Honolulu Personal Injury Lawyer - Head & Brain Injuries

Summer Water Safety Alert: Surf's Up On The South Shore! Be Careful

Wayne Parsons — Fri, 24 Jul 2009 18:34:19 GMT

The waves in Waikiki look white and fluffy and the warm air and water beckon the just arrived tourists. I surf. Its great fun. But beware. Those waves are powerful. The surfers riding them are skilled athletes. Also the Boards are heavy and if one hits you the injury may be serious or even fatal. News flash: South Shore waves keep lifeguards busy at beaches

Lifeguards were busier than usual yesterday with a South Shore swell that brought 8-foot waves.

At Waikiki Beach, lifeguards made eight rescues, 38 assists, and prevented 175 people from entering the surf, said Honolulu Emergency Services Department spokesman Bryan Cheplic. At Ala Moana Beach Park, lifeguards deterred 100 people from going into water and assisted five.

The National Weather Service said a high-surf advisory will remain in effect until noon today. Surf heights of 5 to 8 feet are expected through this morning, then dropping to 4 to 6 feet.

A high-surf advisory means beachgoers should stay out of the water and away from the shore break because of hazardous wave action and the potential for strong rip currents, the weather service said.

A major concern is currents or what some call rip tides. The waves push a lot of water up toward the beach and then it must find a way to go back out. Deeper troughs form in the sand underwater that allow a river of water to flow out to deep water.

http://www.youtube.com/watch?v=PodlRS-N-vE

I have been caught in one of those currents and if I hadn't been a good swimmer I might have become exhausted and drowned.

Scientific studies have cataloged surfer injuries in Acute injury and chronic disability resulting from surfboard riding:

646 surfers were enrolled (90.2% male, median age 27 years, median years of surfing 10). 145 surfers sustained 168 significant acute injuries in the preceding 12 months (0.26 injuries/surfer/year, 95% CI 0.22-0.30). Most were caused by striking a surfboard or another surfer (45.2%, 95% CI 37.6-53.1), "wiping out" (36.3%, 95% CI 29.1-44.1) or striking the seabed (17.9%, 95% CI 12.6-24.7). Injuries included lacerations (46.4%, 95% CI 38.8-54.3), sprains (28.6%, 95% CI 22.0-36.1), dislocations (10.7%, 95% CI 6.7-16.6) and fractures (8.9%, 95% CI 5.3-14.6). Body parts most frequently injured were the lower limb (45.8%, 95% CI 38.2-53.7) and the head/face (26.2%, 95% CI 19.9-33.6). Surfing injuries that were treated in Victorian emergency departments over a six year period revealed a similar pattern, although there was a greater proportion of head/face injuries (42.0%, 95% CI 36.0-48.1, p = 0.001). 20 surfers reported long-term effects from acute injuries, mainly unstable/stiff/painful joints. 136 surfers reported chronic health problems not related to acute injury including chronic/recurrent otitis externa and exostoses, muscle and joint pain/stiffness and pterygium. Significant injury while surfing is not uncommon. Although head injury accounts for a considerable proportion, very few surfers wear protective headgear. Greater use of protective headgear should be considered.

My tips to tourists planning to surf in Hawaii:

Protect yourself by looking for surf warnings in Hawaii.
Take a surf lesson;
Use the Buddy System
Watch out for shallow reefs

And you can read my earlier article on the subject: Visiting Hawaii - Water Safety Tips For Tourists To Avoid A Personal Injury And A Ruined Vacation

Nothing is more fun than riding a surfboard in Hawaii. Keep it fun and surf safely.

Originally posted at InjuryBoard by Wayne Parsons

Fatigue As The Result of Personal Injury

Wayne Parsons — Fri, 24 Jul 2009 16:26:20 GMT

Everyone knows about broken bones, lacerations, traumatic brain injury, loss of vision, spinal cord injury and other physical injuries that follow automobile accidents, medical malpractice, construction site accidents and product defects. One often ignored after effect is fatigue that can become chronic: chronic fatigue syndrome (CFS). Surveys of injured persons often show that fatigue is one of the most significant long term permanent effects of an injury and in particular injury that results in chronic pain. Fatigue, like pain, doesn't show up on an x-ray and doctors rarely spend any time trying to help with fatigue. Even when the pain is recognized as an issue, fatigue is often left out of the list of disabilities.

Chronic fatigue syndrome (CFS) is an illness defined by disabling physical and mental fatigue and physical and mental symptoms that are not explained by conventional medical and psychiatric diagnoses. CFS affects between 400,000 and 800,000 people in the United States and has an average duration of 5 years, but symptoms can persist as long as 20 years. The prognosis for recovery of severely ill CFS patients is poor. Despite CFS's disabling, enduring, and prevalent nature, scant studies have quantified its impact on the health and well-being of those affected, on the health care system, or on society as a whole.

