Guidelines for treating brain trauma

Dr. Jamshid Ghajar, is a well-known neurosurgeon, president of the Brain Trauma Foundation, chief of Neurosurgery at New York’s Jamaica Hospital-Cornell trauma center and a practicing neurosurgeon at New York Hospital. In 1996, he saved the life of a woman who was savagely beaten in Manhattan’s Central Park using innovative neurosurgical procedures.

Interview on Treating Brain Trauma

I was interested in this interview because IF you or a loved one were ever in an accident and need medical attention you would have some understanding of what to ask about the hospital’s protocol.

This interview is from Nova and unfortunately I can’t get the audio to play on my Mac.

Nova: What’s a typical kind of place if you had a severe head injury and you ended up—what would they do?

I would say a sort of typical not very active trauma center would—you’d be put on a respirator. You would be given—you’d be hyperventilated, which means that they’d put you on the respirator and breathe you very rapidly. You would not have your brain pressure monitored. You may be given steroids, which have been shown to have no effect on head injury in terms of outcome. And you’d be given some drugs that cause you to lose a lot of fluids. And eventually you would lose so much fluids that your blood pressure would drop and you would die. More than half the people coming in that situation would die, and the rest of them would end up with significant disability.

Human Brain Synaptic GaspDr. Jamshid Ghajar did a survey with the Brain Trauma Foundation of 260 trauma centers throughout the United States that took care of severe head injury. And he asked them very basic questions like:

How many head injury patients do you see a month?

Do you monitor the pressure in the brain?

Do you treat brain swelling and so on?

And we found indeed there was a great deal of variability. And some of the treatments that were being used were—frankly, there was no scientific evidence supporting them, and in some cases could be deleterious.

So based on this and from my colleagues and my personal experience in talking around the country, we decided to develop guidelines.

What are the key parts of the guidelines?

Probably the key part is monitoring the brain pressure—the key part in treating patients with severe-head injury and trying to prevent the second injury—the first injury is the accident. You’re trying to prevent the second big injury. You’ve got a small piece of brain that’s been bruised and now this is being propagating. It’s going throughout the whole brain. You’re trying to prevent that from occurring. And the way to do that is diagnosis, which is monitoring the brain pressure, putting a tube in the brain and monitoring the pressure. Once you do that you get a number. Once you get that number you know how swollen the brain is, and then you do other things to try to prevent the brain from swelling even more.

How do you prevent the brain from swelling anymore? 

You have this fluid that the brain makes every single day, and it floats in it – the spinal fluid. The thing is to put this tube into the middle of the brain where the spinal fluid is made so that you can measure the pressure in the brain and if the pressure gets too high, you can just drain some of this fluid and relieve the swelling. We always put the tube into the front part of the brain.

One of the main problems is not having an adequate blood pressure in the brain.

Now, what does that mean? It means the brain is swollen.

It’s very high pressure, and you’ve got to get blood and oxygen into it. And if the blood pressure drops, you’re not going to get your oxygen and blood into the brain. The brain’s going to suffer even more injury.

It sounds like treating the brain injury is more work? 

There is more work on the part of the medical personnel.

There is more work.

It’s a lot easier just to put the patient on the ventilator and then turn up the rate and then give them some drugs and come back next week and see how they’re doing. They’re lying there in a coma. They’re not screaming out for help. They’re not saying, “I’m in pain.” And so it would be quite easy to say, “Well, they have half a foot in the grave, why do anything else?”

“That’s the real issue.

I think if these patients were awake and saying, “Listen do something for me,” we’d be doing a lot more for them.

But because they’re in a coma and they cannot speak for themselves, we’re treating them the way they are now.”

Resistance from Doctor’s.

Dr. Jamshid Ghajar was asked if he got any resistance when sharing the guidelines. His answer:

“I think when I talk privately to doctors, they say, “Yeah, I know about the evidence, but I still do what I do.” And there’s no rationale for it. And, you know, scientific data can be disputed. You can be controversial. In fact, the way we did the guidelines to show some evidence is stronger than others. But currently this is the best evidence we have.

Now, you can say, “I don’t believe the evidence. I believe the way I practice.” Well, that’s just not good science. And I don’t think the public wants to be exposed to this kind of variability.”

He continued, “here are a lot of young people, children, especially, who are dying unnecessarily. These kids could live and have a very good quality of life, and they’re dying.

I see it, the way they’re being treated. Kids more than adults are not having their brain pressure monitored and are being severely hyperventilated, having their blood pressure drop and so on. Kids can make a very good recovery, even better than adults. And what’s driving me is that there are deaths occurring every ten minutes as we’re talking. That a potentially salvageable patient that can go on and have a very good quality of life. We’re not talking about an 80-year-old or a 90-year-old with a stroke. We’re talking about a 15-year-old, a 14-year-old. Somebody who’s got the rest of their lives in front of them.”

Scientific Research Studies

Concussion Guidelines

Marked improvement in trauma centers when guidelines are followed. PDF

The entire interview with Dr. Jamshid Ghajar on Nova can be read here.

