Archive for the ‘Traumatic Brain Injury’ Category

FES Equipment Coming to Baltimore’s Mount Washington Pediatric Hospital

Thursday, September 8th, 2011

Author - Sarah Keogh

Back in February, Jon Stefanuca wrote about a study in the Journal of Neurorehabilitation and Neural Repair about Functional Electrical Stimulation (FES) and the benefits it can provide to those individuals who have suffered spinal cord injuries. He explained how FES is able to provide electrical impulses to stimulate paralyzed muscles. The study’s authors found improvements based on using FES that led them to recommend using stimulation therapy in conjunction with occupational therapy for patients with incomplete spinal cord injuries. This technology is now also being used to help people with a wide range of injuries and illnesses including, stroke, multiple sclerosis, traumatic brain injury, and cerebral palsy, in addition to spinal cord injuries. According to the Christopher and Dana Reeves Foundation website, FES works by applying “small electrical pulses to paralyzed muscles to restore or improve their function”. The benefits can be extensive:

FES is commonly used for exercise, but also to assist with breathing, grasping, transferring, standing and walking. FES can help some to improve bladder and bowel function. There’s evidence that FES helps reduce the frequency of pressure sores. From: Christopher and Dana Reeves Foundation website

Improved Technology To Be Locally Available

Since FES was originally developed, the technology improved from being something that was typically integrated into large expensive equipment, such as exercise bikes and wheelchair based equipment, into smaller more portable devices. The good news for individuals with neuro-motor injuries in Baltimore City and the surrounding areas is that this type of FES treatment is about to become more available locally. At the end of August, Mount Washington Pediatric Hospital announced that they have received a “Quality of Life” grant from the Christopher and Dana Reeve Foundation. The article explains:

The money will help Mt. Washington Pediatric Hospital purchase Bioness® equipment for its Adaptive Equipment Rehabilitation Clinic (the clinic). The clinic works with patients with neuro-motor disorders to maximize their movement as much as possible given their physical limitations.

From Bioness.com

The Bioness website explains that they produce a variety of “medical devices designed to benefit people with Stroke, Multiple Sclerosis, Traumatic Brain Injury, Cerebral Palsy, and Spinal Cord Injury. These products use electrical stimulation to help people regain mobility and independence, to improve quality of life and productivity.” While I do not know what particular equipment will be available at the Mount Washington Pediatric Hospital, Bioness makes equipment to assist patients with hand paralysis, foot drop and thigh weakness among other conditions.

MWPH Uses Interdisciplinary Approach Combining FES and Therapy

The article about the grant explains some of the many wonderful things available for patients at the Mount Washington Pediatric Hospital (MWPH):

  • …[an] interdisciplinary approach to the assessment and management of adolescents and children with neuromuscular impairments, paralysis and/or movement disorders
  • … [a] team of 21 experienced specialists in physiatry, occupational therapy, and physical therapy.

The new equipment at MWPH will be used along with the other occupational and physical therapy options available to patients. A study described in US Neurology looked at stroke victims and found the combination of FES and traditional therapies that include repeated motion provide the best results:

Stroke patients with limited voluntary movement could now benefit from technologies such as functional electrical stimulation (fes) combined with necessary repetition of functional tasks (use-dependent plasticity) to enhance the neural repair process and improve outcomes, thus enabling them to begin to overcome their previous limitations and to improve their physical capabilities.

From Bioness.com

The goal at MWPH for children and adolescents is based on a similar idea:

Patients whose muscles can be retrained will require several months of therapy to gain normal range of motion and strength. For those patients with more severe conditions where muscles cannot be retrained, the Bioness® equipment will be used to augment their range of motion. Using these two therapy modalities, patients will acquire greater functionality, range of motion, muscle strength, and the ability to move independently.

This multi-disciplinary approach should allow these children and teens to have the best chances of improved motor use and the most independence in their future lives.

Related Articles:

Coming Soon? Restored Breathing for Spinal Cord Injury Patients

Spinal Cord Injury Updates: More Reasons for Optimism?

New Treatment Holds Promise for Patients With Spinal Cord Injuries

New Microchip Promises to Make Life Much Easier for Paraplegic Patients

Week in Review: (June 13 – June 17, 2001) Eye Opener Health, Law and Medicine Blog

Saturday, June 18th, 2011

Eye  Opener’s Week in Review

 

Jason Penn

From the Editor:  Today marks the end of week two as “guest” editor for the Eye Opener. I can tell you that the title “editor” is a misnomer. When it comes to the Eye Opener and its panel of bloggers, very little (if any) editing takes place. Consistently, our blawgers provide you with timely and topical posts. This week was no different. Let’s take a retrospective look at what the “Eye Opener” offered this week (and, of course, a sneak peek at the week ahead.)

– Jason Penn, Guest Editor

 

(Many thanks to Jason and all those back at the firm, who helped get the word out on some great topics this past week while I’ve been wrapping-up week #2 of the trial from hell…….Brian Nash)

July 1 – New Residents, New Rules……Again!

