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Interviewer: According to the Centers for Disease Control and Prevention, more than two million Americans experience a brain injury each year. While some of these injuries result in relatively short-term impact on a day-to-day function, others can lead to long-term challenges or even a permanent disability.

Today, we'll be speaking with Zoe, a young woman who experienced a traumatic brain injury after an accident and the long journey of her recovery and the daily experience of overcoming the long-term challenges of life after an accident like this.

And to help us better understand the medical side of a traumatic brain injury, joining us is associate professor of neurosurgery at University of Utah Health, Dr. Ramesh Grandhi, the doctor who helped stabilize Zoe after her accident.

Zoe, why don't we start with what kind of led to your traumatic brain injury in the first place? What exactly happened?

Zoe: Yeah. Well, interesting story. I had just moved to Salt Lake City in August of 2020, and this occurred . . . or rather, my accident occurred December 5, 2020. So I had just shy of five months in the state, really.

So I hadn't experienced a lot, but a friend and I really wanted to ski together. I bought a season pass at Alta, was really excited to get up there. And it was day one, in fact, of the ski season that this happened. So really did not get any other skiing in, obviously, but this was day one.

Yeah, I mean, I don't remember a whole lot about the day itself. I have spotty memories of the drive up to Alta, getting to Alta. I actually have some spotty memories of being on the lift up to the first run. After that, I don't remember anything. I remember a bit of skiing, and that's really about it in terms of the day.

And then subsequently, upon waking up, I have absolutely no memory of the remainder of December. My memory is really spotty from about Thanksgiving up to December 5th. So Thanksgiving, I would say, is the last clear memory that I have and everything else is kind of spotty. It appears in my head almost as if I made it all up.

I've had to ask a lot of people, especially family members, "Did this really happen? Can you describe this thing to me or remind me who was at Thanksgiving again?" I never would have guessed something like this when I first started skiing with my dad 10-plus years ago.

And I was maybe 500 yards behind several of my friends, so I was alone during the actual collision. I ran into this group of trees that sat right in the middle of the run that I was on at Alta.

In this tree well, it was icy. I slipped on the snow evidently and collided with some trees in the tree well. What I would assume happened at that point is I was knocked unconscious by the collision and then fell and was hidden by this tree well and this group of trees. And then because I wasn't found until about four hours later, I had become buried or covered by snow by people skiing by, obviously.

Interviewer: Sure. So you're spotty memory-wise from Thanksgiving to . . . When did you start to remember things again?

Zoe: Right. So really, my lucidity, I would say, started to come back right around January 6th, 7th, 8th, right in that area. This is purely what I was told, is that I woke up somewhere mid to end of December. The rest of December went by. I was then transferred to a long-term care facility outside of Salt Lake City. And right around that, again, 6th, 7th, 8th of January is when I have memories that I'm able to go back on and say, "Oh, yeah, that was right in the beginning of January." Before that, though, I have no memories.

Interviewer: Wow. So, Dr. Grandhi, I want to go to you at this point. When did Zoe come into the care of you, your team, the University of Utah Hospital?

Dr. Grandhi: As I recall it, I didn't find out about Zoe until Sunday morning first thing. I know that she presented as a transfer to our hospital, and clearly, she had traumatic injuries. And the first principle of what we do is just stabilize the patient. The trauma surgeons and a number of other services are super important and are our partners in making sure that a patient is appropriately stabilized.

And then my partner was actually on call and received the first call about her. He then got in touch with me. We do a really nice job within our department about communicating about patients with traumatic brain injuries, and specifically, patients with severe traumatic brain injuries.

So I remember that Sunday morning very well because she was downstairs in our surgical ICU. I went and saw her and just looked at her images, and then went out and talked to her dad who was sitting in the waiting room all by himself.

I remember the exact seat he was seated in early on that Sunday morning, probably around 8:00 a.m. or 9:00 a.m. And he was just by himself. I just walked up to him and told him what my assessment was of the situation based on looking at her head CT and things like that.

And at that point, it was just me trying to tell him that we're going to do our best to take care of her, that she presented with what we call a severe traumatic brain injury, and what the principles of managing patients with that are, and also, honestly, giving him hope.

Interviewer: When we talk about traumatic brain injury, is it a lot of skiing injuries, sports injuries? What is the most common type of traumatic brain injury?

Dr. Grandhi: Traumatic brain injury is a significant burden in the Western world. It's the number one cause of death amongst young folks in the Western world.

Traumatic brain injury falls into three buckets: severe traumatic brain injury, moderate traumatic brain injury, and mild traumatic brain injury. And oftentimes, patients with mild traumatic brain injuries don't even come into the hospital. We call it a concussion. And oftentimes, a patient may stay at home after hitting their head, or being involved in a sports injury, or a motor vehicle collision, or falling and hitting their head.

The burden of traumatic brain injury in the United States today is about 2.5 million patients per year. So many patients don't even come into the hospital. Many patients are discharged from the ER.

Interviewer: Zoe and her accident, of those three buckets, what did hers fall into, and why?

Dr. Grandhi: Zoe had a severe traumatic brain injury. And the way we diagnose severe traumatic brain injury is quite simple. We just gauge it in terms of what their neurologic exam is when they come in. So are they able to open their eyes? Are they able to speak? Are they able to follow commands?

Interviewer: And Zoe was unable to do those things?

Dr. Grandhi: Correct.

Interviewer: Wow. Zoe, do you remember any pieces or parts of the story? How did you feel when you were first, I guess, coming out of it?

Zoe: Yeah. Again, like I said before, the first memories I have are really in the long-term care facility that I was transferred to after leaving The U. I think it was sort of a slow realization.

And then since then, I would say I've noticed things that are sort of side effects or fallouts from having a severe traumatic brain injury: getting frustrated much more easily, being able to jump to anger much more easily, having very little patience, amongst many others. So it was very much a slow realization and slow rollout. And then still to this day, new things come up.

So it was much more slow. It wasn't similar to if you broke your arm and someone said, "Oh, you broke your arm," and then they casted it up right then and there. It was much more prolonged than that and slow realization.

My initial thought, honestly, was because I was awake and lucid and conscious, "Oh, my brain is fine. Well, everything is good. I can speak. I can see. I can hear. I can eat. I have my motor functions." And so, initially, I didn't think too much about the effects on my brain, and that did come up much later and still continues to this day.

Interviewer: Dr. Grandhi, when it comes to treatment of a case like Zoe, what was done to help Zoe get from the accident to where she was stabilized and in, I guess, a longer-term facility to kind of monitor her?

Dr. Grandhi: Well, I think we need to kind of dial it back a little bit to understand the management principles of patients with severe traumatic brain injury. And it starts, honestly, in the pre-hospital setting in which those who are on the first line understand how to manage a person, particularly with a pathology as significant as severe traumatic brain injury.

So first things first, getting the patient stabilized in the field, making sure that people are very cognizant of taking care of the patient, immobilizing their neck. Again, we don't know if a patient has had an injury to the cervical spine. Zoe clearly hit trees, so she could have very easily had damage to her neck, to the bones of her neck, spinal cord, etc. So getting a patient stabilized at the point of injury, then making a decision of where the patient goes.

There is data to show improved outcomes in patients who have a severe traumatic brain injury who are taken to Level 1 trauma centers. So understanding where to send the patient when the patient comes in.

Again, we have a huge bevy of services that are there in the ER, in the trauma bay awaiting a patient, because there's pre-hospital notification. And so if a person is coming in as a Level 1 trauma to a Level 1 trauma center, we do have orthopedics right there. Neurosurgery is right there in the trauma bay. Obviously, trauma surgery, the ER doctors, a number of different services and specialties are there awaiting the patient.

Airway management is important, worrying about circulation, blood pressure, ensuring that there's no intra-abdominal injuries. After that, there are a lot of scans that are ordered inclusive of CT scans that are literally performed head to toe to make sure that we're not missing significant injuries that need actionable treatment, such as rushing a patient up to the operating room for an intra-abdominal injury.

That being said, once that is done and there's nothing imminent that needs to be treated emergently, the patient is generally taken up to the ICU. And in Zoe's case and a patient with a severe traumatic brain injury, they're ventilated, and then there's a lot of management that occurs then predicated on blood pressure management, good oxygenation for the patient.

And for patients with severe traumatic brain injury, when we know a patient has a severe traumatic brain injury, we place particular monitors in the patient's brain because we're obligated to make sure that we have good control of intracranial pressure. So we want to make sure that we know what a patient's intracranial pressure is, and we need to keep it below certain thresholds.

We clearly know what the patient's brain perfusion is in terms of what's the state of blood pressure to brain tissue. So we monitor a patient's systemic blood pressure, their body's blood pressure well, and have to get the brain perfusion pressure in a particular range.

That's a quick summation of the management principles of a patient with severe traumatic brain injury. Not every patient requires a big-time operation and removing part of the skull or sucking out blood, but when we do place brain monitors, we do have to drill a small hole in people's skull to place these monitors. We have to remember that brain injury comes in many different flavors, even severe traumatic brain injuries.

Interviewer: So you just keep an eye on all the things that are going on with your monitors and everything to see whether or not there's injury?

Dr. Gandhi: Absolutely. And we use CAT scans liberally to help us understand more about the evolution of the brain injury. Zoe did have blood in her head, no question about it, but we did not feel that this blood would require us to take her to the operating room for an emergent surgery to remove the blood.

Interviewer: It's my understanding that Zoe then was a part of a study dealing with neuromonitoring. So for someone who's listening right now, what exactly is neuromonitoring, and why is it so important that we do research with it?

Dr. Gandhi: Whenever someone is classified as having a severe traumatic brain injury, we know from years of research and guidelines and a lot of work from really experienced, savvy, thoughtful leaders in the field that patients should get particular things monitored.

As I had said, we want to get invasive arterial blood pressure monitoring so that we can get a good second-to-second, moment-to-moment gauge of what a person's blood pressure is not using one of those expandable blood pressure cuffs. So this is something that allows us to know on a moment-to-moment basis what a person's blood pressure is doing.

We also ensure that the patient has adequate ventilation using a breathing tube. We study their intracranial pressure via an intracranial pressure monitor.

Finally, one of the things that has been important recently in the care of patients with severe traumatic brain injuries is the concept of whether brain tissue oxygenation can help guide therapy for a patient with a severe traumatic brain injury.

So historically, many university centers across the world, many experienced Level 1trauma centers have been using brain tissue oxygenation monitoring, basically almost as though you had a pulse oximeter of brain tissue. Many folks around the world have used brain tissue oxygenation monitoring as another way to help manage their patients with severe traumatic brain injury.

Here at the University of Utah and also many sites throughout this country and across the world in a separate study have decided to do a randomized controlled trial on this and understanding whether it will bear out in a huge patient population of improving outcomes. And Zoe was enrolled in that trial, and the trial is called BOOST-3.

Interviewer: So what exactly is BOOST-3 looking to do?

Dr. Grandhi: What we're looking for in the BOOST-3 trial is to determine whether using brain tissue oxygenation monitoring in the care of patients with severe traumatic brain injury improves outcomes at six months.

This is over and above using traditional monitoring techniques such as intracranial pressure monitoring and cerebral perfusion pressure monitoring that are already used commonly as part of guidelines that have been established in taking care of patients like Zoe.

