Flatline to Lifeline With Dr. Long
Consider a world where increasing survival rates in patients typically deemed dead on arrival could be the norm. Is dead actually dead? Is it an assumption or a fact? In Flatline to Lifeline we explore the very real potential for survival within the medical field of trauma and near-death experiences.
During his 50-year career, Dr. Long and his team radically altered the approach to trauma care by applying simple principles in profound ways. We hope to educate the general public and inspire medical practices worldwide to acknowledge and adopt these life-saving approaches to trauma care, because when the need is greatest for the patient, saving time saves lives.
Flatline to Lifeline With Dr. Long
When Every Second Counts: A Motorcycle Officer's Survival Story with Dr. Jeff Chen
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When a motorcycle police officer collided with an SUV at 50 mph, his survival chances seemed slim. With fixed, dilated pupils—a classic sign of severe brain trauma—the clock was ticking. In this riveting exploration of emergency neurosurgery, Dr. Bill Long and special guest Dr. Jeff Chen, former director of trauma neurosurgery at Emanuel Hospital, take us through the life-saving measures that turned catastrophe into recovery.
The episode opens a window into the specialized world of neurotrauma, where minutes matter and millimeters make the difference. The officer suffered severe blunt force trauma to the frontal lobes of his brain. Dr. Chen, who helped develop the pupillometer—a device that measures pupil reactivity to assess brain pressure—explains how this technology revolutionized rapid neurological assessment.
The critical turning point in the operating room was a bifrontal craniectomy, a life-saving procedure where the frontal bone of his skull was temporarily removed. This allowed the officer's severely contused and swollen brain to expand outside the skull, relieving dangerous intracranial pressure. The exposed brain was carefully covered with commercially available cadaver dura until the swelling decreased, a testament to the cutting-edge techniques used in modern neurotrauma.
What makes this case particularly fascinating is the officer's post-surgical journey. As he gradually regained consciousness, an unexpected complication emerged—he couldn't distinguish his wife from her identical twin sister. This symptom, stemming from frontal lobe damage, provides a poignant reminder of how brain injuries affect our most fundamental connections to the world around us. Yet through dedicated rehabilitation, his brain slowly recovered. The removed frontal bone was eventually put back in its normal place and secured with titanium plates and screws, and the officer returned to police work (though never again on a motorcycle).
The conversation goes beyond this single case to address wider issues in trauma care: the dangers of medical silos, the crucial role of specialized nurses in neurotrauma monitoring, and why maintaining hope is as vital as any surgical procedure. As Dr. Long puts it, "You take hope away from somebody and you have crippled them."
Have you ever wondered how the brain recovers from a catastrophic injury or what life-saving measures are taken in those critical first moments? Join us for an intimate look at modern trauma, surgical critical care, and the remarkable resilience of the human brain.
To learn more about these life saving strategies and techniques, look for Dr. Long’s upcoming book, Flatline to Lifeline.
Special Guest Bio: Dr. Jefferson W. Chen, MD, PhD
Dr. Jeff Chen is a board-certified neurosurgeon with a focus on neurological trauma and critical care. He holds an MD and PhD from Johns Hopkins University and is a fellow of the American College of Surgeons (FACS) and the American College of Critical Care Medicine (FCCM).
A leader in the field, Dr. Chen was formerly the Director of Trauma Neurosurgery at Emanuel Hospital and is known for his work in multimodal brain monitoring. He also played a key role in the development of the pupillometer, a device that has become a staple in neuro-ICUs worldwide. His research interests include the molecular mechanisms of brain injury and the flow of fluids through the brain.
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Producer: Esther McDonald
Technical Director: Lindsey Kealey, of PAWsitive Choices
Editing and Post Production: Adam Scott of Atamu Media Productions
© Flatline to Lifeline 2025
Introduction to Flatline to Lifeline
Speaker 1Welcome to Flatline to Lifeline with Dr Bill Long. For three seasons, this podcast has explored unexpected survival outcomes within the medical field of trauma and how Dr Long and his team of trailblazing nurses and doctors began to replicate these unexpected outcomes by applying available technology and simple principles in new and profound ways. The pursuit of these unexpected survivals became a mission for Dr Long's team over his almost 50-year career. We hope to educate those listening from any walk of life and to inspire those in the medical profession to consider and to adopt the life-saving techniques and approaches to trauma care that we show here, because when the need is greatest for the patient, saving time saves lives. Welcome to Season 4, episode 3 of Flatline to Lifeline with Dr Bill Long. My name is Will Omen, I'm your host today and we have a special guest in the house, a friend and colleague of Dr Long. His name is Dr Jeff Chen. Dr Chen, thank you so much for being here today. Thank you for having me and obviously we have Dr Long as usual. Hi, dr Long. How are you, will? I'm doing well and for those of you who don't know, on occasion I will slip up and call Dr Long Uncle Bill, because he is in fact, know, on occasion I will slip up and call dr long uncle bill, because he is in fact my uncle.
Speaker 1So let's get into this season four. We've been so far talking about just what's going on in these severe situations, whether they be something that is an acute trauma or something that is long-term, like one like the situation our producer is going through where there's a cancer diagnosis situation. Our producer is going through where there's a cancer diagnosis. It is very important and it's not stated enough, the back and forth between doctors and patients and learning how to communicate. Dr Long, you brought up just the importance of making a connection and establishing trust with the patient, as that yields positive results because they become more interactive with you.
Speaker 1And then Lindsay, our producer, spoke about her interactions with some of the doctors that come to give updates on her husband and seen that there are very definitive differences between the bedside manners. Some doctors are standoffish and stand away. Some doctors come through and even break the fourth wall and reach out and establish physical touch, all of which are helpful in their own way. But because we have Dr Chen here, we're going to talk today about a specific incident that he and Dr Long both worked on. But before we hop into that really quick, I'll just give a quick synopsis of who Dr Chen is. And then, dr Chen, will you please fill in what I mess up. Is that agreeable?
