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.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
Brain injury is a Process, Not an Event
“Brain injury is a process, not an event.” That one phrase has guided my advocacy with respect to concussion as much as any one thing. The author? Thomas Gennarelli, M.D. I am not sure when the first time he said it, but one such place he says it is the Chapter on Trauma in the famous neuropathology text, Greenfield’s Neuropathology: Graham, Gennarelli, Greenfield’s Neuropathology, ©1996 Oxford University Press, page 209.) He explains that quote further as follows:
“In various combinations and various severities, the resultant cellular dysfunction (of brain injury) defines the nature and extent of the primary injury, the outcome of which may not become apparent for several days or even weeks after injury.” (Graham, Gennarelli, Greenfield’s Neuropathology, 1996, page 197.)
The implications of that one statement are really quite staggering when compared to our normal triage for a brain injured individual. In my experience, a significant concussion will get these two primary evaluations. First, some EMT personnel will be on the scene, asking the person basic questions like what do they remember of the accident, where they hurt, were they unconscious. Then presuming they are transferred by ambulance to the hospital, the emergency room staff and the physician will ask similar questions, including almost invariably the three questions of orientation of the Glasgow Coma Scale: do you know who you are, where you are and what day it is? If they get those three questions right, they get a “perfect” Glasgow Coma Scale of 15 and are likely sent home.
When there are lingering questions about orientation, a report of uncertainty or a corroborated loss of consciousness, they may get a longer evaluation and a CT scan. Mild concussion survivors are sent home three to four hours post injury. More symptomatic survivors may take a little longer for the CT scan to be read and evaluated. Regardless, nearly all concussion survivors are released from the medical system by six hours after their accident. Big deal, brain injuries get better not worse, right?
Not if you believe Dr. Gennarelli’s published words. Greenfield’s says that it takes 24 to 72 hours for typical axonal swelling to occur. But to understand this issue fully it is important to understand more about neurons, the myelin sheath that protects them and the traumatic defect in the cell that occurs at the time of trauma, something called mechanoporation. “Mechanoporation is the creation of a traumatic defect in the cell membrane that occurs as the lipid bilayer is transiently separated from the stiffer protein inclusions such as receptors or channels.” Greenfield’s, page 204.
More about such neuropathology in our next blog.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
“In various combinations and various severities, the resultant cellular dysfunction (of brain injury) defines the nature and extent of the primary injury, the outcome of which may not become apparent for several days or even weeks after injury.” (Graham, Gennarelli, Greenfield’s Neuropathology, 1996, page 197.)
The implications of that one statement are really quite staggering when compared to our normal triage for a brain injured individual. In my experience, a significant concussion will get these two primary evaluations. First, some EMT personnel will be on the scene, asking the person basic questions like what do they remember of the accident, where they hurt, were they unconscious. Then presuming they are transferred by ambulance to the hospital, the emergency room staff and the physician will ask similar questions, including almost invariably the three questions of orientation of the Glasgow Coma Scale: do you know who you are, where you are and what day it is? If they get those three questions right, they get a “perfect” Glasgow Coma Scale of 15 and are likely sent home.
When there are lingering questions about orientation, a report of uncertainty or a corroborated loss of consciousness, they may get a longer evaluation and a CT scan. Mild concussion survivors are sent home three to four hours post injury. More symptomatic survivors may take a little longer for the CT scan to be read and evaluated. Regardless, nearly all concussion survivors are released from the medical system by six hours after their accident. Big deal, brain injuries get better not worse, right?
Not if you believe Dr. Gennarelli’s published words. Greenfield’s says that it takes 24 to 72 hours for typical axonal swelling to occur. But to understand this issue fully it is important to understand more about neurons, the myelin sheath that protects them and the traumatic defect in the cell that occurs at the time of trauma, something called mechanoporation. “Mechanoporation is the creation of a traumatic defect in the cell membrane that occurs as the lipid bilayer is transiently separated from the stiffer protein inclusions such as receptors or channels.” Greenfield’s, page 204.
