The Warrior Princess: Emily Ruckle fights final surgery

Emily Ruckle arrived at Children’s Hospital of Philadelphia clutching root-beer flavored Chapstick.

Two years after a pit bull nearly severed her right arm during an attack in the family home, the 10-year-old braced for her 12th surgery. She would smear Chapstick on the anesthesia mask to hide the dreaded medicine-like smell she associates with surgery.

"You know you're a frequent flier when you bring your own chapstick," her mother, Maria Ruckle of Newark joked as the family waited in the surgical suite.

Doctors hoped this procedure would give Emily more mobility, more dexterity. She couldn't lift her right arm over her head, make a fist with her right hand or grasp her cell phone with her right hand. Picking up whisper-thin pieces of a board game required so much concentration her face burned red with exertion.

Still, Emily did not want to endure another surgery. And she made the case that her arm worked fine, that 11 prior surgeries had saved her arm and repaired enough nerve damage to give her a normal life. She worried it might go wrong.

"They said maybe it will mess with the nerves and it might, like, hurt me," Emily explained in the weeks before returning to CHOP for the final surgery. "So I don’t want any chances of it."

Earlier in the summer, plastic surgeon Ines Lin gently moved the fingers on Emily's right hand to show her and her parents how all four would bend in unison if a tendon transfer surgery was successful. Tendons are strong connective tissues that attach muscles to bone.

In a tendon transfer, surgeons take a working tendon and attach it to tendons and muscles that have nerve damage. Over time the attached tendons fuse together, giving a patient more motion.

In Emily’s case, the tendons would be taken from her right arm.

Securing movement in the thumb would be more complicated, Lin said, but with luck and physical therapy, Emily had a realistic chance of using her right hand to grab and hold objects.

Emily stared into space and brought her legs up to her face. She bit her knees as her parents agreed to the surgery on Aug. 19, one week before Emily started fifth grade.

Todd and Maria Ruckle were certain they had made the right decision. One was the best chance Emily had to be able to use her right hand after the attack.

The day of surgery, nurses applied root-beer Chapstick to Emily's anesthesia mask. But it didn't do its magic this time, and Emily began to panic and cry as the anesthesiologist covered her face.

"Nice, deep, breathing," the anesthesiologist cooed. He removed the tube through which the medicine was applied.

“See?” he said, again placing the mask over her face. Emily relaxed. Then he attached the tube.

Deep breath, he said, "just like a dive in the pool."

Emily's eyes fluttered and slowly closed. She’s asleep. Again.

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One month earlier, on a sweltering day in July, Emily, already sunburned from too much time at Wildwood, New Jersey, turned bright red at A.I. duPont Hospital for Children in Wilmington.

She scrunched her nose and squinted her eyes as she willed her left hand to grip a small game board piece and drop it in a tray. It was as if the piece, about the size of a quarter, weighed 100 pounds.

Emily’s first 11 surgeries left a build-up of scar tissue in her shoulder, which is stiffer and inhibits movement. Therapists at A.I. carefully massaged her shoulder and arm to break up that scar tissue. And martial arts classes helped train both sides of her body, strengthening both arms equally.

Therapist Tracy Shank worked with Emily on reawakening nerve impulses by having her do everyday activities such as tying shoes. Shank rubbed a green pom-pom and materials on Emily's right hand to see if she could feel the sensation. Some worked, others did not.

STORY: Paying for Emily's bills: $3M due, state chips in

Emily has fearlessly stared down her injuries. One day, she did somersaults on the exam room table, careful that her arms did not touch the table. Another day, as her mom helped her get dressed for Taekwondo, Emily announced to her parents: “I can sort of do a cartwheel.”

They smiled nervously in response, happy that Emily's childlike zest for life was returning. But they did not want Emily's energy to cause an unintended injury.

"More time has to pass before we let the daredevil in her to come back out," Todd said.

Casual observers see little evidence of trauma in Emily. Since the mauling, she’s gone from 59 pounds to 83 and sprouted long, limber legs and sinewy arms that help her bend, twist and spin through the day.

The attack did nothing to dim her infectious personality and determination. Emily is not phased by the word "no" from her parents, and uses her rehabilitated arm to hug her mother extremely tight and poke her dad in the stomach.

