Traumatic Brain Injury: A Guide for Caregivers of Service ... · Traumatic brain injuries (TBIs) range from mild to severe. Injuries are rated on the basis of their severity at the

Traumatic Brain Injury: A Guide for Caregiversof Service Members and Veterans

Module 1Introduction to Traumatic Brain Injury (TBI)

IntroductiontoTraumaticBrainInjury

Table of Contents

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Module 1 Summary

Chapter 1:TheBasicsofTBI

Chapter 2:LearningabouttheBrain

WhatarethePartsoftheBrain?HowDoTheyWork?

WhatistheAnatomyoftheBrain?

Chapter 3:CausesandTypesofTBI

WhatTypesofTBIareThere?

WhatInjuriesCo-OccurwithTBI?

Chapter 4:DiagnosisandTreatmentofTBI

HowisaTraumaticBrainInjuryDiagnosed?

HowareTraumaticBrainInjuriesMedicallyTreated?

Chapter 5:PotentialComplicationsFollowingTBI

AreThereCommonComplicationsFollowingSevereTBI?

Chapter 6:RecoveryProcess

WhataretheStagesofRecovery?

Appendix A:GlasgowComaScale

Appendix B:RanchoLosAmigosLevels

References/Credits

An electronic version of this Guide can be found at the following Web address: www.traumaticbraininjuryatoz.org

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Inthissection,youcanfindbasicinformationabout:

•thepartsofthebrainandwhattheydo

•thecausesoftraumaticbraininjury(TBI)

•howthebrainchangesafterTBI

•howthebrainbeginstorecover.

Youcanusethisinformationtounderstand:

•howthebrainworks

•whatyoumightseeduringrecovery

•whyyoumightseechangesinhowyourservicemember/veteranthinksandactsduetoaTBI.

TBIsareclassifiedbyhowsevereorserioustheyareatthetimeofinjury.TBIsrangefrommild(concussion)tomoderatetosevere.

ThismoduleprovidesinformationonmoderatetosevereTBI.Doctors,nurses,andotherhealthcareproviderswhoworkwithTBIguidedthecontent.

Asyoureadthroughthisdocument,askyourhealthcareproviderstoexplainwhatyoudon’tunderstand.

Somekeypointsare:

•Thebrainisthebody’scontrolcenter.

•Thepartsofthebrainworktogethertohelpusthink,feel,move,andtalk.

•ATBIiscausedbyapenetratinginjuryorbybluntforcetraumatothehead.

•TBIisverycommoninbothcivilianandmilitarypopulations.

•Manydifferenthealthcareproviderswillhelpdiagnoseandtreatyourservicemember/veteranwithTBI.

•Itisthegoalofhealthcareproviderstominimizecomplications,thethingsthatcangowrongaftertheinjury.

•Manyservicemembers/veteranswithTBIgothroughcommonstagesofrecovery.Eachperson,however,progressesathisorherownpace.

•RecoveryfromaTBImaybemeasuredinweeks,months,oryears.

•Promisingnewresearchisshowingthebrain’scapacityforhealing.

•Therearemanywaysyoucansupportyourservicemember/veteranwithTBIthroughouthisorherrecovery.

Behopeful.Thebrainisverygoodatrepairingitself.

Module 1 Summary

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What is a TBI? A traumatic brain injury (TBI) is:

•Adirectbloworjolttothehead

•Apenetratingheadinjury,or

•Exposuretoexternalforcessuchasblastwavesthatdisruptthefunctionofthebrain.

Not all blows to the head or exposure to external forces result in a TBI. The severity of TBI may range from “mild”— a brief change in mental status or consciousness—to “severe,” an extended period of unconsciousness or confusion after the injury.

Source:DVBIC(2007).FactSheet.


What is a Traumatic Brain Injury?Atraumaticbraininjury(TBI)happenswhensomethingoutsidethebodyhitstheheadwithalotofforce.Thiscouldhappenwhenaheadhitsawindshieldduringacaraccident.Itcouldhappenwhenapieceofshrapnelentersthebrain.OritcouldhappenduringanexplosionofanIED(improvisedexplosivedevice).Therearemanycausesoftraumaticbraininjury(TBI).

How Long Does It Take to Recover from a TBI?Notwobraininjuriesareexactlyalike.SomepeoplewhohaveaTBIrecoverquickly,otherstakemuchlonger.Somewillhaveveryfewlong-termeffects.Otherswillfacelifelongchallenges.Theeffectsvaryfrompersontoperson.

RecoveryfromaTBImaybemeasuredinweeks,months,oryears.

What Happens Right After the Injury?Inthedaysandweeksrightaftertheinjury,thetissueinthebrainmayswellorbleed.Theremayalsobechangesinthebrain’sneurochemistrysystem.

Sometimesthereissomuchbloodthatdoctorshavetoremoveitduringsurgery.Thissurgeryreducesswellingandpressurewithinthebrain.Ithelpsthebrain’sbloodflowandneurochemistrysystemtorecover.Thisusuallyhelpsthebraintoworkbetter.

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The Basics of TBI

An IED is an improvised explosive device. They are also called roadside bombs. They are placed on the side of the road and explode when someone drives by. IEDS are a leading cause of TBI in Iraq and Afghanistan.

“Neuro” means the body’s nervous system.

Chapter 1

“He actually ended up being in a coma for about three months after the brain injury.” -PamE.

“He really won’t tell me the whole story because I think he doesn’t want to scare me. But, he brought me a piece of metal back home that was embedded in the wall right behind him. He said it missed his head by a few inches. He said that he thanks God every day that he’s still alive, and that’s why he brought the piece of metal home, to show me that that’s how close he had come to dying.”

-LynnC-S.

How Does the Brain Recover Over Time?Noonecompletelyknowswhathappensinthebrainduringlong-termrecoveryfromaTBI:

•Someresearchersthinkthatthehealthybraintissuelearnsovertimehowtodowhatthedamagedbraincellsusedtodo.

•Othersthinkthatconnectionsbetweenbraincellsrearrangethemselvesorbecomemoreefficient.

Thebraincanrepairitselfmorethanpeopleusedtothinkwaspossible.Differentthingsinfluenceaperson’sabilitytorecover.Theyinclude:

•Hisorherage(youngerbrainsoftenrecoverfaster)

•HowseveretheTBIis

•WheretheTBIislocated.

Recovery,however,isaveryindividualprocess.

What Else Affects Recovery?Often,apersonwithaseverebraininjuryalsohasseriousinjuriesinotherpartsofthebody.Theseinjuriescancausebleeding,swelling,anddamagetointernalorgans,bloodvessels,bones,limbs,thesensorysystem,andnerves.

Forexample,thinkaboutaservicemember/veteranwhowasclosetoablastfromanIED.Heorshemayhaveacoupleoffractures,lostanarmorleg,orlostsomehearing.Heorshemayalsohaveinternalinjuries.Alloftheseinjuriestogethercanmakerecoverytakelonger.Theymayevencausemoredamagetothebrain.Prompttreatmentoftheseotherinjurieswillhelplimitdamagetothebrain.

What Kind of Treatment Will My Service Member/ Veteran Receive?Dependingonthenatureofthebraininjuryandotherinjuries,someservicemembers/veteransmayneedonlyregularfollow-upappointmentswiththeirdoctor.

Othersmayreceivetherapy,tests,andmonitoringonanoutpatient basis.

Othersmaybegintreatmentinanintensivecareunitorgeneralhospital.Theymaytransferlatertoarehabilitationunit.Theymayalsoneedoutpatienttherapyforalongtime.

Howmuchandwhatrehabilitationtherapyyourservicemember/veteranneedsdependsonmanythings.

Chapter1-TheBasicsofTBI

Outpatient means living elsewhere and going to the doctor’s office or hospital for care.

A fracture is a broken bone.

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Rehabilitation means re-learning skills needed for everyday life.


Nomatterwhereyourservicemember/veteranreceivescare,heorsheisbeingtreatedwiththemostup-to-datemethodsbasedonwhatdoctorsknowabouttherecoveryprocess.

How Common is TBI?TBIistheleadinginjuryamongU.S.forcesservinginAfghanistan(OperationEnduringFreedom[OEF])andIraq(OperationIraqiFreedom[OIF]).

ThefrequentuseofIEDsinthesewarsincreasesthechancethatservicememberswillbeexposedtoblastsandotherinjuriesthatcancauseaTBI.

AmongservicemembersevacuatedfromOEF/OIFtoWalterReedArmyMedicalCenterin2003-2007becauseofinjuries,30percenthadaTBI.

In2008,theDepartmentofDefense(DoD)reportedthat:

•Sevenoutof10TBIinjurieswereduetoablast

•Morethan1in10wereduetoafall

•Morethan1in20wereduetoavehicularincident

•Onein20wereduetofragments

•Therestwereduetoothercauses.

TheArmyreportedthat88percentofTBIsamongsoldiersweremild.Sixpercentweremoderateandanothersixpercentweresevere.

How Are TBIs Rated?

Traumaticbraininjuries(TBIs)rangefrommildtosevere.Injuriesareratedonthebasisoftheirseverityatthetimeoftheinjury.

HowseveretheTBIiswhentheinjuryfirsthappensdoesnotalwayspredicthowbadthelatersymptomsare.Inotherwords,thosewhowereseverelyhurtsometimesmakeverygoodrecoveries.Otherswhoseemtohavemildinjuriescanexperiencesymptomsformonthstoyears.

It’simpossibletoaccuratelypredictatthetimeoftheinjurywhowillrecoverrapidlyandwhowillgoontoexperiencesymptoms.That’swhythemilitarytriestoscreenanddiagnoseanyoneevenremotelysuspectedofTBI.Thatway,theycanreceivethecareandhelptheyneed.

Mild TBI (Concussion)

MostinjuriestothebrainsustainedinIraqandAfghanistanaremild.AnothertermformildTBI(mTBI)isconcussion.

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mTBI stands for mild TBI, also called a concussion.

ATBIisratedasmildwhentheservicemember/veteran:

•Hasbriefornolossofconsciousness

•Ismomentarilydazedorhasconfusionlastinganhourorless,and

•HasaninitialGlasgow Coma Scale(GCS)scoreof13-15.

In most cases of mTBI:

•Theservicemember/veteranwillcomplainofhaving “hisorherbellrung”

•Thinkingmaybeslow

•Memoryandconcentrationmaybeaffected

•Headaches,dizziness,andfatigue(tiredness)arecommon.

Mostservicemember/veteranswillfeelmuchbetterandbebacktonormalwithinacoupleofweekstomonths.

OtherswithmorecomplexmTBImayexperiencesymptomsforseveralmonthsorevenlonger.