By: Theresa Neumann

While the loss of sleep is rarely a topic on Gray’s Anatomy (or any made-for-television medical drama), it is a genuine quandary for non-actor, medical residents. This past Monday, Theresa Neumann explored the ACGME’s limitations on the hours worked by medical residents in the United States. As Theresa explained, the overall maximum hours per week will not change; it remains at 80 hours.  One big change is the limit on the maximum continuous duty period for first year residents; this will be decreased from 24 to 16 hours.  It will remain 24 hours for residents after their first year, but recommendations include “strategic napping.” Curious about the other changes?  Read more

Newest Word on Crib Safety: Ban the Bumpers?

By: Sarah Keogh

Sleep isn’t only important for medical residents; it is also important for the smallest members of our families. As Sara Keogh explained on Tuesday, Maryland is considering regulations to ban the sale of crib bumpers. For many years, more and more emphasis has been placed on infants sleeping in safe cribs without any additional “stuff” in them. This has included the elimination of lots of former nursery staples. Baby blankets, stuffed animals, pillows and other loose items have been banned from the crib by safety experts for years. As requirements for cribs have required slats that are closer together, the utility of using a bumper to help a child from getting stuck between crib slats has been eliminated. More recently, the Consumer Product Safety Commission has developed even newer crib safety standards, including eliminating the use of drop-sides, and warned against the use of sleep positioners. Yet, despite the advice to put babies to sleep only on their backs in cribs empty of everything except a well fitting mattress and fitted sheet, many parents and caregivers persist in using other items in cribs. Now, with an increasing number of deaths associated with crib bumpers, Maryland is considering a stronger stance. Read more

Legal Boot Camp Class Four. Sean and Kristy’s Story: How a Jury Award is Conformed to the Cap

By: John Stefanuca

On Wednesday blogger Jon Stefanuca broke out his calculator:  bootcamp style.  In the state of Maryland, there is a cap on the damages that can be awarded.  But what happens when a jury returns a verdict in excess of the statutory amount?  Mathematics and law intersect.

To see the results, and a detailed explanation of how it all works, you can read more ….

 

Confusion with Advanced Directives: Palliative Care, End-of-Life and Hospice Care

By: Theresa Neumann

With the death of the always controversial Jack Kevorkian, we revisited a post by Theresa Neumann.  Breathing a little life into the post (pun intended), Theresa provides an excellent primer for readers that are facing end of life situations.  The differences are nuanced and can be difficult to understand at a most difficult time. Are you sure you know the difference between palliative, end-of-life and hospice care?  Read more

Acquired Brain Injuries: Subdural Hematomas

By: Theresa Neumann

When Humpty Dumpty fell, they were able to put him back together again.  Because our lives are nothing like a children’s nursery rhyme, when we fall, we get hurt.  A head injury is particularly serious. Have you ever bumped your head and developed a “goose-egg?” It’s truly amazing how fast that big bruise under the skin grows. That bruise, or hematoma, is from a broken blood vessel, usually a vein. The pressure from the swelling helps with clotting, along with the blood’s own clotting factors. This types of hematoma typically takes a week or more to go away. If it’s on the forehead, it’s often followed by one or two “black eyes.”  That’s because the blood tends to spread along  tissue planes, and gravity notoriously pulls everything downward causing it to pool in the eye sockets, where the blood cells degrade and their components are reabsorbed by the body. Unlike a fairy tale, however, this goose-egg can be serious.  Read more

Sneak Peak of the Week Ahead:

As I told you at the beginning, the Eye Opener’s writers continue in their efforts to provide you with timely and topical blogs for your reading pleasure. As evidenced by the above, this past week was no exception. The Eye Opener and its writers are excited about the week ahead too!  Here’s a sneak peak of what’s in store for you:

  • Service dogs for children:  more than just a pet
  • Changes in Sunscreen:  will regulation prevent cancer?
  • HIV Patients:  Increased risk for developing cancer
  • Legal Boot Camp is back in session and Part III of our Cerebral Palsy tutorial.

Wishing You and Yours a Great Week Ahead!

Images courtesy of:

www.theepochtiems.com

www.sleepzine.com

www.nailsmag.com

www.aginglongevity

 

 


Acquired Brain Injuries: Subdural Hematomas

Friday, June 17th, 2011

Have you ever bumped your head and developed a “goose-egg?” It’s truly amazing how fast that big bruise under the skin grows. That bruise, or hematoma, is from a broken blood vessel, usually a vein. The pressure from the swelling helps with clotting, along with the blood’s own clotting factors. This types of hematoma typically takes a week or more to go away. And, if it’s on the forehead, it’s often followed by one or two “black eyes.”  That’s because the blood tends to spread along the tissue planes, and gravity notoriously pulls everything downward causing it to pool in the eye sockets, where the blood cells degrade and their components are reabsorbed by the body. Recycling at its best!

A subdural hematoma is that same “goose-egg”, but it happens under the skull and between the coverings of the brain. So what makes it so special that it causes a brain injury? A little lesson in anatomy will help.