The burden of CFS is poorly recognized, and the illness remains an inadequately managed health problem. Two population-based studies of CFS have been conducted in the United States, and both found that CFS is one of the more common chronic illnesses among women across all racial/ethnic groups and that less than 20% of those who suffer from CFS have been diagnosed by a health care provider. Only three studies, all of which were clinic based, have attempted to quantify the impact of CFS, and each showed that people with the syndrome were likely to have lost their job or to be unemployed. In addition, it was shown that persons with CFS pose a disproportionate burden on the health care system and their families since they are sick for long periods of time and since there is no known cure for the illness.

The ability of an injured person to get back to a functional life is often affected most severely by fatigue. even when a person is physically able to lift and bend and do the tasks of many jobs, the consequence of fatigue is that the person can't keep any job because fatigue takes them out of a 40 hour work week. As reported in the study The economic impact of chronic fatigue syndrome by Kenneth J Reynolds, Suzanne D Vernon, Ellen Bouchery and William C Reeves, SRA International, Inc., Arlington, U.S.A, Division of Viral and Rickettsial Diseases, Centers for Disease Control and Prevention, Atlanta, U.S.A, The Lewin Group, Falls Church, U.S.A:

The magnitude of the economic impact imposed on the individual and on society by CFS is substantial. Approximately one-quarter of persons with CFS, who would otherwise have participated in the labor force, ceased working. For those who continued to work, average income declined by one-third. This represents an estimated annual loss of almost $20,000 for the individual suffering from CFS. This magnitude of loss approximates half of their labor force and household productivity in a given year. The $9.1 billion national loss is comparable to that estimated for other illnesses, such as digestive system illnesses ($8.4 B) and infectious and parasitic diseases ($10.0 B) [19] and is greater than the estimated productivity losses from immunity disorders ($5.5 B), nervous system disorders ($6.4 B), or skin disorders ($1.3) [23]. This estimate does not include health care costs, which are likely to be substantial and does not address reductions in quality of life, which are likely to be large due to the debilitating fatigue.

We estimated annual lost productivity. However, CFS is a chronic illness. The average duration of CFS identified in population studies is 5 years and most patients with CFS seen by health care providers have been ill for more than 6 years. Thus, productivity losses, health care expenses, and reductions in quality of life continue for many years for most affected individuals and thus would have a substantial long-term impact on the standard of living of individuals with CFS and their family members.

It often starts with pain that doesn't go away and lingers and tortures the injured person 24 hours a day, 7 days a week as reported in a Time Magazine feature article The Right (and Wrong) Way to Treat Pain by Claudia Wallis

With chronic pain, however, the alarm continues to shriek uselessly long after the physical danger has passed. Somewhere along the line--maybe near the initial injury, maybe in the spinal cord or brain--the alarm system has broken down. What researchers have only recently come to understand is that prolonged exposure to this screaming siren actually does its own damage. "Pain causes a fundamental rewiring of the nervous system," says Dr. Sean Mackey, director of research at Stanford University's Pain Management Center. "Each time we feel pain, there are changes that occur that tend to amplify our experience of pain." That is why it is a mistake, despite our grin-and-bear-it tradition, to ignore or under treat severe pain.

Fatigue is often the most disabling feature of chronic pain. The injured person is often told by the insurance company, their employer or even their own attorney that they can go back to work and so they have no claim for future wage loss. On top of that their fatigue is ignored and not understood to be a part of the injury. It is treated like a form of laziness or lack of initiative. The treating doctor has probably told them that they can physically do the work at their old job or at least at some other less strenuous job. What is missing in this analysis is that if the injured person suffers from fatigue they cannot do the work if it involves a 40 hour job.

Unless a careful workup is done of the existence of fatigue and the connection of fatigue to the injury, the injured person will not be compensated for what can be a significant loss of future earnings.

What needs to be done is an analysis of the injured person by a neuropsychologist or other doctor using The Universal Work Skills Evaluation test. Below is a video showing a truck driver taking the test. Although there is no sound the test shows that the person has chronic fatigue.

http://www.youtube.com/watch?v=DphPP1EHj9M

Doctors have several ways of validating fatigue as a disabling factor resulting from personal injury.

Originally posted at InjuryBoard by Wayne Parsons

Billy May and TBI: Another Closed Head Injury Death?

Wayne Parsons — Mon, 29 Jun 2009 15:48:36 GMT

Doctors are looking at a traumatic brain injury (TBI) as the possible cause of the tragic death of TV actor Billy May as Mike Bryant of Minnesota has reported recently in:

Doctors Will Be Looking At Potential Head Injury With Billy May's Death.

Everyone should be on alert that a blow to the head can start a small bleeding process in the brain that is unknown to the person whose head was hit - and can lead to death. Often the person is either unconscious for a period of time, or dazed. After a few moments the person goes through what doctors call a lucid interval where they seem OK.