Moderate to Severe TBI

ATBIisratedasmoderatetoseverewhentheservicemember/veteran:

•Haslossofconsciousnessformorethan30minutes

•Confusionlastingforhours,days,orweeks

•AGlasgowComaScale(GCS)scorerangingfrom3-12.

Computed Tomography(formerlyknownasComputerizedAxialTomography[CAT])scansofthebrainoftenrevealbruisingorbleedinginsideand/oroutsideofthebrain.

Theservicemember/veteranwiththislevelofinjuryoftenspendsweekstomonthsinhospitalandrehabilitationsettings.

Chapter1-TheBasicsofTBI

Glasgow Coma Scale is used to rate someone’s symptoms after a head injury. You can find the Glasgow Coma Scale in Appendix A.

In Computed Tomography (CT), a computer creates cross-sectional images of the inside of the body, based on x-ray pictures.

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Learning about the Brain

Themoreyouunderstandaboutthebrain,theeasieritistounderstandhowTBIaffectsyourservicemember/veteran.

Chapter 2

“Basically, they walked me through the process every day, because I had a lot of questions. I asked a lot of the same questions, and they were patient with me. I was very overwhelmed.

So I asked a lot of questions. They kept explaining to me that this is what happened, that they can fix it but that it’s a long process. The doctors themselves were the best source of information.”

-EmilyS.

What Are the Parts of the Brain? How Do They Work?Thebrainisthebody’scontrolcenter.Thebrainhasbillionsofnervecells.Thecellsarearrangedinsectionsthatworktogethertocontrolallofourmovements,breathing,thoughts,behaviors,andemotions.

Thebrainisconstantlysendingandreceivingsignalsfromallpartsofthebody.Thebodyusesthesesignalstothink,move,talk,andsee.Thebraincontrolsourpersonalities,thewaywebehave,andthewayweunderstandtheworldaroundus.

Eachpartofthebrainhasaspecificjob.Eachpartlinkswithotherpartsofthebraintoperformtasks.

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“In the very beginning, I didn’t want to know anything because I was so scared. But a little while later… the doctors would throw out tidbits to me, like he might never speak again and he might never walk again… but I couldn’t understand why. So then I wanted to understand the part of the brain that was injured and why he was having these symptoms or why he was having this diagnosis.”

-PattyH.

What is the Anatomy of the Brain?Ahealthyadultbrainweighsabout2.5to3pounds.Itislocatedinsidetheskull.

Theundersideoftheskull(referredtoasthebaseoftheskull)isrough,withmanybonyridges.Forcefulinjuriestotheheadcausethebraintobouncerapidlyaroundtheinsideoftheskull.Thisbouncingresultsinbraindamageintheareaoftheseridges.

Justinsidetheskull,thebrainiscoveredbythreethinmembranescalledthemeninges.Theyaretheduramater,arachnoidlayer,andthepiamater.

Youmayheardoctorsandnursesmentionthesemembraneswhentheydescribewhereahematomaislocated.Forexample,asubduralhematomaisbloodthatcollectsrightbelowtheduramater.Asubarachnoid hemorrhageislocatedjustbelowthearachnoidlayer.

Cerebrospinal fluid (CSF)isaclearliquidthatsurroundsthebrainandspinalcord.Itisproducedwithintheventriclesofthebrain.CSFallowsthebraintofloatwithintheskullandcushionsthebrain.

Theoutermostandlargestpartofthebrainitselfiscalledthecerebrum.Thecerebrumcontrolsthoughtsandactions.Ithasawrinkledsurfaceandadeepcreasethatdividesitintotwohalves,knownastheleftandrighthemispheres.

Chapter2-LearningAbouttheBrain

The ventricles are butterfly-shaped spaces in the center of the brain.

Skull

Duramater

Arachnoidlayer

Piamater

Brain

Figure 1. The Meninges

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The skull is the bony part of the head that protects the brain.

A membrane is a thin sheet of tissue.

A hematoma is a collection of blood. It is also called a blood clot.


Figure 2. The Cerebral Hemispheres

Figure 3. The brain controls movement on the opposite side of the body.

Cerebral Hemispheres

RighthemisphereLefthemisphere

Thesehalveslooknearlythesame.Buttheydifferinwhattheydo.Formostpeople,theleft halfofthebraincontrols:

•language(speaking,listening,reading,writing)

•thoughtandmemoryinvolvingwords.

Theright halfisinvolvedin:

•nonverbalprocesses

•recognizingthedifferencesinvisualpatternsanddesigns

•readingmaps

•enjoyingmusicandart

•expressingandunderstandingemotions.

Theleft sideofthebraincontrolsmovementontheright sideofthebody.Theright sideofthebraincontrolsmovementontheleft sideofthebody.Thisisjusttheoppositeofwhatyoumightthink.

Damagetotheright halfofthebrainmaycausemovementproblemsorweaknessontheleft sideofthebody.Damageontheleft half ofthebrainmaycausemovementproblemsorweaknessontheright side.

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The cerebral hemisphere means half the brain.

The Lobes of the BrainThebrainisdividedintofoursectionscalledlobes.Theselobesareknownasthe:

•frontallobe

•temporallobe

•parietallobe

•occipitallobe.

Althoughitiseasiertolearnabouteachlobeseparately,keepinmindthatthelobesofthebrainworktogether.

Chapter2-LearningAbouttheBrain8

FrontalLobe

TemporalLobe

ParietalLobe

OccipitalLobe

Figure 4. Lobes of the Cerebrum

The Frontal Lobe

•Problemsolving

•Planningandanticipation

•Organizingandsequencing

•Understandingabstractconcepts

•Attentionandconcentration

•Memory

•Judgment

•Impulsecontrol

•Socialandsexualbehaviors

•Initiation

•Personalityandbehavior

•Awarenessandself-monitoring

Figure 5. The Frontal Lobe


•Emotions

•Language/speaking

•Movement.

Thefrontal lobeisthelargestofthefourlobes.Itisresponsibleformanyimportantcognitive(thinking)processes.

Youmayheardoctorsusingthetermexecutive functions.Thisreferstothehigher-level,morecomplexthinkingactivitiesperformedbythebrain.Theabilitytoformconcepts,socialize,andthinkabstractlyareexecutivefunctions.

Executivefunctionsallowustobecreative,solveproblems,andfunctionindependently.Thefrontallobeiseasilyinjured1)becauseitislocatedtowardsthefrontofthehead;and2)becauseofwhereitsitsinsidetheskullnearseveralbonyridges.

The Temporal Lobe

•Memory

•Organization,categorization

•Learning

•Conceptoftime

•Understandingverballanguage

•Emotion

•Hearing

•Somevisualperception.

Thetemporallobeisalsoeasilyinjuredbecauseofitslocation.Itisnearseveralbonyridgesontheundersideoftheskull.

The Parietal Lobe

•Senseoftouch

•Identificationofsizes,shapes,colors

•Spatialperception

•Visualattention

•Integrationofsenses

•Manipulationofobjects.

Theparietallobeismoreprotectedfromtraumaticinjury.Butitcanalsobeinjured.

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Figure 6. The Temporal Lobe

Figure 7. The Parietal Lobe

The Occipital Lobe

•Vision

•Visualrecognition.

Theoccipitallobeismoreprotectedfromtraumaticinjurybecauseofitslocationatthebackofthebrain.

Deeper Parts of the BrainThemostbasicfunctionsofthebrainarecontrolledatthedeepestlevel,calledthebrainstem(seeFigure9).Thisprimitivepartofthebraincontrolsautomaticfunctionssuchas:

•breathing

•heartrate

•bloodpressure

•consciousnessandalertness

•sleep/wakecycles

•sweating

•temperatureregulation

•swallowing

•senseofbalance.

Thedeeperstructuresofthebrainincludethebrainstem,thalamus,andhypothalamus.

Thethalamusisnearthetopofthebrainstemandnearlyallinformationfromoursenses(taste,touch,etc.)passesthroughittotheouterlevelsofthebrain.

Thehypothalamussitsunderthethalamus.Itproducessomehormones.Ithelpscontrolmanycriticalfunctions,including:

•bodytemperature

•hunger

•thirst

•emotionalandbehaviorresponses.

Directlybeneaththecerebrumisthelimbic system.Thispartofthebrainisinvolvedwithhumanemotionsandmemories.

Chapter2-LearningAbouttheBrain10

Figure 8. The Occipital Lobe


Locatedatthebackofthebrain,beneaththeoccipitallobes,isthecerebellum.Themainjobofthecerebellumistocontrol,regulate,andcoordinatemovement,posture,andbalance.

Thesedeeperstructuresalsohelptoregulatealertnessandattentionandshareinformationamongthepartsofthebrain.

Understandingthevariouspartsofthebrainandwhateachpartcontrolsallowsyoutounderstandwhyyourservicemember/veteranishavingcertainkindsofeffects.Wheretheinjuryhappenedinfluencestheeffectsyouareseeing.

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“We agreed that the resident doctor could present Jason’s case to a conference of doctors at the University of Maryland. Of course, she wouldn’t use his name. She asked if we would come too, and we said yes.

So we’re in front of this whole room of doctors and she finishes her presentation, and the doctors start asking questions. And this one doctor raised his hand, and he said, ‘I was the surgeon who treated him when he was first injured in Balad. I remember him.’ And he said that seeing how far Jason has come and how responsive Jason is from when he saw him, from when they brought him off the field... he said that the brain is a lot more repairable than they even anticipated was possible.”

-PamE.

Figure 9. Deeper Brain Structures

LimbicSystemThalamus

Hypothalamus Brainstem

Cerebellum

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Causes and Types of TBI

What Types of TBI are There?Therearetwotypesoftraumaticbraininjury:

Penetrating Head InjuryPenetratingheadinjuryhappenswhenanobjectgoesthroughtheskullandentersthebrain.Theseinjuriesareeasytoidentify.Theyarecaredforrightaway.Itemsthatmayenterthebrainare:

•bullets

•knives

•debrisfromanexplosion

•boneormetalfragments.

Closed Head Injury Closedheadinjuryoccursfromanyforcethatcausesviolentshakingofthebraininsideoftheskull.Aclosedheadinjurycanhappeninmanyways:

•exposuretoblastwavesduringanexplosion

•motorvehiclecrashwheretheheadhitsthewindshield

•afall

•whenabluntobject,suchasafistorweapon,strikesthehead.

Chapter 3

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Sometimes,whenthefrontoftheheadisstruckbysomething,thewhiplashmotionsetintoplacecausesthebraintorockbackandforthinsidetheskull.Thisleadstodamagetoboththefrontandbackofthebrain.Thisrockingmotionwithdamagetooppositesidesofthebraincanalsohappeninaside-to-sidemannerorinadiagonalmanner.Thisiscalledacoup-contrecoup injury.

