Atlanta Injury Law Blog

As most parents of teens can attest, teenagers tend to have a solid belief in their own invulnerability.  Now the Brain Injury Association of New Jersey has published a web site  targeting teenagers  who currently are at highest risk for suffering from a brain injury.

The site provides information and educational resources in hopes of preventing teen brain injuries before they start. The site also shows teens the real life consequences of their risky behavior.  Of course, it will only affect those who are not convinced that bad things only happen to other people.

Brain injury survivors can look great even when their mental functioning is scrambled. To make the reality graphically visible to jurors it is often necessary to use sophisticated medical illustrations and animations. Several samples of animations explaining brain injuries are available online, though of course for trial use we would have to pay them.  For examples, see:

• Traumatic Brain Injury Part 1
• Traumatic Brain Injury Part 2
• What If... Brain Injury Rehabilitation

Brain injuries that are referred to as "mild" or "minor" are often actually the underlying cause of social, academic, economic and personal failures. An article by Thomas M. Burton in today's Wall Street Journal reports on current research on the role of such head traumas in causing a variety of ills ranging from learning disabilities to chronic homelessness and alcoholism. The U.S. Centers for Disease Control and Prevention estimates 5.3 million Americans suffer from mental or physical disability that is due to brain injury. However, the CDC admits an undercount as its figures to not include include people who sought no treatment for a severe blow to the head or who were sent home from a doctor's office or emergency room with little treatment.

According to Wayne A. Gordon, director of the Brain Injury Research Center at Mount Sinai School of Medicine in New York, "Unidentified traumatic brain injury is an unrecognized major source of social and vocational failure." Research by his team has consistently found high rates of "hidden" head trauma when screening various populations in New York schools, addiction programs and the general population.

The Wall Street Journal article tells the story of a college instructor who over the course of a year after a "minor" head injury lost her ability to read, keep her home orderly and maintain friendships. She tried to continue teaching but found bright lights and a hectic environment overwhelming, and soon lost her job. She fell behind on paying bills and housekeeping, went to work in a less demanding field, withdrew socially, and wanted to die. However, she never related the meltdown in her life to the blow on the head until contacted by a followup research project at Mount Sinai Hospital.  Eight years after her injury she struggled to complete an n attention and memory rehabilitation program. Now she is training to become a counselor.

A study of homeless men in New York revealed that 82% had a history of head trauma, many of them involving parental abuse in childhood. The article does not break out the percentage that had traumatic brain injury in other types of accidents or in military service.

A study of people involved in alcohol and drug abuse found that 54% of them had a history of head trauma.

In my extended family and in my law practice, I have often seen the subtle and insidious effects of so-called "minor" brain injury in the lives of people who kept struggling through a morass of confusion for decades. In representing people with brain injuries, it is essential to understand these problems and know how to communicate them to judges and juries.  

People who have sustained a brain injury are often advised to keep a detailed calendar and lists to help them keep track of tasks in their lives.  I have seen the necessity and helpfulness of this strategy up close in my family. The traditional Day-Timer calendars have been helpful to people near and dear to me with brain injuries.  Now Day-Timer is marketing a Brain Injury Recovery Kit for $349.99. 

The Kit comes in a large colorful box, which is easy to locate and contains supplies for five steps. The steps of the program are presented as individual entities, rather than part of a large process, to help increase overall efficiency of the kit. Some of the components within the steps include:

1.   DVD tutorial - The DVD, hosted by creator, Lisa Keller, is used to help the Experiencing Person and his/her family learn about brain injury and recovery in a clear, easy-to-understand format.

2.   Buddy Book - The family and friends of the experiencing person can learn how to support an individual with brain injury with the help of the Buddy Book.

3.   The 4 Keys - In order to help remind the Experiencing Person and the buddy about how to reach to recovery, there are four keys: Buddy, Rest, Acceptance and Routine.

4.   DayTimer Planner - Organization and routine are essential to recovery, so the DayTimer planner is included to help improve short-term memory, attention span and organization skills. The planner comes in a bright orange color to make it easy to locate.

5.   Electronic Message Center - An easy-to-use voice recorder that encourages two of the most important methods for remembering: repetition and reminders.

A fascinating new book by Norman Doidge, The Brain That Changes Itself, poses hopeful and intriguing possibilities for brain injury victims -- and for those of us who are merely stuck in the rut of middle age. The author gives numerous examples of patients with brain injury due to either trauma or illness whose brains are "rewired" to recover lost functions.  One may speculate about the implications for learning, for  self improvement, and for enhancement of functions that might otherwise diminish with age. See the New York Times review.

A report this week raises the hopes of people searching for stem cell therapies for victims of brain injury, spinal cord injury and other ailments. Ethical concerns have curbed development of therapies using embryonic stem cells. However, according to the report published this week in Nature Bioitechnology, stem cells with therapeutic value can be harvested from amniotic fluid and placentas.