This article is about the medical sign. For the Cephalic Carnage album, see Lucid Interval.
In emergency medicine, a lucid interval is a temporary improvement in a patient's condition after a traumatic brain injury, after which the condition deteriorates. A lucid interval is especially indicative of an epidural hematoma. An estimated 20 to 50% of patients with epidural hematoma experience such a lucid interval.^[1]^[2] The lucid interval occurs after the patient is knocked out by the initial concussive force of the trauma, then lapses into unconsciousness again after recovery when bleeding causes the hematoma to expand past the point at which the body can no longer compensate.^[3] After the injury, the patient is momentarily dazed or knocked out, and then becomes relatively lucid for a period of time which can last minutes or hours.^[3] Thereafter there is rapid decline as the blood collects within the skull, causing a rise in intracranial pressure, which damages brain tissue. In addition, some patients may develop "pseudoaneurysms" after trauma which can eventually burst and bleed, a factor which might account for the delay in loss of consciousness.^[4]

Because a patient may have a lucid interval, any head trauma is regarded as a medical emergency and receives emergency medical treatment even if the patient is conscious.

Delayed cerebral edema, a very serious and potentially fatal condition in which the brain swells dramatically, may follow a lucid interval that occurs after a minor head trauma.^[5]

Lucid intervals may also occur in conditions other than traumatic brain injury, such as heat stroke^[6] and the postictal phase after a seizure in epileptic patients.^[7]

The skull is solid and the brain is soft. Increasing the pressure with an internal bleeding process is a catastrophe waiting to happen.

I handled a TBI case years ago that I will never forget. A man hit is head when he fell off a ladder in his yard while trimming a tree. His wife was with him and got to him immediately. His eyes were open but when she asked if he was hurt he did not respond. He never was "unconscious" as we usually think of it. That was at 9 o'clock in the morning. By 5 PM he was dead. He went to his family doctor who asked him some questions that he answered correctly. The doctor did not order a CT Scan.

The 20th century has seen critical developments in diagnosis and treatment which have decreased death rates and improved outcome. These include imaging techniques such as computed tomography and magnetic resonance imaging. Depending on the injury, treatment required may be minimal or may include interventions such as medications and emergency surgery. Physical therapy, speech therapy, and occupational therapy may be employed for rehabilitation.

During the afternoon the man slept at home and his headache worsened. He was unresponsive at 5 PM at home. Tragic. A CT scan might have shown the insidious bleed and treatment would have been available.

These head injuries are a leading cause of death in the United States from trauma:

Traumatic brain injury (TBI) is a leading cause of death and disability among persons in the United States. Each year, an estimated 1.5 million Americans sustain a TBI. As a result of these injuries, 50,000 people die, 230,000 people are hospitalized and survive, and an estimated 80,000-90,000 people experience the onset of long-term disability. Rates of TBI-related hospitalization have declined nearly 50% since 1980, a phenomenon that may be attributed, in part, to successes in injury prevention and also to changes in hospital admission practices that shift the care of persons with less severe TBI from inpatient to outpatient settings. The magnitude of TBI in the United States requires public health measures to prevent these injuries and to improve their consequences. State surveillance systems can provide reliable data on injury causes and risk factors, identify trends in TBI incidence, enable the development of cause-specific prevention strategies focused on populations at greatest risk, and monitor the effectiveness of such programs. State follow-up registries, built on surveillance systems, can provide more information regarding the frequency and nature of disabilities associated with TBI. This information can help states and communities to design, implement, and evaluate cost-effective programs for people living with TBI and for their families, addressing acute care, rehabilitation, and vocational, school, and community support.

Billy May was far too young to die. The first lesson is to get to a doctor or hospital immediately. The second is to look for the subtle signs and symptoms of an internal bleed in the head.

Originally posted at InjuryBoard by Wayne Parsons

Health Alert: Recognizing When Someone Is Having A Stroke Can Save Their Or Your Life

Wayne Parsons — Sun, 14 Jun 2009 16:07:00 GMT

STROKE IDENTIFICATION

We saw Natasha Richardson die of a traumatic brain injury (TBI) shortly after hitting her head on a ski slope. A short delay in recognizing the seriousness of her injury because she was alert and conscious, allowed the injury in her head to become fatal. There are many good resources about people who hit their head and suffer an obvious trauma or TBI, but a stroke often goes on without any outside influence. Something is happening inside the brain and the signs are subtle, even to the person having the stroke.

Think of Ms. Richardson when you become aware of the subtle signs of a stroke. Stroke is invisible often. No head trauma. No violent events. If you see a friend stumble and lose their balance or fall at a summer BBQ, ask yourself if perhaps this person - or you if it is you who stumbled - is having a stroke? Most people will assure everyone that they are fine will refuse assistance saying that they must have caught their foot on something. Calling for paramedics is out of the question they will say.

They will get up and the host will bring them a beverage or some food, and the embarrassed guest will go about enjoying the rest of the party. If it was a stroke you will get a call later that the person had been taken to the hospital later and sadly has passed away. If those who saw the person stumble and fall knew how to identify the signs of a stroke, perhaps death could have been prevented.

Here is what you need to know:

A neurologist says that if he can get to a stroke victim within 3 hours he can often totally reverse the effects of a stroke...totally. He said the trick was getting a stroke recognized, diagnosed, and then getting the patient medically cared for within 3 hours, which is tough.

RECOGNIZING A STROKE:

Commit to memory the '3' steps, STR - ask three simple questions:

S: Ask the individual to SMILE.