Chapter3-CausesandTypesofTBI

ForservicemembersinIraqandAfghanistan,attacksinvolvingexplosionsorblastbyrocket-propelledgrenades,improvisedexplosivedevices(IEDs),andlandminesarecommoncausesofTBIs.Gunshotwounds,falls,andmotorvehiclecrashesalsocauseTBIincombat.Over90percentofcombat-relatedTBIsareclosedheadinjuries.

Sometimes,inthecaseofmildTBI(concussion),theremaybenovisiblesignofinjury.

Thebrainisquitefragile.Ithastheconsistencyoffirmgelatin.Imaginethatthebrainislikegelatininabowl.Whenyoutiltthebowl,youcanmovethegelatinaround.Ifyoushakethebowlmoreforcefullyordropthebowl,youcancausetinyorevenlargecracksinthegelatin.Thisissimilartowhathappenstothebrainwhenitisexposedtoexternalforces.Whentheheadisseverelyjarred,thebrainmovesrapidlyaroundtheroughbonyinterioroftheskull.Thebraincanberipped,twisted,torn,andbruised.Thebrainissomewhatprotectedbytheskull,butcanstillbeinjuredifenoughforceisapplied.

Whentheheadisinjured,manythingscanhappen:

•skullfractures

•bleedingontheoutsideorinsideofthebrain(hemorrhage,hematoma)

•bruisingofthebraintissueitself(contusion)

•widespreadstretchingandstrainingofthebraincells (diffusebraininjury).

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“I had no idea really what kind of injury he suffered. They said there was brain shearing. What’s brain shearing? Because I think if I understood what the medical terms meant, it would have educated me to ask more questions.”

-PamE.


What Injuries Co-Occur With TBI?

What is a Skull Fracture?Thereareseveraltypesofskull fracture:

•Simple fracture:Abreakinaskullresemblingathinlineorcrackthatdoesnotsplinter,cavein,orchangetheshapeoftheskull.Nosurgeryisusuallyrequiredforsimplefractures.Theytendtohealontheirown.

•Compound fracture:Abreakinorcrushingofapartoftheskull.Bonefragmentsmayremainontheoutsideoftheduraormaysplinteroffandpenetratethedura.Thisisknownasadepressed skull fracture.Depressedskullfracturesmayrequiresurgery.Duringsurgery,smallscrewsareusedtoholdthebonesinplace.Ifthereisatearinthedura,doctorswillworktopreventaninfectioninthebrain.

•Basal skull fracture:Fracturesatthebase(underside)oftheskullcaninjurenerves,bloodvessels,orotherpartsofthebrain.Somefracturesmaycausecerebrospinalfluid(CSF)toleak.AsignofaCSFleakisclearfluiddrippingfromthenoseorears.Doctorsandnurseswillcloselymonitoranyleaks.Mostleaksstopontheirown,butsometimessurgeryisnecessary.

What about Bleeding?Bleedingcanoccuroneithertheoutsideorinsideofthebrain.Anothertermforbleedingishemorrhage.Youmayalsohearthetermhematoma.

Sometimesthebleedingisverysmallandsimplyrequiresclosemonitoring.Sometimesbloodbuildsupandpushesagainstthesurroundingbraintissue.Ifthishappens,thebloodneedstoberemovedbysurgery.Theneurosurgeonisthespecialistontheteamwhowillmakethisdecision.

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A fracture is a break in a bone.

SimpleFracture

CompoundFracture

BasalSkullFracture

CSF is fluid that allows the brain to float within the skull and cushions the brain.

Figure 10. Skull Fractures

Thereareseveraltypesofbleeding.Typesofbleedingaredescribedintermsofwherethebloodliesinrelationtotheskull,dura,andbrain:

•Epidural hematoma:Abloodclotoutsidethebrainandthedurabutundertheskull.Thisbloodclotcancausefastchangesinthepressureinsidethebrainandmayneedtoberemovedsurgically.Whenthebraintissueiscompressed,itcanquicklychangethebrain’snormalfunctions.

•Subdural hematoma:Abloodclotbetweenthebrainandthedura.Theclotmaycauseincreasedpressureandmayneedtoberemovedsurgically.

•Subarachnoid hemorrhage:Bleedingwithinthelayersofthedura,specificallyunderthearachnoidlayer.

• Intracerebral hematoma:Bleedingwithinthebraintissueitselfcausedbytheruptureofabloodvesselwithinthebrain.

•Intraventricular hemorrhage:Bleedingintotheventricles(butterfly-shapedspaces)ofthebrain.

Chapter3-CausesandTypesofTBI16

SubduralHematoma

EpiduralHematoma

IntracerebralHematoma

IntraventricularHemorrhage

SubarachnoidHemorrhage

Figure 11. Types of Brain Bleeding

The dura is the tough covering of the brain. A hematoma is an accumulation of blood. It’s also called a blood clot. Hemorrhage means bleeding.


What about Bruising?Alongwithbleedingontheinsideoroutsideofthebrain,thebraintissueitselfmaybebruised.Thisisacontusionandcanoccurthroughoutthebrain.Sometimesseverelybruisedbraintissueneedstobesurgicallyremoved.Youmaybesurprisedtoknowthatmanypeoplewhohavesmallportionsofthebrainremovedinordertosavetheirlivesstillhavethepotentialtomakeameaningfulrecovery.

What is a Diffuse Brain Injury?Adiffuse(widespread)braininjuryisoneofthemostcommonandpotentiallyseveretypesofTBI.Inthisinjury,damagetothebrainoccursoveralargearea.Itisoneofthemajorcausesofunconsciousnessandlong-termcomaafteraTBIoccurs.

Braincellsaremadeupofneurons(thebodyofthecell)andaxons(thelongtailofthecell).Axonsareimportantastheyaretheinformationhighwayonwhichsignalstravelinthebrain.Axonsallowcellstocommunicatewitheachotherinordertocarryoutthemanyprocessesofthebrain.

Diffuse axonal injury (DAI)istheresultofstretching,twisting,andshearing(tearing)ofaxons.DAIisoftencausedwhentheheadviolentlystartsorstops,whichcommonlyhappenswhenitisexposedtoexternalforces.

Thediagramsbelowillustratethedifferencesbetweenahealthyaxonandinjuredones.

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Figure 12. Healthy and Injured Axons

HealthyAxon

StretchedAxon

TwistedAxon

ShearedAxon

A contusion is another word for a bruise.

A coma is when someone is unable to be awakened.

Diffuse axonal injury is widespread injury to the axons, the long tails of brain cells.

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Changes in NeurochemistryAlongwithstrainingandstretchingofbraincells,thechemistrysysteminthebrainisoftenaffectedwithTBI.Thebrainhasadelicateneurochemistrysystem.Chemicalscalledneurotransmittershelpbraincellscommunicatewitheachother.Thisallowsthebraintocarryoutitsmanyjobs.TBIdisruptsthiscommunicationsystem.Itcantakeweekstomonthsfortheneurochemistrysystemtoreturntoanormalstate.

Chapter3-CausesandTypesofTBI


Diagnosis and Treatment of TBI

Therearemanyhealth care providersinvolvedinthediagnosisandtreatmentofservicemembers/veteranswithTBI.Theseprovidersareexpertsindisordersofthebrainandhowthesedisordersaffectaperson’sabilitytofunction.

Someofthesespecialistsworkintheacutecarehospitalsettingwherediagnosisandearlymedicaltreatmentarepriorities.OthersworkintherehabilitationsettingwheretreatmentfocusesonrestoringfunctionandadaptingtoresidualeffectsoftheTBI.

TreatmentforsevereTBIcanlastweekstomonths,andsometimeslonger.

How is a Traumatic Brain Injury Diagnosed?WithasevereTBI--especiallyincasesofpenetratinginjury--doctorscanusuallymakeadiagnosisimmediately.Aclosedheadinjurycouldbeoverlookedwhentheservicememberhasotherlife-threateningorseriousphysicalinjuries.However,aclosedheadTBIwillbedetectedlaterwhenmoredetailedevaluationispossible.

Adetailedneurological examishelpfulindetectingTBI.Thisexamusuallyincludesaseriesofquestionsandsimplecommandstoseeiftheservicemember/veterancanopenhisorhereyes,move,speak,andunderstandwhatisgoingonaroundhimorher.

What is the Glasgow Coma Scale and How is it Used?YoumayhaveheardabouttheGlasgow Coma Scale(GCS).TheGCSisusedtoevaluatebrainfunctionandtheseverityoftheTBI.

TheGCSratesthreethings:

•theabilitytoopeneyes

•theabilitytorespondtoacommandtomove

•theabilitytospeak.

Ascoreof3isthelowestscorepossibleandmeansthepersonisinacoma.Ascoreof15isthehighestscoreandmeansthepersonisfullyawakeandunderstandswhatisgoingonaroundhimorher.

GCSscorescanbeaffectedbyotherthings.Forexample,beingsedatedorhavingabreathingtubeinsertedaffectsGCSscores.

What is Post-Traumatic Amnesia (PTA)?AnothermeasureofhowseriousaTBImaybeisseverityanddepthofconfusion,alsoknownaspost-traumatic amnesia(PTA).Thelongersomeoneisconfused,themoreseriousthedamagetothebrain.

Health care providers are all the people on the medical treatment team. They include doctors and nurses, along with many other medical specialists. You can find out more about the members of the health care team in Module 2.

You can find a copy of the Glasgow Coma Scale in Appendix A.


Chapter 4

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Chapter4-DiagnosisandTreatmentofTBI

What is a CT Scan? Why is it Used?Ifyourservicemember/veteranwasknockedunconsciousorwasveryconfusedfollowinghisorherinjury,doctorsprobablyusedaComputed Tomography (CT) (formerlyknownasComputerizedAxialTomography[CAT])scanofthebraintolookforsignsofTBI.

Why Did the Doctor Order an MRI? What is it?Sometimes,whenaCTscanisnegativeforobviousinjurybuttheservicemember/veteranisstillshowingsignsandsymptomsofTBI,aMagnetic Resonance Image (MRI)maybeordered.

What Other Tests are Used to Diagnose TBI?Anelectroencephalograph (EEG)mayalsobeordered.AnEEGmeasureselectricalactivityinthebrain.Specialpatchesareappliedtotheheadtomeasureactivity.EEGisonewaytodetectseizureactivityandtolookforanincreasedriskforseizuresinthefuture.

Elevated intracranial pressure (ICP),thepressureinsideofthebrain,canindicatethepresenceofTBI.AnICP monitormaybeplacedthroughasmallholeintheskulltomeasurethepressureinsidethebrain.