Speaker 2For sure.
Speaker 1Okay, perfect. Dr Chen was brought to Emanuel Hospital in Portland Oregon, and he had previously trained at UCSD in neurosurgery and did a neurosurgery fellowship with a gentleman named Robert Spetzler. If you wanted to say anything on how he influenced you, that'd be fantastic, Dr Chen, but from what Dr Long told me is that they brought you in and you were ultimately selected to be the first director of trauma neurosurgery at Emanuel Hospital. I'm going to need you to explain what exactly that is. But then there was this other side note, and we spoke a little bit about it offline. One of your initial clinical research interests was pupillometry and the usage of an actual instrument called a pupillometer. So let's just really simply start off with that. What is a pupillometer?
Understanding Pupillometry in Brain Trauma
Speaker 2The pupillometer. This is actually a great topic as an icebreaker as we get into this. The pupillometer is a device that measures the pupil reactivity. So we all know that if you shine a light in your eye, your pupil constricts. That's normal. But what has been shown over and over again over many years, many years of research that the people have done, is that how fast that pupil constricts is a reflection of brain dynamics, and one part of brain dynamics that's pretty important is intracranial pressure. That is what we do a lot with head trauma. Is the pressure higher than normal? Because if the pressure is higher than normal it affects pupillary function.
Speaker 2And this is a device that was developed probably in the 1990s was when it started its infancy in the 1990s by Dr Larry Marshall, one of the preeminent neurotrauma neurosurgeons at UC San Diego, and I helped with the development of this when I was at University of Texas, galveston to my first faculty position there between 1995 and 1999 when it was studied in animals 1995, 1999, when it was studied in animals. Subsequently it received the FDA approval and was brought into the clinical arena. Legacy Manual Hospital was one of the first places that adopted this and we were actually involved with some of the initial clinical trials that basically showed that the reactivity of the pupil could statistically predict intracranial pressure, and since that time there have been several other studies that have been done and now it's become very mainstream so that most hospitals at this point have one of these in every ICU room in the neurosurgery realm. So it's become very mainstream and at Legacy Manual Hospital we were one of the first hospitals in the country that started to have these in every ICU room.
Speaker 1Okay, so tell me this you don't need to explain the entirety of the device itself, but with proper training and a person who understands the intricacies of not only the eyeball but people as well, and this device, how quickly can this test be administered?
Speaker 2Probably about 10 seconds, 10 to 15 seconds. It gives a pulse, measures it in each eye and the computer it's really a small computer in there will give you a number, a calculation. And there's a proprietary measurement called the Neuropeupillary Index, which is a compilation of different measures of the pupil and that is what is reported and that is a number that is used very commonly to say this patient is in trouble or this patient is having intracranial pressure problems.
Speaker 1Okay, and is there like just a very quick litmus test where you just go okay, we have this 10 second test and it's going to tell me that this person's brain is functioning at X percentage because of the pressure, or does it simply measure the relationship between pressure and the dilation and that's just that's what it's?
Speaker 2doing. Pressure and dilation is the main thing. However, since this has been around now for nearly 20 years, there are variations on that that people have been studying, for example, patients in coma or patients who've had a stroke or patients who've had a cardiac arrest, patients in coma, patients who've had a stroke or patients who've had a cardiac arrest. So there's a lot of additional studies that have been done that have implicated the pupillometer as being useful in either prognostication or prediction.
Speaker 1Oh okay, that's great. Okay, and that would fit in line with what we've talked about with the whole team and Dr Long. I'm going to come to you on this, but it seems like one of the themes here with Dr Long and the trauma tried and true method. But you're saying now you can extrapolate some different theories potentially upon some of those findings Correct Absolutely, and this has now gone worldwide.
Speaker 2People are using this worldwide and the Europeans in particular have very aggressive neurotrauma and neurocritical care surface where they're really studying this.
Speaker 1Gotcha. How exciting to have a person who is on the show, who actually helped develop the instrument.
Brain Pressure and Herniation Explained
Speaker 3Dr Long, you had something to add to this, I think. The other thing, and maybe it's digressing a little bit, but Jeff and I also knew that certain patients who had brain injury, the pupil was usually normally round and concentric, and so the pupil size can actually become oblong and be distorted, and not many people talk about that. You mean looking like a cat eye almost Can be, and so I'll leave it to Dr Chen. But does a pupilometer pick up on the shape of the pupil as well?
Speaker 2It can pick up on the shape of the pupil. But talking about that cat eye, that is a transitional pupil. That the pupil as it is starting to go from round, oblong and then blown or very large, that is a transitional pupil. That has been noted. The pupilometer can pick up some of that, but really it's our own eyes when you actually look at it. It's actually better than a number that you get.
Speaker 1Just since we're on the topic, I just got to ask if you saw somebody in that transitional pupil, if you saw somebody who all of a sudden went from round to a cat eye immediately I'm thinking of the Michael Jackson thriller video and I'm starting to look for exits. But because I'm assuming a werewolf is now coming at me. In your profession, though, when you see somebody's eye transition to that kind of oblong, little ball shape.
Speaker 2What does that tell you? That tells you that you're probably having a pressure phenomenon problem, where there's increased brain pressure that's going on, whether it's from a blood clot or a hemorrhage or from the head injury, and you would go ahead and move quickly with many of the trauma procedures or protocols to stabilize the patient and prevent what we call secondary injury, which I think Dr Long would be happy to discuss.
