LLU&MC Scope, Autumn 1997, Brain trauma pioneer

Kevan Craig, MD, instructor, physical medicine/rehabilitation, School of Medicine, poses with Devin Holiday. Devin is the victim of a hit-and-run accident and was in a coma for a period of time. Dr. Ashwal regularly refers patients like Devin to Dr. Craig for rehabilitation.

When children do not act like children--when they don't run around playing with a sense of reckless abandon, their faces full of mischief and life--something is obviously wrong. But what of the children who have had their childlike characteristics taken from them as the result of a traumatic brain injury, or a developmental problem? Their cases are no less disheartening to witness. Stephen Ashwal, MD, professor of pediatrics, School of Medicine, specializes in dealing with children who suffer from traumatic brain injury and other forms of neurodamage.

The term "brain injury" refers to any injury of the brain. It can be caused by fracture or penetration of the skull (such as in the case of a vehicle accident, fall, or gunshot wound), a disease process (neurotoxins, infections, tumors, metabolic abnormalities, etc.), or a closed head injury such as in the case of Shaken Baby Syndrome, or rapid acceleration or deceleration of the head. These injuries can have devastating lifelong effects on the physical and mental functioning of the survivor.

Children who have been in accidents or are the victims of abuse may suffer from traumatic brain injury in the forms of either persistent or permanent vegetative state. These terms refer to children who have evolved from eyes-closed coma but who remain unconscious even though they look awake. They may or may not have a chance to regain consciousness once they are in a vegetative state. Dr. Ashwal is recognized as a leading authority on the subject of the persistent vegetative state in children, and has conducted extensive research on the topic, and is constantly involved in current research and diagnosis.

According to Dr. Ashwal, "if the vegetative state is present six months after traumatic brain injury or three months after anoxic or other form of non-traumatic brain injury, it is likely to be permanent--that is, there is little hope for recovery of consciousness. For those patients who do recover after this time period, they usually do so to a state of severe disability."

Since 1968, when the Harvard Criteria for Diagnosing Brain Death were first published, it became necessary for physicians, as well as families to clearly define the terms that indicate death. Previous to 1968, death was widely believed to come as a result of cardiac arrest. Once the Harvard criteria were published, people came to understand that the body can die in more than one way, as in the case of brain death.

Dr. Ashwal, as co-chair of a national task force to establish a clear definition of the vegetative state, has made it a point to be able to clearly understand vegetative state, therefore making it easier to counsel the families of his patients as to what course of action is best to take.

When a child emerges from a coma and exhibits signs that recovery is imminent and possible, rehabilitation is made top priority. As a firm believer in rehabilitative medicine for children who have had brain injuries, Dr. Ashwal enjoys a camaraderie with several excellent specialists in pediatrics and rehabilitative medicine. Among them is Kevan Craig, MD, instructor, physical medicine/rehabilitation, School of Medicine. Dr. Craig often works with children referred to him by Dr. Ashwal as their rehabilitation needs arise. "My goal," explains Dr. Craig, "is this: if a patient has function--even if it is very, very limited--I can take that and expand upon it."

He says Dr. Ashwal "is extremely good. He is a pioneer in the nation and the world on the coma and persistent vegetative state, and has performed what is likely the most complete studies in that field."

"Rehabilitative medicine for kids and adults is extremely important," says Dr. Ashwal. "We have no definite way, with 100 percent certainty, to know how a specific child with brain injury will do. It is good to give him or her the best possible chance to recover." He also aDDS that although intensive therapy is expensive, it is important to give children the best possible chance to improve and enjoy their quality of life for themselves, as well as for their families.

Working with children who are severely incapacitated on a day-to-day basis is part of Dr. Ashwal's job. Though he has an awesome task in helping these children to heal and regain their lives, it is well worth the effort when even one child wakes from a prolonged slumber, and smiles to his parents in a way that lets everyone know that everything will soon be all right.