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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.

Dr. Jones: There are many ways that women's brains are different from men's brains. But what about when brains get bonked like a concussion? Are they different? This is Dr. Kirtly Jones from Obstetrics and Gynecology from University of Utah Health, and this is The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Dr. Jones: As a reproductive endocrinologist, I am interested in the sex differences in the brain and behavior between men and women. Sex differences are differences that are related to sex chromosomes and sex hormones. Of course, I'm also interested in gender differences. Gender differences are related to social and societal norms for behavior that are different between men and women.

When it comes to brain and behavior differences between men and women, there are sex and there are gender differences, and of course they're linked together in many but not all cases. For instance, the verbal part of the brain in women is generally comparatively bigger in women than men. We think that is probably related to hormones and early development, but we're not sure.

However, after babies are born, do moms talk to their baby girls differently than baby boys? That would be a gender difference. If women talk more than men on an average, is that a sex difference or a gender difference or a combination of the two? Women have significantly more migraines than men. We're pretty sure that this difference is largely hormonal, a sex difference and not gender, but it's complicated. Women are more likely to complain of headaches of any type than men are.

Okay, let's get to concussions. Men are more likely to have concussions than women. This may be related to the sports that are prone to concussive interactions: American football, hockey, boxing, you know. It may be related to the fact that men are more prone to risky behavior: cliff jumping, motorcycle riding.

Some of these are sex differences. If a women could get as big and as muscular as a defensive tackle, could she play high school or college football? Unfortunately, there are social situations in which women are much more prone to head injury than men such as domestic violence. So this makes it hard to study differences in closed head trauma in women and men. So if you pick a sport where the rules are the same for women and men and the sport engages a lot of women, then you can begin to study differences.

Soccer is a good case in point. In studies comparing concussion rates in soccer players, women have more concussions than men. Not a lot more, but a little more. Now we get to the interesting sex and gender issues. There are sex reasons why women might be more prone to concussion than men in soccer. Men have larger and more muscular necks so they can brace their head better, less snapping of the neck and shaking of the brain. Women may be slightly more likely to verbalize their symptoms after concussion, therefore they're more likely to be reported and counted. There is evidence that men are slightly less likely to report concussions. Studies show that both male and female athletes will lie about symptoms after head trauma to stay in the game, men about 79% of the time and women about 70% of the time. Actually, these numbers are really terrifying if athletes are so willing to cover up potentially dangerous symptoms.

Now, the hormone part is very interesting. One study of women who were hospitalized for concussion looked at women's hormonal status at the time of concussion. Women who were hurt in the early part of their menstrual cycle when there's just estrogen around, had on average longer times to recovery than women who were in the second half of their cycle or on birth control pills when progesterone or progestin hormones in the pill were around. This was added to some research in rats that suggested that rats that were given progesterone, a woman's hormone, immediately after head trauma, had less adverse brain effects. In the rat case, you can control for sex and gender, and the degree of head trauma.

This led to an early study of giving head trauma patients, both men and women, progesterone after head trauma to see if the brain was less damaged and recovered faster. The early studies suggested that progesterone was somewhat protective, and that was really exciting to me. Of course, most all of us are exposed to truly horrifying head trauma during a normal vaginal birth, but our brains are swimming in progesterone from our placenta so maybe that's protective. That aside, a larger randomized trial of progesterone treatment in head trauma didn't show a difference in outcome.

So what should we do about this? Of course, the National Brian Bank is looking for brains after death of men and women who've been exposed to concussions and is hoping for more brains. Of course, we're sad. We don't want people to die early, but if you do and your brain is useful, that would be something you could do. This bank has made news in their work on chronic traumatic encephalopathy, CTE, in the brains of athletes who died who were exposed to multiple concussions. To date the Bank in Boston University has detected CTE in 236 of 377 brains donated to the research lab. But only four of those brains belonged to women, and none of those women's brains had CTE.

There are more and more studies of women and concussion, and that's encouraging. There's a website and national non-profit organization called Pink Concussions to raise awareness of concussion in girls in women. Most importantly, if a girl or a woman has a head bonk and sees stars or has a temporary change in consciousness, not necessarily losing consciousness, she should stop what she's doing and be evaluated. Any sport that encourages using the head as a tool or a target: heading the ball in soccer, hitting the bead in boxing, should have the rules changed to protect men and women and boys and girls. And don't get me started on football.

