From a Press Release from Air Jamaica Pilots Association:
Organization says that lack of and/or unserviceable airport equipment combined with inclement weather could have seriously compromised the crew of American Airlines Flight 331, which crash landed in Jamaica last Tuesday, Dec. 22, 2009
MIAMI, FL, December 29, 2009 — A former president of the Jamaica Airline Pilots Association (JALPA) has sent an open letter to both Spirit and American Airlines advising of the high potential for disaster, and requested that they exercise extreme care when dispatching flights into Jamaica in marginal weather and not use Jamaican airports as alternates under any circumstances until the NTSB report is final.
Wesley Sampson and his organization, Mayday Air Jamaica (http://www.maydayairjamaica.com), had last month on Nov. 19, 2009, in an open letter to Spirit re: its bid to purchase Air Jamaica, expressed grave concerns over the safety of the international travelling public into Jamaica, and the callous attitude of the Jamaican authorities in this regard.
“We note where the FAA had previously downgraded the islands’ airports, the status of which, although reinstated, remains questionable where emergency equipment and facilities are concerned, as this accident shows. It is not reasonable to assume or expect that two experienced American Airlines pilots, trained to the highest standards of aviation safety, simply flew into Jamaica and crash landed in routine operations,” said Sampson.
Mayday Air Jamaica strongly advises the travelling public not to use foreign carriers in inclement weather conditions, and to await the findings of the NTSB and the supervision of the Jamaican government in implementation of the recommended corrective procedures.
Concussion Diagnosis Still Critical for American Flight 311 Survivors
It has been four days now and the news cycle has spun away from the American Flight 311 crash just short of the Caribbean Sea in Jamaica. Even Google can’t seem to find anything current. One might thus assume that no one was seriously hurt and it was a Christmas miracle. We hope so. But what we know about concussion makes us pause.
Brain injury is a process not an event. Those words were probably first published by noted brain researcher, Thomas Gennarelli, M.D., probably in Greenfield’s Neuropathology. It is a theme I understood early in my career and have written about, advocated about and preached about since. I have a series of web pages devoted to it beginning with http://subtlebraininjury.com/tbiprocess1.html To simplify a very complicated neuropathological phenomenon, several different pathologies can make brain injury more significant at 24 or 48 hours than they are at the two to four hour time window when injured people are often seen in the Emergency Room.
One, the brain may swell or bleed, cutting off internal circulation to the blood vessels within the brain, causing secondary brain damage and even death. This is what happened to Natasha Richardson after her skiing accident.
Two, more likely in a concussion case, the initial injury to the axon in a shearing mechanism, will open up a defect in the insulation around the axon, allowing toxic where they don’t belong neurochemicals to attack the axon. Over next 72 hours, an injured but functioning axon may suffer additional injury. Over time that axon may die. While the brain has millions of axons and no single axon is critical for survival, when enough axons die in a given area, the brain’s internal communication abilities can become compromised. Now processing speed and the way in which the attention centers and the emotional centers of the brain are interconnected may be compromised.
While seeing the damage to any given axon is impossible short of an autopsy, the effect of the progress of brain damage can be measured, if the physician or other health care professionals ask the right questions in the week after injury. The brain that is likely to be permanently changed by a concussion, is the brain that isn’t working efficiently in those first few days. The best way to tell? Ask questions to determine whether there is amnesia for events after the injury. If the person doesn’t remember what happened yesterday, they must be given a much higher priority for brain injury evaluation and treatment.
Brain injury is a process not an event. Those words were probably first published by noted brain researcher, Thomas Gennarelli, M.D., probably in Greenfield’s Neuropathology. It is a theme I understood early in my career and have written about, advocated about and preached about since. I have a series of web pages devoted to it beginning with http://subtlebraininjury.com/tbiprocess1.html To simplify a very complicated neuropathological phenomenon, several different pathologies can make brain injury more significant at 24 or 48 hours than they are at the two to four hour time window when injured people are often seen in the Emergency Room.
