by David Page
The fat gain phase: Convalescence melds imperceptibly into normalcy, the metabolic piper has been paid, structural damage is repaired, extra calories become fat and life goes on.
Rehabilitation and Going Home
Some trauma victims don't go home.
Fifty percent of all head-injured patients die, and almost half of the survivors have a neurologic deficit. Often, these poor souls must be cared for in long-term or chronic care facilities. Unable to perform activities of daily living, the brain-injured patient must rely on constant nursing care. There are institutions around the country that specialize in caring for head-injured and spinal cord-damaged patients.
If your story includes a victim of trauma to the nervous system, here are a number of chronic problems you may wish to visit upon your character:
Quadriplegia: Results in inability to use one's arms or legs due to paralysis. Patient may have slight finger or upper arm movement; some are on ventilators; no control over bowels and bladder.
Paraplegia: Paralysis of the lower extremities; control problems of bowels and bladder; patient can get around in a wheelchair.
Pelvic or genital trauma: May result in permanent colostomy if bowel-controlling anal sphincter muscle is seriously damaged. Disfigurement: Affecting face, hands or other parts. May include
exaggerated scarring, amputations, tissue loss with skin grafting, burns, fused joints, a useless arm or leg.
Loss of voice: Neck trauma with permanent tracheostomy or paralysis of vocal cords.
Other rehabilitation issues include management of chronic bladder catheterization, treatment for urinary tract infections, cleaning and bandaging chronic open wounds, managing feeding tubes (through the abdominal wall into the stomach), bathing of patients with muscle weakness, physical therapy, occupational therapy and psychiatric evaluation and support. Most of these begin in the hospital and must be continued at home. Home care has replaced longer hospital stays in order to complete the rehabilitation process.
At home, the trauma patient begins to see the course of his illness. Lost time, perhaps lost job security and difficulties he has pressed on the family with such a complicated clinical course may cause depression. Anger at the random nature of the accident and at the doctors and nurses who performed so many unpleasant tests and treatments may push the recovering patient to despair. Of course, many find solace and a genuine sense of gratitude that they are survivors.
Lastly, the trauma victim is evaluated in the surgical clinic several times following discharge from the hospital. In addition, the patient may need to see an orthopedic or neurosurgeon for more specific follow-up. At times, the patient must be readmitted for additional surgery. These procedures include skin grafts; removal of pins, screws and other orthopedic hardware; or plastic surgery to revise scars and repair poorly healing wounds.
The areas of the trauma center of most concern to the victim of major body injury are the operating room, the intensive care unit, the rehabilitation unit and the hospital's surgical clinic. Each of these settings provides you with an opportunity to weave another thread of uncertainty about recovery into the fabric of your story.
This is where those writers are mistaken who write books called Generals Die in Bed, because this general died in a trench dug in snow, high in the mountains, wearing an Alpini hat with an eagle feather in it and a hole in the front you couldn't put your little finger in and a hole in back you could put your fist in, if it were a small fist and you wanted to put it there, and much blood in the snow.
—Ernest Hemingway, A Natural History of the Dead
Man and his animal companions developed solid bone shields over eons to protect their brains. The skull bones, a double layer of armament, protected the victim from all sorts of trauma, including, no doubt, getting clobbered with a bison femur by a cave neighbor. But no one in charge of designing skulls back then anticipated the gasoline engine, gunpowder or American football. Man-made weapons infused new meaning into words like deceleration and impact.
In the United States someone suffers from a head injury every fifteen seconds, and someone dies of a head impact every twelve minutes. Although the skull affords adequate protection to the brain for the kinds of forces experienced over the years of our evolution, it cannot deal with the types of impacts encountered in the twenty-first century. More than 60 percent of all auto accident fatalities are from head injury. In this chapter, we will learn about lesser as well as major head trauma, a theme reflected in each chapter in this section via the Master Injury Lists. To make it easier to grasp the spectrum of head injuries, we'll divide them up in the list according to what structures get smashed. Because there are so many elements of anatomy in the head and neck, only common injuries are presented.
