The boy is on board.”

It took both doctors longer than usual to get to sleep; each tossed and turned as they ran through various scenarios. It could go either way.

The Long Night

It was late now, almost midnight, and Xavier’s ICU room was dim. He’d just told doctors and his parents he could stay calm a few more hours. He understood that his life depended on him not trying to pull out the skewer.

He remembered a scene from the movie Black Panther, which the whole family had gone to see. At the end, the hero, T’Challa, impales the villain, Killmonger, with a spear through the chest. Killmonger declares he’s ready to die, pulls the spear out, and collapses dead.

During the drive home that night, Xavier asked about that scene, which had confused him. “So he died because he pulled out the spear?”

“Yes,” his mom said. “If you’re ever stabbed with something sharp, leave it be and get help.”

“Go to sleep, Bear,” his mom told him now, holding his hand as she had almost non-stop since the accident. His head was still wrapped in gauze. The four-pronged end of the skewer was still caked in mud; everyone had been afraid to try to clean it, lest it jiggle the skewer and cause injury. They could only give him painkillers, which made him sleepy, but not sedation; that could cause the tongue to collapse, suffocating him.

“When you wake up in the morning, this thing will be out,” a nurse told him. Gabrielle and Shannon knew they wouldn’t be sleeping that night, but they hoped their son would. Unfortunately, he slept off and on. Each time he woke up he asked, “Is it out yet?”

“No, not yet, sweetie,” Gabrielle would have to tell him, her heart wrenching. Xavier cried softly each time he heard this, then he would ask them to play his favourite Cory Asbury spiritual song, ‘Reckless Love’. They listened to it several times that night and prayed together.

It was dawn when nurses removed the gauze from his head, in preparation for surgery. For the first time since they’d arrived at the Harrisonville hospital some 15 hours earlier, Gabrielle was able to look into Xavier’s blue eyes. She was overwhelmed with love as she and her son connected. “You’re the strongest person I know,” she told him, her eyes brimming with tears. Xavier replied, “Coach says be the hammer, not the nail.”

For Gabrielle and Shannon, watching him being wheeled into the surgery unit was one of the hardest things they’d ever had to do. Would they ever see him again, ever feel the squeeze of his hand? They just held each other and cried.

The Dilemma

“The biggest problem is that barbed end,” Dr Ebersole told the team assembled at 8:30 a.m. in the angiography suite. He pointed to a computer screen; the image on it was an X-ray they already had, which showed the skewer had a notch in the shaft near the point. If they pulled the skewer out the way it went in, the notched tip could rip an artery open. “So, do we push it through?” Dr Ebersole wondered aloud.

X-ray showing the skewer embedded in Xavier's head (Photo courtesy KU Hospital)

It wasn’t the first time he’d had to be very creative. Once, he’d had to seal a blood vessel in the brain of a three-week-old baby with medical superglue, because it was in a spot that surgery couldn’t reach.

Medical superglue had never been used on the brain of someone so young. The team snaked a tiny catheter up to the ruptured vessel and delivered a drop of the glue through it. It worked.

Now, they talked through the idea of pushing the skewer through the back of Xavier’s head to expose the notched end and cut it off before pulling it back out through the front. They decided against it. Breaking the end off the metal skewer would take a lot of force. The movement this would create—they’d likely have to use a surgical crowbar or orthopaedic slap hammer—could cause arteries to break. Even if they successfully broke off the tip, the new edges might not be smooth, and a burred edge could slice something on its way out.

They’d have to pull it out the way it went in—if that were even possible to do without killing him.

One floor below, Dr Kakarala was with the anaesthesiologists, putting a breathing tube into Xavier so he could be anaesthetized with flurane. The skewer had gone through his jaw muscles, and Xavier couldn’t open his mouth widely enough to insert a tube, so the doctors would thread it through his nasal passage and down his throat. This is painful for adults, and worse for a child as the passages are smaller. “I’m sorry, but this is going to hurt,” Dr Kakarala explained gently.

“OK,” Xavier replied.

They numbed his nasal passages and started the procedure. Xavier didn’t complain, even when they struggled to get it around the sharp corner at the top of the nasal passage. “You’re doing great.” He’s a real trouper, Dr Kakarala thought. It took about 40 minutes. Finally, Xavier could be put under—and they’d get a look inside his head.