Speaker 3The other thing that's important is that Jeff Chen, who is one of the first nurses that I ever knew who actually trained the nurses to do this test, that basically raised the level of neurological nursing care, or neurotrauma nursing care, in our hospital, because the doctor is not always there. Because the doctor is not always there, but the nurse is there by the bedside 24 hours a day, and their ability to do this gives you a jumpstart, as opposed to seeing something with the naked eye and then calling the doctor to come in and do the test. That was, to me, a major breakthrough in neurological trauma nursing care.
Speaker 2To amplify what Dr Long said is that at this point in time, when these are used in the ICU, the nurses do. This is part of the hourly vital sign measurements that they will do each hour and it's now computer recorded and uploaded into the medical record so that the physician can be looking at the trend even across campus.
Speaker 1When we first started in season one, we talked about the historical perspective of the brick and mortar hospital and how it was essentially a state transfer. At least the trauma department was the Army Field Hospital put into a brick and mortar setting, and then what your team did with the mobile team is take that field hospital back out into the field. But during that, Dr Long has put such a high priority on both giving the nurses a voice post-surgical, about what they saw, what they felt, but recognizing them as frontline and increasing both their responsibility and their accountability, but also their visibility. Every time I hear it it's just such a really cool dynamic that you guys helped set up there, where the nurses have more responsibility, it sounds, and they're doing lead-off tests that save lives ultimately.
Speaker 2Absolutely. I couldn't agree more.
Speaker 1Dr Long, do you have anything you wanted to add to that, or do you want to go straight into today's anecdote?
Speaker 3As we go forward. We'll talk more about this later with a slightly different detail. I want to emphasize, though in the first three seasons we talk about largely hemorrhagic shock, people bleeding to death, and unless you get shot in the carotid artery, either in the brain or outside the brain a lot of neurosurgical patients correct me if I'm wrong, dr Chan don't exsanguinate per se they bleed into a confined space, which we talked about with the first patient with this cyprid on brain trauma. They bleed into a confined space and the skull can't expand because it's a rigid skull and pressure rises proportionally as the amount of fluid or blood accumulates on the surface of the brain or within the brain, and that creates hypertension and lowers the blood flow through the normal portions of the brain, and it even causes the brain to herniate. So we went through that in detail with the first episode we talked about.
The Motorcycle Officer Case Begins
Speaker 1Thank you for the explanation, dr Chen. Here I'm going to validate my idiot savant nature right now. I can remember this the skull is protecting the brain, and approximately a shot glass or less than two ounces of extra fluid in that skull can start to push the brain down through the hole where the spinal column comes through. You are correct. Okay, there we go. Blows my mind that my body could betray me and start pushing my brain down through the hole at the base of the skull. That sounds so non-medical that it's terrifying. Correct? Yeah, none of that was fun to say.
Speaker 2But on top of that, okay, that is a fundamental that if you have a mass in the brain about 30 cc's, okay, that the brain can't compensate for that in most patients. But if you think about it further, in addition to the mass, the blood clot, the hemorrhage, if the brain is swollen right, if the brain is swollen that also takes up space too. So a swollen, edematous, water-filled brain, meaning that the cells are more filled with water than normal that also can cause the damage that you talk about how the brain can herniate or move from one position to another.
Speaker 3Gotcha. So we pointed out Will. As we all age, unfortunately, our brain shrinks. Maybe Einstein's brain didn't shrink very much as he got older, but a lot of other people that get older. Their brain shrinks in size and so fluid accumulates on the surface of the brain that has a lesser effect until it's almost too late. Is that right, Dr Chen?
Speaker 2Correct, correct, you're absolutely right. As we get older, our brains shrink, okay, meaning that there aren't as many cells, and that's well known, and therefore it can accommodate more of a mass, which sometimes can be very deceptive.
Speaker 1Okay, so as you get older, there's more space because your brain's shrinking, and that's also another super fun thing to think about. I'm getting dumber as I get older, less capacity. But you're saying that because the brain volume is shrinking within the confined space in the skull, there is more space now. That can hide an underlying symptom. You are correct. Okay, yay, I'm ready for jeopardy.
Speaker 3I think. One other thing I'd like to point out, though, especially to a lot of the surgeons who are taking care of trauma patients, even cancer patients who get brain tumors causing all these problems. You can probably gather that I learned a lot. I had become board-certified in cardiothoracic surgery. There's no board certification in trauma as yet, but I've had all this experience. When I worked with Dr Chen, I learned a lot. I was basically in the operating room and he was teaching me how everything works. I didn't pick this up by reading. I listened to him, what he had to say about things, and I think it's important when you're dealing with multiple different specialties and taking care of the patients concurrently, not sequentially or even sequentially it's important to learn from them what they know so that you can integrate all this into a good care of the patient integrated care of the patient.
Speaker 2Absolutely. I think that one of the themes or one of the sort of accomplishments that Dr Long created was the multi-specialty approach to the head injury patient. All right, so you have. So in general, when we train, we get into our own little silos where, for example, just focus on the brain or you focus on the face, or you focus on the bones or the orthopedic or the spine injuries. But I think that when we all look at the patient together, we learned that we need to prioritize certain things and remember what the other specialties are focusing on too.
Speaker 1It's huge that you say that, because I've noticed again just all of our different experiences In the room. Obviously we have world-class surgeons. I've been a patient five times on elective orthopedic surgeries to keep my career going. Lindsay's experiencing leukemia. Esther has been through a long haul deal with a terrible diagnosis with her husband. We've all come around it. But I know for certain what I've experienced with family members is that those silos are very real. It's not. I would see the trend getting into more isolated silos where very few are the times where the whole scope is taken in and very few times does the patient or patient advocate get the whole story and see it from a broad view about how all these intricate body parts and systems are working together. Why is the trend gone that way?
