Recently in Trauma Category
Last month, physicians at Bagram Airfield in Afghanistan removed a 14.5-mm explosive round, containing about 5 g of explosive, from the scalp of an Afghan National Army soldier. The 2 1/2-inch round was lodged into the soldier's scalp after he was involved in a roadside bomb attack, revealed a recent Air Force press release. Friday's NYT picked up the story, adding more details.
Seems that the medical staff first believed that the Afghani merely sustained a shrapnel wound to the head; however, on closer inspection, thanks to CT images, the radiologist realized that the foreign object was an explosive round, "primed to go off." Nice pick up.
The discovery, which prompted the bomb squad, led to the evacuation of the operating suite, and the remaining operating personnel had to wear body armor. Electronic monitoring machines also had to be turned off, for fear of triggering the device. Because the bomb squad suspected that the live round probably had an impact detonator in the tip, instructions to the lead surgeon were, "Just don't drop it."
A frontal skull image provided by the Air Force shows the round lodged in the right frontal area of the patient's scalp, evidently resting on the skull.
However, a horizontal CT image shows that the round is lodged between 2 skull fragments in the right frontal area. This image suggests (to me) that the device impacted the head sideways, probably blasting into the Afghani's head from his left and grazing his brow before burying itself under a created skull fragment.
The round was removed successfully, and the Afghan soldier reportedly continues to recover.
Raising a host of questions, from practical to philosophical, English and Belgian investigators showed that some patients with profound disorders of consciousness may be able to communicate—albeit in rudimentary fashion and with the aid of a million-dollar machine. Their functional MRI study of patients in persistent vegetative or "minimally conscious" state is available online today at the NEJM web site.
Among 54 severely disabled patients, investigators found that 5 could "willfully modulate their brain activity," as seen on fMRI pictures, in response to suggested motor imagery. Specifically when these patients were asked to imagine playing tennis, parts of the supplementary motor area reliably lit up. Four of the 5 patients could also respond to suggested spatial imagery, like navigating through a familiar city, by activating the parahippocampal gyrus. Follow-up bedside testing showed "some sign of awareness" in 3 of the 5 patients—suggesting that voluntary behavioral cues were missed before the fMRI assessment or that fMRI training primed these patients to respond behaviorally at the bedside (the former seems more likely).
The investigators then selected 1 patient with reliable fMRI responses to undergo training that correlated the motor imagery with "yes" and the spatial imagery with "no." The patient was then able to use the technique during fMRI to accurately answer yes-no questions, like Is your father's name Alexander? However, back at the bedside, no form of communication could be established with this patient.
All 5 responsive patients had traumatic brain injury without anoxic damage (among 32 in the study population). It is important to note that none of the 16 patients with anoxic brain injury responded (a fact that editorialist Allan Ropper also stresses).* Before fMRI testing, 4 of the responsive patients were diagnosed with vegetative state, including the patient who underwent communication training.
The American Academy of Neurology, the flagship organization for practicing US neurologists, provides the following criteria for the diagnosis of vegetative state:
- No evidence of awareness of self or environment and an inability to interact with others
- No evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli
- No evidence of language comprehension or expression
- Intermittent wakefulness manifested by the presence of sleep-wake cycles
- Sufficiently preserved hypothalamic and brainstem autonomic functions to permit survival with medical and nursing care
- Bowel and bladder incontinence
- Variably preserved cranial nerve and spinal reflexes
Minimally conscious state, which acknowledges the intermediate stage between no and some awareness in the severely brain damaged, is defined as follows:
A condition of severely altered consciousness in which minimal but definite behavioral evidence of self or environmental awareness is demonstrated.
Diagnosis: limited but clearly discernible self or environmental awareness on a reproducible or sustained basis by demonstrating one or more behaviors, including, following simple commands, gesturing yes/no answers to questions, intelligible verbalizations, purposeful behavior, appropriate smiling or crying, reaching for and touching objects, and pursuit eye movements.
Course: may be a transient stage in the recovery after severe head injury or other brain insult or a permanent condition.
Results of this fMRI study suggest that the imaging technique might be useful for distinguishing the 2 conditions (and that, perhaps, the definition of minimally conscious state should include fMRI-dependent findings) and for establishing communication in patients with reproducible fMRI responses.
