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.

Dr. 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?