First of three parts
Raised in an affluent, loving family on the Main Line, Matt Miller was a straight-A student with a sculpted body that even a Greek god might envy.
He had a devoted girlfriend and the brightest future - shooting for medical school.
Matt was not without his vanities. He loved to wear sleeveless shirts to show off his shoulders and biceps, and his teammates on the University of Virginia swim team nicknamed him "Sleeves."
At college last fall, the 20-year-old pursued a new love - triathlons.
On Sunday, Nov. 2, a gorgeous autumn morning, Matt set out on an 85-mile training ride with two classmates.
They had the hubris of youth - they were going to pedal up mountains.
After their steepest climb, to an elevation of 2,640 feet at Reed's Gap, they paused to peel off a layer of clothing, eat an energy bar, and briefly savor their accomplishment.
That is the last thing Matt remembers of that day.
The trio then cycled north on the Blue Ridge Parkway, a two-lane ribbon in the sky, along the crest of the Blue Ridge Mountains.
Passing them going south was a caravan of 30 classic cars, taking a foliage tour.
About 10:30 a.m., at milepost 12.2, Matt lost control of his bike. He swerved across the double yellow line, and, as he fell, flew face-first, like a torpedo, into an oncoming Porsche, the second-to-last car in the caravan.
The driver of the last car saw Matt hit the Porsche, flip in the air, and land on the road - motionless, still clipped in to his pedals.
"That boy's dead," he told his wife, next to him in their 1970 MGB GT.
Just a moment earlier, celebrating at the summit, Matt Miller, so fit his resting pulse was 42, had believed he could overcome any challenge that life presented.
The driver of the MGB just happened to be Mark Harris, a 1978 graduate of Temple University Medical School and an anesthesiologist at Martha Jefferson Hospital in Charlottesville, Va.
In all his years in classic-car caravans, Harris, 60, had never gone last, in the sweeper position, with the responsibility of stopping for any cars that broke down and radioing up the line for help.
Had he been in any other position, he likely would have motored on toward brunch at the Peaks of Otter lodge, never knowing what had happened behind him, especially because the walkie-talkie given him that morning didn't work.
But he was last. And he was out of his car and at Matt's side in seconds.
Matt was alive, but barely.
"He was not breathing," Harris recalled, "and he was making the kind of posturing that indicates significant brain damage. He was bleeding out of his mouth and from his ear, which indicates a skull fracture. His face was completely crushed."
Harris assessed his options and made a "battlefield decision" to move aggressively.
"If he had a neck injury he might be paralyzed," Harris recalled. "But if I didn't do something to get him breathing again, he'd be dead."
Harris cradled the bleeding youth in his lap.
"His jaw was fractured on both sides and was completely loose," said Harris. "All his teeth were smashed."
Matt was unconscious. Harris turned him on his side so all the blood would spill into the doctor's lap rather than down Matt's throat. He cleared out all the broken teeth with his fingers, and then - what few people would have known to do - tugged Matt's shattered jaw forward.
"It's a painful stimulus," Harris said. "The idea is if you provide a painful stimulus, they will breathe on their own.
"I hurt him as best I could to get him to breathe."
Matt started to breathe.
"All these are basic strategies of airway management," Harris said. "They're not exceptional. They're things I happen to use on a daily basis in my medical practice."
That's one way of looking at it. Here's another, from Matt's father, Mike Miller:
"That Dr. Harris was in the last car, that he was an anesthesiologist, the best person in the world to open an airway, that he was there to save Matt's life - that is plain and simple a miracle."
Matt's fellow riders, Rudy Kahsar, president of the University of Virginia triathlon club, and Chris Morrow, saw the accident happen. The three had been riding single file, with Matt in the middle.
Rudy, in front, heard "a little something" as Matt struggled for control of his bike, and looked back. All he can figure is Matt got distracted by the vintage cars, drifted to his right, off the edge of the pavement, and overcompensated, losing control.
The Porsche had no time to veer or brake, and for a split second Rudy and Chris saw the inevitability of what was about to happen.
They reached their friend as Harris did. He told them to dial 911, which they did so many times in the next few moments that the 911 operator told them to stop calling.
Pulling Matt's jaw had triggered his fight-or-flight mechanism. Matt's brain sensed pain and started the body breathing to prepare for flight.
And that was what Matt tried to do - get up and flee.