Speaker 3I think this is nothing new. If you go back in history, robert luer stevenson, who wrote a lot of great romance stories, basically in the 19th century, wrote an article about specialization at that point in time. So even back in his day, they had people who were so very knowledgeable about the area that they do the most work in, but they had no idea overall. And he lamented the fact that there was no one who had the knowledge to be able to coordinate the team. And that's why I've asked Will to be involved with all this, because he's played professional baseball for five major league baseball teams, maybe more. But baseball requires a coordinated effort with all those players on the field. When they get a double or triple play, you have to have a lot of coordination and timing in order to get an optimal outcome. Same thing in basketball, same thing in football. The only difference between those teams and medicine is that those teams are filmed on national television. You get to see the mistakes and the one that played doesn't work and the one that works exceptionally well.
Speaker 3Everybody gets excited about the exception, well, when everybody laments the bad thing. But in medicine, the only place that we ever taped it in the operating room and then the resuscitation room was at UC San Diego. John Fortune brought it to us and he was one of our younger professors, and John in trauma surgery and he used to tape videos and then we would review with all the specialists involved. We would view the care we deliver in the resuscitation room when patients were unstable and it's very valuable information. But everybody gets worried about malpractice and being liable to lose the respect of their colleague, lose the respect of the nurses and it goes haywire. But if you really want coordinated care, you need to have a system that will do that.
Speaker 1There's a great deal of truth in the layperson as well. I was actually just speaking the other day with just a high school football coach and he was talking to me about how they're running play balls. Now these are 18-year-old kids and they all have a wristband on. A high school football coach and he was talking to me about how they're running play calls. Now these are 18-year-old kids and they all have a wristband on and the quarterback calls the play in the huddle. And there is a tagline, obviously in a play call where it's saying here's what each of these different groups do. So the play call is a 32 wide, right, xz, post option and all those words mean a cue to the offensive line, the wide receivers, the running backs and everybody has a job.
Speaker 1Okay, but that play call, then everybody looks at a wristband and it literally tells them their job, the singular job they're supposed to do. And so I asked him. I was like so do you feel that this has really helped you guys? And he goes yes and no. He said yes, we're better at doing our job, but our total iq as a team has gone down significantly because nobody knows what anybody else is doing. It's because the limited information like. We're giving them so specified information that they can't comprehend where another person is. So if anything requires an adaptation, everybody's lost, and that's how I'm hearing you guys talk about these silos.
Emergency Neurosurgery Procedures
Speaker 2I think that's an excellent analogy that I think people can relate to and understand, because I think that in medicine it's become so subspecialized because there's a plethora of information out there. We have to know everything about the brain, for example, or everything about cancer, and you can't know everything about that. There's just no way to do that. Know everything about that? There's just no way to do that. And because there's so much information out there, we tend to just focus on what we know and are comfortable with. And I think that's where you do have to have a team approach and somebody who's overseeing everything to coordinate things and make sure that the different silos are talking to each other in experiences where I've been point person for a little bit.
Speaker 1You see a lot of people come in doctors. You have the endocrinologist, you have the oncologist, you have everybody under the sun, and then one person will casually walk in and say I'm driving the ship and there's a new term I've heard called a hospitalist, and that's apparently the person organizing the care of the individual. I have not been overly impressed by that title and how that is managed. I don't know about the capabilities. I just know that it a almost as a pr move that this position was invented as a catch-all person for all the questions that aren't specific like is that trend? Am I way off on that too?
Speaker 3from my perspective this will cause a lot of heartburn about this, but I can tell you from personal experience, having been in the hospital for several treatments and surgeries myself. The hospital basically is there almost like a glorified intern. I hate to say this, it's not disparaging. They can coordinate some of the care, like what the family general practitioner used to be able to do in the old days, what the family general practitioner used to be able to do in the old days. But they don't have specific enough knowledge yet about how to sit there and do with highly refined specialists doing highly refined techniques and diagnostic techniques to be able to truly coordinate that.
Speaker 1And so herein lies a question for me Dr Chen or Dr Long either one of you patient under your care, dealing with multiple issues all at the same time? Okay, and you get through the trauma surgery, Everybody's working concurrently and this person is basically in suspended animation. You've gotten them to the point that they're holding, but they're still in critical condition. At that point, the quote hospitalist is supposedly the 30,000 flip view and managing all the different silos. Is that accurate?
Speaker 3I don't think so. This will cause a lot of heartburn about this situation.
Speaker 1Okay, I don't want to get anybody in trouble, we'll glop over it, but allegedly this person is managing the care. I'll leave it at this. Dr Chen, would you ever take a hospitalist recommendation in your specified field over your own opinion?
Speaker 2I think there's a lot of give and take there. We discuss it.
Speaker 2If the hospitalist is concerned about kidney function, for example, I would have to defer that to them because I don't know that much about kidney function. It's great that there is checks and balances Absolutely, and they would defer to me. You know, the patient needs a brain issue, so I think there's got to be a lot of back and forth. But I think the hospital situation is more of an internal medicine situation is more of an internal medicine situation. I think in trauma we have a different situation because trauma is acute care and because it's an acute care you need a team captain. Where I'm at currently we have a trauma system and it is well known or it is well accepted by everybody that the trauma chief, the trauma surgeon, is the team captain and calls the shots and say I want neurosurgery here or I want orthopedic surgery here, and then again we get there, we talk, we discuss things, but the recognized leader in a trauma situation is the trauma chief. They're the team captain.
Speaker 1That speaks to the specificity and the gravity of the situations that you guys are dealing with and the system that Dr Loon helped devise, where, yeah, you can have a hierarchy, but you can also all have a voice at the same time. You have a place, you have a lane, but you have the ability to step up and say I think something's wrong here. So with that, no more gilding the lily, let's go into this kind of story that you guys have here. I'll set the scene. It's a takes place in portland oregon and just a police officer, he's on his motorcycle and then he was not on his motorcycle, he was injured pretty significantly. Who wants to take it away? You guys were there, I wasn, otherwise. I'm just reading a story.
