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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.

Since the day I decided I wanted to do emergency medicine, the amount of negative feedback I got was ridiculous. I remember people telling me things from, "Your lifestyle's going to suck," to, "Your patient's population's going to be so difficult to work with." Even people telling me, "ED doctors are the dumbest doctors. We don't trust their work." That put a lot of self-doubt in my choice of wanting to do emergency medicine.

But on my first night shift ever in the emergency department, I'm sitting with the attending in his office. It's about 2:00 a.m. and we get a notification saying that there's a really critical patient and they're going to be using our parking lot to transfer the patient from an ambulance to a helicopter. But the patient's not going to come into the ED at all.

We get word that the ambulance arrived and the attending said, "Hey, let's just go out there and just eyeball the patient to make sure they're okay."

As we're heading out, we see this helicopter in the distance. And I remember my attending just yelling at me, like, "Duck down." And so we end up sprawling underneath the cars in the parking lot as this helicopter descended from above us. And as soon as it landed, we made our way to the ambulance, and we realized the patient was being bagged. They weren't intubated. There was just so much stuff that needed to be done in order to further stabilize this patient for transport on a helicopter.

That's when my attending made the decision, "No, we need to take this patient inside," which freaked the staff out because they're like, "We're at a small hospital. We're not going to know how to accommodate things." He was insisting. He's like, "No, we've got to take him in because it's going to be way harder to do these procedures on the helicopter that's flying in the air, moving, than it will be in our ED."

So me and the doctor, we roll the patient into the ED. The emergency doctor really took lead at that point, where this doctor does pretty much everything and he stabilizes the patient and he's able to, like, control the room, and he's such a great leader.

My biggest fear is to come up onto a scene where someone is like absolutely sick or hurt and I can't do anything. And this is exactly what the doctor did, is he came up to the scene where this patient was absolutely sick and injured and there was nothing that this hospital could provide, but he ended up providing so much.

And I remember thinking like, "This guy is freaking amazing." He's just jumping around this entire patient. He was a one-man hospital. He was at the head of the bed at one instance, and he was putting the tube down and intubating the patient, and cutting the side of the chest, putting in a chest tube, ultrasounding the patient. And I'm sitting there and I'm just like handing towels, handing whatever he calls for.

And finally, we packaged the patient up, and we rolled him out back into the parking lot and put him onto the helicopter, and they ended up flying away.

I never got to actually work with that attending again. And I actually don't even really remember his name, but the image of him just dealing with everything, doing all the work that had to be done, formed the image of how powerful an emergency physician can actually be. And it melted away all those judgments that I had and all the doubts that I had from other people telling me how awful the field would be.

From there on out, I decided, "No, this is the field I have to do." And so here I am as a . . . what am I? I'm a first-year resident. And I realized when it comes to success, when it comes to truly being the best at whatever you want to be, you have to follow your heart. Every time I was in the emergency room, it was great. I knew this was where I wanted to be, and I just had to push all those voices back and realize I was meant to be in the emergency room as an emergency physician.

Interviewer: How does a patient with diabetes change the way emergency room physicians would treat you? That's next on The Scope.

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

Interviewer: Dr. Madsen, if somebody comes into the emergency room and you find out they have diabetes, does that change the way that you would treat whatever condition that they're in the ER for?

Dr. Madsen: It really does. It affects the way I look at things and it often affects the way I treat things. And the reason for that is, certainly with diabetes, there are the immediate issues where maybe they have a high blood sugar or really low blood sugar. Either they use too much insulin or maybe they haven't been using their insulin, and certainly there's that factor. But diabetes changes a lot of other things as well.

So if someone comes in and they say to me, "I'm having chest pain," I mean, this is a 30-year-old otherwise healthy person, I'm like, "Okay, we'll get an EK to do some tests," I'm not too concerned. If this person has diabetes even, maybe in their 30s, that heightens my concern a little bit more for heart disease. And diabetes can cause coronary disease, causes narrowing of the coronary arteries, that's what we call the heart disease, that causes decreased blood flow, that causes heart attacks. So it's going to raise my concern for that. I'll probably do more testing, be more concerned, possibly even recommend this person stay overnight to see our cardiologists.

