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:

• First, the Emergency Room is involved. That’s where the medical team works to stabilize the patient.
• Next comes the Intensive Care Unit. A TBI patient will stay in the ICU until they move past the immediate danger of losing their life.
• The Neuro-ICU, which is sometimes called a step-down unit. It offers care by neuro-trained nurses. They, in conjunction with doctors, evaluate whether the patient is ready to move to the general neurological floor.
• The general Neurological floor has specially trained staff who help the patient recover to the extent possible and be prepared to go home as soon as medically possible.
• Intensive therapy in the Rehabilitation Unit helps the patients maximize their abilities and develop compensation techniques for any remaining deficiencies.
• Finally, the TBI patient goes back home where he or she will continue on the long and hard road to recovery.

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.

• GCS Scale - The Glasgow Coma Scale (GCS) is the first assessment done with the brain injured patient. It attempts to give the medical team an initial idea of the severity of the injury. The assessment is widely used because it is easily observable and can be pretty consistent. A score of 13 or higher is categorized as a mild brain injury, 9-12 moderate, and 8 or below severe.
• Closed Head Injury - A Closed Head Injury is an injury where the skull stays intact. The rapid movement of the head can be enough to significantly injure the brain. The brain can be slammed into the inside of the skull and there may also be rotational forces that cause shearing in the brain (see diffuse axonal injury). There may be bleeding in the brain, and swelling in the brain will follow.
• Open Head Injury - An Open Head Injury may be the result of some object penetrating into the brain or the skull being fractured by an impact. In the case of a penetrating wound the injury is usually located at a focal point in the brain so very specific identifiable problems will result. Gunshot wounds can cause more extensive damage as they move within the skull and cause shock waves inside the brain. Open head injuries leave the brain susceptible for infection in addition to the damage to the brain itself.
• Coup Contrecoup - This is a French term that describes the impact forces that can happen inside the brain. For example, in a car accident the momentum of the vehicle when it hits something may cause the brain to slam forward into the skull, the coup, then the momentum shifts and the brain then may be slammed again against the opposite side of the skull, the contrecoup. Both sites of impact may cause damage to the brain.
• Diffuse Axonal Injury - This term describes the injuries to axons located throughout the brain. Axons are long thin nerve fibers that may extend across different layers of the brain. As the head moves violently, as in a motor vehicle accident, the brain may experience rotational forces, and the axons may become sheared. The shearing is made worse by the fact that the different layers of the brain have different densities and react at different speeds to the rotational force. The injured axons may also release chemicals that can factor into increased swelling in the brain. The resulting impacts may be widespread and encompass a number of body systems and functions. It is more difficult for doctors to initially assess the impacts of a diffuse axonal injury than a focal injury.
• Hematoma – A hematoma is a collection of blood that has pooled. Surgery may be necessary to remove the blood. Below are two types of hematomas related to brain injuries:
• Subdural Hematoma - The brain is surrounded by a tough, leathery outer covering called the dura. When the brain is injured and blood accumulates within the space between the brain and the dura, it is called a subdural hematoma, or blood clot in the brain.
• Epidural Hematoma - An epidural hematoma is when blood accumulates within the space between the dura and the skull.
• Disabilities and impairments – Those resulting from a brain injury depend upon the severity of the injury, the location of the injury, and the age and general health of the patient. Some common disabilities include problems with cognition (thinking, memory, and reasoning), sensory processing (sight, hearing, touch, taste, and smell), communication (expression and understanding), and behavior or mental health (depression, anxiety, personality changes, aggression, acting out, and social inappropriateness).
• Communication Deficits – Brain injuries can commonly cause a number of communication-related deficits. Some are transient while others are permanent. Some of the deficits may result from the damage to particular communication centers in the brain causing one or more forms of aphasia. Other problems may be a result of motor problems or weaknesses caused by other complications. Some people may have difficulty with the more subtle aspects of communication, such as body language and emotional, non-verbal signals. Communication disorders are complex and need to be identified and treated by speech pathologists.

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:

• Paralysis - You are probably familiar with Quadriplegia and Paraplegia. Another form of paralysis that is common with brain injury victims is Hemipelegia, which is paralysis to one side of the body.
• Spasticity - Spasticity is a condition in which certain muscles are continuously contracted. This contraction causes stiffness or tightness of the muscles and may interfere with movement, speech, and manner of walking. Spasticity is usually caused by damage to the portion of the brain or spinal cord that controls voluntary movement. Treatment may include stretching, medications, and in some cases surgery.
• Apraxia - Apraxia is a movement disorder characterized by the inability to perform skilled or purposeful voluntary movements, generally caused by damage to the areas of the brain responsible for voluntary movement.
• Ataxia - Damage to a lower part of the brain, the cerebellum, can affect the body’s ability to coordinate movement, a disability called ataxia, leading to problems with body posture, walking, and balance.

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:

• Memory - The most common cognitive impairment among brain injured patients is memory loss and the partial inability to form or store new ones.
• Executive Function - There may also be problems with higher level, so-called executive functions, such as planning, organizing, abstract reasoning, problem solving, and making judgments, which may make it difficult to resume work or school related activities.
• Emotional Problems - Emotional problems that may surface include depression, apathy, anxiety, irritability, anger, paranoia, confusion, frustration, agitation, insomnia or other sleep problems, and mood swings. Problem behaviors may include aggression and violence, impulsivity, disinhibition, acting out, noncompliance, social inappropriateness, emotional outbursts, childish behavior, impaired self-control, impaired self-awareness, inability to take responsibility or accept criticism, egocentrism, inappropriate sexual activity, and alcohol or drug abuse/addiction. Many TBI patients who show psychiatric or behavioral problems can be helped with medication and psychotherapy. Family members of TBI patients often find that personality changes and behavioral problems are the most difficult disabilities to handle.

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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