Treating and Preventing Brain Trauma
Treating and Preventing Brain TraumaParamedics and Surgeons
Scalpels and Saws
The Brain Heals Itself
Learning Social Skills
Exercising the Brain
Helmets, Seat Belts, and Air Bags
Although brain trauma can cause long-term disabilities, many people do eventually recover from their injuries and lead full lives. The brain has proven to be a very resilient organ, capable of repairing itself. Surgical techniques have also improved over the years, and thanks to the development of new, more precise surgical tools doctors are able to save healthy portions of the brain that otherwise would have been damaged during surgery.
What’s more, rehabilitation therapists have made great strides in helping people recover from brain trauma. Today, with therapy, many brain-injured people can learn to talk again, walk again, and perform other functions they lost when their brains were injured. Indeed, doctors have found that even when large sections of the brain are cut away during surgery, the remaining parts can compensate by performing functions they did not previously perform. A part of the brain that was not used for communicating, for example, can learn to take over that function as the patient learns to talk again. Darryl Kaelin, director of the Acquired Brain Injury Program at Shepherd Center in Atlanta, Georgia, contends, “Early therapy helps brain cells that are bruised or stunned to recover their function faster. Later, rehab trains brain cells not involved in a particular activity to pick up for the ones that have been destroyed.”48
Still, for most patients it may take many months or even years to recover from traumatic brain injury. Although brain injuries often occur suddenly and without warning, experts agree that if TBI patients had taken some sensible precautions, many of them could have avoided the injuries that have placed their lives and mental health at risk.
The initial treatment of a TBI patient will probably be performed by paramedics or other so-called first responders. After arriving on the scene of an accident, a team of paramedics can help minimize damage to the brain by unblocking the patient’s airway, providing breathing assistance, and keeping the blood circulating. If the brain continues to receive blood and oxygen, neurons can remain active and do not die during the aftermath of trauma. Quick response and competent emergency treatment is vital.
Paramedics may be able to stabilize the patient, but repairing the damage is the job of the surgeon. Doctors have been performing brain surgery for at least thirty-five hundred years. Evidence has surfaced describing brain surgery conducted by Egyptian physicians in the year 1550 B.C. In America today, about 2,850 physicians practice neurosurgery. In addition to responding to TBI, neurosurgeons also treat diseases of the brain, such as cancerous tumors, as well as diseases and trauma related to the spinal column.
The Smith Papyrus
Archaeologists have found evidence suggesting that Egyptian physicians practicing some thirty-five hundred years ago operated on the brains of their patients. Evidence also suggests the operations were not often successful.
An ancient scroll known as the Smith Papyrus—because it was unearthed in 1862 by an American archaeologist, Edwin Smith— includes a description of traumatic brain injury. Believed to have been written in 1550 B.C., the scroll provides advice to physicians on a number of injuries they might encounter. Regarding traumatic brain injury, the scroll advises,
When you examine a man with a . . . wound on his head, which goes to the bone; his skull is broken. . . . Something is there . . . that quivers [and] flutters under your fingers like the weak spot in the head of a child which has not yet grown hard. The quivering and fluttering under your fingers comes because the brain of his skull is broken open. Blood flows from his two nostrils.
Then you must say: a man with a gaping wound in his head; a sickness which cannot be treated.
Quoted in Jurgen Thorwald, Science and Secrets of Early Medicine. New York: Harcourt, Brace and World, 1962, p. 54.
In some cases, brain surgery is performed while the patient has been administered a local anesthetic, just enough to numb the scalp. This is possible because there are no pain receptors in the skull and brain. Surgeons often want the patient awake and alert during the operation so that he or she can follow instructions. During the surgery the doctor may ask the patient a series of questions or instruct the patient to wiggle his or her toes. By using the patient’s responses as a guide, the doctor can avoid shaving away too much brain matter that may leave the patient debilitated after the surgery. Of course, in many severe TBI cases the patient arrives in the emergency room unconscious, leaving the surgeons no option other than to perform the operation without guidance from the patient.
