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?
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
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?
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?
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?
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?
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.
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?
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?
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.
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?
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?
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?
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?
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.
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.