Anatomy of the Brain Coverings

A subdural hematoma is a blood collection from broken blood vessels that occurs below the dura mater and above the arachnoid and pia mater; therefore the blood collection becomes “trapped” between the coverings of the brain. Depending on how bad the bleeding is, there can be a fairly large collection of blood.  Where can it expand? It can expand along the planes of these coverings, but since the hard skull is on the surface, the “goose-egg” effect occurs inward, compressing the brain and all of the neurologic tracts within the brain. This pressure leads to loss of blood circulation, oxygen and glucose delivery and ultimately death of that brain tissue. The brain then responds by becoming swollen, increasing the pressures in the brain/cranium and causing even more damage. Depending on the location of the subdural hematoma,the person affected will react in a specific way.

What Causes a Subdural Hematoma?

Some are spontaneous, but these are relatively rare. There is usually a fall or injury to the head that preceeds the development of a subdural hematoma. Interestingly, the fall can be minor without direct trauma to the head in an elderly person or someone on blood thinners. Looking at the diagram above, small blood vessels supply the meninges with the necessary circulation. As some brains age, they shrink, especially in individuals with dementia. As the brain shrinks, the blood vessels are stretched to continue to supply the various coverings with circulating nutrients. The stretching makes the vessels more fragile, and the brain shrinkage allows more room to move around when “shaken” or “dropped”. Thus, a shearing effect occurs, breaking those vessels and allowing for bleeding to occur.  The addition of blood thinners to prevent clotting can cause a tiny injury to become a huge hemorrhage.  Obviously, the bleeding becomes even more profuse when a person is over-anticoagulated, either incidentally or inadvertantly. A direct blow to the head, either related to a fall or simply bumping one’s head, can provide enough impact to cause damage both externally and internally; external hematomas are an obvious sign to a medical provider to consider internal injuries.

What are the Signs and Symptoms of Subdural Hematomas?

According to the NIH website, signs/symptoms of subdural hematomas in adults include the following:

  • Confused speech
  • Difficulty with balance or walking
  • Headache
  • Lethargy or confusion
  • Loss of consciousness
  • Nausea and vomiting
  • Numbness
  • Seizures
  • Slurred speech
  • Visual disturbances
  • Weakness

Also, according to the NIH website, signs/symptoms of subdural hematomas in infants include the following:

  • Bulging fontanelles (the “soft spots” of the baby’s skull)
  • Feeding difficulties
  • Focal seizures
  • Generalized tonic-clonic seizure
  • High-pitched cry
  • Increased head circumference
  • Increased sleepiness or lethargy
  • Irritability
  • Persistent vomiting
  • Separated sutures (the areas where growing skull bones join)

How are Subdural Hematomas Diagnosed?

According to an emedicine article, the best diagnostic tool for identification of an acute subdural hematoma is a non-contrast CT scan of the head; the blood collection has a typical appearance that is easily recognizable. It becomes more complicated in subacute and chronic subdural hematomas; a contrast head CT or a brain MRI might be more accurate.

Subdural-hematoma-101.jpg

http://www.radswiki.net/main/index.php?title=Subdural_hematoma

How are Subdural Hematomas Treated?

It depends on the size and acuity as well as the presenting condition of the patient. A patient with obvious brain injury and neurologic deterioration requires emergent surgical and medical treatment; the surgical interventions can range from a “burr hole” to relieve the pressure to a full-blown craniotomy to evacuate the hematoma and control additional bleeding. Sometimes, secondary surgeries are required. Some small hematomas can be monitored in patients without neurologic compromise, and these can potentially resolve on their own or become chronic. If a patient with a subdural hematoma is over-anticoagulated (too much Coumadin), it is often necessary to reverse the anticoagulation before performing surgery to prevent additional hemorrhage; however, this delay can often cause additional permanent brain injury and functional deterioration of the patient.

Medical therapies include controlling blood pressure, controlling intracerebral pressure, preventing seizures from occurring (due to irritation of the meninges and brain), supporting heart and lung function, and managing fluid and electrolyte levels.

What is the Prognosis for Subdural Hematoma?

Since there is such a wide range of presentations and since each patient provides a unique set of circumstances, prognoses vary greatly, but overall, morbidity and mortality rates are extremely high. According to the emedicine article, the overall mortality of a simple subdural hematoma (without brain injury) is about 20%; the overall mortality rate for a complicated subdural hematoma (brain injury present) is about 50%! Even with successful evacuation, a patient runs the risk of recurrent bleeding, infection, chronic seizure disorder and permanent neurologic functional loss (depending on location).

Important Pearls….

If you are caring for an elderly person, do everything possible to prevent falls!

Monitor anticoagulant levels diligently. Be aware of potential interactions with specific foods and “new” medications.

If a fall occurs, seek evaluation as soon as possible; earlier interventions generally have better outcomes.

If evaluated and discharged, continue to observe the patient for changes in behavior, cognition and function for up to 1 week after the initial injury; seek treatment emergently if any changes are observed.

Avoid alcohol and narcotics which can both aggravate a potential condition and mask its presentation.

How Much is Your Marriage Worth?

Friday, June 10th, 2011

When you’re injured as a result of someone else’s negligence, it’s easy to see why you have a legal claim. You are entitled to recover for the injuries that you suffered, including economic damages (lost wages, medical bills, etc.) and non-economic damages (pain and suffering). However, if you’re married, there is another category of damages that you may be able to recover – damage to your marriage. It’s called Loss of Consortium and is an important element of damages in the right circumstances. It is a legal recognition that the marital relationship itself – separate and apart from the injury to the individual – is a protected interest that is deserving of compensation if it has been harmed by the negligence of another person.

