The Concussion Crisis

by Linda Carroll

  Within minutes, there were flashing lights and rescue personnel everywhere. Abb jolted awake and screamed, “Help! Get me out of here!” Firefighters cut through the mangled car frame with a Jaws of Life and carefully pulled her out. Once the paramedics stabilized her, she was loaded onto a medevac helicopter and flown to the University of Maryland’s Shock Trauma Center. At the hospital, Abb remained awake long enough to give nurses her mother’s name and phone number. Then she lost consciousness.

  • • •

  A team of surgeons worked on Abb for more than twelve hours. Her chest had been crushed, both arms and both legs broken, her left wrist smashed. Most of the bones in her face had been shattered. The cosmetic surgery to repair that damage would have to wait for several days until the swelling had gone down.

  The doctors opted to put her in a medically induced coma to protect her brain from swelling. They cautioned family members about the possibility of brain damage. Until Abb woke up and the painkillers had left her system, they said, there was no way to know about the condition of her brain.

  When Abb finally did come out of the coma three weeks after the accident, her doctors were relieved that she was able to understand and respond to questions. Her communication skills seemed a bit off—she was having problems finding common words—but she appeared to be alert and functional. Back in 1987 virtually no one was offering rehab for the brain. Abb’s doctors predicted that the word problems would soon pass and that her brain would be fine by the time she worked through the months of rehab she was going to need before she’d be able to walk again.

  Abb surprised everyone by getting out of the hospital in less than five weeks and by powering through her grueling physical therapy sessions at the rehabilitation center in just four weeks. During the months following her accident, she developed a new focus and a sense of purpose. She’d been a waitress at a local restaurant since dropping out of high school. Now, in her mid-twenties, she decided to go back to school and work toward a career. She returned to the community college where she’d taken occasional liberal arts courses before the crash, this time with a plan to get a degree in education and eventually a job teaching elementary school. When the semester began, she was excited to think that she was starting down the path to a career and a new life.

  That excitement was short-lived. For the first time, Abb was struggling with schoolwork. She was easily distracted and would quickly lose track of what the professor was saying. She couldn’t follow complex sentences from beginning to end. She would fall hopelessly behind taking notes because she couldn’t figure out which details were important and would end up trying to write down every word the professor uttered. Tests were impossible; there was never enough time and she would often get sidetracked in the middle of answering a single question.

  Frightened that she was about to fail all her courses, she turned once again to the doctors at the Shock Trauma Center. Only this time it wasn’t for the injuries to her body—it was for the injury to her brain.

  • • •

  Abb wasn’t sure what to expect when she went back to the Shock Trauma Center. On the day of her appointment, she sat nervously in the lobby, hoping that someone would be able to explain the mysterious symptoms she was experiencing. Eventually she noticed a trim, dark-haired man striding toward her. He walked up to her, extended his hand, and introduced himself as Dr. Mark Sementilli, the neuropsychologist who would be evaluating her for possible brain damage stemming from her car accident.

  As they walked down the long hallway leading to his office, Abb looked around and realized that she was on the very floor where she’d been treated after the crash. The acrid smell of the ward hit her nostrils, and she was suddenly overwhelmed by a rush of emotions. Her skin started to feel hot, her legs wobbly. Seconds later she crumpled to the floor, sobbing. Sementilli was taken aback. Reaching down to help her up, he said, “You haven’t dealt with this, have you?”

  When they got to his office, Sementilli asked Abb to detail the symptoms that had led her to seek help. She told him about the troubles she’d been having in school and described the problems she’d been having with memory, concentration, and organization. They talked about the other changes she’d noticed in her life since the accident. She told him that she’d been completely self-sufficient since moving away from home at age sixteen, but now she couldn’t even make it to her parents’ house for Thanksgiving dinner without a reminder. To get a handle on the severity of Abb’s problem, Sementilli turned to a battery of neuropsychological tests that would take her nearly six hours to complete.

  In the days after the appointment, he considered the test results and the observations he’d made during his conversations with Abb. Although her performance on the standardized tests of memory and verbal ability were within the normal range, he had observed signs of frontal lobe damage while talking with her. One symptom in particular stood out: the volatility of her moods. In a flash, she would go from happy, bubbly, and chatty to distraught and weepy.

  When she returned to his office for a follow-up, Sementilli gave her his diagnosis. He told her that he believed the crash had caused damage to the section of the brain located just behind the left side of her forehead. Even before meeting her, he had suspected as much based strictly on the information in her medical files and the description of the accident. “The frontal lobe is very vulnerable because of its location in the brain,” he explained to her. “It’s really packed in there against the orbital floor of the frontal bone. You’d think that the bone would be smooth, but it’s not. There are these bony ridges. And when you have a head-on collision, where the body and the neck and the head are propelled forward and then suddenly stop, the brain is also propelled forward and then back in a sloshing motion. The brain rams into the skull and the orbital floor. Those bones are not forgiving. And that’s a perfect recipe for frontal lobe damage.”

  He told her that the hallmark symptoms of this kind of brain injury could explain the difficulties she was having in school. People with frontal lobe damage often have problems with initiating, planning, and organization. They also have difficulty prioritizing and multitasking.