How are Traumatic Brain Injuries Medically Treated? EarlymedicaltreatmentforTBIseeksto:

•stopanybleeding

•preventandcontrolincreasedpressureinthebrain

A CT scan is a computerized x-ray that doctors use to view areas of the brain and to look for areas of bleeding and bruising.

An MRI scan provides detailed images of the brain using magnetic energy rather than x-ray technology.

Intracranial means within the skull.

“Something that was really helpful for me was the list of the Glasgow Coma Scale because they used that a lot and I didn’t understand what it meant. People would throw out these numbers—’Oh, he’s at number 4 or 5’—well, what does that mean?

When I read the list, it’s up to 15. I could watch Pat’s recovery, too, because at the beginning he was 3, and then I could say, okay, now he’s a 4 or 5, he’s making progress.”

-PattyH.

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•maintainadequatebloodflowtothebrain

•removelargebloodclotsasnecessary.

Treatmentsvarywiththetypeofinjury.Thedoctorsandnurseswilldecidewhichoneswillbeused.Somecommontreatmentsare:

PositioningTheheadofthebedwillbeelevatedandtheneckkeptstraight.Thispositionmaydecreasepressureinsidethebrain.

Fluid RestrictionYourservicemember/veteran’sintakeoffluidsmaybelimited.Thebrainmaybeswollenandlimitingextrafluidscanhelpcontroltheswelling.

MedicationsTherearemanypossiblemedicationsthatdoctorsmayusetotreatTBI.Medicationscan:

•decreasetheamountoffluidinthebodyandbrain

•preventseizures

•preventandtreatinfections

•maintainbloodpressure

•controlpain.

Sometimesmedicationsaregiventopurposefullykeepyourservicemember/veteranasleepwhilehisorherinjuriesarebeingidentifiedandtreated.

“My son had a closed head injury. Initially, he was in a coma. If you’re not in the medical field, it’s pretty horrendous to see your son on a vent and a ventriculostomy coming out of the brain to measure the intracranial pressure. They had to control the intracranial pressure. If it kept going up, they would have to do a cranioplasty. It is horrendous to walk in and see all the tubes and not be able to communicate with him.”

-CindyP.

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Ventricular Drain (Ventriculostomy)Asmalltubemayneedtobeplacedinoneoftheventriclesofthebrain.(Seepage6foradescriptionofventricles.)Thistubedrainscerebrospinal fluid (CSF)ifthereismorethanthereshouldbe.ToomuchCSFcausesunwantedpressureonthebrain.

VentilatorAventilatorisamachineusedtosupportsomeone’sbreathingortoprovidebreaths.Thisisalsosometimescalledarespirator.Strongregularbreathingprovidesgoodoxygenflowtothebrain.

When is Surgery Needed?Therearedifferentkindsofsurgerythatyourservicemember/veteranmayneed:

•Acraniotomyinvolvesopeningtheskulltorelievethecausesofincreasedpressureinsidetheskull.Thecausesmaybefracturedbones,bloodclots,orbruisedbraintissue.

•Burr holesurgeryinvolvesasmallopeningintotheskulltoremoveapoolofblood.

•Craniectomyinvolvesremovingapieceofbonefromtheskulltorelievepressurecausedbyswollenbraintissue.

Itcanbequiteashocktoseeyourservicemember/veteranforthefirsttimeafteracraniectomybecausehisorherheadwillnotbeitsnormalshape.Craniectomyallowsthebraintoswellupwardinsteadofdownward.Thisisveryimportantasdownwardswellinginaclosedvaultliketheskullcanbefatal.Withoutacompleteskulltoprotectthebrain,theservicemember/veteranmayberequiredtowearaprotectivehelmetuntilthebonecanbereplaced.

•Acranioplastywillfollowacraniectomy.Inthissurgery,thebonepiece(alsocalledbone flap)thatwasremovedduringthecraniectomyisreplaced,aftertheriskofbrainswellingisgone.Cranioplastymayinvolveplacementofscrewsorsmallplatestokeeptheboneflapinplace.Iftheoriginalbonewastoodamagedtobereplaced,artificialmaterialsmaybeusedduringcranioplasty.

Cranioplastyisalsoperformedincasesofpenetratinginjuryorcomplexskullfractures.

Chapter4-DiagnosisandTreatmentofTBI22

CSF is fluid that allows the brain to float within the skull and cushions the brain.


What are All These Tubes?VarioustubesmaybeusedintheearlytreatmentphasefollowingTBI.Thesetubeshavedifferentpurposes:

•Someareinplacetoprovidenutrition.Anasogastrictube(NG tube)passesthroughthenoseintothestomach.Itisashort-termsourcefornutrition.Iftheservicemember/veteranisunabletoswallowformanydaystoweeks,apercutaneousgastronomytube(PEG tube)willbeplaceddirectlyintohisorherstomach.

•Othertubeshelpwithbreathing.Ifaventilatorisneededtoassistwithbreathing,theshort-termoptionisanendotracheal tube.Itisinsertedthroughthenoseormouth.Ifalongeroptionisneeded,atracheostomytubemaybeplaceddirectlyintothetrachea.

•Intravenous tubes (IVs)mayalsobeusedforseveraldaysorweekstoprovidemedicationsandnutrition.

•Atubemaybeplacedinthebladdertodrainurine(urinary catheter).

Seeingyourservicemember/veteranwithmanytubescanbescary.Thegoodnewsisthattubesarealmostalwaystemporarymeasuresusedinearlytreatment.Rarelyareanyofthesetubespermanent.

The trachea is the main airway that runs from the base of the throat down to the lungs.

“Intravenous” refers to veins.

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24


Potential Complications Following TBI

DoctorsandnursesworkveryhardtopreventcomplicationsafteraTBI.Duringthefirstseveraldaystoweeksaftertheinjury,theriskoffurtherdamagefromcomplicationsishigh.Sothehealthcareteamtakesallthestepsitcantocontrolcomplications.

Are There Common Complications Following Severe TBI? Somecomplicationsareadirectresultofinjurytothebrain.Otherscomefrombeingbedriddenformanydaysorweeks.Someresultfromtheoverallshockthebodyisexperiencing.

Herearesomecommoncomplicationsthathappeninthedaysorweeksaftertheinjury:

•Increased intracranial pressure (ICP):Thepressureinsidethebraincanincreasetodangerouslevels.Sometimes,thepressureislife-threatening.AnICPmonitoralertsdoctorstothepressure.Medicationscanpreventortreathighpressure.

•Edema:Swellingthatoccurswhenthebraincontainsmorefluidthannormal.Whenswellinghappenswithinthebrain,thereisnoplaceforthetissuetoexpand.Thisisbecausethebrainisencasedintheskull.Swellingcancausepressuretobuildup.Thisresultsindamagetobraincells.Italsointerruptsbloodflow.Medicationsandfluidrestrictionsoftenhelp.Sometimes,surgeryisneeded.

•Hydrocephalus:Alsoknownas“wateronthebrain,”hydrocephalushappenswhencerebrospinalfluid(CSF)collectsintheventricles.ThisconditionmayoccurduringtheinitialperiodafterTBIordeveloplater(usuallywithinthefirstyear).Ifhydrocephalusissevere,doctorsmayplaceashuntinthebrain.Theshuntdrainstheextrafluidfromthebraintootherplacesinthebody.

• Low blood pressure:Bloodcarriesoxygentothebrain.Thebrainneedsoxygen.Doctorsandnursesworkhardtokeepbloodpressurefromgettingtoolow.Thishelpsincreasebloodflowtothebrain.

•Fever:Somepartsofthebrainregulatetemperature.Injurytothesepartsmaycausehighfevers.Thisisespeciallytrueduringthefirsthoursordaysafteraninjury.Feverisalsoasignofinfection.Medicationsand/orcoolingblanketscanbringthefeverdown.

•Pneumonia:Beinginbedandnotabletomovearoundincreasestheriskofpneumonia.Thehealthcareteamwillcarefullymonitoryourfamilymember’sbreathingandlungstatus.Theymaytakefrequentchestx-rays

A complication is a secondary injury that can hamper the recovery process.

Intracranial means within the skull.

Edema is another word for swelling.

A shunt is a tube.

Pneumonia is an infection in the lungs.

Chapter 5

25

Chapter5-PotentialComplicationsFollowingTBI

tolookforpneumonia.Feverisalsoasignofpneumonia,acommoncomplication.Fortunately,antibioticsusuallyworktotreatpneumonia.

•Brain infection:Infectionsmayoccurontheoutsideofthedura,belowthedura,inthemembranessurroundingthebrain(meningitis),orwithinthebrainitself(abscess).Depressedskullfracturesorpenetratingbraininjuriescancausebraininfections.Antibioticstreatbraininfection.Sometimes,surgeryisneeded.

•Other infections:TotreatTBI,yourservicemember/veteranmayhaveoneormoretubes(seepage23).Thesetubesareneeded.Buttheymaycauseinfection.Bodytemperaturereadingsandbloodtestsarewaystomonitorforinfection.Antibioticscontrolinfections.

•Blood clots:Notbeingabletomovearoundleadstoslowerbloodflowthroughoutthebody.Slowerbloodflowcanleadtobloodclotsinthelegsorarms.Theseareknownasdeep vein thromboses (DVT).Signsofaclotincludealegorarmthatiswarm,red,andswollen.

IfaDVTtravelstothelungs,itisknownasapulmonary embolus (PE).APEcanbeverydangerous.Itrequiresimmediatetreatment.Atinyfiltermaybeplacedinalargeveincalledthevenacava.ThiskeepsDVTsfromreachingthelungs.Thisfilterisusuallyremovedlater.Medicationtothinthebloodisoftenusedtopreventandtreatbloodclots.

•Skin breakdown:Beinginbedallthetimeandhavingotherinjuriesmaycausetheskintobreakdown(bedsores).Nursesworkhardtopreventbedsoresbychangingtheperson’spositionoftenandinspectingallareasoftheskin.Varioustreatmentsortopicalapplicationsmaybeused.

The dura is the tough outer membrane around the brain.

An abscess is an inflammation that contains pus.

The veins carry blood to the heart.

Pulmonary refers to the lungs.

An embolism is a mass that blocks the flow of blood in the vein.

Bedsores are ulcers on the skin.

Youareanimportantpartoftheteam.Youknowyourservicemember/veteranbetterthananyone.Ifyounoticeanyofthesesignsorsymptoms,tellthehealthcareteamwhat you are seeingor thinking. Do this even if yousimplyfeelasif“somethingiswrong,”eventhoughyoucan’tquiteputyourfingeronwhatitis.Familymembersmaynoticesmallchangesbeforeanyoneelse.Theearlieracomplicationisdetected,thesooneritcanbetreated.