Ok, so what can we learn from this interview?

  1. There are guidelines and in many cases they are not being used.
  2. Many patients could have a good quality of life if they were treated.
  3. It is important to talk to your local hospital and find out what protocols they are using in the event you or a loved one has a brain injury caused by trauma.
  4. The fluid can be drained off the brain.
  5. That treating brain injuries is more work for the medical personnel.
  6. That fewer people would be pronounced “brain dead” if they were treated and not allowed to just lay there pumped full of drugs.
  7. That the secondary injury is “brain death” not the accident itself.

Flickr photo credit 

At least this is what I learned from the interview with Dr. Jamshid Ghajar, what did you learn?

The retreating boundaries of organ harvesting.

There is an article on Slate which questions when death is and WHO determines it. The author ends with this statement, “Modern medicine has brought us tremendous power. With that power comes responsibility. Boundaries such as death, heart stoppage, and ownership of organs have guided our moral thinking because they seem fixed in nature. Now we’ve unmoored them.

one domino at a time fallsThe author then goes on to state he is a registered donor because he believes in the gift of life, and that the job of providing organs falls to each of us. So does the job of deciding when and how we can rightly take them.

I would love to see that discussion.

Full disclosure as most of those who read my blog know…I believe life and death are NOT human decisions but one that only God can make. He gives life and He takes life away.

Dr. Robert Truog has been saying for years that taking organs from living people is causing death in the process. He has even gone to far as to call it a medical, legal fiction. (it is)

Dr. Truog believes that ethically it is OK to take organs from severely injured people as long as they have given informed consent via a life directive or a surrogate to be terminated (killed) in this way.

Informed Consent?

How is “informed consent” given by any person who signs up to be a donor? You can sign up online, on Facebook or at the Secretary of State or Department of Motor Vehicles. Are you given a pamphlet that talks about ANY of this? Have you been informed?

Since its inception, organ transplantation has been guided by the overarching ethical requirement known as the dead donor rule, which simply states that patients must be declared dead before the removal of any vital organs for transplantation. Before the development of modern critical care, the diagnosis of death was relatively straightforward: patients were dead when they were cold, blue, and stiff. 

The dead donor rule was accepted as a justification for pronouncing a person dead before harvesting organs.

If a family is told their child or loved one is brain dead, 99% of the time they do not question what is said or really even understand it. Nothing matters until it happens to you and then your eyes are open to the legal medical fiction.

In one sense, I agree with Dr. Troug I just don’t agree with his ultimate conclusion that it is OK to kill for organs IF you give permission.

Yes, the boundaries are retreating in organ donation

When Harvard first published their criteria in 1968, EEG’s were a part of the evaluation, then in 1971 the Minnesota criteria along and they decided patients didn’t need EEG’s because too many families got upset when they saw brain waves. Then the “Pittsburgh protocol” came along and they began to take organs not from “just” the “brain-dead” patient but from patients after cardiac death. Now in Denver they are waiting 75 sec for a babies heart to stop and then proceeding with organ harvesting.

Dr. Sam Parna’s book Erasing Death goes into the entire issue of the science of resuscitation.

As the author of the Slate article, Will Saletan states,

“Pick up the New England Journal of Medicine, and you’ll see the far edge of this tortured world. In the journal, doctors at the Denver Children’s Hospital describe how they removed hearts from infants 75 seconds  after their hearts stopped. The infants were declared dead of heart failure even as their hearts, in new bodies, resume ticking. The federal government funded the procedure; other hospitals are looking to adopt it.”

Be informed, discuss this with your families and friends. Know what you believe and why you believe it.

Brain injured patient’s need treatment quickly

Sanjay Varade, Neuro physician, just reported in Times of Indiamost brain injury patients get paralytic strokes as they are not brought for treatment on time.

Jamie CaulkWhen Jamie was injured in the auto accident the social worker told me on my way in route to Nashville that they got to him “in time.” Meaning his accident was close to Vanderbilt.

The accident happened at 3:30 A.M.Jamie was talking and responding. In fact he was talking until he crashed when they were getting ready to do a “procedure.” From the medical records they were inserting a chest tube.

This was at 9:00 A.M.

Five hours later.

The medical records state that he was agitated and complaining of a headache. They gave him fentanyl to keep him calm. We have talked many times in our family about Jamie being agitated. He was an athlete, he had no feeling in his legs. I would have been agitated too. I have read that in assessing a patient in trauma that it is important to find the reason for their agitation.

Did they ask him? Well, we will never know, right?

According to doctors, severe headache, sudden confusion in the head, blurring of vision in one or both the eyes, tingling sensation in the hands and legs, dizziness and inability to balance are the symptoms of brain haemorrhage or damage.

“If any injury to the brain is treated on time, then physical incapacity and death can be prevented.

Most patients suffer debilitating injuries or die due to late treatment.