One, the brain may swell or bleed, cutting off internal circulation to the blood vessels within the brain, causing secondary brain damage and even death. This is what happened to Natasha Richardson after her skiing accident.
Two, more likely in a concussion case, the initial injury to the axon in a shearing mechanism, will open up a defect in the insulation around the axon, allowing toxic where they don’t belong neurochemicals to attack the axon. Over next 72 hours, an injured but functioning axon may suffer additional injury. Over time that axon may die. While the brain has millions of axons and no single axon is critical for survival, when enough axons die in a given area, the brain’s internal communication abilities can become compromised. Now processing speed and the way in which the attention centers and the emotional centers of the brain are interconnected may be compromised.
While seeing the damage to any given axon is impossible short of an autopsy, the effect of the progress of brain damage can be measured, if the physician or other health care professionals ask the right questions in the week after injury. The brain that is likely to be permanently changed by a concussion, is the brain that isn’t working efficiently in those first few days. The best way to tell? Ask questions to determine whether there is amnesia for events after the injury. If the person doesn’t remember what happened yesterday, they must be given a much higher priority for brain injury evaluation and treatment.
Air Crashes and Brain Injuries
People have two completely different images of air crashes. The most common is the complete catastrophe, fiery wreck, everyone dies. The other is Captain Sully’s, the miracle landing, heroic acts and everyone lives. There are air crashes in between. Years ago, we worked with the Nolan Law Group on one of those in between crashes, a crash like the American Airlines Flight 311, that happened on the runway. That crash was the fated Singapore Air Flight, SQ006.
A bit about our relationship with the Nolan Law Group. I do almost exclusively brain injury work. I got to know Don Nolan in 1994 because his firm also did brain injury work, but since then Don’s focus has shifted to large scale disaster litigation, like the SQ006 crash, where the Nolan Law Group represented more than 30 people, who survived that wreck. The Brain Injury Law Group has been affiliated with the Nolan Law Group for more than ten years, primarily in cases where there has been brain injuries as part of a mass catastrophe.
Now a bit about how brains get injured. There are primarily three ways a brain gets hurt. The first is a blow to the head. A blow transfers energy directly from the skull to the brain, causing injury. The second way a brain gets injured is when a rapid change in direction, acceleration or deceleration, causes the brain to collide with the inside of the skull. Both of these first two types of injuries will more often be associated with bleeds or hemorrhages, events which will increase the intracranial pressure in the brain. In intracranial pressure event injuries brain surgery may be needed to avoid a fatal increase in pressure. See http://subtlebraininjury.com/biomechanics1.html
The third way a brain can get injured is through a stretching and tearing of the communication fibers of the brain, the axons. For a detailed explanation of the structure of brain tissue, see http://subtlebraininjury.com/neuron.html Axons are the long thin part of a neuron, which as they cross several layers of brain tissue, are subject to injury when the brain is twisted internally as a result of significant acceleration/deceleration. Such an injury is called a Diffuse Axonal Injury. See http://subtlebraininjury.com/shear1.html
People understand that when you are in a car wreck, the body is subjected to all of these forces. We also now understand that seatbelts and airbags are designed to protect us from such forces, because they restrain the head from hitting the windshield and cushion the body, so that the acceleration/deceleration forces are less.
Airplanes don’t have airbags and the lap belt only seatbelts would no longer be allowed in a car. One thing that struck me about the American Flight 311 complaints of passengers was all the back pain. The reason the lap belt only seatbelt is not allowed in cars is that it causes back injury. The other thing wrong with a lap belt only mechanism is that it may magnify the acceleration/deceleration of the neck and head.
All three types of mechanism of brain injury could have occurred in Flight 311. Near where the spots in the jet where it broke apart, there is a high likelihood of someone hitting their head. The rapid deceleration when the jet suddenly stopped just short of the sea, comes not only the risk of a collision between the brain and the inside of the skull, but also the risk of the internal twisting of the brain that can cause Diffuse Axonal Injury.
To the survivors of Flight 311 and their families and loved ones, keep an eye for the symptoms of concussion – confusion, amnesia, dizziness, headache. Follow-up continuously with the doctor until the symptoms clear.