Loss of consortium has an interesting history. Under Common Law (which roughly translates to “the olden days” in this circumstance) a woman had no right to sue for loss of consortium. It was only the man who had the right. That was because the woman was essentially seen as the man’s property. If she was injured and unable to provide her usual domestic or bedroom duties as a result of someone else’s negligence, the man could recover for the loss of such services. He had basically lost some of the value of his property so he was entitled to compensation. Eventually, the courts (most courts, at least) recognized the unfairness of such a one-sided system and ruled that women could also make such a claim if their husband suffered an injury. However, there are still some states (Virginia, for example) that do not recognize loss of consortium at all, no matter who tries to bring it.

Back to the present day. A loss of consortium claim arises when one spouse suffers a serious injury that impairs the marital relationship. An easy example is if a husband suffers a traumatic brain injury as a result of a doctor’s negligence. In that circumstance, the man would be able to file a claim for his own damages, of course, but he and his wife could also allege loss of consortium because the brain injury impacts the marriage. The couple will now find it more difficult to do the things they use to do together as man and wife – going out together, caring for their children, taking vacations, intimacy, and the day-to-day marital difficulties that arise because the husband now has a brain injury. In Maryland, a jury can award monetary damages for the couples’ loss of companionship, affection, assistance and yes, sexual relations. It is notoriously difficult to put a dollar figure on such injuries, but the law recognizes the right of a husband and wife to recover financially if their marriage has been damaged. How much money to award for such injury is for the jury to decide. Like other damages, it is always the plaintiffs’ burden to prove that the marriage has been injured, which is usually done through the testimony of the husband and wife.

Speaking of intimacy, some pundits say that loss of consortium is just a code-word for damage to the couples’ sex life. This is not entirely true as the marital relationship entails far more than just sex, but these pundits have a point. A loss of consortium claim usually does include an allegation that the couples’ sex life has been impacted. If you are bringing a lawsuit, you have to understand that when you allege loss of consortium, you are opening up the door on the most intimate parts of your life. Defense attorneys will often ask highly personal questions – how often did you have sex before the injury, how often do you have sex now, how exactly does the injury make sex more difficult, have either of you ever strayed from the marriage, etc. Some couples are understandably reluctant to discuss such things. Thankfully, most defense attorneys are just as uncomfortable asking these questions as the plaintiffs are answering them, so the questions tend to be over with relatively quickly. Be aware, though, that if you do file a loss of consortium claim, your sex life may become an issue in open court.

In the District of Columbia, a loss of consortium claim is for similar damages, but with a slight difference. While in Maryland the claim belongs to both the husband and the wife and is brought by them jointly, in the District of Columbia the claim belongs solely to the non-injured spouse. Any money awarded by the jury for loss of consortium goes to the non-injured spouse rather than to the couple jointly.

Lastly, Maryland’s cap on non-economic damages applies to claims for loss of consortium. There is no separate cap for this claim. In other words, there is a single cap that applies to all allegations of injuries, whether it’s an injury to the individual or an injury to the marriage.  The Maryland Legislature does not allow a couple to receive more money for injury to the marriage above and beyond the cap, even if a jury decides that that money should be given. Just another example of how Maryland’s cap punishes plaintiffs.

Have you ever suffered an injury that impacted your marriage? Did you file a loss of consortium claim? What was the result?

Related Nash and Associates Links

Maryland’s alleged healthcare “crisis”

Insurance and Traumatic Brain Injury

Acquired Brain Injuries

 

 

Concussions: The Message of Orioles’ Brian Roberts’ Injury Should Not Go Unheeded!

Sunday, May 22nd, 2011

Brian Roberts - NBC Sports photo (modified)

As I was reading the sports page this morning, after working my way past yesterday’s Preakness news, I was motivated to write this post by the report of Jeff Zrebieck in the Baltimore Sun’s Notebook section. Earlier this week, Brian Roberts of the Orioles was removed from the lineup due to headaches. At the time, I thought back over the games that preceded this news report but couldn’t remember any incident when Roberts could have sustained an injury that led to his headaches. For a guy like Brian Roberts, whose recent career has been marred by injuries, it was hard to believe that as tough and gritty as he is, that something like a sinus problem, allergies or the like had felled this guy. Then within a day or so, following examination and testing, we learned that Brian had sustained a concussion.

Once again, I thought through the games leading up to his line-up departure and still couldn’t remember any play or at-bat that would, in my mind, cause a concussion. There was no high and tight, back-him-off-the-plate pitch, no knee to the head by a middle infielder when he was sliding into second on an attempted steal, not even a take-out at second base while he was turning a double play. As we learned later, he sustained his current injury while sliding into first base headfirst trying to beat out a single. He never struck his head on anyone or anything. So how in the world did Brian Roberts wind-up on the disabled list with a concussion?

