14: Navigating the ICU after a Brain Injury with Dr. Amit Bhardwaj
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Hospitalization after a loved one's brain injury or stroke is an incredibly difficult experience.
In episode 14 of Brightway Answers, internal medicine physician Dr. Amit Bhardwaj walks through the ICU experience after a brain injury. He provides some tips and answers some of the most common questions family members have during this time, including:
- Why is a prognosis so difficult to provide?
- Are there types of injuries that usually see better or worse outcomes?
- Who are the medical professionals in the ICU?
- How is the ICU team monitoring my loved one and what are common procedures after a brain injury?
- How long is a typical ICU stay after brain injury?
- How can I stay connected with the medical team while my loved on is in the ICU?
Dr. Bhardwaj is Brightway Health’s Medical Director and a board-certified internal medicine physician who’s been in practice for 10 years. He started his training initially in neurology before switching to internal medicine, including a chief resident year focused on quality and safety. Since then, he has been involved in both hospital medicine and post-acute care where he’s worked with TBI, stroke, and other neurologic patients.
Get your questions about brain injury answered! On Brain Injury Q&A, you can submit your questions at https://brain.brightwayhealth.org to get answers from doctors, therapists, and other caregivers and survivors.
Listen to all episodes of Brightway Health at https://www.brightwayhealth.org/podcast.
Full Interview Text:
Yannick Cohen: Hello and welcome to the first episode of season two - this is episode fourteen of Brightway Answers! I’m your host Yannick Cohen.
Now, I haven’t talked a lot on this podcast about why I care so much about helping survivors and other families. The reason is that my brother is a brain injury survivor. He fell from a train at the end of 2015 and was kept in a medically-induced coma for three weeks. When he eventually was woken up, he had many of the symptoms that brain injury survivors experience - his memory, balance, speech, and vision were all affected, and he originally had trouble recognizing family members and friends.
He’s come a long way in the last few years, but brain injury is often a lifelong journey. That’s why we’ve created Brightway Health, where our mission is to improve access to specialized care so that every person with brain injury or other chronic neurological conditions can get the best possible outcomes. We’ve teamed up with a number of doctors and therapists and are creating a number of excellent resources, which I encourage you to check out on our website at www.brightwayhealth.org.
Now, if you listened to season one, you know that we sourced our questions from the community. And you can continue to submit questions to get answers from medical professionals or other survivors or caregivers at brain.brightwayhealth.org.
But we have a new format for season two. In this season, we’ll focus on specific parts of the journey to recover from brain injury, like what to expect while you’re in the hospital, inpatient rehabilitation, and the different paths after discharge, including what longer-term can look like.
Today we’re focusing on the first of these - what to expect while you’re in the hospital - specifically the ICU, or the intensive care unit.
To help us understand the ICU a little better, I’m speaking with Dr. Amit Bhardwaj. Dr. Bhardwaj is Brightway Health’s Medical Director and a board-certified internal medicine physician who’s been in practice for 10 years. He started his training initially in neurology before switching to internal medicine, including a chief resident year focused on quality and safety. Since then, he has been involved in both hospital medicine and post-acute care where he’s worked with TBI, stroke, and other neurologic patients. Dr. Bhardwaj, welcome to Brightway Answers!
Dr. Amit Bhardwaj: Thanks so much for having me Yannick, I really appreciate it.
Yannick Cohen: Absolutely. One of the things I remember from our ICU experience is that it’s incredibly overwhelming. You’re dealing with insurance, there are a number of choices to make, and of course you’re most worried about what has happened to your loved one and what the future looks like. We’ll cover insurance in another episode, but let’s try to help walk through some of these issues for someone who’s in the hospital right now.
Before we do so, there is one thing that I want to mention. There’s a saying in the brain injury community - “when you’ve seen one brain injury, you’ve seen one brain injury”. This just means that every brain injury is different, and there often are no easy answers. So the approach that we’ll take today will be focused more on Dr. Bhardwaj’s experience, as well as general statistics to try to help provide an idea of what to expect. Know, however, that people frequently do better, or worse, than expected for reasons the medical team often cannot explain.
To set the stage further, we’ll be talking in this episode what happens in the ICU after a brain injury that causes unconsciousness - either from the injury itself or medically induced. With that, let’s jump in.
The thing that family members are most interested in, but also the most difficult for physicians to answer, is the prognosis of their loved one. Can you give a sense of why this is such a difficult question to answer?
Dr. Amit Bhardwaj: Yeah. I mean, like you said earlier, you know, when you've seen one brain injury patient, you've seen one brain injury patient, you know. Everybody's unique. Our understanding of brain and spinal cord, it's an evolving field, probably the fastest growing field aside from maybe cancer, in America and the world.There are a number of factors which contribute to prognostication. Um, you know, the biggest of which is probably mechanism of injury, what caused the injury. Something that's more minor like hitting your head on a cabinet, which could be, you know, a TBI, if you're elderly, if you're on blood thinners, things like that versus, a major motor vehicle accident, obviously that's gonna play a role in prognostication. And then in medicine, there's this concept of reserve, which is basically how much your body is able to handle a particular insult and have that much extra in reserve to be able to make up for that injury for that sickness, for that illness.
A lot of that is genetic, a lot of that is age related. A lot of that is also based off of your environment, how you've grown up, what your habits have been. For example, have you been an exerciser? Neuroplasticity is an idea that people talk about in which your brain adapts to injuries, to neurologic diseases, to neurologic insults and people that are easily able to adapt better, tend to be, you know, musicians and other people who use like the other side of their brain. So there's so many areas to this. Um, and each individual is unique. So, you know, they're general statistics, but like you said, uh, brain injury for everybody is unique because everybody's different.
