“You’re never the same once the air hits your brain.”
— Bitter neurosurgeon’s joke, source unknown
After dipping my toe in the water with Saturday’s micro-post, I was convinced by the readers of this blog that a “teachable moment” exists to talk about brain injuries with specific reference to Rep. Gabrielle Giffords’s condition and possible recovery.
First off, a disclaimer: I’m not a physician, and even if I were, I wouldn’t try to diagnose someone from a distance. Giffords’s family, understandably enough, has been very sparing in the information released. We don’t have a lot of information to go on, and some of it is self-contradictory. I’ll have to speculate a lot.
People who work with the brain see a lot of sadness. It gives them a demeanor that can seem a bit unfeeling to the outside world, but, like all people who choose to work with human fragility and pain on a daily basis, there is a need to develop defense mechanisms to shield oneself from the awful nature of the day-to-day work. If some of what you see below seems detached, it’s because that’s my personal strategy for dealing with what I know. If you’re interested in seeing how a real brain surgeon deals with his inner demons, I would recommend the book When the Air Hits Your Brain by Frank Vertosick, M.D. (He uses the above quote as the basis for his book title. As bitter as the quote is, I’ve found it to be true in my experience, with a few notable exceptions.)
Recovery from brain injury is a very individual process. Each person’s brain injury is different, and each person’s brain is different. I have seen some truly miraculous things. In general, injuries to children have better prognosis (pro-, “forward”; –gnosis, “knowing”). That is, we expect a better outcome from a child versus an adult with the same injury. That’s in part because our brains are designed to make about one-and-a-half times the number of “parts” we need, then discard one-third of those parts to get the final structure. For example, during the first few years of life, we make 1.5× as many contacts between nerve cells (synapses) as we need, and then trim them down to the adult number. (There is also a slow, steady decline from about the mid-20s to death, but that’s just too depressing for me to contemplate right now.) This accounts for the miraculous recovery made by children with brain injuries, although I’d also add that there are many, many children who struggle for a lifetime with brain injury for every miracle child you see on television.
The goal of physiatrists and occupational therapists is to work with the patient to regain, as much as possible, what are called the “activities of daily living” (ADLs). Typical ADLs would be eating, bathing, cooking, or moving around. Some of the most inspirational and wonderful colleagues I’ve had in a long career come from those areas of the profession. For example, as a graduate student, I trained at the Texas Medical Center and attended seminars at The [Texas] Institute for Rehabilitation and Research (TIRR), where Rep. Giffords is now recovering. I have a lot of confidence in their skill.
Neurologists and neurosurgeons use two rough yardsticks to assess the degree of brain injury, and to communicate the degree of brain injury to each other.
A doctor will determine if a patient is “alert and oriented.” If a patient is said to be “oriented × 3,” that means they know:
- who they are (not only their name, but their relationship to other people)
- where they are (not necessarily GPS coördinates, but a general sense: “I’m in a hospital.”)
- when they are (again, just generally — knowing who the President is, what day of the week it is, etc.)
A patient who can answer all three of these questions accurately is said to be “oriented × 3.”
The second yardstick the physician will use is called the Glasgow Coma Scale (GCS). I hope I would score a 15, which is the maximum possible score. The lowest score (no eye response, no verbal response, no motor response) is 3.
Severe brain injury is defined as a GCS of 3–8. Moderate brain injury is defined as a GCS of 9–12. Minor brain injury is defined as a GCS of 13–15.
In their paper “Neurobehavioural outcomes of penetrating and tangential gunshot wounds to the head,” (Brain Injury vol 14 no 7 pp. 649-657, 2000) Gillian Hotz and co-authors describe the “typical” results of brain injuries from gunshot wounds—but of course nothing is typical. From the paper:
Gunshot wounds are the second-leading cause of injury death in the U.S., with 34,600 firearm-related deaths in 1996.
Individuals with a GCS of 3-5 after a gunshot wound to the head have a death rate of 78-100%.