The fifth-grader is not afraid to wear a bathing suit or pose for pictures with her family. Her biggest challenge, she said, is making it through common core math.

The horror of the attack made Emily's parents realize how fragile life is, and they pushed to create new family memories. They’ve taken Emily on cruises, to Disney World, to the Poconos and to Rome and Turkey – a recent trip inspired by her love of the Magic Tree House novel "Vacation Under the Volcano." Hawaii is now on the radar.

Emily has become comfortable again around most dogs, including those in her home. She remains uneasy about pit bulls, although therapy has helped. At the University of Delaware’s Ag Day in April, Maria was shocked to watch Emily pet a pit bull.

Her parents aren't so trusting of pit bulls. They advocate for stronger animal control laws such as mandatory insurance for dog owners. After the attack, the Ruckles received letters from pit bull advocates, Maria says. One wrote that her daughter should have been shot instead of the dog.

The last surgery

On the morning of the 12th surgery, Todd proved to be a good distraction as the family waited for Lin: He split his shorts along a seam in the crotch. Emily gave him the eye and collapsed in laughter on the gurney.

"It didn't fully rip," Todd groused, looking down at his khakis.

Emily cradled an iPhone in her injured right hand, her index finger and thumb fixed in a straight position. Because of nerve damage, the fingers would not curl over the phone to fully grip it.

Emily talked nonstop and played games on her phone to ease her nerves. Freddy, a new stuffed friend won at Wildwood, sat next to her.

She would not be getting "giggle juice," a medicine given to kids to help them relax before going into the operating room, Emily announced. The taste reminded her of spoiled bubblegum mixed with vomit, she said.

Lin appeared in baby blue scrubs, her engagement and wedding bands on a chain around her neck, and she tried to calm Emily’s nerves.

"How are you doing?" Lin asked, grabbing Emily’s left hand and holding on. This would be Lin's second surgery of the day.

"I'm scared," Emily said. Dressed in royal blue soft cotton pants and a short-sleeved pullover printed with pictures of planets, Emily's eyes looked glassy as Lin explained the surgery – one more time.

Lin stamped Emily’s right hand with a red X and placed that hand over a white blanket so she can intently study it. In addition to the tendon transfer, Lin planned to work on scar tissue to make it look better.

Emily played with Freddy, rubbing his cheeks as Lin finished debriefing the family. Nurse Nicole Peck wheeled Emily to the operating room as her parents reached for one more hug, Maria burrowing into Emily's face.

"I'll be here when you wake up," Maria said.

The operating room smelled like Clorox, and Emily’s mood suddenly changed. Her pupils grew wide as she eyed the pile of scalpels and scissors. She looked around, the apprehension in her face apparent.

Someone shouted out that Emily was allergic to adhesives. Nurses draped a warm blanket over Emily then belted her to the stretcher.

After Emily was sedated, music mixed with the beep, beep, beep of the heart monitor and other machinery.

"Treat You Better" by Canadian pop idol Shawn Mendes crackled to life through the streaming Pandora station. Nurses propped up Emily with yellow foam rollers and placed another layer of blankets over her.

"Freddy gets a mask," Lin said, even though Emily isn’t awake to see it. He would also be fitted with a red cast on his right arm, just like Emily.

At 9:24 a.m., Lin injected a steroid into scars on Emily’s left shoulder to soothe inflammation and smooth the wound. She also cut into a small scar on the outside of her forearm so it could be resown, improving its appearance.

Lin examined a six-inch silver raised scar on Emily’s right forearm, and marked it. This would be the entry point for surgery.

The doctor's cut revealed yellow fat, muscles and tendons, remarkably like a picture out an anatomy textbook. Using glasses with microscopes fitted over the lens, Lin poked through tissue in search of working tendons. She pressed on tendons to determine which would respond to stimuli.

Lin tied nerves with blue string as a marker. She found the tendon attached to the index finger and moved it so she could sew it to tendons connected to muscle that fires the middle, ring and pinky fingers.

If this procedure worked, Emily would be able to bend her fingers and make a fist. All fingers would move together. Lin pressed on the recently tied tendon and the fingers moved in unison – like a scene from a Frankenstein movie.

The thumb was up next. Lin made a small incision near the outside of Emily's wrist and sewed the thumb tendon to another that controls the elbow and wrist. These tendons help the thumb curl into the palm.