T: Ask the person to TALK and SPEAK A SIMPLE SENTENCE, coherently. (i.e.. It is sunny out today.)

R: Ask him or her to RAISE BOTH ARMS.

If he or she has trouble with ANY ONE of these tasks, call the emergency number (911 in many places) immediately and describe the symptoms to the dispatcher.

Another 'sign' of a stroke is to ask the person to 'stick' out his or her tongue. If the tongue is crooked, if it goes to one side or the other, that is also an indication of a stroke.

There are great resources on stroke and STR is not the only catch phrase for us to apply. How about F.A.S.T. as in do something FAST? That comes from the National Stroke Association:

If you think someone may be having a stroke, act F.A.S.T. and do this simple test:

Act F.A.S.T.

FACE
Ask the person to smile.

Does one side of the face droop?

ARMS
Ask the person to raise both arms.

Does one arm drift downward?

SPEECH
Ask the person to repeat a simple sentence.

Are the words slurred? Can he/she repeat the sentence correctly?

TIME
If the person shows any of these symptoms, time is important.

Call 911 or get to the hospital fast. Brain cells are dying.

Stroke Symptoms include:

SUDDEN numbness or weakness of face, arm or leg - especially on one side of the body.

SUDDEN confusion, trouble speaking or understanding.

SUDDEN trouble seeing in one or both eyes.

SUDDEN trouble walking, dizziness, loss of balance or coordination.

SUDDEN severe headache with no known cause.

Call 9-1-1 immediately if you have any of these symptoms

Note the time you experienced your first symptom. This information is important to your healthcare provider and can affect treatment decisions.

If you have experienced any of these symptoms, you may have had a TIA or mini-stroke.

Let others know about S.T.R. and F.A.S.T. -- Saving a life is a beautiful thing.

Originally posted at InjuryBoard by Wayne Parsons

Misdiagnosis of Brain Injury - Its Not Just a Headache - Remembering Natasha Richardson

Wayne Parsons — Sun, 03 May 2009 14:20:41 GMT

Think about tort reform in the context of medical negligence - misdiagnosis of traumatic brain injury - on a national basis. It happens everywhere from Honolulu to Hilo to Washington, D.C. Why don't the tort reform advocates talk about the 15,000 people in the united States whose life threatening head injury will be misdiagnosed by careless physicians this year?

Natasha Richardson died of a headache. She fell while skiing. She seemed OK afterward – there was no panic. All she had was a bad headache. Then in a few short hours she became very ill and then she slipped into a coma. Tragically she died. It was more than a headache. It was more than a bump. In her case I do not know if she was misdiagnosed. But her case draws attention to what every person needs to know when they bump their head.

http://www.youtube.com/watch?v=xWMiBoaJQp8

As doctors and their insurance companies and high paid lobbyists twist the arms of naive legislators in states across the country, begging for tort reform, about 15,000 people in the United States will be misdiagnosed at an emergency room or in a doctors office this year with a brain injury that may kill them. More than 30,000 people in the United States suffer this injury every year: Jonathan A. Edlow & Louis R. Caplan, Avoiding Pitfalls in the Diagnosis of Subarachnoid Hemorrhage, 342 New Eng. J. Med. 29, 29 (2000).

The medical diagnosis is:

Ruptured brain aneurysm, or

Subarachnoid hemorrhage

The plain language version is internal bleed. A ruptured brain aneurysm usually results in blood collecting at the base of the brain. A subarachnoid hemorrhage often is seen with blood collecting on the surface of brain at the site of the blow that caused the injury or at the opposite side of the brain.

Blood flows into the fixed space inside the skull and there is nowhere for it to go. Something has to give. The brain is crushed. It can take an hour or it can take a year. It depends on how fast the bleed is going. There are treatments - both surgical and new drugs - but time is crucial. Not a minute can be wasted and delay can be fatal as it was in the death of Natasha Richardson this past winter.

Now for the most frightening fact for the 30,000 people who will go to a doctor – usually an emergency room doctor – in 2009, with this condition: the common doctor negligence of failure to diagnose the condition is estimated at 53%:

Unfortunately, many will be discharged without receiving the correct diagnosis or the emergency medical treatment they desperately need.

Failure to diagnose is the most common negligence in the treatment of patients with aneurysmal subarachnoid hemorrhage,² and this failure may be as high as 53 percent in patients visiting the emergency room for the first time.³Physicians fail to obtain an adequate history, perform a thorough neurological exam, or understand the significance of the history and physical exam findings. Jose I. Suarez et al., Aneurysmal Subarachnoid Hemorrhage, 354 New Eng. J. Med. 387, 388 (2006).

Less often, but still with troubling regularity, negligence involves failure to obtain or accurately interpret diagnostic tests.

Delay in diagnosis and treatment has dire consequences. In some cases, even minimal delay can mean the difference between life and death.”

Many of these patients will present with a severe headache, some will recall being unconscious and others with think they were only dazed (doctors call that a lucid interval) and every one of them needs a careful examination.

