We just handled a very sad case in Georgia involving a severe traumatic brain injury (TBI) and hopefully made things better for the family we represented. That case was just another classic example of how a TBI affects not only the patient, but also the injured party’s entire family. Although TBI is a most serious medical problem, I have found that there is always hope for a person who has suffered such an injury. It’s been my observation in handling a number of these cases, that, without hope, a person with a severe TBI simply wouldn’t be able to survive. Too many folks take the approach that a TBI patient can never improve, but that isn’t always true. Some doctors often present – by necessity – a very negative picture to a TBI family early in the process. On occasion, a doctor may seem pessimistic because a family has to be prepared for the worst in case the worst actually happens. Unfortunately, that just comes with the territory. Because of the serious nature of TBI cases and the lack of understanding of the complexities involved, I am going to spend a little more space on the subject in this part of the Report.
It seems that the better and more experienced doctors are able to prepare a family for the worst, while still leaving them some realistic hope, and that’s always good for the patient and family. The approach doesn’t break their spirit. It’s also important to understand that it’s a natural reaction for a family whose loved one has suffered a severe TBI to resist the bad news they have been given. The doctors may come across as being very blunt, and somewhat pessimistic, in order to break through the defense mechanism that often is exhibited by the family. In any event, dealing with a severe TBI is very tough and is a real challenge for all concerned. Handling a lawsuit that involves a TBI is also quite a challenge for lawyers and their support personnel.
A factor that makes projecting the long-term outcome more difficult is that the medical community still doesn’t know all there is to know about the brain, and that’s no reflection on anyone. Reportedly, the brain is the least understood organ in the body. A doctor explained it well to me when he said that he can tell me with the CAT scans and MRIs where the brain has been damaged, but he couldn’t tell me whether other areas of the brain would be able to take over some of the tasks previously performed by the damaged area. Recent studies have shown that the brain does indeed exhibit more plasticity than previously thought. I have been greatly impressed with all of the doctors we have dealt with who deal with TBI patients on a regular basis. One such doctor is Ronald Leslie, the Medical Director at the Shepherd Center in Atlanta, who – without question – is one of the very best in his field. This man is not only is a great doctor, but he really cares about his TBI patients and their families.
The following is a typical path many TBI patients take on their road to recovery. The main thing to understand is that each head injury is different, and as a result each recovery will be somewhat different. Below are the general steps that a TBI patient will generally follow after an injury:
Of course, the above steps assume that all of the intensive treatment and rehabilitation required will take place before a patient is discharged. Unfortunately, I have found that few lay persons really understand a TBI. The following is an overview from the National Institute of Neurological Disorders and Stroke that will help you understand what a TBI is all about. First, traumatic brain injury occurs when a sudden physical assault on the head causes damage to the brain. The damage can be focal, confined to one area of the brain, or diffuse, involving more than one area of the brain. TBI can result from a closed head injury or a penetrating head injury. A closed head injury occurs when the head suddenly and violently hits an object, but the object does not break through the skull. A penetrating head injury occurs when an object pierces the skull and enters the brain tissue. Each of these injuries is a most serious event. These terms and those that follow are explained in more detail below.
Several types of traumatic injuries can affect the head and brain. A skull fracture occurs when the bone of the skull cracks or breaks. A depressed skull fracture occurs when pieces of the broken skull press into the tissue of the brain. This can cause bruising of the brain tissue, called a contusion. A contusion can also occur in response to shaking of the brain within the confines of the skull, an injury called “countrecoup.” Shaken baby syndrome is a severe form of head injury that occurs when a baby is shaken forcibly enough to cause extreme countrecoup injury. Damage to a major blood vessel within the head can cause a hematoma, or heavy bleeding, into or around the brain. The severity of a TBI can range from a mild concussion to the extremes of coma or even death. As you know, a coma is a profound or deep state of unconsciousness.
Symptoms of a TBI may include headache, nausea, confusion or other cognitive problems, a change in personality, depression, irritability, and other emotional and behavioral problems. Some people may have seizures as a result of a TBI. Immediate treatment for TBI involves surgery to control bleeding in and around the brain, monitoring and controlling intracranial pressure, insuring adequate blood flow to the brain, and treating the body for other injuries and infection.
The outcome of TBI depends on the cause of the injury and on the location, severity, and extent of neurological damage. Outcomes in TBI areas range from good recovery to death. Doctors often use the Glasgow Coma Scale to rate the extent of injury and chances of recovery. The scale (3-15) involves testing for three patient responses: eye opening, best verbal response, and best motor response. A high score indicates a good prognosis and a low score indicates a poor prognosis. For example a score of 3, or a 1 on each type response, is as bad as it gets.