Another big area where it affects things is infections. If someone comes in and they have, say, an infection on their foot, maybe they stepped on a nail, and they have some sort of infection there, I might just send him home on antibiotics. But if the same person tells me they have diabetes, that's someone where I'm going to do some blood work, I'm going to be looking for a more severe infection. I might even recommend keeping them overnight on IV antibiotics because with diabetes, it may affect your ability to fight infection. So certainly, these are big things in my mind. Anytime someone tells me they have diabetes, things I'm thinking about beyond just, "Okay, what's their blood sugar?"

A third thing where this might change things a little bit for me, again, talking about this person who comes in with a certain symptom, if someone comes to the ER and says, "Okay, I hurt here in my abdomen, it's my upper abdomen," I might think, "Oh, maybe it's an ulcer." Someone in diabetes, my mind might go back to heart disease again because people with diabetes can sometimes have symptoms which are atypical or abnormal for heart attacks. That someone where I'm going to do more testing, not just on, "Okay, is your abdomen okay? Is your pancreas okay?" I'm also thinking more about the heart in that scenario as well.

Interviewer: Does that apply to Type I and Type II diabetes, these kind of rules of thumb?

Dr. Madsen: They certainly do. You know, once someone develops, also Type I diabetes would be something that typically starts when a person's younger, maybe a child or in their teenage years. Type II typically we refer to that as adult onset diabetes, they may not require insulin. But once a person has diabetes, in my mind, all these risks are things that I'm weighing the diabetes and equally with Type I and Type II for heart disease, for infections, for thinking about abdominal pain, possibly more as a heart attack. So it doesn't change a whole lot in my mind.

Interviewer: And it really, is having diabetes really kind of complicates things a little bit, doesn't it?

Dr. Madsen: It sure does. I mean, I imagine it's got to be a really tough thing to do certainly to have to deal with just the blood sugar checks and the insulin. But I think people who are on top of that, who are able to control their blood sugar well, fortunately, they're able to avoid a lot of these complications, but it's a challenging thing to do. And so that's why in the ER, I've got to think about these other potential complications and issues that the diabetes may lead to.

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 episode. The Scope Radio is a production of University of Utah Health Sciences.

Announcer: Need reliable health and wellness information? Don't listen to the guy in the cube next to you. Get it from a trusted source, straight from the doctor's mouth. Here's this week's listener question on The Scope.

Interviewer: Today's listener question is what should somebody look for in an orthopedic surgeon when they're having a knee or hip replacement done. We're talking with Dr. Chris Pelt. He's an orthopedic surgeon and an expert in these types of replacements at University of Utah Health Care. What do you tell somebody if they were to come up to you at a party and say, "What should I look for in a doctor when I'm considering this kind of surgery?"

Dr. Pelt: I tell them to find a surgeon that they feel personally comfortable with, someone that they connect with.

Interviewer: Even if they're really, really good at it, if you're not making that connection you say go find somebody else.

Dr. Pelt: Yeah, exactly. I think that's an important thing because this will become a lifelong relationship with a surgeon. We will follow it for the rest of your life, so you want to be able to connect with that surgeon. But the other thing is you want to find someone who's technically very, very skillful. That's often with experience. Surgeons that perform over 100 hip or knee replacements a year tend to have a better outcome than surgeons that perform fewer surgeries per year, and so often is an important question to find out how many of these types of surgeries your surgeon performs.

Interviewer: And that's something you could just ask. You can just ask, "How many do you do a year?"

Dr. Pelt: Absolutely. And if a surgeon is offended by that question, the patient may want to take pause. Most surgeons that are experienced and comfortable with their own skill set will have no problem answering a question like that.

Interviewer: Beyond the surgeon, where you go, does that make a difference, kind of like the philosophy of the surgical center you do go to?

Dr. Pelt: Just like the surgeon, the facilities are very important both in their quality and cleanliness, their infection rates. A surgical center that does more of the same types of procedures will be better at what they do, so high volume centers that perform high numbers of hip and knee replacements annually will have better outcomes than places that do it more uncommonly.

Announcer: Have a question? Ask it. Send your listener question to hello@thescoperadio.com.