Speaker 3I guess I'll start. This took place. Portland is divided by a river, the Willamette River, and there were about seven bridges that go across it. And he was on the other side of the river, from Emanuel Hospital, but in terms of geographic distance only about two to three miles away from the hospital, when he was on his motorcycle, traveling on the street about 50 miles an hour chasing a perpetrator, when a woman in an SUV came to a stop sign, did not honor it and pulled out and he hit her at that flank speed, wearing his helmet, and he had some body padding, no armor as well, and he slammed the pressure of his head into the side of the door near its upper door frame, and it knocked him, I would say, off his motorcycle and he was unconscious, probably at the time he hit the ground. Somebody called for 911, and EMTs there within, basically within five minutes.
Speaker 3We used to have and they met rule in Portland as soon as 911 is notified and an ambulance appears at the patient's side, in order to minimize the problem that a person could be bleeding to death. So to make an assessment and then make a decision as to whether to try to stay and stabilize the patient or do first aid to the patient or transfer. So they saw, they tried to intubate him. They had removed his helmet, as we had taught them, and I noticed that he had some dilated fixed pupils which are again the sign of severe brain trauma as well as brain hypertension.
Speaker 3He was not moving spontaneously and he did not respond to what we would call pinprick or a little bit of pain stimulation, and so they tried to intubate him and they were unable to do so, which is not unusual because he also had a fractured mandible and that added to the swelling in front of the face and sometimes the tongue can swell and be difficult to put what's called a laryngoscope in to pull the tongue up upward so that you could slide in and tube down behind it into the trachea. They were unable to do that. They knew about our direct OR policy, which we've discussed before, and they chose to transport him to a manual and go directly to our operating room, as we have given them permission to ask for this direct OR by our pre-hospital care protocols, the pre-hospital care response time, the scene time and the transfer time. The time he arrived at Emanuel was less than 20 minutes. That validates the golden hour if you want to talk about it, absolutely.
Speaker 1So, dr Chan, we've established in my world that the best spot to get significantly injured is in the parking lot of a level five trauma center. Level one, I'm sorry, level one trauma center. Is that accurate?
Speaker 2I absolutely agree, level one trauma center is the proximity that you have. That time is of the essence.
Speaker 1Love it. So for everybody, quick reminder out there go online, find your nearest level one trauma center In the worst possible scenario. That is a good piece of information to have. All right, dr Long, back to you for you.
Critical Brain Recovery Process
Speaker 3You're unconscious, most likely with a severe head injury, and you don't make the decision to tell the ambulance where to go or the ambulance group where to go. So your patient arrives in the trauma operating room, the trauma anesthesiologist quickly intubates him, gets a tube in the right place and starts ventilation, while the rest of the team is inserting IV catheters one on each arm and an arterial catheter for blood pressure monitoring and for monitoring serially blood gas analysis, which is called blood drawn through the catheter, and they put in a Foley catheter to assess renal function and whether or not there's any blood in the urine. Clinically, he had a depressed skull fracture just above the eyebrows and his skin was basically had been pushed back about and bone had been pushed back about two centimeters toward his brain. His pupils remained fixed and dilated. So Dr Chan will comment on what that means, but it's an early sign of brain death in our language. And so the trauma nurse, sir John Call, was still in the hospital and he was present.
Speaker 3On patient arrival we get CAT scans of the brain, skull, facial bones and cervical spines, and you have to remember that the way we designed our trauma center trauma CAT scanner is right next to the trauma operating room right next to the ER and not too far from the helipad. So everything was designed to save time. So the brain scan showed bilateral epidural hematomas, depressed frontal bone fractures and no herniation of the brainstem. You can see that on the cat scan. The facial scan showed crushed frontal bone sinuses from the impact basically on the on his eyebrows and a displaced mandibular synthesis fracture and the cervical spine fracture showed no injury or fracture or dislocation. So the neurosurgeon then did a bifrontal craniectomy which largely was introduced in our practice in a manual by, I think, ray Grew, who came back from Korea years ago and had done craniotomies for swollen brains in at his time in korea. Dr chan, you want to comment on the craniotomies versus craniotomies?
Speaker 2so yes, just to define it so our audience knows the difference craniotomy means you take the bone off, all right, take out the offending agent, which which is the blood clot, and then you put it back. The craniectomy is where you leave the bone off, either because the bone is so fragmented that you can't put it back, or because you intentionally want to give the brain room to swell, because you're anticipating that the brain has had a lot of injury and damage, that the brain has had a lot of injury and damage and, as we talked about before, there's swelling that occurs in the individual cells of the brain. So if that happens and the brain swells up, you want to give it room to accommodate for that, so that it's not that closed box that Dr Long talked about, I think, in the previous episodes, where there's no room to expand.
Speaker 1Yeah, because I'm just imagining my head at pressure cooker and it gets too much. You have to release that pressure somehow. When you do actually do a burr hole or you do the craniotomy or craniectomy, you are literally just giving time and space for that swelling, correct, okay? So in this particular case we have a police officer. He's hit from impact to the time he's in the OR. It's 20 minutes.
Speaker 3He arrives in 20 minutes by the time that he finished the cascades and back in the OR.
Speaker 1It basically would be 30, 35 minutes, okay, so he's well within the golden hour and things have worked out to his advantage in that regard, but he is still struggling mightily. This is a very serious situation.
Speaker 3Do a bifrontal craniotomy. Basically, most neurosurgeons will do a scission at the hairline on the front of the skull and then you take the skin and you pull it downward over the eyebrows and that exposes the frontal bone. From there you can start with what's called a burr hole. It makes a hole through the skull to drill and then you can make multiple ones and remove a whole section of the brain. So he had both sides of his frontal bone removed because the brain was herniating through the original incision and the craniotomy was trying to herniating through the original incision and the craniotomy was trying to herniate through. So they need to make room for the brain to decompress. So that was the issue.
