Do you also employ the same methods for head injuries as a result of hypoxia/anoxia?

Arlington, TX
ysp@swbell.net

I don't employ the same methods for hypoxia/anoxia. Studies so far have shown no current benefit of ICP monitoring and treatment in hypoxia/anoxia, probably because this is a situation where the initial lack of oxygen produces damage that is irreversible. Of course the most important thing is that the patient is given oxygen as quickly as possible.

Dr. Ghajar,
I am a prospective medical school matriculant and I was fascinated at the policy struggle that you faced (and conquered) in the recent NOVA special on head trauma. My question is, are other fields of medicine as destandardized in their protocol in similar cases of injury? I realize that the treatment protocol in head trauma is particularly crucial as damage can have dramatic effects in later behavior and prognosis, but surely there are applicable instances in other specialties. Have you encountered other cases of discrepancy? I am considering entering an M.D./M.P.H. or the newer M.D./Master's in the Science of Health Services program as medical policy is of particular interest to me in these times of extreme regulation by Insurance firms.
Thank you for your response,

Christian B. Ramers
San Francisco, CA
cramers@ix.netcom.com

It's been said that only 20 percent of medical practice is supported by scientific evidence. Medicine has evolved over the years by practice and the guidelines movement is a fairly recent event. In the last five years it has really taken off. According to the American Medical Association there are about 1800 guidelines that have been produced. However, the vast majority of these guidelines are cookbook guidelines, where expert panels sit down and write their opinions of how things should be done and they do not review scientific literature to support their recommendations. The guidelines developed by neurosurgeons for massive severe head injuries are based on scientific evidence in that the recommendations are supported by scientific studies. I think that guidelines will play an increasingly important role in the delivery of medical care. They will not only give recommendations when there is scientific evidence supporting them, but will also point to the gaps in our knowledge. Therefore they will drive new clinical trials to fill in these gaps.

Hello Dr. Ghajar,
My name is Doug McCaleb. I am a Physical Therapist Assistant in Sacramento California. I work in a skilled nursing facility and recently we have treated 3 head trauma patients who were between 30 and 50 years old. One patient a GSW was with us 4 months and left our facility 2 weeks ago back home. One is still with us 3 months. I recently saw the NOVA program about ICP treatment and was not only deeply moved by the stories but was intrigued about the outcomes of patients that receive ICP treatment. My question is: After receiving ICP monitoring and the subsequent treatments that the monitoring prompts, do patients have a greater success rate with Physical Therapy over patients that do not receive this monitoring?

Doug McCaleb
Sacramento, CA
lukster@jps.com

If patients make a recovery from severe head injury and undergo rehabilitation therapy, there are differences in the physical therapy requirements of patients who have had ICP monitoring versus those that haven't. I don't know of any literature in this area. However I do know that there is an excellent study from the Medical College of Virginia where they looked at patients that had ICP monitoring but were treated in two different fashions. One group was hyperventilated and the other group was not. The group that was hyperventilated had a poorer outcome in the first couple of months and probably required more rehabilitation. I think that if the guidelines are instituted we will hopefully see a significant increase in patients that survive severe head injury and require a shorter period of rehabilitation and enter the community and become functioning members of society. I think that cognitive rehabilitation will become an increasingly important part of rehabilitation as our diagnostic capability in neuropsychology of traumatic brain injury improves.

I suffered a closed head injury in 1989 & am on disability as a result. I am thankful of my slow but yet better recovery in my brain capacities in mental processing & cognitive abilities. However, my debilitating & disabling symptoms are extreme & chronic fatigue, sleep disorder, migraines, inconsistencies in energy for those brain mental powers. Can the edema cause chemical changes that occurs affect the body's functioning in day-to-day activities, and if so, can it be corrected? Often doctors unfamiliar with post-head trauma patients try to attribute my symptoms to depression, which I don't believe is accurate. I am so happy to be getting closer to "normal" that I want to continue in that path to be productive in society again.

Eliza
Lihue, HI
koral@gte.net

The edema that occurs following a traumatic brain injury usually resolves after the first week or two so it's unusual to have persistent edema.

My 16-year-old niece was in a near fatal accident on Sept.3, 1997. She has suffered extensive injuries. Skull fracture, bruised brain, right arm severed, infections, fevers and four surgeries. The ICP were monitored and she is no longer monitored. She is doing well with that. She is off of the ventilator, but still on a traech. She was a 3 on the Glasgow coma scale, but has been upgraded to a 9. The trauma surgeon said that it is unlikely that she will ever wake-up since it's been so long. How accurate is that? The neurosurgeon is positive, but makes no predictions. She is extremely agitated and constantly moving her legs up and down. Originally she was posturing, but the leg movements are different. She opens her eyes and at times cries tears, yawns, and has followed one command per the medical staff. She is sweating a lot and her pulse is often increasing. Are these signs of awakening?

Suzi Wall
Phoenix, AZ
bnwall@aol.com

Since if has only has only been about a month since her head injury and it looks like she's making progress, it is premature to make a prediction at this point. There are guidelines for recovery from persistent vegetative state that have been published in the New England Journal of Medicine. Patients (especially children) can be in a vegetative state for six months to a year and still make it through recovery. Obviously, the earlier she comes out of vegetative state the better, but I would definitely give it more time to see if she can make a recovery.

I watched the NOVA episode "Coma" with great interest. More accurately put, with great self-interest for I am a BI-survivor (massive hemorrhagic stroke, 8/26/95). Any television programs and print media articles on the subject of brain injury, stroke and their treatment immediately raise my antennae. "Coma" was fascinating! I could especially relate to the young woman who survived the MVA and was interning at a TV station while attending college. I wish her much success in her future endeavors. In my own case, I began making a return to a mainstream lifestyle by beginning driver re-training in January 1996 and returning to my accounting job on a part-time basis on April 1, 1996 (April Fool's Day—prophecy perhaps?). As a parent myself, I could also relate to Alex's mother, her fears, her despair, then her ultimate joy as her son began at last to respond and to improve. That family will be in my prayers daily. I was especially interested in the segment where, if I remember correctly (insert favorite BI memory-deficit excuse here!), an attempt was being made to raise Alex's dangerously low blood pressure to prevent secondary injury to his brain. Did I recall that right?

Deborah Guy
Columbus, OH
DebAguy@aol.com

When the patient's intracranial pressure rose into the 30s (healthy skull pressure is about 10), we raised his blood pressure to push more blood and oxygen into the swelling brain.