Interviewer: So, Zoe, we've been talking a lot about kind of the medical side of things. I want to go back to you. What was it like when you first had Dr. Grandhi or any of the other specialists kind of explain the condition to you and what was going to be expected moving forward?

Zoe: I think in all the research that I've done and the people around me have done and then my discussions with Dr. Grandhi initially and shortly thereafter, and from what I gather from all of that, is that it's largely unexpected. The results and the things that come of it are known and yet unknown, right? It's things that they know come from a severe traumatic brain injury and then there are things that you don't really know will come up until they come up and until you experience them.

So from what I've been able to dissect from this injury is kind of pick apart, or notice rather, the moments in my own life where the thought comes into my head saying, "No, this isn't really you. This isn't really the Zoe that has made it to this point." "This is the TBI speaking," I guess, for lack of a better term or phrase.

An example would be if I'm feeling really, really agitated one day or even one hour and then the next hour I'm back to feeling normal again. So it's really quite a rollercoaster, I would say.

Interviewer: But what did it feel like to kind of hear that? I mean, as an outsider, as someone who's never experienced this kind of thing, that sounds kind of scary to me.

Zoe: Well, I would say more jarring than frightening. As the patient or as the person with a severe TBI, you don't necessarily . . . or I didn't, at least, necessarily believe the things that were being told to me. Not that I would think, "Oh, Dr. Grandhi is a liar," but I didn't necessarily believe it until those things started to show up for me in my own life later on and as time went on.

So months later, it's coming up on a year, so a full year later, I notice things that they told me initially that I might feel or that may come up. And at the time, I was thinking, "Well, I feel fine now, so we're good. We're all good here. Have a nice day." So it wasn't until up to this point that I think, "Oh, okay. I see what they mean by this progression and regression of things that may come and go," and things that I might feel that I didn't think I would feel at the time.

So it was definitely helpful to hear that then, and thinking about it now, "Oh, okay. They were right all along. They know what they're talking about."

Dr. Grandhi: I think it's really important to understand that while we as physicians, particularly as neurosurgeons who take care of patients with severe traumatic brain injury, I look at Zoe, and we raise our hands and we run a victory lap saying that she is a success.

And first things first is just in the acute setting, there's more research coming out that shows that if you are able to get a patient through the acute brain injury setting and manage them correctly and take care of them, we should not be nihilistic about where they will be one year later.

There's new research using big data sets that show that patients such as Zoe who come in with severe traumatic brain injury can have favorable outcomes at one year. Part of this data set also shows that 20% of patients can perhaps have no disability at one year.

But that being said, Zoe's experience alludes to the fact that we cannot forget about our patients. They still sometimes experience some sequalae that are hard to just kind of put a finger on. Like Zoe talks about, just agitation, maybe irritability, maybe memory issues.

So this is a process, an evolution, and it's really important for us to be able to support our patients, get them the correct resources, and really kind of steer them and continue to shepherd them through the process, which may take many more years.

Again, the concept of neuromonitoring for patients with traumatic brain injury only pertains to patients with severe traumatic brain injury, patients who are in a coma, patients who come into a hospital in a comatose state.

And I think we're going to learn a lot through this study as well as over the next years of how to really target various treatment thresholds and really tailor a patient's care to perhaps the type of pathology that they're coming in with.

So this is really important to patients with severe traumatic brain injury, but for the audience out there who is interested in traumatic brain injury in general, because most of the patients who experience a traumatic brain injury don't come in like Zoe in a coma, we're learning a lot about traumatic brain injury in general.

We're learning that there are so many different components to living with a traumatic brain injury. We are understanding that there are perhaps new ways of diagnosing patients and understanding what's called biomarkers and their role and understanding whether they're different symptoms, sequalae, or phenotypes that people experience after a traumatic brain injury.

Finally, it's really, again, very important to support our patients because it's not just the acute recovery stage. One of the people who trained me told me the biggest misnomer in patients who come in with mild traumatic brain injury, which is sometimes called a concussion, is there's nothing mild about it if you experience headaches two months after the fact, or if you have problems with staring at your computer screen if you're a person who works on computers and have eye strain after that, or have problems with balance. There's nothing mild about it.

And now the question is, "How can we support our patients better and get them the needed resources they need to get back on their feet and get their life back in order?"

Interviewer: So, Zoe, you're 25 now. It's been a year since the initial incident. How have you felt along the process? And how do you mark your own success and, I guess, healing from this particular incident?

Zoe: It actually took quite a while for me to recognize my own success, my own progress. It's really been just recently, actually, that I've been able to think to myself, "Oh, okay. You can actually do that thing now that you weren't able to do three months ago, four months ago."

It's more so just the ability to recognize those things. And I wasn't able to recognize those things previously. So it's been really difficult to measure my own progress based on what that looks like or what that has looked like in the past year.

I mean, highs, overall, I would say the ability to remember. Honestly, my short-term memory was completely restarted, completely obliterated in the beginning, and I wasn't able to hold a memory for several minutes. I would forget the thing before. So my working memory and my short-term memory have improved significantly.

Luckily, nothing really ever happened to my long-term memory, so I was able to remember years past. I could tell you where exactly I was and who I was with, especially right in the early beginning.

One of the most difficult things, but probably does not top the list, that I've experienced from the fallout, if you will, is the changing of relationships in my life. Friendships and various other things that have been really difficult to not only maintain, but to offer my lived experience as it is and as I see it and as I experience it. It's extremely difficult to explain the mindset that I have and where my brain is at on any given day.

And luckily, some of them have had extreme understanding and extreme patience with me. And that's really all I ask of the people in my life now, is, "Please be patient with me and my progress and the things you likely don't see on a day-to-day basis." On hour-by-hour basis even.

I've told the people closest to me, "This could be a years-long journey process, if you will, for my mental state, so the patience is so appreciated."

And then the highs . . . To be quite frank, I think the highs for me personally, they've been recognized by the people in my life for a while now, for the last year, but I personally have not been able to see or really process or digest those highs.

So it's really just been very recent in the last few months that I've been able to look at myself and say, "Wow, you can do that now after being completely immobile for nearly two months," or, "Wow, you can move that way again," or, "You can stretch that way again."

I used to and would eventually like to get back to very, very involved in hot yoga. I used to do hot yoga frequently. And before that, I was a gymnast and a dancer. So in the beginning, it was very excruciating for me to, say, not even touch my toes. And that was a huge blow more so to my ego than anything else, but a huge blow nonetheless.

And so I think the highs now are being able to recognize that, "Hey, I am able to touch my toes," and I stretch, and I exercise, and I do all these things every single day to better myself.

Initially, it was very much like, "Wow, you aren't able to do this? What happened?" And then it was up to a few months ago that I started telling myself, "No, you have to be much more patient to yourself, much more kind to yourself," than the completely and constant berating myself for why I'm not able to do something, or accomplish something, or say something in the way that I want to say it, etc.

Dr. Gandhi: I think that was just incredible to hear. As I said before, we run laps when we look at Zoe, but to hear her personal experience and understand that this is not over for her and understand what she goes through and also understand what defines us is the little things that make us who we are. Zoe touching her toes, doing hot yoga, it's incredible. It makes us really take a step back and understand this as a human experience, understand this as a personal experience.

The privilege of being able to be involved in Zoe's care and the care of others is not lost when you hear these things. The story of Zoe and patients like Zoe is not done in December 2021. It's an experience that she's going to live through and get through for the rest of her life.

She's sitting 10 feet away from me right now and her mom is right here as well. She's going to get there, and we just have to do everything we can to support her. She's just incredible. And to just hear Zoe, hear her voice come through in this experience is just profound for us. As many times as I've seen Zoe, I've never known these little things about Zoe, and it's amazing to hear.

Interviewer: To find out more about traumatic brain injury as well as the services offered through the brain injury program at the Craig H. Neilsen Rehabilitation Hospital, visit the link in the episode description.

Interviewer: According to the Centers for Disease Control and Prevention, more than two million Americans experience a brain injury each year. While some of these injuries result in relatively short-term impact on a day-to-day function, others can lead to long-term challenges or even a permanent disability.

Today, we'll be speaking with Zoe, a young woman who experienced a traumatic brain injury after an accident and the long journey of her recovery and the daily experience of overcoming the long-term challenges of life after an accident like this.

And to help us better understand the medical side of a traumatic brain injury, joining us is associate professor of neurosurgery at University of Utah Health, Dr. Ramesh Grandhi, the doctor who helped stabilize Zoe after her accident.

Zoe, why don't we start with what kind of led to your traumatic brain injury in the first place? What exactly happened?

Zoe: Yeah. Well, interesting story. I had just moved to Salt Lake City in August of 2020, and this occurred . . . or rather, my accident occurred December 5, 2020. So I had just shy of five months in the state, really.

So I hadn't experienced a lot, but a friend and I really wanted to ski together. I bought a season pass at Alta, was really excited to get up there. And it was day one, in fact, of the ski season that this happened. So really did not get any other skiing in, obviously, but this was day one.

Yeah, I mean, I don't remember a whole lot about the day itself. I have spotty memories of the drive up to Alta, getting to Alta. I actually have some spotty memories of being on the lift up to the first run. After that, I don't remember anything. I remember a bit of skiing, and that's really about it in terms of the day.

And then subsequently, upon waking up, I have absolutely no memory of the remainder of December. My memory is really spotty from about Thanksgiving up to December 5th. So Thanksgiving, I would say, is the last clear memory that I have and everything else is kind of spotty. It appears in my head almost as if I made it all up.

I've had to ask a lot of people, especially family members, "Did this really happen? Can you describe this thing to me or remind me who was at Thanksgiving again?" I never would have guessed something like this when I first started skiing with my dad 10-plus years ago.

And I was maybe 500 yards behind several of my friends, so I was alone during the actual collision. I ran into this group of trees that sat right in the middle of the run that I was on at Alta.

In this tree well, it was icy. I slipped on the snow evidently and collided with some trees in the tree well. What I would assume happened at that point is I was knocked unconscious by the collision and then fell and was hidden by this tree well and this group of trees. And then because I wasn't found until about four hours later, I had become buried or covered by snow by people skiing by, obviously.

Interviewer: Sure. So you're spotty memory-wise from Thanksgiving to . . . When did you start to remember things again?

Zoe: Right. So really, my lucidity, I would say, started to come back right around January 6th, 7th, 8th, right in that area. This is purely what I was told, is that I woke up somewhere mid to end of December. The rest of December went by. I was then transferred to a long-term care facility outside of Salt Lake City. And right around that, again, 6th, 7th, 8th of January is when I have memories that I'm able to go back on and say, "Oh, yeah, that was right in the beginning of January." Before that, though, I have no memories.

Interviewer: Wow. So, Dr. Grandhi, I want to go to you at this point. When did Zoe come into the care of you, your team, the University of Utah Hospital?

Dr. Grandhi: As I recall it, I didn't find out about Zoe until Sunday morning first thing. I know that she presented as a transfer to our hospital, and clearly, she had traumatic injuries. And the first principle of what we do is just stabilize the patient. The trauma surgeons and a number of other services are super important and are our partners in making sure that a patient is appropriately stabilized.

And then my partner was actually on call and received the first call about her. He then got in touch with me. We do a really nice job within our department about communicating about patients with traumatic brain injuries, and specifically, patients with severe traumatic brain injuries.