Speaker 3So we had a large craniectomy and the bone was sent to our bone bank to be for storage until we could replace the bone later on, because the patient did well and the neurosurgeon basically put a temporary dural graft. I've explained before what a dural graft is. It comes from cadavers to cover the brain that's herniated because a good portion of it is outside the skull. When you think about it a person who has a tire where there's a slit in the hard rubber of the tire and the inner tube is bulging through the hard rubber of the tire. That's what we call herniation Jeff.
Speaker 2Yes, that's a good summary of it, excellent summary of that. And again, there's two things that you're doing. One is to remove any blood clot that's there, the epidural hematoma or subdural hematoma, that blood clot that came from the injury, to give the brain more room. And then, on top of that, you want to repair the duro, which Dr Long talked about, the lining of the brain. So you're doing two things You're both removing the offending agent and also removing the bone so that you give the brain room to accommodate for swelling.
Speaker 3So then he basically makes a burr hole on the opposite side, on the normal left side of his skull, and he puts an intraventricular catheter into the brain's, patient's cerebral hemisphere with their cerebral spinal fluid. And he did this to not only drain fluid, to again reduce the pressure inside the brain, but also to measure what's called the intracranial pressure. Jeff, you want to comment on that?
Speaker 2Yes, that again helps divert fluid, because we all make spinal fluid about 500 cc's a day and so you're offloading that via this ventriculostomy. So ventriculostomy is a tube that goes into the brain and diverts fluid away from the normal ventricular site, which is constantly being made.
Speaker 1Dr Chen, can you say that one more time About what we make every day?
Speaker 2We all make cerebrospinal fluid about 500 cc's a day, Okay, and 500 cc's is day.
Speaker 1500 cc's is about how much Is that? Like a cup? Eight ounces of fluid per day, correct, wow.
Speaker 2Okay, and the body normally absorbs that. What the spinal fluid does to this day, people don't know for sure. Obviously it does something, but we haven't figured it out. But when it accumulates, when it can't get drained because the brain is too swollen, if the brain is so swollen that normal drainage pathways are blocked, what it do is divert that, so it does not build up and add to the problem.
Speaker 3So some people think that the spinal fluid around the surface of the brain, around the spinal cord, acts as somewhat of a bit of a cushion.
Speaker 2What do you think about that, jeff? It does, but I think it does more than that. Analyze it, you'll see. There's all kinds of growth factors and brain protective factors in there, but how they all act and actually work together, we're not sure so there's still a mystery on that.
Speaker 1That's very interesting. With all the work and all the research that's been done, we still can't figure out why the body makes 16 ounces of spinal fluid and what it's technically used for that. It's crazy. It's crazy. To me, that's still a mystery.
Speaker 2It is a big mystery.
Speaker 1That's phenomenal. Look at that. That actually makes me feel good that there is still something for doctors to learn. That's actually comforting the fact that you guys don't know everything. That's awesome.
Speaker 3One of the old axioms of life is the more you learn, the more you realize you don't know. That is definitely a true statement. So, continuing on, after we got the brain covered and banned, you put the dura on the coverage of sterile dressing and things like that. We now needed to know whether he was injured somewhere else, because he had a high impact crash into the side of an SUV. So he goes back to the trauma CAT scan.
Speaker 3We did a total body scan to make sure we had missed any significant injuries anywhere else, and we hadn't.
Speaker 3So that was good to know that. And now we know that if something were, either he were to deteriorate somewhere, we would know that he was not bleeding somewhere else in his body. And that was the idea of the total body scan, because you can put chest tubes in everything else like that, but the scan gives you information in more detail without having to put a lot of tubes in unnecessarily. Okay. So over time the swelling of the frontal lobes reduced and the remaining brain were retracted back into the skull cavity, and so the nurse replaced the dural graft with a bone from the bone back and secured the bone with titanium skull plates, which are very thin titanium plates that fit on the surface of the bone and little tiny titanium screws so it anchors the bone, so that you just like you're putting a patch on. Anchors the bones so that you just like you're putting a patch on, but now you're stabilizing it with these plates so that the bone of the skull doesn't move around as it hears. So it facilitates healing.
Speaker 2Correct. By holding the bone in place, you allow it to try to form some scar at the heel and give some cosmetic appearance to this. One sort of side note is that currently, in this day and age, there's developed a real industry with the 3D printing. So now that many of these that we used to freeze them in the bone bag, now you can get them made with synthetic type of plastic so they can form very nicely. So many of them, if they're cracked or there's divots or they're hosed, it could form very nicely. So maybe if there's a crack or there's divots or the hose.
Speaker 1It compensates for that. I always bring this up. That just casually we're talking about. Ah yeah, I took a titanium plate and I put it on there and I screwed it in and then he made a miraculous recovery. You know, we just gloss over this unbelievably intricate stuff when you're adding a foreign body to a person's body. No worries, we're just going to put a titanium lid on your dome for a bit. What are the risks involved?
Speaker 2Yeah, the titanium plates we use are pretty small, so the titanium plates are bridging the bulb. So the bulb these are like little staples almost that hold the bulb that we're putting there to the parent bulb. Okay, and it bridges it. So these are very small. The titanium is inert as inert as we can get as far as an implant.
Speaker 1These have been tested. What do you mean by inert? I know what the word means, but what do you technically mean by it?
Speaker 2That it has a low probability of reacting with the body, the body rejecting. We have titanium, titanium hips, titanium knees, because that metal or the alloy has been worked out pretty well to not react too much with the body.
