MEDICAL MATTERS:People amazed by congresswoman's progress
‘LIKE AN orchestra conductor that will make sure we will not mess up the music,” was how Dr Gerard E Francisco, chief medical officer of the rehabilitation hospital in Houston, Texas, described his role. He was speaking following the transfer of Congresswoman Gabrielle Giffords to the unit for treatment after she was shot in the head by a gunman outside a supermarket in Tucson, Arizona, last month.
His comments are a sensitive and evocative description of the journey faced by Giffords after a bullet traversed the left side of her brain. For a public who understandably equate being shot in the head with death or severe disability, her remarkable progress to date has captured the imagination and focused interest on how doctors treat brain injuries.
Within 38 minutes of arriving at hospital, the public representative was on the operating table. Surgeons removed debris from the gunshot, a small amount of dead brain tissue and nearly half of Ms Giffords’ skull. This was done to prevent swelling and increased pressure that could cause more extensive and permanent brain damage. The doctors preserved the skull bone which will be replaced in the future.
The next move was to place her in a medically induced coma, which doctors lifted periodically to check the patient’s neurological responses. Amazingly, Giffords was able to communicate in response to simple tests. She responded non-verbally to commands, like squeezing a hand, wiggling toes and holding up two fingers, an indication that key circuits in her brain were working.
But it was her subsequent rapid progress that caused most surprise: being able to bear her own weight; identify colours; scrolling through her husband’s iPad; and holding a pencil. How could the 40 year old through whose brain a bullet had travelled do so well?
One of the principal reasons is the bullet’s trajectory. It entered the back of her skull on the left side and exited on the same side. By not crossing the midline, damage is confined to one hemisphere of the brain. Bullets that travel through both brain hemispheres cause considerably more swelling, leading to greater mortality.
However, by hitting the left hemisphere, the bullet travelled through the half of the brain that is dominant in about 85 per cent of people.
Because of a major crossover of nerve cables in the brain, the left side controls movement on the right side of the body. And while Giffords’ muscles on that side are weak, the fact that she can raise her right fingers is a sign that her dominant hemisphere has retained some function.
It’s far too early to predict how much long-term brain damage she may be left with. Long-term recovery depends on factors such as the area of the brain affected, the trajectory of bullets and their velocity. If the bullet traversed the visual area in the left occiput at the back of the skull, then her peripheral vision on the right may be damaged.
In terms of cognitive function, it will take some time to assess the damage. Dr Francisco will lead a team of rehabilitation specialists who will devise a treatment programme tailored to Giffords’ needs. A long and painstaking road lies ahead of her – learning to walk, speak, dress. A personality change may pose challenges to relatives and friends.
But the one constant throughout the journey of recovery will be the brain’s remarkable ability to heal. I have been privileged to watch a friend’s recovery from a horrific road traffic accident involving the most awful brain injury. Over a two-year period, he was transformed from a silent and comatose existence to a semi-independent life. Sure it’s been a hard road involving determination and heartache. Yet, surely but slowly his brain found new connections: flashes of his old personality, old interests rekindled, and an increasing independence leading to a joyful return home.
A combination of modern medicine, determination and a modicum of luck should see Gabrielle Giffords regain much of her former life.