Last year’s injury set the stage for a recurrence

While no one knows for sure, the speculation during the 2010 season, which was also marred for Roberts by a back injury, was that Roberts had caused the concussion when, out of sheer frustration from a bad plate appearance, he struck himself in the helmet with his bat on the return to the dugout. We’re not talking a violent collision between a defensive back and an unprotected wide receiver, a car crash or a vicious criminal assault. Nevertheless, Roberts’ head injury lingered on well past the end of the season, which ended for him six games early due to dizziness and headache following this incident.

When he reported to spring training, the Orioles faithful were hoping that the past season’s injuries (back, strained abdominal muscle, concussion), which caused him to miss a total of 103 games in 2010, were a thing of the past. Then on Wednesday, February 23, 2011, the report came out that Brian had left spring training that morning due to a stiff neck. What was this all about? Then came the news last week – a slide felled this mighty warrior.

Concussions: a mild traumatic brain injury

Just what is a concussion? Brainline.org, a great resource for those seeking more information about traumatic brain injuries, gives this description:

In a nutshell, a concussion is a blow or jolt to the head that can change the way your brain normally works. Also called amild traumatic brain injury, a concussion can result from a car crash, a sports injury, or from a seemingly innocuous fall.Concussion recovery times can vary greatly.

Most people who sustain a concussion or mild TBI are back to normal by three months or sooner. But others . . . have long-term problems remembering things and concentrating. Accidents can be so minor that neither doctor nor patient makes the connection.

The Days of Yore – “Gut It Out” – are thankfully coming to an end

Anyone who follows sports is well aware that finally the old school mentality of “gut it out and get back in there” following blows to the head are coming (not too soon) to an end. Committees have been formed, articles written and the national spotlight of the media have finally focused on this issue. Those recommendations, debates and guidelines are beyond the scope of this post. Nevertheless, those involved in sports, particularly at the scholastic levels, should constantly be aware of this ever-expanding information, which is available through multiple resources and media channels.

What are the signs and symptoms of a concussion?

While there is apparently no universally accepted definition of concussion despite hundreds of studies and years of research, according to one source, there is some unanimity in what are the worrisome signs and symptoms, which can include:

  • Headaches
  • Weakness
  • Numbness
  • Decreased coordination or balance
  • Confusion
  • Slurred speech
  • Nausea
  • Vomiting

If you or someone in your family has sustained any type of head injury, no matter how minor and they show these signs or symptoms, get to the doctor or an emergency room immediately.

CT Scans, MRI’s and other diagnostic test after head injuries

TBI’s or traumatic brain injuries are reported to be “a major cause of death and disability worldwide, especially in children and young adults.” In cases of obvious severe head trauma, it’s a “no-brainer” that diagnostic testing should be done. But what about cases of mild to moderate head trauma? Who defines what is “minor” and “moderate” when it comes to TBI’s? What testing is necessary; when is it unnecessary?

While these judgments are made by the medical professionals, you need to be your own advocate at times in making this decision-making process. Brian Roberts was tested and submitted to radiographic tests for a host of reasons – probably not the least of which is the fact that he is a very valuable member of a professional sports team. What about the ordinary guy in the street?

Well, the short answer is – the recommendations vary when it comes to mild and moderate head injuries. In fact, the very definition of what constitutes a moderate TBI can also vary depending on whom you read. Nevertheless, certain signs, symptoms and history are not disputed indications for a radiographic study to rule in or rule out a potential brain injury. For example, one need only read the indications for the use of radiographic studies published by MedicineWorld.org or a host of other organizations on this topic.

In a recent case, I personally came across someone whom I believe to be a leader in the field of traumatic brain injuries (TBI), Dr. Andy Jagoda, an emergency medicine specialist in New York. He has done extensive research, writing and lecturing on this topic. I’ll save you the effort, here are the search results for his body of work.

A Lesson – Hopefully – Learned

I started this piece with the story of Brian Roberts. I didn’t simply do this because I am a long-suffering fan of the Orioles (which I am) and an admirer of Brian Roberts (which I also am) but because of the message his story tells us. A self-inflicted bat to the helmet because of a strikeout? A slide into first base with no blow to the head? A concussion none the less – apparently!

Brian Roberts may have a team of medical specialists watching and monitoring his every grimace, complaint and move; you probably won’t have that luxury. If you have a head injury – minor or otherwise – and have any of the known signs, symptoms or risk factors for a traumatic brain injury, be vigilant and pro-active for your own health and well-being.

If you are in an emergency room and the discussion of whether or not you should undergo radiographic testing takes place, get involved – ask questions. If you are discharged from the emergency room, whether you had a CT or an MRI or not, pay very careful attention to the head injury discharge instructions you are given. It is a well known phenomenon that there can be a delay in symptoms and signs of a TBI days if not weeks later. If you are suffering any ill-effects during this post-discharge period, get to a healthcare provider immediately.

The stories of how lives are altered forever more as a result of TBI are legion. Don’t become yet another statistic.

Your time to share

Have you ever had a TBI? Know someone who has? What happened in that situation? Was a test done? Do you think CT scans are overused, particularly in children? Are they underused? How did your “experience” turn out? Any advice for others? Share, Good People, share!

Good luck, Brian – and speed recovery!

