Despite a four day hospitalization, she was sent back out into the community with no brain injury rehabilitation, no information on what to expect.
Miraculously the neuropsychiatrist knew what was wrong with me. While she resisted being taken off work, with his guidance, she realized that her brain wasn’t capable of doing the job she had always done before.
Tell me about your kids.: “Kids are awesome. My oldest daughter, I can almost guarantee she sustained a mild brain injury that day, but again, not diagnosed. She does pretty well but it worries me because a lot of people don’t understand that they’re cumulative over time. So I worry. But (she is) very bright – a straight A student, 15. So she’ll be going to
college at 16.
Because you had such a remarkable recovery they didn’t look for the more subtle but serious issues such as behavioral questions?: “They didn’t. They gave me a flyer. I remember that’s what they gave me, here, here’s a flyer on brain injury. Even though they knew I had a brain injury they never – the diagnosis of that didn’t come until the neuropsychologist, which is interesting.”
Much controversy in the field of brain injury swirls around the degree of an alteration of consciousness sufficient for the diagnosis of brain injury. There is virtually not a mild TBI that does not involve some issue as to whether the acute symptoms were sufficient to support the diagnosis of brain injury. While DJ’s brain injury was severe, not mild, it is still an important illustration as to how seemingly innocuous blows to the head can result in potentially fatal injuries, ala, Natasha Richardson.
Let’s go back. It’s 10:30 p.m.you’ve called for the ambulance and you said the only thing you remember is the color of the ambulance. What happened, what is happening to you in the next 12 hours, so your parents get there at 10:30 in the morning.: “Bad things. I read I vomited in the CAT scan, I read that I was at Cape Canaveral Hospital, the first six hours. I was asked by somebody if I was beaten, abused, thrown down the stairs, drank, drugged, got shot, beat up. I read that I was taking Ativan like candy, I read that I was starting to seizure a little bit. I vomited in the CAT scan around 2:00 in the morning. They ruled out abuse, I mean I read stuff that’s just, you know, they just kept me alive. A lot of drugs, a lot of falling apart basically.
Has your neurologist described what you have as migraines?: “Posttraumatic headaches.
DJ discusses the problems with getting the most accurate diagnosis and how how one condition can effect another: “Mostly the doctors. I don’t know other than, you know, like what I’ve brought to you. I’ve got, you know, a 16-page white study and white paper study, international study on what subarachnoid hemorrhage does to the thyroid. I tell people print this. It’s 22 pages. I’m sorry and it’s some ink but when I brought this to my neurologist, all of a sudden the brain injury is a problem with the thyroid. Then you bring it to the VA and then you send the email to your attorneys and you send it to your medical annuity administrator and they start going this guy is not to be played with.
Diagnosing brain damage requires us to look through the skull, tissue and within an organ with fairly crude measuring tools. What we get in a severe brain injury is usually a clear picture, because blood in the wrong place is easy to image on a CT scan and the processes that involve increases in intracranial pressure often involve pushing brain structures out of alignment. But just because a severe brain injury involves potentially life threatening damage if left untreated, does not mean that injuries to the parts of the brain that can occur in a concussion, do not have the potential to leave devastating long term disability. Diagnosing damage to the uncinate fasciculus requires a clinical judgment by the doctor, not some scan or other electronic gadget. While we hope that the MRI technique of DTI will soon be studying this tract more closely, there is a paltry of research on it to date. But some things, which are infinitely difficult to image in medicine, are easy to
understand when you hear the stories of the survivors. As Elizabeth says: – “The only thing I’m snapping with lately is stress, nerves, fear.
The oddity of missing something as overt as a right sided paresis demonstrates the problem in relying on brain injured individuals for self report. One of the keys to medical diagnosis is to begin with what is called the “chief complaint.” For Fred, there were so many obvious “complaints”, a subtle but predictable problem like this loss of feeling can just go unnoticed.
Fred talks about his father’s TBI; “My father had a brain injury when he was a young kid, and they didn’t know about brain injuries when he was young, so they just thought he was being a misbehaved child and his grades went from really good to really low, and so he got pushed through school and then he just basically had to fight to put everything together to get fixed and I can see a lot of problems that he has that aren’t, that are brain-related injury problems and some, some problems that I have, they’re the same as his, but a lot of the problems he has I’m not suffering from because of the treatment that I’ve gone through.
No other definition of brain injury is so flawed, with the consensus throughout the neurological and neuropsychological community for almost 20 years now that no loss of consciousness is required for a diagnosis of brain injury.
What did you know about the degree of her skull fracture?: “She had a crush injury on her right side up here towards the hairline, frontal lobe. It didn’t get into the temporal lobe that we know of. That was a crush impact injury with the hole being like that. So about inch and a half diameter.
Brain injury is too often thought of as a static injury, with the structural damage appearing almost immediately, with little need for complex diagnostic tools even a year post injury. In Nancy’s case there are two primary problems with such a perspective. First, as she was nine when the injury occurred, much of the areas of her brain which might have been damaged, had not completely developed at the time of her injury.
Some patients may not become aware of, or admit, the extent of their symptoms until they attempt to return to normal functioning. In such cases, the evidence for mild traumatic brain injury must be reconstructed. Mild traumatic brain injury may also be overlooked in the face of more dramatic physical injury (e.g., orthopedic or spinal cord injury). This is clearly what occurred in Otto’s case, with the risk of misdiagnosis being dramatically increased because of the emergency circling around Nancy and the fact that his wife, the person who would most likely have brought his symptoms to the attention of medical personnel, was in Madison, three hours away.
Otto’s wife states: “It’s frustrating with my husband, because he wasn’t diagnosed with a brain injury but he had the symptoms. Every, everything was there. The poor guy through his childhood had been doing – had the injuries where he’d been unconscious before and so that a concussion, you know, score is up to X amount. Here he is with this accident and it
knocked him for a loop but there wasn’t any diagnosing going on. And as a person who sees it in a therapy department and it’s like why isn’t it going on. But I was too far away to really, you know, say anything about it I think.
What was the diagnosis?: “Obviously, the significant head trauma, with something called SIADH, the syndrome of inappropriate anti-diuretic hormone. That means that he has too much anti-diuretic hormone, that he is dehydrating, basically his blood. therefore feeling thirsty and, therefore, drinking so much water; and the water was just going to cause more swelling up in the brain.”