Thanks for your terrific work. I recently heard that trauma treatment efforts have been made to lower temperature in the cranium to slow swelling, in addition to monitoring and relieving pressure. Is this correct and can you comment on prospects for this procedure? Also, are there any proven, effective emergency pharmacological interventions to mitigate the early effects of brain injury?

Jim Petersen
Whitehall, MI
jpeter@gte.net

There are hypothermia trials going on right now in which they cool patients when they get to the emergency room—those patients that are in coma after a severe head injury. Those trials are going on, they are funded by NIH, and Dr. Guy Clifton, who is chairman of neurosurgery in Houston, is the coordinator.

The WMO has accepted the guidelines as standard medical practice. Has the AMA done the same?

Thank you for your dedication and hard work in revolutionizing head trauma treatment. It must be incredibly rewarding to see the progress of many patients who would otherwise be left for life support. Thanks and God bless you!

Sincerely,
Peter and Linnea McGurk
Randolph, MA
PMcgurk@aol.com

The WHO neurotrauma committee has endorsed the guidelines. We haven't had the opportunity to present the guidelines to the American Medical Association.

I have heard that people in comas can hear you when you talk to them, and that talking to the person can help them recover. Is this true?

Brooklyn N.Y.
kjay-1@webtv.com

There is no study showing that talking to a person while they're comatose in the initial phase of head injury makes a difference. However, I have seen patients when their family members talk to them, that their pulse may go up, which may indicate they hear a voice. Whether they know it's their family member or otherwise is not known because these patients do not remember their stay in their first week in the Intensive Care Unit.

About 12 years ago I performed some preliminary research on transcutaneous appliances for early mitigation of intracranial edema primarily directed toward a portable device usable by first response EMT's and permanent hospital installations. I was able to identify one modality which showed great promise and was preparing a program for development when I was redirected and the program was abandoned. Are there any non-intrusive modalities for reducing edema? Is there any interest in developing an appliance which may modulate brain swelling?

John Petrick
New Port Richey, FL
okplus@gte.net

I've never heard of such a device or research in that area. I think we need to do a lot more research to find out how the brain swells first, before we can tackle other methods of reducing the swelling.

How would the treatment featured on the NOVA segment differ for a one month old infant suffering from shaken baby syndrome with severe trauma?

Lisa Gaskell
Virginia Beach, VA
LeddenGaskell@vabch.com

If the baby was in coma with a severe head injury we would practice the same way.

My 14 year old daughter, Vali, was in a car accident 5 weeks ago. She suffered a closed head injury. Her ICP averaged 7-8. The brain doctor told me that she she had general brain trauma with 10 small points of blood clots that will re-absorb into the brain. She should be fine cognitively, but will likely have motor skill deficits. It is now 5 weeks later, Vali is in her 3rd week of rehab at Hershey Medical Center. Just one week ago, she has started to respond to verbal commands and looking very alert. But, also has begun sleeping a lot, but more alert during awake periods. Her trachea tube was removed last Thursday, but she still makes no attempt to speak. The doctors say her recovery will be slow...and they do not know how much she will recover. Her right eye is fully dilated. What are her chances, what can I expect, is there anything else we can do for her? Can it really take months and months? Is it possible her brain is still swollen? How long does it take for swelling

Her father,
Neil Bixler
Bloomsburg, PA
nbixler@epix.net

It sounds like she's making progress; she's only five weeks after the car accident with a severe head injury and this is too early to make any assessment of outcome. Generally one has to wait six months to get a rough estimate of what the final outcome will be. Patients can make significant strides even after that period of time, especially children.

Please comment on specific suggestions regarding pre-hospital care of head-injured patients. In specific, ventilatory support of these patients (hyperventilate or ventilate to maintain a range of end-tidal CO2 levels), use of drugs to reduce ICP early in the injury, and any other points you would like to make. I do a fair amount of teaching and speaking in seminar settings and would like to positively impact the outcome of these patients with information you can share with me. Keep up the good work, it is important! God bless you and your efforts.

Keith Wyss, EMT-P
Churubusco, IN
kwhoosier@mail.fwi.com

I refer you to the recent publication of Emergency Medicine Clinics of North America, August 1997, that is edited by Andy Jagoda. Your questions will be answered in that book.

Dear Dr. Ghajar,
My daughter suffered a severe head injury almost seven years ago. I watched the NOVA episode with great interest. What can I do as an individual to encourage the endorsement of the Guidelines for the Management of Severe Head Injury by my state's medical establishment?

Deanna Traxler
Fremont, MI
TRAXFAM@ncats.net

You should contact the Aitken Neuroscience Center via fax (212-772-0357) and include your name and address. We are developing a package to go out to people to help them with State endorsement of the guidelines.

Dear Dr. Ghajar,
Congratulations on your efforts. It always amazes me to see how many MDs seem to have no appreciation of scientific method. But I'd like to pose a question that wasn't addressed in the NOVA show or in your WWW interview. Loss of brain function seems to involve two steps. First, which you address, the conditions (brain pressure) which potentiate cell damage. And second, the damage itself, which I'll address. Even if brain cell access to blood is temporarily cut off, isn't the damage to those cells amenable to intervention? Isn't one of the main mechanisms of brain cell destruction oxidation? And wouldn't antioxidant suffusion of the brain ameliorate this destruction? More specifically, wouldn't prompt use of DMSO (which does NOT depend upon blood delivery to the threatened cells) serve as an effective and harmless way to avoid much cell damage?

