Back to previous post: Silk and Steel and Tripe

Go to Making Light's front page.

Forward to next post: My New Favoritest Game

Subscribe (via RSS) to this post's comment thread. (What does this mean? Here's a quick introduction.)

March 27, 2009

TMI About TBI
Posted by Jim Macdonald at 01:00 AM * 204 comments

Brain injury is much in the news these days, following the death of Natasha Richardson of a seemingly minor fall.

So, let’s talk about Traumatic Brain Injury (TBI), with a small side-venture into strokes.

The reason head injuries can be so devastating is because the head contains the brain. The brain controls the central nervous system, and without that, we rapidly get dead. The brain is composed mostly of nervous tissue, and, as such, is very sensitive to any lack of oxygen and glucose. For example, four to six minutes without oxygen is all it takes to kill the brain. The body is very, very good at making sure the supply, via the blood stream, doesn’t stop.

Like many other vital organs, the brain is protected by bone. We’re talking the cranium, here, that part of the skull that surrounds the brain. Outside of the cranium we have the skin of the scalp. This is highly vascular (which is the fancy way of saying “It’s full of blood vessels”), then covered with an insulating layer of hair. The reason the scalp is so vascular is because it plays a role in maintaining the brain at an even temperature. Even minor scalp injuries look dramatic, because they bleed heavily. Scalp and facial wounds tend to gape open because, unlike the rest of the body, the skin attaches directly to muscle. (There’s one other place on the human body where this is true: The scrotum. Insert the obvious joke here.)

The skull is made of a number of bones that fuse in very early childhood into a solid piece. Like other bone, it’s a living tissue, and its outer layer is a thick, fibrous material called the periosteum (the Latin word for “around the bone).

Hard against the periosteum on the inside of the cranium you come to the meninges. These are three layers of tissue that surround the brain. When they’re inflamed, the condition is called meningitis, and a nasty, horrible disease it can be, too. The first layer on the way in is the dura mater. That’s Latin for “tough mother.” There isn’t any space between the dura and the periosteum, when things are all okay. Under the dura mater comes the arachnoid membrane, which looks sort of like plastic wrap. (The Romans thought it looked like a spider web, hence the name.) Under the arachnoid comes the pia mater (Latin for “tender mother). The pia mater is attached to the surface of the brain itself.

Between the dura and the pia you find cerebro-spinous fluid (CSF). This bathes the brain, surrounds it, cushions it. The brain floats in it. It’s watery, clear-to-straw color, and seeing it pouring out of your patient’s nose or ears is what we call “a bad sign.”

How to tell if what you’re seeing is CSF: You can do what’s called the “halo test,” where you put a drop of the bloody fluid in the middle of a gauze square. If there’s CSF, you’ll see a red center with a yellow halo around it. Or, if all you have is some clear fluid coming from your patient’s nose, you can test it with your glucometer. If it’s CSF, the glucose reading will be approximately one-half of the glucose reading of his blood.

The meninges don’t just cover the brain; they cover the spinal cord as well. You can think of the spinal cord as a long, thin extension of the brain if you wish. The CSF also surrounds the spinal cord. When someone does a lumbar puncture, they’re sticking a needle between a couple of vertebrae in the lumbar spine, through the dura, and sucking up some CSF to check it for bacteria, or blood, or what-may-have you. When nice young ladies get epidural (from epi- above, and -dural, of or pertaining to the dura mater) anesthesia during childbirth, the drugs go into the spinal column, around the spinal cord, above the dura mater.

There’s a space between the periosteum and the dura mater, but usually it’s a potential space. That is, there could be a space there if something were to go there. We’ll be back to the epidural space anon.

So let’s get to the brain injuries.

The first mnemonic is DIC-HEAD. If the patient is Disoriented, Irritable, Combative, consider Head injury. (That’s right, people with brain injuries can be dick heads. What you don’t know when you arrive on scene is what they’re like day-to-day. Maybe the guy is just naturally a dick head. As in all emergency medicine, assume the worst.)

The brain actually is about the same consistency as Jell-O. When you smack someone upside the head, the brain kinda sloshes around in there. This leads us to the first, easiest, least-damaging TBI: the concussion. You get hit, you see stars. You’re briefly dizzy. You may even get knocked out for a moment. There aren’t any lasting effects (though you should be aware that all brain injuries are cumulative: several concussions and you have people who are permanently punchy, like the palookas of comedy). Post-traumatic amnesia is common. (You don’t remember the events immediately after the injury.) Antegrade amnesia, where you don’t remember the events leading up to the injury, are a bit more serious as symptoms go.

What went on there is an electro-chemical disruption of the brain. It’s a common sports injury. (Note: If your sport traditionally requires a helmet, wear the friggin’ helmet, okay?) Someone who’s had a concussion should be out of the game. A serious concussion, out for a month. A second concussion; out for the season. A third concussion, out for the year. Concussions are cumulative.

One thing that I see a lot: A patient has a concussion. Three days later, he or she has the injury that requires EMS and puts ‘em in the hospital. Their reflexes are just a bit off. Their peripheral vision is just a bit limited. So. If you have a concussion, at the very least, take it easy. And seriously, seriously consider following up with medical assessment, because there’s worse things to come as we look further into Traumatic Brain Injury.

Here’s a description of what it’s like to have a concussion, from one of our own, in this LJ post et seq.

The inside of the skull isn’t soft and smooth. It has all kinds of edges and protrusions. As the brain moves around, it can be bruised. It can bleed. You see brain injury not only at the site of impact, but on the opposite side where the brain sloshed, then sloshed back. (That’s coup and contracoup injuries.) You find lacerations and contusions in the brain itself.

The brain is made mostly of nerve tissue. Nerve tissue does not recover well. Those primary injuries, and any loss of function associated with them, are probably going to be permanent. But this doesn’t mean that you look at someone with a TBI and say, “Oh, well.”

The primary injuries are there. What you want to work on are the secondary injuries.

Like any other body part, when the brain is injured it swells. Unlike any other body part, the brain is trapped inside a hard bony shell. When it swells it doesn’t have anywhere to swell to.

Let’s step back to the dura mater, if you please. The temporal bones (the temples; the sides of the head where the lower jaw hook on) are particularly thin as skull bones go. And directly under those thin bones lie the middle meningeal arteries. A fracture of the temporal bone, say from a low velocity blow (e.g. a baseball), can tear one of those arteries. The epidural space starts to fill up with blood, backed by arterial pressures.

Or, in the course of the trauma, one of the bridging veins gets ruptured. These lie under the dura, so you have a subdural bleed. It’s only backed by venous pressure, though, so it’s usually slower than an epidural.

Cast back your mind to my earlier post on Levels of Consciousness. (Lots of things are going to start coming together, folks.) Recall the mnemonic AEIOU-TIPS? Remember that T was for Trauma and S was for Space-Occupying Lesions. We’re in S territory now. And as I promised back then, now’s the time to introduce the Glasgow Coma Scale.

The Glasgow Coma Scale is a tool for measuring level of consciousness. It goes like this:

Record the patient’s best response:

Eye Opening:
Spontaneous: 4
To Voice: 3
To Pain: 2
None: 1

Verbal Response:
Oriented: 5
Confused: 4
Inappropriate: 3
Incomprehensible: 2
None: 1

Motor Response:
Obeys commands: 6
Localizes pain: 5
Withdraws to pain: 4
Flexion: 3
Extension: 2
None: 1

You’ll notice that normal folks walking around have a Glasgow score of 15. This desk here has a Glasgow score of 3. Recording the Glasgow score, and how it changes, will give you a good idea of what’s going on, and how fast, and how likely it is that you’ll have a live patient a week from now.

Okay, back from that little digression: A drop of two points in the Glasgow score is a bad sign.

We have our friends with the head injuries. Their brains are swelling, or there’s blood collecting inside of their skulls, at some rate. NOTE: That rate could be measured in minutes, in hours, or in days. For a time their bodies compensate for that swelling, or for those masses.

At the mass builds up, the first thing that happens is that the inter-cranial pressure (ICP) increases. There’s more stuff inside the skull, so pressure goes up. As the ICP goes up, the patient’s blood pressure goes up too, because the body desperately wants to get oxygen and glucose to the brain. Lack of oxygen, and lack of glucose, can, all by themselves, cause brain swelling.

While there’s no give to the skull, there is some give in other places. As swelling happens, cerebro-spinal fluid gets forced out. Pressure normalizes, the patient is asymptomatic, and you’d never suspect anything was wrong.

You’ve probably got about 75 mL of CSF that can go that way. Also, as swelling increases, or the size of the hematoma increases, venous blood gets forced out. You probably have another 75 mL of that that can get squeezed out of the skull. But when that 150 mL of reserve is gone, stand by. It’s like you were getting cranked to the very top of the first hill of a roller coaster and the ride is about to get very fast, and down hill all the way.

Pressure on the brain shows up in certain signs. Remember the cranial nerves (previously discussed at Making Light)? One of them is Cranial Nerve III, the Oculomotor nerve. Pressure on that nerve makes the pupil of the eye on the side closest to the injury expand and get sluggish in response to light. A difference of 1 mm between the pupils can be a bad sign (although a significant percentage of the population has unequal pupils normally). Next, as pressure builds up, you start getting weakness in the muscles in the opposite side of the body. Depending on exactly where the injury is, you can see changes in hearing, in verbal response, in sleepiness….

Intercranial pressure is still building up. The blood pressure is still going up. This triggers another mechanism, called “Cushing’s phenomenon” or “Cushing’s reflex” (named after Dr. Harvey Williams Cushing, 1869-1939, a giant among neurosurgeons): The baroreceptors in the carotid bodies and the arch of the aorta notice the increased blood pressure, and stimulate the Cranial Nerve X, the Vagus nerve, to correct that problem. The heart rate slows. The brain continues to swell. The ability of the blood flow to bring in sufficient glucose and oxygen is compromised. The brain swells even faster.

There’s only one place for that swollen brain to go: out through the Foramen Magnum (Latin for “Big Hole”). The brain is soft, and it’s getting squeezed out through that hole, brainstem first, like toothpaste. You’re going to start seeing motor changes as the brain takes mechanical damage from being squeezed out: Posturing. First come “decorticate posturing.” That’s when the arms bend in, taking the hands up in front of the face. (Remember it by Decorticate = movement to the core.) Then comes decerebrate posturing, when the arms are fully extended and the back may arch.

Then we come to patterned respiration, as the part of the brainstem that controls breathing starts to take damage. You can see Cheyne-Stokes breathing, a repeated pattern of slow, shallow breathing, going to rapid, deep breathing, then back to slow and shallow. You can see Central neurogenic breathing (continuous rapid deep breaths — they look just like the Kussmaul’s respiration you get in diabetic ketoacidosis, only the mechanism for why you have ‘em is different). At this point you’re well into Cushing’s Triad: High blood pressure, slow heart rate, and patterned respiration. You are also well behind the power curve.

Then comes ataxic breathing: breaths with no discernible pattern. Then comes apnea: no breathing at all. This is what we call an end point.

Typically, you see a person get a head injury, be unconscious for a while, wake up and be apparently normal (this is called “the lucid interval”), then going unconscious again, and deteriorating rapidly. The initial unconsciousness is from a concussion. The lucid interval is the period while the body is compensating by draining CSF and venous blood from inside the skull while the hematoma is growing. Then comes the bad part.

So, what do we do about all this?

First, if you suspect traumatic brain injury, due to mechanism of injury, get the patient somewhere with a CAT scan or an MRI, and a neurosurgeon on call. You may not have a lot of time to do this; meanwhile the patient’s signs and symptoms may be mild or nil. At a minimum, any head injury involving loss of consciousness deserves close and continuing observation, where any sudden change or deterioration becomes a call for rapid action. Remember that signs and symptoms of a subdural or epidural hematoma may not show up for a significant period.

Any time you have a person who’s on blood thinners, or who’s drunk, assume the worst and treat for same. Alcohol masks the signs and symptoms, and a person who’s drunk has a good chance of falling and striking their head. Just because they act drunk, and smell of whiskey, don’t assume that’s all that’s going on.

A serious TBI is about 30% fatal. Of those who recover, around 99% have permanent neurological deficits.

I promised a side excursion into strokes: Here it is. You have two kinds of strokes: Occlusive, where a blood clot blocks an artery in the brain causing tissue death, and hemorrhagic, where a blood vessel in the brain bursts. The later is indistinguishable from a traumatic brain injury as far as its physical effects; the only difference is why the blood vessel has broken (I urge everyone to check their blood pressure regularly: hypertension is related to stroke). In occlusive strokes, tissue damage due to hypoxia causes brain swelling, with all the rest of the lovely signs and symptoms noted above.

Once in hospital, with neuro services, though, a hematoma can be drained; often with minimal after-effects. (This is particularly true of epidural hematomas since the broken arteries are well away from the brain, no liquid blood enters the brain tissue, and there may be no underlying trauma to the brain itself.) To do this, though, the CAT scan is vitally important.

As for getting to the hospital, here’s what you need to remember. You can’t do anything about the primary injury. But you can slow the secondary injury due to swelling by keeping the patient well-oxygenated, and keeping their blood pressure above 90 (that is, you have to be able to feel a pulse at the patient’s wrist). Your goal is to keep oxygen and glucose going to the brain tissue, to limit swelling. (Note: Do not hyperventilate the patient: Blowing off too much carbon dioxide will also cause brain swelling.)

There isn’t any good place to put this, so I’ll put it here: There’s another kind of brain injury that doesn’t involve bleeding inside the head, doesn’t involve brain swelling (or not much), but is still devastating. That’s the Diffuse Axonal Injury. It’s caused by shearing forces inside the brain, due to the different rates at which gray matter and white matter accelerate. The axons of the nerve cells stretch, break off, and retract. While death is rare, and the lesions often can’t be detected with current imaging devices, 90% of the patients who present with DAI remain in a permanent vegetative state. This is a primary injury; it exists from the moment of the trauma. You most often see it in rotational injuries in high-speed automobile crashes, and in blast injuries. Nothing you can do, prehospital, will make this one better or worse.

Can you tell the difference, pre-hospital, between an epidural hematoma, a subdural hematoma, an intracerebral hematoma, or a hemorrhagic stroke? No, and usually you can’t tell in the ED, either. You need specialists with special equipment to differentiate.

A person with a head injury often has other injuries. Treat for shock. Stop bleeding. Keep the airway open. And good luck. These are scary, scary injuries.

Take away lessons:

  1. Stay alert to the possibility of brain injury, even if the person didn’t get knocked out
  2. Watch for any changes in signs or symptoms, particularly:
    • Sleepiness
    • Headache
    • Nausea/vomiting
    • Motor skills
    • Pupil size
    • Confusion/orientation
  3. Any altered mental status goes to the ER.
  4. Maintain airway, breathing, circulation.
  5. Treat for shock

Copyright © 2009 by James D. Macdonald

I am not a physician. I can neither diagnose nor prescribe. These posts are presented for entertainment purposes only. Nothing here is meant to be advice for your particular condition or situation.

Creative Commons License
TMI about TBI by James D. Macdonald is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 License.

(Attribution URL: http://nielsenhayden.com/makinglight/archives/011126.html)


Index to Medical Posts

Google

Comments on TMI About TBI:
#1 ::: Marna Nightingale ::: (view all by) ::: March 27, 2009, 01:27 AM:

Thank you, Jim.

