First Standard Guidelines for Brain Injury Trauma Care

When I first became an attending in the mid '80s and my focus was on neurotrauma as a neurosurgeon and I went around the country giving lectures, I noticed there was a lot of variability in care of people who were in a coma after a severe traumatic brain injury. And a lot of my other colleagues noted the same things. Randy Chesnut, who is now in Seattle, was one of them, and we got together and said, "Why don't we get together people "and see what the evidence is, "because it seems to me that we should be doing these kinds of things "for people who have severe traumatic brain injury to get the best results, "and it seems that there's a lot of variability "when you go from trauma center to trauma center "about how these patients are getting cared for." And we got together a group of expert neurosurgeons. We worked with the American Association of Neurological Surgeons and the Congress of Neurosurgeons and the World Health Organization and a number of other groups to say, "Why don't we look at the evidence and come up with recommendations "for best diagnosis and treatments?" And we came up with the first guidelines-- actually, it was in any branch of surgery when they first came out. A lot of other surgery societies used that template to do evidence-based guidelines. They were published in 1995. They were the first evidence-based guidelines endorsed by the American Association of Neurological Surgeons. We thought we were done. We had published them. All the people that worked on it, the medical societies, thought, "Okay, it's published, it's out there. People know what to do." Actually, this was started by a survey that the Brain Trauma Foundation did earlier on showing that only, at best, 1/3 of trauma centers were giving the best care to these patients based upon current evidence-- things like brain pressure monitoring, making sure that-- Well, you have to start with brain pressure monitoring and then there's a lot of things that flow out of that. Giving steroids to patients. A lot of people were still giving steroids at that point. We knew a lot of things where there was evidence where it either didn't work or was harmful to the patients--hyperventilation. So we published it in '95 and we thought we were done. We did another survey, and it hardly had budged at all. People hadn't really changed their behavior. And we realized we really needed to implement, we needed to get the word out and change behavior. At that time I took care of the lady in Central Park that was beaten up, and Malcolm Gladwell did an article in The New Yorker about it and talked about creating an even playing field for people who have traumatic brain injury. We should have these guidelines in every trauma center. It doesn't matter who you are. You should get the best care. George Soros read the article and called me up and said, "Why don't you go to Eastern Europe "and train the neurosurgeons that are coming out of communism there?" "We want to teach them about open, transparent medicine, "evidence-based medicine." So we went there, and I took my colleagues with me, and we were in 45 hospitals in 8 countries over 5 years. And what Soros did was actually pay for a database that we could track trauma patients and look at improvements in outcome. It turned out when we put these evidence-based guidelines in practice the mortality dropped by 50%. So we came back, then New York State endorsed the guidelines, we got a program with the Department of Health in New York State, we had the trauma centers in New York State participate, and they've been in there for the last 10 years. And guess what? The mortality in New York State has dropped by 50%. That's after correcting for age, Glasgow Coma Scale, injury severity, and so on. So there's been a real drop of 50% because the guidelines were put into place. The major part of it is brain pressure monitoring went up dramatically and the lack of using steroids and so on. Putting that all into place dropped the mortality. In fact, the CDC came out with a paper in 2007 saying if the Brain Trauma Foundation guidelines were put in every trauma center we'd see a 50%--that number keeps on coming up--50% drop in mortality. It would save the country $3.8 billion a year because people would come out of the trauma centers in better shape, go back maybe to work, be independent. Those kinds of things save a lot of money.

In 1995, the first evidence-based guidelines endorsed by the American Association of Neurological Surgeons were published. But implementing them for equal care for all proved to be more difficult.

See more of Dr. Ghajar's videos here.

Posted on BrainLine February 9, 2012.

Produced by Noel Gunther and Justin Rhodes, BrainLine.