Harris used his own legs to wrap Matt's legs in a scissors grip, to keep him from getting up and running, just like a wounded deer, into the woods, where he certainly would have died.
Rudy and Chris helped hold Matt down and tried to speak to him, but he was unresponsive. Rudy took off Matt's helmet, covered in blood but undamaged.
In 10 minutes, an ambulance from Wintergreen Fire and Rescue, about five miles away, arrived.
"I thought it was an eternity," said the doctor's wife.
"It felt like forever," said Rudy.
"It got there quickly," said Harris.
R.W. Woody, the medic, responded without his partner - and was grateful to find Harris.
Matt was thrashing and combative, which Woody took as a sign of brain injury. He instantly radioed for a helicopter.
His partner arrived moments later, and the ambulance raced Matt the mile and a half back to Reed's Gap, where the parkway was wide enough for a chopper to land.
As the ambulance drove away, Mary Ann Harris remembers her husband telling her: "I don't think he'll make it to the hospital."
Parents hear the news
Matt's parents, Nancy and Mike Miller, are Virginia alumni who had flown in from Philadelphia for the Virginia-Miami football game on Saturday, the day before.
Matt's older brother, Michael, also an alumnus and a student at Stanford Law School, had flown in, too.
Mike Miller had been annoyed that Virginia, in typical fashion, had lost the football game in the final moments.
"I got a better perspective on things quickly," Matt's father recalled.
After the game, Matt had told his parents that he wouldn't see them in the morning, that he'd be riding into the mountains.
"Just be safe," Mike Miller told his son.
The Millers were approaching the Charlottesville airport around 11 Sunday morning when they received a phone call from a very distraught Emily Privette, Matt's girlfriend since their senior year at Radnor High School, who had transferred to Virginia in September.
Rudy, desperate to reach Matt's parents, had gotten word to Emily via a chain of phone calls. She knew only that Matt had been in a terrible accident and was being flown to the University of Virginia Medical Center.
The Millers turned around and drove, in the longest ride of their lives, nine miles back to the hospital. When they arrived, the chopper blades were still turning.
The first person to greet them was a chaplain.
"I want to see a doctor, not a chaplain," barked Mike Miller, a managing director at Vanguard, the mutual-fund company in Malvern, who says he probably barked many things that day that he now regrets.
They were ushered into a private waiting room, not allowed to see their son, not given any information.
A doctor finally came in.
"Could our son die?" Mike asked.
The emergency room
A year earlier, in the fall of his sophomore year, Matt had decided he wanted to go to medical school.
At Virginia, undergraduates can sign up to shadow physicians around the hospital. But Matt had missed the deadline. So he called his father to ask for advice.
Mike Miller, who sits on the Board of Visitors of the Temple University School of Medicine, called its dean, John Daly, who - after a phone conversation with Matt - connected him with his good friend and chief of surgery at Virginia, John Hanks, who had missed a few deadlines himself over the years.
Hanks invited Matt to shadow him.
Many, many undergraduates start out in the shadowing program, Hanks said. But "nine out of 10" quickly decide medicine is not for them and stop coming. Others are blatantly angling for a letter of recommendation.
But Matt "struck it just right," Hanks recalled. He was earnest, respectful, and interested. "He bonded with everybody. Even the med students liked him. We sort of brought him in on the team, as the mascot."
Hanks happened to be working in his office that Sunday when Matt arrived in the emergency room.
"The trauma chief calls me and says, 'There's a guy that you know. He's an undergrad,' " Hanks recalled. "I don't know that many undergrads, and I can't imagine who it is.
"Holy smokes, it was Matt."
"He literally wasn't recognizable. His face looked like a pumpkin, pushed in on the left side."
J. Forrest Calland, the trauma doctor in charge of Matt's care, who had finished his fellowship in trauma surgery at the University of Pennsylvania in 2007, said Matt's face "was essentially soft, like mashed potatoes."
Had he put his thumb inside the roof of Matt's mouth and pulled, Calland said, Matt's whole face would have moved forward.
Calland, like everyone else, worried about brain damage. What had happened to Matt's brain, he said, "was the equivalent of throwing your laptop out the second-story window."
Hanks, understanding the severity of the injury, found the family in the waiting room and took Mike Miller back to see his son. If the father had not known that this was his son, he never would have recognized him.
"It was unbelievable a face could take that shape," the father said.