To search The Scope website by putting concussion in the search box, you can learn more. Thanks.

Announcer: Want The Scope delivered straight to your inbox? Enter your email address at thescoperadio.com, and click "Sign Me Up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

Interviewer: Are you struggling with the decision whether or not you should let your kids play sports because of the danger of concussion? Dr. Greg Hawryluk is a concussion expert and neurosurgeon. Give us your perspective.

Dr. Hawryluk: The first point is that we don't want people to be overly concerned about concussion. There are so many benefits to sporting activities. We're seeing very high rates of childhood obesity. Sports are good for you. We don't want people being pulled out because of fear of concussion.

The second point is that we really want to encourage players to respect their own bodies and the bodies of their competitors. We don't want them using their heads as a battering ram. They need to be using proper tackling technique.

The third point is we really want the coaching staff to have the proper training and experience where they can recognize concussion, they understand the importance of it, and so they know how to take the right steps if concussion happens to one of their athletes.

updated: June 10, 2021
originally published: April 18, 2019

Interviewer: Common sports injuries that end up in the ER, that's next on The Scope.

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

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Healthcare. He wanted to talk about some common sports injuries that could end up in the ER. What are some of the things that you commonly see as a result of somebody engaging in some sort of activity?

Dr. Madsen: One of the biggest things that we see, and I think one of the biggest areas of concern recently, is concussions and head injuries. By definition, if your child gets hit in the head with a ball, or they are playing football, and they're kind of woozy afterwards, or they lose consciousness, or they're nauseated, or they have a headache, by definition they've had a concussion. So that's a case where the brains been kind of shaken up, causes those symptoms, and that can have some long-term consequences, so that's absolutely a time to get medical attention.

And then the question becomes, so okay, do they need to go to the ER right away, or can you get them in to see their pediatrician or family doctor within the next few days? So kind of the big thing there in my mind is that if they lose consciousness, if they are just not acting right, if they are vomiting, that's a reason to go to the ER.

Interviewer: Really? Just no questions asked, if those things are happening, just go?

Dr. Madsen: Just go to the ER . . .

Interviewer: It's serious enough . . .

Dr. Madsen: It is, because there I'm not just concerned about a concussion, I'm also concerned about bleeding in the head.

Interviewer: All right.

Dr. Madsen: That's a time to get a CAT scan of the brain to make sure everything looks okay there. But, if they are confused, and then they get better, they didn't lose consciousness, they're acting okay, good reason to see the family doctor, maybe not having to rush to the ER.

Interviewer: All right. And, it's becoming more and more accepted that you should go see a doctor after something like that, not just shake it off, because there are things that the doctor can recommend to help with the recovery.

Dr. Madsen: Exactly.

Interviewer: From what I understand. All right.

Dr. Madsen: And, you need to make sure they are fully recovered over a period, often of weeks, before they get back into contact sport, because if they get another concussion within that timeframe it can be much more severe.

Interviewer: That's where you're seeing a lot of the danger.

Dr. Madsen: Exactly.

Interviewer: All right. What are some of the other common sports injuries that you see, you've got concussion, what else?

Dr. Madsen: Well, one of the other common things we see are sprains and fractures. So, let's say your child is playing soccer and they roll their ankle, you may look at it, it's swollen up, and ask yourself is this a sprain, or is this something I need to get an X-ray of this? A few things can help you out there. If they are able to walk on it, at least four steps, and they are getting around okay, and let's say you pushed on the ankle on the bone and feel the outside of the leg along the bone that runs down into the ankle, and they're not really tender on there, that's a good sign. They probably don't need an X-ray right off.

Same thing with their knee, if they are able to walk on their knee, maybe it's swollen up a bit, but you push around on the bones, you push around on the knee cap, around on the side, the outside of the leg on the bone there, and they're not really tender there, those are also good signs, may not need to rush in for an X-ray. If it's a sprain, the best thing to do for it is to put some sort of elastic wrap on it, keep it elevated, you can ice it, that might help as well, um, just uh, maybe some ibuprofen can sometimes help decrease that swelling, but it's a common thing we see and often in my mind I'm asking myself the same questions, using the same things in my mind, do I need to get an X-ray or not?

Interviewer: And let's go for number three here.