Charles R. Fred
Maspeth, NY
cfredname@aol.com

You've addressed the problem well. Free radical production has been a major area of research in head injury and I refer you to do a MEDLINE search in the National Library of Medicine on this topic.

Dear Dr. Ghajar,
Although many factors determine or predict whether a physician will be sued for malpractice, patient outcome is probably one of the most readily objective factors. While you state that your research reveals only about 30% of the trauma facilities studied following the protocol set-forth in the Guidelines for the Management of Severe Head Injury, this number suggests to me that the Guidelines may, and should, set the standard of care in assessing physician performance in head trauma cases. Has your research included a study of malpractice claims in which the Guidelines were followed versus cases in which the Guidelines were not followed? From a risk-management perspective, implementation of the Guidelines for improved patient outcome seems critical. In order to overcome the resistance you claim to be facing from long-time practicing physicians, I might suggest that you educate these physicians that the Guidelines ARE the standard of care and that their malpractice exposure increases when the Guidelines are not met.

Ryan Asmus, Esq
Chicago, IL
Ammtaa@aol.com

We have not done any investigation in the study of malpractice claims and guidelines. The guidelines were sent to every neurosurgeon in North America in April of 1995, and there's been no legal assessment of the guidelines as a standard of care.

Dear Dr. Ghajar,
The NOVA presentation of Coma was truly inspiring. I am currently a critical care nurse in the surgical intensive care unit at Reading Hospital and Medical Center. I will be attending The University of Pennsylvania, Master of Science in Adult Acute/Tertiary Nurse Practitioner Program. I have been researching the areas of specialization and, based on your presentation, strongly feel that I will pursue the neuroscience specialization. Are the Guidelines available? Do you envision a collaborative position for advanced practice nurses within this field? Thank you.

Catherine R. Herman
Wyomissing, PA
Crherman@aol.com

The guidelines were sent to neuroscience nurses for their approval. Nurses are key in the management and treatment of patients with severe head injury. We're very interested in having them involved in practicing and collaborating on the guidelines.

How can people insure that the guidelines that you developed are adopted by every state in the Union? How can I personally help you to make that happen? Can federal guidelines be established through NIH? I am particularly interested in helping you because I lost a 19 year old nephew following a car accident 3 1/2 years ago. I do not believe that he would have succumbed to his injuries had the trauma center to which he was med-evacuated used your protocol.

Gayle Spiegel
Newton, MA
gspiegel@unidial.com

You should contact the Aitken Neuroscience Center via fax (212-772-0357) and include your name and address. We are developing a package to go out to people to help them with State endorsement of the guidelines.

The agency for health care policy and research is a government office that has been funding guideline development. However, they have not targeted head injury and that was one of the reasons why our group went ahead and did it.

Dr. Jam,
I'm usually pretty bad when it comes to anything dealing with medical material but I watched Coma with rapt fascination last night.

It really lifted my spirits to know that people like you exist who can stare death and despair in the face on an everyday basis and not only "do your job" but to have such a DIRECT positive impact on reducing the human mortality rate.

Is there a non-invasive way to monitor ICP (ultra sound) and to control swelling (ie drugs)? As Dr Mccoy says in Star Trek 3, it does seem a little medieval to still be drilling into heads. But than again, drilling is better than dying...

Thanks a lot and do more shows.

Avi Weiss
avi@apple.com

There are some non-invasive methods being developed to measure intracranial pressure. However, they're qualitative and not quantitative. The main advantage of drilling a hole and putting the tube in the brain is that if the pressure gets too high the physician can drain the spinal fluid and reduce the pressure.

Dr. Ghajar,
Two questions:
1. Have these guidelines been tried with people who experience a stroke r/t a clot?

2. Any views on the use of hyperbaric oxygen chamber to increase delivery of oxygen to brain tissue after either trauma or stroke?

Thank-you for your time and effort!

Janet Hirschhorn, LPN
Woburn, MA
slvrstag@tiac.net

The guidelines are most likely being used also in patients who are in coma with strokes, because they relate to intensive care management of patients with brain swelling. But there's a lack of study in using the guidelines on patients with stroke.

There have been studies using hyperbaric oxygen on patients with severe head injury and to my knowledge they so far have not shown any efficacy. I would refer you to the medical literature to get a more in-depth understanding of this fascinating area.

Dr. Ghajar,
At the end of the program, it was noted that New York was the only state that had adopted the head trauma procedure that you have introduced. I am interested in having my boss, Assemblywoman Dion Aroner, introduce a Resolution in the CA State Assembly calling for the California Medical Examiners to embrace this procedure. I am wondering if you can direct me. Is there a resolution that other states have passed, that I could take a look at? What do you think is the best method to encourage our medical community to get on board? Let me know if there is anything you think the CA State Legislature can do to help.

Sincerely, Margaret Merritt
Legislative Aide to Assemblywoman Dion Aroner
14th Assembly District, Berkeley, California
merritma@assembly.ca.gov

One of the guidelines' authors is a neurosurgeon at the University of California, San Francisco, Dr. Larry Pitts. I'd encourage you to contact him and he may be able to help you with legislation in California. The best method to encourage use of the guidelines is education of physicians, nurses, the public, and lawmakers. If we could have hearings on this matter I think it would be very important because the scope of traumatic brain injury is not just in the intensive care unit, but it involves pre-hospital care, emergency rooms, hospitals, rehabilitation facilities and families' ability to cope with this problem.