Savage pit bull attack leaves complicated case for Newark girl

Todd Ruckle thought he was driving to Philadelphia to pick up his daughter’s body.

He had seen 8-year-old Emily as she was being loaded into a helicopter at A.I. duPont Hospital for Children in Rockland to go to the Children’s Hospital of Philadelphia. Her skin had turned yellow and clammy, and all he could think about was a corpse in a casket.

An hour earlier, Emily had been attacked by a 100-pound pit bull named Frank that lived with her half-brother in the family’s Newark home. Her right arm was left hanging by a strip of flesh, and she bled profusely.

A.I. immediately transferred her to Children's Hospital of Philadelphia.

Emily’s parents, Todd and Maria Ruckle, were stunned to learn their child had been savagely attacked while they attended a wedding. Drowning in guilt, they screamed at each other while speeding along I-95, searching for directions to CHOP on their smartphones.

Word spread fast about the attack, and family and friends peppered their cellphones with inquiries about Emily. Each ring turned off the GPS, and they got off at the wrong exit in Philadelphia.

"It was just pure chaos," Maria said of Saturday, Sept. 27, 2014.

Finally around 3:30 p.m., two and a half hours after Emily was horribly mauled, Todd and Maria rushed into CHOP's surgical waiting area still dressed for the wedding —Todd in a tuxedo, Maria in a sparkly red dress.

Emily was already in surgery. Her sister, Megan, who had been with Emily when the dog attacked, had left A.I. duPont Hospital and was now at a friend’s house in Newark. Maria's son Jack had met them at A.I. duPont when Emily arrived, but he returned home to clean up his room and throw out his mattress, covered in Emily's blood.

Todd sat by his parents in CHOP's surgical waiting room. He blamed his wife for bringing the dog into their home. He blamed himself for not being able to protect Emily.

He and Maria sat on opposite sides of the waiting room slumped over in chairs, their cellphone batteries now dead.

"He wouldn’t even speak to me," Maria said. "I sat in that waiting room by myself."

Todd doesn’t remember it being that dramatic. He said he sat by a computer so he could have contact with the outside world.

On television, Todd and Maria could see Philadelphia news stations airing reports about the attack. On the screen appeared a picture of their home, cordoned off with yellow crime tape. Maria's ex-husband was interviewed about his pit bull named Frank, which two months earlier came to live with the Ruckles when the ex moved out of town.

Anxious waiting stretched into the evening. Todd stripped down to an undershirt, and Maria kicked off her heels.

Every two hours they got updates from Emily's surgical team. Late in the evening they were told that Emily would survive, but her arm might not be salvageable.

Todd and Maria took to Facebook to keep family and friends informed:

Todd, 5:20 p.m. Sept. 27, 2014: My daughter is alive and will survive. She has 4 to 6 hours of surgery with three different teams of surgeons. We are praying we can save her arm. I am truly in need of love and support. Please send every ounce of positive thoughts right now. 

Mauling sends Newark 8-year-old on journey to save her arm

Dr. Ines Lin, a reconstructive and plastic surgeon, was at her Bryn Mawr home 30 minutes from CHOP when she got an emergency call about a bad dog bite to a child's upper arm.

Lin, who was eight and a half months' pregnant on the day of the attack, raced to the hospital.

"This is by far the worse one I have ever seen," she said.

Lin usually talks to the family before operating. But with Emily's life imperiled, there was no time.

Dr. Joy Collins, a trauma surgeon at CHOP, led the team of doctors and nurses that prepped the 8-year-old, wrapping the wounds in gauze. Two IVs were placed in Emily's left arm because the right arm couldn't support an intravenous line. The team's top priority was ensuring that Emily was breathing and able to survive the surgery.

“We were worried about blood loss,” Collins said.

Emily was assessed for rabies and given a shot to ward off infection. By the time Lin saw Emily, orthopedic surgeons had pinned her fracture together with two bolts — but the arm was a cool, light blue color, indicating a lack of blood flow.

Lin had to act quickly or Emily would lose her arm.

A complete amputation is easier to reattach because doctors can cool the extremity. Cooling prevents tissue damage and gives surgeons more time to operate.

When a severely damaged limb is still on the body, it’s more challenging to maintain blood flow. If muscles and nerves don’t get blood flow within six to eight hours of a major trauma, tissue could die. And even the most delicate surgical movements can harm existing vessels and tissue.

Lin was worried.

"There were definitely times I wasn’t sure we were going to do it," she said.