Dr. Madsen: Yeah, so number and something I do occasionally see are abdominal injuries. And one of the biggest things here, kind of interestingly that we see, and again you see it in football players, soccer players, individuals in contact sports, where something like another player or the ball, comes into contact with their belly, they can get spleen injuries. So the spleen is in the left, upper-side of the abdomen, if you push there under your ribs, that's where your spleen is.

And, it's an organ that is, if you hit it hard enough, it's prone to rupture. And I've certainly seen cases of young athletes who have come in, who have been hit there, who have a lot of pain. Maybe they have pain up into their shoulder as well, it's kind of a classic sign where they get pain not only in their upper abdomen, but also in their left shoulder, we get a CAT scan and they have a ruptured spleen.

Interviewer: Wow.

Dr. Madsen: And that's an important thing to know because spleens can bleed quite a bit and certainly if they have an injury and they keep playing and they get more injured there it can be much more severe.

Interviewer: All right. And is that something that's pretty obvious that the spleen is hurt, you touch that area and there's going to be some "aagghhh".

Dr. Madsen: Exactly. Yeah, you touch that area, they're going to hurt, and again, a reason to come to the ER and get a CAT scan to look at that.

Interviewer: All right. Three common sports injuries that end up in the ER, what to look for and what to do with them. Thank you very much.

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Dr. Gellner: It's common for active kids to bonk their heads, but when should you worry? I'm Dr. Cindy Gellner and I'll tell you all about head injuries today on The Scope.

Announcer: Keep your kids healthy and happy. You are now entering "The Healthy Kid Zone" with Dr. Cindy Gellner on the Scope.

Dr. Gellner: We've all been there as parents. You see it happening, but you just can't get there fast enough to stop it. Your child falls or gets hit in the head. The first rule: don't panic. Remember there are three main types of head injuries.

The first and most benign is a scalp injury. Most head injuries are scalp injuries. It's common for children to fall and hit their heads at some point while growing up. This is especially common when a child is learning to walk. Falls often cause a bruise on the forehead and sometimes black eyes appear one to three days later because the bruising spreads downward by gravity. Big lumps can occur with minor injuries because there's a large blood supply to the scalp. For the same reason, small cuts on the head may bleed a lot.

One head injury to worry about is a skull fracture. Severe head injuries that you can't see on the outside of the head could be a skull fracture or a concussion. Only 1 to 2% of children with head injuries will get a skull fracture. Usually, there are no other symptoms except a really bad headache at the site where the head was hit.

The one that everyone worries about is a concussion. A concussion is a mild injury to the brain that changes how the brain is normally working. It usually is caused by a sudden blow or jolt to the head. Many children bump or hit their heads without causing a concussion. Signs of a concussion can include headache, nausea and vomiting, dizziness and confusion, forgetting what happened around the time of the injury, acting dazed, or being knocked out. Of note, a person does not need to be knocked out or lose consciousness in order to have a concussion.

If your child has a concussion, there may be some ongoing symptoms such as mild headaches, dizziness, thinking difficulties or behavioral and emotional changes for several days, two weeks, or even longer. All children with a concussion need to have a follow-up with their pediatrician.

So how can you take care of your injured child? For scalp injuries, simple wound care is all that needs to be done. If the skin is split open and might need stitches, have them seen right away. If there is just a scrape, wash it off with soap and water. Then, apply pressure with a clean cloth for 10 minutes to stop any bleeding.

For any small cuts, apply an over-the-counter antibiotic ointment twice a day until the wound has healed. For swelling, put a cold pack or an ice bag on for 20 minutes. This will help their pain as well. Encourage your child to lie down and rest until all symptoms have cleared or for at least two hours. Your child can be allowed to sleep. You don't need to keep trying to wake them up continuously. Just have them sleep nearby so that you can periodically check on them.

Vomiting is common after some serious head injuries. Only give clear fluids until your child has gone two hours without vomiting. For pain, you can give Tylenol or Ibuprofen as needed, but be sure to wait two hours after the injury to make sure your child isn't going to vomit up the medicine if they hit their head pretty hard. You also don't want to mask any concerning symptoms with the pain medications.

Although your child is probably fine, watch him or her closely for 48 hours after the injury. Awakening the child to check on the ability to walk and talk isn't really necessary unless his or her breathing or sleep pattern becomes abnormal. If your child does fine for 48 hours, go about your normal routine.

It's also not necessary to check your child's pupils to make sure they're equal in size. Unequal pupils are never seen before other symptoms such as confusion and trouble walking. Head injuries will happen for your child; that's a guarantee. Being prepared for when it does happen will take a lot of the fear out of this scary injury.