Patients that survive to the point of being admitted to an inpatient rehabilitation programme have significant potential for functional improvement, but continue to demonstrate severe residual neurobehavioural sequelae.
Rep. Gabrielle Giffords suffered a penetrating gunshot wound to the head. In other words, the bullet went into her skull, and then exited. Somewhat surprisingly, these individuals fare better than those victims where the bullet does not exit, because the bullet’s energy is released through the exit wound. If the bullet stays inside the skull, the bullet’s energy is transferred to the brain, with disastrous results.
In the Hotz et al. study, the average GCS for victims of a penetrating gunshot wound was 10.5 with a standard deviation of 4.3. This means (assuming a normal distribution) that 2/3 of their patients had a GCS between 6 and 15. I would assume that the population skews heavily to the lower end of the GCS, so I doubt whether the distribution is normal (i.e. perfectly bell-shaped).
Let’s assume that Rep. Giffords is an “average” gunshot wound victim with a penetrating head injury. The mean length of stay is 48 days in acute care, and 34 days in rehabilitation. Mean acute care charges are $150,533 with a range up to a half-million dollars. Mean rehabilitation care charges are $56,842.
The Disability Rating Scale (DRS) is a measure of disability that incorporates the GCS and activities of daily living and ranges from zero (no disability) to 30 (death). The average score on discharge was 8. The average Rancho Los Amigos Scale score was 7. According to Rancho Los Amigos, a person at level 7 (or VII in the linked document) may:
- follow a set schedule;
- be able to do routine self care without help, if physically able. For example, he can dress or feed himself independently;
- have problems in new situations and may become frustrated or act without thinking first;
- have problems planning, starting, and following through with activities;
- have trouble paying attention in distracting or stressful situations. For example, family
gatherings, work, school, church, or sports events;
- not realize how his thinking and memory problems may affect future plans and goals. Therefore, he may expect to return to his previous lifestyle or work;
- continue to need supervision because of decreased safety awareness and judgment. He still does not fully understand the impact of his physical or thinking problems;
- think slower in stressful situations;
- be inflexible or rigid, and he may seem stubborn. However, his behaviors are related to his brain injury;
- be able to talk about doing something, but will have problems actually doing it.
The mean Functional Independence Measure (FIM) was 114. The FIM is proprietary, so I can’t present it here.
Rep. Giffords, by all accounts, has made an extraordinary recovery. The bullet did not cross the midline, which means a much less severe injury. Initial reports said she was shot in the back of the head and the bullet exited through the front, but those initial reports were not supported by the video and on further analysis, doctors apparently concluded she was shot just above the eyebrow at a range of about three feet.
The bullet entered, and remained on, the left side of the brain. Unfortunately, the left side of the brain is responsible for speech in about 95% of individuals. It is unclear whether Rep. Giffords is right- or left-handed, but the left hemisphere is dominant for speech in almost all right-handed people and about 2/3 of the left-handed. Separate regions in the left hemisphere control understanding speech versus producing speech. According to recent news reports, Rep. Giffords can understand speech and is speaking in sentences. She can repeat what is said to her. This indicates moderate to minimal damage to the speech centers.
She can move her arms, and is now able to walk with assistance. This indicates that the motor regions of the left hemisphere, which control voluntary movement for the right side of the body, are damaged, but probably not severely. It is unclear whether she will be able to walk unaided after completing her rehabilitation.
Based on all this, I’m going to make an educated guess about the bullet hole’s location. One challenge in describing brain anatomy is to get people to visualize things in three dimensions. I included two pictures: one is a side view of the brain inside the head, so you can imagine where a bullet would travel if the victim were shot above the eyebrow. From all indications, the bullet track was above the corpus callosum, the “lazy C”-shaped structure seen in the middle of the brain here.