 

 

 

Acquired Brain Injuries: Causes and Impact

Tuesday, May 17th, 2011

On the heels of Jason Penn’s blog regarding calling “911″ for signs of a possible stroke, I decided to introduce a variety of acquired brain injuries for further discussion in future blogs since damage to the brain results in some of the most catastrophic injuries possibly sustained by the human body with significant “collateral damage” for all of the friends and family involved in the individual’s life.

What is an “acquired brain injury”?

Wikipedia defines acquired brain injury as damage to the brain occurring after birth but not including neurodegenerative diseases, such as Parkinson’s or Alzheimer’s, that occur later in life.  These injuries can further be divided into traumatic and non-traumatic acquired brain injuries.

Traumatic brain injuries are a result of some kind of trauma to the cranium/brain, but the actual causes can vary significantly. Trauma, in general, is the leading cause of death in the young-adult age group. An obvious example of a significant head trauma is the gunshot wound to the head sustained by Arizona Representative Gabrielle Giffords earlier this year. Other examples are assaults with blows to the head, falls with blows to the head, car or bicycle accidents with head injuries, sports-related head injuries/concussion, childhood playground head injuries, and even damage sustained during brain surgery. The degree of damage and permanent sequellae obviously varies as well, ranging from fully recoverable within a few days to catastrophic permanent deficits and even death. Interestingly, the amount of external damage (or lack thereof) does not necessarily reflect the damage inside the cranial vault.

Non-traumatic acquired brain injuries, on the other hand, have a wide range of etiologies not related to head trauma that have just as wide of a range of catastrophic effects and recovery times. One of these causes is a stroke, as described by Jason Penn; however, strokes can be either ischemic (blockage of blood flow to the brain by, for example, a blood clot) or hemorrhagic (when a blood vessel in the brain ruptures), and each is treated very differently!  Other possible causes are infections, brain tumors, failure of other body organs (liver, kidney), loss of oxygen delivery to the brain (heart attack, blood clot in lungs), other chemical or drug ingestions with toxic effects, aneurysm rupture, and build-up of carbon dioxide in the blood stream from other lung pathology, including smoking!

A Virtual Tour of the Brain

Described as the most complex organ in the human body, the brain has been the subject of numerous educational videos, which attempt to give the layman a better understanding of the parts and functions of the human brain. YouTube has numerous “brain anatomy” videos for you to peruse. Here’s one from the University of Bristol that does a good job of providing the basics of this incredible organ.

httpv://www.youtube.com/watch?v=9UukcdU258A

Effects of Brain Damage

The brain is the body’s 3-pound computer that controls every conscious and unconscious function of the body. Different areas of the brain control different cognitive, behavioral and emotional functions as well as the everyday metabolic functions of the body. Damage to specific areas of the brain result in specific functional losses, which is why someone with a “stroke” might experience numbness and weakness of one side of the body or no weakness but loss of balance or loss of vision. Larger injuries result in more brain tissue damage and more functional deficits. The object of “the game” is to rapidly diagnose the problem and rapidly treat the problem in order to minimize the amount of brain damage, and thus, minimize the functional deficits. Many acquired brain injuries progressively worsen due to different “normal” pathophysiologic mechanisms. It is imperative to intervene sooner whenever possible.

A Personal Story

My uncle had a stroke 1 month ago while working in the yard.  ”911″ was called immediately, and he was transported to the closest hospital.  He apparently had an undiagnosed abnormal heart rhythm (atrial fibrillation) that caused a large blood clot to form in the heart. This clot ultimately got pumped out into the carotid artery and lodged itself at the beginning of the middle cerebral artery on right side of his brain.  He was initially unconscious, but he later “came to”, only to deteriorate into unconsciousness again as the brain swelled from the blocked artery and infarcted brain tissue. He was transferred to another hospital that was capable of performing brain surgery, and he had back-to-back brain surgeries on 4/10 and 4/11 to try to minimize the damage. They actually had to remove a large part of his skull to allow for the brain swelling to occur without the brain’s tissue being compressed against the skull so as to prevent herniation of the brain.

He was in a coma for several days, but he is slowly making some recovery. In the meantime, he needed a tracheostomy and feeding tube in his stomach, both of which he still has. His entire left side remains completely paralyzed. It is difficult for him to stay awake, although he does seem to know who is around at any given time. My aunt, God bless her, has spent the last month at the hospital, 8 hours or more every day, and she is just exhausted. It is unclear when he will be going home or even if he will be going home. We are hoping and praying for the best recovery possible, but the future remains uncertain.

Collateral Damage

In addition to the person affected by acquired brain injury being functionally limited, whether temporarily or permanently, there is often collateral damage to himself/herself as well as to friends and family members. Emotional issues often arise, whether through mood disorders like depression and anxiety, or with actual personality changes. Those affected can become more belligerent or difficult, angry, withdrawn, and a host of other characteristics, making it very difficult on the person caring for the affected individual. The physical demands alone can overwhelm the care-provider (like bathing, toileting, feeding, transporting to appointments, etc.) and lead to care-provider stress and mood disorders.  Financially, these injuries are often devastating. Marriages end; relationships among family members suffer; sometimes, physical abuse and neglect can even occur when frustrations become overwhelming.

There are support groups available many of which can be accessed through local hospitals, associations or your health department.