Interviewer: How about the next time you need to see the doctor, you don't have to go into the office, but you can see your physician virtually? We're going to talk about virtual doctor visits next on The Scope.

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

Interviewer: Dr. Nathan Bexfield is with University of Utah Health Care at the South Jordan Health Center. A brand new thing, because of technology, is starting to happen called virtual visits and I want to find out more about how I can visit my doctor virtually and what conditions qualify. So thanks for taking time. Tell me more about virtual visits.

Dr. Bexfield: Virtual visits are a very cool thing that we have happening here. You can have a visit with your doctor on your computer, on your iPad, iPhone, on your smartphone and just talk to them about what's going on. And we can even diagnose some disorders and some rashes and illnesses via the technology that we have.

Interviewer: So are you using live video streaming. Is it like I call you on FaceTime?

Dr. Bexfield: Yeah, it's like a FaceTime or a Skype call. It goes through something called True Clinic and we are able to talk to you and interact with you like we would if we were in the office.

Interviewer: All right. So if I have a cold, is that a good thing for Virtual Visit?

Dr. Bexfield: Actually, that one's not.

Interviewer: Okay.

Dr. Bexfield: Because that's one where we actually need to lay hands on you and listen to the heart, listen to the lungs, make sure you don't have any ear infection or anything else going on. So we need you to be in the office for that type of visit.

Interviewer: Yeah. So what virtual visits, what are they good for? What conditions?

Dr. Bexfield: Things that we can see so things like rashes. Sometimes eye things that we can look at and just tell whether or not you have a very simple pink eye or something like that. Other things that it's good for are behavioral health issues like depression, anxiety, ADHD, things like that where we are mostly discussing on how things are going, how medication is working, and things like that.

Interviewer: So a follow-up visit.

Dr. Bexfield: Yes.

Interviewer: And why is that beneficial?

Dr. Bexfield: An initial visit where we diagnose those sort of things requires us to do a physical exam and have a little more interaction face-to-face as opposed to virtually.

Interviewer: Yeah. And then those follow-up visits, why is it advantageous not to have to come into the clinic?

Dr. Bexfield: Well, often those follow-up visits are every 3 to 6 months so while that's not super often, we want to make things as convenient as possible. If you don't have to come in for the visit, and you can just talk to me for 15 or 20 minutes through a call, then we can do that. You can do that on your lunch break at work if you want to.

Interviewer: How do you get on the road to a virtual visit?

Dr. Bexfield: You call and make the appointment through our call center.

Interviewer: Just like I would call to make any appointment.

Dr. Bexfield: Exactly.

Interviewer: Okay.

Dr. Bexfield: And they will send you an email, which will have a link that you just click on and it will take you right to the platform that we use for the actual visit.

Interviewer: Do I have to ask for the virtual visit, or is that something the receptionist will offer based on what I've told them?

Dr. Bexfield: They should offer it to you, depending on what the complaint is. But if they don't, and you're wondering whether or not you can do a virtual visit, then just ask.

Interviewer: Okay. And then after I've made that appointment, how quickly does that turn around?

Dr. Bexfield: Well, it's like any other appointment. If you could be seen in the same day, we could do the virtual visit in the same day.

Interviewer: Gotcha. And if it's a rash you'd just take a look at it and you'd go, "Well, that's an easily identifiable rash. I'll write you a prescription." And bing, bang, boom, done.

Dr. Bexfield: Exactly. If we can diagnose it through the virtual visit, then that's even better. Sometimes, there are going to be cases where we can't really tell for sure whether or not it's something that we can diagnose, or whether or not it's something that we need to see in the office. So if that's the case, we may ask you to come in.

Interviewer: And if you have a physician relationship already, and maybe a reoccurring condition, you just need a refill or something that required an office visit at one point, you might even be able to do that virtually, I suppose.

Dr. Bexfield: That is definitely conceivable.

Interviewer: How is this going to change health care?

Dr. Bexfield: I think it's going to make it easy on the patients. I think if you have trouble with transportation, getting in to the clinic, this is going to make things easy for you to do some stuff at home. We can basically do anything through the Internet these days now, so why not do medicine?

Interviewer: And completely secure and private?

Dr. Bexfield: Yes. And that's why we go through True Clinic, as opposed to a FaceTime or a Skype platform. True Clinic is secure; it keeps everything private.