"We have to let the doctors do their job," Hanks told the Millers. "At this point, there's nothing we can do but pray."
Hanks did one other thing that afternoon. He knew the best man to rebuild Matt's face would be Stephen Park, director of facial plastic surgery at the university, who was leaving Monday morning for Tehran, Iran, to teach for a week.
Hanks asked Park to come in and operate on Matt's face before he left. Park assembled his team.
Mike and Nancy Miller, son Michael, and Matt's girlfriend, Emily, were numb. They looked for every positive sign they could.
If Dr. Park was going to operate on his face, did that mean Matt was going to live?
Doctors did CT scans and X-rays and found that every bone in his face was broken, but that he'd suffered no spinal-cord injuries - in fact, no damage anywhere below the head other than scrapes and bruises and a broken right hand.
Before the surgery, Mike Miller went out to the garage, where he had pulled illegally into the first spot, and decided he'd better make some calls.
His first was to his good friend Jack Brennan, the chairman and former chief executive officer of Vanguard.
The second call was to another close friend, Bill McNabb, Vanguard's current CEO and a bike enthusiast, who had biked once with Matt the previous summer.
His third call was to his parents. He wasn't sure how much to tell them. They're in their 80s, and live only two hours from Charlottesville. They wanted to drive up right away, but he told them no.
The Millers wanted answers. They wanted to know whether Matt would live.
But doctors repeatedly told them that first afternoon that 72 hours was the magic number. If Matt's brain continued to swell like his face, surgeons would need to cut off the top of his skull to give the brain room to expand, according to Jason Sheehan, the neurosurgeon caring for Matt. If this could be avoided and Matt could hang on through Wednesday, his chances of survival would dramatically improve.
"The goal was to keep him alive," Mike Miller recalled. "But everyone was wondering: Would he have a life worth living?"
Doctors that Sunday afternoon put Matt into a drug-induced coma. The theory was that the brain was taxed enough just trying to repair itself. Performing normal cognitive function - thinking - would be too much strain.
A burr hole was drilled into Matt's head so a probe could measure blood flow and oxygen in the brain. A feeding tube was inserted through his nose and down into his stomach.
Doctors performed a tracheostomy, opening a hole in his throat to make sure he had a clear airway. During surgery, when Matt would need a machine to breathe for him, staff could hook the ventilator right to his "trache."
About 8 p.m., Park, the facial surgeon, and his team began the operation.
It lasted six hours.
Nancy Miller fell asleep on the floor of the waiting room, her coat as her pillow. Her husband and older son tried to sleep in chairs.
At 2 a.m. Monday, Park woke the family. He told them that this was one of the worst cases he'd ever seen.
"Your son's face was like a piece of fine china," he said, "dropped from 20 feet."
Park had started reconstruction by lining up the few broken teeth that were left. Then the surgical team tried to realign the jaw and rebuild Matt's face, using titanium plates and screws. When there was nothing to attach screws to, the doctors just hoped the many tiny pieces of bone would grow around the titanium rods.
"You can't fix those bones," Park said. "You just hold it all together and hope they'll heal."
The family found one reason to smile. Park told the Millers that during surgery Matt's pulse was so slow it had triggered alarms. The heart monitor had been set to go off at 50.
"It only took a moment to see he was fine," said Park, "that he's some kind of athlete."
Park also told the Millers that two things had saved Matt's life: "his helmet and his face."
"What do you mean his face?" Mike Miller asked.
"His face was his air bag," Park said.
The face has a "number of air pockets," Park later explained, "and nobody really knows what they're doing there. Are they to lighten the skull, to help our voices resonate, or to act as an air bag? When you get a blow, that force is transmitted into the air pocket rather than to what is directly behind it, which is the brain."
After what they felt was great news from Park, the Millers checked into a motel a few blocks away.
At 7 a.m. the phone rang, waking them, and of course they dreaded the worst.
It was admissions. More forms needed to be signed.
Emily had gone back to her dorm and fallen asleep clutching a teddy bear Matt had given her on their first Valentine's Day, when both were seniors at Radnor. When she pushed a button on the bear, which she had done that night, it recited a recorded message in Matt's voice: "I'm Emily's and she's mine."
Recovering in the ICU
On Monday, compounded by the surgery, Matt's face was even more distorted. Doctors brought him out of the coma every few hours to check his responsiveness, and Matt tried to pull out his airway and feeding tubes.
