>> JUDY FORTIN: This chapter will help you understand brain injury and more about your
loved one’s diagnosis of traumatic brain injury, sometimes called T-B-I for short.
Traumatic brain injuries are those caused by a blow to the head or from violent movement
of the head.
>> DR.
BRUCE DOBKIN: That could be from striking the head against a car windshield, it could
be related to a fall and striking the head.
It could be related to military explosion or shrapnel penetrating the skull.
>> JUDY FORTIN: A person does not have to have an open head wound, a skull fracture,
or even a loss of consciousness to sustain a traumatic brain injury.
>> SUSAN CONNORS: No two people are alike, and no two brain injuries are alike.
Doctors classify traumatic brain injuries as mild, moderate or severe, depending on
the initial length of loss of consciousness and post-traumatic memory loss.
There are overlaps in the symptoms of each of these classifications.
The terms mild, moderate and severe may not correlate or describe the expected outcomes
in a person’s life.
>> JUDY FORTIN: A mild traumatic brain injury occurs when the patient initially loses consciousness
for 15 minutes or less, if they have any memory loss about the trauma event, or they feel
dazed, disoriented, or confused.
It’s often called a concussion.
The majority of traumatic brain injuries are initially rated as mild.
Moderate traumatic brain injuries include a loss of consciousness from 15 minutes to
a few hours, followed by a few days or weeks of confusion.
Severe traumatic brain injuries affect less than 10% of patients and involve a loss of
consciousness for six hours or longer after injury or after a period of clarity.
People who remain unconscious for a very long time may be in a coma, or a vegetative or
minimally-conscious state.
>> DR.
LEON HALEY: Physical symptoms of a traumatic brain injury can include difficulty coordinating
balance and walking, blurred vision, headaches, trouble speaking and swallowing, and lack
of bowel and bladder control.
People with traumatic brain injury may have trouble moving their body normally -- doctors
call this motor impairment.
The person may have seizures, vision problems and changes in sensory perceptions, sleep
patterns, and sexual function.
Persons with traumatic brain injury can have personality changes, trouble communicating
and memory impairments.
They may also be depressed and disoriented, have mood swings, be forgetful, and have difficulty
forming sentences or choosing vocabulary.
They may act inappropriately, and struggle with reason, focus and logic.
After a brain injury, conversation with your loved one may be difficult.
He or she may have poor concentration, a limited attention span, or difficulty remembering
what was said.
As the loved one of a patient with traumatic brain injury, it’s a good idea to prepare
to adapt to these changes by developing coping skills and finding resources for support.
>> DR.
BRUCE DOBKIN: It’s helpful for the medical team to understand what your loved one was
like before that injury so that they can get a sense of their general intellect, their
general rapport with people, the things they like to do.
All of these little things can be used during rehabilitation to try and help reestablish
that quality of life that your loved one once had.
>> JUDY FORTIN: The first step toward helping your loved one regain any recovery possible
is to assess his or her condition using one or several diagnostic measurement scales.
>> DR.
DAVID W. WRIGHT: Right after a brain injury, a medical team may use the Glasgow Coma Scale
to measure the injured person’s level of alertness.
The Glasgow Coma Scale ranges from 3 to 15.
The highest score of 15 describes a fully awake person, while the lowest score of three
describes a person who is in a deep coma.
This scale measures three things: eye response, verbal response and motor response.
A Coma Score of 13 or higher indicates a mild brain injury, 9 to 12 indicates a moderate
injury, and 8 or less indicates a severe brain injury.
The Rancho Los Amigos Scale is an ongoing behavioral evaluation tool most frequently
used after a traumatic brain injury.
It is helpful in assessing the patient because it does not require his or her cooperation.
Ten possible Rancho levels are based on the patient's response to external information.
They provide a description of progress during the recovery process and help track the behavioral,
cognitive and emotional changes that take place during healing.
Your loved one may be assigned a Rancho Level number from one to ten following his or her
initial detailed assessment.
The lowest levels represent lower levels of functionality at the time of the assessment.
For example, a Level 1 patient has no response to voices, sounds, light or touch, and appears
to be in a deep sleep, while a Level 10 patient can handle multiple tasks simultaneously,
but they may get irritable when under stress.
>> DR.
LEON HALEY: If your loved one remains in a coma, vegetative or a minimally-conscious
state, he or she may be assessed using the JFK Coma Recovery Scale.
This scale measures everything from hearing to vision to movement to communication and
arousal to help determine the patient’s long-term prognosis.
The JFK scale can also be used throughout rehabilitation to gauge recovery.
>> JUDY FORTIN: At the same time, or after the Rancho and Glasgow assessments, your loved
one might have x-rays and other diagnostic tests.
>> DR.
LEON HALEY: Computerized Tomography or CT scan provides doctors with more detailed information
about spinal cord or brain damage than x-rays can show.
A CT scan uses computers to form a series of cross-sectional images that show damage
with more accuracy.
Magnetic Resonance Imaging or MRI uses a strong magnetic field and radio waves to produce
computer-generated images.
An MRI can help identify blood clots, swelling or skull fractures that may be compressing
the brain and/or spinal cord.
An MRI offers an even greater level of detail than a CT, although in general CTs are more
common for identifying abnormalities after brain injury.