Yannick Cohen: Interesting. You mentioned musicians, is that because of the creative side that they're used to using?
Dr. Amit Bhardwaj: Yeah. There's a growing number of articles, research going into the creative mindset. People who know a lot of languages, people who are musicians, people who participate in art in some way shape or form, they've have a different degree of neuroplasticity than does someone who hasn't engaged in these things. Their brain is wired a bit differently and is able to rewire itself to neurologic insults that a lot of people who haven't partaken in these sorts of activities, there's nothing that's necessarily a hundred percent proven, but there's growing evidence to that. So there's certainly a role to creativity and you'll often see when you jump into the post-acute world, they implement different types of therapies, and it's more than just physical therapy. You'll have speech therapy, you'll have music therapy a lot of the times too. So there's growing evidence that those types of things are definitely involved.
Yannick Cohen: Gotcha. Thanks for going through that. Let's talk about the range of several things that are top of mind for families starting with personality. Can you give us a sense of the change in personality that survivors can experience after a brain injury like TBI or stroke?
Dr. Amit Bhardwaj: Personality changes are a big thing when it comes to neurologic insults, it depends on where the brain injury is. That's first and foremost. I don't know if you're familiar with the story of Phineas Gage?
Yannick Cohen: I'm not, no.
Dr. Amit Bhardwaj: I don't know exactly when, but sometime in the 19th century or early 20th century, Phineas Gage was an American construction worker who had an accident in which a metal rod went through his left frontal lobe. And an otherwise sweet man turned into a very mean man for the remaining 12 years of his life thereafter. So, often lesions or injuries that involve the frontal lobe, they involve personality changes for sure. But then also, and this is very under recognized, is, if I wasn't able to do the things that I used to do, you know, because say my right arm is weak. Now say I can't walk anymore. Depression, anxiety, all these things are gonna play a role in mood as well. Um, so, you know, a lot of the personality changes are related to both the location of injury, particularly frontal lobe injuries, but also, the depression and anxiety. Sleep issues, chronic headaches, chronic recurring symptoms that impact a person's quality of life. And obviously, you know, you're not gonna be the same after that.
Yannick Cohen: I imagine that hormone changes might have a role to play as well in changing personality.
Dr. Amit Bhardwaj: Yeah. I mean, if you have hit, for example, the pituitary gland, which is a gland that kind of sits right behind your forehead, right. In between your eyebrows, you go back - that is responsible for a lot of hormones that your body produces. So if you have any pituitary involvement, if you have any thalamic involvement, which is an area of the brain, that's, pretty close to that, then you will get some hormonal changes for sure. Yeah.
Yannick Cohen: Got it. Thanks for answering that. Um, we discuss symptoms in a number of episodes, but can you give us a high-level sense of some of the more common symptoms and their prevalence that survivors experience after a brain injury?
Dr. Amit Bhardwaj: Yeah. So again, a lot of this is gonna be contingent on the mechanism of injury. When we're talking about more moderate and severe TBI, we're talking about people that tend to need hospitalization beyond just an ER visit. Those are the people that are gonna tend to have more chronic symptoms than people, you know, who went to the ER for a check-up after, you know, a relatively minor injury and then were discharged. Probably the most common symptoms that you see are chronic headaches. Whether they're chronically there all the time, or if they're there periodically, that's probably the most common symptom that you see. Other symptoms that you see very commonly are sleep disturbances, people's sleep patterns are off. And we can't really explain why that is. And then, like I said earlier, depression, is very, very underdiagnosed for these people.
Dr. Amit Bhardwaj: That's are very common as well. You know, if you're, you know, a professional violin player and you can't play your violin anymore, if you were an athlete and you can't walk anymore, I mean, these things are certainly gonna play a role in your disposition. So anxiety, depression, all that stuff is very, very common as well. Less common symptoms, some people develop seizures afterwards. That's, that's somewhat common depending on the degree of injury. Bowel and bladder incontinence - you're not able to control your bowel and bladder habits, that's fairly common as well. Feelings of hot and cold, depending on where the injury is, you know, those can get shifted as well. But the most common, like I said, are your headaches, your sleep disturbances, anxiety, depression, things like that.
Yannick Cohen: Ones that I've also heard are pretty common are memory as well as some more physical symptoms, like balance or vision problems. Are those like less common or do you see those frequently?
Dr. Amit Bhardwaj: Yeah. I mean, those are probably in the middle of seizures versus the headaches. So more intermediate, I would say balance issues, for sure. Particularly if you involved the cerebellum in your injury, if you've involved the, and I don't want to get too specific, but the posterior column of your spinal cord, balance will become an issue there as well. A lot of people develop vertigo, the sensation of the world spinning around them. Again, that's fairly common as well. Memory problems are an issue, particularly if your injury involves the frontotemporal lobe, that's where your memory centers are, particularly your hippocampus. So, those are very, very common, more related to the location of biggest insult. Um, more generally speaking headache and sleep disturbances, anxiety, depression, those tend to be more common than that.
Yannick Cohen: Got it. Thanks for going through that. Um, everything we're talking about here is incredibly difficult. Let's talk for a moment about the worst case scenario, since not everyone survives a brain injury. Can you talk about the types of injuries or demographics that have higher survival rates after a traumatic brain injury or a stroke?
Dr. Amit Bhardwaj: Yeah, so, a lot of this depends on the individual. The people that tend to do better tend to be younger, they have a more "thick" brain. They are able to handle these insults because they have more reserve, they have neuroplasticity, than say someone who's 80 years old. People who have a major traumatic event, such as a car accident are gonna do worse than are people who, you know, like I mentioned earlier, who bump their head on a cabinet, for example. People who are on blood thinners are higher risk because of the risk of bleeding, hemorrhaging into your brain, whether it's within the brain tissue itself or outside the brain tissue itself between the skull and the brain. People on blood thinners are gonna do generally worse because of that. Those tend to be the biggest areas where I think prognostication can somewhat give you a sense of who's gonna do well or not beyond that. It's really up to how your process progresses in the hospital. So how your injury evolves in the hospital.