I have been thinking all week about "Disoriented, Irritable, Combative".

Actually what I have been thinking about is how often it seems like people with TBIs don't want to go to the hospital, don't want to be looked at, refuse to be treated at all, until it's too late.

And about how much I do not know how this ought to be dealt with. How much persuasion is reasonable.

I have no answers to this, actually.

#2 ::: James D. Macdonald ::: (view all by) ::: March 27, 2009, 02:02 AM:

All this and I didn't mention basal skull fractures, Battle's Sign, raccoon eyes, or Le Fort Fractures.

This is a pity.

Basal skull fractures are when the base of the skull is fractured. Battle's Sign is bruising over the mastoid process (the bump just behind the ear on each side), raccoon eyes is heavy bruising in both eye sockets. Both Battle's Sign and raccoon eyes are late signs: It can take hours for them to develop. By the time they show up I hope you already have your patient at a hospital.

Le Fort fractures are fractures of the facial bones. A Le Fort Type I fracture is a fracture of the maxilla (upper jaw), from side to side, along the bottom of the nose. The upper teeth kinda move around as a unit. A Le Fort Type II fracture, a pyramidal fracture as it's sometimes called, runs from the side of the upper jaw to the top of the nose on both sides. A Le Fort Type III fracture is when all the facial bones have broken off the cranium. It runs from side to side through the eye sockets.

The interesting thing about them is how they got their name. Dr. René Le Fort, a French surgeon (1869-1951), devised the classification by hauling cadavers to the roof of his house in Paris and dropping them, face first, onto the pavement.

With Le Fort fractures you often see difficulties with the patient's airway. With both basal skull fractures and Le Fort fractures, expect TBI.

#3 ::: turtle ::: (view all by) ::: March 27, 2009, 02:49 AM:

Why is it commonly considered that you have to keep a concussed person awake for a very long time? If this is not actually true, how did the misconception come about?

#4 ::: James D. Macdonald ::: (view all by) ::: March 27, 2009, 03:07 AM:

Excessive or unusual or sudden-onset sleepiness or lethargy can be one symptom. Keeping the person awake won't help; what will help is neurosurgery to relieve pressure or drugs to reduce swelling.

I promise you, if you keep someone awake for an excessive period they will get sleepy or otherwise show altered mental status. Even if they don't have a brain injury.

If you have someone with the mechanism of injury to make you suspect brain trauma you may want to awaken a person several times during the night, to assess if some other symptoms have developed.

A patient you can't wake up is another matter entirely.

Dizziness, vomiting, headache, and confusion are far more reliable guides to a deteriorating situation than sleepiness.

(I'm getting sleepy right now and I don't have a head injury.)

#6 ::: Johan Anglemark ::: (view all by) ::: March 27, 2009, 04:54 AM:

This was slightly unnerving to read. I had (apparently) TBI once. Thankfully, it's a long time since, now, so I'm healed from it. I was seventeen, was playing rugby in school and fell to the floor. When I woke up again, the nurse and my classmates told me I had been out for five minutes, and then woken up, spoken a little, and become unconscious again, about five times in a row. They were just going to call an ambulance when I came to for real. I had lost the previous six months of memory. That is, I knew eactly which day in March it was and what I had had for lunch a couple of hourse ago, only that day was in March, not in September.

My memories returned during the day, slowly, all except the five minutes that immediately preceded the accident. No nausea or headache to speak of, though. I wasn't worried at the time, regaining my lost memory was a delightful experience that felt as if taken from a novel.

Reading your text today, 27.5 years later, I realise I should have been more worried at the time.

#7 ::: PurpleGirl ::: (view all by) ::: March 27, 2009, 05:11 AM:

I have a friend who was standing behind a door when it was opened quickly and forcefully knocking him into a cinder block wall. He sustained brain injuries which still affect him some 15 years later. There's a reason doors have signs that warn you to open them slowly. I've often reminded people who open opaque doors that they need to open them slowly because they don't know and can't know if there is someone behind the door.

#8 ::: Torrilin ::: (view all by) ::: March 27, 2009, 07:07 AM:

And about how much I do not know how this ought to be dealt with. How much persuasion is reasonable.

Well, it is entirely reasonable to not want to go to a hospital. The ER is incredibly boring, and if you're not badly hurt, it takes forever to be seen and get out. But a patient in shock isn't necessarily going to exhibit good judgment. If the patient is someone you know well, you have a clear idea of what normal is. If they're normal, great! They still banged their head, and probably have other injuries. Depending on the patient, it may take more or less persuasion... or you may not persuade at all, just say "we're going Mom."

Yes, it came up last fall with my mother. She had a classic face forward fall and tried to break her fall with her arms (of course). Large bruise on her forehead, deep bruise in the eye socket, fractured wrist, and badly bruised knees. She didn't feel unusually bad after a fall that severe, and didn't really want to go to a hospital. I insisted, because she'd gone shocky and a minor fall shouldn't do that. No one else could much tell, but no one else had a 30 year baseline on her either.

With someone you aren't as close to, it's tougher. You can't depend on trust the same way. It's still better to err on the side of hospital if they hit their head tho. And even a minor blackout *should* make most people at least be quiet if you say "we're going." If it doesn't, well... It might be safer for them if they go anyway.

#9 ::: ADM ::: (view all by) ::: March 27, 2009, 08:03 AM:

I'm now feeling less silly about going to the ER when I found myself lying on the kitchen floor one night, no idea how I got there.

#10 ::: Ginger ::: (view all by) ::: March 27, 2009, 08:23 AM:

Blowing off too much carbon dioxide will also cause brain swelling.

Actually, hyperventilation (hypocapnia) causes the brain to shrink; the problem is the electrolyte disturbances that follow (metabolic acidosis/respiratory alkalosis). Under controlled circumstances -- i.e., the OR -- hyperventilation is a tool for shrinking the brain intraoperatively, for a short period of time.

A stroke or bleed can be pretty major by the time clinical signs show up. My personal opinion is, any unhelmeted head that hits gets sent to the hospital, no arguments allowed. Any helmeted head can be assessed on the spot by a knowledgeable individual (EMT, nurse, etc.) and monitored. The delay of 4 hours in Natasha Richardson's case is what ultimately led to her untimely death, although a serious bleed would still have left her with TBI.

The brain is pretty amazing. I saw a quote from a neurosurgeon once that said we can scoop out brain and have a functional patient, or we can get a pinpoint lesion and end up with a nonfunctional patient. We can't tell until the patient wakes up which one it will be.

Clinical signs of TBI are the same in animals. If you think your dog has gotten hit in the head, go to the veterinary hospital. Some of the larger referral practices and most of the veterinary teaching hospitals have at least a CT if not an MRI.

For anyone interested in what scans look like, I recommend the Whole Brain Atlas.

#11 ::: DonBoy ::: (view all by) ::: March 27, 2009, 09:52 AM:

You get hit, you see stars.

Confession: I was in my forties before I realized that this expression refers to tiny points in your vision, and not to the shapes that cartoon characters see. That is, the cartoon thing is a joke about "seeing stars", but I've never been hit on the head, and I've seen a jillion cartoons. So you see my confusion, he said defensively.

(Now watch it turn out that some head trauma causes more complex disruptions to the visual field, such as...)

#12 ::: Diatryma ::: (view all by) ::: March 27, 2009, 10:06 AM:

The only concussion I've had was when I was seven or eight, an incident with a sledded-out hill at the park and investigation of the sleddability of a red tunnel slide. I went home, got a book, and then went crying to Dad because I couldn't read-- the letters had their black reality, plus green and purple shadows that meant I couldn't focus on them very well.

One of my research advisers was in a car crash, got a bump on the head, and ended up with a lesion that caused her to forget the name of the organism she was working on. As far as I could tell from her account, it just didn't take hold in her memory for a few months.

Brain injuries are interesting as long as I hold them at a fictional distance, then they become scary as anything.

#13 ::: ajay ::: (view all by) ::: March 27, 2009, 10:40 AM:

Only time I've ever been concussed was after a long fall; I woke up and thought to myself "Hmm. I don't know where I am, when it is or how I got here. But I know who I am. Therefore I am Alert & Oriented level one."

My next thought was "How interesting that I can forget all that rather important stuff before I forget how to assess my own A&O score..."

#14 ::: meredith ::: (view all by) ::: March 27, 2009, 10:55 AM:

This discussion also brings to mind the secondary injury that befell a friend of one of my best friends. He went on a roller coaster and suffered whiplash during the ride, but other than a stiff neck for a couple days he was fine. Until a couple weeks later when he suddenly had a stroke. (Did I mention he wasn't yet 40 years old?)

Apparently the whiplash had caused some bleeding in one of the blood vessels at the base of his skull that led to a clot which eventually broke off and ended up in his brain.

#15 ::: James D. Macdonald ::: (view all by) ::: March 27, 2009, 11:06 AM:

Other effects of brain injury can include seizure disorders that can manifest months or years later.

#16 ::: Daniel Klein ::: (view all by) ::: March 27, 2009, 11:32 AM:

I have had what might be the most stupid concussion ever. I was in a particularly good mood and decided to jump down the last five or so steps of the stairs. What I was forgetting, though, was how tall I am and that there's a particularly low steel bar over the stairs. So at full speed, in mid-air, I hit my head against that steel bar. My memory loss was weird: I remember very clearly what I thought the instant *after* I'd hit my head (it was something along the lines of "really? This is how I die? How utterly stupid of me!", compressed in the space of a few hundred miliseconds and much less verbal), but after that thought there's nothing for a bit, and then I was lying on the floor at the base of the stairs. I was confused and certain someone was pouring water down my face. Why would anyone do that! Of course it wasn't water. (That bit where Mr. MacDonald mentions how much even small wounds to the head bleed? He's not exaggerating)

I was entirely coherent at this point, though, and I quickly got up and did a mental inventory. I knew where I was, what I had been doing all day, I had retained my sense of balance, and I clearly understood I needed to be seen by a doctor. I was living in the dorms at this point, so I just walked to a friend's door and knocked on it. I actually laughed out loud at his reaction when he opened the door--I guess he doesn't often see people with more red than skin color in their face. I asked him if he had a driver's license, and if so, if he could maybe take me to the hospital.

Thinking back, I'm not sure why I didn't call an ambulance. The idea never entered my mind. I guess my feeling was "hey I can walk and talk just fine, how bad can it be?" Then again, having a friend drive me might actually have saved me some time.

I must have gotten incredibly lucky because the doctor refused to believe that such a small wound was caused by what I described to him. I'm a pretty big guy, and when I jump from a run, there's a LOT of momentum. As far as I can tell, the only consequences of that extremely stupid jump were a headache from hell for about a day (no other symptoms of brain injury at all) and a tiny scar that runs across my hairline where no new hair will grow.

Having said that, I do not plan to repeat the experience and would not recommend it to anyone.

#17 ::: Brian ::: (view all by) ::: March 27, 2009, 11:40 AM:

Great overall view of TBI. Check out http://BrainLine.org for even more TMI about TBI.

Having held a brain the consistency is a bit firmer than jelly, I would say like the feeling of memory foam. It definitely gives, but the jello idea is a good visual showing the movement that the brain sustains in a TBI.

#18 ::: Anna in PDX ::: (view all by) ::: March 27, 2009, 11:41 AM:

16: My son did that. We had moved from an inner-city apartment in Cairo to a house in the desert. He had grown like a foot in the meantime. We came back to our old apartment for a weekend and he decided to leap down the stairs as he had done when he was a foot shorter. He did not knock himself out but he got a big gash on his head and it was really scary how much blood there was. His hair still does not grow on that place (this was about 6 years ago now).

#19 ::: Daniel Klein ::: (view all by) ::: March 27, 2009, 11:42 AM:

I have what might be the most stupid concussion story ever. I was in a particularly good mood and decided to jump down the last five or so steps of the stairs. What I was forgetting, though, was how tall I am and that there's a particularly low steel bar over the stairs. So at full speed, in mid-air, I hit my head against that steel bar. My memory loss was weird: I remember very clearly what I thought the instant *after* I'd hit my head (it was something along the lines of "Really? This is how I die? How utterly stupid of me!", compressed in the space of a few hundred miliseconds and much less verbal), but after that thought there's nothing for a bit, and then I was lying on the floor at the base of the stairs. I was confused and certain someone was pouring water down my face. Why would anyone do that! Of course it wasn't water. That bit where Mr. MacDonald mentions how much even small wounds to the head bleed? He's not exaggerating.

I was entirely coherent at this point, though, and I quickly got up and did a mental inventory. I knew where I was, what I had been doing all day, I had retained my sense of balance, and I clearly understood I needed to be seen by a doctor. I was living in the dorms at this point, so I just walked to a friend's door and knocked. I actually laughed out loud at his reaction when he opened the door--I guess he doesn't often see people with more red than skin color in their face. I asked him if he had a driver's license, and if so, if he could maybe take me to the hospital.

Thinking back, I'm not sure why I didn't call an ambulance. The idea never entered my mind. I guess my feeling was "hey I can walk and talk just fine, how bad can it be?"

I must have gotten incredibly lucky because the doctor refused to believe that what I described to him caused so little injury. I'm a pretty big guy, and when I jump from a run, there's a LOT of momentum. As far as I can tell, the only consequences of that extremely stupid jump were a headache from hell for about a day (no other symptoms of brain injury at all) and a tiny scar that runs across my hairline where no new hair will grow.

Having said that, I do not plan to repeat the experience and would not recommend it to anyone. 1 out of 5 stars.

#20 ::: j austin ::: (view all by) ::: March 27, 2009, 12:20 PM:

It makes me wonder about all the times I really conked myself as a child and teenager. Off the house onto the sidewalk. Out of the mimosa tree onto the sidewalk. On my gran's concrete steps... the list goes on and on.
Never went to the hospital for any of them.

Are kids more resilient when it comes to that kind of thing? I know some injuries are a lot worse when you're an adult.

#21 ::: Ginger ::: (view all by) ::: March 27, 2009, 12:44 PM:

j austin @ 20: No, kids aren't more resistant. Your brain was well-protected*, you didn't quite do enough damage, and you gave yourself enough time between incidents.

*That is the point of having a nice thick skull, after all. Getting a brain injury involves either some underlying pathology which makes it easier to damage the brain, or a really good blow that goes through the bone (or rarely, a blow to the thinner part of the skull).

#22 ::: J austin ::: (view all by) ::: March 27, 2009, 12:53 PM:

Thanks, Ginger,

I am the clumsiest person on the face of the planet (just for embarrasment's sake, I was once scrubbing the butcher-block top of our dishwasher, and sneezed, cracking my forehead on the top. Twice.) I didn't know if I was just really lucky, thick-skulled, or if there was something about wee brains that helped protect them during the inevitable coffee-table incident.

#23 ::: John Houghton ::: (view all by) ::: March 27, 2009, 01:34 PM:

Then there is the possiblity of having your injuries compounded by the Police tasering you for non-compliance while you're lying on the ground after a fall.

#24 ::: RP ::: (view all by) ::: March 27, 2009, 01:46 PM:

I've had a few concussions, which sort of amazes me considering what a sedentary person I am.

The one that still makes me angry was the one at a day camp when I was eight or so. We were in a hayloft at a farm, and I didn't hear the warning not to slide off the hay in one part of the barn. I slid down the hay, through a hatch, onto the concrete floor of the barn. I was knocked out for at least a minute. The "treatment" administered by the camp was that they let me sit on a couch rather than do the next camp activity (only after my initial protests) and eventually let me call my mother to pick me up early (which she didn't like). No one besides me really seemed concerned that I fell 8-10 feet onto concrete.