According to the World Health Organisation, death due to injury to the brain is the third most common cause of death in the world. Around 36.2% of people under 40 years of age across the world suffer from brain injuries. But if the patient is treated within three to four hours, the chances of paralysis or death reduce,” claimed neurophysicians Sanjay Varade and Suhas Patil during the program.

Do you have any idea how hard it is to read this?

I was 7 hours away on my way down to Nashville when I got the call. I am not saying at that point they weren’t trying to help him. I will say after he went into the coma they gave “no hope” and were ONLY trying to get us to donate his organs.

Dr. Paul Byrne has told me over and over to “make sure the doctors are told to do EVERYTHING to protect and preserve their life.”

As many as 25 percent of all patients are harmed by medical mistakes. What’s even less known to the public is that over the past ten years, error rates have not come down, despite numerous efforts to make medical care safer. Makary, Martin (2012-09-18). Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care (Kindle Locations 61-63). Bloomsbury Publishing. Kindle Edition.

Pray for Joey Cronin

January 30, 2015 — Leave a comment

Joey Cronin

Joey is a 12-year-old little boy in Corpus Christie, TX who was rushed to the hospital a few days ago.  He was having an asthma attack and his parents gave him an injection of EPI-pen and called 911.  He was taken by ambulance to a local hospital and stabilized before being transferred to Driscoll Children’s Hospital in Corpus Christi, where he went into cardiac arrest.

As usual the doctors gave the family “no hope” and wanted to do the Apnea test.

DO NOT DO THE APNEA TEST!

Joey has proven to be a fighter. “Over the next four or five days, he continued to improve,” said Joey’s dad.  “He actually seemed to be making some progress toward recovery.  He was moving; he was opening his eyes.”  During a bedside test ordered by the hospital to test his brain function, medical staff squirted water into Joey’s ear canal with a syringe, and he flinched, a clear response that you are NOT brain dead.

Joey’s neurologist was encouraged by his progress, and told the family that his responsiveness was “a very positive sign.”  He said that while Joey’s reactions were slow, the delay could be easily explained by the high doses of medication he was receiving.

This case is similar to the Jahi McMath case, the 13-year-old declared legally dead by hospital and government officials despite having a heartbeat – young Joey Cronin’s fate is in the hands of hospital officials who insist that he is “brain dead,” although he showed signs of brain activity during the test they ran in a failed attempt to prove it.

There is another hospital in TX that is willing to take Joey Cronin and treat him.

Pray for Joey Cronin

Definition of Irreversible ComaThe family is asking for prayers and that Driscoll Children’s Hospital will keep him on life support until he can be transferred and all the insurance be worked out. They are also asking for people to make calls to the hospital on Joey’s behalf.Charlie Johnson reported on his blog a short while ago that the family has received a temporary restraining order to stop Driscoll Children’s from removing life support as the family finds a hospital to move him to.

What the family is going through is horrible and I can so relate. It happens every day in hospital’s all across the nation. Brian death is NOT true death.

Please pray for Joey and call Driscoll Children’s Hospital ask them to do EVERYTHING to protect and preserve Joey’s life.

Driscoll Children’s Hospital can be reached at 361-694-5000 (main switchboard) or 361-694-5662 (Public Affairs).

 

Organ Donor Found Not Quite Dead

SurgeryThe phrase “not completely brain dead”, like “not completely pregnant”, has a Monty Python-esque ring to it. But it is the way the Daily Mail described an alarming organ transplant incident in the German city of Bremen.

Doctors in a hospital in Bremen had already made an incision in the abdomen of a man who was presumed to be dead when they discovered that the deceased donor was still alive according to organ transplant protocols.

The operation was immediately terminated – and the brain-damaged patient died. The incident is being investigated by the German Medical Association.

The Süddeutsche Zeitung (the source for the Daily Mail) was told that “it is quite possible that the man’s brain was so damaged that he would not have been able to return to a normal life, but as long as he was not properly diagnosed as brain dead, nobody knows.”

The article above is published by and BioEdge.org under a Creative Commons licence.

Here are excerpts from the original article in the Süddeutsche Zeitung German Paper  If you go read it there, just translate it to English at the top of your browser.

My takeaway’s from the German article which unfortunately happen’s here in the US but goes unreported.

Critics warn some time: The brain death diagnosis is uncertain

The case proves once again what critics have long admitted: The diagnosis of brain death is not secure enough in Germany. Doctors are not sufficiently trained in how they determine the loss of brain function in a patient correctly. So it always comes back to errors.

Especially terrible was the idea that a patient whose brain still shows residual activity may suffer the pain of surgery and organ removal as opposed to a brain dead.

Did he know he was going to have his organs harvested but couldn’t show anything to stop the doctors? Did he feel pain when the doctors sliced into his abdomen? You do know by now from reading my blog that anesthesia is NOT used

Perhaps the man in Germany felt the way Christina Nichole Thornsberry, did when she was paralyzed in a hospital in Spokane,WA where she stated on her blog, 

“Don’t cut me open — don’t hurt me! Let me wake up!.” While doctors hovered over her bed… discussing organ donation, Christina Nichole could hear every word they said – and their conversation terrified her.