Locally, you may want to visit the Brain Injury Association of Maryland and the Brain Injury Association of Washington, D.C.

Stay posted for more details on some of these causes of acquired brain injury specifically. In the meantime, do you have a story to tell?

 

Image from neuroskills.com

Robot Anesthesiologists?

Tuesday, April 19th, 2011

robotic intubationFor anyone contemplating serious surgery, it can be a scary endeavor. From going through it myself and talking to others, I know that the main fear we have going into it is that the surgeon will make a mistake during the surgery, or that we will develop serious complications such as a hematoma, infection, etc. that leads to death or paralysis. While these are very real risks of many forms of surgery, there is another aspect of surgical procedures that gets less attention from patients – the anesthesiologist. While it may get little notice from patients, anesthesiology is a highly complex field of medicine in which doctors (and certified nurse anesthetists) train for years to be able to do it well. This post will focus on just one aspect of anesthesiology known as intubation, and a new development in robotics that may improve the procedure.

What is intubation?

At its most basic, intubation is the process by which the anesthesiologist places a thin plastic tube into the patient’s windpipe to maintain an airway or to facilitate mechanical ventilation. While this is done in a variety of serious medical situations, it is almost always done during major surgery when the patient is under general anesthesia. During such surgery, the patient is rendered unconscious and is unable to breathe on his or her own. Therefore, the anesthesiologist has to essentially breathe for the patient during the surgery, either using a ventilator or sometimes compressing a bag that replaces natural breathing. The process of intubation allows this artificial breathing to take place. Because intubation itself is a painful procedure (remember – a tube is being inserted far down your throat), the patient is usually given paralytic drugs (drugs to induce paralysis) before intubation. This is a key point we’ll come back to later.

Risks of Intubation

While it may sound as simple as sliding a tube down the throat, intubation carries its own risks separate and apart from the risks of anesthesia itself (risks from anesthesia can include death, paralysis, brain damage and a whole host of other less serious injuries). With intubation, there are minor risks such as chipped teeth, lacerations in the gums and sore throat. However, there are many more serious risks as well, including perforation of the trachea, mistakenly placing the tube down the esophagus (a more common occurrence than you might think), aspiration of stomach contents, vocal cord injury, decreased oxygen and elevated carbon dioxide, and nerve injury. Intubation is a serious procedure that requires a high degree of skill and training to do it well and safely.

What if the tube does not get placed properly?

Inability to secure the airway is a major problem in intubation. To understand why, you have to remember that before the tube is placed, the anesthesiologist paralyzes you with drugs. Therefore, before the tube is placed, you stop breathing on your own. It is then critical that the tube be placed quickly and accurately to ensure that you don’t suffer from a lack of oxygen (or ventilation – the exchange of oxygen and carbon dioxide). So what happens when the anesthesiologist has trouble getting the tube in? It just so happens that I have some personal familiarity with that scenario.

A few years ago I had back surgery. The surgery itself was not complex as far as spine surgeries go (it always amazes me how surgeons are able to describe cutting open your back and operating on your spine as casually as they might describe changing a light bulb). It essentially consisted of trimming off a small piece of disc that was pressing on my spinal cord and causing pain to radiate down into my leg and foot.  I was in and out of the hospital the same day, but of course I was under general anesthesia so I had to spend a couple of hours in the Post Anesthesia Recovery Room (PACU) to make sure that I was not suffering from any ill effects of the anesthesia. While waking up, and still groggy, the anesthesiologist walked up to me and said, “I just want to let you know – you were really hard to intubate. If you ever have surgery again, be sure to tell your doctor that you’re really hard to intubate.”

I asked the doctor what he meant by that. He told me that because of the anatomy of my mouth and throat, he had had a really difficult time getting the tube into my airway. Keep in mind, the tube was placed down my throat after I was given drugs to paralyze me. Even in my post-anesthesia addled state, I knew enough to ask the obvious question – what would have happened if he couldn’t have gotten the tube down in time? He was casual in his response. “Oh, we would have given you drugs to wake you back up.” How comforting. My next thought was, “Maybe you could have checked my anatomy out before you gave me paralyzing drugs.” I didn’t ask that because I am sure they did check me pre-operatively.  That is standard procedure before giving anesthesia to make sure that the anesthesiologist knows the patient’s anatomy and can anticipate problems. Apparently, my anatomy was a little more vexing than he had bargained for. However, he was finally able to get the tube in and the surgery went well.

The use of robotics

Because of the ever-present risk of serious complications, researchers are always working on improving intubation to minimize risk. It has always been a hands-on procedure that depended on the skill of the individual performing it. Now we may be moving into a whole new world of intubation thanks to advances in robotics.

Medical News Today is reporting that Dr. Thomas Hemmerling of McGill University and his team have developed a robotic system for intubation that can be operated via remote control. According to Dr. Hemmerling:

The [device] allows us to operate a robotically mounted video-laryngoscope using a joystick from a remote workstation. This robotic system enables the anesthesiologist to insert an endotracheal tube safely into the patient’s trachea with precision.