26

IntroductiontoTraumaticBrainInjury 27

Itishardtopredictaperson’slong-termrecoveryfromaTBI.Youwanttoknowifyourservicemember/veteranwillfullyrecover.Butdoctorsmaynotbeabletogiveyouadefiniteanswer.

Recovery Process

Chapter 6

“When my son was hurt, I said, ‘What can I expect? What’s going to happen to my son?’ The doctor looked at me, and said, ‘Even we don’t know. The injuries that these guys are coming home with now are new to us. Five years ago, an injury like this would have killed him. He would never survive it. These are young people. They now get better and they survive it. We are re-writing the medical books.’”

-NellieB.

AfteraTBI,thebodybeginstorepairitself.Inmostcases,brainswellingbeginstogodownwithinafewweeks.Thepressureinsidetheskulllessens.Thebrain’schemicalbalancereturnstonormalwithinseveralmonths.

FormostpeoplewithmoderatetosevereTBI,themostrapidrecoverywillhappeninthefirstsixmonthsfollowinginjury.Butthereisreasontostayhopeful.Mostwillalsocontinuetoimproveforyearsafterinjury.Recoveryisindividual.Everyoneprogressesathisorherownpace.

Ittakestimeforpeopleto“wakeup”afterasevereTBI.Itisaprocess.Itdoesnothappenovernight.MostpeoplewithsevereTBIwill“wakeup”and“clearup”overthecourseofseveraldaysorweeks.Sometimes,thistakesmonths.Theextenttowhichsomeonefullywakesupandclearsupisnotfullyknownbyanyone.However,itbecomesclearerastimepasses.

Herearesomewaysthatthebrainrepairsitselfovertime:

•Newconnectionsmaydevelopbetweendamagedcells.

•Existingconnectionsmayalsobeusedinnewwaystomakeupfordamagedones.

•Otherpartsofthebrainmayslowlylearntoassumefunctionsofdamagedbraintissue.

•Thebodymayevenbeabletoreplacedamagedbraintissue.

Sometimes,theterm“brainplasticity”isusedtodescribethebrain’sabilitytobouncebackandrecoverafterTBI.

Peoplewithmilderinjuriestendtorecoversooner.Butthisisnotalwaystrue.Peoplewithmoresevereinjuriesusuallytakelongertorecover.Somerecoverfairlywellovertime.Somewillneedhelpfortherestoftheirlives.

ModeratetosevereTBImayinvolveacomathatlastsdays,weeks,ormonths.Veryrarely,acomalastsevenlonger.Ingeneral,thelongerapersonremainsinacoma,themorechallengingrecoverymaybe.

Recoveryfromamoderatetoseverebraininjuryisalsoaffectedby:

•Howseverethedamageis

•Theareasofthebrainaffected

•Theareasofthebrainnotaffected

•Ageatthetimeofinjury

•Theearlypatternofrecovery

•Thelengthoftimethepersonisveryconfused

•Otherinjuriestothebody

•Theoverallhealthofthepersonbeforethisinjury.

Thereisnowaytospeedtheprocessofrecovery.Goodmedicalcaregivesyourservicemember/veteranthebestchanceofrecovery.RehabilitationbyspecialistsinTBIhelpsyourfamilymemberre-learnhowtodothings.Mostpeoplereturntotheirhomes,families,andcommunities.ThisistrueevenforpeoplewithsevereTBI.

Rehabilitation means re-learning how to do things. A rehabilitation specialist might be a physical therapist, an occupational therapist, or a speech-language pathologist.

Chapter6-RecoveryProcess


“It had been 15 months and he had slowly improved. But he couldn’t talk. He’d kind of start trying to mouth words, but he just couldn’t talk. And so, on October 21st, 2005, I’ll never forget that morning. I came in to the bedroom and I said, ‘Fred, how are you doing?’ And he said, ‘Fine.’ Okay. I think he just talked to me. So I just turned around and went back into the kitchen, got his breakfast, came back in and thought, okay, let me try this again. I said, ‘Fred, how are you doing?’ And he said, ‘Fine.’ It wasn’t a lot at first, but he could talk.”

-DeniseG.

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Asacaregiver,keephopealiveasyousupporttherecoveryprocessofyourfamilymemberwithTBI.Waitingforyourservicemember/veterantobecomemoreawakeandawarecanmakeyoufeelsadandfrustrated.(SeeModule3toreadaboutcaringforyourselfduringthistime.)

Onthepositiveside,youarelikelytoseeprogress.Remember,progressisprogress,evenifit’sslowerthanyouwouldliketosee.

Keepingajournalandwritingdownwhatishappeningduringyourservicemember/veteran’srecoverymayhelpyoutrackrecoverymilestones.Monthsfromnow,youmaylookbackonearlierjournalpagesandbeamazedathowfarheorshehascome.

Usingajournaltorecordyourownfeelingsmayalsohelpyoucopewithstressandanxiety.Mostpeoplehavethesefeelingswhenafamilymemberhasbeeninjured.

What are the Stages of Recovery?Asyourservicemember/veteranrecoversfromTBI,heorsheoftenmovesthroughstagesknownastheRanchoLosAmigosLevels.TheRancho Los Amigos Levels of Cognitive FunctioningdescribethestagesofrecoveryfromTBI.Thelevelsarebasedontheperson’sbehaviors.

You can find a copy of the Rancho Los Amigos Levels in Appendix B.

Key Points to Keep in Mind:

•Thereisnoaccuratewaytopredictexactlyhowrecoverywillprogressorwhatthefinaloutcomewillbe.

•Manyservicemembers/veteranswithsevereTBIgothroughsimilarstagesandpatternsofrecoverybutattheirownpace.

•Mostservicemembers/veteranswillmakeprogress.

•Progressisstillprogress!

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TheRanchoLosAmigosLevelshelpyouunderstandwhatpointyourservicemember/veteranhasreachedinhisorherrecovery.Onthefolllowingpagesarethefourbroadstagesofrecoveryandhowyoucanhelpduringeachstage.

Emergence from Coma (Rancho Levels II and III)Unlikethedramaticreawakeningyoumayhaveseenontelevision,wakingupfromacomaisusuallyverygradualafterasevereTBI.Althoughtheterm“coma”suggestsclosedeyes,yourservicemember/veteran’seyesmayopenbeforeothersignsofconsciousnessappear.

Consciousnessisjudgedbyaperson’sabilitytopayattentiontoorinteractwiththeworldaroundhim.Itisusuallytestedbyhowwellthepersoncanfollowcommandsandrespondtostimulation.

Itmaybehelpfultounderstandthemedicaltermscommonlyusedtodescribeaservicemember/veteranwithTBIwhoisverysleepy:

•Coma–unconscious,nosleep/wakecycles,doesnotrespondatalltotheworldaroundhimorher,doesnotshowemotion

•Vegetative State–sleep/wakecyclesareapparent,maystartle,mayoccasionally“track”withhisorhereyes

•Minimally Conscious State–partlyawakeandconscious,mayreachforobjects,moreoften“tracks”withtheeyes,mightbeabletooccasionallytalkormakenoises,canshowemotion.

SomeindividualswithTBImayremaininaminimallyconsciousstate.Most,however,willprogresstogreaterawareness.Aspeoplecomeoutofacoma,theytypicallymovefrominconsistentresponseswithonlycertainpeopletoresponsesthataremoreconsistent.Yourservicemember/veteran’ssleep/wakecycleimprovesandheorshebeginstofollowobjectswithhisorhereyes(tracking).Othersignsofawakening

Chapter6-RecoveryProcess30

“My brother was in a minimally conscious state. You hear all these miracle stories and you start getting your hopes up. But then day after day goes by, week after week, month after month, and no sign of major improvements. Meanwhile, you watch as others on the same ward or whom you’ve met continue to improve. You want to be happy for them--and you are, but why is your loved one not improving at the same rate? During these times, take comfort and support from those around you. At my most cynical of times, I would continue to be inspired by the generosity and strength of others.”

-LizaB.


mayappearbeforeyourservicemember/veteranbeginsconsistentlyrespondingtocommands.Thesesignscouldbeassistingintherapyorshowingfacialexpressionsoremotions.

Duringthistime,thehealthcareteamlooksforpurposefulresponsesandencouragestheseresponsesbystimulatingtheperson.Stimulationtechniquesinclude:

•range-of-motionexercises

•stimulatingtasteandsmell

•usingsoundstoreachtheperson

•providingvisualstimulation

•usingtouch

•encouragingfrequentpositionchanges.

Familiesandfriendsareoftenuncomfortableaboutinteractingwithapersonwithabraininjury.Thisisparticularlytruewhentheindividualisinacomaorminimallyconscious,inanICU,andfulloftubes.

Theoddsarethatyourfamilymemberwillrecognizeyouwhenheorshebeginstoawaken.Theincidenceoftrue“amnesia”isalmostunheardofafteraTBI.Asearlyconfusionclears,mostpeoplewithTBIkeeptheirlong-termmemoriesandrecognizetheirfamilyandfriends.

What Can I Do To Help?

•Nooneknowsforcertainifpeopleinacomacanhear.Butthatdoesn’treallymatter.Whatmattersisthey“might”hear.Hearingyourvoiceandknowingyouaretherecanbeverycomforting.

•Watchdoctorsandnursesastheytrytostimulatetheperson.Trydoingwhattheydo.

•Dosimpleactivitiesforshortperiodsoftime.Describewhatyouaredoing(“Iamholdingyourhandnow.”).

•Askyourservicemember/veterantolookatyouandothersintheroomwhenhisorhereyesareopen.

•Presentonesimpledirectionatatime.Allowampletimeforaresponse.

•Touchisveryimportantandstimulating.Ifyouareuncomfortabletouchingyourservicemember/veteran,askaboutwaystoeffectivelytouch,pat,ormassagethepersoninreassuringways.

•Bringintaperecordingsoffamiliarmusic,thefamilydogbarking,messagesfromfriends,andothersoundsthatmightbestimulating.

Stimulation means prodding the person to get him or her more active, aware, or involved with the world.

An ICU is an Intensive Care Unit where people with the most serious illness or injury are treated.

Post-traumatic amnesia (PTA) is the inability to acquire new memories. For example, a person with TBI may not be able to remember what he or she had for breakfast. Long-term memories, such as those from childhood, are not affected. PTA may range from a period of just a few minutes to a more permanent condition.

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•Movebackandforthbetweenstimulatingactivitiesandperiodsofrest,quietmusic,orsoothingtouch.

