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In a previous position, I worked at a level 1 trauma center where the chief of neurosurgery referred to some trauma patients as “dingbats.” He did not always use the appellation, generally reserving it for people who injured themselves while intoxicated or through risk-taking behaviors. Still, he sometimes used it generically about any trauma patient. One time, an emergency medicine resident rotating on our service corrected him, noting, “Oh, this guy is not a dingbat. He was working when he fell off the roof. He wasn’t drunk. His wife and kids are worried sick about his brain injury.”

The chief was a respected and well-liked physician with an excellent neurosurgical reputation. He was known for his sense of humor that was often deemed “not politically correct.” Like many neurosurgeons, he perhaps coped with the stress of the job by incorporating dark humor. He would counsel younger neurosurgeons that the way to avoid burnout was to not come in at night or on weekends to operate on “dingbats” — advice that his partners heeded. One of them once told an emergency room physician that his brain injury consult “was not worth my getting out of bed in the middle of the night.”

There are several obvious problems that with this chief’s mindset. A neurosurgical chief who is dismissive or disparaging of the brain-injured patient demonstrates a lack of understanding of neurodiversity and risk-taking behaviors. Human beings are not uniformly cautious, and it may be that some level of risk-taking behavior favors the evolution of our species and society. The majority of Americans likely do not know, for example, that falls are a leading cause of brain injury in people over the age of 65 and that exercise programs and other interventions can reduce their likelihood.

Traumatic injury, and particularly brain injury, has significant psychological consequence. The incidence of affective disorders, psychiatric hospitalization and suicide are higher in people who have sustained a brain injury versus those who have not. When a person sustains a brain injury, there is often a sense of hopelessness created, at least in part by physicians saying there is nothing they can do to help.

In addition to re-examining their behavior and language, neurosurgeons can take five actions to provide the best care for patients in the context of traumatic injury consults

  1. Improve diversity in leadership positions and in all aspects of neurosurgical practice. We need to have people in our clinics and hospitals who can relate to the patients they treat, share their cultural and social backgrounds and understand their rationale in making decisions.
  2. Support patients with brain and other traumatic injuries with positive language. Neurosurgeons should familiarize themselves with the scientific literature regarding brain injury outcomes. Patients should always be referred to a brain injury rehabilitation doctor for follow-up if possible. If not possible, patients should receive separate referrals to physical, occupational, speech, vestibular and cognitive therapy or neuropsychology as needed. Neurosurgeons who see many patients with brain injury should consider hiring an advanced practice provider dedicated to following these patients.
  3. Advocate for legislation supporting risk-reductive measures. Seatbelt, child seat and helmet laws all reduce brain and other traumatic injuries. Measures to control the distribution of firearms also reduce risk. Neurosurgeons need to be vocal with their elected officials, so they understand the connection between firearms and morbidity and mortality.
  4. Advocate for better insurance — including Medicare and Medicaid coverage of brain injury diagnostics and therapeutics. Neurosurgeons need to help their patients and others get the help that they need.
  5. Support ThinkFirst and other mechanisms for injury prevention education. ThinkFirst is an international not-for-profit organization founded by members of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons to enable coordinated education in injury prevention. It has developed curricula for injury reduction for all ages, including babies (inflicted abuse), teens (driving safety) and the elderly (fall prevention.) If there is no chapter at your hospital or clinic, consider starting one. Neurosurgeons can also sponsor a chapter at an underserved location or support other ThinkFirst programs. Educating people to identify risk factors for brain injury is the best way to keep these patients out of your emergency room.

Editor’s Note: March is the first annual ThinkFirst Awareness Month. We encourage everyone to join the conversation online by using the hashtags #ThinkFirstAwareness and #ThinkFirst2021.

Uzma Samadani
University of Minnesota
Minneapolis, Minn.

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