Many operations on TBI patients are performed using knives, scalpels, saws, and other simple instruments. While visiting Balad Air Base in northern Iraq, Michael Paul Mason witnessed surgery performed by military physician Mark Melton on a young Iraqi boy, Jassim, who was injured in a bomb blast at a mosque. As Mason described the surgery,
Melton runs a scalpel across and under the skin, then pulls a large piece of it off Jassim’s head and lays it on the table near his ear. With the scalp cleared away, the underlying bone fracture is apparent. The glistening white skull looks cracked and cobbled at the very crown of the head. . . . Melton uses a small set of pliers to pry the bone fragments away. At moments, he has to wrench the cracked bone free. A pile of small skull chips collects near the discarded scalp.49
Other hospitals are equipped with far more advanced tools than Melton used in Iraq. For example, some surgeons can use ultrasound devices to blast away damaged brain tissue. The equipment, which employs sound waves, is mostly used to destroy cancerous tumors in the brain, but some surgeons have found that it can be effective in cutting away brain tissue damaged during traumatic incidents. Modern drills that can actually liquefy brain matter have also been employed by surgeons. This technique is regarded as a less invasive method of clearing away damaged brain tissue than cutting it off with a scalpel.
Other doctors substitute Gamma Knife radiosurgery for scalpel surgery. This technique employs beams of gamma radiation to slice away damaged brain tissue. Hospitals in the United States have been slow to adopt Gamma Knife radiosurgery because the Gamma device is expensive; the apparatus costs $3.5 million plus another $500,000 to install. The patient who undergoes the surgery wears a helmet containing some two hundred small round holes. The gamma rays are then shot through the holes but aimed at the trouble spot so they can attack the damaged tissue from many angles. Using the Gamma Knife procedure, physicians can seal the leaks in damaged blood vessels in the brain.
Gamma Knife radiosurgery is regarded as an advance over surgery with a scalpel because the procedure does not require opening the skull—the gamma rays can be shot through bone.
Since the surgeons do not cut open the skulls of their patients, they rely heavily on MRI and CT scans to aim the gamma rays. The procedure is bloodless, which reduces the risk of complications and infections.
These surgical techniques have helped reduce the death rate for TBI while helping patients recover more quickly from their injuries. According to CDC statistics, the death rate for TBI has declined by 20 percent since 1980; meanwhile, the hospitalization rate for TBI patients has been reduced by 50 percent. In fact, hospital stays for some Gamma Knife radiosurgery patients have been cut by as much as 90 percent.
Certainly, modern surgical techniques have a lot to do with why people are better able to recover from TBI, but the resilience of the brain is an important factor. Doctors as well as therapists have concluded that the brain contains an incredible ability to heal itself. Mason says:
We tend to think of our brains as a coil of fixed connections, like a complicated electrical panel that reroutes messages back and forth. In recent years, neuroscience has revealed that the brain has a dynamic proclivity for self-recovery. In a global sense, the brain can actually relocate functions from one area of the brain to another. On a microscopic level, the neurons themselves can react to changes by making new connections. From a certain perspective, the brain acts like a switchboard that rewires itself when there’s a short circuit. This sublime attribute, brain plasticity, yields wonder upon wonder.50
Though the brain is very good at repairing itself, it often takes several months or even years for new neurons to form or for other neurons to take over the functions of cells destroyed during the trauma. In 1984 Terry Wallis, then twenty years old, drove his truck through a guardrail and off a 25-foot (7.6m) rise near his home in Mountain View, Arkansas. The car tumbled down the hill. When emergency responders pulled Wallis from the wreckage he was unresponsive. He spent three months in a coma, then opened his eyes. Doctors upgraded his condition to a minimally conscious state, where he spent the next nineteen years unable to communicate with others.