  Abb was astounded. Finally someone had an explanation for what was happening to her. She was at once relieved to have an answer and anxious about what it meant. Sementilli told her that she would need help to get through college. He recommended that she find an academic counselor to assist with her schoolwork and a therapist to help with other deficits resulting from her brain injury.

  Then Sementilli turned to the toughest part of his prescription. He’d determined that her spatial abilities were now significantly better than her language skills, so he advised that she rethink her career goals and give up her dream of teaching. He told her she no longer had the organizational skills that teachers need. “You should find a career that involves working with your hands,” he said.

  Abb was devastated and angry when she left his office. She wondered what career she could possibly choose that would involve working with her hands. In the months that followed, she mulled over his advice while thumbing through the course catalog. Finally she stumbled upon the horticulture department and thought, “Maybe this is the kind of thing he meant. This could be a blessing in disguise: I love nature and working in the dirt with plants.” She switched her major and went back to college with renewed motivation—and with newfound help. Her academic counselor suggested she explain her situation to her professors and tape-record lectures rather than try to take notes. Most of her teachers agreed to give her more time on tests, and the tape recordings allowed her to focus in class strictly on what the professor was saying. Two years later, she had an associate of arts degree and a career.

  It seemed as if her life had finally turned around. She landed a job at a large garden center, caring for plants and advising customers on how to maintain them. On top of that, the ruggedly handsome store manager with the penetrating blue eyes was starting to flirt with her. Soon she and Chris Abb were
spending most of their free time together, hiking, camping, and motorcycling through the Maryland countryside. As they became closer, Chari shared with Chris her dreams of getting married and having a baby by the time she was thirty.

  The job initially seemed to be everything Chari had hoped for. She enjoyed working outdoors. The customers loved her; she was affable and always took the time to teach them about the plants. But soon she started having problems with other aspects of her job. She couldn’t manage her time and seemed to have no organizational skills. She would spend an entire day deadheading a single row of plants. She’d go to rearrange a flower display, only to find herself unable to figure out where to begin. Hours would invariably pass and her boss, shocked to discover how little Chari had accomplished, would remark, “You’re still doing that? What’s the problem?”

  Chari had no answer, and she wasn’t even convinced there was a problem. She just figured she had a grumpy boss and the solution was to find a new job. But her next one didn’t work out any better. Chari bounced from job to job. One thing remained constant: she brought to each new position the same old problems with organization and time management. As her résumé lengthened with a new entry every few months, she began to question whether her bosses were really to blame for all her problems. One day it dawned on her: “My God, there’s something wrong with me.”

  For the first time, she connected her work problems with her brain injury. Since she’d gotten the diagnosis of frontal lobe syndrome from Sementilli, she’d gone blithely along thinking she needed help only to get through college. Now, three years and seven jobs later, she realized that the fallout from her brain injury wasn’t limited to her schoolwork—it was wreaking havoc with every aspect of her life. Not only were her cognitive deficits costing Chari jobs, but they were also exasperating friends and family. No one understood why she would show up hours late for appointments—if she remembered them at all.

  Frustrated by her inability to keep track of anything in her life, Chari sought help from Maryland’s Division of Rehabilitation Services. Because she could no longer depend on her brain to organize her life, therapists taught her compensatory strategies; they recommended she follow a regular schedule, keep a detailed day planner, and make to-do lists. Because she also wanted to avoid more confrontation with bosses, they suggested she try working from home.

  Chari came up with a new strategy. She had recently married Chris and moved to his rolling seventy-acre farm in rural Maryland. There was plenty of room to build a greenhouse for a cut-flower business. No sooner had she bought the plants, however, than she became pregnant. What had been difficult before was now becoming impossible. Once Shelby was born, it was all Chari could do to take care of him. The house fell into disarray. The plants withered, along with her business plans and dreams. Rehab became a luxury she could no longer manage.

  As time went on, Chari focused all her energy and attention on raising Shelby and his kid sister, Emma. She was too overwhelmed to do anything else. The clutter in the house grew and grew, cardboard boxes and piles of paper covering almost every inch of floor. Each night after work, Chris would clear pathways connecting room to room, like a man shoveling his way through a thick blanket of snow.

  • • •

  By the fall of 2008, Chris Abb decided he couldn’t deal with the chaos anymore. He didn’t understand why the house was always such a mess, why his wife would spend hours aimlessly wandering around supermarkets only to come home with just two or three items, why she couldn’t find at least a part-time job now that the kids were in school. Chari would try to explain how the brain injury had ruined her ability to focus and to organize her life. But Chris could only understand the damage he could see: the scars on her lip, neck, and arms.

  Eventually, Chris told his wife he wanted to move out of the house. He wasn’t sure how things were going to turn out, but he needed some time to think. Chari was scared. She couldn’t stop fretting over the prospect of being divorced and on her own. To make ends meet, she’d have to go back to work. Even if she was lucky enough to find a job, she had no confidence in her ability to hang on to it given her history of workplace failures. Making matters worse, this time she would be trying to work while also raising two kids. The idea of reentering the workplace after fifteen years’ absence would have been daunting for any full-time mom, but it was terrifying for a brain-injured forty-five-year-old who couldn’t multitask.