Speaker 1It's just fairly neutral, correct. Okay, there you go. And when I think of the aluminum plate, I think of Cousin Eddie, right before they're doing the snow slide or the sledding in Christmas Vacation and he's got the plate on the side of his head and he doesn't want it to dent. And you're saying these are small. I think of a plate, I don't know, almost half the size of a dollar bill, that's what I'm thinking of. And you're saying they're significantly smaller than that.
Speaker 2The new ones that we use currently? Yes, the new ones, so the old ones were big Perhaps.
Speaker 1Yes, he doesn't divulge trade secrets. I love it. Okay, so we have this very ramshackle titanium plate. It's got jagged edges and a little bit of rust on the side, and so, dr Chen, was it you who put this rusty piece of metal on the guy's skull, or was it someone else?
Speaker 2I don't remember, but I think it's probably somebody else, okay.
Speaker 1Probably no better Gotcha, okay. So this perfectly sterile, neutral titanium plate was put's probably somebody else, okay. Probably no better gotcha okay. So this perfectly sterile, neutral titanium plate was put in by somebody else and there was a. He gradually regained consciousness, but something else began to occur. What was that?
Recovery, Rehabilitation and Hope
Speaker 3as people began to react, remember, they were fixed and dilated and then, as he regains consciousness, he begins to move all four limbs and then he goes up. But the hard work after the surgery is the neurosurgical critical care. And surgery is one thing. You stop the bleeding and you try to prevent further, further complications from recurring from that. But the real issue is that I'm keeping them alive until the brain can recover. We talked about why we use a cardiopulmonary bypass machine. You use it to support the heart and lungs until the heart and lungs can recover, especially when they're not compatible with life to begin with. And the neurosurgical critical care can't be underestimated. It can be hours, it can be days, weeks and months to get somebody to have the brain recover enough to begin to show signs of life and be able to have cognitive life where they can answer questions and be able to talk to you and do things. Jeff.
Speaker 2Correct the ICU, whether it be a neurosurgery ICU or neurocritical care ICU or whether it's surgical ICU Many times it's shared. But what you're trying to do is create the best environment for the brain to recover so you get through the initial swelling, which is usually just within a couple weeks. Then what you want to do is make sure that other factors blood pressure, glucose, utilization, oxygenation are all homeostatic. Again, so that the brain does not suffer secondary insults. What does homeostatic?
Speaker 1mean Probably as close to normal as possible. Okay, I figured it was homeostasis, but I had to confirm. Dr Long, I remember when we talked about the case study with the girl whose liver was crushed by the transformer of the telecom pole and you had been given advice by another leading surgeon to just give it time and it would regenerate itself. Time and it would regenerate itself. Dr Chen, when we're talking about the brain in this manner and you're waiting for swelling to go down, any trauma that occurs to the brain, obviously we know that there are people who suffer for the rest of their life and who go quote brain dead, but in a regenerative sense, when somebody has a large amount of trauma, like this police officer did, is there a gradual, like normal scale for recovery on something like this? When you do a craniotomy or craniectomy, is there some sort of general guideline that people follow along with, or is it completely individualized?
Speaker 2It's pretty much individualized, individualized. It's pretty much individualized. However, what the latest data says is that your outcomes, the best measurement for your outcomes, is at about a year. So if you're trying to make an estimate of your outcome at one month or two months or three months, that may be premature, because the brain recovers much more slowly. And when we say recover, we're talking about not regeneration, because, as we know, the brain cells, as we know them, do not regenerate. You don't make new brain cells, but what you're hoping is that in those initial phases, in the critical care situation, you create such an environment that those cells that are injured or damaged do not die, that you can salvage them, that as the swelling goes down these cells that are perhaps idling, they become active again.
Speaker 1Okay, thank you for the explanation. That is what I was imagining in my head. I just used the wrong word. Don't worry, it'll happen again. Dr Long, you had something to piggyback there.
Speaker 3Years ago I don't know when Dr Chen was involved with these people, but we had some people who were interested in brain plasticity and there was a professor of neurosurgery from University of Virginia and so on who came out and educated us about brain plasticity and the idea is that the brain in its own way can reprogram and develop new conduits around that. And there was a I think he worked with this man at Johns Hopkins University. He used to do craniectomy remove half of the brain in child with intractable epilepsy and you would think that would leave the child permanently paralyzed. But apparently there is some plasticity where the brain reprograms. It doesn't regenerate, but it reprograms and opens up new pathways to carry signals around so that something like this could happen. Is that right or am I wrong?
Speaker 2on that. Well, that's the hope that there is brain plasticity. But that tends to happen again. Younger patients Younger patients we realize have better recovery and part of that is probably because there are opportunities in younger patients for brain plasticity or neuroregeneration.
Speaker 1And that's just got to be because of their, just because of their cells growing and multiplying at just a ridiculous rate. As a youth, I always say with young athletes they're really not at a risk for injury long-term because they're made out of rubber. Their bones aren't brittle yet they just absorb and bounce off of things. And that's what you're saying. You're seeing in the brain as well, that plasticity or almost elasticity.
Speaker 2Yeah, we talk about plasticity. We're talking about more the ability of neurons to grow and differentiate. Okay, so they can become more specialized for specific functions. I see. So we're thinking a little bit differently than you know, thinking more of a physical thing. We're thinking more of the opportunity for cells to grow, gotcha.
Speaker 1And then when we're dealing with the adults, it's the avoidance of those cells dying. Correct, for them to come back and become active again, correct, okay, all right, back to Dr Long. Here there was a temporary lingering effect with this gentleman, but, spoiler alert, he does survive. Okay, take me through his recovery, dr Long.
Speaker 3Yeah, while he was still in the hospital it was conversational things like that. But remember, the frontal lobe is the brain that helps integrate a lot of information and people need their frontal lobe.