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Interviewer: Recovering from a concussion, what you need to know is next on The Scope.

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

Interviewer: Dr. Greg Hawryluk is a neurosurgeon at University of Utah Health Care and a concussion expert. Help me understand what steps are involved for recovering from a concussion.

Dr. Hawryluk: It's important to know that any concussion needs to be seen by a doctor. These days even if there is a suspicion that you may have had a concussion, it's important to see a doctor. Some people have trouble recognizing the signs. It can be things like headache, dizziness, confusion, blurred vision, and just feeling funny. Sometimes those symptoms aren't apparent until maybe the next day. That's the first step is making sure you see a physician.

Interviewer: So don't self-treat. You wouldn't fix your broken arm. Don't try to fix a concussion.

Dr. Hawryluk: That's right. Don't try and fix your brain yourself.

Interviewer: Okay.

Dr. Hawryluk: The biggest advance that we've had in concussion over the last 10 years or so has been the recognition of the need for a gradual return to normal activities and the importance of rest. That's both mental rest and physical rest. This is one of the rare times where we'll counsel young patients not to do homework. In fact, even things like video games, we think can be a little too taxing for a recovering brain.

Interviewer: Really? When the brain is recovering it needs to rest like any other body part might to heal.

Dr. Hawryluk: That's what we are starting to learn.

Interviewer: Okay.

Dr. Hawryluk: That's really step one, it is to get to a doctor and get started on this pathway of greater recovery. We do talk about six steps in terms of recovery and it's really tailored towards athletes. Again, we start with complete mental and physical rest, and then if that goes well you can basically progress through these steps at one step a day. It means the very fastest you're going to get back to your sporting event is going to be about a week.
Once your symptoms have totally resolved or almost completely resolved, normally the next step is going to be resumption of light activities. That might be something like an exercise bike or a brisk walk or something that is not too taxing.

Interviewer: Let me back up. Step one, nothing, mental and physical rest. How many days is that?

Dr. Hawryluk: For sure, one day.

Interviewer: For sure, one.

Dr. Hawryluk: Yeah, it's really based on the symptoms. Once the symptoms have resolved, or almost resolved.

Interviewer: Then step two.

Dr. Hawryluk: Then you're ready to try step two.

Interviewer: Which is light activity, okay continue.

Dr. Hawryluk: What's interesting about concussion is that symptoms can . . . even though at rest your symptoms are gone, once you push your body a little bit it actually can bring on the symptoms. Really the goal of step two is to see if you can do some light physical activity and see if any symptoms happen. If that goes well, we step it up. Step three would be a return to sports-specific activity. For instance, if you're a hockey player, well, we'd say okay, you can go back and skate at this point. We certainly wouldn't want you participating in regular drills. We wouldn't want you participating in body contact. Step three would be return to sports-specific sort of activities.

Interviewer: At this point, could you start feeling those symptoms again?

Dr. Hawryluk: What we want to see is if at any one of these stages, you do have a recurrence of symptoms. We say well, we need to back up. Some doctors would recommend starting back at square one. A lot of people like myself also advised just taking one step back and seeing where you can get to with no symptoms and eventually trying to work your way back up the six steps.
Once you can do sports-specific activity without symptoms, the next step is going to be to participate in practices without body contact. If that goes well for a day, usually we will give the green light to participate in practice with body contact. Ultimately, the last stage is return to gameplay and normal activities.

Interviewer: This is very sports specific. What about someone that has suffered a concussion for some other reason that's not an athlete, and doesn't have practice. Do they go through the same steps?

Dr. Hawryluk: They do. This six-stage process is really built for athletes that most of whom are really keen to get back to playing. It's designed to get people back as fast as we think is safe. We apply the same principle to people that aren't athletes. The principles of rest and greater return to normal activities has been associated with the most efficient recovery, the least chance of setbacks. We think it may be associated with a reduced chance of the so-called post-concussion syndrome.

Interviewer: For an athlete, what is the danger of returning to full gameplay before you go through these steps?