I did learn, though, and when I had my next big concussion (while in grad school, I ran full speed into a pipe in the dark) I insisted on a trip to the ER. It was a nice boring trip, fortunately, although I wish they could have given me some advice on how to treat the following week of unending nausea. And yes, I still got my Ph.D., so my brain must not have sloshed too badly.

#25 ::: Ginger ::: (view all by) ::: March 27, 2009, 01:48 PM:

j austin@ 22: I once sneezed while opening a drawer and smacked my forehead on the top of my dresser. I felt more stupid than pained.

(The only time I felt more stupid was the time I turned my back on the sheep.)

#26 ::: j austin ::: (view all by) ::: March 27, 2009, 01:56 PM:

ginger@25

I'm so glad it's not just me. The sad thing is, if I ever show up to work, dinner, or a funeral with an eyepatch on, no one is going to be surprised.

#27 ::: Serge ::: (view all by) ::: March 27, 2009, 02:16 PM:

Ginger @ 25... The only time I felt more stupid was the time I turned my back on the sheep.

This sounds like a great opening line for a novel about adventurers stuck in a bad place.

#28 ::: Joyce Reynolds-Ward ::: (view all by) ::: March 27, 2009, 02:30 PM:

My standard joke is that I'm safer on horseback or skis than I am on my own two feet, because in both cases I'm either a.) helmeted and b.) more stable (as in I've had more serious trip/fall/hit head injuries than I have in falling from a walk than either off of a horse or off of skis--even before I was helmeted in both activities).

I forget which book I have about skiers and Ski Patrol that talks about the Seckrit Ski Patrol methodologies to manage belligerent head injuries (of which Ski Patrols generally see quite a few). It usually involves more than one person, and sometimes management of the injured person taking a swing at one patroller before they can get the injured person (usually male in this case) safely secured in the toboggan.

#29 ::: Steve C. ::: (view all by) ::: March 27, 2009, 02:38 PM:

Serge @ 27 -

This sounds like a great opening line for a novel about adventurers stuck in a bad place.

The only time I felt more stupid was the time I turned my back on the sheep. To this day, I will never forget the bleating and the insidious smell of lanonlin. And the wool. The wool going over my eyes.

#30 ::: Alex ::: (view all by) ::: March 27, 2009, 03:06 PM:

19 is either a random muppost, a subtle brain injury, or one of the best jokes ever.

#31 ::: Linkmeister ::: (view all by) ::: March 27, 2009, 03:12 PM:

Jo Walton's experience (the LJ post linked in the main entry) is terrifying.

I had a fall about eight years ago which got me MRIs and CAT scans but no lasting effects; apparently slowly crumpling to the floor before banging one's head reduces the trauma.

#32 ::: Lee ::: (view all by) ::: March 27, 2009, 03:27 PM:

Jim, #4: When I was about 11 years old, I fell down the stairs. My parents took me to the doctor, who told them that if I got sleepy before bedtime, that was a bad sign. That made sense; at that age, I didn't require naps during the day, and if I was okay until bedtime, I was probably okay in general.

The funny thing is that I'm pretty sure I did NOT hit my head in that fall; I have clear memories of rotating scenery (very like the cinematography used to indicate that someone is falling!), and of thinking, "OMG, if I knock one of Mom's decanters off and break it, she'll kill me!" The worst I would have been was mildly shaken up.

#33 ::: Lizzie ::: (view all by) ::: March 27, 2009, 03:55 PM:

So in Natasha Richardson's case, is there any way to know if she would have lived if she'd gotten to a doctor sooner? I haven't been following the case closely so I haven't seen analysis of it.

#34 ::: Dan R. ::: (view all by) ::: March 27, 2009, 04:01 PM:

I wonder how much was known in earlier decades about the proper procedures to follow after a concussion.

I was knocked unconscious during a football game played during gym class when I was 13. I have no memory of anything between the game and waking up in a hospital bed about four hours later. I had apparently be out for about a minute, had finished school and gone home on my bicycle. My mother took me to the hospital after dinner when I started acting strangely and being unable to answer simple questions.

Jo Walton's account above makes me feel much more lucky about what might have happened, but it also begs the question about school and teacher responsibility. In 1969, should a gym teacher been more proactive?

I was never one of the jocks, so I'd never had a good relationship with gym teachers.

#35 ::: Ginger ::: (view all by) ::: March 27, 2009, 04:11 PM:

Lizzie @33: There's no way to prove that she would have definitely survived if she'd gone right away. All I can say is, her odds would have been much better if she'd gone to the hospital at once. The type of injury she had -- a ruptured artery with subdural bleed -- is treatable with monitoring, surgical decompression (i.e., removing the blood clot), and medication. Without any treatment, it becomes a fatal injury within hours.

In fact, until they made it clear how long she'd been without medical treatment, her outcome didn't make any sense. Getting any treatment within the first hour (ideal) or out to the first three hours (not ideal) makes a difference in the overall prognosis.

#36 ::: KeithS ::: (view all by) ::: March 27, 2009, 04:13 PM:

My grandfather fell and hit his head a few months ago. Once he realized he was getting slow and having trouble, he got the appropriate medical care. It left him with a rather interesting haircut for a few months. All this is to say yes, please pay attention to this.

Steve C. @ 29:

Is that an excerpt from Baaaad Sheep, or from Three Bags Full, But None for Ewe?

#37 ::: Steve C. ::: (view all by) ::: March 27, 2009, 04:18 PM:

Ginger @ 36 -

Actually, it was from the Thomas Harris thriller, The Violence of the Lambs

#38 ::: Linkmeister ::: (view all by) ::: March 27, 2009, 04:19 PM:

Dan R @ #34, I just remembered a similar experience, albeit without the hospital.

I was about 12, going to a parochial school in Westwood, Ca. Last day of school in SoCal, hotter than the hinges of, and we had a benediction service. I started feeling woozy and got permission from the teacher/nun to leave the church. I got as far as the sanctuary rail and collapsed, banging my head on the railing. Woke up a few minutes later in the nurse's office.

Mom didn't and doesn't drive, and Dad was in Antarctica, so it took her a while to get to the school. By the time she did I was judged to be fine; I'd just had a mild heatstroke event.

As far as I can tell there were no lasting effects, but obviously the powers-that-be made a decision that a trip to the hospital wasn't needed.

#39 ::: Serge ::: (view all by) ::: March 27, 2009, 04:20 PM:

Steve C @ 29... KeithS @ 36... James Hilton's Return to Shangri-Baaah?

#40 ::: Steve C. ::: (view all by) ::: March 27, 2009, 04:20 PM:

Whoops - mis-identified KeithS...sorry.

#41 ::: Joyce Reynolds-Ward ::: (view all by) ::: March 27, 2009, 04:23 PM:

Don't play down the dangers of sheep. I know a 4-H leader who had a serious, life-threatening head injury occur as a result of the prize show sheep of one of her kids knocking her down when they were loading it up in the trailer (not sure, but if it had been one of my family's sheep, that particular sheep's fate would have been as Rack o' Lamb).

Ski-knowledgeable accounts (mostly on The Ski Diva with reference to EpicSki and Teton Gravity Research forums) I've read of Natasha Richardson's injury add that the Ski Patrol tried to encourage her to go get medical attention as quickly as possible. My own personal encounters with Ski Patrol (when my husband--helmetless--fell and broke his shoulder) backs up my own personal conviction that when the Ski Patrol advises you to do something related to medical treatment, it's usually a Good Thing. In DH's case, Ski Patrol recommended ambulance transport--no siren needed, but that was a bloody strong recommendation and somehow between the time they loaded him in the toboggan and I skied downslope to meet up with him at the First Aid station, they'd convinced him and he was loaded up, waiting for me to follow the ambulance down the hill to the hospital.

Ski Patrol. If you're a skier and you get hurt on the slope, listen to them. They know what they're doing--and their paramedic training is significantly higher than the basic first responder training I've had as a teacher.

#42 ::: Xopher ::: (view all by) ::: March 27, 2009, 04:24 PM:

Or John Brunner's unpublished bestiality novel The Sheep Look Up My Dress?

#43 ::: Serge ::: (view all by) ::: March 27, 2009, 04:24 PM:

Ginger... In movies, how often have we seen a person get bopped on the head and regain conscience long enough afterward that the person has been all trussed up? The person will shake his/her head a bit to chase away the headache, and that's it. Is it correct to think that such a long period of being unconscious very likely means a serious concussion?

#44 ::: Steve C. ::: (view all by) ::: March 27, 2009, 04:32 PM:

Serge @ 43 -

I remember Mannix and a host of other detective shows from the 60s and 70s where that scenario happened every week. If that had really happened, poor Mannix would have been a piece of drooling wreckage before very long.

#45 ::: ers ::: (view all by) ::: March 27, 2009, 04:40 PM:

Jim, are the legal issues too complicated for you to publish your medical posts under the title Yog Sysop's Guide to Emergency Medicine for Dummies or something like that? I can't express (and I'm a writer, too) how well-written and well-thought-out these I find these posts. I hope I never have a chance to prove how valuable they are.

Change of topic:
Why do Scotsmen wear kilts?
Because sheep have learned to recognize the sound of a zipper.

I'm sorry, I tried to resist the urge (she said sheepishly).

#46 ::: B. Durbin ::: (view all by) ::: March 27, 2009, 04:48 PM:

Serge: I've actually seen it mentioned in some more recent detective novels that getting coshed on the back of the head is more likely to kill you than neatly knock you out, so maybe they're doing more research these days.

I am so very very glad that the one bicycle accident I was in did not involve a head injury, because that was before minors were required to wear helmets. I refused to go near the bike again until I had one, thank you very much.

I do remember the surprise I felt that I instinctively did the correct roll. My only injuries were whiplash and a cut on my leg from a piece of glass— not bad for getting knocked by a car into the middle of a busy intersection.

#47 ::: Serge ::: (view all by) ::: March 27, 2009, 05:00 PM:

Steve C... How many times was the Seaview's Kowalsky knocked out?

B Durbin... Poor Marlowe...

"I caught the blackjack right behind my ear. A black pool opened up at my feet. I dived in. It had no bottom. I felt pretty good - like an amputated leg. (Upon awakening) My throat felt sore, but the fingers feeling it didn't feel anything. They were just a bunch of bananas that looked like fingers."

#48 ::: James D. Macdonald ::: (view all by) ::: March 27, 2009, 05:17 PM:

In the novels, James Bond tended to vomit every time he woke up from being knocked out. (In my opinion, when a writer has a fictional character get knocked out it's a sign that the writer doesn't know what to do with that character next.)

As it happens I'm a licensed medical professional, and as such I'd hate to have someone think that I was practicing medicine beyond my scope of practice. And I'd hate to think that someone went and hurt themselves because of something that I said, or failed to say, or didn't explain clearly enough. So I hang on a disclaimer, and say "I'm not a doctor. If you have a real medical question, ask a real MD."

Other folks who've died secondary to head trauma: Octavia Butler.

Generally brains are pretty well protected (we do live long enough to reproduce and raise our young), and we recover well-enough from concussion. But when things go wrong with brains, they go really wrong in a remarkably short period of time. You really don't want to have some nice doctor talking to the family about organ donation, do you?

Trauma is the #1 killer of folks under forty in the USA. (After forty it's various medical causes -- but trauma is still right up there.)

#49 ::: LLA ::: (view all by) ::: March 27, 2009, 05:33 PM:

Jim, thank you for this post.

Since other people have shared their "I'm so clumsy stories", I thought I'd share mine.

I once got a black eye by hitting it on the doorknob. Honestly.

You see, my dog's bed was behind the door. When I walked towards the door, he stood up at just the right time in just the right way to trip me midstride. Over I went, hitting my eye on the doorknob. Up I got, feeling silly, and then I watched with mortification as my eye got swollen and a beautiful shiner developed. Instead of going to the hospital, I iced it and spent the next couple weeks explaining that I wasn't a battered woman -- that I really did hit my eye on a doorknob.

I guess I should have set the embarrassment aside and let the doctor tell me that all I needed to do was to apply ice to bring down the swelling.

#50 ::: Scraps ::: (view all by) ::: March 27, 2009, 06:38 PM:

Some people say I'm an "inspiration". I don't know; my paralyzed arm, for instance, shows every sign of being permanent, and my verbal/vocal distress is very hard (though that one shows hopeful signs; maybe two years, or three). I'm an inspiration, maybe, the way you can't help but be.

But I will say this: Please, I beg of you, see a doctor within the year. And if your checkup shows high blood pressure, for god's bring it down.

#51 ::: Scraps ::: (view all by) ::: March 27, 2009, 06:41 PM:

for god's sake

#52 ::: Michael I ::: (view all by) ::: March 27, 2009, 06:48 PM:

ers@45

Baaaaaa Humbug!

#53 ::: Paula Helm Murray ::: (view all by) ::: March 27, 2009, 07:01 PM:

We had a news story on 3/22 about head injuries. Parents won a large amount of compensation from a small rural school district.

Their son was on the football team and got a concussion. They took him to the doctor and brought a note to the school that he was to cease playing football or practicing until cleared. She also spoke directly to his coach about it

Two days later mom came to pick kid up for a doctor's appointment and found him on the football field, Coach had not stopped him at all.

He has permanent brain damage, anger and impulse control problems, memory loss and a considerably lowered IQ. The outcome is that he probably will not make that up again because of the damage.

It's a terrible shame. And a warning to others too.


#54 ::: Michael I ::: (view all by) ::: March 27, 2009, 07:04 PM:

I've sometimes wondered how "hitting one's eye on a doorknob" became the stereotypical cover story for a battered wife.

Especially since it generally takes a rare convergence of events to actually hit one's eye on a doorknob. It's POSSIBLE (e.g. LLA@49), but I suspect the number of people who have really gotten a black eye that way is fairly small.

Does the story trace back to some well-known movie or something? Back to anything at all that's identifiable?

#55 ::: Bill ::: (view all by) ::: March 27, 2009, 07:38 PM:

A friend of mine missed the second half of a con a few years ago - he'd been at home, fallen, banged his head, and had the raccoon-eye symptoms from that kind of head injury and a mild concussion, and went to the hospital about it. The doctors didn't think there was any serious brain injury, but they had the insight to wonder *why* he had fallen since he hadn't tripped over anything, it was daytime, and he was in his forties in good physical shape, awake, and sober. Diagnosis was that he had a heartbeat irregularity problem, and he's now got a pacemaker.

#56 ::: Bill ::: (view all by) ::: March 27, 2009, 07:43 PM:

Michael#54, I thought the stereotype was bumping into a door or doorjamb, not a doorknob. Doorknobs are, as you say, difficult to hit, but doors and doorjambs are big easy targets. I've never gotten a black eye from one, but I've hit them a number of times, usually in the dark, stubbed toes, even banged my head on door-closers more than once.

#57 ::: Torrilin ::: (view all by) ::: March 27, 2009, 07:48 PM:

Some people say I'm an "inspiration". I don't know; my paralyzed arm, for instance, shows every sign of being permanent, and my verbal/vocal distress is very hard (though that one shows hopeful signs; maybe two years, or three).