Out in the waiting room, Todd and Maria had finally stopped slinging recriminations at one another. Their daughter would live, and they knew they needed to be a team for their little girl. At midnight, Emily was still in surgery.

Todd, 12:10 a.m. Sept. 28, 2014: We are waiting patiently. Thank you again for all your prayers.

Doctors had to cut through muscle and tissue to find Emily’s brachial artery, located near the armpit and feeds the arm and hand. When they finally found it, they realized part of it had been shredded and was dark red — a sign of clotting.

To keep blood flowing, doctors tried twice to hook a 12- to 14-centimeter vein from Emily's right thigh to the artery in her arm to rebuild the area damaged by clots. Using a microscope Lin and her team made small sutures, or stitches, about as thin as a strand of hair to sew the vein to the artery. The second time took.

Lin also performed a fasciotomy, a procedure that involved cutting tissue and skin surrounding the arm muscles to allow swelling. That way the muscles would not be restricted when the blood began to flow again.

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The surgeon can't remember precisely when, but Emily's arm gradually moved from blue to pink, a sign the blood was flowing.

Yet that created another problem. To stop the clotting the team gave Emily blood thinners. Now the side effect was excessive bleeding, which had to be contained.

An 8-year-old's body contains only about 2.3 liters of blood, less than a gallon of milk. But during surgery Emily lost 8 liters of donated blood, meaning she essentially bled out four times in the first 12 hours after the dog attacked.

To Todd, it seemed like everything went wrong. But finally they got good news.

Todd, 2:16 a.m., Sept. 28, 2014: Emily has two more hours in surgery. She will not lose her arm, however, she will most likely losemost use of it. In time and a few more surgeries she may have some movement. I am beyond happy she is alive and I hope to see her soon.

Surgery finally ended around 4:15 a.m. — 13 hours after the dog attacked. But no one was celebrating.

Todd, 7:24 p.m., Sept. 28, 2014: Tonight is the critical night. There are issues with fluid in her lungs from all the blood transfusions. Her heart rate isalso too high. She continues to be in a medical coma. They are still picking up a heartbeat in her hand which is good news. If she has no issues tonight she will be going through a second surgery tomorrow morning. 

When Todd and Maria saw Emily, her face was swollen and bloated, her brown eyes shut. She was hooked up to nine machines including a ventilator, respirator and feeding tube. Her chest thumped so violently it looked like her beating heart could crack her ribs.

White gauze was draped over her arms, shielding most of the surgeons' work. Metal rods stuck out of her right arm in open cuts still fresh with blood.

Maria held her little girl's hand while the couple prayed. Maria stayed up all night watching the pulsometer register Emily's blood pressure, anxiously breathing when the numbers dropped.

Emily didn’t open her eyes until dinner time two days after the attack, when she heard her brother Jack's voice.

Maria, 6:34 p.m., Sept. 29, 2014: She's responding by nodding and shaking her head. So happy! 

Todd dreaded what Emily would say when she could talk. He expected her to feel guilty because she knew he did not like her handling Frank.

Still struggling to breathe, she said softly and slowly, drawing out each word, "Daddy, I'm so scared. And I'm so ... sorry."

"I lost it," Todd said. "I couldn't stop crying."

The couple didn't leave the hospital for days. Friends brought toothpaste, shampoo and food. Three days later, friends finally convinced Maria to get out of her sparkly dress and into the shower. Her son Jack had hurriedly grabbed clean clothes, for which Maria was grateful.

"But I'm in sweat pants and a thong," she recalled. "I told him next time, 'Grab the granny panties, please.'"

During the first seven days in October, Emily was in and out of the operating room for three surgeries and to have her wounds cleaned to prevent infection.

Maria, 7 a.m., Oct. 1, 2014: Overnight her temperature dropped — we had to put her in a warmer — but it could be a sign of infection. Won't know for about 24 hours until the cultures come back. She's much more responsive, but she's getting worked up about wanting to go home, not wanting to miss school and she's thrashing. 

Todd, 5:17 p.m., Oct. 1, 2014: Emily is coming in and out of consciousness. She wakes up and she does not know where she is. We explained about 50 times where she is and she says how scared she is. She said she feels trapped in a house. She still cannot breathe on her own. 

Todd, 8:32 p.m., Oct. 1, 2014: By the end of the night I figured out that she is reliving the attack. She keeps screaming I do not want to die. I am no longer me. All we can do is tell her she is safe and we love her. 