>> DR.
SUSAN CONNORS: Once your loved one is stable and has moved on to some type of rehabilitation
program, they may be given a comprehensive neuropsychological assessment.
This series of tests evaluates multiple aspects of the mind, including basic hand-eye coordination,
higher-level thinking and the cognitive skills necessary for everyday functioning.
These tests measure things like:
Knowing and understanding where you are and what happened to you
What new things you can learn How your memory was affected by the trauma
What basic intelligence and language skills you have
How you perceive what you see, and More complex functions like planning, abstract
thinking, understanding and obeying rules, initiating appropriate actions and
inhibiting or avoiding inappropriate actions.
Neuropsychological assessment also focuses on a person's psychological, personal, interpersonal
thoughts, behaviors and skills.
Together this assessment helps your loved one’s treatment team and doctors develop
an effective plan of care for rehabilitation.
>> JUDY FORTIN: Through the tests and diagnostic tools available to them, your loved one’s
doctors will do their best to give you as much information as possible.
Some of the words and definitions they will use will be new to you and may be a bit overwhelming.
Here are some terms you may hear and basic definitions of each:
Axonal shearing is when the brain's axons, or main channels of communication, are stretched
to the point of breaking.
Shearing causes the damaged brain cells to die.
Rising pressure inside the brain can cause parts to shift out of place, or what’s referred
to as a brain herniation.
A large brain bleed or hematoma can also cause herniation.
>> DR.
DAVID W. WRIGHT: Cerebral atrophy is the loss of the brain’s neurons or nerve cells, and
the connections between them.
It can be focused in one particular area of the brain or affect the whole brain, and can
be caused by stroke, traumatic brain injury, or other disease.
Edema is the word for swelling.
After an injury, the brain swells just like any other injured body part.
This swelling inside the skull can squeeze brain cells or interrupt blood flow and oxygen
to the brain tissue.
Severe swelling can also press on the brain stem and cause death.
>> JUDY FORTIN: A hematoma is a pool of blood or bruise inside the skull caused by damaged
blood vessels.
Hematomas can increase pressure inside the brain.
Surgery may be needed to drain blood out of the skull.
A hemorrhage is internal or external bleeding caused by damage to a blood vessel.
>> DR.
DAVID W. WRIGHT: Some of these types of injuries can cause intracranial pressure, or ICP.
Intracranial pressure can be monitored by a catheter threaded into one of the brain's
cavities or just inside the skull.
Shock is a body’s response triggered by loss of blood to the brain and may indirectly
injure brain tissue.
>> JUDY FORTIN: There are three stages of consciousness.
In order from least severe to most severe they are minimally conscious state, vegetative
state, and coma.
A minimally conscious state describes when medical professionals and perhaps family members
can detect some small, consistently identifiable and deliberate behavior by the patient.
A semi-coma or vegetative state is when the patient’s eyes are open, but not always
aware of themselves or their surroundings.
A coma is a deep state of unconsciousness.
The patient cannot be aroused, does not respond to stimuli, and cannot make voluntary actions.
A patient in this state may be referred to as comatose.
Comas can be medically-induced to give the brain time to heal.
>> DR.
DAVID W. WRIGHT: Sympathetic storming is an elevated stress response that occurs in roughly
a third of traumatic brain injury patients.
It can occur anytime from 24 hours to a week after injury, and is thought to be a sign
of returning activity of the sympathetic, or protective, nervous system.
>> DR.
SUSAN CONNORS: During the early weeks after injury, treatment focuses on stabilizing the
patient’s physical condition, preventing complications such as pneumonia and blood
clots, and addressing medical issues that arise from a brain injury.
Because brain injuries run the gamut from mild to severe, some people will only need
regular follow-up appointments with a health care provider after discharge from the hospital
or trauma care center.
Others receive therapy, tests and monitoring on an outpatient basis.
Still others may be transferred to a rehabilitation unit, or a specialized rehabilitation center.
After they leave the rehabilitation facility, outpatient therapy may continue for either
a short or long period.
Medical professionals help you determine when your loved one is ready for the next step.
Through rehabilitation, he or she tries to relearn basic skills like speaking, dressing
and walking.
The goal is to improve function so the patient can become as independent as possible.
Rehabilitation encourages the body’s natural healing process through stimulating and enhancing
physical and cognitive abilities, and teaching new techniques to compensate for lost skills.
Early on, rehabilitation therapy strives to keep the person safe and increase awareness
of his or her surroundings.
Next steps may be stretching, strengthening, balance and range of motion exercises.
At first, the health care team may focus on helping your loved one relearn the basics,
such as the date, time and location, as well as what happened to them.
As cognitive, language and physical abilities progress, the focus shifts to improving their
attention span and mobility, their memory and language skills and increasing their self-care
skills.
Community outings to practice skills learned in the hospital or rehabilitation facility
may be included.
>> JUDY FORTIN: At this time, we’ll continue on to the last chapter of the video.
Chapter five provides practical advice for how to deal with the injury and its consequences
to your loved one and your family.
Lee Woodruff starts off the chapter.
She has some great advice because she and her family have been through and survived
a catastrophic injury themselves.
It’s an important part of the video.