Dunno, you're alive, to me that seems more important than being an inspiration. Death is a pretty lousy alternative. (also isn't much consolation, because having a permanent disability happen as an adult is really painful... mine are all a lot more minor, but they still *suck*)

And you're exactly right about strokes. A family friend had several tiny ones over the last five years. They've seriously damaged his reflexes, so he no longer is able to enjoy his favorite hobbies (flying model and full size aircraft). He knows it isn't safe... and he knows that the odds are good the strokes came from smoking his whole life.

Odds are very good the only reason he's still here is he called 911 for the worst one, when his hand mysteriously stopped working.

#58 ::: Joel Polowin ::: (view all by) ::: March 27, 2009, 07:50 PM:

MIKE:

... I went back to my place, good old 3-D. I no sooner opened the door than they were at me again. This time I was ready. I smashed my eye into his fist, I forced my ribs into his boot, and the first thing I knew I was flat on my back in the hall. He was standing above me now. He spoke.

THIRD READER:

Look, buddy. You do this every night. This is not your apartment. You're in 3-D. This is 3-A.

(Jean Kerr, "Don Brown's Body")

#59 ::: Laurie Mann ::: (view all by) ::: March 27, 2009, 07:52 PM:

Great article, Jim!

It's quite amazing that some people survive much worse than what seems to have happened to Natasha Richardson. A few years back, the QB of the Pittsburgh Steelers was riding his motorcycle without a helmet and went headfirst into the car he crashed into. He's still playing football and led his team to a Superbowl victory this year.

#60 ::: Ginger ::: (view all by) ::: March 27, 2009, 07:52 PM:

Serge @ 43: Anyone who's been hit hard enough to be out that long (long enough for the bad guy to tie him up thoroughly) is a person in danger of never waking up again.

Hollywierd always gets that wrong. There is no safe way to hit someone and knock them out.

(When the writer's done a little more research, and shifts to the administration of anesthetic agents, they're still getting it wrong. There's no instant anesthetic either.)

Joyce @41: Yes, they can be dangerous. All it takes is for your head to be lined up with a fence post when you bend over and the sheep takes exception to your posture. As I found out. Luckily I didn't see anything but red while I rubbed my head and butt.

Scraps @ 50: I work with non-human primates who occasionally get a stroke (by accident, we're not studying strokes). I've seen arm (and leg) paralysis slowly improve over time. Since our monkeys don't have the speech centers, I can't draw any parallels there. Head injuries always have surprises, including during recovery.

#61 ::: Magenta Griffith ::: (view all by) ::: March 27, 2009, 08:08 PM:

A little off the subject, about "seeing stars". If you are persistently seeing little points of light, or flashes of light, or a lightening bolt effect, on one side only, and you *haven't* had a recent head injury, get to an eye doctor ASAP. You may have a detached retina, and need immediate treatment. I had those symptoms a few years ago, which turned out to be a detached vitreous humor. The retina never detached, thank the gods. It was a very scary afternoon.

#62 ::: Ellen Asher ::: (view all by) ::: March 27, 2009, 08:11 PM:

I was knocked out when a horse who was galloping with me in Central Park (it wasn't my idea, but that's another story) fell. I don't know how long I was out, but when I woke up I was surrounded by worried looking policemen and EMTs, and the ambulance was there.

They told me to get in the ambulance and go to the hospital; I said I had to take the horse back to the stable. Then I tried to get up, and I realized they were absolutely right. At the hospital, they x-rayed me, decided nothing was broken and sent me home with a list of things that, if they happened, would signal an immediate need for medical attention.

I had a splitting headache for two days but no other ill effects, and since this happened about 35 years ago, it doesn't worry me. But if I hadn't been wearing a helmet, I would definitely be dead.

#63 ::: Zelda ::: (view all by) ::: March 27, 2009, 08:19 PM:

I'm very fortunate that, on the few occasions when I have taken some blow to the head, there was someone on the scene who knew what to look for. I once walked off a loading dock in the dark-- at an observatory, there are no lights in the parking lot, and some yutz had neglected to put the chain back after the nitrogen truck pulled away. As B.Durbin@46, I was surprised that, klutz that I am, I still managed an instinctive roll that protected the drinking glass I was carrying, so no gashed wrists. And one of the astronomers was an EMT, and was able to assure me that, despite seeing stars without benefit of telescope, I was going to be fine. The satellite-image-of-Chesapeake-Bay bruise from my right hip to knee was probably more of a threat to my health.

On the other occasion, I was on my way to TA a class, and one of my students was an EMT. Strange role reversal, that was-- in a chemistry lab, *I'm* the one meant to be looking out for my kids' health and safety...

#64 ::: LLA ::: (view all by) ::: March 27, 2009, 08:22 PM:

Michael I @ 54:

I think it may have come to be a stereotype because the bruise I came up with was the classic shape that happens when fist meets face, and the part of the face met is the eye.

In other words, it was a beaut of a classic shiner.

In retrospect, I suppose I posted in part because Jim's excellent discourse made me realize that not only could I have suffered brain damage (and was too embarrassed to go to the hospital and make the necessary explanation) but that women (and men) who regularly suffer such abuse are at high risk of ongoing brain damage.

I don't want to hijack this thread. It was just the first time that I connected my moral outrage and feminine solidarity for anyone in a physically abusive relationship with the possibility that our society is made so significantly poorer by the loss of these victims' cognitive abilities.

#65 ::: Jim Macdonald ::: (view all by) ::: March 27, 2009, 08:31 PM:

Incidentally, March is National Brain Injury Month.

#66 ::: Scraps ::: (view all by) ::: March 27, 2009, 08:40 PM:

Ginger, I know. I work at physical therapy five days a week, and I expect to be working at it two years from now, I hope. But the progress is poor, and I have to face it, too.

#67 ::: Linkmeister ::: (view all by) ::: March 27, 2009, 08:40 PM:

I was Googling for the TBI survival rate in soldiers in Iraq and ran across this worrisome Nov. 2008 article in Neurology Reviews.com:

In general, individuals with TBI have about 30 times the risk for epilepsy compared with the healthy population

It goes on to say that the risk of epilepsy increases even more for combat-related TBI.

Yet another residual benefit of the Iraq War.

#68 ::: Linkmeister ::: (view all by) ::: March 27, 2009, 08:46 PM:

From a 2005 article in the New England Journal of Medicine,

According to the Joint Theater Trauma Registry, compiled by the U.S. Army Institute of Surgical Research, 22 percent of the wounded soldiers from these conflicts who have passed through the military's Landstuhl Regional Medical Center in Germany had injuries to the head, face, or neck. This percentage can serve as a rough estimate of the fraction who have TBI, according to Deborah L. Warden, a neurologist and psychiatrist at Walter Reed Army Medical Center who is the national director of the Defense and Veterans Brain Injury Center (DVBIC). Warden said the true proportion is probably higher, since some cases of closed brain injury are not diagnosed promptly.

#69 ::: Julie L. ::: (view all by) ::: March 27, 2009, 09:12 PM:

How about orthostatic hypotension? Does it have any long-term effects in itself, aside from possible sequelae of hitting your head on the way down?

It's a recurrent problem for me-- if I haven't remembered to eat much of anything earlier in the day, it usually manifests when I've crouched down to take a look at something and then everything goes woozy for a few seconds when I stand up. But that's somewhat an improvement on the times when I've been sitting/lying down for too long and then get up to walk across the room, because then there tends to be a delayed effect; by the time it hits, I can be 5-10 ft. away from a convenient piece of furniture to hang onto.

#70 ::: Rob Rusick ::: (view all by) ::: March 27, 2009, 09:36 PM:

Scraps @50: And if your checkup shows high blood pressure, for god's bring it down.

My wake-up call was getting some work done at a dental clinic, where they did a blood pressure reading before getting to work.

I forget the actual numbers, but when the lady doing the reading read them to her supervisor, she insisted on a second read: "That can't be right; he'd be dead."

Bit of an exaggeration, because it was right, and I wasn't dead. But despite no insurance, I did find a doctor to check it out. He started me out with some 'free sample' blood pressure meds, and wrote me a prescription for meds I could pick up for cheap at WalMart. Also suggested that I pick up a blood pressure monitor, which I did; and the numbers I reported back (and other tests) suggested that the meds got my numbers down to a reasonable range.

#71 ::: Rob Rusick ::: (view all by) ::: March 27, 2009, 09:55 PM:

Ginger @60; Serge @ 43: Anyone who's been hit hard enough to be out that long (long enough for the bad guy to tie him up thoroughly) is a person in danger of never waking up again.

Hollywierd always gets that wrong. There is no safe way to hit someone and knock them out.

(When the writer's done a little more research, and shifts to the administration of anesthetic agents, they're still getting it wrong. There's no instant anesthetic either.)

Yeah, the casual concussion (either delivered upon the guards, or received by the hero) is something that has annoyed me in contemporary TV fiction.

I had read an article in a 1960s American Heritage, written by a doctor, describing how much was wrong with television violence then. Apparently even as a kid he was studying medicine, and would describe to his friends the potential complication of the 'just a shoulder wound' that the hero took — the shoulder bones are relatively delicate, and don't mend well; major blood vessels run through the shoulder and would be damaged.

I can't recall if he had anything specific to say about concussions. He did say that people rarely die as quickly and as easily as TV suggests.

#72 ::: David Harmon ::: (view all by) ::: March 27, 2009, 10:19 PM:

Scraps: Perseverance is inspirational! For that matter, so is luck....

turtle @#3: In addition to Jim's points, if someone goes to bed with a concussion, that's likely to be a few hours they aren't getting treated....

#73 ::: Chad ::: (view all by) ::: March 27, 2009, 10:42 PM:

As someone who has had a major concussion (forgot 3 quarters of a high school football game I played in) and who played college football and participated in martial arts, head injury should be a concern. However, it should not be something you are overly concerned with. Don't let this recent freak ski accident hold you back. People rarely rarely die from something like this. If you did, you wouldn't be able to read this, because more than likely you would be dead.

#74 ::: janetl ::: (view all by) ::: March 27, 2009, 11:27 PM:

Daniel Klein @ 16: I was confused and certain someone was pouring water down my face. Why would anyone do that! Of course it wasn't water. (That bit where Mr. MacDonald mentions how much even small wounds to the head bleed? He's not exaggerating)

Yes! Playing at the park when I was about 5, I misjudged and jumped off a swing, landing directly beneath it. This was not one of today's plastic swings — it the seat was solid wood, and it smacked me in the head. People from a picnic table nearby came over to see if I was all right, and I thought they poured a pitcher of Kool Aid over my head. What else could that rush of red liquid be?

#75 ::: James D. Macdonald ::: (view all by) ::: March 28, 2009, 12:31 AM:

Chad has a good point. Brains really are well protected.

What's rare is isolated brain injuries. Usually you see them along with other injuries. The person has a brain injury plus a facial injury plus a penetrating chest injury plus a couple of long bone fractures ... it gets challenging.

Still, trauma is the number one cause of death among Americans ages one through forty-four. Keep a high index of suspicion when the mechanism of injury suggests brain injury, and be prepared to take rapid and effective action (which will probably consist of dialing 9-1-1) if you start seeing signs and symptoms.

#76 ::: P J Evans ::: (view all by) ::: March 28, 2009, 12:46 AM:

#73
On the other hand, it is a real risk - I had a uncle die, not many years back, after falling on a damp sidewalk. (Further details are unknown to me, but I'm assuming TBI was involved.)

#77 ::: Serge ::: (view all by) ::: March 28, 2009, 01:02 AM:

Rob Rusick @ 71... I remember the first cat my wife and I got. The little guy ran into my way, and my shoe connected with his skull. It didn't knock him out, but, for a day or two after that, one of Loki's pupils was more dilated than the other. We didn't notice any change in behavior, but then again there was a reason why we called him the Beast with Ten Neurons.

#78 ::: Diatryma ::: (view all by) ::: March 28, 2009, 01:04 AM:

Strokes are beginning to worry me a bit, if only because every time they come up in conversation, I am reminded of the fact that I will probably have a stroke and think it's a migraine.

A friend of mine was in a car wreck on Monday-- she's fine, car did its job, here's to seat belts and airbags-- and got a bump on the head. She didn't go to the hospital for the simultaneously reasonable and shitty reason that she figured the emergency room would be more of an insurance hassle, but once I was done driving her to empty her valiant but mortally wounded car and talk to her insurance guy, I dropped her at Student Health. She still had a headache three days later, and for all I know, may yet.
And this is without a concussion.

#79 ::: Jim Macdonald ::: (view all by) ::: March 28, 2009, 01:23 AM:

Diatryma, your friend may well have had a concussion. Unconsciousness isn't required.

Meanwhile, strokes. Yes. The number eight cause of death for Americans 25 to 44, when it goes up to the number six slot for 45-54, number five for 55-64, and number three for ages 65+. (Heart disease and cancer still lead the pack for ages 45+.)

If you smoke, stop. If you have high blood pressure, get it under control. A TIA (Transient Ischemic Attack, AKA "mini-stroke") is a warning sign; don't ignore it. There aren't a whole lot of funny stroke stories.

#80 ::: Lee ::: (view all by) ::: March 28, 2009, 01:51 AM:

Chad, #73: You have a point. But the flip side of it is not to neglect basic safety precautions just because the brain is generally well-protected. Go look at Paula's #53; I wonder how much of that resulted from the coach thinking, "Oh, hell, kids get bonked on the head all the time and nothing bad happens to them." So he lets the kid who's had a moderately-severe concussion play the next day, and the day after that, and the result is permanent brain damage. And you know it's even worse if the kid in question is the star linebacker, and the Big Game is coming up.

#81 ::: Nancy Lebovitz ::: (view all by) ::: March 28, 2009, 06:29 AM:

#68 ::: Linkmeister:

I keep seeing "Joint Theater" as a stand-alone phrase. Vertebrae doing Shakespeare?

#68 ::: Linkmeister:

I've heard of a movie which tracks the plausible consequences of someone being shot through the shoulder. Anyone know if it actually exists and if so, what it's name is?

#82 ::: Michael I ::: (view all by) ::: March 28, 2009, 09:09 AM:

Nancy Lebovitz@81

Vertebrae doing Shakespeare?

Either that or actors getting high.

#83 ::: Serge ::: (view all by) ::: March 28, 2009, 10:09 AM:

Thy spine doth protest too much.

#84 ::: janetl ::: (view all by) ::: March 28, 2009, 12:08 PM:

Just watched last Thursday's episode of ER. Teenager brought in who was injured in a fall, having convulsions. They diagnose TBI. I think there was a reference to an injury to the dura mater. They plan to keep him in the hospital, on bed rest, for observation for several days.

The same day as the injury, the doctors are fine with him going to a party in the hospital. He's sitting up in a bed, in a room with loud music and flashing lights, smiling happily, and bobbing his head to the beat of the music. Yeah...

#85 ::: Angiportus ::: (view all by) ::: March 28, 2009, 12:47 PM:

When I was 6, a horse threw me headfirst into a rocky ditch. I was bunged up but not knocked out. But I still wonder if that's why I have what seems to be ADD but doesn't respond to treatment, and as I look over the following 43 years I am surprised I don't hate horses. Maybe I should have ridden a sheep instead...
I think you should do a book...checked over by a real doctor if you aren't one, just to make sure...might help a lot. Thanks for the usual good job.