Yannick Cohen: I guess, in your experience, are there specific things that happen during surgery or in the ICU that correlate to better or worse outcomes?
Dr. Amit Bhardwaj: Yeah. Um, it's almost like a chicken or an egg thing. People who, for example, require a lot of sedation, for example, they tend to not do as well in terms of recovering consciousness and things like that. But is that because they were given too much sedation or is it because they were so ill that they needed to be given the sedation? These are questions that really we can't answer, at least right now. If you need any type of procedure in the hospital where say your pressure in your brain, because the brain is a closed compartment, it's a bony structure that's encompassing a sponge. So in those situations, if there's a lot of swelling that occurs, that can be problematic. So you might need procedures to help offset that pressure, that has shown a worse prognosis. If you require a part of your skull to be removed to help to offset that pressure. Um, so those, those are the things that I would say contribute to it more than anything.
Yannick Cohen: Let's talk about the medical staff and their roles in the ICU. Can you talk about the different positions?
Dr. Amit Bhardwaj: Yeah. So this is often confusing for a lot of people. It's like you're seeing a whirlwind of people, you don't know who's who who's responsible for what, and unfortunately that's just the way medicine is because there's just so much to know within each particular field. So the way things will work if you're admitted to the ICU is you'll have the ICU team. The ICU team is usually, depending on the institution, the primary team that's managing your care. In some places that's not always the case, but generally speaking, you'll have a dedicated ICU team. And that ICU team is gonna consist of an attending, who is the senior doctor who's managing the team. And then you may have residents who are doctors in training below them. And then you might have physician's assistants or nurse practitioners who assist if there are no residents or sometimes if there are residents, they assist with the procedural aspects of the ICU.
Now for more brain specific conditions, you're gonna get brain specialists on board. So the brain specialist is usually a neurologist. The neurologist is a person who is specialized in brain and spinal cord and other neurologic diseases. And within that neurology team, same concept, you can have a neurology attending, you can have a neurology resident, and then you can have neurology PAs and NPs. And now if you needed like a surgical, a neurosurgical procedure - I mentioned this earlier that you sometimes need procedures to help offset the pressure in your brain or to monitor the pressure in your brain. So you might have a neurosurgeon on board with the same relative structure. You have an attending, you may or may not have residents, PAs or NPs. Usually in the ICU, you don't ever get to the point of needing a rehab doctor, but you will often have a rehab team that consists of a physical therapist and an occupational therapist who are trying to get you to be mobile.
When you're critically ill, you lose about 1-2% of muscle mass a day in a hospital. And that's just because we're just fancy machines. We're meant to move. We're supposed to get around. If we're not eating, we're not drinking, we're not exercising those muscles. Your body starts eating your muscles up. And so what you often get is this physical therapy team to help you move. Even if it's passively - say you're on a ventilator, you can't move on your own, you're sedated. The physical therapy team might do like passive range of motion exercises to keep that muscle from breaking down as much. And then you may have, if you're awake and alert, you might have speech therapy involved as well, to help you - in the hospital, it's more to see if you're able to eat certain textures of food or not, to prevent you from choking on it.
Uh, if you're not able to chew, for example, like a sandwich or something they might recommend like a pureed diet, things like that, just to prevent you from choking and getting pneumonia. And then everywhere in the hospital that you go, but in the ICU, you'll have your dedicated nurse who's really your conduit to all the rest of the team. So, if you have a pressing issue that comes up after the team has rounded, whether it's the ICU team, neurology team, neurosurgery team, your nurse who's with you throughout that hospital stay would be the person to go to if you have a question, or "Hey, I wanted to ask the doctor a question". You let your nurse know, and then the nurse would reach out to the respective team on your behalf.
Yannick Cohen: The dedicated nurse - is that someone who is monitoring your vitals the entire time as well, and will alert others, if, if something needs to be done or they'll handle issues as they come up as well?
Dr. Amit Bhardwaj: Yeah. So the nurses are really, really important because they're the eyes at the bedside. They are our eyes. They're the ones who are there with you, you know, 24 hours a day, seven days a week. They're the ones that are managing your day to day. Things like cleanliness, hygiene, things like that, but they're also there to help monitor your vitals. To make sure your blood pressure is good, making sure your pulse is good, making sure your oxygen levels are good, making sure you're not breathing too slow or fast, making sure your urine output is appropriate, making sure you're eating enough. The nurses are involved in all of that. And we as the doctors are gonna rely on them for a lot of that information and nurses in the ICU often have two to three patients that they're taking care of versus the doctors are taking care of anywhere from 15 to up to 25 patients. So we can't be there all the time. So the nurses act as those eyes for us, and they'll often be the ones to tell us, "Hey, you know, this guy or this lady isn't looking quite right. Would you mind coming by to the bedside and taking a look?" So they're very, very important, for a number of things, including vitals monitoring.
Yannick Cohen: How is nutrition done? Particularly if a patient has a tracheostomy, am I pronouncing that correctly?
Dr. Amit Bhardwaj: Yeah. So if you're in the ICU after a, traumatic brain injury, there's a very good chance that you're, what's called intubated. So intubation is basically where you're not able to breathe on your own or you're at risk of not breathing on your own. So they put a tube down into your mouth, into your trachea, which is your windpipe and putting you on a ventilator. You can only be on that ventilator for a very short period of time. Generally not longer than two weeks. That's when they start talking about what's called a tracheostomy where it's a hole in the neck in which now you still will be on a ventilator, but you won't need to be sedated because when we put a tube in your throat, your gag reflex is active. And so you're at risk of pulling it out.