•Eachtimeyouareintheroom,tellyourservicemember/veteranthedateandwhereheorsheis.Themoreyourfamilymemberhearsaccurateinformationaboutwhereheorsheisandwhathashappened,themorethatinformationwillbegintostick.

•Calendars,picturesofthefamily,friends,home,andfavoritethingsarehelpful.

•Encouragevisitorsandthehealthcareteamtonottalkaboutthepersonasifheorsheisnotthere.Everyoneshouldintroducethemselveswhentheyentertheroom,explainwhytheyarethere,andsaywhentheyplantoleave.

•Youdon’tneedtoalwaystalktoyourservicemember/veteran.Itisalsofinetojustbewithyourfamilymemberandspendquiettimetogether.

•Setbacks,suchaspneumonia,arenotunusualintheearlydays.Thesecanbescary.Thehealthcareteamknowshowtomanagecomplications.

•Ashisorherresponsestocommandsbecomemoreconsistent,keepaskingyourservicemember/veterantofollowsimplecommands.

•Askquestionsina“yes”or“no”format.Theseareeasiertorespondto.

•Ifyouareconcernedabouthowmuchstimulationisappropriateforyourfamilymember,pleaseaskforguidancefromthedoctororotherteammembers.


InconsistencythroughoutrecoveryfromTBIisexpected.Don’tbealarmedifyourservicemember/veterandoessomething(followsacommand,openshisorhereyes,speaks)oneday,butnotthenext.Thecapacityisstillthere. Heor shewill again showthebehavior. It isusuallyjustamatterof“when.”

People recovering fromTBIhavegooddaysandbaddays. Fatigue and impaired memory contribute toinconsistency. Many families learn to embrace thegooddaysandtoleratethebaddays.

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Agitated State (Rancho Level IV)Aphaseofrestless,agitated,oraggressivebehaviorcanoccurinyourservicemember/veteranasheorsheprogresses.Heorshewillalsoshowconfusionduringthisperiod.

InanycaseofsevereTBI,theinjuredpersonwillprobablynotremembermuch,ifanything,about:

•whathappened

•howheorshewastransported

•theearlydaysintheICU

•hisorherearlyinteractionswithdoctorsandnurses.

Agitated refers to a lot of movement, sometimes violent movement.

“In the beginning, he thought he was captured. On that kind of heavy medication, he was super-disoriented. Plus, he was injured and he didn’t know about losing his eye. He didn’t know where he was. He couldn’t see. He was strapped down to the bed, and it took eight doctors at different points in time to restrain him because he kept trying to leave.

I had to seriously get down next to him and just explain to him that he was at Walter Reed, because he kept fighting these doctors. He punched out a nurse. It was really bad because they had to restrain him and that’s really sad to see, when you’re all bandaged up like that, to have to be restrained on top of it.”

-EmilyS.

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Yourservicemember/veteranmayperformroutineactivitiessuchassittingupandreachingoutwithoutmuchsenseofpurpose.Heorshemaybeveryfocusedonbasicneeds:goingtothebathroom,eating,andgoingbacktobed.

Behaviormayseembizarreandoutofcharacter.Theperson’sresponsesmayseemoutofproportiontowhatheorsheisseeingandhearingorbeingaskedtodo.Yellingisnotuncommon,norispullingattubes.

Trynottoletthisoverwhelmyouasacaregiver.DoctorsandnurseswhoworkwithTBIareveryfamiliarwiththisstageofrecovery.Theywillhelpyouandyourfamilymemberthroughit.

Safetyand“ridingoutthestorm”aretheprimarygoals.ThevastmajorityofpeoplewithTBIpassthroughthisstageinanumberofdaystoweeks.Theoddsofremaininginthisstateforeverareverylow.

Theinabilitytostorenewinformationandmemoriesiscalledpost-traumatic amnesia (PTA).PTAoftengoeshand-in-handwithextremeconfusion.SignsthatsomeoneisinPTAare:•inabilitytorecallifheorshejustspoketoyou•theuseofrepetitivestatementsandquestions•confusionaboutwhereheorsheis.

Thesebehaviorsarepartoftherecoveryprocess.Yourservicemember/veteranwillprobablynotexhibitthemoverthelongterm.

Duringthistimeofrestlessnessandconfusion,thehealthcareteamwilltakestepslikethese:

•reducedistractingstimuli(i.e.,television,radio,noiselevel)

•trytoestablishnormalsleep/wakepatterns

•createasafeenvironment.

Protectionmayincludetheuseofmatsoraspecially-designedbedtoallowyourservicemember/veterantomovefreelywithoutharm.Behaviormanagementstrategiesandmedicationsarealsohelpfulforsomeindividuals.


•Beawareofandreduceanythingthatpromotesagitation.

•Beingoverstimulatedandovertiredcontributegreatlytofatigue.Workwiththehealthcareteamtosetupaschedulethatpromotesrest.

•MostpeoplewithTBIrespondbesttoaregularschedule.Trytomaintaintheschedulesetupbythehealthcareteam.

•Continuetoseekresponsestocommandsandquestions.Butspeakingentle,lowtones.Moveaboutquietlyandslowly.

•Explaininsimplelanguagewhathappenedtocausetheinjury.

•Speakslowly.Usesimplelanguagewhenspeaking.

•Talkaboutfamiliarthings:familymembers,pets,places,andeventstheindividualhasexperienced.

•Unusualbehaviors,includingswearing,arecommon.Bepatient.Thesebehaviorstendtogoawayovertime.

•Complextasksaredifficulttocomplete.Breaktasksdownintosimplesteps.Offerstep-by-stepinstructions.


Fatigue is weariness and exhaustion.

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Post-traumatic refers to after a trauma or injury. Amnesia means forgetting.


•Don’tgetintolongexplanationsorarguments.Simpleinstructionsorconversationsarebest.

•Distractionisapowerfultool.Changethetopicoftenifyoufindthepersonisbecomingupsetoveracertaintopic.

•Reassurethepersonthateverythingisbeingdonetoprovidethecareandtreatmentneededtorestorehealthandwell-being.

•Movethepersontoanothertypeofactivityifheorshebecomes“stuck”onacertaintopicorbehavior.

•Giveaccurateinformation.Butdon’targue.Itisbestforyourservicemember/veterantohearcorrectinformationandnotbelievethingsthatarenottrue.

•Youcansetlimitsonveryinappropriatebehavior.Butdonotexpecttocontrolyourservicemember/veteraninto“normal”behavior.

•Itisoftenwisetolimitvisitorsduringthisstageofrecovery.Getdirectionsfromthehealthcareteamabouthowtodothis.

•Ifvisitorsareallowed,haveonly1-2intheroomatatime.Haveonlyonepersonspeakatatime.

Itisimportanttorememberthattheagitatedstageisastepforwardintherecoveryprocess.Agitatedbehaviorsmaybedifficulttowatchandrespondto.Buttheyareoftensignsofimprovement.Thisisastagethatrequiresa great deal of open-mindedness and understandingbyeveryone.Thehealthcareteamisveryfamiliarwiththis stage of recovery. They are not embarrassed ortakenabackbyanybehaviors.Safetyforeveryoneistheprimarygoal.

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Confused State (Rancho Levels V and VI)MostindividualswithsevereTBIpassthroughaperiodofconfusionandlingeringrestlessness.Theyhaveahardtimekeepingacoherentlineofthought.Theyoftenmixuppastandpresentevents.

Inthisstage,yourservicemember/veteranwithTBImaynotrecallnewinformationandmaynotknowwhereheorsheis,whathas

happened,thetimeofday,ortimeofyear.Peopleinthisstageoftenhaveahardtimerememberingthenamesandrolesoftheirhealthcareproviders.Theyoftendonotunderstandwhytheyareinthehospitalorrehabilitationunit.

Theabilitytopayattentionisoftenveryshortatfirst.Sometimes,itisonlyafewminutes.Thereisusuallyagradualimprovementintheabilitytopayattention.Learningbeginstotakeplaceduringthisstage.

Asyourservicemember/veteranbecomeslessconfused,theabilitytofocusonandcompletesimpletasksimproves.Sodoestheabilitytorecalltheeventsoftheday(forexample,whatheorshehadtoeat,whovisited,whatheorsheworkedonintherapy).Thehealthcareteamoftenbeginstousecalendarormemorynotebooksystemsatthistime.ThesetoolsremindthepersonwithTBIofimportantfactsandthedailyschedule.

Manyindividualsknowwhentheyneedtousethebathroomandarebeginningtoeatbynow.Awarenessofphysicalproblemsusuallycomesbeforeawarenessofthinkingorbehavioralproblems.

Asrecoverycontinues,youwillfindmoremeaningfulwaystointeractwithyourservicemember/veteran.Yourservicemember/veteranisprobablybecominglesspassiveandabletodomuchmore.

Onceequipmentsuchasfeedingtubesisnolongerneeded,thereismoreopportunitytobeoutofbed.Then,yourfamilymembercangototherapyandotheractivities.Thispromotesrecoveryandbringspleasuretoall.


•Asksimplequestionsthatencouragememory.

•Offergenerouswordsofencouragementandpraiseforattempts torespond.

•Createsteadyroutinestodevelopgreaterorganization.

•Learnthecalendarandmemorynotebooksystemsputintoplacebyhealthcareproviders.Reinforcetheirusebyyourservicemember/veteran.

•Learnhowtobestcuetheperson(seeModule2).Aconsistentcueing approachbetweenthehealthcareteamandfamilymembersisveryuseful.

•Donottreatyourservicemember/veteranasachildbecausehisorherthinkingismuddy.Docontinuetobeashonestanddirectaspossible.

•Asheorsheprogressesthroughthisstage,helpwithorganizationtoperformsimpledailytasks.


Cueing means to give a signal to begin a specific action.

36


•Buildgreaterindependencebyofferingonlyoccasionalsupporttocompletetasks.

•Askhealthcareprovidershowyoucanbeinvolved:

-Askthephysicaltherapist(PT)howtosafelytransferyourservicemember/veteraninandoutofthewheelchairorbed.

-Askthenursetoshowyouhowtoassistwithtoileting.

-Asktheoccupationaltherapist(OT)howtocorrectlyperformrange-of-motionexercisesandhowtohelpwithmealsordressing.

-Askthespeechandlanguagepathologist(SLP)howtocommunicatebestwiththeperson.

•Donotbringinfoodoroffersnackswithoutcheckingwiththehealthcareteam.Eatingthewrongkindsoffoodscancauseproblemsforyourservicemember/veteran.

•Taperecordallfamilyconferenceswiththehealthcareteam.Thiscanbenefitfamilymemberswhocannotattend.Itcanalsogiveyouavaluablereviewofinformationandprogress.