Intravenous lines were placed on the top of Emily’s feet and the top of her hands, and she screamed every time the lines were changed. As she improved, the equipment she had been tethered to was removed.

But her damaged right hand began to spasm, prompting fits of screaming.

Maria, 10:21 p.m., Oct. 6, 2014: I have never felt more helpless in my life 

Yet, at times, Emily was still Emily. She could still beat her dad in a game of Go Fish. She demanded a cheeseburger or chicken sandwich and a vanilla Frosty with fries.

By Oct. 7, Emily was well enough to move to CHOP's fourth floor in a private room with a cot and bathroom. Mom and Dad took turns spending the night on the cot.

The Ruckles made friends with the family of a little girl down the hall, who also was in for a long stay. She lived with a congenital condition that caused deformities in her chest. Maria and her mother would walk the floor or go down to the cafeteria to grab coffee.

Doctors kept Emily pumped with painkillers, resulting in "morphine mumblings," Maria recalled. The little girl thought she was in Minecraft, an online adventure game she adores. She flip-flopped between giggling and having panic attacks. She would screech, "No, no, no, no, no," and then demand, "How do I get out of this room?"

Once Emily looked over and saw Todd sitting by her bedside.

"Dad, you are bouncy," she said. What about her brother Jack, her parents asked. Both men are broad-shouldered and stocky.

She called Jack "Earth," a name that stuck for a while.

Nurses came in hourly to check Emily's vital signs. They equipped her with a Nerf gun so she could shoot the orthopedic resident and sometimes her dad. To get her to take her medicine, another nurse joked she would sit on her if she didn't do as instructed.

Emily's right arm was immobilized in a white sling, with braces on her wrist and elbow and tape on her upper arm and shoulder. Every three days her arm was washed, suctioned and dressed in moist gauze.

Little victories meant a lot. Todd and Maria cheered when Emily could finally sit up on her own.

Megan, Emily's half-sister, occasionally rode the train from Delaware to visit. But Megan mostly coped by focusing on school, trying to forget the dreadful day of the attack. She got straight A's on her report card.

Emily's hospital room overflowed with teddy bears, Auntie Anne's pretzels and visitors. A family friend gave her a hot-pink blanket with the words written in purple thread: Emily Warrior Princess.

She was a warrior then and will forever remain one, her parents say.

Emily had been in her private room only a few days when Lin began to consider surgery to restore connections between the nerves in Emily’s shoulder and arm. She worried it was too soon after restoring her blood flow, but she knew she had to try.

Emily’s posterior nerve cord, which stretches from neck to shoulder, survived the attack. That was fortunate because the cord controls movement of the triceps muscle, and some movement in the fingers and wrist.

But three major nerve branches were damaged: the median, musculocutaneous and ulnar nerves. Median nerves help control the small muscles in the hand while the ulnar gives sensory and motor function to muscles in the elbow and some fingers. The musculocutaneous helps with motion to flex the biceps and elbow.

Lin sees nerves as cables that must be connected for a signal from the brain to activate the muscle or appendage. The ideal way to fix nerves is to sew them back together. But if the nerves can't be directly hooked together, doctors must find cables to reconnect the circuit.

The gold standard is to surgically remove nerves from somewhere else in the body and transplant them to the injured limb. But Lin said that's always a tradeoff: If doctors take a nerve from the ankle, for instance, it will have less function.

Emily needed two sections of nerves in her arm — one 11 centimeters long, the other 14 centimeters. Lin ruled out taking that much nerve function from another part of the body.

Instead, she turned to frozen, donated cadaver nerves. Cells are completely stripped from the cadaver nerves, but proteins are left so that a patient’s own nerve cells can regenerate once they are stitched to the cadaver nerve.

This would be the first time Lin used cadaver nerves for a child. She was worried the procedure would be risky because she had to work around the reconstructed artery and blood vessels. There was a chance she could damage them and set back Emily’s progress.

"If it worked then it was a bonus," Lin said.

Fourteen days after the pit bull attack, on Oct. 10, 2014, Emily was set for nerve graft surgery.

It took about 15 minutes to thaw the cadaver nerve; the surgery itself took more than five hours.

First surgeons sewed together four pieces of cadaver nerves — two to make the 11-centimeter nerve bundle and two to make the 14-centimeter nerve bundle.

Finding Emily's existing nerves was an arduous process. Surgeons cut into her shoulder and lower forearm. They used sutures with glue to attach the cadaver nerves to Emily's nerves, nestled between muscles and arteries.