So I remember that Sunday morning very well because she was downstairs in our surgical ICU. I went and saw her and just looked at her images, and then went out and talked to her dad who was sitting in the waiting room all by himself.

I remember the exact seat he was seated in early on that Sunday morning, probably around 8:00 a.m. or 9:00 a.m. And he was just by himself. I just walked up to him and told him what my assessment was of the situation based on looking at her head CT and things like that.

And at that point, it was just me trying to tell him that we're going to do our best to take care of her, that she presented with what we call a severe traumatic brain injury, and what the principles of managing patients with that are, and also, honestly, giving him hope.

Interviewer: When we talk about traumatic brain injury, is it a lot of skiing injuries, sports injuries? What is the most common type of traumatic brain injury?

Dr. Grandhi: Traumatic brain injury is a significant burden in the Western world. It's the number one cause of death amongst young folks in the Western world.

Traumatic brain injury falls into three buckets: severe traumatic brain injury, moderate traumatic brain injury, and mild traumatic brain injury. And oftentimes, patients with mild traumatic brain injuries don't even come into the hospital. We call it a concussion. And oftentimes, a patient may stay at home after hitting their head, or being involved in a sports injury, or a motor vehicle collision, or falling and hitting their head.

The burden of traumatic brain injury in the United States today is about 2.5 million patients per year. So many patients don't even come into the hospital. Many patients are discharged from the ER.

Interviewer: Zoe and her accident, of those three buckets, what did hers fall into, and why?

Dr. Grandhi: Zoe had a severe traumatic brain injury. And the way we diagnose severe traumatic brain injury is quite simple. We just gauge it in terms of what their neurologic exam is when they come in. So are they able to open their eyes? Are they able to speak? Are they able to follow commands?

Interviewer: And Zoe was unable to do those things?

Dr. Grandhi: Correct.

Interviewer: Wow. Zoe, do you remember any pieces or parts of the story? How did you feel when you were first, I guess, coming out of it?

Zoe: Yeah. Again, like I said before, the first memories I have are really in the long-term care facility that I was transferred to after leaving The U. I think it was sort of a slow realization.

And then since then, I would say I've noticed things that are sort of side effects or fallouts from having a severe traumatic brain injury: getting frustrated much more easily, being able to jump to anger much more easily, having very little patience, amongst many others. So it was very much a slow realization and slow rollout. And then still to this day, new things come up.

So it was much more slow. It wasn't similar to if you broke your arm and someone said, "Oh, you broke your arm," and then they casted it up right then and there. It was much more prolonged than that and slow realization.

My initial thought, honestly, was because I was awake and lucid and conscious, "Oh, my brain is fine. Well, everything is good. I can speak. I can see. I can hear. I can eat. I have my motor functions." And so, initially, I didn't think too much about the effects on my brain, and that did come up much later and still continues to this day.

Interviewer: Dr. Grandhi, when it comes to treatment of a case like Zoe, what was done to help Zoe get from the accident to where she was stabilized and in, I guess, a longer-term facility to kind of monitor her?

Dr. Grandhi: Well, I think we need to kind of dial it back a little bit to understand the management principles of patients with severe traumatic brain injury. And it starts, honestly, in the pre-hospital setting in which those who are on the first line understand how to manage a person, particularly with a pathology as significant as severe traumatic brain injury.

So first things first, getting the patient stabilized in the field, making sure that people are very cognizant of taking care of the patient, immobilizing their neck. Again, we don't know if a patient has had an injury to the cervical spine. Zoe clearly hit trees, so she could have very easily had damage to her neck, to the bones of her neck, spinal cord, etc. So getting a patient stabilized at the point of injury, then making a decision of where the patient goes.

There is data to show improved outcomes in patients who have a severe traumatic brain injury who are taken to Level 1 trauma centers. So understanding where to send the patient when the patient comes in.

Again, we have a huge bevy of services that are there in the ER, in the trauma bay awaiting a patient, because there's pre-hospital notification. And so if a person is coming in as a Level 1 trauma to a Level 1 trauma center, we do have orthopedics right there. Neurosurgery is right there in the trauma bay. Obviously, trauma surgery, the ER doctors, a number of different services and specialties are there awaiting the patient.

Airway management is important, worrying about circulation, blood pressure, ensuring that there's no intra-abdominal injuries. After that, there are a lot of scans that are ordered inclusive of CT scans that are literally performed head to toe to make sure that we're not missing significant injuries that need actionable treatment, such as rushing a patient up to the operating room for an intra-abdominal injury.

That being said, once that is done and there's nothing imminent that needs to be treated emergently, the patient is generally taken up to the ICU. And in Zoe's case and a patient with a severe traumatic brain injury, they're ventilated, and then there's a lot of management that occurs then predicated on blood pressure management, good oxygenation for the patient.

And for patients with severe traumatic brain injury, when we know a patient has a severe traumatic brain injury, we place particular monitors in the patient's brain because we're obligated to make sure that we have good control of intracranial pressure. So we want to make sure that we know what a patient's intracranial pressure is, and we need to keep it below certain thresholds.

We clearly know what the patient's brain perfusion is in terms of what's the state of blood pressure to brain tissue. So we monitor a patient's systemic blood pressure, their body's blood pressure well, and have to get the brain perfusion pressure in a particular range.

That's a quick summation of the management principles of a patient with severe traumatic brain injury. Not every patient requires a big-time operation and removing part of the skull or sucking out blood, but when we do place brain monitors, we do have to drill a small hole in people's skull to place these monitors. We have to remember that brain injury comes in many different flavors, even severe traumatic brain injuries.

Interviewer: So you just keep an eye on all the things that are going on with your monitors and everything to see whether or not there's injury?

Dr. Gandhi: Absolutely. And we use CAT scans liberally to help us understand more about the evolution of the brain injury. Zoe did have blood in her head, no question about it, but we did not feel that this blood would require us to take her to the operating room for an emergent surgery to remove the blood.

Interviewer: It's my understanding that Zoe then was a part of a study dealing with neuromonitoring. So for someone who's listening right now, what exactly is neuromonitoring, and why is it so important that we do research with it?

Dr. Gandhi: Whenever someone is classified as having a severe traumatic brain injury, we know from years of research and guidelines and a lot of work from really experienced, savvy, thoughtful leaders in the field that patients should get particular things monitored.

As I had said, we want to get invasive arterial blood pressure monitoring so that we can get a good second-to-second, moment-to-moment gauge of what a person's blood pressure is not using one of those expandable blood pressure cuffs. So this is something that allows us to know on a moment-to-moment basis what a person's blood pressure is doing.

We also ensure that the patient has adequate ventilation using a breathing tube. We study their intracranial pressure via an intracranial pressure monitor.

Finally, one of the things that has been important recently in the care of patients with severe traumatic brain injuries is the concept of whether brain tissue oxygenation can help guide therapy for a patient with a severe traumatic brain injury.

So historically, many university centers across the world, many experienced Level 1trauma centers have been using brain tissue oxygenation monitoring, basically almost as though you had a pulse oximeter of brain tissue. Many folks around the world have used brain tissue oxygenation monitoring as another way to help manage their patients with severe traumatic brain injury.

Here at the University of Utah and also many sites throughout this country and across the world in a separate study have decided to do a randomized controlled trial on this and understanding whether it will bear out in a huge patient population of improving outcomes. And Zoe was enrolled in that trial, and the trial is called BOOST-3.

Interviewer: So what exactly is BOOST-3 looking to do?

Dr. Grandhi: What we're looking for in the BOOST-3 trial is to determine whether using brain tissue oxygenation monitoring in the care of patients with severe traumatic brain injury improves outcomes at six months.

This is over and above using traditional monitoring techniques such as intracranial pressure monitoring and cerebral perfusion pressure monitoring that are already used commonly as part of guidelines that have been established in taking care of patients like Zoe.

Interviewer: So, Zoe, we've been talking a lot about kind of the medical side of things. I want to go back to you. What was it like when you first had Dr. Grandhi or any of the other specialists kind of explain the condition to you and what was going to be expected moving forward?

Zoe: I think in all the research that I've done and the people around me have done and then my discussions with Dr. Grandhi initially and shortly thereafter, and from what I gather from all of that, is that it's largely unexpected. The results and the things that come of it are known and yet unknown, right? It's things that they know come from a severe traumatic brain injury and then there are things that you don't really know will come up until they come up and until you experience them.

So from what I've been able to dissect from this injury is kind of pick apart, or notice rather, the moments in my own life where the thought comes into my head saying, "No, this isn't really you. This isn't really the Zoe that has made it to this point." "This is the TBI speaking," I guess, for lack of a better term or phrase.

An example would be if I'm feeling really, really agitated one day or even one hour and then the next hour I'm back to feeling normal again. So it's really quite a rollercoaster, I would say.

Interviewer: But what did it feel like to kind of hear that? I mean, as an outsider, as someone who's never experienced this kind of thing, that sounds kind of scary to me.

Zoe: Well, I would say more jarring than frightening. As the patient or as the person with a severe TBI, you don't necessarily . . . or I didn't, at least, necessarily believe the things that were being told to me. Not that I would think, "Oh, Dr. Grandhi is a liar," but I didn't necessarily believe it until those things started to show up for me in my own life later on and as time went on.

So months later, it's coming up on a year, so a full year later, I notice things that they told me initially that I might feel or that may come up. And at the time, I was thinking, "Well, I feel fine now, so we're good. We're all good here. Have a nice day." So it wasn't until up to this point that I think, "Oh, okay. I see what they mean by this progression and regression of things that may come and go," and things that I might feel that I didn't think I would feel at the time.

So it was definitely helpful to hear that then, and thinking about it now, "Oh, okay. They were right all along. They know what they're talking about."

Dr. Grandhi: I think it's really important to understand that while we as physicians, particularly as neurosurgeons who take care of patients with severe traumatic brain injury, I look at Zoe, and we raise our hands and we run a victory lap saying that she is a success.

And first things first is just in the acute setting, there's more research coming out that shows that if you are able to get a patient through the acute brain injury setting and manage them correctly and take care of them, we should not be nihilistic about where they will be one year later.

There's new research using big data sets that show that patients such as Zoe who come in with severe traumatic brain injury can have favorable outcomes at one year. Part of this data set also shows that 20% of patients can perhaps have no disability at one year.

But that being said, Zoe's experience alludes to the fact that we cannot forget about our patients. They still sometimes experience some sequalae that are hard to just kind of put a finger on. Like Zoe talks about, just agitation, maybe irritability, maybe memory issues.

So this is a process, an evolution, and it's really important for us to be able to support our patients, get them the correct resources, and really kind of steer them and continue to shepherd them through the process, which may take many more years.

Again, the concept of neuromonitoring for patients with traumatic brain injury only pertains to patients with severe traumatic brain injury, patients who are in a coma, patients who come into a hospital in a comatose state.

And I think we're going to learn a lot through this study as well as over the next years of how to really target various treatment thresholds and really tailor a patient's care to perhaps the type of pathology that they're coming in with.

So this is really important to patients with severe traumatic brain injury, but for the audience out there who is interested in traumatic brain injury in general, because most of the patients who experience a traumatic brain injury don't come in like Zoe in a coma, we're learning a lot about traumatic brain injury in general.