Speaker 1Dr Lohan, you were saying it reminded you of the movie One Flew Over the Cuckoo's Nest.
Speaker 3Yeah, because the frontal lobe basically helps integrate information. When you lobotomize somebody and they used to do that a lot, basically in the 30s and 40s for a number of diseases they become not quite zombies, but they're not quite themselves and they don't integrate information like they should. Well, this particular fellow, his wife, had a twin sister and so because he looked so much alike, he got her twin sister confused with his wife, and so it created a little bit of pandemonium in the family.
Speaker 3briefly, but ultimately, when he was walking, eating and moving around the hospital, we sent him over to rehab and he recovered. And he recovered enough to become active again as a police officer, but obviously he never rode a motorcycle again.
Speaker 1but I do want to go back. How long would? How long was this poor guy confused that his wife and his wife's twin sister were not the same person? A couple weeks, a couple weeks, yeah, okay, dr. Can we confirm this on your end too?
Speaker 2The best way I can recollect should yes.
Speaker 1That had to provide some very unplanned comedic moments when you're visiting.
Speaker 3Then I had to mess with his wife and the sister, the neurosurgical ICU nurse, got a big giggle out of all this. That's how I learned about it, because they saw it, oh that's funny. And the wife was a little bit concerned because she hoped that wasn't going to be a permanent situation.
Speaker 1Yeah, one would imagine. Going back into the humor is great, but going back into the gravity of this, I remember offline, dr Chen, you had said some of your takeaways on this were building and supporting a dedicated neurotrauma practice and talking about the pupilometer. Those were big takeaways from you, but I'll just put you on the spot as we close up here. Are there any extra things like from this case or just remembering back that you have a chance to say to a medical professional or to a future or current patient what are the things from this particular case, or just your time here, that you just want to pass on?
Speaker 2Well, I think that one of the things is to be aggressive up front with the head of your patient, so you do what you can do it quickly and you work with a good team, like Dr Long has right, so that you work as a multi-specialty team, communicate, you talk to each other and because of that you will have better outcomes. And one of the things that's not mentioned in this particular patient is that a lot of his good outcome came from being in rehab. The Rehabilitation Institute of Oregon was specialized in helping patients with head injuries specifically, and I think that helped him quite a bit, and that's part of the team too. Although it's more chronic down the line, we have to keep in mind that it doesn't end just at the operating room or the ICU. It becomes almost lifelong that they have to have this continual help.
Speaker 1Oh yeah, absolutely. When you have a massive injury, you get into a scenario where you have to redefine normal, and sometimes you have to redefine normal on a daily basis. Okay, and I'm speaking of this only from orthopedic surgeries where you know there's something on my elbow or shoulder and you have to earn the right to get back your normal function. So when you say somebody goes to rehabilitation, for those people in the general public that don't know, rehabilitation is a long and arduous process, regardless of what surgery you have, because you truly are redefining normal, your body is redefining normal and getting to, as Dr Chen said earlier, that homeostatic space where everything is working together, where everything is working together and one of the things to emphasize is you say redefine normal.
Speaker 2It's not just for the patient, it's for the family too, dr.
Speaker 3Long. You had something to add to that. No, I think that for those who are following the veterans of the war in Iraq, where a lot of them from IED lost limbs, part of their pelvis, everything rehab was crucial for them to be able to come back and resume their life as a member of the family a husband, father of children. And rehab is also important for them being able to learn new tasks, be able to function and even have a job. And rehab has exploded now with artificial limbs, and now then they're having this sensory and motor probes put into the brain with microchips to sit there and help people walk again who are paralyzed. It's a huge door that's opening up for potential getting these patients to live more normal lives.
Speaker 1I think the focus on that is completely worthy and just like mental health studies that we do now, people need that elongated care to get and heal a lot of these, a lot of these issues. Do you have any personal takeaways from this, Dr Long?
Speaker 3I think the issue is cautious. Optimism is what helps the family, because they're looking for, as they listen to your words, watch your facial movements, eye contact and body posture. They're trying to get every bit of information that what you're speaking is true and that they have hope. You take some hope away from somebody and you have crippled them, and I can't emphasize the issue. That's what we had. This created this wall of hope of pictures of patients who survived unexpectedly in a manual and that was to give the existing nurses, the future nurses, and the patients and their families come by and they look at those pictures and know that there's somebody who survived this and it's an incredible thing. This issue of hope you take it away and despair sets in and it's almost impossible to deal with after that.
Speaker 2Jeff, I agree. That is, I think, a very nice way to summarize that Hope is really important, not just for the patient but really for the family.
Speaker 3Yeah.
Speaker 1I concur you have to be looking forward to something. You have to have a destination.
Speaker 3So one thing I want to emphasize before we close is that the leg cardiac arrest, hemorrhagic shock from bleeding to death or sanguination. We talk about brain trauma with intracranial hypertension and the threat of herniation through the foramen magnum, which is the whole of the base of the skull, and death. It's just as important to have early intervention as fast as possible to prevent that from happening, prevent death from happening and disability from happening. And so it is a race against time and I don't think still there's a lot of places to really understand that, except people who really concentrate on neurotrauma. Jeff.
Speaker 2Correct. I think that those of us in neurotrauma are frontline, so we see that and constantly appreciate that upfront, aggressive approach and the teamwork that's involved to carry that out.
Speaker 1I guess that's where we're going to end it today. We want to thank you both, dr Chen, obviously, for being here, dr Long for your expertise as well. We hope for those of you who tuned in, this was educational and that you at the very least have more of a plan going forward for what might happen to you should a disaster befall. Again, thank you, dr Chen, for joining us. This has been episode three of season four, flatlines Lifeline, with Dr Bill Long. Thank you for coming and joining with us. We hope to see you again very soon.