#86 ::: Eric Gen ::: (view all by) ::: March 28, 2009, 01:41 PM:

I managed to give myself a subarachnoid hematoma by picking up a large tree branch and carrying it about 100 ft.. It had never occurred to me that you could give yourself a brain hemorrhage by straining too hard. I didn't have any symptoms at all until about a day later when I was out in the yard and started getting a mild headache. Within about 5 minutes it was like someone was trying to twist my spine out of my body. This sensation was slowly working its way down my body.

Even though I was 50 at the time, I'd been doing martial arts for 20+ years and also box. You learn to cope and function in situations where your physically impaired, or rather dazed! :) My first thought was that I might be having a heart attack, but I had no chest pain and my heart was beating just fine. Then I became concerned that if the spinal sensations kept increasing at the same rate, that I might actually pass out. I figured that I better go tell someone what was going on while I could still talk and explain it.

My wife wasn't terribly happy when I walked in with the calmest of voices and mentioned that something strange was happening and, that if it continued at an increasing rate, that I could conceivably pass out. We decided to go to the emergency room. Unfortunately, even though I no longer get motion sickness like I did as a kid, I found trying to ride in a car to be terribly nauseating. We made it about a block, then I got out and walked home.

We next tried EMS. The firetruck got here first, as is normal around here. I described things to them, but by then I had pretty much plateaued and things were not getting any worse. I just had a killer headache. I found out much later the magic question is, "Is this the worst headache you've ever had?". It was!

They took my blood pressure and stuff, and couldn't find anything wrong with me. We cancelled the ambulance and I decided to ride it out a bit. Three days later, and with a large amount of web research, I wasn't getting any worse, but my headache wasn't getting any better. We decided to go to the emergency room again. Driving no longer made me nauseous (at least if I was driving, yes I know, that was poor judgement on my part).

Even though I was easily hitting 15 on the Glasgow Scale above, the doctor asked a few questions and immediately pegged the problem. Cranberry colored spinal fluid and a CAT scan later and I was immediately shipped off to a hospital with a neural unit.

I was incredibly lucky! A cerebral angiogram showed that I had had a subarachnoid hematoma. Eight days in the hospital, followed by another cerebral angiogram, showed that that was it. There were no other visible problems.

That was 6+ years ago. My memory's not as precise as it was some years ago, but that doesn't seem to be directly related, and could just be age. I'm a little bit dingier, but that could also just be age (or perhaps getting hit in the head too much!). So, again, I was incredibly lucky and, if I have any related to the trauma, I only seem to have minimal neuro-deficits.

Nowadays I don't strain as much when picking up heavy things and I will take the time to sharpen the chainsaw instead of trying to pick up heavy branches. I think one of the key things for me was the 'worst headache' question. I would have probably handled things differently if it had been asked early on. As it was, I was quite fortunate.

#87 ::: Lila ::: (view all by) ::: March 28, 2009, 02:38 PM:

Scraps: it's wonderful to see you posting. I'm a physical therapist assistant, and at the risk of being impertinent, I add my dose of optimism to Ginger's. Stroke rehab is a rapidly changing field; lately we keep finding out the brain can do more than we believed it could, even months to years after the event.

#88 ::: Laurie Mann ::: (view all by) ::: March 28, 2009, 03:19 PM:

And if the first blood pressure medicine doesn't work, keep trying different ones until you find one that does. There are many kinds to try.

#89 ::: Mary Aileen ::: (view all by) ::: March 28, 2009, 04:35 PM:

Nancy Lebovitz (81): Probably not what you're thinking of, but in the movie Regarding Henry, the title character (played by Harrison Ford) is shot in the shoulder during a mugging and winds up with brain damage. From the blood loss, I think, but it's been quite a while since I saw it.

#90 ::: P J Evans ::: (view all by) ::: March 28, 2009, 05:20 PM:

What I remember about my father's third stroke - all hemorrhagic, all in the brainstem, and the only one I witnessed - was first, he 'froze up' with only repetitive small movements.
We got him on the floor, on his side - 'dead weight' is not a joke - and by then he was sweating across his forehead, large drops of sweat.
I don't know, and never will, how much awareness he had by then. We talked to him anyway.
That was Sunday morning. On Wednesday morning we turned off the respirator and handed him over to the medical school, according to his wishes.

#91 ::: abi ::: (view all by) ::: March 28, 2009, 06:34 PM:

Scraps:

All questions of inspiration be damned. I'm just glad to see you posting again, and I'm grateful that you're willing to take the trouble do so.

I've missed having you around.

#92 ::: Debbie ::: (view all by) ::: March 28, 2009, 06:42 PM:

The only concussion I've had so far was the result of orthostatic hypertension, but I doubt it's a typical scenario -- during a semester in London, for some reason a group of us were running full-tilt from our classroom to our lodgings several blocks away. I tripped and fell. That wasn't the problem -- I was so embarrassed that I stood up too quickly, got woozy, and fell down again. That's what gave me the concussion. The worst part of the aftermath was having to miss a costume party, so I'm not complaining.

My grandmother fell in the hospital. She'd been in for three weeks with pneumonia, and they were about to release her but wanted one more chest X-ray. She was terribly weak, but they made her stand for the X-ray. Apparently she fell straight backwards and hit the back of her head on the hard tile floor.

When I got to the hospital a couple of hours after it happened, she had raccoon eyes, and I almost passed out when I saw her -- it is a very...dramatic symptom. She had contracoup lesions and resultant problems from frontal damage. It was kind of a classic textbook case, and would have been interesting if I'd encountered it on rounds on my (at that time) recent neuropsych internship, but with my grandmother? Not so much.

#93 ::: abi ::: (view all by) ::: March 28, 2009, 06:47 PM:

I must confess, by the way, that I have hit my head recently. I slipped on black ice while cycling to work. The bike went out from under me, and I slid along on my right side for a bit, giving my head a nice thunk on the ground as I went.

I got back on the bike and rode to work very carefully. Then I tweeted about the fall and mentioned it to my colleagues. I reckoned if I did anything the least bit funny, they would call an ambulance immediately.

I had a headache for much of the day, but nothing else happened. I've been much more careful about ice since then.

#94 ::: Serge ::: (view all by) ::: March 28, 2009, 06:54 PM:

Abi @ 93... I reckoned if I did anything the least bit funny, they would call an ambulance immediately.

Your co-workers sure are a tough audience.

#95 ::: Sarah ::: (view all by) ::: March 28, 2009, 07:29 PM:

He did say that people rarely die as quickly and as easily as TV suggests.

My basic rule of thumb is that real people are way more fragile than major character in movies, and at the same time, way *less* fragile than minor characters.

#96 ::: Wirelizard ::: (view all by) ::: March 28, 2009, 07:54 PM:

My basic rule of thumb is that real people are way more fragile than major character in movies, and at the same time, way *less* fragile than minor characters.

So, most people have speaking parts, but not starring roles. That sounds about right.

#97 ::: Lila ::: (view all by) ::: March 28, 2009, 07:59 PM:

Almost as annoying as the Hollywood concussion with no lasting effects is long immobilization with no effects at all. E.g., the character's been tied to a pole for a day and a half, and can run, jump, and pick locks immediately upon being untied.

One would think anyone who's been alive long enough to be a scriptwriter would at least have experienced having a foot or arm fall asleep.

#98 ::: Tae Kim ::: (view all by) ::: March 28, 2009, 08:04 PM:

Jim's stuff is top-notch as usual. Jim, I wish you'd ben one of my med school professors. Such clarity in communication is sorely lacking in med skool.

I will make one small point. In the ED, you *can* differentiate between subdural, epidural, and to some degree, subarachnoid bleeds by plain (no intravenous contrast) CT scan and a lumbar puncture. But the end result is the same either way: call neurosurgery.

A bunch of us were talking about, as non-neurosurgeons, given the same situation with Richardson, whether we'd say fuck it and do a emergent craniotomy (burr hole) in the ED.

The consensus was that most of us would, but only after explaining in great detail how we weren't neurosurgeons, and it was either that or die on the way to the other hospital. And reams of consent forms. Gotta love lawyers.

#99 ::: Serge ::: (view all by) ::: March 28, 2009, 08:24 PM:

Lila @ 97... the Hollywood concussion with no lasting effects

Speaking of which, TCM just finished showing Houdini. I especially liked the scene where Tony Curtis locks himself inside his employer's big safe. Everybody panicks and, before he can let himself out, they blow the door open with explosives. Tony walks out, waving the smoke off his face, but I didn't see anything oozing out of his ears.

#100 ::: janetl ::: (view all by) ::: March 28, 2009, 08:41 PM:

Lila @ 97 Almost as annoying as the Hollywood concussion with no lasting effects is long immobilization with no effects at all. E.g., the character's been tied to a pole for a day and a half...

I recall a character who had been in a coma for months having the strength to walk down several long hallways and then down a flight of stairs. Oh, yeah.

#101 ::: James D. Macdonald ::: (view all by) ::: March 28, 2009, 09:32 PM:

Years ago, when I was in Panama, we had one young sailor hit another young sailor upside the head with a broomstick. The guy who got hit got sent up to Gorgas Army Hospital, even though he insisted he was fine. Gorgas agreed, and sent him back to the barracks. Later that night he started vomiting, spiked a fever, went rigid, and died, just about all that fast.

We figured that his buddy put him in the hospital; it was the hospital that put him in the ground.

---------

Skiing. Some of my saddest stories are skiing stories. One minute there's a bunch of friends having a great time in a beautiful place, and they're young and happy and healthy and beautiful and rich, and the next minute it all goes straight to hell. And the look on the friends' faces is the worst of it.

It is given to no man to know the day or hour.

#102 ::: Ginger ::: (view all by) ::: March 28, 2009, 10:11 PM:

Tae Kim @ 98: Sure, in the first hour or so after injury, with acute CNS signs, you'd drill that hole and with any luck also get the clot started on suction while you're moving to the OR.

If the patient has waited more than 4 hours (as reported it took for Ms. Richardson), you're likely to have brain herniating through your burr hole. By that time, a CT scan is behind the curve (CT doesn't show edema as well as MRI), and MRI takes too long for an unstable patient.

I suspect that by the time she reached the hospital she had already gotten to transtentorial herniation, or at least swelling into the cerebellum. Once the brain reaches that level of swelling, the surgeon has to take off the calvarium, which is a salvage procedure, really. If they did that, in her case it didn't work.

#103 ::: Torrilin ::: (view all by) ::: March 28, 2009, 10:43 PM:

I've been much more careful about ice since then.

Studded tires. They're pretty common 'round here in the winter.

However, studded tires do not protect against the other great scourge of cyclists... railroad tracks and metal sheets. Last fall I hit a railroad track *just* wrong, and had a nasty fall. I was very lucky, and took the brunt of the impact with my knee. Almost all the damage was to the nice thick cushion of muscle around my knee. The usual injury for the way I fell isn't a busted knee, it's a broken femur, up near the hip socket. (next most common is a head injury, but my helmet was untouched)

On the whole, I'll take the knee.

#104 ::: Tae Kim ::: (view all by) ::: March 28, 2009, 11:41 PM:

Ginger @ 102: I haven't kept up with the chronology, but wasn't Richardson at the first hospital in about two hours after the fall? I agree the longer the wait the more the bleed will clot and not drain, but there was a window during that first hospital encounter that perhaps something could be done.

#105 ::: Paula Helm Murray ::: (view all by) ::: March 29, 2009, 01:24 AM:

from what I have read. she declined any treatment at all right after it happened. Because of that it was way late before she saw any kind of medical assistance.

Which is very sad.

#106 ::: abi ::: (view all by) ::: March 29, 2009, 03:41 AM:

Torrelin @103:
If we had long periods of ice, I'd get studded tires and thank my lucky stars for quick-release wheels all winter (I hate doing bike work in the cold).

What I've done since then is stick to salted or gritted roads on icy days. (I'd taken the scenic route with the unsalted bike path that day.)

Generally:
A fictional example of this phenomenon can be observed in Busman's Honeymoon, by Dorothy L Sayers, where the victim suffers a blow to the head sufficient to fracture his cranium, and still manages to move about and do a number of things before dying.

The police chief in the village researches the matter in Taylor's Medical Jurisprudence*. The scene that riffs on the story of the gentleman thrown from a chaise in 1859 is one of my favorites in the book ("his premature death must have occasioned much lamentation among the crinolines").

-----
* Which we have, albeit in a later edition. It's one of the books we keep on the top shelves, because the pictures would be upsetting for the children who have free run of the books they can reach.

#107 ::: Serge ::: (view all by) ::: March 29, 2009, 09:09 AM:

Abi... Speaking of bicycling accidents...

#108 ::: dcb ::: (view all by) ::: March 29, 2009, 11:14 AM:

abi @ 93

My cycling-on-ice accident involved turning right (which is across the traffic, in the UK) from a gritted to an ungritted road. Did a pretty decent side breakfall, and very little damage (elbow friction-grazed through three layers of clothing). The outcome would have been very different if I hadn't slowed and let the following car turn right ahead of me...

Re. concussion in novels, didn't Nancy Drew get knocked out in nearly every book, with nothing more to show for it than a slight headache?

And yes, if you need that "bullet wound" the hero can still function with, I understand that grazing through the outside of the upper arm is slightly plausible, versus the many important bits which are likely to get involved in the often-used-in-fiction bullet through the shoulder.

Almost-but-not-quite-completely-unrelated, according to Morbidity & Mortality Weekly Report (CDC), there are estimated to be more than 86,000 falls per year in the USA related to dogs and cats - mostly dogs. Most cats I know excel at the game of "wait until the human is in the process of stepping over you, then move so you'll be in the way where their foot will come down" - especially on the stairs and when the human is carrying something large...

#109 ::: Ginger ::: (view all by) ::: March 29, 2009, 11:32 AM:

Tae Kim @ 104: The first reports had Ms. Richardson going to the hospital in about an hour or so after returning to the hotel. The last reports, issued about the same time as the official word from the ME, indicated that the delay had been closer to 4 hours before reaching the hospital.

I had been bothered by the intensity of the damage with respect to a 1-hour delay, thinking that there had to be something else going on -- like a ruptured aneurysm prior to the fall -- but once I saw the revised timeline, it all made more sense.

#110 ::: Ginger ::: (view all by) ::: March 29, 2009, 11:39 AM:

abi @ 106: "the victim suffers a blow to the head sufficient to fracture his cranium, and still manages to move about and do a number of things before dying."

This kind of situation is exceedingly rare. Dr. Jan Garavaglia (Medical Examiner for Orange County, Florida) reported on a suicide in which the gentleman shot himself in the back of the head, which was not immediately fatal. He then stumbled to the railing of the bridge -- possibly intending to throw himself over -- and instead passed out in a position that left him resting on the railing, head down over the water. He was found dead, in this position, with his gun holstered. The initial impression was that he'd been murdered, but the evidence* led to a conclusion of suicide.

*Including the degenerative bone disease in his neck that was causing severe, unrelenting pain. He put the gun right above his neck.

#111 ::: Serge ::: (view all by) ::: March 29, 2009, 11:53 AM:

I read this in Salon.com's column by Alex Koppelman...

On any given day, I get a lot of e-mails from publicists. Some are silly, some are embarrassingly unprofessional, most are completely unrelated to what I cover. Occasionally, one is downright shameful -- callous, even offensive. One of those landed in my inbox today. The headline of the pitch is, "NEWS REPORTS REVEAL NATASHA RICHARDSON’S DEATH MAY HAVE BEEN PREVENTED WITH U.S. HEALTHCARE." And yes, the point of the e-mail is that socialized medicine killed Richardson, whose fatal skiing accident occurred in Canada.

Well, if Michelle Malkin thinks that it's Canada and not that brain injury, that killed Richardson, who am I to argue?

#112 ::: David Harmon ::: (view all by) ::: March 29, 2009, 12:52 PM:

dcb #108: Most cats I know excel at the game of "wait until the human is in the process of stepping over you, then move so you'll be in the way where their foot will come down..."

If they get kicked (moved in front of you walking) or partly stepped-on (above trick) a couple of times, they'll learn fast what a steady walk means. That said, while I had a rabbit, I developed a distinct shuffle. (Rabbits don't learn so good....)

I'm pretty sure this is meant to be a feline social thing, which just interacts poorly with their "buddy" being 5-10 times their weight and height.

#113 ::: JanetM ::: (view all by) ::: March 29, 2009, 01:31 PM:

More personalized stories about concussions: I got one in my car accident seven years ago (photos of the car; the guy in the pictures is the husband of the friend who went to the junkyard to take the pictures for me).

Short form: I was rear-ended by fully-loaded tractor-trailer while I was stopped on the freeway (there had been another accident earlier, where a truck had lost a load all over the road, and the crews were still cleaning that up).

Car rolled and spun; I was thrown out of my seatbelt (yes, I was wearing my seatbelt properly; however, the seat back was broken by the impact and the seatbelt had nothing to hold me against) and put a lovely headstar in the windshield, on the passenger side, with the back of my head. I also broke three ribs and whiplashed my upper back, and acquired an assortment of comparatively minor cuts and bruises.

My memory of the accident goes from "I am stopped on the freeway and should turn on my hazard lights" to "I am upside down and there are paramedics in my car. Something is seriously wrong here." I don't know if I was actually unconscious, but the memory gap is probably about 10-15 minutes.

The first thing I remember saying was to answer the question, "Do you know what happened?" with "I think there's been an accident, is anyone hurt?" (Which was really an incredibly stupid thing to say, and I'm still embarrassed by it all these years later, not to mention by what I might have been saying before my memory and social censors came back online.)

But I knew who I was, where I was, and about what time it was. I think I greyed out or blacked out when they moved me out of the car onto the stretcher, because I don't remember that part very clearly at all (they gave me a blanket and told me to tuck it around my face and arms to protect me from breaking glass, then there were loud crunching noises, then they started to slide a backboard under me, and then I was on the stretcher).

I remember asking in the ambulance if anyone had my purse because that's where my insurance cards were.

The ER x-rayed me and scanned me (I'm pretty sure CT scan because I don't remember it being noisy). Another point of ongoing embarrassment is that I was so uncooperative; I whimpered and moaned when they had to move me around, and I couldn't roll over onto my side for them to X-ray me, they had to get a tech in to roll and hold me. (I did, at least, apologize for being difficult.)

After all the scans and such, they gave me a shot for pain and one for nausea, and were ready to release me to my husband (who I still think folded time and space to get from Maryville, TN to Cleveland, TN as fast as he did). I stood up from the bed, turned grey and sweaty, and started swaying. They sat me back on the bed, tried three times with no success to take my blood pressure, and started an IV.

I dozed off, and when I woke up about four hours later I could stand up without getting sick, so they went ahead and discharged me with scrips for pain and nausea (but no muscle relaxant, which still pisses me off -- I'd been in accidents before, and knew damn good and well that muscle relaxants are more helpful than narcotics in the week following).

It ended up being almost six weeks before I was able to go back to work, although that was mostly my fault for not pushing my own doctor hard enough to refer me to physical therapy (among other things, the first thing the PT showed me was how I could get into and out of bed without screaming -- I'd been sleeping in an office chair tipped back and my feet up on another chair for a month).

And given that I had dizzy spells for the better part of six months, I am (A) more inclined to think Dale was right and the ER should have admitted me for observation, and (B) damn lucky I didn't end up with worse outcomes.

#114 ::: David Harmon ::: (view all by) ::: March 29, 2009, 01:44 PM:

JanetM @#113:

The first thing I remember saying was to answer the question, "Do you know what happened?" with "I think there's been an accident, is anyone hurt?" (Which was really an incredibly stupid thing to say.../blockquote>

Piffle! I think it's very sweet, and implies good things about your character. And where you're embarrassed about being "uncooperative", I'll point back to your prior passage:

the seat back was broken by the impact ... and [I] put a lovely headstar in the windshield, on the passenger side, with the back of my head. I also broke three ribs and whiplashed my upper back, and acquired an assortment of comparatively minor cuts and bruises.

That's called being badly hurt. Wich definitely excuses "I whimpered and moaned when they had to move me around, and I couldn't roll over onto my side for them..."!

#115 ::: fidelio ::: (view all by) ::: March 29, 2009, 02:05 PM:

JanetM @113--
Believe me, in terms of "uncooperative", a badly injured patient who can't roll over on her own and apologizes for being a nuisance is a positive joy compared to some of the other customers, as anyone who's spent much time in emergency medicine can tell you. Friends, family, and co-workers of mine who have been in that line of work have vented more than once about some of what they deal with as part of the job. Ego absolvo te, on their behalf.

You're right about the muscle relaxers and PT, though.

#116 ::: dcb ::: (view all by) ::: March 29, 2009, 03:37 PM:

112 ::: David Harmon @ 112

Cats vs. rabbits. important: rabbits have about half the skeletal mass of cats (relative to total mass). They are much more fragile. You kick or partly step on a cat a couple of times and it yowls and runs away and acts offended (then refuses to move the next time you're having to climb the stairs carrying a large heavy box). Do that to a rabbit and it will probably have a broken back...

JanetM @113

I "wasn't very cooperative" about lying down for radiography when I'd dislocated my shoulder either: or to put it another way, a normal change in posture from sitting up to lying down was no longer in the list of things I could do; being rocked onto my back with my legs bent in sitting position (strong person on either side moving me) then straightening my legs once I was lying down was possible. The tech did offer to throw me onto the table (told me I could scream/swear as loud as I wanted, the room was soundproofed) but I didn't like that option. Your inability to roll over on your own sounds perfectly reasonable for a person with that level of injury.

#117 ::: Serge ::: (view all by) ::: March 29, 2009, 03:41 PM:

Regarding guns... Does anybody remember actor Jon Erik Hexum? He accidentally died in 1984 by putting a prop gun to his head and pulling the trigger. Yes, it was loaded with a blank, but its pad shot out so fast that it shattered his skull.

#118 ::: janetl ::: (view all by) ::: March 29, 2009, 03:50 PM:

Fidelio, JanetM: So right about the value of muscle relaxants in recovering from an injury. I threw my back out awhile ago. Took relaxants, and was already mostly recovered the next day. My (not professionally trained in any way) impression is that the faster recovery is due to not tensing everything up to guard against the pain.

#119 ::: J Austin ::: (view all by) ::: March 29, 2009, 03:54 PM:

Serge@117:

I remember him. He was in Coverup with Jennifer O'neil(sp?)as a male model/secret agent and his photographer, right?

#120 ::: Serge ::: (view all by) ::: March 29, 2009, 04:02 PM:

J Austin @ 119... I think that's what Hexum had been in. I don't think I ever saw it, but I remembered reading about his death.

#121 ::: Tae Kim ::: (view all by) ::: March 29, 2009, 04:03 PM:

Serge @ 117: I went to paramedic school on the Cape with his brother, Gunnar, in the 90's. Never mentioned his brother once.

#122 ::: abi ::: (view all by) ::: March 29, 2009, 04:03 PM:

JanetM @113:
I'm with David Harmon. If your first reaction was to ask if anyone was hurt, it does say something about you.

It doesn't say stupid to me.

#123 ::: Serge ::: (view all by) ::: March 29, 2009, 04:16 PM:

Tae Kim @ 121... I hope it's not because they had hated each other but they loved each other and talking about his death was painful.

#124 ::: Tae Kim ::: (view all by) ::: March 29, 2009, 05:36 PM:

Serge @ 123: I don't honestly know. His brother shot himself in '84, my medic class was '90. Long enough time or never enough?

#125 ::: Russ ::: (view all by) ::: March 30, 2009, 05:18 AM:

Daniel Klein@16 (and @19!)

If it makes you feel any better, I did the exact same thing.

At slightly less velocity, it sounds like, as I avoided the concussion and walked myself to hospital, but I needed 3-4 stitches in my scalp.

And felt like a total buffoon.

#127 ::: David Harmon ::: (view all by) ::: March 30, 2009, 10:14 AM:

Dcb #116: They are much more fragile.

Indeed, but I'm not talking about full-strength kicks or putting even half my weight down. Basically, shoving them aside with my foot, just hard enough to make the point that when I want to go somewhere, they need to get out of the way.

Note that my rabbit died of old age, in his seventh year. This, despite spending his life chewing through an unreasonable number of wires, including live power cords. (aka "The War of the Wires".) And eating through my Euphorbia pseudocactus, despite spines and supposedly-caustic sap.

#128 ::: John L ::: (view all by) ::: March 30, 2009, 10:21 AM:

Rabbits are very fragile. My father raised them for food, and when we killed them the easiest way to do it was hold them by their back feet and tap a blunt object against the base of their skull. That blow was more than enough to break their spine right at the skull, killing them instantly. If you hit them too hard it would nearly rip their head off, and I'm not talking about "swing like you're an executioner" hard either.

Chickens were a lot harder to kill. They had this annoying tendency to pull their heads in on their neck so you didn't have a good target, and if the hatchet wasn't sharp enough you'd just break their neck without cutting the head off.

#129 ::: janetl ::: (view all by) ::: March 30, 2009, 10:21 AM:

David Harmon @ 127: The rabbit ate through a euphorbia pseudocactus without ill effects!? I can't grow euphorbia in my garden, because the tiniest amount of sap on my skin triggers a rash. The thought of eating it makes me shudder. I had no idea rabbits were so tough.

#130 ::: David Harmon ::: (view all by) ::: March 30, 2009, 10:50 AM:

Janetl #129: Yep, IIRC he severed one column and ate about halfway through the other (which naturally killed that one too), both near the base.

Jim @#126: That thing is pretty buggy. On answering the second question, I got this:

Your answer was

Microsoft VBScript runtime error '800a0006'
Overflow: 'CInt'
/quiz/index.asp, line 147


PS: to moderators/webmasters: OK, auto-closing stylistic tabs (i, b) after a paragraph break is vaguely reasonable. But "blockquote" probably shouldn't do that! (Certainly, it, like all comment tags -- should be auto-closed at the end of the comment!)

#131 ::: abi ::: (view all by) ::: March 30, 2009, 10:55 AM:

David Harmon @130:
OK, auto-closing stylistic tabs (i, b) after a paragraph break is vaguely reasonable. But "blockquote" probably shouldn't do that! (Certainly, it, like all comment tags -- should be auto-closed at the end of the *comment*!)

I agree entirely.

Sadly, we are helpless, cringing slaves before the mighty incomprehensibility of Movable Type in this matter.

#132 ::: pedantic Serge ::: (view all by) ::: March 30, 2009, 11:01 AM:

Abi @ 131... we are helpless, cringing slaves

...or are we supposed to be 'cringeing' slaves?

#133 ::: pedantic Xopher admonishes pedantic Serge ::: (view all by) ::: March 30, 2009, 11:24 AM:

No, Serge. Abi got it right. At least for American usage. We also write "aging" (not "ageing").

#134 ::: pedantic Serge responds to pedantic Xopher admonishing pendatic Serge ::: (view all by) ::: March 30, 2009, 11:33 AM:

True, but somehow it looks wrong - to me anyway - without the 'e'. I have the same reaction to 'judgment'.

#135 ::: Serge ::: (view all by) ::: March 30, 2009, 11:46 AM:

Rabbits, fragile? Hah! That's what they want you to believe before they do this to you.

#136 ::: Xopher wonders what "pendantic Serge" is suspended from ::: (view all by) ::: March 30, 2009, 11:50 AM:

I know that you're a jewel, Serge, but are you just a decoration hanging from a chain around the lovely throat of your esteeméd wife? (Actually you said 'pendatic', but hey.)

JanetM, I think "is anyone hurt?" does say you were a little confused, but not stupid, and speaks volumes about your compassion and concern for others. I just hope that in a similar situation I can be that "stupid."

#137 ::: pendatic Serge ::: (view all by) ::: March 30, 2009, 12:00 PM:

Xopher @ 136... It is my curse that I utter so many pearls of wisdom that they add up to a necklace of incalculable worth. (Right.)

#138 ::: abi ::: (view all by) ::: March 30, 2009, 12:05 PM:

Yes, Serge, you rock.

#139 ::: Xopher ::: (view all by) ::: March 30, 2009, 12:12 PM:

Sometimes it seems like he's stoned though. He does come up with igneous puns for those of us with more sedimentary lifestyles, if I may wax metamorphic for a bit.

#140 ::: Pendrift ::: (view all by) ::: March 30, 2009, 12:17 PM:

John L @128: It's called the coup du lapin (rabbit punch) in French, and is also the layman's term for a whiplash injury.

#141 ::: Kathryn from Sunnyvale ::: (view all by) ::: March 30, 2009, 01:46 PM:

My 'why I always wear a bike helmet' tale

I wear one because of a college roommate who had to drop out of school after a simple bike accident.

While biking home late at night he somehow fell. He recalled he was going quite slowly, no more than 6 or 7 mph, because it was dark. There were no other cars, bikes or pedestrians around.

Patrick continued home. Another roommate- a med student- noticed the signs of a concussion. We brought him to the hospital: other than the concussion he seemed fine. No fractures, no stiches needed, no 'chiseled spam' road rash.

Except he lost his grad-school-going intelligence. His was a real Algernon moment. He could read newspapers but not his own notes. He could understand TV shows but not lectures.

His brother put law school on hold and flew out to California to help, but even with his brother shadowing him he couldn't handle school. He dropped out and left for physical rehab in Colorado.

He didn't return to school in the next 2 years. After that I lost track: I don't know if he ever went back to grad school or his original career track.

#142 ::: Jacque ::: (view all by) ::: March 30, 2009, 02:25 PM:

And I'm now wondering about me: we got hit by a Big! Scary! Blizzard! (9 inches, woo hoo. In Boulder, for Ghu's sake!) last Thursday, and first thing I did was go down on my butt when I stepped off the porch. Didn't land on my cocyx, gods be thanked, but rather back on my sacrum. Sort of squnched myself in a C, where my tailbone is the bottom serif and my head the top one.

Since I didn't feel anything much beyond "mumph, that was annoying!" and over-stretched spinal muscles, I assumed I was okay. But now this thread has me feeling paranoid. Especially since I woke up Sunday morning feeling excessively hung-over. But I'm attributing that to having stayed up until O'Dark-thirty embroidering madly. Right?

And what was the deal in Jo's LJ post about no one who gets hit in the head can understand French?

#143 ::: Jacque ::: (view all by) ::: March 30, 2009, 02:34 PM:

#27 & #29: Ah, I'm minded of the time I discovered why they call male sheep "rams." If you want him to go away, do not push on his head.

#144 ::: Lee ::: (view all by) ::: March 30, 2009, 02:57 PM:

Kathryn, #141: From your account, I have to wonder if something was going on there beyond the fall/concussion. Might he have had a mini-stroke or TIA that caused the fall in the first place? (This isn't an argument against helmet-wearing; no matter what caused it, the concussion certainly didn't help matters.)

#145 ::: Kathryn from Sunnyvale ::: (view all by) ::: March 30, 2009, 04:07 PM:

Lee @144,

My now-faded memory tells me it was a very bad concussion he had-- all the force of impact that should've gone into a broken helmet (or at least broken skin and bones) went straight to his head. I recall his parents helped him get extensive tests within a couple of weeks of the accident.

Single-biker accidents were common at my school, especially in winter after the leaves fell and made slick covers along the paths.

#146 ::: nerdycellist ::: (view all by) ::: March 30, 2009, 04:15 PM:

One of the priests at the church I attend just lost his long time partner to TIA. They were on pilgrimage to Israel, and his partner Bob tripped and hit his head on a column in front of their hotel. They rushed him to the hospital where he was held for observation and CAT scanned several times before they released him the following day with the caveat that he should be brought in for follow-up the next day. He didn't remember the accident and but seemed to have a big hematoma on the side of his head.

He felt perfectly fine on the day they released him, but later that day he laid down for a rest and slipped into a coma. He never woke up. Father S. was/is devastated, but was grateful Bob was able to visit Mt. Carmel before he died. He is also grateful that Bob passed, rather than partially recovering.

The brain is a weird thing.

#147 ::: nerdycellist ::: (view all by) ::: March 30, 2009, 04:16 PM:

euch, give me a preview and I still mess it up!

I meant that Bob died due to TBI, not TIA.

#148 ::: Serge ::: (view all by) ::: March 30, 2009, 04:33 PM:

Jacque @ 143... I discovered why they call male sheep "rams."

Considering that the French for 'ram' is 'bouc', you found out what it's like to have the bouc thrown at you?

#149 ::: Serge ::: (view all by) ::: March 30, 2009, 04:35 PM:

Serge @ 148... You fool, a 'bouc' is a billy goat!

#150 ::: CHip ::: (view all by) ::: March 30, 2009, 05:02 PM:

Serge@111: an argument in various places has been that a medevac helicopter would have gotten Richardson to a hospital enough faster to have saved her. What can you tell us about decisions to provide or not provide such in Canada? They're becoming controversial in the U.S. due to numbers of fatal crashes and arguments about how often they're used unnecessarily, but they may still provide value. This doesn't guarantee that Malkin doesn't have her head up her ass, but it may be a difference of interest.

Jim@126, re Harman@130: Is the crash what's supposed to be amusing? I also found it on 2 tries, once immediately and once after one question. I also wonder about a quiz which rates identifying the mitral valve as "very difficult".

#151 ::: Serge ::: (view all by) ::: March 30, 2009, 05:11 PM:

CHip @ 150... The article does go on to say that the helicopter was a valid concern. As for myself, I wouldn't know what the state of affairs is in Canada, having moved to the USA the day Bush Père became President. My own experience growing up there was positive, but I did see some inefficiencies, but not of the kind that caused the death of celebrities or of less known people. As for Malkin... I don't give a bleep what she has to say about anything. Heck, if there were more helicopters, she and her kind would probably assume it's a black-helicopter conspiracy.

#152 ::: Carrie S. ::: (view all by) ::: March 31, 2009, 09:58 AM:

My bike accident involved absolutely no head trauma; I hit the ground on my side and my head didn't touch the pavement until I rolled onto my back (which I immediately thought was a bad idea, and did not move voluntarily again until I got to the ER). The EMTs still had to put a collar on me and get me on the backboard, of course, which kind of sucked because the most important injury I had was a sprain in the lumbar spine--a backboard has little in the way of lumbar support, and my trip to the hospital was rather uncomfortable, if fortunately short. Still glad I was wearing the helmet, though.

Friend of mine died last fall from slipping off his porch roof; he apparently landed on his feet, but the footing was bad and he went over backwards and hit the base of his skull on the corner of a concrete step. It severed his brainstem and though the body kept breathing for two days he was dead from the instant he hit. According to witnesses his eyes were open and never blinked.

Brain injury is not your friend.

#153 ::: Nancy Lebovitz ::: (view all by) ::: March 31, 2009, 10:23 AM:

That's interesting about rabbits having so much lighter skeletons than cats-- I wonder if it's a general predator/prey pattern for animals in the same size range.

It might make sense-- more skeleton can probably support more strength at the cost of needing more calories.

#154 ::: James D. Macdonald ::: (view all by) ::: March 31, 2009, 10:33 AM:

#152 a backboard has little in the way of lumbar support,

A good EMT will put a folded towel in the lumbar void. "Padding the voids" is supposed to be part of the backboarding skill.

#155 ::: Xopher ::: (view all by) ::: March 31, 2009, 11:17 AM:

I jumped out of a tree when I was...six? seven? ...having been "shot" by L-hand "guns" by the other side. A very dramatic "death," and almost turned real when I gave my head a very solid whack, resulting in a concussion. My memories of what happened after have always been vague, and after more than four decades have become no clearer!

I do seem to remember there were strange hallucinations, though. Not things or people, just roiling colored (but mostly silvery) blobs in my vision.

#156 ::: Carrie S. ::: (view all by) ::: March 31, 2009, 12:03 PM:

#154: A good EMT will put a folded towel in the lumbar void. "Padding the voids" is supposed to be part of the backboarding skill.

I don't recall them doing that, though it's possible I just hurt enough that I didn't notice whatever support a towel may have provided. Or they may have been "competent" but not "good". Dunno.

#157 ::: Tae Kim ::: (view all by) ::: April 01, 2009, 02:44 AM:

#154 - Wasn't not padding under the lumbar a loss of points during the backboarding practical skills station? I recall padding the lumbar with ABD pads - and praying that I got a backboard with snapbuckles. No such luck.

#158 ::: Nicole J. LeBoeuf-Little ::: (view all by) ::: April 01, 2009, 09:12 AM:

Off-topic locational shout-out:

And I'm now wondering about me: we got hit by a Big! Scary! Blizzard! (9 inches, woo hoo. In Boulder, for Ghu's sake!) last Thursday,

We were fortunate enough to be out of town until it had all melted. Avedaggio took photos for us though.

(There seem to be quite a few of us ML bit-players in the Boulder/Longmont area... and oh look the Farmer's Market will be starting up soon!)

#159 ::: James D. Macdonald ::: (view all by) ::: April 01, 2009, 10:06 AM:

#157 Tae:

Yes, indeed, properly padding between the torso and the board is a point in the longboarding station.

It makes a big difference, particularly in prolonged transports over bad roads.

#160 ::: Jacque ::: (view all by) ::: April 01, 2009, 10:36 AM:

Nicole @158: Maybe gettin' time for a wee nosh at the Tea House?

#161 ::: Marilee ::: (view all by) ::: April 03, 2009, 06:54 PM:

It was kind of weird having the news about Richardson on the hospital TVs when I was in there for a sub arachnoid hemorrage myself.

Mine was caused by my rheumatology -- my brain swelled and smushed against the skull and bled on the left frontal side. I knew something was wrong the first few days and went to the hospital three times. The doctors at the upper-level hospital (where my insurance helicoptered me twice) were ready to put me in the psych ward because the techs read the first MRI wrong. Fortunately, someone read it right.

Then I really don't remember a lot the next few days. I was seeing extra parts of things on the right -- I thought the nurses might hurt me because they had a third side of their face on my right (too much SF, huh?) and I tried to escape so they restrained me one night. I couldn't make any good words come out, either, so I couldn't say anything.

On my birthday, the 10th, I had the angiogram and I was also able to understand people who talked to me, although I still had trouble remembering things and words. Then I started getting better and went to a brain rehab program for six days and am home.

I'm taking prednisone and two anti-convulsive meds to prevent more problems. I was off the HRT for a month and don't seem to need it, so I've stopped that.

Soren, I felt so guilty getting better quicker than you did, but it took me much longer to get better the first stroke, so I know there's a good chance you will, too.

#162 ::: Serge ::: (view all by) ::: April 03, 2009, 07:27 PM:

Marilee @ 161... I've never met Soren, but I doubt he'd want you to feel guilty over the rapidity of your recovery. You silly girl.

#163 ::: xeger ::: (view all by) ::: April 03, 2009, 11:42 PM:

I've been reading through the various posts and thinking it's most of a miracle that I'm still (I think, at least) tolerably coherent and intelligent[0], given the fine variety of head insults/injuries I've accumulated over time.

LLA @ 49 ... It was a car door being helpfully opened as I bent down to open it that earned me a black eye.

[0] Or should that be "cohneth nde inollegutn"?

#164 ::: Rob Rusick ::: (view all by) ::: April 04, 2009, 01:01 AM:

xeger @163: Thinking the same thing. Recently gave the skull bones over my cerebral cortex a good bang a couple of weeks ago bending down to pick up a bit of trash caught in some metal gates, and failing to pay attention to the concrete column the metal gates were embedded in; caught the corner with my forehead (drew some blood, too).

#165 ::: HeatherM ::: (view all by) ::: April 04, 2009, 04:48 AM:

I'm delurking here to thank you for such a detailed and clear description of TBI. Also, to tell my concussion-related story. All I remember of it is falling to my hands and knees and looking up to see a red car ten feet from me, then nothing until I woke up in a hospital bed with relatives and new toys around me. I might also add that both are false memories.

What happened according to the police reports, medical records and other people: it was winter and I was five. It was mid-December in South Dakota, so the street I was crossing was wide, flat and covered with snow and ice. Midway across, I was frightened by an oncoming car.

If I had kept walking, it wouldn't have hit me. Hindsight being twenty-twenty, I tried to turn around and slipped on the ice. The car would have missed me if the driver had swerved without trying to brake. Unfortunately for myself and the driver, he slammed on the brakes and lost control of the car, which then hit me and sent me into a snow-covered curb. Luckily, the car managed to stop before it crushed me against the curb.

At the time the paramedics came on scene, I was fine. I was taken to the local ER, and while they were examining me, I lost consciousness. Then I stopped breathing and my heart stopped. My mother was in the hall outside the exam room. She remembers hearing them yell code and seeing a crash cart wheeled into the room I was in.

After they stabilized me, I was airlifted by helicopter to a children's hospital in Minnesota. I don't know why they did what they did next, which was to shave the right side of my head and drill two burr holes. My mother claims that at some point, the plan had been to drill another and remove a section of skull, but since they didn't find any swelling, they quit after the two holes. She also thinks the entire hospitalization could have been avoided if they didn't make me lie down during the initial ER exam. I didn't come across any blow-by-blow description of the surgery in the medical records, so I'm inclined to take that with a grain of salt.

This was in 1980 and I don't know what was standard procedure for TBI then. I didn't have any other injuries except a scrape on my chin. I haven't really had any major neurological problems following the injury and if the accident's immediate aftermath wasn't so dramatic, I wouldn't necessarily classify it as a serious accident.

Every time I learn new information and statistics on TBI, I'm profoundly struck by how lucky I was -

"A serious TBI is about 30% fatal. Of those who recover, around 99% have permanent neurological deficits."

- and how grateful I am that this happened when I was young. At the tender age of five, my concept of mortality was pretty much non-existent and I hadn't seen any horror movies featuring drills and skulls. As an adult with the ability to reflect and brood, I would be horrified to be recovering from brain drilling. I can and do squick myself out when I absentmindedly rub the scar under my chin or run my fingers across the two dents in my skull, but it's not the same.

I apologize to all if I've been too long-winded, to Yog and other forces of righteousness for not knowing what URL to submit (indeed, still being a little unclear on what that is) and for not figuring out how to elegantly include the excerpt from James MacDonald's original post like other more experienced members of the board. By way of excuse, it is possible that I have some brain damage...

...and back to the shadows of lurkdom I go.

#166 ::: abi ::: (view all by) ::: April 04, 2009, 05:47 AM:

HeatherM @165:
Thanks for the vivid story; that was not at all long-winded. I'm glad it came out so well for you in the end.

The "URL to submit" is generally used if you want people to be able to follow you to your own blog. You'll note that if you click on my name you get to mine. It's optional; don't worry about it if you don't want to. (I'll speak to Patrick about clarifying the fact that it is optional while the email address is mandatory.)

As for quoting, all we do is use the computer's cut and paste function to get the text into the "Write here" box. You can make it stand out using the "emphasized" tag explained in the HTML Tags section above the text boxes.

#167 ::: James D. Macdonald ::: (view all by) ::: April 04, 2009, 06:42 AM:

Thank you for that story, Heather. I'm glad that fast and efficient EMS was there for you (in 1980, EMS was only about ten years old).

We can talk elsewhere about what URLs are and how to do cut and paste and blockquotes. You did just fine here.

I don't know if a CAT scan was available in your local hospital in 1980. I remember hospitals doing fund drives around then to buy 'em. They were new tech and nowhere near as fast as they are now. I expect that the burr holes were to see if there was any free blood, to relieve pressure, and, if necessary, to go further for neurosurgery.

Opening holes in skulls to relieve pressure works. It's also medicine on the cave man level. Skulls from ancient burials showing trepanation and subsequent bone-growth have been found all over the world.

There's some evidence that sitting a head-trauma case up is helpful, to let gravity be your friend and help drain fluid and limit brain swelling, but in your case I don't see that it would have made much difference.

The number one reason that a little kid's heart stops is because respiration has stopped.

Little kids aren't just miniature adults. They have proportionately larger heads, and so tend to hit head-first when they're thrown. And when about to be hit by a car, adults tend to turn toward the vehicle, while kids tend to turn away, producing different typical injury patterns.

Again, thanks, Heather.

[I see that in my post up above that I failed to even mention sub-arachnoid bleeds. I'll remedy that soon.]

#168 ::: Debra Doyle ::: (view all by) ::: April 04, 2009, 10:24 AM:

I don't know if a CAT scan was available in your local hospital in 1980. I remember hospitals doing fund drives around then to buy 'em.

I remember the fund drive they had going in Inverness back in 1983 or so, during our visit there -- folks with collection cans in the train station and similar places -- raising funds to bring a CAT scanner to the highlands. (I don't know where they had to take patients before that, but it couldn't have been a fast transport no matter where.) We donated our spare change, and got little metal lapel buttons in return.

#169 ::: Mez ::: (view all by) ::: April 04, 2009, 05:45 PM:

"when about to be hit by a car, adults tend to turn toward the vehicle, while kids tend to turn away" (@167)
Fascinating. It gives one to think. If it's consistent in differing groups & circumstances, could it be ancient, embedded predator or danger “adults protect; young 'uns run &/or hide” reaction?

#170 ::: Sylvia ::: (view all by) ::: April 04, 2009, 06:16 PM:

My 14-year-old son and I were talking about sports and head injuries and - full of confidence having read this post - I compared the brain to gelatin and told him that concussions are cumulative and described the risk of further injury because you are off-kilter for the next few days or even worse brain swelling! We had fun thinking about where it could escape the skull - ew! I ended up looking very clever in a "parroting key phrases from the Internet" sort of way.

But then he asked me WHY people go unconscious as a part of the initial concussion.

I told him it was an electro-chemical disruption of the brain and that it was time for bed.

Does anyone have a better answer for me before he asks again in the morning? I need all the Good Mom points I can get!

#171 ::: Ginger ::: (view all by) ::: April 04, 2009, 10:38 PM:

Sylvia @ 170: That's about it. The shock wave of the blow can disrupt the brain function, causing loss of consciousness (LOC) -- but you don't have to have LOC for a concussion. (The LOC might be missed if it's very brief; it might not occur until later. When there is an LOC, of course, people tend to think it's more severe than an incident in which there is no known LOC. )

Other causes of LOC include disruption of the blood flow, and possible cardio-respiratory disturbances as well.

I'm not sure we'll be able to pinpoint the causes of LOC until we're all inside a giant MRI and can watch as some one gets hit accidentally -- it's not the kind of study that would be approved for humans, and it would still be tricky in animals.

#172 ::: James D. Macdonald ::: (view all by) ::: April 05, 2009, 12:27 AM:

People don't always go unconscious in a concussion. You can certainly be concussed without any loss of consciousness.

If the exact mechanism of that electro-mechanical disruption is known, it isn't known by me.

But for more on concussion, particularly in regard to sports by teens, check here and here.

#173 ::: David Goldfarb ::: (view all by) ::: April 05, 2009, 02:53 AM:

I had a concussion when I was about 8 from falling off of a merry-go-round (the small playground type) being spun very fast. I remember having tunnel vision and difficulty speaking; I don't believe I lost consciousness at any point.

#174 ::: Sylvia ::: (view all by) ::: April 05, 2009, 08:11 AM:

Thanks both!

His comment was "well, that's not a very clever survival trait!" It's been a surprisingly interesting topic. He's now focused on how you could get brain scans of people who were likely to get hit in the head (special helmets on boxers?) to find out more.

Neat stuff.

#175 ::: Lila ::: (view all by) ::: April 05, 2009, 10:05 AM:

Re kids and concussions, the CDC has a free "tool kit" on concussion available here.

#176 ::: Marc Mielke ::: (view all by) ::: April 05, 2009, 10:42 PM:

I was in a car accident yesterday (http://marktemporis.blogspot.com for pix) and the po-po made me wait three hours or so for the car to get towed off before I could jaunt off to get looked at by a medical professional. There were no serious injuries, but the docs gave me valium and vicodin, and who am I to argue?

There's some left/right mixing up that I'm doing, but other'n that nothing seems to be wrong. And I mix that shit up all the time.

All my friends are notified to call the authorities if my brain suddenly goes out.

#177 ::: Martin G. ::: (view all by) ::: April 15, 2009, 04:57 PM:

There was a strange episode in Norway recently in which trained EMTs encountered a man who had been having a barbecue with some friends in the park. He got punched by some asshole and his condition quickly deteriorated. When the EMTs arrived, he was disoriented and being a bit of a DICHEAD. The people around him emphasised that he hadn't been drinking, that he was sober, etc.

Disoriented, he urinated on the ambulance and the EMTs, deciding against all the witnesses there that he was drunk, didn't bring him to the hospital. Meanwhile, he had a hemorrhagic stroke and by the time the doctors got him to a CT, he had to be put in a coma for a couple of weeks. Miraculously, he seems to be not-bad-at-all now.

So what I'm not telling you is that the guy is black. He's a Somali social worker living in Oslo. The event started a huge brouhaha over the definition of racism and immigrants and blah blah blah.

My question was always how the EMTs could leave him when there was a serious question over whether or not he had TBI or was just being drunk.

#178 ::: Emily WK ::: (view all by) ::: April 15, 2009, 10:14 PM:

"There’s one other place on the human body where this is true: The scrotum. Insert the obvious joke here."

I've been thinking about this for days. I hope somebody reads this. The human body does not have a scrotum. The male human body does. To ignore that aspect of this sentence is to presume that the human body is by default male and is only female as an anomaly.

Consider your language choices carefully, please.

#179 ::: James D. Macdonald ::: (view all by) ::: April 15, 2009, 10:22 PM:

To ignore that aspect of this sentence is to presume that the human body is by default male and is only female as an anomaly.

This is, of course, both nonsense and obvious sexism.

I reject it utterly.

#180 ::: Xopher ::: (view all by) ::: April 15, 2009, 10:39 PM:

Silliness. Emily, would you have said the same thing if Jim had written "Only one place on the human body—the vulva—has this characteristic"?

#181 ::: David Harmon ::: (view all by) ::: April 15, 2009, 11:20 PM:

I can see Emily's point... ISTM that a very slight change in the sentence would have avoided the impression, at the cost of an implicit redundancy:

"There’s one other place on the human body where this is true: The male scrotum."

And now I'm wondering just how the homology breaks down, but I'm too squeamish to actually investigate.

#182 ::: abi ::: (view all by) ::: April 16, 2009, 01:53 AM:

On a related note, my son denied that he was a mammal, because although he is covered in hair, he will never give birth to his offspring live, nor produce milk.

#183 ::: Earl Cooley III ::: (view all by) ::: April 16, 2009, 05:01 AM:

"Never" is an awfully long time. In this case, a few decades at most, I think. Science marches on.

#184 ::: Raphael ::: (view all by) ::: April 16, 2009, 06:01 AM:

James D. Macdonald @179, that post is a bit ambiguous. What do you reject utterly as nonsense and obvious sexism- the presumption that the human body is by default male, or Emily's claim that your sentence presumed that?


Martin G. @177,
My question was always how the EMTs could leave him when there was a serious question over whether or not he had TBI or was just being drunk.

Simply put, inexcusable sloppyness, perhaps (probably? I'm not sure) with some amount of racism involved.

#185 ::: James D. Macdonald ::: (view all by) ::: April 16, 2009, 06:14 AM:

The default human body has all organs and structures. I might as easily (and correctly) write that the trachea and bronchial tree are lined with specialized cells covered with moving cilia. The only other place in the human body of which this is true are the fallopian tubes.


#186 ::: Serge ::: (view all by) ::: April 16, 2009, 06:31 AM:

Abi @ 182... Is your son's middle name Calvin?

#187 ::: Carrie S. ::: (view all by) ::: April 16, 2009, 09:19 AM:

On a related note, my son denied that he was a mammal, because although he is covered in hair, he will never give birth to his offspring live, nor produce milk.

A group of friends and I once had a longish debate over whether a certain person was a mammal or not. We decided it couldn't be proven. Birds are warmblooded, so we couldn't use that, and when someone said "He has hair", it was refuted with "Tarantulas have hair*. I'm not convinced." And since the man in question had (and still has) never fathered a child, we could not prove he was interfertile with mammals and therefore one himself.

* Yes, we all knew they don't actually. It was just for the fun of it.

#188 ::: abi ::: (view all by) ::: April 16, 2009, 02:44 PM:

Serge @186:
Is your son's middle name Calvin?

Beowulf, actually.

#189 ::: Serge ::: (view all by) ::: April 16, 2009, 02:48 PM:

abi @ 188... Alexander Beowulf? Not only does he have a Spark's mind, he has the name too.

#190 ::: Terry Karney ::: (view all by) ::: April 16, 2009, 08:23 PM:

I agree with Jim, see Emily's point (sort of) and it might have been phrased so as to avoid it, (the only other human body part which does this is the scrotum, or, "the scrotum is the only other human body structure so arranged, etc.), but don't think it's needed.

#191 ::: Emily WK ::: (view all by) ::: April 16, 2009, 08:32 PM:

"Emily, would you have said the same thing if Jim had written "Only one place on the human body—the vulva—has this characteristic"?"

Yes. Absolutely. But that didn't happen, which is part of the point.

I'm not a doctor, and I have never had training as a doctor. How am I supposed to know that the default human body has all parts? Is this not even a little bit related to the idea of there being bicycles, and then a subset of that are women's bicycles? (As an example of a subject I am familiar with.)

Jim said: "The default human body has all organs and structures. I might as easily (and correctly) write that the trachea and bronchial tree are lined with specialized cells covered with moving cilia. The only other place in the human body of which this is true are the fallopian tubes."

You may have easily have said that, but you didn't. How am I supposed to know that your training presupposes something that I am not able to presuppose because I have not had that training?

It is honestly outside of your realm of comprehension that it is possible for me to read that line and consider that you mean the default is male? That surprises me.

Well, I guess it doesn't. I didn't think anyone would respond, but I presumed I'd be utterly dismissed even if you did. Should I thank you for bothering to consider my remarks? Did you, at all?

And, while I'm at it, I am now much more careful when I open doors where I can't see the other side of them. Thank you for that.

#192 ::: Emily WK ::: (view all by) ::: April 16, 2009, 08:42 PM:

Additionally, I would like to say this:

If Jim had responded with "You may not have realized this, but when speaking about medical things, the default human body is assumed to have all parts," that would have explained it, and would have given me helpful information.

To dismiss my concern, which was exceedingly politely worded, accused the author of no ill will or misdeeds, and instead asked nicely for concern and consideration when choosing words, with the nastiness of it being nonsense and utter sexism, well, fuck that.

Instead of educating someone into a world that they didn't know, you instead just acted rudely. And to what end?

#193 ::: Mary Dell ::: (view all by) ::: April 16, 2009, 11:04 PM:

Emily WK @#192:

Your post didn't seem exceedingly polite to me, and it did seem to be accusing Jim of either ill will or a misdeed. You said that he had constructed a sentence that contained or implied the idea that the default human body is male, and you told him to choose his words carefully, which implies that he doesn't already choose his words carefully.

His response to you was a little snappish, maybe, but since he is a medical professional, and you were telling him what you thought he had done and telling him what he should do instead, that's understandable, in my opinion. If you had opened this particular door with a question, instead of an accusation, I believe you would have received a different response.

#194 ::: Raphael ::: (view all by) ::: April 17, 2009, 01:24 AM:

Mary Dell, often, when people strongly believe something, they will interpret everything they see as a confirmation of it, without even noticing it themselves. Often, when people strongly believe something about other people, they will interpret everything they see these other people doing or saying as a confirmation of what they believe about them, without even noticing it themselves. Often, when people strongly believe other people are great, they will interpret everything related to these other people in a way that makes them look good. Conversely, often, when people strongly dislike other people, they will interpret everything they see these other people doing or saying in the worst possible way, without even noticing it themselves. And often, when people strongly dislike something, they will believe almost anything bad about it, because it fits into their preconceived notions about it.

Emily WK strongly believes various bad things about Jim, so it was clear that she would find something bad in anything he'd say.

#195 ::: abi ::: (view all by) ::: April 17, 2009, 03:41 AM:

Raphael @194:
Emily WK strongly believes various bad things about Jim, so it was clear that she would find *something* bad in anything he'd say.

I think I'd give that a Not Proven. Emily came across as one of those finger-wagging types who append their demands with "please" to sound polite*. But some people use those constructions and mean that "please", or have picked them up without hearing the slap-in-the-face undertones that I (and Jim, apparently) react to. This may just be an unfortunate clash of prose styles; they happen on the internet.

I didn't intend my anecdote as a pile-on, by the way. It leapt to mind because it happened about three days ago now. (Context: Calvin's assertion that bats are bugs. No? Then what are they? etc.)

-----
* Whereas it's actually worse with the "please" in that position than without it at all. That's a construction I'd expect to hear from a superior giving orders to an inferior. Not appropriate in this context.

#196 ::: Mary Dell ::: (view all by) ::: April 17, 2009, 10:00 AM:

Raphael #194:

Emily WK strongly believes various bad things about Jim, so it was clear that she would find something bad in anything he'd say.

I didn't see anything in her "view all by" to indicate a previous history with Jim, or anything in what she said that could tell me definitively what her motives are. Everything you say about "people" is true, but I don't think it's necessarily wise to try to infer what kind of person someone is from a few comments. She may, in fact, not be the kind of person you're describing...but that doesn't make her comments any more polite.

#197 ::: Teresa Nielsen Hayden ::: (view all by) ::: April 21, 2009, 09:25 AM:

I missed this the first time around.

Emily went into that interaction sure that Jim was wrong, and looking to tell him so. If her initial comment had been less sharp-tongued and peremptory, Jim would have explained the convention whereby the default human body has all organs and structures, and everything would have been fine.

Unfortunately, since she didn't imagine that he might be speaking precisely and in good faith, she didn't leave room for him to explain that convention of anatomical description. Instead, she said his language presumed that the human body is by default male and is only female as an anomaly.

She was wrong. It's a possible implication of his comment, but it isn't the sole possible reading, and in fact it wasn't the correct one.

I can tell you from experience that Jim reacts badly to being told he must mean or be implying [whatever], when he knows he neither meant nor implied that.

#199 ::: David Harmon ::: (view all by) ::: February 01, 2011, 05:36 PM:

Vanilla Ice Fail. Aside from the obvious irony of Vanilla Ice hitting the ice, he refused overnight observation despite having lost consciousness. The problem with this is discussed in the comments, and yes, Natasha Richardson is mentioned.

#200 ::: Jim Macdonald ::: (view all by) ::: December 30, 2012, 11:08 PM:

Hillary Clinton hospitalized after doctors discover blood clot

Secondary to the fall and concussion she suffered earlier this month.

#201 ::: P J Evans ::: (view all by) ::: December 31, 2012, 08:09 AM:

200
and Natasha Richardson gets mentioned in comments on this, at, e.g., dKos.

Apparently the fall was related to/caused by dehydration from gastroenteritis - there's something going around that's like flu, but with that also, and you really don't want to get it.

#202 ::: albatross ::: (view all by) ::: December 31, 2012, 01:03 PM:

I wonder if there is some bigger health issue going on with Hillary Clinton, given the length and seriousness of her current health problems and her decision (I think made quite awhile ago) to retire from being secretary of state. My impression is that she is seriously ambitious, and that her prospects as a presidential candidate in 2016 would be helped by having a high-profile office for the next four years. (Though it's not so obvious what other positions she could take that woudn't be an obvious step down. Attorney general, maybe?) Hopefully, if there is something serious going on, it's something curable or treatable that doesn't close off her possible political future.

#203 ::: Dave Bell sees spam ::: (view all by) ::: December 07, 2013, 04:32 AM:

This does look like a classic piece of link-spam: the poster's URL, the age of the thread, the only item from the poster, and the very generic nature of the text.

#204 ::: Stefan Jones suspects spam ::: (view all by) ::: March 26, 2014, 10:16 PM:

Go away, Neville. You're spamming.

Welcome to Making Light's comment section. The moderators are Avram Grumer, Jim Macdonald, Teresa & Patrick Nielsen Hayden, and Abi Sutherland. Abi is the moderator most frequently onsite. She's also the kindest. Teresa is the theoretician. Are you feeling lucky?

If you are a spammer, your fate is in the hands of Jim Macdonald, and your foot shall slide in due time.

Comments containing more than seven URLs will be held for approval. If you want to comment on a thread that's been closed, please post to the most recent "Open Thread" discussion.

You can subscribe (via RSS) to this particular comment thread. (If this option is baffling, here's a quick introduction.)

Post a comment.
(Real e-mail addresses and URLs only, please.)

HTML Tags:
<strong>Strong</strong> = Strong
<em>Emphasized</em> = Emphasized
<a href="http://www.url.com">Linked text</a> = Linked text

Spelling reference:
Tolkien. Minuscule. Gandhi. Millennium. Delany. Embarrassment. Publishers Weekly. Occurrence. Asimov. Weird. Connoisseur. Accommodate. Hierarchy. Deity. Etiquette. Pharaoh. Teresa. Its. Macdonald. Nielsen Hayden. It's. Fluorosphere. Barack. More here.















(You must preview before posting.)

Dire legal notice
Making Light copyright 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014 by Patrick & Teresa Nielsen Hayden. All rights reserved.