Sounds pretty damn technical for a blog? What “mechanoporation” means is that a defect is created in the insulation that protects the axon from the potentially toxic neurotransmitter chemicals that surround the axon. Each axon has small channels to allow just the appropriate amount of these neurochemicals into the axon, to allow it to transmit the electrical impulse down the axon. In the traumatic event, the axon gets stretched in such a way that the channels are opened too wide and too much neurochemical gets in to the axon. The result is toxic, but it can take up to 72 hours for the toxin do its damage.
More about such neuropathology in our next blog.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
Seoul hospital refuses to end coma patient’s life
Date: 12/17/2008 12:55 AM
SEOUL, South Korea (AP) — A South Korean hospital said Wednesday it will appeal a court order to let a comatose patient die by removing her from a respirator, saying the case could prompt a trend in devaluing human life.
The order issued by the Seoul Western District Court last month was for Severance Hospital in Seoul to end the life of a 76-year-old patient, citing the people’s right to die with dignity.
The decision — the first court ruling of its kind in South Korea — was issued after the patient’s children filed a lawsuit following the hospital’s refusal to end the women’s life.
Severance Hospital announced Wednesday that it cannot accept the court’s ruling because it could lead to a social trend to take human life too lightly.
“We should make decisions carefully on matters of human life,” hospital spokesman Lee Sung-man said.
Lee said the hospital plans to appeal the ruling directly to the Supreme Court and skip an appellate court because the issue needs to be settled as soon as possible.
The hospital will first need the patient’s family — the plaintiffs in the case — to agree to the streamlined process, and if they refuse the hospital will appeal the case to an ordinary appellate court.
The patient’s children have said their mother had always opposed keeping people alive on machines when there is no chance of revival.
The patient, only identified by her family name Kim, has been in a vegetative coma since suffering brain damage in February. The Seoul district court said in a ruling that doctors at major Seoul hospitals agreed that she has no chance of revival and could live as long as three or four months.
Copyright 2008 The Associated Press.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
SEOUL, South Korea (AP) — A South Korean hospital said Wednesday it will appeal a court order to let a comatose patient die by removing her from a respirator, saying the case could prompt a trend in devaluing human life.
The order issued by the Seoul Western District Court last month was for Severance Hospital in Seoul to end the life of a 76-year-old patient, citing the people’s right to die with dignity.
The decision — the first court ruling of its kind in South Korea — was issued after the patient’s children filed a lawsuit following the hospital’s refusal to end the women’s life.
Severance Hospital announced Wednesday that it cannot accept the court’s ruling because it could lead to a social trend to take human life too lightly.
“We should make decisions carefully on matters of human life,” hospital spokesman Lee Sung-man said.
Lee said the hospital plans to appeal the ruling directly to the Supreme Court and skip an appellate court because the issue needs to be settled as soon as possible.
The hospital will first need the patient’s family — the plaintiffs in the case — to agree to the streamlined process, and if they refuse the hospital will appeal the case to an ordinary appellate court.
The patient’s children have said their mother had always opposed keeping people alive on machines when there is no chance of revival.
The patient, only identified by her family name Kim, has been in a vegetative coma since suffering brain damage in February. The Seoul district court said in a ruling that doctors at major Seoul hospitals agreed that she has no chance of revival and could live as long as three or four months.
Copyright 2008 The Associated Press.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
Nap without guilt: It boosts sophisticated memory
Date: 11/24/2008
By LAURAN NEERGAARD
AP Medical Writer
WASHINGTON (AP) _ Just in time for the holidays, some medical advice most people will like: Take a nap.
Interrupting sleep seriously disrupts memory-making, compelling new research suggests. But on the flip side, taking a nap may boost a sophisticated kind of memory that helps us see the big picture and get creative.
