Pain, gratitude and a long fight back

His halo was a cage, and all Johan Otter could do was stare out through the carbon graphite rods that pinned his head in place.

If he slept, he dreamed, and the dreams bordered on nightmares. He lay in a passageway somewhere between a gym and a locker room. People came and went. He didn’t mind the traffic, only he was puzzled by a black object in the middle of the room. It looked like the Batmobile, dark and sinister. What was it?

Uncertainty brought a tinge of adrenaline and a flood of panic. Trapped by this metal contraption locking his head to his shoulders, treatment for a broken neck, he couldn’t move. The walls of Harborview Medical Center in Seattle closed around him. He tried to find the call button, but it was lost in the bedding. He was alone. He screamed for help.

Morphine for the pain. Valium and Ativan for the anxiety.

Prescriptions were easy. Patience was the hardest part, and though he had been trained as a physical therapist and knew all about the challenge of recovering from trauma, he still found himself spiraling into restless despair. He asked a doctor if he was going to die.

“No way,” the doctor said. “You’re going to live. You’re already over the hump.”

Six days before, on Aug. 25, 2005, Johan, 43, and his daughter Jenna, 18, had been hiking in Glacier National Park. She had just graduated from high school in Escondido. It was a father-daughter trip, and they had surprised a grizzly bear and its two cubs on the trail to Grinnell Glacier. Trying to flee, they had fallen about 70 feet down a rocky cliff.

The bear had followed. For 15 minutes, it attacked them savagely, especially Johan, who stood between it and Jenna. Shivering, cold and in shock, they spent nearly six hours on a mountainside as the National Park Service worked to rescue them by helicopter. Johan was the first one lifted off.

At Kalispell Regional Medical Center in Kalispell, Mont., the first place he was treated, the doctors were shocked that he had survived. His mauling was the worst they had ever seen. He had no scalp. From his hairline to the base of his neck, the bear had torn off everything. There were teeth marks in the cranium. A muscle was detached from his right eye, where there was a blowout fracture. He had broken ribs. His body was pockmarked with deep lacerations and puncture wounds.

When a bear attacks defensively, it behaves like a nipping dog. The bites are quick, deep and incessant. But in fighting to shield Jenna, Johan had enraged the bear, so that each bite became a shake, extending some puncture wounds into longer, ragged gashes. The bear’s jaws were so strong that its teeth plunged deep enough to tear connective tissue from muscle. The teeth stopped only at the bone.

Johan was also at risk for a fatal infection from bacteria in a bear’s mouth. He was given a tetanus shot and started on Rocephin, an antibiotic favored in treating bear attacks.

He was relieved to be off the mountain, to know that Jenna was safe and would soon be arriving at the hospital.

Thank you. Thank you so much. He kept thanking the hospital staff because it was all he could do. The bright lights and hovering doctors felt familiar, reminiscent of Scripps Memorial Hospital in La Jolla, where he worked. And he was clean, the blood and dirt removed.

How had he ever created so much trouble for everyone? He was sorry for that. He never thought of himself as deserving so much attention, especially from complete strangers.

X-rays and CT scans confirmed that his spine was broken in two places: at the base of his skull and at the prominence below his neck. The news unnerved him. This could mean paralysis. If he lived, would he walk again? Would he ever return to his favorite activity, running?

By the time Jenna was taken into the Kalispell emergency room, the medical staff had decided to send Johan to Harborview. His injuries were too complicated for Kalispell. As attendants wheeled her in, they brought the two gurneys side by side. Jenna had a jagged laceration on the right side of her face from her mouth to her chin. She also had a deep wound on the right shoulder and one on the back of her head.

They unstrapped her head, but her neck was too sore for her to look at him directly. Out of the corner of an eye, she saw his bandages. She started to cry.

“Thank you,” Jenna said, for saving her life, and then, “I’m sorry.”

AT Harborview, Johan lost himself in a whirl of exams, tests and X-rays. He stared at the array of IV hangers on tracks dangling overhead and waited for surgery. He closed his eyes, his head wrapped in bloody bandages, and when he opened them again, his wife, Marilyn, was standing there. She had caught the last flight out of San Diego and taken a shuttle to the hospital. It was midnight.

“I’m sorry,” he said, starting to cry.

“There’s nothing to be sorry about.” She reached for his hand.

