When Lightning Strikes

An emergency room doctor faces a summer nightmare

By Pamela Grim|Thursday, August 01, 2002



An old-fashioned Midwestern thunderstorm had been brewing throughout the afternoon, making the paramedics' radios cut in and out. All we knew was that they were bringing in someone who had been hit by lightning.
    That's the kind of disaster that gives an emergency room physician nightmares, a potentially fatal accident she has never been exposed to before.
    "Well?" Vicky, the charge nurse, stood waiting for me. Don't panic, I told myself, lightning equals electricity, and I did have hands-on experience with people who had been shocked by an electrical circuit. The week before, I'd seen a construction worker who had somehow grabbed a very live high-voltage wire. It was so bad the paramedics had called him in as a "crispy critter." Lightning couldn't cause anything worse than that, I thought. It's the same process— an avalanche of electrons temporarily hijacking some human body part in order to complete a circuit.
    So lightning is like an electrical injury. Then I asked myself: But how is it different? I had to reach back into elementary physics. Lightning is direct current (DC), and the charge is extremely fleeting, lasting only a few milliseconds. The victim is zapped and that's pretty much that. Electrical injuries, on the other hand, are usually caused by alternating current (AC), with electrons producing a current that just goes on and on until the person becomes physically disconnected from the source. Alternating current can actually be more dangerous than direct current. Any kind of electricity causes muscles to contract. But human flexors, the grasping muscles, are stronger than extensors, the ungrasping muscles, so often the victim can't let go and break the circuit. That's what happened to the construction worker. The current caused his casual grasp of a piece of wire to become a death grip.
    Still, there is nothing trivial about the power of lightning strikes. A single bolt generates 20,000 to 40,000 amperes of raw energy and 200 million volts or so— enough energy to produce a temperature about four times hotter than the surface of the sun.
    The guy's a goner, I told myself before the ambulance even got him to the hospital. à
    Then the medicine started coming back to me. Lightning can overwhelm the intrinsic circuitry in both the heart and the brain, causing the heart to seize and the brain to short out so severely that breathing stops. After the strike, though, the heart can often stage an immediate comeback. But the brain, especially the part that governs breathing, takes longer to recover, sometimes a lot longer. Someone struck by lightning may have full cardiac function, and yet die anyway if the respiratory center can't recover fast enough to restore normal breathing.
    A raw clap of thunder, then a baritone barrel roll of its echo. I heard the ambulance backup warning signal, and the paramedics rolled through the door. A man sat on the gurney, bolt upright and apparently unscathed.
    All of us were caught by surprise.
    "Dammit!" the man roared. "You're just standing around, and I've been hit by lightning."
    He glared at all of us, arms crossed, furious.
    I closed the intubation kit and took off my gloves.
    "Are you the doctor?" he shouted at me. "Look at my hand. Just look at my hand."
    He waved his right hand in front of me. It looked a lot like the rest of him, no visible damage.
    "My hand is numb," he bellowed. "Numb, I tell you."
    "What's your name?"
    "Frank," he shouted back.
    "Frank, do you have any medical problems? Allergies? Frank?" He wasn't listening. He was distracted by Shawna, the nurse who was undoing the buttons of his shirt and preparing him for an EKG. She asked him, "What's it like to be hit by lightning?"
    "It's loud," he shouted. Maybe Frank was shouting because he was partially deaf— perhaps from the lightning strike itself. "I was just walking across the parking lot and then— ka-boom— there was this gigantic spark right next to me and then it was like someone poured light all over me." He shook his head, then pointed toward his feet. "My feet are numb, too."
    I was more interested in his ears. The current of a lightning strike causes only some of the possible injuries. Thunder can also cause damage because the energy in the electrical discharge displaces air, creating a sound wave that can rupture structures in the ear. We hear this wave as a clap of thunder. And thunder had gotten to this man's ears. His left ear was bright red, with a puncture in the left lower corner of the drum.
    Vicky had just finished working off Frank's wet T-shirt when I saw his skin.
    "Feathers . . ." I said, pointing.
    "Feathers?"
    "Feather burns."
    "Burns?" she asked.
    "Not burns. Not real burns."
    I traced the pattern of a branching red rash that lay like a lace collar over Frank's shoulders. Also called lightning rash or, more poetically, Lichtenberg's figures, it is not really a rash or a burn at all. The figures, named after the 18th-century German physicist who studied them, are actually patterns formed by electrical current.
    Frank said he had gone to the market for some lightbulbs, and it was just beginning to rain hard when he left. He was nearing a rack of shopping carts in the parking lot when he heard a tremendous crack. It sounded as if the lightning had hit the metal rack and the strike had then spread to create a flash burn. Even an indirect strike, however, can be deadly. Most likely, Frank had been saved by the flashover phenomenon, which happens when lightning's electrical current completes its circuit by passing over the skin instead of straight through the body. If you're lucky, this results in a minor singeing of the topmost layer of the skin, which is a relatively decent conductor for electricity. When the path of the current travels through the body, the bones, nerves, and muscles get nailed, which means serious trouble.
    But what did I really know about lightning? Did Frank come through without a scratch, or had I missed something? And just how lucky was Ben Franklin when he flew that kite in 1752?


