Recovering from severe brain injuryBMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c839 (Published 11 March 2010) Cite this as: BMJ 2010;340:c839
- D J B Thomas, patient,
- Martin Skelton-Robinson, honorary consultant neuropsychologist
- Correspondence to: D J B Thomas
- Accepted 5 January 2010
Stopped in my tracks
I was involved in a serious road traffic accident in May 2008. I was amnesic after the accident and have no memory of it. I am told that a stag jumped into my open top Lotus 7 sports car in Epping Forest. I lost control of the car, hit a tree at speed, and sustained a severe brain injury. It took the fire brigade an hour and a half to cut me out of the car, and paramedics recorded my Glasgow Coma Scale score as 9.
At the local accident and emergency department I was found to have numerous soft tissue injuries and a fractured right mandible, maxilla, and clavicle. A magnetic resonance imaging scan of my brain showed bilateral frontal and temporal lobe contusions. I had a grand mal seizure. I was transferred to a neurosurgical unit and spent several days in intensive care. My family were told on my admission that I might die, and subsequently that I would never again be able to care for myself. I was transferred to the rehabilitation ward in the hospital where I had worked as a consultant physician. As a patient I had excellent treatment, and the kindness and concern of the staff were most striking.
I remained amnesic for 10 weeks. I was unaware of my clinical condition. My only memories from this period were of a fabricated world I had created, populated by family members and in-laws. It was semi-dark, and I could not contact anyone directly—with the exception of the luminescent Crossie, an imaginary young daughter who was living several miles away from home. I wanted her to come back to live with me. Some have suggested that she may have represented the cross of Christianity or a “cross” I had to bear. During the amnesic period I spoke, sometimes appropriately, but I have no memory of this. However my wife says she saw glimpses of my previous self.
The fog clears
The fabricated world was all I had, and it seemed very real. As my memory started to return I realised that all the family members it featured were dead and that Crossie had never existed. I went through a second bereavement process for my absent loved family.
My daughter feels that my moving from a ward to a side room enhanced my progress. I began to recognise staff and visitors but could not remember names. I then realised I had forgotten facts like family birthday dates. I had forgotten who I was. I had lost all my mental geographical maps, so I could not be trusted to leave the ward.
I had been nursed one to one, but became embarrassed when I realised I was being accompanied in the toilet. This insight meant the one to one nursing could stop. I was now able to have physiotherapy, and discovered that I had physical disabilities. My balance was poor, I was clumsy, and I had a slight visual field defect.
My insight into my condition improved, and I began to realise what I had lost. I was told that my age, 60, would make recovery harder. I later realised that some memories were false.
My speech and language therapist was Australian. We talked about animal names being used for international rugby teams. I remembered the Australian Kangaroos rugby league team. As I thought of kangaroos I remembered my childhood in Wales with cows in the fields and, I thought, kangaroos in the forest nearby. I found myself theorising on how kangaroos had moved from Wales to Australia. When I realised my mistake I felt embarrassed, but those I told found it amusing.
I was originally upset when the therapist told me I was tangential in my conversational responses. It seemed she was trying to score points rather than help me. A little later, when I was talking to a colleague, I realised that I was indeed being tangential. I respected my therapist more after this. These insights initially had a very dispiriting effect on me, but they were to help me initiate a personal strategy for my recovery.
I called my personal strategy “being back at school” because I could not remember most of what I had learnt or been taught in life. I remembered school as being an ordered environment with expert teachers. It was similar in some ways to the structured rehabilitation programme I was now undergoing, starting the day with exercise followed by a therapy timetable. This strategy gave me great consolation as it was a pathway. By working hard I could regain much of what I had lost. I was starting in primary school again but could sequentially improve and progress through each year until I reached my pre-accident level. In therapy sessions I asked for homework to do in my room and then started setting my own homework.
I obtained my curriculum vitae, which showed how long I had been a consultant, how many papers I had published, and that I had been a Royal College of Physicians examiner and clinical director in medicine. It would be a very long journey to get any of this back. I then saw a psychologist who assessed my cognitive function. I realised I had to redevelop my thinking processes. I did this by reading, accessing the internet, doing Headway exercises (see box 2), playing Sudoku, and taking MENSA IQ tests.
A ray of light
After six months I thought that lost memories would be unlikely to return, but this was not so. First I had to relearn memory techniques, beginning with attention, repeating the process, and practising retrieval. I then found that I could remember my dreams again, and, where laborious attempts to remember things had failed, memory started to return spontaneously. This convinced me that memory was still stored; it was now a question of learning how to relocate it. It was as though I had an encyclopedia, but the index was missing.