Such behavior is a good signal of brain activity, but not good for a patient's immediate care. Staff put mitts on Matt's hands and restrained his arms by his side.
The family and Emily visited him in pairs in the intensive-care unit. They talked to him but didn't know what, if anything, he understood. When doctors lightened the sedatives, sometimes Matt would open his eyes when they spoke, but sometimes not.
"Squeeze my finger," his mother would say. Sometimes he would. Other times not.
Monday afternoon, Brennan arrived from Philadelphia to comfort his friend. "Jack Brennan basically came down for last rites," said Mike Miller. They sat outside on a hospital terrace, down the hall from the ICU.
As Monday rolled into Tuesday, still well before the critical 72-hour marker, the Millers began to feel in their guts that Matt was going to live.
But would Matt be Matt? What was the extent of brain injury?"
The force of the collision caused a "shearing" of Matt's brain; imagine the pulp of an orange being torn away from the peel. As a result, the electrical wiring that connects brain cells had been ripped and bruised. If such wiring had been severed, the brain damage could be permanent and severe.
According to Sheehan, Matt's neurosurgeon, nerves are encased in insulation. The hope in Matt's case was that only the insulation was damaged badly, and that the nerves were still intact.
Even in the best of circumstances, recovery normally takes six months to a year, followed by a stay in rehabilitation, Sheehan said.
What struck Emily most about the first two days, even more than Matt's injuries, was his vulnerability.
Matt had always been in control, so confident about his success at anything he put his mind to. "And he was just laying there," she recalled, "saliva all over himself. He seemed like a baby, so vulnerable. It was coming through his eyes."
On Wednesday afternoon, the two men who'd turned Matt on to cycling, along with McNabb, flew down from Philadelphia to visit Matt and the family.
A Vanguard managing director, Tim Buckley, 40, had helped Matt pick out his Look road bike, which Emily had named Black Beauty. Over the summer, Buckley and Chris McIsaac, a Vanguard principal, had invited Matt to ride with them weekdays at 5:30 a.m.
They were amazed that a college student would rise at 5, and even more amazed at just how good he got.
"In a matter of weeks, he accomplished what it had taken me years to accomplish in terms of fitness on the bike," said McIsaac, 34, who has competed in the Ironman Triathlon - a 2.4-mile swim, 112 miles on the bike, and a 26.2-mile run.
On one of their first rides, at French Creek State Park, Matt crested the nastiest hill right with Buckley, who pointed out that Matt's thighs were quivering, in spasm.
"It's going to take a lot more to break me," Matt had said.
In September, Matt had competed in his first triathlon, the relatively short Sandman Triathlon in Virginia Beach, Va. He finished fourth out of 465 men and was second-fastest on the bike - 26 m.p.h. for 14 miles.
He'd been training for three months.
When McIsaac heard about Matt's accident, "my heart just dropped," he said.
"I know intellectually that we were not responsible. This type of stuff just happens. . . . Nevertheless, there's this gnawing feeling that you had something to do with it, knowing that you had been a big part of his love affair with cycling."
The three men, hoping to see Matt but feeling too awkward to ask, sat in the visiting area with the family for a couple of hours, then got up to leave.
"Hey, tell Matt we're looking forward to seeing him," Buckley said.
"Do you want to see him?" Mike Miller asked.
Absolutely, they all agreed.
"You sure you can handle it?"
Only relatives were allowed in the ICU, just two at a time, but the doctors had said it would be good for Matt to hear familiar voices even if it still wasn't clear what he heard.
"Just follow me and don't stop," Mike told them as he led his three colleagues up the elevator, through the ICU doors, and right into Matt's room.
Mike Miller said to his son, "Matt, some friends are here to see you: Bill McNabb and Tim and Chris."
Matt's eyes opened and stayed open.
He clearly recognized them. He reached up, as if trying to give them a hug. But his arms were restrained.
Not knowing what to say, the men started making small talk and, soon, trash talk.
McIsaac told Matt that his pulse during surgery - 42 - was lower than Buckley's had been during his recent surgery.
Matt gave a thumbs-up.
Then Buckley said, "Hey, Matt, Chris is burning up that the last ride you went on together you dropped him. He thinks he can take you when you get out."
Matt, passionately, shook his head. As if to say, "No way."
At that point, Mike Miller simply wept.
He kissed his son on the forehead, then let him rest.