life is a gamble

Monday, May 6, 2013

Beating the odds, beyond belief, defying logic. Medicine is able to care for things that have already occurred but sometimes struggles to predict the future. Preventive medicine can help minimize risk but why one person gets ill or injured, while another dodges a bullet, remains a mystery. The stories of three athletes.

University of Kentucky football player, Ashely Lowery is involved in a single vehicle accident. He is driving his car on a country road at 4am, when it leaves the road rolls numerous times, he is found 100 feet from the car. He is intubated kept on a ventilator and sedated for a couple of days in ICU, but he wakens, starts telling jokes and aside from scrapes and bruises, is none the worse for wear.. According to Kyle Tucker’s article in the USA Today, doctors thought that Lowery’s life might have been saved by not wearing a seatbelt, since he was ejected from a car that was destroyed. Lowery won the lottery; it may not have been his time to die and despite what the doctors might have said, failure to wear a seatbelt increases the chance of death dramatically. According to the CDC, without a seatbelt, a driver or passenger is 30 times more likely to be ejected from a vehicle. More than 3 of 4 people ejected in a car wreck die from their injuries. For all accidents, seatbelts decrease the risk of death by 45% and the risk of injury by 50%.

The bottom line: 90 people die every day in car wrecks. The CDC research suggests that seatbelt use would save 4,000 lives a year.

Lars Ellers is a Montreal Canadien forward who was skating with his head down, looking for the puck, when he was aggressively bodychecked. He spun around and landed face first on the ice, and lay motionless in a pool of blood. After the dust settle, Ellers ended up with facial fractures, lost teeth and a concussion. After emergency treatment and a night in hospital, he was released the next day, doing well, to sleep in his own bed. Being knocked out for a few seconds guarantees the diagnosis of concussion but it does not predict the severity of the brain trauma. In fact, the guidelines as to whether to do a head CT scan on patients with minor head injury, does not use loss of consciousness as a decision maker. The definition of minor is that he patient has returned to normal within two hours but it does not mean that the brain isn’t injured. Instead, the Ottawa or New Orleans CT Head rules can predict who has no bleeding in the brain. Many brain injuries though, do not have bleeding. Concussions may have subtle symptoms that develop over hours or days. But when the brain turns off after a hit, the diagnosis is solid. It isn’t surprising that being hit in the face can cause a concussion.

The face can break in many ways. The most serious fractures were described by Dr. Le Fort, a surgeon in the early 20th century, who examined break patterns in cadavers that were crushed. The bones broke predictably and potential complications could be anticipated. The most serious fracture, the Le Fort III, in effect dislocates the face from the skull, causing swelling and bleeding that could obstruct the mouth and trachea, potentially causing the victim to stop breathing. The brain is also vulnerable to the force required to break a face.  Up to 50% of major facial fractures are associated with brain injury.

The bottom line: Ellers facial fracture was associated with a concussion. Why he didn’t have a major brain bleed is a question of philosophy.

Ricardo Portillo loved the beautiful game and was refereeing an amateur soccer game in Salt Lake City when he handed out a yellow card. The seventeen year old player became irate and punched Mr. Portillo in the side of the head. There were no immediate symptoms but shortly, Mr. Portillo became dizzy and started vomiting. An ambulance was called and the paramedics found him awake with no obvious injuries, but by the time they arrived in the ER, Mr. Portillo had lapsed into a coma and was unconscious. He never wakened and died a week later. The medical details are limited but Mr. Portillo suffered from brain swelling or cerebral edema. The skull houses the brain and is meant to protect it from injury. The bones are rigid and the brain fits pretty tightly.

When the brain is injured, there is the potential for its cells to swell. The CT scan may be normal and there may not be anything to operate on, no blood to drain, nothing to cut open to relieve the pressure. If a hand is bruised, the skin covering is mobile and flexible enough to tolerate a large amount of swelling. In most people, a tiny amount of brain swelling causes he brain to turn off. The swollen brain, with its increased volume, squashes itself against the rigid skull. If the pressure increases, the brain starts pushing down on the brain stem, the connection of the brain to the spinal cord that contains the centers that control breathing, blood pressure and heartbeat. When the brain stem is damaged, death occurs. There are medications that can decrease intracranial pressure, but they don’t always work and runaway brain swelling can cause death.

There is no hood reason why Mr. Portillo’s brain decided to swell while the players of the field were heading soccer balls without any complication.

The bottom line: Life isn’t fair.






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