A bit about our relationship with the Nolan Law Group. I do almost exclusively brain injury work. I got to know Don Nolan in 1994 because his firm also did brain injury work, but since then Don’s focus has shifted to large scale disaster litigation, like the SQ006 crash, where the Nolan Law Group represented more than 30 people, who survived that wreck. The Brain Injury Law Group has been affiliated with the Nolan Law Group for more than ten years, primarily in cases where there has been brain injuries as part of a mass catastrophe.
Now a bit about how brains get injured. There are primarily three ways a brain gets hurt. The first is a blow to the head. A blow transfers energy directly from the skull to the brain, causing injury. The second way a brain gets injured is when a rapid change in direction, acceleration or deceleration, causes the brain to collide with the inside of the skull. Both of these first two types of injuries will more often be associated with bleeds or hemorrhages, events which will increase the intracranial pressure in the brain. In intracranial pressure event injuries brain surgery may be needed to avoid a fatal increase in pressure. See http://subtlebraininjury.com/biomechanics1.html
The third way a brain can get injured is through a stretching and tearing of the communication fibers of the brain, the axons. For a detailed explanation of the structure of brain tissue, see http://subtlebraininjury.com/neuron.html Axons are the long thin part of a neuron, which as they cross several layers of brain tissue, are subject to injury when the brain is twisted internally as a result of significant acceleration/deceleration. Such an injury is called a Diffuse Axonal Injury. See http://subtlebraininjury.com/shear1.html
People understand that when you are in a car wreck, the body is subjected to all of these forces. We also now understand that seatbelts and airbags are designed to protect us from such forces, because they restrain the head from hitting the windshield and cushion the body, so that the acceleration/deceleration forces are less.
Airplanes don’t have airbags and the lap belt only seatbelts would no longer be allowed in a car. One thing that struck me about the American Flight 311 complaints of passengers was all the back pain. The reason the lap belt only seatbelt is not allowed in cars is that it causes back injury. The other thing wrong with a lap belt only mechanism is that it may magnify the acceleration/deceleration of the neck and head.
All three types of mechanism of brain injury could have occurred in Flight 311. Near where the spots in the jet where it broke apart, there is a high likelihood of someone hitting their head. The rapid deceleration when the jet suddenly stopped just short of the sea, comes not only the risk of a collision between the brain and the inside of the skull, but also the risk of the internal twisting of the brain that can cause Diffuse Axonal Injury.
To the survivors of Flight 311 and their families and loved ones, keep an eye for the symptoms of concussion – confusion, amnesia, dizziness, headache. Follow-up continuously with the doctor until the symptoms clear.
Followup to Injuries in Jamaica Air Crash
I was once a news reporter and I understand the process of gathering news, but it is amusing in retrospect what the first reports of a major event look like. Take for example this story in the New York Times about the American Airlines Flight 311 crash in Jamaica on December 23: http://www.nytimes.com/2009/12/23/world/americas/23briefs-Jamaicabrf.html?scp=1&sq;=american%20airlines%20flight&st;=cse
The story said:
The important thing now is that anyone on board who is having any head injury symptoms go back to the doctor or emergency room and get the kind of follow-up evaluation that an NFL quarterback would get. Most important in that follow-up is a determination as to whether there has been any amnesia, or loss of memory for events, between the time of the accident and the time of the evaluation. Post-traumatic amnesia is the single most important predictor of a negative outcome from a concussion. Other obvious symptoms that should be taken seriously are balance or visions problems, confusion and headache.
Concussions can disable. The concussions that disable are the ones that are symptomatic 24 to 72 hours after the injury. Now is the time to identify those symptoms.