In 2003 his mother visited the nursing home where Wallis lived. As she sat by his bedside, Wallis suddenly said, “Mom.” Over the next few days, he added other words to his vocabulary. In fact, his second word was “Pepsi”—he had asked for the soft drink, his favorite. Since then, Wallis has taken additional steps toward recovery. He has moved out of the nursing home and now lives with his parents. He has also learned to say many more words and count to twenty-five, but he is still confined to a wheelchair, needs help eating, and must receive nursing care. The effects of TBI are still evident—his attention span remains very brief.
Nonetheless, doctors have theorized that Wallis’s brain repaired some of the damage on its own, using spare neurons to replace those damaged in the accident. Nicholas Schiff, a neurologist at Weill Cornell Medical School in New York, states, “In essence, Terry’s brain may have been seeking new pathways to re-establish functional connections to areas involved in speech and motor control—to compensate for those lost to damage.”51
The fact that Wallis is currently conscious and communicative has helped him regain more and more of his cognitive functions. Now therapists can work with Wallis, helping him learn new words and perform skills with his hands. In the years since he awoke from his minimally conscious state, Wallis has gone from being completely paralyzed from the neck down to regaining minimal movement in his hands and feet.
For patients who are conscious and able to participate in their own recoveries, therapists prefer to start brain rehabilitation as soon after the trauma occurs as possible. Ideally, they want new neurons to begin functioning as soon as the cells develop. In most brain trauma cases, patients undergo speech and occupational therapies.
In speech therapy, patients learn how to talk again. It may be necessary for the therapist to teach the patient how to sound out simple words, much the way young children learn to pronounce words in elementary school. Words with multiple syllables will be broken into smaller pieces. The patient will be asked to repeat the pieces of each word over and over again. As the patient improves and learns new words, the therapist will teach the patient how to participate in a conversation by waiting his or her turn to respond, and how to carry on a conversation when there are many distractions, such as how to speak with others in a noisy restaurant.
Occupational therapy is designed to help the patient return to a normal life. After a traumatic brain injury, a patient may have forgotten how to get dressed, brush teeth, comb hair, and perform dozens of other tasks. At Kessler Institute for Rehabilitation in Saddle Brook, New Jersey, occupational therapist Jodi Levin works with about seven TBI patients at a time. One of her patients is an eighteen-year-old man who sustained brain trauma in a motorcycle accident. Remarkably, the man sustained no injuries to his body, but the brain trauma has affected his ability to function. He can’t move his limbs because his brain does not send signals to his arms and legs.
Levin has designed a series of exercises to help the patient relearn the use of his limbs so that he can perform simple tasks for himself. In one exercise she kneels behind the patient and props him up using her arms. In front of the patient, the man’s mother slowly passes photographs of family members by his face while Levin asks the patient to follow the photographs with his head. During the exercise, the man manages to crane his neck slightly from side to side. Levin regards that as an accomplishment. “I’m working on trunk control,” she says. “It’s the basis of everything—for getting out of bed, brushing teeth, getting dressed.”52
Another brain trauma patient under Levin’s care was involved in an automobile accident—his head slammed into the windshield. Doctors had to cut away a piece of his skull to reduce the swelling in his brain. The surgery has affected his motor control; he finds it very difficult to walk and use his hands. To help improve his motor skills, Levin taught him to swat at a balloon with a tennis racket. He also worked with a therapy dog, which led him on walks across a gym floor. The patient spent about a month at Kessler, then was able to return home, although he still returns to the center for outpatient therapy and so Levin can monitor his progress. “He’s a miracle,”53 says Levin.
The patients under Levin’s care suffered brain trauma that left them severely debilitated, but even patients who received lesser degrees of TBI may also need therapy to help them return to normal lives. Iraq War veteran Jason Walsh sustained a head injury caused by a roadside bomb. At first, Walsh’s brain injury seemed to be mild, but during his recovery at Walter Reed Hospital, Walsh noticed his personality changing—he was quick to anger, often lashing out at his parents and a brother during their visits. The personality change was likely caused by damage to Walsh’s frontal lobes, the area of the brain that controls behavior. “Part of what you need your frontal lobes for is to figure out who you are, because you need that to plan your way of life,” says Warren Lux, a Walter Reed neurosurgeon. “That means that people who have all the skills to do things in the world won’t use them because they don’t know who they are.”54
Walsh also noticed his memory failing him. One morning he simply could not figure out how to put on a pair of sweatpants. After a period of recovery at Walter Reed, the army sent Walsh to a brain rehabilitation center in Virginia where he received therapy to help him train his memory and control his moods.