Surgeons then transplanted skin from her right thigh to cover the wounds in the back of her arm and around her shoulder.

The surgery went well. A surgical fellow who sat in on the procedure described it as a miracle. Nerves in Emily's right shoulder opened up like fingers saying, "please attach me," the fellow told Todd.

Yet Lin was hesitant to call the procedure a success. It takes one month for nerves that have been completely severed to regenerate 1 inch.

For an injury like Emily's that reaches a shoulder, regeneration could take up to three years, Lin said. Doctors prepped the family for the worst, saying it would be unlikely Emily will ever regain the lost nerve function.

Maria felt sick.

Maria, 1:34 a.m. Oct. 11, 2014: Todd expected her to be waking up moving her fingers, but that won't happen for months, if ever. I'm overjoyed that she's alive, but I'm mourning the loss of my Emily. Her young life will never be the same. She will never be a gymnast, or compete insports, or play the guitar that sits in her room. She probably won't be able to hold her child without help. 

Emily's nerve graft surgery marked the halfway point of the girl's 32-day hospital stay at CHOP. Todd and his wife had started taking turns driving home to settle medical bills and go to work.

The medical bills climbed to about $3 million. However, the family qualified for Delaware's Children's Community Alternative Disability Program, which helped supplement Emily's hospital bills after she was discharged from the hospital. It saved their home and financial future. They happily paid more than $10,000 out of pocket for services such as therapy, bandages and medication.

Todd, 11 a.m., Oct. 13, 2014: It was gut-wrenching leaving Emily this morning. I cannot wait to get back to her tomorrow morning. This morning right before I left she spiked a high fever. 

During the final weeks of October, Emily had more surgeries on her right arm — bringing the total to nine.

Eventually, she could get out of bed to play games, walk and Skype her third-grade classmates at Newark Charter. She enjoyed visitors. But her parents were worried about the four-legged variety. A pet therapy dog, a golden retriever named Hunter, came to visit. Her parents watched anxiously. Emily swallowed him in one-armed hugs, Hunter's nose nestled in her neck.

Thirty-two days after she was admitted, on Oct. 28, Emily went home. She had a police escort and visited the Newark Police Department to pick up trading cards with pictures of the officers.

Four days later, Dr. Lin gave birth to her second child, a daughter.

Emily's trauma wasn't a clean injury, like a cut with a sharp knife.

"This was a mauling, so the lacerations weren’t clean," said Tracy Shank, Emily's hand therapist at A.I. duPont Hospital for Children. "There were puncture wounds. You don't expect those recoveries to be good."

Emily needed to rest in the first three months after her hospital stay so the blood vessels and tissues could heal. That meant limited movement — difficult for a child with a lot of energy.

To improve her range of motion and to regain sensation in her arm and hand, she needed therapy to retrain her brain. If the nerve and brain are not in sync, over time motor function decreases as well.

"You almost lose the impulse to want to use the hand," Shank said. "The brain's image of the hand has shriveled."

Emily would ultimately see Shank nearly every week at A.I. duPont, but all agreed to wait until after the holidays to begin therapy.

Emily returned to school. Todd and Maria went back to selling homes.

On Thanksgiving 2014, the family took time to reflect.

Todd, 8:26 a.m. Nov. 27, 2014: I am so thankful for my daughter still being with us and everyone that helped us through this journey. Thousands of people prayed for her and our family. So on thisThanksgiving I want to say thank you to everyone. Hug the ones you love and tell them how you feel. We are only here for such a short period of time. 

On Christmas Eve, the family received a particularly special gift. Emily began to feel hard touches to her arm.

By January she had a breakthrough: During her first session at A.I., her right arm snapped back at the elbow and flew toward her, smacking her hand against her face.

She had no control, but she had movement.

"I was laying down, and it went like this," Emily demonstrated one day last summer, making a goofy wide smile and twisting her arm so her hand slapped her face.

She worked so hard and made progress fast. Lin was shocked when she saw Emily for her six-month follow-up.

Todd and Maria recalled the doctor saying, "'Nothing I did did this. This is her body reworking.'"

To which Emily responded: "I'm a kid!"

SPECIAL REPORT: SAVING EMILY'S ARM

PART 1:  THE ATTACK

PART 2:  THE HOSPITAL

PART 3:  THE FINAL SURGERY

Jen Rini can be reached at (302) 324-2386 or jrini@delawareonline.com. Follow @JenRini on Twitter.