Using Knowledge for Better TBI Patient Outcome

The standard medical guidelines published in 1995 have already significantly improved outcome, but more knowledge and change in doctors and the public is necessary to continue to improve outcome in people with TBI.

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The issue has always been, how do you change behavior? And I don't think doctors or neurosurgeons are unique. It has to do with any human behavior. Once somebody is used to doing something, it's very difficult to change them to do something else. It's, "Listen, I've been doing this for 20 years. I'm used to it." "Half my patients die." "I don't want to try anything new because maybe the other half will die too." "I want to just do what I've been trained to do." And changing that behavior or how to do that has been very difficult. I think now the guidelines have been well accepted. People are saying, "Okay, what's next? What do we do?" And right now the second edition of the pediatric guidelines is about to come out. We're about to publish an algorithm for managing intracranial hypertension. So we continually keep up with the guidelines. And we're going to shift to a process of continuous updates so people will get the news right away when--say the crash trial. Don't use steroids for people with severe traumatic brain injury because it actually increases mortality. Those kinds of articles will come up immediately, and recommendations will be in place. So I think there's going to be a direct connection between the person taking care of the patient and what the newest evidence is. So far it's been very disconnected. Some journal somewhere published something. Well, then how do you take that knowledge and then bring it to the bedside? That's been the difficulty. We've had this program in New York State, and we actually have it in other states as well where we actually track patients in coma. We actually have a free tool called So if you go to, it's a free tool. You can put in the person's neurological status and their blood pressure and so on, and it'll tell you if they're following the recommendation of the guidelines and give you the guidelines so you can look at it, look at the evidence supporting the recommendation and so on. We hope to have that as sort of a public bulletin or bulletin for practitioners so they can see what the newest evidence is, have that continual update. But I think this is an issue in terms of changing-- It's one thing going through all the evidence and coming out with recommendations, which is a difficult process. A far more difficult process is changing behavior. And I don't think it's unique to medicine. I think if you look at any area of human endeavor it's difficult. Once somebody learns something and they're practicing a certain way, it's difficult to sort of change the ship to go in a different direction. But we have to do it because it's about patient outcomes, it's about making people better. Since the guidelines have been in place, the mortality has dropped 50% and the people that survive do have a better outcome compared to before. And largely it's because of what we know works. We know that about half the people in coma have high brain pressure. We need to measure it. If you don't measure it, you don't know what it is. We have a paper that's about to come out showing that blind treatment-- Let's suppose I just assume people have high brain pressure. I'm going to treat everyone who comes in coma with mannitol, hyperventilation, and I'm not going to measure their brain pressure. It's like saying I'm an internist and somebody comes in my office, I just assume they have hypertension, and I'm going to give everybody blood pressure medication. Well, there are some consequences to that. We're about to publish a paper showing that blind treatment without brain pressure monitoring leads to much higher mortality. So you should monitor the pressure and just treat those people who have high brain pressure. Don't assume from the CAT scan that a person has high brain pressure and start treating that because that treatment could lead to other things which could produce a worse outcome. So I think the guidelines have been a service and proven that they actually do impact outcomes and improve them, but we need to apply them more thoroughly. I'd like to see the public be able to look at the evidence just as well as medical practitioners. We should make this transparent. I think that's probably the next big effort is to give the public the tools to know what to look for. Right now I get calls and a lot of people who are experts in traumatic brain injury get calls from somebody saying, "You know, my cousin is so-and-so "and he's in the ICU somewhere in severe traumatic brain injury. What should we do?" Well, they shouldn't have to call me up to do that. They should be able to have the facts in front of them and know what to look for. And that serves them well and it serves the people in the hospital taking care of the patient well because they're going to have confidence that the people in the hospital are doing the right thing, and they won't be taking them out and putting them somewhere else. So that helps everybody to have that knowledge transparent.
Posted on BrainLine February 9, 2012.

Produced by Noel Gunther and Justin Rhodes, BrainLine.