Brain Injury

March is Brain Injury month, and I wanted to devote an article to this topic.

Brain injury is a broad topic that includes everything from concussions to gunshot wounds. For this article I will discuss the topic of traumatic brain injuries (TBI). Even though TBIs represent a subset of brain injuries, the causes are diverse, ranging from falls to anoxic brain damage (lack of oxygen to the brain resulting in brain cell death). In 2010 the CDC released a study that looked at data from 2002 – 2006.[1] In the study, among other findings, they concluded that the rate of death among all Emergency Department (ED) visits for TBI was a shocking 3.0%. Meaning that of the 1.7 million visits to the ED per year, 52,000 resulted in deaths from TBI. This number however, while unbelievable, does not portray those of us who do not die yet are left with the sequelae of brain cell death. In fact, because of these unwanted effects, TBIs have been called “the silent epidemic”.[2]

Let me first define TBI: TBI occurs as a result of any external force that causes any trauma to the brain. The most popular form of TBI is from concussion (the one you hear about on the news or Sportscenter), which occurs when someone strikes their head causing a bruising of the brain. The results vary widely, from a brief headache to death. However, for many of us TBI does not occur on a field. For me, it took place in an Operating Room. The CDC estimates that over 50% of all TBIs are the result of a fall.[3]

While the range of symptoms that TBI can cause is vast, the effects it can have on our lives is even more varied including little to no changes to our lives to permanent disability. The National Institute of Neurological Disorders divide TBIs and their consequences into mild, moderate, or severe “depending on the extent of damage to the brain.”[4]

To us, these are merely numbers and definitions that serve to help us understand this entity, however the real ‘meat’ of this topic is rooted in recovery. Yes, we now know that TBIs cause over 50,000 deaths each year and that its effects are far-reaching, but those are all events that have already occurred and are beyond our control; it is more important to know what we can do to help us recover. The human body and the brain are amazingly resilient; thus part of the recovery process simply requires the ‘tincture of time’. This is not a short process, as my physician told me in the hospital, “Chris, remember this isn’t a sprint, it’s a marathon.” I often remember this when I find myself wishing my recovery process were quicker.

When I was discharged from the hospital last year, I was given a prescription for Speech, Occupational, and Physical therapy. These are all modalities of rehabilitation that focus on different areas of recovery: Speech Therapy is self-explanatory, with the goal of improving speech deficits. Occupational Therapy aims at helping with daily and work skills. Physical Therapy attempts to aid patients through improvements to mobility and function. Throughout this process I have been praised for my hard work. While these comments are extremely kind, I assumed that everyone works hard and ‘gives 100%’ when rehabilitating in therapy. However, I feel that a satisfying recovery requires two virtues: patience and determination. Without patience, the thought of a long arduous journey to recovery would be daunting. At times you will feel like Sisyphus pushing that boulder up the hill only to see it roll back down.[5] Without patience you might not see that you are making progress, and that your hard work, your suffering does have a purpose. This patience though will be useless without determination as well. It is determination that pushes you to complete that extra exercise or begin that extra vocal activity. Otherwise, while you may partake in those endeavors, without determination you’d simply be going through the motions and lack the true effort.

In medical school we are introduced to the incredible story of Phineas Gage. On September 13 of 1848, Gage, working as a foreman for a railroad, underwent a horrific accident that resulted in an iron rod piercing through his left eye socket into his brain and out through his skull. His story is an incredible one because not only did Gage live through this incident, but he became a productive member of society afterwards.[6] In considering brain injuries and their effects, we should think about the story of Gage. He reminds us of the power of the mind and its ability to overcome the greatest challenges.

A rare photograph of Phineas Gage
A rare photograph of Phineas Gage

 

[1] http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf

[2] Id.

[3] Id.

[4] http://www.ninds.nih.gov/disorders/tbi/tbi_htr.pdf

[5] http://www.mythweb.com/encyc/entries/sisyphus.html

[6] http://www.smithsonianmag.com/history/phineas-gage-neurosciences-most-famous-patient-11390067/?no-ist

Dreams

All of us have dreams and that they can signify more than just random thoughts. Allow me to clarify; dreams in this context not only are defined by the images we experience when we sleep, but also by our hopes and desires. I know that this expands on more than just one definition of the word, but to me the two are intertwined; the dreams we have at night often are a reflection of our wishes and desires.