Xavier was wheeled to the angiography suite about 10 a.m. Meanwhile, his family and many friends were in the waiting room. Some watched their smartphones and tablets; word had spread about Xavier’s accident that Sunday morning, and the Baptist church they attended broadcast prayers live on Facebook for Xavier. In fact, Gabrielle and Shannon heard that every nearby church was dedicating that Sunday to praying for Xavier.

A Lucky Kid

In the angiography suite, about 20 surgeons, specialists and nurses wearing blue radiation-protective gear and lead-lined glasses were waiting. Some had met with Dr Ebersole earlier. He was in charge. The boy was transferred to the operating table and about a dozen little wires with fine needles were pierced into Xavier’s scalp; they would continuously monitor the brain’s electrical activity. If there was any decrease in activity, the technologist stationed in the corner of the room would alert the surgeon.

Two giant ‘arms’, one attached to the floor and the other to the ceiling, were positioned close to Xavier’s head. Each arm held two X-ray devices that moved in wide arcs around his head to create three-dimensional images. The images appeared in real time on a large flat-panel display hanging from the ceiling just above Xavier.

Drs Ebersole and Kakarala could now see the one-in-a-million trajectory the skewer had taken: It had missed his spine by less than two centimetres. It had missed the cerebellum, located at the bottom of the brain, which controls functions like balance and speech—also by less than two centimetres.

It had punctured the carotid sheath, which contained his hypoglossal nerve and vagus nerve, which control tongue function, swallow reflex and voice box, but didn’t appear to have damaged them. Also in the carotid sheath is the jugular vein. The skewer had torn the jugular, but it appeared to have occluded, or sealed itself, against the skewer. The skewer had missed his facial nerve, which controls facial expression and the sense of taste.

Most importantly, it missed both the carotid and the vertebral arteries. In fact, it appeared to have nudged them out of the way—without puncturing them. I don’t know how a kid can be so lucky, thought Dr Ebersole.

They took a break to discuss next steps. They weren’t worried about the jugular being pierced; yes, it might re-open when they tried to pull the skewer out, but veins carry blood away from the brain. They could easily stop that bleeding. It was the two arteries that carry blood to the brain they needed to focus on. If the sharp edges of the skewer jiggled or rotated even a bit on the way out, it could break them.

“We need to be ready to do a bypass,” said Dr Ebersole.

To prepare for that possibility, they’d need to open up his neck. Dr Kakarala made a six-centimetre incision just under Xavier’s left jaw and exposed the neck vessels. The flaps of flesh and muscle were held aside by surgical ties—yellow rubber tubes with hooks on the ends. Then, he tied one blue rubber band—vessel loops—around each of the jugular, vertebral and carotid vessels; he was ready to cinch the loops if one started bleeding.

Meanwhile, Dr Ebersole prepared a microballoon—a long, thin, flexible catheter with a balloon on the end—that, in an emergency, he could inflate inside an injured blood vessel to temporarily stop the bleeding. He threaded a second catheter into Xavier’s femoral artery in his left leg, up past the iliac arteries in his pelvis, into the aorta, through his abdomen, then straight up towards the neck to his vertebral artery. This catheter was for shooting contrast dye into the boy’s vessels constantly as the skewer was being pulled out, so the team could see if any vessels leaked blood.

“Let’s Go”

The team was now as ready as they’d ever be. Dr Ebersole was standing beside Xavier’s midsection, closest to the imaging monitor so he could watch as the skewer came out. Dr Kakarala was up near the neck, where he’d have to constantly stoop to watch the exposed vessels—through the surgical magnification glasses he wore—and be ready to pull those loops. Now they had a view of things from inside and outside.

Chief Resident Dr Jeremy Peterson, a burly 32-year-old, was standing near the boy’s head. He had already removed the mud-caked prongs that were screwed on with two wingnuts. Though nobody had discussed up to that point who was actually going to attempt to pull out the skewer—there was no rulebook for this situation—Dr Peterson thought it might fall to him, as he was training under Dr Ebersole. And Dr Ebersole had faith in him. He said now, “Jeremy, put your hands on that thing, get a feel for how easily it’ll move.”

Dr Peterson, a little nervous inside but with very steady hands, placed his left hand at the base of the skewer to anchor it, while his right hand grasped just above his left hand. He nudged it back and forth ever so slightly while Dr Ebersole watched on the screen in case the movement harmed a vessel; it barely moved. “It feels pretty solid,” Dr Peterson said.