Ninety minutes into the surgery, the tendons had been fully transferred and the wounds were cauterized to control blood flow. Emily had five new sutures on her arm and a fiberglass cast that prevented her from moving her elbow, wrist or fingers.

The had to stay on for at least a month, then Emily would need a splint and light physical therapy.

"She's a tough cookie," Maria said when Lin warned them that Emily would be sore following surgery.

When Maria and Todd were permitted to see Emily, she was out of it, in pain and angry. She told her parents, again, that she was happy with the way her arm was before.

And she demanded a watermelon Popsicle. A nurse suggested cherry.

"I don't like cherry," Emily wailed, overreacting in the fog of anesthesia. By 3:15 p.m. that afternoon, the family was back home in Newark.

The next day Emily ached, but she refused pain pills. She asked her dad to wear a matching red cast, which he made at home and happily attached to his arm.

Emily's cast was scheduled to come off on Sept. 14, so the family snuck away to their cabin in the Poconos for Labor Day.

When they returned, school was in full swing. Megan, Emily’s half-sister who was with her when the pit bull attacked, had already begun her senior year at Newark Charter.

Megan is considering a career in medicine and has looked at colleges outside of Delaware. But she may choose the University of Delaware because it’s close to home and Philadelphia’s medical schools. Plus, she reasoned, if she chose UD, Emily could occasionally spend the night at her dorm.

The sisters have become closer since the attack, and routinely hop between each other’s bedrooms at home.

“I know that I did a good job because Emily doesn’t harbor any bad feelings,” Megan said. “Even though I always feel responsible, but I know Emily’s not upset about it.”

Neither likes to talk about the attack and they rarely bring it up. So Megan was surprised when, on a late-night drive to Wawa before that final surgery, Emily nonchalantly asked: "Where were we going on that walk before I was attacked by the dog?"

The girls have relived bits of the bloody episode through a sister shorthand of musings and sometimes off-hand comments.

"That's how I deal with it," said Megan, now 17. "I just talk to Emily. She's really the only one who knows exactly what happened."

On Sept. 14, Emily is back on an exam table at CHOP. This time, she’s dressed in her Newark Charter uniform: a light pink polo and tan skort, a skirt with shorts attached.

She does not talk about the surgery or the cast. And she clearly does not like the small hand saw a technician used to cut off the cast, which made the room smell like burning glue as layers of gauze are peeled back.

The technician fitted Emily with a white sling and sent the family in an elevator to Lin.

"I can feel my hand," Emily said as she walked the hall. "I've been waiting so long for this to come off."

"You've been waiting four weeks," Maria said in the practiced tone of a parent with a dramatic child.

"It's a long time for a kid, mom," Emily countered.

Todd has fantasized about this moment. Maybe Emily could play field hockey. Or pursue her dream of riding horses.

It would be amazing if she could just grip her iPhone with her right hand.

Lin, too, is excited. She cut off the gauze and instructed Emily to bend her fingers.

Slowly, deliberately Emily willed the fingers to bend. She also curled her elbow and brought her hand to her face. He thumb curled into her palm, just as the surgeon hoped it would.

Maria’s and Todd’s eyes widen and turn glassy. But they don’t cry. They’re proud. Their warrior princess defied odds again.

Lin warned them that Emily will have a slow recovery and need to do specific exercises to ensure movement in her hand. Other than the exercises, Lin said, Emily should not use the hand much.

The trampoline would be forbidden, Todd immediately warned Emily.

Emily slid off the table and walked over to the mirror in Lin's office. She held her arms out in front of her, her hands down by her waist, and compared her arms from different angles.

Scars curled like faded henna tattoos from her upper chest to her armpit to a six-inch wave on her forearm. Skin puckers a bit around her right shoulder.

But her bulging bicep muscle isn’t as pronounced, and her arms looked almost equal in size.

Satisfied, she smiled, then said, "It sort of looks normal again."

SPECIAL REPORT: SAVING EMILY'S ARM

PART 1:  THE ATTACK

PART 2:  THE HOSPITAL

PART 3:  THE FINAL SURGERY

Contact Jen Rini at (302) 324-2386 or jrini@delawareonline.com. Follow Jen on Twitter at @jenrini.