* Ropper also concludes his NEJM editorial with a groan-inducing pun that should not be reproduced.
Image of Berkeley's fMRI machine from Wikipedia.
A London pediatrician's diary shows that Haiti desperately needs, more than surgeons, supplies and coordination.
Writing for the Evening Standard, Dr. Nathaniel Segaren of the Caris Foundation, logs his week of guilt, frustration, appall, effort, and anguish among the mayhem. He concludes, "I realise we can be of most help with our knowledge of the city's geography and our ability to speak a combination of French, English and Creole." The ultimate intent becomes to select, with exceptional agony, those patients for transfer to a floating US Navy hospital—which is already beyond capacity.
"There are lots of egos here and mini power struggles," Segaren observes, "People are desperate to claim credit and get maximum media coverage."
From the UN via Flickr: Photo of 18-year-old Haitian girl with head trauma being transported to USS Comfort, a floating hospital.
The media failed to educate the public about persistent vegetative state (PVS) in its coverage of the Theresa Schiavo case. This is the conclusion of neurologists who reviewed more than 1000 relevant articles published in the NYT, The Washington Post, or 2 local Florida papers during a 15-year time span. The results of their examination were published in this week's Neurology.
The investigators examined 1141 articles, most of which (75%) were journalistic reports, printed from 1990 to 2005 and found statements denying Schiavo's PVS diagnosis in 71 articles. Other articles falsely claimed brain death (12) or minimal consciousness (10), both inconsistent with PVS. Also some descriptions of Schiavo's behavior (typically obtained from Schiavo's parents or sympathetic individuals)—such as responding, reacting, or communicating—are inconsistent with PVS.
Nearly 30% of articles contained statements that Schiavo "might improve" or "might recover," virtually nonexistent possibilities after spending 15 years in a PVS.* A lower percentage of articles (26%) included statements that Schiavo would not improve or recover. The neurologists, overall, found that "explanations of the basic concept of PVS...were rare."
In an accompanying editorial, neurologist James Bernat—who testified before the United States Senate Health, Education, Labor, and Pension Committee on April 6, 2005, to discuss Schiavo's case—chides the media for "squandering the opportunity to educate the public about disorders of consciousness and end-of-life care." He notes that, instead, coverage fixated on the dispute between Schiavo's husband and her parents and the politicization of the case by ultra-right-wing conservatives in a kind of pro-life stance.
Bernat also reproaches TV media for repeatedly showing an edited videotape of Schiavo, provided by her parents, which was likely to suggest consciousness to an uneducated public. Perhaps most important, the media failed to clarify that Schiavo's desire not to have a feeding tube (at the center of the dispute between Schiavo's husband and her parents) was concluded after "exhaustive hearings," which were based on the testimony of numerous friends and relatives.
On March 31, 2005, Schiavo died 13 days after the court-approved removal of her feeding tube and 15 years after sustaining hypoxic-ischemic brain injury during cardiac arrest (presumed to be due to, ironically enough, hypokalemia as a result of an eating disorder).
The American Academy of Neurology provides criteria for the diagnosis of PVS or, more accurately in the case of Theresa Schiavo, permanent vegetative state.
* Recovery from PVS (due to nontraumatic brain injury) after 3 months is rare.
CT image of normal brain (left) and of Schiavo's brain (right) in 2002, showing marked atrophy with hydrocephalus (presumably ex vacuo). Reprinted, from Wikipedia, under fair-use law.
I'm so out of it. I had no idea that popping water-bottle caps was the current rage among kids. This video demonstrates the practice and shows the tremendous force that can be generated from the flying cap. I'm sure it's always good, clean backyard fun, until somebody gets hurt—which is what happened to a 14-year-old girl whose right eye was hit by such a projectile cap, according to correspondence in this week's NEJM. The girl's injury ultimately required intervention in the form of maximal glaucoma therapy, because of increasing intraocular pressure, and anterior-chamber washout.
Photo, from NEJM, showing blood clot in anterior chamber (white arrow) and hyphema (black arrow) on day 4 after injury.