We're learning that there are so many different components to living with a traumatic brain injury. We are understanding that there are perhaps new ways of diagnosing patients and understanding what's called biomarkers and their role and understanding whether they're different symptoms, sequalae, or phenotypes that people experience after a traumatic brain injury.

Finally, it's really, again, very important to support our patients because it's not just the acute recovery stage. One of the people who trained me told me the biggest misnomer in patients who come in with mild traumatic brain injury, which is sometimes called a concussion, is there's nothing mild about it if you experience headaches two months after the fact, or if you have problems with staring at your computer screen if you're a person who works on computers and have eye strain after that, or have problems with balance. There's nothing mild about it.

And now the question is, "How can we support our patients better and get them the needed resources they need to get back on their feet and get their life back in order?"

Interviewer: So, Zoe, you're 25 now. It's been a year since the initial incident. How have you felt along the process? And how do you mark your own success and, I guess, healing from this particular incident?

Zoe: It actually took quite a while for me to recognize my own success, my own progress. It's really been just recently, actually, that I've been able to think to myself, "Oh, okay. You can actually do that thing now that you weren't able to do three months ago, four months ago."

It's more so just the ability to recognize those things. And I wasn't able to recognize those things previously. So it's been really difficult to measure my own progress based on what that looks like or what that has looked like in the past year.

I mean, highs, overall, I would say the ability to remember. Honestly, my short-term memory was completely restarted, completely obliterated in the beginning, and I wasn't able to hold a memory for several minutes. I would forget the thing before. So my working memory and my short-term memory have improved significantly.

Luckily, nothing really ever happened to my long-term memory, so I was able to remember years past. I could tell you where exactly I was and who I was with, especially right in the early beginning.

One of the most difficult things, but probably does not top the list, that I've experienced from the fallout, if you will, is the changing of relationships in my life. Friendships and various other things that have been really difficult to not only maintain, but to offer my lived experience as it is and as I see it and as I experience it. It's extremely difficult to explain the mindset that I have and where my brain is at on any given day.

And luckily, some of them have had extreme understanding and extreme patience with me. And that's really all I ask of the people in my life now, is, "Please be patient with me and my progress and the things you likely don't see on a day-to-day basis." On hour-by-hour basis even.

I've told the people closest to me, "This could be a years-long journey process, if you will, for my mental state, so the patience is so appreciated."

And then the highs . . . To be quite frank, I think the highs for me personally, they've been recognized by the people in my life for a while now, for the last year, but I personally have not been able to see or really process or digest those highs.

So it's really just been very recent in the last few months that I've been able to look at myself and say, "Wow, you can do that now after being completely immobile for nearly two months," or, "Wow, you can move that way again," or, "You can stretch that way again."

I used to and would eventually like to get back to very, very involved in hot yoga. I used to do hot yoga frequently. And before that, I was a gymnast and a dancer. So in the beginning, it was very excruciating for me to, say, not even touch my toes. And that was a huge blow more so to my ego than anything else, but a huge blow nonetheless.

And so I think the highs now are being able to recognize that, "Hey, I am able to touch my toes," and I stretch, and I exercise, and I do all these things every single day to better myself.

Initially, it was very much like, "Wow, you aren't able to do this? What happened?" And then it was up to a few months ago that I started telling myself, "No, you have to be much more patient to yourself, much more kind to yourself," than the completely and constant berating myself for why I'm not able to do something, or accomplish something, or say something in the way that I want to say it, etc.

Dr. Gandhi: I think that was just incredible to hear. As I said before, we run laps when we look at Zoe, but to hear her personal experience and understand that this is not over for her and understand what she goes through and also understand what defines us is the little things that make us who we are. Zoe touching her toes, doing hot yoga, it's incredible. It makes us really take a step back and understand this as a human experience, understand this as a personal experience.

The privilege of being able to be involved in Zoe's care and the care of others is not lost when you hear these things. The story of Zoe and patients like Zoe is not done in December 2021. It's an experience that she's going to live through and get through for the rest of her life.

She's sitting 10 feet away from me right now and her mom is right here as well. She's going to get there, and we just have to do everything we can to support her. She's just incredible. And to just hear Zoe, hear her voice come through in this experience is just profound for us. As many times as I've seen Zoe, I've never known these little things about Zoe, and it's amazing to hear.

Interviewer: To find out more about traumatic brain injury as well as the services offered through the brain injury program at the Craig H. Neilsen Rehabilitation Hospital, visit the link in the episode description.

Interviewer: For a patient who has experienced any sort of traumatic brain injury, recovery can be something that might seem a little scary. How long is it going to last? What can you expect, etc.?

So to answer some of these questions, we are here with Dr. John Speed. He is a professor in the division of Physical Medicine and Rehabilitation and practices at the University of Utah Health. Now, Dr. Speed, when we talk about a traumatic brain injury, that's a pretty big term. What kind of patients are we talking about here?

Dr. Speed: We're talking about a huge spectrum of people, from an individual that may have sustained a concussion heading a soccer ball all the way to someone that's been in a catastrophic car accident and sustained a brain injury that's left them in a coma for a prolonged period of time.

Interviewer: And what kind of patients do you see the most getting these types of injuries?

Dr. Speed: Well, the most common type of brain injury really is the concussion or mild brain injury that might be seen in the emergency room and sent home. But here at the Craig H. Neilsen Rehabilitation Hospital, we take care of patients in the hospital that have sustained more severe injuries that are perhaps comatose or have much more significant problems that last for a longer period of time.

Interviewer: So someone comes into say the hospital, the emergency room, this particular center with a brain injury, what's the first things that you guys are going to do to, you know, make sure that they're okay?

Dr. Speed: Well, that piece of it really falls to my neurosurgical and emergency room colleagues. They'll do any necessary surgical intervention to, say, remove a blood clot that may have formed. Possibly they'll do a procedure to remove a piece of skull to allow for brain swelling, which can be incredibly frightening for family members because obviously it looks very awful. But then once the person has recovered from a neurosurgical standpoint and they're ready for rehabilitation, they'll transfer over to the Craig H. Neilsen Rehabilitation Hospital and they'll have inpatient rehabilitation here working on all of the problems that they may have as a result of their brain injury.

Interviewer: And what are some of the problems that a patient like this might be experiencing?

Dr. Speed: Well, the brain is awfully complex and it does everything. So it could be emotional problems. It could be cognitive problems. It could be paralysis of one or both sides of the body, swallowing problems, speech problems, visual difficulties, you name it.

Interviewer: So when we talk about emotional or cognitive, what kind of things are we experiencing? Like a change in mood and behavior, lack of memory, what are some of those things?

Dr. Speed: Well, early on a person may still be in what we call post-traumatic amnesia. They have no idea where they are. They have no idea what's going on. They can't process information. They can't make sense of their environment. And I make the analogy that it's somewhat like living inside a kaleidoscope. They're just presented with all of the sensory input that they can't make any sense of. And so, of course, that's a very frightening experience, and oftentimes the reaction is one of thrashing around, being agitated, yelling, screaming, because it's a very frightening and disorienting experience. But as a person continues to recover, that orientation improves and the person can make sense of their environment again and that agitation will eventually settle down.

Interviewer: That sounds like a kind of situation that could cause some anxiety for both a patient and for, say, the loved ones that are looking on. What can, you know, doctors like you or someone at a center like the Craig H. Neilsen Center do to help relieve these kinds of symptoms and get the person, you know, closer to normal?

Dr. Speed: Well, the first thing we do is have the person in a low stimulation environment because the less sensory input coming in, the low light, low sound, the TV is off, blinds are down, etc., and minimize the stimulation. And then if necessary, we may use a person's music that they're familiar with, that they enjoy. That can be calming for lots of people. And interestingly, I had patient years ago, who was a young man who was into head banging heavy metal and that was something that was very calming for him. It was very disturbing for the staff, but it worked to help him feel more comfortable and relaxed.

Interviewer: So after a patient has gone through that post-traumatic amnesia, what are some of the steps that come next, and how long can a patient and their loved ones be expecting the recovery to take?

Dr. Speed: Well, of course, the recovery is incredibly variable, and it depends on the severity of the injury, it depends on the type of injury or injuries, and it also depends to some extent on what the person had in terms of life experience prior to the injury. But once the typical sort of sequence of events is the person will proceed out of post-traumatic amnesia. So they'll be oriented, they'll know where they are, they'll know what year it is, and so forth. They'll know that they're in the hospital and why they're in the hospital.

And our therapists are excellent at working with people to regain physical function, balance coordination, mobility. Our occupational therapists will work on what are called activities of daily living. How does a person get dressed? How do they bathe themselves? And those sound pretty basic, but, you know, if a person has had a brain injury, they may not be able to dress themselves. They may put their pants on and then put the underpants on outside because they just don't know the sequence of events that are necessary and they can't process that. So occupational therapists will work on those kinds of things. And then we also have speech therapists that will work on cognition, memory, and also address any language problems that might exist and also any swallowing difficulties that might result from the brain injury.

Interviewer: So what are the expected outcomes for the types of treatment regardless of what kind of brain injury this individual is having and comes to a center like the Craig H. Neilsen Rehab Center?

Dr. Speed: Well, outcomes, of course, are incredibly variable, but we're very proud of the outcomes that we do achieve here. And more than 80% of the people that we admit to the Craig H. Neilsen Rehab Hospital with brain injury are discharged to home. And that doesn't mean the rehab therapies are finished at that time, but people do go home and continue their therapies in some fashion after discharge to home.

Interviewer: And how long are they typically at a center like the Neilsen Center?

Dr. Speed: Well, our typical length of stay for someone with a brain injury that's admitted here is somewhere between two and three weeks.

Interviewer: Wow. So I guess one of the messages maybe that, you know, with the right help and the right medical assistance, there is hope for someone after a traumatic brain injury.

Dr. Speed: Oh, absolutely. For sure.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: I'm talking with Dr. Bryan Jones, an investigator at the Moran Eye Center at the University of Utah. Now anyone who sees you knows that you carry a camera around with you wherever you go.

Dr. Jones: I do.

Interviewer: And I suspect your love for photography might have come before you delved into science.

Dr. Jones: It did, yeah.

Interviewer: I'm wondering if that passion for photography and how maybe we see the world or how the camera sees the world sort of influenced what type of research you're doing now?

Dr. Jones: I came to photography initially in college. My first major was film studies. And I spent a lot of time with a Leica M6 camera and a Canon 1D camera that my parents had. And I fell in love with photography. I've had the privilege of knowing a couple of friends who have retinitis pigmentosa. One of my friends is an army veteran, and I've watched him go blind. So for me, the ability to do photography and to share what I see is a constant reminder of why the work we do is so important.

Interviewer: And what are you looking at these days? What's driving your research?

Dr. Jones: So our lab has two main focus areas. The first is understanding how the retina is wired. So the retina is this piece of gauzy tissue at the back of your eye that is an extension of the brain. And this brain tissue at the back of the eye is sort of a layer cake-like structure with 7,200 neurons or more in our human eyes. And it captures light, photons of light and then computes all the parameters required for vision. Captures contrast and luminance and edges and movement. And calculates all these parameters and sends that information on to others and brain and cortex and sub-cortex for higher processing.

People have been studying the retina for about 150 years, and we still don't know precisely how all those 7,200 or more neurons are wired. And that's the first mission of our lab is to try and pull apart that wiring and identify all the neurons and figure out how they are precisely wired together. That's a field called connectomics.

