Turning Heads: GW’s Systemic Approach to Treating Concussion and Traumatic Brain Injury
In early 2018, a woman in her 30s, we’ll call her Sue although that’s not her real name, decided that she’d like to try one of those hip electric scooters she’d seen whizzing around town. Bad decision. Unprepared for sharp turns and close encounters with cars and pedestrians, Sue lost control and crashed, suffering a cervical vertebra injury. Rushed to the hospital, she was checked out by the George Washington University (GW) Hospital’s Department of Emergency Medicine (ED) staff and referred to the Department of Neurosurgery. There she had a CT scan to see whether there was any internal bleeding or a skull fracture. The scan came back negative, so attention shifted to the spinal injury. Ultimately, Sue underwent successful surgery.
Months later, still wearing a brace, Sue visited the Concussion and Traumatic Brain Injury (TBI) Program Clinic at GW Hospital, complaining of headaches and dizziness. Marilyn F. Kraus, MD, director of the clinic, determined Sue had been concussed. “She was on pain meds, and in this case, it was hard for her to realize she had a concussion because of the lingering pain from the spinal injury, which may have masked the concussion effects,” says Kraus, who also serves as associate professor of psychiatry and behavioral sciences in the GW School of Medicine and Health Sciences. “Almost all these c-spine injuries have a concussion component.”
After Sue completed her rehabilitation from the surgery and shed the brace, Kraus referred her to the GW Hospital’s specialized physical therapy unit, where Senior Outpatient Physical Therapist Kirsten Quinn, DPT, put her on a therapy program to address the vestibular (or balance) issues. Specialized physical therapy for concussion and traumatic brain injury is relatively recent and is a key component of the continuum of care at the hospital. Following six weeks of therapy, Sue was free of dizziness and her headaches had subsided. She decided to stick to Capital Bikeshare and wearing helmets when getting around town.
Sue’s case is illustrative of GW Hospital’s seamless, multidisciplinary approach to head injuries. Concussion and TBI are increasingly common and GW has responded by developing a systemic continuum of care for treating insults to the brain. Like a point-to-point medical map, the continuum of care links any necessary medical services along the route to wellness. The map ensures each medical service stop along the way is close enough in proximity to allow immediate communication. Patients steadily move on the road to recovery. Seems logical, right? Yet the idea was decades in the making, as concussion and TBI swelled to become significant public health issues.
“When I first started handling care for brain injuries more than 20 years ago, it was like having a compass and a flare gun — you did the best you could,” says Kraus. “Now we have specialists every step of the way and there’s a continuity at GW.”
The challenge is massive. According to the Centers for Disease Control and Prevention, approximately 1.5 million Americans suffer a brain injury each year, 85,000 people suffer long-term disabilities, and 50,000 people die as a result of TBI each year. In the United States, more than 5.3 million people live with disabilities resulting from TBI. The top three causes of TBI are: car accidents, firearms, and falls. Young adults and the elderly are at highest risk for TBI, and both groups are particularly susceptible to spinal cord injuries — another type of traumatic injury that can result from those same top three causes.
The list of common symptoms of a brain injury is long, but it includes dizziness, headache, fatigue, nausea or vomiting, double or blurry vision, and difficulty concentrating or remembering. Many people who suffer a concussion feel better within a few days or weeks. Others, however, may have a lengthier or more complicated rehab, perhaps lasting months. Appropriate evaluation, management, and understanding can help promote a faster, more complete recovery.
With heightened public awareness of concussion and TBI, the volume of cases has risen dramatically. According to GW’s medical records, 861 individuals visited the concussion clinic during fiscal year 2018. Over a period of 18 months, from the beginning of January 2017 through the end of June 2018, the GW Hospital trauma center treated 626 patients — 328 injuries from falls, 97 from assaults, 81 from motor vehicle accidents, 55 pedestrian mishaps, 37 from bicycle accidents, and eight from self-harm.
There are always outliers, of course. Kraus has treated patients who have sustained head injuries from a host of unique activities, including one from roller derby, and another who had to be treated after repeatedly head-butting her dog. Some people will do anything for fun.
Assuming those playful head butts lead to something more serious, there are a number of things patients can expect.
When arriving in the emergency department, the first triage determines whether patients can be treated as an outpatient or if they need to be admitted. One objective measure is nystagmus, sometimes known as “dancing eyes.” Out of approximately 200 patients daily, one-third have been injured (as opposed to a medical complaint) and, of that number, an average of two patients a day have a serious trauma, according to Robert Shesser, MD, MPH, professor and chair of the Department of Emergency Medicine. If the concussion sustained is believed to be mild, the patient is given basic care guidelines and sent home.