The image at right shows the primary motor cortex in a human brain both in side view and in cross-section. The red arrow shows the location of the brain cells that control the right arm’s movement. The red dot with a line extending from it is a symbolic neuron (nerve cell) which extends from the voluntary movement control area of the brain down to the spinal cord, which will eventually control another neuron that drives the muscles. The gray circle is my best guess, based on news reports, as to where Rep. Giffords’s injury is located. It must be above the corpus callosum, seen as a face-down “C” in the left image and as a sort of sling connecting the two halves of the brain in the right image. It may have torn the cables that connect nerve cells to their terminals, and thereby disconnected the brain control cell from the spinal cord (by severing the red line, representing the axon of the nerve cell).
I don’t know if Rep. Giffords will ever return to Congress. No one can know. I do know she has a very difficult road ahead of her. I wish her and her family all the best as she fights back to the very best life she can manage. By all accounts, she is a strong and capable person and so is likely to exceed our expectations in her recovery. I hope I have not caused anyone offense in this analysis. I am convinced that the unfortunate and horrifying attack on Rep. Giffords is a small opportunity for readers of this blog to learn a little bit about brain injuries, and I hope that knowledge will convince readers to support further research in this area.
Monotreme, who is an expert in the field (and an exceedingly nice man ;-)) has expressed all kind of delicacy, sensitivity and even some reluctance about applying his expertise to Ms. Giffords’ condition.
As I told him privately, I think a lot of this sensitivity is related to our societal attitudes toward brain injury (and mental illness as well.) There is still a stigma attached to being “not right in the head” that harks back to the Middle Ages and “Bedlam,” where people with brain injuries and mental illness were locked away in horrific conditions to keep them from contaminating society. We’re all frightened by things that go wrong inside the head and so we tend to recoil from them (and, sadly, often from those who suffer them.)
I wonder how much soldiers returning from battle with TBI or PTSD still have to contend with that stigma. And I think (as I told Treme) that if the bullet had lodged in Ms. Gifford’s lower spine and was only affecting movement and ability to walk, we would be much less reluctant to discuss her condition and prognosis.
I do believe it’s time for society to move toward a more knowledgeable, enlightened attitude toward brain injury and mental illness.. .and the only way to do that is to talk about it.
Clarification… (since for some reason we often seem to have a hard time understanding each other around here… 😉
I don’t think Monotreme feels any such stigma. In fact, I know he doesn’t. This is his field of expertise.
I do think he is being instinctively considerate of the privacy of the Giffords family and others who might have to cope with this stigma as they help their loved ones to recover and rehabilitate.
Speaking as someone who has often been accused of being “overly cold and clinical” when dealing with things that are emotionally difficult, I understand and appreciate your level of detachment as a coping mechanism. Personally, I thought your tone throughout the entire article was appropriately respectful and informative. So, thanks!!
You helped answer many questions that I had about whether Ms. Giffords’ progress was “normal” and why she might have a better chance of recovery than many other victims of gunshots to the head because of the (assumed) location and pass-through of the bullet. As you say, recovery is very individual, because no two brains are wired exactly the same and some may compensate better. (Perhaps because their functions were more distributed in the first place?)
One aspect that often gets overlooked is the psychological impact. From all accounts, Ms. Giffords apparently is upbeat and positive, which bodes well for her resilience through the long and difficult recovery process. But, many survivors of head injuries have a hard time coming to grips with what happened and to the resulting disabilities that they may have. If they don’t understand their impairment (some people feel fine and never really accept that they can’t do things they think they can do), that’s one issue. But, if they recognize what they lost, then that can lead to extreme frustration and depression. Sometimes, it’s harder on the family and friends than it is on the person who was injured.
I’m not saying it’s right, but I think there is such stigma with brain injuries because they are so personally terrifying to us. I can lose an arm or leg and still be me, but if something happens to my brain that changes how I think, that’s scary. It’s easier to imagine our lives with a debilitating physical injury, but not with a mental injury. Also, mental injuries are often invisible and inexplicable and confusing and complicated. If I have a broken arm, everyone can see the cast. If I have a leg amputated, everyone can see the wheelchair. But if I lose my short-term memory or my ability to form coherent sentences (despite still *knowing* what I want to say), then it’s not so easy to see how the injury happened and it’s much more frustrating all around.