The system is still in development. It has been widely tested with mannequins that mimic human anatomy, and clinical testing on patients has now begun. Dr. Hemmerling hopes that the new device will allow anesthesiologists to intubate patients using less force and higher precision, which should help to improve patient safety. Even with the use of robotics, I would think that intubation, including pre-operative assessment of individual anatomy, is going to require close hands-on involvement in order to ensure that it is done safely and properly, but it is always exciting to see what was once science fiction being used in real-life surgeries.

What you can do

While robotic anesthesiology is still down the road for most of us, there are still things you can do to minimize your risk of injury. Before agreeing to surgery, most of us do a good job of vetting our surgeon – how experienced he or she is, how many similar procedures he or she has performed. How many times have you heard a friend describe his or her surgeon as “the best?” Yet virtually no one who has been a patient – at least in my experience – makes any inquiry into the experience level of the anesthesiologist, even though a mistake by this person can render you paralyzed or brain-dead (or even dead) in a matter of minutes.

If you are planning on undergoing serious surgery, I would encourage you to discuss the anesthesia care with your surgeon. Find out ahead of time who your anesthesiologist is going to be (if that’s possible), and discuss your situation with that person. No doubt you will be evaluated by the anesthesiology team before your surgery, but it may well be the same day as your surgery, and it will feel like just another routine matter like signing a few forms. Keep in mind, however, that anesthesiology is just as important as the surgery itself. Stay informed and ask questions. Treat your pre-operative session with the anesthesiologist as if your life and health were depending on it – it just may!

And as for robotics, I’m curious what your comfort level would be if your doctor suggested using a robot to intubate you? Would you be willing to try the procedure, or would you prefer the traditional hands-on, human approach?

Image from “Today’s Medical Developments”

Shaken Baby Syndrome – What We All Should Know To Prevent Child Abuse

Wednesday, April 6th, 2011

Shaken-Baby Syndrome - image: mydochub

Some people should think twice before becoming a parent.  According to the Medical Examiner’s Office in Hampton, Virginia, Natalynn Hamrick died on February 3, 2011 from a brain injury after being shaken by her mother. Natalynn was only eleven months old. Her mother, who is now the subject of a criminal investigation, reportedly told the police that she shook Natalynn while trying to put her in the car seat.

Believe it or not, there is an actual syndrome that describes what happened to Natalynn. It’s called Shaken Baby Syndrome (SBS, also referred to as “Abusive Head Trauma” ) – “a form of physical child abuse that occurs when an abuser violently shakes an infant or small child, creating a whiplash-type motion that causes acceleration-deceleration injuries.”

The injury usually ensues as a result of very violent shaking, which then produces an accelerated rotational movement of the head.  This type of movement may cause the brain to move/rotate within the skull cavity, resulting in trauma to brain tissue.  There may be associated bleeding around the brain caused by torn blood vessels. The bleeding usually leads to pulling within the skull (i.e., subdural hematoma), which in turn can cause additional brain injury by exerting pressure on the brain and causing it to move or herniate.

Diagnosing less severe cases of SBS can be difficult because the child may not initially manifest any signs or symptoms. Radiographic studies may be used to diagnose bone fractures or brain bleeds. An important external manifestation could be bleeding in one or both eyes. The pupils may be blown and/or unresponsive. The following are some additional signs and symptoms:

  • Lethargy / decreased muscle tone
  • Extreme irritability
  • Decreased appetite, poor feeding or vomiting for no apparent reason
  • Grab-type bruises on arms or chest are rare
  • No smiling or vocalization
  • Poor sucking or swallowing
  • Rigidity or posturing
  • Difficulty breathing
  • Seizures
  • Head or forehead appears larger than usual or soft-spot on head appears to be bulging
  • Inability to lift head
  • Inability of eyes to focus or track movement or unequal size of pupils

Some of the long-term consequences of SBS include:

  • Learning disabilities
  • Physical disabilities
  • Visual disabilities or blindness
  • Hearing impairment
  • Speech disabilities
  • Cerebral Palsy
  • Seizures
  • Behavior disorders
  • Cognitive impairment
  • Death

Babies are more prone to develop SBS symptoms because their heads are relatively large when compared with the size of an adult head (i.e., on average a baby’s head represents about 25%of his/her total body weight).  Additionally, babies have relatively weak neck muscles that we not fully capable of supporting the head. Also, a baby’s brain is not fully developed, making it more susceptible to traumatic injury.

The following  prevention measures can easily be implemented to reduce the possibility of SBS injuries:

  • NEVER shake a baby or child in play or in anger. Even gentle shaking can become violent shaking when you are angry.
  • Do not hold your baby during an argument.
  • If you find yourself becoming annoyed or angry with your baby, put him in the crib and leave the room. Try to calm down. Call someone for support.
  • Call a friend or relative to come and stay with the child if you feel out of control.
  • Contact a local crisis hotline or child abuse hotline for help and guidance.
  • Seek the help of a counselor and attend parenting classes.
  • Do not ignore the signs if you suspect child abuse in your home or in the home of someone you know.

April is the National Child Abuse Prevention Month. If you suspect that a child is being abused, be proactive and take steps to allow for timely intervention.  Share your knowledge about SBS with your friends and family because no child should ever have Natalynn’s fate.