How does a doctor detect an internal bleed? CT Scan is the standard of care for seeing an internal bleed. Remember that: CT scan. The exact procedure will be described later in this article:

Q: What if internal bleeding of the brain occurs due to injury?

One of two things can happen; the blood can clot and block circulation to that part of the brain, or the blood can continue to accumulate an create a hemorrhagic area and pressure within the brain on a vessel or surrounding brain structure. In either case, it can lead to an "evolving" stroke with temporary or permanent disability, depending on the area involved and the time until the blockage or pressure is remedied. Also, a generalized response of fluid accumulation around the brain (cerebral edema) can occur to increase pressure around the brain as a whole.

A CT scan or MRI scan can determine the type, area and extent of bleeding to choose the appropriate treatment, which may include "clot-busting enzymatic" drugs, high-dose steroids (hydrocortisone or methylprednisolone) or diuretics to draw fluid away from the brain.

Time is critical, since the brain uses the greatest amount of oxygen in the body (about 20% for a 3-lb organ, far more than the heart), consequently it is exquisitely sensitive to anoxia.

An X-ray will not show an internal bleed. And remember, if you are sent home with instruction to call or come back if it gets worse, if the bleed gets to the point of crushing the brain it will not wait for you to drive back to the emergency room and even if you make it before you die, there is little that the doctors can do at that point – it is too late.

Here is an explanation of what happens inside the skull:

Aneurysms are ballooned areas on arteries. They are often referred to as berry, saccular, or congenital (existing at birth) aneurysms. The most likely cause is a weak area of the artery wall due to a congenital defect combined with degenerative changes that further weaken the tissue.

Aneurysms are typically located on large arteries at the base of the brain and usually occur at branching points. If they stretch and ultimately rupture, arterial pressure forces blood to leak from the aneurysm into the subarachnoid space—the area between the arachnoid membrane and the pia mater, a membrane adherent to the brain. The blood then quickly spreads into the cerebrospinal fluid surrounding the brain and spinal cord.

The problem is greater for women than for men, greater for blacks than for whites and is more common in pregnant women particularly in the third trimester accounting for from 6% to 25% of maternal deaths.Jonathan A. Edlow, Diagnosis of Subarachnoid Hemorrhage in the Emergency Department, 21 Emerg. Med. Clinics of N. Am. 73, 75 (2003),

The sequence is subtle. Many people will have only a small leak at first. At tiny bleed that grows and as the pressure builds causes other leaks and then a cascade due to mounting pressure that all of a sudden becomes critical. That first leak is called a sentinel leak by doctors:

Up to 70 percent of patients will experience a sentinel (warning) leak before suffering a larger hemorrhage. Often these patients have a headache but no other signs or symptoms. Half of the patients with sentinel leaks seek immediate attention, but up to 60 percent of them are misdiagnosed and later suffer a larger hemorrhage. If the sentinel leak is diagnosed and treated promptly, a more serious hemorrhage and the associated significant complications can be prevented.”

Rosen’s Emergency Medicine: Concepts in Clinical Practice (John A. Marx et al. eds., 6th ed. Mosby, Inc. 2006), (subscription required)

At the emergency room the doctor should look for the following signs and symptoms:

severe headache with sudden onset,

nausea, vomiting,

sensitivity to light,

neck pain.

The examination by the doctor must include looking for neck stiffness, an altered state of consciousness (for example, drowsiness, restlessness, or agitation), neurological impairments such as weakness or paralysis, visual problems, abnormal eye movements, or paralysis of eye movements. Rosen’s Emergency Medicine, n. 7.

The doctor should examine the back of the eye, called a funduscopic examination, to see if a retinal or preretinal hemorrhage exists.

Funduscopic examination is a routine part of every doctor's examination of the eye, not

just the ophthalmologist's. It consists exclusively of inspection. One looks through the ophthalmoscope, which is simply a light with various optical modifications, including lenses. The ophthalmoscope illuminates the retina through the normal iris defect that is the pupil. Light rays forming the image of the retina re-emerge through the pupil. The viewing aperture (window) of the ophthalmoscope contains a lens that modifies light rays to assist the user. In the procedure, one looks at structures lying in the innermost aspect of the globe, collectively known as the eyegrounds: retina, retinal blood vessels, optic nerve head (disk), and to a limited degree, subjacent choroid. The pupil is frequently dilated pharmacologically to render retinal inspection easier, and for examination of the macula. One paralyzes the pupilloconstrictor muscle of the iris with nonabsorbable, short-acting topical parasympatholytic drugs, resulting in a larger pupillary aperture. In comparison to the ophthalmologist, the internist, neurologist, or pediatrician concentrates particularly on funduscopic manifestations of systemic disease and less on local ocular disease. Synonyms for funduscopic examination include funduscopy, ophthalmoscopy, and direct ophthalmoscopy. Only ophthalmologists perform retinoscopy and indirect ophthalmoscopy, which require other equipment and provide different information.

Figure 117.4 The value of pupillodilation. (A) External examination (more...)