Dr. Hawryluk: To be totally blunt, one of the biggest things we worry about is death. I say that with a bit of drama on purpose because as physicians, that is the biggest thing we want to prevent in concussion. Some very sad occurrences over the years has taught us that players that return to the sport while they're still symptomatic, in fact, even players that return to the same game, you're at risk of for something called Second Impact Syndrome. We don't fully understand what that is. Fortunately, it's rare. But there's something about an injured brain that it's quicker to swell. We've seen patients that get hit a second time that have dramatic and fatal brain swelling and there have been a number of deaths
So that's the single most important principle for us as physicians in managing concussion. The biggest principle we need coaches and players to be aware of is that if you're concussed, you can't go back to play that game or in any other games until you've been seen by a physician and you work through that greater return.

Interviewer: When it comes to the recovery process, what is the most important piece of advice you would have for somebody?

Dr. Hawryluk: What I often find is true both of athletes and people with jobs and things like that. People are dying to prove to themselves and they want to prove to other people that they are okay. They want to shake this off and they want to be normal. The challenge is that for a lot of patients, that's not a good approach because what happens is you find that you actually are having trouble. And getting back to your activities, if you do it too soon, it doesn't go very well. It kind of becomes a negative experience. Ultimately that can delay an ultimate successful return to what you're doing. The importance of going slow really is key here.

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Interviewer: You're wondering if you should let you kids play contact sports that could lead to concussion injury. What are some of the things that you should discuss and think about? We'll find out from concussion expert Dr. Colby Hansen next on The Scope.

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Interviewer: Dr. Colby Hansen is a concussion expert at University of Utah Orthopedic Center's concussion clinic. Ultimately, I think the question that every parent would want to know given the stories and a lot of talk about concussions in the media, is it still safe or is it safe for my kids to play sports? I suppose you get that question a lot know a days.

Dr. Hansen: I do. I would say, yes, it's totally appropriate for kids to play sports.

Interviewer: Even football.

Dr. Hansen: Yes.

Interviewer: Which seems to be . . . is that the highest risk of a concussion, that sport?

Dr. Hansen: Football is right up there. There are others that are near it - hockey, things like rugby, soccer not too far behind, wrestling.

Interviewer: So it's still safe in, your opinion, for kids to play sports.

Dr. Hansen: I think you have to ask yourself the question, "What is the value of my kid in playing sports?" which I think are numerous.

Interviewer: Maybe basketball would be a better option than football? Where should a parent stand on that?

Dr. Hansen: If we talk about football specifically. Yes, football has some risk to it. Might there be an appropriate age where it's best to start to engaging in football and maybe a younger age where they shouldn't? I don't know. I am not really going to comment on that or try to pretend to be the expert or sounding board for that.

Interviewer: Is there research going on right now or research that would point to an answer to that question?

Dr. Hansen: Well, I know that some groups are interested in taking measures to reduce the number of impacts that people sustain playing a contact sport, like football. There are visible things that people who watch football might see as being measures in that regard - reducing the number of kick-off plays, increasing the number of touch-backs that occur, rules to prevent helmet-to-helmet or targeting types of collisions.

In the background there are lots of efforts to try to educate athletes, and coaches in proper tackling techniques. There are even rules now that are coming down limiting the number of contact practices in full pads, in full gear, to reduce the amount of contact that's sustained over the course of the season.

Those are, I think, appropriate measures. I don't know that we know exactly what's an acceptable amount of collisions to sustain. I think a lot of it eventually comes back to educating coaches, educating parents, educating athletes.

Where I see, perhaps, the biggest problem is when the initial injury may occur and it's not recognized. Instead of taking the kid out of play and observing them or even just making them sit out the rest of that practice or game, there is a tendency to, I think, brush it off. Whether it's on the part of the coach or the athlete, I think, sometimes both at fault, and just rush them out there, and say, "You're okay, let's go at it." That's where you're at risk.

Interviewer: Is that one of the most dangerous things that can happen? You sustain a concussion type head injury, and you go get one immediately right after that?

Dr. Hansen: Exactly.

Interviewer: That's where problems really start arising.

Dr. Hansen: Yeah. There's a saying that goes around in the concussion world, "When in doubt, sit him out." I think that is totally appropriate, there's nothing wrong with that. Is it, perhaps, on the conservative side? Sure. But I think it may well prevent some of these other complications that arise when it's not recognized and then what you have is a situation where kids are, perhaps, sustaining multiple, subsequent collisions over the course of a game or perhaps a few practices. It starts to add up.

Interviewer: Let's go down that path for a second. Are there lasting effects that can occur from those multiple sustained injuries if enough recovery time in between doesn't happen?