According to the report, the amniotic cells can mature into all of the major types of cells, dividing once every 36 hours yet never showing signs of aging and never becoming tumors -- even after living for more than two years in the lab.  Researchers at Wake Forest and at Children's Hospital in Boston coaxed the cells to become brain cells and injected them into the skulls of mice with diseased brains, where new cells filled in diseased areas and appeared to make new connections with nearby healthy neurons. When coaxed to become bone cells and seeded onto a gelatin scaffold that was then implanted in a mouse, the cells calcified and turned into dense, healthy bone.

The study leader, Anthony Atala, director of the Institute for Regenerative Medicine at Wake Forest University School of Medicine, estimates that if 100,000 women donated their amniotic cells to a bank, that would provide enough cells of sufficient genetic diversity to provide immunologically compatible tissue for virtually the entire US popularion.

Meanwhile, pediatric surgeon Dario Fauza at Children's Hospital in Boston has been pursuing a parallel line of research, growing amniotic stem cells into cartilage and diaphragms to repair defects in newborn sheep.  His goal, of course, is to be able to use amniotic stem cells to repair defects in newborn humans.

Whether any of this will become clinically available in time to help today's victims of brain and spinal cord injury, as well as other conditions, is an open question, but for those of us searching for hope for our loved ones, it is a matter of great interest.

An Emory Medical School doctor working with victims of traumatic brain injury at Grady Hospital in Atlanta has published a study suggesting that the female hormone progesterone can be a safe, effective treatment for brain injury. 

Animal studies have indicated that giving progesterone soon after injury reduces brain swelling, prevents nerve death and improves functional outcomes. Lead researcher Dr. David W. Wright and colleagues note that progesterone's advantages over other potential treatments include its ability to quickly enter the brain, history of safe use, ease of administration, and low cost.

Wright, from Emory University in Atlanta, and colleagues included in their study 100 adults with brain injury who reached the emergency department within 11 hours of injury. Patients were randomly assigned to receive an intravenous dose of progesterone or inactive "placebo".

The death rate in the 30 days after injury was 13 percent in the progesterone group compared with 30 percent in the comparison group. This suggests that progesterone cut the risk of death by 57 percent.

Wright's team was able to contact 92 percent of patients who survived 30 days. There was evidence that progesterone improved the recovery of patients with moderate brain injury. Patients with severe injury seemed to glean no benefit from the hormone.

Dr. Wright says his results are preliminary and broader studies are needed.

Science magazine recently published a report on a young woman devastated by a car crash in England. For five months after the accident, tests showed no signs of awareness. Doctors declared her vegetative. Then, scientists put her in a Functional Magnetic Resonance Imaging (FMRI) scanner, which tracks blood flow to different parts of the brain. They asked her to imagine playing tennis and walking through her home. The scan lit up with telltale patterns of language, movement, and navigation indistinguishable  from the brains of healthy people.  Something was awake inside that woman's skull. Without the scanner, no one but her would have known.

The analysis in Science concludes that she has a "rich mental life" but may not be "conscious."   That does that mean? Is she awake inside her skull, though incapable of outward manifestation of awareness?

It is both interesting and horrifying to contemplate the potential ramificaitons of this in brain injury litigation.  In the past doctors have been quite confident in reassuring us that patients in what appeared to be a chronic vegetative state had no awareness of their situation.  Now, with an FMRI test, we may be able to show what appears to be conscious mental activity in the victim of a relatively recent traumatic brain injury.  I'd hate to be on the defense side of a case when that video is played for a jury.

The current issue of Forbes carries an interesting article on driver rehabilitation after a serious injury or illness. Many people with newfound disabilities, including neurological conditions, heart disease and stroke, are overcoming great obstacles to find ways to get back to driving on the highway.  For the impaired person, the ability to drive symbolizes independence and freedom.  I saw that in my daughter after she lost her hearing due to an illness.  The weeks between discharge from the hospital and clearance to drive again were absolutely maddening for her, and for everyone around her.

Here in the Atlanta area, DeKalb Medical Center Rehabilitation Services has a Driving Solutions Program which provides driver assessment, training and adaptive equipment recommendations for vehicle operation. The assessment process includes tests of vision, visual perception and reaction time, as well as assessment of cognitive and physician functioning. Driver training is available to new and experienced drivers to promote safety and competency behind the wheel. Training in the use of adaptive equipment is available. I took my daughter over there for an assessment that cleared her to drive again, restoring freedom and a modicum of normalcy after a traumatic, life changing loss.