Figure 117.4

The value of pupillodilation. (A) External examination shows miotic pupil at baseline. (B) Scant fundus is revealed through this pupil. (Peripheral clouding is an artifact of photography through undilated pupil; actual funduscopy in this case showed retina only where photograph is vivid, and no image where photograph is cloudy or spotted.) (C) Pharmacologically dilated pupil provides much better aperture. (D) Retinal field of view enlarges after mydriatic treatment. Funduscopy grows easy. Almost all retinal photographs are taken through dilated pupils. The student expects a comparable view in undilated patients. The rude reality makes him wonder, unnecessarily, if his technique is defective.

The term temporal is used in describing ophthalmoscopic landmarks and findings, rather than "lateral"; and nasal replaces "medial." The optic nerve head or disk is seen when one looks through the pupil from an angle about 15 degrees temporal to the optical axis (the patient's line of sight, "straight ahead"). The disk is a yellow-pink color that stands out from the redder, browner, or more orange retina proper.

The disk is sharply demarcated temporally and to a lesser degree nasally from the background retina, which is all the retina that is not disk, vessels, or macula. Frequently, a narrow crescent of stippled pigment adjoins the sides of the disk, especially the temporal side (house staff have called the author to see "lesions" that turned out to be this normal feature). The disk is slightly taller than wide. The central part of the disk is paler, and is called the optic cup or physiologic excavation; normally this occupies less than one-third the diameter of the disk. In glaucoma and in high myopia the cup is enlarged. The transverse diameter of the disk is a standard yardstick in fundal description, so that, for example, a lesion may be characterized as "one-half disk diameter out at two o"clock, and extending two disk diameters superiorly therefrom." Although some examiners realize that the disk is 1.5 mm wide, nobody describes a lesion as 3 mm across. Near mid-disk, the central retinal artery and vein emerge from the optic nerve, with which they have run forward into the orbit. Each soon bifurcates into superior and inferior branches, which run "flat," that is, parallel with the retinal surface. Beyond one disk diameter out, they are called arterioles and venules. With all retinal vessels, the artery/arteriole appears slightly smaller, and distinctly lighter, more orange-red and less purple than the vein/venule. The color difference reflects the contained blood column that is visualized: the vascular walls are transparent, and deoxygenated venous blood is darker than arterial blood. Before it crosses the disk edge, each large vessel divides into a nasal and a temporal branch. Thus the principal arteries, veins, and quadrants of any retina are the superior temporal, inferior temporal, inferior nasal, and superior nasal. The avascular, dusky area two disk diameters due temporal to the disk is the macula. This is the area of greatest visual acuity. Apart from this zone, the background retinal color will parallel the patient's skin and hair pigmentation, from pale in light-skinned blondes to an umber shade in the darkest black people.

Normally, the largest veins pulsate slightly and the arteries do not, the reverse of the situation elsewhere in the body. No hemorrhage is seen in normal fundi. Any yellow, yellow-white, gray, or black interruptions of the background retinal color pattern suggest pathologic exudate, edema, or scar. No wrinkling of the retina should be seen. Chalky whiteness or erythema of the disk is abnormal, as are indistinct disk margins. Any sharp change in elevation that renders one area out of focus with the ophthalmoscope, while the remainder of the retina remains in focus, is abnormal. Tortuous blood vessels usually bespeak pathology.

About 50 percent of patients with aneurysmal hemorrhage will have no alteration in consciousness, and most will lack focal neurological signs.

After a person suffers a hemorrhage, his or her electrocardiogram may suggest acute myocardial infarction. This may complicate the patient’s evaluation and delay the correct diagnosis while an acute heart attack is being ruled out.

The physician should know that the patient may not have any of the physical or neurological findings discussed above:

About 12 percent of patients who arrive at the emergency room with severe acute-onset headaches and normal neurological exams have suffered a hemorrhage.¹⁷ Therefore, patients with sudden severe headaches should be thoroughly evaluated for subarachnoid hemorrhage even if they have no other signs or symptoms or the headache abates spontaneously or with pain medication.

Once the differential diagnosis includes subarachnoid hemorrhage, diagnostic testing should immediately follow. Computerized tomography (CT) of the head, without contrast material, is the diagnostic test of choice. It is about 95 percent sensitive for detecting acute subarachnoid hemorrhage if performed within hours of aneurysm rupture. CT is noninvasive, relatively inexpensive, and it can be completed in minutes. CT sensitivity decreases to about 50 percent one week after rupture.Rosen’s Emergency Medicine, supra n. 7.

When the patient is suspected of having suffered a hemorrhage but the CT scan is normal or inconclusive, a lumbar puncture should be performed to look for blood in the cerebrospinal fluid. This is an inexpensive and low-risk procedure that can be completed and evaluated in minutes.

Once a diagnosis of subarachnoid hemorrhage is made, complete diagnostic cerebral angiography should be performed as soon as possible to localize the source of bleeding. Angiography is the gold standard for identifying cerebral aneurysms. Surgical clipping (in which the neurosurgeon opens the skull and places a clip across the neck of the aneurysm to prevent rupture) or less-invasive endovascular treatment (in which coils are placed in the aneurysm via a catheter) should be performed as soon as possible.