So the tracheostomy helps bypass that if you still need a ventilator, whether you're intubated or have a tracheostomy, you're not able to eat on your own. So what they often do is when you're intubated, they put in something called an OG tube. So it's a tube that they put down your mouth into your stomach, and they give you artificial feeding. They call them tube feeds that provide a certain number of calories, certain number of carbohydrates, certain number of fats, certain number of proteins, and the type of tube feed that you get is based off of the dietician who's also part of the ICU team. The nutritionist or dietician is gonna come and help decide what tube feeds are appropriate for you. When you have a tracheostomy, you still can't eat on your own. But it's uncomfortable to now that you're awake to have a tube in your mouth going down into your stomach. So they put what's called a peg tube in, there are different types of tubes. The most common one is peg tube. They put it directly into the stomach and, and you're able to administer tube feeds that way. And based off of your ideal body weight, based off of your height, the dietician or nutritionist, they decide that this is the tube feed you need. This is the rate at which you need to be given it, to help maintain your muscle mass and help you recover.
Yannick Cohen: That makes sense. You had described rounding earlier briefly. Can you describe rounds? How often they're done, what is done during these rounds and how the medical staff monitors a patient while they're in the ICU?
Dr. Amit Bhardwaj: Yeah. So rounds are, if you've ever been in a hospital, you'll hear the nurse say, "oh, the doctors haven't rounded yet, or, oh, the doctors have rounded." So rounding is basically when the physicians are making their rounds. I alluded to earlier 15 to 25 patients that they may have on their service. They're seeing each patient individually. The rounds are conducted by the attending [physician] who heads the rounds, followed by the residents who you'll often see if you're at a teaching hospital or the PAs or NPS, or a combination, depending on if you're in an academic center or not.
And what that entails is, is basically a review of all your labs. You know, that thing that we do every morning to wake you up and really irritate you. They're always drawing blood, we review the labs, we review the vitals, we review urine output, how much urine are you putting out? Have you had bowel movements or not, we review the medications that you're on, we review any new things that may have arisen overnight. And a lot of that is involved with communicating with the nursing staff as well to see if there are any overnight events that need to be addressed. And once we kind of get a picture of what that looks like, then we'll come talk to you and say, based off of the current data that we have, this is what we're gonna do for you today. We're gonna adjust this medication. We're gonna give you this fluid. We're gonna adjust your feedings this way, et cetera. With respect to how many times we round as a team, usually it's once a day. The way it generally works is the ERs tend to start getting busy towards the afternoon times, which is why rounds tend to be in the morning, what you see with most teams in most places.
So generally the way that the day works out, it's only once a day. But that's not to say, if you ask the nurse, like, "Hey, I want someone from the team to come talk to me in the afternoon", oftentimes you'll be able to make that happen - sometimes in person, a lot of times over the phone. But it's generally once a day and every subspecialty will do that. So you'll have your ICU team round, then you'll have your neurology team round and then you'll have your neurosurgery team. If you had a neurosurgery team round, then you'll have the physical therapist, occupational therapist come by, maybe a nutrition, dietician come by, speech therapy. Every team rounds, at least once.
Yannick Cohen: And those are done separately? They don't get together and do a round together?
Dr. Amit Bhardwaj: No, and I know that's a huge source of frustration for a lot of families. Just logistically it's impossible to happen. The ICU team doesn't have clinic, but often subspecialties will have clinic. So is the neurologist rounding in the morning or afternoon? That's contingent on, you know, is their clinic in the morning or in the afternoon? Neurosurgeon, are there any emergency proecedures that came in? You know, surgeons sometimes round at five in the morning, sometimes they round at eight at night, that's contingent on what procedures need to be done emergently, what procedures do you have scheduled as routine. So logistically it's impossible to get everybody to round together. That takes a lot of planning. And even with that planning, and I know this is a huge source of frustration for a lot of families, because you hear one thing from one person, and it sounds like you're hearing something else from another person. And that's frustrating, but just the logistics of the way the system is built, it's impossible to get everybody to round together.
Yannick Cohen: Yeah. I remember that being a very large source of frustration as well. You had mentioned that you'll have these conversations with the patient if possible when they're conscious. But for brain injury, especially TBI, a lot of times the patient will be unconscious. Are you having those conversations with the families each time if they're around? Or how is that done?
Dr. Amit Bhardwaj: Yeah, so people who have traumatic brain injury to the point of unconsciousness, and, you know, for the ICU specifically, if you're intubated, sedated, you know, on a ventilator, you're not gonna be able to make your wishes known. So the hope is that you've identified a healthcare proxy, or different places call it a power of attorney, a medical power of attorney. If you're older, you may have had those discussions. You may have even legal paperwork to that effect. If you're younger, the chances of you having that are probably slim to none. I implore everybody to, and I know it's upsetting to think about who would make these decisions for you if you're not able to, because life is very unpredictable, you know, I don't know what's gonna happen in the next five minutes.
You know, if I'm driving on the road, it could be severely traumatic. So identifying who these people are is very, very important no matter what your age group is, but particularly if you're older. So yes, if you're not able to make those decisions on your own, the team ideally should be communicating with these people that you've identified. I know that's not uniform for everybody. And I know there's a source of frustration there. But it's your right to know what's going on. So that's the point at which you ask the nurse, "Hey, can the doctor talk to me?", "Can you have them give me a call?", et cetera. If you haven't designated a power of attorney, there is a legal sort of structure, generally it's your spouse. And then if it's not your spouse, then it's often your siblings. If it's not your siblings, it's your parents. And every state has its own sort of hierarchy. Generally it's gonna be your spouse, a legal spouse. They will be the one that are there to make those decisions for you if you're not conscious enough to do them and haven't designated someone specifically to do that.