The story said:
An American Airlines flight from Miami overshot the runway in Kingston on Tuesday but came to a safe stop, an airline spokesman said. The spokesman, Charley Wilson, said that there were no reports of injuries or fatalities, and that all the passengers were off the plane.How does American Airlines release a story like that? All one has to do is look at the wreckage of the aircraft to know that people had to be hurt. See the photo from the Jamaica Observer at http://www.jamaicaobserver.com/news/Observer-first-in-the-world-to-report-AA-crash Miracles notwithstanding, there is no way an airplane is torn apart like that without injuring virtually everyone who was near the fracture points. The Jamaica Observer reported further on the status of injuries:
One hundred passengers were reported injured when the plane crashed and broke in three after landing at the airport shortly after 10:00 Tuesday night.It is great news that all but one of the passengers was released from the hospital for Christmas. But as I said in my last blog, being released from the hospital does not give any of that group of injured people a clean bill of health as far as brain injury is concerned. There is no question that there were concussions on that plane. There was simply too much force involved in tearing up that jet to not have injured some brains. To tear apart an airplane like that severe twisting forces must have been involved. Those forces could have been just as severe to any passenger on board, but especially to those sitting in the seats adjacent to where the plane broke up.
Most of the injuries were classified as lacerations and blood trauma. A few fractures of long bones and ribs were also reported. On Thursday, a statement from the Ministry of Health said that 13 of the 14 passengers who were admitted to hospital have since been released.
The important thing now is that anyone on board who is having any head injury symptoms go back to the doctor or emergency room and get the kind of follow-up evaluation that an NFL quarterback would get. Most important in that follow-up is a determination as to whether there has been any amnesia, or loss of memory for events, between the time of the accident and the time of the evaluation. Post-traumatic amnesia is the single most important predictor of a negative outcome from a concussion. Other obvious symptoms that should be taken seriously are balance or visions problems, confusion and headache.
Concussions can disable. The concussions that disable are the ones that are symptomatic 24 to 72 hours after the injury. Now is the time to identify those symptoms.
Christmas Miracle In Jamaica?
Ten Feet. That is all that stood between a broken up airplane and the Caribbean Sea. 154 people on board that American Airlines Boeing 737 came that close to one more risk of life as the plane stopped just short of the ultimate mess. Yet looking at the photos of what is left of American Airlines flight 331 the first thing that came to my mind was concussion and whether in the mess of wreckage, treatment for broken bones and back pain, anyone was giving these survivors of this miracle the kind of head injury evaluation a quarterback would get in the NFL.
One of my first guides as I began my career in brain injury advocacy was a consensus statement on Mild Traumatic Brain Injury by the American Congress of Rehabilitation Medicine (the “ACRM”). That statement can be found at http://www.tbilaw.com/RehabDefinitionPage.php
I have discussed the many aspects of this definition of Mild Traumatic Brain Injury but one of the best parts of that definition is something said in the Comments to the definition:
“Mild traumatic brain injury may also be overlooked in the face of more dramatic physical injury (e.g., orthopedic or spinal cord injury).”
An airplane crash, a near miss catastrophe, broken bones, smell of fuel, panic and real risk of PTSD. Concussion might be the last thing in the differential diagnosis. But the force that can break a bone, can easily injure the brain. The forces that tore that plane apart, can easily injure the brain. The deceleration, the twisting of the fuselage as it broke apart, all risk injury to the neural networks. Remember, the seatbelt in an airplane is no where near as safe as the combination of a shoulder/lap belt and airbags in a modern car.
We are thankful that no one died. We also express our Holiday prayer that anyone suffering from concussion, gets proper diagnosis. As said by the ACRM:
“Some patients may not become aware of, or admit, the extent of their symptoms until they attempt to return to normal functioning.”
Lets hope that with all the attention these survivors are getting, their brains get some attention too.
One of my first guides as I began my career in brain injury advocacy was a consensus statement on Mild Traumatic Brain Injury by the American Congress of Rehabilitation Medicine (the “ACRM”). That statement can be found at http://www.tbilaw.com/RehabDefinitionPage.php
I have discussed the many aspects of this definition of Mild Traumatic Brain Injury but one of the best parts of that definition is something said in the Comments to the definition:
“Mild traumatic brain injury may also be overlooked in the face of more dramatic physical injury (e.g., orthopedic or spinal cord injury).”