Johan believed that he had hurt Marilyn, hurt her because he hadn’t been able to protect their daughter, hurt her because Jenna was still at the hospital in Kalispell, 350 miles away, hurt her because he, too, was hurt. He felt accountable.

“I don’t have my gift for you,” he said. Her birthday had been two days earlier. Earlier in the trip, he and Jenna had bought her some photographs of the Grand Tetons at an art fair in Jackson, Wyo., but they were in the truck and the truck was in Montana.

Marilyn started to cry. “You are my present.”

The nurses left the room.

“Is Jenna OK?” he asked.

“Yes.” She didn’t want to worry him.

“I was fighting for her,” he said. “I tried to protect her.”

“It’s all right,” she said.

The emergency room staff brought in a heater blanket, known as a bear hugger, and gave it to Marilyn. She wrapped herself in it and continued to hold his hand.

I’m safe now, he thought. It wasn’t until 3 a.m. that he was rolled into an operating room. The surgery lasted eight hours. Wherever the bear had bit him, the surgical team assessed the damage and, whenever possible, removed traces of contamination and cleaned the edges of the wound, cut away dead tissue, cauterized blood vessels and, most important, left his wounds open for daily monitoring and cleaning.

Afterward, a plastic surgeon consulted with Marilyn. He warned her again about the risk of infection.

She broke down. On the way from their home to the airport the night before, she had seen on the side of a freight train a sketch of the grim reaper. It was an image she wouldn’t forget.

AS Johan lay on his back in intensive care, wet bloody gauze on his head, saline rolling down his neck, he thought through a haze of helplessness how much he wanted to be normal again. He wanted to run, stretch his legs and feel his body working in easy motion.

He knew the first obstacle was his fractured neck. Every time he was moved — for X-rays, for surgery — he feared the worst. Please be careful, he said.

He had a fracture of the second cervical vertebra, often called a hangman’s fracture. It was in the same part of the neck that Christopher Reeve broke. Johan’s fracture had five distinct breaks, the probable result of the bear shaking his skull. He also had a fracture of the sixth and seventh cervical vertebrae that was even worse. On film, it looked as if someone had tried to push one vertebra onto the other, causing a misalignment that could irreversibly damage his spinal cord.

For such fractures, there were two treatments: fusing the bones in a surgical procedure or wearing a halo. From the beginning, Johan insisted on a halo. He had worked with patients with upper spine fusions. He had seen how limited their range of motion was. He considered it nothing less than a lifelong disability.

But a halo gave him hope. Fractures could heal, scar tissue could serve as cartilage and, in time, if it worked, he could be himself again. His orthopedist agreed. Fusion would be their fallback position.

Johan was happy when an orthopedics team brought in the shoulder harness, halo ring and supporting rods. They pulled the curtain around his bed, propped him up and started to set screws into his skull.

The pain was instantaneous. Johan gasped. They had forgotten to apply lidocaine, a numbing solution.

They backed out the screws and gave him four injections: two above the eyebrows and two behind the ears. Then they torqued the screws into his skull to 8 inch-pounds of pressure. The pain was far beyond the reach of the lidocaine. Johan thought he heard bones crack. It was a feeling he’d always remember. His head felt as if his skull would split like a walnut. Then came a raging headache, a feeling of claustrophobia and panic attacks.

The best he could do was count his birds. Back home, Johan bred exotics in aviaries outside his house. He imagined how he might pair them up. He considered genetic tables and color mutations, the more difficult and complicated the better, anything to get his mind out of the moment.

But the moment never ended.

LYING in bed, soothed by the Ativan, Johan watched the sweep of the second hand on a wall clock to his right, then the minutes and the hours. He became untethered and drifted and slept and dreamed, certain that the day had turned to night, and the night to day — but only an hour would have passed, sometimes just 15 minutes. A day took a week, tomorrow forever.

As helpless as he felt, lying in bandages, unable to move, he knew that everything was happening for the best. Call it stoic optimism. It was something he’d learned growing up in Amsterdam, where the boys in the neighborhood teased him and the jokes turned to fights. He stood his ground and never let anyone know how much the punches hurt. The experience toughened him, taught him to be resourceful and adaptable, to focus on what he had and not what he lacked.