German researchers announced today that they have isolated stem cells in adult mouse testicles that have properties similar to those of embryonic stem cells. When injected into early mouse embryos, the cells contributed to the growth of various mouse organs, including heart, brain, and lungs. If the method works in humans, it could provide an alternative source for stem cells, avoiding the ethical controversy of generating stem cells from human embryos. Like embryonic stem cells, these testicle-derived cells can contribute to the development of multiple organs when injected into embryos, the researchers said.

Every advance in stem cell research is another glimmer of hope that someday there may be more effective treatments for spinal cord injuries and brain injuries.

Two studies released on Februry 16th may show potential for development of stem cell therapies for brain injuries. A Johns Hopkins University study has provided the first comprehensive map of a part of the adult human brain containing astrocytes, cells known to produce growth factors critical to the regeneration of damaged neural tissue and that potentially serve as brain stem cells. Researchers at the University of Minnesota Medical School have discovered a new population of cells in human umbilical cord blood that have properties of primitive stem cells. While neither of these studies have progressed beyond laboratory animals, both show potential for developing future treatments for brain injury without the controversial use of embryonic stem cells.

A variety of injuries, illnesses and genetic disorders can cause damage to the auditory nerve, resulting in hearing loss for which hearing aids provide little or no help. Since sensory nerves have less capacity for recovery than motor nerves, such damage is often permanent and irreparable. The isolating effect of resulting deafness can be devastating. While there has been considerable progress on auditory brainstem implants, there is still a long way to go.

Some researchers have begun work on the prospect of stem cell treatment to repair damaged auditory nerves. See, e.g., "UCI Researcher Pinpoints Cause Of Inherited Auditory Neuropathy," "Investigating a cell replacement therapy in the inner ear," "Central migration of neuronal tissue and embryonic stem cells following transplantation along the adult auditory nerve," and "Tissue Engineering: STEM CELLS".

People who have lost hearing in both ears due to damage to auditory nerves face tough decisions about living with deafness, getting currently available treatments such as ABI which might preclude later stem cell treatment, or waiting years hoping clinically effective stem cell therapy.

According to a report published on 11/29/05, researchers at the Queensland Brain Institute in Australia have identified a process that could lead to development of repair mechanisms for people suffering from dementia and acquired brain injury. It utilizes discoveries in the hippocampus - a part of the brain commonly associated with memory function - where the brain's ability to regenerate nerve cells or neurons is known to degenerate with age. The researchers have demonstrated adult mice produce multi-purpose, or progenitor, cells in the hippocampus.

While progenitor cells in mice do not behave like stem cells, which have the ability to self-renew, the progenitor cells are nevertheless capable of generating nerve cells in the hippocampus. The latest discovery in the hippocampus suggests the human nervous system has the potential capacity to respond to its outside environment by generating new nerve cells.

Hypertonic resuscitation -- a concentrated intravenous (IV) dose of saline and dextran, a sugar solution -- has the potential to help survivors of blunt trauma by improving blood flow and delivery of oxygen to the injured brain while decreasing high pressure in the brain, a common problem for patients with brain injury.

Trauma care begins in the field, with paramedics and flight nurses providing airway management, spinal immobilization and IV fluids. Given to help replace lost blood and support blood flow to vital organs, IV fluids are especially important for trauma patients who have suffered brain injuries. Current pre-hospital treatment includes two liters of an IV saline solution having a similar concentration to human plasma.

The experimental hypertonic saline/dextran (HSD) solution is more concentrated than the current treatment and may offer potential benefits to victims of blunt trauma, Bulger says, including more rapid improvement of blood pressure, improved blood flow to the injured brain while decreasing the high pressure in the brain, and an altered immune system response which may decrease the risk of infection and acute respiratory distress syndrome.

Insurance executives and corporate risk managers know that family caregivers, caring for catastrophically injured loved ones, eventually will be ground down to exhaustion. And they know a wrongful death claim has far less value and jury appeal than a catastrophic injury claim, so if they can delay long enough they may save millions.

Therefore, in representing spinal cord and brain injury victims in claims for their catastrophic injuries, we have learned that the defense will generally follow a strategy of purposeful delay, knowing that the longer a quadriplegic goes without the full array of support services and equipment, the more likely he or she is to die before trial.

A new study from Georgetown University Medical Center may offer hope of drug treatment to prevent formation of scar tissue and thereby prevent worsening effects of traumatic central nervous system injury. Based on studies with rats, the hope is that injection of flavopiridol through nasal passages within thirty minutes after trauma may limit the formation of scar tissue and inflammatory response. See news release and the full study.

Much study with human subjects will be required before flavopiridol becomes a standard medical supply on every ambulance, routinely administered by EMT's at accident scenes. If that day ever comes, it will be too late for today's victims. For those of us who have spent years working with victims of catastrophic brain and spinal cord injuries, it sounds like hopeful news.