Doctors say that traumatic brain injury (TBI) is a catastrophic condition, like burns, amputations, and spinal cord injuries. But TBI is different. It upsets life on multiple levels: physical, psychological, social, and even spiritual. TBI affects the roots of who we are — our ability to think, to communicate, and to connect with other people. For approximately 85 percent of people with TBI, those problems eventually resolve, but the remaining 15 percent have lasting difficulties. If you’re dealing with lingering symptoms of a TBI, or if you’re caring for a loved one, it can help to understand more about the wide range of challenges that TBI can pose.
A tap on the head, and anything can go wrong. Anything usually does go wrong. Light taps — mild TBI — can result in daily headaches, agitated moods, or periods of sleeplessness. Stronger jolts may cause you to forget your name, or make you think you’re someone different. When you tell someone you’re sad, you may unintentionally yell. A TBI can introduce a frustrating amount of confusion and uncertainty into your life
TBI by the Numbers
TBI has a way of affecting everything and everyone in your life. It can make family life tough, and it can seriously impede your ability to work. It can affect the relationships you have and make it harder to make new friends. In the United States, TBI is a quiet crisis. As many as 3.2 million Americans are living with a permanent disability resulting from a brain injury. The Centers for Disease Control and Prevention report that 1.7 million Americans sustain a traumatic brain injury each year. Fifty-two thousand people die from it. Almost a quarter-million people are hospitalized. Some of them go home only to discover they no longer have a sense of smell or taste, or that their sleeping habits have changed, or that they can’t seem to do their job anymore.
If you look at the numbers a little differently, they’re even more upsetting. So many Americans become disabled from a brain injury that each decade they could fill a city the size of Detroit. Seven of these cities are filled already. A third of their citizens are under fourteen years of age. Currently, there are at least 125,000 people with a brain injury so severe that it requires extended hospital care — a service difficult to find and even harder to access. Fortunately, the majority of people who experience TBI will be able to return to a productive life once they receive appropriate treatment
A Closer Look at the Brain
Even though the numbers are large, it’s important to remember that TBI is a human injury. It has a way of showing us that life is fragile and precious. Because the brain is a complicated network of cells, each injury is as distinctive as the person it affects. Our skulls are only a quarter inch thick, although male skulls are a little thicker, which is lucky considering the fact that men tend to get TBI more often than women. The skull is both protective and restricting; it is the brain’s best defense but also its greatest risk in times of trauma.
Surrounding the brain is an almost rubbery, clear layer of tissue called the dura mater. It helps protect the brain from moving around too much. Beneath the dura mater is another layer called the arachnoid layer, which looks and feels like wet cotton candy. The dura mater, the arachnoid layer, and another layer — the pia mater — all form what is known as the meninges, which keeps the brain floating inside the skull. If these layers get infected, ripped, or torn, it can cause serious damage to the brain
Types of TBI
Every brain injury is different, but there are two basic types: open head injuries and closed head injuries. Open head TBIs are a frightening mess. Whether the injury comes from a bullet, a baseball bat, or a high-speed collision, the result is always chaotic and distressing. The scalp bleeds a lot when it is cut, and when the skull is cracked or penetrated, pieces of it can get lodged in the brain. Because the brain is such a complicated tangle of tissue, it’s extremely tricky to remove objects lodged inside a brain. That’s why we put brain surgery right up there with rocket science in our everyday language.
In a closed head injury, nothing penetrates your skull, but a closed head injury can be just as complicated and vicious as an open head injury, sometimes more so. During a closed head injury, the brain may slam against one portion of the skull, then bounce against the opposite side of the wall. Doctors call that a “coup-contracoup” injury, where two injuries occur from a single blow. One of the most common types of closed head injury is a concussion — a strong blow from an external force. If a person’s head is whipped around, a small tearing effect called shearing occurs throughout the brain, resulting in a diffuse axonal injury. Axons are the hairlike extensions of nerve cells that transmit messages, so in a diffuse axonal injury, the messages either get mixed up, or they don’t come through at all
Treating and Living With TBI
An injured brain also has a tendency to swell, so if there is no room in the skull to expand, the swollen brain may start pushing against the eye sockets. The optic nerve eventually gets pinched, and eyesight is affected. A surgeon might drill holes into a skull to test cranial pressure. If the swelling is too extreme, the only option is to create an escape hatch by sawing away a portion of the skull.
The neurosurgeon is in charge of protecting the brain through medical procedures, but the survivor has to manage life with the effects of the TBI. Everyone reacts differently, depending in part on the severity of the injury, the quality of their care, and the strength of the social network around them. Many survivors feel pulled in different directions, feeling at times that the injury has made them less than what they were, and at other times that they can integrate TBI into their lives in a positive way. People with TBI are forced to confront a whole series of personal questions: How does my injury really affect me? Can I regain the things I’ve lost? What am I other than my brain? How can I make the most of my life?
Our understanding of TBI is changing in front of our eyes. As organizations such as the Brain Trauma Foundation continue to define the best practices in treating brain injury, medical care is slowly improving — at least for those patients able to gain access to early trauma care. The war in Iraq has already changed the way we treat TBI in America. Military surgeons who learned life-saving techniques like early cranioplasty are able to employ similar protocols in American trauma centers
In the years to come, we may increasingly see brain trauma as a chronic but manageable condition similar to diabetes or cardio-pulmonary disease. That perspective might also help in reducing the negative stereotypes of TBI. For now, though, TBI survivors and those who care for them continue to face serious challenges in finding help and finding acceptance.
TBI is a much more manageable injury today than it has been in the past, but it remains a major health problem. As people with TBI continue to live longer and face the challenges of aging with TBI, it will be our duty to provide better education and long-term programs and services. We all have brains; let’s continue to use them — injured or not — to support TBI prevention, research, and treatment.
Michael Paul Mason, Michael Paul Mason is the founding editor of This Land, a monthly magazine based in Tulsa. Mason's first book, Head Cases: Stories of Brain Injury and Its Aftermath, is an exploration into the harsh realities endured by people with brain injury.
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