Dr. Hansen: I would say yes. From animal model data, and what we see from following players over time in some studies that have done that over the course of a season, if not given adequate recovery time, I think that certainly is a huge risk factor, maybe one of the biggest, for prolonged problems and symptoms that, unfortunately, in a few instances, may not go away.

Interviewer: What's your advice to a parent that has a kid in a sport that can lead to concussion or multiple concussions? Do you have children?

Dr. Hansen: I do.

Interviewer: And as a parent and an expert on concussions what's your strategy on this? What's your thought?

Dr. Hansen: My kids aren't, frankly, interested too much in those types of sports.

Interviewer: Does that make you a little happy on some level?

Dr. Hansen: So that takes some of the pressure off.

Interviewer: Nobody got a concussion in band.

Dr. Hansen: Exactly. I would say it's appropriate to allow kids to play in sanctioned sports, if there are sanctioned leagues and things out there. I think it's appropriate to make sure that the kids have the correct and correct fitting safety equipment. I think a lot of it comes back to the education piece. If an accident occurs, which there is often times not much you can do to prevent an accident, that you manage that appropriately.

Now there gets to be a point where if somebody sustains a number of injuries where you many have to re-think that. Unfortunately, we don't have the magic answer to what's acceptable. How many is too many? We frankly don't know the answer to that question. It should raise some concern if you're starting to have repeat injuries and cause you to re-think that whole issue.

That too, I think comes back to where it may be helpful to talk to a specialist in this area to help you think through those types of questions. Even understanding that even we may not have a definitive answer based on absolute proven scientific research.

Interviewer: And that's something you do at the concussion clinic here at University of Utah Health Care. You'll have consultations, you do some base-line testing, I saw. You consult with sports teams, that sort of thing to help. So, information, knowledge really the most powerful thing right now.

Dr. Hansen: Yeah, I think that's a huge, huge part to what we do. When is it okay to get back to playing? What's appropriate to kind of think about or do we need to maybe think about maybe switching sports altogether? Or any number of things.

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Interviewer: The Will Smith movie "Concussion" focuses on a condition called Chronic Traumatic Encephalopathy. Dr. Colby Hansen is from the University of Utah Orthopedic Center Concussion Clinic. Dr. Hansen, tell me about this condition.

Dr. Hansen: Well, I think in general there's still so much for us as a scientific community and as a medical community to understand about this entity that is highlighted in the movie, chronic traumatic encephalopathy. I mean, it seems pretty clear that trauma is a common denominator, but we don't know to what degree genetics may play into this, to what degree other types of issues may play into it, either mental health disorders or whatnot. We don't know at what amount of exposure to trauma people are put at risk. Just frankly, there's a lot to tease out before we start being over-reactionary and pulling the plug on sports and things of that nature.

Interviewer: The condition that they're talking about in the movie, what exactly is that?

Dr. Hansen: Chronic traumatic encephalopathy is really a diagnosis that can only be made postmortem or after death by autopsy. What some of these researchers are seeing are abnormal collections of clumps of protein called tau that has also been linked to other degenerative diseases like Alzheimer's dementia. They've seen these under the microscope of some of these former athletes, and there's really no denying that they've seen this. So now they're in a phase of trying to characterize are there maybe certain areas of the brain where you get this kind of collection more than others, to what degree does this correlate with known behaviors or symptoms that the patient was experiencing while they were alive, and then ultimately trying to make the link back to the sport or the activity that they were engaged in. People would generally feel or believe that not every football player who progressed through to the NFL has this disorder, so who does and who doesn't and what are the differentiating factors between who does and who doesn't.

Interviewer: Do people that don't play football develop this disease?

Dr. Hansen: At least in terms of the case series, the group at Boston led by Dr. Ann McKee, who's a neuro pathologist there, has studied the most brains and they are not exclusively football players. This disorder was originally described many, many years ago, many decades ago, in boxers, and was termed Dementia Pugilistica which literally means "boxer's dementia." We would assume that the common denominator is trauma, but we don't know much beyond that. How much trauma, at what age the trauma occurred, there's even a lot of debate now not in just concussions, but just the repeated impacts that don't necessarily produce a clear, observable concussion.

At the end of the day there is so much for us to learn, to understand, about not only the impacts of a single concussion and how is the best way to manage it, how is the best way to assess it, but of course the long-term ramifications of concussions and repeated concussions in the health of our athletes and anybody who's active.