I also found that experiential learning and memory were more efficient than abstract thought. Six months after the accident I visited London Zoo, remembering and learning a lot. A visit to the outside of a previous family home near Swansea triggered the memory of the contents of every room and the internal structure of the house, which I had previously tried to remember and could not. The sensory stimuli from sight, sound, and smell can be very strong. Being near the sea had a remarkable effect, with the sound and smell bringing back old memories.
I came to terms with age delaying my progress. I saw David Attenborough, who is 20 years older than me, talking about animals on the television. This made me realise that increasing age does not always destroy ability: other factors are important for success, such as innate skill and determination. This observation had the effect of increasing my perseverance, and I was able to see that early failure was not necessarily total failure.
My physical injuries resolved. I was able to jog again, and I wanted to resume playing golf. Jogging was easy: it was about getting fitter to run further. When I attempted to hit a golf ball on the practice ground my balance was poor, and every shot went far to the left. However, I was able to analyse what was wrong. I found it was my grip, and when this was adjusted I produced straighter shots.
I am working hard to improve my medical knowledge so that I might do some outpatient work. I am also improving my teaching skills and doing some local archive work. One of the great inspirations for me is Hippocrates. He said that no brain injury is too severe to despair of, nor too trivial to ignore.
Box 1 A doctor’s perspective
My first clinical meeting with Dai was three days after his transfer to the rehabilitation ward some five weeks after his head injury. His article gives little impression of the severity of his cognitive and behavioural injuries at this time, not surprisingly, as he has no recollection of this part of his life. When I met him he had largely lost his identity, his sense of modesty, and his ability to communicate sensibly.
This clinical picture prevailed up until about the end of July 2008, when the period of post-traumatic amnesia ended, and there was rapid recovery of cognitive function. Going from being almost unfit to undertake psychometric testing to returning to scores on standard tests of cognitive function (WAIS-III, WMS-III, DKEFS) close to, or at, his premorbid level happened in just two months, though some measures of his language ability, for example the Similarities subtest of WAIS-III, did not recover as quickly, nor to quite the expected level.
At the initial assessment I expressed a gloomy prognosis to his family and his employer. However, I was completely and agreeably mistaken, and the first lesson for me was a much increased distrust in the value of relying on standard indices of severity when giving a prognosis for head injury.
Dai’s article refers to the contribution of therapists, but it should be stressed that the unit where he was placed is not a dedicated brain injury rehabilitation unit, but one that offers rehabilitation for a variety of chronic medical conditions. In fact, Dai was assessed for and declined to attend the local brain injury unit. I thought his decision wise because he would not have fitted in with the much younger people likely to be attending the unit, some of whom would have had marked behavioural problems and a very poor prognosis.
The reader needs to be aware that Dai, as soon as he was able (early August 2008), set about designing his own rehabilitation strategies with the therapists as his advisers. His rehabilitation was therefore very much self determined. This fact emphasises the second lesson for me: the influence of premorbid personality on recovery. In October 2008 Dai described himself to me as follows: “Quiet, unassuming, sympathetic, hard-working, not volatile or demonstrative.” He failed to mention his modesty, his love of learning, and his pride in the care he had given to his patients over many decades. I suspect that a patient with a less positive set of personality traits would have been much less likely to achieve the same outcome after a severe brain injury.
The third lesson concerns age and prognosis. Physiology documents the adverse effects of age on the brain. The obvious inference is that younger people with traumatic brain injury are likely to have a better prognosis than older people. But this ignores the influence of previous learning. Positive personality traits, which are likely to assist in recovery, will be less firmly established in a younger person. They will not have become, as does a person’s written signature, an over learnt habit almost impossible for the brain injury to eradicate. Dai’s seniority may in fact have been an advantage in his recovery.
Box 2 Organisations and useful websites
Brain injury (www.braininjury.co.uk)—A website providing information and links on brain injury and head injury, it focuses on legal issues such as compensation, personal injury, the Court of Protection, and the Public Guardianship Office.
Headway UK: the brain injury association (www.headway.org.uk)—A charity set up to support people affected by brain injury through a network of groups and branches throughout the UK and Channel Islands.
Cite this as: BMJ 2010;340:c839
This is one of a series of occasional articles by patients about their experiences that offer lessons to doctors. The BMJ welcomes contributions to the series. Please contact Peter Lapsley () for guidance.
Competing interests: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.