An airplane crash, a near miss catastrophe, broken bones, smell of fuel, panic and real risk of PTSD. Concussion might be the last thing in the differential diagnosis. But the force that can break a bone, can easily injure the brain. The forces that tore that plane apart, can easily injure the brain. The deceleration, the twisting of the fuselage as it broke apart, all risk injury to the neural networks. Remember, the seatbelt in an airplane is no where near as safe as the combination of a shoulder/lap belt and airbags in a modern car.
We are thankful that no one died. We also express our Holiday prayer that anyone suffering from concussion, gets proper diagnosis. As said by the ACRM:
“Some patients may not become aware of, or admit, the extent of their symptoms until they attempt to return to normal functioning.”
Lets hope that with all the attention these survivors are getting, their brains get some attention too.
A Fall of Concussions
While I have been away from writing this blog, there has been more concussion news than I can remember. And as always, the real story usually gets lost in the headlines.
Tiger Woods is a perfect example. From all bystander and news accounts, he was undoubtedly knocked out when his SUV hit a tree. Much speculation swirled before the infidelity took over the story, but no one said it quite this clearly:
Tiger Woods must have had a brain injury and his reluctance to speak in public may have been for medical reasons in addition to his reluctance to discuss his marriage. He might have cancelled his next golf tournament because of injuries he suffered. I am not naive to the more likely motivations for his disappearance from the public stage, but concussion is an issue that should not be forgotten.
The good news on the concussion front is that awareness seems to be growing daily. The NFL has gotten headlines for its new concussion policies, which don’t read any different to me than what should have always been its policy, but something clearly has changed. Players who would have been medically cleared to play, have been told they couldn’t. That includes starting quarterbacks on what were playoff caliber teams at the time, the Phoenix Cardinals and the Pittsburg Steelers. Yet the same week, I saw Jermichael Finley take a horrendous hit to his jaw from another players helmet, yet not even be taken out for one play. They stopped the play for the penalty and by the time they had marked off the yardage, he was lined up again.
How could anyone have known what lingering effects he had of a ding everyone clearly saw, if he didn’t even come to the sidelines?
One of the continuing problems with sideline concussion evaluations is the presumption that anyone noticed the initial concussion. That is an organic problem that can’t really be avoided, but if a player isn’t pulled out of a game to talk to the trainer, there is no chance to avoid the catastrophic second impact syndrome that turns a concussion into a severe and even life threatening injury.
The story of concussion in sport and its relevancy to the non-fan in us, will be a focus of the blogs to come.
Tiger Woods is a perfect example. From all bystander and news accounts, he was undoubtedly knocked out when his SUV hit a tree. Much speculation swirled before the infidelity took over the story, but no one said it quite this clearly:
Tiger Woods must have had a brain injury and his reluctance to speak in public may have been for medical reasons in addition to his reluctance to discuss his marriage. He might have cancelled his next golf tournament because of injuries he suffered. I am not naive to the more likely motivations for his disappearance from the public stage, but concussion is an issue that should not be forgotten.
The good news on the concussion front is that awareness seems to be growing daily. The NFL has gotten headlines for its new concussion policies, which don’t read any different to me than what should have always been its policy, but something clearly has changed. Players who would have been medically cleared to play, have been told they couldn’t. That includes starting quarterbacks on what were playoff caliber teams at the time, the Phoenix Cardinals and the Pittsburg Steelers. Yet the same week, I saw Jermichael Finley take a horrendous hit to his jaw from another players helmet, yet not even be taken out for one play. They stopped the play for the penalty and by the time they had marked off the yardage, he was lined up again.
How could anyone have known what lingering effects he had of a ding everyone clearly saw, if he didn’t even come to the sidelines?
One of the continuing problems with sideline concussion evaluations is the presumption that anyone noticed the initial concussion. That is an organic problem that can’t really be avoided, but if a player isn’t pulled out of a game to talk to the trainer, there is no chance to avoid the catastrophic second impact syndrome that turns a concussion into a severe and even life threatening injury.
The story of concussion in sport and its relevancy to the non-fan in us, will be a focus of the blogs to come.