Interviewer: Anything else that you feel compelled to say that I forgot to ask?

Dr. Bexfield: Virtual visits are going to make things way easier on parents, especially parents who have lots of kids. I think we're going to have parents who really appreciate the fact that they can get into and see their doctor whenever they like, provided we have an appointment available, from the comfort of their own home.

Announcer: TheScopeRadio.com is University of Utah Health Sciences radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Interviewer: You're not feeling well. Did you ever consider for a second it could be the medication you're taking to try to feel better that could actually be making you feel worse? We'll discuss that 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. Mark Supiano is the Executive Director of the University of Utah Center on Aging. Sometimes medications can cause more problems than they can actually fix especially if you have multiple medications, prescription and non-prescription that are interacting badly with each other.

Dr. Supiano, let's talk about multiple medications and some of the things you've seen as far as how that makes you feel worse and what you would recommend.

Dr. Supiano: This is a particular issue in older individuals, because older people tend to have more medical conditions that we now have wonderful evidence basis of the benefits of medications to treat those conditions.

When we start to add up those conditions however, if you start to have three, four, five chronic conditions, and you're on three or five medications for each of those conditions, that multiplier effect increases your risk of having an adverse medical event or a side effect from the interactions between those medications.

So older people that we treat are more likely to be on more medications and are therefore at higher risk for exactly these kinds of problems.

Interviewer: So is it the raw numbers that's causing the problem or is it the actual what's in the medication doesn't like what's in another medication or both?

Dr. Supiano: The literature suggests that it's simply the number of medications that you're on. The magic number is if say you're on more than 12 medications, and as you mentioned earlier that is a combination of both prescription medications as well as any over the counter medications that you may be taking, if that number is above 12, there's almost 100% chance that there will be a drug-drug interaction.

Interviewer: Wow. So we're talking over the counter being any sort of pain killers you might take, cough medicine, what about like herbal?

Dr. Supiano: Sedatives or hypnotics or sleep aids that you might be taking over the counter, all of those.

Scott: What about herbal supplements and things like that?

Dr. Supiano: Absolutely and Utah is a hot bed of herbal supplements. So we are very aware of that and really need to be careful about the potential interactions between some of those supplements and prescription and other medications.

Interviewer: So if you are taking a whole bunch of pills, it might be good idea to have somebody professionally reevaluate. I would think that my pharmacist would know or my doctor would already know. Is that not always the case?

Dr. Supiano: If you're going to a single pharmacy, if they have an accurate record of all your prescription medications, there are systems now to screen for the most offensive drug-drug interactions. Most physicians are likewise aware of that but there are other subtleties that individuals trained in geriatrics are more likely to pick up.

Another component is the geriatrics is a team sport and as part of our medical home for example we have a geriatric Pharm.D who has additional expertise to be able to identify the appropriate medications for older people.

The other reason that your pharmacist or physician, if they lack that geriatrics expertise may not be sensitive to this, is that there are changes in aging in how the body gets rid of medications that can increase your risk of having the side effects. So if you're not adjusting the dose of the medication appropriately for that person's age or their kidney function that there may be toxic levels of the medication that accumulate and cause these side effects.

Interviewer: So you really can't set it and forget it? You've got a kind of reevaluate quite often it sounds like?

Dr. Supiano: So I tell patients if they have been on the same drug for many years and it can't be causing problems, well, if you're 20 years older now your body is metabolizing that medication differently and the levels are going to be higher than they were 20 years ago, so it now maybe causing problems.

Interviewer: What might be an indication to somebody that they are actually having some sort of adverse reactions through medication interaction?

Dr. Supiano: Great question and this is really a challenge and particularly since many of these side effects, someone might think, "Well, I'm just getting older, so of course I feel run down the next day or I'm having this particular symptom," say constipation. They may think this is just part of getting older and may not ascribe it to the medication.

So we're taught to teach our trainees that anytime someone has a new symptom, we need to first ask, "Is this potentially caused by an existing medication?" What we really want to avoid is treating that new symptom with yet another medication, because that adds further to this list of medications.

It becomes a vicious cycle and you just keep adding on more and more medications and you get more and more side effects, and the patient isn't getting any better.