Each of these head injuries will be dealt with in some detail as no other group of injuries are as critical to full recovery. And they are no stranger to literature.
It was in this cave that a man whose head was broken as a flowerpot may be broken, although it was all held together by membranes and a skillfully applied bandage now soaked and hardened, with the structure of his brain disturbed by a piece of broken steel in it, lay a day, a night, and a day.
Few writers will express surprise at the words Hemingway chose (again, in A Natural History of the Dead) to depict man's traumatic plight, and few could match his ability to take essential medical principles involving the consequences of impact and translate them into a true, timeless description of the savagery of war. The quote above includes a reference to the meninges, the membranes enveloping the brain; a shattered, open compound fracture of the skull; and its essentially futile field treatment.
A flower pot, a bandage. A shattered brain, a wasted life. Accurate, timeless, it is visual. Disturbing, it is literature.
Skull fractures are open if they are found with a scalp laceration or closed if the scalp is intact. The underlying brain may be compressed, lacerated or both. Buried beneath the flowery cerebral cortex lies the reptilian brainstem, which also suffers from the increased pressure in the cranium as the brain swells above it. Designed to regulate unconscious body functions, the brainstem may be the only survivor of a major brain insult, thus becoming a central neurological headquarters of sorts for the persistent vegetative state (PVS).
A few immediate steps must be taken when either a fracture or lacerated scalp is identified:
• Clean scalp wound and suture if no other injuries exist.
• If a compound (open) skull fracture is present, suture the dura (brain membrane) closed and elevate any depressed skull bone. Remove loose bone fragments. Place the patient on antibiotics.
The most important task for the trauma surgeon treating a head injury is to decide if there is a focal or mass lesion. If a blood clot is forming
Master Injury List For the Head I
Injuries involving the brain and skull (victims may be awake, lethargic or unconscious with any of these skull fractures)
Skull Fractures
■ Simple "straight line" nondepressed: treat underlying brain injury
■ Depressed: some need neurosurgical elevation of fragment to avoid seizures in the future
■ Open: need immediate surgery to close meninges (membranes) to protect brain from infection (brain exposed)
■ Base of the skull: often not seen on x- ray; treat conservatively Diffuse Brain Injuries
■ Concussion
—Mild: temporary confusion, amnesia —Severe: nausea, headache, dizziness, amnesia
■ Diffuse brain injury: also called a closed head injury or a brain stem injury; prolonged coma for days or weeks
Focal Brain Injuries
■ Brain contusion: small or large, single bruise or multiple; prolonged coma, confusion and if large, may cause brain compression and serious neurologic deterioration
■ Bleeding into the brain
—Surface: tear in epidural artery with major clot formation and brain compression or bleeding under the membranes (meni
nges); called a subdural hematoma (clot) —Deep: bleeding into brain substance; impalement or bullet wounds
inside the skull, it must be identified immediately and evacuated by a neurosurgeon. To find a clot hiding inside the skull, the surgeon looks for the following lateralizing symptoms (i.e., only found on one side of the body) in addition to drowsiness or frank coma:
• Enlarged pupil (usually on the same side as the clot)
• Paralysis on the opposite side (arm and leg)
Also, blood pressure may rise as heart rate (pulse) drops. If these signs are present, or if a head trauma victim becomes drowsy after having been awake, the surgeon must perform a head CT scan and search for a subdural, epidural or intracerebral blood clot (Figure 7). The massive clot exerts pressure inside the skull, literally squeezing the victim's brain and, eventually, life away.
Severe impact effects all layers of the head, setting off destructive waves of energy that are transmitted to the deepest, oldest ganglia of the brain where the brain becomes the spinal cord at collar level. We'll work our way through these injuries in a little more detail.