The Strange Case of Phineas Gage
The strange case of Phineas Gage proved the human brain’s ability to withstand trauma as well as the crude surgical techniques of the nineteenth century. In 1847 Gage was severely injured while blasting rock to lay railroad tracks in Vermont. He was struck in the head by an iron bar that pierced his skull like an arrow. Miraculously he survived the accident as well as the operation to remove the iron bar, losing only the vision in his left eye, which had been pierced by the chunk of iron.
Gage’s case also proves, however, that TBI can lead to mental illness and personality change. Prior to sustaining the injury, Gage was regarded as easygoing, energetic, and intelligent and was well liked by others. After his accident he became a man of little patience, quick to grow angry, cool to the opinions of others, unable to finish jobs, and foulmouthed. He died in 1860, thirteen years after the accident.
The physician who removed the rod, John Harlow, became something of a celebrity in the medical community, as he wrote about the surgery and lectured on the case for many years. As for the rod, Harlow donated it to Harvard Medical School’s Warren Anatomical Museum in Boston, Massachusetts, where it remains on display.
His therapist has worked with Walsh to make up a grocery list, take it to the store, shop, and return home. Many people would take such light duties for granted, but for Walsh they have proven to be a challenge. By successfully carrying out a shopping errand, Walsh can learn how to plan his day, navigate through chores, and use his memory. For example, since he takes the bus to the grocery store, Walsh will have to remember where to find the bus stop, the coins he’ll need for the fare, and where to get off the bus.
To help Walsh control his moods, the army has assigned him to an administrative job where he has the opportunity to interact with people and relearn social skills. For Walsh, the progress has been slow. “Sometimes I have to stop and think,” he says. “It’s pretty embarrassing. I’m aware that [my memory] is not back yet. I can feel myself think slower, step by step, instead of just reacting. I hate it.”55
Walsh hopes to one day return to active duty and become an instructor, perhaps even to return to a war zone. These duties would require a high level of cognitive ability. For Walsh and other TBI patients, such accomplishments are not out of the question. Indeed, it is not unusual for TBI patients to recover and go on to lead lives and careers that require a high level of cognitive ability.
As a twelve-year-old girl in Russia, Asya Schween struck a brick wall while riding her bicycle. She walked home, but that night she became very ill. She vomited in her bed and experienced a devastating headache. She recalled writhing in pain, going through seizures, and hallucinating. She also suffered from blurred vision.
Schween received poor medical treatment in Russia; released from the hospital, she continued to exhibit symptoms at home, mostly memory loss and personality changes. She had other physical symptoms as well, including urinary tract infections and a wildly fluctuating heart rate and blood pressure.