Patients with a hemorrhage should be stabilized immediately with particular concern for airway maintenance, blood pressure treatment, correction of any coagulopathy (abnormal blood clotting), and pain and agitation control. They must be admitted to a critical care unit for monitoring and management.

Treatment involves preventing and managing secondary complications—rebleeding, vasospasm (constriction of large-capacity intracranial arteries), hydrocephalus (enlargement of the ventricles in the brain), hyponatremia (abnormally low sodium levels in the blood), and seizures.²¹Testing of serum electrolyte levels, a complete blood cell count including platelets, and clotting time studies should be done to determine whether the patient has other conditions such as an infection or clotting abnormalities.

Frequent neurologic exams should be performed to evaluate the patient for changes in neurological status or evidence of rebleeding. For untreated ruptured aneurysms, there is a 3 percent or 4 percent risk of rebleeding in the first 24 hours, a 1 percent to 2 percent risk per day in the first month, and a long-term risk of 3 percent per year after 3 months. Jonathan A. Edlow & Louis R. Caplan, Avoiding Pitfalls in the Diagnosis of Subarachnoid Hemorrhage, 342 New Eng. J. Med. 29, 29 (2000).

Rebleeding may be due to sudden changes in blood pressure rather than absolute blood pressure. Bed rest, analgesics for headaches, and antihypertensive medications are generally recommended. Because blood in the subarachnoid space can cause seizures, patients should be monitored for seizure activity and given antiepileptic prophylaxis. To prevent vasospasm, the calcium channel blocker nimodipine should be used.

Vasospasm typically occurs between 5 and 14 days after the rupture and gradually resolves over 2 to 4 weeks. If the aneurysm has been treated, ischemia associated with vasospasm can be reduced or prevented using “triple H therapy”or angioplasty to dilate narrowed vessels. However, despite optimal therapy, 15 percent to 20 percent of patients with vasospasm die. Textbook of Clinical Neurology 1041 (Christopher G. Goetz ed., 3d ed., Elsevier 2007).

Hydrocephalus following a rupture occurs in about 20 percent of cases. The patient may undergo a ventriculostomy procedure to drain cerebrospinal fluid, but this intervention can lead to rebleeding and carries a small risk of infection. In symptomatic patients, chronic hydrocephalus may require a shunt to permanently divert cerebrospinal fluid.

Hyponatremia reduces blood sodium levels in 10 percent to 34 percent of patients, and seizures occur in 25 percent of these patients.

As many as 46 percent of the people who survive a ruptured brain aneurysm have long-term cognitive impairment, and one-third of those who survive require lifelong care. The average case fatality rate is 51 percent.Textbook of Clinical Neurology 1041 (Christopher G. Goetz ed., 3d ed., Elsevier 2007).

A patient’s prognosis largely depends on three factors: the patient’s age, level of consciousness on presentation, and the amount of subarachnoid blood seen on the initial CT scan. Younger patients with a good level of consciousness and minimal blood visible on the CT scan tend to do significantly better—and if diagnosed and treated without delay have dramatically better outcomes than patients who present later in the course of a hemorrhage or have diagnosis and treatment delayed.

In Textbook of Clinical Neurology 1041 (Christopher G. Goetz ed., 3d ed., Elsevier 2007) at page 1043 - 1044, they state that a retrospective study has demonstrated that rebleeding occurs in 48% of misdiagnosed patients:

In a major retrospective study involving patients who were treated at four different tertiary-care hospitals, the rate of rebleeding or other deterioration in patients who were initially misdiagnosed was 48 percent, while the rate in patients correctly diagnosed was under 3 percent. The authors concluded that “in patients in whom correct diagnosis was promptly established, the rates of subsequent deterioration and of untoward outcomes were significantly decreased.”

While the public is being bombarded by doctors asking not to be required to pay for their medical negligence as a part of their tort reform agenda, 15,000 Americans will be misdiagnosed with life threatening head and brain injuries this year. Perhaps the doctors should spend less time picketing the state house and spend more time with their patients. By the way, how much time did your doctor spend with you the last time you went in for treatment?

Originally posted at InjuryBoard by Wayne Parsons

Italy And The Vatican Face Constitutional Crisis Over Right-to-die Of Woman In A Coma For 17 Years

Wayne Parsons — Tue, 10 Feb 2009 09:23:31 GMT

Silvia Aloisi of the International Herald Tribune reports that

Italy's Prime Minister Silvio Berlusconi is pushing a law through parliament to force doctors to resume feeding a comatose woman in a right-to-die case that has plunged the country into a constitutional crisis.

Berlusconi wants to save Eluana Englaro from death. Englaro has been in a coma for 17 years and has not been fed for a few days since a high court ruled that she should be allowed to die.

Parliament -- where Berlusconi has a large majority -- could pass the law this week, reversing the court ruling and circumventing the head of state, who blocked Berlusconi's previous attempt to order the resumption of feeding by decree.

"I still believe that saving Eluana is possible," Maurizio Sacconi, Berlusconi's health minister, told Corriere della Sera newspaper on Sunday.

Englaro, 38, has been in a vegetative state since a car crash in 1992.