Yannick Cohen: That makes sense. Thanks for going through that. What are the primary metrics the staff is monitoring and what happens if any of these things get too high or too low?
Dr. Amit Bhardwaj: Yeah, so brain injury is very unpredictable. Like we said, everybody's body behaves very differently. When people talk about vitals, what they're talking essentially are, is your temperature in an appropriate range? Is your heart rate in an appropriate range? Is your blood pressure in an appropriate range? Are you breathing too slow or too fast? And what your what your oxygen levels are, what your oxygen saturation levels are. You want everything to be as normal of a range as possible. So, normal for a patient, is dependent on their age and what their underlying medical problems are. But in general, you want the heart rate to be 60-100. You want the blood pressure to be, the top number to be 90-150 at most the bottom to be, you know, anywhere from 50-90 at most.
Heart rate I think I mentioned 60-100. You know, you don't want to be breathing faster than a rate of 20. You want your temperature to be in a normal range, less than a 100.4, but more than, you know, 96 degrees. Oxygen levels to be higher than 92%. These are all things that we're looking for. Um, now there are exceptions to this. If you came in with a massive stroke, for example, they wanna keep your blood pressure at a much higher range. They wanna keep the top number up to 180 in that case, those are exceptions. Sometimes if you have an infection, and your heart rate is going slightly fast, say one 110 to one 120, we are generally okay with that because your body needs that extra blood supply. And if we give you meds to drop your heart rate, then we can drop your blood pressure and we can run into issues. So there are exceptions to these rules, but generally speaking, we are trying to keep all these vitals within somewhat of a normal range.
Yannick Cohen: You had mentioned intracranial pressure earlier when talking about procedures to keep that down. Can you talk a little bit more about this metric?
Dr. Amit Bhardwaj: Yeah. So people who have brain injury that involves blood in the brain, swelling of the brain or, you have a thin layer of fluid called cerebrospinal fluid that coats your brain and spinal cord, if that fluid gets blocked up, gets plugged up, you start building pressure into your brain. And like I mentioned earlier, your brain is a closed compartment. It's a hard rigid skull that's encompassing a very spongy and soft, organ. And so anytime that starts happening where the brain is starting to get to the walls. If I start compressing on the brain, I'm gonna start damaging the neurons, the brain cells here, and they can potentially stop functioning. So I need to get this structure to open up a bit or relieve pressures in some areas. So different ways that they monitor pressure in the brain is something as simple as looking at your pupils.
Your pupils do something particular if your brain starts getting more pressure to it. If they do a CT scan of your brain and it's showing signs of swelling, then they might do more frequent CT scans, every four to six hours to see is the brain really expanding? Is the swelling getting worse? Is the blood getting worse? If it is, then they might do something called an ICP monitor where they basically put a monitor in the back of the brain to look at your intracranial pressure, to see what's the exact number. And if you see that the pressure's getting higher, then you might need to do things like putting a holes into the skull, or maybe removing a part of the skull to help offset that pressure. So that's certainly involved in neurosurgical cases. You will always have a neurosurgeon on board in that situation.
Yannick Cohen: Can you talk a little bit about measures of consciousness as well and how those are used particularly in traumatic brain injury cases?
Dr. Amit Bhardwaj: Yeah, so, we use something called a Glasgow Coma Scale or Glasgow Coma Score. It's based off of your eye movements, your ability to talk and your motor skills. It's used to get a sense of the degree of neurologic insult. So the highest score is 15. The lowest score is 3. People who are less than 12 are neurologically compromised to the degree where you might need closer monitoring, closer monitoring mean ICU management. Less than nine, you often need to be on a ventilator, to protect your airway, because your muscles and your throat and your neck, your tongue, they may be too floppy. You might not be awake enough to handle the saliva that your body naturally produces. So they'll often put you on a ventilator in that situation. But the biggest one that we use is, is the GCS, the Glasgow Coma Scale. There are other scales, but less known. But when you talk about vitals monitoring for particularly a TBI patient, that will include the GCS as well.
Yannick Cohen: Can you talk a little bit about the types of imaging that is usually done? And what you and the radiologists look for in those scans?
Dr. Amit Bhardwaj: So you cannot get x-rays on the brain. The skull prevents you from getting that one flat image. So the initial imaging that you'll get, and they'll often rush you into this, so when EMS calls in that, "Hey, we have a trauma coming in", they'll get you in for a CT scan of the head. The CT scan of the head is gonna give us a sense of, is there a bony injury? Do you have a skull fracture, for example, is there blood in there, or does it look like there's signs of swelling? You can see that on a CT scan. CT scans are not a great image though, to delineate the fine structures of the brain. The fine structures of the brain are better seen under what's called an MRI, a magnetic resonance image.
MRIs can delineate between two types of tissue that are in the brain. And I don't want to get too technical, but there's white matter and gray matter. So to see that delineation to make sure that the white and gray are well delineated - if they're not, is there swelling, is there blood in the smaller aspects of the brain? Because the CT scan's not gonna be able to look at your brain stem. It's not really gonna be able to look with good clarity in your thalamic structures, hypothalamic structures. So in that case, you'll need an MRI. And at some point, every neurologic patient is gonna require an MRI. The only thing is that MRIs are take a lot of time and they're very expensive. So hospitals often only have one, maybe two machines, if you're lucky. And so that often isn't done right away, especially in smaller hospitals. Uh, but CT scans are very quick. Within five minutes, I can get a full CT scan and a general understanding of what your brain looks like. But those are the two big imaging tests that we use to look at the brain.