•Yourservicemember/veteranislikelyprocessinginformationveryslowly.Ittakestimeformessagestobeprocessedandmotorresponsestobecarriedout.Allowextratimeforresponding. Repeatyourrequestafterallowingtime.

•MemoryisoftenweakduringearlyrecoveryfromTBI.Checkwithhealthcareproviderstolearnwhatrestrictionsyourservicemember/veteranhas(forexample,notgettingoutofbedalone,notleavingthepremises,smokingrestrictions,dietrestrictions).

•Confabulationisnotuncommon.Talkwithhealthcareprovidersabouthowtomanageconfabulation.

•Keepinmindthatrepetitionisimportantinorderforthepersontolearnandremember.

•Yourservicemember/veteran’stolerancelevelsforactivitieswillstillbelow.Trytobepatientandmaintainrealisticexpectations.

•Limitvisitorsduringthisstageofrecoverysoasnottooverstimulatetheperson.

•Encourageyourfamilymembertoparticipateinalltherapysessions.

Confabulation means that the person tries to fill in memory gaps by making things up.

37

High Functional Level (Rancho Levels VII and VIII)AlthoughmostpeoplewithTBIaremedicallystablewhentheyreachthisstage,theymaycontinuetohavephysical,thinking,andbehaviorproblems.

Theyareprobablyabletofollowaschedulewithlittleassistance.Memoryforday-to-dayeventshasimproved.Butactivitiesthatneedhigher-levelthinking(solvingcomplexproblems,makingharddecisions,doingmorethanonethingatatime)areprobablystillchallenging.

Theabilitytoparticipateintherapyfull-timehasimproved.Sohasawarenessoftheneedfortherapy.Yourservicemember/veteranmayknowwhatheorsheneedstodo,buthassometroublecarryingitout.Heorshewilllikelystillfeeloverwhelmedwhenunderstressorinemergencysituations.

Physicalrecoveryhasoftencontinuedtothepointthatothersthinkthepersonlooks“backtonormal.”

Treatmentseekstohelpyourservicemember/veteranrecognizethesedifficultiesandlearnhowtocompensateforthem.Ongoinggoalsaretodevelopindependenceandbegintomakeplanstomovefromthehospitalorrehabilitationsettingtohome.

Yourservicemember/veteranmaybeanxiousaboutreturningtofamily,community,school,and/oractiveduty.Thismaycomeacrossasambivalenceordisinterestinthefuture.Psychologicalcounselingcanhelpyouandyourservicemember/veterantodevelopcopingskillsandbetterunderstandhowhisorherlevelsoffunctioninghavechanged.

Inthisstage,youmayneedtoencouragefullparticipationindailyactivities.Yourservicemember/veteranshouldbegintakingresponsibilityforhisorherpersonalcare.Heorsheshouldbegintousewaysthatwillhelpcompensateforthinkingand/orphysicalproblems.


•Donotpromiseyourservicemember/veteranthatlifewillreturntonormal.Timewillsettlethoseissuesforyou.Thenyouwon’thavetofeelguiltyaboutmakingfalsepromises.

•Notwobraininjuriesarethesame,justasnotwopeoplearethesame.Comparisonswithothersmaybedisappointingandmisleading.

•AlldiscussionsshouldtakeplacewiththepersonwithTBIpresent.Thesediscussionsmayseemharshwhenthereistalkoflong-termeffectsandthefutureimpacttheywillhaveonthelifeofyourservicemember/veteran.Still,itisbesttohavefulldisclosure.Thishelps



developplansthateveryoneagreeswith.Openhonestdiscussionalsodevelopstrustandcoping.

•Whileyourservicemember/veteranisstillinthehospitalorrehabilitationsetting,learnasmuchasyoucanabouthowtohelpyourfamilymemberapplytheskillsheorsheislearningbackinthehomesetting.

•Hospitalsandrehabilitationunitsareverystructured,justlikethemilitary.Routineshavebeensetupthatyoucancontinueathome.Practiceassoonasyougethome.Withoutstructureandroutine,skillsmayseemtobelostandconfusionmayincrease.Butwithagoodfamilysupportsystemandpractice,theseskillsoftenquicklyreappear.

•Discourageyourservicemember/veteranfromusingalcoholordrugs(seeModule3).

•Afteryourservicemember/veteranissettledintoacomfortableandworkablehomeroutine,begintopracticeactivitiesoutsidethehome(groceryshopping,goingtoamovie,seeingfriends).SeeModule3.

•Besureyoufullyunderstandrestrictionsonyourservicemember/veteran.Thesemightlimitdriving,working,beingleftalone,usingpowerequipment,andclimbing.

•Besureyoufullyunderstandtheplanforoutpatienttherapyandfollowupwithallmembersofthehealthcareteam.

•Treatyourservicemember/veteranasanadult.Provideguidance,cues,andassistwithdecisionmaking.Butalwaysrespecthisorheropinions.

39


“The doctor said to both of us, do you believe in miracles? And I said yes. And he said, then you need to pray for a big one. You need to pray for a real big miracle because your son—we don’t know if he’s going to make it. And he said if I were you, I would let him go. I’ll give him my assistance, but he’s not going to make it.

And I said to him, you don’t make those decisions, you don’t tell me he’s not going to make it. That’s not up to you. You go back in there and you do what you said you can do, now, to keep my son alive.

And two weeks later, my son opened his eyes for the first time. Three weeks later, he was taken off the ventilator and has never been on another one.

We were looking at my son three years ago to now. You don’t even think it’s the same person.”

-NellieB.


The questions below can help you reflect on your experience as a caregiver. You can write your thoughts here, copy this page and add it to your journal if you keep one, or reflect on these questions in your journal.

What have the doctors told me about my service member/veteran’s injury? Describe the injury as best you can, in your own words.

What are my strongest fears or concerns at this moment in time?

What do I feel joyful or optimistic about?

Journal

42


TheGlasgowComaScaleisusedtoassesstheconsciousnessandneurologicalfunctioningofapersonwhohasjustreceivedaTBI.Thetotalscoreisthesumofthescoresinthreecategories:eye-openingresponse,verbalresponse,andmotorresponse.TheScaleprovidesascoreintherange3-15.Ascoreof3-8indicatesasevereTBI;ascoreof9-12,amoderateTBI;andascoreof13-15,amildTBI.Foradults,thescoresareasfollows:

Glasgow Coma Scale

Appendix A

Eye Opening Response

Verbal Response

Motor Response

Spontaneous--openwithblinkingatbaseline

Openstoverbalcommand,speech,orshout

Openstopain,notappliedtoface

None

Oriented

Confusedconversation,butabletoanswerquestions

Inappropriateresponses,wordsdiscernible

Incomprehensiblespeech

None

Obeyscommandsformovement

Purposefulmovementtopainfulstimulus

Withdrawsfrompain

Abnormal(spastic)flexion,decorticateposture

Extensor(rigid)response,decerebrateposture

None

4points

3points

2points

1point

5points

4points

3points

2points

1point

6points

5points

4points

3points

2points

1point

44


Family Guide to the Rancho Los Amigos Levels of Cognitive FunctioningCognitionreferstoaperson’sthinkingandmemoryskills.Cognitiveskillsincludepayingattention,beingawareofone’ssurroundings,organizing,planning,followingthroughondecisions,solvingproblems,judgment,reasoning,andawarenessofproblems.Memoryskillsincludetheabilitytorememberthingsbeforeandafterthebraininjury.Becauseofthedamagecausedbyabraininjury,someoralloftheseskillswillbechanged.

TheLevelsofCognitiveFunctioningisanevaluationtoolusedbytherehabilitationteam.Theeightlevelsdescribethepatternorstagesofrecoverytypicallyseenafterabraininjury.Thishelpstheteamunderstandandfocusontheperson’sabilitiesanddesignanappropriatetreatmentprogram.Eachpersonwillprogressathisorherownrate,dependingonavarietyoffactors,includingtheseverityofthebraindamage,thelocationoftheinjuryinthebrain,andlengthoftimesincethebraininjury.Someindividualswillpassthrougheachoftheeightlevels,whileothersmayprogressonlytoacertainlevelandnofarther.

Itisimportanttorememberthateachpersonisanindividualandtherearemanyfactorsthatneedtobeconsideredwhenassigningalevelofcognition.Thereisarangeofabilitieswithineachofthelevelsandyourfamilymembermayexhibitsomeorallofthebehaviorslistedbelow.

Cognitive Level I: No ResponseA person at this level:

•doesnotrespondtosounds,sights,touch,ormovement.

Cognitive Level II: Generalized ResponseA person at this level will:

•begintorespondtosounds,sights,touch,ormovement;

•respondslowly,inconsistently,orafteradelay;

•respondinthesamewaytowhatheorshehears,sees,orfeels.Responsesmayincludechewing,sweating,breathingfaster,moaning,moving,and/orincreasingbloodpressure.

Rancho Los Amigos Levels

Appendix B

45

Cognitive Level III: Localized ResponseA person at this level will:

•beawakeonandoffduringtheday:

•makemoremovementsthanbefore;

•reactmorespecificallytowhatheorshesees,hears,orfeels.Forexample,heorshemayturntowardsasound,withdrawfrompain,andattempttowatchapersonmovearoundtheroom;

•reactslowlyandinconsistently;

•begintorecognizefamilyandfriends;

•followsomesimpledirectionssuchas“Lookatme”or“Squeezemyhand”;

•begintorespondinconsistentlytosimplequestionswith“yes”and“no”headnods.

What family/friends can do at Cognitive Levels I, II, and III

•Explaintotheindividualwhatyouareabouttodo.Forexample,“I’mgoingtomoveyourleg.”

•Talkinanormaltoneofvoice.

•Keepcommentsandquestionsshortandsimple.Forexample,insteadof“Canyouturnyourheadtowardsme?”,say,“Lookatme.”

•Tellthepersonwhoyouare,whereheorsheis,whyheorsheisinthehospital,andwhatdayitis.

•Limitthenumberofvisitorsto2-3peopleatatime.

•Keeptheroomcalmandquiet.

•Bringinfavoritebelongingsandpicturesoffamilymembersandclosefriends.

•Allowthepersonextratimetorespond,butdon’texpectresponsestobecorrect.Sometimesthepersonmaynotrespondatall.

•Givehimorherrestperiods.Heorshewilltireeasily.

•Engagehimorherinfamiliaractivities,suchaslisteningtohisorherfavoritemusic,talkingaboutfamilyandfriends,readingoutloudtohimorher,watchingTV,combinghisorherhair,puttingonlotion,etc.

