Outdated care called threat to head injury patients Some disabilities avoidable, study says

October 16, 1991|By Gina Kolata | Gina Kolata,New York Times News Service John Rivera of The Sun's metropolitan staff contributed to this article.

Medical treatment for the 150,000 Americans each year who suffer severe head injuries is often so outdated that patients are more likely than not to receive treatment that hurts more than helps them.

As a result, people are being left with permanent brain damage that could have been avoided.

This bleak picture is disclosed by a national survey of trauma centers that provides the first extensive look at how intensive care units treat patients who lapse into comas from severe head injuries. Half of these patients die, and most of the rest are left with brain damage and often-severe disabilities.

The care these patients receive in the first week after an injury can make the difference between life and death or between a life of total dependency and a return to work. Yet the study shows that many centers ignore the monitoring procedure recommended in textbooks and apply two methods of treatment that most experts regard as useless or worse.

The study, conducted by the Brain Trauma Foundation, a private organization that finances research on head injuries, shows that treatments vary widely from hospital to hospital. It has not yet been published, but the researchers say they will present the results at the annual meeting of the American Association of Neurosurgeons in April and agreed to discuss them because of their importance.

The group randomly selected 277 trauma centers in 45 states, and 261 participated in the survey, conducted by telephone by specialty nurses. Among the main findings were:

* Only a third of the trauma centers routinely monitored the pressure inside the head that results when an accident causes the brain to swell. Textbooks and leading head trauma researchers say such monitoring is essential.

* Ninety-five percent of the centers have patients hyperventilate, making them breathe rapidly and shallowly, to reduce the pressure in the head. Most experts consider the practice dangerous because it reduces blood flow to the brain.

* Seventy-nine percent of the centers give patients steroids, though studies have repeatedly shown they do not help and may harm.

Dr. Robert Hariri of Cornell University Medical Center, who helped design the survey, said: "We were really shocked." The study showed that neurosurgeons at trauma centers "are not taking advantage of the current state of knowledge in the field," he said, and that "patients are being allowed to develop irreversible brain damage that could have been avoided."

In contrast, Dr. Jamshid Ghajar, a neurosurgeon at Cornell Medical College who was an author of the report, said that virtually every other subspecialty has established guidelines for treatment.

"If we did the same poll of those hospitals and asked how they treat general trauma patients, I'm sure they'd be very uniform," he said.

Neurosurgeons at research centers said they were taken aback by the findings.

"I am surprised," said Dr. Byron Young, chief of neurosurgery at the University of Kentucky Medical School.

"It's an important study," said Dr. Richard Saunders, chairman of neurosurgery at Dartmouth University School of Medicine. It shows, he said, that "things are being done perhaps for the sake of doing something," and not because they have been shown to help.

Dr. Clark Watts, director of neurosurgery at the Maryland Shock Trauma Center in Baltimore, agreed that most experts frown upon the use of steroids in treating brain swelling and that many doctors use hyperventilation treatment too aggressively.

But he said there was valid disagreement about whether monitoring brain pressure helps, because this involves an invasive surgical procedure to put in a monitor, which runs the risk of infection to the brain. He said that the University of Maryland Medical Center was working on a way to measure brain pressure without surgically implanting a monitor.

Dr. Watts said the problem with trauma care was not that it was outdated, but that it was "inconsistent."

"The successful management of trauma in this country requires [that] . . . you set up a set of criteria that you're going to use, and you don't vary from it," Dr. Watts said. "This is the reason trauma is being rejected by a lot of hospitals in this country, a lot of physicians in this country -- because physicians are not used to working according to imposed protocols."

Head injury statistics are disheartening, neurosurgeons say. The typical patient is a young man who struck his head in an auto accident, lost consciousness and slipped into a coma. Others are children without helmets who fell off bikes, adults who were in motorcycle accidents or pedestrians struck by cars.

Severe head injury is the leading cause of death for people under 45 years old. The survivors are usually permanently affected: Their memory is never normal again, or they are paralyzed on one side of the body, or their intelligence is not quite what it used to be. Head injury is a leading cause of epilepsy.

"What we are dealing with is a major national problem," said Dr. Murray Goldstein, director of the National Institute of Neurological Diseases and Stroke.

Brain damage often occurs because the brain starts to swell after an accident, pressing delicate tissue against the unyielding skull. Dr. Anthony Marmarou of the University of Virginia School of Medicine found that 80 percent of patients with serious head injury had brain swelling.

But the survey found that only a third of trauma centers routinely monitor the pressure inside patients' head. The researchers defined routine monitoring as monitoring the pressure for at least 75 percent of comatose patients.

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