Interviewer: So how big of a difference can it make if you identify that there's some sort of a medication-medication problem?

Dr. Supiano: If we can identify someone with side effects from a different medication and the term for this is Polypharmacy, if we identify what that side effect is and either reducing those medications or eliminate it, stop that medication and the patient gets better, that's a victory.

And I can tell you, Scott that in my career of some decades now I am confident that I've made more people better by stopping the medication that is causing one of the side effects, than I perhaps ever will by starting a medication to treat a chronic condition.

Interviewer: That's a powerful statement and a statement to probably keep in mind that more is not necessarily better.

Dr. Supiano: Particularly if it's causing one of these side effects, it's a very grateful patient if you can identify that offending medication and eliminate it from their medication list and their symptoms improve.

Interviewer: If I feel like I'm having this type of reaction, what will be my next steps?

Dr. Supiano: So a comprehensive evaluation to review those medications by someone trained to identify these problems would be the first step.

Interviewer: So my primary care physician not that person?

Dr. Supiano: It could be. I think the main principles, although we do this routinely, what needs to be is a medication chest biopsy. So this is a geriatric procedure. You need to go in and biopsy the medications and the way we do that is not with the needle but we ask people when they've come in for their initial evaluation to get a grocery bag and fill it up with all the prescription bottles, and it's called the brown bag technique.

And if one grocery bag isn't big enough, you load up two or, three, or four and bring them all in and our Pharm.D will sit down and look at each one of those prescriptions and review them and make sure that they're appropriate by with indication, by way of dose and review for these potential side effects.

Interviewer: As we've talked another podcasts, geriatricians, even if you're younger and you have a lot of multiple medications could help you. You don't have to just be an older person.

Dr. Supiano: Correct, so this syndrome of Polypharmacy is not unique to age and our team including geriatrician providers and our geriatric Pharm.D are skilled to evaluate patients for that potential problem.

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Interviewer: Can you test for the flu and should you ask for it when you go visit your physician if you think you have the flu? We'll examine that next on The Scope.

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Interviewer: So wouldn't it just be easier if you could get a test for the flu to know if you have it or not? Well, we're going to find out right now. Dr. Tom Miller is internal medicine at the University of Utah Healthcare. First of all, is there a test for the flu?

Dr. Miller: There are tests for the flu, yes.

Scott: Okay, I want one.

Dr. Miller: You don't get one.

Interviewer: Why don't I want one or get one?

Dr. Miller: You don't need one. First you don't have flu symptoms, and if you do have flu symptoms and you're not severely ill, we would just treat you empirically. Meaning, if you have symptoms, you have a high fever that starts suddenly, shakes, chills, cough, you basically would have the flu until proven otherwise during the middle of the flu season.

Interviewer: So you're saying that the flu for a physician is a pretty obvious thing to diagnose. You don't need a test.

Dr. Miller: Should be, but everybody loves a test Scott.

Interviewer: Okay.

Dr. Miller: Everybody loves the test.

Interviewer: They like to know for sure.

Dr. Miller: So we've talked before on the program about being treated for the flu. So there is a treatment, an antiviral that you can give, but you should give it within the first 48 hours. So if one obtains a test to prove whether you have the flu or not it might be longer than 48 hours before you get the test results back, while in the meantime you're feeling miserable.

Interviewer: Oh. Yeah, so I come into the doctor and they're like, "I'll give you the flu test, if you want it," and then by then it's too late.

Dr. Miller: The decision is made based on a clinical presentation, so looks like the flu, smells like the flu, it's probably the flu. And we go ahead and treat it. We start the treatment.

Interviewer: What do I do if I'm convinced I have the flu, and you're not?

Dr. Miller: I guess we have a problem.

Interviewer: Do you get that? Do you get people that you say, "Oh I'm sorry you don't have the flu."

Dr. Miller: No, I generally don't. I mean it's pretty clear when people have the flu. They feel awful. Now they might have a cold, just a common cold. And I can usually explain to them that, "No, you don't have a high fever. It didn't start suddenly. I think this is a cold, which is due to a virus, but it's not the influenza virus." And basically when they are without a fever, that's something that they just get over after several days, and we really don't have effective treatment for that anyway.