Click on the image to enlarge (47k)
Strike Zone: The average number of lightning strikes in various parts of the United States from 1996 to 2000. The number of strikes in a given region can vary from year to year, but the Southeast, particularly Florida, is the most vulnerable area.
Map courtesy of Vaisala

Not all scientists agree how lightning works, but all agree that crucial to the phenomenon is the separation of positive and negative charges within clouds, often the result of warm, low-lying air being forced upward by an incoming cold front. This division of charges allows the negative charges pooled near the base of a cloud to attract positive charges on the ground or water. The union of the positive and negative current results in an electrical connection, or strike point. When the connection is made, an intense positive charge travels upward at one-third the speed of light, which creates a neon-bright flash.
    About 50 lightning bolts strike the ground every minute in the United States. Yet the National Oceanographic and Atmospheric Administration reports that in the United States, only 300 or so lightning strikes each year involve humans. That works out to roughly one injury for every 83,000 lightning strikes. Among documented cases, about 23 percent died. But there are no uniform methods of reporting, so figures are guesswork. The hardest hit state is Florida, where lightning strikes are estimated at more than 1 million a year.
    Typically, the greatest share of victims are those who have used a tall tree or other prominent structure as refuge during a thunderstorm. Other victims are on open water, often in boats or swimming. The best way to avoid a lightning strike, of course, is to heed storm warnings. But if you are caught in a sudden storm, remember a few rules. First, don't allow yourself to be the tallest thing around, and don't get close to the tallest thing around. If you are on or in the water, get off or out. The best shelter is a large, substantially constructed building with intact, well-grounded wiring and plumbing. Once inside, avoid contact with electrical devices that have a conducting path to the outdoors, such as corded phones and plumbing. If a large building is not available, get into an enclosed vehicle with a metal roof and sides. The metal frame will conduct current around the vehicle rather than through it.
    If you are caught unprotected, avoid isolated shelters, wire fences, aboveground pipes, tractors, or other equipment. In wide-open spaces, find a valley, ravine, or depression in the ground. In wooded areas, seek shelter in dense woods or a growth of small trees. If the threat is imminent, use the lightning crouch: Squat down, tuck your head, and cover your ears. To minimize ground contact, some people recommend balancing, if possible, on the balls of your feet. If you are in a group, spread out to minimize the chance of multiple injuries from side flashes. When the immediate threat has passed, head for safety.
    Give CPR to any person hit by lightning who is not breathing or has no pulse; recovery is possible even if there are no signs of life. Common early complications involve the heart's rhythm mechanism and the brain's neural functioning. Others may involve the ear, with symptoms ranging from vertigo to deafness. The eye may also be involved— cataracts are a classic complication. Long-term problems can be protean and may involve any organ system. The most devastating complications are neuropsychiatric: sleep disturbances, anxiety, pain, nerve damage, fear of storms, depression.
    Benjamin Franklin was a very lucky man, I decided.
    I looked over Frank's EKG for rhythm abnormalities— none. Then I went over him from stem to stern.
    My only findings so far were sensory complaints, except maybe a little short-term memory loss. Five minutes after I'd shown him three objects to recall, Frank could remember only two. I found nothing else. Yet I was sure that something was wrong, something I couldn't put my finger on, maybe some microscopic change in protein configuration that would manifest itself years from now, some subtle shift whose outcome I could only guess. I imagined Frank's brain as intertwined crystals laced by rivulets of neurons, with the bright light of current flickering through, tweaking the amygdala, gliding through the pons, tickling the cerebellum.
    So after all this drama, we ended up just sending him home. Diagnosis: struck by lightning. His eardrum would heal, and his rash and numbness would probably fade away. I decided that if I had missed something, I would probably never know it. But I was wrong. I got a hint while I was sitting in the cafeteria having a cup of coffee several days later. A surgeon rushed by. He was talking on a mobile phone and eating a bagel at the same time. He slowed when he saw me.
    "Hey," he called back, "you had my neighbor in the emergency room the other day. You know— Frank Riley," he called as he turned to back through the door. "He's the pastor of our church. One hell of a nice guy." x


Survivors
A bolt from beyond can change your life permanently

By Barbara J. Paulsen


"I was 48 going on 35," says Michael Utley, a lightning strike survivor and former world-class windsurfer. "Now I'm 50 going on 75. I wake up in the morning and I hurt for two hours."
Photograph by Greg Miller