Yannick Cohen: And you mentioned that patients will sometimes have recurring imaging throughout their stay in the ICU as well. Can you talk about the frequency and what types of images those are?
Dr. Amit Bhardwaj: Yeah. So when you're in the ICU for a brain injury, you will need serial monitoring. The serial monitoring basically tells you the evolution of the brain throughout the hospitalization, depending on what they find on the initial CT scan or the repeat CT scan. So the second CT scan is gonna determine how frequently you get that test. If you have bleeding in your brain, you're gonna have that test done every four to six hours. If there's signs of swelling, you're gonna have that test done every four to six hours. If there's no signs of a change between the first and the six hour one, they may delay it to every 12 hours or every 24 hours. That's a reassuring sign. So when you're talking about serial imaging, you'll often see in notes, everybody's privy to the notes through, the portals that the hospitals provide, you'll see serial imaging under the assessment and plan of a doctor's note.
And that's what that means. Are we serially imaging 4, 6, 12, 24, however much they've determined. Serial imaging also is dependent on how your neurologic exam evolves. So you'll see that the nurse is doing a neurologic exam on you every one hour, every two hours, every four hours, depending on where in your hospitalization you are. And so if they see if the nurse sees a change in your neurologic exam, or if the team that's rounding in the morning or in the afternoon, or whomever sees a change from the day before, then that might prompt a repeat image as well. So in those cases is where you'll see repeat CT scans.
Yannick Cohen: Thanks for that. You've talked a little bit about some of the specific procedures that are done either right before the ICU, or during the ICU, including the imaging, which you just covered. Are there other specific procedures that are common for brain injury patients while they're in the ICU?
Dr. Amit Bhardwaj: Yeah. So oftentimes you'll get a lumbar puncture. Basically that's a needle that goes into the lower back to draw out that cerebrospinal fluid that I had mentioned earlier to see if there's any blood in there, to see if, it should be very clear, clear like water. So if there's any changes to that, then that can indicate, a particular type of bleed in your brain. Sometimes because of the brain injury itself, you are in an inflammatory state, your body is trying to fight something. The way that it fights things is it causes your inflammatory markers to go up. When inflammatory markers go up, you oftentimes get a high heart rate, you get a high fever. Sometimes if that fever stays prolonged for a long time then they might be concerned about meningitis, which is an infection that gets in the surrounding tissue of the brain because that blood brain barrier, your blood is supposed to be protected from your brain. There’s supposed to be nothing crossing through them other than the minerals and things like that your body normally does. If anything is now disrupting that blood-brain barrier, theoretically an infection can get through and meningitis can be very deadly and so they'll often do an a lumbar puncture to try to see if there's an infection, to see if there's meningitis.
Other procedures, like I mentioned, they might put an ICP drain in, they might do burr holes if there's a lot of swelling, they might do a removal of a part of the skull or the whole skull depending on how how bad the swelling is. So those are some of the common things that you'll see with brain injury.
Yannick Cohen: Let's talk about patient visits. One of the most frustrating things that I remember about our time in the hospital was the waiting game. We'd see my brother every day but then we'd often go a couple of days without speaking to a doctor about my brother's condition. Which when he's in a coma is truly awful. What are the best ways that you can recommend that family members can stay informed while their loved one is in the ICU?
Dr. Amit Bhardwaj: So brain injuries in particular are very tough. They often are hospitalized for a long time - we're talking on the order of weeks to months even, depending on how bad the traumatic brain injury is. And especially in this day and age we look for that sort of immediate, you know, Amazon delivers to me within a day now. I'm looking for that immediate sort of satisfaction for things like answers.
But with brain injury it's time. You're not going to see day-to-day changes. There may be nothing that the doctors tell you because there is nothing to report. Most times with brain we're supporting the brain's recovery which it’s doing on its own - there's nothing that we can necessarily intervene on to speed it up, versus you know obviously if there's a lot of swelling, if there's a lot of pressure, things like that. But when it comes to like states of consciousness, we're just giving the body time. So oftentimes this will be frustrating because you know the doctor will come in and say “Oh there's no change today, we're just going to keep going.” If you're older they might say the prognosis is poor maybe we want to start thinking about quality of life over quantity of life. That might be a conversation that you start hearing if there's no meaningful improvement after a few weeks.
But in general if you're looking for immediate answers, that's your right and so that's where the nurse would be the best conduit. Of course, trying to be there during rounds would be the best, but like I mentioned earlier, you don't know when in that 15 to 25 patient rounding period you are. You could be number 25 or you could be number 15 and rounds often take four to five hours. Sometimes you can't just sit there, so that's where maybe having the nurse be your advocate and say “hey we wanted an update, can you please have the doctors give us a call.” But with brain injury, the part of the frustration is certainly the the nature of the disease is that it's mostly a waiting game.
Yannick Cohen: Has COVID-19 changed how family members are allowed to visit ones in the ICU at all?
Dr. Amit Bhardwaj: Absolutely, yeah. Depending on what state you're in, depending on what county you're in, depending on what hospital you're in, for a period of time, almost uniformly, no one was allowed to visit in the hospital. So everything was being done via zoom or over the phone in terms of your ability to see your loved one or the physicians or the nurses talking to you. Now things are a little bit more open - some hospitals, and this is very hospital specific, this isn’t general, and this is often contingent on what state you're in - some hospitals allow one family member in, some people allow two family members in, some allow everybody in. It really just depends on the hospital. And that can change again if there's a new variant that comes out that's you know as deadly as delta. It may go back to nobody being able to go in. So it's ever evolving but absolutely COVID-19 has changed a lot for the healthcare system including visits.
If your loved one isn't doing well, though, I know of very few hospital systems that have said you cannot be there if your loved one looks like they're imminently about to pass or are at high risk of passing. Then they'll allow you in. How many people they allow, that's up to the facility. But oftentimes they will allow you in.