Almost 70 percent of trauma victims with multiorgan system impacts will have a head injury, anything from a torn scalp to lacerations and clots inside the mysterious mind cave, the cranial vault. You may combine single injuries to create horrible results or merely mix and match lesser insults to create a state of confusion about story outcome—adding a ticking clock to your plot.
If your character strikes the windshield of his car, he might sustain a simple linear skull fracture. On x-ray it appears as a dark line engraved in the whiteness of the bone, undisplaced, reducing the likelihood of underlying brain damage—unless the fracture crosses a part of the skull (temporal bone) where a large blood vessel (the middle meningeal artery) lies embedded in the cranium. Major hemorrhage inside the skull may occur when the artery is torn.
There is no specific treatment for a simple linear skull fracture not associated with an epidural clot, unless road dirt became caught in the fracture found with a scalp laceration. At the instant the skull is smashed, the bone opens several millimeters. When it shuts, debris may get caught in the fracture line, and the neurosurgeon must clean it up.
If the impact dents your character's cranium, she has a depressed skull fracture. The neurosurgeon must decide whether or not he needs bone fragments elevated (lifted free of the brain surface) or pieces of the broken skull removed. The underlying dura membrane must be closed as well. With all skull fractures, management is subservient to the under-
lying brain injury.
In particular, open skull fractures—where the lining of the brain (dura mater) is torn leaving the brain exposed—must be repaired as an emergency. Torn meninges (dura mater, Hemingway's "membranes") allow leakage of cerebrospinal fluid (CSF). This unique clear liquid is the waterbed of the brain, and infection will almost certainly ensue if the membranes aren't surgically closed. The patient will also be placed on antibiotics.
Your unfortunate character may have hit something or was struck in an attack and suffered a basal skull fracture. The mass of bone at the base of the skull is complex, and fractures are sometimes difficult to diagnose in this location. Instead of a dent in his "squash"—that's what the intern calls your character's noble cranium—the poor fellow arrives in the ER dripping fluid the color of zinfandel from his ear. Not blood,
mind you, but something suspicious, which the intern mops up with a gauze pad.
A faint pink halo forms about the blood spot from the victim's ear and represents cerebrospinal fluid leaking from a basilar skull fracture. Bruising behind the ear is called Battle's Sign and suggests the same diagnosis. Raccoon eyes refers to periorbital (around the eyes) bruising, which may be from direct facial trauma or from a basilar skull fracture.
Treatment of the other injuries your character suffers from won't matter much if the cerebral sepulcher isn't handled properly. The squash must be intact. For some head injuries, immediate neurosurgical treatment is of utmost importance.
Here's the physiologic deal: Unyielding skull meets expanding mass of brain and blood with no place to go. What happens? The pressure in the system shoots up, squeezes the brain and squirts the vital brainstem down through the hole in the base of the skull like so much toothpaste. Prolonged, the imprisonment of the brain gives way to dysfunction, injury and, eventually, death. It doesn't matter if increased intracranial pressure is from the injured brain swelling diffusely or from a blood clot expanding inside the skull like the big bang, creating a universe of treacherous tension pitted against the trapped brain tissue.
In terms of treatment, the big difference between diffuse and focal brain injury is that a focal problem, e.g., a blood clot, requires neurosurgical intervention to remove it. Diffuse injuries may be mild or severe. Some brain injuries require only a bolt (a monitoring device that is placed through a small hole in the skull to assess intracranial pressure) and IV medications to shrink the brain tissues.
Diffuse Brain Injury
Woof—something, someone, struck her square in the back. The blow knocked all the breath out of her .... It happened again .... Kate was in shocking pain .... He swung hard and struck her in the forehead.
She heard a metallic ring, and felt herself falling, toppling. Felt herself vaporizing, actually. Then her body bounced off the wooden floorboards ....