Marilyn buoyed his spirits with her steadiness. She had taken a leave of absence from the high school where she taught, and she adapted to life at Harborview. When Johan craved something fresh to eat, she walked to Pike Place Market and bought blueberries and blackberries. She held his hand the day that Nicholas Vedder, chief of plastic surgery, introduced himself and explained how he planned to reconstruct his scalp.

“We need to remove the latissimus muscle,” Vedder said, “and transplant it to cover your skull.”

Johan knew this meant the latissimus dorsi, a long muscle on the back that extends from the armpit to the hip. The transplanted muscle would provide its own active blood circulation.

“And our success rate is around 95%,” Vedder said. He also mentioned the risks: excessive blood loss, complications from the anesthesia and, of course, clotting that could lead to the loss of the transplant.

Johan reached for Vedder’s hand and squeezed it. He was grateful to be alive and to know that his daughter was all right.

“Good luck,” he said. “I trust you.”

Vedder checked his schedule. He had an opening in the morning.

VEDDER began by making a 3-inch incision just in front of Johan’s right ear, where he found a small artery and vein network known as the superficial temporal. For three hours he worked, separating the vessels from the dense and fibrous tissue that surrounded them.

Meanwhile, the surgical team prepared Johan’s skull, which for five days had gone unprotected and exposed. Grinding it with a burr until it began to bleed, they brought it back to life.

Now Vedder cut along Johan’s back. Slowly separating the latissimus dorsi from connective tissue that held it to his rib cage, the team lifted this flank steak-like muscle from Johan. Vedder dissected the connecting subscapular artery and vein.

The clock was running. The team had two hours to reinfuse the muscle with blood or it would die. They flushed it with blood thinner, bathed it in an icy saline slush and stretched it like taffy over Johan’s scalp. The contour wasn’t perfect, but Vedder knew that as it atrophied from disuse, the muscle would conform to the bony surface of the skull.

An 8-foot-tall surgical microscope was wheeled in. Looking through a lens that makes a human hair look like rope, Vedder connected the subscapular vessels to the superficial temporal vessels. Each is no wider in diameter than a cocktail straw. Each took 20 stitches. As Vedder pulled them together, the blood vessels bunched up as if they’d been hemmed with a gathering stitch. The bunching would act as a seal.

Then Vedder removed the clamps. Blood from Johan’s carotid artery pulsed through the array of vessels, then infused the muscle. A Doppler probe beside the vein picked up the whooshing sound, like gusts of wind. For the next week it would serve as an audio-warning system. Silence would mean a clot had formed and the transplant was in jeopardy.

Vedder and his team covered the muscle with skin from Johan’s right thigh and stapled it in place. Johan Otter had a new scalp.

Ten hours had passed. He awoke in recovery and was soon wheeled into what the hospital called the Tropicana Room, heated to 80 degrees. Anything colder might make the blood vessels constrict and the blood clot.

Johan lay sweating under a single sheet. He painted pictures in his mind of Glacier National Park and the Grand Tetons. How he loved that stretch of highway from Jackson Hole, Wyo., to Yellowstone National Park where the Rocky Mountains rose from the open plain in jagged grandeur.

Would he ever see it again?

“DAD, I need to thank you for saving my life.”

He looked up into Jenna’s face. He remembered thinking how healthy she looked, and she was smiling. He had expected worse.

Jenna had flown in from Kalispell the day before. Marilyn had met her at the airport gate, where they held each other for the first time since the attack. Jenna made a joke about how good she looked, what with her swollen face, her arm in a sling, her back in a brace, holding a cane and walking with a limp. Her mother smiled.

You don’t need to thank me, Johan said, but her words made him proud. They told him that she understood what he had tried to do, that there was no recrimination or blame, no “why did you take me hiking there?”

Johan was transferred to a private room. He had grown accustomed to it all — the intrusions, the tests, the constant interruptions — and he was making progress. He walked on his own. He watched music videos on television and tried to exercise his legs.

His only setback occurred during another surgery, when the ophthalmologist couldn’t find the torn muscle behind his right eye. It had contracted too deeply into his skull. But Johan refused to be discouraged.

Not that life as a patient was simple. Being dependent on others never was, but Johan managed. Perhaps his stoical nature helped. Perhaps his inherent optimism. Perhaps it was his experience as a physical therapist or his training as a marathon runner.