Yannick Cohen: I imagine that the nurses can't be talking to loved ones over zoom all the time - they have to be attending and monitoring patients. How is that done with the nurses’ time and the rounding teams’ time?
Dr. Amit Bhardwaj: Yeah, this is something that is very important for families to realize. Everybody comes with their own unique perspective and everybody has differing questions. What I would suggest is if your family member is hospitalized for any reason, not just brain injury, for any reason, it's often to have one point person that the team can talk to because we can't talk to 3, 4, 5 different family members. And keep a list of questions. So instead of asking those questions now and then you have another question an hour later and reaching out to the nurses or the doctors, that's where the family-physician or nurse relationship often goes awry. We have to be respectful of everybody's time. And so keeping a list of questions is helpful and keeping that one person as a point of contact is very helpful. And then letting the nurse or the doctors know that whenever they're free, please give me a call and then have your list of questions ready, or have all the family members who might have questions on that one call so that we're able to provide care for everybody equally.
Yannick Cohen: You had mentioned that for brain injury, a typical stay in ICU can last weeks or months. What can lengthen or shorten the stay?
Dr. Amit Bhardwaj: Yeah. So, the things that lengthen or shorten hospitalization are all the things that are involved in prognostication. So people who are older, people who are on blood thinners, people who have a major traumatic event leading to their brain injury, people who have bleeds in their brain, people who have massive strokes. And there's massive stroke versus tiny stroke versus transient ischemic attack or mini strokes. These are terms you might hear. Massive strokes are gonna have a longer length of stay as well. In general, if you are in a hospital more than a week, your prognosis goes down for every day beyond that. Why that is often is because of all the things that I mentioned before. Two weeks is probably a good average, but that encompasses minor as well as the most severe.
So I think two weeks on average, but, you know, we've had people there for three months, I've had people for four months, I've had people, you know, leave from the ER that day with, you know, things that you think would be more severe. But in general, it's age and its mechanism of injury and comorbidity. I think I mentioned this earlier, you lose one to 2% of muscle mass today. So if you're in a hospital for more than two weeks, I mean, you have to start asking yourself that question, you know, they're not gonna be able to walk the same for a while. If they need a tracheostomy, if they need a peg in their stomach, you know, would they want that? And that impacts quality of life significantly. Especially if they've been very ill and their quality of life has been poor up to that point. So these are questions that the team will be asking. You'd have to start asking yourself after probably a week in the hospital. But yeah, in terms of determining length of stay it's age and mechanism of injury and I would imagine two weeks is where I would say anecdotally the average is, I don't know what the data says in particular though.
Yannick Cohen: Do patients ever need to be moved to a different facility while they're in the ICU? What would their reasons be and how are they transported?
Dr. Amit Bhardwaj: Yeah. So there are, and this is contingent on the state that you're in. I practiced in New York for a while. They didn't have a concept of long term acute care (LTAC) hospitals, Pennsylvania does. So basically if a patient is in a hospital for a prolonged period of time, they may start talking to you about transferring to a long term acute care hospital. So these hospitals that you see that have ERs in them, they are acute care hospitals - they're meant for short stays and quick discharges for better or worse. That's just the way healthcare is right now. If you have a patient who needs a prolonged stay, then they might start talking to you about these long-term acute care hospitals, which have more of the rehab component attached to them, than do these acute care hospitals.
So an LTAC might have, you know, not just physical therapy and occupational therapy, they'll have a physiatrist or a doctor who specializes in rehab for patients. They'll have a whole slew of rehab therapies that acute care hospitals just don't have. Acute care hospitals might have physical therapy, occupational therapy and speech therapy, but they're not gonna give you anything more than that. Pet therapy, music therapy, things along these lines and the degree and duration of therapy as well - hospitals, acute care hospitals cannot provide. Acute care hospitals, their physical therapy is gonna involve, you know, 15 minutes, 20 minutes at most versus if you go to an LTAC facility, they'll be doing therapy with you for at least 30 minutes, if not longer.
Dr. Amit Bhardwaj: So it's often in your best interest, if you need to be in a hospital for a prolonged period of time, transferring to these LTAC facilities, to be able to get that therapy component and to help limit that muscle breakdown that I talked about earlier and to help your recovery sooner. But some states don't have that. And so if you're in the ICU, you're in the ICU until you're safe to be downgraded to the general hospital floor. So that's really the only time that you'd be transferred. If you're at an ICU at a smaller hospital, they may transfer you to a more specialized hospital. Some specialized hospitals have neuro ICUs, neurologic ICUs. A lot of smaller hospitals don't have that. So they may look to transfer you to a hospital capable of a neuro ICU. That might be another situation, but for the most, if you're in the ICU, you're in the ICU, they may talk about transfer to an LTAC, but generally speaking, not anything beyond that.
Yannick Cohen: How would they be transported? Is that, you know, typically done in an ambulance?
Dr. Amit Bhardwaj: Yeah, generally it's in an ambulance. If it's an acute transfer, you transfer say, you know, God forbid you developed a GI bleed and you don't have a surgeon on board or a GI doctor on board at that hospital. Then they might transfer you to a hospital that does have those services, in which case they might life flight you on a helicopter. But most times it's via ambulance.
Yannick Cohen: Okay. We're down to the final few questions. What are the types of a coma a brain injury patient might have?
Dr. Amit Bhardwaj: So, the comas that you see tend to be either medically induced or not. Induced comas tend to be where they're fully paralyzing you to allow your body not to break down as much, to give your body full time to be able to direct its resources to its healing. If you develop pneumonia and need to be put on a ventilator, they may need to put you on your stomach. In that case, they may paralyze you and put you in a coma in that situation. Beyond that, if you have lost consciousness and you remain without consciousness, without medicines that you're on, without the medicines that we provide, that's generally a bad prognosis. In which case they might not give you sedation in that, in that situation. But you know, the coma designation is medically induced versus you just came comatose as a result of your injury.