“OK, let’s go,” said Dr Ebersole. He’d be the eyes, watching the monitor constantly and shooting contrast dye, while Dr Peterson would have the feel of the thing as he worked on getting it out. He’d have to do it slowly, strongly, yet smoothly, mostly from his right arm, while being careful that his left ‘base’ hand didn’t exert too much pressure because it was literally on Xavier’s eye.

Dr Kakarala had one hand on Xavier’s face to help steady his head. Dr Peterson decided to sort of squeeze with his right hand while simultaneously pulling up with the same hand in small increments from the bottom—as if squeezing toothpaste toward the top of a tube.

The skewer was surprisingly hard to budge. It took all the strength in Dr Peterson’s right arm. Then it did move about a couple of centi-metres—and stopped. “It feels stuck on something.”

“Okay, hands off,” ordered Dr Ebersole. Dr Peterson carefully let go of the skewer and took a half step back, while Dr Ebersole enhanced the view and asked the electrical technician, “How are the signals?”

“Stable,” was the reply.

The clearer picture showed that it wasn’t stuck on a vessel; it looked like it was hung up on a neck ligament, not a danger. But the skewer was now so close to the vertebral artery that it was bending it.

“Jeremy, I need a new vector; angle it a little towards you.” This would move the skewer away from the artery. Dr Peterson did as asked, and Dr Ebersole started shooting more dye while watching the monitor. Looks like it’ll clear that now, Dr Ebersole thought. “OK, go again,” he told Dr Peterson. It worked. Dr Ebersole watched the tip of the skewer safely pass the vertebral artery.

“Clear,” said Dr Ebersole.

“Hands off.”

Now Dr Ebersole had to remove the catheter docked in the vertebral artery at the neck and navigate it into the carotid artery, so that when the skewer got to that stage, he could shoot dye into it and watch. That done, it was time for Dr Peterson to start pulling again. “It’s sliding pretty easy now,” said Dr Peterson. Yet he continued to pull it very slowly, especially as it passed the jugular. Would it pull open the seal that had formed? It didn’t; the jugular had healed itself.

Then, finally, the last hurdle: the carotid artery. The rod passed it smoothly, too—and suddenly, it was out. Dr Peterson quickly put his finger in the hole, in case blood started gushing out. It didn’t.

Good News

A cheer went up from many in the room—but not from Drs Kakarala, Ebersole or Peterson. It was out, but had it uncorked anything? The next minutes were tense as they watched the monitor for bleeding and waited to see if the brain’s electrical signals changed. They were relieved to see there was no brain bleeding, and the signals remained steady. They still wouldn’t relax until Xavier was conscious and they could know he was definitely unscathed. But for today, they were done; it appeared that the boy was out of danger and unharmed.

It was 3 p.m., just after the surgery, when Dr Ebersole, looking elated, came into the waiting room and told Xavier’s parents simply: “It’s out. He’s okay.” There was a cheer from the crowd of family and friends, and lots of crying and hugging. It was the happiest moment of Gabrielle’s and Shannon’s lives. “Can I hug you?” Gabrielle asked Dr Ebersole, and she did.

“There were no complications,” Dr Ebersole told them. “It’s one in a million. It missed everything important on the way in. And we got it out without any damage. I’ll never see this again.”

When Xavier came out of the anaesthesia a short time later, a Spider-Man Band-Aid covering the wound on his face and with stitches along his neck, he asked, “Is it out?” Yes, it’s out, his parents told him. His eyes filled with tears as he looked out the window. “That sunshine, it’s so beautiful.”

Left to right: Shannon, Teah, Chayah, Gabrielle with Xavier and his dog Max

***

Nowadays, Xavier often grabs the leash to take Max for walks—he’s no longer scared to walk the dog alone. And when he gets a scrape or has a mishap, instead of going straight to a ten on the pain scale, like he used to, he’ll look at his mom calmly and say, “This hurts pretty bad.” “Is it skewer bad?” Gabrielle will ask, and Xavier will laugh—crisis over.

The only evidence of the skewer is a tiny bump beside his nose and some numbness on the left side of his face. He’s doing well in school and wants to be a doctor someday. He had to miss the rest of football season, but as junior coach he helped younger kids get oriented and run drills.

He’s still friends with Gavon and Silas, who were rescued from the wasps by emergency personnel who aimed their hoses at the swarm. Gavon ended up with 150 stings, while Silas, who had knelt to pray, had just one, on his arm—and that entire arm swelled from an allergy he hadn’t known about. He, too, was lucky to be alive.