Or maybe it was the spreading reputation that he was the man who had thrown himself in front of a grizzly bear to save his daughter. As his story circulated in the hospital, staffers marveled and wondered if they could make the same sacrifice.

On Sept. 9, 15 days after the attack and just hours before a hospital plane would fly him and Marilyn home to San Diego, Harborview arranged a press conference. From the beginning, Johan’s story had caught the attention of the media. Bear attacks always do, and initially neither Johan nor Marilyn had wanted to talk. Now that he was doing better, they hoped to shut down speculation and curiosity by letting the story out.

Johan sat in a wheelchair, still confined by the halo, and answered questions. Marilyn knew he was something of a ham, and when the bright lights and cameras finally shut down, he turned to Vedder.

“How did I do?” he asked.

“You did wonderful,” the surgeon said.

Close to 800 newspapers and TV stations picked up the story. Howard Stern declared Johan, because he had fought a grizzly, a legitimate “bad ass.” Oprah, Ellen, Montel and Maury were soon calling.

Five days later, he and Jenna went on the “Today” show and “Good Morning America,” and the more he told the story of the attack, the more he found himself being cast as a hero for taking on a bear. It was a role he assumed with a curious combination of modesty and pride.

“A good attitude will only get you so far.”

Johan listened. No one had said this to him before. He was back at Scripps Memorial Hospital, but instead of walking the halls as an administrator, he was a patient.

“More has to happen. Like a lot of luck and healing,” said Scott Barttelbort, a plastic and reconstructive surgeon who had been asked by Scripps’ chief medical officer to check on Johan. The patient, he said, was “one of our own.”

Barttelbort’s exam begun with the scalp. Johan recalled how soft the doctor’s hands were.

A beautiful reconstruction, Barttelbort thought, but as he slowly tallied the wounds, he came to realize how severe this mauling had been. Twenty-eight lacerations, 28 opportunities for infection, which didn’t even count the flap, the torn eye muscle and the fractured neck. Recovery would be more complicated than anyone could imagine.

Johan found Barttelbort’s starkly pragmatic words strangely comforting. He liked Barttelbort, recognized his determined and knowledgeable manner and could see that the doctor took an interest in him as a person, not just a clinical case.

Scripps scheduled more surgeries. During the first, a reconstructive eye specialist found and reattached Johan’s torn eye muscle. The white and the purple orchids in his room had never looked better.

A new set of X-rays, CT scans and MRIs confirmed that the halo had stabilized the vertebrae in his neck. But Johan knew his trauma was not just physical.

Disassociation had become his protection. Nightmares lurked beneath each day’s progress. He kept them at bay by focusing on his life, on Jenna and on the good that had befallen them. One day, a psychiatrist came into his room for a consultation and noted that Johan appeared a bit “too happy,” that his affect, slightly hypomanic, was “mildly inappropriate.”

“I have had a lot of visitors,” Johan told him, adding, “I do not want anybody going away from here feeling bad.”

But by trying to make others around him feel comfortable, the psychiatrist concluded, Johan put on too many smiles, which could easily dissolve into tears.

Barttelbort was also concerned about Johan, who seemed to expect too much of himself. Barttelbort wondered if it was a problem that Johan was being attended to by co-workers and didn’t feel comfortable enough to let his guard down. Or that Johan had been cast as the courageous fighter of the bear and defender of his daughter.

Probably it was a little of everything.

AFTER nearly two weeks of daily wound management, Barttelbort decided it was safe to start closing some of Johan’s deeper lacerations, a process that required every puncture and tear to be enlarged, essentially made worse, in order for them to be sewn shut.

Heal and disappear were Barttelbort’s goals, for he knew that each visible scar would remind Johan of the attack, make him self-conscious and slow his integration into the world. He also knew that Johan was wearing down, so he worked quickly in the operating room, cutting and cleaning, judging how good the tissue was, how efficient the circulation, before closing each wound.

As the surgery wore on, Barttelbort knew he was exacting a toll. After six hours, nearly twice as long as expected, Johan woke up in the recovery room exhausted. Four days later he got up in the middle of the night, shivering, the first sign of an infection. Three weeks after the attack, he was still fighting the grizzly. By morning, he had a temperature of 101. Barttelbort put him back on wound care and reopened the wounds that looked the reddest and least healthy.