  Desperate, she turned once again to Maryland’s Division of Rehabilitation Services, hoping to pick up where she’d left off so many years before. Counselors there scheduled Chari for a neuropsych exam to determine whether her deficits were still debilitating enough to warrant a prescription for rehab services. She glanced at the doctor’s name on the appointment card and smiled: it was the very neuropsychologist who had evaluated her back when she was in college.

  The day of the appointment, Chari walked into Mark Sementilli’s office and announced, “Remember me?” He looked at her, puzzled. Something about the tall, slender woman with the cascading blond hair was vaguely familiar, but he couldn’t quite place her. She handed him a faded computer printout of a neuropsychological evaluation that he had written seventeen years earlier. As he leafed through the pages, a look of recognition spread across his face. “Oh, I remember you now,” he said.

  Chari smiled broadly and said, “You’re the one who explained all the problems I was having and told me I had frontal lobe syndrome. Do you remember you also told me I should find a career working with my hands? Well, I took your advice.” Chari went on to update him on everything that had happened—both good and bad—since their last meeting. “I’m back because my life is coming apart,” she concluded, tears streaming down her face. “I can’t seem to do anything right. The house is a wreck. I feel like I’m a bad mom. My husband’s threatening to leave me. I can’t be who he wants me to be: I have a brain injury. It took many years for me to accept me for who I am now, but he doesn’t get it. And if he leaves, I’m going to have to go back to work, and I’m terrified I’m going to lose any job I get.”

  As Sementilli talked with her, he observed one of the telltale signs of brain damage: she couldn’t follow complex sentences. Noticing her confusion, he would often find himself having to repeat complicated instructions or break them down into simpler components. More obvious were the mood swings he saw throughout their session. One minute she’d be laughing, the next she’d be crying. It reminded him of the first time he met with her. He could see that she was still having problems regulating her emotions. She seemed to be missing the set of “mental brakes” that stop a healthy person from blurting out every thought—evidence that her brain hadn’t recovered from the frontal lobe damage.

  His observations would be supported by a battery of neuropyschological tests. Chari had trouble with tasks designed to ferret out deficits in memory, organization, planning, and problem solving. In one memory test, she was asked to listen to a story and then to recall details from the narrative; minutes after hearing the story, her recall was almost perfect, but half an hour later, she could remember little of what she’d been told. Another test required her to solve a problem through trial and error; after choosing the wrong solution, she would invariably keep repeating the same mistake. As Sementilli went over the test results, he was struck by how closely they mirrored those from seventeen years earlier. Chari was still showing the hallmark symptoms of frontal lobe damage.

  After explaining everything to Chari, Sementilli told her that he would be recommending to the state that she get rehab therapy and job coaching. She breathed a sigh of relief and thanked him for validating what she’d been experiencing for years. She complained that most people—her husband included—couldn’t look past her healthy exterior to the deficits within. Because her appearance and speech seemed so normal, they couldn’t imagine anything could be wrong with her brain. “The doctors put me back together so well that most people wouldn’t know I’d been in an accident,” she said, “but
that creates a problem: they can’t see that I have a brain injury.” Sementilli told her he wasn’t surprised, because people often underestimate how much lingering damage can follow a jolt to the head. “Even mild injury can result in significant impairment,” he said.

  Chari found that a lot had changed since she last sought therapy for her brain injury. Scientists had learned better ways to help people cope with injuries and had discovered that some damaged sections of the brain could be coaxed to rewire through the proper types of exercises. The state set Chari up with weekly therapy sessions at an independent center specializing in rehab of neurological injury. Her therapist, Tom Thompson, decided that the first priority was to help her organize her life. That meant she would have to get back to using aids such as day planners that scheduled every facet of her day in half-hour increments.

  To address her deficits with planning and problem solving, Thompson turned to a computer game designed to simulate daily life. Each time she played the game, she would guide an animated version of herself through a typical day. Her cartoon self would have to go to work and solve the kinds of problems that she might encounter in everyday life. She’d get points for successfully maneuvering cartoon Chari through life, remembering for example to have her animated self do important things like cooking meals and showing up for appointments, and she’d lose points for mistakes such as forgetting things. One day she asked Thompson how the computer game could possibly help her. He explained that by repeatedly going through daily rituals with her cartoon self, she might actually be able to rewire damaged parts of her brain. Chari’s face brightened. “That gives me hope,” she said with a smile. “I didn’t know that my brain could actually change.”

  Whether it was the result of the game’s impact or Chari’s newfound resolve, things started to turn around in real life. She got a job waiting tables at a local restaurant and enrolled in a class on how to start a small business. After losing his job as a motorcycle mechanic, Chris moved back into the house and took over the domestic chores. She was happy with the role reversal. The house was finally clean and organized. Chris was starting to grudgingly accept the possibility that the reason for all the chaos wasn’t that his wife was lazy but rather that she did in fact have a debilitating brain injury. He was starting to realize that the invisible scars inside her brain were causing the host of odd symptoms he’d observed for the past two decades.