If the head injury is more severe, on the other hand, the patient will go to the trauma bay of the ED. In 2013, GW Hospital first earned a Level 1 Trauma Center designation. There the self-described “maestro” is Babak Sarani, MD ’97, RESD ’04, the director of Trauma and Acute Care Surgery at GW Hospital. Sarani actually functions like an orchestra conductor as much as a physician.
“We start with a physical exam, including assessing the patient’s level of consciousness, then we lean very heavily on getting a CT scan,” Sarani explains. “We look at all injuries not just brain injuries. Then we may initiate the consults to neurology and neurosurgery. We do the coordination of the care. Throughout the patient’s stay in the hospital, we’re the coordinating body. We’re the ones making sure the departments are talking to each other, that the patient is getting adequate nutrition and so on.”
Should surgical intervention be necessary, patients are directed to GW’s Department of Neurological Surgery led by Anthony Caputy, MD, chair of the Department of Neurological Surgery and Hugo V. Rizzoli Professor of Neurological Surgery at SMHS.
The department is staffed by a team of experts trained in all aspects of the treatment and management of neurological disorders. As a discipline, neurosurgery covers a large number of procedures from minimally invasive techniques for the brain and spine — deep brain stimulation to treat movement and mood disorders, craniotomy techniques for mapping brain function, radiosurgery, carotid artery stenting, and minimally invasive treatment of brain aneurysm (coiling) — to more traditional open surgeries to relieve cranial pressure, treat traumatic brain injury, or correct malformations of blood vessels.
“Neurosurgery is the acute part of the continuum of care, and, along with the trauma team, we are the initial evaluators,” says Michael Rosner, MD, professor of neurological surgery, and a key member of Caputy’s surgical team. Rosner brings vast experience with TBI cases. Before coming to GW, Rosner was a staff neurosurgeon at Walter Reed, and he also served with the 86th Combat Support Hospital in Baghdad, Iraq, in support of Operation Iraqi Freedom. As soon as the trauma team identifies any kind of neurological concern, “we are there within seconds,” Rosner says, adding the neurosurgeons do their own imaging and a neurological exam, paying particular attention to whether there is inter-cranial bleeding.
As Caputy notes: “We get more patients because we are a Level 1 Trauma Center. The beauty of the system here is that there isn’t any [discussion] of who takes the patient at the next stage of recovery.
“At GW,” he adds, “the system is among the best in the country at ensuring patients are taken care of appropriately by the next expert at every level of care.”
Last in the line of GW’s continuum of care is the Concussion/TBI Clinic, but in many ways it’s the step that takes patients from better to back to normal. Located in the neurology department, the clinic follows patients and organizes care soon after injury.
Patients receive treatment across the full range of their recovery, from post-operative to the weeks, months, or even years after the precipitating event. Treatment can range from the subacute phase, when the injury is just starting to heal, into the chronic phase, typically six months after an injury and continuing throughout the patient’s life, as needed.
“We see athletes, as well as any other types of head injury, including motor vehicle and work-related incidents,” says Kraus, adding that each case requires a complete evaluation in order to develop a comprehensive treatment plan. No two brain injuries are alike and the consequence of two similar injuries may be very different.
“We address all the potential abnormal conditions relating to TBI/concussion, including headache, neck pain, vestibular disorders, oculomotor disorders, sleep disorders, cognitive and mood changes,” she adds. “Symptoms may appear right away or may not be present for days or weeks after the injury. One of the consequences of brain injury is that the person often does not realize that a brain injury has occurred.”
When Kraus evaluates a patient who is complaining of cognitive difficulty that is interfering with daily life, she frequently refers them to neuropsychiatrist Antonio Puente, PhD, who performs a detailed neuropsychological exam designed to produce cognitive measures through memory, problem solving, and attention exercises. “This will provide cognitive measures but also tells us how the patient is doing emotionally and helps inform treatment,” Puente explains. “More often than not, our findings are used to change their physical routine.”
Ultimately, patients are referred for physical therapy (PT). Senior Outpatient Physical Therapist Kirsten Quinn is a trained therapist specializing in concussion and TBI. Her department receives between 10 and 20 new patients each week suffering from TBI/concussion. They are scheduled for all three therapy disciplines: speech, physical, and occupational “to make sure we’re not missing anything,” Quinn explains. Sessions are scheduled in the hospital but the patient is also expected to do his/her exercises at home. Vestibular, or balance, dysfunction is a common reason patients are referred for PT. “It’s in the patients’ best interest to have this close-knit relationship among all our [medical] teams,” she adds, “because we can better manage the patient and ensure all their needs are handled.”
For patients such as Sue, GW offers an important blend of both the immediacy of treatment and the availability of follow-up care.
“The system in place is designed to handle all comers, at all stages, no matter the cause of the head injury,” says Kraus. Even someone concussed by banging heads with the family pet. “I never did get a clear answer why she was playing chicken with her dog.”