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Closeup of Ghajar in E.R., unmasked

Interview with Dr. Ghajar

Neurosurgeon Dr. Jamshid Ghajar is a tireless proponent of an aggressive approach to treating severe head injury. In 1996 he achieved renown for saving the life of a woman who was savagely beaten in Manhattan's Central Park. The techniques he uses, and his efforts to inform physicians around the world, are explored in the interview below, available in RealAudio and text.

NOVA: You've been at the forefront of a movement to improve treatment for head trauma. What is your goal?
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GHAJAR: Our goal, our dream, is to improve the outcome of patients with brain injury. And that first week, immediately after the accident, is an incredibly fruitful area for intervention and making a difference. If you wait till afterwards—you know, these patients make a slow recovery six months after injury. Those that survive make a slow recovery, and then the hundreds of thousands of brain-injury victims that are with us today, you can do rehabilitation. You can do forms of stimulation. But really the key intervention point is right after the accident. That first week is absolutely key. If you do the right thing in that first week, then you won't have the problems later on.

NOVA: What has been the conventional thinking about what causes brain injury?
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GHAJAR: Physicians caring for patients with severe head injury used to think that when the person came in in a coma after severe-head injury, that the first injury, the original injury, is so horrendous that that's why the person is in a coma. That if they made a recovery from it, they would be tremendously disabled. And we're finding out that's not true—that in most cases the original injury is not that bad. But what happens is that injury gets worse in the first week, and there is more brain damage. And, yes, if they get a lot more brain damage during that first week, they can have a very poor outcome.

NOVA: How should physicians be treating coma patients during that first week in the hospital?

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over the shoulders of two neurosurgeons

GHAJAR: What we're now doing is targeting this area in terms of what therapy we can bring on to bear in the patients and improve the outcome of those patients by treating the brain swelling mainly. What's going on that causes that injury—not the first injury, but the second injury that occurs in the hospital—that's mostly caused by brain swelling. As the brain swells up, then the brain doesn't get enough blood and oxygen, and then parts of the brain die. So that injury in itself can be far worse than the first injury. And we've now recognized that.

NOVA: Given the critical importance of preventing that second injury, is there an accepted, standard way of treating head trauma patients in this country? If I wound up in a coma, and landed in a typical trauma center in this country, how would I be treated?

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GHAJAR: What's a typical kind of place if you had a severe head injury and you ended up—what would they do? I would say a sort of typical not very active trauma center would—you'd be put on a respirator. You would be given—you'd be hyperventilated, which means that they'd put you on the respirator and breathe you very rapidly. You would not have your brain pressure monitored. You may be given steroids, which have been shown to have no effect on head injury in terms of outcome. And you'd be given some drugs that cause you to lose a lot of fluids. And eventually you would lose so much fluids that your blood pressure would drop and you would die. More than half the people coming in that situation would die, and the rest of them would end up with significant disability.

NOVA: How was it that you came to learn that this is the typical way head trauma patients are treated in this country?

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GHAJAR: I did a survey here with the Brain Trauma Foundation of 260 trauma centers throughout the United States that took care of severe head injury. And we asked them basic questions, like how many head injury patients do you see a month? Do you monitor the pressure in the brain? Do you treat brain swelling and so on? And we found indeed there was a great deal of variability. And some of the treatments that were being used were—frankly, there was no scientific evidence supporting them, and in some cases could be deleterious. So based on this and from my colleagues and my personal experience in talking around the country, we decided to develop guidelines.

NOVA: What was involved in developing the guidelines?

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GHAJAR: What we did was we met for two years and we reviewed 3,000 research articles. And we went over every single article, classified it and then came together with a document called "The Guidelines" which give the best current treatment for managing patients with severe head injury. Currently, this is the best evidence we have for treating patients. We took these guidelines, we gave them to the American Association of Neurological Surgeons who approved them and sent them out to every single neurosurgeon in North America last year.

NOVA: What is the key part of the guidelines?

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GHAJAR: Probably the key part is monitoring the brain pressure—the key part in treating patients with severe-head injury and trying to prevent the second injury—the first injury is the accident. You're trying to prevent the second big injury. You've got a small piece of brain that's been bruised and now this is being propagating. It's going throughout the whole brain. You're trying to prevent that from occurring. And the way to do that is diagnosis, which is monitoring the brain pressure, putting a tube in the brain and monitoring the pressure. Once you do that you get a number. Once you get that number you know how swollen the brain is, and then you do other things to try and prevent the brain from swelling even more.

NOVA: How do you prevent the brain from swelling more?

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Dr. Ghajar and another doctor checking patient at bedside

GHAJAR: You have this fluid that the brain makes every single day, and it floats in it - the spinal fluid. The thing is to put this tube into the middle of the brain where the spinal fluid is made so that you can measure the pressure in the brain and also if the pressure gets too high, you can just drain some of this fluid and relieve the swelling. That's the best way to do it. And the way we place this tube is we always put the tube in to the front part of the brain because there's no eloquent functions there. The motor functions, the vision and auditory, all those things aren't there. It's the silent part of the brain. You can go through it - it's basically like as thin as spaghetti, this little tube. And it causes no apparent damage that we can see in patients later on. And so we put the tube in, in the front part, usually in the right side of the brain, but if there is damage on the right side, we put it on the left side. And it takes about 10 or 15 minutes.