•Heorshemayunderstandpartsofwhatyouaresaying.Therefore,becarefulwhatyousayinfrontoftheindividual.

AppendixB-RanchoLosAmigosLevels46


Cognitive Level IV: Confused And AgitatedA person at this level may:

•beveryconfusedandfrightened;

•notunderstandwhatheorshefeelsorwhatishappeningaroundhimorher;

•overreacttowhatheorshesees,hears,orfeelsbyhitting,screaming,usingabusivelanguage,orthrashingabout.Thisisbecauseoftheconfusion;

•behighlyfocusedonhisorherbasicneeds,i.e.,eating,relievingpain,goingbacktobed,goingtothebathroom,orgoinghome;

•notunderstandthatpeoplearetryingtohelphimorher;

•notpayattentionorbeabletoconcentrateforafewseconds;

•havedifficultyfollowingdirections;

•recognizefamily/friendssomeofthetime;

•withhelp,beabletodosimpleroutineactivitiessuchasfeedinghim/herself,dressing,ortalking.

What family/friends can do at Cognitive Level IV:

•Tellthepersonwhereheorsheisandreassurehimorherthatheorsheissafe.

•Bringinfamilypicturesandpersonalitemsfromhome,tomakehimorherfeelmorecomfortable.

•Allowhimorherasmuchmovementasissafe.

•Takehimorherforridesinawheelchair,whenthishasbeenapprovedbythetreatingteam.

•Experimenttofindfamiliaractivitiesthatarecalmingtohimorhersuchaslisteningtomusic,eating,etc.

•Donotforcehimorhertodothings.Instead,listentowhatheorshewantstodoandfollowhisorherlead,withinsafetylimits.

•Sinceheorsheoftenbecomesdistracted,restless,oragitated,youmayneedtogivehimorherbreaksandchangeactivitiesfrequently.

•Keeptheroomquietandcalm.Forexample,turnofftheTVandradio,don’ttalktoomuch,anduseacalmvoice.

•Limitthenumberofvisitorsto2-3peopleatatime.

47

Cognitive Level V: Confused and InappropriateA person at this level may:

•beabletopayattentionforonlyafewminutes;

•beconfusedandhavedifficultymakingsenseofthingsoutsidehim/herself;

•notknowthedate,whereheorsheis,orwhyheorsheisinthehospital;

•notbeabletostartorcompleteeverydayactivities,suchasbrushinghisorherteeth,evenwhenphysicallyable.Heorshemayneedstep-by-stepinstructions;

•becomeoverloadedandrestlesswhentiredorwhentherearetoomanypeoplearound;

•haveaverypoormemory.(Heorshewillrememberpasteventsfrombeforetheaccidentbetterthannewinformationheorshehasbeentoldsincetheinjury.);

•appearto“makethingsup”totrytofillingapsinmemory;

•maygetstuckonanideaoractivity(perseveration)andneedhelpswitchingtothenextpartoftheactivity;

•focusonbasicneedssuchaseating,relievingpain,goingbacktobed,goingtothebathroom,orgoinghome.

What family/friends can do at Cognitive Level V:

•Repeatthingsasneeded.Don’tassumethatheorshewillrememberwhatyoutellhimorher.

•Tellhimorhertheday,date,nameandlocationofthehospital,andwhyheorsheisinthehospitalwhenyoufirstarriveandbeforeyouleave.

•Keepcommentsandquestionsshortandsimple.

•Helphimorherorganizeandgetstartedonanactivity.

•Bringinfamilypicturesandpersonalitemsfromhome.

•Limitthenumberofvisitorsto2-3atatime.

•Givehimorherfrequentrestperiodswhenheorshehasproblemspayingattention.

48 AppendixB-RanchoLosAmigosLevels


Cognitive Level VI: Confused And Appropriate A person at this level may:

•besomewhatconfusedbecauseofmemoryandthinkingproblems.Heorshewillrememberthemainpointsfromaconversation,butforgetandconfusethedetails.Forexample,heorshemayrememberheorshehadvisitorsinthemorning,butforgetwhattheytalkedabout;

•followaschedulewithsomeassistance,butbecomesconfusedbychangesintheroutine;

•knowthemonthandyear,unlessthereisaseverememoryproblem;

•payattentionforabout30minutes,buthastroubleconcentratingwhenitisnoisyorwhentheactivityinvolvesmanysteps.Forexample,atanintersection,heorshemaybeunabletostepoffthecurb,watchforcars,watchthetrafficlight,walk,andtalkatthesametime;

•brushhisorherteeth,getdressed,feedhim/herselfetc.,withhelp;

•knowwhenheorsheneedstousethebathroom;

•doorsaythingstoofast,withoutthinkingfirst;

•knowthatheorsheishospitalizedbecauseofaninjury,butwillnotunderstandalloftheproblemsheorsheishaving;

•bemoreawareofphysicalproblemsthanthinkingproblems;

•associatehisorherproblemswithbeinginthehospitalandthinkthatheorshewillbefineassoonasheorshegoeshome.

What family/friends can do at Cognitive Level VI:

•Youwillneedtorepeatthings.Discussthingsthathavehappenedduringthedaytohelptheindividualrememberrecenteventsandactivities.

•Heorshemayneedhelpstartingandcontinuingactivities.

•Encouragetheindividualtoparticipateinalltherapies.Heorshewillnotfullyunderstandtheextentofhisorherproblemsandthebenefitsoftherapy.

Cognitive Level VII: Automatic and AppropriateA person at this level may:

•followasetschedule;

•beabletodoroutineselfcarewithouthelp,ifphysicallyable.Forexample,heorshecandressorfeedhim/herselfindependently,haveproblemsinnewsituations,andmaybecomefrustratedoractwithoutthinkingfirst;

49

•haveproblemsplanning,starting,andfollowingthroughwithactivities;

•havetroublepayingattentionindistractingorstressfulsituations.Forexample,familygatherings,work,school,church,orsportsevents;

•notrealizehowhisorherthinkingandmemoryproblemsmayaffectfutureplansandgoals.Therefore,heorshemayexpecttoreturntohisorherpreviouslifestyleorwork;

•continuetoneedsupervisionbecauseofdecreasedsafetyawarenessandjudgment.Heorshestilldoesnotfullyunderstandtheimpactofhisorherphysicalorthinkingproblems;

•thinkmoreslowlyinstressfulsituations;

•beinflexibleorrigid,andheorshemayseemstubborn.However,hisorherbehaviorsarerelatedtothebraininjury;

•beabletotalkaboutdoingsomething,butwillhaveproblemsactuallydoingit.

Cognitive Level VIII: Purposeful and AppropriateApersonatthislevelmay:

•realizethatheorshehasproblemswithhisorherthinkingandmemory;

•begintocompensateforhisorherproblems;

•bemoreflexibleandlessrigidinhisorherthinking.Forexample,heorshemaybeabletocomeupwithseveralsolutionstoaproblem;

•bereadyfordrivingorjobtrainingevaluation;

•beabletolearnnewthingsataslowerrate;

•stillbecomeoverloadedwithdifficult,stressful,oremergencysituations;

•showpoorjudgmentinnewsituationsandmayrequireassistance;

•needsomeguidancetomakedecisions;

•havethinkingproblemsthatmaynotbenoticeabletopeoplewhodidnotknowthepersonbeforetheinjury.

Whatfamily/friendscandoatCognitiveLevelsVII/VIII:

•Treatthepersonasanadult;showrespectforhisorheropinionwhenattemptingtoprovideguidanceandassistanceindecisionmaking.

•Talkwiththeindividualasanadult.Thereisnoneedtotrytousesimplewordsorsentences.

50 AppendixB-RanchoLosAmigosLevels


•Becausetheindividualmaymisunderstandjoking,teasing,orslanglanguage,becarefultocheckforunderstandingwhenusinghumororotherabstractlanguage.

•Encouragetheindividualtobeasindependentasissafe.Helphimorherwithactivitieswhenheorsheshowsproblemswiththinking,problemsolving,andmemory.Talktohimorherabouttheseproblemswithoutcriticizing.Reassurehimorherthattheproblemsarebecauseofthebraininjury.

•Stronglyencouragetheindividualtocontinuewiththerapytoincreasehisorherthinking,memory,andphysicalabilities.Heorshemayfeelheorsheiscompletelynormal.However,heorsheisstillmakingprogressandmaypossiblybenefitfromcontinuedtreatment.

•Besuretocheckwiththephysicianontheindividual’srestrictionsconcerningdriving,working,andotheractivities.Donotrelyonthebraininjuredindividualforinformation,sinceheorshemayfeelreadytogobacktohisorherpreviouslifestyle.

•Discouragehimorherfromdrinkingorusingdrugs,duetomedicalcomplications.

•Encouragehimorhertousenotetakingasawaytohelpwithmemoryproblems.

•Encouragehimorhertocarryouthis/herselfcareasindependentlyaspossible.

•Discusswhatkindsofsituationsmakehimorherangryandwhatheorshecandointhesesituations.

•Talkwithhimorherabouthisorherfeelings.

•Learningtolivewithabraininjuryisdifficultanditmaytakealongtimefortheindividualandfamilytoadjust.Thesocialworkerand/orpsychologistwillprovidefamilymembersandfriendswithinformationregardingcounseling,resources,andsupportorganizations.

–LosAmigosResearchandEducationalInstitute(LAREI),1990

Disclaimer: Information presented on this page is for specific health education purposes only. Persons should consult qualified health professionals regarding specific medical concerns or treatment. Each clinician caring for the patient is responsible for determining the most appropriate care.

51

References/Credits

Chapter 1: The Basics of TBI

DefinitionofTBI:DefenseandVeteransBrainInjuryCenter,“OIF/OEFFactSheet”(Washington,D.C.,June2007).

Newresearchonfactorsaffectingrecovery:Novak,T.andBushnik,T.(2008).UnderstandingTBI.Part3:TheRecoveryProcess.Seattle,WA:TBIModelSystemsKnowledgeTranslationCenter.(DRAFT)

StatisticsonTBIinOEF/OIF:CRS(CongressionalResearchService)ReportforCongress.“UnitedStatesMilitaryCasualtyStatistics:OperationIraqiFreedomandOperationEnduringFreedom.”TheLibraryofCongress.OrderCodeRS22452.September9,2008.

References/Credits

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www.DVBIC.orgVersion: 1-2010 | www.traumaticbraininjuryatoz.org

This guide was produced in collaboration with

The Defense Health Board

The Defense and Veterans Brain Injury Center

and

The Department of Veterans Affairs

Documents

Traumatic Brain Injury: A Guide for Caregivers of Service ... · Traumatic brain injuries (TBIs) range from mild to severe. Injuries are rated on the basis of their severity at the