Yannick Cohen: And the medically induced coma. That's temporary, I assume.
Dr. Amit Bhardwaj: Yes, absolutely. If you're in a medically induced coma, they'll keep you in that state until they start seeing some meaningful improvement, generally not more than a couple of weeks though we've seen it longer. But you don't wanna keep that going for too long. If there's a situation where that requires it, then you need to start talking about goals of care, thinking about what are we achieving here by keeping this going? And those are conversations the team will be having with you.
Yannick Cohen: Can you describe the wake-up process, whether it's from a medically induced coma or otherwise? Because from what I remember, it's not immediate, it often takes hours or even days, and consciousness only, only gradually returns.
Dr. Amit Bhardwaj: Yeah. So in the ICU, they all have standard protocols, what's called a sedation holiday. So they'll stop sedation for about an hour or two and see what your neurologic exam is without the sedation. And that's standard. You wanna give that sedation holiday just to get a neurologic baseline, but also you don't wanna keep pumping benzodiazepines and opiates or paralytics into somebody. You don't want to keep giving them because as they build up into the system, it'll take longer for them to come out. Particularly if you have kidney injury, if you have liver injury, these organs that help metabolize medicines or control metabolism in general, if I keep giving these things and I keep getting the levels higher and higher, then that getting them lower and lower will be more difficult.
And people in the ICU, they don't just have one issue. They may come in with one issue and then they develop a whole plethora of them throughout their stay. Their heart might not work as well because of the shock. They may develop a bleed in their stomach. They may develop pneumonia, very commonly develop pneumonia. They may get kidney injury, very commonly get kidney injury or liver injury. These are things that you often see. And so that sedation holiday helps offset some of that medication buildup, but also gives you a sense of where the patient is neurologically. In terms of what they do to wean you off: when they feel that you're able to, your brain is healing, or you're able to breathe on your own.
They have ventilator settings where they put you on a spontaneous mode to see if you're able to breathe on your own, or are you requiring the machine for support? They'll cut back on the sedation slowly, and then they'll see if you're breathing on your own and the point at which you are able to do all that. They'll remove the tube and take you off the ventilator. People who tend to remain sedated long, like I said, tend to be older - or in the ICU longer, not sedated longer - I'll talk about why I made that distinction in a little bit - but people who are older or have a bigger mechanism of injury, they're going to be needing sedation longer. And they're going to be more critically ill, just by the nature of who they are in that situation.
You might not even need sedation in those patients. You know, you may wait until they wake up on their own. They start exhibiting a gag reflex or something like that before you start sedation. Also depends on where the injury is. If you have an injury in the wakefulness pathway, and there is a wakefulness pathway in your brain and brain stem. If you have an injury there, that may require a more prolonged period of time in which you're in a coma or not. The reason that I brought up the distinction of older or younger, younger people may need more sedation because they're stronger, their liver and kidneys are better. And so in that situation, you may need to give them more sedation, but not necessarily longer sedation because you expect those patients to improve quicker.
Yannick Cohen: You had talked about some of the risks of keeping patients sedated for too long. Can you talk about the risks of bringing them off too early?
Dr. Amit Bhardwaj: Yeah. So if you keep them on too long, the medication takes a while for it to dissipate. If you keep them on too short, they're at risk of hurting themselves: pulling out their tube too early, pulling out their lines too early, causing seizures. If you have blood in your brain, particularly in frontotemporal lobes, or if you have a mass in your brain, in the frontotemporal lobes, inducing seizures, if you pull them off too quick. So those are the things that you might see where we might have to keep them under longer to prevent those things.
Yannick Cohen: You've talked a little bit about where a patient might go after the ICU. Between, the long term acute care hospitals , maybe the general hospital floor or neuro ICUs. Are there other places that patients might go after the ICU as well?
Dr. Amit Bhardwaj: So generally after the ICU, it's very rare for the ICU to discharge a patient from the hospital. They're looking to downgrade you. You'll hear that term "downgrade" - to downgrade you to the general medical floor where someone like myself, who's a hospital doctor will take care of you. Aside from the LTAC, aside from a higher level of care ICU, generally you don't see ICU's discharging to any other disposition. Their goal is to get them to me. And my goal is to get you to either home or to a rehab facility so that you can continue on your recovery after that. A lot of people love being in the ICU because of the close monitoring. You know, the nurse has two to three patients.
The rooms are almost always private, they're nice and big to allow family discussions versus the general medical floors aren't like necessarily like that. But your goal is to progress in your hospital care and to provide that bed for someone who needs it, if you don't need it. So your goal is to get to the general medical floor, albeit it may be a smaller room. It may be a shared room. It may not allow as many family members in the room, et cetera, but that's the goal. It's to get you down to a general floor so that we can start talking about sending you home, if you've gotten well enough to do that, if you're independent enough or sending you to a facility to continue on with rehab there.
Yannick Cohen: All right. Well, those are all the questions that we have for you today. Dr. Bhardwaj, thank you so much for joining me today and for all of your very thoughtful answers.
Dr. Amit Bhardwaj: No problem. Thank you for having me. I hope to be back and, uh, look forward to talking to you guys again.
Yannick Cohen: Ok, that’s it everyone! Remember that you can see all of Dr. Bhardwaj’s answers and ask him follow-up questions on brain.brightwayhealth.org. We’ll also post a link to his answers in the show notes.
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I’m Yannick Cohen, thank you so much for listening to Brightway Answers.