NOVA: Why is it so important to prevent the brain from swelling?

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GHAJAR: One of the most common causes of brain injury, the second brain injury, is not having an adequate blood pressure. Now, what does that mean? It means the brain is swollen. It's very high pressure, and you've got to get blood and oxygen into it. And if the blood pressure drops, you're not going to get your oxygen and blood into the brain. The brain's going to suffer even more injury.

NOVA: It sounds like treating the brain swelling is more work.

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GHAJAR: There is more work on the part of the medical personnel. There is more work. It's a lot easier just to put the patient on the ventilator and then turn up the rate and then give them some drugs and come back next week and see how they're doing. They're lying there in a coma. They're not screaming out for help. They're not saying, "I'm in pain." And so it would be quite easy to say, "Well, they have half a foot in the grave, why do anything else?" That's the real issue. I think if these patients were awake and saying, "Listen do something for me," we'd be doing a lot more for them. But because they're in a coma and they cannot speak for themselves, we're treating them the way they are right now.

NOVA: You're saying that a head trauma patient, because of the nature of the injury, is particularly at risk for not getting the best care?

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GHAJAR: Usually for most medical conditions you have a choice. You call your doctor up. You go and do investigations. You talk to people. You talk to friends: "What happened when you had this problem? What did you do? Where did you go?" You hear things in the news. You read books. You can do a lot of investigating. You have your time. The condition is not acute. You don't have to treat it right away. Whereas an accident, it has to be treated right away, and you have to go to a place that's quite close. You don't have a choice. And for a head injury you're unconscious. You don't know where you're going. The ambulance picks you up and takes you to where they think is the best place for you. Now, that place may not be the best place.

NOVA: That's a frightening thought - can you expand on that?

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GHAJAR: Passing by trauma center A, which follow the guidelines, would monitor your brain pressure. If you had a severe head injury and you'd have a good outcome, okay. Then you keep on driving and you get farther and farther away from trauma center A and you start getting into the area of trauma center B. Trauma center B does not monitor your brain pressure, does certain treatments which may be harmful to you. And you end up going there, and you have a far different outcome then if you ended up in trauma center A. Now, that shouldn't be. It's not like you're driving along the freeway, and it's always nice and smooth, the road is nice and smooth, and then it becomes pockmarked and no more road. It should be the same in terms of medical care. When you're driving along the freeway, they're maintaining certain standards of the road. Well, simply when you're driving by those trauma centers, they should be maintaining similar standards of care. So what my colleagues and I are saying is that no matter where you're driving in the United States you should end up with the highest standard of care. It does not cost more. It requires a relocation of trauma centers. It requires the following of certain standards of care which can be easily met.

NOVA: Do you meet any resistance from doctors when you present the guidelines at meetings for the first time?

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Closeup of guidelines document being read by a doctor

GHAJAR: I think when I talk privately to doctors, they say, "Yeah, I know about the evidence, but I still do what I do." And there's no rationale for it. And, you know, scientific data can be disputed. You can be controversial. In fact, the way we did the guidelines to show some evidence is stronger than others. But currently this is the best evidence we have. Now, you can say, "I don't believe the evidence. I believe the way I practice." Well, that's just not good science. And I don't think the public wants to be exposed to this kind of variability.

NOVA: Why should people care about these guidelines? Is head trauma really that common?

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GHAJAR: If you're a young person and you're saying, "Well, something might happen to me medically—what is it going to be?" It's going to be an injury. That's the most common cause of disability. So I think people should think about it and try and prevent it first. That's the best thing to do. And barring that, especially if they have children, they should think about what would happen if their child did have an injury, a head injury, and where would that child go.

NOVA: What motivates you to take this on?

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GHAJAR: What motivates me is there are a lot of young people, children, especially, who are dying unnecessarily. These kids could live and have a very good quality of life, and they're dying. I see it, the way they're being treated. Kids more than adults are not having their brain pressure monitored and are being severely hyperventilated, having their blood pressure drop and so on. Kids can make a very good recovery, even better than adults. And what's driving me is that there are deaths occurring every ten minutes as we're talking. That a potentially salvageable patient that can go on and have a very good quality of life. We're not talking about an 80-year-old or a 90-year-old with a stroke. We're talking about a 15-year-old, a 14-year-old. Somebody who's got the rest of their lives in front of them. So that's what drives me.



The Guidelines for the Management of Severe Head Injury were developed in 1995 as a joint initiative between the American Association of Neurological Surgeons (AANS), The Brain Trauma Foundation and The AANS/Congress of Neurological Surgeons Joint Section on Neurotrauma and Critical Care. These guidelines serve as a parameter for the treatment of severe head injury patients around the world. One of the central concepts that emerged from the clinical research that went into developing the guidelines is that neurological damage does not only occur at the moment of impact, but also evolves over the ensuing hours or days. This has led to the development of better monitoring and treatment methods aimed at preventing this secondary injury and improving the outcome for patients who have suffered a head injury.

For more guidelines information see www.braintrauma.org.


Photos: (1-2, 4-10) NOVA/WGBH Educational Foundation; (3) Aaron Strong.

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