We as a society are fascinated by dreams; they are sometimes portrayed as prophetic. In movies, warnings of future events are usually presented to a clairvoyant person in the form of a dream. As a physician you’re often asked “Doc, I had this dream last night, what does it mean?” The mind is a complex ‘machine’ that I think we’ll never truly understand and our dreams are a small window to the inner workings of this machine. Perhaps this is why there is so much attention given to our dreams; maybe if we unlock the secrets of our dreams, we will then uncover the inner workings of the mind. My take on dreams is this: they are a representation of our subconscious. For example, if buried in our subconscious are fears of an upcoming meeting, then maybe this fear will come to fruition in the form of a dream. The contrary is also true: if you subconsciously value the adulation and approval of your peers, then it might present to you in the form of a dream. This is just my opinion; I have had no formal training on the meanings of dreams.

image

Thus given this framework for possible origins of dreams, allow me to ask you, “Over the last 2 years, I’ve had dreams ranging from my playing tennis to simply conversing with a friend. I also have dreams where I am a doctor to many people in need, while watching my children grow up. What do these dreams mean?” Turning the tables on myself, I would say that these dreams are a manifestation of some of my desires. This led me to wonder, “How have my dreams changed as I’ve become older?” When I was a boy, I would often dream of winning Wimbledon, the pinnacle tournament of any tennis player. In college, I dreamt of becoming a world-renown physician, helping anyone in need, almost a Paul Farmer type.[1] Now I have dreams of simply hitting a tennis ball back and forth, conversing with a friend, treating patients, and watching my children grow. What does this mean? I think in all of us, our dreams change. These changes are a reflection of our experience with life. When I was young (and naïve) I thought I could become a Wimbledon champion, a Roger Federer. When I became older (and a little less naïve) I thought becoming a world changing physician was within my grasp. Does that mean that my dreams now are within my reach, or does it mean I think they are attainable? Dreams do not have to be unattainable; they just reveal our inner hopes and desires. Maybe tonight I will have a dream of having a beautiful, intelligent wife, two amazing children, an incredibly supportive family, friends and co-workers who are all kind and warm hearted, all while living in (gorgeous) Michigan in the spring. Have you ever thought of your dreams? Have they changed over the years?

[1] If you do not know who Paul Farmer is here is the Wikipedia page on him: http://en.wikipedia.org/wiki/Paul_Farmer

Externalities

I graduated from college with a degree in Economics. This is where I came across the term, ‘externalities’. The official meaning of this is the cost or benefit a third party receives from an activity. For example, a negative externality of alcohol use is increased motor vehicle collisions as a result of impaired driving. For the purposes of this post, I see it as an unintended, uncontrollable consequence.

As I’ve mentioned I recently began shadowing physicians in the clinic, beginning my long journey to managing patients again. I usually follow with an Attending Physician, a physician that has already completed residency, but sometimes I will follow a senior level resident. Last week, I had the privilege of being matched up with a resident by the name of Abigail Urish (or Abbie). I met Abbie when she was an eager, bright-eyed intern. She is now a third year resident, elected chief, and ready to embark on her own in only a few short months. I have always admired her, not only for her obvious high intelligence and willingness to learn, but also for her optimistic disposition, finding the light in the dimmest of situations.

 

Abbie and her fiancé, Ken
Abbie and her fiancé, Ken

We entered the room for a patient encounter together. There are times when the moment you enter the patient’s room, you can sense that something’s amiss. Perhaps it is the look in the patient’s eyes, or maybe it is from the way they are sitting, or possibly a combination of factors, but when we entered her room both Abbie and I could sense her depressed mood.

I know I have written on the topic of depression several times before, but what Abbie told her was very poignant and struck a chord with me. During the encounter, the patient told us of several of the hardships she was enduring (i.e. loss of custody, a dispute with her child). Abbie was then faced with the daunting task of describing depression in less than the 15 minutes allotted for each visit. Abbie told her that, “depression is a hard entity to treat, because unlike so much else in medicine, with Depression there are no blood tests or x-rays we can obtain to aid us in diagnosis. Also, response to treatment is so variable and really depends on the individual patient. My thought is that Depression is very much related to how we react or internalize external situations. There are some who face incredible hardships, yet are able to see the silver lining in any situation. You just told me about some very hard events in your life, but you also mentioned some bright happenings too. Unfortunately, someone who suffers from Depression zeroes in on the bad or tough situations. Just to give you an example, if someone takes a test with 100 questions and gets 99 out of 100 right, a depressed person will only remember the one question they missed as opposed to the 99 they got correct. The medications and therapies we prescribe can only serve to help with this outlook. We can’t control much of what happens to us, but what we can change is how we react.”

The more I thought about it, the more I realized how right Abbie was. We as a society are obsessed with trying to control or modify situations that are thought of as immutable. Examples of this are littered throughout medicine: risk factors for developing a disease are generally divided into modifiable and non-modifiable risks. The idea of attempting to alter these modifiable risk factors is drilled into our heads from the first day of medical school. I am by no means saying that these external, changeable factors should be ignored. For example, stopping someone’s smoking habit can have repercussions throughout their life. But I believe that too much of our focus is placed on factors beyond our control. All of us receive a ‘raw deal’ at some point in our lives, and while we cannot control many of these situations, we can change how we face these challenges.