The second main mission of our lab is to understand how that structure and how the neuron identity and how the wiring is altered in diseases like retinitis pigmentosa and age-related macular degeneration that steal vision from us.

Interviewer: So you're looking at circuitry itself?

Dr. Jones: Yes, ma'am.

Interviewer: And how are you doing that?

Dr. Jones: So there are two new approaches that have been pioneered. The first one that was pioneered by Dr. Robert Mark here at the University of Utah called computation molecular phenotyping. We basically use antibodies to serially label tissues and pull out smaller molecule fingerprints that uniquely identify populations of neurons. And then we insert those data into electron microscopy datasets.

So we basically take the retina and section it very thin. Each section is thinner than the wavelength of light. There are about 90 nanometers. And then we section in the case of the mouse retina that we recently finished, about 1,490 nanometer sections, and then we reconstructed those 1,400 sections into a digital layer cake and create a volume and then we go in by hand and trace neurons all the way through the dataset along with all their connections, their synapses and their gap junctions.

Interviewer: So the hope is to create like a three dimensional representation?

Dr. Jones: Yeah. A three dimensional representation that we then extract out circuit topologies. So it turns out the circuit topologies are far more complex than we thought they were. And so we're now having to develop new software that can allow us to visualize how complex some of these topologies are. The circuit topologies are things that give us excitation and inhibition and ultimately end up tuning response profiles in retina.

Interviewer: You know, if you think about circuitry in how most of us think about circuitry, I mean, if you look at the circuitry like in a computer or in the electronic system of a car, I mean, it doesn't exactly tell you how it works. Or does it?

Dr. Jones: So there was a pretty famous paper that came out a few months ago where they took a standard computer integrated circuit chip and they took it apart digitally and they tried to predict how it would work. And it turns out they didn't have a whole lot of information. It didn't function the way it should have functioned. Or at least their models, their predictive models that they thought how it would behave, it didn't actually behave the way the chip actually did.

So while the circuitry is what we're after and the circuitry in any neural system is sort of the substrate that gives us a basic performance profile and ultimately makes us who we are, there is still a lot we don't know. And so for us the connectomics framework, the circuitry framework we're trying to obtain is only the basic starting point.

It is a framework and on that framework we have to hang physiology, we have to hang physics and we have to put molecular biology and we have to put genetics into it. And so for us it's only the very beginning of understanding how neural systems are wired. Even though the science community has been studying the retina for 150 years. In a lot of ways, we are still right at the very beginning.

Interviewer: So it's kind of new frontier. Something that hasn't really been done this way before.

Dr. Jones: Yeah, exactly.

Announcer: Interesting, informative and all in the name of better health. This is The Scope Health Sciences Radio.

Interviewer: When is a fever bad enough that you should go to the ER? We'll examine that next on The Scope.

Announcer: This is "From the Frontlines," with emergency room physician Dr. Troy Madsen, on The Scope. On The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health Care. When is a fever bad enough to go to the ER? Dr. Madsen, shed some light on that for us.

Dr. Madsen: Yeah. You know, it's interesting you bring that question up because I've had people ask me even recently. They've said, "At what point is the fever just going to cook my brain and how high does it have to be to cook my brain"?

Interviewer: That can't happen. Right?

Dr. Madsen: I can't say I've ever seen it happen and I told them that.

Interviewer: Okay.

Dr. Madsen: And it's something that's out there. I remember hearing that too, like people saying, "Wow, you got to keep your fever down, or you're just going to fry your brain." I can't say I've seen that. So when I think of fever I don't think of the absolute number with the fever. We define a fever as being 100.5 degrees Fahrenheit or greater. So I think of fever more in terms of what are the symptoms that you're having or what kind of medical problems do you have.

This is a child, a young infant, less than, say, 12 weeks old, and they have a fever of 100.5 or greater, you got to go to the ER because there, we get concerned about a serious infection. If this is someone who has an immune system problem, who's on chemotherapy, or maybe has HIV, or something that's affecting their immune system, again, another reason to go to the ER. I'm not concerned about is it 105, is it 100.5, if they have a fever, they need to have testing done.

Interviewer: If they are in that particular group?

Dr. Madsen: Exactly.

Interviewer: Okay.

Dr. Madsen: If they have immune system problems, if they're very young, and then, of course, if they're very old, people who are very old also. It's interesting because very old people really don't get high fevers like someone in their 20s might. So in them, a fever or a temperature of 100.5, that's pretty significant. And again, potentially a sign of something going on that's very serious. Whereas the average person walking along, who's healthy, who has really no medical issues, maybe they have a cough, maybe they have a fever up to 102, even 103, in my mind, that's not so concerning.

So when I think of fever, I think of more the whole person, what kind of medical problems do they have. And then, beyond that, I think of "Okay, what else is going on?" If it's someone who has a fever, who says the light bothers my eyes, my neck is stiff, I'm confused, or someone is reporting to me that they're confused, then I think of meningitis. Fever with a really severe cough, or a cough that has been going on for a week, and won't go away, I think of pneumonia or a sinus infection. Certainly, fever is with your unary symptoms, back pain, we think about kidney infections and issues there.

So again, you're taking that whole picture. So I think the big take home point would be that I don't even own a thermometer at home. I don't check my own temperature. I know if I'm hot, or I'm cold, or family member is hot or cold. I've heard some pediatricians say, "Get rid of your thermometer. Just don't use it on your kids unless they're the very young kids less than 12 weeks old," Because there, you are again looking at the whole picture. It's not just the fever.

Is the child lethargic? Are they feeding well? Are they eating? Are they still urinating, meaning that they're still having adequate fluids in their body? You're looking at everything there in addition to the fever.

Interviewer: That's kind of a tough paradigm for me to wrap my head around because I think a lot of people are just driven by "Oh, 103 fever. That's burning up. That's a major problem." But it sounds like you're saying to take that as an indicator to maybe assess, are there some other issues going on and those other issues are actually the reasons why you'd probably go to the ER?

Dr. Madsen: That's exactly it. You could have 103 fever with kind of a run of the mill cold, and you could feel absolutely miserable, but it doesn't mean you have to rush to the ER.

Interviewer: Okay.

Dr. Madsen: And you can. If you're at all concerned, never hesitate to call your doctor. Never hesitate to go to an urgent care or an ER. But in your mind, I want to think of it as like, "Okay. This absolute temperature means you're sick or something less than temperature means you're not." Like I said, some people with 100.5-degree temperatures who have other problems, that's really serious. Whereas another person on 103-degree temperature, probably very well, just could be a viral infection, and it isn't that big a deal.

Interviewer: So this could be probably tough information for somebody to hear because I'm imagining if they're listening to this, they're concerned about somebody in their life with a fever. If they don't fall in one of those two groups, the very young, the very old, they're going to want to do something. But it sounds like what you're saying is a fever should only indicate that maybe you should look and see if there are other symptoms?

Dr. Madsen: That's exactly it.

Interviewer: Yeah.

Dr. Madsen: Yeah. I won't rush to get into the hospital based on a fever alone. Look at the whole picture. Look at all the symptoms. Look at how the person is acting. If they're acting fine, and they're eating well, and drinking well, and they're alert, and they're not confused, and they've got a temperature of 102, they're probably okay. You can give it some time. You can take some Tylenol, some ibuprofen, to bring the fever down and see how they're doing.

Announcer: We're your daily dose of health, sciences, conversation. This is The Scope, University of Utah Health Sciences Radio.

Interviewer: You or somebody you know suddenly seems very confused. Confusion as a symptom, what could that possibly mean?

Announcer: This is From the Front Lines with emergency room physician Dr. Troy Madsen on The Scope.

Interviewer: Dr. Troy Madsen is an emergency physician at University of Utah Healthcare. Dr. Madsen, as far as symptoms go, if somebody seems confused all of a sudden, whether it is myself or somebody I'm with, what could be the underlying cause of that? For example, with elderly people I know a urinary tract infection can cause confusion, which blew me away.

Dr. Madsen: Right. You know, the average person, and we'll try not to get into the elderly people too much here because that's . . . anything, just a urinary tract infection, like you said, can cause issues.

Let's say we've got the average person out there. Let's say it's a 40-year-old male who normally, has no health issues and just suddenly seems confused. This can be very challenging but for me this is where vital signs are vital. I'm looking at the vital signs because that's what is really going to point me in one direction or another.

First of all, I talk to the person. Yeah, let's say they just seem like they're not quite there. They're not answering questions appropriately. Of course I want to know, did they have anything happen? Were they injured? Did they have a head injury? Are they using any drugs or medications? Anything like that, but in looking at the vital signs that's going to push me in one direction or another.

If they have a fever, I'm thinking possibly meningitis. This person might need a spinal tap or a lumbar puncture to look for some kind of infection around their brain that's causing this. It could be another infection maybe like pneumonia, less likely to make someone just suddenly confused who's normally health, but a possibility.

I'll look at their heart rate. If their heart rate's really fast, and this is something I see quite commonly, heart rate up above 150, up to 200, they might be having an abnormal heart rhythm, something we have to treat either with medication or with a shock to the heart to get that back in a normal rhythm because that really rapid heart rate can make them confused. They're not getting as much blood to their brain.

Maybe their blood pressure is low, and if the blood pressure is low I'm thinking about maybe they're bleeding somewhere. I've see people who have had some kind of internal bleeding either in their stomach or in their intestines that causes their blood pressure to drop down suddenly. They seem confused and weak. That's a very serious thing but I have absolutely seen that happen in young people. Very serious cases of bleeding in someone who maybe is taking a lot of ibuprofen for some pain and it causes some stomach irritation and bleeding.

So those are the primary things I'm looking at, and then I might look at their oxygen level as well. I have seen cases of people with low oxygen levels who have had suddenly a blood clot in the lungs and it goes to the lungs, it causes their oxygen level to drop, their heart rate's up. That causes confusion as well.

For me, again, it's one of these things where it could be any of a number of things, but if you're with someone who is normally healthy, really doesn't have a lot of health issues and suddenly they're confused, that's someone absolutely I would get to the ER and then as an ER doctor there I'm going to be going one direction or another based on what's happened to them prior to that and also really looking at those vital signs to see, okay, is there one direction I need to go here either with infection or with the heart or something in the lungs, something that's causing this confusion to happen.

Interviewer: So it sounds like the cause of confusion is just the brain's not getting enough of something.

Dr. Madsen: Exactly.

Interviewer: Whether that be oxygen, blood. What else would it need?

Dr. Madsen: Well, the blood is delivering the oxygen so typically it's something that's decreasing the blood flow there. Maybe there's just not enough oxygen getting in the body. Certainly young people it's less common but you have to think about strokes or bleeding in the brain.

I have occasionally seen cases of people who seem confused but it's because they're just not speaking correctly. Either they're not pronouncing words correctly or they can think of the right words in their brain but they can't get the words out. That's from either some sort of a stroke, from something breaking off and causing decreased blood flow to the brain or actual bleeding in the brain that's affecting that. Again, these are all things that are emergent issues.

Interviewer: Yeah, sudden confusion is not a good thing, I'm gathering.

Dr. Madsen: Not a good thing.

Interviewer: Go to the ER.