Englaro told her father when she was healthy before the car crash, that she did not wish to be kept alive artificially. He has fought a 10-year legal battle in this Catholic country to have her feeding tube disconnected.

The court ruling came in November and doctors have now followed the court order. Berlusconi, backed by the Vatican, issued an emergency decree on the same day stating that food and water cannot be suspended from patients who are not self-sufficient -- the decree over-ruled by President Giorgio Napolitano, a former communist, who said vatican/Berlusconi decree was unconstitutional because it overruled top judges.

Undaunted Berlusconi said he "could not allow the 'killing' of Englaro", adding she could "in theory have a baby" and that not feeding her amounted to euthanasia, which is illegal in Italy. The Vatican, which remains highly influential in Italy, has openly sided with Berlusconi and criticized the president.

Cardinal Tarcisio Bertone, the pope's secretary of state, spoke about the case with Napolitano by phone, the Vatican said on Sunday, adding it welcomed the decision to put Berlusconi's draft law on a fast-track. Medical experts say it could take more than two weeks for Englaro's heart to stop, but that the suspension of food and water will have irreversible effects on her weakened body in a matter of days. Berlusconi is using Englaro to put more power in the executive branch while weakening the president and the courts.

"Berlusconi has chosen the Englaro case as the chance to alter in his favour the balance of power between his office and the presidency," said a Corriere della Sera editorial.

Berlusconi defended his stance on Sunday.

"I can guarantee on my honour and that of my ministers, that our decision was based on moral principles and there was never a plan to attack anybody," he said.

Englaro's father asked Berlusconi to visit his daughter to see for himself her condition.

This is the Terry Schiavo case all over again in Italy where the power of the church is overwhelming. What do you think about this situation?

Originally posted at InjuryBoard by Wayne Parsons

Scuba Diving Should Be Safe But Be careful In Choosing A Dive Company

Wayne Parsons — Wed, 22 Oct 2008 14:11:02 GMT

Hawaii has some of the best scuba diving in the world and people come from all over the world to enjoy the exploration of the world beneath the surface of the waters surrounding these remote islands. With proper supervision, professional instruction and proper ecquipment, scuba diving is a completely safe activity. However, since th diver - and particularly a novice diver - is relying on the company that leads the dive, care should be taken to make sure the company will protect against the risks of diving.

The "bends", also know as "decompression sickness" is a leading cause of scuba diving injury and death. The Bends occur when a diver returns to the surface too rapidly. The air from the tank the diver is breathing causes nitrogen to dissolve in the diver's body and when the diver returns to the surface nitrogen bubbles can form in the blood stream causing a variety of serious problems. The results can be blindness, paralysis, brain injury or even death. Joint pain and skin problems are less serious consequences.

Decompression sickness usually occurs immediately after the dive while the diver is on the boat but it can occur 24 to 48 hours later if the diver goes to high altitude in the mountains or takes an airplane flight. If you dive, avoid flying or going to altitude for 48 hours after the dive.

Professional supervision is the most important aspect of a scuba tour and this is particularly true when you are diving far from home in an unfamiliar environment and with rented equipment. Tourists have a lot of things on their mind and tend to go along with whatever is presented in terms of equipment and location and details of dives.

The company should have adequate supervision so that all dangerous portions of the dive can be monitored to prevent injury. Make sure that everything is explained to your satisfaction and that the parameters of the dive are clearly explained. You don't want to be in a position where you thought the dive was going to limited to certain conditions and then they change the dive and you are put in a situation that is beyond your ability. You also want to make sure that a dive instructor is aware of and supervising all critical aspects of the dive. Talk about these things before you sign up and reconfirm the conditions and supervision before you start the dive. If anything changes while you are underwater find the instructor and do a "careful" ascent.

Most people tend to go along with the dive company supervision (or lack of supervision) and assume that everything must be okay. Usually it is all okay, but be proactive and make sure that nothing changes. The consequences are high.

Originally posted at InjuryBoard by Wayne Parsons

Australia Reserachers Embark On Large Cerebral Palsy Study

Wayne Parsons — Thu, 17 Jul 2008 15:55:23 GMT

In the largest study of its kind, scientists in Australia are attempting to identify genetic causes of cerebral palsy. A spokesperson states that this ".... study will investigate a key issue behind cerebral palsy: whether genetic factors make women more vulnerable to environmental risks that affect the brain of their unborn child.”

Do environmental factors, such as premature birth that affects the child's brain, combine with genetic factors to increase the chances of developing cerebral palsy. 10,000 mothers will participate in the study.

The goal is to develop gene therapy treatments for babies predisposed genetically to develop cerebral palsy.

Originally posted at InjuryBoard by Wayne Parsons

Act F.A.S.T.
FACE	Ask the person to smile. Does one side of the face droop?
ARMS	Ask the person to raise both arms. Does one arm drift downward?
SPEECH	Ask the person to repeat a simple sentence. Are the words slurred? Can he/she repeat the sentence correctly?
TIME	If the person shows any of these symptoms, time is important. Call 911 or get to the hospital fast. Brain cells are dying.