“Not only do we need to remember to sleep, but most certainly we sleep to remember,” is how Dr. William Fishbein, a cognitive neuroscientist at the City University of New York, put it at a meeting of the Society for Neuroscience last week.
Good sleep is a casualty of our 24/7 world. Surveys suggest few adults attain the recommended seven to eight hours a night.
Way too little clearly is dangerous: Sleep deprivation causes not just car crashes but all sorts of other accidents. Over time, a chronic lack of sleep can erode the body in ways that leave us more vulnerable to heart disease, diabetes and other illnesses.
But perhaps more common than insomnia is fragmented sleep — the easy awakening that comes with aging, or, worse, the sleep apnea that afflicts millions, who quit breathing for 30 seconds or so over and over throughout the night.
Indeed, scientists increasingly are focusing less on sleep duration and more on the quality of sleep, what’s called sleep intensity, in studying how sleep helps the brain process memories so they stick. Particularly important is “slow-wave sleep,” a period of very deep sleep that comes earlier than better-known REM sleep, or dreaming time.
Fishbein suspected a more active role for the slow-wave sleep that can emerge even in a power nap. Maybe our brains keep working during that time to solve problems and come up with new ideas. So he and graduate student Hiuyan Lau devised a simple test: documenting relational memory, where the brain puts together separately learned facts in new ways.
First, they taught 20 English-speaking college students lists of Chinese words spelled with two characters — such as sister, mother, maid. Then half the students took a nap, being monitored to be sure they didn’t move from slow-wave sleep into the REM stage.
Upon awakening, they took a multiple-choice test of Chinese words they’d never seen before. The nappers did much better at automatically learning that the first of the two-pair characters in the words they’d memorized earlier always meant the same thing — female, for example. So they also were more likely than non-nappers to choose that a new word containing that character meant “princess” and not “ape.”
“The nap group has essentially teased out what’s going on,” Fishbein concludes.
These students took a 90-minute nap, quite a luxury for most adults. But even a 12-minute nap can boost some forms of memory, adds Dr. Robert Stickgold of Harvard Medical School.
Conversely, Wisconsin researchers briefly interrupted nighttime slow-wave sleep by playing a beep — just loudly enough to disturb sleep but not awaken — and found those people couldn’t remember a task they’d learned the day before as well as people whose slow-wave sleep wasn’t disrupted.
That brings us back to fragmented sleep, whether from aging or apnea. It can suppress the birth of new brain cells in the hippocampus, where memory-making begins — enough to hinder learning weeks after sleep returns to normal, warns Dr. Dennis McGinty of the University of California, Los Angeles.
To prove a lasting effect, McGinty mimicked human sleep apnea in rats. He hooked them to brain monitors and made them sleep on a treadmill. Whenever the monitors detected 30 seconds of sleep, the treadmill briefly switched on. After 12 days of this sleep disturbance, McGinty let the rats sleep peacefully for as long as they wanted for the next two weeks.
The catch-up sleep didn’t help: Rested rats used room cues to quickly learn the escape hole in a maze. Those with fragmented sleep two weeks earlier couldn’t, only randomly stumbling upon the escape.
None of the new work is enough, yet, to pinpoint the minimum sleep needed for optimal memory. What’s needed may vary considerably from person to person.
“A short sleeper may have a very efficient deep sleep even if they sleep only four hours,” notes Dr. Chiara Cirellia of the University of Wisconsin, Madison.
But altogether, the findings do suggest some practical advice: Get apnea treated. Avoid what Harvard’s Stickgold calls “sleep bulimia,” super-late nights followed by sleep-in weekends. And don’t feel guilty for napping.
___
EDITOR’S NOTE — Lauran Neergaard covers health and medical issues for The Associated Press in Washington.
Copyright 2008 The Associated Press.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
By LAURAN NEERGAARD
AP Medical Writer
WASHINGTON (AP) _ Just in time for the holidays, some medical advice most people will like: Take a nap.
