Healing the Brain
It was a routine mother-daughter disagreement--until things went dreadfully awry. Medrith Filley and her 15-year-old daughter, Heather, were having a heated discussion as they pulled up to their Mission Viejo home one Saturday morning in November 1997. Heather suddenly decided to jump out of the car, and the heel of her shoe caught on the doorjamb, flipping her backward, her head hitting the pavement hard.
Filley, a nurse, knew immediately that her daughter’s injuries were grave--her teeth were clenched, a symptom of profound brain injury, and she wasn’t breathing. Heather lapsed into a deep coma after she was rushed to a local hospital. When surgeons operated on her, they discovered blood clots everywhere, and just about every part of her brain had sustained serious damage.
They did everything they could to save her life. But instead of pumping her up with steroids and diuretics to dehydrate her and thus reduce swelling in the brain, which was the traditional method for treating head injuries, Heather’s doctors followed a new protocol. She was tethered to monitors that measured blood pressure in her brain and blood-oxygen saturation, while catheters siphoned off excess fluids. Surgeons removed most of her skull to ease the pressure from the brain’s swelling. All of this was designed to keep her blood pressure high enough to maintain a normal blood flow, and ensure her brain got the oxygen and fuel it needed to heal.
Her condition was touch-and-go for weeks, but gradually she recovered and was well enough to go home at Christmas. She was in intensive rehabilitation for months, and wore a special helmet for six months to protect her exposed brain until it healed enough for her skull to be reattached.
In a way, though, Heather, who’s now a vibrant, college-bound high school senior, was incredibly lucky. It was pure chance that Mission Hospital Regional Medical Center, which had just begun a new program for treating brain injuries, was the closest trauma center to her home. This novel therapeutic approach, say experts, can mean the difference between life and death, or resuming normal activities and a lifetime of dependency.
There’s nothing miraculous about Heather Filley’s remarkable recovery. “It’s just good science, and the technology that saved her should be routine,” insists Dr. Jamshid Ghajar, a neurosurgeon at Cornell Medical College and president of the Brain Trauma Foundation, a nonprofit educational organization in New York. Unfortunately, it’s not. Despite striking gains made by hospitals that have adopted these new brain injury standards, most U.S. hospitals don’t follow this course of treatment.
Little wonder the rates of death and severe disability among brain trauma victims remain stubbornly high. Each year 230,000 Americans are hospitalized with brain injuries from car accidents, falls and assaults, leading to death or serious impairment in more than half the cases. In fact, more than 5.3 million Americans, about 2% of the U.S. population, live with a disability as a result of a traumatic brain injury, and it costs the federal government $45 billion each year for their care. And this doesn’t include costs for private insurers or the inestimable emotional toll on families.
‘A Vast Paradigm Shift’ in Treatment
Yet people such as Heather Filley don’t have to be doomed to life in a coma or having a permanent disability. Recent studies have shown that the traditionally high rates of death and irreversible brain damage can be drastically cut by implementing the simple procedures doctors used on Heather: monitoring the pressure inside the brains of victims, and maintaining blood flow to make sure tissue is supplied with vital nutrients and oxygen.
“We’re in the midst of a vast paradigm shift in the treatment of head injury,” explains Sylvain Palmer, a neurosurgeon and chief of staff at Mission Hospital.
The numbers tell some of the story. In the three years since Mission Hospital established its program, results have improved dramatically. The number of patients with traumatic brain injuries who are able to function normally nearly tripled, death rates plummeted by almost two-thirds and the number of victims who were severely disabled or in a persistent vegetative state was reduced by half. Other U.S. hospitals with comparable brain injury programs report similar results.
However, a survey done last year by the Brain Trauma Foundation revealed that only about a third of the approximately 500 U.S. hospitals that treat traumatic brain injuries are using some of these techniques, and fewer than one in five use all of them. The logical question is, why don’t hospitals adopt a treatment strategy that’s been proven to work? “Trauma is the orphan child of medicine--insurance reimbursement rates are low, so there’s little financial incentive to change standard practices,” Ghajar says.
As a result, cash-strapped hospitals are wary of spending money to set up new systems and buy the special monitors necessary to implement such programs. At Mission Hospital, for instance, treatment costs per brain trauma patient jumped from $196,000 to $300,000. “We have to eat the extra expense,” Palmer says.