Dr. Madsen: It's not, and it could be any of a number of things, and yes, you should go to the ER.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: August 2, 2019
originally published: June 17, 2016

Dr. Miller: Benefits of having a CT scan versus having an MRI. We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: I'm here with Dr. Ulrich Rassner and he is a radiologist here at the University of Utah. And we're going to talk a little bit about the difference between a CT scan and an MRI scan. Ulrich, can you tell us a little bit about the difference and kind of in a nutshell what would be the concern for patients? I know that some patients are concerned about the potential for radiation exposure with CT scans and MRIs use magnetic fields and there's no ionizing radiation in there. So should everybody have an MRI?

Dr. Rassner: No, not everybody should have an MRI. It depends very much on the question that we're trying to answer.

In general terms, a CT is a fancy X-ray. And fancy in the way that we acquire a lot of individual X-rays and then the computer can assemble them and allow us to have cross-sections like we're cutting through the patient. And that is tremendously helpful with complex anatomy. So for example, the facial bone fractures, where if you tried to figure out what is going on a plain film on an X-ray, it is very difficult because there are so many overlapping structures. While on a CT scan, you can see them to much greater detail and see what is injured and needs treatment.

Dr. Miller: Now, how about the MRI? Does it not do the same thing?

Dr. Rassner: The MRI does do the same thing. However, MRI uses the magnetic properties of tissues. So when we put the patient in the scanner, and the scanner's a very powerful magnet, the patient actually will become magnetic while they are in the scanner. And then we can manipulate that magnetization in the patient with radio waves and they are just the same wavelength as a TV channel or so you might tune in.

Dr. Miller: But that's not dangerous.

Dr. Rassner: That is not dangerous and there are very specific guidelines from the FDA in how much energy we can put in a patient. But there is no ionizing radiation so there is no cancer risk associated with that.

Dr. Miller: Now, a CT scan's ionizing radiation exposure is multiple times that of a plain X-ray so get that better imaging, it comes at a cost of greater ionizing radiation.

Dr. Rassner: With CT, yeah. CT has higher radiation doses than a radiograph, but in a lot of cases, the added information that you get is beneficial. And also, in some cases, for example, if you want to look at the skull with a radiograph, you need a lot of different views so you can't just look from the front. You may have to look from the side and then obliquely, and so all those individual radiographs can add up to a similar dose as a CT and yet you don't get as much information out of them. So sometimes, doing the correct study or the better study right away can actually save radiation, rather than doing the first one and then decide, "Well, we can't actually see what we need to see."

MRI, again, just to come back to that point, looks at a magnetization, and then we can look at tissue property. In a sense, when we manipulate it with the radio frequency waves, how long do they stay magnetized and how long does it take to regain magnetization? And the differences between soft tissues is quite striking with that and so we can resolve soft tissue detail that is invisible in CT. And so we can pick up lesions that cannot be seen with other imaging studies. And there are certain things we can see and certain things we cannot see so we are basically looking at hydrogen in the body, which is mostly is in water and which is in fat. And so those tissues that contain that, we can see very well. Other tissues, like bone, we do not see directly. We see the bone marrow, but not the bone.

Dr. Miller: So tell me how a patient would know or how they might sense they would be better off with an MRI versus the CT. I mean, there are a lot of articles out now in the press about the dangers of ionizing radiation. And some patients may think that they should have an MRI just simply because it doesn't have any exposure to ionizing radiation. We talked a little about the need for CT scan for certain types of tissues in the body and MRIs look at another set of tissues in the body, maybe better than the CT scan. So what would a patient to sort of distinguish whether they would benefit most from an MRI or a CT scan?

Dr. Rassner: It depends very much on the question that's trying to be answered. And again, if there are certain soft tissue tumors, it might easier to see them with MRI than with CT, but there is no general rule. What also enters into the equation is that an MRI scan is a much longer study.

Dr. Miller: More expensive, perhaps?

Dr. Rassner: More expensive, as well and in part because it is longer. So while a CT scan, the actual scanning part, may take 10 seconds, an MRI examination may take 50 minutes to an hour or even longer. And so a lot of images, to just acquire them, may take on the order of five minutes. And so, for example, if you're imaging the chest, you can hold your breath for 10 seconds, but you can't hold your breath for five minutes. So there may be much more issues with breathing motion so some lesions that are easily seen on CT, we might see as well on MR because there's a lot of movement during the examination.

Dr. Miller: I suppose one appropriate question from a patient might be, "Have you discussed with radiologists which test might be best for me?"

Dr. Rassner: Yeah.

Dr. Miller: I don't think that happens very often, but that could be a very good question for a practitioner to hear. "Have you discussed that with the radiologist," and that might give them some additional comfort in which test was being ordered.

Dr. Rassner: Yeah. We are always happy to discuss it with our clinicians, and in fact, it often helps us, especially in complex cases, when we do know more of the history of the patient and what is specifically of concern, especially with MRI. The MRI is a much more targeted exam and there are many different ways we can acquire images. And we target those for a specific question. And so, in difficult cases, having that specific information helps us do the best study for that question.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: July 31, 2018
originally published: January 28, 2016

Interviewer: Fish that can repair their own brain up next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs, the Science and Research Show is on The Scope.

Interviewer: I'm talking with Dr. Adam Douglass, Assistant Professor of Neurobiology and Anatomy at the University of Utah. Dr. Douglass, you have this cool result where fish basically repair their own brain. Tell me what you saw?

Dr. Douglass: In particular, we're interested in populations of neurons in the fish brain that release dopamine. So its cells that make the neurotransmitter dopamine release it into the brain and in figuring out what those cells do to behavior. Within our department, I collaborate closely with a group led by Rich Dorsky, whose lab is also interested in fish brains, but in different aspects of it, in particular, regenerative aspects of it.

The experiment that we did with Richard's lab was to ablate those neurons initially using a chemical technique that caused all of the cells, give or take a few, to disappear. What we found is that over the course of almost immediately, really, starting within a day or two of the ablation, the cells start to grow back such that by a couple of weeks after the initial insult in which we've destroyed the cell population, we have a number of neurons in the structure making dopamine that's almost identical to the number that we started with.

Interviewer: You also saw that the fish were able to regain their behavior too.

Dr. Douglass: Right. What we found is that immediately following the ablation and coincident with the loss of these dopamine neurons, the fish swim a whole lot less. If you put a group of young zebrafish, baby zebrafish into a dish, they normally swim around out pretty ruddily. They keep moving continuously and in contrast, after the ablation, the fish more or less just laid there. They could still move and, in particular, it was encouraging to see that if you startle the animals by tapping the dish or leaning over it; things that they normally don't like and try to get away from, they still swim around quite a bit. So it wasn't just a gross defect in the animal's ability to move. It seemed to be something related to its motivation to do so that was missing.

Interviewer: The fish have motivation?

Dr. Douglass: Yeah, they normally like to swim.

Interviewer: And that was able to come back over time after you . . .

Dr. Douglass: Yeah, and it came back in a way that more or less directly paralleled the regeneration of the neurons that we had killed. So while we think that there're probably other regenerative events or neurogenesis events that are ongoing in hypothalamus, some of which may have been upregulated following the ablation of these cells, the fact that the behavior comes back in a more or less proportional way relative to the number of these cells that are present makes us think that these probably are the neurons that are responsible for setting these weights, these tendencies to move or not move. And we are able to support that using other experimental techniques.

Interviewer: So you think a specific cell type regenerates and mediates this recovery. What cell type are you looking at and why is it interesting?

Dr. Douglass: The cells that we study make dopamine, this neurotransmitter which most people have heard about in the context of reward and things like addiction. It's certainly interesting in those contexts, but it turns out that dopamine does a lot of different things in human behavior as well as in fish behavior. For instance, as anybody who's learned about Parkinson's disease knows, dopamine neurons have a very important connection to locomotor behaviors, movement behaviors in every system where dopamine neurons exist.

There's also a variety of other stuff, literally dozens of different behavioral functions for this one neural transmitter. And one of the things I find interesting about this is that we have a poor ability to explain exactly how one molecule does so many different things in behavior. The answer at some level is almost certainly in the fact that there are multiple different brain regions that contain different populations of dopamine neurons. What my lab is trying to do is the relatively straightforward task of seeing what happens to behavior when you manipulate activity in these cells.

Interviewer: Do you think other cells in the brain might be able to regenerate this way as well?

Dr. Douglass: Historically, there's been this notion that brains don't grow back. Certainly the human brain . . . that its regenerative capacity that's capacity for new cell growth falls to zero following very early development. What we've come to realize over the past decades is that that's not true. It's a reasonable approximation for how the system works in the sense that neurogenesis does really fall off as you enter into adulthood and, unfortunately, cell death does increase.

But as people have looked more closely, they've realized that there are several brain areas where there's a significant amount of neurogenesis going on all the time through adulthood. That includes the area of the brain that we're studying, the hypothalamus, both in mammals and in fish exhibits lots of new cell growth.

Interviewer: Are there any implications for what this could mean for us?

Dr. Douglass: Our work is really unique in that it demonstrates not only that there's a cell population that comes back but it's a dopaminergic cell population and it's a dopaminergic cell population with a direct function in locomotor behavior. If you look at mammalian systems, unfortunately, the substantia nigra, the brain area containing dopamine neurons that are affected in Parkinson's disease, is not regenerative. That's one of the reasons that cell loss and Parkinson's ultimately leads to massive defects in locomotion and ultimately the inability to move.

Our brain area, the hypothalamus, which contains the dopamine neurons that we're studying is not functionally equivalent to the substantia nigra in a strict sense, but the fact that these neurons in fish are both connected to locomotion and have the ability to regenerate probably hold some clues as to how regeneration might be made to work in the human brain areas that are affected by neurodegenerative disease.

It's not to say that we're on the brink of having some therapeutic insight to this. That's far from the case, but I do think that it's reasonable to think that we'll learn something about how these systems work and potentially what's missing in the case of the substantia nigra dopamine neurons that makes them not able to regenerate. If you can identify those things, then that gives you potential sites for therapeutic and intervention down the line.

Announcer: Interesting, informative and all in the name of better health, this is The Scope Health Sciences Radio.

Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: So I understand that you can get these deep brain stimulation kits and use them at home. Is that correct?

Dr. House: Folks are not doing deep brain stimulation at home yet, but they're starting to do what we call a direct transcranial electrical stimulation. So, essentially, they go to Radio Shack, get a 9-volt battery, you get a small adapter and it can put a small electrical current in between two pads that people then tape to their head at various locations.

Interviewer: Okay. Is this a good idea? I don't know. It sounds a little Frankenstein to me.

Dr. House: That's a great question. I don't endorse that. I don't do that myself, but it's an emerging field about what this could possibly do, both good and bad.

Interviewer: Why are people doing that? What do they hope to gain out of hooking electricity up to their brain at home?

Dr. House: I think folks have been doing this ever since the battery was invented essentially, with the idea of trying to augment certain abilities at different times or treat depression, for example.

Interviewer: All right. Is there any research that shows that this is okay to do at home or there is a benefit to doing it?

Dr. House: So this is where it gets complicated, of course. There is some research, there is a large amount of research using different amounts of electrical stimulation in the brain and even using some non-invasive stimulation. For example, using transcranial magnetic stimulation to differentially affect the brain.