Johan was discouraged and scared. He knew too much not to be. His infection, known as methicillin-resistant staphylococcus aureus, occurs primarily in hospitals and nursing homes and kills more than 60,000 people a year. Fortunately, tests revealed that it hadn’t spread to his neck or skull, where he was most vulnerable.

Still, as Barttelbort watched Johan — with his halo, a patch on his eye, three suction machines purring away at his open wounds, with his multiple lacerations, a reconstructed scalp and a raw right thigh — he knew everything could fall apart in an instant.

But Johan battled back. A powerful antibiotic, vancomycin, delivered by way of a long catheter running from his arm to his heart, knocked back the infection, and on a Saturday, Sept. 24, four weeks and two days after the bear attack, he was discharged from Scripps. Marilyn had ordered a hospital bed for the living room, and as he lay there watching television, sleeping, slowly walking around, he came to realize what the grizzly had cost him.

There were trails he had hoped to hike in Glacier. There was his ambition to run in the Boston Marathon. There was his strawberry-blond hair, the muscle on his back, his daughter who was already away at UC Irvine. There was any illusion that life was predictable.

As he looked around, he saw other moments that he could not control, moments that can ruin expectations and tear apart all plans.

When his halo came off in November, he found himself crying alone in the car one day. He was scared to be normal and afraid that with the halo gone, he was more vulnerable than ever.

In January, he went back to work and found steady reminders of life’s fragility. During the first week, a colleague died. At the funeral, Johan saw himself in the casket.

Slowly, though, he found his confidence. He started to run again and to think more about the future. One weekend, Jenna came home from school. They went shopping and, for the first time, they didn’t mention the bear. They grew proud of their scars.

In the spring, he was invited to Kalispell to a banquet for the helicopter service that rescued him from the mountain. Before dinner, he took the stage and gave the opening prayer.

“Thank you, God, for giving me the opportunity to give this blessing for these individuals you brought to our rescue,” he spoke into the microphone. “Many of these people here are my true friends. Please guide their hand to reach and touch many more lives.”

In June, he ran in San Diego’s Rock ‘n’ Roll marathon, finishing in 3 hours, 39 minutes and 48 seconds. But it was nine minutes too slow to qualify for Boston. The next day he was depressed.

The bear still had him.

LAST summer, 11 months after the attack, Johan returned to Glacier National Park and set out again on the trail where he and Jenna had encountered the grizzly. He wanted to see Grinnell Glacier. Marilyn joined him, as did Gary Moses, one of the rangers who helped rescue him.

Johan wore the same running shoes that he had had on during the attack. He carried the same camcorder. As he hiked through the woods, a wave of familiarity swept over him. Past Lake Josephine, the sound of waterfalls in the distance broke the stillness. He remembered how quiet it had been when he and Jenna had passed through here, when all they heard was the wind and the water.

He took photos of wildflowers, marveled at the scale of the park and, as the trail rose in a series of switchbacks, he pointed to a moose walking below in the shallows of Grinnell Lake, its wake cutting a perfect V in the turquoise water.

He looked at the surrounding mountains. “It’s cool that we survived.”

He began to recount the story. Here is where I wanted to take another picture. Here is where Jenna grew impatient with me. Here is where I took that last shot of her.

He started to cry.

“I’m a little surprised at how emotional this is,” he said. “I don’t know why.”

He paused to gaze out upon a field of ankle-high wildflowers, the pink-purple tufts and candlestick blooms bending in a gust. In the distance stood a thick, ragged patch of alder scrub and elfin spruce.

“You know there’s a grizzly out there,” he said, almost in awe. After the attack, the National Park Service had determined that the grizzly was acting defensively and did not destroy it.

At the scene of the attack, Johan and Moses climbed down to the ledge where they had waited for the rescue helicopter. Before them stretched the great Grinnell Valley in all its immensity and silence. Zephyrs cut across the lake, its surface changing color in the wind and the shadows of the passing clouds. “It may seem weird to say this,” he said, “but I am glad that this is beautiful. It makes me feel that the battle was worthy.”

They continued along the trail, and at an overlook of the valley, he held the camcorder to his eye and captured the scenery. “OK, Jenna,” he said into its microphone, “this is what we missed.”

On the way back, he stopped again at the ledge. There was no bear. It was gone.

“It’s done,” he said.

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thomas.curwen@latimes.com