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Interviewer: Going to find out what to expect when you go to the University of Utah orthopedic center concussion clinic. That's next on The Scope.

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Interviewer: Let's say something happened to somebody that led to a concussion, whether it's playing football or skiing and took a nasty fall, or maybe even an accident. I've gone to my primary care physician or it's pretty clear that I do have a concussion, and I make an appointment with the concussion clinic. What should I expect after walking in the door?

Dr. Hansen: You'll be evaluated by a specialist in traumatic brain injury. As far as what the evaluation entails it will include a comprehensive look at what types of symptoms you are experiencing, what were the circumstances of the injury, what other medical problems do you have that could contribute in some way to the symptoms you're experiencing. For example, if somebody has a chronic headache disorder already and then they have a head injury, that certainly can affect how they experience their headaches, for example.

We'll want to find out if they've had head injuries before and if so, how did they occur, what was the recovery pattern. Beyond that history gathering, we'll perform a physical examination that looks at a good balance assessment. We know that that is often affected after a head injury. A general neurologic examination which is typically normal. Then, an assessment of how your eyes and vestibular system are working together and maybe provoking or aggravating symptoms.

Those are the main components of our physical exam. Depending on the circumstances there may be other supplementary tests that we do. The ultimate goal is to document what might be aggravating symptoms, what maybe is not back to normal, because in the case of athletes or people who are wishing to return to sports, or otherwise potentially risky activities, it's really important to make sure that you're "100%" before going back out into harms way.

Interviewer: So a lot of basic tests, a lot of questions, some balance tests, but what about some sort of a brain scan?

Dr. Hansen: Brain scans typically aren't very revealing. If you have a severe injury and show acute signs or symptoms that there might be a more serious problem in the brain, people with those sorts of issues usually end up in the emergency room and those appropriate scans are done at that time.

Interviewer: So imaging is not something that you normally would do there at the concussion clinic.

Dr. Hansen: Not typically. Certainly if the story doesn't add up or we're concerned about something else, but I guess I would say that imaging tests don't diagnose a concussion.

Interviewer: What kind of questions should the patient be asking when they're in the clinic? Is there anything in particular they should be actively doing?

Dr. Hansen: If I could put myself in a patient's shoes or in a parent's shoes, and certainly I'm a parent, how do I know when it's safe to go back and play such and such a sport? Or if I'm having symptoms that aren't going away, what can we do about it? It's a tricky process to navigate.

One of the big things that we try to tackle in our clinic is providing adequate education into how to manage this, and adequate support they can then take back to their work environment, their school environment, their coach, or whatever so that they can educate them on what's the right things to do or not to do to help facilitate getting better.

Interviewer: What are some of the treatment options that you might give a patient after they've come in and you've done the diagnosis? You mentioned medications could be one.

Dr. Hansen: Most of medical management of concussion is geared towards symptom management. There's not a pill that cures a concussion. Medications have a role. There are times when the best medicine is just education and helping them understand the right balance between rest and activity, how to scale things back, and how to tailor their daily activities to facilitate recovery. Sometimes we'll get rehabilitative therapies involved, physical therapy if somebody is struggling with a lot of dizziness or vertigo, or even a lot of neck pain sometimes coincides with their concussion.

Interviewer: If I got a concussion it sounds like rest . . . is rest a big part of it? I guess what I'm saying is instead of coming in, why don't I just rest for a few days?

Dr. Hansen: Sometimes that is the trick. We know that about 50% of concussions will spontaneously get better on their own without doing anything particularly special. The important thing in those situations is just making sure that you're not getting back into harms way too soon.

There are however cases research would suggest probably in the ballpark of 20% of patients may still be having problems even a month out from their injury. Continuing to just rest and do nothing there gets to be a point of diminishing returns I guess I would say where that's not helpful and you need to figure out how to balance the right amount of rest with the right amount of activity.

Interviewer: Certainly somebody in that particular category is somebody that you would want to see, if a month has gone by and they've still got symptoms.

Dr. Hansen: Absolutely, yeah. Some guidelines would even argue that anything beyond two weeks may merit a specialist evaluation.

Interviewer: It sounds like if somebody has had no history of having concussions, and has received one, resting for a few days would be fine. They probably don't need to come into the clinic unless those symptoms persist.

Dr. Hansen: Yeah, they probably don't need to come into necessarily our clinic, but it is super important to check in with a healthcare provider.

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