Interviewer: Now, this something a doctor would do in his office

Dr. House: That's right, these are things that a doctor would do. And so there is emerging evidence about the utility of those procedures. But this low-current direct electrical stimulation that people are doing at home actually is now being formally evaluated in a few different instances. So there might be some benefits to it, but there is also some emerging literature that, for example, you can temporarily make your math abilities worse by putting the electrodes in the wrong location. So I wouldn't just try it willy-nilly at home yet.

Interviewer: Are there dangers of doing it at home?

Dr. House: Yes. At the extreme end, if you're hooking up a car battery, sure, you can . . .

Interviewer: Okay. Are people doing that?

Dr. House: People will try lots of extremes. Of course, you could have burns just from the electrodes. You can induce seizures if things get severe enough. Sort of the good news is that there is not a wealth of reports of injuries of people doing this yet. I think with the Internet, there are some forums and that sort of thing where they suggest levels for people to start at that have been proven relatively safe. But, again, I wouldn't just go out and try it.

Interviewer: So I'm still back on even the beginning of this conversation, people go to Radio Shack and build these things. Are there actually commercially available brain stimulators like this that people are buying?

Dr. House: I don't know if there are formally commercially available one or if this is all you sort of buy the parts and put it together yourself.

Interviewer: So this is really a do it yourself sort of a thing?

Dr. House: Yes, this is a do it yourself, DIY it kind of movement, kind of issue.

Interviewer: As a physician, what is your opinion about brain stimulation at home and its rise of popularity?

Dr. House: It's a very interesting time because, from the scientific standpoint, I'm very interested to see if anything is learned by people doing this in large numbers. But, at a personal, individual level, I'm a bit concerned about people doing this at home.

Interviewer: So it sounds like you've been monitoring this. What are people saying this on these forums, like the benefits that they get?

Dr. House: Yeah. So there are reported benefits in everything from mood disorders, personality disorders, just enhanced cognition or enhanced creativity, for example. It's like anything, people report lots of positives and we don't really know if there are many negatives that aren't being reported yet.

Interviewer: And, of course, it's not a scientific method, rigorously . . . I don't have the words, but data is very empirical.

Dr. House: That's right. And everybody is their own best friend and worst enemy in that regard. Something good happens so you're going to blame it on the electrical stimulation and if something bad happens that was just fate.

Interviewer: So what's your final take on this whole thing?

Dr. House: I would not do this at home. That is my final take

Interviewer: All right. So if you're a parent and you have a kid that's doing this at home or you think it's helping, you might want to stop it
Dr. House: Yeah, that's right.

Interviewer: Could it be possible that an actual physician could help solve the problems that people are trying to cure with deep brain stimulation, or is it truly just I want to get smarter?

Dr. House: Sort of all of the above. Not to be too vague, but there are many of the conditions that people are trying to treat that do have very robust, well-established medical therapies that we might be able to help with. There are the other folks that are just trying to make themselves smarter. Right now, we don't have a pill for that.

Interviewer: Yeah, sure. So if they're trying to solve some other problem, does it frighten you that maybe they are not seeking out medical attention, that they are doing it at home?

Dr. House: Well, of course. Yeah. I think that there are limits to medical therapy, of course, but I think lots of time folks just don't really know what all is available. The interesting part is that this is getting a lot of press right now. Wired Magazine had a cover article about it; New York Times has an article about it. So there is certainly a lot more out there, but I think there are a lot more questions that need answers at this point.

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Interviewer: A Link Between Methamphetamine Use and Parkinson's Disease, up Next on The Scope.''

Announcer: Examining the latest research and telling you about the latest breakthroughs, the science and research show is on The Scope.

Interviewer: I'm talking with Dr. Glen Hanson, Interim Dean at the School of Dentistry at the University of Utah and Director of the Utah Addiction Center. You've done some researching looking at a long-term and serious side effect of meth use. What did you find?

Dr. Hanson: We were interested in the dependence on drugs, such as methamphetamine and the amphetamines, and we knew -- we've known for quite a while -- that it interacts with that part of the brain that is associated with the neurological disorder known as Parkinson's disease. And from animal studies, our findings suggested that it may lead to Parkinson's disease in humans, and that's what the study looked at. We found that there was a connection between that dependence on these compounds and Parkinson's disease.

Interviewer: So meth use increases your risk for getting Parkinson's disease. How much of an increased risk do you see?

Dr. Hanson: In the general population, it's about a threefold increase.

Interviewer: This increased risk factor for getting Parkinson's disease is one of actually many terrible side effects of meth use.

Dr. Hanson: Correct.

Interviewer: And is this really the first long-term effect that we know of?

Dr. Hanson: It is, that has looked at a neurological piece to it. We know, in human studies, there are changes in some cognitive functions in people who are long-term users, and they find that some of these neuropsych determinants or elements are still compromised in these people, things such as memory. But even these studies typically only go out two or three years, and none of them have asked the long-term question, ''What neurological diseases may happen down the road to this population of amphetamine users?'' These studies are the first ones to show that this long term, maybe ten, twenty years after you've had the amphetamine problem.

Interviewer: So maybe we can back up a second and you can remind us what Parkinson's disease is.

Dr. Hanson: Parkinson's disease is associated with a fairly select group of pathways in the brain that are involved in motor control, and so some of the earliest signs of Parkinson's are things such as tremors, usually hand tremors, the way someone walks, their posture, they tend to become stooped.

Interviewer: And so you were mentioning in the beginning that there's a particular pathway in the brain that leads to Parkinson's disease. You've also shown that, at least in an animal model, that class of drugs can also damage that part of the brain.

Dr. Hanson: So this pathway uses a chemical called dopamine, and dopamine is a big player in mobility, in behavior, in movement. So there is a selected pathway called the nigrostriatal pathway that methamphetamine or the amphetamines damage when they're used continually and they're used in high doses. So the same pathway gets damaged in Parkinson's. A general figure is that if you damage 70% of that pathway, then you start to see signs of Parkinson's disease.
In everybody, that pathway deteriorates over their lifetime, but most of us die before we reach that critical 70%, so the disease doesn't show up. However, if you take a drug like the amphetamines and it pushes you down that pathway, 20% or 30%, that means you're more likely to hit that magic 70% plateau before you die, which means you're going to have Parkinson's because you got pushed down the pathway earlier on because of your drug use.

Interviewer: Getting this information out there, what do you hope that will accomplish?

Dr. Hanson: We would hope that it would educate the population that there are long-term consequences to misusing drugs in general, not just the amphetamines, but other drugs. As we start to discuss things about, "Do we legalize this? Do we legalize that,'' oftentimes we're not asking the long-term questions. We're asking short-term questions, but we don't say, ''Might there be something showing up in 20 years or 30 years?'' Here's Parkinson's, obvious, but what about other neurodegenerative diseases? May they also be linked? Something like Alzheimer's, may that be linked, and some of these other neurological consequences? So we probably need to be looking at that more closely than what we have done in the past.
Now, we focused on the abuse side. That takes you down the road of: 'Well, what about legitimate use, therapeutic use? Are there drugs we're using for long periods of time, and for good medical reasons . . .

Interviewer: Right.

Dr. Hanson: . . . but they may be doing things, should we look at some of these databases and see is there long-term neurological or psychiatric consequences to them that we're not seeing when we just do our short-term studies?

Interviewer: Right, and you did make the point earlier, when we were talking, that methamphetamines are actually in a larger class of drugs called amphetamines, of which there are many kinds, some of which are used under clinical supervision.

Dr. Hanson: Correct. Well, methamphetamine and amphetamine are prescribed. These are Schedule II drugs. But is there consequences? Is there just the dependence situation, where you're using large doses, and maybe you're binging with it and you're injecting it versus therapeutic doses, which are smaller, you're taking them orally, and we need to look at that. My inclination would be I think that there is a difference. Some of the studies we've done in animals say that the brain responds very differently when it's done with therapeutic caution versus when it's done with abuse abandonment, but we need to make sure that that's the case when we look into our human cohorts.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.

Dr. Miller: You have a tremor in your hand. What's that all about? This is Dr. Tom Miller here today to tell you about that on Scope Radio.

Hi, I'm here with Dr. Lauren Schrock. She's an assistant professor of neurology and specializes in movement disorders. Today, she's going to help us try to figure out what tremors are about. Lauren, my patients talk to me about tremors pretty frequently, and there are different kinds, right? Could you clue us in and tell us a little bit about the different kinds of tremors that people might experience.

Dr. Schrock: There are several types of tremors, but there are two most common ones that people will see in friends or family. Those include Parkinson's disease tremor and . . .

Dr. Miller: That's the one you don't want to have, right? That's what people, I think, might be worried about.

Dr. Schrock: That's what people worry about most commonly when they come in, actually, but they happen to have something called essential tremor.

Dr. Miller: That's more common.

Dr. Schrock: That's more common than Parkinson's disease. There are clear differences between the two. With essential tremor it's mostly tremor, and that's your main symptom. What's unique about it is it doesn't occur when you're resting. If you're resting and not doing anything, your hands are very still, whereas when you try to do something with your hands, such as writing or even holding a coffee cup, your hands will be tremoring. That's something unique.

Dr. Miller: This is interesting, because I remember my grandfather when he reached out to pick up his peas with a fork he would have a lot of trouble with that. Then, of course, when he was resting he didn't have that tremor. He would always tell me that he thought this was Parkinson's, and I guess that's not true.

Dr. Schrock: That's a common misconception, and people really worry about it. That's what they come in frequently to my office worrying about. The reason why they worry is they think of Parkinson's disease, correctly, as more of a progressive disorder.

Dr. Miller: They worry that that might be the start of a long, progressive problem. Essential tremor, it can start mild and stay mild, or does it progress also? Does the essential tremor get worse?

Dr. Schrock: Essential tremor definitely can get worse. Really, when it comes down to it, probably two decades from now we're going to find out there are many different types of essential tremors. There are a lot of varieties of the different severity of tremor, what part of the body it includes. Most commonly . . .

Dr. Miller: So it's not just the hands?

Dr. Schrock: It's not just the hands. Head tremor can be involved, head and voice tremor.

Dr. Miller: I've heard some people that sound like their voice is almost trembling when they talk, and you wonder if they're anxious. Actually, it's the essential tremor, that type of tremor at least, right?

Dr. Schrock: It definitely can be. There's one other thing that can be mixed up or misdiagnosed as essential tremor, and that's something that's much more rare, so most people haven't heard of it. It's something called dystonic tremor, something when someone has dystonia, meaning abnormal spasm of a muscle that causes either pulling or abnormal postures.

Dr. Miller: Is essential tremor mostly in both hands, or is it usually in one?

Dr. Schrock: In most people, essential tremor will come on in both hands. Most patients who come in will complain of it more in their dominant hand, of course, but when you actually examine them they'll have the tremor in both hands. Whereas with Parkinson's disease, by definition it starts with one hand and at rest, so the Parkinson's tremor will be where someone is just sitting down. You see their hand moving on its own, tremoring rhythmically. Often, people describe it as a pill rolling tremor. You'll see the movement of the thumb and the finger kind of together.

Dr. Miller: But the essential tremor is a little finer tremor, it's worse as you move towards something or try to do something. It's a finer base tremor. I guess sometimes it can actually be a pretty marked tremor, depending on who has it.

Dr. Schrock: Yeah, it can become severe. Most people don't come into a doctor for essential tremor. There's a lot more essential tremor out there than we see in our clinics.

