In management of brain injured subjects who have engaged in risk-taking behaviors, there is a natural inclination to ‘blame the patient’ for engaging in an activity with a high propensity for injury. There are several obvious problems that become apparent when a physician does this.
The first problem is that traumatic injury, and particularly brain injury, already have 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. Objective measures of physiologic dysfunction exist, as do some treatments but these are not generally covered by insurance, increasing the sense of hopelessness. Media representation of the chronic effects of neurotrauma may lead to the brain injury sufferer believing themselves to have a progressive neurodegenerative disorder, again increasing hopelessness. The obligation of a neurosurgeon caring for that patient is to provide empathy and relief rather than compound the problem.
The second problem is that imposing our neurosurgical judgments regarding what constitutes risky behavior is an imperfect art since we do not share that person’s environment and background. Our patients are increasingly educated and influenced by social media and anecdotes. 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.
The third problem created by a neurosurgical chief who is dismissive or disparaging of the brain-injured patient is that it betrays 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 irony of our educational snobbism is that our understanding of the risk/benefit threshold for some risk-taking behaviors is poor, and thus we may be erroneously judgmental.
Neurosurgeons can take five actions to provide the best care for patients in the context of traumatic injury consults:
- 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.
- Support patients with brain and other traumatic injury 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.
- Advocate for legislation supporting risk-reductive measures. Seatbelt, child seat and helmet laws all definitively 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.
- 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.
- Support ThinkFirst and other mechanisms for injury prevention education. ThinkFirst is an international not-for-profit foundation started 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 the 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, MD, PhD, FAANS, FACS
University of Minnesota