"They thought I was dead," says Michael Utley. He was playing golf at a charity tournament on Cape Cod on May 8 two years ago when the skies let loose with thunder and rain. Utley was suddenly on the ground, smoldering. "I was carrying my putter, and the electricity just blew my zipper off, went through my groin, down my legs, and knocked off my shoes," he says. He had to spend 38 days in an intensive care unit at Brigham & Women's Hospital in Boston and two months at HealthSouth Braintree Rehabilitation Center. "I couldn't walk. I couldn't bend my fingers. I couldn't even drink water." The lightning had damaged his brain, much as a stroke would have. He had to learn how to walk again, how to swallow again, how to live again.
    I met Utley at the 12th annual Lightning Strike and Electric Shock Survivors International World Conference in Pigeon Forge, Tennessee. Before the accident, he had been a vice president at PaineWebber and a world-class windsurfer. Since the accident, he is on leave from work, walks with a limp, and is frequently in pain. And now he has learned something else: Others here have told him the worst problems may show up three, four, five years down the road.
    Unlike Utley, most of the 225 victims attending the conference did not have a catastrophic injury that required months of hospitalization. A number were struck inside their home while on the telephone or in the shower. Many of them never went to the hospital after they were zapped. And yet weeks or months— sometimes years— after a strike, they had begun to notice a cluster of baffling symptoms called post-electrocution syndrome, which includes irregular heartbeat, heightened startle response, sleep disturbances, and panic attacks. Many suffer from memory problems, seizures, and chronic, debilitating pain in their arms and legs, usually from damage to the peripheral nerves.
    "People who are struck by lightning often won't have any entry or exit wounds and yet suffer very serious neurological injuries," says Bradley Sewick, a neuropsychologist at Spectrum Rehabilitation Centers in Southfield, Michigan. "And a lot of the symptoms have a delayed onset, which can make it difficult to diagnose." A CT scan, EEG, or EKG performed right after the injury will often be normal. It's only later that a PET scan or results from neuropsychological tests may hint at the full damage.
    A handful of neurologists are piecing together an explanation for these lingering problems. The thinking goes like this: Once in the body, electricity follows the path of least resistance, which is the network of nerves, arteries, and veins leading to the heart, the brain, the spinal cord, and the gut. Depending on the severity of the lightning strike, some nerve cells throughout the body may be killed immediately, resulting in acute problems. But the delay of symptoms is thought to be caused by a process called electroporation, in which the electricity causes tiny holes in the membranes of nerve cells. Like a colander trying to hold water, the cell can't keep nutrients in or wastes out, and it eventually dies. When enough cells are killed off through this slow-motion death-by-drainage, the patient begins to notice the onset of various neurological difficulties.
    "I feel cold one minute and am sweating the next," calls out one woman when the audience is asked to name some of their symptoms. Everyone nods. "I have fainting spells," says a burly-looking man. "Me too. I get disoriented and panicky when I'm under the least bit of stress," says a young woman in the back of the room.
    Many of the symptoms are thought to result from damage to the autonomic nervous system, which seems to be particularly vulnerable to electroporation. The autonomic nervous system regulates most of the body's involuntary activities, such as heart rate, digestion, sexual arousal, and temperature control through the communication of the sympathetic and parasympathetic nerves. When this smoothly coordinated system stops working correctly, "your blood pressure might drop to nothing and you pass out," says Blair Grubb, a cardiac electrophysiologist at the Medical College of Ohio in Toledo, who has treated about a dozen lightning patients. "Or else your heart rate will go way up and you get stressed, sweaty, light-headed, anxious. Anyone would say you're having a panic attack." As a result, many lightning patients can end up in the psychiatrist's office.
    But the cognitive problems can be the most troubling. Tests of electrical injury patients commonly show average or above-average intelligence and verbal ability but very low scores for memory, concentration, and organization. A schoolteacher with an electrical injury says her doctors tell her she is lucky she can dress herself and live a normal life. "They say my IQ for most things is average. But I've never been average in my life," she says. "It's so hard living with a stranger when that stranger is you."
    Exactly how much of a recovery patients can expect is unclear. Some improvement often occurs, says Sewick. Patients turn to neural surgery, cognitive rehabilitation, psychotherapy, proper medications— and hope.
    Utley, for example, relies on medications to push down the pain long enough to continue his rehabilitation. And he just keeps checking items off his list of things he needs to relearn. He has played golf again. Last summer, he put training wheels on his bicycle and learned to ride again with his 3-year-old daughter, Sonia.
    One day toward the end of summer, his wife, Tamara, watched from the window as he took her bicycle— the one without training wheels— on his first spin down the hill toward the ocean. "I cried like a mother cries when I saw that. You should have seen the look on his face," she says. "He was just like a kid. It was such a look of total excitement— and sheer terror."


Some details in this article have been changed to protect the patient's privacy.





For facts about lightning, see www.howstuffworks.com/lightning.htm.

The Lightning Strike & Electric Shock Survivors International Web site: www.lightning-strike.org.


ADVERTISEMENT
Comment on this article
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT
DSC-CV1017web
+