Schween slowly recovered. To help their daughter return to normal, her parents committed themselves to her rehabilitation, exercising her brain by making her study hard, play math games, and memorize poetry. They also enlisted tutors to drill her in mathematics and other subjects. Eventually, she immigrated to Los Angeles, California, where she has attained college degrees in mathematics and biology and has become a research biologist. She has also established herself as an artist, specializing in photographic portraiture. Now twenty-five, Schween experiences occasional relapses, often manifested in emotional outbursts that doctors have attributed to her childhood brain injury. “I don’t think I will ever be a great scientist,” she says, “but there is nothing I can’t be successful at.”56
Schween’s success notwithstanding, her case shows that most brain trauma patients will suffer from some impairment of their cognitive functions for many years, if not for life. Lance Trexler, director of rehabilitation neuropsychology at the Rehabilitation Hospital of Indiana, states, “Not many people with moderate to severe injuries fully recover, in terms of the brain working exactly like it used to. About 50 percent do not resume their full activities and live with a chronic disability.”57
If Schween had been wearing a bicycle helmet at the time of her accident, the brain trauma she suffered as a child may have been much less severe, saving herself and her parents years of anguish and rehabilitation. According to the Arlington, Virginia–based Bicycle Helmet Safety Institute, of the 750 American bicyclists who die in accidents each year, some 75 percent succumb to head injuries. According to the institute, helmets can prevent 85 percent of the head injuries sustained by bicycle riders. Many skateboarders could avoid head injuries if they would also wear helmets. “You don’t know how hard pavement is until your head really hits it,” says an institute publication. “If you [break] a wrist or an arm or a collar-bone it heals, but the brain is different.”58
Safety experts urge athletes to wear helmets for all manner of other activities. Athletes who play contact sports such as football, ice hockey, lacrosse, and boxing are encouraged to wear helmets and, in fact, scholastic and community leagues often mandate head protection for participants. Many leagues require baseball and softball players to wear helmets when they bat and run the bases. Others who are urged by safety groups to wear helmets include in-line skaters, snowboarders, skiers, and horseback riders.
Many states do not require motorcycle riders to wear helmets, and, certainly, many riders resist the pleas of safety experts to wear helmets as they race along on their cycles at speeds of 60 miles (96km) an hour or more. Safety experts encourage vehicle drivers and their passengers to wear seat belts and never drive under the influence of alcohol or drugs or ride with a driver under the influence.
Several studies have confirmed that people who wear seat belts and ride in vehicles equipped with front air bags suffer fewer head injuries than people who ride unrestrained. (Air bags were first installed in cars during the 1980s; they are typically hidden in the steering wheel and dashboard; during a collision they automatically inflate, providing a degree of protection to drivers and front-seat passengers.) In a head-on crash, an unrestrained body will be thrown forward—drivers and passengers may slam into the dashboard or windshield. A 2000 study by the Medical College of Wisconsin found that 10 percent of people who do not wear seat belts suffer head trauma when they are involved in front-end vehicular accidents. Meanwhile, the study found, in front-end accidents in which drivers and passengers are restrained by seat belts or protected by air bags, the TBI rate drops to less than 4 percent. The authors of another study claim:
Air bags prevent the violent whiplash motion of the head in a frontal crash, resulting in a more controlled deceleration of the brain. Wrenching forces exerted on the cervical spine are [reduced], and the face is protected from contact with hard or lacerating surfaces. Furthermore, compliance is not a problem with air bags. When a car is equipped with air bags, they are in effect 100 percent of the time, which is important for the protection of high risk groups, such a teenage boys, who tend to wear seat belts less often than other groups.59
While many accidents that cause TBI occur on the roads, many mishaps also happen at home. People who live with elderly relatives are encouraged by safety experts to look around the house to see what may cause a slip—loose rugs or mats in the bathroom, for example. Poor lighting in the home can also cause mishaps. Safety experts urge parents of young children to install gates at the top of stairs and other unsafe places to help prevent falls. According to the National Center for Injury Prevention and Control, a division of the CDC, young children should continue to ride in juvenile car seats until they weigh about 40 pounds (18kg). The seats fit snugly around small children, providing them with extra protection should they get jostled in an accident. Also, the agency says, parents should inspect playgrounds to ensure that their surfaces are made of shock-absorbing materials, such as mulch or sand.
Of course, even the most vigilant attention to safety can’t prevent all accidents. According to the Bicycle Helmet Safety Institute, even careful bike riders are likely to be involved in a crash every 4,500 miles (7,242km) of riding. Even though many riders wear helmets, traumatic brain injuries are still possible if the impact is severe enough to shatter the plastic helmets or jar their brains inside their skulls. If they are well enough to pick themselves up off the street, they may still experience memory lapses, personality change, and long periods of rehabilitation ahead as they struggle to regain their former lives.