Just my hack at a guess as to part of why mental issues continue to carry such stigma in our more “enlightened” age.
I think you hit the nail on the head. Even as a brain scientist, this aspect of mental illness or brain injury is terrifying to me.
As an aside, I’ll note that some of our contributors’ best articles get the least comment action. That shouldn’t be taken as a sign that these articles are not valued!! Possibly because they’re so well-written and reasonable, there just isn’t much to add. 😉 I, for one, am definitely appreciative of articles like this one.
@mac… I think you’re right… we do tend to stigmatize what we most fear. Also, when dealing with somebody who is struggling with brain injury or mental illness, I think we’re all on unfamiliar ground and so afraid of saying or doing the “wrong” thing that we don’t say anything at all. We turn away not from a lack of compassion, but often because of an excess of compassion… and simple awkwardness.
It’s interesting to me that children seem to get this delicate balance exactly right. Our little guy has been mainstreamed since kindergarten and his classmates adore him. They’ve always fought over who gets to be his “buddy” for the day and sit next to his wheelchair, read him stories, hold toys to entertain him, etc. They can also read his signals and tell grownups what he wants or needs. And they TOUCH him. There’s always another kid kissing him, stroking his hair, holding his hand.
Best of all is the frankness. If we encounter a child who doesn’t know him, the new kid will study him with open curiosity and then (invariably)turn to me and ask “What’s wrong with him?” I explain that his head got hurt on the inside when he was born and now there are a lot of things he can’t do, but he loves books, videos and music and he can play lots of games and “talk” on the computer. That’s enough for a kid… at that point he or she is already past the “strangeness” and ready to be friends.
Isn’t it great? Kids are natural scientists, and they’re just curious about the natural world. Once you give them an explanation at a level they can understand, they’re good to go.
Yes we have lamented privately at how disappointing it is to put a lot of effort into an article and have all the action happening in arguments on threads that are four or five days old. But I am of the opinion that really good articles (such as this one; and your guest op-ed as well) have a timeless quality to them. Given the opportunity, we try to refer to these articles with pingbacks and linkbacks in future articles.
The reason you don’t get a lot of comments on these types of posts is that there really isn’t much to say other than nicely written and highly informative, Treme. There isn’t anything contentious in this. Nothing to argue about. It’s like reading any article or paper in a research or educational publication. I feel as if I know a little more than I did before I read it. That is the highest praise I can ever give to something I read. Nice job.
I agree with Gator, Mr. U, and mclever. Great article. One of the best I’ve read anywhere on Mrs. Giffords condition.
The only thing I have to add is in response to mclever’s post at 13:35. I always cringe a little when we loosely throw around terms like “crazy” and “insane” because we may disagree with someone politically or ideologically.
In light of this very informative article about traumatic brain injuries, I thought this was worth noting:
The army is revising/clarifying its rules for purple hearts to ensure that soldiers with concussions due to explosions are recognized. The Army’s official list of wounds that qualify already included concussions, but many senior officers didn’t consider those injuries to be “serious enough” for a purple heart. Soldiers who’d lost consciousness and suffered lingering cognitive impairment were being denied Purple Hearts because of the bias against invisible injuries. The new guidelines provide a checklist to make it clear that if the soldier suffers a concussion that requires medical treatment (including short bed-rest or OTC pain killers), then that qualifies.
General Chiarelli said, “It is very important if we’re going to get at this stigma issue. [The Purple Heart] shows to everyone that these hidden injuries are truly injuries that affect folks.”
Perhaps I should also note that this review and revision occurred because of an NPR investigative report that found soldiers who suffered cognitive impairments were denied Purple Hearts by their commanders. And Congress wants to defund NPR?
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Mrs Gifford was lucky to receive Music therapy. This and Art Therapy are 2 treatments that are only covered by few insurances and in few places where medicine is publicly funded. Numbers are low so RCT’s have not been possible, however, small cohort studies and case studies do support this treatment. Both these treatments would appear to be supported by what we know from neuroscience, music and images can kindle neural pathways that would be impossible by other means.
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