She stayed conscious for a long time. She fought with all her strength. She was stubborn, willful, proud as hell. The light finally
went out for her like a tube in an old-fashioned TV set. A blurry picture, then a small dot of light, then blackness. It was that simple, that prosaic.
James Patterson's point-of-view character in Kiss the Girls is attacked by two men and slips into a coma. The brutal assault bridges the end of one chapter and the beginning of another. Like the terse chapters, his short choppy sentences mimic the assault itself. Kate's "Off" button is punched, the wiring of her brain disrupted, and her visual light, like the TV cathode ray tube, fades.
Kate will be back. She's merely suffered from a concussion. She'll be a little confused, perhaps. She doesn't have a blood clot swelling inside her skull.
A concussion is a diffuse brain injury that produces coma and, often, amnesia with rapid recovery. This insult, as well as the more severe form, is the result of rapid flexion-extension of the head and neck, impact of the brain against the inside of the skull with rotation of the brain. This motion disrupts several areas of neurologic tissue. A concussion may be associated with nausea, headache and/or dizziness, but the examining doctor usually doesn't discover the specific lateralizing (present on one side of the body only) neurologic signs mentioned above.
During the 1994 National Football League season, there were ninety documented concussions. Called "bell-ringers," these injuries may be followed by what is termed the second impact syndrome, another head hit which aggravates the initial injury and cause severe brain swelling. In some victims, the second impact results in death. At least one hockey player's career ended that year because of a severe concussion, and more than a few baseball players got "dinged" by an errantly tossed ball. Concussions probably happen more often than is documented in and out of sport. Treatment?
If your character was knocked out cold for more than five to ten minutes, you'd better have a doctor admit him to a hospital for twenty-four hours of observation. Admit any kids who've been in a coma from a head injury regardless of length of time—unless, of course, your character can't or won't seek medical care and the brain injury becomes a source of story tension.
Diffuse (axonal) brain injury refers to prolonged coma and implies severe injury to different parts of the brain and brain stem. The coma may last for weeks. A third to a half of these poor souls will die of their injuries. Only a CT scan of the head will clearly distinguish this insult from the next group of brain injuries, many of which require emergency surgery.
Focal Brain Injury
Brain Contusion
A brain bruise, or contusion, may be of any size, number or location and may occur at the point of impact or at a distance (contrecoup injury), thus producing a spectrum of confusing clinical signs. You can get away with almost any sort of foreshadowing with this one. Create any neurologic deficit, e.g., paralysis or blindness, by choosing the mechanism of injury and the impact point on the skull.
Intracranial Hemorrhage
Bleeding on the brain surface occurs inside the skull between the unyielding dura mater membrane and the soft brain surface and causes damage by creating increased intracranial pressure as we have seen. This clinical picture is characterized by coma followed by:
• A lucid period during which your character's window of consciousness may not be marked by full awareness
• A second period of unconsciousness
• Clinical findings of paralysis on the opposite side of the body and enlargement of the same side pupil, which doesn't react (become smaller when exposed to direct light)
For the writer, an acute epidural bleed is arterial (so bleeding is brisk) and raises the heat of the scene as the stakes soar. An epidural hematoma collects between the bony skull and the dura mater, the outer brain membrane. Without urgent neurosurgical intervention, the victim will die.
Similar to the acute epidural bleed is an acute subdural hematoma, which results from a tear of veins under the dura mater and above the cortex. Lethal in over 60 percent of patients, this injury may also occur with a skull fracture where bone fragments cut brain tissue and lacerate surface arteries or veins. Three types of subdural hematoma are seen according to when they require surgery:
1. Acute subdural hematoma—operated on within twenty-four hours
2. Subacute subdural hematoma—to OR within two days to two weeks
3. Chronic subdural hematoma—operated on after two weeks
Bleeding Inside the Brain
Bleeding may occur in the substance of the brain tissue, deep in the tangle of pathways and ganglia, disrupting the essential cerebral wiring. A blunt strike on the skull, impalement of a sharp object or a
