I have two questions and a comment:
1) Where could I go to find out which hospitals and doctors practice "The Guidelines" in treating brain trauma?

2) If the doctor treating me does not use "The Guidelines", is there a way to force the doctors to use "The Guidelines" on me or a family member, in the event of an emergency?

I can't express to you (Dr. Jamshid Ghajar) the extent of my gratitude, for making this knowledge available to me. I feel you have saved my family's life, since someday we may need to use the knowledge you have given us. Thank you!!!

Darlene
Albuquerque, NM
Nem742@aol.com

You should go to your trauma center and ask the administration if they are using the guidelines in managing severe head injury.

In the event that your trauma center does not use the guidelines and you would like to have a doctor that does, you can go to another trauma center. This may be a little difficult in an emergency. However, if you research where your trauma centers are and which neurosurgeons use the guidelines then you could anticipate and talk to the neurosurgeons and make sure your family member goes to that trauma center.

Would this temporary tube in the brain, after head trauma, be similar to a shunt used to relieve pressure in the brain caused by certain diseases or birth defects? If so, why is it not "common sense" to more doctors in US hospitals?

Mary Verkler
Fayetteville, AK
VerklerM@aol.com

The ventriculostomy procedure that is shown in the NOVA episode is the first part of a very common operation that neurosurgeons perform and mainly in children with hydrocephalus in which there is enlargement of the cavities in the brain that contain spinal fluid and it requires a tube, a ventriculostomy to be made and the tube is then put underneath the skin and drains usually into the abdomen.

That is called a shunt, so the ventriculostomy is the first part of the shunt. Neurosurgeons are trained to do ventriculostomies. However, it is not done frequently in patients with severe head injury, probably because the ventricle is very small, whereas in the children who have hydrocephalus it is very large and it's easy to put the catheter into the ventricle.

Dr. Ghajar,

I thoroughly enjoyed the "Coma" episode of NOVA. My question is do you use mannitol at all in closed head injuries? Thank you for your time.

Peter Nixon
Medical student Birmingham, AL
pnixon@uab.edu

I reserve mannitol use for patients that are showing signs of herniation, which is when the brain swells so much that it presses on and may cut off blood supply to the brain and that's usually manifested by a dilating eye pupil. I give it to those patients but I reserve it because mannitol is effective in limited amounts. If given frequently it may lead to a reduction in plasma and the blood pressure can drop.

We are two college students who have just finished watching your special documentary on NOVA! We were extremely impressed! It did leave us with lots of questions? Like how would we seek your treatment for head traumas in states other than NY? One of us is from PA the other NJ. Since NY is the only state that has passed your guidelines for treating head traumas, how would we insure that our medical institutions are providing the best care possible in this area?

Carrie Petrosh & Amy Jones
Millersville U., PA
alj63443@marauder.millersv.edu

If you want to ensure that your trauma center is using the guidelines, I would contact your representative on the state level, specifically the governor and the commissioner of health to have them review the guidelines and encourage their use in trauma centers in your state. The other means is to go to the trauma center yourself and visit with the neurosurgeon or the trauma surgeon and ask them if they use the guidelines.

I am a pre-hospital provider (EMT-Intermediate) in rural New Mexico. After seeing your program, how can pre-hospital providers increase the chances of a pt with head trauma? We have transport times anywhere from 5 to 50 minutes to a small hospital, and 1.5 hours to nearest Level 2 trauma center.

Thank you for your time.

Chris LaCounte
Ruidoso, NM
ccandb@lookingglass.net

Three of the sections in the guidelines deal with pre-hospital care for patients with severe head injury and they relate to whether a patient should be treated for high pressure in the head. The recommendation is that they should not unless they show signs of the pressure in the head increasing, such as a dilating pupil or abnormal posturing. Common maneuvers such as hyperventilation, which is rapid breathing, are not recommended because the blood flow in the brain is very low in the first day after head injury. The transport time of 5-15 minutes to a small hospital and one half hour to a level 2 trauma center are important. There is a recent study; in Quebec they found that taking patients to a small hospital and then transferring them to a large trauma center had a more frequent bad outcome than just taking them directly to a major trauma center. That may be because of the time delay of getting definitive care. A study was also done in Chicago showing the trauma centers that received a lower volume of patients had a thirty percent increase in mortality compared to trauma centers that received a high volume of patients. Probably what we need to work on is instructing the emergency medical personnel on proper resuscitation of patients with severe head injury so they can make the longest drive to a definitive trauma center. We're working closely with New York state and the federal government to try and achieve this goal.

Dr. Ghajar,
Your treatment sounds very progressive. I want to know if your treatment only for patients admitted to the ER "initially"? My 27 year-old sister is in a so called "vegetative state". She does open her eyes, she does "lift her head", she makes sounds when in pain. Our family is desperate for any progressive treatment methods or any additional information you can provide regarding progressive treatment for coma victims.

Y. Spence
Arlington, TX
ysp@swbell.net

The most important element in terms of prognosis is how long she has been in the vegetative state. I recommend you read the review article in the New England Journal of Medicine on outcome of persistent vegetative state and the guidelines developed in this study.