Medical professionals are also accustomed to treating brain injuries in a certain way, and are reluctant to make changes. “It’s difficult to pull all the different teams together,” says Mary Kay Bader, a neuroscience clinical nurse specialist at Mission Hospital. “Retraining required an enormous commitment from everyone, from the ambulance drivers to the trauma doctors, nurses and neurosurgeons.”
The Real Injury Occurs After the Impact
Another part of the problem is that this new approach flies in the face of traditional thinking about brain injury treatment. Doctors have long known that the original injury wasn’t usually the source of all the trouble--swelling afterward was the real culprit. When the soft brain tissue pressed against the hard skull, it caused secondary injuries that often did much more damage than the initial insult. Worse yet, blood vessels constricted, which deprived the brain of needed fuel and oxygen, so brain cells died.
Shrinking the brain to relieve the pressure seemed to make the most sense. Trauma doctors used a variety of techniques to do this, such as giving patients diuretics to drain fluids and steroids to reduce swelling. Subsequent research revealed, however, that many of these methods didn’t help, or were actually harmful because they reduced blood pressure so much that it stopped the blood flow. “It turned out we were starving the brain of essential nutrients, which was far more dangerous,” Ghajar says.
To remedy this situation, a committee of the world’s leading neurosurgeons did an extensive review of all the scientific literature on treating brain injuries to determine what methods consistently worked. Based on this, they devised treatment guidelines for brain injuries in 1996, which were adopted by the American Assn. of Neurological Surgeons and have since become the gold standard for treating brain injuries.
Yet most people who suffer traumatic brain injuries are still leaving the hospital with serious impairments because most hospitals don’t follow the guidelines.
Victims Adapt to a New Way of Life
For most brain injury survivors, life is never the same. Like stroke victims, they learn to adapt, and other parts of the brain can be trained to compensate. “Nobody goes back to normal, though, and there’s always some residual effect,” says Dr. Ziyad Ayyoub, chief of adult brain injuries at Rancho Los Amigos National Rehabilitation Center in Downey.
Patients have deficits in memory, in concentration and in the way they process information. Their judgment and intellectual abilities are hampered--and their personalities can change. “They look fine but they can’t cope,” says Bader, of Mission Hospital. “The old self dies and the new person emerges. Friends drift away because they can’t deal with the person they’ve become. There’s often a desperate yearning for their old life, because they know what they want to do but now they’re not able to do it.”
Sadly, many probably could have had better outcomes if their medical treatment had been different.
Leanne Ford, for instance, was once the classic Supermom, taking care of three kids and attending college full time to get her accounting degree. Then, one rainy afternoon in November 1996, her car was rear-ended. The impact of the collision slammed her car into a row of trees, knocking Ford unconscious. Taken to a community hospital in her hometown of Simi Valley, she spent six weeks in a coma.
“When I came home from the hospital, I didn’t remember anything at all,” says Ford, 32. “Basically, I was a stranger in my own family.”
After a lengthy rehabilitation, Ford learned to walk again and do simple tasks, but she no longer drives and can only do light housekeeping. Most of the burdens of caring for the family now fall on her husband, Frank. “I’ve gone from being a smart person to barely able to add and subtract,” she says. “I cried every day for a long time because I’m not the person I used to be. I now accept what happened, but every day is a struggle.”
The Fords are unusual. Most marriages fray in the aftermath of a traumatic brain injury, and more than four out of five couples divorce. “The body is the same,” says Bader, “but the person they loved is no longer there.” Job prospects and earnings are greatly diminished, and some are left destitute, their lives completely altered.
Like Martha Sanchez. The Rowland Heights resident cares around the clock for her 30-year-old daughter, Janice, a budding artist who was severely injured in a car accident three years ago in rural Kansas. Janice’s marriage collapsed and she was forced to quit her dream job at an interior design firm; she now subsists on government grants.
Martha spends her days battling with bureaucrats to get better therapy for her wheelchair-dependent daughter. “Janice is at the mercy of what I can do for her,” says Martha. “I’m stuck in the house. So only my mouth, the phone and the contacts I’ve made are what has enabled us to survive.”