It must be remembered that brain injuries can result from a number of causes. Motor vehicle accidents, falls, sport injuries, and near drownings, as well as medical causes such as strokes, brain tumors, aneurisms, seizure activity, or infectious diseases can cause brain injuries. Brain injuries or head injuries are classified into three categories: mild, moderate, or severe. The categorization is based on the Glasgow Coma Scale rating. The way that works is explained below:
Mild Traumatic Brain Injury
A patient with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function as manifested by at least one of the following: any period of loss of consciousness; any loss of memory for events immediately before or after the accident; any alteration in mental state at the time of the accident and focal neurological deficits that may or may not be transient but where the severity of the injury does not exceed the following: loss of consciousness of approximately 30 minutes or less; after 30 minutes, an initial Glasgow Coma Scale (GCS) of 13-15; and posttraumatic amnesia (PTA) not greater than 24 hours.
Most individuals with a mild brain injury will not have any major functional deficits. There may be some long-term impacts but they are typically more subtle such as headaches or cognitive or memory problems. Sometimes the cognitive symptoms are not readily identified at the time of the injury. Instead, the cognitive symptoms may show up as the person returns to school or work.
Moderate Brain Injury
Brain injuries are classified as Moderate when the GCS score is between 9 -12 and there is a loss of consciousness and/or post-traumatic amnesia of greater than 30 minutes but less than 24 hours and/or a skull fracture. There may be long-term physical or cognitive deficits as a result of a moderate brain injury. Much will depend on the type and location of the specific insults to the brain. Rehabilitation will help to overcome some deficits and help provide skills to cope with any remaining deficits.
Severe Brain Injury
A severe brain injury will present with a Glasgow Coma Scale score lower than 9 that is accompanied by a loss of consciousness or post-traumatic amnesia lasting more than 24 hours. Severe brain injuries are very life-threatening. If the person lives, they will typically be faced with long-term physical and cognitive impairments. The range of the deficits can vary widely from a vegetative state to more minor impairments that may allow the person to still function independently. The patient will require extensive rehabilitation to try to overcome some of the deficits and learn strategies to cope with others.
I believe that becoming familiar with the following terms will help give you a little better understanding of TBIs. I have found that having a basic understanding of the terminology is the first step in dealing with the complex issues involved in TBI cases.
Having represented a good number of clients who have suffered severe TBI’s, I have witnessed first-hand how difficult this type of injury can be for both the victim and the family. There are a great number of problems that are caused by a TBI. The following are some of the speech-related problems that a TBI patient may experience: Aphasia; Global Aphasia; Broca’s Aphasia; Wernicke’s Aphasia; Anomic Aphasia; Apraxia; Dysarthria; and Swallowing Disorders.
Brain injuries can cause a number of movement disorders. In addition, since so many brain injuries happen as a result of accidents, there may be other injuries contributing to the movement disorder. The following are examples of this type of problem:
Many brain injury victims suffer from cognitive disabilities, which may include the loss of higher level mental skills. People may be easily confused or distracted and have problems with concentration and attention. The problems that result prevent a person with a TBI from being able to function in a normal manner even if their motor skills are not significantly impaired. The following are cognitive problems that can result from a TBI:
Many TBI patients have sensory problems, especially problems with vision. Patients may not be able to register what they are seeing or may be slow to recognize objects. Also, TBI patients often have difficulty with hand-eye coordination. Because of this, TBI patients may be prone to bumping into or dropping objects, or may seem generally unsteady. TBI patients may have difficulty driving a car, working complex machinery, or playing sports. Other sensory deficits may include problems with hearing, smell, taste, or touch. Some TBI patients develop tinnitus, a ringing or roaring in the ears. A person with damage to the part of the brain that processes taste or smell may develop a persistent bitter taste in the mouth or perceive a persistent noxious smell. Damage to the part of the brain that controls the sense of touch may cause a TBI patient to develop persistent skin tingling, itching, or pain. Although rare, these conditions are hard to treat.
Finally, I hope this will give you a much better insight into what TBI patients face on a daily basis. My experience in handling these cases has made me realize how much the patients and their families have to deal with. It has also made me appreciate even more the medical community, including doctors, therapists, counselors, and vocational experts, nurses and others who are trained and available for TBI patients.
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