Interrupting sleep seriously disrupts memory-making, compelling new research suggests. But on the flip side, taking a nap may boost a sophisticated kind of memory that helps us see the big picture and get creative.
“Not only do we need to remember to sleep, but most certainly we sleep to remember,” is how Dr. William Fishbein, a cognitive neuroscientist at the City University of New York, put it at a meeting of the Society for Neuroscience last week.
Good sleep is a casualty of our 24/7 world. Surveys suggest few adults attain the recommended seven to eight hours a night.
Way too little clearly is dangerous: Sleep deprivation causes not just car crashes but all sorts of other accidents. Over time, a chronic lack of sleep can erode the body in ways that leave us more vulnerable to heart disease, diabetes and other illnesses.
But perhaps more common than insomnia is fragmented sleep — the easy awakening that comes with aging, or, worse, the sleep apnea that afflicts millions, who quit breathing for 30 seconds or so over and over throughout the night.
Indeed, scientists increasingly are focusing less on sleep duration and more on the quality of sleep, what’s called sleep intensity, in studying how sleep helps the brain process memories so they stick. Particularly important is “slow-wave sleep,” a period of very deep sleep that comes earlier than better-known REM sleep, or dreaming time.
Fishbein suspected a more active role for the slow-wave sleep that can emerge even in a power nap. Maybe our brains keep working during that time to solve problems and come up with new ideas. So he and graduate student Hiuyan Lau devised a simple test: documenting relational memory, where the brain puts together separately learned facts in new ways.
First, they taught 20 English-speaking college students lists of Chinese words spelled with two characters — such as sister, mother, maid. Then half the students took a nap, being monitored to be sure they didn’t move from slow-wave sleep into the REM stage.
Upon awakening, they took a multiple-choice test of Chinese words they’d never seen before. The nappers did much better at automatically learning that the first of the two-pair characters in the words they’d memorized earlier always meant the same thing — female, for example. So they also were more likely than non-nappers to choose that a new word containing that character meant “princess” and not “ape.”
“The nap group has essentially teased out what’s going on,” Fishbein concludes.
These students took a 90-minute nap, quite a luxury for most adults. But even a 12-minute nap can boost some forms of memory, adds Dr. Robert Stickgold of Harvard Medical School.
Conversely, Wisconsin researchers briefly interrupted nighttime slow-wave sleep by playing a beep — just loudly enough to disturb sleep but not awaken — and found those people couldn’t remember a task they’d learned the day before as well as people whose slow-wave sleep wasn’t disrupted.
That brings us back to fragmented sleep, whether from aging or apnea. It can suppress the birth of new brain cells in the hippocampus, where memory-making begins — enough to hinder learning weeks after sleep returns to normal, warns Dr. Dennis McGinty of the University of California, Los Angeles.
To prove a lasting effect, McGinty mimicked human sleep apnea in rats. He hooked them to brain monitors and made them sleep on a treadmill. Whenever the monitors detected 30 seconds of sleep, the treadmill briefly switched on. After 12 days of this sleep disturbance, McGinty let the rats sleep peacefully for as long as they wanted for the next two weeks.
The catch-up sleep didn’t help: Rested rats used room cues to quickly learn the escape hole in a maze. Those with fragmented sleep two weeks earlier couldn’t, only randomly stumbling upon the escape.
None of the new work is enough, yet, to pinpoint the minimum sleep needed for optimal memory. What’s needed may vary considerably from person to person.
“A short sleeper may have a very efficient deep sleep even if they sleep only four hours,” notes Dr. Chiara Cirellia of the University of Wisconsin, Madison.
But altogether, the findings do suggest some practical advice: Get apnea treated. Avoid what Harvard’s Stickgold calls “sleep bulimia,” super-late nights followed by sleep-in weekends. And don’t feel guilty for napping.
___
EDITOR’S NOTE — Lauran Neergaard covers health and medical issues for The Associated Press in Washington.
Copyright 2008 The Associated Press.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney