Brain Injury Law Blog : Head Injury : Coma : Personal Injury : Las Vegas Nevada Lawyer & Attorney Tim Titolo

In this chapter Dr. Firlik takes us through perceptions of Risk. Both from the neurosurgeon’s view and the patient.

She recalls a "warm hand-holding" surgeon who would “pepper” his remarks about the risks of brain surgery, while holding out the consent forms, with "religious-speak" like "We'll get you through this with God's grace."

On the other end are surgeons who personally remind me of Dr. Greg House. The ones who are "blunt" and say "You could have a stroke. (Pause) You could have permanent brain damage. (Pause) You could become a vegetable. (Pause) You could die. (Pause)"

Surgeons typically like dealing with their patients under anesthesia. Not weeping and asking a list of questions with other family members in their office. Unfortunately, this is where many doctors make mistakes. Appropriately, Dr. Firlik comments on the issue of malpractice and lawyers.

It is sad that many lawyers approach any bad outcome with the cynicism of a malpractice lawsuit. It is also sad that too many doctors get annoyed when their obligations to their patients interfere with their golf tee times.

I personally believe that it is hard being a doctor and a surgeon. I believe that sometimes the body responds differently than hoped or expected. I sympathize with a lot of what doctors fear from malpractice lawsuits. However, even those worrisome physicians should appreciate that some doctors are mis-motivated and simply practice bad medicine. Hence, the real need for lawyers, courts, and jury verdicts.

Dr. Firlik states she has never been sued although she expects to at some point. I hope that it will be the result of a mis-motivated lawyer and patient and she will be vindicated professionally and monetarily. That could well depend on the motivation of the insurance company underwriting her and the lawyers it chooses to defend her.

Good luck Dr. Firlik with that.

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The Traumatic Brain Injury Conference in San Antonio ends today. I am moderating on this final day and have the pleasure of introducing David Ball. David is making a half day presentation to a standing room only crowd. This 20th Annual Brain Injury Conference has seen over 500 attendants.

David is a nationally known trial consultant, communications expert and best-selling author who specializes in focus groups, case analysis and presentation, advocacy skills, damages strategies and jury selection.

A few years back David presented for the American Association of Justice (AAJ) Traumatic Brain Injury Litigation Group in Chicago. He spent 3 days conducting focus groups in rooms with see through mirrors while the group of lawyers observed. The education was irreplaceable as we watched deliberations: A “fly on the wall” perspective.

Later today I will introduce Dorothy Sims who will make a multi hour presentation bringing her experiences winning court motions to exclude the infamous Fake Bad Scale (FBS) developed by neuropsychologist Dr. Paul Lees-Haley. Dorothy has become the go to lawyer for cross examination of neuropsychologists. She is known nationally for giving presentations on malingering and other abusive tactics of neuropsychologists doing exams for insurance companies and defendants.

I am thankful to all the presenters and attendants for making this year’s conference and overwhelming success. I also thank Dr. Robert Voogt, Dr. Ronald Savage, Ken Kolpan, Simon Forgette, and Bruce Stern for their commitment and efforts.

Next week I am heading to Portland, Oregon to make several presentations at the Pacific Northwest Brain Injury Conference.

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The North American Brain Injury Society has launched the new Brain Injury Career Center to give employers and job seeking professionals a better way to find one another.

Employers can focus on an audience of qualified brain injury professionals, post jobs, search resumes, and promote their company online.

Job Seekers can post their resume, search job listings and receive automatic email notification whenever a job matches their specific criteria.

This new service will be a great addition to other benefits provided by NABIS.  For more information click http://careers.nabis.org.

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Striking Facts

Estimated amount of glucose used by an adult human brain each day, expressed in M&Ms: 250 (Harper’s Index, October, 1989)

• If you flattened out all of the folds on the surface of the brain, it would cover an area about the size of a pillowcase (2500 square centimeters).
• Average number of neurons in the brain = 100 billion
• Average number of glial cells (supporting cells) in the brain = 10-50 times the number of neurons
• The brain weighs about 3 pounds (about 2% of body weight in a 150-pound person)
• 15-20% of all blood pumped out of the heart goes directly to the brain, despite the fact that the brain accounts for only about 2% of body weight
• The brain is composed of approximately 75% water

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This just in from Laura Schiebelhut [grassroots@biausa.org]:

Congress cleared a bill to provide stopgap funding to continue government operations this week, as none of the annual appropriations bills will be completed in time for the new fiscal year which begins on Monday, October 1.

Also this week, both the House and Senate passed a compromise bill to reauthorize and expand the State Children’s Health Insurance Program (SCHIP). Of particular significance to the brain injury community, this bill includes a six-month moratorium on implementation of a proposed federal regulation to restrict the use of the Medicaid Rehabilitative Services option.

Deliberations continued this week in the Senate on the fiscal 2008 defense authorization bill (H.R. 1585), including the passage of an amendment, supported by BIAA, specifically addressing neuro-optometric care for returning service members with TBI.
_______________________________________________________________________________
Appropriations Update

Congress cleared a bill to provide stopgap funding to continue government operations this week, as none of the annual appropriations bills will be completed in time for the new fiscal year which begins on Monday, October 1. The continuing resolution (CR) passed by Congress this week will fund the government through mid-November, although Senate Majority Leader Harry Reid (D-Nev.) expressed yesterday (Thursday, September 27) that he hopes to send President Bush three fiscal 2008 spending bills within the next few weeks. It is unclear which spending measures these will be and what action the president will take on them, as President Bush has threatened to veto any appropriations bill which provides more funding than he requested in his budget earlier this year. Many insiders agree that an omnibus appropriations bill will likely emerge at some point later this fall.

Senator Reid has specifically indicated that he plans to take up the Labor-HHS-Education spending bill within the next few weeks, likely following the Columbus Day recess, which runs from October 8 to October 12.

BIAA has signed on to a letter spearheaded by The Coalition for American Trauma Care urging House and Senate Appropriations Committee leaders to provide the highest possible funding in a final Labor-HHS-Education conference bill for programs that support trauma care, trauma care research, injury prevention, and TBI-specific programs housed within HRSA and CDC. In its letter, the Coalition urges Congress to support the higher Senate number of $10.091 million for the Traumatic Brain Injury HRSA state grant program, instead of the smaller allocation of $8.910 million proposed by the House of Representatives in its version of the spending bill. Likewise, the Coalition expresses its support of the higher Senate increase for Traumatic Brain Injury activities within the CDC’s National Center for Injury Prevention and Control, which is $1 million over fiscal 2007, versus the more modest House increase of $529,000.

Congress Passes SCHIP Reauthorization, Including Important Medicaid Provisions
Congress passed a compromise bill to reauthorize and expand the State Children’s Health Insurance Program (SCHIP) this week. This bill includes a six-month moratorium on implementing a federal regulation proposed by the Bush Administration which would restrict the use of Medicaid’s Rehabilitative Services option. Rehabilitation services provided under the Medicaid Rehabilitative Services option are often vital to individuals with traumatic brain injury to improve and maintain their health and independence. (Note: BIAA has been working as part of the Coalition to Preserve Rehabilitation to prevent implementation of this restrictive rule, and will soon be submitting comments to the Centers for Medicare and Medicaid Services (CMS) voicing strong opposition to proposed regulation. These comments will be posted on BIAA's website shortly).
Unfortunately, President Bush is expected to veto this SCHIP reauthorization bill. As the Senate already has sufficient votes for the two-thirds majority required for an override of such a likely veto, the question will largely come down to whether the House of Representatives can garner enough votes to override the veto as well. Currently it appears that there is not enough Republican support in the House for an override.

The Senate this week adopted by unanimous consent an amendment to the fiscal 2008 defense authorization bill (H.R. 1585) aimed at closing the gap between traditional optometric care and the non-standard optometric care that is required for returning service members with TBI. The amendment, based on S. 1999, a bill introduced by Sen. Kerry (D-MA) earlier this year, would authorize the establishment of a Center of Excellence in prevention, diagnosis, mitigation, treatment and rehabilitation of military eye injuries. The amendment, supported by the Blinded Veterans Association and BIAA, would create a Military Eye Injury Registry and would also authorize a study on Traumatic Brain Injury Post Traumatic Visual Syndrome. Rep. John Boozman (R-AR) has introduced a companion bill, H.R. 3558, in the House of Representatives.

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I am in San Antonio, Texas at the 5th Annual North American Brain Injury Society (NABIS) Medical and Legal Conference. I attended a workshop hosted by Dr. James Schraa, psychologist, from Craig Hospital in Denver. (I worked with Dr. Schraa on a significant brain injury case in 2005), Dr. Mariusz Ziejewski, engineer, from North Dakota State University, Dr. Robert Voogt, certified rehabilitation counselor, from Virginia Beach, and others.

NABIS is launching its initiative The Blast Injury Institute with hopes of bridging the gap between services available to veterans with TBI and PTSD and the veterans themselves. If today’s introduction was any indication, I think the initiative is the only the beginning of bigger things to come.

The standing room only workshop found military men and women, insurance underwriters and directors of rehabilitation services, from both military and civilian backgrounds, as well as neurologists and other physicians engaging in intense discussions. The atmosphere was charged.

The feeling given by veteran neurologists and trauma personnel nearest the battle zones are that congress is making progress but much more needs to be done while the nation is in this heightened state of awareness. Military physicians are screening 100% of all vets for TBI whatever injury they are being evaluated for. The consensus is to treat every vet as if they have TBI or PTSD until proven otherwise. However, the screening is such a recent procedure that there are still many “missed” brain injuries. One audience military physician pointed out he testified in two recent court martial proceedings for soldiers who he felt had TBI.

Insurance underwriting attendants state they are looking for qualified professionals in the private sector to refer vets to. I sat next to a woman who explained her Houston based rehabilitation group just received a $2,000,000 federal grant to treat military TBI but no one was coming in for treatment! Program Administrators are looking for patients. And they are not in short supply.

The consensus is communication issues disconnect treatment and services from veteran patients. That, along with poor education inhibiting TBI wounded warriors from seeking help until, for instance, their spouse threatens to leave them unless they “get help.” Unfortunately this means some vets do not seek help for years. Hence there is concern that we are not identifying the TBI wounded quickly enough.

The media is currently focused on TBI relating to Iraq and Afghanistan vets. But will it be 3 years from now? What are the long term consequences for these wounded warriors?

Iraq will produce a generation of veterans with injury analogous to PTSD and Agent Orange in Vietnam. It may be honorable and politically correct to espouse a willingness to “die for your country.” But are we willing to espouse “being permanently disabled for the rest of my life for my country?” And will my country take me as I “become” and provide for me medically, emotionally, and cognitively?

The Blast Injury Institute will endeavor to collect data and provide congress with pertinent information about TBI resulting from blasts. The Institute has its eyes on the legislature at the federal and state level and is monitoring the numerous bills being drafted and passed through the senate and house. The objective is to secure funding and apply it appropriately. The objective is care for the wounded warrior.

To read more about NABIS and the Blast Injury Institute click here

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I am reading Another Day in the Frontal Lobe by Katrina Firlik. Dr. Firlik is a neurosurgeon. She was the first woman admitted to the neurosurgery residency program at the University of Pittsburg Medical Center; the largest and one the most prestigious neurosurgery programs in the country. She currently teaches at Yale University and lives in Connecticut.

Dr. Firlik’s book, published in 2006, is 20 chapters of her neurosurgical observations offered to non-neurosurgeons. 20 chapters and glimpses into the mundane an d exciting drama of the operating room and brain surgery.

 
As a neurolawyer, I have a keen interest in the neurosciences. Although neurosurgery is not always present in the cases I handle, I find it very interesting to hear a neurosurgeon’s thoughts on everything from medical school anxiety to the fear doctor’s have of being sued for malpractice. With obligatory forays into operating room procedure, detailed descriptions of what drilling into the skull feels like, and other amazing insider information, I find this book a quick read. Maybe not for everyone, I am enjoying this book.

 
I want to share some of my thoughts about the chapters here. This will be an ongoing effort and I will post more as I go through the book.

 
I am at chapter 8 entitled, “Tools.” Here we find that neurosurgeons harbor great affection for the instruments they use in the acts of surgery. And they actually ascribe nicknames to these items. So “Adson forceps” are referred to as “bunnies.” The scrub nurse had better know the particular nomenclature for the particular surgeon or suffer his or her wrath when she fails to place the right instrument into his hand.

 
One surgeon asked his scrub nurse for “my little nipper,” his particular nickname for a tool properly called a “rongeur.” This tool is used to bite off pieces of bone. Fortunately of all the surgical tools before her, she was able to quickly deduce which one looked like one that nips.

 
The “sound of surgery,” I learned, is the sound of the neurosurgeons most commonly used tool – the suction device. Similar to the suction device used by dental hygienists, brain and spine surgeons use it throughout surgery to remove fluids that accumulate; namely blood and cerebrospinal fluid. Sometimes suction is interrupted due to pieces of tissue or clotted blood clogging the tube. A similar interruption occurs when an observing medical student unknowingly has her foot on the tubing. A mistake she will make only once.

Every intern’s rite of passage is to claim to have placed the first “bur hole” into a patient’s skull. Neurosurgeons use drills to carve out skull bone to expose the brain. These technologically advanced drills automatically stop once the bone is drilled through preventing further drilling into the brain. This was previously done manually and drills sometimes went too far! Interestingly, one cannot stop drilling half way into the skull and stop. If one does, the drill will not restart. I personally cannot imagine bearing down on a drill as it drives its way through a skull trusting it will stop once the bone is cut.

 
Finally “bone dust” from what I have gleaned does not smell very good. And you apparently get it on you when doing brain surgery!

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“We have at present no basis for a scientific explanation of the brain-mind relationship. We can only continue to study the brain without philosophical prejudice. And if the day should ever dawn when scientific analysis of body and brain solves the “mystery,” all men who have sought the truth in all sincerity will rejoice alike: the professing materialist and the dualist, the scientist and the philosopher, the agnostic and the convinced worshipper. Surely none need fear the truth.” (Wilder Penfield, Speech and Brain Mechanisms, 1959)

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A bizarre example of the consequences of brain injury was seen when a Hamilton, Ohio, prosecutor was fired for walking around naked in public office buildings. Scott Blauvelt was ordered to appear in court on two counts of public indecency in 2006.  Blauvelt's actions may have resulted from mental illness, medication or the effects of a brain injury suffered in a car wreck last year. 

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A substance found in broccoli and other vegetables could help protect your brain after a head injury.

That is according to a new study from the University of Texas Medical School where tests on lab rats found the substance helped maintain the blood-brain barrier.

The barrier is made up of a bunch of cells that basically stand guard at the brain only allowing select chemicals in.

Experts say the barrier can be greatly compromised after head trauma.

Watch video clip by clicking here.

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The San Marcos school's principal Brad Lichtman and head football coach Chris Hauser announced Wednesday that after reviewing tapes of the game against West Hills, there is no obvious traumatic incident.


"It did not appear in our first review of that tape that I as a layperson would say that caused that injury," Lichtman said.

Scott Eveland went over to the sideline and was stumbling around early in the second quarter, and administrators said there wasn't very much tape to look at. But they said they did not see Eveland make helmet-to-helmet contact with anyone.

School officials said Eveland was not knocked down and wasn't at the bottom of a pileup.

Meanwhile, a recently released letter shows how much gratitude Eveland had for his parents. The honors student typed it shortly before he slipped into the coma.

"You did a very good job raising me and I hope to achieve what you two have so far," Eveland wrote in the letter.

Lichtman read a statement from Eveland's parents that said, "We continue to be thankful for all the gracious love and support from the community, including well-wishers from all local high schools, and cards from friends and classmates."

Hauser said the team is staying focused, but none of them have ever gone through this before.

"Three Escondido football players came by yesterday's practice and brought over a poster with all of them signed," Hauser said. "Valley center signed a poster and brought it here from their boys. At the hospital today, San Pasqual dropped off a card with all of their teams' signatures on it."

Eveland remains in an induced coma in critical condition at Palomar Medical Center

Watch video by clicking here.

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The ongoing efforts in the news to prevent and treat veterans brain injuries continue. 

Researchers from the Uniformed Services University of the Health Sciences (USU) are pursuing efforts to find new ways to prevent and treat the increasing numbers of combat troops who are suffering from injuries due to traumatic brain injury (TBI). University research teams are also leading efforts to better diagnose and manage post traumatic stress disorder (PTSD).

Of the more than 20,000 service members who have sustained injury in the war in Iraq, TBI from improvised explosive devices (IED) is the most common injury. In addition to efforts to better treat those with such injuries, the university is increasing the focus on diagnosing and treating PTSD. Currently, there is no single test to diagnose either TBI or PTSD. However, researchers at USU are studying the physical and behavioral consequences of moderate and severe TBI to characterize each injury and examine methods of identification and management. The TBI research focuses on injury caused by blasts of air following an explosion and attempts to promote recovery by using anti inflammatory medication and sensory stimulation to regenerate brain cells and growth of brain tissue.

To read the full article click here.

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This year's Medical and Legal Brain Injury Conference in San Antonio is shaping up and under full swing.  I will be among the speakers making presentations.

OVERVIEW
This Conference offers detailed, practical information on every aspect of litigating a case involving brain injury. Over 60 of the leading attorneys and medical experts from North America will provide the tools you need to successfully handle these challenging cases. From case selection to trial techniques, this Conference is a must attend event for professionals involved in brain injury litigation.

Building on the success of last year's pre and post-conference workshops, the program chairs have included several "hands on" panel format discussions that will address the practical issues presented by brain injury cases.

As an added bonus, attendees to this Conference may also attend the concurrent sessions of the NABIS 5th Annual Medical Conference on Brain Injury. To see that program, click here.

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Researchers Try to Predict Epilepsy

WASHINGTON (AP) -- Survivors of traumatic brain injuries - from car-crash victims to soldiers wounded in Iraq - face an extra hurdle as they recover: Thousands of them will develop epilepsy months or years later. The risk is especially high for certain kinds of war injuries. Studies of Vietnam veterans suggest up to 50 percent, says Dr. Nancy Temkin of the University of Washington.

Major new research is beginning into ways to predict exactly who is most at risk and how to protect their vulnerable brains.

Among the efforts: pilot studies to see if the newer seizure-treating drugs Topamax or Keppra might actually prevent epilepsy if they're taken immediately after a serious brain injury.
"It is among the most frustrating things in medicine to know that someone's at risk ... and be unable to do anything about it," says Dr. Marc Dichter of the University of Pennsylvania, who is leading the Topamax study and pushing for better recognition of such patients.

Adding to their struggle: Epilepsy may not begin with the classic jerking seizures, but instead with memory loss, attention problems or other more subtle symptoms that doctors can mistakenly attribute to the original brain injury, post-traumatic stress or some other factor.

 
Almost 3 million Americans have epilepsy, a condition in which the brain essentially suffers periodic electrical storms. When its circuits misfire fast enough, a seizure results.
Epilepsy has multiple causes. Some people are born with it.

But about 5 percent of the nation's epilepsy was caused by traumatic brain injury, or TBI. What's the risk? Roughly 25 percent of survivors of moderate to severe brain injury will develop epilepsy. Even more, perhaps, for certain types of war injuries.

Injuries that cause bleeding inside the brain are the riskiest.

The population at risk is huge: Some 1.4 million children and adults suffer serious brain injuries every year from car or bike crashes, falls, gunshot wounds and other trauma.

After the initial injury, inflammation and treatment comes a "silent period" during which survivors work to recover. It can last months or even years before epilepsy appears.

 
"This silent period is not really silent," Dr. Shlomo Shinnar of the Albert Einstein College of Medicine told a meeting of epilepsy specialists at the National Institutes of Health last week.
Instead, as the damaged brain tries to rewire itself - a crucial process called plasticity - misfiring circuitry can form. Injured neurons can make new connections in wrong places, or overly excitable connections. Even the brain's genes change the way they work after head injury.

"You need the plasticity for recovery. You don't want to stop it. You just want to structure it in a way that it aids recovery without causing seizures," Temkin explains.

 
It's not clear yet how to do that, so scientists instead are testing what's available - seizure-controlling drugs - as possible epilepsy preventers. Three old medications have failed. New pilot studies funded by the NIH and Defense Department are checking Topamax and Keppra, which work differently from older competitors.

 
"It's a bit of a shot in the dark," acknowledges Dr. Pavel Klein, who is running the Keppra study at Washington Hospital Center and Children's National Medical Center in the nation's capitol.
But there are some hints that these newer drugs might work, perhaps by inhibiting cell-harming chemicals wrought by post-injury inflammation, he says.

 
Each study is enrolling about 90 patients, a first step to ensure the drugs won't harm overall recovery before larger trials begin. Participants get the drug within hours of arriving at the emergency room, and take it for one to three months. Klein has treated 60 patients so far with no serious side effects; Dichter's study at Penn begins enrolling soon.

Until some protection is found, Dichter wants a bigger effort at warning about the epilepsy risk so that patients can recognize subtle symptoms. At his urging, the American Epilepsy Society is creating a task force to target brain-injured soldiers, work that Dichter says may eventually translate to the far bigger population of injured civilians.

Consider Denise Pease, an assistant comptroller for New York City. Months after what was initially deemed a minor head injury in a 1995 taxi crash, she began experiencing lost periods of time, increasing confusion and cognitive problems.

"This woman who dealt with the titans of industry ... was unable to make change at the corner store," Pease told the NIH meeting.

Only when a nephew witnessed a muscle-jerking seizure well over a year later did she get the right diagnosis and begin her recovery. Today, after years of trying different medications, she has good epilepsy control, and warns that "my experience ... is not unique."
---

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W. L. Gore & Associates announced today the availability of GORE PRECLUDE® Vessel Guard, the first non-biological membrane indicated as a cover for vessels following anterior vertebral surgery.

This device will make anterior approach surgical procedures safer.  The advanced biomaterial reduces the risk of potential vascular injury by providing a permanent and visible plane of dissection around the vasculature to facilitate anterior revision surgery.

It is well known that anterior approaches to the spine are associated with some risk of vascular injury, particularly among patients having undergone previous anterior spinal surgery.  It is expected that the new membrane will provide a vascular tissue-friendly interface giving surgeons, and their patients, greater confidence and peace of mind during anterior revision procedures.

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The Brain Injury Alliance of South Carolina this week began a new campaign to raise awareness of the issue, which has left 108,000 of the state’s citizens facing rehabilitation or disability.

More than 3,000 new cases of brain injury occur in South Carolina each year.

While the public associates brain injury with war, motor vehicle crashes are the leading cause in South Carolina; falls and violence follow. Males are twice as likely to sustain brain damage.

Living with brain damage is complicated, said Joyce Davis, the alliance’s executive director. The state’s Medicaid program does not cover rehabilitation, and one-third of people afflicted do not have coverage for rehabilitation.

In addition, rehab needs differ from person to person. Some recover quickly, while others need a lifetime of daily care, which is costly.

The public often does not understand the severity of brain injury — the leading cause of death and disability for people 44 and younger in South Carolina.

Alliance members hope that 110 billboards around the state will help raise awareness.

The group also has created a Web site, www.lifewithbraininjury.com, which spells out the issues and lists resources for patients and their families.

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Approximately 250,000 – 400,000 individuals in the United States have spinal cord injuries. Every year, approximately 11,000 people sustain new spinal cord injuries – that’s thirty new injuries every day. Most of these people are injured in auto and sports accidents, falls, and industrial mishaps. An estimated 60 percent of these individuals are 30 years old or younger, and the majority of them are men.

Since many spine injuries result from accidents, seeking legal advise is an important part of recovery and resources.  Be sure the lawyer you choose is trained and experienced to handle your case.

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Motorcyle deaths have doubled during the last 10 years and states are grappling with safety helmet laws.

As motorcycle riding has become more popular, motorcycle deaths have more than doubled since 1997. In 2006, motorcycle deaths increased for the ninth straight year, to 4,810 motorcycle deaths, compared with 4,576 in 2005.

The National Transportation Safety Board unanimously approved Motorcycle safety recommendations which historically pit motorcycle rights activists against consumer safety organizations.  The issue, say those involved, is more education.

Currently  8 states have no helmet laws on the books.  Part of the NTSB recommendations was to provide data on motorcycle deaths and injuries.  Hopefully states will enforce the recommendations for using helmets and the public will be more knowledgeable about the risks of not using them.

To read the full article click here.

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I am pleased to learn that the military has set up a process of detecting and treating soldiers with brain injury.  The Associated Press published an article today about testing military personnel before they are sent into service.  This mini-neuropsychological test is designed to measure memory and attention, among other cognitive domains, before an injury occurs. 

Before they leave for Iraq, thousands of troops with the 101st Airborne Division line up at laptop computers to take a test: basic math, matching numbers and symbols, and identifying patterns. They press a button quickly to measure response time.

It's all part of a fledgling Army program that records how soldiers' brains work when healthy, giving doctors baseline data to help diagnose and treat the soldiers if they suffer a traumatic brain injury — the signature injury of the Iraq war.

There are an extimated 30% of patients at Walter Reed Hospital receiving care for brain injury.  Of those suffering from what is misleadingly referred to as "mild traumatic brain injury," an estimated 20% go on to suffer permanent lingering problems.  According to research. Walter Reed found that irritability and memory, two classic symtoms of brain injury, are reported more on return home then in the battlefield.

Soldiers sometimes walk away from explosions with no obvious injuries. But the concussion from the blast can have a lingering effect that is not always immediately apparent.

"They look physically normal, but their neurocognitive performance is off," said Col. Mary Lopez, a physician specializing in occupational therapy.

Most brain injuries are mild, and soldiers can recover with rest and time away from the battlefield. But the military estimates that one-fifth of the troops with these mild injuries will have prolonged or lifelong symptoms requiring continuing care.

So little is known about traumatic brain injuries that these baseline readings could become an important cornerstone for future study.

To read the full article click here.

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Aids Virus is a "Double Hit" to the Brain

A new study from USD and Burnham Institute for Medical Research concludes the AIDS virus is found to damage brain cells in two ways, killing those that exist and preventing repair of those that are dying. 

AIDS  damages the brain in two ways, by not only killing brain cells but by preventing the birth of new cells, U.S. researchers reported on Wednesday. The study, published in the journal Cell Stem Cell, helps shed light on a condition known as HIV-associated dementia, which can cause confusion, sleep disturbances and memory loss in people infected with the virus.

This interesting finding could substantially help us not only in the treatment of AIDS but in the research helping us understand how brain cells or curcuits regenerate.  Which in turn could help in the prevention, rehabilitation and udnerstanding of brain injury.

The virus kills brain cells but it also appears to stop progenitor cells, known as stem cells, from dividing, the team at Burnham Institute for Medical Research and the University of California at San Diego found. "It's a double hit to the brain," researcher Marcus Kaul said in a statement. "The HIV protein both causes brain injury and prevents its repair."

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Money Magazine (September 2007)[i] recently covered the topic of how the brain controls investment decisions.   A new term, Neuroeconomics, was introduced as the “hybrid of neuroscience, economics and psychology.” Neuroeconomics is making remarkable discoveries about how the brain evaluates rewards, sizes up risks, and calculates probabilities.

Our brains are wired to improve the odds of survival. We crave what looks rewarding and avoid what looks risky.   Similar to Malcolm Gladwell’s, Blink: the Power of Thinking without Thinking, emotions like hope, surprise, regret, fear and greed – as a matter of biology – affect our decision making.

Neuroscientist, Brian Knutson, at Stanford University, concluded that the brain fires neurons more when it anticipates reward then when it gets it. Dr. Knutson’s mentor, Jaak Panskepp of Bowling Green State University in Ohio, calls that function “the seeking system.”

Paul Slovic, a psychologist at the University of Oregon, says our anticipation wiring acts as a “beacon of incentive” that helps us pursue rewards that require patience and commitment. Hence we work hard for imagined wealth in the future and forego smaller gains in our present.

To test whether memory improves when anticipating financial rewards researchers used fMRI to view brain activity. It was revealed that looking at potentially rewarding pictures set off more intense activity in the hippocampus. The hippocampus is the part of the brain that houses long term memory. Emrah Duzel, neurologist, says “The anticipation of reward is more important for memory formation then is the receipt of reward.”

The amygdala is the reflexive part of the brain that acts like an alarm system. Neuroscientist, Gregory Berns, led a study of brain activity when following what others did versus going it alone. When people went against the consensus they showed heightened activity. Berns called it “the emotional load associated with standing up for one’s belief.” The same areas of the brain that trigger physical pain are activated by social isolation. In other words, you go along with others because it hurts not to.

Neurologists, Antonio Damasio and Antoine Bechara, conclude from research tests on persons with damaged amygdalas that decisions are driven by fear even though they do register in the thinking part of the brain and the mind has no idea of being afraid. Just like Gladwell’s Blink: the Power of Thinking without Thinking reveals, Damasio finds that without fear the human brain keeps trying to beat the odds regardless of logic. “The process of deciding advantageously is not just logical but also emotional.”

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The New York Times published a great article about the dangers associated with not recognizing the signs and warnings associated with Football injury.  Too often sporting goals prompt those who could make a difference dealing with injuries to fail players and themselves.  The issues of multiple impacts and multiple concussions seen in many contact sports like football and boxing are getting more and more attention.

The National Football League has recently faced questions about its handling of concussions after four former players were found to have significant brain damage as early as their mid-30s. But teenagers are more susceptible to immediate harm from such injuries because, studies show, their brain tissue is less developed than adults’ and more easily damaged. High school players also typically receive less capable medical care, or none at all.

At least 50 high school or younger football players in more than 20 states since 1997 have been killed or have sustained serious head injuries on the field, according to research by The New York Times.

Read the full article click here

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It's hard to explain and it seems cold. When a client from another state wants to know why they have to pay an out of state cost bond; or why they need to fund certain expenses regarding their own medical care or case costs; I explain that the cost of the case comes from funds, typically mine, that do not earn interest and are not guaranteed to be returned. Therefore, out of state clients need to show their commitment to the case by making an upfront financial contribution to the case.

Injuries that occur in Nevada need to be pursued from Nevada. Many times tourists who are injured in Nevada consult with lawyers from the state they live in. Too many times lawyers do not refer them to or consult with Nevada counsel. They "settle" as much of the case as they can and then pass off the client or send them to Nevada counsel demanding a referral fee. This puts me in an awkward position.

Whatever money was settled is no longer available to reimburse costs and expenses (not fees). The settling lawyer does not explain this to their client. Unknowingly, the client expects a different lawyer (in Nevada) – who has not been paid from any settlement – to put up the costs of pursuing the case. The settling lawyer never offers to assist the client by sharing those advanced costs with the Nevada lawyer.

The cost of proving the TBI case is high; especially the mild or moderate TBI case. While clients with TBI already have inherent cognitive limitations, explaining the reality of funding their case is difficult. Costs of filing suit, retaining experts, taking numerous depositions can rise very quickly since the burden of proof is on the injured party. Typically, in TBI cases I handle, those costs will reach $30,000 within the first 6 months. By the time trial approaches costs easily near $100,000. Taking the matter through trial increases the amount another $50,000.

I recently found myself explaining to an out of state client that the liability aspect of a case against one defendant was tenuous. That the local state lawyer took the "easy money" settling a portion of the case against an “easy” defendant and left the client without options for collecting on the "bigger picture" and the remaining defendant. Filing a lawsuit was absolutely necessary.

The local state lawyer should have explained that they were not able to pursue the case against any defendant in Nevada (because filing a lawsuit requires a Nevada license) and that in order to fund the litigation, part of the settlement portion of the case could be used. Instead the local state lawyer pockets the fee and abandons the client to pursue the matter with another lawyer in Nevada. The client comes to me having paid the out of state local lawyer who never intends to fund the case at all. He never intended to protect the clients interest by filing a lawsuit and could not have even if he wanted to.

I explained that insurance coverage was questionable since liability against the remaining defendant was tenuous. Without it, the case could be worth millions based on the injury but the value, based on liability and coverage, could be nothing. Again, the local lawyer left that information out of the legal advice to the client.

Not all situations are like this. Many times I am consulted by out of state counsel who really is concerned about their client. They desire to bring in Nevada counsel immediately. I wish all situations were like this but unfortunately they are not. This is when I find myself having to explain the hidden cost of a TBI case.

If you are out of state and get hurt in Nevada, be sure to ask your lawyer whether they can file a lawsuit in Nevada or pursue the case without the assistance of Nevada counsel. If not, you may want to consider contacting Nevada counsel first so that the cost of the lawsuit can be borne by the lawyer who you retain to represent you in Nevada.

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I will be speaking at the 2007 Pacific Northwest Brain Injury Conference in Portland, Oregon on October 5 & 6.  I will be joined Dr. Muriel Lezak and other excellent contributors to the knowledge and education of brain injury issues and care.

Details of the conference can be seen at Brain Injury Association of Oregon and the Brain Injury Association of Washington.

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Sherry Stock of the Oregon Brain Injury Association asked me to remind everyone that the 5th Annual Pacific Northwest Brain Injury Conference is fast approaching.  I am supporting the conference and am making several presentations on topics  relating to brain injury lawyering.  I hope to see as many of you there as possible.  I am also looking forward to visiting with Dr. Muriel Lezak who is also presenting. 

Sherry says:

If you have not registered for the 5th Annual Pacific Northwest Conference, there is still time. The 5th Annual Pacific Northwest Brain Injury Conference Living with Brain Injury: Building Bridges to be held October 5–6, 2007 in Portland Oregon at the Holiday Inn Portland Airport. This conference will provide the latest research, techniques and education to professionals across numerous fields and disciplines working with people with brain injury.

The 5th Annual Pacific Northwest Brain Injury Conference focuses on Services to Returning Military, Caregiver Training and Education. Conference presenters will examine issues surrounding veterans returning from the war, caregiving training and education, advances in pediatric therapy, suicide after TBI, depression and coping skills, and legal issues for attorneys by Oregon attorney David Kracke and Nevada attorney Tim Titolo, the new pediatric roadmap for brain injury, Neurological Assessments and how to use them, Meth and TBI, and looking at depression, suicide, sleep disturbances, behavioral problems, coping, life care planning and much more. Friday’s Keynote Speaker, Dr. Harriet Zeiner, Neuro-psychologist, is from the Palo Alto VA Medical Center, Palo Alto, CA. Saturday’s Keynote Speaker, Marie Theresa Gass, is the author of The Caregiver's Tale: The True Story of A Woman, Her Husband Who Fell Off the Roof, and Traumatic Brain Injury.

 
Friday night will end with a reception with music provided by Thom Dudley hosted by Day-Timer. This will also present a time for networking or just catching up with professionals from over 14 states. Exhibitors will present information on housing, accessibility and mobility, rehab services and resources available in the brain injury field.
We hope you will join us for this very special conference and enjoy an invigorating educational experience in beautiful Portland Oregon.

For more information, please call or email Sherry, sherry@biaoregon.org or 503-413-7707.

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The Epidemic of Brain Injury care is far reaching. A recent study shows that brain injury survivors are not cared for. In terms of representing these people’s legal interests, convincing insurance companies and defense lawyers of this reality is imposing. Additionally, the future for these people, as found in the study, makes them victims again.

The report for the State of Virginia reveals what is true in many, if not all states:  veterans returning from the war will face difficult hurdles receiving care for brain injuries.  To read more about the situation click here.

Here are a few of the findings of the Joint Legislative Audit and Review Commission study:

The numbers: Up to 6,650 people with brain injuries are in nursing homes, and about 600 others are in state hospitals or in long-term care facilities, including psychiatric units.

Available care: Outside of institutionalization, only about 20 beds exist in Virginia to provide the intensive and costly treatment needed for tens of thousands of brain-injury survivors with complex neurobehavioral problems that can result in violent outbursts and other unmanageable behavior. "There is virtually no system of care in the community for people with behavioral problems who do not have the financial resources to pay for private care."

Tragic consequences: Brain-injured people often become homeless after their caregivers die; many end up in jails or seek divorce to qualify for care.

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Do liberal brains function better then conservative brains? That is the conclusion of psychologist David Amodio, a professor at New York University, who found that a specific region of the brain is more sensitive in people who consider themselves liberals then in self-declared conservatives.

 
“Say you drive home from work the same way every day, but one day there’s a detour and you need to override your autopilot. Most people function just fine. But there’s a little variability in how sensitive people are to the cue that they need to change their current course.”

That “cue,” as reported in the Chicago Tribune, is processed in the “anterior cingulated cortex.” Dr. Amodio used electroencephalographs and forced choice tests to show that liberals were 4.9 times more likely to show activity in the brain circuits that deal with conflicts and 2.2 times more likely to score in the top half for accuracy. He tested college students who reported their political affiliation as liberal or conservative and showed them a series of letters on a computer. They were instructed to signal every time they saw an M but not a W. There were four times as many M’s as W’s which appeared alternatively on a computer screen.

Liberals were found to be more flexible in the ability to accept changes to routines then conservatives. The results reveal that liberals could be expected to accept new ideas more readily than their counterparts. This will likely be met with staunch arguments from the right who have little use for changing their minds or accepting new ideas.

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Traumatic brain injuries are becoming a huge concern for the military. The Associated Press article reprinted in the Las Vegas Review Journal today reports that as more troops return home from the war, brain injuries are a growing burden: on the military, programs to treat them, and taxpayers to fund the treatment. A study at Walter Reed finds that of the symptoms commonly reported in mild TBI cases, the instances of memory problems and irritability double from the time of the injury to the time the serviceman or woman returns home.

Estimates are that 20% of all mild TBI sufferers will experience problems for the rest of their lives. All those with severe brain injuries will as well.

We know that most “brain injuries” are mild however we are seeing, in a very public way, that the consequences and symptoms are far reaching and many times disabling. The spontaneous recovery or natural recovery time for brain injuries is generally thought to be 12 months with variability.

Servicemen and women, like the general population, those involved in car accidents, falls and other non-war related trauma, are often misdiagnosed with personality disorders. Also similar to the general population, servicemen and women are unable to work because of unrecognized symptoms. People with TBI frequently complain of headaches, dizziness, trouble concentrating, distractibility, trouble sleeping, depression, irritability, and confusion. In addition there can be vision or speech problems.

Such was the case for staff sergeant O’Brien and specialist Bryan Malone. Both were stationed in Baghdad when a bomb exploded near them. Both survived but endured a pressure blast to the brain. Malone was struck in the head by an air conditioning unit which ultimately required multiple surgeries and a titanium mesh to reinforce his skull.

O’Brien was sent back to his unit after removal of shrapnel from his scalp. Later he complained of hip pain. Within 6 weeks he could not walk due to more shrapnel found in his hip. By then he was complaining of headaches and trouble sleeping. Having been through other blasts, O’Brien was suffering from multiple injury syndrome similar to what boxers experience.

The issue is deciding which servicemen and women go back to service and which do not. Soldiers and Marines are proud and want to return to their units. However, as the military is learning, this is often a more complicated decision.

For more information on the web see Centers for Disease Control and National Institutes of Health

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ROBERT WELLER Associated Press Writer reports that the General Accounting Office will be looking closely at Brain Injury in US soldiers.   This can be a great stride foward in the effort to properly care for and diagnose TBI in vets.

Suprisingly, the military did not previous use brain scan technology for vets.  Now they will be.  This will assist vets in receiving proper diagnosis and treatment for this often overlooked injury.

Moreover studies at Fort Carson are revealing just how many brain injuries result from demolition and bombs.  It is sad to think how previous vets have been used to "defend our country" and then forgotten when their lives were forever changed in what was previously thought of as mere "shell shock."  It is encouraging that the American military machine is making inroads to really caring for the protectors of our country.

 

 

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Spinal cord injury (SCI) Statistics reveal that on an annual basis in the United States :

Nearly 11,000 people sustain a traumatic spinal cord injury.
More than 190,000 people in the U.S live with paralysis caused by spinal cord injury.
85 percent of all spinal cord injury patients who survive 24 hours after their injury are still living ten years after the incidents.

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The Tragedy of Brain Injury in the Decade of the Brain

The statistics of brain injury are staggering: 700,000 brain injuries each year in the United States; 100,000 deaths per year; and 70,000 - 90,000 people permanently disabled as a result of brain injury. Most serious automobile accidents involve a brain injury. Many of these injuries are serious, but many also form "mild"  and "moderate" categories. Victims experience significant personality changes, debilitating cognitive deficits and serious physical and social problems, yet they are often seen as "normal" by some in the medical profession. One author called them the "walking wounded." Their plight is often unnoticed and their needs are not served. It is truly "a silent epidemic."

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