Interviewer: That's the tell-tale sign, is you might feel completely miserable, but if you don't have a high fever above 101 then you likely don't have the flu.

Dr. Miller: Then if you have shaking, chills and you just feel awful and two hours ago you didn't feel bad, that's pretty much flu. Those are flu-like symptoms, and could be something else. The main thing is you want to get started on the therapy that could actually reduce the severity of the symptoms and turn the thing around, and cut it back by a day or so.

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Dr. Miller: How worried do you need to be when you receive your lab results in the mail or online before your physician's had a chance to talk to you about them? I'm Dr. Tom Miller and we're going to talk about that next on Scope Radio.

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

Dr. Miller: Hi, I'm here with Dr. Jerry Hussong. He is a clinical pathologist and also the Director of ARUP. He's also Medical Director of ARUP and we're going to talk about abnormal lab results that a patient sees and how important those might be and what guidelines a patient might have so they don't worry too much about it before they talk to their physician.

Now, Jerry, I'll have patients call me before I have a chance to talk to them about what I would consider normal lab results, but they will get those lab results and if any of the values, and there are many values that come back with a series of standard lab results, if any of those values are outside the normal range, they're usually marked in red. And sometimes they're barely over the limit. But patients can be very concerned about that and worry that the world is about to end. Do you have any comments about how patients should look at those lab results and think about them?

Dr. Hussong: Sure. I think to start with, it's really important for patients to realize that all laboratory test results are going to come with a reference range attached to them. And basically, really, reference ranges are ranges that we establish by looking at normal patients and we establish the reference range by looking at 95% of the normal population or having that as our criteria. So the range will include 95% of the total normal population and that's really . . .

Dr. Miller: But 5% could be outside that range.

Dr. Hussong: But 5% could be outside the normal reference range.

Dr. Miller: Normal is not always normal.

Dr. Hussong: That's right. And so it's really important to realize that you can be slightly outside that reference range and still not worry or be alarmed. It's important to realize a laboratory test should always be interpreted in the context of the reference range, but also in the context of many other things that are going on with the patient. So we put this in context with the physical examination that you're going to be doing with the patient, other laboratory test results and how far outside the range is that result.

Dr. Miller: That's one of the things the patient can look at if they have the ability to do that, is to look and see if the number's very far outside the reference range. If it's two or three times the outside limit then there may be an issue. But if it's just a little bit outside perhaps not such a big deal.

Dr. Hussong: And it may mean that there absolutely is nothing underlyingly wrong with the patient at all and they just have to realize that. In some context, this is why we're doing the test to see if there's anything abnormal with those laboratory testing results. But often, if it's only slightly out of the range, it may not have any indication that there's an underlying problem.

It's really important to realize though that there are some conditions that can really affect laboratory results. Extreme exercise, for instance, can cause you to have a protein in your urine. For instance, in times of dehydration if you've been out in the sun for long periods of time there may be some changes in your electrolyte results that you see. So you have to put it together with all of the other things that may be going on and other circumstances that may be affecting the patient.

Dr. Miller: One of the things that I've heard is that if you order a lot of tests and get a lot of results back, the chance that you'll have some abnormal results is normally higher anyways. Can you shed some light on that as a clinical pathologist?

Dr. Hussong: Yes. Sure. As you're thinking, the normal range is going to include 95% of the population but 5% of the population will not be included. As you exponentially increase that with a number of laboratory tests that you perform, you can imagine that your odds of being outside the reference range on any one of those tests greatly increases.

Dr. Miller: So basically, if I have 100 test results probably five of those are going to be normal but outside the reference range.

Dr. Hussong: Absolutely. That is a possibility that could happen with that. But, again, to realize that we're doing these tests for a reason and sometimes the abnormal results indicate that there's something abnormal going on with the patient. But if they're just slightly outside the reference range it may not indicate disease or an underlying issue at all.

Dr. Miller: So the key thing is to take a deep breath and make sure you get in touch with your physician so he can interpret the findings and help you understand them. And essentially, if they're not too far outside the reference range not to worry too much but definitely to talk to the physician about an interpretation of the lab results.

Dr. Hussong: I think that's absolutely right.

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