When people have done studies just knocking on doors and seeing if someone has tremor, the rates are much higher than would be estimated just by how many people come to clinic. Because the majority of people, really it's probably relatively mild, so they don't see a physician about it. In general, when you look at essential tremor you can have some people who have a very fine tremor, almost even a jerky sort of tremor, and then you can have other people who will have a tremor that is much more severe. For example, when they hold up their hand in front of them their finger may move up to three inches.

Dr. Miller: Wow, that would be very difficult to live with, I would think. Do essential tremors travel in families? Are they associated with a family history? Because many of my patients will say, "Yeah, I really haven't worried about it because I knew my dad had it and his mother had it."

Dr. Schrock: Yes. It's very common to see essential tremor strongly travel in families. In medical school, we're taught that it's what they call autosomal dominant disorder, so that each child has a 50 percent chance of getting the gene.

Dr. Miller: Is that still true? Does that hold?

Dr. Schrock: I would say there's definitely a sub-group where you definitely see that, but as I mentioned before, essential tremor probably includes many different tremors, some of them where you see clear family inheritance and others where you actually don't.

Dr. Miller: What about the age difference when these tremors might develop? Does the Parkinson's tremor occur a little bit later, that pill rolling tremor you described? Is that a little bit later on in life, or essential tremor earlier in life?

Dr. Schrock: On average, when you look at the large groups, you will see that essential tremor comes on a little bit earlier than Parkinson's disease. However, even within a single family who has multiple family members with this essential tremor, you may have one family member who has the onset at age 20 and another family member at age 75. There really is not a clear indicator of what your diagnosis is based on the age of onset.

In Parkinson's disease, the large majority of patients have their onset in their 60s, 70s. However, there is a small subset of patients who can have early onset Parkinson's disease. A great example of that would be Michael J. Fox who had his onset around age 30.

Dr. Miller: Also, tremors are related to certain drugs, I think. A lot of us think about people who maybe are withdrawing from alcohol having a tremor. Is that actually a tremor? Is that something that is separate from what we've been talking about?

Dr. Schrock: The answer is yes and no. You can get that with certain drugs. Most commonly, I'm thinking of drugs that block dopamine. That would be in a class of medicines called anti-psychotic medications or medications that can be used for mood stabilization. An old one is called Haldol. Those can cause a Parkinsonian tremor. That's a very true tremor. The tremor will go away when the medication is taken away, but it may take up to six to 12 months for the tremor to actually go away.

Dr. Miller: A long time. I didn't know that.

Dr. Schrock: Then, there is another. You're talking about withdrawal of alcohol, for example, or someone who is under stress. This is something I often describe to my patients who have tremors, because tremors always worsen with stress, whether it be stress of having the flu or stress of having your mother in law coming to dinner.

Every single human being has the potential to have tremor. What we call that is physiologic tremor. Whenever someone is extremely hungry, didn't get enough sleep, they will get some very fine tremor in their hand. There are sayings called to shake with rage. Well, there's a reason for that. Because humans . . .

Dr. Miller: I've had that. It seems like that's about three times a week.

Dr. Schrock: . . . have a natural inherent tendency to have some tremor during times of stress.

Dr. Miller: What would you say to the person that develops a tremor? Should they see a physician about the type of tremor they have if they're concerned? Could they by looking on the web to figure out if it was an essential tremor and maybe diagnose themselves?

Dr. Schrock: In self-diagnosis, I've definitely had patients who've correctly done that, but I would beware. I think that anyone who has a tremor and has a concern about it should bring it up to his or her primary physician. If you're worrying and it's bothering you, then you definitely should see a physician about it.

Dr. Miller: Finally, there's treatment for both types, correct?

Dr. Schrock: Yes. There are treatments for both types. They are very different, the approaches to treatment.

Dr. Miller: That would require a physician to make the diagnosis and provide the treatment. Thanks very much, Dr. Schrock.

Dr. Miller: Advanced Parkinson's disease and movement disorders. We're going to talk about what to do next on The Scope radio. This is Tom Miller.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm here today with Dr. Lauren Schrock. She's an assistant professor in neurology and in charge of the movement disorders program. Lauren, we're going to talk about sort of advanced Parkinson's. I think it's pretty well known that after a period of time, a lot of folks who responded to medications and treatment of their Parkinson's start not doing as well on the medications. I think the thing that we would like to talk with you about today is that there are new therapies and those involve deep brain stimulation. When should a patient maybe start thinking about this option of treatment and whom they should be working with if they're thinking about this option for treatment?

Dr. Schrock: When medications start causing complications is often the term we use in Parkinson's specialists. Basically, over time, medicines don't last as long and they wear off in between doses and people can develop dyskinesias.

Dr. Miller: Yeah, what is a dyskinesia for our listeners?

Dr. Schrock: Dyskinesia is an extra involuntary movement. It almost looks like a wiggling and a squirming. The most known person who most people have seen have this issue publicly would be Michael J. Fox. That wiggling back and forth. That is something that can be caused by a combination of both having the Parkinson's disease and also having taken Parkinson's disease medication.

Dr. Miller: Did Mohammed Ali have a deep brain stimulation device implanted? Do you know?

Dr. Schrock: No. Mohammed Ali did not, as far as I know. His Parkinson's is likely thought to be a secondary Parkinson's disease related to the multiple hits to the head. In that type of Parkinson's disease, that's caused by something else, it's not expected to respond to deep brain stimulation.

Dr. Miller: Okay. Good to know.

Dr. Schrock: Very important point about when a person is considering, "Should I have deep brain stimulation?" because there are many things that go into predicting whether someone will respond well to deep brain stimulation and how they will do afterwards.

Dr. Miller: So tell us about how someone makes the decision about inquiring on this new type of treatment.

Dr. Schrock: I'm going to actually start with one and explain what it is a little bit more. If you imagine almost like a brain pacemaker, in the same way that people have pacemakers to help their heart keep beating, in Parkinson's disease there is something called deep brain stimulation where a wire is placed deep down within the brain. When it's in place it's often not very visible. Some neurosurgeons are going to pay a lot of attention to the aesthetics of it and others put it in the way it was designed, so to speak.

With deep brain stimulation, the first thing you want to do when you're considering asking the question of whether it would be appropriate is you'd want to see a specialist in Parkinson's disease. That would be a type of neurologist who specifically has done specialized training in things like Parkinson's disease and tremors.

Dr. Miller: Both medications and in the deep brain stimulation.

Dr. Schrock: Absolutely. Yes, in medications. Because many of my colleagues, who are involved heavily in D.B.S., like myself, really will say the most important visit is the visit with the Parkinson's specialist or we call movement disorder specialist. It's not uncommon for me to be able to work with a patient and actually say, "Oh, why don't you try this medication change," and then they call and say, "Oh, cancel that neurosurgery idea," which is deep brain stimulation.

Dr. Miller: So that must mean you also have close ties to the surgeons who implant the deep brain stimulation devices. Is that correct?

Dr. Schrock: Absolutely.

Dr. Miller: So you're working with them pretty much hand in glove to design a therapy and treatment for the patient.

Dr. Schrock: Absolutely, because our goal is to have good outcomes in all patients we select. So we have special selection procedures to be able to ensure that, voiding any complications with the surgery as can happen with any type of surgery, that patients are going to do well and have improvement in the symptoms that they want to have improvement in.

Dr. Miller: Now what percentage of patients that you see will benefit from a deep brain stimulation device?

Dr. Schrock: Usually, when we think about a patient who's going to be ready for deep brain stimulation, is someone who despite optimizing their medicines is having lots of ups and downs where their medicines are wearing off and they've developed dyskinesias. They also have not developed significant problems with memory and thinking. Early on in D.B.S. most centers would say maybe 10% of their patients who were referred for deep brain stimulation would actually be candidates.

Dr. Miller: So one out of 10.

Dr. Schrock: Yeah.

Dr. Miller: One out of 10. Okay.

Dr. Schrock: However, I would say that our regional neurologists are very well educated around here and I would say that 70% of the patients who are referred to me specifically for the question of deep brain stimulation end up going on into deep brain stimulation within two years of that referral. So I really feel fortunate here. We have great neurologists in the area who really know what the indications are for the therapy.

Dr. Miller: Once this is put in you're able, just like with a pacemaker for the heart, to make adjustments in the way that you'd provide the treatment.

Dr. Schrock: Yeah, absolutely. So this is not a straight forward, like a medication sometimes can be. What you have is, with deep brain stimulation, you place this wire but it's going into a target in the brain that's about 3 by 6 by 6 millimeters. That target in the brain has several different sub areas that we have to get into. So we have to get into the little motor sub territory so any error more than 2 millimeters in our targeting is the difference between a success and a failure of surgery. So I'm dependent so much on the skills, excellent skills, of the surgeon for my ability to have great outcomes.

Dr. Miller: You say great outcomes. Tell me about that because you've got this person now that's sort of resistant to the medications. They've got the dyskinesias as you've mentioned. What do they see happening if it works?

Dr. Schrock: This only helps with what they call the motor symptoms of Parkinson's disease. So deep brain stimulation helps with tremor, slowness of movement, stiffness in the muscles as well as dyskinesias. So if you imagine a person with Parkinson's disease who's been taking medications for several years, when the medications now are only lasting every two to three hours, some people only one hour before they wear off, they can't count on any certain time. They can't go to a play and expect to be able to . . . they don't know if they're going to be able to get up and go home.

So what deep brain stimulation can do is by helping control these symptoms it can really give the person confidence in their day. That they're not going to go somewhere and get stuck. They're not going to go somewhere and start to have these wild dyskinesias that are going to be embarrassing for them. So really it's more of a smoothing out of the symptoms during the day.

Dr. Miller: How long can one expect to see that benefit from the deep brain stimulator?

Dr. Schrock: There's been growing research looking at the length of time and what symptoms are helped as time goes on. The early studies were one to three years out and showed there was very good persistence of benefits. Then we have now five-year and some 10-year studies. What they show for the symptoms that we expect it to benefit such as tremor, the dyskinesias, those continue to be well controlled even at 10 years.

Immediately after deep brain stimulation we often reduce medications anywhere from 30 to 80% but we have to gradually increase those medicines over time. What does gradually get worse is the slowness of movement. We aren't able to keep up with that as much as we are with tremor. The symptoms that D.B.S. doesn't help in the first place and those include balance, speech, freezing of gait where they get stuck and they can't keep moving, and memory and thinking issues. So all these things that D.B.S. didn't help in the beginning, at 10 years out those are the major issues.

Dr. Miller: But still, this is a great therapy to help people live a better life.

Dr. Schrock: Absolutely. As far as quality of life, all the studies that have looked at comparing optimization of medications or best medication management versus deep brain stimulation in patients with Parkinson's disease have shown much better quality of life in those with D.B.S. as compared to medicines alone. Many patients will explain to me they feel like their disease has been taken back five or 10 years.

Dr. Miller: It sounds like if you're a patient with Parkinson's or a physician's taking care of a patient with Parkinson's and they're staring to develop dyskinesias and they've been on the medications and they've been increasing the doses of the medications and things just aren't getting better, it probably is time to consider referring them to a movement disorder specialist in neurology.

Dr. Schrock: Earlier referrals are always better because we're never going to recommend surgery before it's needed and we can always provide education so you know when the time might be right.

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updated: April 16, 2019
originally published: May 13, 2014